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BOOKS 


BY 


ALBERT  S.  MORROW,  M.  D 


Diagnostic  and  Therapeutic  Technic 

Octavo  of  894  pages,  with  892  line- 
drawings.  Third  Edition. 


Immediate  Care  of  the  Injured 

i2mo  of  355  pages,  with  242  illus- 
trations. Cloth,  $2.75  net. 
The  New  (2d)  Edition 


76n(> 


DIAGNOSTIC 


AND 


THERAPEUTIC  TECHNIC 

A  Manual   of  Practical   Procedures 
Employed  in  Diagnosis  and  Treatment 


BY 

ALBERT  S.  MORROW,  A.B..  M.D..  F.A.C.S. 

LATE  LIEUT.-COLUNEL,  M.  C,  U.  S.  A.;  ATTENDING  SURGEON  TO 
THE  CITY  HOSPITAL.  AND  TO  ST.  BARTHOLOMEW'S  HOSPITAL; 
CONSULTING  SURGEON  TO  THE  NASSAU  HOSPITAL,  MINEOLA.  L.  I. 


THIRD  EDITION,  ENTIRELY  RESET 
WITH  892  ILLUSTRATIONS,  MOSTLY  ORIGINAL 


PHILADELPHIA  AXD  LOXDOX 

W.   B.  SAUNDERS   COMPANY 

1921 


Copirright,    19x1,  by  W.  B.  Saunders  Company.    Reprinted  January, 

X9<2,  and  January,  1913.    Revised,  entirely  reset,  reprinted, 

and  recopyrighted  January,  19x5.    Reprinted  July.  1915, 

and  April.  191 7.    Revised,  entirely  reset,  reprinted, 

and  recopyrighted  January,  193X 


Copyright,  rpai,  by  W.  B.  Saunders  Company 


•  •  • 


•  •  *   • 


PRINTKD    IN     AMKniCA 


r.     ■.     •AUNDCRS    COMPANY 
PHILADELPHIA 


To  the  memory  of  my  Father 

Prince  a.  Morrow,  m.  D., 

This  book  is  dedicated 


is 


1i 


OCT    2  4  1950 


I 


PREFACE  TO  THE  THIRD  EDITION 


In  the  desire  to  have  the  third  edition  of  this  book  conlorm  to 
the  latest  advances  in  methods  of  diagnosis  and  treatment,  a  very 
careful  revision  of  the  text  has  been  made  and  the  book  has  been 
entirely  reset.     While  the  general  plan  of  the  original  work  has  been 
followed  without  change,  several  sections  have  been  rewritten  and 
considerable  new  material  has  been  added.     Additional  illustrations 
have  been  supplied  to  elucidate  the  new  text,  and  some  of  those 
that  appeared  in  previous  editions  have  been  redrawn.     This  work 
has  been  efficiently  performed  by  Mr.  Howard  J.  Shannon  under 
the  author's  supervision.     Every  effort  has  been  made  to  bring  the 
present  volume  up-to-date  and  maintain  the  practical  character  of 
the  previous  editions,  and  it  is  hoped  that  the  changes  and  addi- 
tions that  appear  in  this  new  edition  will  add  materially  to  the 
usefulness  of  the  book. 

A.  S.  M. 

Nkw  York  City, 
January,  1921. 


PREFACE 


In  this  volume  the  writer  has  endeavored  to  bring  together  and 
arrange  in  a  manner  easily  accessible  for  reference  a  large  number  of 
procedures  employed  in  diagnosis  and  treatment.  The  book  has  been 
given  the  comprehensive  title  "Diagnostic  and  Therapeutic  Technic." 
The  scope  of  the  work,  however,  can  be  best  appreciated  by  consulting 
the  table  of  contents  on  page  7. 

While  some  of  the  methods  herein  detailed  belong  essentially  to  the 
domain  of  the  specialist,  the  majority  are  the  every-day  practical  proce- 
dures which  the  hospital  interne  or  the  general  practitioner  may  at  any 
time  be  called  upon  to  perform.  So  far  as  the  writer  is  aware  there  is  no 
single  book  to  which  one  may  turn  for  information  along  these  lines. 
Text-books  of  the  present  day,,  treating  exhaustively  as  they  do  of  the 
larger  problems  of  medicine  and  surgery,  must  of  necessity,  if  they 
are  to  be  kept  within  reasonable  limits,  omit  or  else  describe  in  a  most 
condensed  manner  these  so-called  minor  procedures.  If  the  reader 
desires  fuller  and  more  detailed  information  it  not  infrequently  happens 
that  it  is  necessary  for  him  to  consult  a  number  of  works  before  he 
obtains  all  the  desired  information.  To  supply  such  a  want  is  the 
object  of  this  book. 

The  plan  of  the  work  comprises,  first,  a  description  of  certain 
general  diagnostic  and  therapeutic  methods  and,  second,  a  description 
of  those  measures  employed  in  the  diagnosis  and  treatment  of  diseases 
affecting  special  regions  and  organs  of  the  body.  Operative  methods 
have  been  omitted  as  far  as  possible,  only  those  having  been  considered 
which  are  required  in  emergencies  or  which  form  a  necessary  part  of 
some  of  the  measures  described.  Each  procedure  has  been  given  in 
detail,  leaving  nothing  to  the  reader's  imagination.  For  this  reason, 
and  that  each  section  might  be  complete  in  itself  without  referring  the 
reader  to  other  portions  of  the  text,  some  unavoidable  repetition  occurs. 

All  important  steps  have  been  illustrated  so  that  the  reader  may 
grasp  at  a  glance  the  technic  of  the  various  procedures,  no  expense 
having  been  spared  in  this  direction.  Nearly  all  the  illustrations  are 
line  drawings  made  by  Mr.  John  V.  Alteneder,  head  of  the  W.  B. 

S 


6  PREFACE. 

Saunders'  art  department,  from  photographs  under  the  author's  super- 
vision. The  excellence  and  high  character  of  his  work  has  done  much 
to  elucidate  the  text.  In  instances  where  illustrations  from  other 
sources  have  been  utilized  due  credit  has  been  given. 

I  desire  here  to  express  my  heartiest  thanks  to  my  father,  Dr. 
Prince  A.  Morrow,  and  to  Drs.  T.  J.  Abbott,  J.  M.  Lynch,  J.  H.  Potter, 
and  J.  F.  McCarthy  for  many  valuable  suggestions  and  criticisms,  and 
to  others  wJio  have  assisted  me  in  various  ways  in  the  preparation  of  the 
manuscript. 

My  thanks  are  also  due  the  Kny-Scheerer  Co.,  of  New  York,  for 
having  kindly  furnished  many  of  the  instruments  from  which  drawings 
have  been  made. 

A.S.  M. 

New  York  City. 


CONTENTS 


CHAPTER  I 

Pagb 

The  Administration  or  General  Anesthetics 17 

Preparations  of  the  patient  for  general  anesthesia 18 

Stages  of  anesthesia 22 

Ether  anesthesia 24 

Chloroform  anesthesia 34 

Nitrous  oxid  anesthesia 39 

Nitrous  oxid  and  oxygen  anesthesia 44 

Nitrous  oxid  and  ether  sequence 45 

Ethyl  chlorid  anesthesia 47 

Anesthetic  mixtures 49 

Intubation  anesthesia 51 

Intratracheal  insufflation  anesthesia 52 

Anesthesia  through  a  tracheal  opening 56 

Intravenous  general  anesthesia 58 

Rectal  anesthesia. 61 

Oil-ether  colonic  anesthesia 64 

Scopolamin-morphin  anesthesia 65 

Accidents  during  anesthesia  and  their  treatment 65 

After-effects  of  anesthetics 72 

After-treatment  of  cases  of  general  anesthesia 74 


CHAPTER  II 

Local  Anesthi.sia 76 

Advantages  and  disadvantages  of  local  anesthesia 77 

Methods  of  producing  local  anesthesia 80 

Drugs  employed  for  local  anesthesia 81 

Pref>aration  of  patient  for  local  anesthesia 84 

Conduction  of  an  operation  under  local  anesthesia 85 

Local  anesthesia  by  cold 86 

Surface  application  of  anesthetic  drugs 87 

Infiltration  anesthesia 88 

Kndo-  and  perineural  infiltration 93 

Practical  application  of  infiltration,  endo-  and  perineural  methods  of  anesthe- 
sia to  special  localities 95 

OjK-rations  on  inflamed  tissues  under  local  anesthesia 109 

Bier's  venous  anesthesia no 

Arterial  anesthesia 114 

Spinal  anesthesia 115 

Sacral  anesthesia 122 

Parasacral   anesthesia 125 

7 


8  CONTENTS 

CHAPTER  ni 

Pacb 

Sphygmomanometky 127 

Normal  blood-pressure 128 

Instruments  for  estimating  blood-pressure 1 29 

Technic  of  estimating  blood-pressure 132 

Variations  of  blood-pressure  in  disease 134 

CHAPTER  IV 

Transfusion  of  Blood 137 

Indications  and  contraindications 138 

Selection  of  the  donor 139 

Hemolysis 139 

Method  of  determining  blood  groups 141 

Direct  artery  to  vein  transfusion 143 

Technic  by  Crile's  method 145 

Brewer's  method 148 

Elsberg's  method 148 

Indirect  transfusion, 149 

Lindeman's  method 150 

Unger's  method 152 

Paraffined  tube  method 153 

Sodium  citrate  method 156 

Transfusion  of  preserved  red  cells 161 

Injections  of  Human  Blood  Serl-m 164 


CHAPTER  V 

Infusions  of  Physiological  Salt  Solution 167 

Indications 167 

Preparation  of  normal  salt  solution 168 

Artificial  sera  for  infusions 169 

Gum  acacia  solutions  for  infusions 170 

Intravenous  infusion 170 

Intraarterial  infusion 177 

HypK)dermoclysis 180 

Rectal  infusion 183 


• 


CHAPTER  VI 

Acupuncture 184 

Venesection 185 

Scarification 190 

Subcutaneous  Drainage  for  Edema 192 

Cupping 194 

Leeching 197 


CONTENTS  9 

CHAPTER  VII 

Pagb 

HYPODEsiac  AND  Intramuscular  Injection  OF  Drugs 201 

Administration  ofArsphenamin  and  Neoarsphenamin 206 

Administration  OF  Diphtheria  Antitoxin 214 

Vaconation 2ig 


CHAPTER  Vni 

The  Treatment  of  Neuralgia  BY  Injections 225 

Trifacial  neuralgia 225 

Sciatica 231 


CHAPTER  IX 

• 

Disinfection  .of  Wounds  by  the  Carrel-Dakin  Technic .234 

Preparation  of  Dakin's  solution  by  Daufresne's  method 235 

Mechanical  cleansing  of  the  wound 242 

Arrangement  of  the  tubes 243 

Dressing  the  wound 246 

Bacteriological  examination  of  the  wound 247 


CHAPTER  X 

BiEK*s  Hyperebhc  Treatment 250 

Passive  hyperemia 250 

Effects  of  hyperemia 251 

Indications 253 

General  principles  underlying  hyperemic  treatment 253 

Passive  hyperemia  by  means  of  constricting  band? 255 

Passive  hyperemia  by  means  of  suction  cups 261 

Active  hyperemia 267 

The  pRODicrrioN  of  an  Artificial  Pneumothorax 270 

Effects  of  i 271 

Indications 271 

Method  of  inducing ^ 274 

Complications 275 

The  Diagnosis  and  Trf.atment  of  Fistulous  Tracts  by  Means  of  Bismuth 

Paste 276 


CHAPTKR  XI 

Collection  and  Preservation  of  Pathological  Material 279 

Method  of  making  smear  preparations  for  microscopical  examination      .    .    .279 

Method  of  inoculating  culture  tubes 287 

Collection  of  discharges  and  secretions  for  bacteriological  examination     .    .    .  290 

Collection  of  blood  for  microscopical  examination 297 

Collection  of  blood  for  bacteriological  examination 302 


lO  CONTENTS 

Pack 

Collection  of  sputum 304 

Collection  of  urine 305 

Collection  of  stomach  contents 306 

Collection  of  feces 3^7 

Removal  of  a  fragment  of  solid  tissue  for  examination 307 

CHAPTER  XII 

Exploratory  Punctuiles 311 

Exploratory  punctures  in  general 311 

Exploratory  puncture  of  the  pleura 312 

Exploratory  puncture  of  the  lung 317 

Exploratory  puncture  of  the  pericardium 318 

Exploratory  puncture  of  the  peritoneal  cavity 321 

Exploratory  puncture  of  the  liver .  322 

Exploratory  puncture  of  the  spleen 324 

Exploratory  puncture  of  the  kidneys 325 

Exploratory  puncture  of  joints 326 

Spinal  puncture 329 

Spinal  puncture  as  a  means  of  administering  therapeutic  sera 336 


CHAPTER  XIII 

Aspirations 339 

Aspiration  of  the  pleural  cavity 339 

Aspiration  of  the  pericardium 34  7 

Aspiration  of  the  abdomen  for  ascites 350 

Aspiration  of  the  tunica  vaginalis 354 

Aspiration  of  the  bladder 357 


CHAPTER  XIV 

The  Nose  and  Accessory  Sinuses 358 

Anatomic  considerations 358 

Diagnostic  methods 363 

Rhinoscopy 363 

Inspection  of  the  nasopharynx  by  means  of  Hays'  pharyngoscope 370 

Palpation  by  the  probe 373 

Digital  palpation  of  the  nasopharynx 375 

Transillumination  of  the  accessory  sinuses 376 

Skiagraphy 378 

Therapeutic  measures 379 

Nasal  douching 379 

The  nasal  syringe 382 

The  nasal  spray 383 

Direct  application  of  remedies 386 

InsufDations 38S 

Lavage  of  the  accessory  sinuses 389 

Passive  hyperemia  in  diseases  of  the  nose  and  accessory  sinuses 396 

Tamponing  the  nose  for  the  control  of  hemorrhage 397 


CONTENTS  1 1 

CHAPTER  XV 

Pack 

The  Ear 401 

Anatomic  considerations 401 

Diagnostic  methods 40S 

Direct  inspection 407 

Otoscopy 407 

Determination  of  the  mobility  of  the  drum  membrane.       4^1 

Hearing  tests 4^3 

Inflation  of  the  middle  ear  for  diagnosis 4^5 

Therapeutic  measures 423 

The  ear  syringe 423 

Instillations 425 

Application  of  caustics 427 

Inflation  of  the  middle  ear  for  therapeutic  purposes 428 

Inflation  with,  medicated  vapors 428 

Injection  of  solutions  into  the  Eustachian  tubes 429 

The  Eustachian  bougie 43® 

Massage  of  the  drum  membrane 432 

Incision  of  the  drum  membrane 432 

CHAPTER  XVI 

The  Larynx  and  Trachea 436 

Anatomic  considerations 436 

Diagnostic  methods 439 

Laryngoscopy  and  tracheoscopy 440 

Direct  laryngoscopy 4*7 

Autoscopy 450 

Suspension  lar>'ngoscopy 450 

Direct  trachco-bronchoscopy 453 

Palj)ation  by  the  probe 460 

Skiaj^raphy 460 

Therapeutic  measures 461 

The  lanngeal  spray 461 

Direct  application  of  remedies 462 

Insufflations 465 

Steam  inhalations 465 

I)r>'  inhalations 4^>8 

Intubation 468 

Tracheotomy 477 

CHAPTKR  XVII 

Thk  F^sophagus 488 

Anatomic  considerations 488 

Diagnostic  methods 488 

Auscultation 48g 

Percussion 490 

Palpation 490 

Examination  by  sounds  and  bougies 490 


12  CONTENTS 

Pagb 

Esophagoscopy 498 

Skiagraphy 502 

Therapeutic  measures 502 

Lavage  of  the  esophagus 502 

Dilatation  of  esophageal  strictures  by  the  bougie 504 

Intubation  of  the  esophagus 508 


CHAPTER  XVra 

The  Stomach 513 

Anatomic  considerations 513 

Diagnostic  methods 514 

Inspection 516 

Palpation 518 

Percussion 521 

Auscultation 523 

Inflation  of  the  stomach 524 

Examination  of  stomach  contents 526 

Fractional  method  of  gastric  analysis 533 

Test  of  motor  function 536 

Test  of  absorption  power 536 

Gastrodiaphany 537 

Gastroscopy 539 

Skiagraphy 546 

Exploratory  laparotomy 547 

Therapeutic  measures 547 

Lavage  of  the  stomach 547 

The  stomach  douche 552 

Gavage 555 

Duodenal  feeding 559 

Massage 561 

Electrotherapy 563 


CHAPTER  XDC 

The  Colon  and  Rectum 566 

Anatomic  considerations 566 

Diagnostic  methods 570 

I.  Abdominal  Examination 571 

Inspection 571 

Palpation 572 

Percussion 573 

Auscultation 573 

Inflation  of  the  colon 573 

Skiagraphy 576 

II.  Internal  Examination 577 

Inspection -.    .  579 

Palpation  by  the  finger 579 

Manual  palpation.   . 582 

Examination  by  the  speculum  or  proctoscope 583 


CONTENTS  13 

Pagb 

Examination  by  sounds  and  bougies 590 

Examination  by  the  bougie  k  boule 591 

Examination  by  the  probe 593 

Lavage  of  the  bowel 593 

Examination  of  the  feces 594 

Therapeutic  measures 594 

Enemata 594 

Enteroclysis 594 

Saline  rectal  infusion 607 

Continuous  proctod3rsis 609 

Nutrient  enemata 613 

Injection  of  fluids  or  air  into  the  bowel  in  intussusception 616 

Dilatation  of  rectal  strictures  by  the  bougie 618 

Colonic  massage 621 

Auto-massage 633 

Application  of  electricity  to  the  rectum  and  colon 624 


CHAPTER  XX 

The  Urethra  and  Prostate 627 

Anatomic  considerations 637 

Diagnostic  methods 631 

Glass  tests  for  locating  urethral  pus 632 

Injection  test  for  locating  urethral  pus 634 

Inspection 634 

Palpation 636 

Examination  by  sounds  and  bougies 638 

Examination  by  the  bougie  k  boule 647 

Urethrometry 650 

Estimation  of  the  urethral  length 651 

Urethroscopy  in  the  male 652 

Urethroscopy  in  the  female 658 

Therapeutic  measures 661 

Urethral  injections 661 

Irrigations  of  the  urethra 664 

Instillations 669 

Application  of  ointments 672 

Urethroscopic  treatment 673 

Direct  application  of  cold  to  the  urethra 676 

Prostatic  massage 677 

Meatotomy 679 

Treatment  of  strictures  by  gradual  dilatation 680 

Treatment  of  strictures  by  continuous  dilatation 693 

CHAPTER  XXI 

The  Bladder 696 

Anatomic  considerations 696 

Diagnostic  methods 698 

Urinalysis 699 

Inspection 704 


14  CONTENTS 

Pagb 

Percussion 705 

Palpation 705 

Sounding  for  stone 707 

Test  of  bladder  capacity 711 

Estimation  of  residual  urine 712 

Test  for  absorption  from  the  bladder 713 

Cystoscopy  in  the  male 713 

Cystoscopy  in  the  female 719 

Skiagraphy 725 

Therapeutic  measures 725 

Irrigations 725 

Auto-irrigations 729 

Instillations 730 

Cystoscopic  treatment 731 

Fulguration  of  vesical  growths  by  the  high  frequency  current 732 

Catheterization  in  the  male 734 

Catheterization  in  the  female 741 

Continuous  catheterization 743 

Aspiration  of  the  bladder 746 


CHAPTER  XXII 

The  Kjdneys  and  Ureters 749 

Anatomic  considerations 749 

Diagnostic  methods 752 

Inspection 752 

Palpation  of  the  kidney 753 

Palpation  of  the  ureters 755 

Percussion 757 

Urinalysis 758 

Catheterization  of  the  ureters  in  the  male 759 

Catheterization  of  the  ureters  in  the  female 768 

Pyelometry 774 

Segregation  of  urine 775 

Tests  of  kidney  function 779 

Skiagraphy 791 

Pyelography 792 

Exploratory  incision 792 

Therapeutic  measures 793 

Medication  of  the  renal  pelvis  and  ureters 793 

Dilatation  of  ureteral  strictures 794 


CHAPTER  XXIII 

The  Female  Generative  Organs 796 

Anatomic  considerations 796 

Diagnostic  methods 79^ 

I.  Examination  of  the  abdomen. 

Inspection 803 

Palpation 804 

Percussion 806 


CONTENTS  15 

f  Pagb 

Auscultation 808 

Mensuration * 808 

II.  Examination  of  the  pelvic  organs. 

Inspection • 809 

Examination  of  discharges 810 

Digital  palpation 811 

Bimanual  palpation 813 

Examination  by  means  of  specula 820 

Sounding  the  uterus 825 

Digital  palpation  of  the  uterine  cavity 827 

Examination  of  sections  and  scrapings  from  the  uterus 829 

Exploratory  vaginal  incision 829 

Therapeutic  measures 832 

Vaginal  irrigations 832 

Local  applications  to  the  vagina  and  cervix 835 

Application  of  powders  to  the  vagina 836 

Vaginal  tampons 837 

Intrauterine  douche 840 

Intrauterine  applications 844 

Tamponing  the  uterus 847 

Bier's  hyperemic  treatment  in  gynecology 850 

Pelvic  massage 850 

Scarification  of  the  cervix 852 

Pessary  therapy 853 

Dilatation  of  the  cervix 4    .  864 

Curettage 868 


Index 873 


Diagnostic  and  Therapeutic 
Technic 


CHAPTER  I 


THE  ADMINISTRATION  OF  GENERAL  ANESTHETICS 

The  term  anesthesia  denotes  a  condition  of  insensibility  to  pain 
and  an  anesthetic  is  any  agent  which  produces  such  a  state.  Anes- 
thetics are  divided  into  general  and  local.  The  drugs  most  used 
for  general  anesthesia  are  ether,  chloroform,  nitrous  oxid  gas,  and 
«thyl  chlorid  administered  separately,  in  sequence,  or  in  combina- 
tion with  one  another. 

The  choice  of  the  anesthetic  agent  and  the  decision  as  to  the 
method  of  its  administration  are  questions  of  vital  importance. 
Under  general  anesthesia  the  patient  is  brought  practically  to  the 
border-line  between  life  and  death,  and,  in  many  case,  the  life  of  the 
patient  depends  upon  the  selection  of  the  anesthetic,  as  well  as 
upon  the  way  in  which  it  is  administered.  While  the  safety  of  the 
patient  should  always  be  the  first  consideration  and  the  main  guide 
in  the  choice  of  the  anesthetic,  it  is  unfortunately  impossible  to  lay 
down  any  hard  and  fast  rules.  Each  case  must  be  studied  separately, 
and  the  anesthetic  selected  that  is  best  suited  to  that  particular 
case.  The  production  of  narcosis  with  the  same  anesthetic  under 
all  conditions,  even  though  the  particular  agent  chosen  were  statis- 
tically safe,  would  certainly  be  unjustifiable,  .Aji  anesthetic  that 
could  be  used  with  safety  under  some  conditions  would  be  a  menace 
to  life  under  others.  The  condition  of  the  patient,  the  nature  of  the 
operation,  the  anesthetist,  and  the  operator  himself  are  all  factors 
that  enter  into  consideration.  Furthermore,  in  estimating  the 
relative  safety  of  the  different  anesthetics,  one  must  consider  not 
only  the  immediate  dangers,  but  also  the  more  remote  toxic  effects 
that  frequently  do  not  appear  until  some  time  later.  No  general 
rules  will  be  laid  down  at  this  time  as  to  the  selection  of  the  anes- 
thetic, but  in  considering  each  agent  an  attempt  will  be  made  to 
indicate  the  cases  for  which  it  is  best  suited. 


1 8  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

Preparations  for  Anesthesia  and  Precautions. — ^A  certain  amount 
of  preparation  of  the  patient  is  necessary  before  the  administration  of 
a  general  anesthetic.  Experience  teaches  that  the  patient  takes  an 
anesthetic  better  if  he  be  placed  upon  a  light  but  nutritious  diet  for 
several  days  before  operation,  and  the  bowels  be  properly  regulated. 
In  some  special  cases  it  may  be  necessary  to  subject  the  patient  to  a 
very  careful  regime,  beginning  even  some  weeks  before  operation  in 
order  to  put  him  in  the  best  possible  condition.  In  other  cases  where 
only  a  light  anesthesia — as  from  nitrous  oxid — is  required,  but  little 
preparation  will  be  necessary. 

Care  of  the  Bowels, — When  possible,  the  intestinal  canal  should 
be  emptied  a  number  of  hours  before  anesthetization.  The  usual 
custom  is  to  give  a  purge,  consisting  of  castor  oil,  calomel,  compound 
licorice  powder,  or  magnesium  sulphate,  the  night  before  the  opera- 
tion, followed  by  a  soapsuds  enema  in  the  morning.  Often,  however, 
the  nature  of  the  operation  or  lack  of  time  does  not  permit  of  the 
administration  of  cathartics.  In  such  cases,  a  purgative  enema  is 
relied  upon. 

Diet, — The  diet  for  twenty-four  hours  before  the  operation  should 
be  of  an  easily  digestible  character,  and  moderate  in  amount  to 
prevent  overloading  the  alimentary  canal.  If  the  operation  is  set 
for  early  in  the  morning,  no  food  should  be  given  after  a  light  supper 
the  previous  night;  if  it  is  fixed  for  the  afternoon,  a  very  light  break- 
fast may  be  taken,  not  later  than  8  a.  M.  A  feeling  of  faintness  or 
weakness  may  necessitate  the  giving  of  a  cup  of  hot  broth  or  beef 
tea  even  later  than  this  in  some  cases,  but  it  should  be  a  general 
rule  not  to  give  any  food  by  mouth  within  three  hours  of  the  time 
for  anesthesia,  since,  if  the  stomach  is  not  empty  at  the  time  of 
operation,  vomiting  is  almost  sure  to  occur,  adding  not  only  to  the 
danger  of  the  anesthetic,  but  to  the  subsequent  distress  of  the  pa- 
tient. In  some  cases  of  special  gravity  on  account  of  shock  or 
marked  feebleness,  a  nutrient  enema  (see  page  75),  with  the  addi- 
tion of  whisky  or  brandy,  may  be  given  half  an  hour  before  the 
anesthesia  is  commenced. 

In  an  emergency,  lavage  of  the  stomach  may  be  performed  when 
a  full  meal  has  been  taken  shortly  before.  Preliminary  washing  out 
of  the  stomach  will  be  required  when  that  organ  is  the  seat  of  opera- 
tion; it  should  also  be  practised  if  a  general  anesthetic  is  to  be  admin- 
istered when  intestinal  obstruction  with  vomiting  is  present,  for,  in 
such  cases,  patients  have  been  known  to  fairly  drown  from  the  con- 
tents of  the  stomach  suddenly  pouring  out  under  the  relaxation  of  the 


THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS  I9 

anesthetic.     To  avoid  undue  excitement,  the  lavage  may  be  per- 
formed just  as  the  patient  is  under  complete  anesthesia. 

Preparation  of  (he  Moutk,  Teeth,  Etc. — Preparation  of  the  nose, 
mouth,  and  teeth  lessens  the  dangers  of  aspiration  pneumonia  and 
septic  bronchitis.  As  a  rule,  cleansing  the  nose  and  mouth  with  an 
antiseptic  solution  and  thoroughly  brushing  the  teeth  is  sufficient, 
but.  in  some  instances,  the  neglect  of  the  leeth  results  in  a  very  foul 
and  septic  condition,  necessitating  systematic  treatment  for  several 
days  before  the  anesthetic  can  safely  be  administered. 

The  Preliminary  Use  of  Drugs. — A  good  night's  rest  does  much  to 
fortify  the  patient  and  put  him  in  the  best  possible  condition  for  the 
operation.  In  the  case  of  some  patients  simply  a  rub-down  with 
alcohol  at  bedtime  suffices  to  induce  sleep;  for  others,  especially  if 
nervous,  the  administration  of  a  sedative  is  indicated. 

Many  surgeons  administer  morphin  hypodermically  before  anes- 
thesia.    In  some  cases  this  is  of  advantage,  shortening  the  stage  of 
excitement  and  necessitating  less  of  the  anesthetic  to  maintain  insen- 
Hbiiity,  but  it  should  not  be  a  routine  practice.     In  highly  excitable, 
vigorous,  alcoholic  individuals  it  is  of  distinct  advantage.     With  its 
use,  however,  it  is  necessary  to  maintain  lighter  anesthesia  than 
without  it.     The  chief  objection  to  morphin  is  that  it  depresses 
respiration  and,  by  its  action  upon  the  pupils,  may  mask  symptoms  of 
ovcmarcosis :  furthermore,  it  delays  the  awakening  from  the  anes- 
tiraia.     In  children  or  the  very  old  it  must  be  used  with  caution. 
Any  condition  producing  embarrassed  or  obstructed  respiration  is 
1  contraindication  as  is,  of  course,  any  idiosyncrasy  against  the  drug. 
It  should  not  be  given  to  very  weak  subjects  or  to  those  in  stupor. 
By  some  operators  atropin  gr.  }{qo  (0.00065  S"^-)  '^  given  half 
*■>  hour  before  the  anesthetic  is  started  as  a  routine  procedure  for 
ihc  purpose  of  suppressing  the  secretion  in  the  upper  air  jiassages 
^i"!  bronchi,   thus  lessening  irritation  of  the  respiratory  mucous 
"wmbrane, 

Pliyncal  Examination. — A  thorough  physical  examination  should 
woiade  in  all  cases  as  a  routine  preliminary  to  general  anesthesia,  for 
*^t  knowledge  as  to  the  state  of  health  is  essential  to  an  intelligent 
wlectiun  of  the  anesthetic  and  its  safe  administration.  Such  an 
"*mination  has  a  good  moral  effect  upon  the  patient,  and,  if  assur- 
ance can  be  given  that  nothing  abnormal  can  be  discovered,  it  does 
"luch  to  allay  the  natural  fear  and  timidity  of  a  nervous  individual, 
'te  examination  should  include  a  record  of  the  pulse,  temperature, 
^li  respirations,  a  physical  examination  of  the  heart,  arteries,  and 


20  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

lungs,  and  a  blood  and  urine  examination,  and  should  be  made,  when 
possible,  before  the  day  of  operation,  so  that  if  the  results  of  the 
examination  demand  it,  the  operation  may  be  postponed  without 
subjecting  the  patient  to  unnecessary  preparations.  In  the  presence 
of  acute  bronchitis  or  coryza,  a  postponement  of  the  operation  is 
advisable.  Chronic  bronchitis,  however,  is  sometimes  improved  by 
an  anesthetic.  Heart  disease,  with  good  compensation,  is  not  a 
contraindication  to  general  anesthesia. 

The  urine  should  always  be  examined  if  the  case  is  such  that  time 
allows,  noting  the  total  amount  for  twenty-fDur  hours,  the  specific 
gravity,  and  the  amount  of  urea,  and  making  tests  for  albumin,  sugar, 
etc.,  as  well  as  a  microscopical  examination  for  casts.  The  quantity 
of  urea  eliminated  within  twenty-four  hours  is  quite  important. 
A  normal  adult  male  will  pass  460  to  525  gr.  (30  to  34  gm.),  and 
females  less.  If  the  quantity  eliminated  falls  much  below  this  normal 
minimimi,  the  operator  should  be  put  on  his  guard,  and,  when  the 
total  urea  falls  below  100  gr.  (6.5  gm.),  no  one  can  safely  be  given  a 
general  anesthetic  (Fowler).  If  albumin  be  present,  the  dangers  of  a 
general  anesthetic  are  increased,  especially  with  ether.  In  the  pres- 
ence of  large  quantities  of  albumin  and  casts  the  operation  should  be 
postponed  or  local  anesthesia  substituted.  The  presence  of  acetone 
and  diacetic  acid  is  of  especial  dangerous  significance. 

Another  important  point  is  the  arterial  tension.  When  time  per- 
mits, the  blood-pressure  should  be  taken  in  all  cases  (see  Chapter 
III).  If  it  is  found  to  be  abnormally  high,  nitrites  should  be  admin- 
istered for  several  days,  and,  where  there  is  not  time  for  this,  nitro- 
glycerin should  be  given  by  hypodermic  before  the  anesthetic  is 
begun.  In  the  presence  of  hypotension,  cardiac  stimulants  for  sev- 
eral days  previous  to  the  operation  are  indicated. 

Care  0]  the  Patient. — While  the  patient  is  on  the  operating-table 
care  should  be  taken  to  maintain  the  bodily  heat  and  prevent  chilling 
by  a  proper  amount  of  covering.  The  habit  of  washing  patients  with 
quarts  of  solution  and  leaving  them  lying  in  a  pool  of  chilly  water  is 
to  be  condenmed.  It  is  preferable  to  arrange  the  patient  upon  the 
table  before  the  anesthetic  is  begun.  Anesthetizing  a  patient  in  one 
room  and  then  moving  him  to  the  operating-room  is  not,  as  a  rule, 
advisable;  the  lifting  around  of  the  patient  allows  him  to  partly  come 
out,  and  often  starts  up  vomiting. 

The  position  assumed  by  the  patient  upon  the  operating-table 
should  be  unconstrained  and  as  comfortable  as  is  consistent  with  the 
needs  of  the  case.     A  supine  position,  with  the  head  elevated  suffi- 


THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS  21 

dently  upon  a  small  pillow  to  allow  freedom  in  breathing,  answers  in 
the  majority  of  cases.  Ether  and  nitrous  oxid  may  be  given  with  the 
patient's  head  and  trunk  elevated,  but  great  caution  should  be 
observed  in  administering  chloroform  to  a  patient  sitting  up  or  semi- 
upright,  on  account  of  the  danger  of  cerebral  anemia.  In  weak 
anemic  individuals  the  upright  position  should,  for  the  same  reasons, 
be  avoided  with  any  anesthetic. 

Before  administering  the  anesthetic,  anything  that  interferes  with 
or  obstructs  the  respiration  in  the  slightest  degree  should  be  removed. 
Tight  collars,  bandages  about  the  neck,  clothing,  belts,  straps,  braces, 
etc.,  should  invariably  be  loosened,  no  matter  how  short  the  anes- 


^^tient 


Frc.  I. — The  aneslhetist's   supplies,     i,   Pws  basin;   i,   mouth   wipes   on   artery 
^*''>P';  Si  mouth  wetlgc;  4,  tongue  forceps;  5,  mouth  gag;  G,  hypodermic  syringe. 

tntsla,  The  mouth  should  be  examined,  and  false  teeth,  obturators, 
plilEs,  chewing  gum,  tobacco,  etc.,  should  be  removed  lest  they  fall 
"5ck  into  the  larynx  and  cause  choking.  No  noise  or  talking  should 
b*  permitted  in  the  anesthetic  room.  It  is  always  well  to  have  a 
third  person  present  in  case  help  is  needed,  and  in  the  case  of  a  female 
client  this  is  very  necessary,  as  erotic  dreams  may  lead  to  damaging 

itions  against  the  anesthetist. 
'ihe  Anesthetist's  Supplies. — Besides  the  apparatus  necessary  for 
^tual  administration  of  the  anesthetic,  the  anesthetist  should 
™  provided  with  the  following:  a  mouth  gag,  a  wedge  or  screw- 
^''^pcd  piece  of  hard  rubber  to  force  the  jaws  apart,  tongue  forceps, 
3  DJ'podermic  syringe  in  good  working  order,  with  whisky,  camphor, 
^flfenalin,  atropin,  and  strychnin  at  hand,  a  number  of  small  mouth 
Wpes  with  an  artery  clamp  as  a  holder,  and  a  small  pus  basin  (Fig. 


f 


22  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

■  i).    A  cylinder  of  oxygen  should  be  ready  for  use,  and  an  infusion 
set  and  tracheotomy  tube  should  be  accessible. 

Duration  of  Anesthesia. — The  anesthetic  should  be  administered 
no  longer  than  is  absolutely  necessary.  It  should  not  be  started  until 
■everyone,  including  the  surgeon  and  his  assistants,  is  nearly  ready, 
and  the  completion  of  the  anesthesia  should  be  so  timed  that  the 
patient  is  coming  out  when  he  leaves  the  table. 


— AnangemeDt  of  Che  operating- table  and  the  ancsthclisl's  supplies. 


Stages  of  Anesthesia.— Anesthesia  from  most  of  the  general 
"anesthetics  passes  through  four  stages:  (i)  The  initial,  or  stage  of 
irritation;  (2)  the  stage  of  excitement;  (3)  the  stage  of  surgical 
anesthesia;  and  (4)  the  stage  of  coming  out.  With  some  anes- 
jthetics  the  early  stages  may  be  more  or  less  modified,  or  entirely 
absent,  and  the  rapidity  with  which  the  patient  passes  through  the 
different  stages  depends  upon  the  drug  employed  and  the  technic 
of  its  administration. 

The  Initial  Stage. — The  inhalation  of  ether  or  chloroform  produces 
irritation  of  the  mucous  membrane  of  the  respiratory  tract  and  a 
iprofuse  secretion  of  mucus  with  some  coughing  and  frequent  acts  of 
swallowing.  To  some  persons,  the  odor  and  taste  of  the  anesthetic 
are  exceedingly  unpleasant,  so  that  temporary  holding  of  the  breath 
is  not  uncommon.  If  the  vapor  is  given  in  too  concentrated  a  form, 
violent  coughing  will  be  induced,  accompanied  by  cyanosis,  and 
frequently  a  sense  of  suffocation  is  experienced  and  the  patient  tries 


THE   ADMINISTRATION   OF    GENERAL   ANESTHETICS  23 

to  tear  oflF  the  mask.  If  given  slowly,  the  coughing  passes  off  and 
the  respirations  become  rapid  and  regular.  Spots  appear  before  the 
eyes  and  the  patient  becomes  drowsy.  A  flushed  face,  rapid  and 
full  pulse,  with  hurried  respirations  are  characteristic  of  this  stage. 
The  pupils  dilate,  but  react  to  light,  and  the  cornea  responds  to 
touch.  In  this  stage  the  reflexes  are  increased,  so  that  a  painful 
examination  or  sudden  shock  is  dangerous. 

The  Stage  of  ExcitetnetiL — Following  this  preliminary  stage,  the 
patient  rapidly  passes  into  a  condition  of  excitement  or  intoxication. 
His  speech  becomes  incoherent,  and  often  the  imagination  is  excited 
and  hallucinations  occur.  The  patient  begins  to  struggle,  throws  his 
arms  about,  kicks,  tries  to  tear  off  the  mask,  and  frequently  laughs, 
sings,  yells,  cries,  moans,  or  swears.  He  may  breathe  deeply  and 
rapidly,  or  hold  his  breath  and  refuse  to  breathe,  so  that  he  becomes 
markedly  cyanotic.  The  jaws  are  often  held  together  tightly  by  a 
spasm  of  the  masseter  muscles.  Contractions  of  the  muscles  of  the 
trank  and  extremities  occur.  The  eyes  are  often  rolled  from  side  to 
side.  While  the  patient  usually  hears  those  around  him  talking, 
he  fails  to  understand  what  is  said.  Consciousness  and  sensation  are 
gradually  diminished.  The  pupils  are  still  dilated.  The  pulse  is 
rapid  and  full,  with  very  marked  pulsations  in  the  large  vessels  of  the 
neck. 

Stage  of  Surgical  Anesthesia. — Following  this  period  of  rigidity 
and  excitement,  comes  one  of  general  relaxation.  The  contracted 
muscles  relax;  the  pulse  becomes  slower  and  regular;  the  breathing 
becomes  more  superficial  and  less  hurried,  and  is  accompanied  by  a 
deep  snoring  due  to  the  relaxation  of  the  soft  palate.  The  skin  be- 
comes cool,  pale,  and  moist.  The  pupils  contract  but  still  react 
slowly  to  light,  and  the  conjunctival  reflex  disappears.  Total  insen- 
sibility is  now  produced,  and  the  anesthesia  is  complete.  The  loss 
of  the  conjunctival  reflex  is  taken  as  a  sign  that  unconsciousness 
is  present.     This  is  the  time  for  operation. 

The  guide  to  the  depth  of  anesthesia  after  the  disappearance  of 
the  conjunctival  reflex  is  the  condition  of  the  pupils.  With  light 
anesthesia,  the  pupils  are  moderately  contracted  and  readily  react  to 
light;  under  deeper  anesthesia,  the  pupils  are  contracted  and  fail  to 
react  to  light;  and  when  a  very  profound  and  dangerous  stage  of 
anesthesia  is  established,  the  pupils  dilate  widely  and  remain  so 
without  reaction  to  light,  and  the  respirations  become  shallow  and 
gasping.  In  the  early  stages  of  anesthesia,  and  when  the  patient  is 
coming  out,  the  pupils  also  dilate,  but  they  still  react  to  light  and  the 


24  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

corneal  reflex  is  also  present.  After  complete  anesthesia  has  been 
once  reached,  it  may  be  readily  maintained  by  adding  small  amounts 
of  the  anesthetic  from  time  to  time;  just  enough  should  be  adminis- 
tered to  keep  the  pupils  midway  between  contraction  and  dilatation, 
with  a  response  to  light  at  all  times. 

Stage  oj  Recovery. — ^The  recovery  from  the  anesthetic  is  character- 
ized by  the  occurrence  of  these  same  stages  in  reverse  order.  In 
some  cases  the  recovery  is  more  rapid  than  in  others.  The  breathing 
becomes  slower  and  less  audible,  and  there  is  frequent  sighing.  The 
conjunctival  reflex  reappears,  the  pupillary  reflex  becomes  active, 
and  the  patient  rolls  the  eyes  about.  Frequent  swallowing  occurs , 
followed  by  retching.  Vomiting  of  frothy  and  often  bile-stained 
mucus  is  present  in  most  cases,  and  may  be  continued  for  an  hour  or 
more.  Partial  consciousness,  with  laughing,  crying,  or  incoherent 
speech  follow,  and  it  is  usually  some  hours  before  the  mental  equilib- 
rium is  completely  regained.  Hyperesthesia  is  marked  in  the  period 
of  recovery,  and  general  irritability,  complaints  of  discomfort, 
and  pain  are  to  be  expected.  Some,  however,  especially  children, 
pass  into  a  deep  sleep  lasting  for  several  hours. 

• 

ETHER  ANESTHESIA 

Ether  is  a  very  volatile,  colorless  liquid,  with  a  strong,  pungent 
odor  and  a  burning,  sweetish  taste.  It  is  very  inflammable,  and 
should  not  be  used  near  a  flame,  cautery,  or  X-ray  apparatus.  An 
artificial  light  held  well  above  it  is  safe,  however,  as  the  ether  fumes 
tend  to  sink  downward.  Only  the  purest  ether  should  be  used  for 
anesthetic  purposes,  and  it  should  be  kept  in  hermetically  sealed 
tin  cans,  as  exposure  to  light  and  air  cause  it  to  decompose  into 
acetic  acid  and  other  irritating  products. 

Ether  fumes,  when  inhaled,  prove  very  irritating  to  the  mucous 
membranes  of  the  nose,  mouth,  and  respiratory  tract,  and  produce 
an  increased  secretion  of  mucus  and  saliva,  often  accompanied  by 
coughing.  Lesions  of  the  lungs  are  thus  apt  to  follow  its  use,  and 
may  be  due  to  the  aspiration  of  saliva  as  well  as  to  the  direct 
irritation  of  the  ether  vapor.  Ether  is  a  distinct  cardiac  stimu- 
lant, accelerating  the  heart  action  and  raising  blood-pressure;  this 
effect  is  well  shown  when  ether  is  administered  to  a  very  ill  person, 
the  character  of  the  pulse  often  showing  immediate  improvement 
and  continuing  so  until  the  end  of  the  anesthesia.  While  its  primary 
effect  is  one  of  stimulation,  in  toxic  doses  it  acts  as  a  depressant,  es- 


pecially  upon  the  respiratory  centers.  It  is  estimated  that  ether  is 
about  five  times  as  safe  as  chloroform,  and,  as  it  is  less  rapid  in  its 
action,  danger  signs  can  be  recognized  and  proper  treatment  insti- 
tuted with  more  chance  of  success  than  w-ith  the  latter.  Upon  the 
kidneys  it  acts  as  an  irritant,  and  prolonged  anesthesia  often  results 
in  postoperative  albuminuria.  Ether  produces  a  distinct  leukocy- 
tosis, a  slight  diminution  of  the  hemoglobin,  and  a  marked  decrease 
in  the  coagulation-time  of  the  blood  (Hamburger  and  Ewing).  Ac- 
cording to  Graham  the  phagocytic  power  of  the  blood  is  reduced 
after  an  ordinary  ether  anesthesia. 

Owing  to  its  low  boiling-point  ahd  volatility,  ether  is  very  rapidly 
eliminated  from  the  lungs,  and  it  is  necessary  to  give  it  in  a  more  or 
less  concentrated  form,  differing  in  this  respect  from  the  administra- 
tion of  chloroform.  The  administration  of  ether  is  rendered  safer  if 
preliminary  anesthesia  is  induced  by  some  quick  anesthetic,  as  nitrous 
Olid  or  ethyl  chlorid;  furthermore,  oxygen  and  ether  is  a  safer  mix- 
ture than  air  and  ether.  The  oxygen  may  be  administered  by  passing 
the  oxygen  tube  under  the  mask,  or,  in  the  closed  inhalers,  the  tube 
ouy  be  attached  directly  to  the  ether  bag. 

Suitable  Cases. — When  a  general  anesthetic  is  necessary  and  the 
opeiation  is  not  suited  to  nitrous  oxid,  ether  is  preferable  to  chloro- 
tonn  unless  direct  contraindications  to  its  use  are  present.  In  the 
lunds  of  an  expert,  many  of  the  dangers  attributed  to  chloroform  are 
absent,  but  it  must  be  remembered  that  under  the  same  conditions 
rther  is  also  less  dangerous.  In  unskilled  hands,  however,  there 
can  be  no  doubt  that  ether  is  always  the  safer. 

For  the  stimulating  effects  in  cases  of  shock  or  hemorrhage,  or 
when  it  is  necessary  to  obtain  a  profound  degree  of  narcosis  with 
abolition  of  the  reflexes,  ether  is  by  all  means  the  best  agent  to  use. 
In  aDemia  ether  is  preferable  to  chloroform,  as  it  has  less  marked  an 
(effect  upon  the  hemoglobin.  If  the  patient's  hemoglobin  is  below  30 
per  cent.,  however,  any  general  anesthetic  is  contraindicated  (Dr. 
Costa).  In  heart  disease,  if  the  compensation  is  good,  ether  is  safi-, 
but  with  broken  compensation  or  when  there  is  high  arterial  tension 
Md  degenerative  changes  in  the  blood-vessels,  it  is  contraindicated 
on  account  of  the  danger  from  overstimulation.  In  myocardial 
diteasc  it  is  unsafe,  but  not  so  dangerous  as  is  chloroform. 

On  account  of  its  irritant  action,  ether  should  be  avoided  in 
bronchitis  or  acute  lung  troubles,  and,  for  the  same  reason,  in 
xivanced  Brighfs  disease.  In  individuals  over  sixty  years  old, 
ether,  as  a  rule,  is  to  be  avoided,  as  they  are  very  likely  to  be  afflicted 


26  THE  ADMlNlSTRAnON   OF   GENERAL  ANESTHETICS 

with  respiratory  troubles,  and  the  circulatory  system  is  usually  the 
seat  of  degenerative  changes.  For  children,  a  mixture  of  chloroform 
and  ether,  or  chloroform  alone,  is  the  better  anesthetic,  ether  proving 
irritating  to  the  delicate  respiratory  mucous  membrane  of  a  child, 
and  often  producing  such  a  flow  of  mucus  and  saliva  that  breathing 
is  seriously  interfered  with. 

Ether  is  not  recommended  in  cerebral  operations — at  the  begin- 
ning, at  any  rate — on  account,  of  the  struggling,  resultant  conges- 
tion, and  increased  liability  to  hemorrhage.  /(  s/tould  never  he 
administered  in  operations  about  tlie  mouth  or  face  requiring  lite  use 
of  a  cautery  near  by. 

Apparatus. — Ether  may  be  satisfactorily  administered  by  the  drop 
method,  the  semiopen,  the  closed,  or  the  vapor  method.    Different 


Fig.  3. — The  Esmarch  mask. 


forms  of  inhalers  are  used,  according  to  the  method  employed.  Of 
the  open  inhalers,  any  of  the  chloroform  masks,  such  as  Esmarch's 
(Fig.  3)  or  Schimmelbusch's  (Fig.  4),  will  be  found  satisfactory. 
They  are  very  simple,  consisting  of  a  wire  frame  covered  with  canton 
flannel  or  several  layers  of  gauze,  upon  which  the  ether  is  dropped. 
Such  inhalers  permit  a  very  plentiful  supply  of  air.  An  ordinary 
chloroform  bottle  (Fig.  5)  may  be  used  for  the  dropping,  or  a  very 
convenient  dropper  may  be  improvised  by  cutting  a  groove  in 
opposite  sides  of  the  cork  of  the  ether  can— one  to  admit  air  and  the 
other  to  allow  the  escape  of  the  ether. 

The  AUis  inhaler  (Fig.  6)  is  a  type  of  the  semiopen  cone.  It 
consists  of  an  outer  rubber  case  in  the  upper  part  of  which  is  fitted 
a  metal  frame  provided  with  slits  through  which  is  threaded  a  cotton 
or  flannel  bandage.  A  very  simple  semiopen  inhaler  may  be  made  by 
rolling  several  thicknesses  of  heavy  brown  paper  into  a  cuff  and 


"ETHER   ANESTHESIA 

covering  it  with  a  towel.  The  top  of  the  cone,  which  is  held  partly 
closed  by  safety  pins,  is  filled  with  gauze  upon  which  the  ether  is 
poured  (Fig.  7). 

There  are  many  excellent  closed  inhalers,  such  as  the  Clover 
(Fig.  8)  the  Eennet  (Fig.  9),  the  Gwathmey,  the  Pedersen,  the  Davis, 


Fig,  4, — The  Schlmmdbusch  mask.       Fic.  5. — Chloroform  dropper 

etc.  These  consist  essentially  of  a  metal  face-piece  surrounded  by  an 
in6alable  rubber  rim,  an  ether  chamber  fdled  with  gauze,  and  a 
closed  rubber  bag  into  and  out  of  which  the  patient  breathes.  They 
are  also  provided  with  suitable  openings  for  the  entrance  of  air,' 
With  such  inhalers,  the  tentperature  of  the  ether  vapor  is  raised  by  the 


Fig.  6.— The  Allis  inhaler. 

CJtpired  air  and  the  supply  of  carbon  dioxid,  the  normal  stimulant  of 
the  respiratory  and  cardio-vascular  centers.  Is  maintained  through 
tflc  rebreathing,  thus  adding  to  the  value  and  safety  of  the  anesthetic. 
'Sjace  does  not  permit  a  detailed  description  o£  these  inhalers,  nor  is  it  necessary, 
"  »  <t(scripdoa  ol  the  niedianism  and  full  instructions  are  furnished  «ith  each 
IwlfWwal. 


98 


IRE   ADiamSTKATION  OF  GENEKAL  ANESTHETICS 


To  obtain  the  benefit  of  the  warm  vapor  without  the  disad- 
vaat^es  of  the  closed  inhalets,  the  vapor  method  of  etherization  is 
preferred  by  some.  It  is  an  excellent  method  of  anesthesia  to  use  in 
operations  about  the  mouth,  as  the  \'apor  can  be  delivered  through  a 
small  tube  passed  into  the  mouth  or  two  nasal  tubes  without  inter- 


FiG,  7, — Ton'el  cone. 

fering  with  the  operation.  The  cur\-ed  glass  nasal  tubes  divised  by 
Lumbard(Fig.  10)  are  admirable  for  this  purpose.  There  areanumber 
of  inhalers  suitable  for  the  vapor  method  of  etherization,  of  which 
Gwathmey's  apparatus  is  a  type,     Gwathmey's  vapor  apparatus  (Fig. 


Fig.  8.— The  Clover  ether  inhaler. 


11),  as  described  by  him  {Journal  oj  American  Medical  Association, 
October  27,  1906),  consists  of  two  six-ounce  (180  cc.)  bottles,  one  for 
chloroform  and  one  for  ether.  Both  bottles  are  placed  in  a  tin  vessel 
fX)ntaining  thermolite.  This  " thermolite warmer,"  if  placedin boiling 
water  for  three  minu  tes,  will  remain  warm  for  over  one  and  a  half  hours. 


ETHER    ANESTHESIA 


29 


K  the  beat  is  to  be  continued,  this  can  be  accomplished  by  simply 
taking  the  stoppers  out,  thus  exposing  the  thermolite  to  the  atmos- 
phere.    The  liquid  then  begins  to  recrystallize,  and  on  turning  to 


Fig.  g. — The  Beonet  ethti 


a  solid  fonn  gives  off  heat  for  another  hour  and  a  half.  In  each  of 
the  bottles  there  are  three  tubes,  varying  in  length  from  one  that 
reaches  to  the  bottom  of  the  bottle  to  one  that  penetrates  only  the 


, — Lumbard's  glass  ossii]  tubes  fur  anesthesia  (Warliassc). 

Stopper,  and  representing  three  degrees  of  vapor  strength.  The  small 
**Hches  at  the  top  of  each  bottle  are  so  arranged  that  chloroform 
"t  ether  can  be  given,  combined  or  separately,  and  in  any  strength 


30 


THT   ADMINISTRATION    OF   GENERAL   ANESTHETICS 


deured.  In  addition,  by  simply  turning  a  small  lev^,  without 
removing  the  mask,  the  patient  receives  pure  air  or  a  mixture  of 
coygen  and  air.  By  compres^g  the  hand  bulb,  air  or  oxygen  is 
forced  into  the  apparatus  and  the  warmed  ether  or  chloroform  vapor 
is  carried  to  the  patient  by  the  efferent  tube. 

Inhalers,  whatever  the  variety,  should  always  be  sterilized 
after  use.  Disregard  of  this  precaution  has  been  the  cause  of  many 
of  the  cases  of  postoperative  pneumonia.  Metal  portions  of  the 
inhaler  should  be  boiled  and  the  rubber  parts  soaked  in  a  i  to  20 
solution  of  cjtrbolic  acid  after  each  administration.  The  parts  are 
then  dried,  and  fresh  gauze  packing  is  supplied  for  the  closed  inhalers 
and  the  open  ones  are  covered  with  new  gauze  or  canton  flannel. 


-Gwatbm^'s  vapor  apparatus. 


Administration.' — Drop  Method. — The  usual  precautions  already 
detailed  having  been  observed,  and  the  eyes  of  the  patient  being 
protected  by  a  folded  piece  of  gauze,  the  mask  is  placed  over  the 
mouth  with  the  request  that  the  patient  breathe  naturally  and  regu- 
larly. As  soon  as  several  breaths  have  been  taken,  a  few  drops  of 
ether  are  poured  upon  the  mask.  After  a  few  more  breaths,  more 
ether  is  added,  gradually  increasing  the  amount  each  time.  If  the 
patient  struggles  or  begins  to  cough  and  choke,  the  amount  of  ether 
should  be  reduced  for  the  time  being.  In  from  five  to  six  minutes  the 
stage  of  excitement  and  struggling  begins,  and  the  ether  should  then 
be  dropped  more  rapidly.  Large  amounts  should  never  be  poured 
on  suddenly,  however,  as  this  simply  irritates  the  respiratory  tract 
and  produces  laryngeal  spasm,  causing  the  patient  to  cough,  choke, 
or  hold  his  breath.  If  the  dropping  is  properly  performed,  full 
anesthesia  should  be  obtained  in  from  ten  to  fifteen  minutes.  By 
the  drop  method  an  even  anesthesia  without  cyanosis  is  produced- 


ETHEK   ANESTHESIA 


31 


As  soon  as  the  patient  is  thoroughly  anesthetized^  just  siiffident  ether 
should  be  given  to  keep  him  thoroughly  under  its  influence. 

During  the  anesthesia  the  breathing  must  be  carefully  watched, 
together  with  the  pulse  and  the  eye  reflexes.    Under  the  stimtdation 


Flo.  II. — Showing  the  administration  ot  ether  by  the  drop  method. 


of  the  ether,  the  respirations  are  increased  in  frequency  and  depth, 
and  are  rather  nois>  in  character  on  account  of  the  increased  amount 
of  mucus  and  saliva  that  collects  m  the  throat.  Irregular  rapid 
respiration  approaching  a  gasping  type  is  unsafe.     The  breathing 


Fid.   ij. — Proper  method  o£  holding  the  jaw  forward. 

should  not  be  allowed  to  become  gurgling  or  obstructed.  To  prevent 
this,  the  jaw  should  be  held  well  forward  by  placing  the  fingers  back 
of  the  angle,  as  shown  in  the  accompanying  illustration  (Fig.  13). 
This  prevents  the  relaxed  epiglottis  from  being  forced  back  by  the 


32  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

tongue  over  the  opening  in  the  larynx,  since,  if  the  jaw  is  pushed  for- 
ward, the  tongue  goes  with  it,  giving  a  clear  passage.  In  holding  the 
jaw  forward,  care  should  be  taken  not  to  use  force  or  bruise  the 
tissues.  If  this  maneuver  does  not  overcome  the  obstruction  from 
the  tongue,  the  latter  should  be  pulled  out  and  held  well  forward  by 
means  of  a  tongue  forceps  or  a  silk  thread  passed  through  its  tip. 
This,  however,  is  seldom  necessary  if  the  jaw  is  properly  held  and  the 
head  is  turned  to  one  side  to  allow  the  mucus  and  saliva  to  flow 
out  through  the  corner  of  the  mouth.  Should  vomiting  occur,  the 
inhaler  must  be  removed  and  the  patient's  head  turned  to  one  side  so 
that  the  vomited  matter  can  escape;  and,  before  the  mask  is  reap- 
plied, the  mouth  should  be  well  cleared  of  vomitus. 

The  pulse  under  the  effect  of  ether  becomes  somewhat  rapid,  but 
of  greater  volume  and  increased  tension.     At  first  the  pupils  are 
widely  dilated  and  then  tend  to  moderately  contract.     Should  they  * 
suddenly  dilate  and  remain  so  without  responding  to  light  in  the  ., 
absence  of  the  conjunctival  reflex,  it  is  a  sign  of  overnarcosis.     Other  , 
danger  signs  are  a  weak,  thready,  or  irregular  pulse,  and  marked 
pallor  or  cyanosis.     Hiccough  usually  means  that  the  patient  is 
getting  ready  to  vomit.     Rolling  of  the  eyes  and  repeated  acts  of 
swallowing   are   preliminaries   to   the   patient   coming   out.     Both 
conditions  require  more  ether. 

As  the  operation  progresses,  smaller  quantities  of  ether  should  be 
used,  and  the  anesthesia  should  be  so  regulated  that  the  patient  will 
be  just  coming  out  by  the  time  that  he  is  ready  to  be  moved  from  the 
table.  The  amount  of  ether  used  will  depend  upon  the  skill  of  the 
anesthetist  and  the  form  of  inhaler.  With  the  open  inhaler,  from 
two  to  four  ounces  (60  to  120  c.c.)  should  suffice  for  an  hour;  in 
the  closed  inhalers,  much  less  will  be  consumed.  It  should  always 
be  the  aim  of  the  anesthetist  to  use  just  as  little  as  may  be  necessary 
to  keep  the  patient  under  control. 

Semiopen  Method, — Etherization  with  a  semiopen  inhaler  differs 
in  no  material  way  from  the  drop  method.  The  anesthesia  should  be 
started  slowly  by  pouring  into  the  top  of  the  cone  small  quantities 
of  ether  at  a  time.  After  complete  anesthesia  is  obtained,  it  may  be 
maintained  by  the  use  of  less  ether  than  with  the  drop  method,  as  the 
ether  docs  not  volatilize  so  rapidly. 

Closed  Method, — The  gauze  in  the  ether  chamber  is  well  saturated 
with  ether  before  commencing  the  anesthesia.  The  cone  is  then  ap- 
plied and  the  patient  is  instructed  to  take  regular  breaths,  breathing 
back  and  forth  through  the  bag.     As  soon  as  he  becomes  accus- 


ETHER   ANESTHESIA 


33 


tomed  to  the  apparatus,  ether  is  slou-ly  turned  on  during  an  inspira- 
tion by  gradually  revolving  the  drum  of  the  ether  chamber  (Fig.  14). 
If  cough  or  signs  of  irritation  occur,  the  amount  of  ether  should  be 
cut  down.  Care  should  always  be  taken  not  to  push  the  anestbetic 
loo  fast.  As  the  patient  breathes  into  and  out  of  the  rubber  bag,  it 
shotild  be  seen  that  the  latter  is  kept  about  two-thirds  full  of  air— it 
should  never  be  allowed  to  become  empty.  Usually  with  a  closed 
inhaler  anesthesia  can  be  produced  in  from  four  to  six  minutes.  On 
account  of  rebreathing  the  same  air,  some  duskiness  of  countenance  is 
lo  be  expected,  but  this  may  be  regulated  by  admitting  more  air  or  by 
administering  oxygen.    A  distinct  livid  color  should  not  be  allowed  to 


.—Showing  the  admioislralion  of  ether  with  a  cloaed  itihder. 


Pwsist  with  either  a  closed  or  an  open  inhaler.  Such  a  condition  is  a 
sign  of  poor  administration  of  the  anesthetic,  or  else  the  particular 
*Msthelic  is  not  suited  to  the  case. 

Anesthesia  by  the  closed  method,  besides  being  more  rapid, 
fMuces  considerably  the  amount  of  ether  used.  Recovery  from  the 
™ccls  of  the  anesthesia  is  more  prompt,  and  such  after-effects,  as 
nsusea  and  vomiting,  are  greatly  diminished.  Furthermore,  the 
*"lor  vapor  inhaled  from  the  bag,  being  warm,  is  safer,  more  effective, 
"Mi  less  apt  to  produce  irritation  of  the  respiratory  tract. 

Vapor  Melkod.- — ^It  is  preferable  to  start  the  anesthesia  by  some 
"  the  quick  methods,  as  nitrous  oxid  gas  followed  by  ether,  or  by 
*wiyl  chlorid  followed  by  ether,  and,  when  the  patient  is  well  under 


34  THE   ADMIXISTRATION   OP   GENERAL  ANESTHETICS 

its  influence^  the  ether  vapor  is  substituted.  The  vapor  method  may, 
however,  be  used  from  the  begimiing,  if  desired,  starting  with  a  me- 
dium percentage  of  vapor,  and  then  working  to  the  highesL  When 
completely  under,  a  medium  or  low  percentage  of  vapor  is  used, 
according  to  the  depth  of  anesthesia  desired.  The  mask  used  in  this 
method  is  covered  with  gauze,  over  which  an  impermeable  material, 
as  rubber  tissue  or  oil  silk  is  placed,  with  a  small  opening  in  the  center 
about  the  size  of  a  ten-cent  piece,  through  which  additional  anesthetic 
may  be  dropped  if  it  is  found  to  be  difficult  to  induce  narcosis  with 
the  vapor  alone. 

The  vapor  method  gives  a  light  anesthesia,  just  abolishing  the 
reflexes.  The  breathing  more  nearly  approaches  the  normal,  with- 
out the  snoring  rapid  respiration  usual  to  ether.  The  pulse  is 
nearer  normal,  and  the  duskiness  of  countenance  often  present 
with  the  closed  method  is  absent. 

CHLOROFORM  ANESTHESU 

Chloroform  is  a  clear,  colorless,  heavy,  volatile  liquid  with  a 
sweetish  taste  and  characteristic  odor.  When  used  for  anesthetic 
purposes,  it  should  be  absolutely  pure  and  neutral  to  litmus.  Under 
the  influence  of  heat  or  light,  it  decomposes  into  hydrochloric  acid, 
chlorin,  etc.,  hence  it  should  always  be  kept  in  well-stoppered,  dark 
amber-colored  bottles  and  in  a  cool  place.  It  is  more  irritating  to  the 
skin  than  ether  and,  if  confined,  will  produce  blisters.  For  this 
reason  the  lips,  nose,  and  cheeks  with  which  it  may  come  in  contact 
during  anesthesia  should  be  well  protected  with  vaselin. 

When  inhaled,  chloroform  vapor  has  a  depressant  effect  upon  all 
the  vital  functions,  but  especially  upon  the  circulation,  lowering 
blood-pressure  to  a  marked  degree  through  vasomotor  depression. 
Like  ether,  it  produces  a  leukocytosis.  It  is  less  of  an  irritant  to  the 
respiratory  tract  and  more  agreeable  to  take  than  ether,  hence  the 
primary  stage  of  excitement  is  milder.  Upon  the  kidneys,  it  is 
likewise  less  irritating.  It  causes  slight  temporary  fatty  changes  in 
the  kidneys,  heart  muscle,  and  liver  (more  marked  upon  the  latter) 
which  may  be  severe  and  later  lead  to  fatal  results  if  these  organs 
are  already  diseased. 

Death  from  chloroform  is  usually  sudden  and  with  few  premoni- 
tory signs.  Vasomotor  paralysis  causing  dilatation  of  the  vessels 
and  capillaries  and  fatal  syncope  is  the  primary  cause,  though  the 
inhibitory  action  of  the  drug  upon  the  heart  itself  may  contribute. 


CHLOROFORM    ANESTHESIA  35 

Respiratory  failure  is  not  common  as  a  primary  complication,  but  is 
secondary  to  the  failure  of  the  vasomotor  centers.  Many  of  the 
deaths  from  chloroform  occur  early  in  its  administration  when,  during 
the  stage  of  excitement  and  struggling,  more  of  the  drug  is  inhaled 
than  is  realized,  or  it  is  pushed  too  rapidly  in  an  attempt  to  overcome 
the  struggling.  With  a  trained  and  watchful  anesthetist,  chloroform 
is  robbed  of  many  of  its  dangers,  but  in  inexperienced  hands  it  is  a 
most  dangerous  drug,  being  estimated  to  be  about  five  times  more 
fatal  than  ether. 

Chloroform  is  the  strongest  anesthetic  we  possess,  and  should 
always  be  administered  well  diluted  with  air.  A  stronger  vapor  than 
I  per  cent,  is  a  dangerous  dose.  In  this  respect  it  differs  from  nitrous 
o»d  and  ether,  in  the  use  of  which  a  well-saturated  vapor  is  required. 
K  mixture  of  chloroform  and  oxygen  is  safer  than  chloroform  and  air. 
The  use  of  this  combination  is  less  often  accompanied  by  circulatory 
depression,  while  cyanosis  and  postoperative  vomiting  are  less 
tiequent. 

Chloroform  should  always  be  administered  warm.  This  can  be 
accomplished  by  using  some  one  of  the  warm  vapor  inhalers,  or  by 
amply  placing  the  bottle  containing  the  drug  in  warm  water  (100° 

F,jrc.). 

Chloroform  should  not  be  given  with  the  head  very  high,  or  with 
ihe  ptient  sitting  up,  on  account  of  the  danger  of  syncope;  this 
precaution  is  also  to  be  borne  in  mind  when  lifting  or  moving  per- 
sons under  the  influence  of  chloroform.  As  a  rule,  the  recovery  from 
chloroform  anesthesia  is  quicker  than  from  ether,  though  the  vorait- 
iiginay  last  longer. 

Suitable  Cases. — Chloroform  is  generally  preferred  to  ether  in 
young  children  and  in  those  over  sixty  years  of  age  who  are  free  from 
myocardial  disease,  for  the  reason  that  it  causes  less  irritation  of 
"*  respiratory  tract.  It  is  preferred  to  ether  for  patients  with 
*dvanced  Bright's  disease  who  are  free  from  myocardial  trouble,  in 
obstructive  conditions  of  the  larynx  or  trachea,  and  for  those  suffer- 
'ig  from  tuberculosis,  asthma,  bronchitis,  etc. 

In  heart  disease  with  broken  compensation  and  dyspnea,  in 
*Wirysm,  and  in  cases  of  marked  degeneration  of  the  blood-vessels, 
chloroform  is  preferable  to  ether  on  account  of  the  milder  preliminary 
"ages  In  cases  of  myocarditis  and  of  fatty  degeneration  it  is 
■IwgBTous  and  some  other  drug  should  be  employed. 

In  parturition  it  is  safer  than  in  health,  because  only  a  partial 
*Cwit  ii  required,  and  fright  and  apprehension  which  may  be  the 


3ti  THE  AD>tI>aSTRATIOIf   OF   GENERAL  ANESTHETICS 

cause  of  some  of  the  fatalities  are  absent.  When,  howevCT,  deep 
surgical  anesthesia  is  required  in  such  cases,  ether  is  indicated. 
In  eclampsia  chloroform  should  not  be  used  on  account  of  its  destruc- 
tive action  upon  the  liver.  In  fact,  in  the  presents  of  any  liver  lesion 
it  should  be  avoided. 

Chloroform  should  be  avoided  as  an  anesthetic  in  hemorrhage  or 
shock,  on  account  of  its  depressant  effect  upon  the  circulation;  and 
likewise  in  anemia,  as  it  decreases  hemoglobin.  In  cerebral  surgery, 
it  is  preferred  by  many  surgeons,  and  also  in  operations  about  the 
face  and  mouth,  as  it  causes  but  little  cough  and  flow  of  saliva,  and 
the  anesthesia  can  be  maintained  with  but  a  small  amount  of  anes- 
thetic. As  its  vapor  is  not  inflammable,  it  can  be  employed  in 
operations  about  the  mouth  or  face  while  the  cautery  is  being  used. 
In  minor  surgical  cases,  where  the  operation  is  often  performed  under 


Fig.  is. — Chloroform  mask  improvised  from  the 


incomplete  anesthesia,  chloroform  is  contraindicated.  In  ophthal- 
mic operations,  where  the  condition  of  the  pupil  cannot  be  ascer- 
tained, ether  is  preferred  to  chloroform. 

Apparatus. — Chloroform  should  never  be  administered  in  a  closed 
inhaler.  Either  the  open  drop  method,  with  a  free  mixture  of  air,  or 
the  warm  vapor  method  are  employed.  For  the  former,  a  handker- 
chief, the  corner  of  a  towel  (.Fig,  15),  or  a  piece  of  gauze  will  suffice, 
but  a  mask,  such  as  Skinner's,  Esmarch's  (see  Fig.  3),  or  Schim*- 
melbusch's  (see  Fig.  4),  covered  with  canton  flannel  or  several 
layers  of  gauze,  is  more  suitable.  In  addition,  a  drop  bottle  (see 
Fig.  5)  from  which  the  flow  can  be  accurately  regulated,  and  a  recep- 
tacle for  warm  water  will  be  required. 

Different  forms  of  apparatus  for  accurately  estimating  the 
strength  of  vapor,  as  Junker's  (Fig.  16),  Braun's,  Gwathmey's  (see 
Fig.  11),  etc.,  are  often  used.  These  are  supplied  with  a  tracheal 
tube  and  are  especially  useful  in  operations  about  the  mouth  or 
throat.  By  squeezing  the  bulb,  air  is  forced  through  the  warmed 
chloroform,  and  a  vapor  containing  a  definite  mixture  of  chloroform 


CHLOROFORM  ANESTHESIA 


and  air  is  administered.    By  attaching  the  inflow  tube  to  an  oxygsa 
cylinder,  oxygen  may  be  readily  administered  instead  of  aor. 


Fig.  i6. — Junker's  chlorofonQ  inbalei. 


The  same  care  should  be  taken  as  to  the  cleanliness  of  the  chloro- 
form mask  as  would  be  observed  with  any  inhaler.  After  each 
anesthesia  the  metal  framework  should  be  boiled  and  then  recovered. 


Via.  17. — Showing  the  methtxl  of  administering  chlorofotm  (first  step). 

Administration. — The  patient's  lips,  nose,  mouth,  and  cheeks 
should  be  well  greased  with  vaselin  or  lanolin.  The  anesthetic  is 
started  by  holding  the  mask  wet  with  a  few  drops  of  warm  chloro- 
fonn^or  5  inches  (10  to  12  cm.)  from  the  face  (Fig.  17},  the  patient 


38  THE   ADMINISTRATION   OF  GENERAL  ANESTHETICS 

being  told  to  breathe  naturally  and  regularly.  As  soon  as  the  patient 
grows  accustomed  to  the  vapor,  the  chloroform  is  dropped  steadily  at 
a  rate  of  lo  to  30  drops  a  minute,  and  the  mask  is  brought  nearer  the 
face,  being  careful,  however,  not  to  touch  the  skin  with  portions  of 
the  mask  wet  with  chloroform  (Fig.  18).  When  given  gradually  in 
this  way,  the  struggling  is  not  usually  prolonged  or  violent.  The 
anesthetic  should  never  be  poured  on  suddenly  in  large  quantities; 
it  must  always  be  administered  well  diluted  with  air.  In  the  stage  of 
excitement,  chloroform  must  be  given  with  extreme  care;  if  the  patient 
struggles,  the  drug  should  not  be  pushed, otherwise,  when  the  patient 


Fio.  18, — Showing  the  method  of  administering  dilaroforni  (second  step). 


holds  his  breath,  as  he  will  in  such  cases,  a  large  quantity  of  the  anes- 
thetic is  retained  in  the  lungs,  and,  when  he  takes  a  deep  breath,  a 
dangerous  amount  may  be  inhaled  from  the  already  oversaturated 
mask.  Coughing  and  vomiting  mean  that  the  vapor  is  too  strong, 
and  it  should  be  promptly  diluted  as  it  should  also  if  the  patient's 
breathing  becomes  embarrassed.  The  jaw  must  be  kept  well  forward 
if  there  is  the  slightest  impediment  to  free  respiration  from  the 
tongue.  When  the  patient  is  fully  anesthetized,  only  small  quan- 
tities of  the  anesthetic  should  be  administered,  just  sufficient  to  keep 
him  under. 

With  chloroform  anesthesia,  we  have  practically  the  same  stages 


NITROUS   OXm  ANESTHESIA  39 

as  with  ether,  but  they  succeed  each  other  more  rapidly,  and  a  dan- 
gerous degree  of  anesthesia  is  qxiickly  produced  unless  proper  care 
be  taken.  The  stage  of  excitement  is  less  marked  and  shorter 
than  with  ether,  and  the  patient  presents  a  more  tranquil  appearance 
in  every  way.  It  should  be  the  aim  of  the  anesthetist  to  keep  the 
patient  in  about  the  following  condition:  regular  and  fairly  deep 
respirations,  with  only  a  slight  snore;  pupils  moderately  contracted 
and  sluggishly  sensitive  to  light;  conjunctival  reflex  just  abolished; 
fidl  muscular  relaxation;  and  a  good  color  without  blueness  of  the 
lips  or  cheeks.  The  latter  is  an  indication  for  a  weaker  vapor  and 
more  air  or  oxygen.  With  the  ordinary  chloroform  mask,  oxygen 
may  be  administered  by  simply  inserting  the  tube  leading  from  the 
oxygen  cylinder  under  the  edge  of  the  mask. 

During  the  entire  anesthesia,  careful  and  dose  watch  must  be 
kept  over  the  respirations,  the  puke,  the  condition  of  the  eye  reflexes, 
and  the  general  appearance  of  the  patient.  It  is  only  by  the  constant 
and  undivided  attention  of  the  anesthetist  that  the  safety  of  the 
patient  can  be  guaranteed.  The  slightest  alteration  in  the  respira- 
tions should  be  taken  as  a  warning,  as  this  is  often  the  precursor  to 
circulatory  failure.  Very  shallow,  irregular,  or  gasping  respiration,  a 
weak,  thready,  or  intermittent  pulse,  sudden  and  continued  dilata- 
tion of  the  pupils  in  the  absence  of  eye  reflexes,  and  marked  duskiness 
or  sudden  pallor  of  the  skin,  are  all  indications  that  a  dangerous  stage 
of  narcosis  has  been  reached. 

The  administration  of  anesthetics  by  the  vapor  method  has 
already  been  described  under  ether  anesthesia  (page  33),  and  will  not 
be  repeated  here.  With  chloroform,  it  is  an  especially  valuable 
method  to  employ,  as  the  warm  vapor  may  be  administered  in  a  defi- 
nite strength,  and  with  air  or  oxygen  as  desired. 

NITROUS  OXID  ANESTHESIA 

Nitrous  oxid  is  a  colorless  gas,  heavier  than  air,  and  with  no  per- 
ceptible odor  or  taste.  It  is  obtained  in  a  liquid  form,  highly  com- 
pressed in  steel  cylinders  or  containers,  from  which,  when  liberated, 
it  escapes  as  a  gas.  It  has  a  pleasant  odor  and  a  slightly  sweetish 
taste.  It  has  marked  anesthetic  properties,  though  the  anesthesia 
is  not  so  profound  as  that  from  ether  or  chloroform.  It  increases 
the  rate  and  depth  of  respiration  and  accelerates  the  heart  action, 
at  the  same  time  raising  blood-pressure.  If  pushed  too  far,  the 
respirations  cease,  though  the  heart  continues  to  beat  for  some 


40  THE  ADMINISTRATION   OF   GENERAL  ANESTHETICS 

time.     For  short  operatioiis  it  is  the  safest  of  all  the  general  anes- 
thetics, I  in  100,000  being  the  generally  accepted  death  rate. 

Anesthesia  from  nitrous  oxid  cannot  be  maintained  for  more 
than  fifty  or  sixty  seconds  without  air,  on  account  of  the  develop- 
ment of  symptoms  of  asphyxia.  Used  with  the  proper  admix- 
ture of  air  or  oxygen,  however,  an  anesthesia  for  an  hour  or  more 
may  be  safely  maintained.  According  to  Hewitt,  mixtures  con- 
taining 5  to  7  per  cent,  of  oxygen  are  best  suited  for  adult  males,  and 
mixtures  of  7  to  9  per  cent,  of  oxygen  are  best  for  females  and  chil- 
dren. Mixtures  of  nitrous  oxid  and  air,  composed  of  from  14  to  18 
per  cent,  of  the  latter  for  men,  and  from  18  to  22  per  cent,  for  women, 
give  the  next  best  results. 

Nitrous  oxid  is  very  rapid  in  its  action,  producing  complete 
unconsciousness  in  from  one  to  two  minutes,  and  is  the  most  agree- 
able of  the  general  anesthetics  to  take.  The  patient  comes  out  of  it 
very  quickly,  usually  in  from  thirty  to  sixty  seconds,  and  its  use  is 
not  followed  by  nausea  and  vomiting.  The  lung,  kidney,  and  heart 
complications  of  ether  and  chloroform  are  likewise  absent. 

Suitable  Cases. — When  used  pure,  nitrous  oxid  is  suitable  only 
for  short  procedures  lasting  about  a  minute,  such  as  extracting  teeth 
and  making  incisions  for  drainage,  etc. 

With  the  admixture  of  air  or  oxygen  in  proper  quantities  to  pre- 
vent asphyxial  symptoms,  and  administered  by  an  expert,  it  may  be 
made  applicable  for  anesthesia  in  some  major  surgical  operations 
not  consuming  a  great  deal  of  time,  as  well  as  in  many  of  the  minor 
ones.  It  is  an  excellent  anesthetic  to  employ  for  the  reduction  of 
fractures  requiring  only  a  moderate  amount  of  muscular  relaxation, 
and  for  breaking  up  adhesions  in  ankylosed  joints.  When  local  anes- 
thesia is  contraindicated,  it  becomes  the  anesthetic  of  choice  for 
abscess,  felon,  empyema,  benign  tumors,  strangulated  hernia,  varico- 
cele, minor  amputations,  exploratory  operations,  etc.  Within  the 
last  few  years  the  scope  of  nitrous  oxid  and  oxygen  anesthesia  has 
been  enormously  enlarged,  some  operators  employing  it  in  their  work 
to  the  exclusion  of  ether  in  operations  of  considerable  magnitude 
upon  the  biliary  passages,  kidney,  bladder,  intestines,  and  stomach. 
It  should  be  remembered,  however,  in  connection  with  some  of  the 
above  abdominal  cases,  that  often  complete  relaxation  is  not  obtained 
under  this  form  of  anesthesia. 

Nitrous  oxid  is  contraindicated  in  cases  of  dilated  heart  or 
advanced  valvular  disease,  and  in  patients  with  atheroma  of  the 
blood-vessels,  on  account  of  the  danger  of  cerebral  hemorrhage.     In 


NITROUS    OXID    ANESTHESIA 


41 


children,  the  mask  and  formidable  appearing  apparatus  frequently 
cause  such  fear  as  to  preclude  its  use.  It  is  not  a  suitable  anesthetic 
to  employ  in  patients  with  narrow  or  abnormal  air  passages,  or  in 
those  suffering  from  goiter,  enlarged  tonsils,  or  adenoids.  In  opera- 
tions about  the  rectum  and  perineum,  it  is  sometimes  unsatisfactory, 
as  the  patient  may  stiffen  up  or  straighten  out  the  limbs,  thus  inter- 
fering with  the  operator.  The  same  may  be  said  of  its  use  in  alco- 
holics, or  strong,  robust,  or  fat  individuals,  though,  according  to 
Gwathmey,  by  preliminary  medication  with  raorphin  alone,  or  with 
morphin  and  chloretone,  or  morphin  and  hyoscin,  any  patient  can  be 
anesthetized  satisfactorily. 

Apparatus. — Nitrous  oxid  may  be  administered  alone  or  with  air 
by  means  of  any  of  the  usual  inhalers  for  that  purpose,  such  as  Hew- 
itt's, Gwathmey's,  Bennett's  (Fig.  19),  etc.    In  general  these  consist 


oxid  gas  inhaler. 

™  I  metal  mask  with  a  pneumatic  rubber  rim  that  fits  the  face 
•tturately  so  as  to  exclude  air,  a  gas  chamber  with  inspiratory  and 
'^itory  valves  or  openings,  and,  attached  to  the  gas  chamber, 
snibber  balloon  connected  by  rubber  tubing  with  the  nitrous  oxid 
cylinder.  With  such  apparatus,  air  may  be  admitted  through  the 
'■Pwings  pro\ided  for  that  purpose  or  the  inhaler  may  be  removed 
*^^  two  to  fi^'e  inspirations,  allowing  the  patient  to  get  a  supply  of 
Pire  ar.  Oxygen  may  likewise  be  administered  by  passing  the 
•"^gen  tube  under  the  rim  of  the  mask. 

When  a  definite  amount  of  oxygen  is  to  be  given,  a  special 
apparatus,  as  that  of  Hewitt  (Fig.  20),  Gwathmey  (Fig.  21),  Teter, 
Cunjiingham,  or  Gatch,  is  essential.  With  these  inhalers  any  desired 
tombbation  of  nitrous  oxid  gas  and  oxygen  may  be  obtained  by 
f^lating  special  switches,  which  are  provided  with  indicators 
^omng  the  exact  strength  of  the  vapor  which  the  patient  receives. 


43  THE  ADMINISTRATION  OF   GENERAL  ANESTHETICS 

Carbon  dioxid,  which  is  valuable  as  a  respiratory  stimulant,  is 
provided  by  rebreathing  or  by  connecting  the  apparatus  with  a 
tank  of  COi. 

As  with  all  inhalers,  the  metal  parts  should  be  boiled  and  the  rub-' 
bers  steriliaed  in  a  solution  of  i  to  20  carbolic  add  after  use.  Before 
using,  the  apparatus  should  always  be  tested  to  see  that  it  works 
properly. 


oxid  gas  and  oxygen  inhaler. 


Administration.— In  giving  pure  nitrous  oxid,  the  apparatus  Is 
properly  connected  with  the  supply  cylinder,  and  the  rubber  ballooQ 
is  about  three-fourths  filled  with  gas.  The  gas  shoiild  be  turned  on 
slowly,  as,  at  times,  when  suddenly  released,  It  escapes  from  the  cylin- 
der with  a  loud  noise  which  might  tend  to  frighten  a  nervous  patient. 
The  face-piece  is  then  tightly  applied  over  the  mouth  and  nose,  so 
that  air  cannot  be  drawn  in  around  the  rubber  rim.  The  expiratory 
valve  is  opened  and  the  pjitient  is  told  to  breathe  regularly.  After 
two  or  three  breaths  of  air,  during  which  the  patient  becomes  accus- 
tomed to  the  apparatus,  the  gas  is  allowed  to  enter  the  mask  by  open- 
ing the  proper  stopcock.  The  patient  thus  breathes  In  pure  nitrous 
oxid  and  expires  nitrous  oxid  and  air,  so  that  he  constantly  receives 


NITROUS    OXID    ANESTHESIA 


43 


more  nitrous  arid  into  the  lungs.     After  a  few  breaths,  the  expiratory 
valve  is  closed  and  the  patient  breathes  the  gas  back  and  forth. 

The  first  few  inspirations  of  gas  are  soon  followed  by  a  change 
in  the  color  of  the  face — it  becomes  dusky,  and  finally  a  deep  livid 
hue.  There  is  at  first  incoherent  speech,  but  this  is  soon  followed  by 
the  anesthetic  snoring,  rapid  respiration,  and  laryngeal  stertor. 
There  is  usually  tremor  or  twitching  of  the  superficial  muscles  of  the 
eyes,  mouth,  neck,  etc.,  and  at  times  complete  rigidity  and  violent 
jactitations   of   the   limbs.     The   anesthesia   cannot   be   continued 


Pig    II  — Cwathmey  s  nitrous  o«  1  gas  and  oxygen  inhaler. 

Iwyond  this  point  ivithout  danger  of  asphyxia.  If  the  mask  is 
remuved,  there  is  still  a  period  of  surgical  anesthesia,  lasting  about  a 
"li'iute,  TWs  is  soon  followed  by  a  reactionary  redness  or  blush 
ll»ut  the  face,  and  a  return  to  normal  breathing.  By  reapplying  the 
mask  before  the  patient  comes  entirely  out,  and  administering  more 
nitrous  oxid,  the  anesthesia  may  be  considerably  prolonged,  pro- 
vided sufficient  air  is  admitted  to  avoid  extreme  cyanosis,  stertor, 
wd  muscular  twitching,  and  yet  not  so  much  as  to  keep  the  patient 
"sufficiently  anesthetized.  This  may  be  accomplished  by  allowing 
t*o  to  five  breaths  of  nitrous  oxid  to  one  of  air,  or  the  air  may  be 
administered  in  combination  with  the  nitrous  oxid  through  the  open- 


44  I'HE   ADMINISTKATION  Of  GENERAL  ANESTHETICS 

ing  provided  on  the  inhaler  for  that  purpose.  A  slight  duskiness  of 
the  countenance,  moderate  snoring,  and  regular  respiration  should  be 
aimed  aL 

Administered  with  oxygen,  a  complete  ateence  of  symptoms  of 
asphyxia  is  secured.  An  even  anesthesia  is  best  obtained  with  some 
form  of  apparatus  that  accurately  regulates  the  percentage  of  oxygen. 
The  technic  is  essentially  the  same  as  that  employed  in  giving  pure 
nitrous  oxid.  The  patient  first  breathes  pure  air,  then  the  nitrous 
oxid  is  turned  on,  and  finally  the  oxygen.  Starting  with  but  a  very 
small  proportion  of  oxygen  (a  to  3  per  cent.)  it  may  be  increased  to 
from  5  to  10  per  cent.,  or  more,  depending  upon  the  case.     Enough 


Fig.  22. — SboHing  the  method  ot  administering  nitrous  oxid  gas. 


oxygen  should  always  be  given  to  prevent  cyanosis  without  detracting 
from  the  anesthetic  efEects  of  the  nitrous  oxid.  There  is  no  doubt 
that  it  requires  special  training  for  one  to  become  expert  in  adminis- 
tering this  combination.  Success  depends  upon  the  ability  of  the 
anesthetist  to  pro\'ide  a  combination  of  gas  and  oxygen  that  will 
produce  narcosis  without  cyanosis.  With  the  proper  amount  of 
oxygen,  the  patient  goes  under  the  anesthetic  in  two  to  three  minutes 
without  any  of  those  unpleasant  symptoms  seen  with  pure  nitrous 
oxid,  the  color  of  the  skin  is  normal,  the  breathing  becomes  regular 
and  slightly  snoring,  and  the  pulse  may  be  slightly  increased  in  rate. 


NITROUS   OXID  AND   ETHER   SEQUENCE 


45 


Recovery  is  rapid  and  is  usually  unaccompanied  by  any  unpleasant 
after-eflFects. 


NTTROnS  OXID  AND  ETHER  SEQUENCE 

By  this  method  the  patient  is  thoroughly  anesthetized  with  gas 
and  then  a  change  is  slowly  made  to  ether.  It  is  a  most  valuable 
method  for  avoiding  the  disagreeable  effects  of  the  early  stages  of 
axiesthesia  ordinarily  encoimtered  when  straight  ether  is  admin- 
istered from  the  start.  A  combination  of  gas  and  ether  carries  the 
patient  into  a  stage  of  surgical  anesthesia  very  rapidly — usually  in 
about  one  to  tiiree  minutes.  Much  less  ether  is  required  both  in 
starting  and  maintaining  narcosis  than  when  ether  alone  is  employed, 
and,  the  patient  not  being  saturated  with  the  drug,  the  after-effects 
of  ether  anesthesia  are  not  nearly  so  frequent  or  pronounced.     It  b 


Fig.  23. — ^The  Bennett  gas  and  ether  apparatus.  • 

safer  than  ether  given  alone  by  the  open  or  semiopen  inhalers,  prob- 
ably because  the  stage  of  excitement  is  absent,  and,  in  the  second 
place,  the  carbon  dioxid  content  is  maintained  and  the  ether  vapor 
is  warmed  through  the  constant  rebreathing;  and,  finally,  a  much 
smaller  amount  of  the  anesthetic  is  required. 

Apparatus. — If  desired,  the  gas  may  be  administered  by  any  of  the 
ordinary  nitrous  oxid  gas  inhalers,  and  the  ether  by  the  open  or  semi- 
open  method,  though  a  combination  gas  and  ether  apparatus,  such  as 
Clover's,  Hewitt's,  Bennett's  (Fig.  23),  Gwathmey's  (Fig.  24),  or 
Pedersen's,  is  preferable  and  more  convenient.  These  inhalers  con- 
sist of  the  usual  metal  mouth-piece  and  inflatable  rubber  rim,  inspira- 
tory and  expiratory  valves,  and  gas  bag.     In  addition,  the  inhalers 


ETHYL   CHLORID   ANESTHESIA 


47 


During  this  period,  if  symptoms  of  asphyxia 
r,  small  quantities  of  air  should  be  admitted  from 
igh  the  air  valve,  but  not  in  such  amount  as  to  allow 
jotne  out.  As  soon  as  anesthesia  is  well  established, 
ikes  less  than  two  minutes,  the  gas  is  discontinued 
[ration  of  the  ether  is  proceeded  with  in  the  usual  way 

i  cone. 

»mbination  of  gas  and  ether,  care  must  be  taken  to 

r  rather  slowly  at  first.     If  the  patient  commences  to 

s  breath,  the  ether  should  be  turned  on  less  rapidly, 

imtil  regular  breathing  is  again  established. 

red  properly,  the  patient  goes  under  the  anesthetic 

Kquickness,  without  any  discomfort  or  struggling,  and, 

tis  once  established,  but  little  anesthetic  is  required 

Some  duskiness  of  countenance  and  cyanosis  are  to 

a  the  nitrous  oxid,  and  the  constant  rebreathing  of  the 

rat  this  may  be  controlled  by  a  careful  regulation  of  the 


ETHYL  CHLORID  ANESTHESIA 

jl  chlorid  is  a  colorless,  very  volatile  and  inflammable  liquid. 
■It  has  an  ethereal  odor,  and  should  not  be  acid  to  litmus. 


Fig.  as— Ethyl  chlorid  tube, 

1  anesthetic  purposes  the  purest  quality  of  the  drug  should 

land  only  that  labelled  "  for  general  anesthesia."     This  can  be 

1  in  containers  furnished  with  a  spring  stopcock,  which  per- 

Ibdrug  to  be  administered  in  a  fine  stream  in  any  desired  quan- 

;.  25),  or  in  hermetically  sealed  glass  tubes  containing  about 

1  (5  c.c.)  of  the  drug.     The  latter  is  best  suited  for  the 

uilers,  the  whole  amount  being  emptied  into  the  inhaler  at 

iyl  chloric!  is  decomjxtsed  by  light  and  air,  hence  it  should 

Bin  a  dark  place  and  in  tightly  stoppered  tubes. 

e  it  should  not  be  used  near  a  liame  or  caul 

-■''   ■'  '■  :'  -:!pidly  absorbed  and  is 

.1  in  from  thirty  seconds  to  a  minuttt 
.  L  minutes  after  the  wilhdraw.T'     '  *hii 


I 


48 


THE  ADIUKISTRATION  OF  GENERAL  ANESTHETICS 


Fic  26. — Showing  the  Schimmel- 
buach  DMfk  covered  with  gauze  and  oil 
ulk  for  the  admiuistiation  of  ethyl 
chlorid. 


anesthetic.  Recovery  is  not  quite  so  rapid  as  from  nitrous  ozid,  and 
after-eSects,  such  as  headache,  nausea,  vomiting,  and  dizziness, 
are  not  at  all  uncommon.  It  is  not  nearly  so  safe  as  nitrous  ozid, 
nor  so  pleasant  an  anesthetic  to  take.  It  has  the  advantage,  how- 
ever, of  not  producing  cyanosis,  and  the  anesthetic  effects  are  more 
prolonged;  furthermore,  it  may  be 
administered  without  special  ap- 
paratus. It  stimulates  both  the 
heart  and  respiration,  increasing 
the  rate  and  the  depth  of  the 
latter,  but  it  lowers  blood-preS' 
sure  through  dilatation  of  the 
peripheral  vessels. 

Suitable  Cases. — Ethyl  chlorid 
is  employed  mainly  for  brief  opera- 
tions or  examinations  not  requir- 
ing full  muscular  relaxation,  and  as  a  preliminary  to  ether  to  get  the 
patient  under  rapidly  without  struggling  and  excitement.  It  acts 
especially  well  in  children  on  account  of  its  rapidity  of  action.  It 
should  never  be  immediately  followed  by  chloroform,  as  both  are 
circulatory  depressants.  Its  use  is  contra- 
indicated  when  there  is  any  respiratory 
obstruction. 

Apparatus. — Owing  to  its  great  volatil- 
ity, ethyl  chlorid  is  most  satisfactorily 
administered  by  means  of  a  closed  inhaler, 
though  the  semiopen  method  may  be  em 
ployed,  and  is  preferred  by  many  as  being 
safer.  For  the  latter,  one  may  employ  an 
Esmarch  or  Schimmelbusch  mask,  over  the 
gauze  of  which  is  placed  some  impervious 
material,  as  oil  silk  or  rubber  tissue,  with 
a  small  opening  through  which  the  drug 
is  sprayed  (Fig,  26);  or  an  Allis  inhaler 
may  be  used,  leaving  a  small  opening  in 
the  top.  Any  of  the  ordinary  closed  inhalers  may  be  utilized  f<» 
administering  ethyl  chlorid  by  simply  spraying  the  drug  into  the 
ether  bag. 

There  are  a  number  of  inhalers,  however,  devised  especially  for 
this  drug  and  similar  anesthetics.  Ware's  inhaler  (Fig.  27)  consists 
of  a  pliable  rubber  mouth-piece,  to  the  top  of  which  is  fitted  a  metiil 


-Ware's  ethyl  chlorid 
inhaler. 


ANESTHETIC    MIXTURES 


49 


chimney.  At  the  point  the  latter  joins  the  mouth-piece,  several 
layers  of  gauze  are  interposed  upon  which  the  anesthetic  is  sprayed 
through  the  top  of  the  apparatus.  The  somnoform  inhaler  consists 
of  a  glass  face-piece  with  an  inflatable  rubber  rim  and  rubber  balloon. 
The  balloon  b  attached  to  the  mouth-piece  by  a  T-shaped  chamber 
which  is  pro\"ided  with  a  valve  and  a  small  opening  through  which 
the  anesthetic  may  be  sprayed. 

Admiaistration. — In  administering  ethyl  chlorid  by  the  closed 
method,  the  inhaler  is  placed  over  the  patient's  face  during  expira- 
tion in  order  to  fill  the  bag,  and,  as  soon  as  the  patient  is  breathing 
regularly,  from  i  to  i}-i  dr.  (4  to  5  c.c.)  of  ethyl  chlorid  are  sprayed 
into  the  bag,  or,  if  a  special  inhaler  Is  used,  into  the  opening  provided 
for  the  purpose.  If  the  face-piece  be  tightly  applied,  so  as  to  pre- 
vent the  entrance  of  air,  signs  of  anesthesia  appear  in  from  thirty 
seconds  to  one  minute.  As  soon  as  anesthesia  is  produced,  the  pa- 
tient should  be  allowed  to  have  air. 

Full  anesthesia  is  characterized  by  rapid  and  slightly  stertorous 
breathing,  dilated  pupils,  absence  of  the  conjunctival  reflex,  and  more 
or  less  complete  relaxation.     There  is  no  cyanosis,  though  the  color 
of  the  skin  is  heightened  from  the  dilatation  of  the  peripheral  vessels. 
The  inhaler  should  now  be  removed  and  the  operation  proceeded 
vfilh,  or  else  ether  is  substituted.     If  the  patient  recovers  too  rapidly. 
more  anesthetic  may  be  given,  provided  a  plentiful  supply  of  air  is 
iUowed.     By  an  interrupted  administration  of  ethyl  chlond — that 
IS,  first  securing  deep  narcosis  and  then  gi\ing  air — a  prolonged  light 
anesthesia  may  be  obtained,  though  at  times  muscular  relaxation  is 
lot  complete  and  the  patient  is  apt  to  remain  partly  conscious. 
I^Wger  signs  from  ethyl  chlorid  anesthesia  are  gasping,  shallow  res- 
pirations, pupils  widely  dilated  and  not  reacting  to  light,  and  general 
pallor  of  the  skin. 

Administered  by  the  semiopen  method,  a  greater  quantity  of  the 
'Ifiig  will  be  necessary,  and  somewhat  more  time  will  be  consumed  in 
gttling  the  patient  under  than  by  the  closed  method.  The  mask  is 
[iliiceil  over  the  face,  air  being  excluded  as  far  as  possible  by  surround- 
ing it  with  a  towel,  and  the  drug  is  dimply  sprayed  upon  the  inhaler 
il  a  steady  stream  until  anesthesia  is  proc'nced. 


ANESTHETIC  MIXTURES  .  " 

The  addition  of  ether,  alcohol,  and  other  drugs  to  chloroform  has 
been  extensively  practised  for  the  purpose  of  modifying  the  action 


50  THE  ADMINISTRATION   OF   GENERAL  ANESTHETICS 

and  avoiding  the  dangers  of  the  latter.  There  are  a  large  number  of 
such  mixtures,  varying  both  in  composition  and  in  the  relative  pro- 
portion of  their  separate  constituents.  The  A.  C.  E.  mixture  is 
composed  of: 

Alcohol,  I  part 

Chloroform,  2  parts 

Ether,  3  parts 

A  mixture  somewhat  similar  to  this,  known  as  the  Billroth  mixture, 
contains: 

Alcohol,  I  part 

Ether,  i  part 

Chloroform,  3  parts 

The  C.  E.  or  Vienna  mixture  contains: 

Chloroform,  i  part 

Ether,  3  parts 

Schleich's  mixture  for  general  anesthesia  is  composed  of  ether,  chloro- 
form, and  petroleum  ether.  This  is  furnished  in  three  strengths  of 
solution,  one  for  light  narcosis,  one  for  moderate  narcosis,  and  one  for 
deep  narcosis. 

Anesthol  is  composed  of: 

Ethyl  chlorid,  17        per  cent. 

Chloroform,  35 .  89  per  cent. 

<Ether,  47 .  10  per  cent. 

Of  these,  the  A.  C.  E.  mixture,  the  C.  E.  mixture,  and  anesthol, 
are  most  used  in  this  country. 

In  point  of  safety,  mixtures  occupy  a  place  between  chloroform 
and  ether,  the  added  safety  over  chloroform  depending  mainly 
upon  the  stimulating  effect  of  the  ether.  The  complications  and 
dangers  that  may  arise  during  the  administration  of  these  mixtures, 
however,  are  those  met  with  from  chloroform  rather  than  from  ether, 
and,  as  a  general  principle,  mixtures  should  be  given  with  as  much 
caution  as  would  be  observed  in  the  administration  of  the  most  dan- 
gerous drug  they  contain. 

Suitable  Cases. — When  nitrous  oxid  or  ether  are  considered  inad- 
visable, a  mixture:  of  ohlX)FofC)Fin  ind  ether  is  the  next  choice.  Thus 
in  pJiiyr®J|^:4^^V*^^®r^^^  cfv'er  sixty,  in  the  fat  and  plethoric,  in  cases 
•.^uSir^nJ;  •! n)ifi*  chronic  lung  trouble,  as  emphysema,  bronchitis,  etc., 
in  advanced  cardiac  disease  with  lack  of  compensation,  in  atheroma, 
in  alcoholics,  in  those  with  renal  disease,  and  in  cerebral  op>erations 
nuxtures  are  most  useful.     Being  agreeable  to  take,  they  are  often 


SPECIAL  METHODS   OF  ANESTHESIA  5 1 

used  as  a  means  of  obtaining  primary  anesthesia  to  ether  when  nitrous 
oxid  or  ethyl  chlorid  are  unavailable. 

Apparatus. — Mixtures  containing  chloroform  should  always  be 
given  by  the  open  method,  and  for  this  purpose  some  such  mask  as 
the  Esmarch  or  Schimmelbusch,  previously  described  (see  page  26), 
should  be  used. 

Administration. — The  same  general  rules  and  principles  that 
govern  the  administration  of  chloroform  should  be  followed  in  the  use 
of  mixtures.  They  should  always  be  given  with  the  patient  in  a 
recumbent  position.  The  inhalation  is  begun  gradually  with  the 
admixture  of  plenty  of  air.  Small  quantities  of  the  anesthetic  fre- 
quently repeated  are  to  be  used  in  preference  to  a  few  large  doses. 

The  anesthesia  produced  by  mixtures  is  only  a  slight  modification 
of  chloroform  narcosis.  On  account  of  the  stimulating  effect  of  the 
ether,  the  pulse  is  fuller  and  more  rapid,  respirations  are  deeper,  and 
the  whole  appearance  of  the  patient  is  better  than  when  chloroform 
alone  is  used.  Dangerous  signs,  should  they  appear,  are  not  quite 
so  abrupt  as  with  chloroform  and  may  usually  be  detected  before  a 
serious  or  hopeless  condition  supervenes. 

SPECIAL  METHODS  OF  ANESTHESU 

Intubation  Anesthesia. — In  operations  about  the  mouth,  such 
as  is  required,  for  instance,  in  removal  of  the  tongue,  repair  of  a  cleft 
palate,  resection  of  the  jaw,  etc.,  the  administration  of  the  anesthetic 
by  means  of  tubes  passed  into  the  pharynx  through  the  nose,  known 
as  Crile's  method,  will  be  found  of  great  service.     The  advantages  are 
that  the  anesthetist  and  inhaler  are  removed  from  the  seat  of  opera- 
tion so  that  they  in  no  way  interfere  with  the  operator,  and  the  anes- 
thetic may  be  administered  continuously,  as  it  is  not  necessary  to 
delay  or  stop  the  operation  at  frequent  intervals  in  order  to  get  the 
patient  well  under,  as  is  the  case  when  the  ordinary  interrupted  form 
of  anesthesia  is  employed.     As  the  pharynx  is  packed  with  gauze, 
aspiration  of  mucus  or  blood  from  the  site  of  operation  is  avoided, 
nor  is  there  vomiting  or  coughing  up  of  blood  that  may  have  collected 
^  the  back  of  the  pharynx. 

Apparatus. — The  apparatus  consists  of  two  rubber  tubes  of  a  size 
that  will  comfortably  pass  through  the  nares,  each  about  8  inches 
(20  cm.)  long,  preferably  cut  at  their  distal  ends  at  an  acute  angle, 
^nd  furnished  with  side  openings.  The  upper  ends  of  the  tubes 
^c  connected  to  the  two  arms  of  a  Y-shaped  glass  tube,  to  the  long 


52 


THE  ADMINISTRATION  OF   GENERAL  ANESTHETICS 


arm  of  which  is  attached  by  means  of  a  third  piece  of  rubber  tulnng 
a  funnel  lightly  packed  with  gauze. 

Technic. — After  full  anesthesia  has  been  obtained  in  the  usual 
way,  a  mouth  gag  is  inserted,  the  throat  is  well  cleared  of  mucus  by 
means  of  small  gauze  swabs,  and  the  two  tubes,  well  lubricated,  are 
carefully  passed  through  the  nares  and  down  to  the  epiglottis  with 
their  pointed  ends  directed  downward  and  forward.  The  tongue  is 
then  drawn  well  forward  and  the  whole  pharynx  is  firmly  packed  with 
a  single  piece  of  gauze  in  such  a  way  that  the  packing  does  not  ob- 
struct the  lateral  fenestrx  or  ends  of  the  tubes  (Fig.  28).     Care 


Fig.  18. — Showiog  the  method  of  inserting  the  tubes  and  packing  the  pharynx  for 
intubation  anesthesia. 

should  be  taken  at  this  stage  to  listen  at  the  ends  of  the  tubes  in  order 
to  make  sure  that  the  patient  is  breathing  properly.  If  he  is  not, 
the  gauze  should  be  promptly  removed  and  the  pharynx  repacked. 
As  soon  as  regular  breathing  is  established  through  the  tubes,  the 
funnel  is  connected  and  the  anesthetic  is  continued  by  the  drop 
method. 

Intratracheal  Insufflation  Anesthesia. — Intratracheal  in- 
sufflation anesthesia,  first  suggested  by  Meltzer  and  Auer,  con- 
sists essentially  in  the  introduction  deep  into  the  trachea  of  a  flexible 
tube  with  a  diameter  considerably  less  than  the  lumen  of  the  trachea 
and  the  forcing  of  a  current  of  air  and  ether  vapor  through  the  tube, 
the  space  between  the  tube  and  trachea  permitting  the  return  of  air 


SPECIAL  METHODS   OF  ANESTHESIA  53 

from  the  lungs.  This  method  of  anesthesia  was  originally  adopted  to 
supply  a  positive  pulmonary  pressure  for  operations  upon  the  thora- 
cic viscera,  the  resistance  to  the  return  of  air  through  the  trachea 
being  sufficient  to  prevent  the  lungs  from  collapsing  when  the  thorax 
is  opened.  For  this  purpose  it  has  largely  replaced  the  various  dif- 
ferential pressure  chambers. 

Intratracheal  insufflation  is,  furthermore, .  of  special  value  in 
operations  about  the  mouth,  tongue,  throat,  jaws,  and  nose  as  the 
continuous  reflux  air  current  prevents  the  aspiration  of  blood,  mucus, 
vomitus,  or  other  foreign  matter  from  the  pharynx  into  the  trachea. 
It  is  also  indicated  in  cases  where  normal  respiration  is  interfered 
with,. and  in  operations  about  the  neck,  head,  or  face  it  permits  the 
operator  to  work  in  an  imobstructed  field.  The  easy,  even  anes- 
thesia produced  by  this  method,  the  marked  absence  of  shock  and 
post-operative  vomiting  attending  its  use,  and  the  fact  that  the 
dosage  may  be  accurately  regulated  has  led  some  surgeons  to  employ 
;  it  as  a  routine  in  preference  to  the  ordinary  inhalation  methods. 

While  some  accidents  have  attended  the  use  of  insufflation 
anesthesia,  they  have  been  due  to  faulty  technic.  If  an  approved 
form  of  apparatus  is  used  and  certain  cautions  are  observed,  there  is 
no  danger.  The  apparatus  should  always  be  provided  with  a  safety 
valve  to  guard  against  overpressure  and  there  must  be  no  chance  of 
liquid  ether  entering  the  tracheal  tube.  Furthermore,  before  begin- 
ning the  insufflation,  the  operator  must  assure  himself  that  the  tube 
is  in  the  trachea  and  not  in  the  esophagus,  that  the  tube  is  not  intro- 
duced beyond  the  bifurcation  of  the  trachea,  and  that  during  the 
insertion  of  the  tube  the  pharynx  and  trachea  are  not  injured. 

Apparatus. — There   are   several  good  intratracheal  insufflation 
machines  on  the  market,  such  as  Elsberg's,  Janeway's,  and  Booth- 
by's,  which  are  elaborate  in  their  completeness.    A  very  simple  and 
inexpensive  apparatus  (Fig.  29),  which  answers  all  purposes,  is  de- 
scribed by  Meltzer  (Keen's  Surgery,  Vol.  VI)  as  follows: 

"By  means  of  a  glass-blower's  foot-bellows  (B)  air  is  driven 
through  a  system  of  branching  tubes  into  the  intratracheal  tube 
(In.-T).  The  first  branching  of  the  tubes  is  introduced  for  the  pur- 
pose of  regulating  the  interruption  of  the  air-stream.  From  the 
'^ght  branch  a  tube  is  led  off  laterally,  carrjdng  a  stopcock  (St.  3), 
which  is  to  be  used  for  the  interruptions  of  the  air-current.  During 
^e  opening  of  the  stopcock  a  part  of  the  air-current  continues 
through  the  left  tube,  thus  preventing  too  great  a  reduction  of  the 
pressure,  which  is  undesirable.     By  means  of  a  screw-clamp  (S.C.) 


54  THE  ADMINISTRATION   OF   GENERAL   ANESTHETICS 

the  amount  of  air  which  is  to  pass  through  the  left  tube  can  be 
regulated;  a  narrowing  of  this  tube  causesa  greater  collapse  of  the 
lung  during  the  interruption.  The  second  branching  of  the  tubes  is 
introduced  for  the  purpose  of  regulating  the  anesthesia.  The  ether 
bottle  (E)  is  interpolated  in  the  left  branch;  the  right  branch  runs 
uninterrupted  outside  of  the  bottle  to  unite  with  the  part  of  the  left 
tube  which  comes  from  the  ether  bottle.  When  the  stopcock  in  the 
right  branch  (St.  2)  is  closed,  all  the  air  passes  through  the  ether 
bottle;  when,  instead,  both  stopcocks  in  the  left  branch  (St,  i  and 
St.  4)  are  closed,  only  pure  air  reaches  the  intratracheal  tube,  and 


Fig.   ag. — Apparatus  for  intratracheal   insufflation   anesthesia  (I^Iettzer  ia  Keen's 

Surgery). 

when  all  three  stopcocks  are  open  only  one-half  of  the  air  is  saturated 
with  the  anesthetic.  By  partial  closing  of  the  stopcocks  various 
degrees  of  anesthesia  can  be  obtained.  The  third  opening  in  the 
ether  bottle  carries  a  tube  with  a  funnel  (F)  through  which  the  bottle 
is  filled  with  the  anesthetic;  the  tube  is  otherwise  kept  tightly  closed 
by  means  of  a  screw-clamp  (S.C).  All  three  rubber  stoppers  are 
firmly  and  permanently  wired  down  to  resist  various  pressures. 
When  the  ether  bottle  is  to  be  refilled  during  insufflation,  both  stop- 
cocks on  the  left  side  are  closed,  while  the  one  on  the  right  side  is 
-  open." 

"The  tube  which  connects  the  anesthesia  circle  of  tubing  with  the 
intratracheal  tube  (In,-T)  carries  two  lateral  tubes;  one  is  connected 
with  a  manometer  (M),  which  needs  no  description,  and  the  other 
leads  to  a  safety  valve  (S.V.)  of  a  simple  construction.     To  the  rubber 


SPECIAL  METHODS   OF  ANESTHESIA  55 

tubing  is  attached  a  graduated  glass  tube,  the  lower  end  of  which  Is 
immersed  under  the  surface  of  the  mercury  in  this  bottle  to  a  depth 
corresponding  to  the  pressure  which  is  desired  for  the  intratracheal 
insufflation.  For  instance,  if  the  pressure  should  be  not  more  than 
20  mm.  of  mercury,  the  glass  tube  is  immersed  just  20  mm.  below  the 
surface  of  the  mercury.  The  glass  tube  is  kept  in  the  desired  place 
by  means  of  a  rubber  ring  resting  upon  the  opening  of  the  mercury 
bottle.  This  device  gives  great  safety  to  the  working  of  the  method. 
No  matter  how  strong  and  irregular  the  bellows  is  worked,  the  intra- 
tracheal pressure  could  never  rise  above  the  one  arranged  for;  the 
surplus  of  air  escapes  through  the  tube  from  under  the  mercury." 
The  tracheal  tube  should  be  flexible  and  elastic,  about  14  inches 
(35  cm.)  long,  with  a  mark  loj^  inches  (27  cm.)  from  the  distal  end 


Fig.  30. — Jackson^s  direct  view  lar>'ngoscope. 

and  with  the  opening  preferably  at  the  end.  A  silk  woven  catheter, 
No.  22  to  24  French,  and  for  children  of  a  correspondingly  small  size, 
is  frequently  used.  There  will  be  required  in  addition  a  mouth-gag 
and  a  Jackson's  direct  view  laryngoscope  (Fig.  30).  Elsberg  has 
devised  a  special  bit  or  holder  to  keep  the  tube  from  slipping  up  or 
down  after  it  has  been  properly  introduced,  but,  in  its  absence, 
adhesive  plaster  may  be  employed  for  this  purpose. 

Asepsis. — The  tracheal  tube  and  the  laryngoscope  must  be  sterile. 

Preparations  of  the  Patient. — The  patient  is  prepared  as  for  any 
anesthesia  (see  page  18)  and  is  given  morphin  gr.  3^^  (0.0108  gm.) 
^d  atropin  gr.  Moo  (0.00065  gm.)  by  hypodermic  half  an  hour 
l>efore  the  operation. 

Technic. — The  patient  is  first  etherized  in  the  usual  way  and  is 
placed  upon  the  operating-table  with  his  head  hanging  over  the  edge 
in  which  position  it  is  supported  by  an  assistant  (see  Fig.    452), 


56  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

the  patient's  mouth  being  held  open  by  a  mouth-gag.  The  Jackson 
laiyngoscope  is  then  introduced  (for  the  technic  of  this  see  page  449), 
and,  with  the  epiglottis  pulled  forward  by  the  beak  of  the  instru- 
ment so  that  a  good  view  of  the  larynx  is  obtained,  the  tracheal 
catheter,  wet  in  cold  water,  is  inserted.  No  force  should  be  employed 
in  introducing  the  catheter,  and,  as  soon  as  it  is  well  in  the  larynx, 
the  tubular  speculum  is  removed.  The  catheter  is  then  pushed  for- 
ward imtil  it  meets  a  resistance  which  is  generally  the  right  bronchus. 
The  catheter  is  then  withdrawn  2  to  2  J^  inches  (5  to  6  cm.)  until  the 
mark  on  the  catheter  is  level  with  the  patient's  teeth.  The  operator 
must  be  certain  that  the  catheter  is  in  the  patient's  trachea  and  not 
in  the  esophagus.  The  catheter  is  finally  fixed  in  place,  and,  after 
the  apparatus  is  properly  connected,  the  insufflation  of  the  air  and 
ether  vapor  is  commenced.  The  vapor  at  first  should  be  blown  in 
imder  slight  pressure,  that  is,  about  10  nmi.  of  mercury  and  then 
imder  higher  pressure — 15  to  20  nmi.  of  mercury.  The  air  current 
should  be  interrupted  5  to  6  times  a  minute  by  opening  the  vent  for 
that  purpose  a  second  or  two  at  a  time.  The  anesthesia  is  pushed 
to  complete  muscular  relaxation  and  abolition  of  reflexes,  and,  when 
the  desired  degree  of  narcosis  is  obtained,  the  dose  of  ether  should  be 
kept  imiform,  as  the  degree  of  anesthesia  from  a  certain  dose  is  prac- 
tically stationary.  At  all  times  it  should  be  seen  that  there  is  a  free 
passage  for  air,  and  the  tongue  should  not  be  allowed  to  fall  back  and 
produce  any  obstruction.  A  spasm  of  the  glottis  may  in  some  cases 
be  the  cause  of  obstruction;  if  so,  full  anesthesia  will  relieve  the  con- 
dition. The  color  and  respirations  of  the  patient  should  be  carefully 
watched,  and,  if  the  latter  become  shallow  and  infrequent,  the 
anesthetic  should  be  diminished. 

For  ordinary  cases,  the  manometer  is  kept  at  15  to  20  mm.  of 
mercury.  In  operations  on  the  thoracic  viscera,  the  pressure  will 
depend  upon  the  distention  of  the  lung  desired;  it  should,  however, 
never  be  higher  than  50  mm.  of  mercury.  If  the  catheter  proves  too 
small  to  keep  the  lung  inflated  when  the  thorax  is  opened,  Meltzer 
recommends  that  pressure  be  made  over  the  middle  of  the  thyroid 
cartilage  every  few  moments. 

At  the  completion  of  the  operation,  the  ether  is  discontinued  and 
pure  air  is  insufflated  for  a  moment  or  two  before  the  tube  is  with- 
drawn in  order  to  remove  as  much  of  the  anesthetic  vapor  as  possible. 

Anesthesia  Through  a  Tracheal  Opening. — In  some  opera- 
tions upon  the  tongue,  larynx,  or  pharynx  it  becomes  necessary  to 
administer  the  anesthetic  through  an  oi>ening  in  the  trachea. 


SPECUL    METHODS    OF    .•UiTESTHESlA 


S7 


Apparatus.— For  this  purpose  a  Hahn  or  a  Trendelenburg 
cannula  is  employed.  These  instruments  consist  essentially  of  a. 
metal  funnel,  covered  or  lilled  with  gauze  upon  which  the  anesthetic 
is  dropped,  and  connected  with  a  special  tracheotomy  tube  by  means 
of  3  piece  of  tubing.     The  tracheal  tube  of  the  Hahn  apparatus  is 


Fig.  31. — The  Trentlelenburg  apparatus  [or  tracheal  aneslhesia. 

surrounded  by  a  flat  dried  sponge  fastened  securely  in  place,  which, 
when  wet,  swells  up  and  acts  as  a  tampon,  preventing  blood  from 
descending  along  the  side  of  the  tube.  The  same  result  is  obtained 
li  the  Trendelenburg  instrument  (Fig.  31)  by  surrounding  the 


58  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

care  being  taken  to  see  that  the  tainpK)nade  is  effective,  so  as  to  pre- 
vent blood  from  entering  the  trachea.  The  tube  to  convey  the  anes- 
thetic vapor  from  the  funnel  is  then  attached  to  the  tracheal  cannula, 
and  the  anesthetic  is  administered  by  dropping  chloroform  on  the 
gauze  of  the  inhaler. 

Intravenous  General  Anesthesia. — Burkhardt  in  1909  de- 
vised a  method  of  producing  general  narcosis  by  administering 
ether  intravenously  in  normal  salt  solution.  Since  then  the  method 
has  been  given  a  trial  by  a  number  of  operators  abroad  and  by  a  few 
in  this  country,  but  it  has  never  become  pK)pular.  From  our  present 
knowledge  it  is  not  probable  that  intravenous  etherization  will  ever 
supplant  the  inhalation  method  as  a  routine.  In  certain  operations, 
as  those  about  the  face,  upper  air  passages,  mouth,  tongue,  and 
neck,  the  absence  of  a  mask  near  the  field  of  operation  and  the  even 
and  uninterrupted  anesthesia  that  is  produced  by  this  method  is  of 
undoubted  advantage.  Furthermore,  the  stimulating  effect  of  a 
continuous  saline  infusion  makes  the  method  one  of  special  value  in 
ill-nourished,  debilitated,  or  cachectic  subjects  On  the  other  hand, 
there  are  the  dangers  of  sepsis,  thrombosis,  emboUsm,  and  puhnonary 
edema  if  all  the  details  of  the  technic  are  not  carefully  observed. 
When  properly  administered  it  is  claimed  that  the  anesthesia  is 
rapidly  obtained,  that  there  is  seldom  any  stage  of  excitement,  that 
pulmonary  irritation  and  nausea  are  absent,  and  that  the  recovery 
from  the  anesthesia  is  prompt  and  without  discomfort.  According  to 
Kummell  intravenous  anesthesia  is  contraindicated  in  the  presence 
of  arterio-sclerosis,  myocarditis,  and  general  plethora. 

In  the  early  cases  in  which  this  method  was  employed,  an  inter- 
rupted form  of  anesthesia  was  given,  that  is,  a  quantity  of  ether  solu- 
tion sufficient  to  get  the  patient  under  was  infused  and  the  flow  was 
then  stopped,  the  infusion  being  continued  when  the  patient  com- 
menced to  show  signs  of  coming  out.  The  uneven  anesthesia  this 
produced  and  the  fact  that  some  cases  of  venous  thrombosis  and  pul- 
monary embolism  were  reported  as  a  sequel  led  to  the  adoption  of 
a  continuous  infusion  as  the  only  safe  method. 

Apparatus. — An  apparatus,  such  as  described  by  Rood  {British 
Medical  Journal,  Oct.  21,  191 1),  which  will  permit  a  continuous  but 
slow  flow  of  solution  is  required.^  The  apparatus  should  consist  of 
(i)  a  glass  reservoir  with  a  capacity  of  3  pints  (1500  c.c.)  supported 
upon  a  stand  at  a  height  of  8  feet  (240  cm.)  from  the  floor,  (2)  a  glass 

^  In  this  country  an  apparatus  designed  by  Dr.  Honan  is  manufactured  by  the 
Kny  Scheerer  Co.  of  New  York. 


SPECIAL  METHODS   OF  ANESTHESIA 


59 


drippmg  chamber  with  a  capacity  of  8  ounces  (250  c.c),  and  (3)  a 
warming  chamber  surrounded  by  a  jacket  containing  water  at  a  tem- 
perature of  ioo°F.  (38*^0.)  (Fig.  33).  When  the  apparatus  is  working 
the  solution  drips  from  the  pipette  leading  from  the  reservoir  into 
the  indicator,  the  lower  half  of  which  is  filled  with  solution  and  the 
upper  half  with  air.  A  screw  pinch  cock  below  the  indicator  controls 
the  rate  of  flow,  the  rate  at  which  the  solution 
drips  from  the  pipette  being  an  index  of  the  rate 
at  which  it  will  enter  the  vein. 

Instruments. — The  operator  will  require  a 
scalpel,  a  pair  of  blunt-pointed  scissors,  thumb 
forceps,  an  aneurysm  needle,  a  needle  holder, 
curved  needles  with  a  cutting  edge,  and  No.  2 
plain  catgut  (Fig.  34). 

Solutions. — Ether  is  used  in  a  5  per  cent. 
solution  in  normal  salt  solution  by  Burkhardt 
and  m  a  7.5  per  cent,  solution  by  Rood. 
Hedonal  and  paraldehyde  have  also  been  used 
with  success.  Fedoroff  employs  a  0.75  per  cent, 
solution  of  hedonal  in  normal  salt  solution.  The 
objection  to  the  use  of  this  drug  is  the  length  of 
time  the  hypnotic  effect  persists  when  large 
amounts  are  administered.  Noel  and  Souttar 
(Annals  of  Surgery,  January,  1913)  first  called 
attention  to  the  anesthetic  effects  of  paraldehyde 
when  given  intravenously.  Honan  and  Hassler 
[Medical  Record,  Feb.  8,  1913)  employ  paralde- 
hyde 2}^  per  cent,  and  ether  3  per  cent,  in  nor- 
^  salt  solution. 

Temperature. — The  solution  should  be  given 
^t  a  temperature  of  about  that  of  the  body. 

Quantity. — The  amount  of  solution  used  will 
depend  upon  the  age  and  condition  of  the  pa- 
tient and  the  length  of  anesthesia.  Usually 
from  6  to  25  ounces  (200  to  800  c.c.)  of  solution 
will  be  required. 

Preparations  of  Patient. — It  is  advisable  to  give  the  patient  hypo- 
dennically  an  hour  before  the  operation  morphin  gr.  3^^  (0.0108  gm.), 
atropin  gr.  3^foo  (0.00065  gm.),  and  scopolamin  gr.  }{qq  (0.00065 
gm.).  All  clothing  should  be  removed  from  the  arm  chosen  for  the 
infusion  and  the  arm  should  be  bandaged  to  a  well-padded  splint  so 


Fig.  33. — Appara- 
tus for  intravenous  an- 
esthesia. 


6o 


THE   ADMINISTRATION   OP   GENERAL  ANESTHETICS 


that  the  infusion  cannula  cannot  be  disturbed  by  movements  of  the 
patient. 

Site  of  Injection. — One  of  the  most  prominent  vdns  at  the  bend  of 
the  elbow — preferably  the  median  basilic — is  chosen  for  the  infusion. 

Asepids. — The  solution  must  be  absolutely  sterile.  The  instru- 
ments are  sterilized  by  boilii^.  The  site  for  the  infusion  is  shaved 
and  the  skin  is  sterilized  by  painting  with  tincture  of  iodin. 

Technic. — A  tourniquet  is  placed  about  the  arm  above  the  ate  of 
injection.  Under  infiltration  anesthesia  with  a  0.2  per  cent,  solution 
of  cocain  or  a  i  per  cent,  procain  solution  the  median  c^halic  or  the 
median  basilic  vein  is  exposed   through  a  small    incision.    The 


Fig.  54.~-Inst  rumen  Is  for  intravenous  anesthesia,  i.  Scalpel;  a,  blunt-pointed 
■dssors;  j,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6,  curved  needle*; 
7,  No.  z  plain  catgut. 

distal  portion  of  the  vein  is  ligated,  the  proximal  portion  is  in- 
cised, and  the  cannula  inserted  uith  the  solution  JUnving  as  described 
under  intravenous  infusion  (page  170).  The  constriction  is  then 
removed  Jrom  tite  arm  and  the  ether  solution  is  allowed  to  run,  at  first 
fairly  rapidly  until  anesthesia  is  induced,  and  then  drop  by  drop, 
being  guided  by  the  depth  of  anesthesia. 

It  usually  requires  from  four  to  ten  minutes  to  induce  ftiU  anes- 
thesia, using  3  to  6  ounces  (100  to  200  c.c.)  of  solution.  After 
anesthesia  is  obtained  the  ilow  of  solution  should  be  at  about  the 
rate  of  40  to  60  drops  per  minute.  Should  edema  of  the  eyelids 
appear  at  any  time,  the  infusion  should  be  temporarily  stopped. 


SPECIAL    METHODS    OF    ANESTHESIA 


6i 


During  the  anesthesia  the  aDcsthetist  must  take  the  same  pre- 
cautions to  maintain  unobstructed  air  passages  as  with  inhalation 
anesthesia. 

At  the  completion  of  the  operation  the  cannula  is  removed,  the 
vein  ligated  with  catgut,  and  the  wound  sutured.  A  sterile  dressing 
is  then  applied.  If  a  large  quantity  of  solution  has  been  infused,  it 
IS  a  wise  precaution  to  have  that  patient's  position  in  bed  changed 
liMn  time  to  time,  otherwise  edema  of  the  lungs  or  of  dependent  por- 
of  the  body  may  develop. 

tectal  Anesthesia. — It  consists  in  producing  narcosis  by  means 
"^rann  ether  vapor  slowly  forced  into  the  rectum.  This  method 
»as  employed  in  1847  by  Roux.  Later,  in  1884,  it  was  taken  up  by 
JtfolliSre  and  in  this  country  by  Weir  and  Bull,  but  it  never  came 
bitjo  general  use.  In  the  early  cases  colicky  pains,  diarrhea,  bloody 
stools,  and  painful  distention  of  the  intestine  were  frequently  ob- 
served. These  symptoms,  no  doubt,  were  in  many  instances  due' 
to  faulty  methods  of  administering  the  anesthetic,  and  with  the 
improved  technic  of  Cunningham  and  others  the  method  has  given 
tetter  results. 

Though  it  cannot  be  said  to  be  free  from  risks,  rectal  anesthesia 
oAs  a  definite  place  among  the  methods  of  anesthetizing  at  our  dis- 
posal.    Its  greatest  field  of  usefulness  is  in  cases  of  extreme  pulmo- 
nary or  bronchial  involvement  and  empyema,  and  in  operations 
about  the  face,  mouth,  and  larynx,  where  other  means  of  anesthesia 
are  unsuited.     To  the  former  class  of  cases  it  is  especially  suited  on 
account  of  the  absence  of  pulmonary  or  bronchial  irritation  from  the 
rther.     While  it  is  true  that  the  greater  part  of  the  ether  is  eliminated 
irotn  the  lungs,  the  direct  irritation  of  concentrated  vapor  is  over- 
tome,  as  is  shown  by  the  absence  of  the  bronchial  secretion,  cough, 
rt<.'.    The  method  also  has  the  advantage  of  requiring  but  little  ether 
I"  induce  and  maintain  anesthesia,  and  there  is  practically  no  stage 
cf  excitement  or  postoperative  nausea  and  vomiting.     On  the  other 
the  induction  of  narcosis  is  slow,  and,  in  some  cases  where  the 
itive  power  of  the  rectum  is  limited,  sufficient  of  the  drug  is 
en  into  the  system  to  keep  the  patient  under,  so  that  other 
of   anesthetizing    must   be    utilized.     It    is  not  a    suitable 
"Wthod  to  employ  in  abdominal  operations  on  account  of  the  disten- 
■^00  produced,  nor  should  it  be  used  if  the  intestines  are  inflamed  or 
Ilieir  walls  weakened. 

Apparatus. — A    simple    apparatus    consists    of    the    following: 
■^  ''^h  bottle  to  hold  the  ether,  about  8  inches  (20  cm.)  high  and  4 


n 


62  THE  ADIUNISTRATION   OF  GENERAL  ANESTHETICS 

inches  (lo  cm.)  in  diameter,  supplied  with  a  tight  stopper  in  which 
are  two  perforations.  Through  one  of  these  openings  a  glass  tube 
leads  to  the  bottom  of  the  bottle,  and  through  the  other  a  glass  tube, 
cut  off  flush  with  the  under  surface  of  the  stopper,  leads  out.  A 
double  cautery  bulb  is  attached  to  the  afferent  tube  by  a  piece  of 
rubber  tubing,  while  to  the  efferent  tube  is  connected  a  piece  of  rubber 
tubing  leading  to  a  plain  rectal  tube,  a  glass  bulb  being  interposed  be- 
tween the  rectal  tube  and  the  rubber  tubing  to  catch  any  condensed 
ether  vapor  and  prevent  it  from  entering  the  rectum.  The  efferent 
tube  is  opened  or  closed  by  means  of  a  small  pinch  cock.  In  addi- 
tion, a  short  rubber  exhaust  tube  is  connected  to  the  efferent  tube 
by  means  of  a  Y  shaped  glass  tube  and  is  likewise  supplied  with  a 


Fig.  35. — Apparatus  for  rectal  anesthesia. 

pinch  cock.  The  free  end  of  the  exhaust  tube  is  placed  in  a  bottle 
of  water  in  order  to  readily  recognize  the  escape  of  gas  from  the 
rectum  when  the  exhaust  is  opened.  Both  the  afferent  and  the 
efferent  tubes  should  be  of  sufficient  length  to  permit  the  apparatus  to 
be  moved  to  a  distance  from  the  patient  if  necessary.  The  ether 
bottle  is  surrounded  by  a  metal  container  holding  warm  water. 
This  should  be  kept  at  a  temperature  of  about  goT.  (32°C.),  but  not 
much  above,  as  the  ether  will  boil  at  96°F.  (35°C.).  A  thermom- 
eter should  be  provided  for  the  purpose  of  regulating  the  tem- 
perature. By  compressing  the  cautery  bulb  air  is  forced  into  the 
ether  through  the  long  tube  and  leaves  the  apparatus  saturated  with 
warm  ether  vapor. 

More  elaborate  forms  of  apparatus  have  been  devised,  such  as 


SPECIAL   METHODS   OF   ANESTHESIA  63 

Sutton's,  in  which  oxygen  takes  the  place  of  air  as  a  vehicle  for  the 
ether  vapor  and  the  degree  of  distention  of  the  bowel  is  controlled 
by  means  of  a  manometer. 

Preparation  of  the  Patient. — A  thorough  cleansing  of  the  boweb  is 
absolutely  necessary,  other^vise  absorption  cannot  take  place  and  the 
&ist  essential  of  the  anesthesia  is  defeated.  A  cathartic  is  given  to 
the  patient  the  night  before  the  operation,  and  on  the  following 
morning  a  colonic  irrigation,  followed  by  an  ordinary  soapsuds 
an  hour  before  the  operation,  complete  the  preparations. 
'echnic. — The  patient  lies  upon  the  table  with  one  thigh  elevated 
a  sand-bag  so  as  to  afford  room  to  insert  the  tube,  etc.  The 
bottle  is  filled  about  two-thirds  with  ether,  leaving  one-third  of  its 
capacity  for  vapor,  and  the  apparatus  is  tested  to  see  that  it  works 
properly.  The  rectal  tube,  well  lubricated,  is  inserted  8  to  10  inches 
(20  to  35  cm.)  within  the  bowel,  and  the  ether  vapor  is  forced  in  by 
means  of  gentle  compressions  of  the  rubber  bulb  every  five  to  ten 
seconds.  As  the  rectum  becomes  distended,  the  exhaust  tube  is 
opened  and  the  clip  on  the  tube  leading  from  the  ether  chamber  is 
closed  to  permit  the  gases  already  present  to  escape,  otherwise  the 
absorption  of  the  vapor  is  interfered  with ;  on  complaints  of  disten- 
tion, the  superfluous  vapor  must,  likewise,  be  allowed  to  escape. 
The  exhaust  tube  must  also  be  opened  when  violent  coughing  occurs, 
otherwise  the  rectal  tube  is  liable  to  be  expelled. 

In  from  three  to  five  minutes  the  odor  of  the  drug  will  be  distin- 
guished in  the  patient's  breath,  and  the  patient  soon  begins  to  feel 
drowsy.  The  breathing,  at  first  rapid,  becomes  regular  and  linally 
sKghtly  stertorous,  and  the  patient  then  passes  into  complete  surgical 
iiucosis,  generally  without  the  preliminary  stage  of  excitement.  The 
tinw  necessary  for  this  varies  from  five  to  fifteen  minutes,  according 

ylhe  patient  and  the  ability  of  the  bowel  to  absorb.  The  anesthetic 
Bot  be  pushed,  however,  for  the  more  the  bowel  is  distended 
fond  a  certain  point  the  less  is  the  absorption.  As  soon  as  anes- 
&  is  complete  it  may  be  maintained  by  gently  squeezing  the  bulb 
*^  minute  or  so.  The  same  signs  as  to  the  depth  of  anesthesia, 
•^■"Kiition  of  the  patient,  etc.,  should  guide  the  anesthetist  as  in  the 
wniinistration  of  pulmonary  anesthesia,  and  the  same  precautions 
*w>iit  keeping  the  tongue  and  the  jaw  forward  should  be  observed. 
'"  llie  completion  of  the  anesthesia,  the  rectal  tube  is  disconnected 
"uni  the  apparatus,  and,  by  gentle  abdominal  massage  of  the  colon, 
w  vapor  remaining  unabsorbed  is  forced  out.  This  should  be  fol- 
""wl  by  a  cleansing  enema. 


64  THE   ADMINISTRATION   OF  GENERAL  ANESTHETICS 

Oil-ether  Colonic  Anesthesia. — Gwathmey  of  New  YoA 
has  developed  a  method  of  rectal  anesthesia  by  means  of  a  mixture 
of  olive  oil  and  ether  injected  into  the  rectum  to  which  he.  applies 
the  name  "oil-ether  colonic  anesthesia"  (N.  Y.  Medical  Journal^ 
Dec.  0,  1913).  This  form  of  anesthesia  has  been  used  by  its  origi- 
nator in  a  large  number  of  cases  and  is  a  most  valuable  addition  to 
the  field  of  rectal  anesthesia.  The  method  is  especially  useful  in 
operations  about  the  head  and  neck,  though  it  has  been  used  in  a 
great  variety  of  operations.  According  to  Gwathmey,  it  is  contra- 
indicated  in  colitis,  hemorrhoids,  fistula  in  ano,  or  other  pathological 
conditions  of  the  lower  bowel,  and  in  most  cases  where  ether  is  con- 
traindicated.  Under  this  form  of  anesthesia  there  is  complete 
relaxation,  the  reflexes  remain  active,  and  there  is  an  absence  of 
nausea.  For  from  one  to  three  hours  following  the  anesthesia  there 
is  a  pain-free  period.  So  far  no  diarrhea  or  bloody  stools  or  other 
untoward  effects  have  been  observed. 

Apparatus. — The  necessary  equipment  is  very  simple,  consisting 
of  a  catheter  and  furmel  for  introducing  the  oil  and  ether  mixture  and 
two  small  rectal  tubes  for  emptying  and  irrigating  the  colon. 

Solutions  Used. — ^A  ihixture  of  ether  in  olive  oil  is  employed  in 
the  following  strengths:  For  cases  over  fifteen  years  of  age  a  75  per 
cent,  mixture;  for  children  of  from  six  to  twelve  years  of  age  a  55  to 
65  per  cent,  mixture;  and  for  those  under  six  years  of  age  a  50  per 
cent,  mixture. 

Quantity. — One  ounce  (30  c.c.)  of  the  mixture  is  administered  for 
each  20  pounds  (8  K.)  of  weight. 

Preparations  of  Patient. — The  usual  preparations  as*for  any  anes- 
thetic are  carried  out,  and  the  colon  is  irrigated  until  the  fluid  returns 
clear.  For  adults  a  preliminary  hypodermic  injection  of  ^i  to 
34  gr.  (0.0081  to  0.0162  gm.)  of  morphin  and  3^oo  gr.  (0.00065 
gm.)  of  atropin  is  given  half  an  hour  before  operation  and  at  the  same 
time  5  gr.  (0.3  gm.)  of  chloretone  in  2  drams  (8  c.c.)  of  olive  oil  and 
2  drams  (8  c.c.)  of  ether  is  introduced  into  the  rectum.  For  children 
preliminary  medication  is  generally  omitted,  as  the  weaker  solutions 
are  not  irritating  to  the  bowel. 

Technic. — The  anesthetic  mixture  is  introduced  into  the  bowel 
while  the  patient  is  in  bed  in  the  Sims  position.  The  small  catheter. 
well  lubricated,  is  inserted  a  few  inches  into  the  rectum  and  the  desired 
quantity  of  solution,  depending  upon  the  weight  of  the  patient,  is 
slowly  poured  into  the  funnel.  About  five  minutes  should  be  con- 
sumed in  introducing  8  ounces  (250  c.c),  the  quantity  generally 


ACCIDENTS   DURING  ANESTHESIA  AND   THEIR  TREATMENT         65 

required  for  an  adult  of  ordinary  size.  The  tubes  should  be  left  in 
place  until  the  patient  is  partially  unconscious.  In  from  five  to 
twenty  minutes  the  anesthesia  is  established.  During  the  anesthesia 
the  anesthetist  should  keep  the  air  passages  free  and  the  jaw  well  for- 
ward and  should  keep  careful  watch  over  the  general  condition  of  the 
patient  Should  the  patient  become  too  deeply  under  the  influence 
of  the  anesthetic,  shown  by  cyanosis,  shallow,  embarrassed  or  ster- 
torous respirations,  a  rectal  tube  is  introduced  and  2  to  3  ounces 
(60  to  90  c.c.)  of  solution  are  withdrawn. 

At  the  completion  of  the  operation,  two  small  rectal  tubes  are 
passed  well  up  in  the  bowel  and  the  latter  is  irrigated  with  cold  water 
soapsuds,  the  injection  being  made  through  one  tube  while  the  second 
one  permits  the  escape  of  the  washings.  Two  to  3  ounces  (60  to  90 
c.c.)  of  olive  oil  are  then  injected  into  the  rectum  to  be  retained  by  the 
patient,  and  the  tubes  are  withdrawn. 

Scopolamin-morphin    Anesthesia. — Hypodermic    injections    of 
scopolamin  and  hyoscin  (which  is  claimed  to  be  chemically  the  same) 
have  been  used  quite  extensively  in  combination  with  morphin  to 
produce  anesthesia.     From  the  number  of  deaths  reported  from  this 
combination  when   used   in   large  enough   quantities   to  produce 
anesthesia  unaided,  it  would  appear  to  be  a  very  dangerous  form  of 
anesthesia,  and  up  to  the  present  time  it  has  a  higher  death  percent- 
age than  chloroform  or  ether.     In  small  doses,  however,  hyoscin 
and  morphin  may  be  used  with  good  results  as  an  adjunct  to  local 
or  general  anesthesia.     In  such  cases  they  can  be  given  as  follows: 
Hyoscin,    gr.    3^100  •  (0.00065    gm.)    and    morphin,    gr.    }^    to    }^ 
(0.0108  to  0.0162  gm.)  by  hypodermic,,  one  hour  to  two  hours  before 
operation.     This  combination  is  more  efficacious  than  morphin  alone, 
and  has  the  effect  of  producing  a  drowsy  state  and  even  sleep,  which 
may  last  five  to  six  hours  after  the  operation.     It  is  contraindicated 
in  patients  with  heart  disease  or  when  there  is  a  tendency  to  pulmon- 
ary edema.     In  the  young  and  the  aged  hyoscin  and  morphin  should 
be  used  with  great  caution. 

ACCIDENTS  DURING  ANESTHESIA  AND  THEIR  TREATMENT 

The  accidents  and  dangers  that  may  arise  during  the  adminis- 
tration of  anesthetics  are  connected  with  the  respiratory  or  circula- 
tory systems  and  include  asphyxiation,  respiratory  paralysis,  and 
cardiac  paralysis.  Theoretically,  the  dangers  of  nitrous  oxid,  ether, 
^d  ethyl  chlorid  are  those  to  be  expected  from  failure  of  the  respira- 


66  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

tory  centers,  while  the  accidents  from  chloroform  narcosis  are  pri* 
marily  those  occurring  as  the  result  of  the  depressing  effects  of  the 
drug  upon  the  circulation.  Practically,  however,  in  severe  cases 
failure  of  the  respiratory  center  and  circulatory  paralysis,  if  not 
coincident,  precede  or  follow  one  another  in  such  rapid  sequence  that 
it  is  often  impossible  to  distinguish  between  the  two  or  to  determine 
which  is  the  primary  cause,  and  treatment  must  be  directed  toward 
both  conditions. 

Accidents  may  be  avoided  in  the  great  majority  of  cases  if  propter 
precautions  are  taken  beforehand  in  the  preparation  of  the  patient 
and  due  care  is  observed  in  the  administration  of  the  anesthetic. 
These  points  have  already  been  considered,  but  it  may  not  be  out  of 
place  to  emphasize  by  repetition  the  most  important  of  them. 
Never  allow  the  patient  to  have  food  within  three  hours  of  the  time 
of  anesthesia.  See'  that  all  foreign  bodies,  false  teeth,  plates,  etc.^ 
which  might  fall  into  the  throat  and  obstruct  the  respiratory  passages 
are  removed  beforehand,  and  that  tight  bandages  or  clothing  that 
might  constrict  the  neck  or  chest  are  loosened.  When  relaxation 
occurs,  turn  the  patient's  head  to  one  side  to  allow  mucus  and  saliva 
to  flow  from  the  mouth,  and  see  that  the  tongue  does  not  fall  back 
in  the  throat  and  act  as  an  obstruction.  The  anesthetist  must 
devote  his  entire  attention  to  the  anesthesia,  taking  particular  care 
to  watch  the  respirations,  at  the  same  time  not  forgetting  to  give 
due  attention  to  the  pulse,  the  condition  of  the  eye  reflexes,  and  the 
general  appearance  of  the  patient.  The  assistant  chosen  for  this 
duty  should  be  a  person  of  large  experience  in  the  administration  of 
anesthetics  so  that  he  may  be  competent  to  interpret  danger  signs 
before  they  proceed  too  far.  If  there  is  any  doubt  as  to  the  meaning 
of  a  sudden  change  in  the  patient's  condition  or  of  unusual  symptoms, 
it  is  always  better  to  err  on  the  safe  side  and  allow  the  patient  to 
partly  recover  than  to  induce  a  deeper,  and  what  may  be  a  danger- 
ous, state  of  narcosis. 

Asphyxiation. — It  is  characterized  by  a  moderate  cyanosis 
or  a  marked  lividity  of  color  and  gasping  respirations.  It  may 
be  only  transient,  or  it  may  become  progressively  worse  and  severe- 
Such  a  condition  should  be  promptly  treated  by  removal  of  the 
cause  which  will  be  found  to  be  some  one  of  the  following:  coughing, 
struggling,  locking  of  the  jaws,  awkward  position  of  the  patient, 
an  improper  holding  of  the  cone,  the  so-called  "  f orgetf ulness  to 
breathe,''  falling  back  of  the  tongue  and  epiglottis,  obstruction  to 
the  air  passages  by  blood,  mucus,  saliva,  or  foreign  bodies,  partial 


ACCIDENTS    DirRlNG    ANESTHESIA    AND    THEIR    TREATMENT         67 

or  complete  occlusion  of  the  nose  from  deformities  of  the  bones  and 
nusal  growths,  or  from  collapse  and  falling  in  of  the  alie  nasi  during 
inspiration  under  deep  narcosis. 

Treatment — Cyanosis  due  to  coughing  or  struggling  may  be 
overcome  by  simply  removing  the  inhaler  and  permitting  the  patient 
to  get  a  breath  of  fresh  air.     When  the  position  of  the  patient  is 


Fig.  30.— Method  of  hiilding  the  jaw  forward. 


^/r\ 


responsible,  it  should  be  corrected  without  delay.     If  the  cyanosis 
be  due  to  obstruction  or  partial  occlusion  of  the  nares,  the  mouth 
should  be  kept  sufhclently  open  by  means  of  a  mouth-gag  to  permit 
the  entrance  of  the  necessary  amount  of  air.     "Forgetting   to 
breathe,"i*  met  by  removing  the  inhaler  and,  after  waiting  a  moment, 
the  patient  will  in  the  majority  of  cases  take  a  breath.     If  this  is  not 
sufficient,    a   sharp   slap  upon   the 
sternum  with  a  wet  towel  or  a  mo- 
mentary compression   of  the  ster- 
num b  frequently  all  that  is  neces- 
»iy.    Failing  by  these  means,  the 
i»ws  should  be  held  apart  and  rhy- 
"Unic   traction    exerted   upon    the 
tongue  to  excite  a  reflex  inspiration. 
Oijstruction  caused  by  the  fall- 
H  back  of  the  tongue  and  epiglot- 
tis is  corrected  by  properly  holding 

"IC  lower  jaw  forward  (Fig.  36),   or      d^a^ng  the  tongue  and  epiglottis  for- 
^y  traction    upon    the   tongue   by     ward, 
"leans  of  tongue  forceps  or  a  silk 

suture.  An  e0ective  temporary  means  for  overcoming  obstruction 
from  this  cause  is  to  pass  the  index  finger  into  the  mouth  over  the 
'***  of  the  tongue  and  hook  it  forward  together  with  the  epiglottis 
^^'  37).     In  persistent  cases  the  use  of  a  pharyngeal  breathing 


Fic.  37. — Showing  the  method  of 


68  THE  ADMINISTRATION   OP   GENERAL  ANESTHETICS 

tube  is  of  the  greatest  aid  in  obtaining  an  unobstructed  airway. 
This  mechanical  device  {Fig.  38)  consists  essentially  of  a  hollow  rigid 
rubber  or  metal  tube  curved  to  conform  to  the  shape  of  the  base  of 
the  tongue  through  which  the  patient  breathes  when  the  tube  is 
placed  in  the  pharynx. 


Fic.  38. — Connell's  pharyngeal  breathing  tube. 

When  the  asphyxia!  symptoms  are  due  to  obstruction  by  collec- 
tions of  fluid  in  the  throat  or  foreign  bodies,  the  patient's  head  should 
be  turned  to  one  side,  the  jaws  forced  open,  and  the  air  passages 
cleared.  Solid  bodies  may  be  removed  by  the  finger  or  forceps.  If 
this  is  not  possible,  tracheotomy  (page  447)  should  be  performed 
without  hesitation. 


— .^rtificiol    respiration 
lo  make  cuunlerpre; 


In  any  case  of  asphyxia,  if  the  cyanosis  is  severe  and  grows  pro- 
gressively worse  in  spite  of  the  above  line  of  treatment,  the  anesthetic 
and  the  operation  should  be  discontinued  while  artificial  respiratioa, 
combined  with  inhalations  of  oxygen,  is  carried  out.  This  is  effec- 
tively performed  by  a  combination  of  the  Sylvester  and  Howard 
methods,  or  by  the  use  of  Meltzer's  insufflation  apparatus  or  some 
one  of  the  machines  made  especially  for  performing  artificial  respira- 


ACCIDENTS  DUIONC   ANESTHESIA  AND  THEIR   TREATMENT        69 

tion.  Any  of  the  methods  of  artificial  respiration  are  useless,  how- 
ever, as  long  as  there  is  any  obstruction  in  the  air  passages,  and 
these  should  always  be  first  cleared  out,  as  previously  directed. 

In  the  absence  of  special  apparatus,  artificial  respiration  is 
carried  out  as  follows:  The  foot  of  the  operating^table  is  raised 
upon  a  stool  and  the  patient  is  slid  down  so  that  the  head  hangs 
partly  over  the  edge.  The  anesthetist,  standing  at  the  patient's 
head,  takes  a  firm  hold  just  below  the  elbows  and  draws  the  arms 
upward  and  outward  until  they  are  very  nearly  perpendicular  above 
the  head  (Fig,  39).  This  thoroughly  expands  the  chest  and  pro- 
duces an  inspiration.    The  arms  are  maintained  in  this  position  for 


Fig.  40.— Artificial    respiration    (cipiralion).     The    operator    brings    the    patient's 
arms  firmly  against  the  chest  while  the  assistant  makes  counterpressure. 

a  second  or  two,  to  allow  the  air  to  thoroughly  expand  the  lungs. 
Aspiration  is  produced  by  the  reversal  of  the  above  maneuver, 
bnnging  the  arms  downward  with  firm  pressure  against  the  chest 
"^1  while  at  the  same  time  an  assistant,  with  palms  of  the  hands 
outstretched  over  the  margins  of  the  ribs  and  epigastrium,  presses 
upward  toward  the  diaphragm  (Fig.  40),  This  counterpressure 
prevents  the  effects  of  the  expiratory  maneuver  being  lost  upon 
"16  diaphragm  and  abdominal  viscera.  After  another  second  or 
^1  the  assistant  suddenly  releases  the  lower  portion  of  the  chest  and 
at  the  same  time  elevation  of  the  arms  is  again  performed.  The 
movements  producing  artificial  respiration  should  be  made  as  nearly 


70  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

as  possible  at  the  rate  of  normal  respiration,  certainly  not  over  twenty 
times  a  minute.  As  an  adjunct  to  the  above,  forcible  dilatation  of 
the  sphincter  g,ni  may  be  performed  for  the  purpose  of  exciting  reflex 
inspiration. 

A  favorable  response  to  treatment  is  denoted  by  a  gradual  return 
of  the  natural  color,  at  first  feeble  gasps  and  then  stronger  attempts  at 
respiration,  and  a  return  of  the  pulse  at  the  wrist.  If,  after  five  or 
ten  minutes,  there  is  no  response  to  the  treatment,  the  prognosis  is 
exceedingly  bad,  but  the  artificial  respiration  should  be  persisted  in 
for  at  least  half  an  hour.  Deaths  from  asphyxia  alone  during  anes- 
thesia can  be  prevented  in  nearly  all  cases  by  following  the  sugges- 
tions and  the  treatment  above  described. 

Respiratory  Paralysis. — This  is  a  more  serious  condition.  In 
the  first  s.tages  of  anesthesia  it  may  be  due  to  a  spasm  of  the  glottis, 
diaphragm,  or  respiratory  muscles  through  reflex  irritation  from  over- 
stimulation of  the  nasal  branches  of  the  trigeminal  nerve,  when  large 
quantities  of  ether  are  suddenly  poured  upon  the  inhaler  or  the 
strength  of  the  drug  is  too  rapidly  increased.  The  patient  suddenly 
stops  breathing  and  "becomes  cyanosed,  but  the  pupillary  reaction 
remains  and  the  pulse  is  usually  good;  and,  if  artificial  respiration  be 
promptly  performed,  the  danger  is  overcome. 

When  the  condition  occurs  in  the  later  stages,  after  deep  narcosis, 
it  is  the  result  of  too  much  anesthetic,  producing  paralysis  of  the 
medullary  centers,  and  is  a  more  dangerous  condition.  The  pupils 
suddenly  dilate  and  fail  to  respond  to  light,  and  the  conjunctival 
reflex  is  lost;  the  respirations  become  progressively  weaker  and  more 
superficial,  and  finally  stop.  The  patient  has  an  ashen-gray  look, 
lies  in  a  state  of  extreme  relaxation,  and  the  heart  ceases  to  beat  after 
a  few  seconds. 

Treatment — This  is  a  condition  requiring  prompt  and  energetic 
treatment.  The  anesthetic  and  the  operation  should  be  immediately 
stopped  and  every  effort  made  to  revive  the  patient.  It  should  be 
seen  that  there  is  no  impediment  to  the  free  entrance  of  air  into  the 
respiratory  passages,  and  then  the  foot  of  the  table  should  be  elevated 
upon  a  stool,  while  artificial  respiration  is  performed  after  the  manner 
above  described  (page  69). 

Cardiac  Paralysis. — Syncope  may  occur  during  anesthesia  from 
chloroform  or  ether,  but  is  more  apt  to  be  produced  by  the  former. 
It  is  the  most  serious  of  all  the  anesthetic  accidents.  From  the  fact 
that  a  large  proportion  of  the  deaths  from  chloroform  anesthesia 
occur  in  the  early  stages,  when  only  a  small  quantity  of  the  anesthetic 


^^*     ACCIDENTS    DURING    ANESTHESIA    AND    THEIU    TREATMENT 

has  been  given,  it  has  been  contended  that  fright,  producing  vaso- 
motor paralysis,  is  the  cause.  There  is  no  doubt  that  fright  or  strug- 
gling during  the  early  stage  of  anesthesia  is  sufficient  in  some  cases 
to  cause  dilatation  of  the  heart  and  vasomotor  paralysis,  especially 
if  the  individual  is  already  affected  with  degenerative  changes  in  the 
heart,  or  is  suffering  from  severe  anemia  or  shock.  But  fatal  syncope 
has  occurred  in  many  cases  after  only  a  few  inhalations  of  chloroform, 
when  the  patient  was  in  strong  physical  condition  and  exhibited  no 
fear  of  the  operation  whatever.  Such  cases  and  those  occurring  after 
full  anesthesia  has  been  established  can  only  be  ascribed  to  the  toxic 
action  of  the  drug  from  sudden  overdosage. 

When  circulatory  paralysis  occurs,  the  pulse  first  becomes  weak 
and  irregular,  and  then  feeble  and  fluttering;  the  skin  becomes  pal- 
lid, the  pupils  dilate  and  remain  fixed,  and  finally  the  heart  stops 
entirely.  Irregular  attempts  at  breathing  may  continue  for  a  few 
moments  after  cessation  of  the  heart-beat.  Postmortem  examina- 
tion reveals  a  heart  dilated  and  overcharged  with  blood,  and  general 
dilatation  of  the  capillaries  and  veins,  especially  in  the  abdomen, 
showing  that  the  patient  has  practically  bled  into  his  own  vessels, 
and  nearly  all  the  blood  is  withdrawn  from  the  cerebral  centers. 

Treatment. — The  treatment  of  such  a  condition  should  consist 
in  artificial  respiration  and  in  adopting  moans  to  overcome  the  cere- 
bral anemia  and  to  empty  the  engorged  heart.    In  the  presence 
of    signs  pointing   to  syncope,  the  treatment  should  be  instituted 
I>r«jmptly,  without  waiting  for  cessation  of  respiration.     The  foot  of 
the  table  should  be  immediately  elevated  to  an  angle  of  45  degrees, 
s*>     that  the  patient  is  in  an  exaggerated  Trendelenburg  position. 
Children  may  be  inverted  by  simply  holding  them  by  the  heels. 
CointMned  with  position,  compression  of  the  limbs  and  abdomen  by 
■rieaiis  of  bandages  may  be  employed  to  force  the  blood  from  the 
"ilated  capillaries  and  splanchnic  areas.     Artificial  respiration  and 
*Xygen  inhalations  should  be  employed  from  the  start,  as  already 
^•scribed.     Massage  of  the  heart  for  the  purpose  of  emptying  it  of 
Ac  engorged  blood  should  also  be  practised. 

Bxiernal  cardiac  massage  may  be  readily  carried  out  with  the 
^ml  placed  over  the  precordium  by  elevating  and  depressing  the 
"ri^t-joint  at  about  the  rate  of  the  normal  beat.  In  abdominal 
•^rations  the  heart  may  be  massaged  by  grasping  it  between  the 
tbiiml)  and  forefinger,  through  the  relaxed  diaphragm,  and  alter- 
"^lely  compressing  and  relaxing  it  twenty  to  forty  times  a  minute. 
;t  cardiac  massage  can  be  practised  through  an  incision  in  the 


72  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

fourth  intercostal  space  and  opening  the  pericardium.  This  opera- 
tion has  been  successfully  performed  in  some  seemingly  hopeless 
cases,  and  is  worthy  of  trial. 

Cardiac  stimulants,  such  as  strychnin,  are  of  little  use  until  the 
circulation  is  reestablished;  a  hypodermic  of  some  rapid  acting  drug, 
however,  as  adrenalin  chlorid,  5  to  2oTTl  (0.30  to  1.25  c.c.)  injected 
into  a  vein,  camphorated  oil,  20ITI  (1-25  c.c),  whisky,  20III  (1-25 
c.c),  etc.,  may  be  tried  with  better  chances  of  success.  An  intra- 
venous infusion  of  hot  salt  solution,  combined  with  15  to  30TII 
(i  to  2  c.c.)  of  a  I  to  1000  solution  of  adrenalin  chlorid  injected 
drop  by  drop  by  means  of  a  hypodermic  directly  into  the  rubber 
tube  of  the  infusion  apparatus  while  the  solution  is  flowing,  should 
be  given  by  an  assistant  while  the  other  means  of  treatment  are  being 
carried  out.  According  to  Crile's  experiments,  an  intraarterial  in- 
fusion of  adrenalin  in  salt  solution  injected  toward  the  heart  (see 
page  177)  has  more  effect  in  raising  blood-pressure  and  would  be  a 
more  rational  form  of  treatment.  When  there  is  no  improvement 
within  ten  or  fifteen  minutes,  the  case  is  usually  hopeless. 

THE  AFTER-EFFECTS  OF  ANESTHESIA 

Vomiting. — This  is  the  most  frequent  postanesthetic  complica- 
tion. The  best  way  to  avoid  it  is  by  careful  preparation  of  the 
patient  before  anesthesia  and  a  skilful  administration  of  the  anes- 
thetic. In  some  cases,  however,  it  occurs  in  spite  of  all  that  can  be 
done,  and  may  be  persistent.  That  from  chloroform  is  usuaUy 
more  severe  and  more  difficult  to  treat. 

For  the  ordinary  vomiting,  inhalations  of  vinegar,  ice  in  small 
quantities  by  mouth,  or  very  hot  water  in  small  doses  (teaspoonfuls) 
are  the  common  remedies.  The  latter  is  most  efficient,  serving  to 
dilute  the  mucus  and  wash  out  the  stomach  contents.  Fifteen  to 
20  gr.  (i  to  1.3  gm.)  of  bicarbonate  of  soda  in  a  glass  of  warm  water 
is  also  recommended.  Likewise  pure  olive  oil  in  ounce  doses  has 
been  successfully  employed.  Cerium  oxalate,  gr.  v  (0.3  gm.),  bis- 
muth subnitrate,  gr.  v  (0.3  gm.),  acetanilid  in  i  gr.  (0.065  gm.) 
doses  every  one-half  hour  until  8  gr.  (0.5  gm.)  have  been  taken, 
morphin,  or  small  doses  [3^2  gr-  (0.0054  gm.)]  of  cocain  every  half 
hour  up  to  I  gr.  (0.065  S^-)  ^^Y  ^^  ^^^^  ^^  ^^®  more  troublesome 
cases.  If  the  condition  becomes  persistent  and  severe,  lavage  of  the 
stomach  (see  page  547)  should  be  carried  out  and  repeated  as  often 
as  necessary.     In  fact,  it  is  the  best  means  of  preventing  vomiting 


THE    APTER-EFFECTB    OP    ANESTHESIA 


73 


in  any  case,  and  some  surgeons  employ  it  as  a  routine  while  the 
patient  is  still  on  the  operating- table  before  becoming  conscious. 

Respiratory  Complications.: — These  are  seen  more  frequently 
after  ether  than  chloroform,  and  include  edema  of  the  lungs,  bron- 
chitis, bronchopneumonia,*  and  lobar  pneumonia.  They  should  be 
Ireated  along  the  lines  ordinarily  followed  in  such  cases.  Lung  com- 
plications are  especially  liable  to  follow  anesthesia  where  a  diseased 
condition  is  already  present,  as  bronchitis,  emphysema,  or  tuber- 
culosis, or  in  the  aged  or  feeble. 

To  avoid  as  far  as  possible  such  complications,  the  mouth,  nose, 

and  teeth  should  be  carefully  cleansed  before  anesthesia,  the  appa- 

1-a.lus  employed  for  administering  the  anesthetic  should  not  be  carried 

from  one  patient  to  another  without  sterilization,  and  due  care  should 

t»^  observed  while  administering  the  anesthetic  to  prevent  aspiration 

cp.f   fluids  or  vomitus.     As  a  further  precautionary  measure,  the  pa- 

ti^snt  should  always  be  carefully  protected  against  chilling,  both  dur- 

'■"^S  the  anesthesia  and  while  he  Is  being  removed  to  his  bed. 

Renal  Complications.^ — Temporary  albuminuria  and  casts  are 
™-*^=»t  uncommon  after  both  ether  and  chloroform,  and,  if  a  diseased 
*^*^^^*"]i<!ition  of  the  kidneys  be  present  beforehand,  it  is  much  aggra- 
^^■^*-Ied,  though  of  the  two  drugs  chloroform  exerts  less  of  an  irritant 
*"*-^  tion.  Scanty  excretion  of  urine  with  actual  suppression  and  hema- 
^-*  "ria  axe  occasionally  seen.  Such  a  condition  should  be  treated  by 
'*~*-*ld  diuretics,  cathartics,  and  saline  rectal  irrigations. 

_       Postoperative  Anesthetic  Paralyses. — These  are  mostly  pe- 

•"^■-l^heral  from  pressure  upon  some  nerve  during  the  period  of  uncon- 

**-^*ou5ness,  though  paralysis  of  central  origin  may  take  place  as  the 

'*^=sult  of  cerebral  embolism  or  hemorrhage,  especially  in  those  with 

'*■*¥;''  arterial  tension  and  degenerative  changes  in  the  blood-vessels. 

•^^^ripheral  paralysis  may  affect  the  arm,  leg,  or  face.     Injury  to  the 

^**"»isculospirai  nerve  from  pressure  by  the  edge  of  the  table  if  the  arm 

*^   allowed  to  hang  down,  and  injury  to  the  brachial  plexus  from  pres- 

^^*re  between  the  clavicle  and  first  rib,  or  by  the  head  of  the  humerus 

'^hen  the  arms  are  fastened  above  the  head  are  the  most  frequent 

^^sions. 

Delayed  Poisoning. — Certain  of  the  late  deaths  occurring  after 
^•Wsthesia,  that  were  formerly  supposed  to  be  due  to  sepsis,  shock,  fat 
embolism,  etc.,  are  now  known  to  be  due  to  an  acid  intoxication, 
'^  condiUon,  variously  designated  as  cholemia,  acidosis,  aceto- 
"wia,  and  add  intoxication,  most  frequently  follows  chloroform  nar- 
k's and  is  more  common  among  children.     The  symptoms  do  not 


t 


74  THE   ADMINISTRATION    OF    GENERAL    ANESTHETICS 

app>ear  until  the  patient  has  recovered  from  the  anesthesia  develop- 
ing in  from  lo  to  150  hours  (Bevan  and  Favill). 

The  condition  is  characterized  by  persistent  vomiting,  jaundice, 
sweetish  breath,  rapid  pulse,  Cheyne-Stokes  respiration,  in  some 
cases  extreme  restlessness  and  excitability,  in  others  delirium,  con- 
vulsions, and  coma.  In  some  the  temp>erature  is  exceedingly  high, 
in  others  it  is  subnormal.  Death  in  fatal  cases  occurs  within  three 
to  five  days.  At  postmortem  there  is  found  a  condition  of  fatty 
degeneration  of  the  kidneys,  heart  muscle,  and  liver,  most  marked 
in  the  latter,  and  at  times  actual  necrosis  of  the  liver  is  seen.  This 
condition  is  the  result  of  the  destructive  action  of  chloroform  upon  the 
cells.  The  insufficiency  of  the  liver  results  in  the  accumulation  of 
toxins,  and  acetone,  diacetic  acid,  and  oxybutyric  acid  appear  in  the 
blood  and  urine  as  by-products. 

Bicarbonate  of  soda  given  by  mouth  in  mild  cases,  and  in  salt 
solution  by  rectum,  by  hypodermoclysis,  or  intravenously  in  the 
severer  ones,  is  a  most  valuable  remedy  for  this  condition.  For 
intravenous  injection  i^^  ounces  (45  gm.)  of  bicarbonate  of  soda 
is  dissolved  in  i  quart  (liter)  of  normal  salt  solution  [salt  3  ii  (8  gm.) 
to  the  quart  (1000  c.c.)  of  water],  and  ^^  pint  (250  c.c.)  is  admin- 
istered every  three  or  four  hours  until  the  entire  amount  is  injected. 
Glucose  is  also  frequently  employed.  It  may  be  given  in  doses  of 
J^  to  I  dram  (2  to  4  gm.)  to  children  and  3^  ounce  (15  gm.)  to  adults 
by  mouth,  rectum,  or  intravenously.  In  addition,  free  elimination 
by  the  skin  should  be  encouraged,  and  the  bowels  should  be  kept 
freely  open. 

THE  AFTER-TREATMENT  OF  CASES  OF  GENERAL 

ANESTHESIA 

Before  moving  a  patient  from  the  operating-table  to  his  bed,  it 
should  be  seen  that  he  is  well  protected  and  properly  wrapped  in 
warm  dry  blankets.  During  the  process  of  moving,  care  should  be 
taken  not  to  elevate  the  head  or  chest.  The  recovery  room  should  be 
well  ventilated,  but  the  patient  should  be  protected  from  any 
draughts.  The  bed  should  have  been  previously  prepared  and  well 
warmed  by  means  of  hot-water  bags,  wjiich  are  to  be  removed,  how- 
ever, when  the  patient  is  received,  unless  there  is  some  special  indi- 
cation for  their  use,  as  in  shock  or  collapse.  Hot-water  bags  should 
always  be  covered  with  flannel  and  care  should  be  taken  to  see  that 
they  are  not  hot  enough  to  burn  the  patient. 


;   AFTER-TREATMENT   OF   CASES   OF   GENERAL   ANESTHESIA     75 

The  best  position  for  the  patient  is  flat  upon  the  back,  with  the 
head  level  or  a  little  lower  than  the  body,  and  with  the  face  turned 
to  one  side.  If  vomiting  occurs,  the  patient  should  be  turned 
slightly  to  one  side  and  the  vomitus  received  in  a  basin,  after  which 
the  mouth  should  be  wiped  out.  Frequent  rinsing  of  the  mouth 
with  warm  water  may  be  practised  if  the  patient  is  conscious,  and 

I  will  be  found  to  be  very  grateful.  The  patient  should  be  watched 
by  an  attendant  until  consciousness  returns,  for,  if  left  alone,  he  may 
choke  from  mucus  or  vomited  material  collecting  in  the  throat,  or 
Attempt  to  sit  up,  remove  his  dressings,  or  in  other  ways  do  himself 
harm.  Delirious  patients  should  be  gently  restrained,  but  not  tied 
irx  bed.  Inhalations  of  oxygen  or  vinegar,  and  washing  the  patient's 
S^txie  in  cold  water,  are  of  aid  in  arousing  to  c 


— The  ether  bed. 


The  patient  should  not  be  allowed  to  sit  up  for  at  least  six  hours. 

Small  quantities  of  hot  water  or  cracked  ice  are  given  in  the  first 

'«;*  hours,  but  no  food  is  allowed  within  six  hours,  and  not  then 

^*nies5  the  patient  has  stopped  vomiting.     In  cases  of  collapse,  or 

lor  patients  who  are  very  weak,  nutrient  or  stimulating  enemata 

*ay  be  prescribed  to  sustain  the  patient  until  food  can  be  taken. 

Tlie  first  food  taken  by  mouth  should  be  liquid  in  character,  consist- 

'"?  of  broth,  beef  tea,  or  soup.     If  this  is  retained,  other  articles  of 

**t  diet  should  be  added,  until  the  ordinary  diet  is  being  taken.     It 

^  important  to  have  the  urine  examined  for  several  days  after  anes- 

'nsia,  and  after  the  use  of  chloroform  special  reference  should  be 

W  to  detecting  the  presence  of  acetone  or  diacetic  acid. 


CHAPTER  II 

LOCAL  ANESTHESIA 

By  local  anesthesia  is  understood  the  abolition  of  pain  sensation 
in  a  chosen  region,  without  the  production  of  unconsciousness. 
Analgesia  is  a  more  correct  term  to  apply  to  this  variety  of  anes- 
thesia, but  usage  has  so  perpetuated  the  term  "local  anesthesia "^ 
that  it  will  be  employed  in  these  pages. 

The  introduction  of  cocain  by  KoUer,  in  1884  first  made  possible 
local  anesthesia  as  it  is  employed  at  the  present  time,  previously,  com- 
pressiom  of  the  nerve  trunks  supplying  the  field  of  operation  by  means 
of  a  tourniquet,  and  the  application  of  cold  to  the  part,  being  the 
methods  most  frequently  resorted  to.  A  further  impetus  was 
given  to  the  development  of  local  anesthesia  by  the  discovery  that 
infiltration  with  cocain,  or  similar  local  anesthetics,  into  or  around  a 
nerve  trunk  in  any  part  of  its  course  effectually  blocked  the  sensa- 
tion in  the  region  supplied  by  that  particular  nerve  p>eripheral  to  the 
point  of  injection.  The  introduction  by  Schleich  of  the  method  of 
infiltrating  the  tissues  with  weak  anesthetic  solutions  was  another 
important  step  and  one  that  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

Through  improvement  in  the  technic  of  the  methods  of  infiltra- 
tion and  nerve  blocking  much  progress  has  been  made  in  enlarging 
the  field  of  local  anesthesia  until  it  can  now  be  employed  with  entire 
success  in  a  large  number  of  major  operations,  as  well  as  the  usual 
minor  ones.  Indeed,  it  is  safe  to  say  that  fully  half  the  operations 
performed  at  the  present  time  under  general  narcosis  could  be  as 
satisfactorily  carried  out  under  local  methods  intelligently  used. 

In  the  choice  between  local  and  general  anesthesia  for  any  given 
case,  the  question  to  be  decided  is  whether  under  local  anesthesia 
pain  sensibility  can  be  entirely  abolished  and,  at  the  same  time, 
sufficient  muscular  relaxation  be  obtained  to  insure  the  proper  per- 
formance of  the  procedures  contemplated.  If  these  conditions  can 
be  satisfactorily  obtained,  and  if  the  operator  possess  the  necessary 
ejcperience  and  skill  in  its  use,  then  local  anesthesia  should  be  offered 
to  the  patient,  if  for  no  other  reason,  simply  to  avoid  the  well-known 
unpleasant  after-effects  of  general  narcosis,  and  to  obtain  a  less  dis- 


LOCAL    ANESTHESIA  77 

turbed  and  more  rapid  recovery,  regardJess  of  whether  the  particular 
operatiun  be  classified  as  a  major  or  a  minor  one. 

Advantages  and  Disadvantages  of  I^ocal  Anesthesia.- — There  are 
certain  advantages  peculiar  to  local  anesthesia  that  should  be  care- 
fully considered  when  selecting  the  anesthetic  in  any  given  case. 
Mtwt  important  is  the  absolute  safety  to  the  life  of  the  patient  when 
this  form  of  anesthesia  is  employed  with  proper  precautions.     With 
I     the  substitution  of  the  wealt  for  the  old-time  strong  cocain  solutions, 
^^^Mthe  discoverj-  of  the  newer  less  toxic  analgesics,  together  with  a 
^^^■pirledge  of  the  amount  of  these  drugs  that  can  be  safely  used,  the 
^^Pfakgers  of  poisoning  may  be  disregarded. 

Furthermore,  under  local  anesthesia,  shock  is  lessened,  and  the 
depression  observed  after  the  use  of  general  narcosis  is  absent  to  a 
"larked  degree,  so  that  this  form  of  anesthesia  becomes  the  method 
<*'  choice  when  an  anesthetic  is  required  for  those  in  collapse  or  with 
loivered  Wtality.  This  is  especially  true  when  the  nerve-blocking 
method  is  employed,  for  it  is  well  known  that  cocain  or  drugs  with 
siinilar  anesthetic  properties  injected  into  a  nerve  effectually  blocks 
"le  passage  of  all  shock-producing  impulses  along  that  particular 
"MA'-c.  As  Crile  puts  it:  "As  no  impulses  of  any  kind  can  pass 
cither  upward  or  downward,  there  is  no  more  shock  in  dividing  the 
tissues,  even  the  nerve  trunks  thus  "blocked,"  than  in  dividing  the 
sleeve  of  the  patient's  coat."  The  value  of  this  principle  is  so  well 
fslablished  that  the  injection  of  a  local  anesthetic  into  nerve  trunks 
supplying  a  region  of  operation  is  frequently  performed  for  the  pur- 
pose ol  preventing  shock  even  where  general  anesthesia  is  employed, 
*s.  for  example,  the  preliminary  blocking  of  the  sciatic  nerve  in  hip 
'"'ipmations  and  the  preliminary  indltration  of  the  field  of  operation, 
'"«  so-called  "anoci-association"  of  Crile. 

Under  local  anesthesia  the  postoperative  blood  changes  and  the 
**<iney,  heart,  and  lung  complications  are  all  avoided,  while  the 
***lpleasant  after-effects  that  pertain  to  general  anesthesia  are  re- 
^*Jcc(i  to  a  minimum.  The  avoidance  of  vomiting  is  especially  im-  ' 
***5rtint  for  the  proper  healing  of  wounds,  and  the  prevention  of 
_  'Jch  complications  as  hernia.  A  further  advantage  in  operat- 
^^g  under  local  methods  is  that  the  most  favorable  conditions  for 
t*riinary  union  are  obtained,  for,  as  gentleness  in  handling  tissues 
*  essential  for  the  successful  employment  of  this  method  of  anes- 
*-httia^  the  minimum  amount  of  trauma  will  be  inflicted  upon  the 
•issues. 

Another  feature  connected  with  an  operation  under  local  anes- 


78  LOCAL   ANESTHESIA 

thesia  is  that  it  does  away  with  the  necessity  for  an  anesthetist,  and 
often  of  any  kind  of  an  assistant — a,  very  important  consideration 
under  some  circumstances. 

In  certain  operations — hernia,  for  example — there  is  a  distinct 
advantage  in  having  the  patient  conscious,  that  he  may  demonstrate 
the  protrusion  by  coughing.  On  the  other  hand,  in  some  cases 
consciousness  and  the  knowledge  of  what  is  going  on  is  of  distinct 
disadvantage,  and  in  nervous  or  hysterical  individuals  it  may  become 
a  contraindication,  depending  upon  the  control  the  operator  has  over 
his  patient. 

There  is  no  doubt  that  it  requires  more  time  to  oi>erate  under 
local  than  under  general  anesthesia,  and  that  it  necessitates  the  pos- 
session of  patience  and  tact  upon  the  part  of  the  oi>erator.  As 
Matas  observes,  *'it  is  this  tax  upon  the  operator's  attention,  and  the 
vigilance  required  to  keep  the  inhibitory  powers  of  the  patient  under 
control,  and  the  time  consumed  in  the  anesthetizing  procedxire  that 
will  prevent  cocain  and  the  local  analgesics  from  gaining  ascendency 
in  the  crowded  amphitheaters  of  popular  teachers  where  quick  and 
brilliant  work  is  expected  by  an  impatient  audience."  This  incon- 
venience to  which  the  operator  is  subjected,  coupled  with  the  general 
unfamiliarity  with  the  proper  technic,  probably  accounts  for  the  fact 
that  the  wide  scope  of  local  anesthesia  is  not  more  generally  taken 
advantage  of  at  the  present  time. 

Suitable  Cases. — Besides  the  minor  surgical  procedures,  such  as 
the  incision  of  an  abscess,  exploratory  puncture,  removing  small 
cysts,  amputating  toes  or  fingers,  i>erforming  circumcisions,  etc- 
major  operations  of  any  magnitude  and  extent  may  be  j>erformed, 
provided  the  region  is  capable  of  being  anesthetized  by  infiltration 
or  nerve  blocking. 

For  the  removal  of  practically  all  benign  growths  such  as  lipo- 
mata,  wens,  cysts,  benign  tumors  of  the  breast,  and  for  the  removal  of 
superficial  isolated  glands,  local  anesthesia  is  quite  sufficient.  Whe- 
ther tuberculous  glands  of  the  neck  should  be  attempted  under 
local  anesthesia  will  depend  upon  their  extent.  If  we  can  be  sure 
there  are  but  one  or  two  superficial  glands,  it  may  be  readily  done, 
but  in  the  writer's  opinion  it  is  rarely  possible  to  define  the  extent  of 
these  operations  beforehand,  and  it  is  not  an  uncommon  experience 
in  apparently  simple  cases  when  the  field  of  operation  is  thoroughly 
exposed  to  find  a  chain  of  matted  glands  requiring  deep  and  wide 
dissection  for  their  removal.  For  the  same  reasons,  and  because  the 
limits  of  the  disease  are  not  well  defined  when  the  tissues  are  swollen 


LOCAL   ANESTHESIA 


79 


by  the  infiltrated  fluid  local  anesthesia  is  not  as  a  rule  suitable  for 
the  removal  of  malignant  growths. 

Amputations  of  any  of  the  limbs  may  be  performed  if  the  large 
sensory  nerves  are  properly  blocked.  By  means  of  a  preliminary  co- 
cunization  of  the  sciatic  and  anterior  crural  nerves,  amputation  of 
lie  leg  has  been  often  painlessly  performed  when  a  general  anesthetic 
Was  contraindicated.  The  same  principle  applies  to  amputations  of 
other  limbs. 

Many  of  the  operations  upon  the  superficial  bones,  such  as  wiring 
and  plating  fractures  and  rib  resections,  may  be  painlessly  performed 
if  the  periosteum  as  well  as  the  more  superficial  tissues  are  rendered 
insensible  by  proper  infiltration.  Thus  fractures  of  the  lower  jaw, 
the  davicle,  the  olecranon,  and  the  patella  can  readily  be  operated 
tijxm  by  local  methods.  The  latter  operation  lends  itself  especially 
to  local  anesthesia  on  account  of  the  superficial  position  of  the  bone 
i«»<l  the  scarcity  of  sensory  nerves  in  that  region. 

For  the  majority  of  abdominal  operations  local  anesthesia  is  not 

sa-tis(actory.     It  Is  not  that  there  is  any  diiiiculty  in  entering  the 

a-Vxlominal  cavity — this  can  be  very  readily  done  under  careful  in- 

6J  traljon  of  the  various  layers  of  the  abdominal  wall — ^but  the  trouble . 

is    in  meeting  the  various  complications  that  may  be  present.     We 

tn«w  that  the  abdominal  organs  are  insensible  to  pain,  but  the 

parietal  peritoneum  is  most  sensitive,  especially  if  inflamed.     The 

separation  of  adhesions  and  procedures  that  require  dragging  upon 

the  mesentery   are  likewise   painful.     Exploratory  operations  and 

procedures,    such   as  colostomy,   gastrostomy,   gastrotomy,   simple 

dramage   of   the   gall-bladder  and  appendiceal  abscess,  suprapubic 

cystotomy,   suture  of  the  intestines  following  typhoid  perforation, 

M>pendicostomy,  and  jonte  interval  operations  for  appendicitis,  requir- 

"ig  but  little  intraabdominal  manipulation,  can  be  readily  performed 

without  a  general  anesthetic;  but  when  extensive  manipulation  is 

'''quired,  with  theseparationof  adhesions  necessitating  more  or  less 

lulling  upon  the  mesentery,  local  anesthesia  is  contraindicated. 

'Utihermure,  in  abdominal  surgery  complete  muscular  relaxation 

Is  usually  required  to  secure  the  necessary  wide  retraction,  and  this 

'^aot  always  be  obtained  under  local  anesthesia. 

Local  anesthesia  is  ideal  in  the  operation  for  inguinal  hernia  on 
^o\iM  of  the  superficial  location  of  the  structures  involved  and  the 
'•'iuiitc  position  and  course  of  the  sensory  nerve  trunks  supplying  the 
'*pun  of  operation.  Other  forms  of  hernia  may  be  operated  upon 
■^y  employing  infiltration  alone,  but  not  with  the  entire  satisfaction 


i 


8o  LOCAL  ANESTHESU. 

obtained  in  the  inguinal  variety.  For  strangulated  hernia  of  any 
variety,  local  anesthesia  should  always  be  the  choice.  The  addi- 
tional strain  of  general  anesthesia  upon  these  patients,  already  toxic, 
frequently  produces  more  depression  than  they  can  withstand,  and, 
as  there  is  no  need  for  haste,  abundance  of  time  may  be  taken  in 
attempts  at  restoration  of  gut  of  doubtful  vitality,  without  adding 
a  particle  to  the  shock  of  the  operation. 

Tracheotomy,  thyroidectomy,  the  ligation  of  blood-vessels,  the 
repair  of  the  perineum  and  cervix,  and  any  of  the  operations  about 
the  scrotum,  as  those  for  castration,  varicocele,  or  hydrocele,  are 
all  amenable  to  local  anesthesia.  Quite  extensive  operations  about 
the  rectum  have  been  performed  by  some  op>erators  imder  local 
anesthesia,  but  for  most  of  the  work  in  this  region  thorough  stretch- 
ing of  the  sphincter  ani  is  essential,  and  this  cannot  be  p)erformed 
painlessly  by  this  method;  for  this  reason  it  is  unsuitable  in  the 
majority  of  cases.  However,  simple  op>erative  procedures,  such  as 
those  for  fissure,  external  and  thrombotic  hemorrhoids,  and  straight 
imcomplicated  fistulae  are  within  the  scop>e  of  local  anesthesia. 

By  a  skilful  use  of  local  anesthesia  in  the  hands  of  one  thoroughly 
familiar  with  the  technic  of  infiltration  and  nerve  blocking,  this  list 
may  be  considerably  enlarged.  Furthermore,  it  should  not  he 
forgotten  that  in  many  operations  too  painful  for  local  anesthesia 
alone,  the  major  portion  of  the  operation  may  be  performed  under 
local  methods,  and  then  nitrous  oxid  gas  or  a  small  quantity  of  ether 
may  be  administered  to  tide  the  patient  over  the  more  painful  pro- 
cedures, thus  avoiding  a  prolonged  general  narcosis. 

Those  cases  in  which  local  anesthesia  is  impracticable  have  been 
aheady  indicated  in  a  general  way.  In  addition,  for  young  children, 
for  those  who  are  greatly  excited  or  hysterical,  and  for  insane  or 
delirious  individuals,  local  anesthesia  is  generally  contraindicated 
or  at  best*  it  is  very  unsatisfactory  on  accoimt  of  the  difiiculty  of 
obtaining  the  necessary  quietude. 

Methods  of  Producing  Local  Anesthesia. — ^At  the  present  time 
two  classes  of  local  anesthetics  are  recognized:  (i)  Agents  which 
freeze  the  tissues,  and  (2)  chemical  anesthetics  or  analgesics,  of 
which  cocain  is  a  type.  Freezing  of  the  tissues  has  a  very  limited 
field  of  usefulness — practically  none  in  major  surgery — and  it  is 
upon  some  of  the  analgesic  agents  that  we  have  to  rely  largely. 

The  methods  of  employing  anesthetics  may  be  in  turn  divided 
into  two:  (i)  Where  the  drug  is  used  in  such  a  way  that  the  endings 
of  the  sensory  nerves  are  paralyzed  (terminal  anesthesia);  and  (2) 


LOCAL   ANESTHESLA  8 1 

where  the  drug  is  brought  in  contact  with  a  nerve  tnmk  in  some 
part  of  its  course,  thereby  blocking  the  sensory  conductivity  of  thdt 
particular  nerve  and  rendering  the  area  supplied  by  it  devoid  of 
sensation  (regional  anesthesia).  To  the  first  class  belong  the  topical 
application  of  analgesic  drugs  to  mucous  membranes,  and  their 
injection  into  the  tissues  (infiltration  anesthesia),  though  by  this 
latter  method  a  mixture  of  terminal  and  regional  anesthesia  is  often 
produced;  while  regional  anesthesia  may  be  produced  by  the  injec- 
tion of  analgesics  into  a  nerve  trunk  (endoneural  infiltration),  about 
a  nerve  tnmk  (perineural  infiltration),  into  the  subarachnoid  space 
(spinal  anesthesia),  or  into  the  extradural  space.  Another  method 
of  producing  local  anesthesia,  termed  venous  anesthesia,  has  lately 
been  introduced  by  Bier,  whereby  the  analgesic  agent  is  injected 
into  the  venous  system  and  is  thus  brought  in  contact  with  the  nerve 
tninks  and  nerve  endings.  This  is  a  combination  of  the  terminal 
and  regional  methods  of  anesthesia. 

Drugs   Employed  for  Local  Anesthesia. — Of  the  many  local 
anesthetics  cocain  was  the  first  employed  and,  being  the  most  power- 
ful of  all  local  anesthetics,  holds  the  most  important  place.     In  the 
early  history  of  its  development  cocain  was  used  in  solutions  as 
strong  as  lo  and  15  per  cent.,  with  the  result  that  frequently  a  set  of 
dangerous  symptoms,  and  in  some  cases  death,  were  the  sequels. 
To  avoid  these  untoward  effects  a  number  of  drugs,  as  eucain  B, 
tropacocain,  stovain,   alypin,  novocain   (procain),  acoin,  nirvanin, 
orthoform,  anesthesin,  subcutin,  propasin,  quinin  and  urea  hydro- 
chlorid,  etc.,  which  are  less  toxic,  but  have  in  varying  degrees  the 
same  action  as  cocain ,  have  been  introduced  as  substitutes.     Of  these 
eucain  B.,  procain  (novocain),  and  quinin  and  urea  are  probably 
most  frequently  used. 

Cocain. — When  applied  to  the  unbroken  skin  it  is  without 
effect,  but  in  contact  with  mucous  membranes  it  completely  deadens 
sensibility  within  a  few  moments.  Injected  into  the  tissues,  cocain 
produces  anesthesia  within  the  area  of  contact;  when  injected  into 
or  about  a  sensory  nerve,  it  is  rapidly  absorbed  and  produces  com- 
plete insensibility  in  the  whole  distribution  of  the  nerve  peripheral  to 
the  point  of  injection. 

Solutions  of  cocain  should  always  be  freshly  prepared  at  the  time 
of  operation,  as  it  is  well  known  that  they  are  prone  to  decompose, 
^d  in  a  short  time  become  capable  of  producing  suppuration.  A 
iJiedium  isotonic  with  the  fluids  of  the  body,  as  normal  salt  solution, 
IS  the  best  for  dissolving  the  cocain.     Such  a  solution,  producing 

6 


82  LOCAL   ANESTHESIA 

neither  swelling  of  the  tissues,  as  water  does,  nor  shrinkage  of  the 
cells,  as  is  the  case  with  the  more  concentrated  saline  solutions,  has 
no  injurious  effects  upon  the  tissues.  The  effectiveness  of  the 
solution  is  also  increased  by  using  it  warm. 

As  solutions  of  cocain  will  not  stand  prolonged  boiling,  the  salt  or 
tablet  should  be  previously  sterilized  by  dry  heat.  An  efficient 
method  is  to  place  the  cocain  in  a  small  test-tube  plugged  with  cotton, 
and  then  to  sterilize  it  by  means  of  dry  heat  at  a  temperature  of  300** 
F.  for  fifteen  minutes.  Several  firms^  prepare  hermetically  sealed 
glass  tubes  of  sterilized  salt  and  cocain  according  to  Bodine's  for- 
mula, each  tube  containing  2%  gr.  (0.18  gm.)  of  sodium  chloridand 
I  gr.  (0.065  gm.)  of  cocain  muriate.  The  contents  of  one  of  these 
tubes  dissolved  in  an  ounce  (30  c.c.)  of  sterile  water  gives  approxi- 
mately a  I  to  500  solution  of  cocain  in  normal  salt  solution.  Alkalis 
render  cocain  inert.  For  this  reason  soda  should  not  be  put  in  the 
water  in  which  the  syringes,  needles,  and  solution  glasses  are  boiled. 

Solutions  of  cocain  used  in  the  following  strength  will  be  found 
amply  strong  for  the  purj>ose  for  which  they  are  recommended,  Yqi[ 
anesthetizing  the  skin  and  for  perineural  injections,  a  i  to  500  (J^^ 
of  I  per  cent.)  solution;  for  deeper  infiltration,  a  i  to  1000  (J^o  ^^ 

1  per  cent.)  solution;  for  massive  infiltration,  a  i  to  3000  (^0  of  i 
per  cent.)  solution;  and  for  endoneural  injections,  10  to  30III  (0.6  to 

2  c.c.)  of  a  I  to  200  {\^  of  I  per  cent.)  solution  are  employed- 
Schleich  has  three  solutions  containing  a  combination  of  cocaixrm 
morphin,  and  sodium  chlorid: 

Xo.  I,  strong        Xo.  2,  medium    ,      Xo.  3,  weak 


\  I  .  . 

Cocain  hydrochlorate gr.  3  (0.2  gm.)         gr.  i3»2  (01  gm.)     gr.  V^  (o.oi  gm.    ■* 

Morphin  hydrochlorate gr.  H  (o-02  gm.)    gr.  yi  (0.02  gm.)     gr.      Vfj     (0.00^ 

'  gm.) 

Chlorid  of  sodium gr.  3  (0.2  gm.)         gr.  3  (0.2  gm.)       |  gr.  3  (0.2  gm.) 

Distilled  sterilized  water oz.  33*3  (100  c.c.)    oz.  ^^i  (100  cc.)    oz.  3}-^  (100  c.c.  T 


The  strong  solution  is  used  for  the  skin,  perineural  injections- 
etc.  An  ounce  (30  c.c.)  may  be  used  without  risk.  Of  the  mediun^ 
strength  solution,  used  for  ordinary  infiltration  of  the  tissues  belovT 
the  skin,  2  ounces  (60  c.c.)  may  be  used;  while  as  much  as  10  ounces 
(300  c.c.)  of  the  weaker  solution,  which  is  employed  for  massive- 
infiltration  of  large  areas,  may  be  safely  injected.     Tablets  according 

*  Park,  Davis  &  Co.,  and  Squibbs. 


LOCAL  ANESTHESIA  '      83 

to  the  Schleich  formulae  may  be  obtained  from  most  pharmacists, 
■with  full  directions  for  the  preparation  of  a  solution  of  any  given 
strength.  Schleich's  solutions  find  favor  with  many  operators,  but 
personally  the  writer  prefers  to  administer  the  morphin  separately 
in  a  definite  dose  by  hypodermic  half  an  hour  before  operation. 

The  addition  of  adrenalin  chlorid  to  the  cocain  solution,  as 
advocated  by  Braun,  is  of  distinct  advantage.  Adrenalin  is  a  vaso- 
constrictor and  has  the  same  effect  in  the  way  of  an  adjunct  to  local 
anesthesia  as  constriction  of  the  part  has,  increasing  as  well  as  pro- 
lon^g  the  anesthetic  efltects  to  a  marked  degree.  At  the  same  time, 
by  preventing  capillary  oozing,  it  gives  a  much  drier  field  of  opera- 
tion. With  its  use  there  is  some  danger  of  secondary  hemorrhage 
i£  the  large  blood-vessels  are  not  properly  secured,  since,  owing  to  its 
stj-ptic  action,  even  arteries  of  some  size  may  be  prevented  from 
bleeding  at  the  time  and  so  be  overlooked.  It  is  a  good  rule,  there- 
fore, to  at  least  clamp  any  vessel  that  bleeds,  however,  slightly,  when 
losing  adrenalin.  From  5  to  10  minims  (0,3  to  0.6  c.c)  of  the  i 
to  1000  solution  of  adrenalin  chlorid  is  added  to  the  cocain  and  salt 
solution  before  it  is  to  be  used. 

The  high  toxicity  of  cocain  has  already  been  referred  to.  This 
toanc  action  is  due  to  the  absorption  of  more  of  the  drug  than  the 
tissues  can  take  care  of.  The  amount  of  the  drug  that  can  be 
•^^Jected  into  the  tissues  with  safety  depends  upon  the  strength  of 
ti*e  solution  as  well  as  the  method  of  injection.  To  be  well  within 
'he  limits  of  safety,  not  more  than  -f^  gr.  (0.0486  gm.)  of  cocain 
sJiodd  be  allowed  to  remain  unconfined  in  the  tissues,  nor  should 
'***4  amount  be  exceeded  when  applied  to  mucous  membranes  from 
""hich  rapid  absorption  takes  place.  With  the  weaker  cocain  solu- 
^**lia  (0.2  to  o.  I  per  cent,)  it  is  rarely  necessary  to  exceed  this  amount, 
*"*'*ii  in  extensive  operations.  Of  course,  when  a  large  proportion  of 
^'**  solution  escapes,  or  when  the  circulation  is  impeded  by  constric- 
^*Mi,  a  larger  amount  may  be  used  with  safety. 

fi-Eucaiu.^ — Eucain  was  one  of  the  first  substitutes  for  cocain. 
*t  isclaimed  to  be  one-fourth  as  toxic  as  cocain;  on  the  other  hand  the 
***sthetic  effect  is  slower  and  less  pronounced.  It  has  the  advan- 
**Eeover  cocain  that  its  solutions  may  be  boiled.  Eucain  is  a  vaso- 
^tor  and  the  addition  of  adrenalin  to  its  solutions  has  not  nearly 
**  pronounced  an  effect  as  when  added  to  cocain.  The  drug  is 
Efierally  used  in  3-^  per  cent,  solution  with  adrenalin. 

Cocain.' — Procain,  one  of  the  more  recent  and  at  the  present 
'untthe  most  popular  substitute  for  cocain,  was  introduced  in  1905 


84 


LOCAL   ANESTHESIA 


under  the  trade-name  "novocain/'  It  is  estimated  to  be  one-sixth 
to  one-seventh  as  toxic  as  cocain,  thus  permitting  the  use  of  fairly 
large  quantities  without  danger.  It  is  non-irritating  to  the  tissues 
and  is  not  a  vaso-dilator.  Like  eucain,  its  solutions  are  not  affected 
by  boiling.  It  is  precipitated  from  solution  by  free  or  carbonated 
alkalis,  so  syringes,  needles,  etc.,  should  be  boiled  in  pure  water. 
Used  in  conjunction  with  adrenalin  its  anesthetic  powers  are  about 
equal  to  cocain  when  injected  into  the  tissues,  but  is  somewhat 
slower  in  its  action.  As  a  local  anesthetic  for  mucous  surfaces  it  is 
far  inferior  to  cocain,  and  has  never  become  popular  in  nose  and 
throat  work.  Solutions  of  this  drug,  like  those  of  cocain  should  be 
isotonic  with  the  body  fluids  and  freshly  prepared. 
Braun  employs  four  novocain  solutions: 


No.  I 


No.  II 


No.  Ill 


No.  IV 


Novocain 

Normal  salt  solution 
Adrenalin 

i-iooo  or 
Homorenon 

4  per  cent. 


3^48^-  (0-25  gm.) 
SH  OS*  (lOO  c.c.) 

5  drops 


3H  gf-  (0-25  gm.) 
iHoz.  (so  c.c.) 

S  drops 


iH  gr.  (o.i  gm.) 
2>i  dr.  (lo  c.c.) 

S  drops 


iHsr,  (o.igm.) 
iJ4  dr.  (s  c.c) 


lo  drops 


No.  IV  is  employed  only  for  injecting  large  thick  nerves. 

Procain  is  supplied  in  tablet  form  and  in  strengths  corresponding^ 
to  the  above. 

Quinin  and  Urea  Hydrochlorid. — This  combination  was  intro-^ 
duced  into  surgery  in  1907.  So  far  as  known,  it  has  no  toxic  effects^ 
and  the  anesthesia  produced  by  it  is  a  protracted  one,  often  las  in^S 
four  or  five  days.  In  its  early  use  solutions  of  i  per  cent,  were  em- 
ployed, but  it  was  found  they  produced  an  exudate  of  fibrin  that::^ 
sometimes  interfered  with  wound  healing,  so  that  at  the  present::^ 
time  the  drug  is  employed  in  ^-^  to  3^  p)er  cent,  solutions.  Upon-J 
mucous  membranes,  solutions  of  10  to  20  per  cent,  may  be  used. 
It,  however,  does  not  produce  a  shrinkage  of  the  tissues  as  cocain  does  - 
and  for  this  reason  is  inferior  to  it  in  nasal  work. 

Preparation  of  the  Patient — The  usual  preparation  of  the  bowels, 
etc.,  recommended  as  preliminary  to  general  anesthesia,  is  advisable. 
There  is  no  need  for  the  patient  to  fast,  however,  and  a  light  meal  of 
eggs,  coffee,  milk,  toast,  etc.,  may  be  allowed,  unless  the  character 
of  the  op>eration  contraindicates  it.  If  it  seems  probable  that  a 
general  anesthetic  will  be  required  to  complete  the  operation,  the 
patient's  stomach  should,  of  course,  be  empty,  and  the  same  pre- 


LOCAL   ANESTHESIA  8$ 

cautions  should  be  taken  as  for  general  anesthesia  (see  page  i8). 
Apprehensive  anticipation  on  the  part  of  the  patient  should  be  pre- 
vented as  far  as  possible  by  reassurances  and  by  a  good  night's  sleep 
before  the  opeiation. 

Preliminary  medication  with  morphin  is  advisable  in  all  cases, 
where  the  operation  is  to  be  at  all  extensive,  unless  some  distinct 
contraindication  to  its  use  exists.  It  serves  a  threefold  purpose:  it 
aDajTs  nervousness  on  the  part  of  the  patient  and  thus  removes  the 
psychic  element;  it  somewhat  deadens  sensibility;  and  it  is  the 
physiological  antidote  for  cocain  poisoning.  It  may  be  given  hy- 
podermicaUy  in  the  dose  of  J-e  to  J^  gr.  (0.0108  to  0.0162  gm.)  a 
Julf  hour  before  operation.  In  some  cases,  where  the  patient  is 
especially  nervous  or  unusual  difficulties  are  expected,  morphin 
^  gr.  (0.0162  gm.)  combined  with  '500  gr-  (0.00065  g'"-)  of  hyoscin 
may  be  administered  hypodermically  two  hours  before  operation. 

The  Conduction  of  the  Operation. — The  successful  and  satisfac- 
torj-  employment  of  local  anesthesia  depends  upon  an  intelh'gent 
appreciation  of  its  b'mitations,  upon  the  experience  and  skill  of  the 
operator,  and  upon  an  accurate  knowledge  of  the  sensory  nerve  supply 
in  any  given  region.  These  arc  essential.  Much  also  depends  upon 
*he  temperament  of  the  operator  and  upon  his  method  of  operating. 
I^or  this  reason,  with  some  operators,  the  use  of  local  anesthesia  will 
"C  impossible;  with  others,  it  will  necessitate  a  radical  change  in  their 
**P«rative  technic,  A  nervous  fidgety  operator,  in  a  hurry  to  get 
trough  his  work,  will  never  lind  much  to  encourage  him  in  attempts 
*o  employ  local  anesthesia  in  major  surgery. 

It  is  important,  in  the  first  place,  to  make  the  patient  as  comfort- 

*ole  as  possible  upon  the  operating- table.     Operations  under  local 

^•lesthesia  consume  considerable  time,  and  it  is  a  hardship  to  keep  a 

Conscious  patient  upon  the  ordinary  hard-topped  operating-table  for 

***hour  or  more.     Several  thicknesses  of  blanket,  an  air  mattress,  or 

*  layer  of  soft  pillows  placed  upon  the  table,  will  add  much  to  the 

I'^tieiit's  comfort,  as  well  as  to  the  peace  of  mind  of  the  operator. 

*« patient  should  always  be  recumbent,  and  a  comfortable,  relaxed 

*WtU(le  should  he  assumed,  with  the  arms  folded  over  the  chest  or 

^*3speU  above  the  head.     Wliile  washing  the  patient  in  preparation 

*oi  the  operation,  it  should  be  borne  in  mind  that  he  is  conscious 

*"<!  great   gentleness   should   be   employed  in  the  process.     Care 

should  also  be  taken  not  to  soak  the  patient  with  large  quantities  of 

*^«tion  and  leave  him  lying  in  a  chilly  pool  for  the  remainder  of  the 

"Pttition. 


86  LOCAL   AXESTHESL4 

Viith  very  ner\'ous  iiidi\'iduals.  it  is  well  to  keep  the  instruments 
covered  from  \iew  and  to  avoid  all  reference  to  knives,  scissors,  etc. 
In  fact,  strict  silence  should  be  enjoined  upon  all.    The  patient's 
mental  attitude  can  be  further  influenced  to  advantage  by  observing 
a  quiet  demeanor  in  the  operating-room,  by  the  avoidance  of  haste, 
and  by  a  most  careful  handling  of  the  tissues.     Clean-cut  dissection 
only  is  allowable  in  operations  imder  local  anesthesia.     Rough  ma- 
nipulations, or  tearing  of  the  tissues,  or  unnecessary  pulling  with 
retractors  by  an  awkward  assistant  causes  pain  by  dragging  upon 
structures  outside  the  anesthetized  area  and  is  often  sufficient  to 
cause  restlessness  and  apprehension  on  the  part  of  the  patient,  a 
state  of  mind  which,  if  produced  in  the  early  part  of  an  operation, 
rapidly  changes  to  complete  demoralization,  necessitating  the  use 
of  a  general  anesthetic  for  completion  of  the  operation.    Rough 
wiping  of  the  woimd  is  like\iTse  to  be  avoided.     In  fact,  in  every 
move  and  step  the  aim  of  the  operator  should  be  extreme  gentleness- 
Neglect  in  observing  these  small  and  apparently  tri\'ial  details 
resix>nsible  for  many  of  the  failures  with  local  anesthesia,  and  oft^^*^ 
results  in  condemnation  of  the  method,  though  the  fault  lies  wi 
the  operator. 

THE  PRODUCTION  OF  LOCAL  ANESTHESIA  BY  COLD 

The  anesthetic  properties  of  intense  cold  have  long  been  recc^ 
nized  and  utilized  in  minor  surgerj'.     The  tissues  may  readily 
frozen  sufficiently  for  anesthetic  purposes  by  the  application  of 

and  ice,  or  by  spraying  the  part  wi 

( jf^-^"^-"'  ^'-TT!]'^     some  rapidly  evaporating  chemica.— -^ 
h/^  ■    '  ■  i  '  ~m    'w^it^^Lr      such   as   ether,    rhigoline,    or   eth>-^ 
V^^  chlorid.    The  tissues  as  a  result 

Yiv..  42.— Kthyl  chlorid  spray  tube,     come  first  red  and  then  blanch 

and  a  superficial  anesthesia  is  pro- 
duced, which  persists  but  a  few  minutes.    This  form  of  anesthesi^^ 
has  a  very  j^mall  field  of  usefulness,  and  is  only  suitable  for  smal^ 
incisions  or  punctures;  even  in  these  cases  the  method  is  open  to^ 
the  objection  that  the  tissues  become  so  hard  that  it  is  difficult  to-^ 
cut  through  them  at  times,  and  any  dissection  is  out  of  the  ques- 
tion.    Furthermore,  the  thawing  out  process  is  attended  with  more 
or  less  pain.     Freezing  often  lowers  the  vitality  of  the  tissues  to 
such  an  extent  that  sloughing  results;  especially  is  this  so  when  ap- 
plied to  the  tissues  of  poorly  nourished  individuals. 


THE    SURFACE   APPLICATION   OF   ANESTHETIC   DRUGS  87 

Ethyl  chlorid  is  now  used  almost  exclusively  for  the  purpose  of 
freezing,  and  is  both  quick  and  effective.     It  is  obtained  in  glass 
tubes  with  one  end  drawn  out  to  a  fine  point  and  furnished  with  a 
spring  tip  (Fig.  42)  or  with  a  screw  cap.    The  method  of  applica- 
tion is  extremely  simple.    The  tube  is  uncovered  and  held  inverted 
in  the  hand  at  a  distance  of  12  to  18  inches  (30  to  45  cm.)  from  the 
surface  of  the  skin.    Under  the  heating  influence  of  the  hand  the 
liquid  is  forced  out  of  the  container  upon  the  tissue  in  a  fine  jet  or 
spray.     Rapid  evaporation  occurs,  and,  in  about  thirty  seconds,  the 
skin  becomes  white  and  sufficiently  frozen  to  be  devoid  of  sensation. 

THE  SURFACE  APPLICATION  OF  ANESTHETIC  DRUGS 

Cocain  and  other  drugs  with  similar  anesthetic  action  may  be 

applied  to  mucous  surfaces  (i)  by  instillation,  as  in  the  eyes,  bladder, 

urethra,  etc. ;  (2)  by  means  of  a  spray  or  atomizer,  as  in  the  mouth  or 

iiose;  and  (3)  upon  swabs  or  compresses,  either  in  solution  or  in 

crystals.     Only  the  surface  of  the  mucous  membranes  is  anesthetized 

in    this  way,  but  a  number  of  operations  not  involving  the  deeper 

tissxies,  such  as  the  removal  of  polypi  or  small  tumors,  and  opening 

of  infections  may  thus  be  p>erformed. 

For  op>erations  about  the  eye,  a  drop  or  two  of  a  2  to  4  per  cent, 
solution  of  cocain  is  instilled  into  the  eye  every  ten  minutes  until 
tlir^e  or  four  drops  have  been  given. 

Xocal  anesthesia  of  the  nasal  mucous  membrane  may  be  pro- 
dixoed  by  applying  a  4  per  cent,  solution  of  cocain  upon  swabs  of 
cotton  directly  to  the  part  to  be  anesthetized.     Spraying  is  not 
so   desirable,  as  the  solution  is  liable  to  run  down  into  the  pharynx 
tlirough  the  posterior  nares  and  produce  a  very  unpleasant  sensa- 
tion in  the  throat,  and,  at  the  same  time,  the  amount  of  solution 
necessary  to  produce  anesthesia  being  larger,  the  danger  of  poisoning 
is  greater.     To  increase  the  effectiveness  of  the  cocain  and  obtain  a 
bloodless  field  of  operation,  a  spray  of  a  i  to  1000  adrenalin  solution 
n^y  be  employed  after  the  cocainization. 

In  the  larynx  cocain  may  be  applied  more  freely  without  danger 
^ban  is  the  case  when  it  is  applied  to  the  nasal  mucous  membrane. 
Small  quantities  of  a  10  per  cent,  solution  may  be  applied  by  means 
of  a  spray,  or,  better,  applied  directly  to  the  desired  spot  on  a  swab, 
with  the  aid  of  a  laryngeal  mirror. 

The  anterior  urethra  may  be  sufficiently  anesthetized  by  filling  it 
^th  a  0.2  per  cent,  cocain  and  adrenalin  solution,  introduced  by 


88  LOCAL  ANESTHESLA 

means  of  a  urethral  syringe.  The  solution  should  be  confined  in  the 
urethra  for  at  least  fifteen  minutes,  by  holding  the  meatus  closed. 
The  posterior  urethra  may  be  anesthetized  by  instilling  into  it  a  few 
drops  of  a  I  p>er  cent,  cocain  and  adrenalin  solution  or  a  2  per  cent 
procain  adrenalin  solution  by  means  of  an  instillation  syringe  or 
through  a  soft  rubber  catheter. 

For  the  bladder,  a  o.i  per  cent,  cocain  and  adrenalin  solutionis 
sufficient.  Five  ounces  (i  50  c.c.)  of  such  a  solution  to  which  is  added 
twenty  drops  (1.25  c.c.)  of  adrenalin  is  slowly  introduced  warm  by 
means  of  a  catheter,  the  bladder  having  been  previously  irrigated. 
The  operator  should  then  wait  fifteen  to  twenty  minutes  for  the  drug 
to  take  effect. 

INFILTRATION  ANESTHESIA 

Infiltration  anesthesia  was  devised  by  Schleich  after  a  series  of 
careful  experiments  with  salt  solutions  of  different  strengths,  com- 
bined with  minute  quantities  of  morphin,  cocain,  and  carbolic  add. 
From  his  work  has  been  evolved  the  weak  cocain  solution,  as  used  at 
the  present  time,  which  has  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

By  infiltration  is  meant  the  production  of  analgesia  in  a  part  by 
edematization  of  the  tissues  with  weak  anesthetic  solutions.  The 
fluid  is  introduced  into  the  tissues,  carefully  avoiding  important  vas- 
cular structures,  without  particular  reference  to  the  nerve  tnmks. 
The  resulting  anesthesia  is  partly  due  to  the  direct  action  of  the  drug 
upon  the  nerve  endings,  partly  to  the  pressure  of  the  fluid,  and  also  to 
the  interference  with  the  blood  supply.  The  anesthesia  may  be  in- 
creased and  indefijiitely  prolonged  if  the  circulation  be  kept  station- 
ary by  some  form  of  constriction  applied  to  the  part,  centrally  to  the 
seat  of  injection,  or  by  incorporating  in  the  fluid  infiltrated  vaso- 
constrictor drugs  like  adrenalin.  With  the  infiltration  method  of 
anesthesia  it  is  necessary  to  thoroughly  edematize  or  literally  pack 
the  tissues  with  the  anesthetic  fluid,  for,  without  this,  the  weak  solu- 
tion employed  would  be  worthless. 

Apparatus. — For  the  purposes  of  ordinary  infiltration  the  6oTIl 
(4  c.c.)  or  the  10  c.c.  (2}^  dram)  sub-Q  syringe  is  very  satisfactory. 
This  syringe  has  a  solid  glass  barrel  and  glass  piston  with  asbestos 
packing,  and  can  be  readily  sterilized,  and  is  cheap.  Several  of  these 
syringes  should  be  on  hand  for  the  op)eration,  and  are  to  be  kept  filled 
in  readiness,  so  that  the  infiltration  may  be  carried  on  rapidly  without 
waiting  to  recharge  the  same  syringe.     The  needles  should  be  sharp 


INPILTBATION   ANESTHESIA  89 

and  &De,  with  a  very  short  bevel,  and  they  should  fit  the  syringe  with- 
out any  leakage  at  the  joinL  It  will  be  convenient  to  have  a  short 
needle,  i  inch  (2.5  cm.)  long,  for  skin  infiltration,  and  a  second  one, 
2  to  a>^  inches  (5  to  6  cm.)  long,  for  infiltration  of  the  deeper 
tissues. 


Fic  43. — Apparatus  for  infiltration. — i,  Medicine  glasses  far  cocain  solutions; 
1,  ampule  of  sterile  cocain  and  salt  crystals;  3,  dropper  for  adrenalin;  4,  syringe  armed 
with  a  short  needle;  5,  long  fine  needle  for  deep  infiltration. 

For  massive  infiltration  a  large  syringe  or  a  special  apparatus 
which  will  allow  a  continuous  and  rapid  infiltration  of  the  tissues  is 
more  satisfactory.  The  Matas  infiltrator  (Fig.  44)  consists  of  a 
heavy  glass  graduated  receptacle  for  the  solution  with  an  air-tight 
screw  cap.     Into  this  cap  is  fitted  a  T-tube  with  two  stopcocks,  one 


Fig.  44.     The  Matas 


for  the  introduction  of  air,  and  one  for  the  escape  of  the  fluid.  A 
rubber  inflating  apparatus  is  attached  to  the  first  cock,  and  to  the 
other  is  a  needle  connected  by  a  suitable  length  of  hose.  The  reser- 
voir is  filled  about  three-fourths  full  and  is  then  charged  with  air, 
and  the  bulb  and  tubing  are  removed.    Infiltration  is  performed  by 


90 


LOCAL  ANESTHESLA. 


inverting  the  apparatus  and  opening  the  outflow  stopcock.  Several 
needles  of  different  lengths,  shapes,  and  sizes  are  provided  with  this 
instrument.  The  author  uses  an  infiltrator  made  on  much  the  same 
principles  as  the  Matas  instrument.  It  consists  of  a  long  graduated 
glass  cylinder  capable  of  holding  lo  ounces  (300  c.c),  with  an  outlet 
at  the  bottom  and  a  rubber  stopper  fastened  in  the  top  by  a  clamp. 
A  small  glass  tube  connected  with  an  inflating  bulb  passes  through 

this  stopper  (Fig.  45).  The  reser- 
voir is  almost  filled  with  the  solution, 
leaving  about  one  quarter  for  air 
space,  and  the  instrument  is  charged 
with  sufficient  air  to  cause  the  fluid  to 
flow  through  the  needle  in  a  strong 
stream. 

Asepsis. — The  syringes,  needles, 
and  receptacles  in  which  the  solu- 
tions are  mixed  should  be  boiled  in 
pure  water  without  the  addition  of 
soda  or  other  alkali. 

Technic. — In  all  cases  where  an 
extensive  or  prolonged  operation  is 
contemplated  morphin,  gr.  ^  (0.0162 
gm.),  should  be  given  hypodermic- 
ally  half  an  hour  beforehand,  unless 
contraindicated.  For  the  skin  in- 
filtration, a  warm  0.2  per  cent,  solu- 
tion of  cocain  and  adrenalin  or  a  i 
per  cent,  procain-adrenalin  solution 
in  normal  salt  solution  may  be  used. 
The  syringe  is  filled  with  solution 
and  the  needle  is  shown  to  the  pa- 
tient with  an  explanation  of  just  what  is  intended  to  be  done. 
This  is  necessary  in  order  to  avoid  an  often  unexpected  shock  from 
the  first  prick  of  the  needle.  The  needle,  held  almost  parallel  to 
the  surface,  is  pushed  into  the  skin  just  beneath  the  epidermis — 
not  beneath  the  skin — so  as  to  anesthetize  the  sensitive  end  organs. 
If  the  needle  lies  properly,  its  point  will  be  almost  visible  imme- 
diately below  the  skin  surface.  A  few  drops  of  solution  are  in- 
jected and  the  skin  becomes  blanched  and  raised  into  a  wheal  about 
the  size  of  a  ten-cent  piece  (Fig.  46).  The  needle  is  then  reinserted 
into  the  edge  0]  the  wlteal  and  more  solution  injected  in  the  same 


I'lG.  45. — The  author's  apparatus  for 
massive  infiltration. 


INFILTRATION     ANESTHESIA 


91 


manner,  until  the  entire  line  of  the  proposed  incision  is  one  continuous 
wheal  (Fig.  47).  In  this  way,  only  the  first  prick  of  the  needle  is  felt 
by  the  patient. 

The  subcutaneous  tissue,  which  is  in  itself  insensitive  but  carries 
sensitive  nerve  trunks  and  blood-vessels,  is  next  very  thoroughly 


Fig.  46. — Showing  the  metbod  of  infiltrating  the  skin.  The  needle  is  inserted 
■D  such  a  way  that,  with  the  injection  of  a  few  drops  of  solution,  a  wheal  the  size  of  a 
■"■■cent  |Mece  is  produced. 

""filtrated,  using  a  longer  and  somewhat  larger  needle.  For  this 
Purpose  cocain  and  adrenalin  in  a  i  to  1000  solution  for  ordinary 
*^3ses  and  in  a  i  to  3000  to  i  to  loooo  solution  for  massive  infiltration 
*''  '^X"ge  areas  or  a  J^  to  }^  per  cent,  procain-adrenalin  solution  may 


Fig.  4;.^Shovving  mc  reinsertion  of  the  needle  into  the  edge  of  the  wheal. 

be  Xised.  The  needle  is  inserted  into  the  line  of  the  skin  cocainiza- 
uorx^  and  the  solution  is  injected  in  all  directions  from  this  point,  so 
2S  to  practically  surround  the  area  of  proposed  incision  with  anes- 
"*^tic  solution.     Special  care  is  taken  to  thoroughly  infiltrate  known 


g2  LOCAL   ANESTHESIA 

sensitive  re^ons,  as,  for  instance,  in  the  operation  for  inguinal  hernia 
about  the  external  ring  where  the  main  nerve  trunks  break  up  into 
their  terminal  ^laments.  In  the  case  of  an  operation  upon  a  dr- 
cumscribed  growth,  the  infiltration  is  carried  out  in  such  a  way  as  to 
completely  encircle  the  diseased  area  and  isolate  it  from  nerve  com- 
munication with  the  surrounding  parts.     In  like  manner  fascia  and 


Fig.  48. — Showing  the  direct  on^   n      h  ch  the  needle  should  be  inserted  in  masait 
nfiltrat  on  of  deep  structures 

muscles,  down  to  or  including  the  periosteum,  may  be  infiltrated  in 
a  mass,  after  the  method  of  Matas  (Fig.  48),  or  each  structure  sepa- 
rately as  it  is  exposed  during  the  course  of  the  operation.  Muscle, 
tendon,  bone,  and  cartilage  have  no  sensation,  but  their  coverings 
are  extremely  sensitive;  hence  particular  care  must  be  tak^en  to  in- 


Fic.  49. — Showing  the  ajiplu 


I  constricting  band  to  the  t 
intensify  the  anesthesia. 


filtrate  fascia,  muscle,  and  tendon  sheaths,  periosteum,  and  joint 
capsules,  and  when  operating  upon  joints  to  anesthetize  the  synovial 
membranes  by  a  preliminary  instillation  of  weak  cocain  solution 
into  the  joint  before  operation.  With  proper  infiltration  the  whole 
field  is  thoroughly  edematized  and  is  changed  into  a  tumor-like  mass 
that  is  perfectly  anesthetic. 


ENDO-   AND   PERINEURAL  INFILTRATION  93 

While  the  infiltration  method  is  carried  out  without  any  attempt 
to  specially  anesthetize  nerve  trunks,  the  larger  ones  should  never- 
theless be  injected  after  the  method  to  be  described  whenever  they 
are  encountered  during  the  operation. 

Upon  an  extremity,  more  complete  and  prolonged  anesthesia  may 
be  obtained  if,  after  infiltration,  stasis  of  the  circulation  is  produced 
by  means  of  elastic  constriction  applied  centrally  to  the  seat  of 
infiltration   (Fig.  49).     In  such  a  case,  where  large  quantities  of 
solution  are  used  and  remain  in  the  tissues  when  the  operation  is 
completed,  it  is  a  wise  precaution  to  loosen  the  constrictioil  gradu- 
ally and  intermittently,  so  as  not  to  rapidly  flood  the  system  with  a 
large  volume  of  cocain  solution. 

ENDO-  AND  PERINEURAL  INFILTRATION 

The  discovery  that  injections  of  cocain  and  similar  analgesics  into 
the  tissues  surrounding  a  nerve  (perineural  infiltration)  or  directly 
into  it  (endoneural  infiltration)  will  effectually  block  the  particular 
iierve  and  produce  anesthesia  in  the  entire  area  of  its  distribution  has 
niade  possible  many  op>erations  of  magnitude,  such  as  those  for  hernia, 
amputations,  etc.     Successful  nerve  blocking  presupposes  an  accu- 
rate knowledge  of  the  course  and  distribution  of  the  sensory  nerves. 
It  may  be  performed  at  a  distance  from  the  seat  of  operation  by  in- 
jecting the  anesthetic  solution  around  the  nerve,  or  by  cutting  down 
^^d  exposing  the  nerve  before  injection;  or  the  blocking  may  be 
performed  by  separately  injecting  each  nerve  as  it  is  exposed  during 
t^he  course  of  the  op>eration.     The  action  of  the  anesthetic  is  in- 
t^ensified  and  indefinitely  prolonged  by  arresting  the  circulation  in 
t^^e  injected  and  anesthetized  nerve  trunks  by  means  of  elastic  con- 
striction, as  already  spoken  of  under  infiltration,  and  to  a  lesser 
^^gree  by  the  addition  of  adrenalin  to  the  analgesic  solution. 

The  perineural  method  of  infiltration  is  more  suited  to  regions  sup>- 
plied  by  the  smaller  superficial  nerves  and  to  the  smaller  extremities, 
^  ^he  fingers  and  toes.  For  anesthetizing  the  large  nerve  trunks 
y^^H  thick  sheaths,  direct  injection  of  the  nerves  as  they  are  exposed 
^^  the  field  of  operation,  or  at  some  point  along  the  course  of  the  nerve 
<^eatral  to  the  seat  of  operation,  will  give  more  certain  results.  When 
^  ^^gion  is  supplied  by  several  nerves,  each  will  have  to  be  separately 
isolated  and  blocked. 

Apparatus. — The  ordinary  60TII  (4  c.c.)  or  10  c.c.  (23^  dr.)  "Sub- 
Q  '  syringe,  with  a  fairly  long  needle  will  be  found  most  satisfactory. 


94  LOCAL  ANESTHESLA 

Asepsis. — The  needles,  syringes,  and  solution  glasses  are  sterilized 
by  boiling  in  pure  water  without  the  addition  of  soda  or  other  alkali. 

Technic. — In  the  perineural  method  of  infiltration  the  analgesic 
solution  is  injected  in  such  a  way  as  to  surround  the  nerve  trunk  or 
"envelop  the  nerve  in  an  anesthetic  atmosphere,"  as  Matas  expresses 
it.    A  spot  in  the  skin  from  which  the  nerve  can  be  reached  with  the 
hypodermic  needle  is  infiltrated  as  already  described,  and  through 
this  area  the  needle  is  inserted  toward  the  known  location  of  the  par- 
ticular nerve  to  be  anesthetized.    The  syringe  is  charged  with  a  0.2 
per  cent,  solution  of  cocain  and  adrenalin  or  a  i  per  cent,  procain 
adrenalin  solution  and  from  15  to  20  drops  are  injected  into  the 
tissues  surrounding  the  nerve.     The  solution  is  allowed  to  become 
diffused,  and  then,  if  the  nerve  be  in  an  extremity,  the  part  is  ex- 


•  Fig.  50. — Method  of  infiltrating  a  large  nerve  trunk.  The  anesthetic  solution 
should  be  injected  into  the  nerve  in  all  directions  so  that  the  entire  nerve  is  rendered 
anesthetic  below  the  point  of  injection. 

sanguinated  by  elevation  and  an  elastic  constriction  is  applied  cen- 
trally to  intensify  and  prolong  the  anesthesia.  In  a  few  moments  the 
entire  region  supplied  by  the  blocked  nerve  becomes  insensible.  It 
may  happen  that,  in  regions  where  constriction  is  inapplicable,  the 
anesthesia  may  not  be  sufficiently  lasting  for  a  prolonged  operation, 
and  it  will  be  necessary  to  repeat  the  injection  more  than  once  to 
maintain  the  anesthesia. 

By  the  endoneural  method,  if  the  nerves  are  injected  in  the  field 
of  operation,  the  technic  is  very  simple,  the  individual  nerves  being 
infiltrated  with  a  few  drops  of  a  0.5  per  cent,  solution  of  cocain  or  a  2 
per  cent,  solution  of  procain  as  they  are  exposed.  When  the  injec- 
tion is  made  at  a  point  distal  to  the  seat  of  operation  the  nerve  is 
first  exposed  by  dissection  under  infiltration  anesthesia  and  is  then 
thoroughly  infiltrated,  the  fluid  being  injected  into  all  portions  of 


ENDO-   AND   PERINEURAL   INTILTRATION  95 

the  nerve  so  that  an  entire  transverse  section  is  thoroughly  blocked 
(Fig.  50).  Other  nerves  supplying  the  region  of  operation  are 
similarly  dealt  with.  The  part  is  then  exsanguinated  by  eleva- 
tion and  an  elastic  constriction  is  applied  centrally  to  the  point  of 
injection.  In  a  short  time  all  sensation  below  the  seat  of  injection 
becomes  benumbed,  and  operations  of  any  magnitude  may  be 
performed. 

Practical  Application  of  Infiltration,  Endo-  and  Perineural 
Methods  of  Anesthesia  to  Special  Localities. — The  methods  of 
locally  anesthetizing  a  part  just  described  all  have  their  special  indi- 
cations.    The  operator  should  not  employ  one  method  to  the  exclu- 
sion of  the  others,  but  should  make  his  selection  so  as  to  successfully 
meet  the  indications  in  a  particular  case.     In  a  certain  proportion  of 
the  cases  infiltration  alone  will  suffice;  in  others,  the  nerve  blocking 
can  be  used  to  better  advantage;  but  in  the  majority  of  extensive 
operations  it  will  be  found  that  a  combination  of  infiltration  with 
endoneural  injections  is  essential  to  a  successful  anesthesia  in  a  given 
region.    A  brief  description  of  the  application  of  these  methods  to 
different  regions  of  the  body  will  furnish  some  idea  as  to  the  scope  and 
capabilities  of  each. 

The  Head. — Operations  upon  the  scalp,  such  as  wound  suture, 
th.^  removal  of  tumors,  cysts,  etc.,  and  even  procedures  requiring 
irxcrision  of  the  periosteum  and  opening  into  the  brain,  may  be  per- 
formed painlessly  under  a  combination  of  infiltration  and  perineural 
anaesthesia.  An  accurate  knowledge  of  the  nerve  supply  of  the*  region 
is    essential,  however. 

Briefly,  the  scalp  has  the  following  nerve  supply  (Fig.  51).     The 
srrxall  occipital  and  great  occipital  nerves  supply  the  posterior  part 
of  the  scalp  as  far  forward  as  the  vertex.     The  great  auricular  nerve 
supplies  the  mastoid  region,  as  does  also  the  small  occipital.     The 
parietal  portion  of  the  scalp  receives  its  supply  from  the  auriculo- 
temporal and  a  branch  of  the  temporomalar.     The  supratrochlear 
branch  of  the  frontal  nerve  supplies  the  integument  of  the  lower  part 
^f  the  forehead  on  either  side  of  the  median  line.     The  supraorbital 
supplies  the  cranium  over  the  frontal  and  parietal  bones.     Blocking 
these  nerves  by  cross  strips  of  infiltration  at  the  points  where  they 
penetrate  the  muscular  fascia  and  become  subcutaneous  (Fig.  52), 
Qr  performing  a  thorough  circumscribed  infiltration  around  the  area 
^f  operation,  with  infiltration  of  the  periosteum,  if  necessary,  renders 
many  cases  amenable  to  local  measures  which  are  now  performed 
under  general  narcosis.     Constriction  by  means  of  a  rubber  tourm*- 


go  LOCAL   ANESTHESIA 

quet  passed  around  the  forehead  aboVe  the  ears  and  over  the  occipital 
protuberance  will  be  found  most  useful  as  an  aid  to  anesthesia. 

About  the  lips,  chin,  nose,  cheeks,  tongue,  mouth,  and  lower  jaw 
local  means  of  anesthesia  are  often  quite  sufficient.  Blocking  of  the 
mental  nerve  as  it  emerges  from  the  mental  foramen  will  render 
insensitive  the  region  of  the  chin  and  the  skin  and  mucous  membrane 
of  the  lower  lip  of  the  same  side  (see  Fig.  52).  In  like  manner  the 
upper  lip  may  be  anesthetized  by  blocking  the  infraorbital  nerves. 


Fio.  SI.  Fig  ;». 

Fio.  s'- — The  superficial  nerves  of  Ihe  scalp  and  face,    i,  SupratrochJear  iwTve; 

a,   supraorbital    nerve;  3,  temporal  branch  of  the  tcmporoDialar  nervei  4,  auriculo- 

temporal  nerve;  ;.  great  auricular  nerve;  6,  small  occipital  nerve;  7,  grett  ocdpi- 

tal   nerve;   S,  infratrocblear  nerve;  9,  infraorbital  nerve;  10,  nasal  nerve;  11,  mental 

Fig.  51. — Showing  the  area  of  anesthesia  after  blocting  the  supratrochlear,  supra- 
orbital, and  mental  nerves.     The  dots  iodicate  the  points  for  infiltration. 


The  inferior  dental  nerve  is  readily  reached  for  blocking  as  it  enters 
the  inferior  dental  foramen  at  the  outer  side  of  the  spine  of  Spix. 
This  point  lies  near  the  median  line  of  the  internal  surface  of  the 
ramus  of  the  jaw  about  half  an  inch  (i  cm.)  above  the  upper  surface 
of  the  last  molar  tooth  (Fig.  53).  The  lower  jaw  may  be  thus  anes- 
thetized and  teeth  may  be  painlessly  extracted.  The  lingual  nerve 
may  be  perineurally  infiltrated  at  about  the  same  point,  as  it  lies 
close  to  the  inferior  dental.  The  floor  of  the  mouth  and  the  tongue 
are  thus  rendered  insensitive,  and  quite  extensive  operations  may 


ENIH)-    AND   PERINEURAL    INFILTRATION' 


97 


be  performed.    Infiltration  alone,  however,  is  often  sufficient  in  the 
smaller  operations  about  the  lips  and  mouth. 

Blocking  of  the  branches  of  the  trifacial  nerve  at  their  points  of 
exit  from  the  base  of  the  skull  gives  a  wide  area  of  anesthesia  and 
permits  the  painless  performance  of  very  extensive  operations  in  the 
region  supplied  by  these  nerves,  such  as  removal  of  the  tongue, 
resection  of  the  upper  and  lower  jaws,  operations  upon  the  orbit, 
etc.  As  early  as  1900  Matas  reported  a  resection  of  both  upper 
jaws  after  cocainization  of  the  second  division  of  the  fifth  nerve. 
More  recently  Bratm  and  others  have  reported  extensive  operations 


Fig.  S3- — Showing  the  method  of  blocking  the  inEerior  dental 


perfonned  by  similar  methods.  The  technic  of  reaching  these  nerves 
IS  similar  to  that  employed  by  Schlosser,  Patrick,  and  others  in  the 
use  of  alcoholic  injections  for  trifacial  neuralgia  (see  page  228). 

The  Neck. — Operations  upon  the  neck  for  the  removal  of  benign 
powths,  isolated  freely  movable  glands,  or  for  the  ligation  of  vessels 
^  performed  by  infiltration  of  the  lines  of  incision  combined  with 
'''^ve  infiltration  of  the  surrounding  tissues.  As  already  men- 
wied,  thyroidectomy  and  tracheotomy  may  be  carried  out  by 
lollowing  the  same  principles.  In  superficial  operations  upon  the 
lienor  and  posterior  triangles,  perineural  blocking  by  a  strip  of 
Miration,  or  direct  injection  of  the  superficial  branches  of  the  cervi- 
^  plexus  as  they  escape  from  the  posterior  border  of  the  sterno- 


.  LOCAL  ANESTHESIA 


mastoid  muscle  at  or  about  its  middle  will  be  of  great  aid  (Fig.  55). 
Operations  upon  the  larynx  may  be  performed  under  infiltration 
anesthesia  combined  with  blocking  of  the  superior  laryngeal  nerve 
at  the  tip  of  the  greater  cornu  of  the  hyoid  bone. 

The  Thorax. — Exploratory  punctures,  aspiration  of  the  peri- 
cardium and  pleura,  rib  resection  for  empyema,  and  the  removal  of 
benign  growths  from  the  breast  may  all  be  satisfactorily  performed 
under  in&ltration.  In  the  operation  of  rib  resection  the  infiltration 
should  be  carried  out  layer  by  layer,  including  the  periosteum. 
Perineural  blocking  of  the  intercostal  nerves  as  they  pass  between  the 


Fic.  54-  Fic    js 

Tic.  54. — The  superficial  cervical  plexus.     The  dotted  lines  indicate  the  coune 

of  the  stcrnomastoid  muscle. 

Fig.  sS- — Showing  the  area  of  anesthesia  after  blocking  the  superficiftl  cervical 

plexus.     The  dots  indicate  the  points  for  infiltration. 

intercostal  muscles  in  the  upper  portion  of  the  intercostal  space  or 
endoneural  injection  of  each  nerve  as  it  is  exposed,  will  assist  in  ren- 
dering the  operation  painless  where  more  than  one  rib  is  to  be  re- 
sected. For  a  perineural  injection  the  needle  is  inserted  close  to 
the  lower  margin  of  the  rib  about  one  and  one-fifth  inches  (3  cm.) 
from  the  median  line  and  is  pushed  in  for  a  distance  of  1  ^  to  2  in. 
(4  to  5  cm.)  when  it  strikes  the  bone.  An  attempt  is  next  made  to 
guide  the  needle  below  the  lower  edge  of  the  rib.  The  injection  is 
then  commenced  and  is  continued  as  the  needle  is  carried  inward 
and  toward  the  median  line  well  into  the  subcostal  angle  for  a  distance 
of  3-i  to  y^  an  inch  (6  to  12  mm).    As  many  of  the  other  inter- 


ENDO-  AJID  PERINEURAL  INFILTRATION  99 

costal  nerves  as  may  be  necessary  are  similarly  blocked.  After  the 
periosteum  over  the  rib  is  incised  and  reflected,  the  rib  may  be  ex- 
sected  without  pain.  The  parietal  pleura,  like  the  peritoneum,  is 
very  sensitive  and  requires  infiltration  before  incision. 

The  Vjfpet  Extremity. — Almost  any  operation  may  be  performed 
in  this  region  under  a  skilful  use  of  local  anesthesia.  The  brachial 
plexus  may  be  anesthetized  by  exposing  it  under  infiltration  anes- 
thesia above  the  clavicle  (Fig.  56)  and  blocking  each  branch  sepa- 
rately by  direct  injection  with  a  0.5  per  cent,  solution  of  cocain  or  a 
2  per  cent,  solution  of  procain,  or  by  a  perineural  injection  after  the 
method  of  KulenkampfF.  His  technic  is  as  follows :  The  patient  is 
placed  in  the  sitting  position  and  the  subclavian  artery  is  located  by 
palpation.  This  is  usually  at  a  point  where,  if  the  external  jugular 
vein  were  extended,  it  would  strike  the  clavicle.    The  needle  is 


Fio.  j6. — Exposure  of  the  brachial  plexus  tor  infiltration,     i.  External  jugular 

"u;  1,  transversalis  colli  artery;  3,  scalenus  anticus  muscle;  4,  fifth  cervical  root; 
SjSiitt  cervical  root;  6,  seventh  cervical  root;  7,  clavicle. 

nsetted  just  outside  this  point  immediately  above  the  clavicle  in 
an  oblique  direction  slightly  back  and  downward  in  a  line  which,  if 
carried  back,  would  strike  the  spines  of  the  ad  or  3d  dorsal  vertebra. 
At  a  distance  of  about  i  J^  inches  {3  cm.)  the  needle  should  reach 
UI6  nerve  trunks.  Paresthesia  throughout  the  arm  and  motor  phe- 
nomena indicate  when  this  has  been  accomplished.'  If  the  needle 
strikes  the  first  rib  it  has  been  introduced  too  far.  Kulenkampff  in- 
jects 2  3^  drams  (10  c.c.)  of  a  2  per  cent,  solution  of  novocain  (pro- 
'^  and  adrenalin.  In  10  to  30  minutes  all  sensation  in  the  area 
™ow  the  point  of  injection  is  destroyed,  and  amputations  or  other 

Tninry  to  the  phrenic  nerve  with  embarrassed  respiration  and  diminished  breath 
""Wds  his  been  reported  following  perineural  injection  of  the  brachial  plexus,  so  that 
^*n  ifiould  be  taken  to  determine  the  presence  of  paresthesia  before  making  the  in- 
jectioi]  and  not  to  anesthetize  both  sides  at  the  same  time. 


lOCAL  ANESTHESIA 


operations  may  be  performed  at  any  level  below  the  seat  of  mjection. 
In  shoulder-girdle  amputations,  however,  infiltration  of  the  lines  of 
incision  also  should  be  performed  in  order  to  block  small  branches 
from  the  cervical  plexus,  i.e.,  the  supraacromial  and  suprascapular 


Operations  upon  the  forearm  require  blocking  of  the  median,  ul- 
nar, and  musculospiral  nerves.  This  may  be  accomplished  by  block- 
ing the  brachial  plexus  as  already  described,  by'directly  injecting  all 
three  nerves  after  exposure  under  infiltration  anesthesia  in  the  upper 
portion  of  the  arm,  or  by  separately  exposing  and  blocking  each  n^ve 
just  above  the  elbow.     In  following  the  latter  method,  the  median 


Fig.  57.  Fic.  58. 

Fic.  37. — Exposure  of  the  musculospiral  and  median  nerves  at  the  dbow.    I, 
Musculospiral  nerve;  2,  median  nerve. 

Fig.  58.— Exposure  of  the  ulnar  nerve  just  above  the  internal  condyle. 

nerve  is  exposed  by  an  incision  across  the  elbow  to  the  inner  side  of 
the  biceps  muscle,  the  brachial  artery  lying  just  external  to  it;  the 
ulnar,  in  the  groove  between  the  internal  condyle  and  the  olecranon; 
and  the  musculospiral,  between  the  biceps  tendon  and  the  supinator 
longus  muscle.  Blocking  each  nerve  with  a  0.5  per  cent,  solution  of 
cocain  or  a  2  per  cent,  solution  of  procain  produces  complete  in- 
sensibility of  the  extremity  below  the  point  of  injection  excepting 
the  skin  and  subcutaneous  tissues  of  the  upper  central  portion  of  the 
forearm,  supplied  by  the  musculocutaneous  and  internal  cutaneous 
nerves.  A  circular  area  of  subcutaneous  infiltration  at  the  elbow, 
however,  as  advised  by  Matas,  abolishes  any  remaining  sensilnlity 
in  this  region  (Fig.  59). 


ENDO-   AND    PERINEURAL    INFILTRATION 


Just  above  the  wrist,  the  median,  ulnar,  and  radial  nerves  are 
available  for  perineural  injection.  The  median  is  reached  by  intro- 
ducing the  needle  to  the  uhiar  side  of  the  tendon  of  the  palmaris 
longus  and  inserting  it  obliquely  for  a  distance  of  ^2  to  ^  inch 
^i  to  2  cm.)  in  the  direction  of  the  radius.     The  ulnar  nerve  may  be 


JfHh  J9. — Siiowing  the  method  of  ancsthFti/ing  the  small  5upeificia.l  r. 
cul&r  strips  of  subcutaneous  mbltratlon. 

anesthetized  perineurally  a  little  above  the  head  of  the  ulna  by  insert- 
ing the  needle  to  a  depth  of  about  ^£  inch  (2  cm.)  between  the  ulna 
and  the  tendun  of  the  flexor  carpi  ulnaris.  The  radial  nerve  and  its 
branches  are  best  caught  by  a  cross  strip  of  subcutaneous  infiltra- 


ti6.  to. — Cross-section  of  the  Coretirm  above  the  wrist  showing  the  direction 
wwtnteiilelbr  perioeural  infittrBtioo  of  the  ulnar  and  median  nerves.  (After  Braun.) 
Ipl^'worarous  nerve;  2.  radial  nerve;  3,  radial  artery;  4,  median  nerve;  Si  ulnar  nerve; 
»i  "tis  of  )lun  infiltration;  7,  Sexor  carpi  ulnocis  tendon;  8  palmaris  longus  tendon; 
*i  ioof  aqu  radialis  tendon, 

hofl  just  above  the  styloid  process  of  the  radius  (Fig.  60) .  Perineural 
"ijeciion  alone  for  operations  upon  the  wrist  is  not  satisfactory,  as 
this  region  is  also  supplied  by  small  branches  given  off  from  these 
nerves  higher  up.  A  circular  strip  of  subcutaneous  inliltration  above 
ifc  wrist,  however,  will  render  the  anesthesia  complete  (see  Fig.  59). 


LOCAL  ANESTHESIA 


In  thin  individuals,  massive  circular  infiltration  alone  is  gaio^Ij 
sufficient  to  produce  anesthesia  below  the  site  of  injection. 

Anesthesia  of  the  fingers  is  obtained'  by  infiltrating  two  points  in 
the  skin  on  the  dorsal  surface  near  the  base  of  each  fii^r  (Fig.  6k)' 


Fia.  6i. — Points  tor  inserting  the  needle  in  perineural  infiltration  of  the  distal  nerV^* 

Through  these  points  the  needle  is  inserted  toward  each  of  the  fo**' 
digital  nerves,  and  the  anesthetic  solution  injected  (Fig.  62).  A-^ 
nerve  communication  is  thus  blocked  and  the  finger  may  be  indsedi 
amputated,  etc.,  without  pain.    By  injecting  in  the  known  location' 


Fio.  63. — Cross-seclion  of  Ihe  finger  showing  the  direction  o(  the  needle  for  peri- 
neural infiltration  of  the  digital  nerves,  {After  Braun.)  i,  E:ttensor  tendons;  3,  bone; 
3,  flexor  tendons;  4,  areas  of  skin  infiltration. 

of  the  digital  nerves  as  they  pass  between  the  metacarpal  bones,  the 

bases  of  the  fingers  and  even  the  metacarpals  may  be  anesthetized. 

The  Abdomen. — The  abdomen  may  be  opened  in  any  region  by 

simple  infiltration,  combined  with  endoneural  injection  of  nerves  as 


^^^P  ENDO-   AND   PERINEURAL   INFILTRATION  IO3 

they  are  exposed.  The  skin,  the  subcutaneous  tissues,  the  fascia;, 
the  muscular  layers,  and  the  peritoneum  should  be  separately  in- 
filt.rated,  layer  by  layer.  More  perfect  anesthesia  may  be  obtained 
by  combining  with  the  infiltration  a  paravertebral  injection  of  the 
nerves  supplying  the  field  of  operation  after  the  method  of  Kappis. 
For  work  about  the  kidney  or  upper  abdomen  the  last  five  thoracic 
and  upper  two  lumbar  nerves  should  be  blocked.  The  technic  is 
as  follows:  The  needle  is  inserted  about  i  ?5  in,  (3.5  cm.)  from  the 
me<Jian  line  on  a  level  with  the  lower  border  of  the  rib  and  is  inserted 
for  a  distance  of  i  55  to  z  in.  (4  to  5  cm.)  when  the  bone  should  be 
J^a.ched.  The  needle  is  then  made  to  pass  beneath  the  lower  border 
of  the  rib  and  the  injection  is  begun.  The  solution  is  slowly  injected 
while  the  needle  is  pushed  onward  for  a  distance  of  3^  to  }-i  in. 
(6  to  12  mm.)  slightly  toward  the  median  line  into  the  subcostal 
^-figle.  The  same  method  is  employed  for  the  lumbar  nerves,  the 
transverse  processes  of  the  vertebrie  being  the  guides  instead  of  the 
"t»s.  The  limitations  of  local  anesthesia  in  abdominal  surgery  have 
^ready  been  considered  (page  79). 

Hemia-^While  operations  for  hernia  of  any  variety  may  be 
t^arried  out  under  local  anesthesia,  the  inguinal  will  be  found  espe- 
<:ially  suited  to  this  method  of  anesthesia,  the  umbilical  and  femoral 
varieties  less  so. 

For  inguinal  hernia  a  combination  of  infiltration  and  endoneural 
n*)ection  is  possible  on  account  of  the  anatomical  arrangement  of  the 
Kiguinal  region,  which  is  supplied  by  three  fairly  large  nerve  trunks 
having  a  rather  constant  course — namely,  the  iliohypogastric,  the 
iUwnguinal,  and  the  genitocrural.  The  iliohypogastric  will  be  found 
Ihc  upper  angle  of  the  hernial  incision  after  reflecting  the  ap'oneu- 
of  the  external  oblique,  usually  running  downward  and  inward 
i  line  drawn  from  about  the  anterior-superior  spine  to  a  point 
Ml  inch  (2.5  cm.)  above  the  external  ring.  The  ilioinguinal  will 
tisually  be  found  in  the  line  of  incision  just  beneath  the  aponeurosis 
of  the  external  oblique,  and  on  a  lower  level  than  the  iliohypogastric, 
rutuiiiig  downward  in  the  long  axis  of  the  hernia  (Fig.  63),  It  may 
^w  lie  as  far  out  as  Poupart's  ligament.  This  nerve  is  often 
smaller  than  the  iliohypogastric,  and  in  some  cases  it  may  be  absent, 
in  ifUch  event  its  place  is  taken  by  the  genitocrural.  The  genito- 
crura]  will  be  found  after  reflecting  the  aponeurosis  of  the  external 
oWifjue  lying  among  the  structures  of  the  cord,  and  frequently  it 
lie  behind  the  cord.  Infiltration  anesthesia  is  employed  until  the 
aponeurosis  of  the  external  oblique  is  reflected,  when  the  above  nerves 


1 


I04  LOCAl  ANESTHESIA 

are  separately  blocked.  In  performing  the  infiltration,  specjal  care 
should  be  taken  to  inject  plenty  of  solution  in  the  region  of  the  eztental 
ring  where  the  nerves  break  up  into  their  terminal  filaments.  After 
the  nerves  are  properly  blocked,  the  remainder  of  the  operation 
may  be  painlessly  performed  without  the  use  of  additional  anesthesia, 
though  it  is  better  to  infiltrate  about  the  neck  of  the  sac  before 
ligating  and  removing  that  structure.  Omentum  may  be  amputated, 
adhesions  within  the  sac  separated,  and  gut  resected  if  necessary, 
without  pain. 

Femoral  hernia  may  be  operated  on  under  simple  infiltration  of 
the  skin,  subcutaneous  tissues,  and  sac;  or,  preferably,  by  a  combi- 


FlG.  63. — Sfaoning  the  nerve  supply  of  the  inguinal  region.  (After  Cushing.) 
I,  Biohypogastru;  nerve;  i,  ilimnguinal  nerve;  3,  conjoined  tendon;  4,  cremaiter 
muscle;  j,  aponeurosis  of  the  external  oblique  incised  and  edges  reflected. 

nation  of  infiltration  and  endoneural  injection.  If  this  latter  method 
is  employed,  the  incision  is  placed  so  as  to  expose  in  addition  the 
external  abdominal  ring.  The  aponeurosis  of  the  external  oblique 
is  thus  exposed  and  is  incised  for  a  short  distance,  so  that  the  ilio- 
inguinal and  genitocrural  nerves  may  be  identified  and  injected. 
Blocking  of  these  nerves,  combined  with  infiltration,  renders  the 
field  of  operation  more  nearly  anesthetic  than  infiltration  alone. 

In  operations  for  umbilical  and  ventral  hernias,  the  infiltration 
method  is  employed.  The  structures  are  separately  injected,  as 
would  be  done  for  an  abdominal  operation,  taking  special  care  to 
thoroughly  infiltrate  about  the  neck,  of  the  sac. 


ENDO-  AND  PERINEURAL  INFILTRATION 


los 


The  Scrotum. — ^Any  of  the  operations  about  the  scrotum  and 
testicles,  such  as  those  for  varicocele,  hydrocele,  castration,  etc., 
may  be  carried  out  by  perineural  injection  around  the  cord  as  it 


Fio.  64. — Showing  the  method  of  infiltrating  about  the  cord  in  operations  upon  the 

testicle. 

escapes  from  the  external  ring  (Fig.  64),  combined  with  infiltration 
along  the  site  of  incision. 

Penis  and  Urethra. — Circumcision  may  be  performed  by  infiltrat- 
ing  the  skin  and  mucous  membranes  along  the  lines  of  proposed 


\</ 


] 


Fig.  65. — Points  for  injection  in  infiltration  about  the  anus. 

^cision,  being  careful  to  infiltrate  the  frenum  thoroughly.  More  ex- 
pensive operations  upon  the  pendulus  portion  may  be  performed  by 
subcutaneous  infiltration  of  a  ring  about  the  base  of  the  penis,  care- 
^h  injecting  the  solution  around  each  of  the  dorsal  nerves.     Exter- 


io6 


LOCAL  ANESTHESIA 


nal  urethrotomy  may  be  performed  under  infiiltration  combined 
with  topical  anesthesia  of  the  mucous  membrane  (see  page  87). 

Rectum  and  Anus. — The  limitations  of  local  anesthesia  in  rectal 
operations  have  been  previously  pointed  out.  For  the  removal  of 
external  hemorrhoids,  skin  tabs,  etc.,  injecting  a  small  amoimt  of 
anesthetic  solution  into  the  base  of  the  growth  is  sufficient.  When 
it  is  necessary  to  stretch  the  sphincter,  anesthesia  may  be  obtained 
in  the  following  manner:  Four  wheals  are  made  in  the  skin — ^in 
front,  behind,  and  at  the  sides  (Fig.  65) — and  through  these  points 
the  hypodermic  needle,  guided  by  a  finger  in  the  rectum,  is  carried 
up  along  the  bowel  and  the  sphincter  is  thoroughly  infiltrated. 

Lower  Extremity. — Blocking  of  the  anterior  crural,  the  external 
cutaneous,  and  the  sciatic  nerves,  combined  with  a  circular  strip  of 


Fig.  66. — Exposure  of  the  anterior  crural  and  external  cutaneous  nerves  for  injec- 
tion. I,  Anterior  crural  nerve;  2,  external  cutaneous  nerve;  3,  femoral  artery;  4,  femo- 
ral vein. 


subcutaneous  infiltration,  completely  blocks  all  sensation  in  the  lower 
extremity  below  the  level  of  the  **block,''  and  amputations  can  thus 
be  performed  as  high  as  the  lower  and  middle  thirds  of  the  thigh. 
Above  this  point,  however,  the  nerve  supply  is  complicated  and  it 
will  be  necessary  to  massively  infiltrate  along  the  line  of  incision  as 
well  as  to  "block''  the  nerve  trunks  already  mentioned.  The  exter- 
nal cutaneous  nerve  may  be  reached  for  injection  by  an  incision  so 
placed  as  to  expose  the  nerve  as  it  emerges  from  under  the  anterior 
superior  spine  (Fig.  66),  or  it  may  be  blocked  by  a  perineural  injec- 
tion, the  needle  being  inserted  just  to  the  inner  side  of  the  anterior 


ENDO-   AND    PERINEURAL    INFILTRATION  I07 

superior  spine.  Skin  grafting  may  be  readily  performed  by  blocking 
the  nerve  after  the  manner  just  described  and  taking  the  grafts  from 
the  outer  side  of  the  thigh.  The  anterior  crural  nerve  may  be  ex- 
posed by  an  incision  placed  about  }2  inch  (i  cm.)  external  to  the 
center  of  Poupart's  ligament.  The  nerve  will  be  found  just  external 
to  the  femoral  artery.  The  sciatic  nerve  may  be  reached  for  peri- 
neural injection  by  inserting  the  needle  at  a  point  where  a  horizon- 
tal line  through  the  tip  of  the  great  trochanter  cuts  a  vertical  line 
through  the  outer  margin  of  the  tuberosity  of  the  ischium.  A  needle 
about  5  inches  (8  cm.)  long  is  required.  It  is  introduced  directly 
backward  until  bone  is  reached  and  is  then  withdrawn  for  a  distance 
of  J^5  inch  (i  mm.).     After  injection  of  the  anesthetic  solution  about 


Fic.  67. — Exposure  of  the  scialic  nerve  in  the  upper  part  at  the  thigh  for  injec- 
on.      I,  Gluteus  insiiinus  muscle)  2,  biceps  muscle;  3,  seniitendiDOsus  muscle;  4.  sdatic 


J^  an  hour  is  required  for  complete  anesthesia.     The  sciatic  may  also 

be  blocked  after  exposure  under  infiltration  anesthesia  at  the  lower 

border  of  the  gluteus  maximus  muscle,  or  at  the  upper  border  of  the 

popliteal  space.     In  the  former  case,  an  incision  3  to  4  inches  (7.5  to 

to  cm.)  long  is  made  between  the  tuberosity  of  the  ischium  and  the 

great  trochanter,  with  its  center  over  the  lower  margin  of  the  gluteus 

raaamus  muscles.     By  retracting  the  gluteus  maximus  upward  and 

the  ham-string  muscles  inward,  the  nerve  will  be  found  lying  under 

thcouter  edge  of  the  biceps  muscle  (Fig.  67).     In  the  upper  portion 

of  the  popliteal  space  the  nerve  may  be  exposed  by  a  vertical  incision 

">  the  mid-line;  it  will  be  found  lying  between  the  biceps  and  semi- 

niembtanosus  muscles.     It  should  be  injected  before  it  divides,  or 

'wboth  the  internal  and  external  popliteal  nerves  are  to  be  blocked. 


I08  LOCAL  ANESTHESIA 

In  operations  below  the  tubercle  of  the  tibia,  it  is  unnecessary  to  blod 
the  anterior  crural  and  external  cutaneous;  blocking  the  sdatic  in 
the  popliteal  space  and  the  external  saphenous  as  it  passes  to  the 
inner  and  posterior  aspect  of  the  knee-joint  is  sufficient  (Fig.  68). 


Fig.  68. — Exposure  of  the  internal  saphenous  nerve  for  injection,     i,  Intemil  upbe 
nous  nerve;  z,  internal  saphenous  vein. 

Below  the  knee,  the  large  nerves  are  not  available  for  injection 
until  the  ankle  is  reached.  Behind  the  ankle  the  posterior  tibial  may 
be  perineurally  injected  by  inserting  the  needle  on  the  inner  side  of 


Fig.  69. — Cross-section  of  the  leg  above  the  anlde-jc^t,  showing  the  directioa 
o(  the  needle  for  perineural  infiltration  of  the  posterior  tibial  nerve.     (After  Braun.) 

I,  Posterior  tibial  nen'e;  2,  external  saphenous  nerve;  3,  area  of  skin  infilttation; 
4,  musculocutaneous  nerve;  5,  anterior  tibial  nerve;  6,  tendo  achillis;  7,  peronei  muscles; 
8,  flexor  longus  hallucis;  q,  extensor  longus  digitorum;  10,  extensor  longua  haDuds; 

II,  tibialis  anticus;  11,  tibialis  posticus;  13,  flexor  longus  digitorum. 

the  tendo  achillis  directly  forward  almost  to  the  posterior  surface  of 
the  tibia  (Fig.  69).  The  anterior  tibial  may  be  likewise  perineurally 
injected  by  inserting  the  needle  on  the  dorsum  of  the  ankle  between 


ENDO-   AND   PERINEURAL   INFILTRATION  109 

the  tendons  of  the  tibialis  anticus  and  the  extensor  longus  halluds 
and  the  innermost  tendon  of  the  extensor  longus  digitorum.  By  a 
circular  strip  of  subcutaneous  infiltration,  the  remainder  of  the  sen- 
sory nerve  supply  may  be  blocked  and  complete  anesthesia  of  the  foot 
may  be  obtained. 

In  anesthetizing  the  digits  and  metatarsals,  the  same  principles 
already  described  for  the  hand  are  applicable.  Amputations  of  toes, 
operations  for  ingrowing  toe-nail,  osteotomy  for  hallux  valgus,  etc., 
may  be  readily  performed  under  perineural  injection  of  the  proper 
nerves. 

Operations  upon  Inflamed  Tissues  under  Local  Anesthesia. — 
Upon  the  extremities  some  of  the  methods  of  endoneural  or  peri- 


Fro.  70.— Showing  the  method  of  anesthetizing  an  inflamed  area. 


''^*-*~al  blocking  of  the  nerves  supplying  the  region  affected  gives 

'^''^"t  satisfaction.     Where  these  methods  are  not  applicable  infiltra- 

^'°*^    anesthesia  may  be  employed  if  care  is  taken  not  to  inject  the 

s^'^tion  directly  into  the  inflamed  tissues.    An  attempt  should  be 

''^^e  to  surround  the  diseased  area  with  the  anesthetic  solution, 

''^^^ng  the  injections  through  healthy  skin  into  the  subcutaneous 

lissxies  (Fig.  70),  thus  cutting  off  all  sensory  communication  with  the 

stttrounding  parts.    Infiltration  of  the  inflamed  tissues  should  be 

avoided  as  any  increase  in  distention  of  the  already  swollen  structures 

causes  intense  pain  and  in  some  cases  seems  to  lower  the  resistance  to 

such  an  extent  that  cellulitis  results. 


no  LOCAL  ANESTHESIA 

BIER'S  VENOUS  ANESTHESIA 

The  idea  of  using  the  blood  vessels  for  the  purpose  of  diffusing 
local  anesthetics  through  the  tissues  for  surgical  operations  orginated 
with  Bier,  who  described  the  method  before  the  37th  German  Sur- 
gical Congress  in  1908.  Previous  to  this  the  first  record  of  the  in- 
jection of  local  anesthetics  into  the  circulation  was  in  1886,  soon 
after  the  introduction  of  cocain,  when  Alms  injected  cocaine  experi- 
mentally into  the  iliac  artery  of  a  frog  and  obtained  complete 
anesthesia  of  the  lower  limb.  Venous  anesthesia  consists  essentiaUy 
in  rendering  the  limb  bloodless  and,  after  isolating  the  field  of  opera- 
tion from  the  circulation  by  means  of  tourinquets  applied  above  and 
below  the  area  to  be  anesthetized,  injecting  the  anesthetic  solution 
into  one  of  the  veins  between  the  two  tourniquets.  What  is  termed 
"direct  anesthesia"  rapidly  develops  between  the  two  bandages; 
while  somewhat  later,  after  the  anesthetic  solution  has  had  time,  to 
act  up>on  and  paralyze  the  nerve  trunks  within  the  isolated  area,  the 
anesthesia  extends  to  the  entire  limb  beyond  the  bandage.  This 
is  termed  ''indirect  anesthesia.'' 

While  venous  anesthesia  is  suitable  for  any  operation  upon  an 
'  extremity  which  will  permit  of  ischemia  of  the  limb,  it  is  not  intended 
that  it  should  supplant  the  ordinary  methods  of  local  anesthesia 
which  are  sufficient  for  the  superficial  tissues;  its  special  field  is  for 
major  operations,  such  as  amputations,  resection  of  joints,  and  opera- 
tions upon  bones,  muscles,  tendons,  etc.  It  is  especially  indicated 
in  cases  with  heart  and  lung  complications  which  are  poor  risks  for 
general  anesthesia;  and  for  cases  of  severe  traumatism  of  the  limbs 
with  the  patient  deeply  shocked  it  is  invaluable.  According  to  its 
originator,  diabetic  and  senile  gangrene  and  arteriosclerosis  are  con- 
traindications to  its  use. 

Apparatus. — ^A  syringe,  such  as  the  Sub-Q  or  the  Janet,  with  a 
capacity  of  about  3  ounces  (90  c.c).  Bier's  special  cannula,  a  short 
heavy  piece  of  rubber  tubing  for  connecting  the  syringe  with  the  can- 
nula, a  small  medicine  glass,  a  small  syringe  and  fine  needle  for  infil- 
trating the  site  of  operation,  a  glass  graduate  for  the  vein  solution, 
and  three  rubber  bandages,  each  23^^  inches  (6  cm.)  wide  and  6 
feet  (180  cm.)  long  (Fig.  71),  will  be  required. 

Bier's  cannulas  are  }^iq  inch  (1.5  mm.)  in  diameter  for  children  and 
M4  to  K2  inch  (1.75  to  2  mm.)  in  diameter  for  adults.  The  distal 
end  of  the  cannula  is  provided  with  grooves  into  which  fit  the  liga- 
tures with  which  it  is  tied  in  the  vein,  and  at  the  other  end  there  is 


BIER  S   VENOUS    ANESTHESIA 


a  stopcock  and  a  bayonet  connection  (Fig.  72).  In  the  absence  of  a 
spedal  cannula,  an  ordinary  infusion  cannula  may  be  used,  an  artery 
clamp  applied  to  the  rubber  tubing  acting  as  a  stopcock. 

Instniments. — Instruments  necessary  for  an  ordinary  infusion  are 
lequired;  namely,  a  scalpel,  mouse-toothed  thumb  forceps,  a  pair  of 
blunt- pointed   scissors,    an   aneurysm   needle,   needle   holder,   two 


Fio.  71. — Apparatus  for  venous  anesthesia,  i,  Rubber  tourniquets;  i,  medicine 
glass;  j^  glass  graduate;  4,  large  glass  syringe  and  Bier's  cannula;  5,  ampule  of  anes- 
"letic;  6,  syringe  tot  preliminaty  infiltration  of  the  skin  at  the  site  of  operation. 

curved  needles  with  a  cutting-edge,  No.  2  plain  catgut,  and  a  few 
*''tery  damps  (Fig.  73). 

Solution. — ^Bier  employs  a  0.5  per  cent  solution  of  novocain 
(procain)  in  normal  salt  solution. 

Quanti^  Used. — From  5  drams  to  2  ounces  (20  to  60  c.c.)  of 
solution  are  ordinarily  injected,  depending  upon  the  extent  of  the  area 


Fig.   7». — Enlarged 


cannula  for  venous  anesthesia. 


'<>    te  injected.    The   quantity   employed   shoidd   not,    however, 
e'tceed  2^  ounces  (80  c.c). 

Site  (rf  Iiijection.^The  vein  sdected  for  the  injection  should 
Preferably  be  one  of  the  larger  main  subcutaneous  veins  which  follow 
a  definite  course,  rather  than  a  tributary.  Likewise  veins  imbedded 
in  Scar  Ussue  are  to  be  avoided.  For  the  arm,  the  basilic  vein  and 
ior  the  leg  the  internal  saphenous  vdn  is  usually  chosen. 


113  LOCAL  ANESTHESU 

Asep^. — The  limb  is  sterilized  by  painting  with  tincture  of 
iodin.  The  instruments  are  boiled,  and  the  operator's  hands  cleansed 
as  for  any  operation. 

Technic. — Before  rendering  the  limb  bloodless,  it  is  well  to  make 
a  small  scratch  with  a  scalpel  in  the  skin  over  the  vein  in  order  to 
mark  its  site,  as  it  is  sometimes  a  difficult  matter  to  recognize  an 
empty  vdn  in  bloodless  tissues.  The  limb  is  then  elevated  and  ren- 
dered ischemic  by  the  application  of  an  Esmarch  bandage  applied 
from  the  extremity  of  the  limb  up  to  a  point  well  above  the  site  of 
injection.  Some  care  should  be  taken  in  applying  this  bandage  as 
it  is  necessary  that  the  veins  be  thoroughly  emptied.    A  tourniquet 


Fig.  73. — Instruments  for  venous  anesthesia,  i,  Scalpel;  2,  blunt-pointed  icision; 
3,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6,  curved  needles;  7,  No.  t 
plain  catgut;  8,  artery  clamps. 

is  then  applied  at  the  upper  limit  of  the  bandage  used  to  exsanguinate 
the  part  by  wrapping  a  soft  rubber  bandage  about  the  limb  in 
broad  bands  so  as  not  to  cause  the  patient  any  unnecessary  discom- 
fort, and  the  first  bandage  is  removed  for  a  distance  of  4  to  10  inches 
(10  to  25  cm.).  At  this  point  a  second  tourniquet  is  applied  and  the 
remaining  portion  of  the  Esmarch  is  entirely  removed  (Fig.  74). 
The  appearance  of  the  limb  after  the  removal  of  the  expulsion 
bandage  is  important.  Mottling  or  cyanosis  of  the  skin  indicates 
that  the  veins  have  not  been  completely  emptied,  whereas,  if  the 
expulsion  bandage  has  been  properly  applied,  the  skin  will  appear 
perfectly  white  and  there  will  be  a  segment  of  the  limb  lying  between 
the  two  bandages  in  which  the  vessels  are  entirely  empty  of  blood. 


BIERS  VENOUS  ANESTHESIA  113 

When  the  operation  is  near  an  extremity  only  one  tourniquet  need 

be  employed.    It  should  not  be  placed,  however,  higher  than  the 

middle  of  the  forearm  or  leg.     Under  infiltration  anesthesia  with 

a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution  of  procain, 

one  of  the  main  subcutaneous  veins,  previously  selected,  is  exposed 

by  a  small  transverse  incision  in  the  proximal  part  of  the  isolated 

area.    The  vein  is  opened  by  cutting  with  scissors,  its  proximal  end 

is  tied  off,  and  the  cannula  is  secured  in  its  distal  end.    Any  small 

voDs  that  may  be  cut  are  securely  clamped  to  prevent  leakage  of 

the  solution.    The  anesthetic  is  then  injected  under  considerable 

pressure  toward  the  periphery,^  i.e.,  against  the  valves  of  the  veins, 

until  the  superficial  veins  swell  and  the  whole  segment  between  the 

(wo  bandages  becomes  paler  than  before.    The  stopcock,  is  then 

cJosed  and  the  syringe  removed,  the  cannula  being  left  in  place  for 

further  injection  if  necessary. 


74. — Bier's  venous  anesthesia.     Showing  the  application  of  the  bandages  and 
the  site  at  injection +  . 

In  this  way  the  anesthetic  solution  is  distributed  through  the 
"ssues  between  the  two  tourniquets  and  is  brought  in  contact  with 
"*e  nerve  trunks  and  nerve  endings  of  the  whole  area.     Direct  anes- 
tnesia  follows  between  the  bandages  in  three  to  five  minutes,  and 
indirect  anesthesia  beyond  the  distal  bandage  is  observed  in  six  to 
twenty  minutes.     If  the  proximal  bandage  causes  pain,  as  is  some- 
unies  the  case,  a  second  one  may  now  be  placed  immediately  below  it 
^1  the  anesthetized  area  and  the  first  one  may  be  removed.     As 
1  rule,  some  motor  paralysis  occurs  in  the  anesthetized  area,  but  it 
soon  disappears  after  removal  of  the  bandages.    Anesthesia  per- 
ils as  long  as  the  bandages  remain  in  place  and  rapidly  disap- 
pears after  their  removal,  so  it  is  necessary  that  the  operation, 
induding  hemostasis  and  suturing,  be  completed  before  the  bandages 
are  removed.    If  difficulty  is  experienced  in  recognizing  cut  vessels, 
saline  may  be  injected  into  the  cannula  and  it  will  spurt  from  the  open 


Bin  in  a  later  communication  (Edinburg  Medical  Journal,  Aug.,  1910)  states 
"'*'■  the  injection  may  also  be  made  centrally,  opening  the  vein  close  to  the  distal 


114  LOCAL  ANESTHESLA. 

ends.  The  danger  of  poisoning  from  absorption  of  the  drug  em- 
ployed for  anesthesia  may  be  disregarded.  This  apparent  danger 
was  formerly  guarded  against  by  washing  out  the  veins  with  saline  at 
the  end  of  the  operation.  This  precaution  is  now  regarded  as  unnec- 
essary, for,  according  to  Bier,  the  anesthetic  quickly  goes  through 
the  vein  wall  and  the  greater  portion  of  it  becomes  bound  up  in  the 
tissues,  returning  to  the  circulation  very  gradually. 

Variations  in  Technic. — Following  Bier's  lead,  others  have 
injected  local  anesthetics  into  the  arterial  system  instead  of  into  a 
vein.  Thus  Goyanes  (quoted  in  Centralblatt  fur  Chiriirgiej  1909, 
Vol.  XXVI)  describes  a  method  of  regional  anesthesia  by  the  injec- 
tion of  the  anesthetic  solution  into  an  artery.  Two  to  3  ounces  (50 
to  100  c.c.)  of  a  0.5  per  cent,  solution  of  novocain  (procain)  in  normal 
salt  solution,  colored  with  a  few  drops  of  concentrated  methylene 
blue  solution  so  that  the  operator  may  note  the  penetration  of  the 
tissues  by  the  anesthetic,  are  slowly  injected  by  means  of  a  fine 
needle  inserted  obliquely  into  the  vessel  between  Esmarch  bandages 
in  a  manner  very  similar  to  the  method  of  Bier. 

Ransohoff  {Annals  of  Surgery,  April,  1910)  describes  a  method  of 
terminal  arterial  anesthesia  obtained  by  injecting  cocain  solution  into 
an  artery  supplying  the  area  of  operation.  He  reports  two  cases  in 
which  the  method  was  employed,  as  well  as  a  number  of  experiments 
upon  animals  which  would  seem  to  show  that  it  is  a  safe  and  efficient 
procedure  in  suitable  cases.  He  recommends  this  method  as  being 
especially  applicable  to  operations  upon  the  upper  extremity  where 
the  brachial,  ulnar,  or  radial  artery  may  be  exposed  without  difficulty 
and  in  operations  upon  the  foot  or  ankle  after  exposure  of  the  anterior 
"tibial  artery. 

Ransohoff 's  technic  is  as  follows:  ''The  main  artery  supplying 
the  part  to  be  anesthetized  is  exposed  under  infiltration  anesthesia. 
An  Esmarch  strap  is  now  bound  about  the  limb  some  distance 
above  the  point  of  proposed  injection  into  the  artery.  The  Esmarch 
should  be  used  as  in  the  Bier  hyperemic  treatment;  that  is,  snug 
enough  to  constrict  the  veins,  but  not  so  tight  as  to  interfere  with  the 
arterial  circulation.  From  4  to  8  c.c.  (i  to  2  dr.)  of  a  0.5  per  cent, 
solution  of  cocain  in  normal  salt  solution  should  be  injected  into  the 
artery  in  the  direction  of  the  blood  stream.  The  needle  used  should 
be  as  fine  as  possible.  After  anesthesia  is  complete,  the  Esmarch  may 
be  tightened  if  perfect  hemostasis  is  desired." 

It  is  claimed  that  the  cocain  thus  introduced  is  carried  by  the 
capillaries  to  the  individual  nerve  endings  and  the  solution  is  diffused 


SPINAL   ANESTHESIA  115 

through  the  capillary  walls  into  the  surrounding  tissues  so  that  little, 
it  any,  solutiou  is  returned  to  the  general  circulation. 

It  has  not  been  shown  that  arterial  anesthesia  possesses  any  ad- 
vantages over  venous  anesthesia,  and  the  arterial  method  is  far  more 
difficult  to  carry  out  and  on  account  of  the  deep  situation  of  the  vessels 
which  have  to  be  exposed  for  the  purpose  of  making  the  infection. 


SPINAL  ANESTHESIA 

This  form  of  anesthesia  is  produced  by  injecting  weak  solutions  of 
d jTigs  having  local  analgesic  properties  into  the  subarachnoid  space. 
Cocainization  of  the  spinal  cord  was  first  suggested  by  Coming  in 
i'SS5.  Bier,  in  1899,  improved  upon  the  method  and  made  it  prac- 
t'«:^^ble  for  surpcal  purposes. 

The  enthusiasm  with  which  spinal  anesthesia  was  first  received 
li^«.s,  however,  proved  unwarranted  by  practical  results.  The  mor- 
t^J-ity  b  higher  than  from  ether  or  chloroform,  and  it  is  not  absolutely 
•■^■"tain  that  permanent  harm  to  the  cord  may  not  result.  Certainly, 
^^*-^cs  have  been  reported  which  would  suggest  such  a  possibility.     In 

*  ^rertain  percentage  of  the  cases  anesthesia  does  not  develop  or  is 
i^<:romplete,  and  at  times  most  unpleasant  symptoms  accompany 
't*.^  anesthesia;  headache,  nausea,  vomiting,  sweating,  chills,  rise  of 
'^•^perature,  or  collapse  are  by  no  means  rare.     Spinal  anesthesia  has 

*  I>lace  in  surgery,  without  doubt,  but  it  should  be  reserved  for  those 
*^<:repUonal  cases  in  wMch  general  anesthesia  is  contraindicated 
■**"  other  methods  of  local  anesthesia  are  impracticable.  Recent 
'y^hilitic  infections,  diseases  of  the  brain  and  spinal  cord,  marked 
J**rv3ture  of  the  spine,  and  cases  of  general  septicemia  are  contra- 
^-ciications  to  spinal  anesthesia. 

Injections  have  been  made  in  all  portions  of  the  cord,  but  for 
P*"^ctica]  surgical  purposes  they  are  now  limited  to  the  lumbar  region. 
'^  ■!«  danger  of  inducing  respiratory  paralysis  is  too  great  to  warrant 
'*^e  introduction  of  analgesics  into  the  higher  regions  of  the  cord. 

Solutions  Used. — AU  the  various  local  anesthetics  have  been  used, 
'**3t  at  the  present  lime  stovain  and  tropacocain  are  the  drugs  most 
'*^uentiy  employed  for  spinal  anesthesia. 

Cocain  is  now  generally  discarded  for  some  of  the  less  dangerous 
sibsUtutes.  If  employed,  it  may  be  used  in  a  2  per  cent,  solution  in 
iiortaal  salt  solution,  10  to  4oltl  (0.6  to  2.5  cc.)  of  such  a  solution, 
contmning  between  yi  and  i  gr.  (0.01296  and  0.065  S"^-)  of  cocain, 
"t injected.     The  addition  of  a  few  drops  of  a  i  to  looo  solution  of 


Il6  LOCAL   ANESTHESLA. 

adrenalin  chlorid  to  the  cocain  is  said  to  be  of  great  benefit,  prevent- 
ing the  rapid  diffusion  of  the  anesthetic,  and  many  of  the  unpleasant 
after-effects. 

Stovain  is  less  toxic  than  cocain  and  is  very  highly  recommended 
by  many  authorities.  A  5  per  cent,  solution  is  used,  the  dose  being 
^i  to  I  gr.  (0.0486  to  0.065  S^')- 

Procain  (novocain)  is  also  frequently  employed.  It  is  about 
seven  times  less  poisonous  than  cocain.  A  5  per  cent,  solution  in 
normal  salt  solution  is  employed.  The  ordinary  dose  is  from  ^  to 
i/^  gr.  (0.0486  to  0.0974  gm.). 

Tropacocain  is  another  substitute  for  cocain  frequently  used,  and 
the  anesthesia  is  more  lasting.  It  is  given  in  a  dose  of  from  ^  to 
I  gr.  (0.0324  to  0.065  S^O  i'^  3.  5  per  cent,  solution. 

At  the  present  time  many  operators  employ  solutions  with  a 
higher  or  a  lower  specific  gravity  than  the  cerebrospinal  fluid,  so  that 
when  the  solution  is  injected  it  will  either  fall  or  rise.  To  render  the 
solution  lighter  or  more  diffusible  alcohol  is  added.  Babcock  (/.  A. 
M,  A.,  Oct.  II,  1913)  gives  the  following  formulae  for  light  solutions: 

(Approximately) 

A.  Stovain,  0.08  gm.  i)4  gr. 
Lactic  acid,  0.04  c.c.  %  gr. 
Absolute  alcohol,  0.2  c.c.  3  minims 
Distilled  water,  i .  8  c.c.  30  minims 

B.  Tropacocain,  o.i  gm.  iMgr. 
Absolute  alcohol,                                  o .  2  c.c.             3  minims 
Distilled  water,                                    i .  8  c.c.             30  minims 

C.  Novocain  (procain),  o.i6gm.  aj^  gr. 
Absolute  alcohol,                                  0.2  c.c.  3  minims 
Distilled  water,                                       i .  8  c.c.  30  minims 

One  to  1.5  c.c.  (16  to  25  minims)  of  these  mixtures  is  given  as  the  adult  dose 

Barker  employs  the  following  solution: 

Stovain,  five  parts 

Glucose,  five  parts 

Distilled  water,  ninety  parts  (all  by  weight). 

This  solution  is  heavier  than  the  cerebrospinal  fluid,  having  a 
specific  gravity  of  1023  against  1007  for  the  cerebrospinal  fluid,  and 
sinks  to  the  lowest  level  of  the  canal.  It  is,  therefore,  p>ossible  to 
obtain  an  anesthesia  at  any  level  by  adjusting  the  patient's  position 
by  the  aid  of  pillows  so  that  the  desired  vertebra  lies  at  the  lowest 
level. 

The  injection  of  a  solution  of  Epsom  salt  has  been  advocated  by 
Meltzer,  Haubold,  and  others.     Sixteen  minims  (i  c.c.)  of  a  25  per 


SPINAL   ANESTHESIA 


"7 


cent,  solution  are  given  for  every  2$  pounds  (10  K.)  of  body  weight. 
Three  to  four  hours  after  the  injection  paralysis  and  analgesia  in  the 
legs  and  pelvic  regions  appear  and  persist  for  from  eight  to  fourteen 
^urs.  It  is  claimed  that  overdosage  endangers  life  from  respiratory 
paralysis. 

Apparatus. — A  special  stylet  needle  and  an  appropriate  syringe 
with  a  capacity  of  about  ij^  drams  (5  c.c.)  should  be  provided.  The 
leedle  should  be  of  platinum  or  nickel,  }4&  inch  (i  mm.)  in  diameter, 
and  about  3^  inches  (9.5  cm.)  ioi^.  The  stylet  must  be  ground  to  a 
Point  with  the  needle  and  should  fit  the  latter  accurately  at  the  point, 
to  avoid  carrying  in  fragments  of  tissue  as  it  traverses  the  flesh.  It 
is  important  that  the  point  of  the  needle  be  not  too  long — the  more 


-''^■75- — Apparatus  for  spinal  anesthesia,  i.  Ethyl  chlorid;  j,  medicine  glastest 
""■'  C<3r  receiving  the  spinal  fluid  and  the  other  for  the  anesthetic  solution;  3,  ampule 
w>nt-«i[|ijg  (]jg  anesthetic;  4,  scalptel;  5,  syringe  and  trocar. 

trajusygPggly  jj  jg  ground  the  better.  With  a  short-pointed  needle 
the  liability  of  injecting  only  a  portion  of  the  solution  into  the  canal 
^"i  part  outside  the  subarachnoid  space  is  quite  remote.  In  addi- 
tioix,  a  scalpel  for  making  the  preliminary  puncture  and  sterilized 
loeclicine  glasses  for  holding  the  solution  to  be  injected  should  be 
provided  (Fig.  75). 

location  of  the  Puncture. — ^Any  of  the  spaces  between  the  second 
lumbar  and  the  first  sacral  vertebra  is  available  for  the  puncture,  but 
"le  Usual  site  is  between  the  third  and  fourth,  or  the  fourth  and 
fifth  lumbar  vertebra  (Fig.  76).  The  spaces  may  be  identified  by 
counting  down  from  the  seventh  cervical  vertebra.  If  this  is  difl&cult 
on  account  of  excess  of  fat,  the  fourth  lumbar  spinous  process  may  be 
f^wlily  located,  and  from  it  the  other  vertebrie,  by  passing  a  line 


ii8 


LOCAL  Al^STHESIA 


between  the  highest  points  of  the  iliac  crests.     Such  a  line  pass^^ 
through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  verteh 
(Fig.  77).    Puncture  in  the  mid-line  is  generally  practised,  as 


,S^-.''l' 


Fig.  76. — Points  for  injecting  the  anesthetic  solution  in  spinal  anesthesia. 


of 


insures  the  solution  being  more  evenly  distributed  on  both  side* 
the  cord  and  lessens  the  chance  of  a  one-sided  analgesia.     A  p(^ 


between  the  two  spines  in  the  mid-line  is  chosen,  and  starting  iiC^^ 


S^ 


Fig.  77. — Showing  the  method  of  locating  the  fourth  spinous  process  by  passing  a 

line  through  the  highest  points  of  the  iliac  crests. 

this  point  the  needle  is  passed  slightly  upward  and  forward  between 
the  spinous  processes.  The  average  space  available  for  the  pimcture 
between  the  bones  in  the  lumbar  portion  of  the  cord  is  1^5  to  % 


i 


SPINAL  ANESTHESIA 


119 


lOJCK  (18  to  20  mm.)  in  the  transverse,  and  %  to  %  inch  (10  to 
5    xmn.)  in  the  vertical  diameter. 

3^eparation  of  the  Patient. — This  should  be  the  same  as  for  an 
p^^jration  under  general  anesthesia  (see  page  18) .    If  the  operation 


Pig.  78. — Sitting  position  for  spinal  puncture. 

is   to  be  a  prolonged  one,  morphin  gr.  3^  (0.0162  gm.)  should  be 
given  hypodermically  half  an  hour  beforehand. 

Position  of  the  Patient. — The  body  of  the  patient  is  curved  well 

forward  so  as  to  widen  the  intervertebral  spaces  as  much  as  possible. 

For  this  purpose  the  patient  sits  up,  leaning  well  forward,  with  his 


Fio.  79. — ^Lateral  position  for  spinal  puncture. 

back  to  the  operator  (Fig.  78),  or  else  lies  upon  one  side  with  the 

"^  in  the  form  of  an  arch  (Fig.  79). 

Sepsis. — The  operation  should  be  performed  with  the  greatest 
aseptic  care.  The  needle  and  syringe  should  always  be  boiled  in 
plain  water,  the  solution  injected  must  be  sterile,  and  the  operator's 


rUS. 


I20 


LOCAL  ANESTHESIA 


hands  and  site  of  operation  should  be  prepared  with  all  the  care  that 
would  be  observed  in  any  operation. 

Technic. — The  spot  chosen  for  the  puncture  is  anesthetized  with 
ethyl  chlorid  or  by  infiltration  with  a  few  drops  of  cocain,  and  a  small 
puncture  is  made  in  the  skin  with  a  scalpel  (Fig.  80),  tx)  lessen  the 
danger  of  carrying  in  infection  with  the  needle.  The  operatx)r  then 
identifies  with  his  finger  a  point  in  the  mid-line  between  the  two  spi- 
nous processes  bounding  the  space  for  the  pimcture,  and  inserts  the 
needle  armed  with  its  stylet  in  a  slightly  upward  and  forward  direc- 
tion until  it  enters  the  subarachnoid  space  (Fig.  81).  Lessened  resist- 
ance, followed  by  the  escape  of  the  fluid  from  the  needle,  determines 


Fig.  80. — Spinal  anesthesia.  First 
step,  nicking  the  skin  at  the  site  of 
puncture. 


Fig.  81. — Spinal  anesthesia.    Second 
step,  inserting  the  needle. 


when  this  is  accomplished.  The  distance  necessary  to  be  traversed 
varies  from  i  to  i}4  inches  (2.5  to  4  cm.)  in  a  child,  2^  to  3  inches 
(6  to  7.5)  in  an  adult.  In  inserting  the  needle,  if  it  strikes  bone,  it 
should  be  withdrawn  slightly  and  its  direction  changed.  The  cere- 
brospinal fluid  should  gush  out  with  some  force  on  removal  of  the 
stylet  and  should  be  clear.  If  only  a  few  drops  escape  or  the  fluid  is 
reddish  in  color  it  indicates  that  the  needle  is  not  properly  inserted, 
and  a  new  puncture  should  be  made.  A  quantity  of  cerebrospinal 
fluid,  corresponding  to  the  amount  of  anesthetic  to  be  injected,  should 
be  allowed  to  escape  before  the  analgesic  solution  is  introduced  (Fig. 
83).     This  will  vary  from  10  to  40^1  (0.6  to  2.5  cc),  according  to 


SPINAL   ANESTHESIA 


the  Strength  of  the  solution  to  be  used.  As  soon  as  the  desired 
quaxktity  of  cerebrospinal  fluid  has  escaped,  the  flow  is  stopped  by 
placing  a  finger  over  the  end  of  the  needle, 
and  the  syringe,  £Jled  with  the  proper 
amount  of  solution,  is  attached.  Some 
i^>erators  prefer  to  dissolve  the  analgesic 
agent  in  the  cerebrospinal  fluid  withdrawn 
and  reinject  the  solution  thus  formed. 
The  solution  should  always  be  slowly  intro- 
duced (Fig.  84).  The  needle  is  then  with- 
drawn and  the  puncture  sealed  with  collo- 
dion and  cotton,  or  is  dressed  with  a  piece 
of  gauze  held  in  place  by  adhesive  plaster. 
If  a  heavy  solution  is  employed  and  the 
operator  desires  a  low  anesthesia  only,  the 
patient  is  kept  in  the  upright  position  for 
a  few  moments  after  the  injection  to  allow 
the  solution  to  gravitate  downward,  but,  if 
a  light  solution  is  used,  the  patient's  head 
must  be  immediately  lowered  to  prevent  its 
rapid  spread  upward. 
A.S  the  solution  comes  in  contact  with  the  nerve  roots  it  blocks 


Fig.  82. — Showing  the 
direction  of  the  needle  in 
entering  the  spinal  canal. 


Fig.  83, —Spmal  anesthesia.    Third  Pic  84 — Spmal  anesthesia.    Fourth 

•"?•  ■Ilowing  the    cerebrospinal    fluid  step    injectiog   the  anesthetic  solution. 

totsom, 

their  conductivity,  and  in  from  ten  to  fifteen  minutes  loss  of  sensa- 
tWD,  often  accompanied  by  muscular  paralysis,  takes  place.     The 


122  LOCAL  AKESTHESLA. 

anesthesia  becomes  marked  first  in  the  anal  and  perineal  regions,  and 
then  in  the  lower  extrqpiities,  being  limited  above,  as  a  rule,  to  a  zone 
not  higher  than  the  waist  line.     With  a  successful  injection,  any  op- 
eration about  the  lower  extremities,  the  anus,  perineimi,  or  pelvis 
may  be  readily  performed.    The  anesthesia  thus  obtained  persist::^ 
for  two  hours  or  longer. 

Following  the  operation  the  patient  is  kept  recimibent  in  bed  wi' 
the  upper  part  of  his  body  slightly  raised  and  is  not  permitted  to 
upright  for  twenty-four  hours. 

SACRAL  OR  EPIDURAL  ANESTHESIA 

The  idea  of  anesthetizing  the  sacral  nerves  by  injecting  dru| 
into  the  extra-dural  space  through  the  lower  end  of  the  sacral 
originated  with  Cathelin.    Later  the  method  was  employed  in  ol 
stetrics  for  the  purpose  of  obtaining  painless  deliveries,  but  it 
came  into  general  use.     More  recently  sacral  anesthesia  has 
revived  and  the  technic  improved  by  La  wen  and  others  to  such 
extent  that  the  method  is  now  of  recognized  value  in  operatioi 
upon  the  genital  and  anal  regions  below  the  level  of  the  fifth 
nerve. 

The  injection  into  the  sacral  canal  of  normal  salt  solution  aloi 
or  in  combination  with  drugs  has  also  been  employed  extensively  as 
therapeutic  measure  for  eneuresis  and  pelvic  neuralgias  and  neuros< 

Like  spinal  anesthesia,  the  sacral  method  fails  in  a  certain  propo: 
tion  of  cases  even  in  the  hands  of  those  skilled  in  its  use,  and  in  soi 
cases  only  partial  anesthesia  is  obtained.     Most  of  the  failures 
met  with  in  very  stout  individuals.     In  a  successful  case  the  an< 
thesia  usually  lasts  for  from  ^  to  an  hour.     The  anesthesia 
not  accompanied  by  unpleasant  symptoms,  such  as  headache  an- 
vomiting,  that  are  sometimes  observed  in  spinal  anesthesia,  thoug^^^ 
a  transient  pallor,  acceleration  of  the  pulse,  and  a  fall  in  blooc^^'' 
pressure  may  occur. 

Anatomy. — Up>on  the  dorsal  surface  of  the  sacrum  in  the  mediae^ 
line  may  be  recognized  the  spinous  processes  of  the  three  of 
four  upper  vertebrae,  the  fourth  spine  sometimes,  and  the  fifth  spin? 
always  being  absent  through  failure  of  the  lamina  to  coalesce.  A 
triangular  gap,  known  as  the  hiatus  sacralis,  is  thus  formed  through 
which  a  needle  may  be  readily  passed  into  the  sacral  canal.  The 
lower  margins  of  this  opening  are  prolonged  downward  as  two  tuber- 
cles, the  sacral  cornua  (Fig.  85). 


SPINAL   ANESTHESIA 

The  sacral  canal  contains  the  lower  end  of  the  cauda  equina,  the 
fiitim  terminale,  and  the  spinal  dura.  The  latter  extends  to  the  level 
*f  the  second  sacral  vertebra  or  to  within  2?.^  inches  {6  cm.)  of  the 
Li.atus  (Fig.  86). 

Instruments. — The  instruments  required  are  the  same  as  for 
=>xnal  anesthesia  (page  117),  e-vcept  a  larger  syringe — one  with  a 
ikpacity  of  about  5  drams  (20  c.c.) — will  be  found  preferablei 

Solutions  Used. — Cocain,  procain,  and  quinin  and  urea  have  all 
e^in  used  for  sacral  anesthesia,  but  procain  is  the  drug  generally 
ixTMployed.     It  is  claimed  that  the  addition  of  sodium  bicarbonate  to 


FiO.  8s.— The  posterior  aur- 
lice  o{  the  sacrum,  ahowiag  the 
Umu9  sacral  is- 


to  the  anesthetic  effect, 


tht  procain  solution  adds 
made  up  as  follows: 

Sodimn bicarb.,  punas.,  0.25  gm,  (j^i  gr.) 

Sodium  chlorid,  0.5  gm.  (8  gr.) 

ProcoiD,  1  gm.  (is  gr.) 

TTiis  is  dissolved  in  100  c.c.  (3^^  ounces)  of  cold  sterile  distilled 
water,  and  is  sterilized  by  boiling.  When  it  has  cooled,  $  drops  of  a 
I  to  1000  adrenalin  chlorid  solution  are  added  The  quantity  of 
procain  used  at  a  dose  is  from  0.4  to  0.6  gm.  (6  to  9  gr.). 

Preparatioa  of  Patient ^The  patient  is  given  by  hypodermic  half 
iii  hour  before  the  operation  morphiii  gr.  }-^  (0.0108  gm.)  and  atro- 
i""!  gr-  Hoo   (6.00065  g""-)'     To  this  may  be  added  scopolamin 


124 


LOCAL  ANESTHESU 


gr.  Hoo  (0.00065  S^)<  if  ^^^  operation  is  especially  difficult  or 
prolonged. 

Position  of  Patient — The  patient  should  be  in  the  Sims  position. 
Site  of  Puncture. — The  puncture  is  made  in  the  median  line    1 
through  the  lower  end  of  the  sacral  canal.    The  opening  is  identified 
by  palpating  the  spinous  processes  of  the  sacrum  downward  untilit     1 
is  felt  that  they  divide  in  a  fork-like  manner,  forming  the  boundaries 
of  a  triangular  area,  the  hiatus. 

Asepsis. — The  instruments  are  sterilized  by  boiling  in  plain  watei, 
the  solution  is  boiled,  and  the  operator's  hands  are  cleansed  as  fot 
any  operation.    The  patient's  skin  at 
the  site  of  proposed  puncture  is  painted 
with  tincture  of  iodin. 

Technic. — The  point  of  propose<i 
puncture  is  located  and  the  skin  is  io-- 
liltrated  with  a  0.2  per  cent.  solutivXi 
of  cocain  or  a  i  per  cent,  solution  oi 
procain.  A  small  nick  is  then  mad' 
in  the  skin,  and  the  needle,  with  tlx* 
trocar  in  place,  is  inserted  at  an  angl* 
of  about  45  degrees  until  it  strikes  tta-^ 
bone  forming  the  anterior  waU  of  ttm-' 
canal  (Fig.  87).  The  trocar  is  th(S^ 
withdrawn,  and  the  direction  of  tt»-' 
needle  is  changed  to  correspond  wit-^ 
the  direction  of  the  sacral  canal.  It  :^ 
then  pushed  into  the  canal  for  a  di^^ 
tance  of  about  an  inch  (2.5  cm.).  ^^ 
the  needle  is  in  the  canal  its  point  maj^ 
be  freely  moved  about,  and,  upon  mal^^ 
ing  a  test  injection  with  normal  sal 
solution,  the  solution  can  be  injected  with  ease.  If  difficulty  is  me' 
in  inserting  the  needle,  the  sacral  opening  may  be  first  exposed  by^ 
an  incision  under  infiltration  anesthesia. 

A  little  blood  may  flow  from  the  needle,  due  to  injury  to  som^ 
small  veins,  and  may  be  disregarded,  but,  if  the  bleeding  is  profuse, 
or  if  blood  escapes  in  spurts,  the  injection  should  be  abandoned; 
the  same  is  true  if  clear  fluid  escapes  from  the  needle  indicating  that 
the  dura  has  been  punctured.  The  anesthetic  solution  should  be 
injected  very  slowly,  and,  when  the  desired  quantity  has  been  intro- 
duced, the  needle  is  removed  and  the  point  of  puncture  is  sealed  with 


Fig.  87.— Di  reel  ion  taken  by 
the  needle  in  entering  the  sacral 


PARASACRAL  ANESTHESIA 

collodion  and  cotton.     The  patient  is  then  brought  into  position  for 
op^ation,  and  in  from  3  to  5  minutes  the  anesthesia  is  complete. 


PARASACRAL  ANESTHESIA 

Another  method  of  securing  anesthesia  for  operations  in  the 
r^on  of  the  perineum  is  the  parasacral  blocking  of  the  sacral  nerves 
is  they  emerge  from  the  sacral  foramina.  When  properly  per- 
formed, paralysis  of  the  sphincter  ani  is  produced,  and  the  prostatic 
nrelhra  and  the  bladder  are  anesthetized.  The  anesthesia  is  thus 
su£Sdent  for  vaginal,  prostatic,  and  rectal  operations,  but  does  not 
ext:end  sufficiently  high  for  operations  involving  the  uterus  and 
aduexa.  The  anesthesia  is  more  certain  than  that  following  an 
epadural  sacral  injection  and  is  without  after  effects. 

Anatomy. — Examination  of  the  anterior  surface  of  the  sacrum 
sl*ows  that  the  distance  between  the  adjoining  sacral  foramina  from 
ti*e  5th  to  the  2nd  measures  ^-i  of  an  inch  {2  cm.)  and  between  the 
«x<3  and  1st  one  inch  (2.5  cm.),  and  that  a  straight  line  between  the 
Sth.  and  ist  sacral  foramina  will  pass  directly  over  the  intervening 
I*«"aimna,  Such  a  line  starts  at  the  lower  free  margin  of  the  sacrum 
7^  of  an  inch  (2  cm.)  from  the  median  line  and  diverges  slightly, 
'**Out  tg  of  an  inch  (0,3  cm.),  as  it  passes  up  to  the  ist  sacral  foramen. 
Viewed  laterally,  the  anterior  surface  of  the  sacrum  is  practically 
"*t  between  the  5th  and  snd  sacral  foramina,  but  from  the  znd  to  the 
■**  it  is  curved  anteriorily. 

The  sacral  foramina  may  thus  be  readily  reached  by  a  needle  and 

"C  nerves  blocked  as  high  as  the  2nd  sacral  by  passing  a  needle 

ipward  in  a  straight  line  with  a  slight  outward  divergence  from  a 

point  ?^  of  an  inch  (2  cm.)  from  the  median  line  on  the  lower  edge  of 

1^  sacrum.     The  needle  cannot  be  advanced  further  without  strik- 

Wg  bone,  owing  to  the  forward  curve  of  the  sacrum,  and  to  reach  the 

'sl  sacral  foramen  and  nerve,  the  point  of  the  needle  must  first  be 

tW\-ated  about  half  an  inch  (i  cm.)  and  then  inserted  along  the  same 

wieas  before  an  inch  (2.5  cm.)  further. 

Instruments. — A  syringe  with  a  capacity  of  5  drams  (20  c.c),  a 
iiirly  fine  needle  5  inches  (12  cm.)  long,  and  a  glass  graduate  with  a 
^piicily  of   3  ounces  (100  c.c.)  will  be  required. 

&)lutioa. — A  I  per  cent,  procain-adrenalin  solution  in  normal 
wli  solution  is  employed. 

Quantity,^ — For  blocking  the  nerves  on  both  sides  about  3  ounces 
("» c.c.)  of  solution  will  be  required. 


1 


126 


LOCAL  ANESTHESIA 


,^P^ 


Preparation  of  the  Patient. — The  patient's  rectum  should 
empty.    Half  an  hour  before  the  operation  the  patient  is  given  m 
phine  gr.  J^    (0.0108   gm.)    and  atropin  gr.   J^oo   (0.00065  gi 
hypodermically. 

Position  of  Patient. — ^The  patient  should  be  in  the  lithotoi 
position. 

Site  of  Puncture. — ^The  needle  is  inserted  into  the  tissues  al 
point  ^  of  an  inch  (2  cm.)  from  the  median  line  on  the  right  a: 
left  of  the  sacro-coccygeal  articulation. 

Asepsis. — The  instruments  are  sterilized  by  boiling  in  pla 
water,  the  solution  is  boiled  and  the  operator's  hands  are  prepared 
for  any  surgical  operation.  The  skin  at  the  points  of  puncture 
painted  with  tincture  of  iodin. 

Technic. — If  a  fairly  fine  needle  is  employed,  preliminary  anc 
thesia  of  the  skin  at  the  point  of  proposed  pimcture  may  be  di 

pensed  with.  Braun's  technic  for  bloc 
ing  the  nerves  is  as  follows:  The  needle 
inserted  on  a  level  wath  the  sacro-cocc 
geal  point  ^^  of  an  inch  (2  cm.)  from  t 
median  line  parallel  to  the  anterior  si 
face  of  the  sacrum.  The  lower  edge 
the  sacrum  is  sought  for,  and  from  tl 
point  the  needle  is  passed  2\i,  to  3  inch 
(6  to  7  cm.)  along  the  inner  surface  of  t 
sacrum  on  a  line  diverging  slightly  frc 
the  midline  until  bone  is  reached.  Tl 
will  be  at  the  2nd  sacral  foramen.  Fi 
drams  (20  c.c.)  of  the  anesthetic  soluti* 
is  injected  as  the  needle  is  withdra\ 
from  the  2nd  to  the  5th  sacral  foramina.  With  the  needle  withdraw 
to  the  lower  edge  of  the  sacrum  its  direction  is  changed  by  elevj 
ing  its  point  toward  the  innominate  line,  and  it  is  again  insert 
nearly  parallel  to  the  mid-line  to  a  depth  of  3  J^  to  4  inches  (9 
10  cm.)  from  the  edge  of  the  sacrum,  when  it  should  strike  bone 
the  ist  sacral  foramen.  Here  5  drams  (20  c.c.)  more  solution  is 
jected.  Finally  i]-^  drams  (5  c.c.)  of  the  solution  is  injected  ^ 
tween  the  rectum  and  coccyx.  The  same  procedure  is  carried  < 
on  the  opposite  side. 

If  the  rectum  is  empty  and  the  needle  is  kept  in  close  cont 
with  the  sacrum  while  it  is  being  inserted,  there  is  little  dangei 
injuring  the  bowel,  but,  as  a  precaution,  the  index  finger  may 
inserted  into  the  rectum  as  a  guide. 


Fig.  88. — Method  of  in- 
serting the  needle  for  para- 
sacral anesthesia  (Warbasse). 


SPHYGM  OMANOMETRY 


Sphygraomanometry  is  the  instrumental  estimation  of  arterial 
blcKxi- pressure.     The  determination  of  blood-pressure  has  become  a 
subject  of  such  practical  importance  that  both  physicians  and  sur- 
geons should  be  familiar  with  the  technic.     In  certain  cases  it  is 
oilen  of  the  greatest  value  not  only  in  making  a  diagnosis,  but  for 
purposes  of  prognosis  and  as  a  guide  to  the  treatment.     It  is  es- 
pecially important  in  surgical  work  in  determining  the  fitness  of  a 
subject  for  anesthesia  (see  also  page  20)  andlduring  an  operation 
in  revealing  impending  danger  from  shock  or  cardiac  weakness. 
For  the  latter  purposes  it  should  be  employed  as  a  routine  in  all 
serious  operations  likely  to  be  attended  by  shock  or  considerable 
hemorrhage. 

In  studying  blood-pressure  two  measurements  are  made,  namely, 

the  systolic  and  the  diastolic  pressure,  and  from  these  readings  the 

■rt^  pressure  and  the  mean  pressure  are  determined.     The  systolic 

^^■nre  is  the  maximum  pressure  caused  by  the  systole  of  the  heart; 

^^^SoUc  pressure  is  the  minimum  pressure  in  the  artery.     The  pulse 

pBssiire  is  the  difference  between  the  systolic  and  the  diastolic  pres- 

suie,  while  the  mean  pressure  is  the  arithmetic  mean  of  the  systolic  and 

faolic  pressures;  for  example,  if  the  systolic  pressure  is  estimated 

*tH5mm.  and  the  diastolic  pressure  at  105  mm,,  the  mean  pressure 

wJuUbe  125  mm. 

The  instrument  employed  for  estimating  blood-pressure  consists 
Wtntially  of  a  hollow  rubber  band  for  compression  of  an  artery, 
'"HMcted  with  a  manometer  and  inflating  bulb.  The  amount  of 
("Ksore  necessary  to  obliterate  the  pulse  distal  to  the  point  of  constric- 
win  measured  in  millimeters  of  mercury  represents  the  systolic  blood- 
PKsnire.  The  diastolic  pressure  is  obtained  by  gradually  releasing 
'heiiirfrom  the  compression  band  after  the  pulse  has  been  obliterated 
Md  noting  the  oscillations  of  the  column  of  mercury  in  the  manom- 
«'w,  the  base  line  of  the  greatest  oscillation  representing  the  dias- 
lolic  pressure-  Both  systolic  and  diastolic  pressure  should  be  taken 
*hai  it  is  possible,  but  of  the  two  the  determination  of  the  systolic 
pressure  is  of  most  importance,  as  pathological  conditions  affect  it 
fflore  than  the  diastolic. 


1 28  SPHYGMOMANOMETRY 

The  average  normal  systolic  pressure  obtained  with  the  wide 
cm.)  armlet,  according  to  Janeway,  is  as  follows: 

For  children  up  to  two  years,  75-90  mm.  of  mercury 

For  children  over  two  years,  90-1 10  mm.  of  mercury 

For  adults,  100-130  mm.  of  mercury 

In  females  the  pressure  is  about  10  mm.  less  than  in  males.  Ai 
middle  life  the  pressure  generally  reads  higher — often  as  high  as 
mm.  A  systolic  pressure  between  145  and  90  mm.  in  an  adult  m 
therefore,  be  considered  within  the  limits  of  health.  K,  on  repea 
examinations,  the  pressure  registers  above  or  below  these  limits 
should  be  viewed  with  suspicion.  A  pressure  above'  2cx)  ncmi 
considered  very  high  and  below  70  mm.  very  low,  while  below  4« 
40  mm.  the  pulse  can  rarely  be  recognized.  The  diastolic  press 
normally  registers  25  to  40  mm.  less  than  the  systolic.  If  the  dif 
ence  between  the  two  is  less  than  20  mm.  or  more  than  50  mm. 
indicates,  in  the  first  instance,  an  abnormally  small  pulse,  and,  in 
latter  case,  an  abnormally  large  pulse. 

As  blood-pressure  is  dependent  upon  the  quantity  and  velocity 
the  blood  entering  the  circulation  with  the  contraction  of  the 
ventricle,  the  elasticity  of  the  arterial  walls,  the  volume  of  blooc 
the  circulation,  and  on  the  resistance  in  the  peripheral  vessels,  it  > 
be  readily  seen  that  it  may  be  subject  to  considerable  variatior 
health  and  may  be  modified  by  many  circumstances.  Anyth 
which  increases  one  or  other  of  these  factors  will  raise  the  blood-pi 
sure  and  vice  versa.  Thus  a  recent  meal,  fear,  anxiety,  self-consdc 
ness,  mental  application,  pain,  drugs  which  act  upon  the  vasci 
system,  such  as  camphor,  caffein,  strychnin,  digitalis,  adrenalin,  e 
increase  blood-pressure.  Cold  causes  a  rise  in  blood-press 
through  its  constricting  effect  upon  the  peripheral  vessels;  wan 
has  the  opposite  effect.  Smoking  likewise  increases  it  if  it  ha 
stimulating  effect,  but  causes  it  to  fall  if  it  depresses.  Exercise 
the  same  effect,  that  is,  it  increases  pressure  unless  it  is  carried 
exhaustion,  when  the  pressure  falls.  The  posture  of  the  individ 
also  modifies  the  pressure  reading,  it  being  10  to  15  mm.  higher  i» 
the  person  standing  than  when  lying  down.  Likewise,  the  press 
is  generally  higher  in  the  afternoon.  The  size  of  the  encircling  hi 
is  also  important,  the  narrow  bands  giving  a  higher  reading  than 
broad  ones.  Furthermore,  as  the  estimation  of  pressure  depends 
the  tactile  sense  of  the  individual  palpating  the  pulse,  the  press 
readings  in  the  same  patient  will  vary  somewhat  with  differ 
observers.     Therefore,  to  avoid  these  sources  of  error  and  obt 


SPHYGMOUANOUETRY  1 29 

Tea.<liiigs  of  value  for  comparison,  the  determination  of  pressure 
should  always  be  made  by  the  same  observer,  imdet  the  same  con- 
ditions, at  the  same  time  of  day,  with  the  patient  in  the  same  position, 
aad  at  rest  mentally  and  physically,  and  employing  the  same  size 
arnnJet 

Instruments.— There  have  been  a  number  of  excellent  sphyg- 
momanometers devised,  such  as  the  Riva-Rocci,  Stanton,  Erlanger, 
Jarkeway,  Hill  and  Barnard,  Faught,  Rogers,  etc.  A  few  of  these  will 
be  described. 


Fig.  80.— The  RKa  Rocci  Sphj  gmomancii 


The  Riva-Rocci  sphygmomanometer  (Fig.  89),  as  modified  by 
^Ook,  consists  of  a  portable  manometer  with  a  jointed  tube  and  scale 
reading  up  to  320  mm.    The  armlet  consists  of  a  rubber  bag  4)^^ 
laches  (11. 5  cm.)  wide  by  16  inches  (40  cm.)  long,  covered  with  can- 
vas, and  supplied  with  hooks  and  eyes  for  fastening  it  in  place.    A 
Wchardson  double  inflating  bulb  is  connected  with  the  armlet,  and 
also  with  the  manometer  by  means  of  a  glass  T-tube  and  rubber  tub- 
ing.  A  second  glass  T-tube  is  inserted  in  the  rubber  tubing  near  the 
manometer,  to  the  long  arm  of  which  is  attached  a  short  rubber  tube 
supplied  with  a  pinchcock,  for  the  purpose  of  releasing  the  pressure. 
Stanton's  instrument  (Fig.  90)  consists  of  a  rubber  compression 
annlet  4)^  inches  (11.5  cm.)  wide  by  16  inches  (40  cm.)  long,  in- 


SPHYGMOMANOUETKY 


Fig.  91, — Janeway's  Sphj'gmo  manometer. 


SPHYGMOMANOMETRY  131 

closed  in  a  cuff  of  leather  or  thick  canvas  reinforced  by  tin  strips. 
In  the  center  of  the  cuff  is  cemented  a  glass  tube  J-^  inch  (6  mm.) 
in  diameter.  The  manometer  consists  of  a  metal  cistern  connected 
by  a  metal  tube  with  a  glass  mercury  tube  having  a  scale  registering 
to  300  mm.  The  metal  cistern  is  provided  with  a  screw  cap  having  a 
T-sha.ped  metal  tube,  one  arm  of  which  is  connected  with  the  armlet 
and  the  other  with  the  inflating  apparatus,  which  consists  of  a  double 
inflating  bulb.  At  the  top  of  the  metal  cistern  is  a  screw  valve  "B" 
for  the  gradual  release  of  pressure,  and  on  the  arm  connected  with  the 
inflating  apparatus  is  a  stopcock  "A"  to  shut  off  the  inflation. 

Janeway's  instrument  (Fig.  91)  consists  of  a  U-shaped  manometer 
with  a  sliding  scale,  connected  with  a  cistern,  to  one  side  of  which  is 
attached  the  armlet  and  to  the  other  a  Politzer  bag  for  the  purpose  of 


Fic.  Qi. — Rogers'  Sphygmomanoi 


"^flation.    The  armlet  is  a  closed  rubber  bag  measuring  4^^  inches 
(*^2    cm.)  in  width  and  18  inches  (45  cm.)  in  length,  inclosed  in  a 
leather  cuff  that  k  fastened  to  the  limb  by  means  of  two  straps.    A 
stopcock  containing  a  needle  valve  for  the  release  of  pressure  is  inter- 
P*>sed  between  the  cistern  and  inflating  bag.    The  instrument  is 
iinassembled  for  packing  in  its  case  as  follows :  The  scale  is  slid  down 
md  the  upper  part  of  the  manometer  is  removed  and  placed  in  rings 
provided  for  this  purpose  on  the  lid.    The  open  end  of  the  manometer 
^  plugged  bya  small  cork" A  "  and  the  other  end  is  closed  automatic- 
^y  when  the  lid  is  shut  by  a  block  which  compresses  the  rubber 
B- "  'The  inflation  bulb  is  removed,  and,  as  the  box  shuts,  the  stop- 
cock slips  under  a  spring  "  C. " 

Rogers'  Sphygmomanometer  (Fig.  92)  registers  blood-pressure 
liy  means  of  an  aneroid  scale.  The  instrument  consbts  of  a  rubber 
*f™let  connected  by  two  tubes  with  a  gage  and  an  inflating  bulb. 
'The  dial  registers  from  o  to  260  mm.  of  mercury.     Upon  the  tube 


132  SPHYGMOMANOMETRY 

leading  from  the  inflating  bulb  is  placed  a  valve  for  releasing  the  air 
from  the  armlet.  The  readings  obtained  by  this  instrument  corre- 
spond very  closely  to  the  figures  obtained  with  the  mercury  instru- 
ments, and  the  instrument  has  an  advantage  over  the  latter  in  its 
simplicity  and  ease  of  operation. 

Whatever  form  of  instrument  is  employed,  a  wide  armlet  (4^^  to 
4^  inches  (11.5  to  12  cm.))  should  be  used. 

Site  of  Application. — ^The  compression  band  may  be  applied  to  the 
arm  or  the  thigh,  the  former  being  preferable. 

Position  of  Patient. — The  patient  should  be  recumbent  with  the 
part  subjected  to  pressure  on  a  level  with  the  heart. 

Technic  (Riva-Rocci  Instrument). — ^The  armlet  is  fastened  about 
the  arm  midway  between  the  shoulder  and  elbow  by  passing  the  open 
end  of  the  cuff  beneath  the  band  on  the  closed  end  and  hooking  it  in 
place.  The  manometer  is  placed  upon  a  table  near  by,  and  care  is 
taken  to  see  that  the  upper  portion  of  the  mercury  tube  is  fitted 
securely  in  the  top  of  the  lower  ond  and  that  the  mercury  is  at  the  zero 
point.  The  inflating  bulb  is  then  properly  connected  with  the  arm- 
let and  manometer,  and  the  pinchcock  is  closed.  The  examiner, 
with  the  fingers  of  one  hand  palpating  the  patient's  pulse,  gradually 
inflates  the  armlet  by  squeezing  the  bulb  with  the  other  hand  imtil 
the  pressure  obliterates  the  pulse,  when  the  height  of  the  mercury  is 
noted.  The  mercury  is  then  allowed  to  drop  slowly  until  the  pulse 
just  reappears  which  represents  the  systolic  pressure.  For  the  sake 
of  greater  accuracy,  this  maneuver  is  repeated  by  squeezing  and  relax- 
ing the  reservoir  bulb. 

StanUm^s  Instrument. — ^The  armlet  is  buckled  in  place  and  is 
connected  with  the  manometer,  the  scale  of  which  is  adjusted  so  that 
the  mercury  registers  zero.  With  the  valve  "B  "  closed  and  cock  "A" 
open,  and  with  the  fingers  of  the  operator  on  the  patient's  pulse,  the 
atrmlet  is  slowly  inflated  until  the  pressure  causes  the  pulse  to  dis- 
appear. The  inflation  cock  "A"  is  then  closed  and  valve  "B"  is 
gradually  opened  until  the  pulse  just  reappears.  The  height  of  the 
mercury  when  this  occurs  represents  the  systolic  pressure.  The  pres- 
sure is  further  slowly  reduced  a  few  millimeters  at  a  time,  and,  as  the 
mercury  falls,  its  column  oscillates  up  and  down,  increasing*  in  size 
unta  a  maxunum  is  reached  and  then  diminishing.  The  base-line  of 
the  maximum  oscillations  represents  the  diastolic  pressxwe,  which  is 
normally    25    to   40    mm.    below    the   systolic    pressxwe. 

Janeway^s  Instrument. — ^The  armlet  is  properly  secured  about  the 
limb  as  described  above  and  the  scale  is  so  adjusted  that  the  level  of 


SPHYGUOUANOMETRY 


133 


the  two  columns  of.mercury  is  at  zero.  With  the  fingers  on  the  radial, 
pulse  the  armlet  is  gradually  infiated  by  qompressing  the  bulb, 
Tmtil  the  pulse  disappears.  Then,  by  slowly  releasing  the  bulb  until 
the  pulse  just  returns,  the  systolic  pressure  is  estimated.  In  cases  of 
very  high  pressure,  it  may  be  necessary  to  employ  more  than  one  bulb 
full  of  air  to  obliterate  the  puke.  In  such  a  case,  the  stopcock  is 
closed,  and,  after  the  bag  is  refilled,  the  cock  is  opened  again  and  the 
pressure  raised  as  high  as  described.  The  diastolic  pressure  is  ob- 
tained in  the  same  manner  as  described  under  the  technic  with  the 
Stanton  sphygmomanometer. 


FlC.  93. — Tecfanic  of  sphygmomanometry  with  the  Stanton  mstrumeot. 

Rogers'  Instrument. — The  compression  band  is  applied  about  the 

3nn  like  a  bandage  and  is  secured  by  slipping  the  free  end  under  the 

i*5t  turn.     The  aneroid  gage  is  hung  from  a  hook  on  the  outer  aspect 

01  the  armlet  and  the  gage  and  inflating  bulb  are  properly  connected. 

To  measure  the  systolic  pressure  the  cuff  is  inflated  until  the  radial 

pulse  is  obliterated,  and  the  pressiire  in  the  cuff  is  raised  1  to  2  mm. 

^her.    Air  is  then  allowed  to  escape  slowly  from  the  armlet  until 

the  radial  pulse  beats  just  reappears.    The  figure  on  the  dial  at  which 

thehand  points  at  this  moment  represents  the  systolic  pressure.    The 

diastolic  pressure  is  obtained  by  allowing  air  to  escape  from  the  arm- 

kt  Very  slowly  until  the  dial  shows  a  maximum  range  of  oscillations. 

The  valve  is  then  quickly  closed  and  the  minimum  oscillation  is 

t**en  as  the  diastolic  pressure. 


134 


SPHYGHOHANOHETRY 


The  Auscultatory  Met/tod  of  detennining  systolic  and  diastolic 
pressure  is  carried  out  by  the  aid  of  a  stethoscope  instead  of  by  pal- 
pation.   The  cuff  is  applied  and  the  pulse  obliterated  in  tit  usual 
way.    The  operator  then  places  a  stethoscope  over  the  iKachbl 
artery  below  the  cuff  and  listens  for  the  ref^)peaiance  of  the  fint 
sound  (Fig.  94).    The  height  of  the  column  of  mercury  when  this 
occurs  represents  the  systolic  pressure.    If  the  armlet  be  furtha 
deflated  there  will  still  be  heard  murmurs  which  rapidly  dis^peax 
when  the  mercury  drops  30  to  45  mm.  below  the  systolic  reading. 
The  point  at  which  all  sounds  disappear  represents  the  diastolxc 
pressure. 


by  the  auscultatory  method. 


With  this  method  the  systolic  pressure  is  recorded  at  a  slightly 
higher  and  the  diastolic  pressure  at  a  lower  reading  than  by  the  pal- 
pation method,  and  as  a  result  the  pulse  pressure  will  be  also  higher. 

Variations  of  Blood-pressure  in  Disease. — Pain  of  all  kinds 
causes  an  increase  in  the  peripheral  resistance,  and  a  rise  in  pressure. 
Thus,  in  conditions  attended  with  severe  pain,  as  in  acute  biliary  or 
renal  colic,  during  labor,  in  acute  peritoniris,  etc.,  the  blood-pressure 
in  elevated.  If,  however,  the  patient  is  already  in  a  weakened  state  or 
is  suffering  from  shock,  the  addition  of  pain  may  cause  a  fall  in 
pressure. 

Wasting  diseases,  or  cachetic  conditions,  as  cancer,  tuberculosis, 
etc.,  are  as  a  rule  accompanied  by  low  pressure.    In  tuberculosis,  if 


w.\nometrY" 


the  pressure  is  normal  or  increased,  it  is  li>oked  upon  as  a  good  prog- 
nostic sign. 

/n  injeciious  diseases  low  pressure  is  the  rule.  In  typhoid  fever  a 
lapid  drop  is  indicative  of  hemorrhage;  if  perforation  occurs,  there  is 
a  sudden  rise  in  pressure. 

Toxic  conditions,  such  as  lead  poisoning,  acute  gout,  uremia, 
eclampsia,  exophthalmic  goiter,  etc.,  are  accompanied  by  increased 
pressure  through  reflex  vasomotor  stimulation. 

Renal  AJcctions. — ^Acute  nephritis  may  or  may  not  produce  eleva- 
tion of  pressure.     The   same  is   true  of   chronic  parenchymatous 
nephritis,  but  in  the  chronic  interstitial  variety  high  pressure  is  the 
ruie.     In  any  variety,  with  the  onset  of  uremic  symptoms^  the  blood- 
pressure  rises,  but  falls  as  improvement  in  the  condition  sets  in. 

Cardiovascular  Diseases. — In  valvular  lesions  pressure  may  or 
ma,y  not  be  elevated;  in  fact,  the  results  of  blood-pressure  observa- 
•■"*  ris  in  this  class  of  cases  are  too  varied  to  be  of  value.  In  primary 
"myocarditis  the  blood-pressure  is  low,  but  when  secondary  to  arterial 
^^r  kidney  disease  it  may  be  high.  In  arteriosclerosis  the  pressure  is 
Bdierally  elevated,  especially  with  hypertrophy  of  the  left  ventricle, 
^''t^eriosclerosis  may  exist,  however,  without  elevation  of  pressure, 
^'^•i,  if  cardiac  muscle  insufficiency  be  present,  the  pressure  may  be 
''^lo-w  the  normal. 

-Acute  Peritoniiis. — In  the  early  stages,  the  pressure  is  abnormally 
^*K1s.     a  sharp  rise  may  precede  all  other  symptoms  in  the  beginning 
'        peritonitis    from    typhoid,   appendicular,   or    other    forms    of 
P»«=«-f  oration. 

Sead  or  Brain  /ty'ttrtVi.^Blood-pressure  is  increased  in  compres- 

^**n  of  the  brain  from  depressed  bone,  extra-  or  subdural  clots,  ab- 

^^^ss,  tumors,  fracture  of  Ihe  base,  apoplexy,  etc.,  in  proportion  to  the 

**^gree  of  intracranial  tension.     In  acute  compression  from  hemor- 

^■liage  a  high  and  rising  blood -pressure  indicates  an  increase  in  the 

^Ceding  and  a  progressive  failure  of  the  circulation  in  the  medulla. 

"'•len  the  paralytic  stage  of  compression  appears,  the  pressure  falls. 

^■•^w  pressure  is  also  found  in  concussion  of  the  brain. 

nemorrhage. — The  loss  of  considerable  blood  results  in  a  rapid 
■         'all  of  pressure. 

H  In  shock  and  collapse  a  fall  in  blood-pressure  is  uniformly  present. 

|H  According  to  Crile,  in  shock,  the  fall  in  pressure  is  gradual,  wliile  the 

>»-         ^enn" collapse"  should  be  limited  to  those  conditions  in  which  there 
IS  1  sudden  fall  in  blood-pressure  due  to  hemorrhage,  injuries  of  the 
^  vasomotor  centers,  or  to  cardiac  failure. 


\ 


136  SPH  YGMOMANOMETR  Y 

In  Surgical  Operations. — Ether  causes  a  rise  or  else  has  no  effect 
even  in  large  quantities,  it  rarely  causes  a  fall.     Chloroform,  on  thi 
other  hand,  causes  a  fall  in  pressure.     Nitrous  oxid  as  a  rule  cause^^ 
an  increase  in  pressure. 

Superficial  cutting  operations  cause  a  rise  through  irritation  of  the 
peripheral  nerves — irritation  of  the  larger  nerve  trunks  causing 
greater  rise.    Opening  the  abdominal  cavity  likewise  produces  a  ris 
followed  by  a  fall,  the  degree  depending  upon  the  length  of  exposure 
of  the  viscera  to  the  air,  the  amount  of  handling,  separation  of  adhe- 
sions, and  sponging. 

Under  local  anesthesia  alterations  in  blood-pressure  are  less 
marked  than  when  the  same  procedures  are  carried  out  under  general 
anesthesia. 


CHAPTER  IV 

TRANSFUSION  AND  THE  INJECTION  OF  HUMAN 

BLOOD  SERUM 

TRANSFUSION 

The  term  transfusion,  as  commonly  used,  is  applied  to  the  trans- 
ference of  blood  from  the  vessels  of  a  healthy  individual  (the  donor) 
to  those  of  the  patient  (the  recipient),  while  the  term  infusion  is 
restricted  to  cases  in  which  other  media  than  blood  are  so  introduced. 
There  is  good  evidence  from  records  of  cases  that  transfusion  has 
been  practised  for  many  centuries,  but  it  was  not  until  Lower,  in 
1665,  a^d  Denys,  in  1667,  published  their  results  that  the  operation 
w-as  used  to  any  great  extent.  After  this,  it  was  employed  for  such  a 
vaxiety  of  purposes  and  so  extravagant  were  the  claims  of  its  expo- 
Events  that  the  French  government  prohibited  its  use,  and  it  soon  fell 
into  disrepute.  Early  in  the  nineteenth  century  the  operation  was 
revived,  and  it  became  a  recognized  means  of  supplying  the  body  with 
fluids  to  replace  that  lost  from  excessive  hemorrhage,  notably  that 
^>ccurring  after  childbirth. 

The  transfusion  was  either  performed  directly  by  means  of  glass 

^^^Jinulae  tied  in  the  blood-vessels  and  joined  by  rubber  tubing,  or  else 

^^directly,  the  blood  being  drawn  from  the  donor,  and,  after  first 

t>eing  defibrinated  by  whipping,  the  serum  resulting  was  injected  into 

^e  veins  of  the  recipient.    Frequently  the  blood  of  dissimilar  species, 

such  as  sheep's  blood,  was  employed.    There  were  many  accidents 

^^ulting  from  the  use  of  alien  blood,  and  from  the  employment  of 

^ansfusion  in  an  improper  class  of  cases,  to  say  nothing  of  the  dangers 

^f  infection  and  of  embolism  to  which  the  patient  was  exposed  by  the 

itiethods  used,  so  that  the  results  were  variable  and  uncertain,  and  in 

some  cases  even  fatal. 

As  the  subject  became  more  thoroughly  studied  and  better  under- 
stood, it  was  recognized  that  the  blood  of  dissimilar  species,  through 
Its  faculty  for  breaking  up  the  red  blood-corpuscles,  was  impractic- 
able and  dangerous  for  the  purpose  of  introduction  into  the  human 
circulation,  and  that  direct  transfusion  from  artery  to  vein  or  vein  to 
vem  only  was  permissible.     Furthermore,  it  was  contended  by  many 

137 


138      TRANSFUSION   AND   INJECTION   OF  HUMAN  BLOOD   SERUM 

that  transfusion  was  a  failure  outside  of  increasing  the  volume  of  fluid 
in  the  circulation,  as  the  blood  elements  did  not  retain  their  vitality, 
and  quickly  died  in  the  vessels  of  the  receiver.  Added  to  this,  tho 
uncertainty  of  blood-vessel  anastomosis  as  formerly  practised  and 
the  fact  that  transfusion  required  the  use  of  material  and  instruments 
often  difficult  to  procure  in  an  emergency,  materially  limited  the  use — 
fulness  of  the  operation,  and  it  became  less  and  less  used.  Finally^ 
with  the  introduction  of  infusions  of  normal  salt  solution  as  a  sub — 
stitute,  transfusion  practically  became  extinct. 

During  the  past  fifteen  years,  largely  through  the  work  of  Carrd^ 
Crile,  and  others  in  this  country,  transfusion  was  revived,  and 
with  the  development  of  improved  methods  of  blood-vessel  anasto — 
mosis  it  became  a  practical  operation,  the  value  of  which  in  cer — 
tain  cases  even  outside  of  hemorrhage  and  shock  is  well  established  ^ 
both  experimentally  and  clinically.     More  recently  still  attention  has 
been  again  focused  upon  indirect  transfusion  through  improvements 
in  the  syringe  cannula  method  by  Lindeman,  Unger,  and  others, 
and  the  use  of  paraffin  coated  tubes.     Success  with  these  methods, 
however,  depends  upon  the  ability  of  the  operator  to  transfer  the 
blood  from  the  donor  to  the  recipient  before  coagulation  takes  place. 
A  further  step  in  simplifying  indirect  transfusion  was  the  addition  to 
the  blood  of  sodium  citrate,  which  prevents  coagulation  and  at  the 
same  time  does  not  alter  the  normal  properties  of  the  blood.    The 
development  of  this  method  was  largely  the  work  of  Weil  and  Lewis- 
ohn,  and  at  the  present  time,  owing  to  its  simplicity,  transfusion  o^ 
citrated  blood  enjoys  the  widest  popularity  and  is  the  method  ^^ 
choice. 

Indications  and  Contraindications. — ^The  principal  indication  f  ^^ 
transfusion  is  severe  hemorrhage.     Crile  has  shown  that  if  perform^ 
early  enough  it  is  a  specific  remedy.     Experimentally  he  has  sU-^' 
cessfuUy  treated  every  degree  of  hemorrhage;  dogs  were  even  bled  ^^ . 
the  last  drop  that  would  flow  and  were  then  successfully  transfus^^' 
Transfusion  is  also  indicated  in  pathologic  hemorrhage,  where  tt*^ 
coagulability  of  the  blood  is  deficient,  as  in  hemophilia,  hemorrha^^ 
of  the  new  born,  cholemia,  hemorrhage  from  the  bowels,  etc.    I^ 
these  cases  the  condition  of  the  patient  has  been  at  least  improved  by 
the  operation  and  in  most  cases  the  hemorrhage  has  been  controlledf 
though  more  than  one  transfusion  may  be  required  before  permanent 
improvement  is  noted. 

For  shock,  transfusion  is  at  times  of  the  greatest  value.    It 
exerts  far  greater  influence  on  blood-pressure  than  does  saline  solu- 


TRANSFUSION  I39 

tion.  Both  will  raise  blood- pressure,  but  the  latter  will  not  maintain 
the  rise  in  pressure.  Transfusion,  on  the  other  hand,  frequently 
r^ses  the  blood-pressure  above  normal  and  will  sustain  it  at  a  high 
level  for  a  number  of  hours. 

For  illuminating-gas  poisoning,  where  chemical  changes  occur 
which  prevent  the  blood  cells  from  giving  up  carbon  dioxid  and  com- 
bining with  oxygen,  venesection  followed  by  transfusion  is  the  best 
treatment. 

In  secondary  anemia  transfusion  has  given  good  results  where  the 
cause  has  been  removed.  In  pernicious  anemia  transfusion  causes 
temporary  improvement,  but  it  is  extremely  doubtful  if  it  effects  a 
cure.    For  acute  leukemia  it  seems  to  be  of  no  value. 

In  pellagra  marked  improvement  and  some  cures  have  followed 
the  transfusion  of  blood  from  healthy  donors  or  healed  pellagrins, 
but  it  has  not  proved  as  valuable  a  remedy  in  this  disease  as  was  lirst 
tlwught.  The  beneficial  effects  are  probably  the  result  of  an  in- 
creased resistance  on  the  part  of  the  patient,  due  to  the  restoration 
of  the  blood  to  a  more  normal  condition.  For  the  same  action, 
ttinsfusion  is  indicated  in  subacute  forms  of  sepsis  associated  with 
anemia,  emaciation,  and  devitalized  tissues  such  as  is  frequently  seen 
in  War  surgery  in  patients  with  large  suppurating  wounds  and  in- 
'Hted  Compound  fractures.  Repeated  transfusions  of  small  amounts 
■>!  blood  is  of  untioubted  value  in  this  class  of  cases  for  the  purpose  of 
increasing  their  resistance. 

Transfusion  has  been  employed  in  many  other  conditions,  such 
**  tuberculosis,  acute  suppuration,  acute  infectious  diseases,  etc., 
iiut  the  results  have  not  been  encouraging.  It  is  contra-indicated 
"1  p&tients  with  organic  heart  disease  as  there  is  danger  of  overtax- 
•"S  the  heart  by  a  sudden  increase  in  the  amount  of  fluids  in  the 
orculation. 

Selection  of  the  Donor. — A  young,  healthy,  vigorous  adult  should 
w  selected  to  supply  the  blood  as  the  value  of  a  transfusion  depends 
III  a  large  extent  upon  the  type  of  donor.  The  subject  should  prefer- 
ably be  from  among  the  relatives  of  the  patient — a  close  blood  rela- 
wa,  as  a  brother  or  sister,  if  possible.  It  is  essential  that  the  donor 
■*  free  from  arterio-sclerosis,  organic  heart  disease,  malaria,  syphilis, 
ft<^-f  and  a  thorough  physical  examination,  including  a  Wassermann 
"action,  should  be  made  to  determine  his  fitness. 

Hemolysis, — Of  the  greatest  importance  is  the  selection  of  a 
clonor  whose  blood  is  compatible  with  the  blood  of  the  recipient. 
I'dIcss  the  delay  is  considered  more  dangerous  than  the   risk  of 


I40       TRASSFVSIOS   AXD    IXJECTIOX   OF  HUMAN  BLOOD  SERUM 

hemolysis,  the  blood  of  the  donor  and  recipient  should  always  be 
tested  for  hemolysis.    An  exception  to  this  is  in  the  case  of  a  new 
bom  infant,  as  it  has  been  shown  by  Cherry  and  Langrock  that  tJie 
mother  is  alwavs  a  safe  donor. 

Moss*  work  on  grouping  the  blood  according  to  the  power    of 
agglutination  has  proved  of  great  practical  value  in  transfusion.    He 

found  that  ever\'  indix-idual  mav  be  arbitrarilv  classified  in  one    of 

«  »  » 

four  groups  according  to  the  ability  of  his  serum  to  agglutinate  thie 
corpuscles  of  other  indi\'iduals.  and  according  to  the  ability  of 
corpuscles  to  be  agglutinated  by  the  sera  of  other  indi\'iduals.  A 
glutination  may  occur  independently  of  hemolysis,  but  if  agglutiiM.^ 
tion  is  absent  hemolysis  never  occurs;  hence,  from  the  agglutination 
reaction  it  is  possible  to  determine  whether  hemoh'sis  will  occur. 

Moss  classifies  the  four  groups  as  follows: 

Group  I. — Senmi  agglutinates  no  corpuscles. 
Q>rpuscles  agglutinated  by  sera  of  Groups  11,  HI,  and  IV. 

Group  n. — Serum  agglutinates  corpuscles  of  Groups  I,  and 
Q>rpuscles  agglutinated  by  sera  of  Groups  m,  and  r\'. 

Group  in. — Senmi  agglutinates  corpuscles  of  Groups  I  and 
Corpuscles  agglutinated  by  sera  of  Groups  11  and  IN*. 

Group  IN'. — Serum  agglutinates  corpuscles  of  Groups  I,  II  aM^d 
III.     Corpuscles  are  not  agglutinated  by  any  serum. 

The  above  may  be  conveniently  tabulated  as  follows: 

Serum  of  Group 

I       n     III    vr 

Corpuscles  of  Group  I o  -f  +  -h 

Corpuscles  of  Group  II o  o  +  + 

Corpuscles  of  Group  III o  +  o  + 

Corpuscles  of  Group  I\'  o  o  o  o 

(-r  =  Ajijelulinaiion  ■ 

(o    =  Xo  agglutination  or  hemoI\*sis) 

It  has  been  estimated  that  5  per  cent,  of  all  individuals  belong 
to  Group  I;  40  per  cent,  to  Group  II;  10  per  cent,  to  Group  III;  and 
45  per  cent,  to  Group  I\\ 

While  it  is  preferable  that  the  donor  and  recipient  belong  to  th^ 
same  group,  it  is  not  imperative,  and,  in  the  case  of  patients  belong-^ 
ing  to  the  less  common  groups  I  and  III,  this  is  often  difficulL  The? 
important  thing  is  to  choose  a  donor  ivhose  corpuscles  are  not  ag^ 
gluiinated  or  hemolyzed  by  the  serum  of  the  recipient.  The  fact  that 
the  donor's  serum  may  agglutinate  or  hemolyze  the  patient's  cor- 
puscles may  be  disregarded,  as  the  high  dilution  of  the  donor's  serum 


TRANSFUSION"  n 

tliat  results  when  it  is  added  to  the  blood  \-a!ume  of  the  recipient, 
Vtevents  any  harmful  action.  The  groupsj  whose  blood  may  be 
Safely  mixed,  is  shown  by  the  following  table: 

//  the  rccipmil  belongs  to  Group  I,  the  donor  may  be  selected  from 
Groups  I,  n,  III,  or  IV. 

IJlhe  recipietU  belongs  to  Group  'II,  the  donor  may  be  selected  from 
■Grtwps  11  or  IV. 

//  the  recipient  belongs  to  Group  III,  the  donor  may  be  selected 
b-om  Groups  III  or  IV. 

//  the  recipient  belongs  to  Group  IV,  the  donor  should  be  from 
!£x~oup  IV. 

Members  oi  Group  I  are  thus  termed  universal  recipients,  as  the 
^nmi  of  this  group  docs  not  agglutinate  the  corpuscles  of  any  of  the 
itlier  groups,  while  members  of  Group  IV  are  termed  universal  donors 
1^   iheir  blood  may  be  transfused  with  safety  into  any  patient. 

Method  of  Determining  Blood  Groups. — Vincent  {Journal  oj  the 
A  rmrican  Medical  Associatiott,  April  37,  1918),  describes  a  rapid  and 
sinnple  method  of  determining  blood  groups  by  testing  the  individ- 
ual's blood  against  known  dtrated  sera'  of  Groups  II  and  III.  Ci- 
traled  sera  are  employed  to  avoid  coagulation  of  the  fresh  blood 
I  which  is  mixed  with  the  sera  in  making  the  test,  otherwise  the  reac- 
tion might  be  confusing. 

The  technic  is  as  follows:  A  drop  of  the  Group  II  serum  is  placed 
upon  one  half  of  a  clean  glass  slide  and  a  drop  of  Group  III  serum 
upon  the  other  half.  The  lobe  of  the  ear  of  the  individual  to  be 
teled  is  then  punctured,  and  by  means  of  glass  rods  about  }£  of  a 
■liop  of  the  blood  is  added  to  each  serum,  thoroughly  mixing  the 
Hood  and  serum.  Separate  glass  rods  should  be  used  for  each  trans- 
fer of  blood  so  that  there  will  be  no  mixing  of  the  two  sera,  and  care 
oust  be  taken  to  make  the  transfer  before  the  blood  coagulates. 

The  red  cells  at  first  show  a  uniform  suspension  in  the  serum  which 
ptt^ls  if  there  is  no  agglutination.  Agglutination,  if  it  occurs,  is 
'fcognized  by  the  formation  of  masses  of  agglutinated  cells,  and  can 
be  distinguished  by  the  naked  eye.  The  reaction  usually  occurs 
tnabouta  minute.     If  there  is  any  doubt  as  to  the  reaction,  the  slide 

'Tilt scrum  is  prepared  by  collecUng  5  drams  (20C.C.)  o£  biood  from  individuals  of 
fifoufttUandlll,  under  aseptic  precautions.  The  serum  rcsiUting  from  each,  when  ihc 
l'*"Iiai  coagulated  and  iheclot  contracted,  is  drawn  off  by  means  of  separate  ptpelles 
tl«  Meiile  flasks,  and  sufRcient  sodium  citrate  is  added  to  each  serum  to  give  a  t.5 
ffdnt.  citnted  terum.     Tricresol  0.15  per  cent,  is  also  added  to  each  bottle  of  serum 


I 


142       TRANSFUSION  AND    INJECTION    OF  HUMAN  BLOOD   SERUM 

should  be  examined  under  the  microscope.  Rouleaux  formation 
sometimes  occurs  and  must  not  be  mistaken  for  agglutination. 
According  to  the  reactions  obtained,  it  is  possible  to  determine 
to  which  of  the  four  groups  the  individual  belongs.  The  accompanying 
illustrations  (Fig.  95)  readily  explain  the  reactions. 

Quantity  of  Blood  Transfused. — The  quantity  of  blood  transfused 
will  vary  according  to  the  age  of  the  patient  and  the  condition  for 
which  the  transfusion  is  performed.  Between  20  and  25  ounces 
(600  and  750  c.c.)  of  blood  for  an  adult,  and  from  2]^^  to  5  ounces 
(75  to  150  c.c.)  for  an  infant  is  an  average  dose. 

In  direct  transfusion  it  is  impossible  to  estimate  the  exact  amount 
of  blood  transfused  and  the  guides  should  be  the  tlie  condition  of 


Serum  n 


Se  rum  ra 


sScrumn 

sScrumw 

n 

9 

HI 

§ 

J 


C  roup  I 

IT 

III 

f 

Croup  n 


jr 


Q 


m 


• 


Groupnr  Grouprsr 

Fig.  95. — Agglutination  test  as  seen  macroscopicaJly, 

the  donor  and  the  recipient;  the  amount  should  also  vary  accordi^ 
to  the  condition  for  which  the  transfusion  is  performed.     Twenty 
to  forty-five  minutes'  flow  in  a  good  anastomosis  is  usually  suflideX*^' 
As  soon  as  the  donor  shows  signs  of  loss  of  blood — indicated  by  * 
gradual  pallor  about  the  nose  and  ears,  deepening  of  the  lines  01 
expression,    sighing   or  irregular  respiration,  etc. — the  transfusiol* 
must  be  immediately  stopped.     If  it  is  carried  too  far,  the  donor 
goes  into  a  state  of  collapse,  and  a  condition  is  produced  m  him  similar 
to  that  for  the  relief  of  which  the  operation  was  performed.    Fur- 
thermore, transfusion  of  excessive  amounts  of  blood  may  cause  ser- 
ious damage  to  the  viscera  of  the  recipient,  and  even  death.    Acute 
dilatation  of  the  heart,  manifested  by  dyspnea,  cyanosis,  cough, 
pain  over  the  precordium,  and  falling  blood-pressure,  is  the  most 
frequent  sequel  to  overtransfusion.     Should  such  a   complication 
ensue,  the  transfusion  must  be  immediately  stopped,   the  patient 


ij 


DIRECT  ARTERY   TO  VEIN   TRANSFUSION  143 

should  be  placed  in  a  reverse  Trendelenburg  pK)sition  with  the  feet 
lowered,  and  external  massage  of  the  heart  (page  71)  performed  to 
assist  in  emptying  it. 

lucidity  of  Flow. — ^The  rate  with  which  the  blood  is  injected  into 
the  recipient  or  flows  from  the  donor  to  the  recipient  should  be  care- 
fully regulated,  for  fear  of  overcharging  the  heart  and 'producing  an 
acute  cardiac  dilatation.  In  direct  transfusion  this  may  be  deter- 
mined by  noting  the  strength  of  the  pulsation  in  the  veins.  If  too 
strong,  the  flow  may  be  controlled  by  partially  compressing  the 
lumen  of  the  artery  by  means  of  the  fingers. 

Repetition  of  Transfusion. — The  blood  picture  and  the  general 
condition  of  the  patient  will  indicate  the  need  for  repetition  of  a 
transfusion.  Often  repeated  transfusions  of  moderate  amounts  of 
blood  give  better  results  than  a  single  large  transfusion.  Intervals 
of  seven  days  may  be  taken  as  an  average  for  repeated  transfusions, 
and  the  same  donor  should  not  be  employed  more  frequently  than 
this. 

DIRECT  ARTERY  TO  VEIN  TRANSFUSION 

An  anastomosis  between  the  artery  of  the  donor  and  the  vein  of 
the  recipient  may  be  effected  by  means  of  the  special  tubes  of  Crile, 
or  some  of  the  modifications  of  these  tubes,  or  by  means  of  the  direct 
suture  method  of  Carrel.  Crile's  method  is  without  doubt  the  more 
rapidly  and  easily  performed  of  the  two.  It  consists  essentially  of 
slipping  the  tube  over  the  vein,  turning  the  free  end  of  the  vein  back 
over  the  outer  surface  of  the  tube,  and  then  drawing  the  artery  over 
this  venous  cuff.  By  this  method  the  intimae  of  the  vessels  are 
brought  into  apposition  and  there  is  no  foreign  substance  in  contact 
^th  the  stream  of  blood,  thus  lessening  the  chance  of  thrombosis. 
Anastomosis  by  direct  suture,  while  it  brings  about  the  same  result, 
IS  difficult  to  perform  except  by  one  accustomed  to  blood-vessel  su- 
ture. In  addition,  there  is  frequently  a  contraction  of  the  vessels 
at  the  point  of  suture,  and  thrombosis  is  more  likely  to  occur. 

Instruments. — There  will  be  required  a  scalpel,  an  ordinary  pair 
of  blunt-pointed  scissors,  a  small  pair  of  curved  scissors,  thumb  for- 
ceps, very  fine  tissue  forceps,  two  small  Crile  clamps,  mosquito  hemo- 
stats,  and  transfusion  caimulae.  If  direct  suture  is  employed ,  instead 
of  the  Crile  tubes,  there  will  be  needed  several  No.  16  cambric  needles 
and  fine  strands  of  silk  (Fig.  96).  The  silk  should  be  thoroughly 
impregnated  with  vaselin  and  should  be  threaded  into  the  needles 
bdore  the  operation  is  begun. 


144       TBANSFUSION    AND    INJECTION    OF   HUHAN  BLOOD    SEKXJIC 

The  tube  devised  by  Crile  is  of  German  silver  and  is  provided  w 
a  small  handle  and  with  two  grooves  upon  the  outer  siu^ace  of  i 
cannula  portion  into  which  fit  the  ligatures  holding  the  van  a 
artery  in  place  (Fig.  98).     At  least  four  sizes  of  these  tubes  should 


Fig.  96, — Instluments  for  transfusion,  i,  Scalpel;  i,  Ihumb  forceps;  3,  bli 
pointed  scissors;  4,  mosquito  hcmostats;  5,  fine  tissue  forceps  6,  Crile  clamps;  7,  m 
pur  of  curved  scissors;  8,  Crile  cannulai;  9,  needles  threaded  with  fine  strands  of : 

at  hand,  and  the  largest  size  that  can  be  used  without  injury  to 
arterial  coats  by  undue  stretching  should  be  employed. 

Position  of  the  Donor  and  Recipient. — The  donor  should  lie  u] 
an  operating-table  of  a  type  that  will  permit  his  head  to  be  quic 


Fio,  97. — Enlarged  view  o(  Crile's 
damps.  (After  Fowler.)  1,  Clamp 
without  rubbers;  2.  rubber  lubes  to  fit  on 
jaws   of  clamps;  3,   clamp   applied    to 

lowered  if  he  becomes  faint  while  the  operation  is  in  progress.  ' 
recipient  is  placed  upon  a  second  table,  with  the  head  turned 
the  opposite  direction.  Both  tables  should  be  provided  with  a 
ions  or  a  layer  of  pillows,  so  that  the  patients  will  be  comfort 


DIRECT   ARTERY    TO   VEIN    TRANSFUSION  I45 

'  durii^  the  operation.     Between  the  two  operating-tables  is  placed  a 
small  square  table  upon  which  the  arms  of  the  donor  and  recipient 

I  test  during  the  operation.  The  operator  is  seated  upon  a  stool  in 
iront  of  this  table,  and  his  assistant  opposite  (Fig.  99), 
Asepsis.— The  strictest  asepsis  must  be  observed  during  the 
entire  operation.  The  instruments  are  boiled,  and  the  hands  of  the 
operator  are  prepared  in  the  usual  way.  The  forearms  of  the  donor 
and  the  recipient  should  be  sterilized  by  painting  with  tincture  of 
lodin. 

.Anesthesia. — The  operation  is  performed  under  local  anesthesia, 
ploying  a  0.3  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution 


tle,cipient~  i 


)□© 


Operatmff ;  Tahle 
2?onor 


•w.  <M. — .\.mingement  of  [he  opera  ting- tables  for  a  Iransfuaion.  (After  Crile.) 
1,  Title  [lit  recipient  ;  2,  table  fur  donor;  3,  [able  for  arms  of  recipient  and  donor; 
t  *™1  S.  stools  (or  operator  and  assistant;  6,  instrument  table;  7,  table  for  dressings, 


ul  ptwain  for  the  skin  and  a  0.1  per  cent,  cocain  solution  or  a  0,5 
j-crtent.  solution  of  procain  for  deejier  infiltration. 

Teduiic  by  Crile's  Method.^The  radial  artery  of  the  donor  and 
ii"y  01  the  superficial  veins  in  front  of  the  elbow  of  the  recipient  are 
tbusen  for  making  the  anastomosis — in  a  child  the  popliteal  vein 
"lay  iie  utilized.  Both  the  donor  and  the  recipient  are  given  ^^ 
P-  (0.0162  gm.)  of  morphin  hypodennically  half  an  hour  before  the 
^niion  unless  it  is  contraindicated. 

The  area  of  incision  Is  anesthetized,  and  about  iH  inches  (4  cm.) 
<•■  Ihe  radial  artery  is  exposed  and  dissected  free.  Any  branches  are 
ai'ofded  if  possible;  if  they  cannot  be  avoided,  they  may  be  tied  off 
*itli  line  silk  and  cut  close  to  the  trunk.     A  Crile  clamp  is  gently 


146       TRANSFUSION   AND   INJECTION   OF  HUMAN  BLOOD   SERUM 


applied  as  high  as  possible  to  the  proximal  end  of  the  artery,  or,  in  the 
absence  of  a  special  clamp,  a  piece  of  tape  may  be  placed  around  the 
artery  and  clamped  sufficiently  tight  to  compress  the  vessel  and 
shut  off  the  circulation.     The  distal  end  of  the  artery  is  thenligated 
and  the  vessel  is  cut.     The  adventitia  is  pulled  over  the  end  of  the 
vessel  and  is  snipped  off  as  clean  as  possible.     The  field  of  operation 
is  now  covered  with  a  compress  well  soaked  with  hot  saline  solution  • 
The  vein  of  the  recipient  is  then  exposed  in  the  same  manner,  anc3l. 
about  i}4  inches  (4  cm.)  of  it  is  freed  from  the  surrounding  tissues . 
The  distal  end  of  the  vein  is  ligated,  and  to  the  proximal  end  L^ 
applied  a  Crile  clamp  (Fig.  100),  or  a  narrow  piece  of  tape  fastene<f| 
as  described  above.     The  vessel  is  divided  and  the  adventitia  is 
snipped  off  after  pulling  it  out  over  the  end  of  the  vessel.    A  Cril^ 
cannula  of  appropriate  size,  held  in  an  artery  clamp,  is  pushed  ovt 


I 


Fig.  100. — Transfusion  by   Crile's  method.     First  step,  exposure  of  the  vein 

artery  wiih  Crile's  clamps  applied. 


the  vein.    A  suture  inserted  in  the  edge  of  the  vein,  as  shpwn  in  Fx^- 
loi,  aids  in  drawing  the  latter  through  the  cannula.    The  projecti^^^ 
portion  of  the  vein  is  seized  by  three  mosquito  clamps  and 
turned  back  as  a  cuff  (Fig.  102),  and  is  tied  in  the  second  groove 
the  cannula.    The  forearms  of  the  donor  and  the  recipient  are  ther-^^ 
placed  so  that  the  hand  of  the  donor  is  directed  toward  the  elbow  c^^ 
the  recipient.     The  cuffed  portion  of  the  vein  is  lubricated  witE^ 
sterile  vaselin,  three  mosquito  forceps  are  applied  to  the  edges  of  th^^ 
artery,  and  it  is  gradually  drawn  down  over  the  cuffed  vein  (Fig.103) 
and  is  tied  in  place  by  a  silk  ligature  which  fits  into  the  first  groove  on 
the  cannula.    The  clamp  is  removed  from  the  vein    first.    The 
damp  upon  the  artery  is  then  very  gradually  opened,  allowing  the 
blood  to  flow  into  the  vein  of  the  recipient  (Fig.  104).    At  the  com- 


DIRECT   ABTERV    TO   VKIN    TRANSFUSION 


M7 


pletion  of  the  operation  the  vessels  are  ligated,  the  tube  is  excised 
and  the  skin  incision  is  sutured  and  dressed  with  sterile  gauze. 

In  performing  the  operation  there  are  several  precautions  to  be 
obser\-ed.    The  vessels  to  be  anastomosed  must  be  handled  with  the 


method.     (A/lef   Crile.)     Second   step. 


II. — TransFuSfoa  by   Crili 
tbt  vein  through  ihe  cannula. 

Xic.  loi.— Transfusion  by   Cri!e"s  method.     (.Vler   Crile.)     Third  step, 
a(   crufliBg  back  the 

~  —Transfusion  by  Crile's  method.     (After  Crile.)     Fourth  step,  showing 


cuffed  back  over  the  cannula  and  the  method  o(  drawing  the  artery  o 


greatest  care.  They  should  never  be  bruised  with  artery  clamps  or 
^cked  up  with  toothed  forceps.  Some  difficulty  may  be  experienced 
liom  retraction  of  the  vessels  when  they  are  cut.     This  may  be  over- 


ethod 


r  the 


""ne  to  a  great  extent  by  keeping  them  constantly  moistened  with 
ml  saline  solution.  In  the  case  of  a  contracted  artery,  Crile  advises 
liat  it  be  dilated  by  gently  inserting  a  fine  pair  of  closed  artery 


.  148       TRANSFUSION  AND    INJECTION   OF  HUMAN  BLOOD   SERUIC 

-  clamps  covered  with  vaselin  and  using  it  as  one  would  a  glove 
stretcher.  Care  should  be  taken  that  the  anastomosis  be  made 
without  undue  tension,  and  that  the  cannula  be  placed  accurately  in 
the  long  axis  of  the  vein  and  artery,  otherwise  the  flow  will  be  more  or 
less  impeded. 

Variations  in  Technic. — Brewer  has  simplified  Crile's  method 
of  making  an  anastomosis  by  employing  long  glass  tubes  lined  with 
paraflSn  (Fig.  105).  These  tubes  are  about  2)'^  inches  (6  cm.)  long, 
and  are  made  small  at  the  end  to  be  inserted  into  the  artery  and  large 
at  the  end  over  which  the  vein  is  drawn.     Each  end  is  slightly  bul- 

'  bous,  and  is  provided  with  a  sulcus  into  which  the  ligature  holding 
the  vessel  in  place  falls. 

The  tubes  are  thoroughly  sterilized  and  are  then  dipped  in 
melted  paraflin,  shaken  out,  and  allowed  to  cool.  The  vein  and 
artery  are  exposed  and  isolated  in  the  usual  way  and  two  Crile  damps 


'•  iin~3 


c 


Fig.  105. — Brewer's  glass  tubes  lined  with  paraffin  for  transfusion* 

are  applied  as  shown  in  Fig.  100.  The  artery  is  drawn  over  oneca-^ 
of  the  tube  and  is  secured  by  a  ligature.  A  longitudinal  or  a  tra»-^* 
verse  cut  is  made  in  the  wall  of  the  vein  (see  Fig.  131),  and,  aft.^' 
loosening  the  arterial  clamp  sufficiently  to  permit  the  tube  to  fill  wi*^ 


blood,  the  distal  end  of  the  tube  is  quickly  inserted  into  the  vein  in 
maimer  shown  in  Fig.  132,  and  is  secured  in  place  by  a  ligature, 
clamps    are    then    removed    and    the    blood   is    allowed    to    fl^' 

Elsberg   {Journal  of  the  American  Medical  AssocicUiony  Me^^f^ 
13,  1909)  describes  a  very  practical  cannula  that  does  away  with 
necessity  for  the  Crile  clamps.     His  method  of  performing  the  anast^^ 
mosis  dififers  from  the  Crile  method  in  several  points.     "The  cannU^ 
(Fig.  106)  is  built  on  the  principle  of  a  monkey  wrench,  and  can  ^ 
enlarged  or  narrowed  to  any  size  desired  by  means  of  a  screw  at  it^ 
'    end.     The  smallest  lumen  obtainable  is  about  equal  to  that  of  th^ 
smallest  Crile  cannula,  and  the  largest  greater  than  the  lumen  of  anjT 
radial  artery.     The  instrument  is  cone-shaped  at  its  tip,  ashortdis- 


i 


INDIRECT    TRANSFUSION  I49 

tance  from  which  is  a  ridge  with  four  small  pin  points  which  are 
directed  backward.  The  lumen  of  the  cannula  at  its  base  is  larger 
than  at  its  lip." 

In  using  this  instrument,  after  first  exposing  and  separating  the  - 
artery  from  the  surrounding  tissues  in  the  usual  manner,  the  cannula 
is  widely  opened  and  is  placed  around  the  artery  before  the  latter  is ' 
cut.  The  cannula  Is  then  screwed  together,  thereby  shutting  off  the 
arterial  flow.  The  distal  end  of  the  artery  is  next  ligated  at  about 
J-^  inch  (i  cm.)  from  the  end  of  the  cannula,  and  three  line  silk  trac- 
tion sutures  or  small  tenacula  are  passed  through  the  artery  at  equi- 
distant points  on  its  circumference  a  short  distance  from  the  ligature. 
The  artery  is  then  cut  close  to  the  ligature,  and  the  end  is  cuffed  back 
hy  drawing  upon  the  traction  stitches  or  tenacula  and  is  caught  in  the 
teeth  upon  the  clamp.  The  vein  of  the  recipient  is  then  exposed  and 
two  ligatures  are  applied,  the  distal  one  being  tied  (see  Fig.  130). 


w 


The  vein  is  opened  by  means  of  a  small  transverse  slit  in  the  same 
"laimer  as  for  an  intravenous  infusion  {see  Fig.  131),  and  the  cannula 
wth  the  cuffed  artery  is  inserted  into  the  vein  and  tied  securely  in 
Piace  by  means  of  the  loose  ligature.  The  cannula  is  then  screwed 
'•pen  and  the  blood  is  allowed  to  flow,  the  rapidity  of  flow  being  con- 
'•"olled  by  the  extent  to  which  the  cannula  is  opened. 


INDIRECT  TRANSFUSION 

Indirect  transfusion  the  blood,  instead  of  passing  directly  from 
"*e  vessels  of  the  donor  into  those  of  the  recipient,  is  withdrawn  into  a 
Syringe  or  receptacle  and  is  then  injected  into  the  vessels  of  the  re- 
^^ent.  Its  success  depends  upon  making  the  transfer  of  blood  from 
"*  donor  to  the  recipient  without  coagulation  taking  place.  This 
•"sybe  accomplished  by:  (i)  making  the  transfer  with  such  rapidity  ■ 
"Wtlhe  blood  has  not  time  to  clot;  (2)  coating  the  receptacle  through  ■ 
'oich  the  blood  flows  with  parafl[in,  and  (3)  mixing  with  the  blood 
'Wlium  citrate,  which  prevents  coagulation. 

Transfusion  by  some  of  the  indirect  methods  Is  preferred  at  the 
l^Kent  time  to  direct  transfusion  for  the  reason  that  it  is  simpler, 


150       TRANSFUSION   AND    INJECTION    OF  HUMAN  BLOOD   SERUM 

and  requires  less  skill  in  its  performance  and  at  the  same  time  is 
quite  as  effective;  furthermore,  indirect  transfusion  has  this  ad- 
vantage, that  the  quantity  of  blood  transfused  may  be  accurately 
measured. 

Indirect  Transfusion  by  the  Syringe  Method  of  Lindeman. 
In  1892  von  Ziemssen  reported  having  perform6d  transfusions  by 
means  of  venous  puncture  ui>on  the  donor  and  recipient  and  with- 
drawing syringesf ul  of  blood  from  the  donor  and  injecting  them  into 
the  recipient.    The  method  did  not  receive  much  attention,  how; 
ever,  until   19 13  when  Lindeman  improved  upon  it  and  made  it 
suitable  for  transfusing  large  quantities  of  blood  by  using  numerous 
syringes  and  special  cannulae  with  which  injury  to  the  interior  of 
the  vein  during  manipulation  of  the  syringes  was  avoided.    Two 
operators   and   an   assistant   are   necessary;  and   they   should  be 
specially  trained,  as  success  with  the  method  depends  upon  dexterity 
and  speed  in  handling  the  syringes  to  avoid  clotting  of  the  blood. 
For  this  reason  the  syringe  method  is  sometimes  disappointing  in  the 
hands  of  those  of  limited  experience. 

As  no  skin  incision  is  made,  the  only  discomfort  to  the  donor  and 
recipient  is  from  the  puncture  of  the  skin  by  the  needles  entering  the 
veins.    The  same  vein  may  thus  be  utilized  for  subsequent  trai^s^ 
fusions  if  desired. 

Apparatus. — There  will  be  required  (i)  two  sets  of  cannulae-'-ot^^ 
for  the  donor  and  one  for  the  recipient,  (2)  two  tourniquets,  (3- 
twelve  record  syringes  with  a  capacity  of  5  drams  (20  cc.)  each,  aX*^ 
(4)  three  basins  for  rinsing  the  syringes — two  for  sterile  water  and  oX^' 
for  saline  solution. 

The  cannulae  consist  of  three  to  each  set,  which  telescope 
within  the  other.  The  innermost  cannula  is  of  small  calibre 
sharp  pointed.  It  closely  fiits  cannula  No.  2,  which  in  turn  fits  ]^3"  ^ 
3.  The  distal  ends  of  cannulae  No.  2  and  3  are  smooth  and  roimd  ^ 
so  as  not  to  injure  the  intima  of  the  veins.  On  the  proximal  end  ^ 
cannulae  No.  i  and  2  are  stationary  thumb  screws.  The  proxinB-  ^ 
end  of  No.  3  is  made  to  fit  a  record  syringe. 

Asepsis. — Before  using,  the  syringes  are  cleaned  in  peroxide  ^ 
hydrogen,  then  washed  in  a  10  per  cent,  sodium  carbonate  solutio  ^ 
rinsed,  and  sterilized  with  the  cannulae  in  95  per  cent,  alcohol.  TB^ 
arms  of  donor  and  recipient  are  sterilized  by  painting  with  iodi^ 
and  the  hands  of  the  operators  and  assistant  are  prepared  as  for  a0^ 
operation. 


INDIRECT  TRANSFUSION  15I 

Technic. — ^A  tourniquet  is  placed  about  the  arm  of  the  recipient 
aad  a  cannula,  lined  with  a  thin  coating  of  liquid  petrolatum,  is  in- 
serted into  the  vein  held  almost  parallel  with  the  skin   surface. 
As  soon  as  the  first  joint  "A"  enters  the  vein,  cannula  No.   i  is 
withdrawn  H  ^m  inch  (i  cm.).    This  prevents  any  injury  to  the  vein 
wall  from  a  sharp  pointed  cannula  and  leaves  No.  2  only,  in  contact 
with  the  vein.    Cannula  No.  3  is  now  inserted  ^  of  an  inch  (2  cm., 
mto  the  vein  and  No.  i  and  2  are  removed.    If  the  vein  has  been 
successfully  entered  blood  quickly  flows  from  the  cannula.    When 
this  occurs,  the  tourniquet  is  removed,  .and  a  syringe  containing 
warm  saline  solution  is  attached  to  the  cannula  and  the  solution  is 
slowly  injected.    In  the  same  manner  the  cannula  is  inserted  into  the 
vein  of  the  donor  and  an  empty  syringe  attached.    A  syringeful 
of  blood  is  now  rapidly  withdrawn  from  the  donor  and  is  passed  by 
the  assistant  to  the  operator  on  the  recipient,  who,  after  removing 

3  »  * 


Iffi'jffl 


Fig.  107. — Lindeman's  cannula  assembled  and  separated. 

^^  saline  syringe,  attaches  the  one  containing  blood  and  quickly 

Injects  the  contents  of  the  syringe  into  the  recipient.    While  this  is 

being  done,  the  operator  on  the  donor  attaches  another  syringe  and 

"lis  it  with  blood.     Syringesf ul  of  blood  are  rapidly  withdrawn  from 

^^  donor  and  injected  into  the  recipient  until  the  desired  quantity 

•^  been  transferred.    A  little  saline  solution  is  injected  through  the 

^liiiula  of  the  recipient  to  keep  it  free  of  blood  and  prevent  clotting 

€very  2d,  3d,  4th,  or  5th  syringeful  of  blood  according  to  the  speed 

<^{  flow  from  the  donor. 

Syringes  are  not  used  a  second  time  without  being  thoroughly 
leaned.  This  is  done  by  a  nurse  who  rinses  the  syringes  through 
two  basins  of  sterile  water  and  then  in  saline  solution.  It  is  empha- 
sized by  the  author  of  this  method  that  only  syringes  and  cannulas 
With  bright  polished  surfaces  should  be  used. 


152        TRANSFUSION   AND    INJECTION    OF    HUMAN  BLOOD    SEKUU 

Unger's  Instrument  for  Syringe  Transfusion. — Unger  (Jeur 

Amer.  Med.  Assoc.,  Feb.  13,  1915)  describes  a  cock  for  use  in  tlu 


Fig.  108.— Unger' s 
I.  Blood  syringe  connected 


t  for  sjrringe  transfusion. 

>  blood  outlet,  C.  stop-cock,  D.  doaar'i  caiuiiili ' 

P.  pedestal  by  which  the  stop-cock  is  raised  or  turned,  K.  redpient'i  ouinnla.  S.  ttlb^^K 
syringe  connected  to  saline  outlet,  and  St.  stand. 

syringe  cannula  method  of  transfusion  whereby  the  number  of  syrin||< — ^ 
is  reduced  to  two,  the  handling  of  the  cannula  necessitated  by  lie — 


rR      D^ 


Fig.  109. — I'nger's  instrument.     Donor's  position  (Atler  Unger  / 
can  Medical  Associntion,  July  17.  1916.) 

Fig.  110, — ^Unger's   instrument.     Recipient's   position,    (.^fter   Unger,  JeurtuJ    ' 

AiHfrican  Medital  Association,  July  17,  igi6.) 

quent  changing  of  syringes  is  avoided,  and  clotting   is   prevented 
by  regular  flushing  of  the  apparatus  with  saline  solution.     With  tlu^ 


INDIRECT    TRANSFUSION 


153 


Hood  may  be  withdrawn  from  the  donor  and  injected 
ipient  without  making  any  disconnections. 
bument  (Fig.  io8)  has  four  outlets:  (i)  blood  outlet  (B), 
ltiet{S),  (3),  recipient  outlet  (R),  and  (4)  donor  outlet  (D). 
ao  c.c.)  Record  syringe  Ls  attached  to  B  and  through  it 
^ated  and  injected,  while  to  S  a  second  syringe  for  saline 
fby  means  of  a  piece  of  rubber  tubing.  To  R  and  D 
It's  and  donor's  cannula;  are  connected  by  means  of  two 
nbber  tubes  i^i  inches  (4  cm.)  long.  The  cock  is  arranged 
^ugh  an  arc  of  45  degrees.  When  rotated  so  that  the 
Ige  operates  upon  the  donor,  saline 
pcted  into  the  recipient  (Fig,  109), 
Wood  is  being  injected  into  the  re- 

IB  solution  may  be  injected  into  the 
110). 
Tnosfusion  by  Paraffined  Tubes. 
[  known,  coagulation  of  blood  Is 
■  retarded  when  the  blood  is  col- 
[receptacle  lined  with  parafiin,  and 
pe  to  fill  a  container  of  moderate 
be  donor's  blood  and  empty  it  into 
it  before  coagulation  occurs  if  the 
R  shaken.  Among  the  numerous 
t  performing  transfusion  by  this 
Ky  be  mentioned  the  parafhned 
lavid  and  Curtis,  Kimpton  and 
I  Vincent. 

tin  their  use  requires  most  careful 
tof  the  tubes,  as  it  is  essentia!  that     Broivn  imlirect"  trsAsfii- 
nn  of  the  apparatus  with   which    sion  tube. 
[comes  in  contact  be    completely 
ra  thin,  smooth  lining  of  paraffin  to  avoid  clotting. 
b«.^The  tubes  of  Kimpton  and  Brown  consist  of  glass 
nh  a  capacity  of  5  to  8  ounces  (150  to  350  c.c.)  closed  at 
pd  by  a  cork.     A  cannula  leads  from  the  bottom  of  the 
■nwards  and  then  at  right  angles  to  the  axis  of  the 
xim  the  last  bend  the  cannula  measures  2  to  3  inches 
)  and  gradually  tapers  to  a  point  H2  to  H  of  ^1  inch 
n  diameter.    A  side  tube  opens  into  the  cylinder  on  the 
e  cannula  a  little  below  the  cork,  to  which  a  cautery 
i  (Fig.  III).     The  apparatus  of  David  and  Curtis  con- 


154       TRANSFUSION  AND   INJECTION   OF  HUMAN  BLOOD   SERUM 


sists  of  a  3  ounce  (loo  c.c.)  glass  syringe  with  rubber  tube  and 
way  valve  and  a  double  cannula  tipped  glass  bulb  of  13  ouol 
(400  c.c.)  capacity  (Fig.  112). 

Vincent's  apparatus  is  very  similar  to  Kimpton's  and  Broinr 
except  that  the  lower  end  has  a  ground  glass  joint  which  fit^ 
needle  and  thus  permits  its  use  without  preliminary  exposure 
the  veins. 

Preparation  of  the  Tubes. — Paraffining  the  tubes  must  be  do 
under  rigid  asepsis.  A  mixture  of  stearin  i  part,  paraffin  2  pas' 
and  vaseline  2  parts  is  sterilized  in  an  autoclave  or  by  boiling,  and 
glass  tubes  are  likewise  sterilized  in  an  autoclave.  The  par 
mixture  is  melted  in  a  water  bath,  and  after  first  moderately  heat 
the  tube  equally  over  an  alcohol  flame,  the  cork  is  removed 
about  I J-^  ounces  (50  c.c.)  of  the  melted  paraffin  mixture  is  pou 
into  it  and  is  allowed  to  run  over  the  entire  interior  of  the  tube. 


a 

Df 


Fig.  112. — David  and  Curtis  apparatus  for  indirect  transfusion. 

eluding  the  cork  which  has  been  replaced  in  the  tube,  forming 
uniform  coat,  and  some  of  it  is  allowed  to  escape  through  the  cannu 
The  tube  is  then  turned  so  that  the  excess  of  paraffin  runs  back  a 
out  of  the  side  opening.  In  the  David  and  Curtis  apparatus  t 
excess  of  paraffin  is  drained  oflf  through  the  cannula  tips.  T 
junction  of  the  cork  and  glass  is  finally  sealed  with  paraffin  on  t 
outside.  The  tubes  are  then  wrapped  up  in  a  sterile  towel  and  a 
ready  for  use. 

Another  method  of  coating  the  tubes  is  described  by  Alton  {Jou 
nal  of  the  American  Medical  Association^  Aug.  16,  1919.) 
tubes  are  sterilized  by  dry  heat  and  are  then  rinsed  out  with  a  sm 
amount  of  alcohol  and  then  ether.  A  mixture  of  paraffin  with 
melting  point  of  53°  C.  i  part  and  ether  80  parts  is  sterilized  in 
autoclave  and  an  ounce  (30  c.c.)  of  this  is  poured  into  the  tube,  a 
the  tube  is  shaken  and  rolled  so  that  the  entire  inner  surface  is  coat 
with  the  solution.    A  small  amount  of  the  solution  is  allowed 


INDIRECT    TRANSFUSION 


^55 


escape  through  the  cannula  tu  coat  its  interior,  the  excess  solution 
^ing  emptied  out.  As  the  ether  evaporates  it  leaves  a  thin  even 
coating  of  paraffin.  It  is  advisable  to  wait  several  hours  for  the 
parafiin  to  harden  before  using  the  tubes. 

AsepsiB.— Syringes  and  rubber  portions  of  the  apparatus  are 
Sterilized  by  boiling.  The  arras  of  the  donor  and  recipient  are 
sterilized  by  painting  with  tincture  of  iodin  and  the  hands  of  the 
operator  and  his  assistant  are  prepared  as  for  any  operation, 

Technic  with  the  Kimpton  and  Brown  Apparatus. — A  tourmquet 
is  placed  upon  the  donor's  ami  with  sufficient  tension  to  produce 
venous  obstruction,  but  not  obliterate  the  pulse.  Under  local 
anesthesia  with  a  0.5  per  cent,  procatn-adrenalin  solution  one  of  the 
prominent  veins  at  the  bend  of  the  elbow  is  then  exposed  through 
isioa  1  inch  (2.5  cm.)  long.    The  vein  is  tied  proximally  and 


I 


Method  o{  holding  the  filled  tube  in  carrj-ing  to  the  recipient. 


Bture  is  placed  around  it  distaUy,  but  is  not  tied.  This  ligature, 
oBld  taut  by  an  assistant,  acts  as  a  clamp  and  the  vein  is  opened, 
'he  vein  of  the  recipient  is  similarly  exposed  without  using  a  tourni- 
l^iet  and  is  tied  off  distally,  the  proximal  ligature  being  used  as  a 
''amp.  The  vein  is  then  opened,  and,  with  the  tube  held  upright, 
"le  cKinula  is  inserted  into  the  donor's  vein,  and  the  tube  fills 
*"h  blood  under  the  venous  pressure,  which  may  be  augmented  by 
"^^Tiig  the  donor  open  and  close  his  hand.  When  filled,  the  tube  is 
'*ieo  to  the  recipient  in  a  horizontal  position  with  the  side  opening 
uppermost  (Fig.  113)  and  the  cannula  is  inserted  into  the  vein  of  the 
^ipient  with  the  tube  held  upright.  A  cautery  bulb  is  attached 
^  the  side  opening  of  the  tube  and  enough  pressure  is  made  on  the 
Qutery  bulb  to  empty  the  tube.     The  cannula  is  withdrawn  while 


H 


156      TRANSFUSION  AND   INJECTION   OF  HUUAN  BLOOD   SESim 

there  is  still  a  little  blood  left  in  it.     More  tubes  may  be  filled  and 
emptied  in  this  manner,  utilizing  the  same  veins.    At  the  condusi<«, 
of  the  transfusion  the  veins  are  ligated,  the  incisions  closed  with  a. 
few  stitches,  and  a  sterile  dressing  is  applied. 

Transfusion  of  Citrated  Blood. — The  development  (rf  tb^ 
method  of  transfusing  blood  to  which  sodium  citrate  is  added  to 
prevent  coagulation  is  mainly  the  result  of  experimental  work  by 
Weil  and  I«wisohn.  It  was  found  that  citration  of  blood  to  0.  .3 
per  cent,  was  sufficient  to  pre\'ent  coagulation,  and  that  the  trans- 


fusion of  such  blood  is  apparently  just  as  effective  as  whole  blood, 
the  blood  is  injected  within  an  hour  after  it  is  withdrawn  from  tL-**^ 
donor.     Contrary  to  what  -would  be  supposed,  the  coagulation  tiin* 
of  the  recipient's  blood  after  the  introduction  of  citrated  blood  is  nc^ 
retarded,    but   is    shortened    immediately    after   such    transfusioc*'' 
If  used  in  proper  strength  citrated  blood  is  without  danger.    XC^" 
cording  to  Lewisohn  75  grains  (5  grams)  can  be  injected  into  a** 


INDIRECT   TRANSFUSION  157 

adxalt  intravenously  with  safety.  The  injection  of  unlimited  quan- 
tities into  the  circulation,  however,  is  toxic,  depriving  the  blood  and 
tissues  of  calcium  and  producing  dyspnoea,  tonic  and  clonic  con- 
\Talsions,  tetany,  paralysis,  etc.  There  is  no  doubt  that  a  reaction 
follows  the  transfusion  of  dtrated  blood  more  frequently  than  when 
'W'lxole  blood  is  used.  This  is  manifested  by  chills  and  fever,  but, 
\srlxile  unpleasant  for  the  patient,  it  is  not  harmful.  Many  theories 
ha.'ve  be^n  advanced  to  explain  these  reactions,  but  up  to  the  present 
a  satisfactory  reason  has  not  been  found. 

Transfusion  by  the  citrate  method  f)ossesses  a  distinct  advantage 
o-ver  other  methods  in  permitting  the  transfer  of  blood  from  one 
pla.ce  to  another  without  detriment,  so  that  the  donor  and  recipient 
need  not  be  in  the  same  room.  Furthermore,  it  reqtures  none  of  the 
skiJ]  essential  for  the  successful  transfusion  by  other  methods,  and 
only  the  simplest  form  of  apparatus  is  needed.  In  fact,  the  method 
is  about  as  simple  as  an  intravenous  saline  infusion. 

Strength  of  Citrate  Solution. — ^A  0.2  per  cent,  citrate  blood  was 
the  strength  originally  employed,  but  as  an  added  factor  of  safety 
against  clotting  it  is  of  advantage  to  employ  a  slightly  higher  per- 
centage of  citrate — a  0.25  per  cent.,  or  0.3  per  cent.  In  the  U.  S. 
Army  a  0.7  per  cent,  was  used.  Ampules  containing  1%  ounces 
(50  c.c.)  of  a  2.5  or  3  per  cent,  sterile  sodium  citrate  in  a  0.9  per  cent. 
saline  solution  may  be  obtained.  One  ampule  of  the  2.5  or  3  per 
P^r  cent,  sodium  citrate  in  15  ounces  (450  c.c.)  of  blood  gives  a 
^^rated  blood  solution  of  0.25  or  0.3  per  cent. 

Apparatus. — Transfusion  of  citrated  blood  may  be  performed  with 
^  Very  simple  apparatus.  There  will  be  required:  (i)  a  graduated 
^Ivarsan  flask,  to  which  is  attached  a  piece  of  rubber  tubing  }4,  inch 
V^  lUm.)  in  diameter  and  4  feet  (120  cm.)  long  supplied  with  a  glass 
^dicator;  (2)  ampules  of  sterile  citrate  solution;  (3)  two  glass 
graduates  of  i  pint  (500  c.c.)  capacity,  for  collecting  the  blood, 
^d  a  glass  stirring  rod;  (4)  a  small  measuring  glass  graduated  in 
^^bic  centimeters  up  to  50;  (5)  a  large  gauge  Kaliski  transfusion 
'^^^le  for  collecting  the  blood,  and  one  of  smaller  calibre  for  in-! 
fusing  the  citrated  blood  into  the  donor;  (6)  two  pieces  of  rubber 
^^bing  for  tourniquets;  (7)  two  artery  clamps  for  holding  the  tourni- 
quets in  place  (Fig.  115).  An  ordinary  glass  irrigating  jar  or  a 
'^^ge  glass  funnel  may  be  used  in  place  of  the  salvarsan  flask. 

The  Medical  Department  of  the  U.  S.  Army  supplied  an  excellent 
apparatus  whereby  the  blood  is  collected  in,  a*hd  injected  from,  the 
^^e  container.     It  consists  of  a  quart  (litre)  bottle  graduated  in 


i 


158      TRANSFUSION  AND   INJECTION   OF   HTJICAN  BLOOD   S£SUH 

100  C.C.,  400C.C.,  and  700  cc,  two  rubber  stoppers  haviogtwoperfon 
UoQS,  two  transfusion  needles,  and  glass  and  rubber  tubing.  Tube 
for  applying  suction  in  withdrawing  the  blood  and  pressure  to  fill  tb 


Fic.  115. — Apparatus  for  transfusing  citrated  blood,  i.  Gnduated  n 
rubber  tubing;  a,  ampules  of  sterile  sodium  citrate;  3.  two  glass  graduates  and  ^ 
rod  for  stirring;  4.  small  glass  graduate;  5.  large  end  small  calibre  needles;  6.  rabbe 
tourniquet;  7.  artery  clamps. 

tubing  of  the  injection  apparatus  are  also  provided     (Figs,  ii; 
and  118). 

Asepsis. — The  apparatus  is  sterilized  by  boiling  or  in  an  autoclave 
the  arms  of  the  donor  and  recipient  are  sterilized  by  painting  witl 


of  the  Kaliski  needle. 


tincture  of  iodin,  and  the  operator's  hands  are  prepared  as  carefa^ 
as  for  any  operation. 

Technic- — A  tourniquet,  consisting  of  a  piece  of  rubber  tubing, 
applied  to  the  arm  of  the  donor  with  sufhcient  tension  to  produce 


INDIRECT   TRANSFUSION 


159 


flG- 

bcU. 


7. — Apparatus  for  transfusing  dtrated  blood  used  by  the  Medical  Department 
>.  Army  assembled  for  withdrawing  blood  from  the  donor. 


^^^'  118. — Apparatus  for  transfusing  citrated  blood  used  by  the  Medical  Depart- 
uictit  o(  the  U.  S.  Army  assembled  for  infusing  blood. 


l6o      TRANSFUSION'   AND    INJECTION   OF   HUICAN  BLOOD  SERUIC 

marked  venous  stasis,  and  is  secured  by  clamping  with  an  artery 
clamp,  A  tube  of  citrate  solution  is  broken  at  the  file  mark,  the 
open  end  is  passed  through  a  flame  and  25  c.c.  (6%  drams)  of  the 
citrate  solution  is  placed  in  the  graduate  in  which  the  blood  is  to  be 
collected,  and  the  blood  is  drawn  into  it  by  inserting  the  large  needle 
into  one  of  the  prominent  veins  at  the  bend  of  the  elbow  directed 
toward  the  hand.  As  the  blood  is  withdrawn,  the  blood  and  citrate 
are  stirred  together  with  d  glass  rod  to  obtain  a  thorough  mixing 
(Fig.  119).  Blood  is  withdrawn  up  to  the  250  c.c.  mark  on  the 
graduate.  Another  35  c.c.  (6%  drams)  of  citrate  solution  is  poured 
into  the  graduate  and  more  blood  is  withdrawn  until  the  500  cc. 


mark  is  reached.  If  more  than  500  cc.  (  i  pint)  of  blood  is  required 
the  second  graduate  is  used  to  collect  it,  employing  the  citrate  solu- 
tion as  before  in  the  proportion  of  25  c.c.  (6^  drams)  to  each  225  cc 
iy}i  ounces)  of  blood.  When  the  desired  amount  has  been 
collected,  the  tourniquet  is  removed  and  the  needle  withdrawn  from 
the  recipient's  vein.  Pressure  is  applied  over  the  site  of  puncture 
a  moment  or  two  and  the  wound  dressed  with  sterile  gauze. 

Introduction  of  the  dtrated  blood  is  accomplished  by  first 
placing  a  tourniquet  about  the  arm  of  the  recipient  to  make  the  veins 
stand  out  prominently.  The  citrated  blood  is  then  transferred  to 
the  flask,  into  which  about  2  ounces  (60  c.c.)  of  normal  salt  solutioQ 


TRANSFUSION  OF  PRESERVED  RED  CELLS  l6l 

has  been  previously  placed,  and  care  is  taken  to  sec  that  the  rubber 
tubing  is  completely  filled  with  salt  solution  and  that  it  contains  no 
air.  The  needle  is  then  introduced  into  the  recipient's  vein  directed 
toward  the  heart,  and,  as  soon  as  blood  flows  from  it,  the  rubber 
tubing  of  the  injection  apparatus _^//eii  mtk  Ike  sail  solutum  is  quickly- 
attached  and  liie  tourniquet  is  removed.  The  reservoir  b  then  elevated 
about  3  feet  C90  cm.)  and  the  blood  allowed  to  flow  by  gravity  (Fig. 


uilucing  cllraltd  lilood  inlcj  ihc  recipient. 


lao).  It  should  run  iu  slowly,  care  being  taken  not  to  suddenly 
overcharge  the  right  heart,  and  the  needle  should  be  removed  before 
the  reservoir  b  completely  drained.  Upon  completion  of  the  trans- 
fusion the  puncture  is  dressed  as  described  above. 

TRANSFUSION  OF  PRESERVED  RED  CELLS 

Experimentally  it  was  shown  by  Rous  and  Turner  in  1916  that 
red  blood  corpuscles  suspended  in  a  fluid  isotonic  with  blood  plasma 


l62       TRANSFUSION   AND   INJECTION   OF  HUMAN  BLOOD   SERUM 

may  be  kept  for  several  weeks  in  a  cool  place  and  when  inject:«il 
into  an  animal  of  the  same  species  will  still  functionate.  "Pliey 
employed  as  an  isotonic  medium  a  5. 4  per  cent,  dextrose  and  33.8  per 
cent,  sodium  citrate  solution  in  the  proportion  of  roughly  3  parts 
blood,  2  parts  isotonic  citrate  solution,  and  5  parts  isotonic  dextrose 
solution. 

This  method  has  been  successfully  applied  to  humans  by  Robert- 
son (British  Medical  Journal,  June  22,  1918)  who  employed  it  at  tbe 
front,  using  for  the  purpose  the  blood  of  Group  IV  donors,  and  it 


seems  that  blood  lost  through  hemorrhage  may  be  as  effectively 
replaced  by  this  means  as  by  fresh  whole  blood.  The  advantages 
of  a  method  of  transfusion  that  permits  the  use  of  blood  collected 
beforehand  and  kept  stored  in  any  desired  quantity  are  obvious, 
and  as  an  emergency  method,  where  a  suitable  donor  is  not  available, 
it  is  invaluable. 

Preparation  of  the  Isotonic  Preserving  Fluid. — The  isotonic  med- 
ium is  a  5.4  per  cent,  dextrose  and  a  3.8  per.  cent,  sodium  citrate 
solution.     The  solutions  are  made  separately  from  freshly  distilled 


TRANSFUSION    OF    PKESERVED    RED    CELLS  163 

water,  and  are  sterilized  separately  in  an  autoclave.  For  preparing 
the  dextrose  solution  powdered  dextrose  is  employed. 

For  500  C.C.  (i  pint)  of  blood,  350  c.c.  (12  ounces)  of  isotonic 
dtrate  solution  and  850  c.c.  (28  ounces)  of  isotonic  dextrose  solution 
are  required. 

Apparatus. — The  apparatus  employed  by  Robertson  (British 
ifedical  Journal,  July  23,  1918)  for  collecting  the  btood  consists  of  a 
1  quart  (2  litre)  glass  bottle,  with  a  stopper  containing  two  periora- 


FlG.  112, — Robertson's  apparatus  arranged  for  syphoning  off  the  supernatant  fluid. 

tions.  One  of  these  gives  passage  to  a  short  right  angled  piece  of 
^ass  tubing,  to  the  free  end  of  which  a  suction  bulb  is  attached. 
Through  the  other  passes  a  piece  of  right  angled  glass  tubing  with  a 
iongann  reaching  nearly  halfway  down  the  bottle  and  a  short  arm, 
to  which  is  attached  by  means  of  a  short  rubber  tube  a  vein  needle 

(%I2l). 

ABepsis. — The  apparatus  is  sterilized  in  an  autoclave,  and  the 
usual  preparations  of  the  patient's  skin  and  operator's  hands  are 
followed. 


164      TRANSFUSION   AND   INJECTION   OF  HUMAN  BLOOD  SERUIC 

Technic. — The  blood  is  collected  in  the  usual  way  by  venous 
puncture  (page  302)  in  the  bottle  containing  the    "isodertrose" 
and  "isocitrate*'  solutions.     The  glass  tube  through  which  the  blood 
enters  should  extend  down  to  the  citrate  solution  so  that  the  blood 
does  not  fall  into  the  solution  through  the  air.    Slight  negative 
pressure  may  be  produced  in  the  bottle  by  means  of  the  suction  bulb 
to  aid  the  flow  of  blood,  and,  as  the  blood  is  being  withdrawn,  the  bot- 
tle is  gently  rotated  so  as  to  mix  it  with  the  solution.    When  500  c.c 
(i  pint)  of  blood  has  been  collected,  the  stopper  is  removed  and  the 
bottle  is  plugged  with  sterile  cotton  and  placed  in  an  ice  box. 

The  red  cells  slowly  gravitate  to  the  bottom  and  in  4  or  5  daj?^ 
they  will  have  settled  to  800  or  900  c.c.  (26  to  30  ounces),  and,  aftc^ 
the  supernatant  fluid  has  been  syphoned  off,  the  blood  can  be  use^i- 
If  the  supernatant  fluid  has  a  pinkish  tint,  the  blood  should  be  dis- 
carded as  this  is  indicative  of  hemolysis.  When  the  blood  has  beeD^ 
stored  for  some  time,  the  red  cells  may  sink  to  a  level  lower  than  th^tt; 
of  the  original  blood,  and,  in  such  a  case,  Robertson  employes  3. 
2.5  per  cent,  solution  of  gelatin  in  normal  salt  solution  to  bring  tb^ 
blood  up  to  the  required  amount. 

Before  transfusing,  the  blood  is  poured  through  two  layers  of 
sterile  gauze  into  the  transfusion  apparatus  in  such  a  way  that  i* 
flows  down  the  side  of  the  container  and  does  not  fall  into  it.  Tb^ 
container  is  stoppered  and  placed  in  a  water  bath  so  as  to  bring  it^ 
temperature  up  to  41°  to  42°C.  (106°  to  loy^F.).  It  is  then  read 3^ 
for  use. 

INJECTIONS   OF  HUMAN  BLOOD  SERUM 

For  many  years  it  has  been  known  that  blood  serum  contain^"  ^ 
some  agent  that  hastened  the  coagulation  of  blood.  In  1882  Haye^^^ 
established  this  fact  while  performing  experiments  with  differerr:^^ 
sera  to  determine  their  effect  on  coagulation.  It  is  only,  howeve-  ^» 
since  Weil  in  1905  published  the  results  of  his  work  along  this 
that  the  injection  of  fresh  am'mal  and  human  serum  has  become  „ 
erally  recognized  as  a  method  of  value  for  the  prevention  and  contrC^^ 
of  certain  forms  of  hemorrhage,  such  as  is  seen  in  hemophilia,  choh 
mia,  and  purpuric  conditions  supposed  to  be  dependent  upon  d< 
cient  coagulability  of  the  blood.  More  recently  Welch  of  New  Yorl 
has  shown  that  the  subcutaneous  injection  of  human  blood  sei 
is  almost  a  specific  remedy  for  the  treatment  of  hemophilia  neona- 
torum; from  the  rapid  gain  in  weight  after  its  use  he  also  consider^^ 
it  a  most  efficient  food  for  premature  and  malnourished  infants-^ 


IKJECTIONS    OF   HUMAN   BLOOD    SERUM 


I6S 


^lood  serum  is,  likewse,  claimed  to  be  of  value  in  septic  conditions 
on  account  of  its  bactericidal  action. 

While  horse  serum,  rabbit  serum,  and  human  serum  have  all 
been  employed  in  these  cases  of  pathologic  hemorrhage,  the  latter 
should  always  be  used  in  preference.  With  animal  sera  there  is 
danger  of  producing  serum  sickness  and  anaphylaxis,  especially  where 
■^peated  injections  are  made,  but  this  is  apparently  not  the  case 
nth  human  serum. 

It  should  be  remembered  that,  while  the  injection  of  human  serum 
i  an  efficient  method  of  controlling  pathologic  hemorrhages,  it  does 
t>t,  of  course,  replace  the  cellular  elements  lost  through 
l^^ding.  In  such  cases,  where  the  cellular 
laments  are  greatly  diminished,  transfusion  is 
medicated. 

Apparatus.^The    apparatus    for   collecting 
(be  blood,  described  by  Welch  {American  Jour- 
n^i/  0/  Medical  Sciences,  June,   1910),  consists 
of  an  Erlenmeyer  flask,  stoppered  with  a  rubber 
cork   through    which    are    two    perforations. 
Thiough  one  is  fitted  a  U-shaped  tube,  to  the 
outer  end  of  which  is  attached  a  short  aspirat- 
ing needle   of  No.    19  caliber  by  means  of  a 
nibber  tubing.     The  needle  is  cotton  plugged 
in  a  small  test-tube  in  which  it  is  sterilized. 
Tiirough   the   other   perforation   is  inserted  a 
fusiform  glass  tube  containing  cotton  to  prevent 
contanunating  the  contents  of  the  flask.     Upon 
Itc  end  of  this  tube  is  placed  a  small  suction 
'ube  for  drawing  the  blood  into  the  0ask  (Fig. 
»3). 

A  30  to  60  c.c.  (i  to  2  ounces)  glass  syringe  with  a  glass  piston 
should  be  provided  for  injecting  the  serun*. 

Selection  of  Donor. —  Preferably  young  adults  from  among  the 
tdatives  uf  the  patient  should  be  selected.  The  donors,  of  course, 
must  be  free  from  any  constitutional  or  other  disease,  and  a  thorough 
ptij'sical  examination,  including  a  Wassermann  test,  should  be  made 
^  liftcrmine  their  fitness. 

Dosage. — In  hemophilia  neonatorum  Welch  advises  that  i 
*'^6  (jo  c.c.)  of  serum  be  given  tmce  a  day  to  moderate  bleeders 
^»,  if  the  bleeding  is  excessive,  that  it  be  given  every  four  hours 
"^'il  the  bleeding  is  under  control. 


jj.— Welch's 

for  collect  bx 


1 66       TRANSFUSION  AND   INJECTION   OF   HUMAN  BLOOD   SERUM 

As  a  preventive  of  postoperative  hemorrhage  in  chronic  jaundii 
Willy  Meyer  advises  that  i  to  2  ounces  (30  to  60  c.c.)  of  seniran 
be  administered  three  times  a  day  beginning  two  days  before  tk.^ 
operation  and  continuing  for  forty-eight  to  seventy-two  hou 
afterward. 

Site   of  Injection. — The  serum  is  injected   subcutaneously 
the  loose  tissues  of  the  axilla  or  in  the  subcutaneous  tissues  of  tt 
abdomen  on  either  side  of  the  umbilicus.     In  cases  of  great  urgenc 
it  may  be  given  intravenously. 

Asepsis. — The  apparatus  for  collecting  the  blood  and  thesyring'^ 
for  injecting  the  serum  should  be  sterilized,  the  operator's  haniss 
should  be  cleansed  as  for  any  operation,  and  the  arm  of  the  dono^ 
and  the  site  of  injection  are  sterilized  by  painting  with  tincture  of 
iodin. 

Technic. — To  collect  the  blood,  a  tourniquet  is  first  place<J 
about  the  arm  of  the  donor  with  sulBScient  tension  to  make  the  vein^ 

stand  out  prominently.     One  of  the  veins  at  the  bend  of  the  elbow ' 

preferably  the  median  basilic — is  then  identified  and  the  needle  of- 
the  collecting  apparatus  is  thrust  into  it,  holding  the  needle  almo^'*^ 
parallel  with  the  skin  surface.  About  10  ounces  (300  c.c.)  of  blooc^ 
is  then  drawn  into  the  flask,  which  is  promptly  stoppered  with  ^^ 
sterile  plug  of  cotton.  The  flask  is  then  placed  in  a  slanting  poa — ' 
tion  until  the  serum  has  formed.  It  usually  takes  four  to  six  hour^ 
for  all  the  serum  to  separate.  When  this  has  taken  place,  ther 
serum  is  transferred  to  a  sterile  flask  and  is  placed  on  ice  until 
used. 

The  technic  of  injecting  the  serum  is  as  follows:  The  neck  of 
the  flask  is  sterilized,  and  the  desired  quantity  of  serum  is  drawn 
into  the  syringe.  Care  should  be  taken  to  see  that  all  the  air  is 
expelled  from  the  syringe.  A  fold  of  skin  in  the  region  decided 
upon  for  making  the  injection  is  then  raised  up  between  the  thumb 
and  forefinger  of  the  left  hand,  and,  with  the  right  hand  the  needle 
is  quickly  thrust  into  the  subcutaneous  tissues  at  the  base  of  this 
fold  of  skin.  The  serum  is  injected  slowly,  and  the  resulting  swell- 
ing is  very  gently  massaged  until  the  serum  is  all  absorbed.  After 
withdrawal  of  the  needle,  the  point  of  puncture  is  sealed  with  col- 
lodin  and  cotton.  Usually  within  twenty- four  to  forty-eight  hours 
after  beginning  the  injections  the  bleeding  will  be  controlled. 


CH.\rTF.R  V 

INFUSION  OF  PHYSIOLOGICAL  SALT  SOLUTION 

The  admimstration  of  physiological  salt  solution  was  originally 
introduced  as  a  substitute  for  transfusion  of  blood  in  the  treatment 
of  hemorrhage  on  account  of  the  numerous  risks  that  attended  the 
latter  operation  as  formerly  performed,  and  the  difficulty  of  obtain- 
ing a  suitable  donor  when  most  needed.  The  technic  of  blood 
transfusion  has,  however,  been  wonderfully  perfected,  and  it  can 
nuw  be  said  to  be  an  operation  without  danger  if  employed  with 
proper  precautions;  but,  notwithstanding  this  and  the  fact  that  no 
'Dedia  has  been  found  as  efficient  as  blood  in  making  up  the  loss 
'rom  a  severe  hemorrhage,  the  infusion  of  salt  solution  is  still  exten- 
sively employed  in  place  of  transfusion.  This  may  be  readily  under- 
^ttHxl  when  we  consider  that  the  methods  of  administering  salt 
^lution  can  be  carried  out  on  short  notice,  that  they  require  but 
"ttle  preparation,  that  they  are  marked  by  simplicity  in  technic, 
***d  that  they  are  within  the  reach  of  all. 

Salt  solution  may  be  introduced  into  the  circulation  through  a 
*^a  (intravenous  infusion),  through  an  artery  (intraarterial  iniu- 
^•or),  through  the  subcutaneous  tissues  (hypodermoclysis) ,  and 
'*y  way  of  the  bowel  (rectal  infusion). 

Indications. — The  use  of  physiological  salt  solution  is  indicated 
Itt  the  following  conditions: 

(i)  In  collapse  following  severe  hemorrhage  to  replace  the  cir- 
culating fluid,  thus  gi'ving  the  heart  a  volume  of  fluid  to  contract 
iipon  and  raising  blood-pressure.  Salt  solution,  however,  cannot 
rtpliice  the  cellular  constituents  of  the  blood,  and  in  the  severest 
Rfapdes  of  hemorrhage,  when  the  number  of  oxygen-carrying  red 
wlls  (alls  below  a  certain  point,  the  injection  of  fluids  into  the  cir- 
culation will  not  avail— only  the  transfusion  of  blood  can  avert  a 
fata!  issue  in  such  cases. 

U)  In  the  prophylaxis  and  treatment  of  mild  surgical  shock, 
for  the  purpose  of  restoring  heat  to  the  body  and  raising  arterial 
twsion.  As  sho^vn  by  Crile,  however,  in  severe  shock,  unless  due 
to  hemorrhage,  the  rise  of  blood-pressure  is  so  temporary  that  the 
first  benefits  derived  from  the  infusion  are  not  maintained.     In 


1 68  INFUSION   OF  PHYSIOLOGICAL   SALT   SOLUTION 

such  cases,  the  combination  with  salt  solution  of  drugs  which 
blood-pressure,  such  as  adrenalin  chlorid,  is  followed  by  more 
marked  and  beneficial  results.  For  a  single  infusion,  lo  to  30  H 
(0.6  to  2  c.c.)  of  the  I  to  1000  solution  of  adrenalin  chlorid  may  he 
added  to  a  pint  (500  c.c.)  of  salt  solution,  or  the  adrenalin  may  l)e 
administered  by  thrusting  a  hypodermic  into  the  rubber  tubing 
near  the  cannula  and  injecting  the  drug  as  the  solution  flows  into 
the  vein. 

(3)  To  increase  the  fluids  in  the  tissues  where  there  is  deficient 
absorption  of  food,  as  in  excessive  vomiting,  peritonitis,  etc.,  or  to 
replace  the  fluids  lost  through  purging,  as  in  dysentery  and  cholera. 
The  administration  of  salt  solution  may  also  be  used  to  advantage 
before  undertaking  operations  upon  poorly  nourished  individuals. 

.  (4)  For  its  stimulating  effects  and  the  production  of  a  rapi^ 
elimination  of  impurities  from  the  body  by  causing  diuresis,  saliix^ 
infusion  is  indicated  in  suppression  of  urine,  uremia,  diabetic  comB^^ 
eclampsia,  septicemia,  various  forms  of  toxemia,  and  in  poisonin^^ 
from  carbonic  acid  gas,  illuminating  gas,  etc. 

(5)  For  the  purpose  of  relieving  postoperative  thirst. 

The  administration  of  saline  solution  is  contraindicated  in  ad- 
vanced dropsy,  pulmonary  edema,  or  marked  cardiac  insufficiency 
and  in  the  presence  of  high  blood  pressure  or  secondary  anemia 
with  greatly  reduced  hemoglobin  it  should  be  employed  with  caution. 

Preparation  of  the  Solution. — To  be  exact,  normal  physiological 
salt  solution  that  is  isotonic  with  the  blood,  consists  of  nine  parts 
sodium  chlorid  to  one-thousand  parts  of  water.  A  variation  in  the 
strength  of  the  solution  between  0.6  per  cent,  and  0.9  per  cent,  is 
permissible,  however,  and  in  practice  the  solution  is  generally  made 
up  in  the  strength  of  0.7  per  cent. — roughly,  i  dram  (4  gm.)  of  chem- 
ically pure  sodium  chlorid  to  a  pint  (500  c.c.)  of  distilled  water.  It 
is  of  the  utmost  importance  that  the  solution  be  accurately  made, 
and  it  should  not  vary  much  from  this  strength  of  seven  parts  per 
thousand,  as  solutions  not  isotonic  with  the  blood  produce  certain 
untoward  changes  in  the  corpuscles.  It  is  the  opinion  of  Mummery 
that  symptoms,  such  as  chills  and  sweating,  which  are  sometimes 
seen  after  intravenous  infusions,  are  due  to  the  incorrect  chemical 
composition  of  the  fluid  employed.  Carelessness  in  this  respect,  as 
well  as  disregard  of  the  proper  temperature  of  the  solution,  are 
without  doubt  also  responsible  for  many  of  the  cases  of  reported 
sloughing  of  the  tissues  after  subcutaneous  infusion. 

A  convenient  method  of  keeping  the  salt  solution  ready  for  use 


INFUSION   OF  PHYSIOLOGICAL  SALT   SOLUTION  1 69 

• 

is   to  have  a  sterilized  and  very  concentrated  solution  put  up  in 

hermetically  sealed  tubes,  in  such  strength  that  the  contents   of 

one  tube  emptied  into  a  quart  (looo  c.c.)  of  sterile  water  gives  a 

normal  salt  solution  (Fig.  124).    In  hospital  practice  it  is  customary 

to  keep  the  solution  in  stock  bottles  ready  for  use. .  The  solution  is 

made  up  in  the  proper  strength  from  sterile  salt  dissolved  in  sterile 

water,  and  is  then  prepared  as  follows.^    "Filter  into  flasks  (sterilized 

by  washing  with  bichlorid  solution,  then  rinsing  with  sterile  water) 

stoppered  with  nonabsorbent  cotton,  sterilize  for  one  hour  for  three 

successive  days  at  a  temperature  of  220°  F.,  and  cover  the  cotton 

stoppers  with  a  small  square  of  rubber  tissue  held  in  place  by  a 

rubber  band.     When  needed,  place  the  flask  in  a  deep  basin  filled 

with  hot  water  until  raised  to  the  proper  temperature."     A  more 


SALT  SOLUTION  )1 


Fig.  124. — A  tube  of  concentrated  sterile  salt  solution. 

convenient  method  of  bringing  the  solution  to  the  required  tempera- 
ture when  needed  for  use  is  to  have  at  hand  very  hot  and  cold  salt 
solutions  in  separate  flasks.  The  solution  may  be  quickly  heated 
by  placing  the  flasks,  surrounded  by  water  to  their  necks,  in  a  steril- 
izer or  a  deep  basin,  and  bringing  the  water  to  the  boiling-point. 
Some  of  the  cold  solution  is  poured  into  the  reservoir  first,  and  suffi- 
cient of  the  hot  solution  is  then  added  to  bring  the  contents  of  the 
reservoir  to  the  proper  temperature. 

Artificial  Sera. — Some  operators  prefer  to  employ  artificial  sera 
prepared  according  to  certain  formulae,  the  object  being  to  obtain 
a  solution  as  nearly  identical  to  the  blood  serum  as  possible.  Some 
of  those  most  frequently  used  are  as  follows : 

fare's  formula:  (Approximately.) 

Calcium  chlorid,  o.2Sgm.             gr.  iv. 

Potassium  chlorid,  o.iogm.             gr.  i^^ 

Sodium  chlorid,  9       gra.             dr.  2Ji 

Distilled  water,  1000        c.c.              qt.  i. 

^^Htr's  formula: 

Potassium  chlorid,  o.  25  gm.  gr.  iv. 

Calcium  chlorid,  0.3    gm.  EX- 4H 

Sodium  chlorid,  7        gra.  dr.  i  % 

Distilled  water,  1000        c.c.  qt.  i. 

*  Fowler.    "The  Operating-room  and  the  Patient." 


(Approzimatd 

0.2 

gm. 

••• 

gr.  m. 

0.42  gm. 

gr.  vL 

0.3 

gm. 

gr.4« 

I 

gm. 

gr.  XV. 

9 

gm. 

<ir.2)i 

1000 

c.c. 

qt.  i. 

6 

gm. 

dr.  i« 

I 

gm. 

gr.  XV. 

1000 

c.c. 

qt.  i. 

170  INFUSION   OF   PHYSIOLOGICAL  SALT   SOLUTION 

Locke's  farmtda: 
Calcium  chlorid, 
Potassium  chlorid, 
Sodium  bicarbonate/ 
Glucose, 
Sodium  chlorid, 
Distilled  water, 

Szumann's  formula: 
Sodium  chlorid, 
Sodium  carbonate, 
Distilled  water 

Gum  Acacia  Solutions. — For  the  purpose  of  providing  a  solut 
of  the  same  viscosity  as  blood  which  would  remain  in  the  tiss 
and  produce  a  more  lasting  elevation  of  blood  pressure  in  shock  i 
hemorrhage  than  is  possible  to  obtain  from  salt  solution,  solutions 
gum  acacia  have  been  advocated.  The  English  shock  commit 
first  used  a  6  per  cent,  gum  acacia  in  2  per  cent,  bicarbonate 
soda  solution,  but  later  a  6  per  cent,  gum  acacia  in  0.9  per  ce 
salt  solution,  as  recommended  by  Bayliss,  was  employed.^  Wl 
the  gum  salt  solution  was  used  both  in  the  American  and  Brit 
armies  during  the  recent  war  in  the  treatment  of  shock,  then 
still  considerable  difference  of  opinion  as  to  its  value;  some  observ 
being  very  enthusiastic,  claiming  that  it  is  an  effective  substit 
for  blood,  while  others  assert  that  at  best  it  is  of  no  more  ben 
than  ordinary  salt  solution.  That  gum  salt  solution  is  not  with< 
danger,  in  certain  cases  at  least,  is  evident  from  the  alarming  z 
in  some  cases  fatal  reactions  that  have  been  reported  following 
use,   for   which  a  satisfactory'  explanation  has  not  been  offer 

INTRAVENOUS  INFUSION 

The  introduction  of  salt  solution  directly  into  a  vein  assures  U! 
its  immediate  entrance  into  the  circulation  and  the  certainty  of 
absorption.     The  intravenous  method  is  thus  indicated  in  any  of 
conditions  previously  mentioned  where  there  is  necessity  for  gr 
haste  and  a  prompt  response  to  the  treatment.     The  advantages 

^  More  recently  Erlanger  and  Gasser  {Annals  of  Surgery y  ApriliigiQ  and  Amer 
Journal  of  Physiology,  Oct.,  191 9)  report  results  from  the  intravenous  injection 
hypertonic  solution  of  gum  acacia  and  glucose.  They  recommend  a  25  per  cent.  | 
acacia  and  18  per  cent,  glucose  solution.  This  makes  a  very  viscid  solution  and  mu£ 
administered  slowly,  i^i  drams  (5  c.c.)  of  the  solution  for  each  2}^  lbs.  (ELilc 
body  weight  is  given  in  an  hour.  The  writers  have  used  this  solution  in  the  treatn 
of  shock  and  hemorrhage  in  humans  as  well  as  in  experimental  work  on  animals  1 
apparent  beneficial  results.     The  work  is  still  in  the  experimental  stage,  however. 


'  INTRAVENOUS   INFUSION 

this  method  of  infusion  are  pointed  out  by  Matas  as  being  almost 
unrestricted  in   possibilities  in  regard  to  quantity,  comparatively 

much  less  painful  than  the  subcutaneous  method,  and  requiring  the 

simplest  and  most  readily  improvised  apparatus. 

Apparatus.- — There  should  be  prodded  a  thermometer,  a  gradu- 

ited  glass  irrigating  jar,  about  6  feet  {i8o  cm.)  of  rubber  tubing, 

!^   inch  (6  mm,)  in  diameter,  and  a  blunt-pointed  metal  infusion 

rannula  (Fig.  135).     In  addition,  a  constrictor  for  the  arm,  a  gauze 

ximpress,  and  a  bandage  will  be  required. 

In  an  emergency,  a  fountain  syringe  or  a  large  funnel  will  answer 

lor  "the  reservoir,  and  the  glass  tube  of  a  medicine  dropper  will  take 

the  place  of  a  cannula. 


Fic.  tJ5. — .\ppBr&tua  for  giving  an  intravenous  infusion.     (Ashton.) 

'^strumentB. — The  operator  will  require  a  scapel,  a  pair  of 
"  "^  t-pointed  scissors,  mouse-toothed  thumb  forceps,  an  aneurysm 
"^^"^le,  a  needle  holder,  two  curved  needles  with  a  cutting  edge, 
^  >s'o.  2  plain  catgut  (Fig.  1 26) , 

Sepsis. — Strict  asepsis  should  be  observed.  The  instruments 
^  apparatus  should  be  boiled,  the  thermometer  should  be  im- 
""^'^d  in  a  t  to  500  solution  of  bichlorid  of  mercury  for  ten  minutes, 
^  then  rinsed  in  sterile  water,  and  the  operator's  hands  should  be 
^  Carefully  prepared  as  for  any  operation. 


172  INFUSION   OF   PHYSIOLOGICAL  SALT  SOLUTION 

Tempmature  <^  Solution.— Most  operators  advise  that  the  s 
tion  be  administered  at  a  temperature  of  a  few  degrees  above  tht___i 
of  normal  blood,  i.e.,  at  about  105°  F.  (41°  C.)-  The  stimulating^ 
effect  of  heat  upon  the  circulation,  however,  should  not  he  lo^^ 
sight  of,  and,  when  such  an  action  is  desired,  the  solution  may  !»-< 
used  at  a  temperature  of  115°  to  118"  F,  (46°  to  48"  C.)  withoi^ut 
harmful  affects.  It  should  be  borne  in  mind  that  there  will  be  soin^^ 
loss  of  heat  while  the  solution  is  flowing  from  the  reservoir.  F^  t 
this  reason,  the  fluid  in  the  reservoir  should  be  kept  at  a  temperatuc-'* 
of  from  2°  to  3°  higher  than  the  temperature  at  which  it  is  wish&^d 
to  give  the  infusion. 


Fig.  126. — Insttumenls  for  intravenoua  infusion,  i,  Scalpel;  a,  bJunt-ptunted 
scissors;  3,  thumb  forceps;  4,  aneurysm  needle;  s.  needle  holder;  6,  curved  needles; 
7,  No.  2  plaJn  catgut. 

It  is  of  the  greatest  importance  that  the  solution  be  introduced 
into  the  body  at  a  uniform  temperature  throughout  the  entire  opera- 
tion. To  insure  this,  a  thermometer  is  kept  in  the  solution  con- 
tinuously. By  watching  the  thermometer  and  adding  hot  solution 
from  time  to  time,  as  that  in  the  reservoir  cools,  a  uniform  temper* 
ature  may  be  maintained. 

Itapidi^  of  FIow.^ — The  speed  of  the  flow  may  be  regulated  by 
raising  or  lowering  the  reservoir,  or  compressing  the  rubber  tube. 
The  rate  of  flow  should  be  about  one  pint  (500  c.c.)  in  five  to  ten 
minutes.  It  should  be  remembered  that  the  weaker  the  action  of 
the  heart  the  slower  must  the  fluid  be  introduced.    Acute  dilation 


INTRAVENOUS    INFUSION  1 73 

of  the  heart  may  be  produced  by  disregard  of  this  caution.  Further-, 
more,  if  the  solution  enters  the  circulation  too  rapidly,  the  fiuid 
(hat  is  driven  from  the  heart  to  the  lungs  may  consist  of  pure  salt 
solution,  and  signs  of  imperfect  oxygenation  of  the  blood  with 
embarrassed  respiration  and  restlessness  will  follow.  If  such 
symptoms  appear,  the  infusion  must  be  discontinued  until  the 
dangerous  signs  have  passed. 

Quantity  Given. — It  has  been  shown  that  only  a  certain  amount 
of    the  solution  will  be  retained  in  the  circulation;  after  a  time  it 
escapes  into  the  tissues  and  produces  edema. 
Hence  there  is  no  object   in  infusing  enor- 
mous quantities.     The  average  amount  ad- 
ministered at  a  time  varies  from  one  pint  (scxj 
c.c.)  to  three  pints  (1500  c.c),  depending  on 
the  case,  but  larger  quantities  may  be  re- 
fjuired  in  cases  of  severe  hemorrhage,  or  after 
venesection.     The  operator  will  be  guided  as 
to  the  requisite  quantity  chiefly  by  the  re- 
tiitn  of  the  pulse,  the  increase  in  its  volume, 
^iid  by  the  improvement  in  the  color  of  the 
patient's  skin.    In  severe  cases  it  may  be 
*d^^sable  to  repeat  the  infusion  two  or  three 
**nies  within  twenty-four  hours  rather  than 
to  infuse  an  enormous  quantity  at  one  time. 
Site    of    Operation. — One    of    the    most 
prcminent  veins  at  the  bend  of  the  elbow  is 
Usually   chosen    (Fig,    127),    preferably    the 
"^icdian  basilic  which  runs  across  the  bend  of 
^«  elbow  from  without  inward.     The  infu- 
^On  may  also  be  performed  through  the  in-  ^^^    ^^,  —The  supcr- 

'^•Tiiil  saphenous.     At  times  a  vein  exposed     ficinl  veins  of  the  forearm. 
"*   the  course  of  an  operation  may  be  con-     (Ashton.) 
^'^"liently  utilized. 

Preparation  of  the  Patient. — All  clothing  should  be  removed 
"■^m  the  area  selected  for  the  infusion,  and  that  about  the  axilla 
'<*csened  if  the  arm  is  chosen  for  the  infusion.  The  bend  of  the 
elbow  is  shaved,  if  necessary,  and  is  then  painted  with  tincture 
^^  iocUn.  A  sterile  bantlage  is  tightly  wrapped  above  the  elbow  to 
•compress  the  veins  and  make  them  more  prominent  (Fig.  128). 
"■  the  circulation  is  very  feeble,  even  this  expedient  may  fail  to 
"liike  the  veins  stand  out  conspicuously. 


174 


INFUSION   OF  PHYSIOLOGICAL  SALT   SOLUTION 


Anesthesia. — ^Anesthesia  of  the  skin  is  obtained  by  infiltration  at 
the  site  of  the  incision  with  a  0.2  per  cent,  solution  of  cocain  freshly 
prepared  or  a  i  per  cent,  solution  of  procain,  or  by  freezing  with 
ethyl  chlorid  or  a  piece  of  ice  dipped  in  salt. 

Technic. — ^With  the  forearm  supinated,  a  transverse  incision  is 
made  over  the  median  basilic  vein  (Fig.  129).  The  vein  is  dissected 
from  its  bed  for  a  distance  of  i  to  i}4  inches  (2.5  to  4  cm.),  and  is 
raised  from  the  wound  while  two  catgut  ligatures  are  passed  beneath 
it  by  means  of  an  aneiuysm  needle,  or,  in  its  absence,  by  a  pair  of 
thumb  forceps.  The  distal  portion  of  the  vein  is  tied  off  as  low  as 
possible  with  one  ligature,  and  the  second  ligature  is  placed  high  up 


Fig.  128.- 


-Showing  the  application  of  the  bandage  to  the  arm  to  constrict  the  veins 

(Ashton.) 


around  the  portion  of  the  vein  nearest  the  heart,  ready  to  be  tied 
(Fig.  130).  A  portion  of  the  exposed  vein  is  now  grasped  in  a  mouse- 
toothed  forceps  at  a  short  distance  from  the  distal  ligature,  and, 
while  the  vein  is  put  upon  the  stretch,  a  cut  directed  obliquely  ujh 
ward  is  made  with  scissors  through  half  the  vein,  exposing  its  lumen 
(Fig.  131).  The  solution  is  first  allowed  to  flow  through  the  cannula 
held  elevated  to  expel  any  air  or  fluid  that  may  have  become  cold  by 
standing,  and  the  cannula,  with  the  solution  still  flowing,  is  then 
inserted  well  into  the  cut  vein  (Fig.  132)  and  is  secured  in  place  by 
tying  the  second  ligature.  It  is  well  to  tie  this  ligature  in  a  bow  knot 
so  that  it  may  be  easily  loosened  when  the  cannula  is  to  be  withdrawn 


INTRAVENOUS   INFUSION 


175 


e  end  of  the  operation  (Fig.  133).     The  bandage  is  now  removed 
above  the  elbow,  and  the  saline  solution  is  allowed  to  enter  the 


X29. — Intravenous  saline  infusion.     (Ashton.)     First   step,  showing  the   vein 

exposed  by  a  small  incision. 


^.  130. — Intravenous   saline   infusion.     Second   step,   showing   the   distal   end 
'  Vein  tied  and  a  second  ligature  being  passed  under  the  proximal  end  of  the  vein. 

elation,  the  reservoir  being  raised  2  to  6  feet  (60  to  180  cm.) 
Ve  the  patient.     During  the  infusion  the  temperature  of  the 


176  INFUSIOX   OF   PHYSIOLOGICAL  SALT  SOLUTION 

solution  must  be  kept  uniform,  the  thermometer  in  the  reservoff 
being  constantly  watched,  and  care  must  be  taken  to  repleniik  Ik 
fluid  in  the  reservoir  before  it  has  all  escaped,  otherwise  air  will  enter  the 
vein  when  a  fresh  supply  is  added. 


Fic.  iji 
Fig,  131. — Intraveno 

indung  the  vein. 

Fro.  131. — Intraveno 

cannula  being  inserted  ii 


Fig.  13a. 
>   saline   infusion.     Third   step,   ghowing   the    metlwcl    of 


saline   infusion.     (.Ashton.)     Fourth   step,   sbgwing     tht 


I'lo.  133.  Fro.  134. 

— Inlra\'i.-nuus   saline   infusion.     Fifth   step,   showing   the   ( 


;.  1J4. — Inttavenous    saline    infusion,     (Ashlon. 
n  cannula  removed  an<i  the  proximal  end  of  the  v 


Siitb    st^,    shovring 

n  ligated. 


When  sufficient  solution  has  been  introduced,  the  ligature  ab*^*f 
the  cannula  is  loosened,  and  the  latter  is  withdrawn.  With  t.i^ 
same  ligature  the  proximal  end  of  the  vein  may  be  then  tied  ^^ 
(Fig.  134).    The  edges  of  the  skin  wound  are  united  with  sevc^*'    J 


INTRAA»TERL4L  INFUSION  1 77 

catgut  sutures,  and  a  sterile  gauze  dressing,  held  in  place  by  a  few 
turns  of  a  bandage,  is  applied. 

Variation  in  Technic. — Some  operators  perform  intravenous 
infusion  without  making  a  preliminary  incision  to  expose  the  vessel. 
The  same  apparatus  is  employed  as  for  an  ordinary  intravenous  infu- 
sion^ except  that  a  hypodermic  or  a  small  aspirating  needle  is  substi- 
tuted for  the  blunt  cannula.     The  needle,  with  the  solution  flowing, 
is  plunged  through  the  skin  directly  into  the  wall  of  the  vein. 

The  difficulty  in  placing  the  needle  accurately  in  the  vein,  espe- 
cially if  the  subject  is  very  fat,  or  when  the  veins  are  collapsed,  as  is 
sometimes  the  case  following  a  hemorrhage,  places  a  limitation  upon 
the  field  of  usefulness  of  this  method. 

« 

mTRAARTERIAL  INFUSION 

SaJine  solution  may  be  injected  into  the  artery  instead  of  intra- 
venously, if  desired.  The  solution  may  be  injected  either  into  the 
^tal  end  of  the  vessel,  or  into  the  proximal  end  against  the  blood 
^^rent.  The  advantages  claimed  by  its  advocates  for  this  method 
^*  infusion  over  the  venous  route  is  that  the  fluid,  being  first  driven 
^  the  capillaries,  is  sent  to  the  heart  more  gradually  and  is  more 
^Venly  mixed  with  the  circulating  blood  than  when  the  entire  volume 
^f  solution  enters  a  vein,  and,  as  a  result,  there  is  less  disturbance 
PJ^cduced  in  the  circulation.  Infusion  against  the  blood  current  has, 
^^  addition  it  is  claimed,  a  stimulating  effect  upon  the  heart. 

Crile    and    Dolley    {Journal  of  Experimental  Medicine,    Dec., 
^906)  have  shown  that  the  infusion  of   normal  salt  solution  and 
adrenalin  into  an  artery  against  the  blood  current  in  suspended  ani- 
ftiation  from  the  effects  of  anesthesia  or  other  causes  is  the  most 
effective  way  of  raising  the  blood-pressure  and  stimulating  the  heart. 
They  point  out  that  adrenalin  administered  by  the  venous  system 
comes  in  contact  with  vessels  having  the  least  power  of  influencing 
blood-pressure,  and  that  before  a  material  rise  can  be  effected  by  the 
action  of  the  adrenalin  upon  the  arteries  it  is  necessary  for  the  solu- 
tion to  p^s  through  the  right  heart,  the  lungs,  and  then  back  to  the 
left  heart  before  it  reaches  the  aorta  and  coronary  arteries.     This 
often  causes  an  accimiulation  of  solution  and  blood  in  the  dilated 
chambers  of  the  heart,  defeating  resuscitation.     On  the  other  hand, 
by  the  arterial  route,  the  blood  and  solution  are  driven  back  toward 
the  heart  directly  affecting  the  coronary  arteries,  thus    restoring 

blood-pressure  and  stimulating  the  heart  to  beat  again.     They  have 
12 


178        INFUSION  OF  PHYSIOLOGICAL  SALT'  SOLUTION 

shown  that  it  is  possible  by  this  method  to  resuscitate  animals  that; 
were  apparently  dead. 

Apparatus. — The  same  apparatus  described  on  page  171  forintra^ 
venous  infusion,  or  an  infusion  cannula  attached  to  a  large  gla< 
funnel  by  a  piece  of  rubber  tubing,  may  be  employed.    In  additioa  _^ 
a  hypodermic  syringe  will  be  required. 

Site  of  Infusion. — The  carotid  artery  or  one  of  its  large  brancbg-a,^^ 
is  chosen  for  the  injection  as  being  the  most  direct  route  to  tlu,^^^ 
coronary  arteries. 

Technic. — Crile    {American  Journal  of  Medical  Sciences,    ^pr^g^- 
1909)  gives  the  following  technic  for  employing  arterial  infudon  ~        -= 


■  Fig.  135. — Showing  ihe  method  of  infusing  salt  and  adrenalin  solution  ir 
artery.     (After  Pa  Costa.) 


htmians  for  purposes  of  resuscitation.  "The  patient,  in  the  prone 
position,  is  subjected  at  once  to  rapid  rhythmic  pressure  upon  the 
chest,  with  one  hand  on  each  side  of  the  sternum.  This  pressure 
produces  artificial  respiration  and  a  moderate  artificial  circulation. 
A  cannula  is  inserted  toward  the  heart  into  an  artery.  Normal  sa- 
line, Ringer's  or  Locke's  solution,  or,  in  their  absence,  sterile  water, 
or,  in  extremity,  even  tap  water  is  infused  by  means  of  a  funnel  and 
rubber  tubing.  But  as  soon  as  the  flow  has  begun  the  rubber  tubing 
near  the  cannula  is  pierced  with  a  hypodermic  syringe  loaded  with  i  to 
1000  adrenalin  chlorid  and  15  to  3oTll  (i  to  2  c.c.)  are  at  once  injected. 
Repeat  the  injection  in  a  minute,  if  needed.     Synchronously  with 


JNTHAARTERIAL   INFUSION  179 

the  injection  of  the  adrenalin,  the  rhythmic  pressure  on  the  thorax  is 

broughl'to  a  maximum.    The  resulting  artificial  circulation  distributes 

'the  adrenalin  that  spreads  its  stimulating  contact  with  the  arteries, 

'ave  of  powerful  contraction  and  producing  a  rising  arterial, 

race  coronary,   pressure.     When   the   coronary  pressure  rises  to,' 

say,  40  mm.  or  more,  the  heart  is  liable  to  spring  into  action.     The 

first  result  of  such  action  is  to  spread  stil!  further  the  blood-prcssure- 

raising  adrenalin,  causing  a  further  and  vigorous  rise  in  blood-pres- 

_nre,  possibly  even  doubling  the  normal."   .    ,    ,   "Just  as  soon  as 

B'&e  heart-beat  is  established,  the  carmula  should  be  withdrawn,  first, ' 

rbecause  it  is  no  longer  needed,  and,  second  the  rising  blood-pressure 

will  drive  a  current  of  blood  into  the  tube  and  funnel." 

Dawbarn's  Emergency  Method  of  Intraarterial  Infusion. — 
This  consists  in  injecting  saline  solution  into  the  circulation  through  a 


artcrj-  in  Dawbarn's  emergency 

^T*odernuc,  or  a  long  fine  aspirating  needle,  inserted  into  the  com- 

**1  femoral  artery.     Dawbarn   recommends  it  as  an    emergency 

^t-iiod  in  the  absence  of  cannula  and  instruments  necessary  for  in- 

.,*Venous  infusion,  or  where  the  superficial  veins  are  small  and  very 

^^*ficult  to  locate. 

-^paratus. — A  hypodermic  needle,  or  a  long  fine  aspirating 
**dle,  and  an  ordinary  Davidson  syringe  (Fig.  136)  are  all  that  are 
'*<luired. 

Technic. — The    femoral    artery    is    first    carefully    defined    just 

^*Mjw  Poupart's  ligament.     The  aspirating  needle  is  then  forced  by 

*  *low  rotary  movement  directly  into  the  artery,  entering  It  at  right 

^'^gles.    As  soon  as  the  needle  enters  the  vessel,  bright  red  blood 

*«1  fill  its  lumen.     The  rubber  tubing  of  the  syringe,  which  has  been 


j8o  INFDSION   OF  PHYSIOLOGICAL  SALT  SOLUTION 

previously  filled  with  saline  fluid,  is  then  slipped  over  the  base  of  tbe 
needle  and  is  firmly  secured  in  place  by  tying.  The  fluid  is  th.^n 
steadily  pumped  from  a  basin  directly  into  the  arterial  drculation 
(Fig.  137).  According  to  Dawbam,  it  requires  about  half  an'hour  to 
inject  a  pint  (500  c.c.)  of  solution  by  this  method.  If  a  founl^LiJXi 
syringe  is  used  instead  of  a  Davidson  syringe,  it  must  be  held  ^t 
least  6  feet  (180  cm.)  above  the  patient  to  secure  the  necessa-1-5 
pressure,  otherwise  the  blood  will  be  forced  back  up  the  tube. 


Fig.  137. — Showing  the  method  of  infusing  sa't  solution  into  the  femoral  Uteiy. 

HYPODERM  OCLYSIS 

The  subcutaneous  method  of  infusion  does  not  permit  as  rapid 
an  introduction  of  large  quantities  of  solution  as  the  intravenous, 
on  account  of  the  slowness  with  which  the  solution  is  absorbed.  It 
is  indicated  in  the  same  conditions  as  venous  infusions,  when  urgency  " 
is  not  of  prime  importance.  It  is  also  frequently  used  as  an  adjunct 
to  intravenous  infusion.  Hypodermoclysis  is  contraindicated  where 
the  tissues  are  edematous  from  dropsy,  or  where  the  circulation  is 
so  feeble  that  absorption  of  the  solution  is  very  slow  or  impos^ble. 

Apparatus. — There  will  be  required  a  thermometer,  a  graduated 
glass,  irrigating  jar,  6  feet  (iSo  cm.)  of  rubber  tubing,  }/^  inch  (6 
mm.)  in  diameter,  E,nd  an  aspirating  needle  of  fair  size  (Fig.  138). 
When  it  is  desired  to  introduce  the  fluid  under  both  breasts  at  once, 
two  needles  fastened  to  the  rubber  tubing  by  means  of  a  Y-shaped 
glass  connection,  as  shown  in  Fig,  139,  may  be  employed. 

In  an  emergency,  a  glass  funnel  or  a  fountain  syringe,  to  which  is 


HYPODEKMOCLY5IS 


l8l 


att3.ched  an  ordinary  hypodermic  needle  by  several  feet  of  rubber 
tubii>g>  may  be  utilized. 

7enq»erature  of  the  Solution. — The  solution  should  enter  the 
body  at  about  iio°  F.  (43**  C).  When  using  a  large  aspirating 
needle  the  fluid  in  the  reservoir  should  be  kept  at  a  constant  tempera- 


Fic    138 — Apparatus  Eor  giving  hypodennodyus.     (Asht< 


t*tt"e  of  about  3  degrees  higher.    If  a  hypodermic  needle  be  employed, 

a-'bovit  5  degrees  should  be  allowed  for  cooling. 

Kapidity  of  Flow. — ^As  the  fluid  is  taken  up  with  comparative 
slo-viniess  from  the  subcutaneous  tissues,  the  injection  is  given  less 
rapidly  than  by  the  intravenous  method.     With  a  fair-sized  needle 


Pic.  139. — Showing  two  needles  arranged  for  hypodermoclyas. 


about  a  pint  (500  c.c.)  of  fluid  may  be  injected  in  from  twenty  to 
uurty  minutes,  the  reservoir  being  held  from  3  to  4  feet  (go  to  120 
o**-)  above  the  patient.  When  a  hypodermic  needle  is  employed, 
u^e  needle  being  so  small  in  caliber,  it  will  be  necessary  to  raise  the 
reservoir  5  or  6  feet  (150  to  180  cm.)  to  get  sufficient  force. 

Quantity  Given. — Injections  of  small  quantities  of  solution,  re- 
peated several  times,  give  better  results  than  a  single  large  injection. 


1 82  INFUSION   OF  PHYSIOLOGICAL  SALT  SOLUTION 

As  a  rule,  8  to  i6  ounces  (250  to  500  c.c.)  of  solution  are  intro- 
duced at  a  single  injection,  and  repeated  in  a  few  hours,  if  necessaiy. 
According  to  Hildebrand,  it  is  not  safe  to  introduce  a  larger  quantity 
of  solution  in  fifteen  minutes  than  i  dram  (4  c.c.)  to  each  pound 
(453  gm.)  of  body  weight.  If  this  ratio  is  exceeded,  the  fluid  accu- 
mulates and  the  tissues  become  water-logged,  as  the  kidneys  do  not 
secrete  rapidly  enough  to  carry  it  off.  Furthermore,  very  latp 
quantities  of  solution  should  not  be  injected  into  one  areay  as  it  may 
produce  undue  distention  of  the  tissues  and  consequent  sloughing 
from  the  prolonged  anemia. 

Sites  of  Injection. — The  area  chosen  for  the  injection  should  t>^ 
in  a  region  free  from  large  blood-vessels  and  nerves  and  where  thex* 
is  an  abundance  of  loose  connective  tissue.  The  usual  sites  bX^* 
(i)  under  the  mammary  glands;  (2)  in  the  subcutaneous  tissue  V> 
tween  the  crest  of  the  ilium  and  the  last  rib;  (3)  in  the  subcutaneo 


Fig.  140. — Sites  for  hypodermoclysis. 

tissue  in  the  axillary  ^ace;  (4)  in  the  subcutaneous  tissue  on  the  ii 
surfaces  of  the  thighs  (Fig.  140). 

Asepsis. — The  necessary  apparatus  should  be  boiled,  the  seat, 
injection  painted  with  tincture  of  iodin,  and  the  operator's 
carefully  cleansed.     The  thermometer  is  sterilized  by  immersion 
a  I  to  500  bichlorid  solution  for  ten  minutes,  followed  by  rinsing 
sterile  water. 

Anesthesia. — The  point  of  skin  puncture  may  be  anesthetized 
the  injection  of  a  drop  or  two  of  a  0.2  per  cent,  solution  of 
or  a  I  per  cent,  solution  of  procain,  or  by  freezing  with  ethyl  chloi 
or  salt  and  ice. 

Technic. — The  reservoir  is  raised  from  3  to  4  feet  (90  to  120  cn-"^ 
above  the  patient,  and  some  of  the  fluid  is  allowed  to  escape  from  t^-^ 
needle,  to  expel  any  air  or  cold  solution.     With  the  solution  st — 
flowing,  the  operator,  using  steady  pressure,  inserts  the  needle  o 
liquely  well  into  the  subcutaneous  tissue.     As  the  solution  enters, 


HYPODERUOCVLSIS  183 

swelHng  appears  in  the  subcutaneous  tissues  which,  however,  slowly 
subsides  as  the  fluid  is  absorbed  (Fig.  141).  If,  as  soon  as  the  tissues 
in  one  area  become  distended,  the  needle  be  partly  withdrawn  and 
its  direction  be  changed  slightly,  a  large  amount  of  solution  may  be 
infiltrated  over  a  wide  area  without  producing  too  great  tension  at 
any  one  spot.  The  absorption  of  the  solution  may  be  hastened  by 
gentle  massage  over  the  infiltrated  area.     During  the  operation,  the 


Flo.  141. — Giving  tiypodermoclysis  under  the  left  breast.     (Ashton.) 

temperature  of  the  solution  is  to  be  kept  uniform,  and  sufQcient 
solution  must  be  in  the  reservoir  at  all  times  to  prevent  air  from 
altering  the  tube. 

When  the  desired  quantity  of  solution  has  been  introduced,  the 
needle  is  withdrawn  and  the  finger  is  placed  over  the  puncture  to  pre- 
vent the  escape  of  fluid.  The  puncture  is  then  sealed  with  sterile 
^^onand  collodion. 

RECTAL  INFUSION.     (See  page  607.) 


CHAPTER  VI 

ACXJPUNCTURE,   VENESECTION,    SCARIFICATION,    SUBClT- 
TANEOUS  DRAINAGE  FOR  EDEMA,  CUPPING,  AND 

LEECHING 

ACUPUNCTURE 

This  is  a  small  operation  which  consists  in  the  insertion  of  needl^^ 
or  other  small  sharp  instruments  either  into  the  superficial  tissues  fc^' 
the  purpose  of  relieving  the  tension  in  swollen  or  edematous  areas,  o' 
directly  into  muscles'  or  nerves  for  the  relief  of  the  pain  of  muscula-*' 
rheumatism  or  of  neuritis. 

For  the  relief  of  tension,  and  to  furnish  an  exit  for  the  effusioJ3- 
beneath  the  skin,  acupuncture  is  frequently  employed  in  edem^' 
involving  the  extremities,  labia,  or  scrotum,  though,  if  the  tissues  ar^' 
so  greatly  distended  that  sloughing  seems  imminent,  incisions  should 
be  substituted  for  the  punctures.  In  acute  epididymitis  and  simfljLX' 
cases  acupuncture  is  also  often  used  with  good  results. 

Of  the  second  class  of  cases  it  is  employed  with  greatest  success 
in  lumbago  and  sciatica.  Just  how  acupuncture  acts  in  such  cases  is 
not  clear;  relief  of  pain  is  not  invariably  afforded,  for  in  some  cases  it 
seems  to  have  no  effect,  but  at  any  rate  the  method  is  worthy  of 
trial,  especially  before  more  severe  forms  of  treatment,  as  ncrv-c 
stretching,  etc.,  are  instituted. 

Instruments. — To  relieve  tension,  the  punctures  may  be  ma-de 
with  triangular-pointed  surgeon's  needles  or  with  a  very  narro"^' 


^ 


Fig.  142. — Instruments  for  acupunpture. 

bladed  bistoury  (Fig.  142).     Employed  for  the  relief  of  the 
muscular  rheumatism  or  neuritis,  half  a  dozen  cylindrical  n 
about  3  or  4  inches  (7.5  to  10  cm.)  long  will  be  required.     Long 
ing  needles  or  sharp  hat  pins  will  answer  very  well. 

Asepsis. — The  skin  should  be  sterilized  by  painting  the  site^ 
puncture  with  tincture  of  iddin;  the  instruments  are  to  be 


_  o  . 


VENESECTION 


and  the  operator's  hands  are  cleaused  as  for  any  operation.  It  is 
especially  important  to  observe  all  aseptic  precautions  both  during 
and  after  puncture  of  dropsical  effusions,  as  the  tissues  in  such  cases 
have  poor  resistance  and  are  a  good  soil  for  infection. 

Anesthesia. — There  is  but  little  pain  connected  with  this  opera- 
tion., but  if  desired  the  skin  at  the  sites  of  puncture  may  be  frozen  with 
ethyl  chlorid. 

Technic. — Puncture  for  the  relief  of  tension  simply  consists  in 
naJcing  a  single  or,  when  required,  numerous  deep  stabs  with  the 
neetlle  or  bistoury  into  the  swollen  area,  avoiding  injury  to  important 
vessels  or  nerves.  This  allows  the  escape  of  serum  which  may  be 
encouraged  by  the  application  of  moist  heat  in  the  form  of  dressings 
Btvirated  with  some  mild  antiseptic,  as  boric  add. 

"VTien  treating  muscular  rheumatism  by  this  method,  several 
rfia.rp  round  needles  are  thrust  through  the  skin  into  the  painful  parts 
rf  the  affected  muscle  to  a  depth  of  i  to  iji  inches  (2.5  104  cm.), 
or  more,  depending  on  the  amount  of  adipose  tissue,  and  are  allowed 
to  remain  in  place  five  to  ten  minutes.  In  removing  them,  care  must 
^  taken  not  to  break  them  off  in  the  tissues.  Not  infrequently  the 
relief  of  pain  is  immediate. 

Applied  to  a  nerve,  the  same  technic  is  employed.  An  endeavor 
is  made  to  transfix  the  affected  nerve  with  from  four  to  six  needles 
along  the  painful  part  of  its  course.  It  may  sometimes  be  difficult 
to  strike  some  of  the  smaller  nerves,  but  with  a  large  nerve  like  the 
static  there  is  usually  no  trouble.  The  patient's  sensations  will  be  a 
piide  as  to  whether  the  nerve  is  reached,  for,  as  soon  as  this  occurs, 
B  sharp  pain  will  be  felt  different  from  that  experienced  as  the  needle 
P*sses  through  the  superficial  tissues.  The  needles  when  properly 
placed  should  be  left  in  site  about  five  or  ten  minutes. 


VENESECTION 

The  operation  of  venesection,  or  phlebotomy,  consists  in  the  open- 
**8  of  some  superficial  vein  and  the  abstraction  of  blood  from  the 
S'^'ieral  circulation  for  therapeutic  purposes. 

The  beneficial  effects  of  bleeding  have  been  recognized  from  the 
^-'ftie  of  Hippocrates.  Unfortunately,  though',  bleeding  was  formerly 
"^^Uch  overdone,  and  in  the  early  part  of  the  last  century  it  came  to  be 
**e  custom  to  bleed  indiscriminately  for  almost  any  sickness.  In 
^risequence  of  its  abuse  this  valuable  operation  has  lost  much  of  its 
?<*I>alarity  and   is  now  but  rarely  practised.     Popular  prejudice, 


i 


l86  ACUPUNCTURE,  VENESECTION,   SCAKIFICATION,   ETC. 

furthermore,  often  prevents  its  employment,  so  that  even  in  cas-^^-s 
where  it  is  of  undoubted  therapeutic  value  the  practitioner  of  to-da^^r 
prefers  to  put  his  trust  in  drugs  to  accomplish  the  desired  effect=_^. 
In  spite  of  this  neglect,  bleeding  is  a  powerful  and  bene£cial  flifr-g-i 
peutic  measure  when  employed  in  the  proper  class  of  cases,  and,  ^^a.s 
Hare  points  out,  "  the  indications  for  venesection  are  as  dear  and  »<=— ^1 
defined  as  are  the  indications  for  any  remedy." 

Indications. — These  may  be  better  appreciated  by  an  understan^c^- 
ing  of  what  venesection  accomplishes.  In  the  first  place,  throup^^fc 
the  mechanical  effect  upon  the  circulation  of  removal  of  a  quantiflfc.^ 
of  blood,  the  tension  in  the  blood-vessels  is  diminished,  and  the  va.— — ^v- 
cular  tone  becomes  more  evenly  balanced,  so  that  an  engorged  arter  -^, 
where  the  vessels  are  relaxed  and  dilated,  is  relieved.  At  the  ii^  ■  r 
time  the  speed  of 'the  circulating  blood  in  the  capillaries  is  accelerate-— ^Jj 


FiC.  143. — Instruments  fur  vcncs(>clion.     i,  Glass  graduate;  2,  ethyl  chlolid;  3,  tcllpc^ 
4,  sticL  for  patient  to  grasp;  S,  bandages. 

and  stasis  is  further  prevented,   and   the  absorption  of  exudatei"' 
hastened. 

Upon  the  general  system  venesection  also  has  beneficial  < 
causing  a  lessened  activity  of  the  various  functions;  the  cardiac  and 
respiratory  actions  become  less  active,  the  temperature  is  lowered,^ 
and  cell  proliferation  is  diminished. 

In  general,  then,  it  may  be  said  that  venesection  is  indicated  for  " 
the  relief  of  congestion  tn  cases  of  excessive  vascular  tension  evi- 
denced by  a  rapid,  strong,  full,  incompressible  pulse,  while  low  arte- 
rial tension  and  circulatory  depression  with  a  slow,  soft,  irregular,  and 
compressible  pulse  are,  as  a  rule,  contraindications.  Thus  in  sthenic 
types  of  croupous  pneumonia  with  dilated  right  heart,  dyspnea,  and 


VENESECTION  187 

cya.xiosis,  in  pleurisy,  peritonitis,  pulmonary  edema,  pulmonary 
hemorrhage,  emphysema  with  marked  dyspnea  and  cyanosis,  conges- 
tion of  the  brain,  cardiac  valvular  disease  with  engorged  right  heart, 
bleeding  both  lowers  vascular  tension  and  relieves  engorgement.  In 
cases  where  toiins  or  other  deleterious  substances  are  present  in  the 
blood,  as  in  eclampsia,  uremic  convulsions,  illuminaUng-gas  poison- 
ing, poisoning  by  hydrogen  sulphid,  prussic  acid,  etc.,  bleeding  serves 
the  double  purpose  of  reducing  arterial  tension  and  removing  a  defi- 
nite quantity  of  toxic  material.  Largo 
quantities  of  blood  may  be  abstracted  in 
such  cases,  followed  by  transfusion  or  saline 
infusion  (the  so-called  "blood  washing") 
w^th  unquestionably  good  results. 

Instruments. — There  will  be  required  a 
sca,lpel  or  bistoury,  a  sterile  gauze  pad, 
se-v^ral  bandages,  a  round  object  as  a  stick 
or  roller  bandage  for  the  patient  to  grasp, 
*^rid   a  large  glass  graduate  (Fig.  143). 

^uanti^  Withdrawn. — On  an  average 
froxxi  6  ounces  (180  c.c.)  to  15  ounces  (450 
c.c-)  may  be  abstracted  from  an  adult,  and 
f^om  I  ounce  (30  c.c.)  to  3  ounces  (90  c.c.) 
f  rotn  a  child,  depending  on  the  condition 
***-«!  the  character  of  the  pulse  and  upon 
*-«  ^      appearance     of     the     patient.     This 
^■***ount  may  be  increased,  however,  if  the 
^'"^'lesection  is  to  be  supplemented  by  trans- 
fusion or  saline  infusion.     Under  such  con- 
*  tions  20  ounces  (600  c.c.)  or  more  may  be 
^**ioved  from  an  adult. 

Site  of  Operation. — Some  one  of  the  large  veins  in  front  of  the 
_  ■'^t»ow-joint  is  usually  selected  (Fig.  144),  but  the  internal  jugular  or 
"^**-*^«mal  saphenous  may  be  utilized. 

Position  of  the  Patient. — The  patient  should  be  sitting  upright 

*"    in  a  semireclining  position  on  a  couch,  with  his  head  turned  away 

.V^^^m  the  seat  of  operation,  as  the  sight  of  blood  may  cause  faintness. 

"^  l*.e  semiupright  position  is  a  safeguard  against  withdrawing  too 

r**-"*Jch  blood,  as  the  patient  becomes  faint  sooner  than  if  he  were 

i'^ng  down. 

Asepsis. — While  this  is  a  small  operation,  at  the  same  time  all 
^-s«ptic  precautions  shouU  be  observed.     In  former  times  many 


Fig.    144. — Superficii 
of  the  forearm.     (Ashton.) 


i88 


ACUPUNCTURE.  VENESECTION,   SCARIFICATION,   ETC 


patients  lost  their  lives  from  septic  thrombosis.  Accofdingly,  the 
instruments  and  dressings  should  be  sterile,  and  the  hands  of  the 
operator  should  be  as  carefully  prepared  as  for  any  operation.  The 
bend  of  the  patient's  elbow  is  first  shaved,  if  necessary,  and  is  thca 
painted  with  tincture  of  iodin. 

Anesthesia. — The  area  of  incision  may  be  anesthetized  by  infil- 
trating with  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain  or  a  x 
per  cent*  procain  solution,  or  by  freezing  with  ethyl  chorid  or  salt 
and  ice. 

Technic. — ^A  few  turns  of  a  roller  bandage  are  placed  about  the 
patient's  arm  above  the  elbow  with  just  sufficient  tension  to  obstnxct 


Fig.  145. — Venesection. 


First  step,  showing  the  application  of  the  bandage  tc^ 
arm.     (Ash  ton.) 


the  venous  circulation  and  make  the  veins  stand  out  prominei^^ 
(Fig.  145).  By  directing  the  patient  to  grasp  some  object  and  yr^^^ 
his  fingers  while  the  arm  is  hanging  down,  the  veins  will  become  e^^^ 
more  distended.  The  patient's  arm  is  then  placed  in  an  extended  ^^ 
abducted  position.  The  operator  next  identifies  either  the  medi^ 
basilic  or  median  cephalic  vein,  and,  compressing  it  with  his  1^ 
thumb  placed  just  below  the  seat  of  incision,  makes  a  small  cut  tra^ 
versely  to  the  long  axis  of  the  vein  (Fig.  146),  which  is  exposed  ^ 
dissection  and  a  small  opening  made  in  its  anterior  wall  (Fig.  14.  ^ 
The  arm  is  then  turned  over,  the  thumb  removed,  and  the  blood 
permitted  to  escape  into  a  glass  graduate  (Fig.  148). 


VENESECTION 

While  cutting  down  on  the  vein  care  must  be  taken  not  to  disturb 
tile  relative  positions  of  the  skin  and  vein  by  drawing  on  the  skin, 
otheraise  the  cut  through  the  skin  and  that  into  the  vein  will  not 
coincide  when  the  finger  is  removed  and  the  skin  released,  with  the 
result  that  the  blood  will  escape  under  the  skin  into  the  subcutaneous 
If  the  median  basilic  vein  is  utilized,  the  incision  into  its 
will  must  not  be  made  too  deeply  for  fear  of  wounding  the  brachial 
Irtery. 


.^^^ 

ZJ 

u 

i  \  £^ 

h, 

ii '■<"/' 

f\ 

}i)^y 

i'\ 

^■^^  Hd. — Venesection.    Second  atep,  vein  exposed  and  operator's  finger  compressing 
»«  <*wtil  portion  of  the  vessel. 

'KS.  hj. — Venesection.     Third  step,  showing  incision  into  vein's  wall. 

WTieuasufiicient  quantity  of  blood  has  been  abstracted,  a  gauze  pad 
^  acid  over  the  wound  by  the  thumb,  and  the  bandage  ia  removed 
™tn  the  arm.  The  incision  is  then  dressed  with  a  sterile  gauze 
"■""ipress  held  in  place  by  a  bandage.  If  simple  compression  is  not 
""icient  to  stop  the  bleeding,  both  ends  of  the  vein  should  be 
"Sht  and  Ugated  with  fine  catgut.  The  patient  should  be  in- 
"""cted  to  carr)-  the  arm  in  a  sling  for  a  few  days  following  this 
•Oration. 

Complications. — The  most  serious  complication  is  a  puncture  of 
^*  brachial  artery  by  the  incision  into  the  vein  producing  an  arterio- 
'Ous  aneurysm.     This  may  be  avoided  by  carefully  cutting  down 


190 


ACUPUNCTURE,  VENESECTION,   SCARIFICATION,   ETC. 


upon  the  vein  and  not  incising  skin,  superficial  tissues,  and  vem  at 
one  cut. 

Sometimes  a  very  painful  neuralgia  is  a  sequel  to  the  operatioa, 
probably  due  to  injury  to  some  of  the  cutaneous  nerves  of  the  region. 
If  the  instruments  are  clean  and  proper  aseptic  precautions  are 
observed,  septic  thrombosis  is  not  to  be  feared. 

Variations  in  Technic. — Some  operators  extract  the  blood  by 
means  of  a  medium  sized  aspirating  needle  attached  to  a  large 
antitoxin  syringe  or  through  a  vein  trocar  to  which  is  attached  a pi&oc 
of  rubber  tubing  which  leads  to  a  glass  graduate.  The  needle  or  tro- 
car is  plunged  through  the  skin  into  the  vein  in  the  same  manner   ^ 


Fig.  148. — Venesection.     I'ourth  step,  showing  the  operator's  finger  removed 
the  vein  and  the  blood  being  collected  in  a  glass  graduate. 

is  done  in  withdrawing  blood  for  bacteriological  examination 
page  302). 

SCARIFICATION 


L'— 


as 


Scarification  consists  in  making  multiple  incisions  into  the  tis& 
for  the  relief  of  local  congestion  or  tension.     By  this  method  of  lo 
bleeding,  engorged  blood-vessels  are  emptied  and  effusions  of  scl 
are  permitted  to  escape;  thus  undue  tension  from  exudates  is  reliev^^^^    ' 
and  the  tendency  of  the  tissues  to  slough  is  lessened. 

For  the  relief  of  inflammatory  conditions  of  the  skin  and  mucC^ 
membranes  scarification  finds  its  chief  application.     Thus  in  inflan^- 
ulcers,  threatened  gangrene  from  extreme  tension,  phlegmonous 
sipelas,  etc.,  prompt  relief  often  follows  its  use.     Scarification  m 


SCAKIFICATION 

also  be  employed  in  the  place  of  multiple  punctures  for  the  relief  of 
tension  in  marked  edema  of  the  extremities,  labia,  and  scrotum. 
In  urinary  infiltration  deep  scarification  becomes  necessary  to  allow 
the  escape  of  the  extravasation  and  to  prevent  sloughing.  In  inflam- 
inatorj'  affections  and  edemas  of  the  pharynx,  uvula,  tonsils,  and 
glottis  it  is  often  indicated ;  in  involvement  of  the  latter  with  progres- 
sive dyspnea  and  cyanosis  the  scarification  should  be  performed  with- 
out any  delay. 

Instruments.- — An  ordinary  scalpel  or  bistoury  is  all  that  is  neces- 
sary. 


For  incising  the  tonsil,  glottis,  etc.,  a  sharp-pointed  curved  bis- 
toury wrapped  with  adhesive  plaster  to  within  i^  inch  {6  nun.)  of  its 
P**iTit  (Fig.  149)  should  be  employed  in  the  absence  of  a  protected 
'^'"yrigeal  knife  (Fig.  150). 

-A.sepsis.— The  operation  must  be  performed  with  all  the  usual 
*^*^I>tic  precautions. 


Flc.  ISO. — Protected  larjTigeal  knife. 

Anesthesia. — Where  extensive  incisions  are  required,  as  in  urinary 
-^^'"avasation,  for  example,  nitrous  oxid  anesthesia  will  be  required. 
^^  other  cases  local  anesthesia  with  a  0.2  per  cent,  solution  of  cocain 
*"  a  I  per  cent,  procain  solution,  or  by  freezing,  if  the  nutrition  of 
^^*  parts  is  unimpaired,  will  suffice.  Mucous  surfaces  may  be  anes- 
~*^«lizcd  with  a  4  per  cent,  solution  of  cocain  sprayed  upon  or  applied 
***«ectly  to  the  parts. 

Tecbnic. — The  ind^ons  are  made  in  parallel  rows  over  the  in- 
^^fncd  area,  and,  according  to  the  indications,  they  may  or  may  not 
^^^lend  through  the  entire  thickness  of  the  skin.     They  should  always 
^^G  made  in  the  long  axis  of  a  limb  (Fig.  151)  and  in  other  regions 


192 


ACUPUNCTURE,  VENESECTION,   SCARIFICATION,   ETC. 


parallel  to  the  lines  of  cleavage,  care  being  taken  not  to  wound  the 
superficial  nerves  or  large  veins.    Warm  fomentations  applied  to  the 
scarified  area  assist  in  maintaining  the  escape  of  blood  and  serom. 
Scarification  of  the  larynx  is  performed  with  the  aid  of  laiyn- 
goscopy  (page  440).    When  a  clear  view  of  the  edematous  parts  lias 
been  obtained,  incisions  about  3^  inch  (6  mm.)  in  length  are  made 
with  the  point  of  the  protected  bistoury  in  the  areas  of  most  marked 
swelling.     When  it  is  feasible,  these  incisions  are  made  on  the  outer 
surfaces  of  the  parts  to  avoid  having  blood  flow  into  the  larynic 
A  gargle  of  hot  water  or  an  inhalation  of  steam  is  then  employed  tci 
encourage  the  bleeding  and  escape  of  the  serum.    This  often  givi 
complete  relief  in  a  few  hours;  if  the  symptoms  are  not  improve 
however,  or  the  dyspnea  recurs,  tracheotomy  (page  477)  must  be  pc^''' 
formed  without  hesitation. 


Fig.  151. — Sho^\'ing  the  method  of  scarifying  a  limb. 


DRAINAGE  IN  EDEMA  OF  THE  LOWER  EXTREMITIES 

Three  operative  procedures  may  be  employed  for  relieving  edema 
of  the  lower  extremities  when  the  tension  becomes  too  great,  namely, 
multiple  punctures  (page  184),  incision  (page  190),  and  drainage  by 
the  trocar  and  cannula.  Of  these,  the  latter  is  less  troublesome, 
more  cleanly,  and  certainly  far  more  comfortable  for  the  patient. 

From  one  to  four  cannulas  may  be  employed  at  a  time,  and  con- 
siderable fluid  may  be  drained  off  in  this  way.  When  more  than  one 
cannula  is  used  several  quarts  may  be  abstracted  in  twenty-four 
hours,  but  the  operator  should  be  cautious  about  withdrawing  too 
great  a  quantity  for  fear  of  inducing  a  condition  of  cerebral  anemia. 
Should  such  a  condition  be  produced,  the  drainage  shoidd,  of  course, 
be  immediately  stopped  and  stimulants  administered. 

Apparatus. — Southey's  tubes  (Fig.  152)  or  those  of  Curschmann 
may  be  employed.     The  former  are  made  in  a  set  consisting  of  one 


DRAINAGE   Hi  EDEUA   OF  THE   LOWER   EXTREMITIES  193 

trocar  and  four  cannuUe.  Each  cannula  has  lateral  openings  as  well 
as  a  distal  opening.  The  lumen  of  the  cannula  is  about  He  i^^^ 
(i  mm.)  in  diameter.  In  addition,  pieces  of  rubber  tubing  about 
3  feet  (90  cm.)  long  to  lead  from  the  tubes  to  receptacles  are  required. 
Sites  for  Puncture. — The  back  or  outer  sides  of  thf  legs  are 
usually  chosen, 

Asep8is.^Rigid  asepsis  should  be  observed  to  avoid  infection. 
The  trocar  and  cannula  are  boiled,  the  operator's  hands  carefully 
cleaosed,  and  the  spot  chosen  for  puncture  is  first  shaved  and  then 
painted  with  tincture  of  iodin. 


Fio.  151. — Southey'a  trocars  and  cannula. 


T*cluiic. — One  cannula  at  a  time  is  placed  on  the  trocar  and  is 
inserted  an  inch  (2.5  cm.)  or  more  into  the  subcutaneous  tissues  at 
right  angles  to  the  surface.  The  trocar  is  then  removed  and  to  the 
free  end  of  the  cannula  is  attached  a  rubber  tube  filled  with  some 
antiseptic  solution.  The  distal  end  of  the  tube  is  allowed  to  drain 
into  a  basin  placed  upon  the  floor  by  the  side  of  the  patient's  bed 
(^'S- 153)-  Three  or  more  cannulae  are  introduced  in  this  manner. 
The  cannube  should  be  secured  in  place  by  means  of  adhesive  plaster, 
and  sterilized  dressings  should  be  placed  about  them.  Elevation  of 
the  head  of  the  bed  from  6  to  24  inches  (15  to  60  cm.)  allows  the 
fluid  to  gravitate  to  the  extremities  and  is  of  considerable  help  when 
the  edema  is  generalized.     Care  should  be  taken  that  the  cannulse 


194 


ACUPUNCTUltE,  VENESECTION,   SCARIFICATION,   ETC. 


are  not  displaced,  and  for  this  reason,  with  restless  patients,  it  \& 
better  to  remove  them  at  night.     It  is  preferable  in  any  case  tjc^ 
make  new  punctures  than  to  leave  the  cannula;  in  place  for  sevec  s^"\ 
days.    After  the  removal  of  the  cannula,  the  sites  of  the  punctur^  ^=s 
should  be  pealed  with  collodion  and  cotton. 


Fig.  IS3. — Showing  the  method  of  draining  an  edematous  limb  with  Southcy's  cann^^^ 
(.\fter  Gumprecht.) 


CUPPING 

Cupping  may  be  either  dry  or  wet  according  to  the  method 
application.     Dry  cupping  produces  a  local  congestion  of  the  sup< 
ficial  tissues  and  relieves  congestion  of  the  deeper  su' 
jacent  organs  by  deviating  the  blood  from  these  p 
Wet  cupping,  in  addition,  actually   abstracts   blo( 
from  the  tissues.     Cupping  finds  its  chief  applicatic::;:--"^ 
in  the  relief  of  congestion  of  deeply  placed  organs  isJtf' 
the  brain,  spinal  cord,  lungs,  liver,  kidneys,  etc. 

Apparatus. — Special  cupping  glasses  supplied  wit::^^^^ 
rubber  bulbs  for  exhausting  the  air  (Fig.  154)  ai-^*^ 
Fic.  154.—  obtainable  and  will  be  found  very  convenient,  bi^  "' 
Bu!b  form  of  jjjg  ordinar)'  cupping  glasses  in  which  the  vacuum  ^^^^ 
cupping  g  ass.  created  by  igniting  a  little  alcohol  smeared  over  th— -  "" 
interior  of  the  cup  are  just  as  efficient.  In  an  emergen*^,  2-ouncr^^^ 
(.60  c.c.)  whisky  or  wineglasses,   or   thick   tumblers  with   smootB::^' 


I9S 


ounded  edges  will  answer  equally  well.  From  8  to  12  cups  will  be 
quired  in  dry  cupping  and  from  2  to  6  in  wet  cupping  dqiending 
■yoa  the  extent  of  surface  to  which  tbey  are  to  be  applied. 


X  55. — Instrumenta  for  wet  cupping,     i,   Cupping  glasses;   3,  swab  in  alcohol; 
3,  alcohol  lamp;  4,  scalpel. 

Tti  addition  to  the  cups  there  should  be  provided  some  alcohol,  a 
aJl  stick  to  the  end  of  which  a  cotton  swab  is  attached,  and  matches 

an,  alcohol  flame.  If  wet  cupping  is  to  be  employed,  there  will 
o  be  required  a  sharp  scalpel  or  lancet  (Fig.  155). 


Sites  of  Application. — Cupping  glasses  are  never  to  be  applied 
^ectly  over  inflamed  tissues  on  account  of  the  pain  that  would 
^»llt.  Nor  should  they  be  placed  over  bony  or  irregular  surfaces  on 
^^^^unt  of  the  impossibility  of  excluding  air.    Where  the  brain  is  the 


ig6  ACUPUNCTUEE,  VENESECTION,   SCARIFICATION,   ETC. 

seat  of  the  trouble,  the  cups  are  applied  to  the  back  of  the  neck;  in 
pericarditis,  to  the  precordial  region;  in  involvement  of  the  lungs  or 
pleura,  to  the  chest  between  the  vertebral  column  and  scapular  line; 
in  renal  congestion  or  acute  nephritis,  to  the  lumbar  regions;  in  afFec- 
tions  of  the  eye,  to  the  temples;  etc.  Wet  cups,  however,  are  ofteiL 
followed  by  scarring,  hence  they  should  not  be  apphed  over  conspiai~ 
ous  regions  or  upon  the  shoulders  or  chests  of  women. 

Technic. — i.  Dry  Cupping. — ^Any  hair  should  be  first  shaved  o^£ 
the  part  and  the  surface  of  the  skin  dampened  with  warm  water  s«3 
that  the  cups  will  adhere.  To  apply  cups  supplied  with  an  exhaust- 
ing bulb,  simply  compress  the  rubber  bulb,  then  place  the  cup  upo:^ 


Fic.  157. — Cupping.     Second   step,   igniting   the   alcohol   in  the   cupping  gli 


the  skin,  and  release  the  bulb.  A  partial  vacuum  is  thus  produa^^ 
and  the  skin  and  underlying  tissues  engorged  with  blood  are  sucke^^** 
up  into  the  cup. 

When  ordinary  cups  are  employed,  the  swab,  saturated  wiC^^ 
alcohol,  is  lightly  wiped  over  the  interior  of  each  cup  (Fig.  156!^'*' 
care  being  taken  not  to  leave  any  excess  of  alcohol  that  may  run  dofl— ^^ 
over  the  edges.  The  alcohol  is  then  ignited  (Fig.  157),  and  the  cup  ^■—^ 
quickly  and  tightly  applied  to  the  skin.  The  contained  air  is  rapidl^S' 
exhausted  by  the  flame,  and,  as  the  cup  cools,  a  strong  vacuum  l — — ^ 
created,  which  draws  up  the  underlying  tissues  (Fig.  158)  and  pro-"^ 
duces  local  congestion.  A  number  of  cups — anywhere  from  eight  tc^^ 
ten — may  be  applied  in  the  same  manner  over  any  given  region,  fc^^-" 
the  cups  are  air-tight,  the  flame  is  extinguished  before  the  patient' 
feels  the  heat  from  the  burning  alcohol.  When  the  swelling  of  th^^ 
skin  and  underlying  tissues  has  taken  place  to  such  an  extent  as  to^^ 
replace  the  exhausted  air,  the  cups  become  loosened  and  drop  off.    -" 


If,  however,  it  is  desired  to  remove  the  cups  before  this  has  occurred, 
simply  tip  the  cup  to  one  side  and  press  down  the  skin  at  the  edge  of 
tie  glass  and  thus  allow  air  to  enter. 

2.  Wet  Cupping. — By  this  method  a  definite  amount  of  blood 
msL^  be  removed,  each  cup  being  capable  of  abstracting  from  i  to  3 
dra.ins  {4  to  li  cc).  The  cups  are  first  applied  to  the  region  as 
already  described;  then  with  a  scalpel  parallel  incisions  about  J3 
in«-l-i  (8-5  nun.)  apart  are  made,  care  being  taken  to  incise  the  skin 
jaJ^-,  for,  if  the  subcutaneous  tissues  are  cut  into,  particles  of  fat  will 
be  <drawn  up  into  the  cuts  when  the  cups  are  reapplied.  The  cups  are 
Ih^n  immediately  applied  for  the  second  time.     Blood  will  be  drawn 


"r  ■ 

Fic.  15S. ^Cupping.     Third  step,  the  application  of  lie  cups, 

im  Uie  scarified  area  into  the  cups  until  the  vacuum  is  exhausted 

^"'^  the  cups  fall  off.    If  it  is  desired  to  withdraw  more  blood,  the 

ps  are  emptied  and,  after  washing  away  the  clots  from  the  cut  sur- 

^^'  Uiey  are  applied  again,  or  hot  fomentations  may  be  employed  to 

JMom-ggg  fj,g  bleeding.     When  sufficient  blood  has  been  withdrawn, 

^M^le  gauze  dressing  is  applied  over  the  scarified  region. 

^^r  LEECHIITG 

^<rching  may  be  employed  for  the  purpose  of  abstracting  blood 
s  inaccessible  to  wet  cupping.     It  is 


198  ACUPUNCTURE,  VENESECTION,   SCARIFICATION,   ETC. 

thus  a  valuable  means  of  local  blood-letting  in  ecchymoses,  or  begin- 
ning acute  inflammation  about  the  eye,  ear,  nose,  gums,  genitals,  etc 

There  are  two  varieties  of  leech  used  for  this  purpose;  the  smaD 
American  leech  which  is  capable  of  withdrawing  about  a  dram  (4 
C.C.)  of  blood  and  the  Swedish  leech  which  will  suck  from  3  to  4 
drams  (4  to  15  c.c).  According  to  the  amount  of  blood  it  is  desired 
to  remove,  from  one  to  six  leeches  may  be  applied  at  one  time.  Onlj 
those  coming  from  clean,  uncontaminated  water  should  be  used 

Sites  of  Application. — It  should  be  remembered  that  the  leed 
produces  a  triangular  cut  in  the  skin  which  results  in  a  permaneiL 
scar,  hence  they  should  not  be  placed  upon  conspicuous  portions  oi 
the  body.  They  should  never  be  applied  to  regions  where  there  i 
much  loose  cellular  tissue,  such  as  the  eyelids,  labia,  scrotum,  or  penis 
for  extensive  ecchymoses  may  be  the  result.  As  their  bite  is  irritat 
ing,  they  should  not  be  applied  directly  to  an  inflamed  area;  instead 
they  are  to  be  applied  to  the  periphery.  They  should  never  b- 
allowed  to  take  hold  of  the  skin  directly  over  a  superficial  arterjr 
vein,  or  nerve. 

Leeches  are  generally  applied  to  the  temples  or  the  back  of  th 
neck  in  congestion  or  inflammation  of  the  brain,  to  the  mastoid  ana 
in  front  of  the  tragus  in  acute  mastoiditis  and  acute  otitis  media,  t^ 
the  perineum  when  the  scrotum,  penis,  or  labia  are  the  regioM 
affected,  and  to  the  coccyx  for  the  relief  of  congested  or  inflame^ 
hemorrhoids. 

Asepsis. — To  avoid  infection  the  skin  over  the  region  to  whic: 
the  leech  is  applied  should  be  washed  with  soap  and  water.  If  tt 
part  is  hairy,  it  should  be  first  shaved. 

Technic. — The  leech  is  applied  to  the  part  and  confined  unA* 
a  pill-box  or  wineglass  until  it  takes  hold.  A  special  leech-tube  ' 
a  test-tube  may  be  employed  for  this  purpose,  in  which  case  ^ 
leech  is  placed  in  the  tube  tail  or  large  end  first  and  the  tube  is  tb- 
inverted  so  that  the  leech's  head  comes  in  contact  with  the  sl^ 
This  may  be  removed  as  soon  as  the  leech  takes  hold,  but,  in  empl^ 
ing  leeches  about  the  orifices  of  mucous  cavities,  they  should  alw^ 
be  confined  so  as  to  prevent  their  escape  into  the  interior.  If  ^ 
leeches  are  removed  from  the  water  an  hour  or  so  before  using,  tJ^ 
will  take  hold  more  readily.  Making  a  puncture  in  the  slgj"  ^ 
applying  the  leech  to  the  bleeding  spot  or  rubbing  the  skin  W^ 
sweetened  water  or  milk  will  cause  the  leech  to  take  hold,  if  it  d^ 
not  seem  inclined  to  do  so.  When  once  the  leech  has  begun  ' 
draw  blood,  it  should  not  be  pulled  off — it  will  drop  off  when  fill^ 


LEECHING  199 

Q  it  b  desirable,  however,  to  remove  it  sooner,  sprinkling  salt  over 

it  will  induce  it  to  let  go. 

By  applying  hot  fomentations  to  the  part  after  the  removal  of 
tlie  leech  bleeding  can  be  encouraged  and  often  an  ounce  (30  c.c.)  or 
Diore  of  blood  may  be  withdrawn  in  this  way.    After  removal  of  the 


Fio,  159, — ArtiScial  leech. 

leecli. ,  the  bite  should  be  bathed  with  sterile  water  and  a  small  gauze 
dressing  applied. 

Sometimes  a  considerable  and  troublesome  bleeding  continues 
from  -the  leech  bite,  due  to  the  fact  that  the  tissues  become  infiltrated 
with    material  excreted  from  the  throat  of  the  leech  which  prevents 


"    *6o. — Application   of   the  artificial   leech   to   the   mastoid.     (After   Ballenger.) 
First  step,  showing  the  method  of  scarifying. 

,    *guIation  of  the  blood.     The  bleeding  can  usually  be  controlled, 

"^^ever,  by  compression  or  by  applying  a  piece  of  cotton  saturated 

^^h  some  styptic,  as  a  solution  of  i  to  1000  adrenalin  chlorid,  alum, 

^  tamiic  acid.    The  use  of  the  actual  cautery  or  passing  a  harelip 

•^^  or  needle  beneath  the  bite  and  winding  a  thread  about  the  two 


200  ACUPDNCTUHE,  VENESECTION,   SCARIFICATION,   ETC. 

ends  so  as  to  constrict  the  part  are  also  advised.     Failing  in  these 
measures,  the  bite  should  be  excised  and  the  tissues  sutured. 

The  Artificial  Leech. — This  apparatus  may  be  onployed  instea(^ 
of  live  leeches.  It  consists  of  a  small  cupping  apparatus  combino:^ 
with  a  scarifier  (Fig.  159).  The  latter  is  in  the  form  of  a  small  stee3 
cylinder  containing  a  circular  lancet  propelled  by  a  cord  or  a  sprinftg, 
The  skin  is  first  scarified,  by  drawing  upon  the  cord  which  causes  tt»^ 


Pig.  161.— ApplicatioD  of  the  artificial  leech  to  the  mastoid.    (After  B*Ilen^^'' 
Second  step,  withdrawing  blood. 

iancet  to  rapidly  rotate,  as  shown  in  the  accompanying  illustr»t* 
(Fig.  160),  the  blades  of  the  instrument  being  adjusted  so  as  to  *^  . 
to  the  desired  depth.     Then  the  cupping  tube  is  applied  and  bl'-'   . 
abstracted  by  withdrawing  the  piston  and  creating  a  vacuTun  (^^^^j> 
161).     With  this  instrument  as  much  as  1  ounce  (30  c.c.)  of  bl*-"^^ 
may  be  withdrawn. 


CHAPTER  Vn 

HYPODERMIC    AND    XNTRAMUSCULAR    INJECTIONS, 
THE  ADMINISTRATION  OF  ARSPIOINAMIN  AND  NEO- 
ARSPHENAMIN,  THE  ADMINISTRATION  OF  DIPHTHE- 
RIA ANTITOXIN,  VACCINATION 

THE  HYPODERMIC  AND  INTRAMUSCULAR  INJECTION  OF  DRUGS 

Drugs  may  be  administered  by  injection  into  the  subcutaneous 
or  muscular  tissues  when  a  rapid  eflfect  is  desired,  or  when,  for  any 
reason,  medication  by  the  mouth  is  undesirable  or  is  contraindi- 
cated.  The  injection  of  soluble,  nonirritating  substances  is  made 
into  the  subcutaneous  tissues,  from  which  the  absorption  is  very 
rapid;  but  when  the  solution  is  insoluble  or  irritating,  so  that  its 
presence  in  sensitive  tissues  would  produce  pain,  it  had  best  be 
given  intramuscularly. 

The  advantages  of  hypodermic  medication,  besides  the  prompt- 
ness of  the  eflfects  obtained,  consist  in  affording  a  method  whereby 
it  is  possible  to  administer  remedies  in  the  presence  of  nausea  and 
vomiting,  or  inability  or  unwillingness  on  the  part  of  the  patient  to 
swallow;  furthermore,  the  absorption  of  the  drug  is  not  dependent 
^pon  the  functional  activity  of  the  gastrointestinal  tract. 

The  Hypodermic  Sjrringe. — The  ordinary  hypodermic  syringe 
consists  of  a  glass  barrel  protected  by  a  metal  case  and  furnished 


Fig.  162. — Ordinary  glass  and  metal  hypodermic  syringe. 

^th  a  leather-covered  piston  (Fig.  162).  Such  syringes,  however, 
^re  difficult  to  keep  clean  and,  if  they  are  frequently  boiled,  the 
^^ther  packing  soon  dries  out  and  becomes  inefficient  unless  carefully 
attended  to.  Syringes  of  solid  metal  (Fig.  163)  or  those  consisting 
^\^  glass  barrel  and  solid  glass  piston,  as  the  Luer  CFig.  164),  or 
^^  an  asbestos-covered  piston,  as  the  "Sub-Q,"  will  be  found  pref- 
erable, and  may  be  easily  cleaned  and  repeatedly  boiled  without 
*^^nn.  A  syringe  with  a  capacity  of  30TTI  (2  c.c.)  is  amply  large  for 
ordinary  use. 

201 


202  HYPODERMIC  AND   INTRAMUSCULAR  INJECTIONS,   ETC. 

The  needles  should  be  as  fine  as  possible  (28  to  27  gauge)  and 
very  sharp,  and  for  mjection  beneath  the  skin  they  should  be  about 

1  inch  (2.5  cm.)  in  length.     For  the  administration  of  liquids  of  st. 
heavy  consistency  a  needle  of  somewhat  larger  caliber  will  be 
quired.     For  intramuscular  injections,  the  needle  should  be  i  H 

2  inches  (4  to  5  cm.)  long,  and,  if  one  of  the  insoluble  preparatioi 
of  mercury  is  employed,  the  caliber  of  the  needle  should  be  correr — 
pondingly  large.  To  prevent  the  needles  rusting  and  the  lumen  be^- — 
coming  plugged,  they  should  be  first  well  cleaned  out  with  wate=^^ 
after  using,  followed  by  alcohol  and  ether  to  remove  any  remaininiHt 


Fig.  163. — All  metal  hypodermic  syzinge. 

fluid  from  the  interior  that  might  cause  rusting,  and,  finally,  thej^^ 
should  be  put  away  with  a  fine  wire  inserted  in   the  lumen. 

Preparation  of  the  Solution. — The  drugs  most  frequently 
for  hypodermic  medication  are  morphin,  atropin,  strychnin,  hy< 
pilocarpin,  caffein,  cocain,  apomorphin,  quinin,  mercury,  digitali 
ergo  tin,  nitroglycerin,  adrenalin,  alcohol,  ether,  etc.    As  the  majc 
ity  of  these  are  either  very  powerful  or  poisonous,  the  dose  should 
accurately  measured  in  every  case. 

The  solution  employed  for  the  injection  should  always  be  stei 
and  preferably  freshly  prepared.     The  strength  of  the  solution  is  a! 


Fig.  164. — ^Lucr*s  h>'podermic  syringe. 

important,  for,  if  too  concentrated,  it  may  prove  irritating,  wl>^ 


if  greatly  diluted,  the  bulk  of  solution  necessary  for  the  injec 
becomes  objectionable.     Most  of  the  drugs  for  hypodermic  use 
be  obtained  in  the  form  of  soluble  tablets  which  are  dissolved 
to  loTH,  (0.3  to  0.6  c.c.)  of  boiled  water  when  required  for  use. 
solutions  of  the  drugs,  however,  may  be  obtained  in  hermetic 
sealed  glass  ampules,  each  containing  sufficient  for  one  dose.    'J'-' 
solution  must  be  as  nearly  neutral  as  possible;  irritating  solutions 
strongly  alcoholic  preparations  should  be  avoided  on  account  of  th 


< 


HYPODERKIC  AND  INTRAMUSCULAR  INJECTION  OF  DRUGS      203 

danger  of  subsequent  sloughing  at  the  seat  of  injection.  When 
whisky  or  brandy  is  employed,  it  is,  therefore,  well  to  dilute  them 
with  an  equal  amount  of  water  before  using.  Insoluble  preparations, 
as  the  salicylate  of  mercury,  for  example,  are  best  administered  in 
some  sterile  oil  as  albolene  or  benzoinol. 

Sites  for  Injection. — For  ordinary  injections  the  least  sensitive 

portions  of  the  body  provided  with  plenty  of  cellular  tissue  are 

seiected,  the  spot  chosen,  of  course,  being  distant  from  the  immediate 

iieigliborhood  of  large  blood-vessels  or  nerves,  bony  prominences,  or 


Fig.  165. — Sites  for  hypodermic  injections. 

^^^iXied  areas.     The  common  sites  are  the  outer  surfaces  of  the  arm, 
^^^^nn,  thighs,  or  the  buttocks. 

For  deep  intramuscular  injections  of  drugs  not  rapidly  absorbed 

^^  a.rea  in  the  gluteal  region,  lying  between  the  gluteal  fold  below 

^^  a  Horizontal  line  through  the  upper  margin  of  the  great  trochan- 

^^>  is  usually  chosen  (Fig.  165).     Where  numerous  injections  are 

P^en  care  should  be  taken  to  alternate  between  the  two  sides  and  to 

avoid  repeating  the  injections  in  the  same  spot  each  time.     Meltzer 

[Medical  Record,  March  25,  191 1)  recommends  that  intramuscular 

Ejections  be  made  in  the  lumbar  muscles,  claiming  that  absorption  is 


204 


HYPODERMIC    AND    INTRAMUSCULAR  .INJECTIONS,    ETC. 


more  rapid  than  from  the  glutei.  The  spot  chosen  is  at  the  junction 
of  the  inner  and  middle  thirds  of  a  line  uniting  the  highest  points  o£ 
the  iliac  crest  with  the  third  or  fourth  lumbar  spinous  process. 

Position  of  Patient.— For  a   deep   intramuscular  injection  tli.^ 
patient  lies  upon  the  opposite  side  or  upon  the  abdomen. 


-^i 


Fig.  i66. — Shoning  the  method  of  gi\inB  a  hjiiotic 


injectjon. 


Asepsis. — The  strictest  regard  as  to  cleanliness  should  alwa)'~  m  ^^ 
be  observed.  The  needle  and  syringe  should  be  boiled  or  at  lea_  ~  ' 
immersed  in  some  antiseptic  solution  before  use,  and  the  skin  .» — *■ ' 
the  site  of  the  injection  should  be  painted  with  tincture  of  iodin  i  ->*" 
rubbed  clean  with  a  piece  of  cotton  or  gauze  saturated  with  akoho^^l- 


FlG.  167. — Deep  intramuscular  injection,     first  step,  inserting  the  needle. 

Technic— The  required  amount  of  solution  is  drawn  into  the 
barrel  of  the  syringe  with  the  needle  in  place  and  any  air  is  expelled 
by  elevating  the  needle  end  and  depressing  the  piston.  The  skin 
over  the  site  of  the  proposed  injection  is  then  pinched  up  betw-een 
the  thumb  and  forefinger  of  the  left  hand,  while  with  the  right  hand 
the  needle  is  quickly  thrust  at  an  angle  of  45  degrees  into  the  sub- 
cutaneous tissues  at  the  base  of  this  fold  (Fig,  ibf).    If  the  needle 


HYPODERMIC   AND    INTRAMUSCULAR    INJECTION    OF   DRUGS       205 

issbarp  and  it  be  quickly  plunged  through  the  skin,  but  little,  if  any, 
piin  wll  be  experienced.  The  solution  should  be  injected  slowly  to 
avoid  too  sudden  distention  of   the   tissues.     When  the   required 


Tre.  168. — Deep  intramuscular  injection.     Second  step,  showing  the  syringe  removed 
and  inspcctbn  of  the  needle  for  the  Qovi  of  blood. 

amount  has  been  introduced,  the  needle  is  quickly  withdrawn,  and 
the  finger  is  placed  over  the  site  of  puncture,  and  gentle  massage  is 
practised  for  a  moment  or  two  to  diffuse  the  solution. 


Third  step,  injecting  the  solution. 

"*  £*^ng  a  deep  intramuscular  injection,  the  skin  over  the  chosen 
five  '^  "^M  tense  by  the  fingers  of  the  left  hand,  and  the  needle  is 
iVea^'V  lorced  through  the  skin  and  subcutaneous  tissues  directly 


ii 

i 


206  HYPODERMIC  AND  INTRAMUSCULAR  INJECTIONS,  ETC. 

into  the  glutei  muscles  up  to  its  hilt  (Fig.  167).  As  soon  as  the  needl 
is  in  place,  it  is  advisable  to  remove  the  syringe  and  observe  whetlie 
there  is  any  flow  of  blood  from  the  needle  (Fig.  168);  if  so,  a  na 
puncture  should  be  made.  Observance  of  this  precaution  wi! 
obviate  injecting  the  solution  into  the  blood  current  should  the  needl 
point  penetrate  some  vein.  The  solution  is  then  injected  slowl 
(Fig.  169),  and  at  the  completion  of  the  operation  the  site  of  punc 
ture  is  sealed  with  collodion  or  by  means  of  a  small  piece  of  adhesiv 
plaster. 

THE  ADMimSTRATION  OF  ARSPHENAMIN  AND 

NEOARSPHENAMIN 

ARSPHENAMIN 

Arsphenamin  is  a  yellowish  crystalline  powder  containing  abon 
}i  of  its  weight  of  arsenic.  It  was  introduced  imder  the  name  c 
salvarsan  or  "606"  by  Ehrlich  in  1910  for  the  cure  of  syphilis  aftc 
years  of  experimental  work  upon  animals  with  spirilliddal  drugs 
Although  arsphenamin  has  proved  a  most  important  addition  t 
therapeutics,  we  have  been  compelled  to  revise  materially  our  earl; 
conceptions  of  its  value.  It  was  originally  claimed  that  one  larg 
dose  would  entirely  destroy  the  spirochetes  of  syphilis,  but  unfortv 
nately  this  early  promise  has  not  been  realized  in  the  majority  c 
cases.  There  is  no  doubt  that  it  is  a  powerful  spirochetal  poison  am 
it  unquestionably  causes  certain  of  the  manifestations  of  syphilis  t 
disappear  very  rapidly,  but  whether  the  results  obtained  from  it 
use,  even  in  repeated  doses,  are  permanent  or  only  temporary  wi 
require  many  years  to  establish.  Owing  to  numerous  relapses  tha 
have  followed  single  injections,  it  is  now  generally  agreed  that  a  smgl 
dose  is  not  curative.  At  the  present  time,  the  majority  of  author 
ties  advise  that  the  injection  should  be  repeated  one  or  more  timi 
and  that  its  use  should  be  followed  by  the  administration  of  mercui 
for  the  usual  period. 

Arsphenamin  is  indicated  in  all  stages  of  syphilis.  It  gives  tl 
best  results,  however,  the  earlier  in  the  disease  it  is  used,  being  mo 
rapidly  effective  than  mercury,  especially  upon  mucous  lesions,  ai 
causing  the  Wassermann  reaction  to  become  more  quickly  negati\ 
So  that  in  the  primary  and  early  secondary  stages  the  most  brillia 
results  are  obtained,  while  in  the  late  secondary  and  tertiary  stag 
it  becomes  more  difficult  to  eradicate  the  infection.  It  has  little 
no  effect  in  well  marked  locomotor  ataxia  and  paresis,  unless 


ADinmsTRATtoa  of  assfhenauin  and  neoarsphenahin    207 

^nxn  by  Swift  and  Ellis  it  is  administered  intraspinously  in  the 

Jonn  of  salvarsanized   (arsphenaminized)    serum   (see  page  338). 

It  is  coDtraindicated  in  advanced  degenerative  processes  of  the 

ctQtral  nervous  system  and  in  long-standing  cardiac  and  vascular 

degenerations,  and  in  nonsyphilitic  retinal  and  optic  nerve  affections. 

^>piulitic  eye  and  ear  diseases,  however,  are  not  contraindications 

to  Its  use.    Any  known  idiosyncrasy  against  arsenic  should  lead  to 

Sfeat  caution  in  its  use. 

Arsphenamin  has  also  been  employed  in  the  treatment  of  other 

"tseases  due  to  spirilla  with  excellent  results.    In  relapsing  fever, 


I^.  170.— Apparatus   tor   intravenous   injection   of  aisphenamin,     i.  Graduated 

I        I'Mrvou',  rubber  tubing,  and  vein  needle;  i,  graduate  and  glass  rod  for  mixing  the 

■"lutioii;  3,  decanter  for  distilled  water;  4,  glass  funnel;  s,  medicine  dropper;  6,  bottle  of 

'''^liuii]  hydiDidd  solution;  7,  tube  of  arspheoamiu;  8,  file;  9,  catheter  for  constricting 

"""j  w,  artery  clamp. 

^'sriasis,  yaws,  and  in  some  forms  of  malaria,  it  has  proved  very 
^cacious,  frequently  one  injection  sufficing  to  produce  a  cure.     It 
^s  also  been  tried  in  leukemia,  splenic  anemia,  leprosy,  tuberculosis, 
**<3  pellagra  with  questionable  results. 

Aisphenamin  was  at  first  given  subcutaneously.  Then  intra- 
^^Xiscular  injections  were  substituted,  but  these  proved  very  painful. 
"*■  »i€  drug  was  not  always  absorbed,  and  at  times  caused  great  irri- 
^^tion  at  the  site  of  injection  and,  in  some  cases,  sloughs  that  were 
^^r-y  slow  in  separating.  At  the  present  time  the  intravenous 
Method  of  administration  is  generally  adopted. 


208  HYPODERMIC  AND   INTRAMUSCULAR  INJECTIONS,   ETC. 

Its  administration  is  likely  to  be  followed  in  from  one  to  six  houi 
by  a  systemic  reaction,  consisting  of  a  chill,  a  rise  of  i  to  2  degrees  i 
the  temperature,  gastric  irritation,  and  diarrhoea.  These  symptom 
however,  are  not  always  present,  and  the  temperature  and  chill  ai 
less  likely  to  occur  iifresMy  distilled  water  is  used  in  the  preparatio 
of  the  solution.  In  exceptional  cases,  following  an  injection,  or  i 
late  as  one  or  two  days  after,  the  patient  becomes  quite  sick;  he  lu 
headache,  vertigo,  severe  gastric  irritation,  high  temperatup 
loose  stools,  and  disturbance  of  circulation.  A  transient  album 
nuria  may  be  present  during  elimination  of  the  drug.  In  some  casi 
death  has  resulted  with  all  the  symptoms  of  arsenical  poisoning. 

Apparatus. — There  will  be  required  (i)  a  graduated  glass  cylind^ 
with  a  capacity  of  about  10  ounces  (300  c.c),  (2)  4  feet  (120  cm.)  < 
rubber  tubing  with  a  short  piece  of  glass  tube  inserted  in  it  to  alio 
detection  of  any  air  bubbles,  (3)  a  Schreiber  infusion  needle,  2J 
inches  (6  cm.)  long  and  of  No.  18  caliber,  (4)  a  glass  decanter  for  di 
tilled  water,  (5)  a  glass  graduate  for  mixing  the  solution,  (6)  a  funn 


Fig.  171. — Enlarged  view  of  vein  needle. 

in  which  is  placed  filter  paper  or  sterile  cotton  to  filter  the  solutic 
through,  (7)  a  glass  stoppered  bottle  containing  a  solution  of  15  p 
cent,  sodium  hydroxid,  (8)  a  medicine  dropper,  (9)  a  glass  stirrii 
rod,  (10)  a  catheter  and  artery  clamp  for  constricting  the  arm  of  tl 
patient,  (11)  a  tube  of  arsphenamin  and  a  file  to  open  it  with  (Fi 
170). 

In  addition,  it  is  well  to  have  at  hand  a  scalpel  and  a  coca^ 
syringe  in  case  it  is  necessary  to  expose  the  vein  before  inserting  t3 
needle. 

Asepsis. — The  apparatus  is  sterilized  by  boiling.  The  tube  ca 
taining  the  arsphenamin  and  the  file  are  placed  in  alcohol,  and  t^ 
operator's  hands  are  prepared  as  carefully  as  for  any  operation. 

Preparation  of  the  Solution. — It  has  been  found  that  much 
the  immediate  systemic  reaction  is  due  to  impurities  in  the  wat< 
for  this  reason  only  freshly  distilled  sterile  water  should  be  employe 
in  the  preparation  of  the  solution.  The  ampule  of  arsphenam 
is  dried  off,  the  glass  is  nicked  with  the  file,  the  tube  is  broken  ope 
and  its  contents  are  poured  into  30  to  40  c.c.  (i  to  i  J^^  ounces)  of  h- 


IDMINISTRATION  OF  ARSPHENAMIN  AND  NEOARSPHENAMIN       209 


sterile  distilled  water  previously  placed  in  the  mixing  glass.  The 
solution  is  then  shaken  or  stirred  until  all  the  drug  is  thorough!)' 
dissolved.  To  the  resulting  clear  acid  solution  is  added  drop  by 
drop  the  15  per  cent,  sodium  hydroxid  solution  by  means  of  the 
dropper,  the  solution  being  shaken  after  each  drop  is  added.  This 
causes  a  precipitate  to  form,  which  dissolves  as  the  solution  becomes 
alkaline.  It  requires  about  20  drops  of  the  sodium  hydroxid  solution 
to  render  a  mixture  containing  0.5  gm.  (7.1  j  gr.)  of  arsphenamin  per- 
fectly clear.  Haxing  obtained  an  absolutely  clear  solution,  it  is 
diluted  with  sterile  0,5  per  cent,  saline  solution,  made  from  chemically 
pL»r«  sodium  chlorid  and  sterile,  freshly  distilled  water,  up  to  250  c.c. 
(8  Ounces)  if,  for  example,  0.5  gm.  {7  j.^  gr.)  is  the  dose,  that  is,  50  c.c. 
(i?^  ounces)  of  fluid  is  used  for  every  0.1  gm.  (1^-2  gr-)  of  arsphenamin. 
The  solution  is  now  ready  for  use  and  is  finally  filtered  through 
iterile  cotton  placed  in  a  funnel  into  the  intravenous  apparatus. 

Temperature  of  the  Solution.^The  solution  is  given  at  about  a 
tcTiaperature  of  105°  F.  (41°  C). 

Dosage.— An  average  dose  for  men  is  0.4  to  0.5  gm.  (6  to  7)-^ 
p".),  for  women  0.3  to  0.4  gm.  (4>^  to  6  gr.),  for  children  o.a  to 
0-3  gm.  (3  to  4}-i  gr.),  and  for  infants  0.02  to  0.05  gm.  (J-^  to  ^ 
gr.).  In  this  country  it  is  becoming  customary  to  employ  smaller 
initial  doses,  that  is,  o.a  and  0.3  gm.  {3  and  4H  gr.)  doses  and,  if 
[lo  unpleasant  symptoms  follow,  the  second  dose  may  be  increased 
0.1  gm.  (iH  gr-)- 

Repetitioii  of  the  Dose. — The  injection  may  be  repeated  in  from 
i  one  to  four  weeks,  depending  upon  the  reaction  produced  and  the 

1*ffect  on  the  lesions.  In  the  early  cases  from  three  to  four  injections 
*re  usually  given,  and  in  the  late  cases  from  five  to  six,  or  more,  un- 
til the  Wassermann  reaction  remains  negative. 

Site  of  Injection, — Some  one  of  the  prominent  veins  on  the 
Ulterior  aspect  of  the  arm  in  front  of  the  elbow-joint — preferably 
ttienedian  basihc — is  chosen  for  the  injection. 

PositioiL  of  the  Patient. — The  injection  should  be  given  with  the 
patient  in  the  recumbent  posture. 

Preparations  of  Patient. — All  tight  clothing  should  be  removed 
fr"[n  the  arm  selected  for  the  infusion.  The  site  of  puncture  is 
Pointed  with  tincture  of  iodin,  and  the  rubber  catheter  is  secured 
*tiom  the  arm  with  sufficient  tension  to  make  the  veins  stand  out 
Pfominently. 

Techaic. — With  the  tourniquet  properly  applied  about  the  fore- 
*^,  the  operator  identifies  the  vein  into  which  he  wishes  to  insert 


i 


2IO  HYPODERMIC  AND   INTRAMUSCULAR  INJECTIONS,   ETC. 

the  needle  and  instructs  the  patient  to  work  his  fingers  until  tl 
vein  becomes  quite  prominent.  The  needle,  held  almost  flat  wit 
the  skin  surface,  is  then  thrust  through  the  skin  into  the  vein  towai 
the  axilla  (Fig.  172).  The  successful  entrance  into  the  vein  is  ind 
cated  by  a  flow  of  blood  from  the  end  of  the  needle.  Care  must  I 
taken  to  insert  the  needle  into  the  vein  and  not  through  the  opposi' 
wall  of  the  vein.  If  the  needle  is  held  almost  parallel  with  the  su 
face  of  the  arm,  this  accident  is  not  likely  to  occur.  If  there  is  an 
difficulty  in  finding  the  vein,  it  should  be  exposed  by  a  small  tran 
verse  nick  through  the  skin  under  infiltration  anesthesia  and  tl 
needle  inserted  by  sight.  The  tourniquet  is  then  removed  from  tl 
patient's  arm,  and,  after  seeing  that  all  the  air  is  expelled  froi 


Fig.  172. — Method  of  inserting  needle  into  the  vein, 

the  tubing  of  the  intravenous  apparatus,  the  latter  is  connect: 
with  the  needle,  and  the  solution  is  permitted  to  flow  into  the  ve-: 
The  solution  is  injected  very  cautiously  at  first  until  it  is  cert^ 
that  it  is  entering  the  vein  and  not  the  surrounding  tissues,  or 
test  injection  of  a  small  amount  of  normal  salt  solution  is  maC 
Any  leakage  of  the  arsphenamin  solution  into  the  tissues  caus 
a  severe  burning  pain  and  necessitates  the  immediate  stoppage 
the  injection.  During  the  injection  the  reservoir  is  raised  24 
30  inches  (60  to  75  cm.)  above  the  level  of  the  patient.  It  tak 
about  ten  minutes  for  the  entire  quanity  of  solution  to  flow  in< 
the  vein:  at  the  completion  of  the  operation  the  needle  is  quick! 
removed  and  a  sterile  pad  is  placed  over  the  site  of  pimcture  an 
is  secured  by  a  few  turns  of  a  bandage. 


NEOARSPHENAMIN 


BEOARSPHEHAMIH 
The  genera]  properties  of  neoarsphenamin  (neosalvarsan)  are  simi- 
lar to  those  of  aisphenamin  and  it  is  claimed  to  be  just  as  efficacious. 
It,  however,  possesses  certain  decided  advantages  over  arsphenamin  in 
that  it  b  better  tolerated  and  is  less  often  followed  by  a  systemic  reac- 
tion, so  that  larger  doses  can  be  employed  and  the  dose  may  be  repeated 
more  frequently.    Furthermore,  the  preparation  of  the  solution  is  very 


Fic.  173. — Method  of  giving  Srsphcnamin  intravenously. 

"'P'e,  the  drug  being  quite  soluble  in  water  and  not  requiring  to  be 

^"''"a.lized  with  caustic  soda. 
,    -^  eoarsphenamin   is   given   intravenously   or   by   intramuscular 

J^ti^jn — preferably  by  the  former  method. 
*-t»paratus. — For  the  intravenous  administration  of  dilute  solu- 

'^tii  Q[  neoarsphenamin  the  same  apparatus  described  for  the  admin- 
'^"S't-ion  of  arsphenamin  (page  208)  will  be  required. 


212  HYPODERMIC  AND   INTRAMUSCULAR  INJECTIONS,   ETC. 


For  the  intravenous  administration  of  concentrated  solutions  and. 
for  intramuscular  injections  there  will  be  required:  (i)  aLueror 
Record  syringe  with  a  capacity  of  lo  to  20  c.c.  (2)^  to  5  dr.),  (2) 
a  needle  about  2^^^  inches  (6  cm.)  long  and  of  No.  18  caliber,  (3) 
glass  decanter  for  distilled  water,  (4)  a  medicine  glass  for  mixing 
solution,  (5)  a  tube  of  neoarsphenamin  and  a  file  to  open  it  with, 
(6)  a  glass  rod  for  stirring  (Fig.  174).  In  additioh,  for  an  intnu- 
venous  injection  a  tourniquet  will  be  required- 
Asepsis. — The  apparatus  and  instruments  are  sterilized 
boiling,  the  operator*s  hands  are  cleansed  as  for  any  operation,  an 
the  tube  of  neoarsphenamin  and  the  file  are  immersed  in  alcoho 
Preparation  of  the  Solution. — For  intravenous  injections  a  dilu^ 
or  a  concentrated  solution  may  be  used.     The  former  is  prepared  l^ 


1  z  9  • 

Fig.  1 74. — Apparatus  for  intramuscular  and  intravenous  injections  of  concen 
solutions  of  neoarsphenamin.    i,  Decanter  of  distilled  water;  2,  medicine  glass;  3, 
glass  syringe  and  needle;  4,  tube  of  neoarsphenamin;  5,  small  file. 

dissolving  each  0.15  gm.   (2  }i  gr.)  of  neoarsphenamin  in  25  c. 
(6^  dr.)  of  freshly  distilled  sterile  water.     The  water  should  not 
heated,  but  should  be  at  the  temperature  of  the  room,  that  is,  68^ 
71.6°  F.  (20°  to  22°  C). 


The  concentrated  intravenous  solution  is  prepared  by  dissol 
0.45  to  0.6  gm.  (6^^  to  9  gr.)  of  neoarsphenamin  in  10  c.c.  (2%  dr.) 
oi  freshly  distilled  sterile  water,  or  0.75  to  0.9  gm.  (11^  to  14  gr.) 
of  neoarsphenamin  in  15  c.c.  (4  dr.)  oi  freshly  distilled  sterile  water. 

The  solution  for  an  intramuscular  injection  is  prepared  by  dis- 
solving each  0.15  gm.  (2^^  gr.)  of  neoarsphenamin  in  about  3  c.c 
(48  minims)  of  fresldy  distilled  sterile  water. 

Temperature  of  the  Solution. — The  solution  should  not  be 
injected  at  a  higher  temperature  than  68°  to  71.6°  F.  (20°  to  22°  C). 

Dosage. — The  average  dose  of  neoarsphenamin  for  men  is  0.6  to 
0.75  gm.  (9  to  iij-^  gr.),  for  women  0.45  to  0.6  gm.  (6^  to  9  gr.), 


NEOAHSPHENAMIN  213 

for  children  0.15  to  0.3  gm.  {2}i  to  4%  gr.),  and  for  infants  0.05  gm. 

(H  gr.). 

Repetition  of  the  Dose. — Injections  of  neoarsphenamin  may  be 

repeated  at  intervals  of  from  3  to  7  days. 

Site  of  Injection. — Intravenous  injections  are  given  in  the  median 
basflic  or  some  other  prominent  vein  at  the  bend  of  the  elbow. 

Intramuscular  injections  are  given  in  the  gluteal  i*egion  (see 
page  203). 

Position  of  Patient. — For  an  intravenous  injection  the  patient 
should  be  recumbent;  for  an  intramuscular  injection  the  patient 
lies  upon  the  abdomen. 

Preparation  of  the  Patient. — If  the  intravenous  method  is  em- 
ployed, all  constricting  clothing  should  be  removed  from  the  patient's 
arza.     The  site  of  puncture  is  well  painted  with  tincture  of  iodin. 

Tedinic. — (i)  Intravenous  Administration. — The  technic  differs 
in  no  material  way  from  that  already  described  for  the  administra- 
tion, of  arsphenamin  (see  page  209) .  When  the  concentrated  solution 
is  employed,  however,  the  injection  is  more  conveniently  made  with 
a  syringe  instead  of  a  gravity  apparatus. 

(2)  Intramuscular  Injection. — ^A  spot  in  the  gluteal  region  dis- 

tan-t.  from  the  course  of  the  sciatic  nerve  is  chosen,  and  the  needle  is 

thriist  deeply  into  the  muscle.     If  there  is  no  bleeding,  about  60 

^ops  of  0.5  per  cent,  procain  solution  is  injected  into  the  region  in 

order  to  diminish  the  sensibility.     Then,  after  waiting  a  few  moments, 

^e  desired  quantity  of  neoarsphenamin  is  injected  through  the  same 

Needle.     The  site  of  puncture  is  finally  sealed  with  a  piece  of  adhesive 

plaster.     (The  technic  of  intramuscular  injections  is  more  fully 

described  on  page  205.)     Following  the  injection,  the  patient  is 

*^^pt  in  the  recumbent  position  on  his  side  or  abdomen  for  15  to  20 

^iautes. 

The  Rectal  Administration  of  Arsphenamin  and  Neoars- 
phenamin.— ^Arsphenamin  and  neoarsphenamin  have  been  adminis- 
tered in  an  enema  by  rectum,  and  reports  would  seem  to  show  that 
tt^e  results  are  about  as  prompt  as  ^hen  the  intravenous  method  is 
^'^ployed.     The  method  is  especially  useful  in  children.     Reactions, 
^^crli  as  chills,  fever,  gastric  irritation,  diarrhoea,  etc.;  which  may 
*^llcw  the  intravenous  administration  are  claimed  to  be  absent. 

Apparatus. — ^Ahy  of  the  forms  of  apparatus  described  on  page  595 
^^^y  be  used,  or  a  salvarsan  flask,  attached  by  a  piece  of  rubber 
*vit>ing  to  a  rectal  tube,  may  be  employed. 


214  HYPODERMIC   AND   INTRAMUSCULAR  INJECTIONS,   ETC. 

Preparatiqfi  of  Solution. — The  solution  is  prepared  in  the  usual  W  -^ 
way  (see  pages  208,  212),  the  appropriate  dose  being  diluted  in  150  wL^ 
to  250  CO.  (5  to  8  ounces)  of  saline  solution.  m:^ 

Preparation  of  the  Patient. — The  rectum  should  be  empty.  Il^ 
Inability  to  retain  the  enema  may  be  overcome  by  giving  a  dose  ^vj 
of  paregoric  or  tinct-  of  opium  by  mouth. 

Technic. — The  enema  is  administrated  with  the  patient  in  the 
knee  chest  or  the  Sims  position.     (For  a  full  description  of  tV^e 
technic  see  page  598.)     Following  the  injection  the  patient  shoii^i 
remain  in  bed  4  or  5  hours,  with  the  foot  of  the  bed  elevated. 

Enemata  are  given  once  or  twice  a  week. 


THE  ADMINSTRATION  OF  DIPHTHERIA  ANTITOXIlf 


Antitoxin  is  now  almost  universally  used  in  the  treatment  of 
theria.     It  has  enormously  reduced  the  mortality  from  this 
and,  if  the  serum  is  of  reliable  quality,  its  use  is  without  dan^' 
The  diphtheria  bacilli  are  not  killed  by  the  antitoxin,  but  the  to: 
are  neutralized  and  a  condition  is  produced  in  the  blood 
inhibits  the  growth  of  the  bacilli  so  that  they  gradually  disapp^^^*'*^• 

The  Serum. — The  serum  should  always  be  obtained  from  ^^* 
unquestionable  source.  Antitoxin  of  the  greatest  concentratic:^  ^^> 
that  is,  containing  as  little  serum  and  as  many  units^  of  antitoxirx  ^^ 
is  possible,  should  be  used  in  preference,  as  smaller  amounts 
dose  wiU  be  required  and  joint  pains,  skin  eruptions,  etc- 
which  are  now  considered  to  be  due  to  the  horse  serum  and  not 
antitoxin — will  be  avoided. 

Dosage. — There  is  no  definite  rule  for  fixing  the  dose.     It       ^^ 
known  how  much  antitoxin  is  required  to  neutralize  a  given  amoxx 
of  toxin,  but  in  practice  there  is  no  method  of  estimating  the 
in  any  given  case.     Conclusions  drawn  from  experience  and  clini 
studies  give  the  only  practical  guides.     The  dose  will  depend  u] 
the  age  of  the  patient  and  the  severity  and  the  stage  of  the 
It  should  always  be  large  for  the  serum  is  harmless  and  it  is  better* 
administer  too  much  than  not  enough.    According  to  Holt  "fo 
child  over  two  years,  an  initial  dose  for  a  severe  attack,  including 
laryngeal  cases,  should  not  be  less  than  4000  to  5000  units;  and 
dose  should  be  repeated  in  six  or  eight  hours  provided  no  impro^ 
ment  is  seen.     Children  under  two  years  should  receive  from  21 


^  The  strength  of  the  scrum  is  measured  in  units,  a  unit  being  the  amount  of 
toxin  necessary  to  neutralize  in  a  guinea-pig  100  fatal  doses  of  diphtheria. 


ABMINISTBATION  OF   DIPHTHERIA   .\NTITOXIN  215 

to  3000  units.  Cases  of  exceptional  severity  where  the  injection  is 
gi-ven  late  should  receive  from  Sooo  to  10,000  units,  to  be  repeated  in 
Irom  ax  to  eight  hours  if  the  progress  of  the  disease  is  unfavorable. 
liSild  cases  should  receive  from  2000  to  3000  units  as  an  initial  dose, 
a,  second  being  rarely  required." 

Schick,  who  has  done  considerable  experimental  work  on  the 
dosage  of  diphtheria  antitoxin,  recommends  giving  100  units  of 
antitoxin  In  mild  cases  and  in  severe  cases  500  units  for  each  kilo- 
gram (2.1  a  lbs)  of  weight. 

An  immunizing  dose  should  be  given  to  those  exposed  to  the  con- 
tagion in  all  cases,  1000  units  for  a  child  under  two  years  old,  and  for 
older  children  and  adults  a  larger  dose  (jooo  units)  may  be  adminis- 
tered. The  immunity  thus  furnished  is  not  permanent,  however, 
lasting  only  three  or  four  weeks. 

Time  of  Administration.— Antitoxin  should  be  given  as  soon  as  a 
clinical  diagnosis  is  made,  not  waiting  for  a  bacteriological  examina- 
tion. There  are  no  contraindications  to  its  use  in  the  presence  of 
urgent  symptoms.  No  matter  how  late  a  case  is  seen,  an  injection 
should  be  given,  though  it  may  not  be  possible  to  undo  the  harm 
already  produced  by  the  diphtheria  toxin.  Cases  treated  very  early 
pve  the  best  results. 

The  Syringe. — The  simpler  the  syringe,  the  better.  The 
syringe  should  have  a  capacity  of  about  iH  to  23-i  drams  (5  to  10 
c-c).      Glass  syringes  with  asbestos  packing  or  those  with  the  solid 


8'*Bs  piston,  as  the  Luer,  are  most  easily  sterilized.     The  record 

syriogg  (Fig.   175)  is  also  an  excellent  instrument.     A  moderately 

**«  Beedle  or  the  smallest  through  which  the  serum  will  flow  is 

"   ^lerable  to  one  of  very  large  caliber.     In  charging  the  syringe  it 

setter  to  remove  the  piston  and  pour  the  antitoxin  into  the  syringe, 

^     it  b  difficult  to  draw  it  up  through  the  needle.     The  piston  is 

~^^n  inserted  and,  with  the  syringe  elevated,  any  air  is  expelled, 

'^^ny  of  the  manufacturers  at  the  present  time  supply  a  syringe 

^'""eady  sterilized  and  filled  with  antitoxin  (Fig.  176).     Theadvant- 

Kes  of  this  in  the  saving  of  time  are  obvious. 


2l6  HYPODERMIC  AND  INTRAMUSCULAR  INJECTIONS,  ETC 


Site  of  Injection. — The  subcutaneous  tissues  of  the  outer  aspect 
of  the  thigh,  of  the  back  part  of  the  axilla,  or  of  the  upper  portion  of 
the  abdomen  are  usually  chosen  for  the  injection  (Fig.  177). 

Asepsis. — The  syringe  and  needles  should  be  sterilized  by  a 
thorough  boiling  before  use.     The  operator's  hands  are  cleansed  as 
for  any  operation,  and  the  skin  at  the  site  of  injection  is  sterilized  br^ 
painting  with  tincture  of  iodin. 

Technic. — In  order  to  prevent  any  undue  excitement,  the  inj 
tion  should  be  made  with  the  patient  in  such  a  position  that  he  cann 


Fig.  176. — ^The  New  York  Board  of  Health  Antitoxin  Syringe.  The  syringe  co 
sterilized  and  already  loaded  with  antitoxin  and,  upon  inserting  the  neecile  into 
distal  end,  is  ready  for  use. 


see  what  is  going  on;  in  children  this  is  especially  necessary, 
must  be  taken  to  expel  any  air  from  the  syringe  by  elevating  its 
and  depressing  the  piston  a  little.  A  fold  of  the  skin  from  the 
previously  sterilized  is  then  raised  up  betv/een  the  thumb  and 
finger  of  the  left  hand,  and  with  the  right  hand,  the  needle  is  qui 
plunged  into  the  subcutaneous  tissue  (Fig.  178).  If  done  qui 
with  a  sharp-pointed  needle,  preliminary  local  anesthesia  of  the 


Fig.  177. — Sites  for  antitoxin  injection. 

flip 

is  unnecessary.     The  serum  is  then  injected  very  slowly  and 
swelling  produced  is  not  massaged,  being  allowed  to  subside  as  . 

serum  is  absorbed.     After  withdrawal  of  the  needle  the  punctu^^"^^ 
sealed  with  collodion  and  cotton.     Following  the  injection  there 
be  a  slight  reaction  consisting  of  some  redness,  edema,  and  pain  at 
site  of  puncture,  but  these  usually  subside  in  a  short  time. 

Effects  of  Antitoxin. — In  favorable  cases  a  prompt  and  mar! 
improvement  in  the  local  and  general  symptoms  follows  the 


ed 
of 


ADMUnSTRATION   OF  DIPHTHERIA   ANTITOXIN  217 

antitoxin.     In  a  few  hours  the  pseudomembrane  begins  to  lose  its 

•iirty   color  and  becomes  blanched  and  somewhat  swollen.     Within 

twelve  to  twenty-four  hours  the  membrane  loosens  at  the  edges  and 

roUs  up,  becoming  detached  in  a  mass,  or  in  small  pieces.  ,  This  seems 

*<*  take  place  more  rapidly  about  the  tonsils  than  elsewhere.     The 

•Kual   time  for  restoration  to  the  normal  condition  in  the  throat  is 

*wenty-f  our  hours  to  three  or  four  days.     Sometimes  the  membrane, 

^ter  disappearing,  forms  again;  such  cases  should  promptly  receive 

™ore  antitoxin. 

In    nssal  diphtheria  similar  effects  are  observed,  each  irrigation 
bringing-   away  small  or  large  pieces  of  detached  membrane.     The 


a  antitoidn  in  the  subcutaneous 


nasal  <lischarge  and  swelling  soon  diminish,  and  at  the  same  time  the 
mout-h.  breathing  ceases. 

"*^  laryngeal  diphtheria  antitoxin  prevents  the  extension  of  the 
ineint>rane  into  the  trachea  and  bronchi  in  the  majority  of  cases,  and 
^^'•^  Its  introduction  it  has  been  necessary  to  operate  upon  a  much 
*'"^*^r  proportion  of  cases  than  formeriy. 

**e  effects  upon  the  constitutional  symptoms  are  likewise 
irap'"essive.  In  favorable  cases  the  general  condition  of  the  patient 
unptoygg  noticeably  within  twelve  to  twenty-four  hours.  The 
constitutionaJ  symptoms  of  toxemia  disappear,  the  color  and  general 
^P^rance  are  altered,  and  the  appetite  begins  to  improve.  The 
tanperature  may  rise  i  or  2  degrees  in  the  first  four  or  6ve  hours  after 


2l8 


HYPODERMIC   AND   INTRAMUSCULAH  INJECTIONS,   ETC. 


the  injection,  and  the  pulse  may  be  accelerated  at  the  same  time,  but 
this  is  followed  in  favorable  cases  by  a  fall  of  the  fever  either  by  crisis 
or  by  lysis,  the  temperature  becoming  practically  normal  ia  two  or 
three  days.  The  persistence  of  fever  is  an  indication  for  a  seconil 
dose  of  antitoxin. 

The  reduction  in  the  mortality  rate  since  the  introduction  of  ants- 
toxin  is  well  shown  in  the  following  table  (Fig,  179)  prepared  by  ti« 
New  York  Department  of  Health,  the  small  reduction  shown  in  t3* 
first  three  years  of  its  use  being  explained  by  the  fact  that  sufficierv^? 
large  doses  of  antitoxin  were  not  used  at  first  and  that  the  serum  t*--^ 
later  was  more  efficient. 


Si  ,                                                    ''^''^   ^ 

e                                                                                  II 

"^         -                        z 

t         ^31                          ^ 

Z  ^    C<^'"\  1 

j;       '                    3-^                                                          Z 

»^                             ■            V-                                                 ■* 

.             -^  \                    t 

,                  ^                                 I 

^-Z^^^z-^   ,.,   I 

.                 *="    ^~-;::  I 

C""   <"TE. 

Fig.  179.— Chart  prepared  by  the  New  York  Board  of  Health,  showing  the  w 
tion  in  the  mortality  from  diphtheria  since  the  introductioD  of  antitoun. 


Complications. — In  a  certain  percentage  of  cases  skin  enipti- 
develop  after  several  days.     These  may  be  erythematous,  scarl 
form,  morbiliform,  or  urticarial  in  character.    Urticaria  is  sait^- 
follow  in  about  30  per  cent,  of  the  cases  and  usually  comes  on  from 
eighth  to  the  fourteenth  day.     It  frequently  develops  upon  the  b^ 
tocks,  abdomen,  and  chest  and  may  be  the  cause  of  great  discomtf' 
and  annoyance  to  the  patient.     Infection  and  cellulitis  may  re^*" 
from  the  injection  if  due  regard  to  asepsis  is  not  observed. 

Painful  conditions  in  the  large  joints,  as  the  hips,  knees, 

and  shoulders,  occur  in  a  small  proportion  of  the  cases.     These  syi*^"^-^^:^ 
toms,  however,  are  not  due  to  the  antitoxin,  but  are  caused  by 


ult 


;ts, 


VACCINATION 


2ig 


Jjorse-     serum,  and  depend  upon  the  susceptibility  of  the  patient  to  the 
seruEKzs.  , 

VACCINATION 

V.^a_ccination  is  the  inoculation  with  the  vaccine  or  virus  of  cowpox 
lot  tl*-  ^2;  purpose  of  inducing  that  disease  in  man  and  thereby  affording 
ImxO^*-3  or  permanent  protection  against  smallpox. 
I        T  iie  immunity  rendered  by  vaccination  is  not  claimed  to  be  invari- 
ably    tromplete.     In  a  great  majority  of  case^,  though,  a  successful 
inoculation  grants  a  person  immunity  to  smallpox  for  a  number  of 
^■cara,    though  the  effects  may  in  time  wear  oG  and  the  individual 
ajpia.   become  susceptible.     The  mortality  in  such  cases,  however,  is 
'■*'T  lew  compared  with  the  mortality  in  those  who  have  never  been 
vacc\iiated.     According  to  Osier,  in  the  former  it  is  6  to  8  per  cent. 
'id  in  the  imvaccinated  not  less  than  35  per  cent.     The  nature  of  the 
P''otection  thus  afforded  is  not  absolutely  understood,  but  the  results 
**'  Vaccination  are  unquestionable  and  admirably  attest  its  efficiency. 
^^alities  in  which  vaccination  is  systematically  carried  out  develop 
^^'tT  cases  and  present  the  lowest  death  rate  from  smallpox. 

The  Virus. — The  vims  should  always  be  obtained  from  a  reliable 
I      **U.r(e.     That  from  the  calf  is  to  be  used  by  preference.     Humanized 
'       y'liiph  should  never  be  employed  except  upon  imperative  occasions 
*'Oeii  bovine  lymph  is  not  procurable. 

The  virus  is  obtained  under  rigid  aseptic  precautions  by  curetting 
'^e  pustule  from  a  calf  and  making  an  emulsion  of  it  with  glycerin. 
^Has  b  then  collected  in  capillary  tubes  and  is  hermetically  sealed 
^^^til  used.  The  lymph  should  not  be  distributed  until  it  has  been 
^sted  for  tetanus  and  other  pathogenic  germs,  and  an  autopsy  has 
''Cten  performed  upon  the  calf  to  make  certain  it  was  free  from  disease. 
fhe  lymph  may  also  be  obtained  spread  upon  ivory  or  celluloid 
P'^^-Bts,  but  they  are  not  preferable  to  the  capillary  tubes  as  there  is 
u^-nger  of  the  virus  being  contaminated  by  handling. 

ITime  for  Vaccination.- — In  choosing  the  time  for  vaccination  the 
aSe  and  the  general  health  of  the  individual  should  be  taken  into 
C'itisideration.  As  a  general  rule,  unless  contraindicated,  the  child 
snould  be  three  to  six  months  old  before  vaccination.  The  operation 
*nould  be  avoided  if  possible  in  dentition;  and  children  who  are 
delicate  or  suffering  from  malnutrition,  syphilis,  or  skin  eruptions 
slwiuid  not  be  vaccinated  until  in  good  condition.  The  best  season  is 
m  the  early  fall  or  spring  when  there  is  less  danger  of  epidemics  of 
contagious   diseases,    such   as   scarlet    fever,    measles,    diphtheria, 


220  HYPODERMIC   AND   INTRAMUSCULAR   INJECTIONS,   ETC. 


whooping-cough,  etc.  Upon  exposure  to  small-pox,  whether  the  indi- 
vidual is  in  infancy  or  in  old  age,  he  should  always  be  immediately 
vaccinated. 

Instruments. — A  sharp-pointed  scalpel  or  a  lancet  is  as  useful 
instrument  as  can  be  found  for  performing  the  scarification, 
needles  may  also  be  employed  and,  as  they  are  cheap,  the 
needle  need  not  be  used  for  more  than  one  case.     Special  scarificato 
are  made,  but  they  have  no  advantages  over  a  lancet  or  a  needle, 
the  vaccine  points  are  used,  no  scarificator  is  necessary. 

The  New  York  Department  of  Health  supplies  with  each  capi 
tube  of  vaccine  virus,  a  needle,  a  flat  tooth  pick  for  spreading 
virus,  and  a  piece  of  small  rubber  tubing  which  fits  over  one  end 
the  capillary  tube  and  is  used  to  force  the  vaccine  out  of  the  tu 
(Fig.  i8o). 


z    c 


d    G 


^  <^ 


6  cee: 


^s 


I,  Instrumen 


Fig.  i8o. — New  York  Department  of  Health  vaccination  outfit, 
in  case;  2,  rubber  tube  for  forcing  the  virus  out  of  the  tube;  3,  tube  containing  xiru^sst- 
4,  needle  for  scarification;  5,  stick  for  spreading  the  virus. 

Site  of  Vaccination. — The  vaccination*  is  performed  either  upo 
the  arm  or  leg.     As  a  rule,  the  arm  is  preferred  as  a  site,  especially  i 
children  who  are  running  about,  as  being  more  easily  kept  at  rest  ani 
less  likely  to  be  injured.     Mothers  often  prefer  to  have  their  girls^^ 
vaccinated  upon  the  leg  to  avoid  the  disfiguring  effect  of  the  scar.   -^ 
If  the  arm  is  chosen,  the  point  selected  is  at  about  the  insertion  of  the 
deltoid  muscle;  in  the  leg  a  spot  on  the  outer  aspect  at  the  junction 
of  the  middle  and  upper  third  is  selected. 

Asepsis. — The  operation  of  vaccination  should  be  regarded  as  an 
important  one  and,  as  most  of  its  dangers  are  due  to  infection,  the 
operator  should  see  that  all  aseptic  precautions  are  observed.  The 
instrument  employed  for  scarifying  the  skin  should  be  carefully  ster- 
ilized and  the  same  instrument  should  not  be  used  more  than  once 
without  resterilization.  The  hands  of  the  operator  are  prepared  as 
carefully  as  for  any  operation.     The  patient's  skin  is  washed  with 


VACCINATION 


I  soap  and  warm  water  followed  by  alcohol  and  ether  and  is  allowed  to 
I  (Jty.      The  use  of  strong  disinfectants  is  not  advised  as  the  chances  of 
a  successful  inoculation  may  be  lessened. 


■Vaccination.     First  step,  scnrifying  the  ann, 

Teclxxiic, — (i)  By  Scarification.    Vaccination  by  the  scarifica- 
ion  metliod  is  generally  practised  in  this  country.     A  proper  spot  is 


chosco  Upon  the  arm  or  leg,  and  an  area  M  to  ?^  inch  (3  to  6  mm.)  in 
disrttettr  is  scarified  by  making  a  number  of  scratches  at  right 


HYPODERMIC  AND   INTRAMUSCITLAR  INJECTIONS,   ETC 


angles  to  each  other  in  the  skin  with  the  point  of  the  instnunent. 
just  deep  enough  to  draw  serum,  but  no  blood  (Fig,  181).  If  more 
than  one  inoculation  is  to  be  made,  as  is  frequently  done,  the  are^^ 
scarified  should  be  at  a  distance  of  at  least  i  inch  (2,5  cm.)  apart_. 
The  virus  is  then  deposited  upon  the  scarified  area,  being  rubbed  i-^-^^ 
with  some  sterile  instrument  for  a  full  minute  and  allowed  to  dr — -^ 
(Fig.  182).  The  site  of  vaccination  is  finally  covered  with  a  piece^cz^kf 
sterile  gauze  held  in  place  with  two  small  strips  of  adhe^ve  pkst^^^. 
or,  if  desired,  a  wire  shield  (Fig.  183)  may  be  used,  provided  it  jj 
implied  in  such  a  way  as  not  to  constrict  the  arm  (Fig.  184).  Affe:^.^ 
the  vesicle  has  formed,  the  part  should  be  gently  washed  with  stec — iJle 


\ 


Fifi.  183. — Vscdnation  shield.        Fig.  184, — Showing  the  shield  in  place. 


water  once  a  day  and  dressed  with  fresh  gauze  or  ravered  witt*- 
shield  to  prevent  contact  with  the  clothing. 

(2)  By  Acupuncture  or  Epidermic  Puncture. — ^By  some  t^^^-*^ 
method  of  vaccination  is  preferred  to  scarification.  Hill  (panada  ^^^ 
Medical  Association  Journal,  March,  1916)  describes  the  method  -, 

follows:  The  arm  is  washed  with  soap  and  water,  then  with  alcot»^^^ 
and  finally  with  ether.  Drops  of  thevirus  are  deposited  upon  the  s^^^~-^  ■■ 
at  three  ]x>ints  so  that  each  drop  forms  one  of  the  angles  of  a  tnan-f^^^ 
with  sides  2  inches  (5  cm.)  long.  The  skin  is  then  drawn  tight  by  fc  ' 
operator's  left  hand  which  grasps  the  part  from  behind,  while  w  J 
the  tip  of  a  sterile  needle,  held  almost  parallel  with  the  surfa  * 
punctures  are  made  through  the  virus  into  the  superficial  layer  of  C'  - 
skin  to  the  depth  of  Kooo  ^^  ^n  inch  (.035  mm.).     Six  punctu:* 


VACCINATION 


223 


are  made  close  together  at  the  site  of  each  drop.     The  excess  of  the 
yirus  is  then  wiped  off,  no  dressing  or  shield  being  required. 

Course  of  Vaccination.— Outside  of  a  little  irritation  and  redness 
at  the  site  of  inoculation  there  are  no  immediate  developments  and 
the  wound  heals.  On  the  third  day  a  papule  appears  surrounded  by 
an  area  of  slight  redness.  This  is  followed  in  twenty-four  hours  by 
the  formation  of  a  small  vesicle  which  by  the  seventh  or  eighth  day 
reaches  its  full  development.  It  is  usually  round,  '4  to  },2  inch 
(6  to  13  mm.)  in  diameter,  and  full  of  limpid  fluid.  The  center  of  the 
vesicle  is  depressed,  while  the  margins  are  elevated  and  slightly  indur- 
ated. By  the  tenth  day  a  bright  red  areola  has  developed  covering  a 
space  of  from  i  to  2  inches  (2.5  to  5  cm.)  around  the  vesicle  and  the 
contents  of  the  vesicle  become  purulent.  In  a  day  or  two  more  the 
areola  commences  to  fade  and  the  vesicle  dries  up  forming  a  dark 
brown  crust.  Usually  about  the  twenty-first  day  this  crust  falls  off, 
leaving  a  bluish  pitted  scar  which  later  slowly  fades  to  white. 

Constitutional  symptoms  more  or  less  marked  accompany  the 
^niption.  Remittent  fever  of  from  101°  to  104°  begins  on  the  fourth 
"*y  and  may  persist  until  the  eighth  or  ninth  day,  when  it  drops 
P^dually  to  normal.  In  children  irritability,  loss  of  appetite,  and 
'^Uessness  at  night  may  accompany  the  fever.  The  axillary  or 
•^Kuinal  glands  become  swollen  and  sore,  depending  upon  whether 
™*  arm  or  leg  is  the  seat  of  inoculation. 

Certain  irregular  tjpes  of  vaccination  are  sometimes  met  with. 
"*  rare  cases  a  generalized  vaccine  eruption  with  marked  fever  and 
*^a  severe  sjTnptoms  may  occur.  Single  vesicles  may  also  be  pro- 
'''*ced  on  other  parts  of  the  body  distant  from  the  site  of  inoculation 
V  autoinoculation  from  scratching.  Sometimes  the  period  of  incu- 
^tion  is  prolonged  and  the  vesicle  formation  is  delayed. 

CompUcations. — Urticaria,  impetigo  contagiosa,  and  rashes  re- 
*^*»bling  those  of  scarlet  fever  or  measles  have  been  observed. 
*-*^pclas  may  occur  at  any  time  before  the  sore  heals. 

Suppuration  and  abscess  of  the  axillary  or  inguinal  glands  some- 
l^'wies  follow  vaccination.  In  anemic  and  unhealthy  subjects,  if 
"*-f«ction  occurs,  cellulitis  and  deep  ulcers  may  form,  followed  by 
**tenave  loss  of  tissue  and  large  scars. 

Syphilis  is  no  longer  feared  under  modern  methods  of  vaccination; 
same  is  true  of  tuberculosis,  and  it  has  been  shown  in  addition 


the 


^t  the  tubercle  bacillus  is  destroyed  in  glycerinated  lymph.  Tet- 
'^^s  can  only  follow  carelessness  as  to  asepsis  and  neglect  of  pre- 
^utions  in  preparing  the  lymph. 


n 


224  HYPODERMIC  AND   INTRAMUSCXTLAR    INJECTIONS,   ETC. 

Revaccination. — Immunity  furnished  by  vaccination  is  not  p 
manent,  and  in  all  persons  revaccination  should  be  performed  seve 
years  after  the  first  va(:cination.  The  New  York  Health  Departmc 
advises  that  revaccination  be  repeated  at  intervals  of  not  more  th 
three  years  if  permanent  immunity  is  to  be  acquired.  The  vacdi 
tion  should  be  as  thoroughly  carried  out  as  in  the  first  instance, 
cases  of  exposure  to  contagion  during  the  interval,  revacdnati 
should  be  performed  at  once. 


CHAPTER  VIII 
rREATMENT  OF   NEURALGIA  BY  INJECTIONS 

TIC  DOULOUREUX 


For  the  purpose  of  relieving  the  pain  of  trifacial  neuralgia  v 
drugs  and  gases,  such  as  stovain,  cocain,  chloroform,  antipyrin,  osmic 
acid,  and  air,  have  been  injected  into  the  branches  of  the  fifth  nerve 
or  subcutaneously  into  the  painful  areas.  SchlOsser  in  1900  was  the 
first  to  practise  direct  injection  with  80  per  cent,  alcohol  of  the  different 
branches  of  the  fifth  nerve  at  their  exit  from  the  skull  through 
the  basal  foramina.  Schlosser's  method  of  injection  was,  however, 
rather  difficult,  and  it  was  not  until  Levj'  and  Baudouin  in  1906 
devised  a  comparatively  simple  technic  that  alcoholic  injections  were 
employed  to  any  great  extent.  While  injection  of  the  superficial 
branches  of  the  fifth  nerve  with  osmic  acid  and  the  deep  branches 
'*ith  alcohol  have  both  given  brilliant  results,  the  use  of  osmic  acid 
necessitates  exposure  of  the  affected  nerve  or  nerves  and,  for  this 
reason,  it  has  been  largely  discarded  in  favor  of  alcohol  alone  or  in 
"*>*ibination  with  other  drugs. 

Alcohol  when  injected  into  a  nerve  causes  a  degeneration  of  its 
HDers.  Relief  from  pain  is  thus  obtained  usually  for  a  period  of  six 
"^nths  to  two  years,  but  it  varies  considerably  depending  upon  the 
"Wroughness  with  which  the  nerve  is  injected.  In  some  cases  one 
ejection  has  given  an  apparent  cure,  but,  as  a  rule,  the  injection 
"Is  to  be  repeated  several  times. 

All  three  branches  of  the  nerve  have  been  injected,'  but,  on 
account  of  the  difficulty  of  reaching  the  ophthalmic  branch  and  the 
proximity  of  the  optic  nerve,  and  the  third,  fourth,  and  .sixth  nerves. 
deep  injection  of  this  branch  has  been  abandoned  by  the  majority  of 
operators. 

Anatomy. — The  fifth  nerve  closely  resembles  a  tj-pical  spinal 
nen'e,  being  a  mixed  nerve  with  its  sensory  and  motor  roots  arising 
separately  from  the  brain,  and  the  sensory  root  possessing  a  ganglion, 
the  Gasserian  ganglion.  The  latter  is  a  crescent-shaped  body,  com- 
posed of  nerve  fibers  and  nerve  cells,  lying  in  a  depression,  Meckel's 
cave,  on  the  apex  of  the  petrous  portion  of  the  temporal  bone.  From 
the  anterior  convex  borderof  the  ganglion  the  sensory  portion  emerges 
'  More  recently  injccUona  havf  been  made  directly  into  the   Cosstrian  ganglion. 


H 


326  TREATMENT   OF   NEURALGIA  BY  INJECTIONS 

in  three  trunks:  the  ophthalmic,  the  superior  maxillaTy,  and  tihe 
inferior  maxillary.  The  superior  maxillary  division  is  joined  on  tfce 
distal  side  of  the  ganglion  by  the  motor  root. 

The  first  division  passes  from  the  skull  through  the  sphenoidal  fis- 
sure in  three  branches:  the  lachrymal,  the  frontal,  and  the  nasal  It 
is  purely  a  sensory  nerve  supplying  the  upper  eyeHd,  conjuncti~^n, 
eyeball,  lachrymal  gland,  forehead,  anterior  portion  of  the  s(».lp, 
frontal  sinus,  and  the  root  and  anterior  portion  of  the  nose. 

The  second  division  leaves  the  skull  through  the  foramen  rot-«jii- 
dum,  crosses  the  spheno-maxillary  fossa,  and,  after  entering  the  oarlii- 


FiG.  185,— Anatomy  of  the  trifacial  nerve,     (After  Campbell.) 


tal  cavity  through  the  spheno-maxillary  fissure,  passes  to  the  fac  by 
way  of  the  infraorbital  groove.  It  is  also  a  sensory  nerve,  supplying 
the  cheek,  anterior  portion  of  the  temporal  region,  the  lower  eyelid, 
ridge  of  the  nose,  upper  lip,  upper  teeth,  mucous  membrane  of  the 
nose,  nasopharynx,  antrum,  posterior  ethmoidal  cells,  soft  palate, 
tonsil,  and  roof  of  the  mouth. 

The  third  division  is  a  mixed  nerve  formed  from  a  sensory  and 
motor  root.  The  two  pass  from  the  cranium .  through  the  foramen 
ovale  and  immediately  unite  to  form  a  single  branch.  The  sensory 
portion  of  the  nerve  supplies  the  skin  of  the  side  of  the  head,  auricle 
of  the  ear,  external  auditory  meatus,  lower  portion  of  the  face, 
lower  Up,  lower  teeth  and  gums,  mucous  membrane  of  the  mouth, 
tongue,  and  mastoid  cells,  and  salivary  glands.  The  motor  portion 
supplies  the  muscles  of  mastication. 


TIC   DOULOUREUX 


227 


Instruments.— There  will  be  required  a  special  needle  4^  inches 
[u  cm.)  long  and  ^{^  in.  (1.75  mm.)  in  diameter,  a  glass  syringe 
witi  a  capacity  of  at  least  30  minims  (3  c.c),  a  scalpel,  a  fine  needle, 
i'j  inches  (5  cm.)  long  which  can  be  fitted  to  the  syringe  for  the 
purpose  of  infiltrating  the  skin  at  the  site  of  puncture  or  performing 
peripheral  injections  of  nerve  branches,  and  two  medicine  glasses, 
one  for  a  cocaln  solution  and  the  other  for  the  alcohol  solution 
(%  186). 

A 


I».  186. — Apparatus  for  injecting  the  branches  of  the  liftli  iien'e.  i,  Two  medicine 
S""^>  3,  Luer  syringe;  j,  Livy  and  Bauckiuin  needle;  4,  small  hypodermic  needle; 
J,  unpnle  cootaimng  anesUietic;  6,  scalpel. 

The  needle  should  have  rather  a  blunt  point  and  should  be  pro- 
vided vfith  a  stylet  which  extends  flush  with  the  point  of  the  needle 
when  pushed  home.  The  outside  of  the  distal  portion  of  the  needle 
IS  graduatgj  in  centimeters  up  to  five.  The  proximal  end  of  the 
"^""C  should  be  made  to  accurately  fit  the  end  of  the  syringe  (Fig. 
187)- 


*T«.  187.— Enlarged  view  of  the  Lfivy  and  Baudouin  needle  and  stylot. 

*^lution  Used.— The  solution  originally  used  was  a  mixture  of 
CiCWn,  morphin,  chloroform,  and  So  per  cent,  alcohol,  but  the  mor- 
phin  and  chloroform  are  generally  discarded  at  the  present  time. 
The  addition  of  chloroform  causes  considerable  reaction  at  the 
site  of  injection  and  the  formation  of  scar  tissue.  Patrick  {Jour- 
lui  of  ifie  American  Medical  Associatitm,  Jan.  20,  1912)  uses  the 
Roving: 

Cocsin  muriat.,  gr.  ii  (0.13  gm.) 

AJtobol,  dr.  iiias  (13  c.c.) 

Aq.  desL,  qj.  ad.,  oz,  ss  (iS  c.c.) 
ne  Mlution  tbould  be  freshly  prepared  toi  each  injection. 


338  TKEATUENT   OF   IfEtTKALGIA  BY   INJECIIONS 

Quantify  Used. — For  a  deep  injection  30TII  (3  cc.)  of  stdotka 
are  generally  injected  into  each  branch.  Eig^t  miniirm  (o.j  c.c.)  is 
sufficient  for  a  peripheral  injection. 

Position  of  Patient — The  injection  is  made  with  the  patient  A- 
tii^  upright  in  a  chair  or  the  recumbent  position  may  be  en^lojtd 
with  the  patient's  head  resting  on  the  side. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  the  apeaia^s 
hands  cleansed  as  for  any  operation,  and  the  site  of  injection  painted 
with  tincture  of  iodln. 

Anesthesia. — General  anesthesia  is  to  be  avoided  if  possible, as 
the  best  guide  to  a  successful  injection  is  the  spasm  of  pain  and  tbe 


Inesthesia  that  results  over  the  area  of  distribution  of  the  ner"*' 
anfiltration  of  the  skin  with  a  few  drops  of  0.2  per  cent,  cocain  sol**" 
tion  or  a  I  per  cent,  procain  solution  at  the  point  through  whi**' 
the  needle  enters  is  usually  sufficient. 

Technic. — The  site  of  injection  and  the  direction  in  which  tie 
needle  is  inserted  will  vary  according  to  the  branch  injected. 

First  Division. — Deep  injection  of  this  nerve  at  the  sphenoidal 
fissure  is  rarely  practised  on  account  of  its  dangers;  instead,  the 
supraorbital  nerve  is  injected  at  the  supraorbital  notch  or  foramea 
The  supraorbital  notch  is  located  by  palpation  or  by  the  sensations 
of  the  patient  when  the  nerve  is  compressed  between  the  finger  and 
the  skull.  The  skin  over  the  site  of  the  notch  is  anesthetized,  and  an 
attempt  is  made  to  insert  the  fine  needle  into  the  foramen,  the  eye- 


TIC  DOXTLOXJKEUX  239 

baQ  bemg  protected  by  the  index  finger  of  the  operator's  left  hand 
(Fig.  188).  When  the  needle  strikes  the  nerve  a  sharp  shooting  pain 
ezteoding  up  the  forehead  will  be  felt  by  the  patient.  If  possible, 
the  needle  should  be  inserted  for  a  distance  of  ^  to  ^  of  an  inch 
(5  to  10  mm.)  into  the  canal.  About  lo  minims  (0.6  c.c.)  of  the 
alcohol  solution  is  then  injected.  A  successful  injection  will  result 
in  immediate  anesthesia  within  the  distribution  of  the  nerve. 

The  Second  Division  is  injected  at  the  foramen  rotundum.  The 
posterior  border  of  the  orbital  process  of  the  malar  bone  is  identified 
and  from  it  is  dropped  a  vertical  line  to  the  lower  border  of  the  zy- 
goma; }^  inch  (0.5  cm.)  behind  the  point  where  this  perpendicular 
line  crosses  the  zygoma  is  the  point  for  entrance  of  the  needle.    The 


^     w?^ 


Iio.  189. — Needle  in  place  for  injecting  the  second  division  of  the  fifth  nerve. 


^tin  at  this  point  is  infiltrated  with  cocain  and  is  nicked  with  a 

^*^lpel.     The  needle  is  inserted  with  the  stylet  withdrawn  until  it  is 

'^'ell  into  the  subcutaneous  tissues;  then  the  stylet  is  pushed  home  in 

'^•■<ier  to  furnish  a  blunt  point  and  avoid  any  injury  to  the  blood- 

y^ssels.    The  direction  of  the  needle  should  be  at  first  horizontally 

**i\vard  and  then  slightly  upward,  and  at  a  depth  of  2  inches  (5  cm.) 

tte  needle  should  reach  the  nerve  at  the  foramen  rotundum.    If, 

^ter  passing  through  the  subcutaneous  tissue,  the  needle  strikes  the 

coronoid  process  of  the  lower  jaw,  it  will  have  to  be  re-inserted  at  a 

I>oiiit  slightly  more  forward.     This  will  necessitate  changing  the 

*ngle  of  the  needle  to  correspond  with  the  new  site  of  entrance.     Care 

must  be  observed  against  inserting  the  needle  so  far  forward  that  the 

''''bit  will  be  entered  or  so  deep  that  the  sixth  nerve  is  reached.     With 


230  TREATMENT   OF  NEUILAXGIA  BY  INJECTIONS 

the  needle  introduced  the  correct  distance,  the  stylet  is  withdraiii: 
and  the  alcohol  solution  is  slowly  injected  and,  if  the  needle  is  prtp- 
erly  placed,  a  sharp  pain  will  be  felt  by  the  patient  in  the  area  cf 
distribution  of  the  nerve.  If  the  nerve  is  not  reached,  the  needte 
should  be  withdrawn  a  little  and  its  direction  slightly  changed.  At 
the  completion  of  the  injection,  the  needle  is  removed  and  the  point 
of  puncture  is  sealed  with  collodion  and  cotton.  The  patient  sboaSs 
be  kept  in  a  recumbent  position  for  10  to  15  minutes  following  th 
injection. 

If  it  is  found  impossible  to  reach  the  nerve  at  its  exit  from  tJ 
skull,  its  infraorbital  branch  may  be  injected  at  the  infraorbit 
foramen,  using  a  long  fine  needle  for  this  purpose.     About  10  to 
minims  (0.6  to  1  c.c.)  of  the  solution  are  injected. 

The  Third  Division  is  injected  at  the  foramen  ovale.    The  <I- 
cending  root. of  the  zygoma  is  identified,  and  at  a  point  i  inch  C 


Fig.  190, — Needle  in  place  for  injecting  Uie  third  divisbn  of  the  fifth  nerve. 


cm.)  in  front  of  it  just  below  the  zygoma,  the  needle  enters  the  sfc; 
The  skin  at  this  point  is  anesthetized  and  is  nicked  with  a  scalp« 
and  the  needle  with  the  stylet  withdrawn  is  pushed  through  the  sul 
cutaneous  tissues  in  a  direction  slightly  upward  and  backwar* 
The  stylet  is  then  pushed  home,  and  needle  is  carried  in  through  tb 
deeper  tissues,  still  slightly  upward  and  backward,  until  it'reacht 
a  depth  of  ij^  inches  (4  cm.);  It  should  then  be  at  the  forame 
ovale.  When  the  needle  strikes  the  nerve,  the  patient,  as  arule,wi 
be  conscious  of  a  sharp  pain  in  the  tongue  or  lower  jaw.  Tl 
stylet  is  then  removed,  the  syringe,  loaded  with  the  alcohol  solutio] 
is  fitted  to  the  needle,  and  the  injection  is  made.     At  the  completic 


} 


TIC  DOULOUREUX 


«3i 


of  tlie  operation,'  the  needle  is  withdrawn  and  the  skin  puncture  is 
sealed  with  collodion  and  cotton. 

Pollowing  a  deep  injection,  there  is  considerable  swellli^  of  the 
/ace,  which  the  patient  should  be  warned  beforehand  to  expect. 
Soznetimes  a  hematoma  may  result  from  puncture  of  some  vessel 
dirring  the  insertion  of  the  needle.  To  avoid  this,  Patrick  advises 
th.a.t  the  needle  always  be  inspected  for  oozing  and,  if  present,  that 
th.^  needle  and  stylet  be  left  in  place  until  it  stops. 

SCIATICA 

The  injection  of  alcohol  and  other  drugs  which  have  a  destruc- 
*i"v«  action  upon  nerves  and  which  have  been  effectively  employed  in 
i=L^iaralgia  of  the  fifth  nerve  should  be  avoided  in  sciatica,  as  the 


^"10.  191.— Apparatus  for  injectins  the  sdatic  nerve,  i,  Medicine  glass;  3,  glass 
ETsftduate;  3,  large  glass  syringe  and  blunt  needle  for  injecting  the  nerve;  4,  ampule  of 
cocaia;  5,  small  syringe  and  needle  for  the  preliminary  infiltration  of  the  site  of  puncture; 
6.  scalpel. 

sciatic  is  a  mixed  nerve  and  the  use  of  such  drugs  has  produced  grave 
motor  changes  in  the  nerve.  The  injection  of  physiological  salt 
solution,  however,  has  given  good  results  in  relieving  the  pain  of  scia- 
uca  without  causing  any  harmful  results.  The  injection  is  made 
mto  the  nerve-sheath  with  the  idea  of  separating  the  adhesions  that 
■lave  formed  around  the  inflamed  nerve,  and,  if  it  is  used  in  the 
proper  cases,  in  the  great  majority  of  instances  it  gives  relief.  Fre- 
quently more  than  one,  and  in  the  severe  cases,  a  number  of  injections 
*•*  required  to  produce  a  cure. 

Apparatus. — There  will  be  required  a  needle  4^  inches  (la  cm.) 
'•"•g  and  J.^g  inch  {1.5  ram.)  in  diameter,  a  glass  syringe  with  a 
f*padty  of  3  to  4  ounces  (90  to  120  c.c),  a  piece  of  rubber  tubing  to 


232 


TREATMENT   OP  NEURALGIA  BY   INJECTIONS 


connect  the  syringe  and  needle,  a  scalpel,  a  cocain  syringe,  a  small 
medicine  glass  for  the  cocain  solution,  and  a  glass  graduate  for  the 
salt  solution  (Fig.  191). 

The  needle  is  of  a  type  similar  to  that  used  for  trifacial  injectioiM 
(see  Fig.  187).  It  should  be  graduated  in  centimeters  from  i  to  10, 
and  the  point  should  be  rather  blunt. 

Solution  Used.^Normal  salt  solution  (salt  i  dram  (4  gm.)  to  a 
pint  (500  c.c.)  of  boiled  water)  with  or  without  the  addition  of  a  loc:^ 
anesthetic  is  used. 

Temperature  of  the  Solution. — The  solution  is  injected  either  at 
about  the  temperature  of  the  body  or  at  32°F.  (0°  C). 


Fig.  19a. — Showing  the  method  of  locating  the  point  tor  injecting  the  sdatic  wfvp.-^ 

(After  Hoecht.) 

Quantity. — Two  to  4  ounces  (60  to  120  c-c)  of  the  warm  solution 
and  2li  to  5  drams  (10  co  20  c.c.)  of  the  cold  solution  may  be 
injected. 

Intervals  between  Injections. — When  it  is  necessary  to  repeat 
the  injections,  they  may  be  given  at  intervals  of  24  to  72  hours. 

Site  of  Injection. — Several  points  for  reaching  the  nerve  are  ad- 
vised. That  used  by  D'Orsay  Hoecht  and  one  that  gives  access  to 
the  nerve  high  up  is  as  follows:  A  line  is  drawn  from  the  sacrococ- 
cygeal joint  to  the  postero-external  border  of  the  great  trochanter, 
and  one  finger's  breadth  external  to  the  junction  of  the  inner  one- 
third  and  outer  two-third  of  this  line  is  the  point  for  inserting  the 
needle  (Fig.  192). 

The  nerve  may  also  be  reached  by  inserting  the  needle  at  a  point 
where  a  horizonal  line  through  the  tip  of  the  great  trochanter  cuts  a 


SCIATICA  333 

i  through  the  outer  margin  of  the  tuberosity  of  the 

of  the  Patient. — The  patient  lies  upon  the  abdomen  with 
tended  and  with  a  pillow  beneath  the  groins. 
. — The  instruments  are  boiled,  the  hands  of  the  operator 
id  as  carefully  as  for  any  operation,  and  the  field  of  opera- 
ited  with  tincture  of  iodln. 

■The  point  on  the  skin  through  which  the  needle  is 
s  anesthetized  by  infiltration  with  a  few  drops  of  a  0.2 
solution  of  cocain  or  a  i  per  cent,  solution  of  procain, 
ic. — The  syringe  is  filled  with  the  salt  solution  of  the  proper 
»  and  is  placed  ready  for  use  near  at  hand.  A  small 
de  in  the  skin  at  the  point  chosen  for  the  puncture,  and 
armed  with  the  stylet,  is  inserted  perpendicularly  to  the 
^  the  tissues  until  it  hits  the  nerve.  If  the  needle  strikes 
then  withdrawn  J.25  hich  (i  mm.)  and  should  be  in  close 
to  the  nerve.  The  moment  the  nerve  is  reached  the  pa- 
lences  a  sharp  lancinating  pain  low  down  the  back  of  the  " 
e  heel,  frequently  accompanied  by  a  jerking  motion  of  the 
stylet  is  then  removed,  the  syringe  is  attached  to  the 
I  the  desired  amount  of  solution  is  slowly  and  steadily  in- 
I  the  end  of  the  injection,  the  needle  is  removed,  and  the 
Q  puncture  is  sealed  with  collodion  and  cotton. 
ing  the  injection,  the  patient  should  be  instructed  to  keep 
several  days.  For  the  first  few  days  there  may  be  some 
not  infrequently  there  is  a  slight  rise  of  temperature 
|.  to  48  hours. 


;  1. '- 


CHAPTER  DC 

DISINFECTION  OF  WOUNDS  BY  THE  CARREL-DAXIK 

TECHNIC 

The  Carrel  method  of  treating  mfected  wounds  is  based  on  tb* 
belief  that  a  non-toxic  and  non-irritating  antiseptic,  applied  to,  and 
kept  in  contact  with  all  parts  of  a  wound  during  a  certain  period  oi 
time  and  in  a  constant  concentration,  is  capable  of  destroying 
microorganisms  and  eventually  sterilizing  the  wound.  The  apgoc^ 
tunity  to  employ  the  Carrel  technic  during  the  recent  war  has  fullj^ 
demonstrated  the  soundness  of  Carrel's  teachings,  and  the  value  9^ 
the  method  not  only  in  preventing,  but  in  suppressing,  suppuration- 
Under  this  treatment  wound  complications  are  greatly  diminished  ^ 
convalescence  is  more  rapid  than  under  the  old  methods  of  treatment^ 
and  the  period  of  incapacity  is  reduced  to  a  minimum.  Favorable 
results,  however,  depend  upon  the  strict  adherence  to  all  the  details 
of  the  technic  so  carefully  developed  by  Carrel,  for,  as  he  emphasizes 
"the  success  of  the  method  which  enables  us  to  render  asq>tic  aim 
infected  wound  is  not  due  to  the  marvellous  properties  of  a  new  drag* 
It  should  rather  be  attributed  to  a  combination  of  means,  whidx 
enables  us  to  make  use  of  a  definite  antiseptic  substance,  under  sudx 
conditions  of  concentration  and  duration  that  its  action  becomes 
efficacious.  This  method  is  a  combination  of  which  each  sin^^ 
part  is  essential  to  the  rest.  The  antiseptic  cannot  be  altered  withoat:- 
changing  the  manner  of  using  it.  In  the  same  way,  a  modificatiouo* 
the  technic  demands  an  antiseptic  endowed  with  different  chemic^-* 
properties." 

Dakin's    hypochlorite    solution,    having    powerful  bacterid^^^ 
powers  and  at  the  same  time  being  but  slightly  irritating  to 
tissues,  was  chosen  as  the  antiseptic  best  meeting  the  requirements 
the  Carrel  method  after  an  exhaustive  examination  of  many 
stances  with  regard  to  their  bactericidal  action  and  effect  u 
normal  tissues.     The  solution  is  instilled  into  the  wound  at  freque 
intervals,  the  object  being  not  to  irrigate  the  wound,  but  to  keep 
constantly    bathed    in    the    solution.     Frequent   instillations 
necessary,   because,    in   contact   with   wound  fluids,    the   solutio: 
rapidly  loses  its  chlorin.     If  the  solution  is  used  early  in  a  wound^' 

234 


^v-*'     * 


JC 


'■j:   -a 


«   ^ 


.-— i 


DISINFECTION    OF    WOUNDS  235 

before    the    microorganisms   have   time   to   multiply   and   spread, 
infection  may  be  aborted  and  the  wound  closed  by  suture  without 
suppuration,  while,  if  suppuration  is  already  present,  it  can  be 
I  tontroUed,  provided  the  focus  is  reached  by  the  solution,  the  wound 
j  being  gradually  freed  from  infection  and  put  in  such  condition  that 
[  it  can  be  early  closed  by  suture.     Favorable  response  to  the  treat- 
ment is  not  gauged  only  by  the  clinical  appearance  of  the  wound, 
out  is  determined  first  by  a  diminution,  and  finally  the  disappearance 
itf  microorganisms  demonstrated  by  microscopical  examination  of 
^e   secretions. 

I*roperties  of  Daldn's  Solutios.^ — Dakin's  solution  is  a  0.5  per 
rent.,  neutral  h>'pochJorite  of  soda  solution.  It  differs  from  Javel 
*'3-tier,  Labarraque's  solution,  and  other  hypochlorites  in  that  it 
ror»  tains  no  free  alkali  and  so  is  non-irritating  to  the  tissues.  The 
^ffe^zts  are  entirely  local  and,  regardless  of  the  amount  used,  there 
IS  JTko  danger  of  toxemia  from  absorption.  It  has  the  property  of 
(iii«J3tegrating' necrosed  tissue,  blood  clots,  etc.,  but  does  not  harm 
ther  tissues  undergoing  repair  or  normal  tissues  with  blood  supply. 
The  solution  of  sodium  hypochlorite  for  the  treatment  of  wounds 
shc>»jld  meet  the  following  requirements.  It  must  contain  no 
cau.stic  alkali  and  the  hypochlorite  content  must  be  between  0.45  per 
cent,t,  and  0.5  per  cent.  Solutions  of  hypochlorite  with  a  strength 
belciw  0.45  per  cent,  are  not  active  enough,  while  above  0.5  per  cent. 
"*&  solution  is  irritating.  The  solution  must  be  carefully  prepared, 
Preferably,  by  a  trained  chemist,  and  should  be  tested  regularly, 
It  should  be  kept  in  a  cool  place,  free  from  exposure  and  light. 
"  sboutd  never  be  heated,  as  by  so  doing  its  composition  is  altered 
'nd  it  loses  its  antiseptic  properties. 

Preparation  of  Dakin's  Solution  by  Daufresne's  Method'.— -For 
"le  preparation  of  the  solution  three  chemicals  are  necessary: 
'^Icium  chlorid,  sodium  carbonate  (dry,  obtained  in  the  market 
Under  the  name  of  Solvay's  soda),  and  sodium  bicarbonate.  The 
*3at  two  ingredients  are  fairly  uniform  in  compositions,  but  the 
•^^iimercial  chlorid  of  lime  is  subject  to  wide  variations  as  to  the 
***iount  of  active  chlorin  it  contains,  and,  for  this  reason,  it  is 
f^^^nlial  to  determine  by  titration  the  percentage  of  active  dilorin 
***  the  calcium  chlorid  employed. 

Titration  of  the  Calcium  Chlorid — For  this  purpose  there  will  be 
***^Uired  a  25  c,c.  buret,  graduated  in  tenths  of  a  cubic  centimeter,  a 
^'^  C.C.  pipet,  and  a  decinormal  solution  of  sodium  hyposulphite. 
'  Infected  Wounds,  Carrel  and  Dehelly. 


236 


DISINFECTION   OF  WOUNDS 


An  average  sample  of  the  calcium  chlorid  is  obtained  by  selecr't 
ing  small  amounts  from  dififerent  parts  of  the  stock  and  mixing  th^: 
carefully.     Twenty  grams  of  this  average  sample  are  then  wei; 
out  and  are  dissolved  in  one  liter  of  tap  water.    This  solution 
allowed  to  stand  for  several  hours.    Ten  c.c.  of  the  clear  fluid  is  th. 
measured  off  and  to  it  is  added  20  c.c.  of  a  10  per  cent,  solution 
potassium  iodid  and  2  c.c.  of  acetic  or  hydrochloric  acid.     To 
resultant  mixture  a  decinormal  solution  of  sodium  hyposulphite 
added  drop  by  drop  until  the  mixture  is  decolorized.     The  number 
cubic  centimeters  of  the  hyposulphite  solution  employed  to  deed 
ize  the  mixture,  multiplied  by  1.775,  gives  the  weight  of 
chlorin  contained  in   100  grams  of  calcium  chlorid.     The  estiisrs. 
tion  of  the  chlorin  must  be  carried  out  for  each  new  sample  of 
dum  chlorid  employed. 

Daufresne  gives  the  following  table  of  the  quantities  of 
chemicals  required  to  obtain  a  correct  solution,  according  to 
amount  of  active  chlorin  contained  in  the  calcium  chlorid: 


i 


Quantities  to  be  used  to  obtain  10  liters  of  solution  of  hypc^- 

^^ 

chlorite  of  0.47s  per  cent 

Titration  of  chlorid 

1 

of  lime  (CI  per 

Chlorid  of  lime, 

Carbonate    of    soda 

Bicarbonate  of  sc^** 

■:*•■ 

cent.) 

grams 

anhydrous,  grams 

grams 

20 

230                 ■                 IIS 

96 

21 

220* 

no 

92 

22 

210 

loS 

88 

23 

:TOO 

100 

84 

24 

192 

96 

80 

25 

184 

92 

76 

26 

177 

89 

72 

27 

170 

8S 

70 

28 

164 

82 

68 

29 

159 

80 

66 

30 

154 

77                                   64 

31 

148 

74 

62 

32 

144 

72 

60 

33 

140 

70 

59 

34 

135 

68 

57 

35 

132 

66 

55 

36 

128 

64 

53 

37 

124 

62                                       52 

^.^ 

Preparation  of  DakirCs  Solution. — (i)  To  make  ten  liters  of 
solution,  weigh  the  exact  quantities  of  the  calcium  chlorid,  sodi 


DISINFECTION  OF  WOUNDS  237 

carbonate,  and  sodium  bicarbonate  determined  by  titration  of  the 
calcium  chlorid.  For  example,  if  the  calcium  chlorid  contains  25  per 
cent,  active  chlorine  there  will  be  required: 

Calcium  chlorid 184  grams 

Sodium  carbonate,  dry,  Solvay 92  grams 

Sodium  bicarbonate 76  grams 

(2)  Place  the  calcium  chlorid  in  a  12  liter  flask  with  5  liters  of 
water  and,  after  shaking  thoroughly  for  several  minutes,  allow 

t:o  stand  over  night. 

(3)  Dissolve  the  carbonate  and  bicarbonate  of  soda  in  another 
S    liters  of  cold  water. 

(4)  Pour  the  solution  of  soda  salts  into  the  flask  containing 
'tlx^  super-saturated  solution  of  calcium  chlorid  and,  after  shaking 
ATxgcrously  for  a  few  moments,  allow  it  to  stand  so  that  the  carbonate 
of  calcium,  which  is  formed,  can  settle. 

(s)  At  the  end  of  half  an  hour  syphon  off  the  clear  fluid  and 
filter  it  through  two  thicknesses  of  filter  paper.  A  perfectly  clear 
fl^d  should  be  the  result. 

The  fluid  is  now  ready  for  use.  To  avoid  mistaking  it  for  other 
solutions  permanganate  of  potash,  (5  mgm.  to  the  liter  of  filtered 
^^lution),  may  be  added  for  the  purpose  of  coloring  it. 

Titration  of  Dakin^s  Solution. — The  strength  of  the  solution 
^ould  be  determined  from  time  to  time  by  titration.  It  is  performed 
^^  follows.  To  10  c.c.  of  Dakin's  solution  add  20  c.c.  of  a  10  per  cent. 
^^lution  of  potassium  iodid  and  2  c.c.  of  acetic  or  hydrochloric  acid. 
^^  this  mixture  is  added  drop  by  drop,  a  decinormal  solution  of 
sodiujQ  hj'posulphite  until  it  is  decolorized.  The  number  of  cubic 
^^ritimeters  of  the  sodium  hyposulphite  solution  used,  multiplied 
^y  0,03725,  will  give  the  weight  of  hypochlorite  of  soda  contained 

^^  J^ 00  c.c.  of  solution. 

Test  of  Alkalinity  of  Dakin^s  Solution. — Place  20  c.c.  of  the  solu- 

^^^    in  a  glass  and  drop  a  few  centigrams  of  powdered  phenol- 

^'^tiialein  on  the  surface  of  the  liquid.   *If  the  solution  is  properly 

^^^I^ored,  it  will  remain  colorless,  while  a  red  t?iit  indicates  the 

f^^^scnce  of  free  caustic  soda. 

Apparatus. — For  instilling  the  solution  into  a  wound  there  will 
^  i^equired:  (i)  A  glass  reservoir  with  a  capacity  of  i  quart  (liter), 

^^^  a  red  rubber  irrigating  tube  ]/i  inch  (6  mm.)  in  diameter  and  6 
^^t:  (2  m.)  long,  (3)  a  glass  drop  counter,  (4)  a  clamp  for  controlling 
^^  flow  of  the  solution,  (5)  glass  connections  and  distributing  tubes, 

^^^  (6)  rubber  instillation  tubes  about  16  French  in  diameter  and 


238 


raSINTECnON  OF  WOUNDS 


[2  to  16  inches  (30  tx>  40  cm.)  long.  For  intermittent  insti 
mth  numerous  tubes,  which  is  the  usual  method  employ* 
apparatus  is  assembled  without  the  "drop-coimter"  (Fig.  193) 
latter  is  essential  only  when  continuous  instillations  with  a  sin{ 


Fig.  193. — Carrel  apparatus  assembled  for  intermittent  instillation  wit 
)us  tubes.  Small  figure  shows  the  arrrangement  of  the  perforations  and  the  < 
tube  tied  off. 

s  used,  a  screw  pinch  cock  regulating  the  flow  of  the  solutic 
[94). 

The  instillation  tubes  are  of  two  varieties — (i)  non-i>erf 
mth  ends  open  and  a  large  flat  lateral  opening  3^  of  an  inch 


DISINFECTION  OF  WOUNDS 


239 


om  the  distal  end  (see  Fig.  194),  and  (2)  perforated  tubes,  with 
e  distal  end  closed  with  a  ligature  (see  Fig.  193).  A  punch  pro- 
long a  hole  with  a  diameter  of  about  J^s  of  an  inch  (i  mm.)  (Fig. 
5)  is  used  to  make  the  perforations.     The  tubes  are  perforated  over 


^«  194. — Carrel  apparatus  assembled  for  continuous  instillations.  Note  the 
'  ^^be,  drop-counter,  and  screw  pinch-cock  for  regulating  the  flow.  The  small 
'  ^1)0 ws  an  enlarged  view  of  the  distal  end  of  the  tube  with  lateral  opening. 

^^ce  of  from  2  to  8  inches  (5  to  20  cm.)  from  the  closed  end, 
^t  eight  perforations  being  made  in  each  2  inches  (5  cm.)  of 
•^-    For  use  on  a  large  circular  area  such  as  an  amputation 


240 


DISINFECTION  OF  WOUNDS 


stump,  tubes  may  be  employed  in  which  the  perforations  are  made 
in  the  middle  third  of  the  tube,  leaving  both  ends  open.     For  supv* 


k-i? 


Fig.  195. — Punch  for  making  the  perforations  in  the  tubes. 


=>  /: 


t«? 


Fro    106. — Carrel    tubes.    A.  Two    way  tube  with  p>erforations  in  the  center. 

Perforated  tubes  covered  with  Turkish  towelling. 


flcial  wounds  where  it  is  desired  to  distribute  the  fluid  over  a 
surface  and  for  wounds  with  dependent  openings,  perforated 


1 


I 


DISINPECnON  OF   WOUNDS 


241 


are  covered  with  Turkish  towelling,  and  threads  are  fastened  to  the 
towelling  and  left  long,  to  act  as  guy  ropes  and  maintain  the  tubes 
in  position.    The  threads  may  be  sutured  to  the  skin  edges,  or  they 
can  be  held  sufficiently  fixed  if  covered  by  the  vaseline  gauze  used  to 
protect  the  skin  edges. 

The  glass  distributing  tubes  are  employed  for  connecting  the 
instillation  tubes  with  the  main  conducting  tube.     They  are  pro- 
vided with  I,  2,  3,  or  4  branches,  so  that  the  instillation  may  be 
ca.x-xied  out  through  one  tube  or  through  groups  of  2,  3,  or  4  tubes, 
en  more  than  four  tubes  are  required,  a  Y  shaped  glass  tube  is 
jrted  into  the  conducting  tube,  thus  allowing  two  sets  of  instilla- 
tubes  to  be  connected  with  one  reservoir. 
Dressings,   etc. — For   protection   of  the  skin  in  the  neighbor- 
of  the  wound,  strips  of  gauze  bandage,  2^^  by  5  inches  (6  by 
cm.)  in  size,  impregnated  with  sterile  vaseline,  are  employed, 
may  be  conveniently  prepared  by  laying  the  strips  of  gauze 


^>-iC-V-'-<^^^/''^'*v<yf>^^^'r-^r;^/ 


:97. — Cross  section  of  large  pad,  showing  ix  and  D.  gauze,  B.  non-absorbent 
cotton,  and  C.  absorbent  cotton.  (After  Carrel  and  Dehelly.) 


t  shallow  tin  wafer  box  and  pouring  yellow  vaseline  melted  to  a 
^^vii<i  over  them,  so  that  the  vaseline  soakes  into  all  portions  of  the 
S^VL^e.  The  box  is  then  covered  and  the  whole  is  sterilized  in  an 
^^tioclave.  Sterile  gauze  tampons  for  holding  the  tubes  in  place  in  the 
^^oxxnd,  are  also  required. 

The  dressings  are  in  the  form  of  pads,  of  three  sizes:  one  large 
^liovigh  to  encircle  the  thigh,  one  for  the  arm  or  leg,  and  a  smaller 
^^^^-  These  pads  consist  of  a  layer  of  absoibent  cotton  and  then  a 
^>^^r  of  non-absorbent  cotton  wrapped  in  a  layer  of  gauze,  which  is 
^^*"^fuUy  folded  over  the  back  of  the  pad.  Secretions  are  thus 
^^^^orbed,  yet  do  not  escape  to  the  exterior.  For  holding  these 
^"^side  dressings  in  place  web  straps,  safety  pins,  or  clamps  may  be 
utilized. 

In  addition  to  the  above,  scissors,  dressing  forceps,  and  rubber 
^  ^^^^ves  are  required. 

Asepsis. — The  instillation  tubes  are  sterilized  by  boiling  or  in 
^'^     autoclave  and  the  dressings  are  sterilized  in  an  autoclave.     In 
^^sing  the  woimds  everything  that  comes  in  contact  with  the 

16 


242  DISINFECTION   OF   WOUNDS 

wound  is  handled  with  sterile  forceps,  and  not  even  the  gloved, 
hands  are  allowed  to  touch  the  dressings  or  tubes.  The  instrumeris- 
must  thus  be  freshly  sterilized  for  every  case,  and  it  is  sometimes 
necessary  to  use  newly  sterilized  instruments  in  dressing  different 
wounds  on  the  same  patient. 

Frequency  of  Instillations. — Intermittent  instillation,  the  method 
applicable  to  the  great  majority  of  wounds  is  practiced  every  twc^ 
hours  day  and  night. 

Quantity  of  Solution  Instilled. — ^The  length  of  time  the  solutioi 
flows  should  be  suflScient  to  thoroughly  bathe  the  wound  and  yet  no 
flood  it  and  wet  the  patient.  The  quantity  of  solution  necessary 
fill  the  wound  may  be  determined  at  the  first  dressing  by  aUowin^g 
the  solution  to  flow  after  the  tubes  are  in  place  before  the  woimd  L^ 
covered.  Usually  the  pinch  cock  is  opened  from  a  half  to  thre:^ 
seconds,  depending  on  the  size  of  the  wound.  The  amount  of  solm.— 
tion  that  escapes  will  thus  vary  from  %  to  3  ounces  (20  to  100  c.c.^  9 
and  from  8  ounces  to  2\^  pints  (250  to  1200  c.c.)  in  the  tWenty-foiLX" 
hours. 

For  continuous  instillations  the  pinch  cock  should  be  so  regu--^ 
lated  that  the  solution  flows  at  the  rate  of  5  to  6  drops  per  minuter^ 

Height  of  Reservoir. — The  pressure  under  which  the  solutior*- 
enters  the  wound  is  regulated  by  the  height  of  the  reservoir,  and 
will  vary  according  to  the  sensitiveness  of  the  patient  and  the  typ^ 
of  wound.  The  pressure  should  not  exceed  three  feet  (i  meter)  andi- 
often  16  inches  (40  cm.)  is  sufficient.  The  entrance  of  the  flui<^- 
should  not  cause  the  patient  pain;  if  it  does,  the  cause  is  either  ex- 
cessive pressure  or  an  inability  of  the  solution  to  escape  from  the 
wound  from  a  small  opening. 

Duration  of  Instillations. — The  instillations  are  maintained 
day  and  night  until  all  microorganisms  disappear  from  the  woimd. 
This  usually  requires  from  5  to  8  days  in  moderate  sized  wounds  of 
the  soft  parts,  and  longer  if  there  is  bone  involvement. . 

Technic.  (i)  Mechanical  Cleansing  of  the  Wound. — ^The  first 
essential  of  the  treatment  is  the  preparation  of  the  woimd  for  the 
penetration  of  the  liquid  by  a  thorough  mechanical  cleansing. 
This  should  be  carried  out  at  the  earliest  possible  moment  before 
the  inflammatory  stage  sets  in.  It  consists  of  a  careful  and  thorough 
debridement  of  the  wound  and  the  removal  of  any  shell  fragments, 
pieces  of  clothing,  dirt,  etc.  It  must  be  thoroughly  and  methodi- 
cally done  with  all  aseptic  precautions  under  a  general  anesthetic. 

The  field  of  operation  is  sterilized  with  tincture  of  iodin.     The 


DISINFECTION  OF  WOUNDS  243 

wound  must  be  opened  up  suflSdently  to  enable  the  operator  to  ex- 
plore by  sight  the  entire  tract  of  the  missel.    The  incisions  should 
therefore,  be  free  and  one  should  not  hesitate  in  this  respect,  as 
closure  is  readily  effected  when  the  wound  is  steriUzed.     The  in- 
dsions  are  made,  as  far  as  possible,  in  the  long  axis  of  limbs  or  par- 
allel with  underlying  muscle  fibers,  large  vessels,  and  nerves.    The 
debridement  is  commenced  by  cutting  away  with  the  aid  of  a  scal- 
pel and  thumb  forceps  the  bruised  edges  of  the  skin.     The  instru- 
ments used  for  this  are  then  discarded  for  clean  ones,  and  the  same 
procedure  is  applied  to  the  subcutaneous  and  muscular  tissues. 
The  indsion  exposing  the  tract  through  the  muscles  is  of  the  same 
^ent  as  the  skin  indsion  so  that  the  depths  of  the  wound  may  be 
^d  open.    The  entire  tract  is  then  carefully  explored,  removing 
^^trated  blood,  all  tissues  contaminated  with  particles  of  dothing, 
^^^y  grass,  or  other  fordgn  bodies,  and  tissues  of  doubtful  vitality. 
"^    pockets  are  carefully  explored  for  foreign  substances.     The 
^^^e  mechanical  cleansing  is  applied  to  injured  bone,  removing 
^^ititers  lying  free  but  preserving  those  adherent  to  periosteum. 

If  drainage  of  the  wound  is  required,  counter  openings  at  depen- 

^^^t  portions  should  be  avoided  as  far  as  possible,  for  the  success 

^*    tlxe  instillation  treatment  depends  upon  keeping  the  solution  in 

f^^tact  with  the  wound  and  not  allowing  it  to  escape  through  the 

•^titiom. 

Xn  the  handling  of  the  tissues  gentleness  is  essential  to  avoid 
^"^^ising  and  additional  traumatism.     Rough  wiping  of  the  wound 
f"^^    the  careless  use  of  retractors  frequently  aggravate  the  preex- 
^iti^g  damage  and  increase  the  chances  for  injection. 

Before  completing  the  operation  it  should  be  seen  that  there  is 
^^^^*^icxplete  hemostasis  and  no  oozing.     Tissues  infiltrated  with  blood 
prone  to  infecti6n  and,  furthermore,  carelessness  in  this  re- 
may  invite  secondary  hemorrhage,  as  Dakin's  solution  has  the 
•er  to  dissolve  fresh  blood  clots. 
^2)  Arrangement  of  the  Tubes, — The  tubes  are  so  placed  in  the 
^^^vand  that  the  solution  will  coipe  in  contact  with  every  portion  of 
^-^         They  are  placed  directly  in  contact  with  the  wound  surface 
^^^"•Ji  a  gauze  compress  over  them  (Fig.  198).  Gauze  should  not  be 
'^^^^^^ed  between  the  wound  and  the  tubes,  as  the  gauze  quickly  be- 
^^^*>ies  impregnated  with  wound  secretions  and  prevents  the  solution 
^^^^31  reaching  the  woimd. 

In  superficial  wounds  one  or  more  perforated  tubes  according  to 
^^^  size  of  the  wound  are  placed  on  the  wound  surface,  the  tubes 


244 


DISINFECTION   OF   WOUNDS 


being  prevented  from  sUpping  by  gauze  compresses  laid  over  tin 
or  a  two-way  f  ow  tube  in  the  form  of  a  ring  with  perforations  in 
center  may  be  employed  (Fig.  199).    By  means  of  rubber  a 


Fig.  198. — Method  o£  placing  the  tube  in  a  wound  and  covered  with  ■  gaoze  comp: 
[After  Carre]  and  Dehelly.) 

and  threads  the  tube  may  be  arranged  in  any  desired  shape.    If 
wound  is  on  the  lateral  aspect  of  the  body  so  that  the  wound  surf 


Fig    i99-~\rrangcmcnt  of  a  perforated  tio  nay  tube  on  a  large  superficial  m)'' 

{Carrel  and  Dehell>  modified  ) 

is  inclined,  the  tubes  are  placed  along  the  superior  border  so 
solution  will  spread  by  gravity  over  the  surface  (Fig.  200). 


—Method  of  placing  lubes 


ind  with  an  inclined  surface  (After  Ca 


Penelrati»g  wounds   with    the   opening  situated  above  reqi 
but  a  single  tube.    A  tube  without  perforations,  the  opening  be 


DISINFECTION   OF    WOUNDS 


245 


at  the  extremity,  is  introduced  to  the  bottom  of  the  wound,  and  the 
wound  filled  with  solution  (Fig.  201).  It  is  to  this  type  of  wound 
lljat  continuous  instillation  drop  by  drop  is  applicable.     When  the 


— Siogli 


cup-shaped  wound  (Carrel  and  Dehelly  modified.) 


Opening  is  on  the  lateral  aspect  of  a  part,  perforated  tubes  are  em- 
ployed and  retention  of  the  fluid  is  attained  by  placing  a  light  com- 
press about  the  orifice  of  the  wound.    A  wound  with  the  opening 


F».  ««.— Method  of  using  a 

soft  pHTti 


th   Turkish  tonelliQg  in  a  wound  of  the 
a  dependent  portion  of  a  limb 


locaW  dependently  is  more  difficult  to  sterilize.  In  such  a  case  a 
tube  covered  with  Turkish  towelling,  which  tends  to  spead  the 
soluUoa  over  the  wound  and  keeps  it  in  contact  for  a  longer  period  is 


3^6 


DISINFECTION   OF   WOUNDS 


employed  (Fig.  202),  or  in  large  wounds  several  perforated  tub< 
may  be  used,  the  solution  being  introduced  under  slightly  great' 
pressure. 

,       Perforating  wounds  with  the  openings  on  the  anterior  surface 
of  the  body  present  no  great  difficulty  in  the  arrangement  of 
tubes.     When  one  of  the  openings  is  dependent,  the  fluid  tends 
escape  by  gravity  from  the  lowest  opening,  and  the  tubes  must 
arranged  in  such  a  way  that  the  solution  will  escape  at  the  highe^s! 
point  and  flow  back  over  the  wound  surface.     Retention  of  tt 
I  solution  is  favored  by  lightly  tamponing  the  wound  orifices  {Fij 


Fig.  103,— Method  of  plat 


g  the  tubes  in  a  large  irregulnr  perforating  wouucl,     (Cairet 
and  Dehclly  modified.) 


* 


(3)  Dressing  the  Wmind. — When  the  tubes  are  properly  arranged, 
they  are  fi.\ed  in  position  by  small  gauze  compresses  soaked  in 
Dakin's  solution.  Care  must  be  taken  to  see  that  all  of  the  perfora- 
ted portion  of  the  tubes  lies  in  the  wound,  otherwise  the  solution 
will  escape  outside  the  wound.  Squares  of  vaseline  gauze  are 
placed  on  the  skin  adjoining  the  wound  for  its  protection,  and  readi- 
ly adhere  in  place.  (Fig.  204).  The  dressing  is  completed  by  apply- 
ing a  cotton  pad  with  the  absorbent  layer  next  to  the  wound.  The 
dressing  is  secured  in  place  by  web  straps  or  by  safety  pins.  The 
endsof  the  instillation  tubes  which  emerge  from  the  dressing  at  different 
points  are  grouped  in  twos  or  fours  and  are  attached  to  the  branched 


/ 


DISINFECTION   OF   WOUNDS 


247 


uaioDs.  The  tube  from  the  reservoir  is  then  attached  and  the 
branched  cannula  is  fixed  in  place  by  safety  pins  to  the  highest 
point  of  the  dressing  (Fig.  205).  Motion  of  the  injured  part 
must,  of  course,  be  guarded  against  by  proper  splinting. 


"S-     304. — lAound   partly   dressed       Instillation   tubes  held  in   place  by  gauze  and 
slun  protected  by  squares  of  laseluie  gauze      (Carrel  and  Dehelly  modified.) 

liressings  are  renewed  every  twenty-four  hours,  at  which  time 
'"^  ^ound  is  carefully  inspected  and  the  tubes  renewed. 

^acteriologic  Examination  of  the  Woimd.     This  consists  of  an 
**^rrunation  of  smears  from  the  wound  at  regular  periods  and  the 


estimation  of  the  number  of  bacteria  in  the  wound.  Such  exam- 
ination, carried  out  from  the  beginning  during  the  course  of  the 
treatment,  not  only  enables  the  surgeon  to  determine  the  proper 


248  DISINFECTION   OF  WOIJNDS 

time  for  closure  of  the  wound  without  danger  of  the  infection  le- 
curring,  but  it  also  shows  the  progress  of  the  sterilization.  The 
method  of  examinaUon  is  simple  and  consists  in  transferring  one 
or  more  specimens  of  the  secretions  from  the  wound  by  means  of  a. 
standard  platinum  wire  loop,  previously  sterilized  by  pasang  through 
an  alcohol  flame,  to  a  slide  and  counting  the  number  of  miaoor- 
ganisms  to  the  microscopic  field.    This  is  done  every  other  day  a-nd 


I 


Fig.  ao6. — Showing  the  arrttngcment  of  the  irrigating  apparatus  in  an  injuty  of  ttt 
lower  extremity.     (Da  Costa,  modified  from  Carrel  and  Dehelly.) 

the  results  entered  on  a  chart  kept  for  the  purpose  to  show  at  a 
glance  the  progress  of  the  disinfection.  The  specimens  should  not 
be  taken  within  less  than  two  hours  after  fluid  has  been  instilled 
into  the  wound,  and  care  should  be  taken  to  obtain  specimens  of 
secretion  from  those  parts  of  the  wound  which  seem  to  be  most  in- 
fected, such  as  the  deeper  portions,  necrosed  points,  pockets  under 
exposed  bone,  cul  de  sacs,  or  small  tracts  less  likely  to  be  reached  by 
the  solution. 


DISINFECTION   OF   WOUNDS  249 

Under   the  treatment  the  number  of  microorganisms  should 
diminish.    If  the  count  remains- stationery  for  several  days  or  in- 
creases   the  wound  should  be  carefully  examined  with  a  view  to 
modif>ring  the  treatment.     The  failure  to  obtain  favorable  results 
may  h>^  due  to  errors  in  the  preparation  of  the  solution,  to  insuffi- 
cient distribution  of  the  solution  from  too  few  tubes,  to  the  fluid  not 
reachixiL^  all  parts  of  the  wound,  to  the  presence  of  necrotic  tissue, 
seques  t  Ta  of  bone,  and  foci  of  infection  around  foreign  bodies  that  have 
been  o^v^erlooked,  etc.      When  the  bacteria  are  absent  from  the  wound 
or  the    iTiumber  is  reduced  to  one  in  every  four  or  five  fields,  and  this 
is  verified  by  three  successive  examinations  at  intervals  of  two  days, 
the  wc^vind  is  considered  surgically  sterile  and  may  be  closed.     In 
streptoooccic  infections,  however,  the  wound  should  not  be  closed 
until  tlxere  is  a  complete  absence  of  bacteria. 

As  at  rule,  moderate  sized  wounds- of  soft  parts  may  be  closed  in 
from  fi."ve  to  eight  days.  Large,  badly  traumatized  wounds  may  re- 
quire tTvelve  days  or  more  to  sterilize.  Compound  fractures  re- 
quire SL  longer  period — from  two  to  four  weeks.  In  these  cases  it 
will  be  found  that  sequestra  of  bone  are  a  frequent  obstacle  to  ster- 
ilization and  require  removal  before  success  is  attained 


CHAPTER  X 

BIER'S  HYPEREMIC  TREATMENT,  THE  PRODUCTION 
OF  AN  ARTIFICIAL  PNEUMOTHORAX,  AND 
THE  DIAGNOSIS  AND  TREATMENT  OF 
FISTULOUS  TRACTS  BY  MEANS 
OF  BISMUTH  PASTE 

HYPEREMIC  TREATMENT 

While  the  value  of  artifically  producmg  hyperemia  with  the 
definite  purpose  of  increasing  the  inflammatory  reaction  has  only 
been  recognized  comparatively  recently,  it  is  interesting  to  note 
that  as  early  as  the  sixteenth  century  Ambroise  Par6  employed 
artificial  congestion  in  delayed  union  of  fracture  due  to  insuffidoit 
callus  formation.  Others  later  and  independently  have  called 
attention  to  the  value  of  hyperemia  in  similar  conditions.  To  Bier, 
however,  belongs  the  credit  of  placing  treatment  by  hyperemia 
upon  a  logical  and  scientific  basis,  and  of  demonstrating  its  great 
practical  value. 

There  are  two  distinct  forms  of  hyperemia,  namely,  active  and 
passive.  The  former,  obtained  by  means  of  dry  hot  air,  produces  aa 
active  flow  of  arterial  blood  through  the  parts,  and  is  especially 
useful  for  the  absorption  of  the  products  of  chronic,  nontuberculous 
inflammations.  The  passive,  venous,  or  obstructive  form  of  hypere- 
mia, as  it  is  designated,  has  for  its  object  the  increase  of  the  amount 
of  venous  blood  in  the  part,  and  may  be  produced  by  means  of  elastic 
compression  of  the  venous  circulation,  or  by  suction  cups.  This 
form  gives  the  best  results  in  pyogenic  infections,  whether  acute  or 
chronic. 

PASSIVE  HYPEREMIA 

Bier  was  first  led  to  employ  passive  hyperemia  through  study  of 
the  observ^ations  of  Farre  and  Travcrs  who,  as  far  back  as  1815, 
called  attention  to  the  frequency  of  phthisis  in  persons  whose  lungs 
were  rendered  anemic  because  of  stenosis  of  the  pulmonary  orifice, 
and  by  the  reverse  of  this,  namely,  the  rarity  of  pulmonary  tubercu- 
losis in  individuals  suffering  from  cardiac  conditions  tending  to  pro- 
duce congestion  or  hyperemia  of  the  lungs,  as  later  pointed  out  by 

250 


PASSIVE   HYPEREMIA 

Rokitansky.  Impressed  by  these  observations,  Bier  conceived  the 
idea  of  artifically  producing  a  hyperemia  for  the  cure  of  tuberculous 
affections  in  other  parts  of  the  body.  Encouraged  by  the  results 
obtained  in  the  treatment  of  tuberculous  affections,  he  soon  extended 
the  use  of  hj'peremia  to  the  treatment  of  acute  inflammatory  surgical 
conditions,  with  most  remarkable  results.  In  this  he  was  materially 
aided  by  his  associate,  Klapp,  who  broadened  the  scope  of  the  method 
by  devising  variously  shaped  glass  cups  and  vacuum  apparatus  for 
producing  a  hj-peremia  of  regions  of  the  body  not  amenable  to  the 
constricting  band,  though  it  is  true  Bier  had  himself  employed  this 

K^'hod  previously  and  had  abandoned  it. 
freatment  by  hyperemia  is  based  on  the  theory  that  inflamma- 
represents  nature's  efforts  for  protection  of  the  body  against 
jenal  invasion  and  in  the  restoration  of  a  part  to  a  healthy  condi- 
tion. Bier's  teachings  in  regard  to  inflammation  take  exactly  the 
opposite  view  from  what  has  hitherto  been  held  and  taught.  For- 
■"erly  it  was  the  aim  of  treatment  to  combat  in  everj'  way  possible 
"le  phenomena  accompanying  an  inflammation.  In  the  presence  of 
P*in,  heat,  redness,  and  swelling,  cold  applications,  elevation  of  the 
pift,  rest,  and  immobilization  were  advocated  for  the  relief  of  these 
'ytnptoms.  According  to  Bier,  however,  the  redness,  heat,  and 
belling  of  an  inflammation  are  but  the  outward  signs  of  the  eflfort  on 
t^e  part  of  nature  to  overcome  noxious  influences  and  produce  a  cure; 
^<i  these  are  to  be  encouraged  as  beneflcial  instead  of  combated.  An 
attempt  was  accordingly  made  to  artifically  reproduce  the  most 
^dent  of  these  phenomena,  namely,  congestion  or  hyperemia)  and 
"lereby  increase  the  natural  resistance  of  the  tissues. 

Difficult  as  it  may  be  to  give  up  our  old  ideas  and  accept  a 
method  of  treatment  so  radically  at  variance  with  former  teachings, 
tie  results  obtained  under  hyperemia,  properly  carried  out,  are  in 
certain  cases  so  remarkable  and  so  far  in  advance  of  any  other 
methods  as  to  furnish  ample  evidence  of  its  superior  value  and  to 
prove  conclusively  the  correctness  of  the  theories  upon  which  Bier's 
treatment  rests. 

Effects  of  Hyperemia. — The  beneficial  effects  of  hyperemia  are 
IDOat  striking — the  more  marked,  the  earher  the  treatment  is  begun. 
Diminiilicm  of  Pain. — The  prompt  relief  of  pain  is  one  of  the  most 
remarkable  features  of  the  treatment.  Accepting  the  theory  that 
pua  from  an  inflammation  is  due  to  irritation  of  the  cells  and  end 
organs  by  toxins,  as  well  as  to  the  high  specific  gravitj'  of  the  inflam- 
ffHtory  exudate,  its  relief  under  the  influence  of  hyperemia,  which 


252  bier's  hyperemic  treatment 

both  destroys  and  dilutes  toxins  and  also  dilutes  the  exudates,  may 
be  readily  understood.  If  pain  be  not  relieved,  or  at  least  mitigated 
or  if  discomfort  results  from  the  treatment,  the  operator's  tedmicis 
probably  at  fault.  The  patient  should  always  be  impressed  with  the 
necessity  of  reporting  any  discomfort  in  the  part  subjected  to  the 
h3^eremia,  and  his  sensations  should  be  an  important  guide  for  the 
operator. 

Through  the  prompt  decrease  of  pain  and  sensitiveness,  refla 
contracture  of  muscles  is  avoided  and  earlier  motion  in  a  part  is  pos- 
sible. This  is  especially  important  in  infections  involving  tendoi 
sheaths  and  joints,  as  with  early  motion  much  better  functional  re 
suits  are  possible.  Even  in  an  extremely  sensitive  joint,  it  is  remaA« 
able  how  quickly  slight  motion  may  be  painlessly  practised  undei 
h3^eremia. 

Bactericidal  Actioft. — It  has  been  shown  by  experiments  upoi 
animals  as  well  as  by  clinical  evidence  that  through  hyperemia  cer 
tain  forces  are  brought  to  bear  which  either  directly  or  indirectl} 
antagonize  bacterial  growth  and  either  destroy  or  dilute  the  toxins 
Beginning  infection,  such  as  a  furuncle  or  a  carbuncle,  in  which  red 
ness,  tenderness,  swelling,  and  slight  inMtration  are  the  only  sign: 
present,  can  thus  often  be  made  to  subside  without  suppuration 
while,  if  suppuration  has  already  developed,  the  infectious  pioces 
may  be  prevented  from  extending  to  the  deeper  tissues  and  the  clin 
ical  course  be  greatly  shortened.  Accidental  soiled  wounds,  whid 
from  experience  we  have  every  reason  to  believe  will  become  infected 
under  the  influence  of  hyperemia  can  often  be  made  to  heal  withou 
infection,  and  not  infrequently  by  primary  union,  and  there  is  r» 
better  means  than  the  increased  secretion  induced  by  the  hyperemi 
for  thoroughly  flushing  out  and  rapidly  cleansing  these  dirty  wounds 

Limitation  of  the  Pathological  Process. — Under  hyperemia,  necrosi 
of  even  badly  damaged  parts  is  often  prevented  by  the  superabundan 
nourishment  of  the  tissues,  or,  when  the  infection  has  advanced  to  th 
destruction  of  tissues,  the  disease  process  is  more  promptly  localL^ec 
and  a  line  of  demarcation  between  the  healthy  and  diseased  tissues 
earlier  in  evidence.  Sloughs  and  sequestra  are  thus  early  separate 
and  cast  off,  while  in  tuberculous  affections  connective  tissue  replac 
the  tuberculous,  and  the  disease  gradually  dies  out. 

Solvent  and  Absorbent  Action. — Both  the  active  and  thepassi' 
forms  of  hj'peremia  act  as  solvents,  while  the  active,  in  addition,  h 
a  very  marked  absorbent  action.     The  products  of  inflammation, 
infiltrations,  exudates,  and  plastic  changes,  are  dissolved,  so  to  spea 


PASSIVE    HYPEREMIA 


•nd  thdr  absoiption  is  thus  favored.  Careful  application  of  hyper- 
emia thus  makes  unnecessary  many  of  the  operations  of  resection,  etc. 
This  is  well  illustrated  in  the  excellent  functional  results,  with  free- 
dom from  ankylosis  and  deformity,  obtained  in  tuberculous  and  other 
joint  affections, 

icatioQS. — Passive  hyperemia  has  been  recommended  for  all 
of  acute  inflammatory  processes  and  many  of  the  chronic  ones, 
the  literature  contains  numerous  favorable  reports  of  its  use, 
not  only  in  purely  surgical  affections,  but  in  the  specialties  and  in 
medidne  as  well. 
The  surgical  conditions  in  which  it  has  been  found  to  be  especially 
,1  may  be  summarized  as  follows:  Acute  infections  and  in- 
lations,  such  as  furuncles,  carbuncles,  felons,  infected  wounds, 
feelion  of  tendon  sheaths,  lymphangitis,  IjTnphadenitis,  mastitis, 
gonorcheal  arthritis,  and  other  forms  of  acute  infections  of  joints, 
acute  bone  infections,  bums;  as  a  prophylactic  measure  in  soiled  or 
dirty  wounds,  compound  fractures;  in  chronic  affections,  such  as 
tuberculosis  of  bones,  joints,  glands,  tendon  sheaths,  testicles;  de- 
layed union  of  fractures;  fistula;;  old  discharging  sinuses;  and 
infected  leg  ulcers  uncomplicated  by  varicose  veins.  Its  use  is, 
however,  contra-indicated  in  lesions  complicated  by  thrombosis  of 
^'cins,  In  erysipelas  its  value  is  doubtful;  in  fact,  erysipelas  has 
twn  known  to  develop  under  prolonged  hyperemia  in  tuberculous 
iKions  which  were  complicated  by  open  sinuses.  In  diabetes, 
bitwise,  the  results  have  not  always  been  good. 

Passive  hyperemia  has  also  been  employed  with  success  in  medi- 
■Me  [or  such  conditions  as  acute  rheumatism,  gout,  and  pulmonary 
tuberculosis.  For  the  latter  condition  Kuhn  has  devised  a  mask  of 
"M  celluloid  which,  by  means  of  an  adjustable  valve,  cuts  off  some  of 
"It  air  entering  the  alveoli  and  thus  idduces  a  suction  hyperemia, 
loahost  of  other  afTections  falling  within  the  domain  of  rhinology, 
"tology,  gj-necology,  obstetrics,  and  dermatology,  passive  hyperemia 
ll^been  recommended  and  applied  with  varying  degrees  of  success. 
General  Principles  Underlying  Hyperemic  Treatment. — As  cm- 
ptiasiztd  by  the  author  of 'this  method  of  treatment,  and  others,  it  is 
^  a  panacea  or  cure  for  all  troubles.  One  should  recognize  that  it 
l**i  its  limitations.  In  some  of  the  milder  forms  of  infection,  com- 
plete cure  may  often  be  effected  by  hj-peremia  alone;  in  other  cases, 
of  the  more  severe  infections,  it  forms  only  a  part  of  the  treatment, 
and  operative  interference  should  never  be  delayed  when  indicated. 
ftamist  always  be  promptly  evacuated,  and  cold  abscesses  likewise 


1 


254  bier's  hyperemic  treatment 

are  to  be  opened.  This  is  accomplished  by  small  incisions  or  punc- 
tures, the  old-time  extensive  incisions,  which  often  result  in  imsi^itly 
scars  and  even  deformities,  being  unnecessary  under  this  form  oi 
treatment.  The  hemorrhage  incident  to  such  incisions  should  be 
controlled  by  packing  the  wound  for  two  to  three  hours  before  tin 
h3^eremia  is  induced.  In  an  ^lfection  of  the  tendon  sheaths,  th< 
anatomy  of  the  parts  should  be  carefully  kept  in  mind  and  the  ind 
sions  made  accordingly.  Small  multiple  incisions  are  employed  am 
should  be  so  placed  as  to  avoid  cutting  the  transverse  palmar  Ega 
ments  opposite  the  finger  joints.  In  the  case  of  infection  of  a  larg 
joint,  the  pus  is  aspirated  and  the  joint  cavity  is  irrigated  through  i 
large  trocar;  in  other  localities,  ordinary  surgical  principles  should  b 
the  guide  as  to  the  incision.  The  curettage  of  abscess  cavities  i 
avoided,  while  drains  and  tampons  are  discarded,  as  the  secretion 
that  are  poured  out  under  the  artificial  hyperemia  serve  to  keep  th 
wound  open.  Certain  cases  of  very  rapidly  extending  infection,  wU* 
acute  onsety  however,  require  early  incision  in  conjunction  with  th 
hyperemia,  even  before  softening  has  occureed.  If  incisions  are  no 
made,  the  hyperemia  may  do  harm  and  the  local  inflanmiatio] 
become  worse,  for  the  transudate  which  i?  induced  by  the  hyperemia 
added  to  the  exudate  already  present,  has  no  outlet  and  may  driv 
the  bacteria  and  their  toxins  into  healthy  tissue  and  favor  the  exten 
sion  of  the  infection. 

In  inflammations  involving  joints  or  tendon  sheaths,  mild  activ< 
and  passive  motion  are  carried  out  from  the  first  in  order  to  obtaij 
the  best  functional  results,  provided  this  can  be  done  without  pro 
dudng  pain.  Slight  motion  is  harmless  so  long  as  it  is  painless.  Fo 
this  reason,  no  immobilizing  dressing  need  be  applied  during  th< 
treatment,  open  wounds  being  merely  covered  with  moist  antiseptic 
gauze. 

In  acute  infections,  the  results  are  often  prompt  and  most  strik 
ing.  In  favorable  cases,  the  temperature  declines,  pain  is  relieved 
extension  to  deeper  tissues  is  prevented,  and  the  process  rapidly  sul 
sides  or  at  least  the  clinical  course  is  much  shortened.  Swelling  an 
redness  are  temporarily  increased,  and  are  to  be  expected  as  part  < 
the  treatment.  The  discharge  from  open  wounds  is  at  first  mo 
abundant,  but  this  likewise  rapidly  subsides,  and  with  it  the  eden 
and  redness. 

In  chronic  lesions  of  a  tuberculous  nature,  the  treatment  must 
carried  out  for  months.     In  the  case  of  joints,  the  pain  and  swelli 
slowly  diminish,  the  contour  of  the  joint  again  becomes  distinguis 


PASSIVE   HYPEREMIA 

able,  and  mobility  gradually  increases;  secretions  from  sinuses  be- 
come serous  instead  of  purulent,  the  sinus  tabes  on  a  healthy  appear- 
ance and  finally  closes.  In  tuberculous  affectionS)  likewise,  slight 
motion  of  the  affected  limb  is  allowed,  provided  it  produces  no  pain. 
Fixation  of  the  joint,  in  cases  of  tuberculosis  of  the  wrist,  elbow,  or 
ler  can  thus  usually  be  dispensed  with — a  sling  at  most  is  used — 

ija  knee  or  foot  tuberculosis  a  suitable  apparatus  should  be  worn, 

tiie  part  so  immobilized  by  a  movable  splint  when  the  patient  is 
moving  about  that  pressure  is  removed  from  the  diseased  articular 
surfaces.  In  the  presence  of  contractures  of  the  joints,  suitable 
extension  is  applied  and  used  in  conjunction  with  the  hyperemic 
treatment. 

Bier  gives  as  contraindications  to  the  use  of  hyperemia  in  tuber- 
caki^of  joints  the  following: 

I.  Commencing  amyloid  disease  and  advanced  pulmonary 
involvement. 

J.  Large  abscesses,  filling  up  the  whole  joint  cavity  and  demand- 
fag  operation. 

3.  Faulty  position  of  the  joint,  such  that  cure  would  give  a  joint 
k»  useful  than  could  be  obtained  by  resection.  In  such  conditions 
he  advises  operative  interference. 

Successful  hyperemic  treatment  necessitates  correct  technic,  and 
many  of  the  poor  results  at  first  obtained  by  those  unfamiliar  with 
uismethod  may  be  ascribed  to  errors  in  this  direction.  It  certainly 
wtluires  time  and  close  attention,  as  well  as  considerable  experience 
on  the  part  of  the  attendant,  to  obtain  good  results;  but,  if  the  treat- 
"lOit  be  properly  carried  out  with  perseverance,  one  will  be  amply 
Kpiid,  At  first  the  patient  must  be  carefully  watched  as,  with  the 
"leof  the  elastic  band,  for  instance,  it  may  be  necessary  to  remove  or 
ftspply  the  constriction  several  times  in  the  course  of  a  single  treat- 
"lent  in  order  to  maintain  the  proper  degree  of  hyperemia.  Intelli- 
pnt  patients  may  later  be  instructed  in  carrying  out  the  treatment 
*•"!  ather  the  bandage  or  the  cup,  and  in  time  they  themselves  can 
*Pp\y  the  treatment  at  home,  but  they  should  always  remain  under 
tb*  supervision  of  the  surgeon. 

Methods  of  Producing  Passive  Hjrperemia. — As  already  indicated 
tlH  passive  form  of  hyperemia  may  be  produced  by  means  of  soft 
rubber  bandages  or  by  special  suction  apparatus.  The  principle  in 
each  is  the  same,  but  the  technic  requires  special  description. 

Passive  Hyperemia  by  Means  of  Constricting  Bands.  This 
ii  the  oldest  method  of  producing  an  obstructive  hyperemia.     It  is 


356  bier's  hvpekehic  tseatment 

especially  applicable  to  affections  involviog  the  extremities, 
and  neck.  The  hip- joint  is  the  only  one  in  dther  of  the  eztn 
to  which  the  method  cannot  be  satisfactorily  applied.  Thai 
doubt  that  the  proper  appUcation  of  the  band  requires  mot 
than  does  cupping.  Exact  technic  is  necessary,  and  great  c 
must  be  observed  not  to  exceed  the  proper  grade  of  hyperemi 
in  tuberculous  cases  not  to  lower  the  vitality  of  the  tissues  by  t 
longed  obstrucdon.    Only  a  mild  hyperemia  is  necessary  to  p 


Fig.  207. — Esmarch  elastic  bandage  for  obstructive  hypereiai&. 

results;  otherwise,  distinct  harm  is  done.  For  this  reason,  thf 
age  should  be  applied  by  the  surgeon  himself  until  an  inb 
£ind  competent  person  of  the  household  can  be  instructed 
proper  application. 

Apparatus. — For  most  cases,  a  soft,  thin  elastic  bandage,  i 
Esmarch's  or  Martin's,  about  2H  inches  (6  cm.)  in  breai 
employed  (Fig,  207). 

For  the  shoulder- joint  and  testicles,  rubber  tubing  is  used  i 
of  a  bandage.     That  used  about  the  shoulder  should  be  of 


.-■^J 


Fig.  »o8. — Elastic  garter  for  producins  obstructive  hj-peremia  of  the  necL 
Meyer  Schmieden ) 

stout  rubber,  and  about  a  foot  long  {30  cm.);  while  for  the  sc 
a  catheter  or  a  piece  of  drainage-tube  of  small  size  answers. 

To  produce  hjperemia  of  the  head  and  neck,  a  rubber  b 
measuring  about  iH  inches  (3  cm.)  in  width  may  be  use< 
special  neck-band  made  for  the  puqiose  may  be  obtained,  A 
elastic,  about  i  inch  (2.5  cm.)  in  width  and  provided  with  hot 
eyes  so  that  it  may  be  adjusted  to  any  size,  as  shown  by 
companying  illustration  (Fig.  208,)  answers  the  purpose  ada 


PASSIVE    HYPEREMIA  357 

Site  of  Application. — The  constriction  should  always  be  applied 
over  healthy  tissue  and  well  above  the  area  of  inflammation.  In 
involvement  of  the  hand,  for  instance,  the  bandage  is  applied  above 
the  elbow,  and  above  the  knee  if  the  foot  be  the  seat  of  trouble.  To 
avoid  undue  compression  continually  at  the  same  spot,  it  is  well  to 
change  the  location  of  the  bandage  at  each  application,  moving  it  a 
liltle  either  up  or  down  the  limb. 

Duration  of  Application.— In  the  treatment  of  acute  processes, 
the  hest  results  are  obtained  from  prolonged  stasis,  namely,  from 
titenty  to  twenty-two  hours  a  day.  The  bandage  is  accordingly 
ipplied  for  ten  or  eleven  hours,  then  discarded  for  two  or  one  hours, 
and  reapplied  for  another  ten  to  eleven  hours.  The  bandage  is 
applied  daily  and,  as  the  condition  improves,  the  duration  of  the 
duly  constriction  may  be  diminished  until  it  is  only  of  from  one  to 
two  hours. 

For  tuberculous  affections  the  applications  are  of  shorter  dura- 
lion,  the  bandage  being  applied  once  or  twice  a  day  from  one  to  four 
bours  at  a  time.  In  his  early  work  on  tuberculous  affections.  Bier 
first  employed  short  periods  of  hyperemia,  and  then  prolonged 
»nd  almost  continuous  hyperemia,  but  he  experienced  many  fail- 
ures and  bad  results  with  the  latter.  He  found  that  prolonged 
slaas  in  this  class  of  cases  was  apt  to  devitalize  the  parts  and  lead  to 
wf  rapid  formation  of  cold  abscess,  as  well  as  to  the  development  of 
Mptic  abscess,  lymphangitis,  adenitis,  erysipelas,  etc.,  so  that  he  re- 
turned  to  the  short  applications  of  from  one  to  four  hours  a  day.  In 
^*«sof  acute  hot  abscess  formation,  however,  due  to  a  mixed  infec- 
tion of  open  sinuses,  the  application  may  be  extended  to  the  longer 
P*riods — twice,  ten  or  eleven  hours— until  the  acute  process  has 
.  aibaded. 

Technic.— To  apply  the  bandage,  its  initial  extremity  is  first  wet 
wffidently  to  make  it  adhere  to  the  skin  and  prevent  it  from  slipping, 
"le  bandage  is  wound  around  the  limb  with  moderate  tension  six  or 
^i  limes  well  above  the  seat  of  disease,  each  layer  overlapping  the 
P'sceding  by  about  i-i  inch  (i  cm.).  The  bandage  is  then  made 
*flire  by  adhesive  plaster  or  tapes  previously  sewed  to  the  terminal 
'"'ifFig.  309). 

The  degree  of  hyperemia  is  of  the  utmost  importance.     The  , 
oliject  is  to  moderately  constrict  the  veins  of  a  part,  without  in 
anyway  interfering  with  the  arterial  supply,  thereby  partly  checking 
tie  reflux  of  blood  and  increasing  the  quantity  of  venous  blood  nor- 
present.     It  requires  practice  and  careful  attention  to  detail 


1 


358  bier's  hypereuic  treatment 

to  apply  the  bandage  in  such  a  way  that  the  arteries  are  not  com- 
pressed, while  at  the  same  time  the  right  amount  of  venous  obstniC' 
tion  is  obtained.  If  the  constriction  is  applied  properly,  the  veins 
in  the  part  distal  to  the  bandage  become  slightly  distended,  and  tkc 
part  takes  on  a  bluish  red  hue  and  becomes  warm  to  the  touch.  This 
degree  of  hyperemia  is  essential,  as  the  hot  hyperemia  only  h&s 
therapeutic  value.  As  already  emphasized  tite  pvlse  should  never  be 
obliterated.  It  must  at  all  times  be  distinguished,  not  even  weakened. 
Furthermore,  the  application  of  the  bandage  should  never  cause  puaa 
or  annoyance,  or  hyperesthesia  of  the  part.  If  too  great  a  degree  of 
compression  is  employed,  nutritional  disturbances  from  the  increased 


\ 


Fic.  S09. — Showing  the  method  of  applying  the  elastic  bandage  to  the  um. 

stasis  injures  the  tissues  and  reduces  their  natural  resistance.    T^-^ 
such  a  case,  a  white  edema  is  produced,  or  the  skin  becomes  grayist*- 
bluein  color,  or  has  a  mottled  redand  white  appearance,  and  the  par"* 
remains  cold  to  the  touch.     Such  a  condition  demands  removal  o^' 
the  bandage  and  its  proper  reapplication. 

For  obtaining  the  proper  degree  of  hyperemia,  it  has  been  sug- 
gested that  a  sphygmomanometer,  such  as  the  Riva-Rocci  instru- 
ment, for  example,  be  employed.  The  cuff  is  secured  about  the  part 
in  the  same  manner  as  would  be  done  in  taking  the  blood-pressure 
and  the  systolic  pressure  is  estimated  (seepage  132).  The  mercury  is 
then  allowed  to  drop  about  10  mm,,  which  gives  the  proper  tendon, 
after  which  the  tube  leading  to  the  inflation  band  is  tightly  clomped. 

In  chronic  cases  it  is  sometimes  very  dlfhcult  to  obtain  the  proper 
amount  of  hyperemia,  and  several  procedures  have  been  advised  to 


PASSIVE   HYPEREMIA  259 

increase  the  congestion.  Placing  the  part  in  a  bath  of  very  hot  water 
for  ten  minutes  before  the  constriction  is  applied  often  suffices.  In 
other  cases,  the  part  may  be  first  exsanguinated  by  means  of  an 
Esmarch  bandage,  as  would  be  done  preliminary  to  an  amputation, 
and  upon  removal  of  the  bandage  a  profuse  reactionary  flow  results, 
after  which  the  constrictor  is  applied. 

If  the  constriction  is  to  remain  in  place  for  long  periods  at  a  time, 
it  is  advantageous  to  apply  a  soft  flannel  bandage  beneath  the  rubber 
to  prevent  undue  pressure  upon  the  soft  parts,  which  might  produce 
an  irritation  of  the  skin,  or  even  atrophy  of  the  muscles.  This  is 
espedally  necessary  when  treating  aged  or  thin,  flabby  individuals. 
While  the  bandage  is  in  place,  all  dressings,  splints  etc.,  are  removed 
so  as  not  to  interfere  with  the  hyperemia.  If  open  wounds  or  sinuses 
'>e  present,  they  are  simply  covered  loosely  with  sterile  or  antiseptic 
gauze. 

A  marked  edema  results  from  the  hyperemia,  extending  up  to  the 

seat  of  constriction,  and  this  has  to  be  kept  within  proper  limits. 

W^en  the  application  is  only  for  short  periods  of  a  few  hours  each 

^^y,  the  edema  is  absorbed  spontaneously  in  the  intervals,  but  under 

prolonged  hyperemia  of  twenty  to  twenty-two  hours  the  time  for 

^'^  absorption  is  very  short,  and  it  is  often  not  possible  to  entirely 

reduce  it  between  applications.     Elevation  of  the  part  upon  pillows 

^Ust  consequentiy  be  performed  during  the  intermissions.     Massage 

^f  the  region  subjected  to  the  pressure  of  the  constriction  should  also 

"^  practised  in  order  to  guard  against  pressure  atrophy. 

In  producing  hyperemia  of  the  shoulder- joint,  head  and  neck,  or 
^^ticles,  a  slight  variation  in  technic,  requiring  separate  description, 
^  necessary. 

Bead  and  Neck, — About  the  neck  a  special  band,  already  de- 
scribed (page  256),  is  used.     It  should  be  appUed  about  the  root  of 
tte  neck,  well  below  the  larynx,  with  only  moderate  tension.     To  ob- 
^^in  the  greatest  degree  of  hyperemia  with  least  constriction,  small 
pieces  of  felt  or  wadding  may  be  placed  under  the  constricting  band 
0^   either  side  of  the  larynx  over  the  great  veins  (Fig.  210).     If 
prop>erly  applied,  such  a  bandage  can  be  worn  with  entire  comfort. 
It  causes  a  pronounced  edema  of  the  face,  particularly  about  the 
^y^lids.    This  is  no  contraindication  to  its  use,  however.     Care 
should  be  taken  not  to  apply  the  band  too  tightly — of  course  it  should 
^^cver  strangulate  or  interfere  with  eating  or  swallowing.     If  throb- 
t^g  or  a  feeling  of  marked  fullness  in  the  head  is  complained  of,  the 
bandage  should  be  removed  and  reapplied. 


i 


26o 


BIER  S  HYPEREMIC  TREATMENT 


Shoulder. — ^A  soft  bandage  or  cravat  is  placed  loosely  about  the 
patient's  neck  and  tied.    Through  the  loop  a  stout  piece  of  rubber 


Fig.  2ZO. — Showing  the  application  of  the  neck  band. 

tubing  about  a  foot  in  length  is  passed  as  a  ligature  endrclinj 
shoulder-joint,  the  middle  portion  being  placed  in  the  axilla  an 


Fio.  211. — Showing  the  method  of  obtaining  obstructive  nyperemia  of  the  shoul^^ 


two  ends  passing  up — one  in  front  and  the  other  behind  the  joint- 
a  point  above  the  shoulder,  where  they  are  secured  by  tying  or  ^ 


PASSIVE    HYPEREMIA 


a6i 


amp.  A  second  piece  of  bandage  is  secured  to  the  tub- 
i  the  joint,  and  passes  across  the  chest,  under  the  oppo- 
id  around  the  back,  where  it  is  secured  to  the  portion  of 
Bg  behind  the  joint  (Fig.  211).  By  adjusting  the  band- 
dating  the  tightness  of  the  rubber  tubing,  the  proper 
istriction  may  be  obtained. 

onical  reasons  it  is  not  possible  to  change  the  location  of 
or  at  each  application,  as  is  done  upon  the  extremities, 
re  and  attention  is  necessary  to  avoid  pressure  necrosis, 
un,  it  is  better  to  apply  the  constriction  for  short  periods 
;>r  four  hours — at  a  time,  repeated  several  times  in  the 


Mng  the  method  of  producing  obstructive  hyperemia  of  the  testicles. 
Il  (After  Meyer-Schmieden.) 

(liours,  with  correspondingly  longer  intenmssions,  in 
ij-the  ten  or  eleven  hour  applications. 
i^Tuberculous  and  other  affections  of  the  testicle  may  be 
jeans  of  constriction  about  the  root  of  the  scrotum.  A 
(  rubber  tubing  or  catheter  is  wound  several  times  about 
Ibe  scrotum  over  a  layer  of  cotton  and  is  secured  in  place 
h  a  piece  of  tape  or  cord  (Fig.  212). 
Ua  by  Means  of  Suction  Cups. — Innumerable  forms 
t  suction  cups  for  producing  hyperemia  in  regions  not 
»nstriction,  as  well  as  large  chambers  for  use  upon  the 
I  large  joints,  have  been  deviseci.  The  hyperemia 
iese  devices  is  also  a  venous  one,  and  is  apphcable  to 
f  cases  as  is  obstructive  hyperemia  by  the  bandage. 
B  of  the  constricting  band,  exact  technic  is  necessary. 


BIER  S   HYFEREHIC   TSEATHEMT 


and  the  Importance  of  obtaining  the  proper  degree  of  hyperemia 
cannot  be  too  strongly  emphasized. 


I'IG.  31J. — Cup    for    sty.     2i^ 
abscess.     216.     Cup  for  gums. 
219,     Hrcast  cup.     120.     Cup  for 
glass.     223.     Hand  suction  glass. 


Fig.  223 

Cup    for   small    abscess.     115.     Cup    for  lirp<* 
[7.     Cup   for  carbuncle.     218.     Cups  for  tonoK 
cnix.    2:1.    Cup  for  aoae.    aia.    Finger  suction 


When  one  of  the  cups  is  applied  to  a  surface  and  a  vacuum  pro- 
duced, the  skin  and  underlying  tissues  are  sucked  into  the  chamber 
and  venous  stasis  with  a  consequent  increase  in  the  supply  of  blood 


PASSIVE   HYPEREMIA 


263 


in  the  sl^in  and  deeper  layers  results.    Besides  producing  hyperemia, 
the  mechanical  effect  of  the  cupping  glass  is  also  of  distinct  advan- 
tage.   From  an  open  discharging  wound  pus  and  broken-down  tissues 
are  rapidly  and  effectually  aspirated.    Small  sequestra  of  bone  are 
often  quickly  separated  and  discharged  through  a  sinus  under  the 
influence  of  the  hyperemia  combined  with  suction.    In  the  presence 
of  tuberculous  sinuses,  daily  applications  of  the  suction  cups  may  be 
employed  in  conjunction  with  the  rubber  bandage. 


Flo.  224. — ^Pump  for  producing  a  vacuum  in  the  larger  cups  and  suction  glasses. 

Apparatus. — Cups  suitable  for  furuncles,  styes,  carbuncles,  breast 
abscess,  etc.,  chambers  in  which  are  placed  the  fingers,  hands,  feet, 
^nd  large  joints,  as  well  as  apparatus  to  be  used  by  the  gynecologist, 
ortliopedist,  otologist,  and  other  specialists  are  now  manufactured. 
T3rj>es  of  some  of  these  are  shown  in  the  following  illustrations  (Figs. 
213  to  223).  If  there  is  considerable  discharge,  a  type  of  cup  shown 
in  Fig.  213  will  be  found  most  useful. 


^^-    225. — Showing  the  method  of  obtaining  motion  in  a  stiff  wrist  by  the  aid  of 

passive  hyperemia. 

In  selecting,  the  cup,  one  should  be  chosen  of  sufiiciently  large 

^^.ineter  to  extend  well  outside  the  limits  of  an  acute  inflammation, 

^^d  with  edges  that  are  thick  and  smooth,  in  order  to  avoid  undue 

pressure  upon  the  skin.     In  the  smaller  glasses  the  suction  is  obtained 

"y  means  of  small  rubber  bulbs.     With  the  larger  apparatus,  stronger 

suction  is  required  and  a  special  exhausting  pump  is  necessary  (Fig. 

^24).    A  further  convenience  for  use  with  the  larger  apparatus  is  a 

Wee-way  stopcock  inserted  between  the  glass  chamber  and  the 


264  bier's   HYPESEUIC   IK£AT]f£NT 

pump  to  allow  admis^on  of  air  when  the  negative  pressun  is 
great  or  is  to  be  discontinued. 

In  addition  to  these  cups  and  chambers,  larger  and  stronger  a{ 
ratus  for  orthopedic  use  is  made  for  the  purpose  of  bending 
joints  by  atmospheric  pr^sure,  as  shown  by  Fig.  325.  Here  the: 
is  drawn  fijmly  in  the  glass  case  as  the  air  is  exhausted  until  the  h 
meets  the  obstacle  at  the  lower  end  of  the  chamber,  when  the  » 
turns  in  the  direction  of  least  resistance.  Other  joints  of  the  h 
may  be  similarly  treated  by  the  use  of  suitable  apparatus.  B 
has  also  devised  metal  chambers  which  are  provided  with  an 
pump  and  a  heavy  rubber  bag  for  obtaining  motion  in  a  parti 
ankylosed  joint.    Upon  exhausting  the  air  in  the  apparatus, 


Fig.  316. — Showing  tne  method  of  obtaining  motion  in  a  stifE  knee-joint  by  the  i 
passive  hyperemia. 


rubber  bag  descends  and  exerts  an  evenly  regulated  pressure  u 
the  part  to  be  treated,  as  shown  in  Fig.  226. 

Asepsis. — In  using  suction  apparatus  in  the  neighborhood  of  c 
wounds  or  sinuses,  strict  asepsis  should  be  observed.  To  avow 
danger  of  adding  to  the  infection,  the  cups  should  be  boiled  b< 
used.  They  should  be  again  boiled  and  well  cleaned  before  h 
put  away. 

Duration  of  Application. — In  the  use  of  cups,  brief  applical 
often  repeated  are  essential.  Accordingly  the  cup  is  applied  for 
minutes,  and  is  then  removed  for  an  interval  of  two  or  three  mirn 
to  allow  the  congestion,  edema,  and  swelling  to  subside.  The  ci 
then  again  applied  for  five  minutes,  and  an  entirely  fresh  supp! 
blood  with  bactericidal  properties  is  brought  to  the  part,  the  e 
treatment  consuming  about  three-quarters  of  an  hour. 


PASSIVE   HYPEREMU  265 

Technic. — Pus,  if  preseTit,  is  always  lo  be  evacuated  by  means  of  a 
srrMil  incision  or  puncture,  as  previously  described,  before  application 
of  the  suction  apparatus. 

To  apply  the  cup,  the  edges  of  the  glass  are  first  moistened  with 
vaselin,  to  avoid  leakage  of  air.  Gentle  pressure  is  then  made  on  the 
hulb,  and  the  cup  is  placed  over  the  affected  region,  care  being  taken  to 
use  a  cup  that  is  large  enough.  Upon  releasing  the  bulb,  the  air  in 
the  cup  is  partly  exhausted,  causing  the  area  covered  by  the  cup  to 
be  drawn  up  into  it,  and,  if  a  proper  amount  of  suction  is  exerted, 
the  cup  adheres  to  the  surface  and  a  pronounced  hyperemia  restilts 
(Fig.  227),  If  the  application  is  made  over  an  open  infected  wound, 
pus  vrill  be  drawn  out,  accompanied  by  some  blood. 


h. 


Fic.  137. — Shouing  a  cup  applied  to  a  carbuncle. 

The  importance  of  obtaining  just  the  proper  degree  of  hyperemia 

■^^  already  been  strongly  emphasized  and  is  reiterated  here.     It 

^**ist  be  remembered  that  the  suction  should  be  just  sufficient  to 

^**glitly  decrease  the  outflowing  blood  without  interfering  with  the 

^**flow.    The  object  is  to  produce  a  reddish-blue  color  of  the  part. 

■^   distinct  blueness  or  mottling  of  the  skin,  or  complaint  of  pain  on  the 

P<x  rt  of  the  patient,  indicates  loo  great  an  amount  of  suction  and  requires 

""^tfiirawal   and  reapplication   of  the   cup.     Pain   should   never   be 

produced  even  in  acutely  inflamed  regions.    Sometimes  more  than 

One  application  of  the  cup  is  necessary  before  the  proper  degree  of 

■hyperemia  is  obtained.    With  the  suction  pump,  the  degree  of 

nypetemia  may  be  more  nicely  regulated.     In  this  case,  the  cup  with 

the  edges  well  lubricated  is  simply  applied  to  the  affected  region, 


I 


266 


BIEK  S  HYFES£MIC  TSEATHENT 


and  the  air  is  slowly  exhausted  until  the  proper  d^ree  of  hyperenua. 
is  induced.    If  the  vacuum  is  produced  too  rapidly,  it  is  apt  to  caus£ 
some  pain.     Should  it  be  found  that  too  great  a  degree  of  suction  is 
produced,  the  stopcock  may  be  opened  slightly  and  air  aUoweeJ- 
to  enter  the  chamber  imtil  the  desired  degree  of  congestion  i^ 
attained. 

In  the  use  of  the  large  chambers,  such  as  are  employed  for  th^S 
treatment  of  a  hand  or  foot,  the  member  to  be  subjected  to  hyperemi^^ 
is  first  coated  with  soap  or  vaselin  so  that  the  rubber  sleeve  will  moi^^ 
easily  slip  over  the  skin  and  at  the  same  time  leakage  of  air  may  b^^ 

avoided.     The  patient  then  thrusts  the  arm  or  foot  into  the  iq)para. 

tusj  and  the  rubber  sleeve  is  bandaged  securely  about  the  limb  witt^ 
a  rubber  bandage  (Fig.  228).  A  partial  vacuum  is  then  productd — 
This  causes  the  part  to  be  drawn  more  deeply  into  the  chamber,  anr^ 


\ 


glass  applied  tn  the  hand. 


some  care  will  be  necessary  to  avoid  injuring  the  limb  by  suddaiL;^'' 
drawing  it  against  the  closed  end  of  the  apparatus.  A  (Ustiiic^^  ^ 
hyperemia  of  the  whole  part  within  the  chamber  is  thus  producec^B^» 
which  may  be  increased  or  lessened  at  will  by  increasing  or  deoea^^^ 
ing  the  amount  of  air  in  the  apparatus. 

During  the  intermissions  between  applications,  the  congestio-^*' 
may  be  relieved  by  elevation  if  the  part  be  an  extremity.    Discharg^-"^^ 
or  secretions  from  open  wounds  or  sinuses  should  be  removed  be ' 
tween  applications  by  gentle  bathing  of  the  part  with  warm  sterile^ 
water  or  some  antiseptic  solution.    At  the  end  of  the  treatment  the^^ 
whole  part  should  be  gently  bathed  with  warm  solution,  and  all  - — 
loose  exudate  or  necrotic  tissue  removed  with  forceps  or  sterile  gauze. 
A  simple  wet  dressing  is  then  applied.    At  the  next  atting,  if  a  cnist 
has  formed  o\'er  the  opening  or  sinus,  it  is  gently  removed  with 
forceps  and  the  treatment  is  continued  as  outlined  above. 

The  suction  treatment  should  be  applied  daily  at  first.  The 
amount  of  pus  usually  rapidly  decreases  each  day,  first  becoming  less 
purulent  and  more  serous,  until  finally  only  a  little  sehim  is  with- 
drawn with  each  application.     The  swelling  diminishes  and  the  part 


ACTIVE     HYPEREMIA 

begins  to  regain  its  normal  appearance  and  dimensions.  As  the 
sufjpuration  decreases,  the  treatment  may  be  given  every  second  day, 
ankci  finally  every  third  dij.y,  until  recovery  is  complete. 

ACTIVE  HYPEBEMU 

The  active  or  arterial  form  of  hyperemia  is  produced  by  means  of 
di-y  hot  air.  Any  portion  of  the  body  when  subjected  to  heat  be-  - 
conies  red  and  hjperemic  through  local  increase  in  the  supply  of 
arterial  blood.  The  effects  of  hot-water  bags,  hot  compresses,  hot 
poultices,  hot  sand,  etc.,  are  all  familiar  examples  of  active  hyperemia 
Itot  air  in  a  dry  form,  however,  is  the  most  effective  means  for 
ittd  ucing  such  a  hyperemia  on  account  of  the  high  degrees  of  heat  that 
cajn  be  borne  without  discomfort.  A  part  may  be  subjected  to  the 
i»^fl.uence  of  dry  hot  air  of  a  temperature  of  212°  F.  (100°  C.)  or  more 
"^thout  danger  of  producing  a  burn  or  other  injurious  effects.  On 
tti^  other  hand,  moist  heat  of  a  temperature  of  125°  F.  (52*  C.)  is 
'^^  liable  of  doing  distinct  harm,  and  is  unbearable  even  for  short 
Pe^riods. 

The  use  of  hot  air  as  a  therapeutic  agent  is  by  no  means  new, 
"^<d  has  been  employed  with  varying  degrees  of  success  for  ages,  but 
■  "^^  methods  of  application  were  crude  and  often  unsatisfactory. 
"^*Xprovements  in  the  modern  baking  apparatus  have  placed  this 
"^^thod  upon  a  firm  basis,  and  properly  applied  in  certain  cases  active 
''3'~5)eremia  becomes  a  therapeutic  agent  of  distinct  value. 

Indications. — Active  hyperemia   has   a   solvent   and   absorbent 

*^^tion  upon  exudates,  infiltrations,  adhesions,  etc.,  and  a  marked 

**^algesic  effect,  causing  a  sensirive  part  to  become  less  so  or  to  be 

f'ltirely  relieved  soon  after  the  application  is  begun.     It  thus  acts 

ia.-vorably  in  chronic  rheumatism,  chronic  arthritis,  chronic  synovitis, 

i^^<l  arthritis  deformans.     It  aids  greatly  in  promoting  the  absorption 

oS  edemas  and  of  effusions  of  blood  into  the  soft  parts,  and  in  synoWal 

^3-cj— as  in  traumatic  synovitis.     Other  affections  in  which  active 

^Mwremia  has  given  good  results  are  neuralgia,   sciatica,   neuritis 

lumbago,  gout,  varicose  veins,  varicose  ulcers,  etc. 

In  fractures  near  a  joint  with  painful  involvement  of  the  Joint 
"-*eif.  it  is  of  great  value  in  reducing  the  edema  and  at  the  same 
time  hastening  the  repair,  thus  increasing  the  chances  of  obtaining  a 
more  useful  limb  through  the  ability  to  perform  early  passive  motion. 
Id  a  Colles'  fracture,  for  example,  the  bones  should  be  properly  re- 
duced and  within  a  few  days  the  part  should  be  daily  subjected  to 


aoS  BIEK  S  HYFEREUIC  TSEATUENT 

the  influence  of  heat.  After  ten  days  the  splint  may  be  discaided 
entirely,  unless  there  seems  a  likelihood  that  the  deformity  will  recur, 
and  the  hot-air  treatment  is  daily  continued,  with  the  addition  of 
both  active  and  passive  motion. 

While  active  hyperemia  is  of  distinct  therapeutic  value,  it  should 
not  be  employed  to  the  exclusion  of  other  means  of  treatment- 
Internal  medication  should  always  be  carried  out  when  the  condition 
is  such  that  it  seems  indicated,  and  the  hot-air  treatment  used  as  an 
adjunct.    In  affections  of  the  joints,  neuralgias,  etc.,  massage  should 


FlQ,  319. — Apparatus  for  applying  active  hyperemia  to  the  hand  and  writt  and  tht 
method  of  its  application. 

form  an  important  part  of  the  treatment,  foo  much  stress  cannot 
be  laid  on  the  value  of  massage  when  judiciously  used  in  appro- 
priate cases. 

Apparatus. — Active  hyperemia  may  be  induced  either  by  the  use 
of  hot-air  boxes  or  hot-air  douches.  There  are  many  mates  of  hot- 
air  boxes  on  the  market.  The  simplest  are  made  of  cotton-wood 
carefully  fitted  together  and  covered  with  cloth  to  prevent  any  leak- 
age of  air.  They  are  provided  with  a  lid  and  have  openings  at  one  or 
both  ends  for  receiving  a  limb.  These  openings  are  lined  with  cuffs 
of  felt  to  avoid  any  danger  of  burning  the  skin,  and  are  provided  with 
straps  so  that  the  cuffs  may  be  securely  fastened  to  a  limb.     Open- 


ACTIVE  HYPESEMIA 


369 


ings  for  hot  air  axe  provided  on  both  sides  of  the  box,  the  one  not  in 
use  being  shut  by  a  slide.  Into  one  of  these  a  chimney  is  fitted, 
through  which  the  hot-air  is  conducted  from  the  heating  apparatus. 
The  heat  is  supplied  by  an  alcohol  lamp  or  a  gas  burner  secured  to  a 
bracket  so  that  the  lamp  may  be  raised  or  lowered  at  wilL  The  lids 
have  one  or  more  openings  for  ventilation  of  the  apparatus.  The  air 
is  thus  constantly  in  motion,  which  is  important  in  order  to  permit 
evaporation  of  the  perspiration  upon  the  part  and  to  maintain  the 
dryness  of  the  air.  A  thermometer  is  also  provided  with  each  box 
for  indicating  the  temperature.  Such  boxes  are  made  to  fit  various 
parts  of  the  body^  as  the  arm,  hand,  shoulder,  foot,  knee,  hips,  etc. 


*1G.  230. — The  hot-air  douche  being  applied  in  sciatica.     (The  nozzle  of  the  apparatus 
should  be  shown  directed  more  to  the  posterior  surface  of  the  limb.) 

Hot-air  douches  may  also  be  obtained  for  use  over  small  areas,  as 
^^ng  the  course  of  a  nerve,  about  the  ear,  etc.  The  douche  consists 
of  a  long  metal  movable  chimney,  imderneath  which  is  the  lamp  or 
ga-s  burner  (Fig.  230). 

Temperature. — The  degree  of  heat  to  which  the  part  is  subjected 
inay  vary  from  150°  F.  to  212*^  F.  (60*^  C.  to  100°  C.)  or  even  higher, 
^^e  temperature  must  never  be  high  enough,  however,  to  cause  dis- 
comfort, and  the  patient's  feelings  should  be  the  guide.  It  should  be 
remembered  that  the  prolonged  application  of  a  very  high  degree  of 
*^^t  lowers  the  sensibility  of  a  part,  and  great  care  must  be  taken  not 
^  burn  the  patient;  the  same  caution  must  be  observed  when  apply- 


270  bier's  hyperemic  treatment 

ing  active  hyperemia  to  tissues  with  lowered  resistance.  A  moder 
temperature  should  be  employed  at  the  start,  and  this  should 
increased  gradually  as  tolerance  is  attained.  The  temperatiun 
regulated  by  raising  the  lamp  nearer  the  box  or  moving  it  farl 
away,  and  also  by  the  size  of  the  flame. 

Duration  of  Applications. — ^The  heat  should  be  applied  from 
an  hour  to  an  hour  daily,  or  on  alternate  days.  In  exception 
stubborn  cases  it  may  be  applied  for  the  same  length  of  time  t 
daily. 

Technic. — The  patient  assimies  a  comfortable  attitude,  d 
seated  or  lying  down,  with  the  apparatus  dose  at  hand.  The  ] 
to  be  baked  is  then  placed  in  the  box  and  the  lid  is  closed, 
lighted  lamp  is  placed  under  the  funnel  and  the  temperatui 
gradually  raised  imtil  a  degree  of  heat  is  attained  that  can  be  < 
fortably  borne  by  the  patient.  The  vent  in  the  top  of  the  appar 
should  always  be  open  when  it  is  in  use,  in  order  to  obtain  the  m 
sary  draught  for  the  flame  and  proper  ventilation  of  the  appan 
When  the  desired  degree  of  temperature  has  been  reached,  it  sh 
be  maintained  from  half  an  hour  to  an  hour.  The  light  is 
extinguished  and  the  temperature  is  allowed  to  slowly  fall  be 
the  member  is  removed.  A  sudden  change  of  temperature,  sue 
would  be  occasioned  by  immediately  removing  the  part  to  the  oul 
atmosphere,  is  to  be  avoided.  The  part,  when  removed  i 
the  baking  apparatus,  is  hot  and  hyperemic  and  remains  s< 
some  little  time.  Immediately  following  the  treatment,  gc 
massage   and   passive  motion,  if  indicated,   should   be  pract 

THE  PRODUCTION  OF  AN  ARTIFICIAL 

PNEUMOTHORAX 

The  production  of  an  artificial  pneumothorax  by  the  repc 
injections  into  the  pleural  cavity  of  a  slowly  absorbable  gas  foi 
purpose  of  collapsing  a  tuberculous  lung,  orginated  with  Fori 
of  Italy  in  1894.  Independently  of  Forlanini,  the  same  open 
was  performed  in  1898  by  ]Murphy  of  Chicago,  but  at  the  tii 
did  not  excite  a  great  deal  of  attention  in  this  country,  in  spi 
its  successful  use  abroad  by  Brauer,  Spengler,  Saugmann  and  ot 
Today,  however,  it  is  recognized  as  a  therapeutic  measure  o: 
greatest  value  for  certain  cases  of  pulmonary  tuberculosis,  a 
procedure  that  is  reasonably  safe  if  performed  under  rigid  as 
and  with  proper  precautions. 


^ODUCnON   OF  AN  ARTIFICIAL   PNEUMOTHORAX  271 

The  aim  of  the  treatment  is  to  collapse  a  diseased  lung  and  put 
at  rest  on  the  same  theory  that  a  tuberculous  joint  or  other  tuber- 
culous process  is  immobilized.     With  reduction  in  the  volume  of  the 
lang,  its  contents,  such  as  the  pus  and  cheesy  collections  in  cavities 
ancd  inflammatory  exudates  in  the  alveoU  and  small  bronchial  tubes, 
are  gradually  evacuated,  so  that  toxic  absorption  is  lessened.    At 
first,  while  the  cavities  are  undergoing  collapse,  expectoration  may 
be    temporarily  increased,  but  It  rapidly  decreases  in  amount  if  the 
o{>erat{on  is  successfull.     As  the  cavities  collapse  and  become  ob- 
literated, the  diseased  parts  are  brought  into  apposition  so  that 
cicatrization  is  favored  and  the  extension  of  the  disease  is  limited. 
The  effects  of  compression  on  the  circulation  of  the  blood  and 
lymph  is  also  important.     In  a  collapsed  lung  the  circulation  of  the 
blood  is  impeded  and  a  condition  of  venous  stasis  results,  which, 
as  is  well  known,  is  an  important  factor  in  increasing  the  resistance  of 
the  tissues  against  the  tubercle  bacilli.     Likewise,   through   com- 
pression of  the  lymph  channels,  toxic  absorption  rapidly  decreases, 
*nd  the  fever,  nightsweats,  general  weakness,  and  other  symptoms 
"^  toxemia  disappear. 

The  operation  is  comparatively  simple  and  consists  in  puncturing 
^e  chest  with  a  needle  which  is  connected  with  a  reservoir  of  nitro- 
S^fi  gas  and  a  water  manometer,  and  allowing  the  gas  to  flow  into 
"'^  pleural  cavity  in  small  amounts  at  a-  sitting.  By  some  operators 
"•e  parietal  pleura  is  first  exposed  by  an  incision  as  an  aid  to  the  proper 
P'acing  of  the  needle  in  the  pleural  cavity,  but  this  method  is  formid- 
*"le  in  comparison  with  simple  puncture  and  is  generally  reserved 
***■  those  cases  when  the  simpler  technic  fails. 

Indications. — Success  in  creating  an  artiiidal  pneumothorax 
f^uires  that  the  pleura  be  permeable,  as  the  lung  will  not  collapse 
^  there  are  adhesions. 

The  cases  best  suited  to  this  treatment  are  those  with  an  active 
y^Volvement  of  a  considerable  portion  of  one  lung  with  little  or  no 
mvolvement  on  the  other  side.  Bilateral  involvement,  however,  is 
not  a  contra-indication  if  less  than  a  third  of  the  good  lung  is  affected. 
ui  rapidly  progressive  cases  and  in  cases  that  do  not  improve  under 
^e  usual  hygienic  and  climatic  treatment,  it  is  also  indicated.  It 
pves  excellent  results  in  those  cases  where  there  is  persistent  and 
copious  hemoptysis  if  its  source  can  be  deftnitely  traced  to  one  or 
the  other  lung. 

In  cases  where  there  are  cavities  with  very  rigid  walls,  the  results 
•Woftcn  uncerta.in,  as,  while  healthy  parts  of  the  lung  may  collapse, 


1 


973  BIEK  S    HYPEKEUIC    TSEATUENT 

the  lung  at  the  site  of  the  disease  does  not  and  outside  of  a 
temporary  improvement  the  operation  is  a  failure.  In  brondui 
the  same  difficulty  is  met  in  collapsing  the  thi<i  walled  ( 
bronchioles,  and,  while  use  of  the  method  has  been  follov 
improvement,  permanent  benefit  is  doubtful. 

Artificial  pneumothorax  is  contra-indicated  in  the  prese 
exten^ve  involvement  of  both  lungs,,  diy  pleurisy,  pleuris] 
effu^on,  where  there  is  such  extensive  cavity  formation  that  t 
danger  of  the  needle  entering  the  lung,  in  myocarditis  or  other ; 
cardiac,  renal,  or  constitutional  disease  that  would  in  its 
sufficient  to  prevent  recovery,  and  in  early  favorable  cases. 


for  artificial  pneumothorax. 


Apparatus. — There  are  various  makes  of  apparatus  on  the  a 
which  are  all  much  the  same  in  principle.  The  manometer 
most  important  part  of  any  apparatus,  as  it  demonstrates  the  lo 
of  the  needle  during  its  insertion  and  registers  the  pressure 
thorax  before  and  after  the  injection. 

The  Robinson  apparatus  consists  of  two  bottles  with  a  ca 
of  2  quarts  (2000  c.c.)  each,  connected  with  a  manometer, 
bottle  "A"  is  stationary  while  the  other"B"  is  arranged  so 
be  elevated  or  lowered.  The  stationary  bottle  is  filled  with 
water  containing  two  drams  (8  c.c.)  of  pyrogallic  acid  to  ti 
any  oxygen  that  may  enter  with  the  nitrogen.    Nitrogen 


PRODUCTION    OF    AN   AHTrFICIAL    P>rEUMOTnOR.«C  273 

!i  forced  into  bottle  "A"  forcing  the  solution  into  bottle  "B". 
The  apparatus  is  then  ready  for  use,  and,  on  opening  the  proper 
cock,  the  solution  in  bottle  "B"  forces  the  nitrogen  out  of  bottle  "A" 
under  pressure  regulated  by  the  height  of  bottle  "B".  As  the  water 
levels  in  the  two  bottles  approach  one  another,  bottle  "B"  is  elevated 
to  maintain  the  desired  pressure.  When  cock  "D"  is  closed  and 
"E"  &  "F"  are  open  a  direct  connection  between  the  needle  and 
the  manometer  results.  With  cock  "F"  closed  and  "C"  and  "D" 
open  connection  is  established  between  the  manometer  and  the 
nitrogen,  the  pressure  recorded  being  the  difference  in  the  water 
levels  of  bottles  "A"  and  "B,"  With  cock  "E"  closed  and  the  other 
two  open  the  nitrogen  passes  directly  from  bottle  "A"  into  the  needle. 
The  needle  should  preferably  be  provided  with  an  obturator  and 
arm  for  coimection  with  the  tube  to  the  gas  bottle.  The  needle 
shoidd  be  J25  inch  (i  mm.)  in  diameter  and  about  i}-^  inches 
(4  cm.)  long. 


Pig  J33-- — Floyd  needle  for  artificial  pneumothorax. 

Gas  Used. — Nitrogen  gas  is  generally  employed,  as  it  is  claimed 
^  temore  slowly  absorbed  than  atmospheric  air  and  is  non-irritaling. 
*^    should  be  chemically  pure  and  should  be  filtered  through  sterile 
^*-*Von  on  the  way  to  the  chest. 

Temperature.—  The  gas  should  be  at  about  the  temperature  of 
J**«  body.  It  ma  J-  be  warmed  by  immersing  the  tube  through  which 
'*-      passes  to  the  patient  In  a  basin  of  hot  water. 

Quantity  Injected.^ — The   injection  of  small   amounts    of  gas 

^^^     preferable.     Two  hundred  to  400  c.c.   (12  to  24  cubic  inches) 

*•*"«  btroduced  at  the  first  sitting  and  this  is  increased  to  from  300  to 

^^»  c.c.  (18  to  36  cubic  inches)  at  the  second,  and  to  from  800  to 

*^xio  c.c.  (48  to  60  cubic  inches)  at  the  third  operation. 

Frequency  of  Injections.— Injections  are  given  at  intervals  of 

1         Irom  3  to  5  days  until  complete  collapse  of  the  lung  is  obtained, 

i        "Ononstrated   by   disappearance   of   the  respiratory   murmur   and 

A-tay  examination.     To  insure  permanency  of  the  pneumothorax. 


274  bier's  hyperemic  treatment 

further  injections  are  made  once  or  twice  a  month  depending  on  the 
rapidity  with  which  the  gas  is  absorbed. 

Point  of  Puncture. — ^A  point  as  far  away  from  the  seat  of  tlxe 
disease  as  possible  should  be  selected  in  order  to  avoid  adhesioos. 
For  lesions  of  the  apex  the  needle  is  inserted  in  one  of  the  intercos- 
tal spaces  between  the  6th  and  9th  ribs,  between  the  anterior 
and  posterior  axillary  lines.  For  lesions  of  the  lower  lobe  the  tliix<l 
space  outside  the  mamillary  line  is  selected. 

Preparation  of  Patient. — The  patient  should  be  given  morphia 
gr.  3^  (0.0108  grams)  by  hypodermic  half  an  hour  before  the  operation. 

Position  of  Patient. — The  patient  should  lie  on  the  side  with 
the  diseased  side  uppermost  and  the  arm  elevated  above  the  head 
so  as  to  widen  the  intercostal  spaces  as  much  as  possible. 

Asepsis. — The  bottles,  tubing  and  needles  are  sterilized  and  the 
operator's  hands  cleansed  as  carefully  as  for  any  operation.  The 
skin  at  the  site  of  puncture  is  sterilized  by  painting  with  tincture  of 
iodin. 

Anesthesia. — ^A  0.5  per  cent,  procain-adrenalin  solution  is  used. 
The  skin  at  the  point  of  pimcture  is  first  anesthetized  and  then  the 
tissues  of  the  intercostal  space  down  to  and  including  the  pleum  aie 
infiltrated. 

Technic. — ^A  point  on  the  skin  over  the  interspace  through  whidi. 
the  injection  is  to  be  made  is  selected  at  a  little  distance  from  the 
upper  margin  of  the  lower  rib  bounding  the  space,  and«  after  bang 
anesthetized,  a  small  nick  is  made  in  the  skin  with  a  scalpel    Tte 
thiunb  and  forefinger  of  the  left  hand  are  used  to  steady  the  tissues 
while  the  needle  is  introduced  with  the  right  hand,  the  forefinger 
being  placed  on  the  needle  to  guard  against  its  being  inserted  too 
deeply.     The  needle  is  then  pushed  through  the  intercostal  muscles 
into   the  pleura,   which  is  usually  entered   at  a  depth  of  about 
one  inch  (2.5  cm.)  and  is  recognized  by  the  added  resistence  oflFered 
to  the  needle.    The  needle  is  now  connected  with  the  manometer,  th^ 
trocar   being  withdrawn   and   the   connection  with   the  nitrogen, 
bottle  remaining  closed,  as  the  manometer  is  the  only  means  of 
determining  whether  the  needle  has  entered  the  pleura.    While  the 
needle  remains  outside  the  endo-thoracic  fascia,  the  manometer 
regbters  zero,  but  as  it  reaches  this  structure  there  is  a  slight  osdll*- 
tion  between  o  and  3,  due  to  the  respirator}"  movements  of  the 
pleura.     The  entrance  of  the  needle  within  the  two  layers  of  the 
pleura  is  indicated  by  a  negative  pressure  of  from  5  to  10  an-* 
and  there  will  be  observ-ed  distinct  oscillations  of  the  fluid  in  the 


PRODUCTION    OF    AN    AKTXF1CI.\I.    PNEUMOTHORAX  275 

nanometer  corresponding  to  inspiration  and  expiration.  Should 
the  needle  enter  a  blood  vessel  or  adherent  pleura  negative  pressure 
and  the  respiratory  oscillations  are  absent.  If  the  lung  is  entered 
respiratory  oscillations  may  be  present,  but  there  is  no  negative 
pressure.  Unless  the  negative  pressure  registers  3  cm.  or  over,  the 
injection  of  the  gas  should  not  be  attempted,  and  another  site  should 
be  chosen. 

When  it  is  certain  that  the  needle  is  in  the  pleural  cavity,  the 
manometer  is  dosed,  and  the  gas  is  allowed  to  enter,  which  it  does 
under  the  influence  of  the  negative  pressure  in  the  cavity  or  under 
positive  pressure  in  the  gas  reservoir,  if  necessary.  After  100  c.c. 
(6  cubic  inches)  of  gas  has  been  introduced,  the  gas  is  shut  off  and  the 
pressure  in  the  pleural  cavity  is  taken,  and,  if  the  manometer  still 
registers  a  negative  pressure,  100  c.c,  (6  cubic  inches)  more  gas  may 
be  introduced.  The  final  reading  of  the  manometer  should  indicate 
only  a  slight  negative  or  a  positive  pressure  of  from  0.5  to  3  cm.  At 
the  completion  of  theoperationtheneedle  is  withdrawn,  pressure  being 
made  over  the  site  of  the  puncture  for  a  few  moments  to  prevent 
leakage  of  gas  into  the  subcutaneous  tissues,  and  the  wound  is 
sealed  with  collodion  and  cotton.  The  patient  should  be  kept  in 
bed  for  twenty-four  hours  subsequent  to  the  operation,  and  any 
tendency  to  cough  should  be  controlled  by  small  doses  of 
codein. 

At  subsequent  operations  the  same  site  is  chosen  for  inserting 
the  needle  as  at  the  first  operation,  and  the  needle  is  introduced  with 
'be  same  precautions. 

Complications. — Some  pain  may  be  felt  during  the  introduction 
'**  the  needle  through  insufficient  anesthesia.  When  it  occurs 
'™ring  or  following  the  injection  of  the  gas,  it  is  usually  the  result  of 
™*&king  up  of  adhesions.  A  slight  dyspnoea  is  not  uncommon 
'ttmediately  following  the  injection,  but  soon  passes  off.  Should 
*^ere  dyspnoea  and  pain  occur  during  the  inflation,  it  should  be 
stopped  at  once. 

Occasionally  a  condition  known  as  "pleural  shock"  which  is 
'"finifested  by  an  increase  in  the  pulse  rate  and  respirations, 
Pallor,  and  d)'spnoea,  is  observed.  It  usuaUy  passes  off  quickly, 
W  may  result  fatally. 

Oat  embolism,  the  result  of  gas  entering  a  vessel,  may  occur  if 
^  precaution  of  demonstrating  the  location  of  the  needle  by  the 
ni*oometer  before  making  the  injection  is  not  followed.  It  is 
dmaclerized    by    rapid    pulse,    irregular    respirations,    faintness, 


276  bier's  hyperemic  treatment 

collapse,  inequality  of  the  pupils^  etc.    If  a  large  quantity  of  ga& 
enters  a  vessel,  it  may  produce  fatal  results. 

Subcutaneous  emphysema  is  sometimes  observed  in  the  neighbor- 
hood of  the  puncture  from  the  escape  of  the  gas  into  the  tissues 
through  the  pimctu're.    It  is  more  apt  to  occur  with  the  opCiXi 
method. 

Pleural  effusions  are  a  frequent  complication.    It  is  serious  9^ 
it  may  result  in  a  pyothorax. 

Accidental  pneumothorax   sometimes   occurs  as   the   result  o^ 
injury  to  the  lung  by  the  needle,  or  from  tearing  of  the  lung  whe: 
adhesions  are  broken  up. 

• 

THE  DIAGNOSIS  AND  TREATMENT  OF  FISTULOUS 
TRACTS  BY  MEANS  OF  BISMUTH  PASTE 

The  injection  of  a  mixture  of  bismuth  and  vaselin  for  tL 
diagnosis  and  treatment  of  fistulae,  tuberculous  sinuses,  and 
cavities  was  devised  by  Beck  of  Chicago.    He  originally  employ 
the  method  for  the  purpose  of  determining  the  size,  course,  and 
tent  of  fistulous  tracts.    His  first  injection  of  a  fistula  for  diagnostl 
purposes  resulted,  however,  in  the  prompt  closure  of  the  sinus,  an 
led  him  to  extend  the  use  of  the  injections  to  curative  purposes  wi 
most  favorable  results. 

For  diagnostic  purposes  the  fistula  or  abscess  cavity  is  filled  wi 
the  bismuth  mixture  and  then  a  radiograph  k  taken.    As  the  bi 
muth  offers  great  resistance  to  the  penetration  of  the  X-rays,  a  d« 
shadow  of  the  fistula  and  all  its  ramifications  is  obtained, 
gives  much  more  information  than  the  usual  methods  of  probin; 
and  injecting  colored  fluids,  peroxid,  etc. 

As  a  therapeutic  measure  the  method  of  application  is  equall 
simple,  the  bismuth  paste  being  injected  into  the  fistula  or  absces 
cavity  and  allowed   to   remain  there.    Later  it  is  absorbed.    I' 
is  claimed  that  the  bismuth  has  a  bactericidal,  chemotactic,  an 
astringent  action  on  the  tissues.     Furthermore,   through  its  me-^ 
chanical  effect,  it  promotes  healing  by  keeping  the  walls  of  the  sinu 
separated  and  forming  a  framework  for  the  granulating  tissue  t 
work  through.     The  method  is  applicable  to  all  fistulae  or  abscess 
cavities  except  biliary  or  pancreatic  fistulae  and  those  communicating 
with  the  cranial  cavity  or  urinary  bladder.     It  is  contraindicated 
in  acute  processes  and  new  sinuses,  as  absorption  occurs  very  readily 
from  the  fresh  lining  of  the  walls.     In  old  sinuses  and  abscess  cavities 


BISMUTH   PASTE   INJECTIONS 


277 


tliis  is  not  the  case,  the  thick  fibrous  walls  possessing  a  greatly  dunln- 
iahed  power  of  absorption. 

Toxic  effects  have  been  observed  after  the  use  of  bismuth  paste, 
ajld,  in  some  instances,  death  has  resulted.  The  symptoms  are  those 
of  nitrite  poisoning:  black  lines  upon  the  gums,  ulcerative  stomatitis, 
vomiting,  diarrhea,  albuminura,  cyanosis,  and  collapse.  To  avoid 
ttis  danger  not  more  than  100  gm.  {j  ounces)  of  the  mixture  should 
l>e  iDJecled  the  first  time,  and  the  patient  should  be  carefully  watched 
for  the  appearance  of  any  toxic  symptoms.  Should  they  develop 
the  cavity  must  be  promptly  evacuated.  This  may  be  accomplished 
I>y  injecting  into  the  cavity  some  warm  sterile  olive  oil  and  removing 
It  within  twenty-four  to  forty -eight  hours  by  aspiration.  The  ca\'ity 
should  never  be  curetted,  as  this  simply  opens  up  new  channels  for 
absorption. 


Apparatus.— ^There  will  be  required  a  vessel  to  heat  the  bismuth 
*'^lure  in,  a  glass  rod  to  stir  the  mixture,  and  a  large  blunt-pointed 
Sla&s  syringe  with  asbestos  packing.  For  injecting  rectal  fistula 
"^ck  has  devised  a  syringe  with  a  nozzle  of  soedal  shape  and  curve 
^^'g-  233)-- 

I'ormulary. — Two  mixtures  are  used  by  Beck: 


No.  I.    Bismuth  subnitrotc 

^o.  II.  Biamuth  subnitrate, 
White  wan. 

Soft  paraffin  (r2o°  F,  melting  point), 
Vaselin, 


33% 
67% 

30% 
5% 
5% 

60% 


Formula  No.  1  is  used  for  diagnostic  purposes  and  for  early  treat- 
^Milts,  while  No.  11  is  used  for  late  treatments  after  the  discharge 
ttoin  the  sinus  has  ceased.  Only  arsenic-free  bismuth  should  he  used. 
Tile  paste  is  mixed  by  melting  the  vaselin  and,  while  still  hot ,  stirring 
into  it  the  bismuth.  It  is  claimed  that  the  efficiency  of  the  paste  is 
increased  by  adding  0.5  to  i  per  cent,  formalin. 


—  3 


278  bier's  hyepremic  treatment 

To  avoid  the  dangers  of  nitrite  poisoning,  various  other  substancr 
have  been  incorporated  in  the  vaselin,  such  as  the  subcarbona 
oxychlorid,  and  subgallate  of  bismuth,  chalk,  oxid  of  iron, 
but  in  the  opinion  of  Beck  they  are  inferior  to  bismuth  subnitrate  f< 
therapeutic  purposes. 

Asepsis. — The  syringe  and  receptacle  for  warming  the  bismutJ* 
mixture  and  the  stirring  rod  should  be  sterilized  by  dry  heat.    If  tl:^- 
S)ainge  needs  lubricating  the  packing  may  be  dipped  in  sterile  oliv^^ 
oil.     The  paste  is  sterilized  by  heating  over  a  water  bath,  care  bfiii^ 
taken  not  to  allow  any  water  to  come  in  contact  with  the  mixturi^* 

Preparations  of  the  Patient. — No  general  preparation  of  the  pa^— 
tient  is  necessary;  the  sinus  or  cavity  to  be  injected  may  be 
out  by  means  of  a  strip  of  gauze  if  this  is  feasible,  but  no  irrigatio 
should  be  attempted.     The  opening  of  the  sinus  is  carefully  wiped 
with  alcohol. 

Technic. — The  paste  is  heated  over  a  water  bath  and  is  sti 
imtil  thin  enough  to  be  drawn  into  the  syringe.     The  syringe  is  thez^ 
filled  with  the  melted  mixture,  the  point  of  the  syringe  is 
closely  into  the  mouth  of  the  sinus,  and  the  mixture  is  injected  und 
sufficient  pressure  to  distend  and  penetrate  all  the  ramifications 
the  sinus.     Both  for  purposes  of  diagnosis  and  treatment  it 
absolutely  essential  that  the  paste  be  made  to  enter  all  portions  of 
the  tract.     When  the  patient  feels  a  sense  of  distention  from  tha 
injection,  the  latter  is  stopped  and  a  pledget  of  gauze  is  quickly  placed 
over  the  opening.     An  ice-bag  is  then  applied  to  the  part  and  the 
patient  is  kept  quiet  for  a  few  hours. 

As  a  rule,  after  the  first  injection,  the  secretions  change  in  char- 
acter and  become  first  seropurulent,  then  serous,  and  finally  cease. 
Should  the  discharge  continue  the  injection  may  be  repeated  at  the 
end  of  a  week  and  after  that  every  three  to  five  days  until  the  sinus 
closes.  If  any  improvement  is  going  to  take  place  it  should  be 
noticed  inside  of  a  month.  Tracts  that  show  no  disposition  to 
close  should  be  carefully  examined  for  the  presence  of  dead  bone 
or  other  foreign  body,  which,  if  present,  must  be  removed.  A  small 
per  cent,  of  the  cases  show  no  results  at  all  from  the  treatment. 


CHAPTER  XI 

THE  COLLECTION  AND  PRESERVATION  OF  PATHO- 
LOGICAL MATERIAL 

With  the  present-day  refinements  of  laboratory  methods,  the  aid 
furnished  by  an  examination  of  discharges,  blood,  urine,  sputum, 
etc.,  is  of  great  importance,  and  often  without  the  information  so 
obtained  a  correct  diagnosis  is  impossible.  It  is  not  within  the  scope 
of  this  work  to  enter  into  the  details  of  laboratory  methods — these 
in.ay  be  found  in  books  devoted  to  the  subject — but  it  is  the  writer's 
purpose  in  this  section  to  give  brief  instructions  as  to  the  methods  oif 
collecting  material  and  the  preparation  of  specimens  for  subsequent 
p3,tliological  examination.  This  work  usually  falls  to  the  lot  of  the 
practitioner  or  surgeon  himself,  and  often,  through  faulty  technic 
*^i  the  inoculation  of  a  culture,  in  the  preparation  of  slides,  or  in  the 
collection  of  discharges,  etc.,  the  results  of  the  pathologist's  examina- 
^on.  are  misleading  or  useless. 

In  any  case  where  material  is  sent  to  a  laboratory  for  examination, 
^3,ch  specimen  should  be  clearly  labeled  with  the  name  of  the  patient, 
^^  by  a  distinguishing  number,  and  the  clinical  diagnosis  and  a  short 
^^liriical  history  of  the  case,  together  with  a  statement  of  from  what 
of  the  body  or  from  what  organ  the  pathological  material 
obtained,  should  accompany  the  specimen.  If  chemicals  have 
^^^n  employed  for  preserving  the  specimen,  this  should  also  be 
^^^^-ted  on  the  slip  sent  to  the  pathologist. 

METHOD  OF  MAKING  A  SMEAR  PREPARATION 
FOR  MICROSCOPICAL  EXAMINATION 

Equipment. — ^A  number  of  clean  glass  slides,  sterile  swabs,  and 
^vxi  table  specula  for  exposing  to  view  deep-seated  regions  from  which 
^^t^^  discharge  may  originate,  will  be  required. 

The  slides  should  be  absolutely  clean  and  free  from  grease. 

^ixless  the  slides  are  very  dirty,  the  following  method  of  cleansing 

^-*^^  glass  will  suffice:  First  wash  ofiF  the  slide  with  soap  and  water, 

'^n.en  wipe  with  alcohol  and  ether  and  rub  dry  with  an  old  linen  or 

^^^  cloth;  finally  pass  the  slide  through  an  alcohol  flame.     When 

279 


28o 


COLLECTION   OF  PATHOLOGICAL  MATERIAL 


once  cleansed,  care  should  be  taken  that  the  surface  of  the  slide  doe 
not  come  into  contact  with  the  skin,  as,  if  it  does,  a  thin  film  of  grea£ 
will  be  left  upon  the  glass. 

The  swabs  consist  of  steel  wires  or  applicators  about  one  extremis 
of  which  some  cotton  is  wound.  They  may  be  obtained  sterilize 
and  ready  for  use,  or  may  be  easily  extemporized  as  follows:  A  tes 


Fig.  234. — Roughened  wire  for  making  a  swab. 

tube  and  a  piece  of  stiff  wire,  of  a  length  somewhat  longer  than  tia 
of  the  tube,  are  obtained.     One  end  of  the  wire  is  first  roughened 
a  file  (Fig.  234)  and  is  then  tightly  wrapped  with  a  small  roll 
cotton  (Fig.  235).    The  swab  is  then  loosely  laid  in  the  test-tube  a 
the  mouth  of  the  tube  is  plugged  with  sterile  cotton  (Fig.  236),  a 


Fig.  235. — Showing  the  method  of  wrapping  cotton  on  the  end  of  a  wire. 

the  whole  is  sterilized  by  dry  heat.  A  supply  of  swabs  may 
prepared  in  this  way  and  be  kept  ready  for  use  almost  indefinite 
Technic. — ^The  slides  are  arranged  upon  a  towel  and  the  tu"^ 
containing  the  sterile  swabs  are  placed  near  at  hand.  With  the  ^^ 
of  thie  disease  well  exposed,  the  swab  is  removed  from  the  gL 
container  and  dipped  into  the  pus  or  the  secretion  care  being  tat^ 


Fig.  236. — Sterile  swab  in  a  glass  test-tuoe. 

that  it  touches  nothing  but  the  material  from  which  the  specimen* 
to  be  obtained.  The  swab  is  then  rubbed  over  the  surface  of  a^ 
of  the  glass  slides  so  as  to  spread  the  material  in  a  thin  transpar^ 
film  (Fig.  237).  At  least  two  smears  should  be  made  from  ea-< 
locality,  and  each  slide  should  be  labeled  with  a  distinguishiP 
number.     The  slides  are  allowed  to  dry  and  are  then  piled  up  au< 


SHEAR   PREPARATION  FOR   MICROSCOPICAL   EXAMINATION      281 


secured  one  upon  another,  but  with  their  surfaces  separated  by 
matches  or  tooth-picks,  as  shown  in  Fig.  238, 


From 
swabs,  glas 


Fig.  337. — Method  ot  making 


the      Mouth     and      Pharynx.      Equipment.^Sterile 
slides,  and  a  tongue  depressor  will  be  required  {Fig.  239). 


I      •'IG,    ajS. — Glass  slides  separated  by   match  sticks  and  held  toRcther   with   rubber 
1  bands  ready  for  shipment  to  the  laboratory.     (Ashtnn.) 

Technic. — It  should  be  seen  that  no  antiseptic  mouth  washes  or 
gargles  have  been  used  for  at  least  two  hours  previous  to  the  time  the 
smear  is  made.     The  patient  is  seated  in  a  good  light,  with  h's 


,  Sterile  swabi: 


nwuih  widely  opened,  and  the  tongue  controlled  by  the  tongue  de- 
pressor held  in  the  operator's  left  hand,  so  that  a  good  view  of  the 


382  COLLECTION   OF  PATHOLOGICAL  MATEEIAL 


\ 


diseased  area  may  be  obtained.  The  sterile  swab  is  then  removed 
from  its  container,  taken  in  the  right  hand,  and  is  passed  into  the 
mouth,  the  operator  being  careful  not  to  allow  it  to  come  in  contart. 
with  the  lips  or  tongue.  When  in  contact  with  the  area  from  whirfi. 
the  material  is  to  be  obtained,  the  swab  should  be  rotated  about  ao 
as  to  bring  as  much  as  possible  of  its  surface  in  contact  with  tlM 
secretions  (Fig.  240).  In  removing  the  swab  the  same  care  i^aLxrx;^ 
contamination  from  contact  with  the  tongue,  etc.,  should  be  ^izik'V 
served.  A  thin  smear  is  then  made  upon  a  slide  in  the  matt^-:»^g 
described  above,  and  the  swab  is  returned  to  its  contaiaei  for  fut:,-^  -^„ 
inoculation  of  culture  tubes  if  necessary. 


Fic.  240. — Show-ini;  the  method  of  taking  a  smear  from  the  pharynx. 

From  the    Nose.     Equipment.— -Swabs,   slides,  a  nasal  spe^  ^ 
lum,  a  head  mirror,  and  an  angular  pipette  (Fig.  241)  will  be  requir^^' 

Tedinic. — Ordinarily,  for  microscopical  examination,  a  smcaX^ 
made  in  the  usual  way  from  secretions  blown  from  the  nose  into  a 
piece  of  sterile  gauze  is  sufficient.     If,  however,  it  is  desired  to  obtain 
a  smear  fiom  any  one  locality,  the  secretion  should  be  first  removed 
by  means  of  a  pipette  (page  294),  and  from  this  the  smear  is  made. 

From     the     Eyes.     Equipment. — Slides,    a    sterile    swab,  a 
platinum  needle,  and  an  alcohol  lamp  (Fig.  242)  will  be  necessary. 

Technic. — There  should  be  no  preliminary  cleansing  of  the  eyes. 
The  platinum  needle  is  first  sterilized  by  passing  it  through  the 


SlCEAh  f  SEPASATIOH  TOK  UICBOSCOPICAX  EXAMINATION   >  383 

flame,  and  when  it  has  cooled  the  lids  are  separated,  the  loop  is 
brought  into  contact  with  the  pus  and  some  of  it  is  transferred 
to  a  slide.    A  smear  is  then  made  by  means  of  the  swab. 


Fbi,  341.— Instniments  for  taking  a  tmeu  from  the  uose.    i,  Sterile  airab;  a,  nasal 
speculum;  3,  glass  slides;  4,  angular  pipette;  5,  bead  rairtDr. 

From   the  Urethra.     Equipment. — Slides  and   sterile  swabs 
(Fig.  243)  should  be  provided. 


*  341. — Instruments  for  taking  a  smear  from  the  eyes,    i.  Sterile  swab;  3,  ^aas 
slides;  3,  alcohol  lamp;  4,  platinum  needle. 

Technic. — In  a  male,  the  meatus  should  be  cleansed,  and  a  drop 
Pus  is  expressed  by  stripping  the  urethra  with  the  finger  from 

^«ind  forward.     The  swab  is  then  dipped  in  the  pus  and  a  thin 

^ear  is  made  upon  a  slide  in  the  usual  way. 


284 


COLLECTION   OF  PATHOLOGICAL  UATESIU 


Fic.  Hi. — Instrumeats  for  taking  a  smear  from  the  urethra,     i.  Sterile  mb;  z 


Fig.  344. — Forcing  the  disctiargc  out  of  the  urethra  by  pressure  Bgaintt  the  0 
with  the  tip  of  the  finger  in  the  vagina.     (Ashton.) 


}uchmg  the  vulva  and  is  rubbed  in  the  discharge,  mucous 
whatever  it  may  be.     A  smear  is  then  made  from  the 

bus  obtained. 
the  Cervix.     Equipment. — -A  long  swab,    a  speculum, 

ula,  a  sponge  holder,  and  glass  slides  (Fig.  246)  should  be 

c. — The  speculum  is  introduced  so  that  the  cervix  is  well 
1  view,  and,  by  means  of  a  tenaculum  placed  in  each  lip, 

is  drawn  as  far  down  as  possible.  The  swab  is  then  passed 
jrvical  canal  (Fig.  247),  but  care  is- taken  that  it  does  not 

uterus  for  fear  of  carrying  infection  to  what  may  be  a 
gan  from  a  diseased  cervix.  The  swab  is  then  withdrawn, 
ar  is  made  in  the  usual  way. 


386  COLLECTION   OF  PATHOLOGICAL  MATERIAL 


Fig.  346. — Instruments  for  taking 
cula;  3,  Simon's  speculi 


Feo.  347. — Method  of  coUecting  the  secretions  from  the  uterus.    (Ash 


METHOD  OF  mOCDlATING  CDLTUM:   TDBES  287 

METHOD  OF  moCULATING  CULTURE  TDBES 

Equipment. — Culture  tubes,  sterile  swabs,  platinum  needles, 
thumb  forceps,  and  an  alcohol  lamp  (Fig.  248)  will  be  required. 

A.  Variety  of  media  are  employed  for  the  growth  of  bacteria,  such 
as  brot±»,  agar-agar,  gelatin,  and  blood  serum,  according  to  the  kind 


*G.   a^S. — Instniments  for  making  a  culture,     i,  Alcohol  lamp;  «,  thumb  forceps; 
3,  sterile  swatu;  4,  culture  tubes;  5,  platinum  needle. 

Of  bacteria  to  be  cultivated.  The  culture  media  are  sold  in  sterile 
J~st-tubes,  generally  plugged  with  cotton.  When  they  are  to  be 
*-cpt  for  any  length  of  time,  the  tubes  should,  in  addition,  be  sealed 
^itli  rubber  caps  or  oiled  paper  to  prevent  their  contents  from  drying 


Fig.  »49. — Platinum  needles. 

The  inoculation  of  the  tubes  is  performed  by  means  of  a  swab 
*^  a  platinum  needle.  The  method  of  making  and  sterilizing  the 
***tner  has  been  described  above  (page  280).  The  needle  consists 
*  a  platinum  wire,  3  to  4  inches  (7.5  to  10  cm.)  long,  which  is  in- 
^ted  into  the  end  of  a  glass  rod  6  to  8  inches  (15  to  20  cm.)  long, 
^oich  serves  as  a  handle.    The  free  end  of  the  wire  may  be  made 


388  COLLECTION   OV   PATHOLOGICAL  ICATEKIAL 

into  tHe  form  of  a  loop  or  it  may  be  simply  left  straight  (Fig.  149], 
according  to  whether  a  streak  or  a  stab  culture  is  to  be  made.  Befote 
use,  the  wire  should  be  sterilized  by  passing  it  back  and  forth  thnn^ 
a  Same  for  a  few  seconds. 

Tecbnic. — In  malung  a  culture  the  greatest  care  must  be  exs3> 
dsed  as  to  the  asepsis  and  the  avoidance  of  contamination.    T\t 
culture  tubes,  platinum  needles,  etc.,  are  arranged  upon  a  tovii 
within  easy  reach,  and  the  alcohol  lamp  is  lighted.    The  end  of  Ik 
culture  tube  containing  the  cotton  plug  is  first  passed  througli  ibt 
flame,  the  cotton  being  singed  so  as  to  destroy  any  germs  that:,  xntj 
be  deposited  upon  it  (Fig.  250).     The  culture  tube  is  held  bct-^vecu 
the  thumb  and  forefinger  of  the  left  Iiand,  with  the  mouth  <:>£  the 


Fig.  aso. — Singeing  the  cotton  stopper  of  a.  culture  tube  preparatory  to  its  inociil»- 


tube  pointing  downward,  if  it  contains  a  solid  medium,  so  as  to  f ' 
vent  the  entrance  of  any  dust.    A  pair  of  thumb  forceps,  after  b^*T 
passed  through  the  flame,  are  used  to  remove  the  cotton  plug  wh*^ 
is  then  transferred  to  the  left  hand  where  it  is  held  between  the  incJ^ 
and  second  fingers  while  the  culture  is  being  made. 

If  a  streak  culture  is  to  be  made,  a  looped  platinum  needle  •* 
sterilized  by  passing  it  through  the  flame,  including  the  portion  <» 
glass  handle  that  will  enter  the  tube,  and,  after  permitting  it  to  cool. 
the  tip  of  the  needle  is  dipped  into  the  secretion  or  pus — care  being 
taken  that  it  touches  nothing  else — and  is  passed  to  the  bottom  oE 
the  culture  tube  and  then  gently  withdrawn  over  the  culture  medium  ' 
so  as  to  spread  the  material  in  a  thin  streak  upon  its  sloping  surface 
(Fig.  251).     The  platinum  needle  is  again  passed  through  the  flame 


HETHOD  OF  INOCULATING   CULTURE  TUBES  289 

iod  is  then  laid  a^de.  The  tube  is  finally  closed  with  the  cotton 
plug,  first  singeing  the  cotton,  however,  in  the  flame  while  held  with 
the  thumb  forceps. 


Fto.  151. — Method  of  making  a  stretk  cultiue,    (Lcrvy  uid  Klemperer.) 


Fig.  351. — Showing  "a"  stab  culture,  and  "b"  smear  culture. 

AVhen  a  stab  culture  is  to  be  made,  a  straight  needle  is  employed 
*tead  of  a  looped  one.  The  technic  is  precisely  the  same  as  for  a 
^eak  culture  except  that  the  needle  is  inserted  straight  into  the 
'^Hure  medium  and  is  then  withdrawn. 


290  COLLECTION   OF   PATHOLOGICAL   MATEMAL 


\ 


A  smear  culture  with  a  swab  is  made  as  follows:  The  culture  tube 
and  tHe  tube  containing  the  sterile  swab  are  held  side  by  ^de  between 
the  thumb  and  the  index  dnger  of  the  left  hand.     The  cotton  ptu@ 
are  removed  with  sterile  forceps,  the  ends  of  the  tubes  and  the  ex- 
posed cotton  being  first  singed,  as  described  above.     The  cot-tsca 
plugs  are  held  between  the  ring  and  little  finger  and  the  ring  stJtA 
middle  fingers  of  the  left  hand,  while,  with  the  right  hand,  the  s.-^ 
is  withdrawn  from  its  tube,  dipped  in  the  secretion,  and  is  thetia 
serted  into  the  culture  tube  and  is  rubbed  thoroughly  over  the  siu 
of  the  culture  medium  (Fig.  253).     The  swab  is  then  replaced  i^^Br»il 
container  and  the  cotton  plug  is  singed  and  reinserted  into  the  m  ^  -^^i 
of  the  culture  tube. 


Fig.  iS3- — The  method  of  making  a 

When  a  number  of  cultures  are  being  made,  care  should  be  -t^*^*" 
to  immediately  number  each  tube  as  it  is  inoculated. 

COLLECTING   DISCHARGES   AND  SECRETIONS  FOR  B^^' 
TERIOLOGICAL  EXAMINATION 

When  in  the  absence  of  culture  tubes  or  for  other  reasons  it  . 
necessary  to  send  fluid  material  to  a  laboratory  for  bacteriologicT'-"^^ 
examination  it  is  best  collected  in  sterile  glass  pipettes  which  if^ 
then  hermetically  sealed.  This  insures  against  leakage  as  well  a-^ 
any  chance  of  contamination  during  transportation. 

Equipment. — A  number  of  glass  pipettes,  a  rubber  suction  bulb  01 
a  suction  syringe,  an  alcohol  lamp,  scissors,  and  suitable  specula  (Fig. 
254)  will  be  required. 


COLIfCTING  DISCHASGES  AT4D  SECRETIONS 


291 


The  pipettes  may  be  easily  made  from  thin  glass  tubing  of  an  ex- 
ternal diameter  of  about  ^  inch  (6  mm.).  The  center  of  a  piece  of 
sach  tubing  about  6  inches  (15  cm.)  long  is  heated  over  a  flame,  the 


FtG.  354.— Apparatus  for  collecting  discharges  for  bacteriological  exanunation.  i.  Alco- 
hol lampi  I,  scissors;  3,  sucttoD  syringe;  4,  pipettes. 

tube  continuaUy  being  turned  the  while,  until  the  glass  is  softened 
over  about  J-^  inch  (i  cm.)  of  space  (Fig.  255).  The  tubing  is  then 
removed  from  the  flame,  and,  while  the  glass  is  still  soft,  the  two  ends 
are  drawn  apart  so  that  the  softened  central  portion  is  stretched  out 


*^-  '55- — Heating  the  glass  tube  at 


a  Bunsen  Same.     (Asbtou.) 


"ito  a  capillary  tube  several  inches  long  Fig.  (256).  The  center  of 
^  capillary  tube  is  again  heated  in  the  flame  until  it  melts,  and,  by 
<"awiiig  upon  the  ends,  it  parts  in  the  center,  leaving  two  pipettes, 


292 


COLLECTION  OF  PATHOLOGICAL    liATERIAL 


\ 


each  with  one  sealed  end  (Fig.  257).     The  center  of  the  thick  po'T 
tions  of  each  of  these  pipettes  is  then  melted  in  the  same  way  and 
<irawn  out  into  a  capillary  tube  an  inch  (2.5  cm.)  or  more  long, 


e 


Tm- 


Fig.  256. — The  glass  tube  is  shown  drawn  out  at  its  center.     (Ashton.) 

that  we  have  as  a  result  two  pipettes  each  drawn  to  a  point  at  one  en 
wide  at  the  other,  and  between  the  two  ends  a  bulb  separated  fro 
the  wide  end  by  a  capillary  constriction  (Fig.  258).     The  pipettes  a 


iM 


Fig.  257. — Fusing  apart  the  center  of  the  drawn-out  portion  of  the  tube.     (Ashto 

sterilized,  after  inserting  a  piece  of  cotton  wool  in  the  wide  ends, 
passing  the  whole  tube  through  the  flame  until  it  is  hot  (Fig.  2 
but  not  so  hot  as  to  melt  the  glass  or  burn  the  cotton  plug. 


Fig.  258. — Making  a  bulbous  pipette  by  heating  the  thick  portion  and 

out  to  a  thin  tube.     (Ashton.) 

sterilized,  the  pipettes  may  be  kept  on  hand  ready  for  use  aim 
indefinitely. 

The  suction  for  drawing  up  secretions  into  the  pipettes  may 


it 


Fig.  259. — Sterilizing  the  interior  of  the  bulbous  portion  (b)  and  the  slender 

(a)  of  the  pipette;  (d)  plug  of  cotton.     (Ashton.) 

furnished  by  the  bulb  of  a  medicine  dropper,  or  by  attaching  a  pi 
of  rubber  tubing  to  the  pipette  and  applying  the  lips  or  a  small  s 
tion  syringe  to  the  free  end  of  the  rubber  tubing. 


COLLECTING    DISCHARGES    AND    SECRETIONS 


293 


Technic.^ — The  pipettes  are  arranged  near  at  hand  upon  a  towel, 
lnd  the  alcohol  lamp  is  lighted.     The  sealed  end  of  the  pipette  should 
3lt  off  with  scissors  (Fig.  260)  and  should  be  then  rounded  off 


j^fUt  o 


I  (a)  of  the  pipette  with 


***-     lOo.— Snipping  off  the  fused  point  of  the  slender  e 

^^t  scissors.     (AshtoB.) 

Pig.  j6i. — Rounding  off  the  rough  eiigea  of  thi? 

nooth  in  the  flame,  so  as  to  avoid  producing  any  injury  to  the  tissue 
^ig.  261). 

The  pipette  is  then  slowly  passed  through  the  flame  so  as  to 
exTlize  the  entire  outer  surface  of  the  tube  (Fig.  262).     When  the 


^*^  163. — ItemKtically  seuling  t 

by  fu5ing  it  in  the  flnme  a 


the  bulbous  portion  of  the  pipette 

(Ash  ton.) 


™oe  has  cooled,  the  rubber  nipple  or  tubing  is  placed  upon  the 
'^e  end,  and  the  small  end  is  inserted  in  the  discharge  or  secretion, 
"iiich  is  then  drawn  up  into  the  pipette  by  suction.     The  suction 


COLLECTION    OF   PATHOLOGICAL    UATERIAL 


bulb  is  then  removed,  and  the  small  end  of  the  pipette  is  sealed  by 
melting  it  in  the  flame.  The  constricted  portion  is  likewise  melted 
in  the  flame,  and  the  portion  of  the  pipette  containing  the  cotton, 
wool  is  removed,  and  the  remaining  end  of  the  pipette  is  sealed 
(Fig.  263).  In  this  way  the  discharge  is  hermetically  sealed  in  cn»^l1 
glass  tubes  (Fig.  264)  and  can  be  sent  to  any  distance  for  later  ba.c- 
teriologicai  examination.  Each  tube  as  it  is  prepared  should  l>e 
carefully  labeled  with  a  distinguishing  number. 


Fig.  164. — Showing  the  bulbous  portion  of  the  pipette  sealed  and  oontuning    tbc 

secretion.     (Ashton.) 

From  an  Abscess  Cavity. — Care  must  be  taken  that  no  arxti' 
septic  irrigating  fluid  is  used  before  the  discharge  is  secured.  -A 
specimen  should  be  obtained  free  from  blood,  if  possible.  To  avoid 
contamination,  the  first  portion  of  the  pus  should  be  allowed     to 


\ 


Fig.  »6s. — Instruments  for  obtaining  secretions  from  the  nose  for  bacteriologr^*-'^^ 
examination,  j,  Sterile  angular  pipette;  3,  alcohol  lamp;  3,  scissors;  4,  nasal  speculb^^  "*' 
5,  head  mirrof. 

escape ;  the  edges  of  the  incision  are  then  separated  while  the  pipe"*^  ** 
is  inserted  into  the  cavity,  and  a  specimen  is  withdrawn  from  ^  * 
depths. 

From  Serous  Cavities. — ^The  method  of  obtaining  fluid  frc^  *^ 
serous  cavities  is  described  under  exploratory  punctures  (Chap*^^^ 
XH). 

From   the   Nose  and   Accessory  Sinuses.     Equ^ment.- 
angular  pipette  will  be  required,  as  weU  as  an  alcohol  lamp,  scissors  r 


COLLECTING    DISCHARGES    AND    SECREHONS 


29s 


il  speculum,  suitable  illumination,  and  a  head  mirror  (Fig.  265). 
The  angular  pipette  may  be  made  by  taking  a  straight  pipette 
I  a.  long  capillary  tube,  heating  the  latter  at  a  distance  of  about 
ches  (7.5  cm.)  from  its  extremity  and,  when  soft,  bending  it  to 
tugle  of  135  degrees.  The  end  should  be  well  smoothed  off  in  a 
le  before  using. 

technic. — The  same  general  principles  as  outlined  above  are 
■wed.  The  patient  is  seated  as  for  an  anterior  rhinoscopic  exami- 
Dn  (page  366),  the  nasal  speculum  is  introduced,  and  the  light  is 


\r^«^ 


—Method  of  sucking  secretion  into  a 
(Ash  ton.) 


pipette  from   the   female   urethra. 


icted  so  that  the  interior  of  the  nose  can  be  clearly  observed, 
tip  of  the  pipette  is  then  inserted  until  it  comes  in  contact  with 
discharge,  care  being  taken  not  to  have  it  touch  the  mucous  mem- 
ae  or  the  vibrissa;  about  the  vestibule.  The  point  of  the  instru- 
ct is  moved  about  in  the  secretion  while  suction  is  exerted  and 
le  of  the  discharge  will  thus  be  withdrawn.  The  pipette  is  then 
loved,  sealed,  and  properly  labeled. 

From  the  Eyes.^The  technic  is  not  different  from  that  already 
icribed  for  collecting  discharges  from  other  regions,  and  no  special 
ms  of  pipettes  are  necessary.  Any  preliminary  cleansing  of  the 
s  should,  course,  be  avoided. 

From  the  Urethra.  Equipment. — -Pipettes  and  the  other  ap- 
alus  necessary  for  collecting  discharges  (see  Fig.  254)  will  be 
aired. 


acjfi  COLLECTION   OF   PATHOLOGICAL   ICATEKIAL 

Technic. — The  urine  should  not  be  voided  for  several  hours  prior 
to  obtaining  the  specimen.     The  urinary  meatus  is  first  exposed, 

and,  after  the  end  of  the  pipette  has  been  inserted  into  the  c&n&l,  tl&« 
secretion  is  sucked  into  the  pipette  (Fig.  366).  When  the  dischai^e 
is  scanty,  sufficient  may  be  obtained  by  e^ressing  the  pus  from  Cbt 
posterior  portion  of  the  urethra  by  drawing  the  finger  along  tkr 
urethra  from  behind  forward.  In  the  female  the  same  method  may 
be  employed  with  the  index  finger  in  the  vagina  (see  Fig.  1+4). 
When  a  specimen  has  been  obtained,  the  ends  of  the  pipette  xtR 
sealed  and  the  tube  is  properly  labeled. 


\ 


Fig.  j6 7.— Instruments  for  obtaining  secretions  from  the  vagins  for  1 
bgical  examination,     i,  Alcohol  lamp;  3,  sciuon;  3,  suctioaayiiiige; 4, sterile; 

5,  vaginal  speculum. 

From  the  Vagina.     Equqiment. — Pipettes,  a  suction  syrin^^t 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  and  a  vaginal  ^jcculuc:^^^^-^^ 
(Fig.  267)  will  be  required. 

Technic. — The  labia  are  separated  and  the  speculiun  is  introduces 
into  the  vagina,  so  that  the  posterior  cul-de-sac  is  exposed  to  v 
The  distal  end  of  the  pipette  is  then  carefully  introduced  into  thedi 
charge,  and  sufficient  secretion  for  the  purposes  of  the  examination 
withdrawn  by  means  of  suction.     The  pipette  is  then  removeC^^^^^^'^ ' 
both  ends  are  sealed,  and  the  specimen  is  properly  labeled. 

From   the  Uterus.     Equipment. — Pipettes,  a  suction  syiin^^ 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  vaginal  specula,  tw^-^ 
tenacula,  and  sponge  holders  (Fig.  268)  will  be  required. 

Technic. — The  speculum  is  introduced  into  the  vagina  and  thff 
cervix  is  well  exposed  to  view.  Any  vaginal  secretions  are  rwmovrf 
by  means  of  sponges  on  holders,  tenacula  are  inserted  in  the  anterior 


losterior  lips  of  the  cervix,  and  the  latter  is  drawn  well  down, 
lipette  is  then  inserted  into  the  cervical  canal,  care  being  taken 
3  push  it  into  the  uterus,  and  the  secretion  is  sucked  into  it. 
hen  withdrawn,  and  both  ends  are  sealed. 


cfcobob 


.  afiS.^-lnEtruments  for  collecting  discharges  from  the  uterus  fnr  bactci 
eiHimnalion.  {.Ashlon.)  i,  Pijicttes;  i,  suction  Ej-ringe;  i,  Simon'a  speculi 
calk;  5,  scissors;  6,  sponge  holder;  7.  alcohol  lamp. 

t  COLLECTION  OF  BLOOD  FOR  MICROSCOPICAL 
EXAMINATION 


lood   may  be   examined   microscopically  either  from   a   fresh 
nea  or  from  a  dried  smear.     The  former  procedure  is  suitable 


).  a6<). — Instrumi-nts  for  collecting  blood  foi 
iforceps;  3,  sp«ar-poi filed  needlcj.j,  cover-glasses; 


isslides;i,  alcohol  lamp. 


»hen  the  blood  can  be  examined  promptly — say  within  half  an 
A  smear  is  made  when  the  morphology  of  the  cellular  ele- 
i  is  to  be  studied  after  being  properly  stained. 


I 


298  COIXECTION   OF   PATHOLOGICAL   HATEBIAL 

Equipment. — Slides,  cover-glasses,  an  alcohol  lamp,  thumb  (ot- 
ceps,  and  a-spear-pointed  needle  or  a  lancet  (Fig.  269)  are  necessaiy. 
The  cover-glasses  and  slides  should  be  of  the  best  material  ITie 
former  should  be  very  thin  and  about  %  inch  (22  mm.)  aqnare. 
Both  should  be  absolutely  clean  and  free  from  grease;  the  c 
may  be  performed  after  the  method  described  on  page  279. 

lH>catioii  of  Puncture. — The  blood  may  be  withdrawn  from  a 
prick  in  the  lobe  of  the  ear  or  in  the  tip  of  the  finger.  The  former 
region  is  preferable,  however,  as  it  is  not  so  sensitive  as  the  finger, 
and  it  is  usually  cleaner,  so  that  the  chances  of  infection  are  less. 


Fig.  370. — Making  a  fresh  blood  smear.     First  step,  puncturing  tbe  tu. 


Furthermore,  when  the  puncture  is  made  in  the  ear,  the  operatioi»  ** 
removed  from  the  view  of  the  patient,  which  is  an  important  c****' 
sideration  in  the  case  of  childern  and  nervous  individuals. 

Aeepsis. — The  site  of  puncture  should  be  cleaned  by  first  rubb***^ 
it  with  a  wipe  wet  with  alcohol,  and  then  drying  it  with  ether.  X^**^ 
needle  or  lancet  is  sterilized  by  boiling  or  passing  it  through  a  flar***" 

Technic.  1.  Fresh  Specimen. — Care  should  be  taken  to  av*^"^ 
chilling  the  specimen  and  exposing  it  to  the  air  any  longer  thais-  *^ 
necessary;  accordingly,  everything  should  be  in  readiness  for  *-t** 
examination.  The  slide  is  warmed  over  the  alcohol  lamp  or  ^^ 
vigorously  rubbing  it  with  a  piece  of  linen,  and  is  then  laid  or»  * 
sterile  towel.  The  cover-glass  is  likewise  warmed  and  placed  near  ** 
hand.  The  lobeof  the  ear  is  grasped  between  the  thumb  and  f»r^ 
finger  of  the  left  hand  and  with  a  quick  stab  the  lowest  portion  of  'tbff 
lobe  is  punctured  (Fig.  270).     The  blood  should  be  allowed  to  flof 


COLLECTION  OF  BLOOD  FOK  MICKOSCOPICAL  EXAMINATION        299 

nlkout  pressure  or  ruibing,  as  these  maneuvers  produce  a  hyperemia 
aod  the  constituents  of  the  blood  may  be  changed  in  character  or 
the  blood  cells  may  be  defonned.  The  first  drop  is  wiped  away 
and  a  serond  drop  is  allowed  to  flow.  The  cover--gla*s  is  then  taken 
op  in  the  thumb  forceps  and  is  appUed  by  its  under  surface  to  the 


^c.  37i.^MBking  a  fresh  blood 


Second  step,  collecting  tbe  drop  o: 
glass. 


apes  of  the  drop  (Fig.  271),  but  is  not  allowed  to  touch  the  skin. 
The  cover-glass  is  then  gently  lowered  upon  the  warmed  slide  (Fig, 
*72)  and  the  drop  of  blood  is  thus  caused  to  spread  out  in  a  thin 
circular  layer  between  the  slide  and  the  cover-glass.  If  the  drop  is 
not  too  large,  the  blood  will  not  spread  beyond  the  margins  of  the 


^'    373. — MaluDg  a  fresh  blood  smear.     Third  step,  placing  the  cover-glass  holding 
the  blood  drop  on  a  slide. 

*^Ver-glass.     The  cover-glass  should  not  be  pressed  down  upon  the 
^e,  as  this  will  injure  the  corpuscles, 
a.  Dried  Specimen. — A  puncture  is  made  in  the  lobe  of  the  ear 
^  the  manner  described  above,  and,  after  the  first  drop  of  blood  has 


300  COLLECTION    OF   PATHOLOGICAL   llATEKIAL 

been  wiped  away,  the  second  drop  is  received  upon  a  slide  neu  at 
end.  As  quickly  as  possible  the  edge  of  another  slide  is  d^ 
into  the  drop  thus  collected  and  is  drawn  along  the  surface  of  U 
first  slide,  spreading  out  the  drop  in  a  broad  thin  anear  (Fig.  j/; 
To  be  of  any  value  the  smear  must  be  spread  out  evenly  and  thii^ 


A  second  method  is  to  employ  cover-glasses.     Two  covCT-gla. 
are  thoroughly  cleansed  and  are  placed  conveniently  at  hand.- 
ear  is  punctured  in  the  way  described  above  (see  Fig.  270),  and 
first  drop  of  blood  is  removed.     One  cover-glass  is  then  held  l»3 


—Making  a  dry  blood  smeat  with 
the  drop  1 


■glass. 


Second  step,  coUedi 


sides  between  the  thumb  and  forefinger  of  the  right  hand,  while  t) 
second  one  is  grasped  by  its  sharp  angles  in  the  fingers  of  the  b 
hand.  The  under  surface  of  the  first  cover  is  then  applied  to  the  ^i 
of  the  drop  of  blood  (Fig.  274),  and  is  quickly  placed  upon  the  seco 
glass,  with  the  angles  of  the  two  not  coinciding  (Fig.  275),  sothati 


COLLECTION  OF  BLOOD  FOR  MICROSCOPICAL  EXAMINATION 


301 


<!rop  spreads  out  by  its  own  weight  in  a  thin  film  between  the  two 
covers  (Fig.  276).  If  too  large  a  drop  is  taken,  the  upper  cover  will 
simply  float  around  upon  the  lower.  The  upper  cover  is  finally 
seked  between  the  thumb  and  forefinger  of  the  right  hand  and,  still 


375. — Making  a  dry  blood  s 
■atthod  o[  holding  the  two  cover-glas 
drop  upon  the  second  one. 


ir  with  two  c 
preparatory  t 


ver-glasses.     Third  step,  the 
placing  the  one  holding  the 


-     376, — Making   a   dry   blood  smear   with   two   cover-glasses.     Fourth   step, 
S    the  two  covers  with  their  surfaces  in  contact  and  the  drop  of  blood  spread 
Intina.   thin  layer  between  them. 


—  Making  a  dry  blood  smear  with   I 

the  method  of  drawing  the  two  ci 


Kifth  step,  showing 


Iwding  the  lower  cover  in  the  left  hand,  the  two  covers  are  drawn 
Ipart  in  the  same  plane  (Fig.  277).  Unless  too  small  a  drop  has 
J  oecD  taken,  this  is  readily  accomplished.  The  films  thus  obtained  are 
f  lien  allowed  to  dry,  and  later  they  may  be  fixed  and  properly  stained. 


302  COLLECTION   OF  PATHOLOGICAL  UATEBIAL 

It  is  always  well  to  make  three  or  four  of  these  smears,  assomeofthe 
films  may  be  poorly  spread,  or  may  be  broken  in  handling. 

THE  COLLECTION  OF  BLOOD  FOR  BACTERIOLOGICU. 
EXAMINATION 

The  best  method  of  securing  blood  for  culture  is  by  a  venous  punc- 
ture.   The  ordinary  method  of  obtaining  blood  through  a  piick  o£ 


the  ear  or  of  the  finger  is  worthless  for  bacteriological  purposes  on  a^ 
count  of  the  small  amount  of  blood  obtained  and  the  chances  of  coO' 
tamination,  especially  from  the  skin.  If  properly  performed,  a  ven- 
ous puncture  is  harmless  and  gives  the  patient  but  little  discomfort 


COLLECTION  OF  BLOOD  POR  BACTERIOLOGICAL  EXAMINATION    303 

£qvu|>ment. — A  glass  syringe  with  a  capacity  of  2^  drams 
^3,1:>«ut  10  C.C.))  a  moderately  large  needle  with  a  sharp  point,  broth 
3jacl  agar-agar  culture  tubes,  and  a  bandage  (Fig.  278)  are  necessary. 
Site  of  Puncture. — The  median  cephalic  or  median  basilic  vein  is 
f23ually  chosen  (see  Fig.  127),  but,  if  these  are  not  available,  theinter- 
xia.1  saphenous  vein  in  the  leg  or  any  of  the  smaller  veins  about  the 
-wrist  may  be  made  use  of. 


3So. — Method  of  transfixing  wall  of  vein  with  sewing  needle  to  steady  it  and  en- 
large its  Jumen  to  receive  an  aspirating  needle.      (Warbasse.) 

-  ,       -Asepsis. — The  skin  at  the  site  of  puncture  is  painted  with  iodin, 

^  liands  of  the  operator  are  as  carefully  sterilized  as  for  any  opera- 

**,  and  the  instruments  are  boiled. 

-        Anesthesia. — In  ordinary  cases  anesthesia  is  unnecessary.     K  it 

.      *iecessary  to  expose  the  vein  by  an  incision,  as  in  the  case  of  an 

^ividual  with  much  fat  or  whose  tissues  are  edematous,  infiltration 

^^tli  a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  procain  solution 

*^  etnployed. 

Technic. — A  bandage  is  wound  about  the  arm  between  the  seat  of 
PUncture  and  the  heart  with  sufficient  tension  to  produce  a  slight 
"^etn)us  stasis  and  cause  the  veins  to  stand  out  prominently,  but  with 


304  COLLECTION   OF  PATHOLOGICAL  MATERIAL 

not  enough  compression  to  cut  off  the  arterial  flow.     By  gently  forc- 
ing the  blood  along  toward  the  seat  of  constriction  by  means  of  the 
forefinger  or  thumb,  the  vein  may  be  made  to  stand  out  more  promi- 
nently.    In  stout  persons,  however,  it  may  be  necessary  to  expose 
the  vein  by  an  incision. 

The  needle  with  the  syringe  attached  is  then  passed  obliqiidy 
through  the  skin  into  the  vein  (Fig.  279),  and  the  blood  is  gently 
sucked  into  the  syringe  by  slowly  withdrawing  the  piston.  If  too 
great  an  amount  of  suction  is  exerted,  the  wall  of  the  vein  will  be 
forcibly  collapsed  and  will  act  as  a  valve  against  the  further  with- 
drawal of  blood.  About  i}i  drariis  (5  c.c.)  of  blood  may  be  takea 
from  a  child,  and  about  2}^^  drams  (10  c.c.)  from  an  adult.  The 
needle  is  then  withdrawn,  the  constriction  being  first  removed  from 
the  arm  to  avoid  subcutaneous  hemorrhage  from  the  punctured  veiii. 
Moderate  pressure  should  be  made  over  the  site  of  puncture  by  a. 
piece  of  gauze  held  in  place  by  the  patient  or  by  an  assistant  while 
the  culture  tubes  are  being  inoculated. 

Watson  {Journal  of  the  American  Medical  AssocicLtumy  July  29, 
191 1 )  describes  the  following  method  as  an  .aid  in  introducing  the 
needle  into  the  vein:  A  fine  sewing  needle  is  passed  through  the  skin, 
overlying  the  vein  so  as  to  transfix  the  anterior  wall  of  the  distended, 
vein  transversely  to  its  long  axis.  This  is  then  lifted  forward,  and 
the  vein  needle  is  introduced  into  the  vein  just  behind  the  transfixioix 
needle  (Fig.  280). 

During  the  inoculation  of  the  tubes  the  greatest  care  should  he 
taken  to  avoid  contamination;  the  needle  is  removed  from  the  syringe 
as  it  is  very  apt  to  be  contaminated  with  staphylococci  from  th^ 
skin,  no  matter  how  carefully  the  sterilization  may  have  been  carried 
out,  and  the  inoculation  is  made  through  the  sterile  end  of  th^ 
syringe.  In  doing  this,  the  same  technic  described  on  page  28  y 
should  be  followed.  Inoculations  are  usually  made  with  i61Il  (i  c.c-) 
of  blood  into  definite  quantities  of  media.  At  the  completion  of  th^ 
operation  the  seat  of  puncture  is  sealed  with  collodion. 

THE  COLLECTION  OF  SPUTUM 

Sputum  should  be  collected  in  absolutely  clean,  wide-mouth, 
ounce  (30  c.c.)  glass  bottles,  provided  with  a  water-tight  cork  (Fig. 
281),  so  that  there  can  be  no  leakage  during  transportation.  Suit- 
able bottles  may  be  obtained  from  any  laboratory  or  from  most  drug 
stores.     The  specimen  should  be  obtained  from  the  sputum  coughed 


,    COLLECTION    OF    ITRIIT 


Up  early  in  the  morning  before  any  food  has  been  taken,  and  it  should 
be  seen  that  the  material  is  couglted  up  from  the  lungs  and  that  it  is 
amply  an  accumulation  from  the  mouth  and  pharj'nx.  As  an 
precaution  against  contamination  from  par- 
of  food,  tobacco,  vomitus,  etc.,  the  mouth  and 
pharynx  should  first  be  thoroughly  rinsed  out.  When 
there  is  not  sufficient  sputum  from  one  collection, 
the  whole  amount  for  the  day,  or  for  twenty-four 
hours,  should  be  preserved.  The  specimen  thus 
collected  should  be  sent  to  the  laboratorj'  promptly, 
that  It  may  be  examined  in  as  fresh  a  condition  as 
possible. 

In  the  case  of  infants  and  young  children  it  may 
be  next  to  impossible  to  obtain  sputum  in  the  ordinary  *  " .  , 
way.  A  method  sometimes  employed  is  to  pass  a 
stomach  tube  into  the  esophagus  and  then  examine  the  mucus  found 
adhering  to  the  tube  upon  its  withdrawal.  Holt  advises  {Archives 
"! t nlcrnal  Medicine,  May  15,  1910)  the  following  method:  The  child 
is  made  to  cough  by  irritating  the  pharynx  with  a  bit  of  gauze  or 
cotton  held  in  the  jaws  of  an  artery  clamp,  and 
any  secretion  which  is  brought  into  view  is  then 
secured  on  this  swab. 

THE  COLLECTION  OF  URINE 

When  a  simple  chemical  examination  of  urine 
is  called  for,  it  Is  only  necessary  to  collect  the 
specimen  in  some  perfectly  clean  receptacle,  the 
tirst  portion  as  it  comes  from  the  meatus  being  re- 
ceived in  another  vessel  and  then  rejected;  but  if  a 
culture  is  to  be  made,  the  urine  must  be  obtained 
by  catheter  under  rigid  asepsis.  The  catheter  must 
be  boiled  and  the  hands,  of  the  operator  must  be 
sterilized  as  for  any  operation.  The  meatus  and 
surrounding  parts  are  then  washed  with  an  anti- 
septic solution,  and  the  catheter  is  gently  inserted 
into  the  bladder  without  touching  the  adjacent 
parts  (see  also  page  741).  The  first  portion  of  the 
unne  is  to  be  discarded,  and  then  from  iVi  to  a^^  drams  (about  5 
f  10  cc.)  are  collected  in  a  sterile  test-tube,  which  is  immediately 


P"'»  urine  collector. 


3o6  COLLECTION   OF   PATHOLOGICAL   MATERIAL 

When  it  is  desired  to  obtain  a  separate  specimen  from  each  Ud' 
ney,  the  ureters  may  be  catheterized  (see  page  759)  or  a  urmry 
separator  may  be  employed  (see  page  775). 

To  obtain  a  twenty-four-hour  specimen,  as,  for  example,  wh^*^ 
it  is  desired  to  determine  the  total  daily  amount  of  urine  secret^^ 
or  to  estimate  the  total  solids,  it  is  necessary  to  begin  and  end  witJ^ 
an  empty  bladder.  The  patient  is  therefore  instructed  to  empty  tt^-* 
bladder  at  a  certain  hour  and  to  discard  this  specimen.  All  tim^ 
urine  passed  for  the  following  twenty-foiu:  hours,  including  th»-^ 
voided  at  the  end  of  this  period,  is  saved  in  a  large  clean  bottli 
For  cases  of  incontinence,  a  retained  catheter  must  be  used  ( 
page  743).  or  else  a  rubber  urinal  devised  for  such  cases  may  1^^ 
employed. 

When  considerable  time  must  elapse  before  a  specimen  can  1^< 
examined,  some  preservative,  such  as  boric  acid  in  the  proportio:* 
of  I  grain  (0.065  g"^-)  ^  ^^.ch  ounce  (30  cc),  formalin  in  the  prc^ 
portion  of  i  drop  to  each  4  ounces  (i  20  c.c),  or  a  few  drops  of  chlorc^ 
form  to  each  4  ounces  (120  cc.)  may  be  added  to  the  specimen, 
cultures  or  inoculations  are  to  be  made,  preservatives  should 
avoided. 

In  the  case  of  infants  there  are  several  methods  for  collectirB-j 
urine.  With  male  infants,  for  an  ordinary  examination,  the  spedm^a 
may  be  collected  by  means  of  a  condom  which  is  secured  to  the  bod; 
by  adhesive  plaster,  and  into  which  the  penis  and  scrotum  are  passe<3 
or  a  bottle  may  be  employed,  in  the  neck  of  which  the  penis  is  placed 
Chapin  has  devised  a  urine  collector  (Fig.  282)  that  may  be  employ ^^ 
for  both  males  and  females.  A  method  sometimes  employed  wi 
females  is  to  place  absorbent  cotton  over  the  vulva,  and  after 
child  has  saturated  the  cotton,  to  express  the  urine  into  a  bottle; 
the  child  may  simply  be  placed  upon  a  rubber  sheet  from  which 
urine  is  collected  as  often  as  it  is  voided.  If  it  is  necessary  to  obt^i-i' 
an  uncontaminated  specimen,  catheterization  must  be  resorted  tOj 
employing  a  small  catheter  (9  to  11  French). 

THE  COLLECTION  OF  GASTRIC  CONTENTS 

For  a  microscopical  examination  of  the  stomach  contents  a  test 
meal  is  not  necessary,  the  vomitus  or  a  portion  removed  by  the 
stomach  tube  (see  page  529)  being  all  that  is  required.  The  spedmen 
should  be  received  in  a  clean  glass  receptacle. 

For  a  complete  chemical  examination  and  to  test  the  condition  oi 


REMOVAL     OF    SOLID    TISSUE    FOR    EXAMINAnON  307 

(be  stomach,  the  gastric  conteats  an  hour  after  a  test-meal  will  be 
required  (see  page  527). 

THE  COLLECTION  OF  FECES 

Ordinarily  a  small  amount  should  be  received  in  a  sterilized 
»<ie-mouth  glass  jar  and  the  examination  made  as  soon  as  possible. 

When  examining  for  the  ameba,  it  becomes  necessary  to  collect 
Ifc^  stools  in  a  clean  warm  receptacle  and  to  make  the  examination 
[ODiediately  upon  a  warmed  slide,  or  else  to  provide  some  means  for 
e^ping  the  specimen  warm  until  the  examination  can  be  con- 
'eniently  made. 


r:BE  REMOVAL  OF  A  FRAGMENT  OF  SOLID  TISSUE  FOR 
EXAMINATION 

The  excision  of  pieces  of   tissue  for  microscopical  examination 
la. 3-  be  required  in  cases  where  it  seems  probable  that  a  tumor  is 


Tic  a8j. — Instruments  tor  excaing  a  fragment  ol  solid  tissue  for  examination. 
►  Scajpel;  »,  curved  sharp-pointed  scissors;  3,  stin  punch;  4,  thumb  forceps;  5,  artery 
•*-««ips;  6,  retractors;  ;,  ne«U«  holder;  8,  No,  i  catgut;  q,  curved  cutting-edge  needles; 
1^,  sptdmcn  bottle. 

Malignant  but  where  the  clinical  signs  and  symptoms  are  not  pro- 
nounced enough  to  make  a  positive  diagnosis.  The  information  thus 
(Attained  is  especially  valuable  in  growths  of  recent  development,  as 
•D  these  the  evidence  of  malignancy  is  often  not  apparent  from  a 
Ero^examination. 

Instruments. — In  ordinaly  cases  there  will  be  required :  a  scalpel, 
sds6ors,  a  cutaneous  pimch,  artery  clamps,  plain  thumb  forceps. 


i 


308  COLLECTION    OF    PATHOLOGICAL    ICATERIAL 

mouse-toothed  forceps,  small  sharp  retractors,  a  needle  holder,  No.  2 
catgut  sutures,  curved  needles  with  cutting-edges,  and  a  wide-mouth 
clean  bottle  provided  with  a  water-tight  cork  and  containing  a  a 
per  cent,  aqueous  solution  of  formalin  (Fig.  283). 

For  regions  which  are  not  readily  accessible,  as,  for  example,  ib 
female  genitals,  volsellum  forceps  and  suitable  specula  are  necessar-^ 

For  collecting  material  from  the  interior  of  the  uterus,  curetUk.] 
instruments,  etc.,  will  be  required  (see  page  868). 


Fro.  384.— !■ 


(.\shton.) 


Asepsis. — The  instruments  are  boiled,  the  hands  of  the  operaK'^ 
are  sterilized,  and  the  site  of  operation  is  cleaned  as  for  any  operation'- 

Anesthesia. — As  a  rule,  local  anesthesia  by  infiltration  wilb  * 
0.2  per  cent,  solution  of  cocain  or  i  per  cent,  solution  of  proem  1" 
normal  salt  solution  is  sufficient.  For  skin  tumors,  freezing  with 
ethyl  chlorid  usually  suffices. 

Technic. — The  line  of  proposed  incision  is  first  anesthetized- 
Then,  with  the  tissues  well  retracted  so  as  to  expose  the  growth,  i 
wedge-shaped  piece  of  tissue  is  removed  by  means  of  a  scalpel  from 
the  portion  of  the  growth  where  the  pathological  changes  are  most 


REMOVAL   OF   SOLID   TISSUE   FOR   EXAMINATION 


309 


marked  or  the  tumor  is  nodular  (Fig.  284).  The  tissue  is  then  trans- 
ferred to  the  bottle  containing  the  4  per  cent  formalin  solution,  and  a 
proper  label  is  applied.  Any  hemorrhage  is  controlled,  the  incision 
is  closed,  and  a  sterile  dressing  is  finally  applied. 


Pig.    285. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch. 

A.  fragment  of  a  very  superficial  timior  or  of  a  skin  growth  may  be 
removed  by  means  of  a  pimch  if  desired.  The  skin  is  frozen  with 
ethyl  chlorid,  and  by  a  rotary  motion  the  punch  is  made  to  cut  out  a 
circular  piece  of  tissue  (Fig.  285).    The  punch  is  then  removed  and 


'^^*  286. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch.     Second 

step,  cutting  loose  the  base  of  the  section. 

^^  circular  core  is  seized  in  thumb  forceps  and  is  freed  from  its 
base  by  cutting  with  a  pair  of  curved  scissors  (Fig.  286).  The  pimch 
"^^y  be  employed  in  the  same  way,  if  desired,  for  removal  of  deeper 
seated  growths  after  first  exposing  the  tumor  by  an  incision. 


3IO  COLLECTION  OF    PATHOLOGICAL  MATERIAL 

When  tissue  is  removed  by  ciirettage  for  eicamination,  the  uterus 
should  be  scraped  systematically,  and,  as  soon  as  collected,  the  frag- 
ments thus  obtained  should  be  placed  in  a  bottle  containing  the 
preserving  fluid.  The  bottle  is  then  carefully  labeled.  Care  should 
be  taken  to  avoid  rough  handling  of  the  tissues  and  to  preserve  for 
examination  all  the  fragments  removed.  For  the  technic  of  curettage 
see  page  870. 


CHAPTER  XII 


EXPLORATORY  PUNCTURES 


^n  exploratory  puncture  consists  in  the  introduction  of  a  hollow 
«ile  attached  to  an  aspirating  syringe  into  a  diseased  region,  and  a 
(sequent  aspiration.  This  comparatively  simple  operation  may 
performed  for  the  purpose  of  determining  the  presence  or  absence 
fluid  in  any  particular  area,  or  to  obtain  a  specimen  of  fluid  for 
■  purpose  of  determining  its  character  by  subsequent  examination, 
addition,  exploratorj-  punctures  are  made  prior  to  therapeutic 
ictures  to  determine  the  exact  location  of  the  fluid  to  be  evacuated, 
deeply  seated  processes,  as  suppuration  and  fluctuating  tumors, 
ccessible  to  other  means  of  diagnosis,  this  method  of  exploration 
en  gives  most  valuable  information.  The  liver,  the  lungs,  the 
Ural  and  pericardial  cavities,  the  spinal  canal,  and  other  organs 
1  regions  diflScult  of  access  may  thus  be  tapped  and  explored  with 
nparative  safety. 

Wlien  fluid  is  detected,  a  quantity  sufficient  for  examination 
uld  be  withdrawn.  Frequently  by  a  gross  examination  of  the 
d  sufficient  information  may  be  obtained  as  to  its  character, 
th  the  naked  eye,  one  can  often  make  a  diagnosis  between  a  serous, 
ody,  or  purulent  fluid,  by  carefully  noting  the  color,  clearness,  and 
sistency  of  the  material  withdrawn.  Valuable  information  can 
■'vise  be  obtained  from  the  odor. 

For  more  definite  and  exact  information,  a  chemical,  microscopi- 
.  and  bacteriological  examination  will  be  necessary.  In  prepara- 
I  for  such  an  examination  a  few  drops  of  the  liquid  should  be 
scted  into  culture  tubes,  and  the  remainder  placed  in  a  sterilized 
t-tube,  previously  provided,  and  kept  in  readiness  for  this  purpose. 
times  the  aspirated  fluid  may  be  so  thick  that  only  a  few  flakes  or 
:cules  of  purulent  matter  can  be  obtained.  Such  material,  or  any 
gments  of  tissue  adhering  to  the  needle  point  should  be  carefully 
^sfcrred  to  a  glass  slide  for  later  microscopical  examination. 
'en  specimens  from  solid  growths  large  enough  for  microscopical 
aniination  may  at  times  be  obtained  by  rotating  the  needle  and 
oving  it  back  and  forth  sufficiently  to  detach  a  small  fragment, 
iiich  may  then  be  secured  by  producing  a  strong  vacuum  in  the 
finge  and  very  carefully  withdrawing  the  needle. 


i 


312  EXPLORATORY  PUNCTURES 

The  laboratory  examination  of  the  fluid,  the  technic  of  which  ma 
be  found  fully  described  in  manuals  on  clinical  laboratory  method 
should  be  made  along  the  following  lines  and  with  reference  to  tl 
special  points  mentioned. 

1.  Physical  Characteristics. — The  color,  odor,  clearness,  consis 
ency,  reaction,  coagulability,  and  specific  gravity  of  the  fluid,  an 
the  character  of  the  sediment  should  be  noted. 

2.  Chemical  examination  should  include  tests  for  albumin,  sera: 
globulin,  sugar,  bile,  urea,  blood,  pus,  etc. 

3.  Microscopical  examination  is  made  for  the  purpose  of  detectii 
the  presence  of  blood-corpuscles,  epithelial  cells,  hematoidin  ai 
cholesterin  crystals,  specific  tumor  cells  or  fragments,  necrotic  tissi 
ameba,  hydatid  hooklets,  ray  fungi,  etc. 

4.  Bacteriological  Examination. — Smear  preparations  are  ma 
and  examined  for  pathogenic  bacteria,  while  organisms  susceptil 
of  culture  are  inoculated  upon  suitable  media  and  later  examin 
microscopically.  Thus  organisms  may  be  indentified  which  are  i 
readily  detected  by  direct  examination. 

5.  Cyiodiagnosis. — By  this  is  understood  the  determination 
the  cause  of  an  effusion  from  the  relative  number  and  the  charac 
of  its  cellular  constituents. 

EXPLORATORY  PUNCTURE  OF  THE  PLEURA 

This  is  a  safe  and  simple  operation  employed  to  confirm  t 
diagnosis  of  a  pleural  eflfusion  or  to  as  certain  the  nature  of  the  flu 
The  danger  of  injuring  the  lung  and  producing  a  pneumothorax  nc 
not  be  considered  if  reasonable  care  be  observed  in  performing  1 
puncture. 

Apparatus. — Aspirating  needles  and  a  syringe  of  appropriate  s 
should  be  provided.  It  will  be  found  convenient  to  have  an  asso 
ment  of  needles  of  different  lengths  and  diameters.  They  shoi 
measure  in  length  23^2  inches  (6.5  cm.),  3  inches  (7.5  cm.),  3 
inches  (9  cm.),  and  4  inches  (10  cm.) ;  and  in  diameter  J^o  i^ch  (< 
mm.),  3'^5  inch  (i  mm.),  3-^8  ^^^  (i-S^im.),  and  K2  i^ch 
mm.).  For  ordinary  use  the  needle  should  be  at  least  3  inches  ( 
cm.)  long  and  about  }i^  inch  (i  mm.)  in  diameter,  so  that  it  t 
readily  give  passage  to  fluids  of  heavy  consistency. 

It  is  preferable  to  have  a  syringe  with  a  capacity  of  from  i  t 
drams  (4  to  8  c.c),  though  an  ordinary  hypodermic  syringe  may 
employed  if  the  large  needles  are  made  to  fit.     The  syringe  should 


EXPLORATORY   PUNCTURE   OP   THE   PLEURA  313 

capable  of  exerting  a  strong  suction,  and  the  joint  between  it  and  the 
needle  should  be  absolutely  air-tight.  The  best  form  of  syringe  con- 
sists of  a  solid  glass  barrel  and  a  tight-fitting  piston  provided  with  an 
asbestos  or  rubber  packing  (Fig.  287).  Such  a  syringe  is  simple  in 
mechanism,  easy  to  clean,  and  can  be  readily  sterilized  by  boiling. 
If  confirmation  of  the  diagnosis  of  fluid  is  to  be  immediately  followed 


Fic.  J87.— .\spirating  ayrin^  and  needles. 

by  its  evacuation,  the  aspirating  apparatus  of  Potain  or  Dieulafoy 
(see  page  340)  may  be  used  for  the  exploration,  thus  sparing  the 
patient  a  subseqeunt  operation. 

In  addition  there  should  be  provided  a  scalpel  and  a  cocain 

syringe  or  tube  of  ethyl  cMorid  for  anesthetizing  the  point  of  puncture. 

Sefore  making  a  puncture  the  syringe  should  always  be  tested 

by  withdrawing  the  piston  with  the  finger  held  over  the  end,  to  see  if 


ft 

D 

J 

■ 

'J 

'''*^'   388. — Apparatus  for  making  smears  and  cultures  from  fluids  removed  by  explora- 
tory puncture,     i.  Glass  slides;  2,  sterile  test-tube;  3,  culture  tubes. 

it  ■flail  exert  proper  suction.  The  syringe  should  hkewise  be  tested 
^'^th  tfie  needle  fitted  in  place.  After  use,  the  syringe  should  be 
'^en  apart,  and  both  it  and  the  needle  should  be  thoroughly  cleansed. 
**  guard  against  rusting,  the  lumen  of  the  needle  should  be  cleansed 
**"!  alcohol  and  ether  and  a  wire  of  suitable  size  inserted. 


314  EXPLORATORY  PUNCTURES 

In  cases  where  a  complete  chemical,  microscopical,  and  bac- 
teriological examination  is  desired,  sterilized  test-tubes  for  collecting 
and  transporting  the  material  aspirated,  glass  slides,  and  a^ai-agar 
culture  tubes  (Fig.  288)  should  be  at  hand. 

Location  of  the  Puncture. — No  fixed  rule  can  be  laid  down,  the 
point  chosen  for  the  puncture  depending  upon  the  phy^cal  ezamioa.- 
tion.  The  needle  should  enter  a  spot  where  there  is  dullness  and  ^q 
absence  of  respiratory  sounds,  voice,  and  fremitus,  and,  at  the  s&xxie 
time,  the  point  of  puncture  should  lie  well  below  the  upper  level  of 
the  effusion.     If  it  is  made  too  high,  the  point  of  the  needle  Qaay 


Fic,  aSg.— Shoeing  the  points  for  inserting  the  needle  in  exploratory 

the  pleura.     0.^rge  dots  represent  points  of  election.) 

lacerate  the  lung;  or,  if  too  low,  injury  to  the  diaphragm,  liver,  €^ 
spleen  may  result.    As  general  thing,  entrance  of  the  needle  i^! 
the  sixth  interspace  in  the  anterior  axillary  line,  in  the  sixth  or  seventl^ 
interspace  in  the  midaxillary  line,  or  the  eighth  interspace  below 
the  angle  of  the  scapula  will  reveal  the  presence  of  fluid  if  such  exists 
(Fig.  s89). 

Position  of  the  Patient. — If  too  weak  to  sit  upright,  the  patient 
may  lie  semirecumbent  for  a  lateral  puncture,  and  for  a  posterior 
puncture  in  a  lateral  prone  position,  with  the  body  curved  forward 
and  the  arm  of  the  affected  side  elevated  (Fig.  290).  In  uncom- 
plicated cases,  an  upright  sitting  posture  should  be  assumed,  with  the 


EXPLORATORY   PUNCTOTtE   OP   THE  PLEURA 


;  of  the  affected  side  elevated  for  the  purpose  of  widening  the 
rcostal  spaces  (Fig.  291). 


'10.  agi. — Exploratory  puncture  o[  the  pleura  vdth  the  patient  sitting  upnght. 


Asepsis. — The  strictest  regard  to  asepsis  must  be  observed  in  mak- 
any  exploratory  puncture,  otherwise  there  is  great  risk  of  in- 
ion  and  of  converting  a  simple  serous  exudate  into  a  purulent  one. 


3i6 


EXPLORATORY   PUNCTURES 


The  site  chosen  for  the  puncture  should  be  well  painted  with 
ture  of  iodin.  The  operator's  hands  should  also  be  there 
scrubbed,  followed  by  immersion  in  an  antiseptic  solution, 
needles,  syringes,  and  other  instruments  employed  are  ste 
by  boiling. 

Anesthesia. — Local  anesthesia  by  freezing  with  ethyl  chic 
salt  and  ice,  or  infiltrating  with  a  0.2  per  cent,  solution  of 
or  a  I  per  cent,  solution  of  procain,  will  be  all  that  is  require 
emplo3ang  cold  as  an  anesthetic,  if  the  patient  is  poorly  nou 
or  the  skin  is  edematous,  care  should  be  taken  not  to  freeze  tl: 
too  thoroughly,  on  account  of  the  danger  of  local  necrosis. 

Technic. — To  avoid  injury  to  the  upper  intercostal  arte 
needle  is  inserted  near  the  upper  margin  of  the  rib  which  fon 


Fig.  292.  Fig.  293. 

Fig.  292. — Showing  the  failure  to  withdraw  fluid  from  the  needle  being  ; 
too  far.     (After  Gumprecht) 

Fig.  293. — Showing  the  failure  to  withdraw  fluid  from  the  needle  entei 
pleura  at  too  high  a  level.     (After  Gumprecht.) 


lower  boundary  of  the  space  chosen  for  the  puncture.  The  p 
puncture  is  anesthetized  and  a  small  nick  is  made  in  the 
The  thumb  and  forefinger  of  the  left  hand  steady  the  tissues, 
the  needle  is  slowly  and  steadily  inserted  upward  and  inward 
its  point  enters  the  pleural  sac.  From  i  to  i  3^^  inches  (2. 
cm.)  under  ordinary  conditions,  and  more  in  fat  subjects  or  ir 
with  very  thick  pleura,  may  be  estimated  as  the  thickness 
thoracic  wall  through  which  the  needle  will  have  to  pass  bef< 
tering  the  pleural  cavity.  The  lack  of  resistance  and  the  m 
of  the  needle  will  demonstrate  its  entrance  into  a  cavity. 

If  fluid  is  not  immediately  obtained,  the  direction  of  the 
may  be  changed  slightly,  or  it  may  be  entirely  withdrawn  and  ii 


EXPLORATORY  PUNCTURE  OF  THE  LUNG 


317 


in  other  locations  before  the  attempt  is  abandoned.  Failure  to 
ft-ithdraw  fluid  may  be  due  to  the  needle  entering  the  lung  (Fig.  293) 
«r  to  the  fluid  being  encapsulated  in  a  space  not  entered  by  the 
aspirating  needle.  Again,  the  point  of  the  needle  may  become  buried 
ia  adhesions  or  a  thickened  pleura  (Fig,  294),  or  its  caliber  may  be- 
came blocked  by  coagulated  material.  In  addition  to  determining 
tile  presence  of  fluid,  any  unusual  thickness  or  density  of  the  pleura 
ma^y  be  appreciated  by  the  operator  through  the  amount  of  resist- 
ance offered  to  the  entrance  of  the  needle.  Upon  completion  of  the 
aspiration,  the  needle  is  quickly  with- 
dra-wn,  and  the  site  of  the  puncture  Is 
dosed  with  collodion  and  cotton. 

EXPLORATORY  PUNCTURE  OF  THE 
LUNG 


Previous  to  undertaking  any  opera- 
tl"%^e  procedure  upon  a  pulmonary  cavity, 
s^c:!)   as    a    tubercular,    bronchiectatic, 

^clxinococdc,  or  abscess  cavity,  an  ex-    

p'oratory  puncture  will  be  of  great  ser-    ^       1 

^''ci^,  not  only  as  an  aid  to  a  physical        ^'k'-  »54.— Showing  the  faU- 

'^^^mination  in  detecting  such  a  cavity,  "^^  f  7'^,^'""  f""  {^"  ^^' 
I  o  J 1   point   of    the    needle   becoming 

"^i  t  likewise  in  determining  its  size  and  imbedded  in  a  thickened  pleura. 
^"^^.ct  location,  and  its  character  by  an  (-Uter  Gumprecht.) 
^'^a.mination  of  the  fluid  withdrawn. 

There  is  considerable  risk  of  infecting  the  pleura  or  of  producing 
Cellulitis  if  aspiration  of  a  pulmonary  cavity  without  immediate 
■^■■^Inage  be  performed,  hence  the  exploratory  puncture  should  only 
"^  performed  on  the  opera  ting- table  with  the  patient  ready  to  be 
***«sthetized,  and  with  all  preparations  to  incise  and  drain  the  cavity 
'^mpleted  beforehand,  in  case  pus  is  obtained. 

Apparatus.— Exploring  needles  and  a  glass  aspirating  syringe,  a 
5*^pel,  ethyl  chlorid  or  a  cocain  syringe,  test  tubes,  and  culture 
tubes  will  be  required  (see  page  312), 

Location  of  the  Puncture. — This  will  depend  entirely  upon  the 
approximate  situation  of  the  cavity,  as  determined  by  the  physical 
signs. 

Asepsis. — The  instruments  should  be  boiled,  the  operator's  hands 
slerilized  as  for  any  operation,  and  the  site  of  puncture  painted  with 
iodin- 


1 


3l8  EXPLORATORY  PUNCTURES 

Anesthesia. — Infiltration  of  the  site  of  puncture  with  a  0.2  p 
cent,  solution  of  cocain  or  a  i  per  cent,  procain  solution,  or  freezu 
by  means  of  ethyl  chlorid  or  salt  and  ice  will  be  sufficient. 

Technic. — A  fair-sized  aspirating  needle,  at  least  4  inches  (10  or 
long,  will  be  required.  The  point  of  pimcture  is  anesthetized  a] 
the  skin  is  nicked  with  the  point  of  a  scalpel.  Then,  while  the  patie 
holds  the  breath  to  limit  movement  of  the  lungs,  the  needle  is  i 
serted  in  the  direction  of  the  supposed  cavity,  close  to  the  upp 
margin  of  the  rib,  in  the  same  manner  as  already  described  for  c 
ploratory  puncture  of  the  pleura  (page  316).  As  the  needle  is  slo^ 
advanced,  attempts  to  withdraw  fluid  are  made  at  successive  deptl 
The  abscess  may  be  superficial,  and  even  adherent  to  the  chest  w; 
where  it  can  be  easily  reached,  but  more  often  it  will  be  necessary 
insert  the  needle  a  distance  of  3  to  4  inches  (7.5  to  10  cm.)  before  t 
cavity  is  entered.  Failing  to  withdraw  pus,  the  needle  should 
removed  and  reinserted  at  another  spot.  It  may  even  be  necessa 
to  make  a  number  of  punctures  before  being  successful,  as  the  loca 
zation  of  a  pulmonary  cavity  is  at  times  a  most  difficult  matt( 
When  a  needle  enters  a  cavity,  some  idea  of  its  size  may  be  obtain 
from  the  range  of  motion  of  the  needle  and  from  the  quantity 
secretion  withdrawn,  though,  if  there  has  been  considerable  expc 
toration  previous  to  the  puncture,  little  or  no  fluid  will  be  obtaine 
even  though  the  needle  enter  a  cavity. 

When  pus  is  obtained,  the  needle  should  be  left  in  place  as 
guide  for  the  incision  and  drainage,  and,  while  the  patient  is  beii 
anesthetized,  great  care  should  be  taken  to  see  that  the  needle  is  n 
displaced. 

EXPLORATORY  PUNCTURE  OF  THE  PERICARDIUM 

An  exploratory  puncture  may  be  required  as  a  means  of  makin{ 
positive  diagnosis  of  the  presence  of  fluid  within  the  pericardiiun 
for  the  purpose  of  choosing  a  route  through  which  such  fluid  may 
reached  and  evacuated.  Puncture  of  the  pericardium  shotdd  not 
imdertaken  lightly,  and  the  dangers  of  injuring  the  internal  ma 
mary  vessels  or  pleura,  or  of  puncturing  the  thin-walled  auricles 
the  heart,  should  impress  upon  the  operator  the  necessity  of  eztrei 
care  when  performing  this  operation. 

Apparatus. — A  fine  exploring  needle  and  a  glass  aspirating  s)rrin 
a  scalpel,  ethyl  chlorid  or  a  cocain  syringe,  test-tubes,  and  culti 
tubes  will  be  required  (see  page  312). 


EXPLOR-\rORY  PUNCTUEE   OF   THE   PERICARDIUM 


319 


Location  of  the  Puncture. — To  eliminate  as  far  as  possible  the 

dangers  of  the  operation,  special  sites  for  puncture  have  been  rec- 
onainended,  as  follows:  (1)  In  the  fourth  or  fifth  interspace,  either 
dose  to  the  sternal  margin  or  i  inch  (2.5  cm.)  to  the  left  of  it.  Either 
of  these  points  will  avoid  the  internal  mammary  artery  and  veins 
which,  run  vertically  downward  '2  inch  (i  cm.)  from  the  ster- 
nal margin.  {2)  In  the  fifth  intercostal  space,  close  to  the  right  of 
the  stfiTiium.  It  is  claimed  that  from  this  point  tt  is  impossible  to 
wjure  the  heart,  but  this  avenue  of  approach  is  only  suitable  when  the 
Mnoiint  of  fluid  is  large.     (3)  Inserting  the  needle  directly  upward 


^-   *5j, — Points   for  puneturiog   the   pericardium.     The   dotted   tiue   indicates 
»™teiide(l  p«ricttrdial  wc.     The  course  of  the  internal  mammary  vessels  is  also  shown, 

M^  Dackward  close  to  the  costal  margin  in  the  space  between  the 
ensiorm  cartilage  and  the  seventh  costal  cartilage  on  the  left  side. 
W)  AMien  it  is  possible  to  outline  accurately  the  shape  of  the  peri- 
cardium and  locate  the  position  of  the  apex  beat  by  means  of  pulsa- 
DoQ  or  friction   rubs,   the  method   recommended  by   Curschman, 
Romberg,  Kussmaul,  and  others,  may  be  employed.    The  puncture 
is  made  in  the  fifth  or  sixth  left  interspace  outside  the  nipple  line 
between  the  apex  beat  and  the  outer  limit  of  dullness  (Fig,  295). 
The  selection  of  one  of  these  sites  over  the  others  will  be  made 
according  to  the  degree  of  distention  of  the  pericardium  and  its 
sb3ipe,  which  is  determined  by  outlining  the  area  of  dullness. 


3aO  EXPLORATORY   PUNCTTTRES 

Asepsis. — ^All  aseptic  precautions  must  be  observed.  Tfcm 
instruments  are  boiled  and  the  hands  of  the  operator  are  ptq>ai^ 
as  for  any  operation.  If  the  patient  be  a  male,  the  chest  should  t» 
shaved,  and,  in  any  case,  the  skin  must  be  sterilized  by  ptaintiag  mtiZ 
tincture  of  iodin  before  making  the  puncture. 

Anesthesia. — Infiltration  cocain  or  procain  anesthe^  or  free^nj 
with  ethyl  chlorid  will  suffice. 

Position  of  the  Patient. — ^The  operation  may  be  performed  witJ 
the  patient  semirecumbent  or  in  the  upright  sitting  posture. 

Tecbnic. — The  area  of  dullness  is  accurately  mapped  out  and  the 
point  for  puncture  thereby  determined  upon.  This  pKiint  is  anes- 
thetized and  a  small  nick  is  made  in  the  skin.    The  thumb  of  the  left 


Fig.  3g6. — Showing  the  method     f    nserting  the  needle  In  an  cTpIoratoi)  poKtuK 
of  the  pvricartlimn. 

hand  is  placed  as  a  guide  upon  the  lower  rib  bounding  the  intercostal 
space  selected,  and  the  needle  point  is  inserted  just  above  the  margU* 
of  the  rib  so  as  to  a^'oid  the  upper  intercostal  artery  (Fig.  296).  The 
needle  should  be  introduced  slowly  and  with  great  care  almost  in  lb* 
sagittal  plane  and  directed  slightly  toward  the  median  line.  En- 
trance into  the  pericardial  sac  is  recognized  when  resistance  to  the 
progress  of  the  needle  is  no  longer  encountered,  or  when  the  heart  i5 
felt  striking  against  the  needle  point.  The  needle  should  not  be 
inserted  a  greater  distance  than  i  inch  (2.5  cm.),  and,  if  fluid  bnft 
reached  at  this  depth  from  one  location,  the  other  points  of  entrant* 
above  mentioned  maj'  be  employed.  Should  the  fluid  obt^edl'* 
purulent  in  character,  prompt  incision  and  drainage  is  indicated 


EXPLORATORY  PUNCTURE   OP   THE   PERITONEAL   CAVITY      321 

"^^hen  the  purpose  of  the  puncture  is  accomplished,  the  needle  is 
slowly  withdrawn,  and  the  point  of  puncture  is  sealed  with  collodion 
axi.d   cotton. 


EXPLORATORY  PUNCTURE  OF  THE  PERITONEAL 

CAVITY 

Aspiration  of  small  quantities  of  peritoneal  fluid  and  examination 

of  tiie  specimen  obtained  may  be  required  to  determine  the  type  of  an 

effixsion  into  the  peritoneal  cavity — whether  it  be  serous,  inflam- 

mattery,  hemorrhagic,  or  chylous. 


Puxicture  of  solid  or  fluctuating 
masses  within  the  abdomen  may 
likewise  be  performed  as  a  diag- 
nostic measure,  but  the  dangers 
of    producing   serious   complica- 
tions through  puncture  of  the  in- 
testine or  other  organs,  or  from 
leakage  of  fluid,  especially  if  it 
^  purulent,  into  the  peritoneal 
cavity  stamps  it  as  an  unsafe 
Method    except   in    those  cases 
^here  the  tumor  is  in  close  rela- 
^^n     to    the    abdominal    wall. 
'^en  the  presence  of  pus  is  sus- 

P^^ted,  it  is  not  wise  to  perform 

^^    exploratory  puncture  unless 

^vei^thing  is  in  readiness  for  an 

^^ttiediate  operation.     The  com- 

P^rative  safety  of  an  exploratory 
^P^rotomy  and  the  fact  that   much  more  valuable  information 

^^^  be  thus  obtained  renders  this  the  operation  of  choice. 

Apparatus. — ^A  long  exploring  needle,  a  glass  aspirating  syringe, 
^^a.lpel,  a  cocain  syringe,  test-tubes,  etc.,  should  be  provided  (see 

P^8e3i2). 

Asepsis. — The  instruments  and  the  hands  of  the  operator  are 
^^t^lized  as  for  any  operation. 

Ilrocation  of  the  Puncture. — For  puncture  of  the  peritoneal  cavity, 
EK>int  midway  between  the  umbilicus  and  the  pubes  in  the  median 

^^^  or  a  point  at  the  junction  of  the  outer  and  middle  thirds  of  a  line 

■^^t^een  the  anterior  superior  spine  and  the  navel  should  be  chosen 
21 


Fig.  297. — Points  for  puncture  of  the 
peritoneal  cavity. 


322  EXPLORATORY  PUNCTURES 

for  the  insertion  of  the  needle.    Both  these  sites  will  escq)e  the 
deep  epigastric  artery  (Fig.  297). 

Position  of  the  Patient. — The  patient  either  sits  upright,  in  order 
to  allow  the  gravitation  of  the  fluid  to  the  lowest  level,  or  he  maybe 
propped  up  in  a  semireclining  position.  For  a  lateral  puncture  the 
patient  should  lie  upon  his  side. 

Anesthesia. — Infiltration  cocain  or  procain  anesthesia  or freezmg 
with  ethyl  chlorid  will  suffice. 

Technic. — The  point  chosen  for  the  puncture  is  anesthetized,  and 
a  small  nick  is  made  in  the  skin.  The  needle  is  iiiserted  directly  bad- 
ward  until  the  resistance  of  the  abdominal  wall  is  no  longer  felt  and 
the  point  of  the  needle  moves  freely  within  the  abdominal  cavity. 
Sufficient  fluid  is  withdrawn  for  examination,  and,  after  removal  of 
the  needle,  the  site  of  entrance  is  closed  with  a  thin  layer  of  collodioii 
and  cotton. 

EXPLORATORY  PUNCTURE  OF  THE  LIVER 

Exploration  of  the  liver  by  means  of  an  aspirating  needle  may  be 
required  for  the  purpose  of  making  a  positive  diagnosis  in  cases  of 
suspected  amebic  or  pyogenic  abscess,  or  hydatid  cyst.  Exploratoiy 
puncture  should  not  be  performed,  however,  unless  the  preparaticHis 
for  an  immediate  operation,  if  such  be  jiecessary,  are  completed 
beforehand,  for  no  matter  how  small  the  puncture  may  be,  leakage  of 
fluid  is  liable  to  occur  and  cause  serious  damage. 

Apparatus. — ^An  exploring  syringe,  needles,  a  scalpel,  test-tubes, 
etc.,  such  as  is  required  for  any  exploratory  puncture  (see  page  3i2)» 
should  be  provided. 

Location  of  the  Puncture. — This  will  depend  upon  the  symptoms 
and  physical  signs  in  each  individual  case.  If  at  any  one  point  there 
be  localized  pain,  tenderness  on  palpation,  peritoneal  crepitation,  or 
distinct  bulging,  such  spot  should  be  chosen  for  the  puncture,  b 
the  absence  of  signs  pointing  to  localization,  the  fact  that  most  liver 
abscesses  are  situated  in  the  upper  posterior  portion  of  the  right  lobe 
should  be  borne  in  mind  and  the  puncture  made  accordingly,  the 
needle  being  inserted  in  the  midaxillary  line  on  the  right  side  through 
the  ninth,  tenth,  or  eleventh  interspace,  or  below  the  angle  of  the 
scapula  through  the  tenth  interspace  (Fig.  298).  Puncture  may  also 
be  made  anteriorly  directly  into  the  area  of  liver  dullness  below  the 
line  of  the  pleura. 


EXPLORATORY    PTJNCTUKE    OF    THE    LIVER 


325 


Isepsis.— The  operation  is  performed  under  all  aseptic  precau- 
s  (see  page  315). 

^esthesia. — The  puncture  may  be  made  under  local  anesthesia, 
if  it  is  likely  that  a  number  of  punctures  will  be  necessary  and  aa 
ation  is  to  be  performed,  it  is  better  to  give  a  general  anesthetic 
ae  start 

Cechnic. — After  making  a  small  nick  in  the  skin  with  a  scalpel  at 
site  chosen  for  the  puncture,  the  needle  is  slowly  introduced 
ird  and  slightly  upward  to  its 
extent,  and  suction  is  attempted, 
luid  is  not  obtained,  the  needle  is 
ifly  withdrawn,  a  vacuum  being 
intained  in  the  syringe  in  the  mean- 
le,  so  as  to  withdraw  pus  in  case  I 
point  of  the  needle  has  previously 
ised  through  a  cavity  into  healthy  \ 
iUe.  Near  the  surface  of  the  liver 
■  direction  of  the  needle  is  alteied, 
i  it  is  inserted  again  in  a  different 
ne.  In  this  manner  a  large  area 
the  liver  may  be  explored  in  all 
xtioos  from  one  external  punc- 
e,  provided  care  is  exercised  not  to 
ire  the  pleura  and  lung  above,  or 
gall-bladder  and  intestines  below. 
!  needle  should  not  be  inserted  to 
[reater  depth  than  ^%  (9.5  cm.) 
ies  from  the  surface  of  the  body 
fear  of  injuring  the  inferior  vena 

I.  To  avoid  lacerating  the  liver,  the  exploring  needle  must  be 
»ed  to  move  freely  with  the  liver  as  it  rises  or  descends  during 
liration.  K  fluid  is  not  immediately  found,  a  number  of  punc- 
s  should  be  made  before  the  operation  is  abandoned.  Failure 
draw  pus  into  the  syringe  does  not  necessarily  signify  absence 
in  abscess,  for  at  rimes  the  material  forming  the  abscess  is  so 
i  that  it  will  not  pass  into  the  needle,  and  only  a  drop  or  two  of 
will  be  discovered  on  close  examination,  clinging  to  the  needle 
It 

Saving  located  an  abscess,  the  needle  should  be  left  in  situ  as  a 
le,  for  it  is  not  an  uncommon  experience,  when  pus  is  discovered 


E3CFL0RAT0RY  FUKCTUKES 


by  aspiration  and  the  needle  removed,  to  fail  to  locate  the  abscess  it  i 
subsequent  operation. 

EXPLORATORY  PUNCTURE  OF  THE  SPLEBH 

As  a  diagnostic  measure,  puncture  of  the  spleen  may  be  pofonud 
without  danger  if  the  oi^n  is  hard,  as  is  found  in  chronic  malam, 
but  in  infectious  diseases  with  a  large,  soft,  and  friable  ^een  it  is 
an  unjustifiable  procedure.  Laceration  of  the  capsule  followed  bf 
hemorrhage,  suppuration  in  the  spleen,  and  peritonitis  have  beet 
known  to  result.  Likewise  puncture  of  the  spleen  in  suspected  casa 
of  typhoid  fever  is  no  longer  warranted, 
!  we  have  other  methods  of  diif 
nosis,  such  as  Widal's  test,  wluch  ue 
both  safe  and  adequate.  When  flUctui- 
tion  has  been  demonstrated,  as  iiL 
splenic  abscess  or  hydatid  disease,  ex- 
amination of  the  fluid  obtained  by  »*- 
piration  may  give  conclusive  infomu- 
tion;  but  here  again,  as  in  exploratory 
punctures  of  the  liver  or  lungs,  prepan- 
tions  for  incision  and  drainage,  in  case 
such  should  be  necessary,  should  be 
completed  before  the  puncture  is  made 
Apparatus. — Exploring  needles,  i*^ 
aspirating  syringe,  and  other  instni.- 
ments  necessary  for  any  exploratco 
puncture  (see  page  312)  should  1>* 
pro\-ided. 

Location  of  Puncture.— The  spleen 
n  be  reached  by  inserting  the  nedl* 
through  the  tenth  intercostal  space  in  the  midaxillary  line  ontheleft 
side  (Fig.  2p9).  If  the  organ  is  markedly  enlarged,  some  point  be- 
low the  left  costal  margin,  determined  by  percussion  of  the  ¥'**"' 
may  be  chosen. 

Position  of  the  Patient. — The  patient  may  assume  other  the 
sitting  posture  with  the  left  arm  elevated  and  the  hand  on  theopp'>' 
site  shoulder,  or  the  recumbent  position,  depending  upon  whiw 
gives  the  most  read}-  access  to  the  region  of  operation. 

Asepsis. — The  same  as  for  an;-  exploratory  puncture  (see  p»? 
315)- 

Anesthesia.— Local  iniiltraliun  anesthesia  or  freezing  will  suffi* 


Fig.  399.— Point  for  puncturing 
the  splctn. 


EXPLORATORir  PUNCTCKE   or  THE  KIDNKYS  325 

Techttic. — ^A  fine  and  fairly  long  aspirating  needle  should  be 
employed.  The  patient  is  instructed  to  hold  his  breath,  to  lessen  the 
danger  of  lacerating  the  organ,  and  the  operator  makes  a  small  nick 
m  the  skin,  quickly  inserts  the  needle  at  the  chosen  site,  and  makes 
the  aspiration  with  as  littie  delay  as  possible.  The  needle  is  then 
withdrawn,  and  the  site  of  puncture  is  closed  with  a  thin  covering  of 
aiUodion  and  cotton. 

ESPLORATORY  PUNCTURE  OF  THE  KIDNEYS 

E^loratory  aspiration  may  be  employed  to  detect  collections  of 
pus  or  other  fluids  in  the  region  of  the  kidney.    An  exploratory 


Fio.  J03. — Showing  the  relations  of  the  kidneys  from  behind. 


"'cision,  however,  and  subsequent  aspiration  after  exposure  of  the 
"'^ss  is  a  far  more  satisfactory  method  of  diagnosis. 

^tparatus. — An  aspirating  syringe,  exploring  needles,  and  other 
apparatus  necessary  for  making  an  exploratory  puncture  (see  page 
3*2)  should  be  at  hand. 

Irftcation  of  the  Puncture. — The  needle  should  be  introduced  at  a 
P^mt  about  2  yi  inches  (6  cm.)  from  the  median  line,  to  avoid  the 
^«ctor  spins  muscles,  and  a  little  below  the  last  rib  on  the  left  side, 
^d,  on  the  right  side,  between  the  last  rib  and  the  crest  of  the  ilium. 

Position  of  Patient. — The  patient  may  sit  up,  with  the  back  bent 


326  EXPLORATORY  PUNCTURES 

forward)  or  he  may  lie  partly  upon  the  unaffected  side  and  partly  upon. 
the  abdomen,  with  the  body  bent  forward  in  a  curve. 

Asepsis. — The  usual  aseptic  precautions  are  to  be  observed  (see 
page  315). 

Anesthesia. — Local  infiltration  anesthesia  or  freezing  will  suffice- 
Technic. — ^A  long  fine  needle  should  be  employed.  After  nicking 
the  skin  with  a  scalpel  at  the  site  chosen  for  the  puncture,  the  needier 
is  slowly  introduced  forward  and  slightly  inward  toward  the  mediair 
line,  frequent  tests  at  aspiration  being  made  as  the  needle  is  advanced- 
When  fluid  is  discovered,  a  sumdent  quantity  for  diagnosis  is  with- 
drawn, and  the  site  of  puncture  is  sealed  with  a  cotton  and  collodion, 
dressing. 

EXPLORATORY  PUNCTURE  OF  JOINTS 

This  constitutes  a  most  valuable  aid  in  ascertaining  the  character' 
of  a  joint  effusion.     Therapeutic  puncture  of  joints  for  the  purpose 
of  injecting  fluids  in  the  treatment  of  tuberculous  synovitis  anct 
acute  infections  involving  joints  is  also  becoming  a  frequent  opera — 
tion.     Puncture  of  a  joint  is  not  difficult  if  the  joint  is  distoided- 
with  fluid.     Care  should  be  exercised  not  to  insert  the  needle  at  &^ 
point  where  blood-vessels  or  important  nerves  would  be  encountered, 
and  to  avoid  producing  any  injury  to  the  cartilage  of  the  joint,  I 
serious  complications  result. 

Apparatus. — Exploring   needles,   a  glass  aspirating  fringe, 
scalpel,  a  cocain  syringe,  etc.,  should  be  provided  (see  page  312). 

Asepsis. — Puncture   of   a  joint,   as  all  exploratorj'  punctures 
should  be  made  under  all  aseptic  precautions.    The  instruments 
are  to  be  sterilized  by  boiling,  the  operator's  hands  are  as  carefufly 
prepared  as  for  any  operation,  and  the  site  of  puncture  is  painted 
with  tincture  of  iodin. 

Anesthesia. — ^Local  infiltration  anesthesia  is  employed. 

Technic. — The  skin  over  the  site  of  pimcture  is  infiltrated  with  a 
0.2  per  cent,  solution  of  cocain  or  a  i  per  cenL  procain  solution  and 
the  deeper  tissues  down  to  the  joint  capsule  are  similarly  anesthe- 
tized. A  small  nick  is  then  made  in  the  skin  at  the  point  chosen  for 
insertion  of  the  needle,  and  the  needle  is  inserted  into  the  joint  in  the 
same  manner  as  for  any  exploration  puncture. 

The  sites  for  puncture  of  those  joints  to  which  the  method  is 
most  often  applied  are  as  follows: 

The  Shoulder- Joint.— Entrance  to  the  joint  best  effected  by 
introducing  the  needle  from  the  side  through  the  groove  between  the 


EXPLORATORY  PDNCTUBE   OF  JOINTS  327 

gcx^omion  process  and  the  head  of  the  humerus.  The  direction  of  the 
ne^sdle  should  be  somewhat  downward  and  backward  (Fig.  301),  if  it 
is  xxiserted  straight  in  from  the  side  it  is  apt  to  enter  the  subacromial 
ba.rsa. 

The  ElboW'-Joint. — ^Puncture  of  the  joint  may  be  made  from 
betund  or  from  the  outer  side. 

To  enter  the  joint  behind,  the  forearm  is  flexed  to  an  angle 
of  135  degrees,  and  the  needle  is  inserted  downward  and  forward 
behind  the  olecranon  (Fig.  302). 

To  puncture  the  joint  from  the  outer  side,  the  arm  is  flexed  and 
the  radial  head  is  identified  by  the  finger  as  the  forearm  is  rotated. 


'*^-    301. — Point    for    puncturing     the         Fig.  302. — Point     for     puncturing     the 
shoulder-joint.  elbow-joint. 

■^  **e  needle  is  then  inserted  into  the  joint  between  the  external  con- 
^^yle  of  the  humerus  and  the  head  of  the  radius. 

The  Wrist-Joint. — The  joint  is  best  entered  from  the  dorsal  sur- 
^^^,  inserting  the  needle  near  the  radius  between  the  tendons  of  the 
^tensor  indicis  and  the  extensor  longus  pollicis  at  the  level  of  a  Une 
J'^iHing  the  styloid  process  of  the  radius  and  that  of  the  ulna. 

The  Hip- Joint. — The  hip  may  be  readily  entered  by  theexploring 
*^®»c31e  from  in  front,  at  what  is  known  as  BUngner's  point,  or  from 
^«  side. 

Ulterior  puncture  is  performed  as  follows:  A  spot  is  chosen 
^'^d-way  on  a  line  joining  the  point  at  which  the  femoral  artery 
^^'lerges  from  under  Pouparf  s  ligament  and  the  tip  of  the  great  tro- 
^anter  (Fig.  303),  and,  with  the  femoral  artery  identified  by  the 


3*8  EXPLORATORY  PDNCTURES 

forefinger  of  the  left  hand  to  avoid  injuring  it,  the  needle  is  piulw 
directly  back  into  the  joint. 


Fio.  303. — Points  for  puncturing  the  hip-jnint  (modilied  from  Pds-Leniden). 


For  a  lateral  puncture  the  leg  should  be  slightly  adducted.  T 
needle  is  then  pushed  into  the  joint  toward  the  median  line  erf  t 
body  from  the  side  just  above  the  great  trochanter  (see  Fig.  303). 

The  Knee- Joint. — The  needle  may  be  inserted  into  either  side 
the  joint — but  preferably  in  the  outer  side — beneath  the  patella  ai 


Fig.  304. — Point  for  puncturing  the  knee-joEot. 

point  where  fluctuation  or  distention  is  most  in  evidence.  When  1 
swelling  is  more  marked  above  the  patella,  the  needle  may  be  int 
duced  from  above  downward  behind  the  bone  (Fig.  304),  the  ope 


SPINAL    OR   LUMBAR   PUNCTURE 


329 


tor's  left  hand  grasping  the  Joint  below  the  patella  and  forcing  the 
intraarticular  fluid  upward  into  the  suprapatellar  recess. 

The  Ankle-Joint. — To  avoid  injuring  the  vessels  and  nerves 
which  lie  opposite  the  middle  of  the  Joint,  the  needle  should  be  intro- 
duced from  in  front  midway  between  the  bundle  of  tendons  which 
pass  in  front  of  the  Joint  and  the  corresponding  malleolus.  On  the 
inner  side  the  needle  is  inserted  }-^  inch  (i  cm.)  above  the  malleolar 
process  in  a  direction  obliquely  outward  and  backward;  on  the  outer 
ade  the  needle  enters  54  of  an  inch  (2  cm.)  above  the  malleolar 
process  in  a  direction  obliquely  inward  and  backward. 


SPINAL  OR  LUMBAR  PUWCTTTRE 

Lumbar  puncture,  an  operation  first  proposed  by  Quincke  for 
the  withdrawal  of  cerebrospinal  fluid  from  the  spinal  canal,  has 
hoth    diagnostic     and     therapeutic  , 

value.  This  procedure  is  of  diag- 
nostic importance  in  cerebro-spinal 
lues,'  intracranial  hemorrhage, 
tumors  of  the  cord,  meningitis, 
poliomyelitis,  etc,  through  the  in- 
formation that  may  be  obtained  in  ■ 
^timatmg  the  pressure  of  the  cere- 
'*'tBpinal  fluid  and  determining  its 
•-^laiicteristics  by  physical,  chemical, 
*Ucroscopical,  and  bacteriological 
^*amination. 

Among  its  therapeutic  uses  is 
'*^s  employment  as  a  "decompressive 
*ficnt. "  in  cases  of  meningitis,  hy- 
***"oicphalus,  intracranial  tumors, 
'^febral  abscess,  uremia,  delirium  tremens,  etc.,  etc.  On  account 
***  the  continuity  of  the  spaces  in  the  brain  and  spinal  column, 
'^mporary  relief  of  intracranial  and  intraspinal  pressure  may  be 
**otained  in  the  above  cases  by  the  withdrawal  of  small  amounts 
^  fluid  from  the  spinal  canal.  Lumbar  puncture  should  be  em- 
ployed with  great  caution,  however,  in  cases  of  brain  tumor,  for 
*'*'Wen  death  may  follow  removal  of  a  large  amount  of  fluid,  the  in- 
'^'^sed  intracranial  tension  causing  the  medulla  to  be  forced  against 
">*  foramen  magnum  when  the  intraspinal  pressure  is  relieved.  In 
Cerebrospinal  meningitis,  drainage  by  lumbar  puncture  isof  ten  follow- 


1 


S$o 


EXPLORATORY  PUNCTDSZS 


ed  by  good  results,  as  not  only  is  the  pressure  upon  the  cord  and  ce^-^ 
bral  centers  lessened,  but  pus  is  withdrawn,  and  the  toxicity  of  tJta 
spinal  fluid  is  thereby  diminished. 

It  is  in  the  administration  of  antitetanic  serum  and  antisaiajK 
in  cerebrospinal  meningitis,  the  treatment  of  cerebral  syphilis,  kks.< 
the  production  of  spinal  anesthesia,  however,  that  lumbar  punctia..r 
finds  its  chief  therapeutic  applications. 


Fic.  306.— Stylet  needle  for  sinnal  puncture. 

Anatomy. — In  the  lumbar  portion  of  the  vertebral  colimm  t^* 
spinous  processes  do  not  project  downward  to  such  a  degree  as  i^ 
other  portions,  and  there  is  a  distinct  space  (about  %  inch  (23  mcx^' 
in  the  transverse  and  %  inch  (15  mm.)  in  the  vertical  diamet^s* 
between  the  vertebral  arches  Med  with  ligaments  through  whtct^ 


ffil 


ej 


Fig.  307. — Apparatus  for  spinal  puncture. 


^d 


y 

:th>4  chlorid  tube;  3,  i 


glass  graduate;  4,  hydrometer;  5,  sterile  teat-tube;  6,  culture  tubes. 

needle  may  be  readily  passed  into  the  spinal  canal  (Fig.  305.)  The 
spinal  cord  reaches  only  to  the  second  lumbar  vertebra,  so  if  the 
puncture  be  made  below  that  point,  and  the  introduction  of  the  needle 
be  carried  out  under  rigid  asepsis  the  operation  is  practically 
harmless. 


SPINAL   OR   LUMBAR   PUNCTURE 


33^ 


Xhe  Needle. — ^The  puncture  is  best  made  with  a  special  stylet 
needle  devised  for  tiie  purpose.  It  should  be  of  platinum  or  nickel, 
at  least  3^2  inches  (9  cm.)  long  and  about  3-25  of  an  inch  (i  mm.)  in 
diameter,  and  the  point  should  be  short  and  ground  almost  squarely 
across  (Fig.  306).  In  addition,  a  scalpel,  a  sterilized  graduated  test- 
tube,  culture  tubes,  and  an  ordinary  hydrometer  (Fig.  307)  will  be 
required.  When  it  is  desired  to  estimate  accurately  the  cerebrospinal 
pressure,  a  small  mercury  manometer  will  also  be  required. 

location  of  the  Puncture. — The  space  between  the  third  and 
lourth  or  that  between  the  fourth  and  fifth  lumbar  vertebra;  is 
usually  chosen  (Fig.  308),  though,  if  the  puncture  is  performed  for 
diagnostic  purposes,  it  may  be  made  lower — between  the  fifth  lirm- 
bar  and  first  sacral  vertebtie  in  order  to  withdraw  any  sediment  that 


Fig.  308.— Points  for  spinal  puncture. 


^V  be  present.  A  point  just  below  the  tip  of  the  spinous  process  of 
^  vertebra  forming  the  upper  boundary  of  the  chosen  interspace 
*  distance  of  about  J^  inch  (i  cm.)  to  one  side  of  the  median  line 
Elected  for  the  insertion  of  the  needle.     In  children,  however,  the 

T*l*ious  processes  being  short,  the  needle  may  be  inserted  in  the 

"tteciian  line. 

The  spinous  processes  may  be  readily  identified  by  counting 
uowq  from  the  seventh  cervical  vertebra,  unless  the  individual  be 
very  stout.  If,  however,  any  difficulty  is  experienced  in  locating 
this  vertebra,  the  landmarks  may  be  quickly  determined  by  passing 
a  Irunsverse  fine  between  the  highest  points  of  the  iliac  crests  with 
the  patient  standing  erect,  and  it  will  be  found  that  such  a  line  passes 


332 


EXPLORATORY   PUNCTURES 


through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra 
(Fig.  309). 

Position  of  the  Patient. — The  operation  may  be  performed  with 
the  patient  sitting  in  a  chair,  with  the  body  bent  well  forward  in  the 


Fig.  309. — Showing  the  method  of  locating  the  fourth  spinous  process  by 

line  through  the  highest  points  of  the  iliac  crests. 


Fig.  310. — Sitting  posture  for  spinal  puncture. 

form  of  a  curve  (Fig.  310),  so  as  to  widen  the  intervertebral  qwtces^ 
much  as  is  possible.  K  this  is  impracticable,  the  patient  may  lie  o0 
his  left  side  with  his  knees  drawn  up,  shoulders  forward,  and  bod/ 
bent  forward  in  an  arch  (Fig.  311). 


SPINAL   OR   LUMBAR   PUNCTURE  33 1 

TTie  Needle. — The  puncture  is  best  made  with  a  special  stylet 

tkcc<^^  devised  for  the  purpose.     It  should  be  of  platinum  or  nickel, 

a^t  l^ast  ijr^  inches  (9  cm.)  long  and  about  ^i^  of  an  inch  (i  mm.)  in 

^SLxnetei,  and  the  point  should  be  short  and  ground  almost  squarely 

3^cr'Oss  (Fig.  306).    In  addition,  a  scalpel,  a  sterilized  graduated  test- 

tuto^j  culture  tubes,  and  an  ordinary  hydrometer  (Fig.  307)  will  be 

Tec5>iircd.    When  it  is  desired  to  estimate  accurately  the  cerebrospinal 

pressure,  a  small  mercury  manometer  will  also  be  required. 

Xocation  of  the  Puncture. — The  space  between  the  third  and 
foxirth  or  that  between  the  fourth  and  fifth  lumbar  vertebrae  is 
\isually  chosen  (Fig.  308),  though,  if  the  puncture  is  performed  for 
diagnostic  purposes,  it  may  be  made  lower — between  the  fifth  lum- 
bar and  first  sacral  vertebrae  in  order  to  withdraw  any  sediment  that 


Fig.  308. — Points  for  spinal  puncture. 

^>^  be  present.    A  point  just  below  the  tip  of  the  spinous  process  of 

^    "Vertebra  forming  the  upper  boundary  of  the  chosen  interspace 

^   distance  of  about  J^  inch  (i  cm.)  to  one  side  of  the  median  line 

^^lected  for  the  insertion  of  the  needle.    In  children,  however,  the 

^^^cus  processes  being  short,  the  needle  may  be  inserted  in  the 

^^ian  Une. 

The  spinous  processes  may  be  readily  identified  by  counting 

^"^^n  from  the  seventh  cervical  vertebra,  unless  the  individual  be 

^^^  stout.     If,  however,  any  dif&culty  is  experienced  in  locating 

^^^  vertebra,  the  landmarks  may  be  quickly  determined  by  passing 

^J*ansverse  line  between  the  highest  points  of  the  iliac  crests  with 

^^^  patient  standing  erect,  and  it  will  be  found  that  such  a  line  passes 


332 


EXPLORATORY   PUNCTURES 


through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  ve 
(Fig.  309). 

Position  of  the  Patient. — The  operation  may  be  peiformei 
the  patient  sitting  in  a  chair,  with  the  body  bent  well  forward 


Fig.  309. — Showing  the  method  of  locating  the  fourth  spinous  process  by  pi 

line  through  the  highest  points  of  the  iliac  crests. 


Fig.  310. — Sitting  posture  for  spinal  puncture, 

form  of  a  curve  (Fig.  310),  so  as  to  widen  the  intervertebral  spj 
much  as  is  possible.  K  this  is  impracticable,  the  patient  may 
his  left  side  with  his  knees  drawn  up,  shoulders  forward,  anc 
bent  forward  in  an  arch  (Fig.  311). 


SPINAL    OR    LUMBAR    PUNCTURE 


333 


A8ep8is.^The  ate  for  the  puncture  should  be  painted  with 
iodin,  and  thorough  asepsis  must  be  observed  during  the  entire 
operation.  The  needle  should  be  boiled  and  the  operator's  bands 
should  be  properly  sterilized. 


Flc,  311. — Lateral  position  for  spinal  puncture. 

A-nesthesia. — With  children  general  anesthesia  may  be  necessary. 
In  other  cases,  local  anesthesia  with  a  o.j  per  cent,  solution  of  cocain 
or  a  t  per  cent,  procain  solution,  or  by  freezing,  as  for  any  puncture, 
^1  answer  all  purposes. 


Fig.  313. — Spinal    puncture.    Second 
Blep,  inserting  the  needle. 

Technic. — To  avoid  contaminating  the  needle  by  the  bacteria 

nl  the  skin  as  well  as  to  make  the  insertion  of  the  rather  blunt  needle 
easier,  a  puncture  should  be  made  with  a  scalpel  through  the  skin  at 
the  chosen  spot  (Fig.3i2).  The  operator's  left  thumb  or  index  finger 
is  then  placed  between  the  two  spinous  processes  as  a  guide,  and  the 


334  EXPLORATORY  PUNCTURES 

point  of  the  needle  is  inserted  on  the  same  level  as  the  finger  about  ^ 
inch  (i  cm.)  from  the  median  line,  in  an  ui)ward  and  inward  direction 
(Fig.  313),  until  it  enters  the  spinal  canal.  In  a  child  this  will  usu- 
ally occur  at  a  depth  of  from  ^^  to  i  }^  inches  (about  2  to  4  cm.) 
and  in  an  adult  from  2 3-^  to  3  inches  (about  6  to  7.5  cm*).  If  the 
needle  strikes  bone,  it  should  be  sUghtly  withdrawn  and  then  leb- 
serted,  its  direction  being  changed  somewhat. 

As  soon  as  the  canal  is  entered,  the  stylet  is  withdrawn,  and  the 
fluid,  as  it  oozes  from  the  needle  drop  by  drop,  is  collected  in  a  sterik 
test-tube  (Fig.  314).  The  first  few  drops  are  usually  blood  stained, 
and,  if  so,  they  should  be  discarded.  Not  more  than  i^  drams 
(about  5  CO.)  of  fluid  should  be  withdrawn  from  the  spinal  canal  of  a 


Fig.  314. — Spinal  puncture.    Third  step,  collecting  the  cerebrospinal  fluid. 

child,  nor  more  than  }^i  ounce  (15  c.c.)  from  an  adult,  at  one  tim^ 
for  diagnostic  purposes.  When,  however,  the  puncture  is  performed 
to  relieve  intracranial  pressure,  from  i  ounce  to  i}^i  oimce  (30*0 
45  c.c.)  of  fluid  may  be  removed,  according  to  the  tension,  and  even 
more  if  no  ill  effects  are  observed.  Withdrawal  of  too  much  &^^ 
may  cause  dizziness,  pallor,  sweating,  and  vomiting  and  later  a 
sharp  headache.  A  dry  puncture  is  sometimes  encountered  and  may 
be  due  to  the  needle  not  entering  the  canal,  to  its  being  plugged 
by  blood  clot,  or  from  the  fluid  being  too  thick  to  flow  througb  its 
lumen. 

At  the  completion  of  the  operation,  the  site  of  puncture  is  seaW 
with  collodion  and  cotton  and  the  patient  is  kept  recumbent  in  bed 
for  24  hours. 


SPINAL   OR   LITMBAE   PUNCTURE  335 

Nonnal  Cerebrospinal  Fluid  and  its  Pathological  Variations. 
>nnal]y,  the  cerebrospinal  fluid  escapes  slowly,  while  in  certain 
iCased  conditions  with  increased  pressure,  as  meningitis,  tumor  of 
e  brcdn,  uremia,  paresis,  hydrocephalus,  etc.,  and  in  certain  infec- 
)us  diseases,  it  may  spurt  out.  The  pressure  may  be  roughly 
timated  by  the  strength  of  the  flow  from  the  needle,  a  strong  spurt 

fluid  indicating  an  increased  amount  of  pressure,  and  very  slow- 
■ming  drops  the  reverse.  It  may  be  more  accurately  measured  by 
taching  to  the  needle  a  small  mercury  manometer  by  means  of  a 
lali  rubber  tube.  8  to  16  inches  (20  to  40  cm.)  long,  filled  with  a  i 
Tcent.  solution  of  carbolic  acid.  This,  of  course,  is  to  be  done  he- 
re any  of  the  fluid  is  permitted  to  escape.  According  to  Sahli,  the 
'nnai  dural  pressure  in  the  horizontal  position  is  60  to  100  mm.  of 
Iter  (5  to  7.3  mm.  of  mercury),  and  3oo  to  800  mm.  of  water  {15 

60  mm.  of  mercury)  in  certain  pathological  conditions. 
Nonnal  cerebrospinal  fluid  is  colorless  and  water -like  in  clearness, 
■es  not  change  color  on  standing,  and  shows  no  sediment.  It  Is 
irile  and  gives  a  negative  Wassermann  reaction.  It  has  an  al- 
Jine  reaction,  a  specific  gravity  of  from  1001  to  1008,  a  freezing 
int  of  —56°  to— 58°,  and  exists  in  the  spinal  canal  In  but  small 
lounts,  varying  between  }--i  and  2  ounces  (15  and  6oc.c.)  in  adults 
din  infants  between  2^2  and  5  drams  {10  and  20  c.c).  The  total 
antity  in  the  ventricles  and  subarachnoid  space  is  estimated  by 
lerent  observers  as  anywhere  from  2  to  5  ounces  (60  to  150  c.c). 

contains  traces  of  protein  (0.013  to  0.07  per  cent.),  the  greater 
^portion  of  which  is  globulin,  some  chlorides  (0.7  per  cent.)  a 
ppcr-reducing  body  claimed  to  be  glucose  (0.07  to  o.i  per  cent.), 
d  traces  of  urea  (0.035  to  0.04  per  cent.).  Some  endothelial  cells 
d  small  lymphocytes  are  present  in  the  fluid,  but  these  cellular 
^ents  normally  do  not  exceed  5  per  cubic,  mm. 

Under  pathological  conditions  the  fluid  may  undergo  marked 
edifications.  In  certain  infectious  diseases,  intracranial  tumor, 
iningitis,  hydrocephalus,  general  paresis,  etc.,  the  amount  may  be 
2atly  increased.  In  nephritis  and  uremia  the  urea  is  largely  in- 
aased  and  there  may  be  a  rise  in  the  chlorides;  in  hydrocephalus 
ere  may  likewise  be  an  increase  in  the  urea.  Sugar  is  increased  in 
abetes,  but  is  usually  absent  in  cases  of  meningitis.  In  apoplexy, 
eningitis,  paresis,  hydrocephalus,  and  brain  tumor,  the  quantity 

globulin  may  be  markedly  increased.  Both  the  globulin  content 
id  the  cell  count  are  increased  in  cerebrospinal  syphilis,  but  by  the 
action  to  the  colloidal  gold  test  it  is  possible  to  differentiate  be- 


336  EXPLORATORY  PUNCTURES 

tween  general  paresis  and  other  forms  of  syphilis.  A  bloody  01 
blood-stained  fluid  will  be  found  in  intrameningeal  cranial  hemor 
rhages  and  in  injuries  of  the  skull  extending  through  the  dura,  batii 
extradural  injuries  the  fluid  will  be  clear;  bloody  fluid  may  ab 
occur  in  meningitis.  In  jaundice  it  may  be  greenish-ydlow  ii 
color.  A  cloudy,  purulent  fluid  indicates  inflammation  of  th 
meninges,  as  does  a  rise  in  the  specific  gravity.  In  tuberculous  ma 
ingitis,  however,  the  fluid  is  clear  and  limpid.  The  cell  count  bii 
creased  in  all  inflammations  of  the  meninges,  but  the  character  ( 
the  cells  will  differ  according  to  the  type  of  inflammation.  P6I3 
nuclear  cells  predominate  in  acute  inflammations,  while,  as  a  ruli 
in  the  subacute  and  chronic  forms  lymphocytes  are  found.  It 
only  possible  to  determine  the  specific  form  of  infection  by  bacteri( 
logical  examination.  Identification  of  the  diplococcus  intracellt 
laris,  pneumococcus,  streptococcus,  staphylococcus,  bacillus  < 
influenza,  or  tubercle  bacilli  will  definitely  settle  the  nature  oftl 
infection. 

Lumbar  Puncture  as  a  Means  of  Administering  Therapei 
tic  Sera. — When  lumbar  puncture  is  employed  for  the  purpose  of  ai 
ministering  therapeutic  sera  in  tetanus  and  cerebrospinal  menii 
gitis,  a  fairly  large  syringe,  one  with  a  capacity  of  at  least  i  cum 
(30  c.c),  is  required  in  addition  to  the  other  instruments  necessai 
for  spinal  puncture. 

Meningococcus  Meningitis. — The  value  of  the  administradc 
of  antimeningococcus  serum  intraspinously  in  meningococci 
meningitis  is  now  generally  recognized.  The  early  administradc 
of  the  serum  is  of  prime  importance  and  in  suspected  cases,  if  tl 
cerebro-spinal  fluid  drawn  by  the  first  puncture  shows  any  tu 
bidity,  it  is  advisable  to  give  the  serum  at  once  without  waiting  fi 
the  results  of  a  bacteriological  examination.  Much  valuable  timem? 
be  thus  saved  without  doing  the  patient  any  harm.  One  to  i] 
ounces  (30  to  45  c.c.)  of  serum  are  injected  into  the  third  or  fourl 
lumbar  space  after  a  like  amount  of  cerebrospinal  fluid  has  been  eva 
uated.  Subsequent  injections  are  given  at  intervals  of  twelve  1 
twenty-four  hours,  according  to  the  severity  of  the  case,  for  three  or  foi 
days.  If  after  a  lapse  of  several  days  the  symptoms  return,  anoth< 
series  of  injections  is  given.  In  place  of  a  syringe,  a  glass  funn 
or  small  glass  reservoir  holding  about  2  oimces  (60  c.c.)  attached  1 
the  needle  by  rubber  tubing  may  be  employed,  the  serum  bcii 
allowed  to  flow  into  the  subarachnoid  space  by  gravity  (Fig.  31S 


SPINAL    OR    LUMBAR    PUNCTURE 


337 


It  takes  usually  from  lo  to  15  minutes  to  administer  the  required 

amount  in  this  manner. 

Tetanus. — Antitetanic    serum    may   be  given  intramuscularly 

or  intravenously,  but  the  best  results  seem  to  follow  large  doses 

given  by  intraspinous  injection — 16000  units  of  high  potency  serum 
may  be  administered  at  a  dose  and  repeated  at  24  hours  intervals 
tor  several  days.  The  puncture  is  made  in  the  manner  described 
above,  and  a  quantity  of  cerebrospinal  fluid  equal  to  the  amount  of 
serum  to  be  injected  is  allowed  to  escape  from  the  canal ;  the  serum  is 
then  warmed  and  is  allowed  to  flow  by  gravity  or  is  slowly  injected 
through  the  same  needle  employed  for  the  puncture. 

Rogers  {Journal  of  the  American  Medical  Association,  July  i, 
1905),  injects  2  H  to  5  drams  (10  to  20  c.c.)  of  antitetanic  serum  into 


Fio,  315, — ^Gravily  method  of  ad  ministering  serum  by  lumbar  punctur 


"le  Derves  of  the  cauda  equina,  as  well  as  subcutaneously  in  the 
"sigbborhood  of  the  wound,  intravenously,  and  into  the  nerves  of 
"le  brachial  plexus  if  the  site  of  infection  is  upon  the  upper  extremity, 
^^  bto  the  sciatic  and  anterior  crural  nerves  if  the  wound  is  in  the 
lower  extremity.  In  making  the  spinal  injection  the  needle  is  in- 
*fled  in  the  space  between  the  second  and  third  lumbar  vertebrje, 
^  as  to  strike  the  cauda  equina,  and  is  manipulated  back  and  forth 
^ith  the  object  of  wounding  some  of  the  nerves,  which  is  mani- 
■ttlfti  by  twitching  of  the  legs;  2  ,'^  to  5  drams  (10  to  20  c.c.)  of 
*nira  are  then  injected  into  and  around  these  injured  nerves. 

PoliomyelitiB. — Favorable  reports  have  followed  the  treatment 
"f  epidemic  poliomyelitis  with  a  serum  prepared  by  Nuzum  and 
Wiiiy.    There  is  some  difiference  of  opinion,  however,  as  to  its 


338  EXPLORATORY  PUNCTURES 

value  and  further  trial  will  be  necessary  before  this  can  Im 
mined.  When  administered  early,  it  is  apparently  cap 
preventing  and  arresting  paralysis,  but  is  of  questionable  1 
clearing  up  paralysis  already  present. 

Cerebral  Syphilis. — Recently,  Swift  and  Ellis  of  the  Roc 
Institute  have  developed  a  new  line  of  treatment  for  syphiU 
central  nervous  system,  employing  intraspinous  injections 
varsanized  (arsphenaminized)  serum.  The  results  in  the 
far  reported  have  been  most  encouraging,  and  it  would  seem 
some  cases  of  tabes  and  paresis  a  cure  may  be  effected  and 
well-marked  cases  the  disease  may  be  checked  by  the  intn 
serum  treatment. 

The  technic  is  briefly  as  follows;  salvarsan  (arsphem 
given  intravenously,  usually  in  a  maximum  dose,  and  an  he 
10  drams  (40  c.  c.)  of  blood  are  withdrawn  from  the  patient  b} 
puncture  into  a  bottle-shaped  centrifuge  tube.  This  is  all( 
coagulate,  after  which  it  is  centrifuged.  The  next  day  ^ 
(12  C.C.)  of  the  resulting  clear  senmi  are  removed. by  mei 
pipette,  mixed  with  5  drams  (18  c.c.)  of  sterile  normal  salt  s 
and  heated  for  half  an  hour  at  a  temperature  of  132®  F,  ( 
This  serum  is  then  injected  by  lumbar  pimcture,  after  withdi 
small  quantity  of  the  cerebrospinal  fluid. 


CHAPTER  Xm 

ASPIRATIONS 

ASPIRATION  OF  THE  PLEURAL  CAVITY 

Paracentesis  thoracis,  also  spoken  of  as  thoracentesis  and  pleuro- 
t^«3tesis,  consists  in  The  evacuation  of  fluid  from  the  pleural  cavities 
03-'  means  of  a  hollow  needle  or  trocar  to  which  an  aspirator  is 
at  tached. 

Indications. — When  the  presence  of  fluid  has  been  made  out  by 
tfc»^  physical  signs  and  the  diagnosis  verified  by  an  exploratory  punc- 
t»-ire,  thoracentesis  is  indicated  in  sero-fibrinous  effusions  under  the 
fol  lotting  conditions: 

1.  When  the  fluid  is  sufficient  to  produce  dyspnea,  cyanosis,  and 
cardiac  weakness. 

2.  In  very  large  effusions  whether  or  not  pressure  symptoms 
^'*~^  present,  especially  if  bilateral. 

3.  WTien  the  heart  is  displaced  by  the  presence  of  fluid. 

4.  When  the  fluid  is  not  absorbed  within  a  week  or  ten  days  in 
SF*ite  of  medical  treatment. 

The  advantages  of  early  aspiration  are  that  adhesions  may  be 
pi" evented  and  the  course  of  the  disease  considerably  shortened. 
L*>Bg  continued  pressure  upon  the  lung  by  an  effusion  may  prevent 
it^  subsequent  full  expansion,  and  reappearance  of  the  fluid  is  more 
*I>t  to  occur  when  the  operation  has  been  delayed. 

Apparatus,  Etc.^ — Evacuation  of  the  fluid  is  accomplished  *  by 
^'^Oans  of  suction;  for  this  purpose  a  hollow  needle  or  a  trocar  con- 
'^ccted  with  either  an  aspirator  or  a  syphonage  apparatus  may  be 
*^**Vployed.  In  addition,  a  scalpel,  and  collodion  and  cotton,  or  a 
P^<d  of  sterile  gauze  and  adhesive  plaster  for  the  dressing,  should 
'^^  supplied. 

The  Aspiraling  Needle. — Whether  an  ordinary  aspirating  needle 
K  **'  trocar  and  cannula  be  employed  does  nor  make  any  material 
■  difference,  though  the  latter  has  some  advantages.  Where  the  tro- 
^  '^T  form  of  needle  is  employed,  the  point  of  the  cannula  may  be 
^■H^Oved  about  without  danger  after  the  stylet  is  removed,  and,  should 
^^^Bb  lumen  of  the  cannula  become  plugged,  the  obstacle  may  be  re- 
^^^^L  339 


340  ASPIRATIONS 

moved  without  the  necessity  of  withdrawing  the  cannula  by  woflf 
reinserting  the  stylet.  With  an  aspirating  needle,  on  the  other  hand, 
the  unprotected  point  of  the  needle  may  injure  the  lung  or  diaphragm, 
and,  furthermore,  should  the  lumen  of  the  needle  become  bloded, 
it  may  be  necessary  to  withdraw  it  entirely  in  order  to  dear  out  the 
obstruction.  If  an  aspirating  needle  is  used,  one  should  be  chosen  at: 
least  3  inches  (7.5  cm.)  long  and  from  3^5  inch  (i  nmi.)  to  Ka 
inch  (2  mm.)  in  diameter  depending  upon  the  consistency  of  the 
material  to  be  evacuated. 

In  a  properly  made  trocar  the  stylet  should  fit  the  point  of  th^ 
cannula  accurately,  and  the  cannula  and  stylet  should  graduaD>r 
taper  to  a  point,  as  if  in  one  piece.  The  cannula  is  provided  with  a. 
stopcock  near  the  proximal  end  to  prevent  leakage  of  air  when  th^ 
stylet  is  withdrawn,  while  a  lateral  opening,  for  connection  with  tL^ 
aspirator,  is  placed  at  a  point  distal  to  this  stopcock,  so  that  thestjr- 
let  may  be  moved  back  and  forth  without  disturbing  the  connections 
(Fig.  316). 


Fig.  316. — Aspirating  trocar. 

Aspirators. — The  Potain,  the  Dieulafoy,  or  the  heat  vacti^*^ 
apparatus  is  most  commonly  employed,  though  the  aspiration  fXi^y 
be  satisfactorily  made  in  a  large  proportion  of  cases  by  sirrap*^ 
syphonage.  The  Dieulafoy  instrument  is  most  convenient  *^^ 
evacuating  small  collections  of  fluid  and  when  it  is  desirable  to  be  e^^^ 
in  the  quantity  removed,  while  for  large  effusions  the  Potain  or  ^^ 
heat  vacuum  apparatus  is  best. 

The  Potain  instrument  (Fig.  317)  consists  of  an  exhausting  puxnP' 
a  large  glass  bottle,  a  rubber  stopper  through  which  passes  the  lon^ 
arm  of  a  Y-shaped  metal  tube  with  a  stopcock  in  each  limb,  and  t^^ 
pieces  of  heavy  rubber  tubing,  one  connecting  the  needle  or  XxocbX 
with  one  arm  of  the  Y,  and  the  othei  joining  the  second  arm  and  th^ 
exhausting  pump.     The  instrument  is  assembled  by  inserting  tb^ 
stopper  firmly  into  the  glass  receptacle  and  attaching  one  end  of  ^ 
piece  of  tubing  to  the  stopcock  a  and  the  other  to  the  needle  or 


ASPIRATION    OF   THE    PLEURAL   CAVITY 


341 


trocar.  By  means  of  the  second  tubing  the  exhausting  syringe  is 
conixected  with  stopcock  6.  The  instrument  should  be  carefully 
lest^  before  using  to  see  that  all  the  connections  are  air-tight.  To 
produce  a  vacuum,  stopcock  a  is  closed  and  stopcock  6  is  opened, 


Fro.  3i7.~Polajn  aspiTEtor. 

wiien,  by  pumping  from  thirty  to  fifty  strokes,  the  air  will  be  suffi- 
ciently exhausted.  Stopcock  b  is  then  closed,  and  the  needle  is 
inserted  into  the  chest.  As  soon  as  its  point  enters  the  tissues,  the 
vacuum  is  extended  to  the  point  by  opening  stopcock  a,  so  that  the 


•""ment  fluid  is  reached  it  will  be  drawn  by  suction  into  the  bottle. 
"  the  trocar  is  employed,  the  stylet  is  not  withdrawn  until  the  tro- 
*f  enters  the  chest,  as  this  is  done  the  stopcock  on  the  cannula  is 
dosed,  so  as  to  exclude  air. 


343  ASPHtATIOMS 

The  Dieulafoy  apparatus  (Fig.  31S)  consists  of  a  glass  syringe, 
with  a  capacity  of  3  to  4  ounces  (90  to  120  cc),  provided  with  two 
outlets,  each  furnished  with  a  stopcock,  and  to  which  are  fitted, 
heavy  rubber  tubes.  To  the  extremity  of  one  tube  a  trocar  or 
aspirating  needle  is  attached,  and  at  a  distance  of  about  4  inda 
(10  cm.)  from  the  needle  enij  a  piece  of  glass  tubing  is  inserted  as  m 
index.  The  other  piece  of  tubing  leads  from  sto[>cock  (  to  a  baan 
to  carry  off  the  fluid  discharged  from  the  cylinder.  To  use  the  in- 
strument both  stopcocks  are  closed,  and  the  piston  is  fully  withdrawn 
and  fixed  in  place  by  a  spring.    This  produces  the  vacuum.    The 


Fic.  319.— Connell's  heat  vacuum  aapintor. 

aspirating  needle  is  then  introduced  into  the  skin  at  the  chosen  s**^ 
and,  as  soon  as  the  needle  point  is  buried  in  the  tissues,  the  stOpcocJc  ^ 
is  opened,  allowing  the  vacuum  to  extend  to  the  needle.     Theneeo*^ 
is  then  pushed  on  in  until  it  enters  the  chest,  the  presence  of  flu*" 
being  first  demonstrated  as  it  passes  through  the  glass  index.    WhcO 
the  aspirator  is  filled,  stopcock  a  is  closed  and  stopcock  b  opened,  ana 
the  fluid  is  discharged  from  b  by  driving  the  piston  back  in  place- 
This  process  of  aspiration  may  be  repeated  as  often  as  neccssai? 
without  removing   the  needle  or  disconnecting  the '  aspirator. 

A  very  excellent  form  of  aspirator  and  one  that  is  frequently 
employed  is  the  vacuum   bottle  described  by  Coimell  (Medvd 


ASPIKATION  OF  THE  PLEXTRAL  CAVITY 


343 


Record,  July  4,  1903).    It  consists  of  a  strong  glass  bottle  with  a 

capacity  of  about  5  pints  (2.5  liters),  having  a  mouth  i  inch  (2.5 

cm.)  wide,  fitted  with  a  rubber  stopper  through  which  passes  a  glass 

tube  with  a  heavy  piece  of  rubber  tubing  attached,  ending  in  an 

aspirating  needle.    Three  drams  (12  c.c.)  of  95  per  cent,  alcohol  are 

poured  into  the  bottle  which  is  so  manipulated  that  its  iimer  surface 

^  entirely  coated,  when  the  excess  of  alcohol  is  poured  oflf.    The 

^cohol  is  then  ignited,  and,  as  the  flame  reaches  the  bottom  of  the 

'^ttJe,  the  cork  is  quickly  inserted,  the  rubber  tubing  having  been 

P'^viously  clamped  (Fig.  319).    A  vacuum  is  thus  produced  which 

^  amply  sxiffident  to  aspirate  a  chest. 

Removal  of  an  effusion  by  syphonage  may  be  readily  accom- 
Pfished   by  means  of  a  very  simple  apparatus.    A  piece  of  heavy 


*n-i' 


Fig.  320. — Syphonage  aspirator. 

ouxg  about  3  feet  (90  cm.)  long,  a  clamp  to  close  one  end  of  the 
^^g,  a  funnel,  sterile  water  or  saline  solution  to  fill  the  tubing,  and 
^^eptacle  to  collect  the  fluid  are  the  necessary  requisites.  One 
^4  of  the  tubing  is  fastened  to  a  large  caliber  needle  or  the  side  out- 
^  of  the  trocar  and  the  other  to  the  glass  funnel  (Fig.  320). 

Site  of  Aspiration. — The  needle  should  be  inserted  at  a  point 
*^^re  the  physical  signs  or  an  exploratory  puncture  demonstrate  the 
P^^sence  of  fluid  and  at  the  lowest  level  of  the  fluid,  that  its  with- 
^^Wal  may  be  facilitated  as  far  as  possible  by  the  action  of  gravity. 
"^  *^^  sixth  intercostal  space  in  the  anterior  axillary  line,  the  sixth  or 
^^^nth  space  in  the  midaxillary  line,  and  the  eighth  space  below 
^^  angle  of  the  scapula  are  the  points  of  election  (Fig.  321). 


344 


ASPIRATIONS 


Quantity  Withdrawn. — It  is  not  essential  to  empty  the  chest  a 
tirely  at  one  sitting.  The  amount  of  fluid  evacuated  should  be  deta 
mined  more  by  the  manner  in  which  the  patient  bears  the  operation 
the  condition  of  the  pulse,  and  signs  of  impending  collapse  rathet  tk: 
by  the  quantity  of  fluid  present.  In  vety  large  effusions  as  mudi  a 
3  pints  (1500  c.c)  may  be  removed,  but  It  is  better  to  withdn- 
too  little  than  too  much,  for  what  remains  may  be  evacuated  at 
subsequent  period;  and  it  not  infrequently  happens  that  spontaneoi 
absorption  of  the  effusion  follows  the  removal  of  even  sms 
quantities. 


Fig.  3!i. — Sites  for   aspii 


(The  large  dots  represent  the  p" 


Position  of  the  Patient. — The  aspiration  is  preferably  perforB 
with  the  patient  on  a  bed  so  as  to  avoid  the  extra  exertion  of  movi 
after  the  operation.  When  possible,  an  upright  sitting  positi 
should  be  assumed,  with  the  arm  of  the  affected  side  raised,  and  t 
hand  placed  on  some  support  or  on  the  opposite  shoulder  to  increa 
the  breadth  between  the  intercostal  spaces  (Fig.  322).  If  this  b  m 
practicable,  the  patient  may  lie  near  the  edge  of  the  bed,  upon  tl 
back  for  a  lateral  puncture,  or  rolled  slightly  to  the  opposite  side  wit 
the  arm  extended  over  the  head  for  a  posterior  puncture  (see  Fig.  190 

Asepsis. — The  skin  at  the  site  of  operation  should  be  painted  w* 
tincture  of  iodin;  the  operator's  hands  should  also  be  pn^ 
cleansed,  and  the  needle  or  trocar  sterilized  by  boiling. 


ASPIRATION    OF   THE    PLEURAL   CAVITY  345 

^esthesia.^ — Local  anesthesia  by  freezing  with  ethyl  chlorid  or 
''y  infiHration  with  a  few  drops  of  a  0.2  per  cent.- solution  of  cocain 
*"■  a  1  per  cent,  solution  of  procain  at  the  point  of  puncture  will  be 
*''%eat. 


Fic.  31J. — Paction  of  patient  for  aspiration  of  the  pleura. 


Tftclinic, — A  vacuum  is  first  produced  in  the  aspirator  and  the 
needte  or  trocar  attached.  A  point  is  then  selected  in  the  chosen 
mterspacg  ^t  a  little  distance  from  the  upper  margin  of  the  lower  rib 
Doun^ing  ^^  space,  so  as  to  avoid  the  upper  intercostal  artery,  and 
™  skin  is  nicked  with  a  scalpel.    The  thumb  and  forefinger  of  the 


Fic.  313. — Method  of  holding  thi 

'"t  hand  are  used  to  steady  the  tissues  overlying  the  intercostal 
^te,  while  the  needle  or  trocar  is  introduced  with  the  right  hand,  the 
'orefinger  being  placed  on  the  needle  to  guard  against  its  being  in- 
*fled  too  deeply  (Fig.  ;i2;i).  As  soon  as  the  point  of  the  needle 
^ters  the  tissues,  the  vacuum  already  present  in  the  aspirator  is 
Wtended  to  the  needle  point  by  opening  the  proper  stopcock,  and  the 


34<S  ASPIRATIONS 

needle  is  steadily  pushed  in  until  it  enters  the  pleural  sac,  wUch  vtl 
usually  be  at  a  depth  of  i  to  i^^  inches  (2.5  to  3.5  cm.).  Thefloil 
should  be  withdrawn  rather  slowly  in  order  that  the  structures  ma/' 
have  time  to  adjust  themselves  to  the  changed  conditions  in  tbe 
chest;  at  least  twenty  minutes  to  half  an  hour  should  be  consumed  in 
removing  2  pints  (1000  ex.). 

Should  the  patient  feel  faint  or  suffer  from  vertigo  or  dy^nea 
the  operation  should  be  temporarily  interrupted  and  the  patient's 
head  lowered.  Complaints  of  severe  paih,  persistent  cough,  or  eipcc- 
toration  of  blood  also  demand  that  the  aspiration  be  discootinned. 


Fig.  334. — Aspiration  of  the  pleura  with  the  Potain  ftpparatus. 


At  the  completion  of  the  operation  the  tissues  are  pinched  *f 
around  the  shaft  of  the  needle  which  is  quickly  withdrawn.  Tl** 
site  of  puncture  is  then  dressed  with  collodion  and  cotton,  or  with  * 
sterile  pad  of  gauze  held  in  place  by  adhesive  strips. 

In  employing  the  syphonage  apparatus  the  tubing  is  first  filled 
with  sterile  solution,  and  the  clamp  is  placed  near  the  end  of  the  tube 
to  prevent  the  solution  escaping.  The  needle  is  then  introduced 
into  the  chest,  while  the  free  end  of  the  tube  is  placed  under  water 
in  the  receptacle  provided  for  the  collection  of  the  fluid.  On  remov- 
ing the  clamp  from  the  tube  the  column  of  water  is  released  and  the 
fluid  withdrawn  by  a  process  of  s>phonage. 


'  a  yellowish,  frothy  fluid,  and  it  is  accompanied  by  dysp- 1 
Bsis,  and  a  weak  pulse.  This  condition  usually  begins 
:  withdrawal  of  the  fluid,  or  comes  on  shortly  afterward, 
ined  on  the  supposition  that  the  rapid  withdrawal  of  fluid 
removes  the  pressure  from  the  lung,  which  as  a  result 
ongested,  and  transudation  into  the  air  cells  follows. 
nation  of  blood  may  result  from  the  rupture  of  small  pul- 
ffisels,  from  congestion  of  the  lung,  or  from  injury  to  the 
[  by  the  aspirating  needle. 

I  death  is  unusual,  though  it  may  occur,  and  at  times  with- 
ent  cause.  Embolism,  cerebral  anemia,  from  the  sudden 
ood  to  the  expanding  lung,  hemorrhage  into  the  pleural 
jm  injury  to  the  lung,  and  irritation  of  the  terminations  of 
logastric  nerve  have  been  suggested  as  explanations. 
ccurreace  of  these  complications  may  be  reduced  to  a 
by  the  employment  of  rigid  aspesis,  the  observance  of 
in  the  use  of  the  needle  or  trocar,  and  the  removal  of  only 
amounts  of  fluid  without  haste. 


ASPIRATION  OF  THE  PERICARDIUM 

Dtesis  pericardii,  or  pericardicentesis,  consists  in  the  evacu- 
lie  contents  of  the  pericardial  sac  through  aspiration  by 
i  needle  or  a  fine  trocar  attached  to  a  vacuum  apparatus. 
Sons. — Paracentesis  of   the   pericardium    should   be  per- 


be  effusion  is  sufficiently  large  to  endanger  life  through 
disturbance  in  the  cardiac  action  indicated  by  severe 
mall,  rapid,  and  irregular  pulse,  and  cyanosis,  tiie  indicatio 


346  ASPIKATIONS 

needle  is  steadily  pushed  in  until  it  enters  the  pleural  sac,  whidivilL 
usually  be  at  a  depth  of  i  to  iM  inches  (2.5  to  3.5  cm.).  The  flnil 
should  be  withdrawn  rather  slowly  in  order  that  the  structures  majr 
have  time  to  adjust  themselves  to  the  changed  conditions  in  tlie 
chest;  at  least  twenty  minutes  to  half  an  hour  should  be  consumed  ia 
removing  2  pints  (1000  c.c). 

Should  the  patient  feel  faint  or  suffer  from  vertigo  or  dy^nea 
the  operation  should  be  temporarily  interrupted  and  the  patient's 
head  lowered.  Complaints  of  severe  pain,  persistent  cough,  or  eipec- 
toration  of  blood  also  demand  that  the  aspiration  be  discontiiiiKd. 


f^G.  334. — Aspiration  of  the  pleura  with  the  Potaln  sppaiatns. 


At  the  completion  of  the  operation  the  tissues  are  pinched  up 
around  the  shaft  of  the  needle  which  is  quickly  withdrawn.  Tb* 
site  of  puncture  is  then  dressed  with  collodion  and  cotton,  or  with* 
sterile  pad  of  gauze  held  in  place  by  adhesive  strips. 

In  employing  the  syphonage  apparatus  the  tubing  b  first  filled 
with  sterile  solution,  and  the  clamp  is  placed  near  the  end  of  the  tube 
to  prevent  the  solution  escaping.  The  needle  is  then  introduad 
into  the  chest,  while  the  free  end  of  the  tube  is  placed  under  walH 
in  the  receptacle  provided  for  the  collection  of  the  fluid.  On  remov- 
ing the  clamp  from  the  tube  the  column  of  water  is  released  and  the 
fluid  withdrawn  by  a  process  of  syphonage. 


ASPIRATION    OF   THE    PERICARDIUM 


347 


omplicationB  and  Dangers. — Sepsis  is  not  to  be  feared  if  the 
arj-  aseptic  precautions  are  observed. 

neumolhorax  may  follow  injury  to  tiie  lung  by  the  aspirating 
e  or  trocar,  or  be  due  to  the  rupture  of  adhesions  or  a  cavity 

expansion  occurs,  or  to  the  entrance  of  air  along  the  trocar. 
Ibuminous  expecloralion  has  been  observed  as  a  sequel  to  the 
ai  withdrawal  of  large  quantities  of  fluid.  The  expectoration 
sts  of  a  yellowishj  frothy  fluid,  and  it  is  accompanied  by  dysp- 
cyanosis,  and  a  weak  pulse.  This  condition  usually  begins 
ig  the  withdrawal  of  the  fluid,  or  comes  on  shortly  afterward, 
explained  on  the  supposition  that  the  rapid  withdrawal  of  fluid 
enly  removes  the  pressure  from  the  lung,  which  as  a  result 
nes  congested,  and  transudation  Into  the  air  cells  follows. 
xpecloralion  of  blood  may  result  from  the  rupture  of  small  pul- 
iry  vessels,  from  congestion  of  the  lung,  or  from  injury  to  the 
tissue  by  the  aspirating  needle. 

uddcn  death  is  unusual,  though  it  may  occur,  and  at  times  with- 
ipparent  cause.  Embolism,  cerebral  anemia,  from  the  sudden 
of  blood  to  the  expanding  lung,  hemorrhage  into  the  pleural 
ies  from  injury  to  the  lung,  and  Irritation  of  the  terminations  of 
ineumogastrlc  nerve  have  been  suggested  as  explanations. 
he  occurrence  of  these  complications  may  be  reduced  to  a 
num  by  the  emplojTnent  of  rigid  aspesis,  the  observance  of 

care  in  the  use  of  the  needle  or  trocar,  and  the  removal  of  only 

»te  amounts  of  fluid  without  haste. 


nte  ; 


ASPIRATION  OF  THE  PERICARDIUM 


aracentesis  pericardii,  or  pericardiceatesis,  consists  in  the  evacu- 
of  the  contents  of  the  pericardial  sac  through  aspiration  by 

IS  of  a  needle  or  a  fine  trocar  attached  to  a  vacuum  apparatus. 

idications. — Paracentesis  of   the  pericardium   should  be  per- 

ed: 
If  the  effusion  is  sufficiently  large  to  endanger  life    through 

lund  disturbance  In   the  cardiac  action  indicated  by  severe 

nea,  small,  rapid,  and  irregular  pulse,  and  cyanosis,  the  ittdicatio 

I,  as  death  may  result  from  syncope  if  the  condition  be  not 

ed  without  delaj-. 

When  a  large  effusion  does  not  show  any  tendency  to  absorp- 

ifter  a  prolonged  and  fair  trial  of  medical  means. 

I  the  presence  of  a  purulent  exudate,  though  temporary  relief 


348  ASPIRATIONS 

may  be  obtained  by  aspiration,  the  conditioa  is  one  that  sboolA  be 
treated  by  incision  and  free  drainage,  as  in  empyema. 

Apparatus,  Etc. — In  tapping  the  pericardimn  a  Potain  or  Diai* 
lafoy  aspirator  to  which  is  attached  a  fine  needle  or  trocar  and  can- 
nula may  be  employed  in  the  same  way  as  used  in  the  pleural  cavi^; 
a  scalpel,  collodion  and  cotton,  or  gauze  and  adhesive  plasta  for 
the  purpose  of  dressings,  should  also  be  at  hand. 

Site  of  Aspiration. — The  point  for  making  the  a^iration  sbmld 
be  determined  upon  after  having  first  detected  the  presence  of  fluid 


Flo.  315.— Points  for  aspiration  of  the   pericardium.     The  dotted  line  incfoti*  * 
distended  pericardial  sac.     The  course  of  the  internal  manunaiy  vessel*  is  jJso  A"^ 

by  an  exploratory  puncture  (page  318),     For  the  introduction  of  d* 
needle  there  are  four  sites  recommended: 

1.  In  the  fourth  or  fifth  intercostal  space  close  to  the  left  sten* 
margin,  or  else  i  inch  (2,5  cm.)  to  the  left  of  it,  thus  passing  dthd 
internal  or  external  to  the  internal  mammary  artery, 

2.  In  the  fifth  interspace  close  to  the  right  of  the  sternum. 

3.  Close  to  the  costal  margin  in  the  angle  between  the  enafM''' 
cartilage  and  seventh  costal  cartilage  on  the  left,  inserting  the  needU 
upward  and  backward. 

4.  In  the  fifth  or  sixth  left  interspace  outside  the  nipple  line  I* 
tween  the  apex  beat  and  outer  border  of  dullness  (Fig.  325). 


ASPIRATION    OF    THE    PERICARDIUM 


349 


Quantity  Withdrawn. — In  small  effusions  the  fluid  may  be  re- 
loved  at  one  silting;  but  in  large  effusions,  in  order  to  avoid  suddenly 
moving  the  extracardial  pressure,  it  is  preferable  to  withdraw 
Jtmore  than  3  to  4  ounces  (go  to  izo  c.c.)  at  the  first  sitting.  This 
ay  be  followed  by  absorption  of  the  rest  of  the  fluid,  as  is  often  the 
.se  in  pleurisy.  If  there  is  no  improvement  at  the  end  of  a  day  or 
fo,  however,  it  will  be  necessary  to  perform  a  second  tapping. 

Position  of  Patient.^ — The  operation  may  be  performed  either  with 
e  patient  recumbent  or  sitting  upright. 

Asepsis. — The  greatest  regard  to  aseptic  precautions  should  be 
'sen-ed.  The  area  of  operation  should  be  shaved,  if  necessary,  and 
e  skin  painted  with  tincture  of  iodin.  The  operator's  hands  are 
oroughly  cleansed,  and  the  apparatus  to  be  used  in  the  operation  is 
iled. 

Anesthesia.^ — Local  anesthesia  by  freezing  with  ethyl  chlorid 

other  freezing  agents,  or  by  injecting  a  few  drops  of  a  0.2  per  cent. 
lution  of  cocain  or  a  i  per  cent,  solution  of  procain  into  the  skin 
II  be  found  useful. 

Technlc. — A  nick  is  made  through  the  skin  with  a  scalpel  at  a 
•mt  not  far  from  the  upper  margin  of  the  rib  forming  the  lower 
lundary  of  the  space  previously  determined  upon  for  aspiration, 
le  tissues  are  steadied  between  the  thumb  and  forefinger  of  the 
thand,  and  the  needle  is  held  in  the  right  hand,  the  index  linger 
ing  placed  on  its  shaft  as  a  guide  to  the  proper  depth  of  insertion, 

shown  in  Fig.  323.  The  direction  of  the  needle  as  it  is  introduced 
ould  be  at  first  backward,  until  it  enters  the  thorax,  and  then 
ghtly  inward  into  the  pericardium;  but  if  the  approach  is  made 

the  left  seventh  costoxyphoid  angle,  the  needle  is  introduced 
rectly  upward  and  backward.  .  The  introduction  of  the  needle 
list  be  performed  slowly,  steadily,  and  with  great  care.  The 
■cmim  previously  produced  in  the  aspirator  is  extended  to  the 
«l!e,  by  opening  the  proper  valve,  as  soon  as  the  needle  point  enters 
e  tissues,  so  that  fluid  will  be  withdrawn  at  the  earliest  possible 
oment  and  thus  injurj-  to  the  heart,  through  inserting  the  needle 
0  deeply,  will  be  avoided.  Usually  at  a  depth  of  i  inch  (2.5  cm.) 
«  pericardium  will  be  entered.  Care  must  be  taken  not  to  produce 
0  great  a  vacuum  in  the  aspirator  lest  the  fluid  be  withdrawn  too 
pidly — it  should  simply  trickle  into  the  aspirator. 

As  soon  as  the  desired  quantity  is  removed,  the  aspirating  needle 
quickly  withdrawn,  and  the  seat  of  puncture  is  occluded  with 


3SO 


ASPIRATIONS 


cotton  and  collodion,  or  else  by  a  pad  of  sterile  gauze  held  in  plai 
by  adhesive  plaster. 

Complications  and  Dangers. — It  should  be  remembered  th 
aspiration  of  the  pericardium  is  no  simple  procedure,  but  is  an  opa 
tion  attended  by  danger.  Infection  of  the  pericardium,  injury 
the  internal  mammary  vessels,  pimcture  of  the  pleura,  and  lace 
tion  of  the  coronary  artery  and  the  heart  itself  by  the  aq)irati 
needle  have  all  been  observed.  Strict  attention  to  asepsis,  extrei 
care  in  introducing  the  aspirating  needle  or  trocar,  and  observance 
the  various  points  in  technic  that  have  been  emphasized  will 
much  in  preventing  such  accidents. 


ASPIRATION  FOR  ASCITES 

Paracentesis  of  the  abdomen  consists  in  pimcturing  the  pa 
oneal  cavity  by  means  of  a  trocar  and  cannula  and  withdrawing  t 
fluid  therein  contained.  It  is  an  operation  attended  by  practically 
risks  and  can  safely  be  repeated  many  times  in  the  same  individi 
when  necessary. 

Indications. — The  abdomen  may  be  aspirated  in  cases  of  asdl 
when  the  physical  signs  show  the  presence  of  fluid,  and  distcnti* 


Fig.  326. — Trocar  and  cannula  for  aspirating  the  peritoneal  cavity,     i,  T^x>car  I 
cannula  assembled;  2,  showing  trocar  removed  from  the  cannula. 

becomes  distressing  from  pressure  upward  upon  the  diaphragnL 
should  also  be  performed  when  the  fluid  reaccumulates  after 
previous  tapping  and  gives  rise  to  pressure  symptoms. 

Instruments,  Etc. — A  straight  or  slightly  curved  cannula  a 
trocar  of  fair  size — about  ^iq  to  j^i  inch  (1.5  to  3  mm.)  in  diame 
— should  be  used.  The  trocar  is  spear-pointed  and  should  fit  \ 
cannula  perfectly  so  as  to  prevent  the  point  of  the  latter  catch: 
in  the  tissues  during  its  introduction  (Fig.  326).  An  excellent  fonr 
cannula,  and  one  frequently  used,  contains  a  lateral  opening  ab 


ASPIRATION  FOR  ASCITES 


351 


^  inch  (3  mm.)  from  its  end,  for  the  purpose  of  avoiding  stoppage 
of  tie  escaping  fluid,  •  should  the  intestines  or  omentimi  obstruct 
the  ^nd  opening  of  the  instrument. 

Xf  desired,  the  aspirating  apparatus  of  Potain  or  Dieulafoy  (page 
ucy)  may  be  used  in  place  of  the  simple  trocar. 

Xn  addition,  a  scalpel  to  make  a  small  preliminary  incision,  a 
sterile  abdominal  binder,  a  many-tailed  bandage  or  large  towel,  and 
collodion  and  cotton  or  sterile  gauze  and  adhesive  plaster  for  the 
dressing  should  be  provided. 


I 


Fig.  327. — Sites  for  aspiration  of  the  peritoneal  cavity. 

Site  of  Puncture. — The  selection  of  a  location  free  from  vessels 
^^  where  the  abdominal  wall  is  thin  is  desirable.  Usually  a 
P^J^t  in  the  linea  alba  midway  between  the  umbilicus  and  pubes  is 
^*^ted,  but  the  puncture  may  be  at  a  point  in  the  linea  semilu- 
^ris  just  outside  the  rectus  muscle  at  the  junction  of  the  outer  and 
^ddle  thirds  of  a  line  between  the  umbilicus  and  the  anterior  supe- 
^^^  iliac  spine  (Fig.  327).  A  puncture  at  either  of  these  sites  will 
^^^id  the  deep  epigastric  vessels.     Should  repeated  punctures  be 

^^^^^e,  it  will  be  of  advantage  to  change  the  site  a  little  each  time  so  as 

^  avoid  entering  adhesions  which  may  have  been  produced  by  a 

Previous  puncture. 

Quantity  Withdrawn. — Whether  all  the  fluid  should  be  removed 

^^  once  will  be  determined  by  the  condition  of  the  patient  and  the 


353  ASPIRATIONS 

manner  in  which  he  bears  the  operation.  As  a  general  thing  then  is 
no  hann  in  removing  all  the  fluid,  provided  it  is  not  evacuated  too 
rapidly. 

Position  of  Patient. — ^The  patient  should  sit  upright  on  the  edge 
of  the  bed,  if  possible,  or,  if  unable  to  do  this,  he  may  lie  propped  up 
in  a  semirecumbent  position  so  as  to  favor  gravitation  of  the  fluid  tiO 
the  lowest  level  of  the  peritoneal  cavity.  When  the  puncture  k  mad.^ 
in  the  linea  semilunaris,  the  patient  should  lie  upon  the  side  on  whicZ] 
the  puncture  is  made. 


Preparations. — The  bladder  attd  bowels  should  always  be  tmpfy 
bejore  operation.  The  abdominal  wall  is  shaved  and  the  site  of  punc- 
ture is  painted  with  tincture  of  iodin.  The  operator's  hands  shouJd 
likewise  be  sterilized,  and  the  trocar  is  to  be  boiled. 

Anesthesia. — ^Local  anesthesia  with  ethyl  chlorid,  ether,  ice  end 
salt,  or  infiltration  with  a  few  drops  of  a  0.2  per  cent.  solutioD  oi 
cocain  or  a  i  per  cent,  solution  of  procaJn  may  be  used. 

Technic, — A  broad  abdominal  binder,  or  a  Scultetus  bandage 
with  a  central  slit  corresponding  to  the  point  where  the  trocar  is  to  be 
introduced,  is  first  fitted  about  the  patient's  abdomen  (Fig.  328)  uw* 
is  to  be  tightened  at  intervals  during  the  operation,  so  that  unifwin 
pressure  may  be  applied  while  the  fluid  is  flowing  off  and  a  suddeo 
overfilling  of  the  abdominal  vessels  with  blood  prevented.    With  a 


ASPIRATION   FOE  ASCITES 


353 


scalpel  tbe  skin  is  incisea  for  a  distance  of  J^  inch  (6  mm.)  at  the 
spot  chosen  for  the  puncture  {Fig.  329),  and  the  trocar  is  slowly  and 
I  steadily  inserted,  with  the  index  finger  held  along  the  instrument  as 
a  guide  to  the  depth  it  is  to  enter,  and  to  prevent  it  from  being  sud- 
denly lorced  in  too  far  (Fig.  330).  As  soon  as  it  is  judged  that  the 
intoneal  cavity  has  been  reached,  the  trocar  is  withdrawn  and  the 

d  is  permitted  to  escape. 
PThe  fluid  should  be  evacuated  slowly,  and,  if  it  flows  too  freely, 
■  is  well  to  stop  the  flow  at  intervals  by  placing  the  finger  over  the 
"w  of  the  trocar,  in  order  to  allow  the  abdominal  contents  to  adapt 
elves  to  the  changed  conditions.     If  the  stream  is  suddenly 


"■■  JiQ.— ,\3piration  of  the  peritoae&l  cavity.     Second   step,   nicking  the  skin  at 
the  point  of  puncture. 

'topped  by  the  intestines  or  omentum  occluding  the  end  of  the  instru- 
^^Qt,  a  slight  turn  of  the  cannula  or  a  change  in  its  position  may  be 
'efficient  to  relieve  the  obstruction;  if  not,  it  may  be  necessary  to 
,  '^r  the  lumen  by  passing  a  sterile  probe  through  it.  As  the  fluid 
^  withdrawn,  and  the  distention  of  the  abdomen  decreases,  neces- 
^Tj-  support  is  given  to  the  lax  abdominal  walls  by  drawing  the 
^^Ddcr  tighter.  Syncope  may  be  thus  avoided;  should  it  occur,  how- 
*^'er,  the  escape  of  tlie  fluid  must  be  temporarily  stopped  by  placing 
"le  finger  over  the  end  of  the  trocar  and  the  patient's  head  must  be 
"'wered,  care  being  taken  to  see  that  air  does  not  enter  the  cannula 
*llile  this  is  being  done. 


354 


ASPIRATIONS 


When  fluid  ceases  to  flow,  the  cannula  k  qulcUy  removed  ud, 
if  a  large  opening  has  been  made  by  the  trocar,  the  skin  may  be 
drawn  together  by  a  subcutaneous  stitch  and  the  line  of  indaon 
sealed  with  collodion  and  cotton.     If  there  seems  to  be  a  good  deal 
of  oozing  of  fluid  along  the  track  of  the  trocar,  however,  a  stoil'C 
gauze  dres^g,  held  in  place  with  rubber  adhesive  plaster  arm.4. 
changed  as  often  as  necessary,  will  be  found  more  satisfactory^ 
After  the  aspiration  the  patient  should  be  kept  in  bed  for  at  lea-^a 
twenty-four  hours.    ■ 


FlO,  330. — Aspiration  of  the  peritoneal  cavity.     Third  step,  eliowiiig  tiie  metli  ^  """^ 
inserting  tbe  trocar. 

ASPIRATION  OF  THE  TUNICA  VAGINALIS 

This  operation  is  employed  for  the  cure  of  hydrocele.    It  roa^isfe 
in  introducing  an  aspirating  needle  or  trocar  and  cannula  into  tJt 
tunica  vaginalis  and  removing  the  contained  fluid.    It  may  be  p^'- 
formed  simply  to  withdraw  the  hydrocitic  fluid  or  as  part  of  ti« 
radical  cure  by  injection  of  carbolic  acid.    The  former  is  rardy  mff*^ 
than  a  palliative  measure,  as  the  fluid  usually  promptly  recur* 

The  treatment  by  a  combination  of  aspiration  and  the  injectky 
of  95  per  cent  carboUc  acid  is,  however,  successful  in  more  than  3^ 
per  cent,  of  cases  (Bevan).  It  is  especially  applicable  to  hydrocetes 
with  thin  sacs;  in  the  old,  chronic  cases  with  thick  sacs  it  is  not  ofte0 
successful. 


ASPIR,\TION-   OF    THE    TUNICA    VAGINALIS  355 

The  operation  is  practically  without  danger,  if  performed  with 
[oper  tecJmic  and  care  is  taken  to  prevent  injury  to  the  structures 
t  the  cord  and  the  testicle.  The  latter  usually  lies  posterior  to 
(be  mwior,  though  in  rare  cases  it  may  be  in  front.  Its  position 
^uld  always  be  ascertained  first,  if  possible,  by  palpation  and 

tiansiUummation. 


=3t=»^ 


■^G.  33t. — Trocar  and  syringe  for  aspirating  and  injecting  a  hydrocele. 

Instruments. — A  medium  size  trocar  and  cannula,  or  a  large 
'^P'ratijig  needle,  to  which  may  be  attached  a  small  aspirating 
syringe,  will  be  required  (Fig,  331). 

Site  of  Puncture.— The  trocar  should  be  introduced  at  the  junc- 
tion of  the  lower  and  middle  thirds  of  the  anterior  surface  of  the 
W^tutn,  at  a  spot  where  visible  blood-vessels  are  scarce. 


''■  33J.— Aspirating  a  hydrocck.     .Showing  tlic   metliod  i>f  t'fi^P'ng  tlie 
and  the  trocar  being  inEerted. 

Awpsis. — The  usual  aseptic  precautions  should  be  observed. 
'« skin  at  the  site  of  puncture  should  be  shaved  and  then  painted 
*"Jl  tincture  of  iodin.  The  operator's  hands  should  be  prepared 
*s  for  any  operation,  and  the  instruments  boiled. 

Anesthesia. — The  spot  of  intended  puncture  may  be  anesthetized 
oy  the  injection  of  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain 
Of  a  I  per  cent,  solution  of  procain,  or  frozen  by  ethyl  chlorid. 


356  ASPIRATIONS 

Teclmic. — The  operator  places  his  left  hand  behind  the  sootum 
and  grasps  the  neck  of  the  hydrocele  between  the  tfanmb  and  fon- 
fiqger,  thus  making  the  tumor  tense  by  compiession.    HoUiiig  Ik 


ittC 


^  -ydi 


Fig.  333. — Aspirating  *  hydrocele.    Slowing  the  canmito  io  placb 

trocar  and  cannula  in  the  right  hand  with  the  index  finger  placed 
about  I  inch  (2,5  cm.)  from  its  tip  so  as  to  prevent  the  ini 
being  introduced  too  deeply,  the  operator  thrusts  it  into  the  t 


Fig.  334, — Method  of  injecting  a  bydiocde. 


vaginalis  in  an  upward  and  backward  direction  (Fig.  332).  As  soon 
as  the  trocar  enters  the  sac,  indicated  by  a  lack  of  resistance  to  its 
further  progress,  the  point  of  the  instrument  is  turned  upward  thus 


ASPIRATION   OF   THE  BLADDER  357 

ag  the  free  end  and  the  trocar  is  removed  (Fig.  333).  All  the 
hen  allowed  to  escape,  and,  to  make  sure  the  sac  is  empty, 
rator  may  be  attached  and  suction  employed, 
rannula  is  left  in  site  and  from  5  to  30  drops  (0.3  to  2  c.c.) 
:  cent,  (deliquescent)  carbolic  acid,  depending  upon  the  size 
yrdrocele,  are  injected  through  the  cannula  (Fig.  334).  If  a 
aimot  be  attached  directly  to  the  cannula,  the  injection  may 
:  by  means  of  a  hj^dermic  syringe  and  a  long  needle  in- 
LTough  the  cannula.  The  skin  is  then  pinched  up  around  the 
which  is  quickly  removed,  and  the  scrotum  is  manipulated 
smear  the  acid  over  the  whole  interior.  The  pimcture  is 
Jly  sealed  with  collodion  and  cotton. 

patient  should  remain  in  bed  twenty-four  to  forty-eight 
ter  the  operation  with  a  supporting  dressing  applied  to  the 
Some  swelling  follows  the  injection,  but  it  usually  sub- 
thin  a  week  or  ten  days.  During  this  time  the  patient 
rear  a  well-fitting  suspensory. 

ASPIRATION  OF  THE  BLADDER 

•ation  of  the  bladder  will  be  considered  under  the  section 
to  that  organ  (see  page  746). 


CHAPTER  XIV 
THE  NOSE  AND  ACCESSORY  SINUSES 

Anatomic  ConsidercUions 

The  Nose. — For  purposes  of  description  the  nose  is  divided  mt^ 
an  external  and  an  internal  portion. 

The  external  nose  forms  a  prominence  upon  the  face  resembling  ^ 
triangular  pyramid,  made  up  chiefly  of  bone  and  cartilage  aa^ 
covered  with  muscles  and  integument.  The  bony  portion,  o^ 
bridge,  is  composed  of  the  nasal  portions  of  the  superior  maxilla  an^ 
the  two  nasal  bones.  The  arch  forming  the  forepart  of  each  side  *^ 
the  nose  is  composed  of  two  large  lateral*  cartilages  which  converge 
to  form  the  ridge  and  tip.  These  are  supplemented  usually  by  thrc 
smaller  cartilages  bound  together  by  connective  tissue,  which  aid  u 
forming  the  wings  or  alaj. 

The  interior  of  the  nose  is  divided  by  the  septum  into  two  chanL — 
bers,  or  fossae,  narrow  above  and  more  expanded  below.    Thes^ 
open  anteriorly  by  the  anterior  nares,  two  pear-shaped  aperture:^ 
measuring   about    i  inch  (2.5  cm.)  vertically  and  }4  inch  (i  cm.^ 
transversely  at  their  widest  points.     Posteriorly,  the  nasal  fossae 
communicate  with  the  nasopharynx  by  two  corresponding  openings  ^ 
the  posterior  nares.     Each  fossa  also  communicates  with  air  spac( 
situated  in  the  frontal,  ethmoid,  sphenoid,  and  superior  maxillj 
bones.     The  roof  is  formed  by  the  nasal  bones,  the  cribriform  pla"ft^« 
of  the  ethmoid,  and  the  body  of  the  sphenoid.     The  floor,  conca^i^^c 
from  side  to  side,  is  formed  by  the  palatal  process  of  the  superi^n^r 
maxilla  and  the  horizontal  process  of  the  palate  bones.     It  separat^ss 
the  nose  from  the  mouth.     The  inner  wall,  or  septimti,  is  form^^ 
posteriorly  by  the  perpendicular  plate  of  the  ethmoid  and  the  vom^^> 
and  anteriorly  by  the  triangular  cartilage.     The  septum  is  seldc^xn 
exactly  in  the  median  line,  but  is  usually  more  or  less  deflected,  s^ 
that  it  is  unusual  to  find  the  two  fossae  of  equal  size.     The  outer  waJ^ 
of  the  nose  are  formed  by  the  superior  maxillary,  the  lachrymal,  tb^ 
ethmoid,  the  palate,  and  the  sphenoid  bones.     They  are  very  irreg^ 
ular,  due  to  the  presence  of  the  turbinate  bodies  which,  project  into 
the  fossae  and  partly  divide  them  into  three  separate  recesses,  the 
superior,  the  middle,  and  the  inferior  meatus  (Fig.  335). 


-O 


ANATOMIC    CONSIDERATIONS  359 

The  superior  meatus  lies  between  the  superior  and  middle  turbi- 
nates. It  is  narrow  and  groove-like,  and  is  the  smallest  of  the  three. 
The  orifices  of  the  posterior  ethmoidal  cells  open  upon  the  upper  and 
forepart  of  its  outer  wall. 

The  middle  meatus  lies  between  the  middle  and  inferior  turbinates^ 
and  is  more  capacious  than  the  superior,  extending  along  the  pos- 


^IG.  335. — Tiaiuvetse  section  of  the  nasal  cavities.     (After  ZudcerlcaudL) 

terior  two-thirds  of  the  outer  wall  of  the  nose.  Opening  into  the 
middle  meatus  on  the  outer  wall  is  a  crescentic  slit-like  aperture, 
the  hiatus  semilunaris.  Just  above  it,  and  at  times  partly  occluding 
"lis  opening,  is  a  protuberance,  the  bulla  ethmoidalis,  which  marks 
the  atuation  of  the  anterior  ethmoidal  cells.     Upon  the  lateral  wall 


''w,  336. — Showing  the  structures  in  the  outer  wall  ot  the  nasal  cavity,     i.  Opening 
"' til"  tpheooidal  sinus;  1,  superior  meatus;  3,  middle  meatus;  4,  inferior  meatus. 

of  ihe  middle  meatus  and  extending  from  the  hiatus  semilunaris  up- 
fard  and  forward,  is  a  curved  groove  bounded  internally  by  the  un- 
cinate process  of  the  ethmoid,  known  as  the  infundibulum.     From 


360  THE  NOSE  AND  ACCES50KY  SINUSES 

this  a  closed  duct  leads  into  the  frontal  sinus.  At  the  deepest  pn:- 
tion  of  the  infundibulum  near  the  posterior  end,  is  the  opening  of  the 
maxillary  sinus,  and  behind  this  at  times  is  found  an  accessory 
opening.  The  anterior  ethmoidal  cells  also  open  into  the  infmu&a- 
lum  on  the  upper  part  of  the  outer  wall  or  else  they  communicate 
with  the  frontonasal  duct. 

From  the  anatomical  relariou  of  these  (qienings,  it  can  be  under- 
stood how  readily  infecriou  of  the  maxillary  sinus  may  follow  a  sap- 
purative  condition  of  the  anterior  ethmoidal  cells  or  frontal  sinus, 
discharges  from  the  latter  being  very  apt  to  find  their  way  into  the 
ostium  of  the  maxillary  sinus. 


Hid 
.-a 


Fig.  337.— Lateral  wall  of  the  right  nasal  cavity  showing  the  orifices  of  the  acctwo*^ 
tinues.     (After  Schultze  and  Stewart.)     The  dotted  line  indicates  the  outline  of  tt-^ 
middle  turbinate,  which  has  liecn  removed  to  show  the  structures  beneath.    A  portiii^^^'. 
of  the  inferior  turbinate  has  also  Ireen  removed,     i.  Frontal  sinus;  2,  infundibulun:;^^j^ 
3,  hiatus  semilunaris;  4,  orifice  of  the  nasal  duct;  s,  bulla  ethmoidalis;  6,  inferior  turi^~^ 
nate;  7,  accessory  orifice  of  the  maxillary  sinus;  8,  orifice  of  Eustachian  tube;  g,  iooi':^^^^ 
Rosenmtlller;  10,  sphenoidal  sinus;  11,  orifice  of  the  sphenoidal  unus;  11,  orifice  of  th^ 
middle  and  posterior  ethmoidal  cells;  13,  orifice  of  the  anterior  ethmoidal  cella. 

The  inferior  meatus,  the  largest  of  the  three,  lies  between  the-^  ^ 
inferior  turbinate  bone  and  the  floor  of  the  nasal  cavity,  extending  '^^—t 
along  the  entire  length  of  the  outer  wall  of  the  nose.  The  nasal  duct,  V,^ 
leading  from  the  orbit,  opens  into  the  inferior  meatus  at  the  juncticm  *'^ 
of  the  anterior  third  with  the  posterior  two-thirds.  ^ 

The  mucous  membrane  lining  the  nasal  cavity  is  continuous  ^^ 

anteriorly  with  the  integument  and  also  with  the  mucous  monbranc 
of  the  pharynx,  Eustachian  tubes,  and  accessory  sinuses  In  the 
upper  portion  of  the  nose  the  mucous  membrane  is  of  the  columnar 
variety.  In  this  region  it  is  thin  and  closely  botmd  to  the  pmos- 
teum  and  perichondrium  beneath,  and  contains  the  endings  of  the 
olfactory  ner\'es.    The  remainder  of  the  nasal  cavity  is  lined  with 


ANATOMIC   CONSIDERATIONS  361 

cOisted  epithelium.  Over  the  inferior  turbinates,  the  lower  portion 
of  the  middle  turbinates,  and  corresponding  parts  of  the  septum  the 
mucous  membrane  is  thick  and  very  vascular,  containing  numerous 
thin-walled  venous  channels  capable  of  becoming  so  enormously  dis- 
tended with  blood  that  they  may  even  occlude  the  nares.  On  the  floor 
of  the  nose  the  mucous  membrane  again  becomes  thinned  out.' 

The  Accessory  Sinuses. — Hollowed  out  of  the  bones  surround- 
ing the  nasal  fossx  are  four  caviUes  filled  with  air,  known  as  the 
maxiUary,  frontal,  ethmoid,  and  sphenoid  sinuses.  These  accessory 
sinuses  are  lined  with  a  thin,  pale,  mucous  membrane  continuous 
with  that  of  the  meatus  into  which  each  sinus  respectively  opens. 


*    338. — Cross-section  of  the  maxillary  sEnuses,  showing  the  close  relation  of  the 
roots  of  the  molar  teeth  to  the  floois  of  the  sinuses.     (After  ZuckerkaQdl.) 

^^^  function  of  the  sinuses  is  to  give  resonance  to  the  voice  and  at 

^   same  time  add  to  the  lightness  of  the  skull. 

The  maxillary  sinus,  or  antnmi  of  Highmore,  Ues  to  the  outer  side 

J  J      the  nasal  fossa,  occupying  the  greater  portion  of  the  superior  max- 

j     ^*y  bone.     It  is  the  largest  of  all  the  accessory  sinuses.     In  shape 

*"esembles  a  three-sided  pyramid,  with  the  apex  at  the  zygomatic 

•■j^^^ess  of  the  maxilla,  and  the  base  directed  toward  the  nasal  cavity. 

»^**c  roof  of  the  antrtim  is  very  thin  and  forms  the  floor  of  the  orbit. 

**«  anterior  wall  is  directed  toward  the  face  and  corresponds  to  the 

^^■*aine  fossa  externally.    The  floor,  which  is  directed  toward  the 

^'^■^^uth,  is  formed  by  the  alveolar  margin  and  outer  portion  of  the  hard 

^^-late.     The  roots  of  the  molar  teeth  almost  protrude  through  the 

*^*«r  into  the  antrum  (Fig.  337),  being  often  separated  from  the 

^^•"vity  by  a  thin  shell  of  bone,  or  merely  mucous  membrane,  so  that 


362  THE  NOSE  AND  ACCESSORY  SINUSES 

ulceration  of  the  teeth  may  readily  lead  to  infection  of  thesiiiu 
This  anatomical  arrangement  is  sometimes  taken  advantage  of  i 
draining  the  antrum,  a  tooth  being  extracted  and  the  sinus  openi 
through  the  alveolus. 

Ordinarily,  the  antrum  has  a  capacity  of  about  4  drams  (15  cc 
but  its  size  varies  greatly,  and  in  the  same  individual  the  two  sid 
are  frequently  disproportionate.  The  antnmi  communicates  wi 
the  middle  meatus  by  an  ostium  opening  into  the  infimdibulum,  a 
thence  through  the  hiatus  semilunaris.  This  aperture  cannot 
seen  until  the  middle  turbinate  has  been  removed.  In  a  small  p 
centage  of  cases  an  accessory  ostium  is  found  lying  posterior  to  t 
main  opening. 

The  Frontal  Sinus. — The  frontal  sinuses  are  two  air  spaces  sq 
rated  from  each  other  by  a  septimi,  lying  between  the  tables  of  t 
frontal  bones  above  the  orbits.  Each  consists  of  a  vertical  porti 
passing  upward  on  the  forehead  and  a  horizontal  portion  extendi 
backward  over  the  roof  of  the  orbit.  Their  size  is  variable  and  tli 
are  often  imequal  through  deflection  of  the  septum  to  one  su 
Cases  have  been  observed  with  one  sinus  entirely  absent.  The  flc 
of  the  sinus  forms  by  its  external  portion  the  roof  of  the  orbit,  and 
its  inner  portion  the  roof  of  some  of  the  anterior  ethmoidal  cd 
The  latter  part  of  the  floor  is  extremely  thin,  so  that  suppuration 
the  frontal  sinus  is  liable  to  extend  to  the  anterior  ethmoidal  cd 
The  posterior  wall  separates  the  sinus  from  the  frontal  lobes  of  t 
brain  by  an  extremely  thin  plate  of  bone.  The  anterior  wall  is  thi 
and  is  represented  externally  by  the  superciliary  ridge.  In  t 
posterior  portion  of  the  floor  of  the  sinus  is  the  rounded  or  o^ 
aperture  leading  into  the  infundibulum  and  thence  to  the  mid( 
meatus  by  means  of  the  hiatus  semilunaris. 

The  ethmoidal  cells  lie  in  the  lateral  masses  of  the  ethmoid  boi 
These  cells  vary  in  size  and  number.  They  are  divided  into  t) 
sets,  anterior  and  posterior.  The  anterior  open  into  the  midc 
meatus,  generally  by  the  infundibulum,  while  the  posterior  set  op 
into  the  superior  meatus.  These  cells  are  separated  from  the  crani 
cavity  and  orbit  by  extremely  thin  plates  of  bone. 

The  sphenoidal  cells  are  situated  in  the  body  of  the  sphenoid  bo 
close  to  the  base  of  the  skull.  They  are  quadrilateral  in  shape  aj 
variable  in  size,  and,  like  the  frontal  sinuses,  they  may  be  asymmet 
cal  from  deviation  of  the  septum.  The  anterior  wall  looks  downwa 
and  forward  and  forms  a  part  of  the  roof  of  the  nasal  cavity.  T 
upper  wall  is  very  thin  and  separates  the  sinus  from  the  cran 


RHINOSCOPY  363 

cavity.    The  cells  communicate  with  the  nasal  cavity  through  an 
opening  situated  above  and  behind  the  superior  turbinate. 


Diagnostic  Methods 

Prior  to  making  an  internal  examination  of  the  nasal  cavities, 
careful  notes  should  be  taken  of  the  patient's  history  and  symptoms, 
for  future  reference,  and  a  thorough  inspection  should  be  made  of  the 
external  nose.     On  general  inspection  one  should  note  the  shape  of 
the  nose,  with  reference  to  signs  of  cretinism,  syphilis,  new  growths, 
deviations,  or  deformities.    The  shape  of  the  jaws  also  should  be 
observed;  likewise  the  presence  or  absence  of  any  prominences  or 
bulging  in  the  neighborhood  of  the  accessory  sinuses;  the  presence  or 
absence  of  enlarged  cervical  glands;  the  presence  of  excoriations, 
herpes,  or  crusts  about  the  anterior  nares  and  upper  lip,  as  indica- 
tions of  nasal  discharge.    It  should  be  ascertained  whether  the 
patient  breaths  through  the  mouth,  and  the  patency  of  the  nose 
should  be  tested  by  alternately  closing  each  nostril  with  the  finger 
^hfle  the  patient  breaths  through  the  opposite  one.    The  odor  of  the 
breadth,  the  presence  or  absence  of  marked  movement  of  the  alae  nasi,  or 
^^y  sounds  produced  during  nasal  breathing,  and  the  character  of  the 
voice  should  also  be  carefully  noted.     Having  completed  this  pre- 
^^^ninary  examination,  that  of  the  interior  of  the  nose  may  be  pro- 
ceeded with. 

For  an  examination  of  the  nasal  cavity  and  accessory  sinuses 
^^^  methods  are  available:  namely,  (i)  inspection  or  rhinoscopy; 
^^)    probing;  (3)  palpation;  (4)  transillumination;  and  (5)  skiagraphy. 

RHINOSCOPY 

Inspection  of  the  interior  of  the  nose  may  be  performed  by 
^^t-erior  and  by  posterior  rhinoscopy.  In  anterior  rhinoscopy  the 
^^a-xnination  is  made  through  the  anterior  nares  with  the  aid  of  a 
^^ table  speculum  and  a  strong  light.  Posterior  rhinoscopy  consists 
^^  an  examination  of  the  nose  from  within  the  pharynx  by  the  aid 
^f  reflected  light  and  a  rhinoscopic  or  small  laryngeal  mirror.  The 
^^riner  is  simple  and  requires  no  great  skill,  but  the  latter  is  by  no 
^^^ans  an  easy  procedure  for  one  not  specially  trained,  and  at  times 
^^cjuires  considerable  patience  on  the  part  of  the  operator  to  com- 
plete successfully  and  satisfactorily. 

Illumination. — To  obtain  a  satisfactory  view  of  the  interior  of  the 
^^se,  it  is  necessary  to  have  good  illumination.     Strong  sunlight 


364  TEE  NOSE  AND  ACCESSORY  SINUSES 

may  be  utilized  for  anterior  rhinoscopy,  but  it  is  not  suitable 
examination  of  the  posterior  nares.  A  Welsbach  burner  fitted 
mica  chimney,  over  which  is  placed  a  Mackenzie  condenser 
excellent  illumination  (Fig.  339).  Electric  light  from  a  I 
lamp  is  also  much  used  and  has  an  advantage  in  that  it  dc 
give  out  much  heat. 

Whatever  the  form  of  light,  it  should  be  so  arranged  i 
suitable  bracket  that  it  may  be  raised,  lowered,  or  turned  fro 


Fic.  33(). — Gas  lamp  upon  an  adjustable  stand  fitted  with  a  Mackeniie  cond 

to  side  without  inconvenience  to  the  operator.  The  light  sho 
placed  upon  the  patient's  right,  somewhat  behind  him,  and 
on  a  level  with  the  tip  of  his  ear. 

Many  operators  prefer  an  illumination  furnished  by  aa  de 
head  Ught  (Fig,  340).  Such  a  light,  with  the  current  fumishe* 
a  small  pocket  storage  battery  will  be  found  a  great  conve 
outside  the  examining  room. 

Instruments. — In  addition  to  a  suitable  light,  there  will 
quired:  a  concave  head  mirror,  about  3)-^  to  4  inches  (9  to  i' 
in  diameter,  with  a  large  central  eye-hole,  and  secured  to 
leather  headband  by  a  ball-and-socket  joint;  a  rhinoscopic  : 


RHINOSCOPY 


365 


yi  inch  (i  cm.)  in  diameter,  set  at  an  angle  of  100  to  no  degrees 
with  the  shaft,  which  is  curved  to  follow  the  line  of  the  tongue;  a 
Myles  soHd-blade  nasal  speculmn;  a  Fraenkel  tongue  depressor;  a 
^^te  palate  retractor;  and  a  nasal  applicator  with  a  triangular- 
%)ed  shaft  (Fig.  341). 


Fio.  340. — Electric  head  light. 


^IG.  541. — Instruments  for  rhinoscopy,     i,  Alcohol  lamp;  2,  rhinoscopic  mirror; 
^»    ^^^te's  palate  retractor;  4,  Myles'  nasal  speculum;  5,  head  mirror;  6,  nasal  appli- 
►r;  7,  Fraenkel's  tongue  depressor. 


Asepsis. — Instruments,    such    as    tongue    depressors,    specula, 

applicators,  etc.,  may  be  sterilized  by  boiling.     The  rhinoscopic 

^'^rrors,  however,  which  are  soon  destroyed  by  boiling,  may  be 

sterilized  by  immersion  in  a  solution  of  i  to  20  carbolic  acid  and 

^en  wiped  dry  before  using. 


i 


366 


THE  NOSE  AND  ACCESSORY  SINUSES 


Position  of  the  Patient. — The  patient  is  seated  upright  upon  a 
firm,  straight-backed  chair.     The  examiner  sits,  facing  the  patient, 
upK)n  an  adjustable  seat,  such  as  a  piano  stool,  which  may  be  readily 
raised  or  lowered  according  to  the  height  of  the  patient. 

Technic. — i.  Anterior  Rhinoscopy, — The  operator  adjusts  th« 
head  mirror  in  such  a  way  that  the  central  opening  is  opposite  his 
left  eye  and  the  light  is  reflected  into  the  nostrils  of  the  patient    Th.o 
outline  of  the  anterior  nares  is  then  brought  into  view,  and  th^ 
relative  size  of  the  two  fossae  may  be  appreciated.     Care  should 
taken  to  look  for  fissures,  abrasions,  or  pimples  on  the  inner  surface 
of  the  vestibule  of  the  nose,  contact  with  which  would  make  the  ici.— 
troduction  of  the  speculum  painfid,  without  preliminary  cocainiza* — 

tion.  The  speculum  is  then  introducescii 
with  the  blades  closed,  and,  upon  slid — 
ing  them  apart,  the  necessary  amouis.'ti 
of  dilatation  is  obtained  (Fig.  342). 

The  inspection  of  the  cavity  shoul^l 
proceed    from    before    backward,  tt».^ 
light  being  thrown  into  all  recesses.    R  y 
slightly  elevating  the  tip  of  the  nos-^» 
the  floor  of  the  nose,  the  inferior  turl>i^ 
nate,    and    the    inferior    meatus   ax~^ 
brought  to  view.     In  some  cases  whe*"^ 
the  nose  is  very  broad  or  the  inferior 
turbinate  small  or  shrunken,  it  may 
even  be  possible  to  see  as  far  bacJt 
as   the   posterior   wall    of    the    naso- 
pharynx.    By   bending  the  patient's  head  backward  and    raising 
the  chin,  the  middle  meatus  and  the  middle  turbinate  may  be  seen ;  only 
when  the  latter  has  been  removed,  or  is  very  much  atrophie^lf 
however,  is  it  possible  to  obtain  a  view  of  the  apertures  leading  'to 
the  accessory  sinuses.     Tilting  the  patient's  head  still  further  back' 
ward  exposes  to  view  the  upper  portion  of  the  middle  turbinate  and  tb^ 
roof  of  the  nose.     Occasionally  the  opening  of  the  sphenoidal  sia*^ 
may  be  made  out,  but  only  in  exceptional  cases  is  it  possible  to  see  tb^ 
superior  turbinate. 

By  the  direct  application  of  cocain  or  adrenalin  to  the  muca^^ 
membrane  with  cotton  pledgets  or  by  spraying,  the  membrane  msy 
be  caused  to  shrink  and  a  more  satisfactory  view  of  the  structure^ 
within  the  nose  may  be  obtained.     This  is  especially  useful  whwetb^ 
nasal  cavity  is  narrow  or  the  turbinates  -are  hypertrophied. 


^- 


FiG.  342. — Myles*  speculum  in 
place. 


3«7 

Secretions  that  obstruct  the  view  are  gently  wiped  away  by 
means  of  a  cotton-wrapped  nasal  probe  or  applicator.  The  appear- 
mce  and  general  condition  of  the  mucous  membrane  are  thus  in- 
spected and  the  apparent  source  of  any  discharge  noted.  In  general, 
pits  in  the  middle  meatus  means  that  the  frontal  or  maxillary  sinus 
or  anterior  ethmoidal  cells  are  involved,  as  they  all  drain  into  this 
recess;  while  a  discharge  seen  in  the  space  between  the  middle  tur- 
binate and  septum  dgnifies  infection  of  either  the  sphenoidal  or  pos- 
terior ethmoidal  cells.    To  ascertain  exactly  which  sinus  is  involved, 


Fic,  343. — Showing  Ihr  method  of  performing 


Irecjuently  other  aids  to  diagnosis,  as  probing,  transillumination,  or 
skiagraphy,  must  be  employed. 

The  attention  of  the  examiner  is  finally  directed  to  the  bony  and 
cartilaginous  portions  of  the  nose.  Deviations,  ulcerations,  perfora- 
tions, and  spurs  of  the  septum,  contracture  or  hypertrophy  of  the 
twbinal  bodies,  the  presence  of  foreign  bodies,  the  presence  of  new 

S^ow-ths  and  their  point  of  attachment,  etc.,  etc.,  are  in  a  general 

'■ay  the  conditions  to  be  looked  for. 

a .  Posterior  Rhinoscopy. — The  operator  adjusts  the  head  mirror 

°^«r  his  left  eye  so  that  the  light  is  thrown  upon  the  patient's  mouth. 


Th. 


Md 


■e  patient  is  instructed  to  open  the  mouth,  and  a  tongue  depressor 


between  the  thumb  and  the  index  and  middle  fingers  of  the  left 


$6&  THE   NOSE   AND  ACCESSOKY   SINUSES 

hand,  is  inserted  and  passed  over  the  dorsum  of  the  tongue  ustQ  the 
tip  of  the  instrument  rests  just  behind  its  arch.  The  tongue  istiien 
drawn  downward  and  forward  into  the  floor  of  the  mouth  (Fi;. 
344) .  If  care  be  taken  not  to  insert  the  depressor  too  far  and  to  aviil 
pushing  back  on  the  tongue,  gagging  will  be  prevented.  Aminwof 
suitable  size  is  then  warmed  and,  with  the  light  reflected  upon  the 
posterior  pharyngeal  wall,  the  mirror  is  gently  introduced  into  tlie 
mouth,  lightly  held  between  the  thumb  and  forefinger  of  the  liglit 
hand  with  its  metal  surface  directed  toward  the  tongue.    The  wnar 


Fig.  344.— First  step  in  posterior  rhinoscopy,  inserting  the  tougue  deprwsor 


should  then  be  carefully  carried  back  into  the  nasopharynx,  avoidU*? 
the  back  of  the  tongue,  the  palate,  and  uvula.  After  the  instru- 
ment has  entered  the  nasopharyngeal  space,  a  clear  view  of  the  pOS- 
terior  ends  of  the  turbinates  and  the  other  postnasal  structures  ^*^ 
be  obtained  by  depressing  the  handle  of  the  instrument  slightly  s* 
that  the  upper  border  of  the  mirror  lies  behind  the  soft  palate.  ^ 
the  same  time,  the  handle  of  the  mirror  should  be  so  held  towa*^ 
the  left  angle  of  the  patient's  mouth  that  illumination  is  not  interfere*-^ 
with  (Fig.  345). 

It  should  be  remembered  that  it  is  not  possible  to  obtain  a  viewf^ 
the  whole  postnasal  space  at  one  time,  but,  on  turning  the  mirror  u* 


RHINOSCOPY  369 

various  direcdoQs  by  rotating  its  liandle,  different  portions  may  be 
brou^t  into  view  and  the  entire  space  may  thus  be  examined  in 
detail.  By  first  holding  the  handle  of  the  instrument  well  up,  the 
vault  of  the  pharynx  will  be  brought  into  view,  and  the  presence  or 
absence  of  adenoids  or  other  tumors  may  be  ascertained.  The 
pharyngeal  vault  is  usually  smooth  and  dome-shaped,  but  it  may  be 
almost  completely  filled  up  and  show  depressions  and  elevations 
d^>eiiding  on  the  size  and  condition  of  the  pharyngeal  tonsil.  On 
depr^ang  the  handle  slowly,  the  posterior  nares  may  be  examined 
la  detail  from  above  downward.    In  the  median  line  is  seen  the  sep- 


Fio.  345.  Fic.  346. 

■^^O-  34S- — Showing  the  rhinoscopic  mirror  in  place. 

^10,  346. — Posterior  rhinoscopic  image,  i.  Root  of  pharynx;  a,  iiv\i[&;  3,  soft 
P*^*-**;  4>  opening  of  Eustachian  tube;  s,  superior  turbinate;  6,  middle  turbinate;  7, 
■^erior  turbinate. 

tuin;  on  dther  outer  wall  from  above  downward  will  be  seen  the 
'idge  of  the  superior  turbinate,  with  the  superior  meatus  lying  just 
below  as  a  darkened  depression.  Below  this  will  be  observed  the 
'•uddle  turbinate  as  a  pinkish-white  fusiform  body,  and,  underlying 
^^j  the  middle  meatus.  The  inferior  turbinate  appears  just  below 
^s  as  a  grayish-white  body.  Finally,  by  turning  the  mirror  to  either 
^^^,  the  orifices  of  the  Eustachian  tubes  and  the  Eustachian  cushions 
f  c  brought  to  view.  Care  should  be  taken  not  to  keep  the  mirror 
^  the  throat  too  long  or  the  patient  will  be  tired  out;  to  make  a 
'^'^^plete  examination,  it  is  better  to  reinsert  it  more  than  once  if 


In  some  cases  it  may  be  almost  an  impossibility  to  make  a  satisfac- 
^ry  posterior  rhinoscopic  examination.     This  may  be  from  the  for- 


370 


THE  NOSE  AND  ACCESSORY  SIKDSES 


mation  of  the  parts,  as,  for  example,  in  the  presence  of  a  hard  palate 
which  extends  so  far  back  that  there  is  no  room  for  the  niirror,  ot  i 
broad  soft  palate  with  a  long  uvula,  or  it  may  be  due  to  the  piesous 
of   a   growth  in   the  nasopharynx.     The  most  common  obstade, 
however,  is  the  involuntary  elevation  of  the  sof  tpalateon  theintrodac- 
tion  of  the  mirror,  so  that  the  view  of  the  parts  above  is  blocked,    liv- 
structing  the  patient  to  breathe  through  the  nose  with  the  mouth opex^ 
or  to  pronounce  "en"  with  strong  nasal  sound,  of  ten  suffices  to  ovea> 
come  this  impediment.     In  other  cases  it  will  be  necessary  to  u 
palate  retractor,  such  as  White's.   After  applying  cocain  to  the  paLs 
the  wire  palate  loop  of  the  instrument  is  passed  behind  the  soft  p 


Fig.  347. — WHte's  palate  retractor  in  place. 


■  and  the  stem  of  the  instrument  so  adjusted  as  to  draw  the  palate  wc^ 
forward  into  the  desired  position.  The  instrument  is  maintained  1* 
position  by  means  of  the  wire  loops  which  rest  within  the  noS* 
(Fig-  347)- 


INSPECTION  OF  THE  NASOPHARYNX  BT  MEANS  OF 
HAYS  PHARYNGOSCOPE 

To  overcome  the  difficulties  encountered  in  examining  the  naso--^^ 
pharynx  with  a  rhinoscopic  mirror,  Hays  has  devised  an  instrumeoti^^^^ 
made  on  the  plan  of  an  indirect  view  cystoscope,  which  he  calls  the      " 


INSPECTION    OF   THE    NASOPHARYNX 


371 


With  this  instrument,  the  use  of  which  requires 
wne  of  the  skill  necessary  for  the  ordinary  posterior  rhinoscopic 
exsmination,  it  is  possible  to  obtain  a  clear  picture  of  the  nasophar- 
yoi,  posterior  nares,  Eustachian  tubes,  as  well  as  the  larynx  with- 
out tiie  slightest  discomfort  to  the  patient.  Furthermore,  as  the 
various  structures  are  brought  to  view  they  may  be  inspected  in  a 
Very  sj-stematic  and  thorough  manner  and  with  the  avoidance  of  any 
liiste,  as  the  instrument,  once  inserted,  may  be  left  in  place  anywhere 
from  five  to  twenty  minutes,  during  which  time  its  position  need  not 

fce  changed. 

Instruments. — All  that  is  required  is  the  pharyngoscope  and  a  six- 

diy-ceil  battery.     The  instrument  is  made  in  the  form  of  a  tongue 


Fic.  348, — Haj-s'  pfiarynKostoiJC. 

"^pressor,  the  horizontal  portion  of  which  is  flattened  in  its  inner 
"^thirds,  and  in  its  widest  part  measures  less  than  ?§  inch  (1.6 
****•)■  It  contains  a  central  tube  into  which  a  movable  telescope  fits 
*****  also  two  wire  carriers.  At  the  distal  end  of  the  instrument  are 
P'aced  two  lamps,  one  on  each  side  of  the  telescope.  On  the  cir- 
^**uference  of  the  eye-piece  of  the  telescope  is  a  small  metal  guide, 
^  indicate  the  direction  in  which  the  lens  is  turned.  The  length  of 
^^  horizontal  portion  Including  the  telescope  is  about  8  inches  (20 
^^-).  The  vertical  portion  or  handle  of  the  instrument  contains  the 
^**es  which  carry  the  current  to  the  lamps.  Near  its  upper  end  is 
'^ced  a  switch  for  turning  on  or  off  the  current  (Fig.  348). 

Asepsis. — The  instrument  must  be  thoroughly  sterilized  before 
^^.    This  is  accomplished  by  means  of  formalin  vapor  or  by  ii 


'  Harold    Hays,    in    the    Ncv; 
**>»(M«o^  July,  1909. 


York   Mfdkal    Journal,    April   ig,  1909,  and  the 


373  IHE  NOSE  AND  ACCESSOKY  SINUSES 

sion  in  a  I  to  20  carbolic  acid  solution  followed  by  linsing  in  ak 
or  sterile  water.    It  will  not  stand  boiliiif 
A.^\  Anesfliesia. — As  a  rule,  anesthesia  is 

'xTTT^^:^  necessary.    Should,   however,  ga^ng  b« 

duced    by    the    instrument,    the    post 
pharyngeal  wall  may  be  cocaimzed. 

Technic. — The  patient  is  instructo 
open  his  mouth  widely  and  breathe  qui 
The  instrument  is  then  inserted  in  the  ; 
manner  as  a  tongue  depressor,  until  its  d 
end  lies  about  He  inch  (1.5  mm.)  from 
pharyngeal  wall  (Fig.  349).  The  instrui 
is  kept  steadily  in  place  upon  the  ton 
and  the  patient  is  told  to  close  the  m 
and  breathe  through  his  nose.  This  pnxj 
relaxation  and  consequent  widemng  of 
r349.-Shou-ing    pharynx  and  nasopharynx.    The  light  is 

the  method  of  inserting    tumed   OH,    and   the   examiner   inspects 

the  Hays  pharyngoscope  structures  as  they  are  separately  brougl 
view  by  rotation  of  the  telescope.  Thus 
the  lens  pointing  upward,  as  shown  by 

knob  on  the  eye-piece,  the  pharyngeal  vault  is  brought  to  1 


(after   Hays    Am.    Jour. 
Surg.,  May,  1909). 


Fig.  350. — Showing  the  pharyngoscope  in  place  nith   the 
postnasal  space. 


and,  by  tilting  the  distal  end  of  the  instrument  slightly  1 
the  posterior  nares  are  viewed. 


PALPATION  BY  THE  PROBE 


373 


To  inspect  the  region  of  the  Eustachian  tubes,  the  lens  is  rotated 

about  30  degrees  to  one  side,  when  the  orifices  of  the  tubes,  Rosen- 

znfiJler's  fossa,  etc.,  will  be  dearly  shown.    By  rotating  the  lens  so 

that  it  points  downward  the  epiglottis,  larynx,  and  base  of  the  tongue 

are  similarly  inspected. 


PALPATION  BY  THE  PROBE 

The  use  of  the  probe  is  essential  to  a  complete  examination  of  the 
nose*  By  its  aid  the  consistency  and  character  of  structures  norm- 
ally present,  as  well  as  the  presence  of  abnormal  growths,  adhesions, 
for^^n  bodies,  and  the  patency  or  obstruction  Of  the  openings  lead- 
ing "to  the  accessory  sinuses,  may  be  determined. 

Izistruments. — The  instruments  comprise  those  necessary  for  a 
rhincDscopic  examination;  a  nasal  applicator;  a  nasal  probe;  and  a 
probe  (Fig.  351). 


lo 


IG.  351. — Instruments  for  palpating  the  interior  of  the  nose,     i,  Nasal  applicator; 
1  probe;  3,  sinus  probe;  4,  Myles'  nasal  speculum;  5,  head  mirror. 

The  nasal  probe  should  be  of  silver,  fairly  stiflF,  but  at  the  same 

«  capable  of  being  bent.     It  should  be  about  8  inches  (20  cm.) 

^,  and  set  into  its  handle  at  an  angle  of  135  degrees. 

The  instrument  employed  for  examination  of  the  sinuses  must  be 

X^ure  soft  silver  and  fine  in  size  so  that  it  may  be  readily  bent  to 

curve  or  be  adjusted  to  the  shape  of  the  region  through  which  it 

to  pass. 

Asepsis. — The  speculum,  applicator,  and  probes  are  sterilized  by 
ling. 

Anesthesia. — The  nasal  mucous  membrane  is  very  sensitive  and 
nipulatJons  are  apt  to  produce  sneezing,  so  that  the  parts  should 
cocainized  before  the  probe  is  employed.     This  may  be  done  by 
replying  a  4  per  cent,  solution  on  a  small  pledget  of  cotton,  allowing 


374  THE  NOSE  AND  ACCESSORY  SINUSES 

sufficient  time  to  elapse  for  the  cocain  to  take  effect  before  pioceei^ 
with  the  ezammation. 

Position  of  Patient. — The  positions  of  the  patient  and  i^>eratOT 
are  the  same  as  for  a  rliinoscopic  examination  (see  page  366). 

Technic. — By  means  of  a  speculum  and  reflected  light  the  inter- 
ior of  the  nasal  cavity  is  brought  into  view  and  is  then  systemati- 
cally  explored  by  the  probe.    Any  growths  are  palpated  to  detcnninc 
their  consistency,  and  masses  that  may  be  hidden  beneath  the  turbi- 
nates and  otherwise  escape  attention  may  be  rolled  into  viewbymta 
of  the  probe.     The  condition  of  the  mucous  membrane,  the  presoice 
and  depth  of  ulcerations,  etc.,  are  ascertained.    All  recesses  should  t>e 
thoroughly  examined,  and  especially  the  walls  of  the  sinuses  shouW. 
be  gently  palpated  for  the  presence  of  dead  bone. 

In  the  presence  of  symptoms  or  signs  pointing  to  involvement  ol 
the  sinuses,  the  sinus  probe  should  be  employed  to  determine  ti».cai 


Fig.  351. — Showing  the  steps  in  the  passage  of  a  probe  into  the  froatal  sinus-.' 

condition  and  the  patency  of  their  ostia  as  a  preliminary  to  irrigatJ*^*"- 
On  account  of  the  anatomical  arrangement  of  the  parts,  probing  "^ 
practically  limited  to  the  sphenoidal  and  frontal  sinuses  unless  't'* 
middle  turbinate  is  first  removed.  Before  making  any  e^Ioratioi*  ** 
these  cavities,  any  visible  pus  or  discharge  is  wiped  away  and  *-*" 
nasal  cavity  cleansed  by  syringing. 

To  enter  the  frontal  sinus,  the  distal  end  of  the  probe,  bent  to  ^^ 
angle  of  135  degrees,  is  inserted  within  the  middle  meatus  at  the  ji****" 
tion  of  the  anterior  third  and  posterior  two-tiiirds  of  the  middle  f**^" 
binate.  Its  tip  is  made  to  hug  the  outer  wall  of  the  middle  turbine-*'*' 
and  is  passed  upward  and  forward  through  the  hiatus  and  into  "tl** 
infundibulum.  By  depressing  the  handle  of  the  instrument,  its  *^? 
will  traverse  the  infundibulum  and  pass  through  the  ostium  front*^* 
unless  some  obstruction  exists.     Gentleness  ^ould  be  employed  ** 


DIGITAL   PALPATION  375 

tils  maneuver,  and  no  attempt  should  be  made  to  force  the  instru- 
ment if  any  obstruction  to  its  passage  exists. 

To  enter  the  sphenoidal  sinus,  the  end  of  the  probe  is  bent  to  a 
slight  ctiTve  and  is  passed  into  the  nose  with  its  convexity  upward. 
The  tip  of  the  instrument  is  made  to  traverse  the  roof  of  the  na&al 
fossa  until  it  meets  the  resistance  of  the  anterior  sphenoidal  wall. 
The  pro  be  is  then  moved  gently  about  in  various  directions  until  its 
point  enters  the  cavity  of  the  sinus,  which  is  then  carefully  explored. 
In  e£ther  case,  when  the  probing  is  employed  as  a  preliminary  to 
inigati<3n,  and  the  particular  sinus  has  been  successfully  entered  by 
"le  prol>«.  if  the  shape  of  the  irrigator  be  made  to  correspond  to  that 
"'  the  p»robe  it  will  be  of  great  help  in  the  introduction  of  the  former. 


r 


(. — Showing  the  steps  in  the  passage  of  a  probe  into  the  sphenoidal  sini 


DIGITAL  PALPATION 

'  alpation  of  the  posteiior  nares  by  means  of  the  linger  is  employed 
to  coQiJrm  the  diagnosis  made  by  posterior  rhinoscopy,  or  to  obtain 
'^'^ation  as  to  the  condition  of  these  parts  when  the  latter  is  not 
P''_^lble,  No  instruments  are  needed,  except  in  the  case  of  unruly 
.  'dren,  when  a  mouth  gag  may  be  required.  WTiile  digital  palpa- 
^^  is  a  rather  unpleasant  procedure  for  the  patient,  if  performed 
t^'dly  and  skilfully  many  oi  the  disagreeable  features  may  be 
^^naled. 

Preparations. — The    operator's   hands    should    always   be   well 
^*llbbed  before  making  such  an  examination. 

Technic—It  is  well  to  first  explain  to  the  patient  what  is  intended 

I^  be  done.     The  patient  is  then  directed  to  open  the  mouth  widely. 

•deleft  hand  of  the  operator  supports  the  patient's  head,  and  at  the 

^tne  time  with  the  thumb  or  index  finger  of  the  same  hand  he  forces 


376  THE   NOSE   AKD   ACCESSORY  SINUSES 

the  cheek  in  between  the  open  jaws  to  prevent  the  examinmg  finger 
from  being  bitten  (Fig.  354).  The  index  finger  of  the  right  hand  ia 
then  gently  but  quickly  introduced  into  the  mouth  and  is  hooker^l 
around  the  posterior  border  of  the  soft  palate  into  the  nasopharyn:^^ 


Fig.  354. — Showing  the  method  of  palpating  the  postnasal  apace  with  the 


and  the  parts  are  palpated.  In  this  way  the  presence  of  adenc^ids, 
hypertrophies  of  the  posterior  ends  of  the  turbinates,  or  other  grow^ths 
are  readily  recognized. 

TRANSILLUMINATION 

Transillumination  is  a  valuable  aid  for  determining  the  conditi*-"' 
of  the  frontal  or  maxillary  sinuses.     Its  use  in  connection  with  ott*-*' 


<^S 


Fic.  355-— Coakley's  transilluminator.    a.  Apparatus  asserablerf  for  tnuisilluw**  ■*^' 
tion  of  the  antrum;  h,  gla.«9  hood  for  use  in  transillununation  of  the  antrum;  c,  hoo<J 
use  in  transillumination  of  the  frontal  sinus. 

sinuses  is  futile.     This  method  of  diagnosis  becomes  possible  from  t-**^ 
fact  that  the  air  spaces,  when  in  a  healthy  state,  transmit  lig-*^ 


TRANSILLUMINATION 

"**"ough  their  thin  walls,  which  power  is  diminished  when  pus  is 

P'"feseiit  or  the  mucous  membrane  lining  the  cavity  is  much  thickened. 

Transillumination  is  not  an  infallible  method,  the  chief  causes  of 

^■^cr  being  imperfect  symmetry  of  the  two  sides,  due  to  a  difference 

"^   the  size  of  the  two  sinuses  or  to  a  variation  in  the  thickness  of  the 

"'^Hy  walls.     Another  source  of  error  occurs  when  involvement  of 

'^^^th  sides  of  a  pair  of  sinuses  exists,  and  there  is  therefore  nothing 

"l^cn  which  to  base  a  comparison.     The  method  is  of  greatest  service 

,    '^   the  diagnosis  of  empyema  of  the  antrum  and  of  the  frontal  sinus. 

^  the  latter  it  is  not  so  valuable  or  nearly  so  reliable  an  aid  as  in  the 

''^»Tner,  for  the  size  of  the  two  frontal  sinuses  and  the  thickness  in  the 

^*lcli\-idual  bones  are  apt  to  vary. 


t'li-  357— Transillumination  effect  in  a. 
diseased  left  frontal  sinua. 

Apparatus. — There  are  many  lamps  adapted  to  the  purpose  of 
transillumination,  Coakley's  being  an  excellent  model.  This  con- 
sists of  a  handle  of  nonconducting  material  containing  a  lamp  and 
glass  hood  for  transillumination  of  the  maxillary  sinus,  and  a  second 
hcMxl  to  fit  over  the  lamp  in  place  of  the  glass  one,  for  use  about  the 
frontal  sinus  (Fig.  355).  The  lamps  are  of  about  four  or  five  candle- 
P*^wer,  the  electricity  being  supplied  by  a  small  battery  or  the  street 
cxxnent.  In  emploj-ing  the  latter,  a  current  controller,  by  which  the 
^**iount  of  current  may  be  regulated,  will  be  necessary. 

Tecbcic.  I.  Transillumination  of  lite  Frontal  Sinus. — The  pa- 
•^enl  is  seated  in  a  dark  room.  The  black  hood  is  drawn  over  the 
*^fanalIuminator  and  the  instrument  is  placed  beneath  the  orbital 
t**>rtion  of  the  brow  at  the  nasal  side.  The  light  is  turned  on  and  the 
^'■Tius  is  clearly  illuminated,  the  operator  noting  the  effect.  The 
*-*Pposite  side  is  treated  in  the  same  manner,  and  the  two  are  cora- 
t^^red  as  to  the  intensity  with  which  the  light  is  transmitted. 

Through  a  large  sinus  in  a  normal  condition  the  light  is  trans- 


378  TITE   NOSE   AND   ACCESSORY   SINTL'SF-S 

mitted  with  greater  intensity  than  through  a  small  cav-ity,  or  through 
one  with  thickening  of  the  bony  walls  or  the  lining  membrane,  or  one 
complicated  by  the  presence  of  pus  or  a  tumor. 

2.  Transillumination-  of  the  Antrum.-^Thc  patient  is  seated  in.    »■ 
darkened  room,  any  dental  plates  or  obturators  that  might  obstna*:*- 
the   light   having   been   previously   removed.     The   electric   lair»-I>' 
covered  with  the  glass  hood,  is  then  introduced  into  the  mouth,  ai"**^ 
the  patient  is  instructed  to  close  his  lips  firmly.     Under  normal  cc**^*-" 
ditions  when  the  lamp  is  lighted,  the  cheeks,  up  to  the  infraorbic^^*^' 
margins,  and  both  pupils  are  clearly  illuminated.     If  one  antrum  ct^  -»^^' 
tains  pus  or  a  solid  tumor,  the  malar  region  of  that  side  will  appe^  -^^w 


Fio.  35S.— Trnnsilluminatio 
in  the  nnrmal  case.  (Afttr 
Smith,  in  Keen's  Surgery.) 


Fic.  359.— Transilluminalion  cf 
in  sinusitis  of  the  right  antrum.  i\ 
Harmon  Snuth,  in  Keen's  Surgery.) 


darker  and  an  absence  of  illumination  of  the  pupil  will  be  noted.    TX^e 
transmission  of  light  will  also  be  interfered  with  in  the  presence 
thickened  walls  or  lining  mucous  membiane. 


SKIAGRAPHY 

The  X-ray  gives  important  information  in  regard  to  the  fronts 
ethmoid,  and  maxillary  sinuses,  and,  when  possible,  it  should  be  reg»-J- 
larly  employed  as  one  of  the  aids  in  diagnosis.     To  be  of  any  valii* 
however,  it  must  be  applied  by  a  competent  radiographer.    It  i-* 
especially  valuable  in  diseases  of  the  frontal  sinuses.     In  a  healthy^ 
condition,  the  outlines  of  the  sinuses  are  clear  and  distinct;  while  la 


NASAX  DOUCHING 


379 


diseased  conditions  the  outlines  are  not  so  clearly  indicated  and  the 
whole  area  of  the  sinus  appears  cloudy.  In  addition  the  X-ray  will 
show  the  size  and  shape  of  the  frontal  sinus  and  the  position  of  the 
sqjtum,  all  of  which  are  important  points  in  making  a  decision  as  to 
tile  method  of  operating,  should  it  be  necessary.     To  determine  the 


si^e  of  a  sinus  it  Is  necessary  to  take  two  p 
other  full  face. 


e  in  profile  and  the 


^^^asa 


Therapeutic  Measures 
NASAL  DOUCHING 


WtsaX  douching  is  employed  for  the  purpose  of  cleansing  the  nasal 
^"Vity  prior  to  operative  procedures  or  for  the  purpose  of  removing 
pyTfitinm  or  crusts  preparatory  to  the  application  of  other  remedies. 


*«^ 


^^  Jnust  always  be  used  with  due  precautions,  for  there  is  considerable 
•^sli  where  fluid  is  forced  into  the  nose  in  bulk  that  some  of  it  will  enter 
•^e  Eustachian  tubes  and  cause  an  otitis  media.  For  this  reasoQ 
f*'*^ly  small  quantities  of  solution  are  employed  at  a  time,  and  the 
^j€cUoo  should  be  made  without  any  force.  If  one  side  of  the  nose 
^'^  obstructed,  the  solution  should  enter  by  that  nostril  and  escape 
'"'^m  ihe  more  open  one.  As  a  further  precaution,  any  excess  of  fluid 
^'^iBaining  after  the  irrigation  should  be  allowed  to  flow  from  the  nose 
^f  be  drawn  into  the  mouth  and  expectorated,  but  not  blown  from  the 
**■>«  for  fear  of  forcing  some  into  the  Eustachian  tubes.     For  the 


38o 


THE   NOSE   AND  ACCESSORY   SINUSES 


patient's  own  use  nasal  spraying  is  a  safer  method  to  employ,  and,  if 
it  becomes  necessary  to  prescribe  a  nasal  douche,  the  surgeon  should 
carefully  instruct  the  patient  in  the  proper  method  of  its  use. 

Apparatus. — ^An  ordinary  douche  bag  with  a  capacity  of  about  a 
pint  (500  cc),  fitted  with  a  nasal  nozzle,  forms  a  simple  and  eflfective 
douche.    There  are  a  number  of  douches  especially  made  for  the 
nose,  a  convenient  type  for  use  with  large  quantities  of  solution  bring 
shown  in  Fig.  360.     It  consists  of  a  pint  bottle  to  the  bottom  of  which 
is  attached  a  rubber  tube  fitted  with  a  nasal  nozzle.     The  small  glass 
douche  (Fig.  361),  known  as  the  "Bermingham  douche,"  is  useiul 
where  the  cleansing  is  to  be  carried  out  by  the  patient. 

Solutions. — For  ordinary  cleansing  purposes  the  solution  slxo\iiA 
be  alkaline  and  as  imirritating  as  possible. 

One  of  the  following  formulae  may  be  employed. 


Q.  Sodii  bicarbonatis, 
Sodii  biboratis, 
Acidi  carbolid, 
Glycerini, 
Aquaj, 

R.  Sodii  bicarbonatis, 
Acidi  salicylici, 
AqusB, 

R.  Sodii  bicarbonatis, 
Sodii  biboratis, 


aa.  dr.  i  (4  gm.) 
TTlxv  (i  c.c.) 
oz.  i  (30  C.C.) 
q.   s.   ad.      Oi  (500  c.c.)    M- 

dr.  i  (4  gm.) 
gr.  X.  (0.65  gm.) 
q.  s.  ad.         Oi  (500  c.c.)    M. 


SI.  oz.  i  (30  C.C.)  M. 


Sodii  chloridi, 
Sig.  A  teaspoonful  to  a  pint  of  warm  water 

Some  of  the  proprietary  preparations,  such  as  listerin,  borol 


tol, 


glycothymolin,  alkalol,  etc.,  will  be  found  of  value  where  an  anticrg^^tic 


Fig.  361. — ^The  Bermingham  nasal  douche. 


action  is  also  desired.  They  may  be  used  in  the  proportion  of 
to  dr.  i  (2  to  4  c.c.)  to  the  ounce  (30  c.c.)  of  water.  When 
is  an  offensive  discharge,  the  following  may  be  employed. 


Q.  Potassii  permanganatis, 
Aquas, 


gr.  i— ii  (0.06-0.1 
ad.  oz.  i  (30  C.C.) 


.ss 
ere 


NASAL   DOUCHING  381 

TenqMntore. — AH  solutions  should  be  used  warm,  at  a  tempera- 
ture of  about  100°  F.  (38°  C.)- 

Quantl^. — For  ordinary  cleansing  purposes  or  for  the  removal 
of  free  secretion  from  the  nose,  a  few  oxmces  of  solution  are  sufficient. 
Vben  hard  crusts  are  abundant,  however,  it  sometimes  requires  a 
fiat  (500  C.C.)  of  solution,  or  more,  to  loosen  them  and  effect  their 
lemovaL 

Ri^dity  of  Flow. — The  solution  should  be  injected  with  only 
sufficient  force  to  permit  its  return  from  the  opposite  nostril  in  a  slow, 


Fig.  3G3. — Showing  the  method  of  using  the  nasal  douche. 

'™tle  stream — never  under  high  pressure.    Accordingly,  thereser- 
-  ^  should  be  raised  only  2  or  3  inches  (5  to  7,5  cm.)  above  the  level 
*lie  nose. 

Technic. — The  patient  sits  with  his  head  bent  sUghly  forward 

^''  a  basin  or  sink,  with  a  towel  or  napkin  placed  about  his  neck  for 

*^tection  of  the  clothes.    The  douche  nozzle,  held  in  the  right 

*id,  is  then  inserted  into  one  nostril  with  sufficient  firmness  to  pre- 

5*  t  the  solution  from  escaping,  while  with  the  left  hand  the  reservoir  is 

*sed  a  few  inches  so  that  the  solution  enters  the  nose  in  a  weak 

■*^«am.     The  patient  is  directed  to  breathe  through  his  mouth  and 

*Void  swallowing  during  the  lavage.     In  this  way,  when  the  pa- 

^*it's  head  is  bent  forward,  the  fluid  does  not  escape  into  the 


382 


THE  NOSE  AND  ACCESSORY  SINUSES 


pharynx,  but  passes  through  one  nostril  back  into  the  nasopharynx 
and  out  through  the  other  nostril  (Fig.  362),    When  no  obstnictioriL 
exists  in  either  side,  half  the  solution  may  be  injected  through  one 
nostril  and  the  remainder  in  the  reverse  direction  through  the  othe 
With  the  small  glass  douche  cup  the  technic  is  very  simpli 
The  patient  inserts  the  nozzle  of  the  partially  filled  instrument  int-^ 
one  nostril,  holding  the  finger  over  the  side  opening.    He  then  throyw*"  i> 

his  head  well  back  and  removes  his  finger  from  the  opening,  whic \i 

allows  the  solution  to  flow  through  the  nose  into  the  mouth,  whence  ^3t 
is  expectorated.    Each  nostril  in  turn  may  be  thus  irrigated. 


i'j* 


THE  NASAL  SYRINGE 

The  nasal  syringe  is  employed  mainly  for  cleansing  the  noi 
The  solution  may  be  injected  either  from  the  front,  returning  throu; 
the  opposite  nostril,  after  the  manner  of  the  nasal  douche,  or  the  no: 
may  be  washed  out  from  behind  forward.  By  the  latter  method 
postnasal  space  may  be  more  effectually  cleansed  of  sticky  secretio 
and  mucus  than  by  injecting  the  solution  from  the  front.  The 
precautions  should  be  observed  in  using  the  syringe  as  have 
mentioned  for  the  use  of  the  douche. 

Instruments. — ^A  syringe  with  a  capacity  of  i  to  2  oimces  (30 


t 
«ns 
c 


to 


60  C.C.),  made  of  metal  or  hard  rubber,  will  be  required.    It  shoiif  ^  M 


Fig.  363. — Nasal  syringe  with  anterior  and  posterior  nasal  tips. 

be  supplied  with  a  straight  nozzle  for  injection  through  the  anterioi^ 
nares,  and  with  one  bent  up  almost  at  right  angles  for  cleansing  th 
postnasal  space  (Fig.  363). 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  page 
380  may  be  employed.     They  should  always  be  used  warm. 

Technic. — In  employing  the  nasal  syringe  much  the  same  technic 
is  followed  as  with  the  douche,  observing  due  care  against  injecting 


or 


^  THE  NASAL   SPHAY  383 

r 

i  the  solution  with  too  much  force,  etc.  The  nozzle  of  the  syringe  is 
inserted  into  one  nostril  and  the  patient  is  .directed  to  keep  his  head 
bent  well  forward  over  a  receptacle  and  to  breathe  througli  the 
mouth.  The  solution  is  then  slowly  injected  and  returns  through  the 
opposite  nostril.  The  irrigation  should  be  so  regulated  that  the  fluid 
returns  as  quickly  as  it  enters,  thus  avoiding  any  undue  accumula- 
tion in  the  postnasal  space  and  lessening  the  dangers  of  infecting 
the  Eustachian  tubes. 

To  syringe  from  the  posterior  nares,  a  tongue  depressor  is  intro- 
duced into  the  mouth  to  keep  the  tongue  out  of  the  way,  while  the 
distal  end  of  the  postnasal  tip  b  introduced  behind  the  soft  palate. 


|FiG.  364. — Showing  the  method  of  syringing  the  nose  from  behind. 


-■-"b-e  patient  is  then  directed  to  hold  his  head  well  forward,  the  fluid  is 
slo-vrly  injected  and  escapes  from  the  anterior  nares,  flushing  out  the 
I***stnasal  space  and  nose  from  behind  forward  (Fig.  364).  On 
^■*^c:ount  of  the  sensitive  condition  of  the  parts  in  some  cases  it  may  be 
^^cessary  to  cocainize  the  pharynx  and  soft  palate  before  the  syring- 
^'^■S  can  be  properly  performed. 


THE  N ASAI,  SPRAY 

Sprays  or  atomizers  are  utilized  either  for  cleansing  purposes  or 
|Oi7  the  application  of  remedies  to  the  nasal  mucous  membrane  when 
*   is  not  necessary  to  confine  the  solution  to  one  particular  spot. 

Apparatus. — The  simplest  form  of  atomizer  usually  proves  most 
*^tisfactory,  and  is  less  liable  to  get  out  of  order.    The  Whitall 


384  THE  NOSE   AKB  ACCESSORY   SINUSES 

Tatum  (Fig,  365),  the  Davidson,  or  the  De  Vilbiss  (Fig.  366)  ue 
all  good  atomizers.  The  latter  is  especially  serviceable,  aad  the 
.  spray  part,  being  of  metal,  may  be  readily  sterilized.  The  mstru- 
ment  should  be  provided  with  a  straight  nasal  tip  as  well  as  with  1 
postnasal  tip.  The  air  current  may  be  supplied  by  a  rubba  com- 
pression bulb  orfrom  a  compressed  air  tank  (Fig.  367),  lliebtB 
will  be  found  more  convenient  for  office  work. 


Fig,  365. — WhiuU  Tatum  atomizer. 

For  cleansing  purposes,  the  spray  should  be  rather  coarser  •^ 
that  employed  for  medication.  Oily  preparations  may  be  spr^s 
with  an  ordinary  atomizer  provided  with  an  oil  tip,  or  a  special 
nebulizer  may  be  employed. 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  p 
may  be  employed  in  a  spray. 


Fig.  366.— De  Vilbiss 


When  a  mild  antiseptic  action  is  desired,  the  solutions  give«i- 
page  380  or  the  following  may  be  used: 

gr.  V  (0.3  gm.) 
dr.i(4C.c) 
q,  B.  ad.  oz.  i  (30  c.c.}    M. 


1.  Acidi  carbolic! 
Glycerini, 


THE   NAS.\I.   SPRAY 


.Stringent  solutions,  for  purposes  of  lessening  secretions,  include 
such  drugs  as  zinc  suiphocarbolate,  zinc  sulphate,  copper  sulphiite, 
aium,  tannic  acid,  silver  nitrate,  etc.,  used  in  the  strength  of  5  gr, 
{0.3  gm.)    to  the  ounce  (30  c.c.)  of  water. 

Oily  preparations,  with  albolene  or  benzoinol  as  a  base,  are  fre- 
quently used  after  the  application  of  aqueous  solutions  for  the  pur- 
pose of  protecting  the  parts,  the  oil  being  deposited  upon  the  mucous 
membrane  in  a  thin  coat.  Usually  eucalyptol,  camphor,  menthol,  or 
lfi\Tnol  are  combined  with  the  oil  in  the  proportion  of  2  to  5  gr.  (o.i 


Flc.  367. — Comprmsed-Hlr  atomizing  apparati 


^'-S   gm.)  or  more  to  the  ounce  (30  c.c.)  for  the  sedative  effect,  as 
"*^   following:  I 


'^licalyptol, 

A-Icnthol, 

-"cnioinol, 

Albolene, 

Menthol, 
Mboline, 


n^  (0.6  cc.) 

gr.  V  (0.3  gm.) 
oz.  i  (30  cc.)  M. 


V  (0.3  gm.) 
i  (30  cc)  M. 


I 


aV>' 


"^^en  a  stimulating  action  is  indicated,  the  proportion  of  the 

^e  drugs  may  be  increased. 

TeeJuiic, — The  tip  of  the  nose  is  gently  raised  and  the  nozzle  of 


4» 


Spray  is  inserted  into  the  vestibule.     To  avoid  injuiing  the 


386 


THE   NOSE   AND   ACCESSORY   SINUSES 


mucous  membrane  of  the  septum  or  turbinates,  care  should  be  taken 
to  keep  the  long  axis  of  the  spray  and  that  of  the  nose  in  the  same  fine. 
By  alternately  compressing  and  relaxing  the  rubber  bulb,  the  sdutioa 
is  forced  into  the  nose  in  a  spray.    The  direction  of  the  spray  should 
be  altered  from  time  to  time  by  raising  or  lowering  the  proximal md 
of  the  atomizer. 

For   spraying  from   the  posterior  nares,   the  same   technic  is 
employed  as  with  the  postnasal  syringe  (see  page  383). 


THE  DIRECT  APPLICATION  OF  REMEDIES 

This  method  is  employed  for  the  application  of  strong  solutions  ^^ 
solid  caustics,  or  when  it  is  desired  to  confine  the  action  of  the  reti^^^ 
to  any  particular  area. 


Fig.  368. — Fusing  chromic  acid  on  a  probe.     First  step,  heating  the  probe.     (GU 


,^sonJ 


Instruments. — For  the  application  of  solutions,  a  nasal  applic^^^^' 
the  tip  of  which  is  wound  with  a  thin  layer  of  cotton,  is  employ^' 
Solid  caustics,  as  chromic  acid,  silver  nitrate,  etc.,  are  best  app*'^ 
fused  upon  a  probe  or  applicator. 

Chromic  acid  may  be  prepared  for  application  as  follows:  Tl'^ 
probe  tip  is  brought  to  a  red  heat  over  an  alcohol  flame  (Fig.  3W 
and  is  then  dipped  into  crystals  of  the  acid  (Fig.  369).     Upon  Witk' 
drawing  the  probe  a  few  cr}- stals  will  be  found  adhering  to  its  poiD^ 
This  mass  is  then  heated  in  the  flame  until  the  crystals  begin  to  incl^ 


^^^^^^^^   THE   DIRECT    .APPLICATION    OF   REMEDIES  387 

(Fig.  370),  and,  upon  cooling,  they  recrystallize  in  the  form  of  a  bend 
]    on  the  end  of  the  instrument  (Fig.  371).     If  it  is  desired  to  employ 
silver  nitrate  in  this  way,  a  few  of  the  crystals  should  be  melted  in  a 
crucible.     The  tip  of  a  probe  or  applicator  is  then  dipped  into  this 
liquid  mass  until  sufficient  of  the  caustic  adheres,  and,  as  soon  as  it 
solidifies,  it  is  ready  for  use.     In  applying  chromic  acid  a  second  cot- 
ton-wrapped applicator,  saturated  with  a  solution  of  bicarbonate  of 
soda. — 30  gr.  (2  gm.)  to  the  ounce  (30  c.c.)— should  be  at  hand  to 
JieutraJize  any  excess  of  acid. 


Fig.  369. 
'^"».  36g, — Fusing  chrumic  add  o 
*«  crystals.    (Glcason.) 

""■  370. — Fusing  chromic  aciil 
into  1  bead.     (Glcason-) 

-  3  71- — Fusing  chromic  acid  on  b  probe.     Showing  the  finished  probe. 


probe      Second  step,  dipping  the  hqt  probe  in 

a  probe.     Third  step,  heating  the  crystals 

(Cleason.) 


^ttesthesia. — The  parts  should  be  cocainized  by  the  application  uf 
»4per  cent,  solution  of  cocain. 

Technic. — The  mucous  membrane  is  well  cleansed,  and,  when 
"^  caustics,  the  area  to  be  treated  is  rendered  as  dry  as  possible  to 
prevent  the  caustic  spreading  over  too  large  a  surface.  The  appli- 
<^''on  is  then  made  to  the  diseased  spot  under  guidance  of  the  nasal 
'I'eculmn,  being  careful  not  to  allow  the  applicator  to  touch  any  other 
f^nts.  If  acid  is  employed,  any  excess  is  immediately  neutralized 
•iththe  strong  solution  of  bicarbonate  of  soda  by  means  of  an  appli- 
Olor  previously  prepared  and  in  readiness. 


n 


388 


THE   NOSE  AND   ACCESSORY   SINUSfiS 


INSUFFLATIONS 


Various  powders  with  sedative  or  antiseptic  properties  are  applied 
to  the  nasal  mucous  membrane  by  means  of  a  special  powder  blower. 
Finely  powdered  starch,  stearate  of  zinc,  or  powered  acacia  is  iisu- 
ally  employed  as  a  base,  in  the  proportion  of  two  parts  to  one  of  th© 
active  principle.    Nosophen,  aristol,  europhen,  iodoform,  iodal,  etc«i 


Fig.  372. — Powder  blower. 

are  remedies  frequently  applied  in  this  manner.     Morphin  and  cocr^ii 
in  small  doses  may  be  combined  with  these  powders  when  indica'tc^- 
Instruments. — The  insufflator  shown  in  Fig.  372  or  that  shown  i^ 
Fig.  373  may  be  used.     The  former  is  made  on  the  same  principle 
as  a  hand  spray,  but  with  larger  tubes.     It,  however,  requires   tiie 


Fig.  373. — Scoop  powder  blower. 


use  of  both  hands  in  its  manipulation.  The  latter  instrument  c 
sists  of  a  rubber  compression  bulb  to  which  is  fitted  a  vulcani^^ 
rubber  tube.  Into  this  latter  fits  the  nasal  tip,  the  proximal  enci 
which  is  made  in  the  form  of  a  scoop  for  taking  up  the  powcJ^^' 
When  the  instrument  is  filled,  a  sudden  compression  of  the  bulb  for^^ 
air  through  the  apparatus,  blowing  the  powder  out  in  front  of  it.  T*^ 
instrument  may  be  manipulated  with  one  hand,  and  the  quantity  ^ 
powder  used  can  be  accurately  measured.     Insufflators  are  supptt^ 


LAVAGE   OF  THE   ACCESSORY   SINUSES  389 

with  straight  tips  for  the  anterior  nares,  and  with  curved  tips  for 
making  applications  to  the  posterior  nares. 

For  the  patient's  use,  an  insufflator  such  as  Sajous'  (Fig.  345)  will 

be  found  convenient.    It  consists  of  a  small  glass  receptacle  with  an 

opening  for  pouring  in  the  powder,  to  one  end  of  which  a  rubber 

xnoxithpiece  is  attached,  the  other  end  being  rounded  o£f  to  fit  into  the 

nostril. 

Technic. — With  a  suitable  powder  blower,  the  application  of 
j>o^^ders  is  very  simple.  The  instnunent  being  properly  filled,  the 
tip  is  inserted  into  the  nostril  or  up  behind  the  soft  palate,  according 
to  iivhether  the  anterior  or  the  posterior  p>ortions  of  the  nose  are  to 
be    xnedicated,  and,  with  two  or  three  rapid  compressions  of  the  bulb, 


Fig.  374. — Sajous'  powder  blower. 

the  jx)wder  is  forced  out  of  the  instrument  and  is  deposited  upon  the 
mucous  membrane. 

When  the  insufflation  is  performed  by  the  mouth,  as  with  the 
Sajous  insufflator,  the  tip  is  inserted  into  the  nostril,  the  instrument 
^ing  held  with  one  finger  over  the  opening  in  the  bottom  of  the 
receptacle  to  make  it  air-tight.  The  mouthpiece  is  held  between  the 
lips  and,  by  one  or  more  gentle  puffs,  the  powder  is  blown  out  upon 
™^  parts  to  be  medicated. 

LAVAGE  OF  THE  ACCESSORY    SINUSES 

This  procedure  is  employed  as  a  means  of  diagnosis,  for  the  pur- 
pose of  removing  purulent  secretions,  and  for  cleansing  the  mucous 
Ainiixg  in  the  treatment  of  suppuration  involving  the  accessory  sinuses. 
It  is  performed  by  means  of  a  suitable  cannula  introduced  into  the 
suivxs  through  the  natural  or  .an  artificial  opening.     Treatment  by 
irrigation  is  most  successful  in  the  early  cases  of  empyema;  in  those 
complication  by  granulation  tissue  or  dead  bone,  it  is  not  so  satisfac- 
^ry .    It  should,  however,  be  given  a  trial  in  any  case  before  the  more 
radical  surgical  measures  are  considered. 

Solutions  Used. — Normal  saline  solution  (salt  3i  (4  S^-)  to  the 
pint  (^oo  c.c.)  of  boiled  water),  a  saturated  solution  of  boric  acid, 
or  any  of  ^he  solutions  mentioned  on  page  380  may  be  used. 


390  THE  NOSE   AND   ACCESSOKY   SINUSES 

Temperature. — All  solutions  employed  in  irrigating  should  be 
warm — ^at  about  ioo°  F.  (38°  C). 

Lavage  of  the  Hazillar;  Sinus. — It  is  rarely  possible  to  insot  a. 
probe  or  cannula  into  the  maxillary  sinus  through  its  Dormal  opemng, 
on  account  of  its  hidden  position  and  the  fact  that  the  opemng  is 
directed  somewhat  downward  and  forward  from  the  infundibulim- 
If  an  accessory  opening  be  present,  however,  it  may  be  possible  tx) 
irrigate  through  it,  but  in  most  cases  an  artificial  opening  will  have't^ 
be  made  through  the  inferior  turbinate,  or  through  the  alveolus  aft^ 
removal  of  the  second  bicuspid,  or  the  first  or  second  molar  tootJh- 
The  former  approach  should  be  chosen  when  the  teeth  are  sound  aJ^ 


Fic.  375- — Instruments  for  lavage  of  the  inaidllarj'  sinus  tfarougb  a  punchi*^ 
the  inferior  meatus.     1,  Head  mirn>r;  a,  syringe;  3,  applicator;  4,  Myles' nasal  sptcwl**^ 
5,  tubing  to  connect  the  s>-rinBe  and  cannula;  6,  Myles'  trocar  and  cannula. 


the  origin  of  infection  is  apparently  from  the  nose.  When  a  deca>'' 
tooth  is  the  source  of  trouble  and  the  tooth  is  beyond  saving,  punct*-* 
through  the  alveolus  is  justifiable. 

Instruments. — For  irrigating  through  the  inferior  meatus,      ^ 
antrum  trocar  and  cannula  and  small  syringe  will  be  required.     J^ 
opening  through  the  alveolus,   there  should  be  provided  suita.t' 
tooth-pulling  forceps,  an  alveolar  drill,  a  syringe,  and  a  silver     ^^ 
aluminum  tube  of  the  same  caliber  as  the  drill,  \^  to  y^  inch  {1  t*^ 
cm.)  long  and  provided  with  a  fiange  to  prevent  its  slipping  into  t** 
antrum. 


Jit,  a  point  is  selected  just  beneath  the  inferior  turbinate 
mt  }i  inch  (i  cm.)  behind  its  anterior  extremity,  and  the 
I  introduced,  pushing  it  in  an  outward,  backward,  and  slightly 


I 


39*  THE  NOSE  AND  ACCESSORY  SINUSES 

upward  direction,  through  the  thin  bony  wall  into  the  antnim  (Fig. 
377).    The  relation  of  the  sinus  to  the  orbit  should  be  bome  in 
mind  when  malting  this  puncture  and  care  taken  not  to  enter  the  lat- 
ter; this  may  happen  if  the  puncture  be  made  through  the  iniddle 
meatus  (Fig.  '37S}.    As  soon  as  the  antrum  has  been  entered,  the 
trocar  is  withdrawn.    The  syringe  is  then  attached  to  the  cannula  by 
a  piece  of  rubber  tubing,  and  the  cavity  thoroughly  irrigated.   Any 
secretion  is  thus  forced  out  through  the  normal  opening  of  the  sina^ 
and  appears  in  the  middle  meatus.     During  the  irrigation,  the  head 
should  be  held  downward  over  a  receptacle,  so  that  the  solution  vlU 
readily  escape  from  the  nose. 

The  sinus  should  be  irrigated  daily  until  the  discharge  ceases, 
employing  stronger  or  more  stimulating  solutions  if  they  seeni  indi- 


I 


Fig.  378. — Transverse  section  through  the  nose,  showing  cannula,  a,  Ent^'** 
antrum  through  inferior  meatus;  and  h,  cannula  entering  the  orbit  through  the  n»S*^*^ 
meatus.     (After  CofBn.) 

cated.     Usually  there  is  no  great  dif&culty  in  reinserting  the  cann**^ 
through  the  opening  each  day,  if  it  is  provided  with  a  blunt  obturaf '* 
The  parts  should  be  cocainized,   however,   before  each  irrigati*^*^' 
2.  Through  the  Alveolus. — The  puncture  is  made  through    ti>® 
socket  of  the  second  bicuspid  or  the  inner  root  socket  of  the  first   *^ 
second  molar  tooth  (Fig.  379).    The  affected  tooth  is  first  remov^**' 
and  the  drill  inserted  by  a  boring  motion,  as  follows:  For  the  fi*"* 
molar,  in  an  upward  and  slightly  inward  direction;  for  the  sec"" 
molar,  in  an  upward,  slightly  inward  and  forward  direction;  and  »*' 
the  second  bicuspid,  upward,  slightly  inward,  and  backward.    Val^^ 
the  approximate  position  of  the  antrum  is  kept  in  mind  and  the  d^*" 
inserted  accordingly,  the  cavity  may  be  missed.    As  soon  as  the  ^^' 
trum  has  been  entered  the  cavity  is  irrigated  by  means  of  a  syrio^ 


0. — InstrumcnlB  tor  lavage  ot  the  (rontal  ainua.     i,  Myles'  nasjil  speculum; 
Tor;  3,  syringe;  4,  tubing  to  connect  the  syringe  to  cannula;  s,  sinus  probe; 

[rficator;  7,  s 

rrigations  may  be  performed  once  or  twice  a  day,  and  later 
'  be  carried  out  by  the  patient  himself.     When  the  discharge 


394  THE   NOSE  AND  ACCESSORY   SINUSES 

ceaseSj  the  irrigations  are  discontinued  for  a  day  or  two,  and,  if  tlun 
is  no  recurrence  of  the  trouble,  the  tube  is  then  removed  and  the 
opening  aUowed  to  close. 

Lavage  of  the  Frontal  Sinus. — The  frontal  sinus  may  beini- 
gated  by  means  of  a  small  cannu^  introduced  through  the  fronto- 
nasal duct.  In  some  cases,  where  the  opening  is  occluded  by  tlL« 
middle  turbinate  or  an  enlarged  bulla  ethmoidalis,  the  middle  tuit&.- 
nate  will  have  to  be  removed  before  the  attempt  is  successfiLl 
Another  difficulty  presents  itself  in  the  close  proximity  of  the  anterk^M 
ethmoidal  cells,  and  the  cannula  may  enter  this  group  instead  of  tt:&e 
frontal  sinus. 

Instruments. — A  head  mirror,  a  speculum,  a  nasal  applicator.  > 
sinus  probe,  a  pure  soft-silver  cannula  that  may  be  easily  bent  'to 
accommodate  itself  to  any  curve — such  as  Hartmann's — and  a  s^y' 


Fig.  381, — -Showing  the  steps  of  passing  a  cannula  into  the  frontal 


inge  that  can  be  attached  by  means  of  rubber  tubing  will  be  requ*-**^**^ 
(Fig.  380). 

Asepsis. — The  instruments  are  sterilized  by  boiling,  and      '•-■^ 
patient's  nose  is  cleansed  by  gentle  syringing. 

Anesthesia.— A  4  per  cent,  solution  of  cocain  should  be  appi' 
to  the  middle  meatus  for  twenty  minutes  before  the  operation. 

Technic.^ — The  cannula,  bent  at  its  distal  end  to  an  angle  of  at>*^^ 
135  degrees,  is  introduced  into  the  middle  meatus  at  the  junction* 
the  anterior  third  with  the  posterior  two-thirds.    The  tip  of    ^^ 
cannula  is  passed  into  the  hiatus  and  then  forward  and  upward  »*• 
the  infundibulum,  and  thence  still  upward  and  slightly  forward  i"* 
the  sinus,  through  the  fronto-nasal  duct  (Fig.  381).     The  syringe 
then  attached  to  the  cannula  and  the  sinus  is  gently  irrigated  with  of 
of  the  warm  cleansing  solutions  previously  mentioned. 


'-  3^3- — Showing  the  steps  of  passing  a  cannula  into  the  sphenoidal 


«psts. — The  instniments  are  boiled,  and  the  patient's 
«d  by  gentle  syringing. 


I 


396  THE   NOSE   AND   ACCESSORY   SINTJSES 

Anesthesia. — The  region  is  anesthetized  with  a  4  per  cent,  solu- 
tion of  cocain. 

Technic. — The  cannula  is  passed  into  the  nasal  cavity  with  the 
convexity  upward.     The  point  of  the  instrument  is  inserted  between 
the  middle  turbinate  and  the  septum,  and  should  follow  the  roof  oi 
the  nose  until  it  meets  the  resistance  of  the  anterior  wall  of  tk^ 
sphenoidal  sinus.     By  gently  moving  the  instrument  up  and  dowi^ 
and  from  side  to  side,  its  tip  will  eventually  be  made  to  enter  th^ 
sphenoidal  opening  (Fig.  383).     The  depth  of  the  sinus  is  only  about 
%  inch  (1.5  cm.),  and  care  should  be  taken  not  to  force  the  instru^' 
ment  through  its  thin  walls.     The  syringe  is  attached  to  the  cannula 
by  rubber  tubing,  and  the  cavity  thoroughly  but  gently  irrigated - 
During  this  procedure  the  patient's  head  should  be  bent  forward 
and  the  mouth  opened  to  prevent  the  backward  flow  of  the  retumirB-f 
solution. 

PASSIVE   HYPEREMIA  IN   DISEASES   OF  THE  NOSE  AN 

ACCESSORY  SINUSES      . 

The  beneficial  effects  of  passive  hyperemia  in  the  treatment 
inflammations  have  already  been  discussed  in  Chapter  X,  to  whi< 
section  the  reader  is  referred  for  a  full  consideration  of  the  subj 
and  the  technic  of  its  application.  According  to  BaUenger,^  the  in 
cations  for  passive  hyperemia  in  rhinology  are:  (i)  in  the  first  fi 
days  of  acute  rhinitis;  (2)  in  the  first  five  days  of  acute  sinusitis;  C 
in  the  first  five  days  of  acute  inflammation  of  the  pharyngeal  tonsil-  ^ 
(4)  in  acute  tubal  catarrh;  (5)  in  chronic  purulent  inflammation  ^^ 
the  sinuses. 

The  hyperemia  may  be  effected  by  means  of  a  neck  band  (  ^ 
described  on  page  256)  or  by  a  special  form  of  suction  apparatus-- 
The  latter  is  more  efficacious  in  the  presence  ofa  purulent  discharge  ^ 
the  vacuum  serving  to  remove  secretions  as  well  as  to  induce  a  bener^ 
cial  hyperemia;  but  it  must  be  used  with  great  care  not  to  induce?^ 
harmful  degree  of  hj-peremia.  The  apparatus  shown  in  Fig.  221  ^ 
one  provided  with  glass  tips  which  fit  into  the  nostrils  may  be  user-^ 
With  the  apparatus  applied  to  the  nose,  the  air  is  slowly  rarefi^^ 
while  the  patient  swallows.  This  causes  the  soft  palate  to  rise  up  ^^ 
apposition  with,  the  posterior  wall  of  the  pharynx  and  to  close  tt:^ 
naso-pharynx  and  nose  from  the  pharynx,  and  a  hyperemia  of  tl^^ 
mucous  membrane  of  naso-pharynx,  nose,  accessory  sinuses,  an-  - 
Eustachian  tubes  is  thus  induced. 

*  Ballenger:  "Diseases  of  the  Nose,  Throat,  and  Ear." 


TAMPONING    THE    NOSE    FOR    CONTROL    OF    HEMORRHL\GE 


397 


TAMPONING  THE  NOSE  FOR  THE  CONTROL  OF 
HEMORRHAGE 


|l  Nasal  hemorrhage  may  be  the   result  of  trauma,  ulcerations. 

ne'v/  growths,  cardiac  disease,  certain  constitutional  diseases  and  in- 
/ections,  diseases  of  the  blood,  etc.  Usually  the  bleeding  ceases 
sf>c»ntaneou3iy  or  under  simple  treatment  which  aims  at  lessening 
tti«5  congestion  of  the  nasal  mucous  membrane  and  favoring  the  for- 
in.£«.tion  of  a  clot,  such  as  the  application  of  cold  over  the  nose  and 
at  the  base  of  the  neck,  removing  tight  collars,  etc.,  from  the  neck, 
or"  having  the  patient  remain  quietly  in  an  upright  position  with 
tti^  head  erect,  at  the  same  time  forbidding  any  attempts  at  blowing 
tt*.^  nose. 

If  these  simple  measures  are  insufficient,  a  speculum  should  be 
iatioduced  and  the  interior  of  the  nose  inspected  for  the  source  of 
s  hemorrhage.     If  the  bleeding  point  is  within  reach,  it  should 


r   for    tamponing    the    : 
r;  3,  narrow  strip  of  gaii 


rior    narfs.     i,    Nasal    applicator; 
I,  Myles'  nosal  speculum. 


^  cauterized  by  touching  with  the  electro-cautery  or  with  silver 

^ate;  or  else  some  stjptic  solution,  as  pero.\id  of  hydrogen,  a 

*terj'  solution  of  tannic  acid,  or  a  i  to  looo  solution  of  adrenalin 

^"rid  should  be  applied  to  the  part  upon  a  pledget  of  cotton.     It 

^*y  be  impossible  to  locate  the  bleeding  point,  or  the  hemorrhage 

"^y  continue  in  spite  of  such  treatment,  so  that  in  the  presence  of 

Ifofuse  hemorrhage  it  becomes  necessary  to  pack,  the  nose.     In 

r**^  majority  of  cases  tamponade  through  the  anterior  nares  will 

^^  sufficient;  in  others,  the  bleeding  may  occur  posteriorly  and  the 

*^^sterior  nares  as  well  will  have  to  be  packed. 

Instruments,  etc. — To  pack  the  nose  from  the  front,  a  head  mir- 
"^t,  a  nasal  speculum,  a  nasal  applicator,  and  a  single  narrow  strip 
"  gaiiTP  should  be  provided  (Fig.  384). 


398 


THE   NOSE   AND   ACCESSORY   SINUSES 


For  packing  the  posterior  nares  a  tampon  about  i  inch  (2.5  cm.) 
long  and  y^  inch  (i  cm.)  thick,  should  be  prepared  by  rolling  a 
strip  of  gauze  to  the  required  size,  to  the  center  of  which  a  heavy 
piece  of  silk  thread  is  tied,  the  two  ends,  which  should  each  be  aboat 
18  inches  (45  cm.)  long,  being  left  free.     For  the  purpose  of  adjusting 
the  tampon  in  place,  a  rubber  urethral  catheter  of  a  size  that  wiXV 
readily  pass  through  the  nose  into  the  mouth  (Fig.  385),  or  an  instrwi— 


c^ 


i*-> 


r^-V- 


FiG.  385. — Catheter  for  drawing  plug  into  the  posterior  nares. 

ment  especially  made  for  this  purpose,  known  as  Bellocq's  so 
(Fig.  386),  will  be  necessary.     This  latter  consists  of  a  curv 
metal  cannula  containing  a  concealed  steel  spring,  which  is  protnid 
into  the  pharynx  and  mouth  when  the  cannula  is  in  place  in  the  m 
and  to  the  end  of  which  the  tampon  is  then  attached. 

Asepsis. — The  instruments  are  boiled,  and  the  gauze  used  for 
tampon  should  be  sterile. 


^ 


Fig.  386. — Bellocq's  cannula. 

Technic  (i)  {Anterior  Nares). — In  tamponing  the  anterior  nares 
speculum  is  inserted  in  the  nose  and  a  good  view  of  the  interi( 
obtained.    A  narrow  strip  of  gauze,  saturated  with  peroidd  of 
gen,  is  then  gently  carried  well  back  into  the  nose  by  means  of  at^ 
applicator,  and  by  forcing  in  more  gauze  the  whole  nose  is  tampon 
and  the  hemorrhage  controlled  (Fig.  387).     This  packing  shoul^^ 
always  be  removed  within  forty-eight  hours.     Only  a  single  strip 


ncthod  of  drawing  a  plug  into  the  poster 
of  Bellocq's  cannula. 

(i)  (Posterior  Nares). — The  tampon,  as  already  described,  should 
Fell  lubricated  with  sterile  vaselin  and  placed  near  at  hand.     The 


i 


400  THE   NOSE   AND   ACCESSOSY   SINUSES 

Bellocq  cannula  is  passed  along  the  floor  of  the  nose  on  the  bleeding 
side  until  its  tip  appears  back  of  the  soft  palate.  The  steel  spring  is 
pushed  home  and  is  protruded  into  the  mouth.  The  tampon  bthezx 
tied  to  the  end  of  the  carrier  by  one  of  the  strings  (Fig.  388),  ih^ 
spring  is  returned  within  the  cannula,  and  the  latter  is  removed  from. 
the  nose  and  with  it  the  end  of  the  tampon  spring.  By  pulling  upon 
the  string,  assisted  by  a  finger  placed  in  the  naso-pharynjt,  the  tampon 
is  drawn  lightly  into  the  posterior  nares  (Fig.  389).  In  addition,  it  is 
well  to  pack  the  anterior  nares  with  gauze  or  a  plug  of  cotton,  over 
which  is  tied  the  string  protruding  from  the  nose.     The  other  end  of 


Fic.  389.— The  pof 


the  string,  which  is  left  in  place  for  the  purpose  of  removing  the  p*  ' 
is  brought  out  through  the  mouth  and  loosely  fastened  to  the  ^^' 
When  an  ordinary  catheter  is  employed  in  place  of  a  special  soi*^*^' 
precisely  the  same  technic  is  followed. 

The  packing  should  be  removed  in  twenty-four  hours,  sinc^^ 
left  in  longer,  it  is  apt  to  set  up  an  irritation  and  may  lead  to  infec*^' 
of  the  Eustachian  tube.     To  remove  the  pack,  the  string  tied  to  *" 
anterior  tampon  is  first  cut  free.     The  naso-pharynx  should 
cleaned  of  blood-clots,  and  the  whole  region  sprayed  with  adreD*-^ 
chlorid  to  cause  the  tissues  to  shrink  as  much  as  possible.    The  po** 
nor  plug  is  then  removed  by  gentle  traction  upon  the  string. 


CHAPTER  XV 


Anatomic  Considerations 

TTie  ear  is  divided  into  three  portions:  the  external  ear,  the 
in*clcile  ear,  and  the  internal  ear.  For  the  purposes  of  this  work,  a 
consideration  of  the  anatomy  of  the  external  ear  and  the  middle  ear 
'vriXl    suffice. 

'-■-'lie  external  ear  comprises  the  auricle  or  pinna  and  the  external 
atxei  itory  canal. 

IZ'he  auricle  is  the  irregular  shaped  mass  composed  of  fibrocarti- 

^K^,  covered  by  perichondrium,  connective  tissue,  and  skin,  which 

P*^<^  j  «cts  from  the  side  of  the  head.     It  has  the 

^"-"-^^tition  of  collecting  sounds  and  reflecting  them 

^*^     the  external  auditory  meatus.     The  central 

"^p»r-essed  portion,  resembling  a  shell  in  form, 

1^     called  the  concha.     It  is  bounded  by  a  rim, 

^"^    antihelix,  which  runs  at  first  backward  and 

'•tien  upward  and  forward,  finally  dividing  into 

'-^'■o   arms.     The  space  between  these  two  arms 

^^    Itnown  as  the  fossa  of  the  antihelix.    From 

^**e    front  portion  of  the  concha  extends  a  ridge, 

^***>'wn  as  the  helix,  at  first  in  a  forward  and 

^P"v^ard  direction  and  then  around  the  circum- 

f~- ,     ,  .   ,  111  auricle       i    Concha    i 

Terence  of  the  auncle  toward  the  lowest  por-  ^^^^^  ^  [„^  „, 
"***i.  The  space  between  the  antihelix  and  anbheiu  4  helu  s 
^^e  helix  is  designated  the  fossa  of  the  helix.  f<«sa  of  the  heU  6  tra 
THe  smaU  backward  projecUon  lying  in  front  ^^*^,J  antitragus  8 
*^<  "the  concha  is  called  the  tragus,  and  the 
^'**a-ll  tubercle  at  the  lowest  portion  of  the  antihelix,  the  antitragus. 

^*i«  lobule  of  the  ear  is  the  lowest  soft  pendulous  portion  of  the 
auricle. 

y/ie  external  auditory  canal  extends  from  the  concha  to  the  drum 

'^lembrane.     It  serves  the  purpose  of  conveying  sounds  collected  by 

he  auricle  to  the  drum  membrane.     The  canal  measures  about  iM 

^"clje3  (4  cm.)  in  length,  the  floor  being  slightly  longer  than  the  roof 


Fio   390— The  left 


402  THE  EAK  ' 

on  account  of  the  oblique  position  of  the  drum  membrane.    Itsouter 
third  is  composed  of  cartilage,  a  continuation  of  that  fonning  the 
auricle,  while  the  inner  two-thirds  has  a  bony  framework.    The  in- 
terior is  lined  with  thin  skin,  which  contains  hair  follicles  aad 
cerumenous  glands,  the  latter  being  most  abundant  at  the  junctioEk. 
of  the  cartilaginous  and  bony  portions.    The  widest  portion  of  ttm.^ 
canal  is  near  the  external  orifice,  the  narrowest  portion  near  tba—C 
center,  and,  beyond  this,  as  it  nears  the  drum  membrane,  the  c 
expands  again.    The  direction  of  the  canal  traced  from  i 
inward  is  at  first  upward  and  forward,  then  backward,  and  fiiial^^^~3 
forward  and  downward.     By  traction,  however,  in  an  upward,  I 


ward,  and  outward  direction  upon  the  auricle  the  canal  may  I 
straightened  out  and  its  interior  viewed. 

The  middle  ear,  or  tympanum,  is  an  irregularly  shaped  cavit  - 
situated  in  the  petrous  portion  of  the  temporal  bone,  between  t 
external  and  the  internal  ear.     The  interior  of  the  cavity  is  lined  witl- 
a  delicate  raucous  membrane.     Within  it  lie  the  chain  of  o 
tympanic  muscles,  and  the  chorda  tympani  nerve. 

The  tympanic  cavity  is  bounded  above  by  the  roof,  consisting  of 
thin  plate  of  bone,  the  tegmen  tympani  et  antri,  wluch  separates  ■ 
from  the  dura;  below  by  the  floor  which  corresponds  to  the  jugula^^^^^ 
fossa;  by  an  outer  wall  composed  of  the  drum  membrane  and  th^ 
ring  of  bone  into  which  it  is  inserted;  by  an  inner  wall  which  b  coc:^^^^:^^"^ 
tiguous  to  the  labyrinth,  and  presents  an  oval  window  closed  by  th^*^^^-^^^ 
stapes  and  a  round  window  closed  by  membrane;  by  an  anterior  wa— — ^^^^ 


^s-        it 


ANATOMIC   COXSIDERATIONS  403 

■rhjch  separates  the  tympanic  cavity  from  the  carotid  canal,  and  in 
the  upper  part  of  which  is  the  tympanic  orifice  of  the  Eustachian  tube 
and  above  this  the  canal  for  the  tensor  tympani  muscle;  and  by  a 
posterior  wall,  in  the  upper  part  of  which  lies  the  narrow  opening 
ie^cluig  into  the  mastoid  antrum,  the  aditus  ad  antrum.  The  cavity 
IS  practically  divided  by  the  chain  of  ossicles  into  two  portions,  an 
ur>j>er  epitympanic  space  or  attic,  and  a  lower  cavity  or  atrium. 

The  ossides  are  three  small  bones,  the  malleus  or  hammer,  the 
iucrxis  or  anvil,  and  the  stapes  or  stirrup,  joined  together  by  movable 
articulations,  and  forming  an  osseous  chain  between  the  drum  mem- 
braXLC  and  the  labyrinth.  They  are  held  in  place  by  the  attachment 
of    "tlie  malleus  to  the  membrana  tympani  and  of  the  stapes  to  the 


Fig.  sgi. — Anatomy  of  the  ossicles,    (Pyle.) 


*1  window,  and  in  addition  by  various  ligaments  extending  between 
aern  and  the  bony  walls.  Their  function  is  to  convey  sound  waves 
'^*H  the  drum  to  the  labyrinth. 

The  malleus  consists  of  an  oval  head  which  extends  upward  and 
"^^culates  with  the  incus,  a  neck,  a  manubrium  or  handle  which 
T^*^ttds  downward  and  is  embedded  in  the  membrana  tjonpani,  a 
Qort  process,  which  extends  outward  from  the  neck  to  the  membrana 
^'^^ipani  and  pushes  the  latter  outward  before  it,  and  a  long  process 
**Jch  passes  anteriorly  into  the  Glaserian  fissure. 

The  incus  is  the  middle  ossicle.    It  consists  of  a  body  which  artic- 

*T~^tes  with  the  malleus,  a  short  horizontal  process  which  extends  to 

^  posterior  wall  where  it  is  attached  by  ligaments,  and  a  long  proc- 


404 


\ 


ess  which  extends  downward  and  outward  and  then  near  its  tip 
sharply  inward  to  articulate  by  its  orbicular  process  with  the  head  o£ 
the  stapes. 

The  stapes  consbts  of  a  broad  base  or  foot-piece  which  fits  into  tlie 
oval  window,  to  the  membrane  of  which  it  is  attached,  two  crura  ox 
legs,  and  a  head  which  articulates  with  the  orbicular  process  of  tl>^ 
incus. 

The  membrana  tympani,  or  ear-drum,  is  a  ttun  elastic  membntk.^ 
stretched  obliquely  downward  and  inward  across  the  inner  end  of  tlk--^ 
external  auditory  canal  forming  the  outer  wall  of  the  tympani*: 
cavity.  The  drum  membrane  is  made  up  of  three  layers,  an  out^*" 
one  of  skin,  a  middle  of  iibrous  tissue,  and  an  inner  formed  by  Ub-  ^ 
reflection  of  the  mucous  membrane  of  Urn.  ^ 
middle  ear.  It  serves  the  purpose  of  receivim-^ 
and  transmitting  sound  waves  to  the  chain  cz»f 


It  may  be  described  as  elliptical  in  outlin^^^ 
and  of  a  pearly  gray  color,  but  at  the  same  tiirr^e 
translucent.    Its  outer  surface  is  concave  ai^-'*! 
surfa«    of 'the  right     normally  smooth.     By  the  aid  of  a  speculiwm 
membrana  tympani.  ■  and  suitable  illumination  there  will  be  noted     ■^ 
(Gieason.)     a,  Mem-     whitish    ridge   formed   by  the  handle  of  tt»« 
t'^"^  t  Id-   c.  '^^     malleus,  running  from  a  tubercle  near  the upp^*" 
process;  J,' incudosta-     ^nd   anterior  periphery  downward   and  bacl*=-'' 
pcdial  articulation;  e,     ward  toward  the  ccntcr  of  the  membrane.    Th*-* 
to""'coneo?i'hi'""      tubercle    represents    the   short  process  of  th^ 
malleus.     Where  the  handle  of  the  malleus  end  ^^ 
near  the  center  of  the  membrane  is  a  depression,  the  umbo.    Unde*^^ 
illumination  in  the  anterior  and  lower  quadrant  of  the  dnun  wil^^^ 
also  be  noted  a  triangular  area  of  light  (the  reflection  of  light)  with    "^ 
its  apex  at  the  tip  of  the  handle  and  its  base  at  the  periphery  of  the       "^ 
drum.     Extending  anteriorly  and  posteriorly  from  the  short  process 
of  the  malleus  are  two  delicate  folds  of  membrane  which  divide  the 
drum  into  two  portions.     That  portion  above  these  folds  is  known 
as  Shrapnell's  membrane,  or  the  membrana  flacdda,  and  that  below 
as  the  membrana  tensor. 

T/ie  Eustachiav-  tube  Is  a  canal  about  i}^  inches  (4  cm.)  long, 
connecting  the  pharynx  with  the  tympanic  cavity.  It  has  a  general 
direction  from  the  tympanum  forward,  downward,  and  inward, 
opening  upon  the  lateral  wall  of  the  pharynx  near  the  inferior  meatus 
of  the  nose  in  front  of  Rosenmuller's  fossa  as  a  crater-like  eminence. 


DIAGNOSTIC  METHODS 

7TI»«  tube  is  made  up  of  a  framework  which  in  the  outer  third  is  bony 
an<3  in  the  inner  two-thirds  cartilaginous  and  membranous,  and  is 
'  in  ^1  with  ciliated  epithelium  which  waves  in  a  direction  toward  the 
pt»^rynx.  The  two  ends  are  enlarged,  but  approaching  the  juncture 
of  the  osseous  and  cartilaginous  portions  the  tube  narrows  conslder- 
ah>ly.  Normally  the  walls  are  in  apposition,  but  when  the  palatal 
m'^a.scles  contract,  as,  for  example,  in  the  act  of  swallowing  or  yawn- 
ia.,^^,  the  walls  are  separated.  The  function  of  the  Eustachian  tube 
|is  to  equalize  the  atmospheric  pressure  on  the  outer  and  inner  sides 
of  the  drum,  and  to  provide  drainage  for  the  tympanic  cavity  and 
ttL.^».stoid  cells. 

Diagnoslic  Methods 

A  complete  examination  of  the  ear  should  comprise  a  clinical  his- 
■^'K—y,  an  examination  of  the  nasopharynx,  and  then  an  investigation 
*f       the  ear  itself. 

A  history  is  quite  essential,  but  it  need  not  necessarily  be  an 

'^^-I^austive  one.     It  should  first  be  ascertained  what  symptoms  or 

sy^*~nptom  the  patient  complains  of,  and  whether  only  one  ear  or  both 

'^~*2  affected.     The  duration  of  the  trouble  is  also  of  importance,  as  it 

"^*-^  considerable  bearing  upon  the  prognosis  in  any  given  case.     The 

P*~<3bable  cause  of  the  condition  should  also  be  determined  as  far  as 

1^        possible  by  careful  questioning.     Among  the  many  etiological 

la-«rtors  of  ear  diseases  are  severe  colds,  grippe,  some  injury,  foreign 

^>*:xies,  acute  infectious  diseases,  syphilis,  tuberculosis,  etc.    The 

sy»Bptoms  or  symptom  complained  of  should  then  be  investigated 

ir»ore  in  detail. 

Deafness  and  tinnitus  are  the  common  complaints  for  which  relief 
is  sought,  and  are  frequently  associated.  In  the  presence  of  the 
former  it  should  be  learne<l  whether  the  deafness  developed  slowly  or 
suddenly,  whether  one  or  both  ears  are  involved,  and,  if  the  latter  be 
^e  case,  which  ear  is  more  aflfected.  The  duration  of  the  condition 
I  "iiust  also  be  ascertained.  Not  infrequently  in  the  presence  of 
cnroriij.  catarrh  of  the  middle  ear,  the  patient,  while  not  actually  deaf, 
"^^I"  complain  of  certain  disturbances  of  hearing,  as,  for  example,  the 
ability  to  hear  better  in  the  presence  of  noise,  as  on  a  railroad  train  or 
™  eet  car  (paracusis  WiUisii) ,  or  hearing  sounds  as  if  repealed  twice 
'P*tatusis  duplicata),  or,  again,  In  the  presence  of  marked  unilateral 
^*tness  the  inability  to   locate  the  source  of  sounds   (paracusis 

Tinnitus,  or  subjective  noises,  are  present  in  middle-ear  diseases 


4o6  THE   EAR 

as  well  as  affections  of  the  internal  ear,  in  neurasthenic  conditions^ 
arteriosclerosis,  and  may  follow  the  taking  of  certain  drugs,  as,  loT 
example,  quinin  or  the  salicylates.     They  may  be  described  by  th^ 
patient  as  singing,  whistling,  buzzing,  loud  and  roaring  or  musica^l- 
in  character,  or  they  may  resemble  voices.    When  present,  it  shoul 
be  learned  whether  they  are  located  in  the  ear  or  in  the  head,  wheth( 
unilateral  or  bilateral,  and  whether  they  are  modified  by  mental  < 
physical  exertion  or  by  the  time  of  day.    As  a  rule  they  are  worse 
night,  and  in  some  cases  they  may  be  entirely  absent  during  the  da; 

In  the  presence  of  pain  or  earache,  its  character,  the  duratioi 
and  whether  constant  or  intermittent  should  be  noted.     Pain  may 
the  result  of  morbid  conditions  in  the  ear  or  it  may  be  reflex,  as,  i 
example,   from  a  decayed  tooth,  or  from  an  inflammation  of 
pharynx,  tonsils,  etc.     When  it  suddenly  develops  in  an  ear  pr 
x-iously  healthy  it  generally  points  to  an  acute  inflammation  of 
middle  ear,  while,  if,  on  the  other  hand,  it  occurs  during  the  course 
some  chronic  affection  of  the  ear,  a  collection  of  fluid  in  the  middle 
or  destruction  of  bone  may  be  suspected.     Pressure  tenderness 
also  of  diagnostic  importance  in  determining  the  origin  of  the  troubl 
Thus,  pain  caused  by  traction  upon  the  auricle  or  by  pressure  on 
tragus  points  to  an  inflammation  involving  the  external  auditor;:;;^^ 
canal,  tenderness  elicited  by  pressure  in  the  depression  below 
lobule  of  the  ear  to  middle-ear  inflammation,  and  pressure 
over  the  mastoid  to  involvement  of  that  bone. 

The  presence  or  absence  of  a  discharge  is  next  determined.  Wi 
a  historj^  of  a  discharging  ear,  the  length  of  time  the  discharge  ha.^ 
lasted,  the  character  of  the  discharge,  whether  serous,  bloody,  o 
purulent,  whether  scanty  or  in  large  amounts  and  whether  continuo 
or  intermittent  should  be  noted.  It  is  also  important  to  ascertain  i 
the  discharge  is  accompanied  by  pain,  and  the  relation  the  pain  an 
discharge  bear  to  one  another. 

In  addition  to  the  above  points,  the  occupation  and  habits  of  the 
patient  should  be  investigated  as  having  an  etiological  bearing  upon 
the  case,  and  in  certain  cases  a  general  physical  examination  should  be 
made.  One  should  never  fail  to  investigate  the  condition  of  the  nose 
and  throat,  especially  the  nasopharynx,  noting  the  presence  or 
absence  of  congestion,  swelling  of  the  mucous  membrane,  adenoid 
growths,  ulcers,  etc.,  and  the  condition  of  the  pharyngeal  ends  of  the 
Eustachian  tubes.  The  technic  of  such  examination  has  already 
been  described  in  Chapter  XIV.  The  parts  in  the  vicinity  of  the  ear 
should  likewise  be  inspected  as  well  as  palpated  for  signs  of  inflamma- 


Ijon,  swellings,  new  growths,  enlarged  glands,  or  signs  of  tenderness. 
Having  completed  these  preliminaries,  the  actual  examination  of  the 
car  should  be  instituted. 

The  examination  of  the  ear  comprises  (i)  direct  inspection  of  the 
external  ear,  {3)  inspection  of  the  external  auditory  canal  and  tym- 
panic membrane  by  the  aid  of  specula,  (3)  determination  of  the 
mobility  of  the  drum  membrane,  {4)  various  tests  of  the  power  of 
hearing,  and  (5)  determination  of  the  patency  of  the  Eustachian 
tubes.  In  all  cases  the  examiner  should  not  fail  to  investigate  the 
condition  of  both  ears. 

DIRECT  INSPECTION 

A  thorough  inspection  of  the  auricle  and  external  auditory  canal 
should  always  precede  the  use  of  a  speculum.  In  this  way  the  exam- 
iner may  be  enabled  to  recognize  pathological  conditions  at  the 
wi trance  of  the  auditory  canal  that  might  otherwise  escape  attention 
or  be  hidden  from  view  by  the  speculum, 

Instrumeots.^All  that  is  required  is  suitable  illumination.  This 
iQay  be  furnished  by  means  of  an  electric  head  light  (see  Fig.  340),  or 
by  means  of  light  reflected  upon  the  part  by  a  head  mirror. 

Position  of  Patient, — The  patient  is  seated  upon  a  stool  with  the 
**<■  to  be  examined  turned  toward  the  surgeon,  who  is  also  seated 
upon  a  stool  of  such  height  that  his  eyes  are  on  a  level  with  the  ear  of 
*he  patient.  If  reflected  light  is  employed,  the  source  of  illumination 
should  be  a  little  above  the  level  of  the  patient's  ear  and  upon  the 
examiner's  left  side. 

Technic. — Under  full  illumination  the  auricle  is  first  carefully 
'**spected,  noting  the  presence  or  absence  of  excoriations  from  dis- 
charges, eczema,  swellings,  deformities,  new  growths,  etc.  Then  by 
'^eans  of  traction  upon  the  auricle  in  an  upward  and  backward  direc- 
*'*^n,  the  external  .auditory  canal  is  straightened  out  and  a  view  of  a 
•^^isiderable  portion  of  its  interior  becomes  possible.  The  examiner 
5*ioul{j  note  especially  the  color  of  the  canal  for  signs  of  inflammation, 
^^  presence  or  absence  of  swellings,  fissures,  foreign  bodies,  new 
^^o^wths,  etc. 

OTOSCOPY 

Otoscopy  is  the  inspection  of  the  external  auditory  canal  and 
i"nipanic  membrane  by  the  aid  of  a  speculum  and  suitable  illumina- 
^ft.     By  this  means  parts  of  the  auditory  canal  and  the  drum  mem- 


4o8 


THE   EAR 


brane  invisible  to  direct  inspection  may  be  viewed  in  detail,  and  the 
presence  or  absence  of  pathological  conditions  recognized. 

Instruments. — There  will  be  required  a  strong  light,  such  as  is 
obtained  from  a  Welsbach  burner  covered  by  a  Mackenzie  condenser, 
mounted  upon  an  adjustable  bracket  so  that  it  may  be  raised  to  any 


Fig.  394. — Instruments  for  otoscopy,     i,  Head  mirror;  2,  aural  specula;  3,  ear  pi 

4,  ear  curet;  5,  angular  ear  forceps;  6,  ear  syringe. 


desired  height,  a  concave  head  mirror  3J^  to  4  inches  (9  cm.  to 
cm.)  in  diameter  with  a  central  perforation  for  the  eye,  three  sizes 
metal  aural  specula,  a  fine  ear  curet,  a  probe,  a  pair  of  Poli 
angular  ear  forceps,  and  an  ear  syringe  (Fig.  394).     If  desired, 
place  of  reflected  light,  illumination  from  an  electric  head  light  m 
be  substituted. 


0 
0 

0 


Fig.  396. — Boucheron*8  speculum. 


Fig.  395. — Gruber's  speculum. 


For  purposes  of  examination  Gruber's  specula  (Fig.  395)  are 
satisfactory,  as  they  are  elliptical  in  shape  upon  transverse  secti« 
thus  corresponding  to  a  transverse  section  of  the  external  audito 
canal.     Where,  however,  operative  procedures  are  indicated  a 
ulum  with  a  wide  proximal  end  that  will  permit  the  manipulation 
instruments,  such  as  Boucheron's  (Fig.  396)  or  Toynbee's  is  prefe- 


>t 
n 


OTOSCOPY 


fectric-lighted  specula  (Fig.  397)  are  now  used  to  a  large 
nd  amplify  the  operation  considerably, 
is, — To  avoid  carrying  infection  from  one  patient  to  another 
iments  employed  in  otoscopy  should  be  boiled  or  immersed 
20  carbolic  add  solution  and  then  rinsed  in  sterile  water 
I  before  use. 

on  of  Patient. — The  patient  and  examiner  should  be  seated, 
;r  with  the  ear  turned  toward  the  examiner.  The  examiner's 
lid  be  on  a  level  with  the  patient's  ear  and  in  a  horizontal 
th  the  external  auditory  canal.  If  reflected  light  is  em- 
tie  source  of  illumination  should  be  a  little  above  the  level  of 
nt's  ear  and  upon  the  examiner's  left. 


Fic.  397. — Electric-lighted  speculum. 

lie, — The  examiner  directs  the  light  full  upon  the  external 
meatus  and,  grasping  the  auricle  between  the  thumb  and 
jer  of  the  left  hand  (if  the  right  ear  is  being  examined  and 
),  makes  traction  in  an  upward,  backward,  and  slightly 
direction,  to  straighten  out  the  auditory  canal.  In  infants, 
alish  this,  it  is  necessary  to  pull  the  auricle  outward  and  a  Ut- 
ward,  as  the  wall  of  the  canal  has  no  bony  support  at  this 
lies  collapsed  against  the  side  of  the  head.  The  speculum  is 
med  and,  grasped  by  its  rim  between  the  thumb  and  index 
the  right  hand,  it  is  gently  introduced  by  a  slight  rotary 
ntil  it  has  passed  the  junction  of  the  cartilaginous  and  bony 
of  the  canal.  In  inserting  the  instrument,  care  must  be 
follow  the  long  axis  of  the  auditory  canal  by  watching  the 
minated  at  the  distal  end  of  the  speculum  until  the  drum 


membrane  is  brought  to  view.  With  the  speculum  properly  in  pUct, 
the  left  hand  is  shifted  from  the  auricle  to  hold  the  q>eciilum,  tlie 
right  hand  being  thus  left  free  to  manipulate  any  instnimmts  (Fig. 

(398). 

Before  examining  the  drum  menbrane,  the  external  auditory 
canal  should  be  inspected,  noting  its  color,  size  and  shapeT,  and  the 
presence  or  absence  of  foreign  bodies,  polypi,  discharges,  secretions, 
or  cerumenous  plugs.    Signs  of  inflammation  and  furuncles  should 
also  be  looked  for.     Sometimes  secretions  and  collections  of  w 
require  removal  before  inspection  is  possible.    This  may  be  accom- 
plished, as  a  rule,  by  gently  syringing  the  canal  with  warm  sail 
solution  or  a  saturated  solution  of  boric  acid  (see  page425).    Sm^L.U 


Fig.  398. — Otoscopy  ivith  the  reflector  and  1 
course  of  light. 


IT  speculum.    The  urons  rtpns 

(Gleason.) 


masses  of  wax  and  flakes  may  require  removal  by  means  of  the  cur^*^ 
followed  by  gentle  syringing.  The  ear  is  then  thoroughly  dried  t*'^ 
means  of  small  mops  of  sterile  cotton  held  in  angular  forcqis  *^' 
wrapped  about  the  tip  of  a  probe. 

The  examiner  next  inspects  the  drum  membrane.     It  is  placed     ^*^ 
the  distal  end  of  the  canal,  inclining  downward  and  inward  at  an  an.^^ 
of  about  45  degrees.     The  normal  drum  appears  translucent  and  »^ 
pearly  gray  color,  with  its  circumference  appearing  as  a  white  li^^^  ' 
Extending  from  above  downward  and  backward  in  the  upper  half 
the  drum  is  seen  the  handle  of  the  malleus.    In  the  upper  and  *-^      . 
terior  portion,  about  Ms  inch  (i  mm.)  from  the  superior  wall^  , 

the  short  process  of  the  malleus,  and  running  forward  and  baAwJ-  ^ 


^^^P  DETERUIN-ATIOX   OF    MOlilLITV    OF    URfU' MEUBRANT  4I I 

W  jtbove  the  short  process  are  two  folds  of  membrane  above  which  lies 
I  Siia^nell's  membrane.  Extending  from  the  tip  of  the  malleus  to- 
I  ffS-rd  the  periphery,  in  the  lower  and  anterior  quadrant,  will  be  noted 
tke  bright  cone  of  reflected  light.  In  addition  to  these  landmarks 
nonnally  to  be  observed,  if  the  membrane  Is  very  thin  and  retracted, 
tli,^re  may  be  seen  the  long  process  of  the  incus  as  a  whitish  line  run- 
nixig  down  behind  and  parallel  to  the  handle  of  the  malleus. 

On  inspection  of  the  drum  membrane,  one  should  note  first  its 
color,  whether  congested  and  red  and  if  uniformly  so,  also  whether 
trajislucent,  as  it  normallj-  should  be,  or  thickened  and  exhibiting 
li>cali2ed  opacities.  The  presence  or  absence  of  granulations  or 
perforations  should  also  be  determined,  the  latter  being  evidenced  by 
tlie  greater  depth  of  the  drum  at  the  point  of 
perforation.  Note  also  it  the  membrane  is 
retracted  or  bulging  with  fluid.  If  retracted. 
the  short  process  of  the  malleus  appears  more 
plainly,  the  handle  is  shortened,  and  the  con- 
ical folds  are  deepened.  At  the  same  time- 
the  cone  of  reflected  light  will  appear  altered 
■"  shape  and  dbplaced.  If  bulging  is  pres- 
et, its  location  should  be  noted.  As  a  rule, 
"^giiig  occurs  in  the  posterior  portion  of  the 
''Membrane,  or  the  entire  drum  may  be  dis- 
tended. If  it  occurs  in  the  upper  portion 
"•Jy,  involvement  of  the  attic  is  present.  By 
"*»nging  the  position  of  the  speculum  slightly 
^  portions  of  the  drum  maj'  be  \'iewed  in 
detail.  By  means  of  a  cotton-tipped  probe, 
"*spection  may  be  supplemented  by  careful  palpation,  if  further  in- 
'onnation  as  to  the  conditions  found  is  desired.  In  all  manipula- 
*Ons  of  ti]g  speculum  or  instruments  great  gentleness  should  be 
observed. 

!        ^DETERMINATION  OF  THE  MOBILITY  OF  THE  DRUM 

MEMBRANE 
1  By  the  aid  of  a  pneumatic  otoscope  with  which  the  air  in  the  exter- 

I     ,   *  auditory  canal  may  be  alternately  condensed  or  rarefied,  it  is  pos- 
"le  to  determine  the  degree  of  mobility  possessed  by  the  membrana 
I     ^^pani,  and  thus  recognize  undue  rigidity  or  laxness  of  the  drum  or 
■^  existence  of  intratympanic  adhesions  binding  the  drum  or  ossicles 
^  tie  walls  of  the  tympanum. 


Fii..  3Q9,  —  The  appear- 
ance of  the  tlnim  mem- 
brane as  seen  through  the 


\ 


412  THE    EAK 

Apparatus. — Siegle's  pneumatic  otoscope  (Fig.  400)  coDosts  oi 
an  air-tight  chamber,  the  proximal  end  of  which  is  closed  by  a  plun 
glass  window  or  convex  lens  placed  at  an  angle  of  45  degrees  to  ibe 
long  axis  of  the  instrument,  while  to  the  distal  end  may  be  screwed 
different  sized  specula.    Upon  the  side  of  the  air-tight  chamber  is 
placed  a  small  perforated  knob  to  which  is  attached  a  piece  of  rubber 
tubing  and  a  hand  bulb.     The  instrument  may  be  obtained  with  aA 
electric  light  .in  its  interior  or  illumination  may  be  supplied  by  an 
electric  head  light  or  reflected  from  a  head  mirror. 

Position  of  Patient. — The  patient  and  the  operator  occupy  tt»-e 
same  relative  positions  as  employed  for  an  ordinary  otoscopic 
ination  (see  page  409) . 

Asepsis. — The  speculum  portion  of  the  instrument  should 
sterilized  by  boiling. 


Fig.  400. — Siegle's  pneumatic  otoscope. 

Technic. — Some  of  the  air  is  expelled  from  the  bag  which  is  heJ<^ 
in  the  examiner's  right  hand,  and  the  instrument  is  fitted  snugly  int* 
the  auditory  canal  in  the  same  manner  as  an  ordinary  speculum.     -^ 
small  piece  of  rubber  tubing  may  be  slipped  over  the  end  of  the  specu- 
lum, if  necessary,  to  insure  its  fitting  the  auditory  canal  more  acctl" 
rately.    The  examiner  then  observes  under  good  illumination  tb-* 
movement  of  the  drum  membrane  through  the  window  in  the  otc:^ 
scope,  as  he  relaxes  or  compresses  the  bulb.     As  the  air  is  rar^ed,  th»-* 
drum  is  sucked  outward  and  becomes  convex  in  shape.     As  the  a  ^^^ 
is   condensed   by   compression  of   the  bulb,   the  drum   membraw^ 
moves  inward  and  becomes  more  concave.     The  presence  of  adh^^ 
sions  will  be  evidenced  by  absence  of  any  mobility  at  that  particu  ^ 
lar  point,  while  other  parts  of  the  drum  will  move  freely.     Too  ener-'^ 
getic  use  of  the  instrument  must  be  avoided  for  fear  of  rupturin^^ 
a  weakened  drum. 


HEARING    TESTS 


HEARING  TESTS 


Hearing  tests  are  very  important  in  the  diagnosis  of  ear  diseases, 
since  they  not  only  furnish  information  as  to  the  extent  the  hearing  is 
iinjDaired,  but  also  ser\'e  to  localize  the  seat  of  a  lesion,  that  is, 
whether  in  the  conducting  apparatus  or  in  the  nervous  mechanism. 
While  there  have  been  a  number  of  hearing  tests  devised,  the  fol- 
b-%«ring  are  sufficient  for  all  practical  purposes:  (i)  testing  the  acuteness 
of  bearing  by  means  of  the  watch  and  voice,  {2)  testing  the  percep- 
tioK  of  high  and  low  notes,  (3)  Weber's,  and  (4)  Rinne's  test. 

^paratus. — While  It  is  of  advantage  to  have  a  complete  set  of 
tuning-forks,  the  ordinary  tests  may  be  carried  out  with  a  low  tone 
fork  (C-2,)  having  thirty-two  vibrations  per  second,  a  Galton's 
whistle  for  high  tones,  and  a  C  2  fork  having  512  vibrations  per 
second  for  Weber's  and  Rinn^'s  tests.  Galton's  whistle  gives  tones 
ranging  from  about  7000  vibrations  per  second  to  the  highest  per- 
,  ceptible  tone  limit.  The  instrument  is  provided  with  a  scale  and 
screw  whereby  the  number  of  vibrations  may  be  regulated  so  as  to 
gi■^^e  any  tone  within  the  limits  stated  above. 

Tests  of   Acuteness  of  Hearing.— 1.  The  WaUh  Test.  —The 

test  is  made  in  a  room  free  from  noise  and  with  a  watch  that  ticks 

rather  loudly.     Since  the  ticking  of  different  watches  varies  con- 

^derably,  the  distance  at  which  the  particular  watch  is  heard  by  a 

oorinal  ear  must  be  determined  by  experience.     Each  ear  is  tested 

separately  in  the  following  manner;  The  patient  is  seated  in  a  chair 

with  his  eyes  closed,  and  with  his  forefinger  closing  the  ear  not  under 

**aiiunation.     The  examiner  first  holds  the  ticking  watch  close  to 

^e  ear  being  tested  so  that  the  patient  can  hear  it  distinctly  and  then 

slowly  brings  it  from  a  distance  beyond  the  lange  of  hearing  power 

'oward  the  ear  in  a  line  perpendicular  to  the  auricle  until  the  patient 

^8ain  recognizes  the  ticking.     The  distance  from  the  ear  at  which 

"*e  ticking  is  heard  is  then  accurately  measured,  and  the  result  is 

'^Pressed  in  a  fraction  of  inches,  the  denominator  of  which  represents 

'^^  number  of  inches  at  which  the  parricular  watch  is  normally  heard 

^^fX  the  numerator  the  number  of  inches  it  is  heard  by  the  ear  under 

'^^mination.     For  example,  if  the  watch  is  heard  at  forty  inches  (100 

°**-)  by  the  normal  ear  and  the  patient  hears  it  at  ten  inches  (25  cm.), 

^^  result  is  expressed  as  10/40, 

3.  The  Voice  Test. — The  patient  is  seated  in  a  large  room  with  the 
'^s  dosed  and  the  ear  not  under  examination  plugged  with  the  fore- 


'n, 


'ger.     The  examiner  then  repeats  words  of  one  syllable  or  numerals 


■1 


in  an  ordinary  voice  and  also  in  a  whisper  at  the  end  of  ez[Mrati(iii 
with  the  residue  air  from  various  distances,  and  measures  tbe  &■ 
tance  at  which  the  patient  can  hear  and  repeat  them  correctly.  Tta 
result  is  expressed  in  a  fracUon  of  feet,  the  denominator  of  which  rep 


m 


N5/ 


Q 


W 


V 


\v 


SY/ 


:t  of  tuning-forks  varying  from  i  iS  v 


0  1048  vs, 


resents  the  distance  in  feet  at  which  the  normal  ear  can  hear  t^ 
voice  and  the  numerator  the  actual  distance  at  which  it  b  heard 
the  ear  under  e^camination.     In  employing  this  test  it  is  importa. 
that  the  patient  does  not  see  the  Ups  of  the  examiner  and  that  t- 


modification  of  Gallon's  whistle. 


sounds  are  transmitted  to  the  ear  under  examination  at  right  ang^ 
to  the  auricle. 

Testing  the  Perception  of  Different  Notes. — The  nonn 
range  of  hearing  in  adults  for  musical  notes  lies  between  1 6  and  48,0 
vibrations  per  second.     The  majority  of  individuals,  however,  possf 


INFLATION  OP  THE  MIDDLE  EAR  415 

a  more  limited  range  than  this,  varying  from  about  34  to  16,000  vibra- 
tions per  second.     In  this  test  the  hearing  is  tested  for  low  tones  with 
a  low-toned  fork  and  for  high  tones  with  the  Galton  whistle.     The 
(est  is  of  diagnostic  value  in  differentiating  between  disturbance  of 
hearing  due  to  affections  of  the  conducting  and  those  of  the  percep- 
tive  apparatus.     AVTiere  the  conduction  apparatus  is  at  fault  high 
tones  are  heard  better  than  low,  while  in  diseases  of  the  perceptive 
apfsaratus,  the  low  tones  are  heard  well,  but  high-tone  hearing  is  lost 
or-      diminished.     It  should   be  remembered,   however,   that   in   ad- 
vaaadng  age  the  upper  tone  limit  is  lowered. 

Weber's  Test. — It  is  employed  for  the  purpose  of  locating  the 
ses>.t  of  unilateral  deafness.  In  this  test  a  C  2  (512  vs.)  fork  is  set 
■vit>rating  and  the  handle  is  placed  on  the  incisor  teeth  or  upon  the 
cranium  in  the  mid-line.  If  the  sound  is  heard  best  in  the  affected 
*a-x-,  il  is  indicative  of  some  affection  of  the  conduction  apparatus,  as 
*T\ i<ddle-ear  disease,  impacted  cerumen,  or  occlusion  of  the  Eustachian 
t-iitie,  while  if  the  perceptive  apparatus  Is  at  fault,  it  wiU  be  heard 
butler  in  the  normal  ear. 

Rinne's  Test.^This  test  depends  upon  the  fact  that  aerial  con- 
di-xction  is  better  than  bony  conduction.     In  a  normal  ear,  if  a  C  2 
(511  vs.)  fork  be  placed  upon  the  mastoid  until  the  patient  no  longer 
tears  any  sound,  and,  if  the  fork  is  then  brought  close  to  the  external 
esir,  ihe  sound  will  again  be  heard.     This  is  known  as  a  positive  Rinne. 
If,  howe\'er,  the  sound  is  not  heard  again  when  the  fork  is  thus  trans- 
posed, it  is  known  as  a  negative  Rinne.     Therefore,  in  a  deaf  ear,  if 
we  obtain  a  positive  Rinne,  it  is  indicative  of  a  lesion  in  the  perceptjve 
apparatus,  while  if,  under  the  same  conditions,  the  test  is  negative, 
't  shows  that  bony  conduction  is  increased ;  i.e. ,  there  is  some  obstruc- 
tion or  disease  of  the  conduction  apparatus. 

f  INFLATION  OF  THE  MIDDLE  EAR 

Inflation  of  the  middle  ear  has  both  diagnostic  and  therapeutic 

^'ue.     As  a  diagnostic  measure  it  is  employed  to  determine  the  pat- 

*^cy  Qf  tj,g  Eustachian  tubes,  that  is,  whether  or  not  an  unobstructed 

'^**iiiiunication  exists  between  the  middle  ear  and  the  pharynx;  for 

^  purpose  of  detecting  the  presence  or  absence  of  an  exudate  in  the 

''**ddJe  ear,  and,  if  so,  the  character  of  the  exudate ;  to  detect  the  pres- 

"^^e  of  a  perforation  of  the  membrana  tympani;  and  to  determine  the 

"Johility  of  the  membrana  tympani.     The  therapeutic  uses  of  infla- 

^1  will  be  considered  later  {see  page  428). 


4l6  THE   EAR 

An  auscultatory^  tube  is  employed  in  conjunction  with  inflation 
for  the  purpose  of  determining  whether  air  enters  the  middle  ear  and 
to  distinguish  the  character  of  the  sound  produced  which  is  of  diag- 
nostic importance.     Thus,  in  a  normal  condition  of  the  Eustadiian 
tubes  and  tympanic  cavity,  air  will  be  heard  to  enter  the  middle  ear 
with  a  soft  blowing  sound;  if  the  tube  be  obstructed,  the  sound  will 
have  a  more  or  less  whistling  character,  while,  if  the  obstruction  is  not 
overcome,  air  will  not  be  heard  to  enter  the  middle  ear  at  all  and  the 
sound  will  be  distant.     When  the  middle  ear  contains  an  exudate,  the 
sound  will  vary  according  to  the  character  of  the  fluid;  if  it  is  thin 
and  watery,  a  fine  bubbling  sound  will  be  heard;  if  it  is  thick  aad 
viscid,  the  sound  will  be  a  coarse  bubbling  one.     In  the  presence  of  a. 
perforation  of  the  membrana  tympani,  inflation  causes  a  characteris- 
tic hissing  or  whistling  sound  and  often  secretion  will  be  forced  out 
through  the  perforation  into  the  external  auditory  canal.    By  the  aid 
of  a  speculum,  the  drum  may  be  inspected  and  the  effect  of  theinfla.- 
tion  upon  it  noted  and  the  mobility  determined. 

There  are  three  methods  by  which  the  middle  ear  may  be  inflated  • 
(i)  Valsalva's  method,  (2)  Politzer's  method,  and  (3)  catheteriza- 
tion.    Before  practising  inflation  it  is  a  wise  precaution  to  inspect  tt*^ 
ear-drum  to  see  if  it  is  sufficiently  strong  to  stand  the  strain,  as  cas^?^ 
have  been  reported  where  a  diseased  drum  has  been  ruptured  by  tt»>^ 
Politzer  bag. 

Position  of  Patient. — The  patient  should  be  seated  upon  a  chaL:*^- 
The  examiner  is  also  seated,  facing  the  patient. 

Preparations  of  Patient. — In  all  cases  the  nose  and  phar>T::»-* 
should  be  thoroughly  cleansed  before  inflation  is  performed  by  mear:*-^ 
of  gargling  and  the  use  of  a  nasal  spray  (page  383). 

Valsalva's  Method. — This  method  of  inflation  is  the  simplest  ^^* 
the  three  and  at  the  same  time  is  the  least  reliable.     It  is  fairl^'' 
successful,  however,  if  only  a  slight  obstruction  exists.     On  blccommtm^ 
of  the  ease  with  which  it  can  be  performed  by  the  patient,  it  is  apt 
be  repeated  frequently,  with  the  risk  of  producing  a  flaccid  coi 
dition    of    the  drum   unless  the  patient  is  cautioned  against  i'^^ 
overuse. 

Apparatus. — There  will  be  required  a  head  mirror  and  so: 
source  of  illumination,  or  an  electric  head  light,  aural  specula,  anda^ 
aural  stethoscope.     The  latter  instrument  (Fig.  403)  consists  of  ^ 
piece  of  rubber  tubing,  about  3  feet  (90  cm.)  long  into  the  two  endso.- 
which  are  fitted  hard-rubber  ear-pieces — a  white  one  for  the  exam 
iner's  ear  and  a  black  one  to  fit  into  the  patient's  ear. 


INFLATION   OP  THE   MIDDLE   EAR 


417 


—The  specula  and  ear  pieces  of  the  aural  stethoscope 
sfaould  be  sterile. 

Technic. — The  patient's  mouth  should  be  shut  and  the  nostrils 
held  closed  by  the  fingers.  Then  the  patient  is  instructed  to  give  a 
forced  expiration  and  at  the  same  time  swallow.  The  act  of  swallow- 
ing causes  the  tubes  to  relax,  and  the  air,  under  pressure,  is  thus 


Aural  stethoscope. 


forced  through  the  tubes  into  the  middle  ear.  As  this  occurs  the 
patient  will  have  a  feeling  of  distention  in  both  ears,  and  the  exam- 
iner by  means  of  the  aural  stethoscope  will  hear  the  sound  of  air  en- 
tering the  middle  ear.  If  the  drum  membrane  is  inspected  as  the 
infla.tion  is  performed,  it  will  be  noticed  that  the  membrane  moves 
out-wfard  and  becomes  somewhat  congested. 


'^-   404.— Instnimcnts  for  Politicr's  method  of  inUation.     i,  Head  mirror:  2,  aural 
specula;  3,  aural  stclhoacope;  4,  Politzer  inflation  bag.- 

Politzer's  Method.— This  is  probably  the  most  frequently 
***ipIoyed  method  of  inflation. 

Apparatus.^There  will  be  required  a  head  mirror  and  suitable 
^Hinination  or  an  electric  head  light,  aural  specula,  an  aural  stetho- 
*^^pe.  and  a  Politzer  air-bag  (Fig.  404).  The  Politzer  air-bag  con- 
***t:s  of  a  soft  pear-shaped  bag  of  such  size  and  shape  that  it  can  be 
*^dfly  compressed  in  the  operator's  hand,  supplied  with  a  piece  of 


4l8  I'HE  EAS 

rubber  tubing  about  8  inches  (20  cm.)  long,  to  the  end  of  whidis 
attached  an  olive-shaped  glass  nose-piece. 

Asepsis. — The  glass  nose-piece  and  the  specula  should  be  steriUad 
by  boiling  before  use.  The  ear  pieces  of  the  aural  stethoscope  shouU 
also  be  sterile. 

Technic. — The  patient  is  first  given  a  small  amount  of  wato-- 
about  a  teaspoonf  ul  is  sufficient — which  be  is  instructed  to  hold  in  lu 
mouth  until  told  to  swallow.  The  exaniiner  then  inserts  the  ma- 
piece  of  the  Politzer  bag  into  one  nostril  for  a  distance  of  aboot 
^i  inch  (i  cm.),  apd  compresses  both  nostrils  about  it  by  means  of 
the  left  thumb  and  forefinger.  The  patient  is  them  told  to  swallot, 
and,  as  the  larynx  is  seen  to  rise  up  at  the  commencement  of  the  let 


Fic.  405. — Inflation  by  PoIiUer'a  method. 

of  swallowing,  the  examiner  compresses  the  air-bag  with  his  ngM 
hand  (Fig.  405).  The  act  of  swallowing  causes  the  soft  palate  to  rise 
upward  and  shut  off  the  naso-pharynx,  and,  at  the  same  time,  the 
Eustachian  tubes  tend  to  open  so  that  the  air  is  readily  forced  through 
the  tubes  into  the  middle  ear.  In  children,  crying  has  the  same 
effect  as  swallowing. 

With  the  auscultatory  fube  the  character  of  the  sound  produced 
is  recognized.  When  it  is  desired  to  inflate  only  one  ear,  the  patient's 
head  should  be  turned  to  one  side,  so  that  the  affected  ear  lies  uppef" 
most,  while  at  the  same  time  the  opposite  ear  is  closed  by  the  fingers 
pressed  against  the  external  auditory  meatus.  In  using  PolitierS 
bag  care  should  be  taken  not  to  use  a  great  amount  of  force  uw 
thereby  avoid  causing  the  patient  pain. 


INFLATION  OF  THE  MIDDLE  EAR 


419 


Catheterization. — Inflation  through  an  Eustachian  catheter  is 
only  indicated  when  inflation  by  the  methods  previously  mentioned  Is 
impossible.  The  passage  of  a  catheter  into  the  Eustachian  tube  is  a 
delicate  operation  requiring  skill  as  well  as  gentleness  of  touch  for  its 
jafe  and  successful  performance.  If  carelessly  performed,  there  is 
[er  of  injuring  the  mucous  lining  of  the  tube  or  of  making  a  false 
;e  and  injecting  air  into  the  submucous  tissues  of  the  tube. 
Certain  cases  it  may  be  impossible  to  perform  catheterization, 
as,  for  example,  in  the  presence  of  marked  deviations  of  the  septum, 
considerable  narrowing  of  the  nasal  fossie,  tumors,  or  adenoids, 
and  in  nervous  or  hysterical  individuals  or  in  those  upon  whom 
attempts  to  pass  the  catheter  excite  coughing,  retching,  or  spasm  of 
ti>e  pharj'ngeal  muscles. 


Pin.  406. — Instruments  for  infiation   through   an  Eustachian  catheter,     i,  Head 
^^Tor:  1,  aural  specula;  3,  aural  slcthoacopt;  4,  Politzer's  infiation  baa;  S.  Eusta- 
n  catheters. 

Apparatus. — There  will  be  required  a  head  mirror  and  suitable 
''lumination  or  an  electrical  head  light,  aural  specula,  an  aural  stetho- 
^ope,  a  Politzer  air-bag  with  an  Eustachian  catheter  tip,  and  several 
*^*es  of  Eustachian  catheters  (Fig.  406).  The  catheter  is  a  metal 
tube  6'^  inches  (16  cm.)  long,  curved  at  its  distal  end,  the  extreme 
**p  of  which  is  slightly  bulbous,  and  with  an  expanded  proximal  end 
'^^to  which  the  Up  of  a  Politzer  bag  may  be  fitted.  It  should  be  of 
Pure  silver  so  that  its  curve  may  be  changed  to  fit  the  individual  case. 
^  ring  is  placed  upon  the  side  of  the  instrument  near  its  proximal 
'^d  to  indicate  the  direction  of  the  beak.  Three  sizes  should  be  pro- 
*^ed  J-is,  112-  ii  '^^^^  (i.  2'  ^°d  3  mm.)  in  diameter,  respectively. 

Asepsis. — The  catheter  and  the  specula  should  be  sterilized  by 
•filing;  the  ends  of  the  aural  stethoscope  should  be  likewise  sterile, 


430  THE   EAR 

and  the  hands  of  the  operator  should  be  cleansed  as  for  any  operadn 
procedure. 

Anesthesia. — In  sensitive  individuals  the  nose  may  be  anesthe- 
tized by  means  of  a  small  amount  of  a  4  per  cent,  solution  of  cocun 
applied  by  means  of  a  cotton-tipped  probe  to  the  inferior  meatus. 

Technic. — The  operator  first  inspects  the  nose  by  the  aid  d 
illumination  for  the  presence  of  deviations  of  the  s^tum  or  othet 
pathological  conditions  which  might  interfere  with  the  passage  of  the 
catheter.    The  catheter  may  then  be  inserted  by  one  of  two  methods; 

I.  Limienberg  Melkod. — The  proximal  end  of  the  lubricated  cathe- 
ter is  grasped  lightly  between  the  thumb  and  forefinger  of  the  ri^t 
hand,  while  by  means  of  the  thumb  of  the  left  hand,  the  tip  of  the 


Fig.  407. — Catheterizing  the  Eustachian  tube.     First  step,  showing  the  position  of  the 
catheter  for  its  introduction. 

patient's  nose  is  elevated  so  as  to  straighten  out  the  canal.  The 
beak  of  the  instrument  is  then  introduced  within  the  anterior  nares, 
the  shaft  of  the  instrument  being  in  an  almost  vertical  position  (Fig. 
407).  The  catheter  is  then  elevated  to  a  horizontal  position,  and, 
with  the  tip  kept  constantly  in  contact  with  the  fioor  of  the  nose,  it  is 
gently  pushed  inward  until  the  beak  comes  in  contact  with  the  pos- 
terior wall  of  the  pharynx  (Fig.  408).  The  beak  is  then  rotated 
through  an  angle  of  90  degrees  toward  the  median  line,  until  the  guide 
ring  lies  horizontal,  and  the  catheter  is  drawn  forward  until  its  beak 
is  found  to  impinge  upon  the  nasal  septum  (Fig.  409).  The  beak  is 
then  rotated  downward  and  outward  through  an  angle  of  a  Uttk 


INFLATION   OF   THE   UIDDLE   EAR  42I 

iDore  than  iSo  degrees  until  the  guide  ring  points  toward  the  outer 
canthus  of  the  eye;  at  the  same  time  the  proximal  end  of  the  catheter 
is  moved  toward  the  nasal  septum,  and  its  tip  thus  enters  the  Eu- 


FXG.    408. — Catheterizitig  the  Eustachian  tube.    Second  step,  catheter  being  passed 
along  the  Soor  of  the  nose. 

stachian  tube  (Fig.  410).     In  all  these  manipulations  care  should  be 
taken    to  employ  the  greatest  gentleness.     The  entrance  of  the 


Fig.  409. — Showing  the  different  positions  of  the  beak  of  the  catheter  in  its  insertion 
into  the  Dii&ce  of  the  Eustachian  tube.     (After  Barnhill  and  Wales.) 

catheter  into  the  tube  will  be  recognized  by  the  fact  that  the  tip  is 
firmly  fixed  and  cannot  be  rotated.  The  catheter  is  now  held 
in  place  by  the  thumb  and  forefinger  of  the  left  hand,  the  other  fin- 


439  THE   EAS 

gers  resting  upon  the  bridge  of  the  nose,  and,  with  the  nozzle  a 
air-bag  fitted  into  the  proximal  end  of  the  catheter,  inflation  is 
formed  by  compressing  the  bag  in  the  fingers  of  the  right  hand  ' 


Fig.  410.— Catheteriring   the   Eustachian   tube.     Third   step,   allowing  dw  pt 
of  the  guide  when  the  catheter  tip  is  entering  the  orifice  of  the  tube. 

411).     While  this  is  done  the  examiner  notes  the  sound  produce 
means  of  the  auscultation  tube. 


f 

Fig.  411. — Inflation  through  an  Eustachian  catheter.     (Gleaaon.) 

In  removing  the  catheter  it  is  first  rotated  until  its  beak  p 
downward  and  is  then  gently  withdrawn  by  a  reversal  of  the  r 
ments  employed  in  its  insertion. 


THE    EAR    SYRINGE    ' 

.  Binnafont  or  Kramer  Method. — The  instrument  is  introduced 

io  the  same  manner  as  described  under  the  Lowenberg  method  until 

tie  beak  is  in  contact  with  the  posterior  pharyngeal  wall.     The 

Aeat  is  then  rotated  outward  through  more  than  an  angle  of  90  degrees 

iciiich  causes  its  tip  to  rest  in  Rosenmiiller's  fossa.     The  catheter  is 

lAen  -withdrawn  until  its  tip  is  felt  to  slip  over  the  bulging  posterior 

ip   of  the  Eustachian  mouth  when  its  tip  will  beat  the pharj-ngeal 

Orifice  of  the  tube.     The  distance  it  is  necessary  to  withdraw  the 

"^tlieterto  accomplish  this  varies  usually  from  1/4  to  3/8  inch  (6  to  9 

^rn . )  _     The  catheter  is  then  rotated  until  the  guide  ring  points  to  the 

ou  tei-    canthus  of  the  eye  and  the  tip  slips  into  the  tube.     With  the 

catfa^*er  in  position  inflation  is  performed  as  described  above. 


Therapeutic  Measures 

THE  EAR  SYRINGE 

S>nringing  of  the  ear  is  employed  for  the  purpose  of  removing 

iorei^j,  bodies  or  cerumenous  masses  from  the  external  auditoiy  canal 

"^^^     to  keep  the  ear  free  from  purulent  material 

"'^'clj  collects  after  perforation  or  incision  of  the 

"'^^^   membrane.     In  using  an  ear  syringe  one 

''^^st  always  employ  extreme  gentleness  and  solu- 

*^*ls   of  the  proper   temperature,  otherwise   the 

P'"*>cedure  is  not  only  rendered  painful,   but   is 

^^Pabie  of  causing  harm.     Especially  is  it  neces- 

^^'  to  avoid  forcible  injections  in  cases  where  the 

Vi^panum  is  exposed  through  destruction  of  a 

*^*isiderable  portion  of  the  drum  membrane. 

The  Syringe. — ^The  syringe  should  be  simple 

^    construction  and  of  such  material  that  it  may 


easily  sterilized,  and  should  have  a  capacity 


412.— AUport'a 
s  syringe. 


'     I  or  2  ounces  (30  to  60  c.c).     It  should  be  pro- 

^<Je<i  with  a  blunt  conical  nozzle— the  ordinary 
**\e-shaped   tip  is  not   to   be  commended,  as  it  interferes  with  a 
""^  return  flow.     A  syringe  with  a  long-pointed  nozzle,  such  as  is 

^•*own  in  Fig.  413,  will  often  be  found  more  eflicacious  in  removing 
*^*"eign  bodies  than  the  ordinary  syringe. 

For  irrigating  the  internal  ear  through  a  perforation  in  the  attic, 
^  smaller  syringe,  such  as  Blake's  (Fig.  414),  with  a  capacity  of  1/2 
'Itara  (2  c.c).  provided  with  specially  bent  tips,  is  used.     There  will 


i 


INSTn-LATIONS 


425 


then  grasps  the  auricle  between  the  left  thumb  and  forefinger  and 
draws  it  upward  and  backward,  so  as  to  straighten  out  the  external 
auditory  canal.  With  the  right  band  he  then  introduces  the  nozzle 
of  the  syringe  into  the  external  canal  in  such  a  way  that  the  tip  of 
the  sjTinge  rests  against  the  superior  wall  of  the  canal,  so  that  the 
solution,  as  it  is  injected,  will  pass  along  the  upper  wall  and  washout 
purulent  matter  or  foreign  material  below  (Fig.  415).  The  solution 
is  then  injected  with  only  a  small  amount  of  force  in  sufficient  quanti- 
ties for  the  purpose  of  the  operation.  Should  dizziness  or  syncope 
supervene,  the  operation  should  be  immediately  stopped. 


Via,  415. — Waahing  impaclcd 

to  ttnjghteii  the  canaJ  aad  whi 


from  caant.     Showing  how  to  hold   auricle 
I  diri^ct  the  stream  of  water.     (Gleasnn.) 


-^t  the  completion  of  the  syringing  all  moisture  is  removed  by 
"leans  of  a  cotton-tipped  probe  and,  in  the  presence  of  a  discharge,  a 
^Wp  of  sterile  gauze  is  lightly  placed  in  the  external  canal. 

In  cases  where  it  is  necessary  to  cleanse  out  the  attic  through 

*  perforation,  the  drum  is  exposed  by  the  aid  of  a  speculum  and 

SOOfi  illumination,  and  Blake's  angular  cannula  is  inserted  through 

*"^    perforation  under  direct  vision.     The  cavity  is  then  carefully 

*^»i5ed  by  gentle  syringing, 

INSTILLATIONS 

In  some  cases  of  otorrhea  where  the  discharge  has  become  scanty, 
^'*  kmg  continued  use  of  douches  often  seems  to  keep  up  an  irritation 


426  THE   EAK 

and  a  persistence  of  the  discharge.     In  these  cases  the  insti 

astringent  solutions  for  the  purpose  of  promoting  healthy 

tions  may  be  substituted.  The  solutions  may  be  thus  appli 
external  auditory  canal 
the  lining  of  the  canal  or  ni 
tympani  or  to  the  tympan 
through  a  perforation  « 
latter  contains  unhealthy 
tion  tissue. 

Instruments. — To  insti 
tion  into  the  external  audita 
an  ordinary  glass  medicine 
may  be  employed.  For  1 
instillations  a  pipette  glass 
with  a  small  curved  tip, 
mirror  and  illuminatioa, 
aural  speculum  will  be 
{Fig.  416). 

Asepsis. — The   instr 
should  always  be  sterilize 
use. 
Solutions. — Solutions  of  silver  nitrate  5  to  ao  per  c«it 

sulphate  5  per  cent.,  zinc  sulphate  5  per  cent.,  and  alcohol 

per  cent,  may  be  used. 

Temperature. — The  solutions 

should  be  warm — at  about  100°  F. 

(38°  C). 

Position  of  Patient.— The  patient 

should  be  seated  with  the  head  bent 

sideways  so  that  the  affected  ear  lies 

uppermost. 

Technic. — The  ear  is  first  cleansed 

and    all  secretion  or  fluid  removed 

by  means  of  a  cotton-tipped  probe. 

The   operator  then    straightens  out 

the  external  auditory  canal  by  grasp- 
ing the  auricle  between  the  thumb 

and  forefinger  of  the  left  hand  and 

exerting  traction  in  an  upward  and 

backward  direction.     With  the  right  hand  he  then  instil 

drops  (0.3  to  0.6  C.C-)  of  the  desired  solution  into  the  audito 


Fig.  416. — Instruments  tor  tym- 
panic   instillation.     :,  Head    mirror; 

I,  aural  specula;  j,  glass  instillator. 


Fig.  417. — Shoning  1 
pipette  inserted  for  a  ty: 

St  illation. 


APPLICATION  OF   CAUSTICS 


437 


Til's  is  retained  for  from  five  to  ten  minutes,  or  for  a  shorter  time  if 
it  causes  burning  or  pain,  and  is  then  permitted  to  escape  by  having 
the  patient  incline  the  ear  downward. 

Jn  making  intratympanic  instillations  the  auditory  canal  is  first 
c/eansed  and  the  drum  is  exposed  by  means  of  a  speculum.  The 
poiijt  of  the  pipette  is  then  carefully  inserted  through  the  perforation 
and  a  few  drops  of  weak  solution  are  injected  (Fig.  417). 

APPLICATION  OF  CAUSTICS 
The  application  of  chemical  caustics  to  the  ear  may  be  required 
for  tbe  purpose  of  destroying  granulations  or  small  polypi.     The  most 
fre<j\jently  employed  agents  for  this 
pur-|:>ose  are  chromic  acid  or  silver 
*"tt-s»te.    They     are     applied    fused 
"!>«:>  n  the  tip  of  a  delicate  ear  probe. 
"^       making   such  applications  with 
**^orig  chemicals  great  care  must  be 
^^ke^n  that  the  caustic  only  comes  in 
cont_act  with  the  area  to  be  treated. 


Th, 


•y  should,  therefore,  only  be  ap- 


P"e^  by  the  aid  of  a  speculum  and 
™***^ci  illumination. 

Instruments. — There  will   be  re- 

r*^'*"ed  a  head  mirror  and  a  strong 

S*>t.  aural   specula,  a  delicate  aural 

^**^tie,  and  an  aural  applicator  (Fig. 

The  method  by  which  the  add 
*~       silver   nitrate  is  fused   upon  the 
Jr*~*^Ije  has  been  previously  described 
*-^«^pagej86). 

^sepsis.^The  instruments  should  be  boiled  before  use. 

f  ositioQ  of  the  Patient. — The  patient  and  the  operator  art 

tJie  same  relative  positions  as  for  an  ordinary  otoscopic 


plying  c 


— Instruments  tor  api- 
ca  to  the  ear.     i,  Head 
.ura!   specula;   j,   aural 
probi-;  4,  applicator. 


seated 


Technlc. — With  the  speculum  inserted  in  the  ear  and  the  parts 

'^"IX  illuminated,  the  site  of  the  intended  application  is  cleansed  and 

-«^  thoroughly  dried  by  means  of  cotton  wrapped  upon  the  end  of 


tH, 


i 


^^  ^ural  applicator.  This  is  very  important,  for  if  any  fluid  be  in  the 
^^•^  the  caustic  will  spread  to  other  parts  as  soon  as  it  is  applied.  The 
'^^'^Jstic  is  then  carefully  applied  to  the  area  it  is  desired  to  destroy. 


428 


THE  EAR 


INFLATION  OF  THE  MIDDLE  BAR 


The  value  of  inflation  in  diagnosis  has  been  previously  considered 
(see  page  41 5) .    As  a  therapeutic  measure  it  is  employed  in  tubal  aiic\ 
middle-ear  disease  with  occlusion  of  the  tube  for  the  purpose  of  r^s— 
storing  the  normal  tension  between  the  drum  membrane,  ossicle^s 
and  the  internal  ear.     The  circulation  is  thus  improved  and  hype"^c" 
emia  and  infiltration  of  the  tubal  and  tympanic  mucous  membrane 
diminished.    At  the*same  time  morbid  secretions  are  removed  fro 
the  Eustachian  tube  and  tympanic  cavity,  and  newly  formed 
hesions  are  broken  down. 

The  methods  by  which  inflation  may  be  performed  and  the 
will  be  found  described  on  page  416. 


INFLATION  WITH  MEDICATED  VAPORS 

In  certain  cases  of  subacute  or  chronic  nonsuppurative  oti 
media,  inflation  with  medicated  vapors  is  often  employed  to  bet 


Fig.  419. — Dench's  vaporizer  and  Eustachian  catheter. 

advantage  than  plain  air.  '  The  vapor  of  drugs  having  either  a  sedi 
tive  or  stimulating  action  may  be  used.     In  this  way  all  the  benefi 
of  inflation  plus  the  sedative  or  stimulating  effect  of  the  vapor  upo: 
the  mucous  membrane  are  obtained. 

Apparatus. — A  vaporizer,  in  which  the  air  current  passes  over  th 
volatile  drug  it  is  desired  to  employ,  attached  to  an  Eustachian  cath- 
eter, forms  the  necessary  apparatus.  There  are  a  number  of  con- 
venient vaporizers,  such  as  Hartmaim's,  Pynchon's,  or  Bench's 
(Fig.  419).  The  latter  apparatus  is  especially  useful,  as  plain  air 
or  medicated  vapor  may  be  obtained  by  simply  turning  a  key  on  the 
top  of  the  bottle. 

Asepsis. — The  catheter  should  be  sterilized  by  boiling  before  use. 


INJECTION  OF   SOLUTIONS   INTO   THE   EUSTACHIAN   TUBES      429 


■  Formulary.— Vapors  of  menthol,   camphor,    eucalyptol,   iodin, 

W     turpentine,  chloroform,  and  ether  alone  or  in  combination  are  most 
'      /requently  employed. 

Preparation  of  Patient. — Same  as  for  catheterization  (see  page 
416). 
I  Position  of  Patient. —  Same  as  for  catheterization  (see  page  416), 

I  Technic. — The  Eustachian   catheter   is  passed    by   one   of   the 

jri^tiiods  described  on  pages  420  and  423  and  with  all  the  precautions 
derta-iled  therein.  Inflation  with  air  is  then  performed  in  order  to 
ferst:  force  out  from  the  tube  any  collection  of  mucous  or  secretion  and 
t]:i«.is  permit  the  medicated  vapor  to  come  in  contact  with  the  mucous 
m^rxibrane.  The  medicated  vapor  is  then  blown  into  the  tympanic 
ca.>.^it:y  in  the  same  manner,  after  attaching  the  vaporizer  to  the 
ca.  t-i:^  eter. 


INJECTION  OF  SOLUTIONS  INTO   THE  EUSTACHIAN 
TUBES 

lOirect  medication  of  the  Eustachian  tubes  may  be  used  to  advan- 
ta.g^   in  the  treatment  of  middle-ear  catarrh  for  the  purpose  of  lessen-- 


-    420. — Eustachian  catheter  and  syringe  for  medication  of  the  Eustachian  tubes. 

S  the  swelling  of  the  mucous  membrane,  and  to  diminish  secretions, 
^•"«by    rendering   the   tubes  more  permeable.     Weak  astringent 
**»tionb  are  generally  employed  for  this  purpose,  injected  through 
^    t^ustachian  catheter. 

-^iparatus. — There  will  be  required  an  Eustachian  catheter,  a 

r-^^^ll  syringe,  graduated  in  drops,  and  provided  with  a  tip  that  will 

into  the  pro.\imal  end  of  the  catheter  (Fig.  420),  and  aPolitzer 

Asepsis. — The  catheter  and  syringe  should  be  boUed,  and  the 
^»Mtion  employed  should  be  a  sterile  one. 

Solutions  Used. — lodid   of  potassium   5   gr.   (0.32  gm.)   to  the 
"^liice  (30  C.C.),  silve  nitrate  2  to  5  gr.  (0.13  to  0.32  gm.)  to  the  ounce 


430  THE   EAR 

(30  C.C.),  sulphate  of  zinc  i  gr.  (0.065  gm.)  to  the  ounce  (30  cc),      B 
protargol  10  to  50  per  cent.,  bicarbonate  of  soda  2  to  5  gr.  (0.13  to 
0.32  gm.)  to  the  ounce  (30  cc),  etc,  may  be  employed. 

Quantity. — About  five  to  ten  drops  (0.3  to  0.6  cc.)  of  thcsdected 
drug  are  injected  at  a  time.  If  perforation  of  the  drum  exists  more 
solution  may  be  safely  used,  but  in  its  absence  small  amounts  only 
are  applicable. 

Preparation  of   the  Patient. — Same  as  for  catheterization  (sec 
page  416). 

Position  of  Patient. — Same  as  for  catheterization  (see  page  41&). 

Technic. — The  catheter  is  introduced  into  the  tube  by  one  of  \bkt 
methods  described  on  pages  420  and  423  and  the  ear  is  inflated  by  tk^e 
Politzer   bag   to  empty  it  of  secretion.     The  small  syringe  is  th^si^ 
charged  with  the  warmed  solution,  and  the  desired  amount  is  dow  Hy 
injected  through  the  catheter.     The  air-bag  is  then  substituted  f^^>i 
the  syringe  and  the  solution  is  blown  into  the  tube. 

THE  EUSTACHIAN  BOUGIE 

Eustachian  bougies  are  employed  in  overcoming  tubal  obstru  -^" 
tions  which  will  not  yield  to  inflation  and  for  the  purpose  of  dilatic^ig 
tubal  strictures.  In  the  latter  condition,  however,  the  use  of  tfci^c 
Eustachian  bougie  is  rarely  curative  if  the  stricture  is  composed  ^^i 
dense  connective  tissue. 

The  bougie  is  passed  into  the  tube  through  a  catheter,  and  ^t 
should  always  be  inserted  with  the  greatest  care  and  gentleness, 
it  is  a  very  easy  matter  to  injure  the  mucous  membrane  with 
result  that,  if  inflation  be  immediately  performed,  air  may  be  forc^^ 
under  the  mucous  membrane  through  the  tear  and  cause  emphysem.  s- 
It  is,  therefore,  advisable  to  wait  a  day  or  two  after  passing  the  bou^^e 
before  inflation  is  attempted.  Care  must  also  be  observed  not  ^0 
pass  the  bougie  a  greater  distance  than  the  length  of  the  tube;tli^t 
is,  not  more  than  i3^^  inches  (3  cm.)  beyond  the  tip  of  the  cathet^^r- 

Instruments. — There   will   be  required  an  Eustachian  cathet^^r» 
Eustachian  bougies,  and  a  Politzer  air-bag  (Fig.  421).     The  bougi^^> 
are  made  of  silkworm  gut  or  whalebone,  with  tips  conical  or  bullx^"*^ 
in  shape,  and  varying  in  diameter  from  3'^4  to  J^5  inch  (0.4 
to  I  mm.).     The  catheter  used  to  guide  the  bougie  into  the  tu 
should  be  somewhat  shorter  than  ordinary  with  a  Idnger  curved  bea— ■^ 

Asepsis. — The  catheters  are  sterilized  by  boiling  and  the  bougt- 
by  immersion  in  a  saturated  solution  of  boric  acid. 


TECE   EUSTACHIAN  BOUGIE  431 

■frequency.— Bougies  should  not  be  inserted  more  frequently 
M3ii  two  or  three  times  a  week  In  order  to  permit  the  reaction  from 
ODe  insertion  to  subside  before  another  is  attempted. 

Plfeparations  of  Patient. — Same  as  for  catheterization  (see  page 

Position  of  Patient — Same  as  for  catheterization  (see  page  416). 

Technic. — The  bougie  is  lubricated  and  is  introduced  within  the 
catheter  until  the  tip  is  level  with  the  distal  end  of  the  catheter  (Fig. 
421).        The  catheter,  with  the  bougie  in  place,  is  then  introduced 


■♦21. — rastrumcnls  for  dilntalion  of  the  Eustacliian  tubes,     i,  Eustachian  cathe- 
ters; 2,  Eustacbian  bougies;  3,  Poiitzer's  inHation  bag. 

'^  the  tube  in  the  manner  described  on  page  420.  The  bougie  is 
~*CH  carefully  passed  into  the  tube  for  not  more  than  i  '4  inches 
*^  Cm.)  which  can  be  accomplished  in  a  normal  tubewithout difficulty. 
'^s  the  bougie  passes  into  the  Eustachian  tube,  the  patient  will  com- 
I**3in  of  some  pain  in  the  ear,  neck,  or  occiput,  whereas,  if  it  doubles 
'^^ck  into  the  pharynx,  discomfort  will  be  felt  in  that  region.  When 
''Csistance  is  encountered,  the  bougie  should  be  pushed  forward 
^owly  and  with  great  caution,  occasionally  rotating  the  bougie; 


1=^. 


I°^cif)if  manipulalions  must  always  be  avoided  for  fear  of  injuring  the 
*Ucous  membrane.  Having  successfully  overcome  the  obstruction, 
^^  bougie  is  left  in  situ  for  live  to  ten  minutes.  At  the  next  sitting 
'&>"ger-sized  bougie  is  employed. 
The  Medicated  Bougie.— A  medicated  bougie,  obtained  by  dip- 
^}*ig  a  silkworm-gut  bougie  in  some  astringent  solution,  such  as 
^^Cr  nitrate,  before  its  passage,  often  has  more  pronounced  and  more 
^folonged  effect  than  the  plain  bougie  in  overcoming  a  stenosis  due 


432  THE  EAR 

to  congestion  or  inflammation  of  the  mucous  membrane.  Tie 
medicated  bougie  is  introduced  in  the  same  manner  as  an  ordiiuiy 
bougie,  and  should  be  allowed  to  remain  in  place  about  fifteen  to 
twenty  minutes  to  obtain  a  prolonged  action  of  the  astringent 

MASSAGE  OF  THE  MEMBRANA  TTMPANI 

Massage  of  the  ear-drum  is  performed  by  alternately  rarefying 
and  condensing  the  air  in  the  external  auditory  meatus.    This;  pto 
duces  an  increased  mobility  in  the  membrana  tympani  and  ossicU 
with  the  result  that  adhesive  processes  between  the  drum  membra^ 
and  inner  wall  of  the  tympanum  are  avoided  or  broken  up  wb-^ 
formed  and  likewise  ankylosis  of  the  ossicular  chain  is  prevent^ 
The  method,  therefore,  has  greatest  value  in  adhesive  forms 
middle-ear  disease;  in  acute  conditions  its  use  is  contraindicat« 
In  all  cases  an  accurate  diagnosis  is  the  first  essential,  otherwr^ 
massage  may  result  in  harm.    It  should  be  avoided  in  all  cases 
relaxed  drum  or  where  portions  of  the  membrane  are  atrophic. 
the  latter  condition  the  atrophied  weakened  portion  will  move  imc3 
the  influence  of  suction  while  the  rest  of  the  drupi  will  be  unaffect^ 

Apparatus. — The  massage  is  performed  with  the  Siegle  type 
mstrument  (see  Fig.  400),  by  means  of  which  the  drum  membrai^ 
may  be  observed  and  the  effect  of  the  massage  noted. 

Asepsis. — The  speculum  portion  of  the  instrument  should 
sterile. 

Duration. — The  massage  may  be  applied  for  one  to  two  minuL't 
at  a  sitting. 

Frequency. — Treatments  should  be  given  two  to  three  times 
week,  but  only  so  long  as  improvement  in  distance  hearing  taJ^< 
place. 

Technic. — The  otoscope  is  introduced  into  the  ear  in  the  manxi^ 
described  on  page  412,  and  the  air  is  alternately  rarefied  and  cc^ 
densed  by  relaxation  or  compression  of  the  bulb.  The  amount 
pressure  used  should  be  regulated  by  noting  the  effect  upon  the  m^"- 
brane  and  ossicles.  If  the  procedure  causes  pain,  the  press^"*- 
should  be  promptly  reduced. 

INCISION  OF  THE  MEMBRANA  TYMPANI 

Incision  of  the  drum  membrane  should  always  be  promptly  p-^ 
formed  in  otitis  media  when  the  drum  is  bulging,  for  the  purpose 


INCISION    OF    THE    LtEMBRANA    TYMPAI 


433 


ing  drainage  for  the  exudate  and  thereby  preventing  necrosis 
p  merabrana  tympani  and  tympanic  contents.  It  is  also  indi- 
t  in  acute  cases  in  which,  while  the  membrane  is  not  actually 
:,  it  shows  marked  hyperemia  and  infiltration  and  the  patient 
s  from  severe  pain  and  exhibits  constitutional  symptoms  of  a 
I  severe  infection.  Especially  in  infants  is  early  incision  required 
I  uncfer-  such  conditions.  If  incision  is  delayed  until  bulging  is  present, 
[  eilensive  destructive  changes  may  have  occurred  and  the  process 
I  Jnaj-     T-apidly  extend  to  the  mastoid  antrum  or  to  the  cranial  cavity. 


"•^  4aj. — Instmmenta  for  incisiog  the  dram  membrane,     i,  Head  mirror;  a,  aural 
specula;  3,  angular  paracenCtsis  kniFe;  4,  Allport's  ear  syringe. 

''^ally,  early  incision  is  always  indicated  if  in  the  course  of  middle- 
^  disease  there  are  signs  of  mastoid  involvement  or  of  meningitis. 
The  extent  of  incision  is  of  importance.  As  a  rule  simple  punc- 
"*^  or  paracentesis,  is  not  enough ;  instead,  the  incision  should  be  of 
^ftdent  size  to  afford  free  drainage  for  the  products  of  suppuration, 
J^^yjixg,  according  to  the  age  of  the  individual,  from  li  to  ^i  inch 
^     to  9  mm.)  in  length. 

Instniments.— There  wnll  be  required  a  head  mirror  and  source 
*  illumination  or  an  electric  head  light,  aural  specula,  a  sharp 
"^^Tacentesis  knife  (straight  or  angular),  and  an  ear  syringe  (Fig. 

iaepsis. — The  instruments  should  be  sterilized  by  boiling,  and 
**ie  operator's  hands  cleansed  as  thoroughly  as  for  any  operation. 


Fio.  424. — Incision  of  the  membrana  tympani  in  acute  otitis  media  inTiJriinJ 
lower  portion  of  the  tympanic  cavity.     (Dendi.} 


—Incision  of  the  mrmbrana  tjmpani  in  acute  otitis  media,  i 
upper  portion  of  the  tympanic  cavity,     (Dench.J 


INCISION   OF   THE    MEMBRANA   TYMPANI  435 

Ions  of  Patient. — The  external  auditorj-  canal  should  be 
deansed  by  syringing  with  warm  saturated  boracic  acid 
(rith  a  I  to  5000  bichJorid  of  mercury  solution. 
1^. — The  operation  is  quite  painful.  In  children  general 
ty  chloroform  is  indicated,  while  in  adults  nitrous  oxid 
{orm  of  local  anesthesia  may  be  used.  Local  anesthesia, 
if  a  solution  of  cocain  applied  to  the  unbroken  mem- 
t  satisfactory,  as  the  cocain  is  not  absorbed.  Instead, 
k  mixture  may  be  employed : 

b  hydrochlorate,  gr.  vi  '0.4  gm.) 

M,  aa5iUc.c.) 

jont  of  this  solution  is  instilled  into  the  external  auditory 
allowed  tO' remain  for  fifteen  minutes.  It  must  be  used 
a  perforation  be  present,  as  it  will  thus  enter  the  tyni- 
f  where  absorption  is  rapid  and  toxic  symptoms  may 

•—The  dnim  is  exposed  by  means  of  a  speculum  under 
jation,  and  the  external  canal  is  thoroughly  dried.  The 
i  inserted  through  the  membrane  in  the  postero-inferior 
bd  the  posterior  quadrant  of  the  drum  is  incised  in  a 
td  to  the  tympanic  vault  (Fig.  424).  In  doing  this,  the 
I  only  be  inserted  through  the  drum  membrane,  so  as  to 
pg  the  inner  tympanic  wall  which  lies  distant  J-^2  ^^ 
to  4  ram.).  Of  course,  if  there  is  any  localized  bulg- 
lion  should  be  so  placed  as  to  relieve  it.  When  the  tym- 
lalone  is  involved,  the  knife  is  entered  in  the  posterior 
iposite  the  short  process  of  the  malleus  and  the  incision 
(ward  through  Shrapnell's  membrane.  The  knife  is  then 
Jrard,  and,  as  it  is  withdrawn,  the  tissues  of  the  posterior 
iUditory  canal  are  incised  down  to  the  bone  for  a  distance 
.'inch  (3  mm.)  from  the  drum  (Fig.  425).  In  this  way 
ie  tympanic  vault  and  mastoid  is  relieved. 
ps  then  carefully  cleansed  by  syringing  and,  after  being 

I  loosely  packed  with  gauze. 

ktment. — The  ear  should  be  syringed  with  a  warmsatur- 

II  of  boric  acid  or  a  i  to  5000  bichlorid  of  mercury 
'tften  as  secretion  collects.     At  first,  this  will  necessitate 

■  two  or  three  hours.    As  the  discharge  decreases, 
5  may  elapse. 


CHAPTER  XVI 

THE  LARYNX  AND  TRACHEA 

Anatomic  Considerations 

The  larynx  is  that  portion  of  the  upper  air  passages  extaidi^' 
between  the  base  of  the  tongue  and  the  trachea.     It  lies  in  the  medi^^ 
line  of  the  neck,  opposite  the  fourth,  fifth,  and  sixth  cervical  v 
brae.    Anteriorly,    it   is   practically   subcutaneous;   posteriorly, 
forms  part  of  the  anterior  boundary  of  the  pharynx;  while  on  d 
side  of  it  lie  the  great  vessels  of  the  neck.    Above,  it  is  broad  a-^^-^ 
triangular  in  shape,  while  below  it  is  narrow  and  cylindrical. 
.    The  framework,  consisting  of  a  number  of  cartilages  held  togetl*-^ 
by  ligaments,  is  lined  with  mucous  membrane,  and  is  capable      ^^ 
being  moved  by  muscles  which  change  the  relative  positions  of 
cartilages  and  thus  modify  the  approximation  of  the  vocal  co: 
during  respiration  and  phonation.     The  most  important  of  th 
cartilages  are  the  thyroid,  the  epiglottis,  the  cricoid,  and  the  t 
arytenoids. 

The  thyroid  cartilage  is  the  largest  of  all,  and  consists  of  t 
broad  lateral  alae  joined  in  front  at  an  acute  angle.     Above,  it^ 
joined  to  the  hyoid  bone  by  the  thyrohyoid  membrane,  and,  below, 
the  cricoid  cartilage  by  the  cricothyroid  membrane.     The  s] 
between  the  thyroid  and  cricoid  cartilages  in  an  adult 
about  half  an  inch  (i  cm.)  in  height;  an  opening  made  through 
space  gives  easy  access  to  the  larynx  below  the  vocal  cords. 

The  epiglottis  is  a  leaf -shaped  piece  of  elastic  cartilage  i  J^  i 
(3.5  cm.)  long,  guarding  the  superior  entrance  of  the  larynx.    It- 
attached  by  its  stalk  to  the  upper  and  posterior  aspect  of  the 
between  the  thyroid  alae  and  to  the  hyoid  bone  by  ligaments.       ^^ 
lies  directly  behind  the  tongue,  and  in  swallowing  it  is  pushed 
ward  by  the  bolus  of  food,  closing  more  or  less  completely  the 
geal  opening  and  thereby  preventing  the  entrance  of  food  into 
larynx. 

T/ie  cricoid  cartilage  is  a   small,   nearly  semicircular  cartiLi^^  "^ 
forming  the  lower  part  of  the  cavity  of  the  larynx.     It  is  narrow 
front,  but  becomes  broadened  and  high  posteriorly.     Upon  its  su] 
rior  border  on  either  side  it  supports  the  arytenoid  cartilages. 

436 


c 


i 


ANATOMIC   CONSIDERATIONS 


437 


T'ke  arytenoid  cartilages,  two  in  number,  are  irregularly  pyram- 
idal in  shape  and  rest  by  their  bases  on  the  superior  border  of  the 
cricoid  cartilage.  They  rotate  upon  a  vertical  axis  and  also  move 
laterally.  Through  these  movements  the  vocal  cords  are  approxi- 
mated or  drawn  apart. 

The  Interior  of  the  Larynx. — The  superior  opening  is  wide  and 
semicircular  in  front  where  it  is  bounded  by  the  epiglottis.  The 
sides  are  formed  by  the  arj'tenoepiglotlic  folds  of  mucous  membrane 
which  run  from  the  sides  of  the  epiglottis  to  the  tops  of  the  arytenoid 
cartilages  and  gradually  approach  posteriorly,  so  that  the  opening  is 


l^^^i^^^J' 


Fig.  4i6.  Fig,  427. 

l^C.  436^ — Anterior  viev  of  the  laryrw.  (After  Deaver.)  i,  Epiglottis;  2,  lesser 
""liu  o(  hyoid  bone;  i,  greater  eornu  of  hyoid  bone;  4,  thyrohoid  membrane;  5,  thyroid 
^''tilagi;  6,  cricothyroid  membrane;  /,  cricoid  cartilage;  8,  trachea, 

F"lO.  417. — The  interior  of  the  larj-nx.  i.  Epiglottis;  1,  thyroid  cartilage;  3, 
^[Witricle  of  larynx;  4,  cricoid  cartilage;  s,  false  vocal  cords;  6,  vocal  cords;  7,  first 
"•JR  of  trachea. 

***rrowed  behind.  More  or  less  distinct  nodular  prominences 
*ofTned  by  the  cuneiform  and  corniculate  cartilages  are  recognized 
°n  these  folds. 

The  cavity  of  the  larynx  extends  from  the  superior  aperture  to 
^e  lower  border  of  the  cricoid  cartilage.  It  is  divided  into  two  por- 
"^ons  by  the  vocal  cords — above,  into  the  supraglottic  region,  and, 
^^low,  into  the  subglottic  region.  The  vocal  cords  consist  of  two 
**^Ucate  bands  of  elastic  tissue  enclosed  in  thin  layers  of  mucous  mem- 
"*^tie  having  a  whitish  appearance.  They  are  attached  anteriorly 
^  the  thyroid  cartilage  and  posteriorly  to  the  arytenoids.     They 


438  THE  LARYNX  AND  TRACHEA 

measure  about  ^  inch  (2  cm.)  in  length  in  the  male,  and  ^  iuk 
(i  cm.)  in  the  female.  Between  the  two  cords  is  a  long  namnr 
chink,  the  glottis.  Above  and  parallel  to  the  vocal  cords  aie  tm 
second  folds  of  mucous  membrane  enclosing  ligamentous  tissue, 
attached  to  the  thyroid  cartilage  in  front  and  to  the  two  aiytetMudi 
behind,  commonly  called  the  false  vocal  cords.  Lying  between  the 
vocal  cords  and  these  two  bands  are  two  oblong  fosss,  the  ventiidei 
of  the  larynx. 

The  mucous  membrane  of  the  larynx  is  continuous  above  with 
that  lining  the  pharynx,  and  below  with  that  of  the  trachea  and  broii- 


Fig.  438. — Anatom]r  of  the  trachea  and  its  relatioiis. 


chi.  It  is  of  the  columnar  ciliated  variety,  excepting  where  it  co'^^ 
the  vocal  cords  and  the  space  above  the  vocal  cords,  in  which  regJ^ 
it  is  of  the  stratified  variety.  It  contains  many  mucous  glands,  eS'r 
cially  numerous  upon  the  epiglottis. 

The  trachea  is  a  cylindrical  tube,  composed  of  cartilages  ^^ 
membrane,  extending  from  the  cricoid  cartilage,  at  the  level  of  '•^ 
sixth  cervical  vertebra,  to  a  point  opposite  the  fourth  dorsal,  wher^ 
divides  into  a  right  and  left  bronchus.     It  is  from  4  to  4  3/4  incJ* 


DIAGNOSTIC  METHODS 


439 


'  to  13  cm.)  long  in  males,  and  from  3  2/3  to  4  1/2  inches  (9  to  ri 
.)  long  in  females.  Its  transverse  diameter  measures  on  an  aver- 
14/5  of  an  inch  (2  cm.)  in  males,  and  less  in  females.  In  a  child 
irom  two  to  four  years,  the  transverse  diameter  measures  1/3  of  an 
h  (8  mm,);  in  a  child  under  eighteen  months,  it  measures  1/4  of 
inch  (6  mm.). 

The  framework  of  the  trachea  is  composed  of  from  sixteen  to 
eteen  rings  of  hyaline  cartilage,  incomplete  behind,  each  measur- 

1/12  to  1/5  of  an  inch  {2  to  5  mm.)  in  breadth.  The  narrow 
:e  between  these  rings  is  filled  with  an  elastic  fibrous  membrane 
ch  splits  into  two  layers  to  enclose  each  cartilage,  and  also 
'es  to  complete  the  tube  posteriorly.  Internally,  the  trachea  is 
i  with  a  smooth  mucous  membrane  of  the  ciliated  variety,  con- 
ous  above  with  that  of  the  larynx  and  below  with  that  of  the 
ichi.  It  contains  an  abundance  of  lymphoid  tissue  and  mucous 
ids. 

rhe  trachea  lies  in  a  mass  of  loose  fat  which  permits  free  motion 
ard,  downward,  and  horizontally.  In  its  upper  part  it  lies  com- 
Ltively  superficial,  but  becomes  more  deeply  placed  as  it  ap- 
iches  the  thorax.  The  isthmus  of  the  thyroid  gland  lies  opposite 
second  and  third  rings;  below  this  the  following  structures  will 
aet  from  above  downward :  the  inferior  thyroid  veins,  the  arteria 
■©idea  ima  {if  present),  the  sternohyoid  and  sternothyroid  mus- 

the  cervical  fascia,  an  anastomosis  of  the  anterior  jugular  veins; 

in  the  thorax,  the  remains  of  the  thymus  gland,  the  left  innomi- 
^  vein,  the  arch  of  the  aorta,  and  the  innominate  and  the  left 
mon  carotid  arteries.     Behind  h'es  the  esophagus.     Laterally, 

trachea  is  in  relation  with  the  common  carotid  arteries,  the 
Fal  lobes  of  the  thyroid,  the  inferior  thyroid  arteries,  and  the  re- 
ent  larj-ngeal  ner\'es.  These  relations  arc  important  to  bear  in 
i  in  performing  tracheotomy. 


Diagtiostic  Methods 

The  diagnostic  methods  employed  in  connection  with  the  larynx 
trachea  consist  in  (i)  inspection  by  means  of  a  laryngeal  mirror, 
direct  inspection  through  endoscopic  tubes,  (3)  palpation  by  the 
>e  or  finger,  and  (4)  skiagraphy. 

4s  a  preliminary  to  the  local  examination,  attention  should  first 
Ijiven  to  the  general  condition  of  the  patient,  and  the  history  of 
er  affections  that  may  have  a  bearing  upon  the  conditions  should  be 


440  THE  LARYNX  AND  TRACHEA 

inquired  into.  This  is  important,  for,  while  the  symptoms  of  pioc-  MJ^^ja 
esses  involving  this  portion  of  the  respiratory  tract  are  characteris-  WL  ^ 
tic  (  consisting  of  cough,  dyspnea,  aphonia  or  dysphonia,  d)rsphagia, 
etc.),  and  as  a  rule  clearly  indicate  the  seat  of  the  trouble,  it  shouiA 
be  borne  in  mind  that  many  of  these  symtoms  are  secondary  U) 
other  conditions,  such  as  gout,  diphtheria,  rheumatism,  diabet^s^ 
nephritis,  tuberculosis,  syphilis,  diseases  of  the  nervous  system,  cfc-c 
Thus  it  becomes  of  the  utmost  importance  to  examine  other  orga-^*^ 
as  well  and  not  to  limit  the  investigation  to  the  affected  repi 
alone. 

Having  completed  this  portion  of  the  examination,  external 
spection  and  palpation  of  the  parts  should  be  performed.    In  tb — *^ 
way  the  presence  of  inflammation,  swellings,  new  growths,  enlargi^'^^ 
glands,  fractures  of  the  cartilages,  etc.,  may  be  determined,  and  tK— ^^ 
mobility  or  fixation  of  the  parts  during  swallowing  and  req)iratic:^-^^ 
may  be  noted. 

LARYNGOSCOPY  AND  TRACHEOSCOPY 

By  this  method  the  interor  of  the  larynx  and  trachea  are  ii 
spected  by  means  of  a  laryngoscopic  mirror  and  reflected  light.    Tfc^  J^* 
technic  is  not  difficult,  and,  if  properly  carried  out,  a  satisfactory  ic*^^-^' 
spection  of  the  tissues  may  be  made  as  far  as  the  true  vocal  cords^^^' 
and  under  favorable  conditions  the  region  beyond  the  glottis  as  fa^^  ^ 
as  the  subdivision  of  the  trachea  may  also  be  explored,  and  foreigr"^^!^ 
[bodies  or  pathological  conditions  recognized.     Such  examination  S^ 
best  made  before  a  meal,  as,  otherwise,  retching  and  vomiting  ma^-^^^ 
be  induced. 

Instruments  and  Apparatus. — Requisites  for  an  ordinary  laryngo-^^^^ 
scopic  examination  are:  a  strong  light,  such  as  is  obtained  from  * 
Welsbach  burner  covered  by  a  Mackenzie  condenser;  a  concave  heac^-^^*^^ 
mirror,  3  1/2  to  4  inches  (9  to  10  cm.)  in  diameter  with  a  centra^^"^^ 
perforation  for  the  eye;  laryngeal  mirrors  of  three  sizes,  1/2,  3/^^^  /^ 
and  I  inch  (i,  2,  and  2.5  cm.)  in  diameter,  that  they  may  be  adapte**^^^-^ 
to  the  size  of  the  individual  fauces;  and  an  alcohol  lamp  (Fig.  42g^^^?9/' 
The  light  should  be  placed  upon  a  suitable  bracket,  that  it  may  fc^   ^ 
raised  or  lowered  to  any  desired  height  (see  Fig.  339). 

Asepsis. — The  laryngeal  mirrors  should  be  sterilized  by  immersic 
in  a  I  to  20  solution  of  carbolic  acid,  then  rinsed  oflf  in  sterile  wal 
and  dried  before  use.  1 


LARYNGOSCOPY  AND  TRACHEOSCOPY 


441 


Position  of  Patient  and  Examiner. — To  obtain  tlie  best  results, 
the  examination  should  be  performed  in  a.  partially  darkened  room. 
The  patient  sits  in  a  straight-backed  chair  with  the  head  raised  and 


Fig.  419. — Instruments  tor  laiyngoacopy.    i,  Laryngenl  i 
3,  alcohol  lamp. 


'*  430. — LatynS'^s'^py-     fii^t  step,  showing  the  method  of  grasping  the  tongue- 


'^'^lined  slightly  backward.  The  light  is  located  upon  the  patient's 
"Sht,  a  little  behind  him  and  about  on  a  level  with  the  ear.  The 
operator  sits  facing  the  patient,  with  his  knees  to  one  or  the  other 


442 


THE   LARYNX  AND  TRACHEA 


side  of  the  patient's,  and  with  his  eye  on  a  level  with  the  patient's 
mouth,  at  a  distance  of  about  a  foot  (30  cm.),  or  the  focal  leagthof 
the  mirror. 

Anesthesia. — Ordinarily,  cocainization  of  the  parts  is  unneces- 
sary, but,  where  the  mucous  membrane  of  the  pharynx  is  very  sen- 
sitive, brushing  a  4  per  cent,  solution  of  cocain  over  the  posterior 
pharyngeal  wall  and  soft  palate  may  be  required  before  a  satisfactory 
examination  is  possible. 

Technic. — The  operator  places  himself  and  patient  in  the  proper 
positions,  and  adjusts  the  head  mirror  over  the  left  eye  in  such  a 
manner  that  the  light  will  be  reflected  in  a  circle  upon  the  mouth  of 
the  patient.    The  patient  is  then  directed  to  protrude  the  tip  of  the 
tongue,  which  is  surrounded  with  a  piece  of  clean  gauze  or  small 
napkin  and  is  grasped  between  the  thumb  and  forefinger  of  the  opera- 


X 


Fig.  431. — Laryngoscopy.     Second  step,  heating  the  minor. 

tor's  left  hand  (Fig.  430).    Light  traction  is  made  outward    3-^^^ 
slightly  upward  rather  than  downward,  so  as  to  avoid  forcing   t^^ 
under  surface  of  the  tongue  against  the  lower  incisor  teeth.     'TT^^ 
laryngeal  mirror  is  then  warmed  to  avoid  condensation  of  moist.'i^^ 
upon  its  reflecting  surface,  by  holding  it  at  a  little  distance  aboV^  * 
flame  for  a  few  seconds  (Fig.  431),  the  precaution  being  taken  ta  ^ 
the  temperature  of  tfie  mirror  be] ore  introducing  it  into  the  fik^^'^' 
this  is  determined  by  bringing  the  back  of  the  mirror  in  contact  v^^ 
the  back  of  the  operator's  hand.    To  introduce  the  mirror,  it  sho^^" 
be  held  lightly  between  the  thumb  and  forefinger  of  the  right  k^-^" 
with  its  reflecting  surface  downward  (Fig.  432),   and   should     ^ 
made  to  folloW'  the  curve  of  the  hard  palate  until  its  back  toucb^ 
the  uvula  and  soft  palate.     It  is  then  pushed  upward  and  backwani 
raising  the  uvula  as  far  out  of  the  way  as  possible.     Care  must  be 


LARYNGOSCOPY  AND  TRACHEOSCOPY 


443 


n  in  performing  this  maneuver  to  avoid  touching  the  base  of  the 
ue,  and,  when  the  mirror  is  in  position,  to  keep  it  held  steadily  in 
2  so  as  not  to  excite  gagging  or.  retching.  Should  this  accident 
r,  the  mirror  must  be  removed  and  sufficient  time  must  be  al- 


FiG.  43a.— Showing  the  method  of  holding  the  n 


ri  for  the  patient  to  recover  his  breath  and  the  irritability  to 
ide  before  it  is  reintroduced.  As  soon  as  the  instrument  is  in 
ter  position,  the  handle  is  moved  to  one  side  of  the  patient's 
th  so  as  to  be  well  out  of  the  line  of  vision.  The  mirror  is  then 
iy  and  gently  turned  until  a  view  of  the  base  of  the  tongue  is 


C-  433* — Laryngoscopy.     Third    step,    showing    the    mirror    being    introduced 
iao  the  relative  positbn  of  the  patient  and  examiner  and  the  position  of  the  light. 

ined,  and  any  abnormalities  of  the  organ  are  noted;  it  is  then 
ted  in  such   a  manner  that  its  face  looks  downward  and  the 
TX  is  brought  into  view  (Fig.  434). 
t  should  be  remembered  that  the  laryngeal  image  will  be  in- 


d 


THE   LARYNX  AND  TRACHEA 


verted — that  is,  the  structures  of  the  front  part  of  the  laiym  appeir , 
on  the  upper  part  of  the  mirror,  and  pice  versa;  the  right  and  kft 


FlO.  434. — Laryngoscopy.     Fourth  step,  showing  the  minor  in  place.     0-  M.  And^ 


Fic.  435,  Fro.  436. 

Fig  43S- — The  laryngoscopic  image,      i,  Epiglottis;  a,  false  vocal  cords;  3,  »«^ 
cords;  4,  glossoepiglottic  fossa;  5,  interarytenoid  space;  6,  cartilage  of  Santoriiiiuidt^ 
location  of  the  nrytenoid  cartilage;  7,  cartilage  of  Wrisbetg. 
Fig.  436. — The  laiynx  during  gentle  respiration. 

sides  of  the  laryngeal  image,  of  course,  correspond  to  the  same  M* 
of  the  patient.  In  a  normal  case,  the  following  are  noted:  at  tJj 
upper  part  of  the  picture,  the  saddle-shaped  epiglottis  of  a  yellowis 


LARYNGOSCOPY  AND  TRACHEOSCOPY  445 

iversed  by  its  pink  blood-vessels;  extending  backward  across 
ror  back  of  the  epiglottis  are  a  pair  of  pearly- white  bands, 
al  cords;  parallel  to  the  vocal  cords,  but  lying  anteriorly  and 

are  a  second  pair  of  bands  with  a  reddish  hue,  the  ventric- 
[ids,  or  false  vocal  cords;  between  the  vocal  cords  and  the 
Jar  bands  may  be  obsen.-ed  the  ventricles  of  the  larynx, 

into  better  view  if  the  head  is  tilted  to  the  side;  where  the 
ards  terminate  at  the  lower  part  of  the  image  are  to  be  seen 
:enoid  cartilages,  and  between  them  the  interarytenoid  space; 
ig  from  either  side  of  this  notch  to  join  the  epiglottis  are  the 
ottic  folds,  with  the  two  prominences  marking  the  site  of  the 
es  of  Wrisberg  and  Santorini,  the  latter  lying  on  top  of  the 
id  cartilages;  on  either  side  of  the  image  will  be  noted  the 
liglottic  fosstc. 

nake  a  complete  examination,  the  larynx  should  be  inspected 
quiet  respiration,  deep  respiration,  and  phonation.     During 


■The  larjTui  in  phonation. 


Fic,  438. — The  larynjc  during  deep 
respiration. 


ion  the  vocal  cords  are  seen  to  move  with  each  expiration 
the  median  line,  and  away  from  the  median  line  with  inspira- 
g.  436).  By  requesting  the  patient  to  say  "ee"  or  "he,"  a 
)btaincd  of  the  larynx  with  the  cords  abnost  in  apposition  and 
rarytenoid  space  obliterated  (Fig.  437).  During  deep  respi- 
he  cords  are  widely  separated,  and  a  \new  is  obtained  of  the 

wall  of  the  region  below  the  vocal  cords  (Fig.  438).  There 
ieen  the  broad  yellow  cricoid  cartilage  and  the  yellowish  car- 
Lis  rings  of  the  anterior  wall  of  the  trachea  with  the  inter\"en- 
membranous  portion.  By  tilting  and  carefully  adjusting  the 
the  bifurcation  of  the  trachea  and  the  openings  of  the  two 

in  favorable  cases  may  be  brought  into  \-iew.  To  obtain 
it  favorable  position  for  inspection  of  the  trachea,  the  pa- 
leck  should  be  held  straight  and  the  chin  extended  somewhat 
.     The  mirror  will  also  require  a  different  adjustment,  being 


446  THE  LARYNX  AND  TRACHEA  _ 

held   more  horizontally   than  for  laryngoscopy,  and  the  suigecm      %z\tz 
should  be  seated  lower. 

The  examiner  should  j&rst  note  the  color  of  the  various  parts 
brought  to  view  for  signs  of  congestion  or  inflammation,  bearing  in 
mind  that  if  cocain  has  been  employed  the  parts  will  appear  anemic, 
and  that  gagging  or  retching  may  be  responsible  for  congestion  He 
should  look  for  the  presence  of  exudations,  foreign  bodies,  and  any 
structural  changes,  such  as  ulcerations,  swellings,  abscesses,  edema, 
new  growths,  malformations,  and  dislocations  of  the  arytenoid  car- 
tilages, etc.     Finally,  the  condition  and  mobility  of  the  vocal  cords 
during    respiration    and    phonation   are   observed.     They   should 
approximate  symmetrically  in  the  mid-line  during  phonation,  aaci 
separate  equally  with  inspiration.     The  whole  examination  should 
be  made  as  rapidly  as  possible,  not  more  than  half  a  minute  or  so 
being  consumed,  to  avoid  tiring  the  patient  and  inducing  an  irritabl.^ 
state  of  the  parts.     Since  often  only  a  glimpse  of  the  various  struct- 
tures  may  be  thus  obtained,  it  may  be  necessary  to  make  more 
one  inspection  before  the  whole  examination  is  completed  in 
satisfactory  manner. 

Difficulties  in  Laryngoscopy. — It  is  sometimes  a  diffiailt  matt 
for  a  beginner  to  inspect  the  parts,  owing  to  faulty  technic  or 
structural  peculiarities.    A  view  of  the  larynx  may  be  missed  entii 
through  an  improper  adjustment  of  the  light,  faulty  position  of 
patient's  head,  or  holding  the  mirror  at  a  wrong  angle.    ChimS'3^ 
and  hasty  introduction  of  the  ndrror,  the  use  of  a  mirror  too  hot  c^X" 
too  cold,  or  rough  traction  on  the  tongue,  all  militate  against  succesj^ 
In  some  cases  an  excessive  irritability  of  the  pharjmx  precludes     3- 
successful  examiation  without  preliminary  cocainization.    In  oth^ 
cases  the  presence  of  enlarged  tonsils  may  prevent  a  good  view  of 
parts.     If  such  a  condition  is  present,  a  small  oval  mirror  should 
substituted.     A  large  pendulous  epiglottis  is  not  infrequently  a  cause 
of  difficulty.     By  placing  the  mirror  close  to  the  posterior  pharyxi- 
geal  wall  and  holding  it  more  nearly  vertical  than  usual,  with  tb^ 
patient's  head  thrown  back,  a  better  view  may  often  be  obtained. 

In  young  children  considerable  difficulty  may  be  encountered. 
It  is  best  to  wrap  the  child  in  a  sheet  so  that  the  arms  are  restrained, 
and  to  have  it  held  upon  the  lap  of  an  assistant,  who  also  steadies 
the  child's  head.  A  tongue  depressor  with  a  curved  tip  should  l>* 
employed  to  hold  the  tongue  forward,  and,  if  necessary,  a  mouth-g»^ 
may  be  inserted  between  the  teeth.  A  small  laryngeal  mirror  is 
then  introduced,  and  the  examination  is  made  in  the  usual  way.    ^ 


DIRECT   LARYNGOSCOPY  447 

carefully  and  gently  performed,  a  satisfactory  examination  may 
often  be  made  even  upon  unruly  children. 

DIRECT  LARYNGOSCOPY 

The  larynx  and  portions  of  the  air  passages  beyond  may  be  exam- 
ined under  direct  vision  either  by  the  aid  of  illuminated  tubes  or  by 
means  of  a  suitable  tongue  depressor  and  illumination  from  a  head 
Kght,  the  latter  a  method  designated  by  Kirstein  as  autoscopy.    The 
parts  inspected  in  this  manner  appear  more  nearly  normal  as  to  posi- 
tion and  color  than  when  a  laryngeal  mirror  is  employed.     Further- 
more, foreign  bodies  and  new  growths  may  be  removed,  and  applica- 
tions made  to  diseased  areas  imder  direct  vision.    The  method  may 
be  employed  in  yoimg  children  upon  whom  ordinary  laryngoscopy  is 


I^IG.  439. — ^Jackson's  self-illuminated  tube  spatula  for  direct  laryngoscopy. 

^^^ciilt,  and  it  may  also  be  performed  upon  a  patient  under  general 
^'^^sthesia.  It  is,  however,  more  uncomfortable  for  the  conscious 
'^^^ent  than  ordinary,  laryngoscopy. 

Instruments. — ^A  tubular  spatula,  self-illuminated,  such  as  Jack- 

*^^'s  (Fig.  439),  or  with  the  illumination  furnished  from  an  electric 

^^<i   light,  as  Killian's,  is  generally  employed.     Kirstein  uses  a 

P^gue  depressor  of  special  shape  (Fig.  440)  and  an  electric  head 

8ht  (Fig.  441).     In  addition  a  liiouth-gag  and  a  Sajous  applicator 

^^  required  (Fig.  442). 

iVsepsis. — The  tubes  and  tongue  depressor  may  be  boiled,  while 
^^  light-carrying  apparatus  in  the  self -illuminated  tube  is  sterilized 
V  immersion  in  alcohol. 

Position  of  the  Patient. — The  patient  is  seated  on  a  low  stool  with 
^^  upper  part  of  the  body  bent  slightly  forward  and  with  the  head 


448  THE  LARYNX  AND  TBACEEA 

raised  and  thrown  back  so  that  a  direct  view  from  above  downwird 
is  possible.  An  assistant  stands  or  sits  behind,  supporting  tlie 
patient's  head,  and  holding  the  mouth-gag  in  prop^  poation.  I^e 
operator  stands  in  front. 

A  child  should  be  seated  upon  the  lap  of  a  nurse,  who  encircles 
its  body  with  her  arms,  confining  the  child's  arms  closely  to  its  sida 


Fic.  440. — Kitstein's  tongue  depressor. 

and  clasping  its  legs  between  her  knees.  The  child's  head  rests  iqw 
the  nurse's  shoulder,  being  held  in  the  proper  position  from  bchiwl 
by  an  assistant. 

Anesthesia. — Cocainization  of  the  parts  is  usually  necessary  to 
avoid  unpleasant  gagging  and  retching.     This  is  accomplisb«l  'f 


Fic.  441. — Kirstcin's  head  light. 


the  application  to  the  larynx  and  neighboring  parts  of  a  4  per  cflit- 
solution  of  cocain  by  means  of  a  cotton  swab  held  by  a  Sajous  app 
cator.  This  should  be  performed  by  the  aid  of  a  laryngeal  iiun«> 
If  operative  procedures  are  required,  the  application  of  a  20  pa  cent- 
solution  of  cocain  should  follow  the  preUminary  cocainization.   U 


DIRECT  LARYNGOSCOPY 


449 


}oaog  children  the  examination  may  be  carried  out  under  general 
,  Anesthesia. 

Technic. — ^The  operation  should,  when  possible,  be  performed 
whea  the  stomach  is  empty,  as,  otherwise,  retching  may  result  in 


Fig.  442. — Sajous'  applicator  and  mouth-gag. 

regurgitation  of  the  stomach  contents.  The  parts  having  been  co- 
<:ainized,  and  with  the  patient  seated  in  the  proper  position,  a  mouth- 
^gSLg  is  inserted  in  one  side  of  the  mouth  and  is  held  in  place  by  the 


[ 


Fig.  443. — Direct  laryngoscopy  with  Jackson's  self-illuminated  spatula.     (Modi- 
^ed  from  Ballenger,)  a,  Electric  cord  supplying  lamp  of  speculum;  6,  conduit  for  light 
carrying  tube;  c,  shows  the  tube  holding  the  epiglottis  forward;  dy  conduit  for  removing 
secretions,  etc.,  by  aspiration  during  the  examination. 

assistant  who  supports  the  head.  With  the  lamp  at  the  end  of  the 
instrument  properly  lighted,  if  a  self -illuminated  spatula  is  employed, 
or  with  the  head  lamp  lit  and  adjusted  so  as  to  throw  the  light  into 

29 


4  so  THE  LARYNX  AND  TRACHEA 

the  mouth,  if  a  nonilliuninated  tube  is  used,  the  tubular  q)ecuhimis 
introduced  past  the  base  of  the  tongue  until  the  epiglottis  2q^)ears. 
Its  tip  is  passed  to  a  point  about  1/2  inch  (i  cm.)  below  the  free  edge 
of  the  epiglottis,  which  is  then  drawn  forward,  and  with  it  the  base 
of  the  tongue  out  of  the  line  of  vision  by  exerting  pressure  upon  tiie 
handle  of  the  instrument  in  an  upward  and  backward  direction 
(Fig.  443). 

The  operator  then  inspects  the  larynx  by  looking  down  the  tube. 
The  arytenoid  cartilages,  vocal  cords,  interior  of  the  larynx,  and  por- 
tions of  the  trachea  may  thus  be  viewed  in  detail.  The  points  eq>e- 
cially  to  be  noted  in  such  examination  have  already  been  referred  tf> 
tmder  laryngoscopy.  By  the  aid  of  these  tubes,  applications  may 
also  be  made,  if  desired,  to  diseased  areas,  and  growths  may  be  re- 
moved by  means  of  delicate  instruments  of  special  design. 

Under  the  method  designated  by  Kirstein  as  autoscopy,  tbe 
patient  is  placed  in  the  same  position  as  above,  the  mouth  is  illumi- 
nated from  the  electric  head  light,  and  the  special  tongue  depressor  • 
is  gently  introduced  behind  the  tongue  until  its  tip  rests  between  the 
epiglottis  and  the  base  of  the  tongue.     By  elevating  the  handle  of 
the  instrument,  the  base  of  the  tongue  is  drawn  downward  and  foX"- 
ward,  and  the  epiglottis  is  raised,  sp  that  a  groove  is  formed  aloixfi 
the  back  of  the  tongue.     With  the  head  light  properly  adjusted  tt^.^ 
operator  looks  down  this  groove  and  inspects  the  larynx.    Tt^"^ 
posterior  walls  of  the  larynx  and  trachea  are  clearly  viewed  by 
method,  but  the  anterior  parts  are  not  seen  so  well  as  with 
laryngoscopic  mirror. 

SUSPENSION  LAJlYNGOSeOPY 

A  method  of  laryngoscopy  of  great  value  for  certain  cases 
been  devised  by  Killian  under  the  name  of  suspension  laryngoscopy 
It  is  performed  with  the  patient  in  the  dorsal  position,  his  head  so^^ 
pended  by  means  of  a  specially  made  spatula  introduced  over 
tongue.  The  curved  region  from  the  teeth  to  the  larynx  is  th\ 
converted  into  a  straight  line,  and  it  is  possible  to  obtain  a  direc^^ 
view  of  the  larynx  and  surrounding  parts  not  possible  under  othe^^ 
methods. 

Suspension  laryngoscopy  is  not  intended  to  take  the  place  of^ 
indirect  laryngoscopy  for  routine   office  examinations,  and,  as  a 
diagnostic  measure,  should  be  reserved  for  cases  in  which  difficulty 
is  jnet  in  making  a  satisfactory  examination  by  the  usual  methods. 


SUSPENSION    LARYNGOSCOPY 


451 


0==^^ 


1  value  for  operative  procedures,  such  as  the  removal  of 
iies  or  growths  from   the  larynx,   the  cauterization  or  , 
f  ulcerations,  etc.,  and  as  an  aid  in  introducing  the  bron- 
!r  esophagoscope.     Its  advantages  over  the  other  methods 

»py  for  operating  is  that  the  operator  is  brought  near 
f  operation  and  both  of  the  operator's  hands  are  left  free. 

;  on  account  of  the  position  of  the  patient's  head,  blood 
jpns  escape  toward 
f  the  pharynx  and 

lire  the  operative 

r  the  larynx. 

n  laryngoscopy 
k  limitations,  how- 
jb  not  suitable  for 
I  Rigidity  of  the 
irtion  of  the  verte- 
Id,  a  very  thick 
gf  prominent  upper 
ifcny  condition  that 
file  mouth  being 
(the  fullest  extent 
bindications.  The 
Bs  has  a  wider  ik'ld 
IBS  in  children  than 
1  It  is  claimed  that 
^on  causes  only 
tanfort  and  that  the  tf"*^ 

ts  are  mild.  " 

tag, —  Killian's    ^'°-  444 ■ — Tiaveinnt"    crane   for    suspension 
itmment,  as  modi-  larynao^opy; 

ftch,  consists  essentially  of  a  travelling  crane,  or  "  gallows, " 
:  spatula.  The  gallows  (Fig.  444)  can  be  raised  or  lowered, 
in  a  horizontal  direction.  The  horizontal  arm  of  the  gal- 
ivided  with  notches  to  receive  the  handle  of  the  hook 


i  spatula  consists  of  a  handle,  tongue  holder,  and  mouth 

Lndle  consists  of  a  vertical  arm  with  a  Joint  in  the  center, 

lation  of  which,  the  arm  may  be  bent  or  straightened.     One 

1  terminates  in  a  hook  and  to  the  other  end  a  tongue 

E  mouth  gag  is  attached.     The  mouth  gag,  which  may  be 

iosed  by  means  of  a  screw,  has  a  plate  which  engages  the 


452  THE  LARYNX  AND  TRACHEA 

upper  teeth  and  prevents  the  spatula  from  slipping  out  of  the  montti 
(Fig.  445). 

niumination  is  furnished  by  a  Kirstein  head  lamp,  reflected 
li^t  from  a  head  mirror,  or  by  a  lamp  designed  to  be  fastened  to  qca* 
of  the  bars  of  the  mouth  gag. 

An  operating  table  that  can  be  raised  or  lowered  to  suit  tfcae 
hei^t  of  the  operator  is  necessary. 

Asepsis. — The  operation  should  be  performed  under  the  usim_  jI 


Fic,  445-^ — Lynch 's  modification 
of  Killian's  book  spatula. 


-Suspcnsioa  laiyngoscopy. 
(Modified  fiam  Lynch.) 


asepUc  precautions.  The  hook  spatula  and  mouth  gag  are  boiled 
and  the  operator's  hands  are  prepared  as  for  any  operation. 

Position  of  the  Patient. — The  patient  should  be  in  the  dorsal 
position  on  a  table,  with  the  shoulders'  brought  to  the  edge  of  the 
table  and  the  head  supported  by  an  assistant. 

Anesthesia.— In  this  country  general  anesthesia  is  usually  em- 
ployed for  adults  and  always  for  children.  If  local  anesthesia 
is  used,  the  patient  is  given,  two  hours  before  the  operation,  i/ioo 
of  a  grain  (.00065  S^)  ^^  scopolamin  and  1/4  of  a  grain  (0.0162 
gm.)  of  morphin  hypodermically.  Anesthesia  is  obtained  by  ap- 
plying a  20  per  cent,  solution  of  cocain  to  the  base  of  the  tongue, 
pharynx,  epiglottis,  and  larynx. 


DIRECT    TRACHEO-BRONCHOSCOPV  453  1 

Teduiic. — The  patient  is  placed  on  the  table,  with  his  shoulders 
at  the  edge  and  bis  head  supported  by  an  assistant,  and  the  crane 
is  secured  to  the  table  on  the  right  side.  Then  under  illumination 
from  a  head  light,  the  tongue  spatula,  with  the  mouth  gag  closed,  is 
ca-refully  passed  well  over  the  base  of  the  tongue  in  liie  median  line 
until  its  tip  engages  in  front  of  the  epiglottis.  Pressure  of  the  tongue 
against  the  lower  teeth  should  be  prevented  by  means  of  a  small  wad 
of  gauze  previously  placed  between  the  inner  surfaces  of  the  teeth 
aricj  the  tongue.  The  tooth  plates  are  adjusted  and  the  mouth  gag  is 
then  opened  to  its  fullest  extent  and  securely  locked.  The  operator 
brings  the  vertical  arm  of  the  hook  toward  him,  thereby  crowding 
tHe  tongue  forward  and  at  the  same  time  elevating  the  epiglottis. 
The  hook  is  finally  hung  on  the  horizontal  arm  of  the  crane,  the 
Assistant  slowly  releasing  the  head  until  it  hangs  by  its  own  weight 
suf>ported  by  the  hook  spatula.  Any  additional  adjustment  that 
uia.y  be  necessary  may  be  made  by  moving  the  crane  in  a  vertical 
Or  horizontal  direction.  The  illumination  is  finally  turned  on  ex- 
IXisJng  to  direct  view  the  larynx  and  the  neighboring  parts. 

DIRECT  TRACHEO-BRONCHOSCOPY 

In  1897  Killian  devised  long  endoscopic  tubes  that  could  beintro- 
•i'J.cred  through  the  mouth  or  througli  a  tracheotomy  wound,  with 
^*'t»-ich  the  trachea  and  bronchi  may  be  examined  by  the  aid  of  illu- 
*^^>-ixiation  from  an  eletric  head  light.     This  operation  is  designated 
""^^spectively  as  "upper  direct  tracheo-bronchoscopy,"  and  "lower 
*^r«cl  tracheo-bronchoscopy, "     In  this  country,  Chevalier  Jackson 
"^-s  perfected  similar  tubes,"  in  which,  however,  the  illumination  is 
^^E>plied  by  a  small  electric  light  at  the  distal  end  of  the  instrument. 
The  bronchoscope  is  employed  both  for  diagnostic  and  ther- 
apeutic purposes,  and  is  of  especial  value  in  locating  and  removing 
****"eign  bodies  and  growths  from  the  air  passages,  or  in  making  direct 
applications  to  ulcers  and  other  lesions  in  the  trachea  and  bronchi. 
"Marvelous  results  have  been  obtained  by  those  expert  in  the  use  of 
"*ese  instruments,  and  foreign  bodies  have  been  frequently  removed 
Irotn  the  bronchi  of  patients  upon  whom  thoracotomy  would  other- 
*Tsc  have  been  required.     The  use  of  the  bronchoscope,  however, 
ff^uires  such  skill  and  practice  as  to  be  only  of  service  in  the  hands 
"f  an  accomplished  specialist;  in  unskilled  hands  it  becomes  a  danger- 
""« inslrumenl. 

Tracheo-bronchoscopy   through    a   tracheotomy   wound    is   the 
simpler  of  the  two  methods,  and,  as  larger  tubes  may  be  employed 


454 


a* 


THE  LARYNX  AND  TRACHEA 


than  in  the  upper  operation,  it  is  often  of  value  for  the  removal  of 
foreign  bodies  too  large  to  be  extracted  by  upper  tracheo-brondio&- 
copy.  Upper  tracheo-bronchoscopy,  however,  should  be  the  opeia- 
tion  of  choice  when  possible. 

Instnunents. — The  tubes  employed  are  of  rigid  metal  hig^y 
polished  internally,  somewhat  similaT  to  the  endoscopic  tubes  eia- 
ployed  in  the  urethra.    They  vary  in  size  according  to  the  age  ol 
the  patient  and  the  part  of  the  air  passages  to  be  explored.   O11X7 


S 


S 


^ 


*""      -^ 


Fig.  447. — Killian*s  bronchoscope. 

the  smallest  sized  tubes  should  be  used  for  the  bronchia    Jacksci^^ 
employs  for  lower  tracheo-bronC:hoscopy  a  tube  J^  inch  (8  mm.) 
diameter  by  8  inches  (20  cm.)  long  for  adults,  and  one  yi  m 
(S  mm.)  in  diameter  by  $}4  inches  (14  cm.)  long  for  children; 
for  upper  tracheo-bronchoscopy  a  tube  J^5  inch  (7  mm.)  in  diam 
ter  by  18  inches  (45  cm.)  long  for  adults,  and  one  J^  inch  (5  mm 
in  diameter  by  8  inches  (20  cm.)  long  for  children. 


-^\ 


Fig.  448. — ^Jackson's  bronchoscope. 

In  Killian's  instruments  (Fig.  447)  illumination  is  supplied  from 
an  electric  head  light.  In  the  Jackson  tubes  (Fig.  448)  the  illu- 
mination is  supplied  by  a  small  electric  light  at  the  distal  end  of 
vthe   instrument.     These  latter  are  somewhat  easier  to   use  than 


DIRECT   TRACHEO-BRONCHOSCOPV 


455 


Eillian's  instruments.  In  addition,  the  Jackson  instraments  are 
provided  with  a  conduit  to  which  is  attached  a  suction  apparatus 
and  exhaust  pump,  for  the  purpose  of  removing  secretions  that 
may  collect  and  obscure  the  view  (Fig.  449).  For  inserting  these 
Instruments,  a  special  split  tube  (Fig.  450),  resembling  that  used 
n  direct  lar>-ngoscopy.  is  supplied  which  is,  removed  in  two  halves 
if  ter  the  bronchoscope  has  entered  the  glottis. 


Fig.  449.^ — Jackson's 

A  portable  battery  with  rubber-covered  cords,  a  mouth-gag,  a 
Sajous  appUcator,  variously  shaped  forceps,  applicators  for  applying 
cocain  or  drugs  to  the  mucous  membrane,  hooks,  etc.,  for  the  removal 
of  foreign  bodies  through  the  instrument,  and  a  tracheotomy  set 


I 


buuUe 


450. — Jackson's  separable  i^pcculuni  for  passing  the  bronchoscope.  The 
ai.  (or  use  when  the  patient  is  in  a  sitting  pusture;  c,  shows  the  oirongement 
amp  at  the  distal  end. 


Vsee  page  479)  are  required.  The  operator  should  also  be  provided 
^^^t  a  number  of  extra  lamps  to  replace  those  that  may  burn  out. 
Sepsis. — Strict  asepsis  in  all  details  is  necessary.  The  tubes  and 
accessory  instruments  are  boiled,  the  lighting  apparatus  is  sterilized 
'ly  immersion  in  alcohol  or  in  a  i  to  20  carbolic  acid  solution  followed 
by  rinsing  in  alcohol,  and  the  rubber-covered  battery  cords  are  wiped 
o3  with  bichlorid  solution.     The  hands  of  the  operator  and  assistants 


4S6 


THE   LARYNX  AND   TRACHEA 


should  be  as  thoroughly  cleansed  as  for  any  operation.    On  account 
of  the  danger  of  sepsis  from  the  mouth,  the  patient's  teeth  shook! 


Fig.  451. — Accessory  instruments  for  tracheo-brohchosoopy. 

be  brushed  and  the  mouth  well  cleansed  with  an  antiseptic  v 
before  passing  the  instruments.    A  tube  employed  in  the  u] 


Fig.  452. — The  position  of  the  patient  and  the  assistant  for  upper  tracheo-bronchoscc 

(After  Jackson.) 

operation    should   not   be   used   for   lower   bronchoscopy   withe 
resterilization. 


DIRECT   TRACHEO'BRnNCHOSCOPV 


457 


Preparation  of  the  Patient.— If  general  anesthesia  is  to  be  em- 
pioyed,  the  patient  should  be  prepared  according  to  the  usual  method 
(page  1 8).  In  any  case,  the  operation  should  be  performed  on  an 
empty  stomach.  For  lower  tracheo-bronchoscopy,  the  neck,  if 
hairy  should  be  shaved  and  painted  with  tincture  of  iodin. 

Position  of  the  Patient. — If  done  under  local  anesthesia,  upper 
tracheo-bronchoscopy  may  be  performed  with  the  patient  in  the 
'  upright  position.     The  patient  sits  on  a  low  stool,  with  the  head  ex- 
tended backward  as  far  as  possible  and  the  tongue  projected  forward. 
An   assistant  holds  the  head  from  behind  and  steadies  the  mouth- 


f^B.  while  the  operator  stands  in  front.  When  a  general  anesthetic 
^tupioyed,  and  in  all  cases  of  lower  bronchoscopy,  the  patient 
_^Uld  be  in  the  dorsal  position  on  a  table,  the  front  of  which  is 
.  Shtly  elevated,  with  the  head  hanging  over  the  edge  of  the  table, 
^  *hich  position  it  is  supported  by  an  assistant  who  takes  care  of  the 
^Quth-gag,  as  shown  in  Fig,  452- 

Aneethesia. — In  children,  general  anesthesia  is  necessary.  In 
*^iuits,  preliminary  cocainization  of  the  pharyn.\  and  larynx  with  a  4 
^r  cent,  solution  of  cocain,  followed  by  a  20  per  cent,  solution  of 
,  applied  to  the  larynx  and  trachea  is  in  most  cases  sufficient, 


458  THE  LARYNX  AND  TRACHEA 

unless  the  patient  is  very  excitable,  although  general  anestbesu 
renders  the  operation  easier  in  any  case.  Even  when  general  anes- 
thesia is  used,  cocain  should  be  applied  by  means  of  cotton  afftlica- 
tors  to  the  larynx  and  trachea  before  the  introduction  of  the  tube,  to 
avoid  dangerous  reflexes  from  stimulation  of  the  endings  of  the  sn- 
perior  laryngeal  nerve. 

Technic. — i.  Upper  Tracheo-bronchoscopy. — With  thepadentin 
the  proper  position,  and  the  parts  cocainized,  the  mouth  is  widely 
opened  and  the  mouth-gag  is  inserted  and  given  to  the  asastant  to 
inaintain  in  position.  The  larynx  and  vocal  cords  are  exposed  by 
introducing  a  split  tube  spatula,  as  for  direct  larjmgoscopy  (page 
449).  The  bronchoscope,  well  lubricated  with  sterile  vaselin,  and 
with  the  illumination  properly  turned  on,  is  passed  through  the  ^t 
tube  as  far  as  the  epiglottis  under  the  guidance  of  the  operator's  eye. 


Vvi.  454. — Lower  bronchoscopy.     (Modified  from  Ballengei.) 


The  operator  notes  the  vocal  cords  and  instructs  thepatient  to  breat^^^^ 
deeply,  and,  while  the  cords  are  open  during  inspiration,  the  inst^^ 
ment  is  gently  passed  through  the  glottis  until  it  enters  the  trach^^' 
The  split  tube  is  then  separated  and  removed.  As  the  bronchosco^P* 
is  advanced,  the  mucous  membrane  in  front  should  be  anesthetize^ 
by  means  of  a  20  per  cent,  solution  of  cocain  applied  with  cottc^ 
swabs  on  a  long  applicator.  The  instrument  is  thus  slowly  pass^~ 
to  the  bifurcation  of  the  trachea,  and  the  parts  are  examined  in  deta--*^ 
as  the  tube  advances. 

To  enter  the  right  bronchus,  the  instrument  should  be  turned 
toward  the  left  angle  of  the  patient's  mouth,  and  toward  the  righ*' 
side  if  the  left  bronchus  is  to  be  entered.  By  very  careful  and  gentle 
manipulations  with  the  tube,  and  by  using  the  smallest  sizes,  the 


DIRECT   TRACHEO-BRONCHOSCOPV 


459 


Y  and  even  the  third  division  of  the  bronchi  may  be  inspected 
ipeciaUy  skilled  in  this  work. 

Lg  the  examination,  secretions  or  blood  may  be  removed  by 
cotton  wrapped  on  long  applicators  or  by  the  special  aspirat- 
ratus  supplied  with  the  instrument,  the  manipulation  of 
entrusted  to  an  assistant.  In  this  way  the  entire  mucous 
le  lining  the  trachea  may  be  examined,  foreign  bodies  located 
>ved,  and  lesions  treated  by  direct  application, 
wer  Traclteo-lyrotuiioscopy. — Low  tracheotomy  is  first  per- 
s  described  on  page  486.  After  all  the  bleeding  has  been 
d,  a  Trousseau  dilator  is  inserted  and  the  tracheal  wound  is 
1.  The  mucous  membrane  of  the  trachea  is  then  cocainized 
>  per  cent,  solution  of  cocain.  A  short  bronchoscope,  with 
lination  turned  on,  is  introduced,  and  the  instrument  is 
I  under  the  guidance  of  the  operators  eye,  which  is  applied 
id  of  the  instrument.  As  soon  as  the  bifurcation  of  the 
s  reached,  the  tube  may  be  directed  into  either  bronchus 
'  manipulation.  The  patient's  head  is  turned  sideways,  and, 
tt  bronchus  is  to  be  entered,  the  tube  is  inserted  on  the  left 
le  head;  if  the  left  bronchus  is  to  be  examined,  the  tube  is 
it  the  right  side  of  the  head.  The  bronchi  should  be  ancs- 
as  before,  in  advance  of  the  instrument  with  cocain  applied 
g  applicators  through  the  instrument,  and  the  examination 
d  with  as  above. 

f  ter-treatment  of  the  patient  consists  in  inserting  a  tracheot- 
;  which  is  worn  for  several  days.  After  the  removal  of  this 
wound  should  be  carefully  protected  by  a  gauze  dressing  and 
iiy,  being  allowed  to  hea!  from  the  bottom  up. 


daily, 


PALPATION  BY  THE  PROBE 


tion  by  the  probe  is  of  value  in  determining  the  consistency 
it  of  new  growths,  the  depth  and  size  of  ulcerations,  the 
of  necrosed  cartilage,  and  the  sensibility  of  the  mucous 


iments. — ^A  laryngeal  mirror,  an  alcohol  lamp,  a  head  light, 
yngeal  probe  are  necessary  (Fig.  455). 

is. — The  probe  should  be  boiled  and  the  laryngeal  mirror 
by  immersion  in  a  i  to  30  solution  of  carbolic  acid,  then 
1  sterile  water  and  dried  before  use. 


458  THE  LARYNX  AND  TRACHEA  i 

unless  the  patient  is  very  excitable,  although  general  anutbegs  ' 
renders  the  operation  easier  in  any  case.  Even  when  general  anes- 
thesia is  used,  cocain  should  be  applied  by  means  of  cotton  ai^lia- 
tors  to  the  larynx  and  trachea  before  the  introduction  of  the  tube,  to 
avoid  dangerous  reflexes  from  stimulation  of  the  endings  of  the  sa- 
perior  laryngeal  nerve. 

Technic. — i.  Upper  Tracheo-bronchoscopy. — With  the  patient  in 
the  proper  position,  and  the  parts  cocainized,  the  mouth  is  widely 
opened  and  the  mouth-gag  is  inserted  and  given  to  the  assistant  to 
maintain  in  position.  The  larynx  and  vocal  cords  are  exposed  by 
introducing  a  split  tube  spatula,  as  for  direct  laryngoscopy  (page 
449).  The  bronchoscope,  well  lubricated  with  sterile  vaselin,  and 
with  the  illumination  properly  turned  on,  is  passed  through  the  split 
tube  as  far  as  the  epiglottis  under  the  guidance  of  the  operator's  eye. 


I'ic..  454. — Lower  bronchoscopy.     {Modified  from  BallcDger.) 

The  operator  notes  the  vocal  cords  and  instructs  thepatient  to breaC^** 
deeply,  and,  while  the  cords  are  open  during  inspiration,  the  inst*^ 
ment  is  gently  passed  through  the  glottis  until  it  enters  the  trach^^* 
The  split  tube  is  then  separated  and  removed.  As  the  bronchosci>JPj 
is  advanced,  the  mucous  membrane  in  front  should  be  anesthetiz^^^ 
by  means  of  a  20  per  cent,  solution  of  cocain  applied  with  cott^^ 
swabs  on  a  long  applicator.  The  instrument  is  thus  slowly  pass^^ 
to  the  bifurcation  of  the  trachea,  and  the  parts  are  examined  in  det^-^ 
as  the  tube  advances. 

To  enter  the  right  bronchus,  the  instrument  should  be  turn^^ 
toward  the  left  angle  of  the  patient's  mouth,  and  toward  the  rigk>' 
side  if  the  left  bronchus  is  to  be  entered.  By  very  careful  and  gentle 
manipulations  with  the  tube,  and  by  using  the  smallest  sizes,  the 


DIRECT    TRACHEO-BRONCHOSCOPY  459 

condary  and  even  the  third  division  of  the  bronchi  may  be  inspected 
'  one  especially  skilled  in  this  work. 

During  the  examination,  secretions  or  blood  may  be  removed  by 
eans  of  cotton  wrapped  on  long  applicators  or  by  the  special  aspirat- 
g  apparatus  supplied  with  the  instrument,  the  manipulation  of 
oich  is  entrusted  to  an  assistant.  In  this  way  the  entire  mucous 
embrane  lining  the  trachea  may  be  examined,  foreign  bodies  located 
id  removed,  and  lesions  treated  by  direct  application. 

2.  Lover  Tracheo-bronchoscopy. — Low  tracheotomy  is  first  per- 
frmed  as  described  on  page  4S6.  After  all  the  bleeding  has  been 
antroUed,  a  Trousseau  dilator  is  inserted  and  the  tracheal  wound  is 
eld  o^&i.  The  mucous  membrane  of  the  trachea  is  then  cocainized 
'ith  a  20  per  cent,  solution  of  cocain.  A  short  bronchoscope,  with 
le  illumination  turned  on,  is  introduced,  and  the  instrument  is 
ivanced  under  the  guidance  of  the  operator's  eye,  which  is  applied 
t  the  end  of  the  instrument.  As  soon  as  the  bifurcation  of  the 
■achea  is  reached,  the  tube  may  be  directed  into  either  bronchus 
y  gentle  manipulation.  The  patient's  head  is  turned  sideways,  and, 
the  right  bronchus  is  to  be  entered,  the  tube  is  inserted  on  the  left 
■de  of  the  head;  if  the  left  bronchus  is  to  be  examined,  the  tube  is 
iserted  at  the  right  side  of  the  head.  The  bronchi  should  be  anes- 
tietized,  as  before,  in  advance  of  the  instrument  with  cocain  applied 
pon  long  applicators  through  the  instrument,  and  the  examination 
roceeded  with  as  above. 

The  after-treatment  of  the  patient  consists  in  inserting  a  tracheot- 
omy tube  which  is  worn  for  several  days.  After  the  removal  of  this 
'be,  the  wound  should  be  carefully  protected  by  a  gauze  dressing  and 
^ansed  daily,  being  allowed  to  heal  from  the  bottom  up. 


PALPATION  BY  THE  PROBE 

Palpation  by  the  probe  is  of  value  in  determining  the  consistency 
'<i  extent  of  new  growths,  the  depth  and  size  of  ulcerations,  the 
«sence  of  necrosed  cartilage,  and  the  sensibility  of  the  mucous 
Embrane. 

Instruments. — A  laryngeal  mirror,  an  alcohol  lamp,  a  head  light, 
W  a  laryngeal  probe  are  necessary  (Fig.  455). 

Asepsis. — The  probe  should  be  boiled  and  the  laryngeal  mirror 
■erilized  by  immersion  in  a  i  to  20  solution  of  carbolic  acid,  then 
nsed  off  in  sterile  water  and  dried  before  use. 


46o  THE  LARYNX  AND  TRACHEA 

Position  of  Patient. — The  patient  is  in  the  same  position  is  In 
ordinary  laryngoscopy. 

Anesthesia.— The  larynx  should  be  cocainized  by  spraying  or  b}- 
the  application  of  a  lo  per  cent,  solution  of  cocain. 

Technic. — The  tongue  is  protruded  and  held  by  the  patient  with  a 
cloth,  and  the  laryngeal  mirror  is  wanned  and  inserted  in  sudi  i 
position  that  a  good  vier  of  the 
larynx  is  obtained.    The  probe  i& 
held  in  the  operator's  right  huxl 
and  is  introduced  into  the  patient's 
mouth  turned  on  its  side,  with  the 
laryngeal  portion  horizontal  and 
the  handle  in  the  angle  of  the 
mouth  until  it  almost  reaches  the 
posterior  pharyngeal  wall  (sec  fig. 
456).     It  is  then  brou^t  into  the 
natural  position,  with  thelaiyngeal 
portion  vertical  and  the  handkin. 
the  mid-line,  thepointof  theinstni- 
ment  lying  in  the  pharynx  beluwl 
the    epiglottis.     By    raising  the 
handle  of  the  instrument,  tbepotot. 
is  then  brought  forward  ov«  the 
arytenoids.     By      directing    the 
point  of  the  probe,  guided  by  the 
-Instrumenis  for  probing  image  in  the  mirror,  the  dis««<i 
Lar>ng<'alpn>f'e,  2,  laryn-  atcas  are  then  explored  (see  fig- 
1,  alcohol  lamp,  4,  head  ^.^^      In  performing  this  manipu- 
lation, it  must  be  remembered  that 
the  image  in  the  mirror  is  reversed,  so  that  movements  of  the  instru- 
ment will  likewise  appear  reversed,  and  that  the  distance  between  the 
arytenoids  and  the  vocal  cords  is  much  greater  than  appears  in  the 
image. 


the  larynx 

geal    mim 


SKIAGRAPHY 

Skiagraphy  is  employed  as  an  adjunct  to  other  diagnostic  meas- 
ures for  locating  metal  and  other  foreign  bodies  which  are  impene- 
trable to  the  rays,  and  also  for  localizing  certain  growths  of  greater 
density  than  the  surrounding  tissues. 


THE    L.\RVNGEAL    SPRAY 


461 


Therapeutic  Measures 

THE  LARYNGEAL  SPRAY 

laryngeal  spray  is  employed  for  the  purpose  of  cleansing  and 
tcation.  Cleansing  of  the  larynx  is  frequently  required  for 
jval  of  purulent  secretions  the  result  of  syphilitic  or  tubercu- 
srations,  and  to  soften  and  wash  away  the  crusts  which  are 
1  accompaniment  of  fetid  laryngitis.  Whenever  possible, 
;  of  the  larjTix  should  be  done  by  the  surgeon  himself,  as  it 
i  be  performed  by  the  aid  of  direct  vision  in  a  thorough  man- 

this  is  not  feasible,  the  patient  must  be  very  carefully  in- 

in  the  use  of  the  instrument. 

ication  of  the  larynx  may  be  required  in  the  treatment  of 
id  chronic  inflammations,  ulcerations,  etc.,  and  according  to 
nations  of  the  individual  case,  remedies  with  an  antiseptic, 
nl,  sedative,  stimulating,  or  caustic  action  are  employed, 
lay  be  used  in  the  form  of  watery  or  oily  solutions.  The 
nsitiveness  of  the  laryngeal  mucous  membrane  should  be 
nind  in  making  any  topical  application,  and  the  use  of  very 
;  drugs  should  be  avoided. 

uments.^ — It  is  important  to  select  a  spray  that  will  not  expel 
tion  in  such  a  powerful  stream  as  to  produce  irritation  and 

add  to  the  local  inflammation.  The  Davidson,  the  Whitall 
see  Fig.  365),  and  the  De  Vilbiss  atomizers  (see  Fig.  366)  are 
nd  very  efficient  instruments.  They  should  be  provided  with 
eal  nozzle,  which  turns  downward.     The  air  current  may  be 

by  a  rubber  compression  bulb  or  by  means  of  a  compressed- 
ratus  (see  Fig.  367). 

ad  mirror,  a  laryngeal  mirror,  and  proper  illumination  will 
Kjuired  when  the  spraying  is  to  be  done  by  the  operator  under 
sion. 
dons. — For  cleansing  purposes,  the  alkaline  solutions  recom- 

on  page  380  for  use  in  the  nose  may  be  employed.  For 
.pplications  to  the  larynx,  the  formulse  of  antiseptic,  astrin- 
lative,  and  stimulating  solutions  given  on  page  385,  for  use 
)ae,  may  be  employed  according  to  the  indications, 
jerature.^ — The  solutions  should  always  be  used  warm,  at 
■ature  of  about  100°  F.  (38°  C). 
thesia. — When  the  parts   are  very   sensitive,   preliminarj' 

with  a  10  per  cent,  solution  of  cocain  may  be  required. 


462  THE  LARYNX  AND  TRACHEA 

Technic. — The  patient  is  directed  to  open  his  mouth  widely  and 
to  protrude  his  tongue,  which  he  may  hold  forward  with  the  fingers  rf 
his  light  hand  if  desired.  The  operator  then  warms  and  introduces 
a  laryngeal  mirror,  holding  it  so  as  to  obtain  a  good  view  of  the  parts 
Then,  with  his  right  hand,  he  introduces  the  spray  nozzle  into  tb 
mouth,  and  with  the  aid  of  the  mirror  passes  it  behind  the  epiglott 
and  depresses  the  tip  so  that  it  points  toward  the  diseased  arc 
When  the  nozzle  i^in  proper  position,  the  mirror  is  removed  and  tJ 
bulb  of  the  spray  is  sharply  compressed,  the  patient  being  instructs 
to  phonate  while  this  is  being  done.  The  spray  is  then  immediate 
removed,  as  the  patient  will  cough  and  want  to  expectorate.  Whi 
performed  for  cleansing  purposes,  the  spraying  should  be  repeati 
several  times  until  the  larynx  is  well  washed  out.  Each  time  tl 
patient  coughs,  mucus,  purulent  secretion,  and  crusts,  which  ha^ 
been  softened  and  separated  by  the  spray,  will  be  expelled. 

When  the  spraying  is  carried  out  by  the  patient,  the  mouth 
widely  opened  and  the  tongue  protruded  as  before.  The  spray  no 
zle,  held  in  the  patient's  right  hand,  is  then  introduced  well  back 
the  tongue,  with  the  tip  directed  downward  and  forward  over  tl 
larynx,  and,  while  the  patient  phonates,  the  bulb  is  sharply  compresse 
In  employing  oily  preparations,  the  patient  should  take  an  inspir 
tion  at  the  moment  of  compressing  the  bulb,  so  as  to  aid  in  drawii 
the  solution  into  the  larynx.  Until  the  patient  becomes  skilled  in  t] 
introduction  of  the  spray,  it  is  well  for  him  to  perform  the  operatii 
standing  in  front  of  a  mirror. 

THE  DIRECT  APPLICATION  OF  REMEDIES 

This  method  is  indicated  when  it  is  desired  to  apply  remedies 
some  particular  spot,  especially  when  strong  stimulants  or  causti 
are  used.  Liquids  may  be  applied  by  means  of  swabs  or  brusha 
Solid  caustics  should  be  fused  on  a  probe.  The  application  shou 
be  made  with  the  aid  of  a  laryngeal  mirror,  and  great  care  must  ' 
taken  to  avoid  bruising  the  tissues  or  causing  trauma. 

Instnmients. — For  the  application  of  liquids,  a  camel's-ha 
brush,  mounted  on  a  wire  which  is  bent  at  right  angles  about  2} 
to  3  inches  (6  to  7  cm.)  from  the  end  and  inserted  into  a  handle, 
Sajous  applicator  (see  Fig.  442),  or  an  ordinary  laryngeal  applicati 
wrapped  with  cotton  may  be  employed.  In  making  use  of  the  lattc 
care  should  be  taken  that  the  cotton  is  wrapped  tightly  about  the  ei 
of  the  instrument,  so  that  there  is  no  danger  of  its  falling  off  and  sli] 
ping  into  the  larynx. 


THE    DIRECT   .APPLICATION    OF    REMEDIES  463 


Solid  caustics,  as  silver  nitrate  and  chromic  acid,  may  be  applied 
fused  on  the  end  of  a  laryngeal  probe,  as  described  on  page  386, 


the  larym  by  the  aid 


Anesthesia. — The  parts  should  be  anesthetized  by  means  of  a  10 
per  cent,  solution  of  cocain  applied  by  means  of  a  spray  or  on  a  cotton 

applicator. 


464  THE  LAKYKX  AND  TKACHEA 

Technic. — The  laryngeal  mirror  is  warmed  and  introductd  by 
the  operatx)r's  left  hand,  so  as  to  obtain  a  clear  view  of  the  parts  to  be 
medicated.  If  secretion  or  mucus  be  present,  the  parts  skukl  be 
first  cleansed  by  spraying.  The  applicator  is  then  dipped  in  tbe 
solution  to  be  applied,  and  any  excess  oj  fluid  is  removed  to  prevent  it 
from  running  into  the  trachea.  This  precaution  is  especially  nece- 
sary  when  using  strong  solutions  or  caustics.  The  instrument,  trid 
in  tbe  operator's  right  hand,  is  then  introduced  into  the  moutb,  vilk 
the  curved  surface  held  first  horizontally  (Fig.  456),  and  then,  as  soon 


—Instruments  for  applying  powders  to  the  larynx.     1,  Powder  bIoir« 
laryngeal  mirror;  3.  alcohol  lamp;  4,  head  mirror. 


as  the  tip  of  the  instrument  reaches  the  pharynx,  turned  to  a  verticai 
position.  The  applicator  is  then  guided  to  the  desired  spot  by  tbe 
aid  of  the  laryngeal  miiror  (Fig.  457).  The  application  should  be 
made  with  great  gentleness  and  care  and  the  instrument  quickly 
removed. 

The  application  of  acids  is  carried  out  in  the  same  manner,  any 
excess  of  acid  being  immediately  neutralized  by  the  application  of « 
solution  of  bicarbonate  of  soda,  gr.  xxx  (2  gm.)  to  the  ounce  (30 cW- 
A  dusting  powder  may  finally  be  applied  to  the  cauterized  are*. 


STEAM   IMIALATIONS  46$ 

INSUFFLATIONS 

;rs  may  be  applied  to  the  larynx  by  means  of  a  special 
r.  They  are  of  use  chiefly  in  cases  of  ulceration,  where  a 
)r  antiseptic  action  is  desired.  A  combination  of  nosophen, 
irophen,  iodoform,  etc.,  with  finely  powdered  starch,  stear- 
:,  or  powdered  acacia  as  a  base,  are  usually  employed  in  the 
a  of  one  part  of  the  active  principle  to  two  parts  of  the  base. 
ounts  of  morphin  or  cocain  may  also  be  combined  with  the 
applied,  when  indicated,  for  the  relief  of  pain, 
ments. — A  laryngeal  powder  blower,  a  head  light,  a  laryn- 
ir,  an  alcohol  lamp,  and  suitable  illumination  are  necessary. 
Bator  shown  in  Fig.  458  is  verj'  convenient,  as  with  it  the 
f  powder  may  be  accurately  measured,  and  the  instrument 
lanipulated  with  one  hand. 

ic. — The  laryngeal  mirror  is  warmed  and  properly  inserted 
harynx,  so  that  a  good  view  of  the  parts  to  be  medicated  is 
The  insufflator,  filled  with  the  desired  amount  of  powder, 
1  in  the  mouth  and  carried  back  to  the  larynx  under  the 
of  the  image  in  the  mirror.  When  in  proper  position,  a 
mpression  on  the  bulb  forces  out  the  powder  and  deposits  it 
eased  surface.  If  it  is  desired  to  carry  the  powder  deep  into 
:,  the  patient  should  be  requested  to  phonate  at  the  moment 
'ssing  the  bulb. 

I  STEAM  INHALATIONS 

Sans  of  steam  inhalations  the  active  principle  of  certain 
t  are  readily  volatilized  by  heat  may  be  brought  into  con- 
the  mucous  membrane  of  the  respiratory  tract  and  carried 
le  larj'nx  to  the  trachea  and  bronchi.  The  effect  of  the 
If  is  also  valuable,  for  it  acts  as  an  anodyne  upon  inflamed 
lembranes  by  supplying  moisture  and  so  relieving  the  heat 
rss  of  congestion.  In  the  latter  stages  of  an  inflammation 
,  furthermore,  dilutes  and  assists  in  removing  secretions, 
alations  are  thus  of  great  value  in  congestion  and  edema  of 
i,  croup,  membranous  laryngitis,  and  bronchitis.  They 
illy  serviceable  in  softening  the  thick  tenacious  secretion  of 
ryngitis. 

ihaler. — When  it  is  simply  intended  to  convey  the  vapor  to 
.y  of  the  patient,  a  croup  kettle  with  a  long  spout,  such  as 


4ti6  THE   LARYNX   AND   TRACHEA 

shown  in  Fig.  459,  is  most  convenient.     For  direct  inhalation,  mne 
or  less  elaborate  forms  of  apparatus  are  manufactured  (F^.  460},  but 


Fig.  460. — Steam  atomuer.  Fic.  461. — Steam  inhilei  impff^ 

vised  from  ■  coffee-pot. 

a  coffee-pot  with  a  funnel  of  heavy  paper  placed  in  the  top  makes 
simple  and  efficient  inhaler  (Fig.  461). 


STEAM    INHALATIONS 

Formulary. — Sedative,  stimulating,  or  antiseptic  drugs  are  the 
ones  usually  employed  for  inhalation.  These  include  tincture  of 
benzoin  compound  in  the  strength  of  i3  (4  c.c.)  to  the  pint  (500 
C-C-);  creosote,  5  to  loTTl  (0.3  to  0.6  c.c.)  to  the  pint  (500  c.c);  ol, 
cubebffi,  sin  (0.3  c.c.)  to  the  pint  (500  c.c);  spirits  camphori,  sTTl' 
(o.j  c.c)  to  the  pint  (goo  c.c);  ol.  pinus  sylvestris,  sTTl  (0.3  c.c) 
to  the  pint  (500  c.c),  etc 

Temperature. — When  directly  inhaled,  the  vapor  should  not  be  of 
a  higher  temperature  than  150'^  F.  (65"*  C),  If  used  too  hot  irrita- 
tion of  the  mucous  membrane  may  be  produced  and  there  is  danger 
of  the  steam  scalding  the  face. 


Fig,  46;.— Crib  arranged  tor  steam  mhaiations.     (After  Kcrley.) 


Technic. — Into  an  inhaler  a  pint  (500  c.c.)  of  nearly  boiling  water 

**  placed  and  the  proper  quantity  of  the  drug  is  added.    The  patient. 

^^n  places  his  nose  over  the  cone  and  inhales  the  escaping  vapor, 

"^•ting  about  six  to  eight  breaths  a  minute.     The  inhalation  should 

*^t  be  continued  for  more  than  five  or  ten  minutes  at  a  time.     It  may 

"^  employed  three  or  four  times  daily.     The  treatment  should  be 

^*rri«i  out  in  a  warm  room,  i.e.,  at  a  temperature  of  about  68° 

^■.  (20"  C.)  and  care  should  be  taken  to  protect  the  patient  from 

Oughts.     As  the  steam  relaxes  the  mucous  membrane  and  renders' 

«ie  patient  susceptible  to  cold,  he  should  not  be  allowed  out  of  doors 

'Or  several  hours  afterward. 

In  using  the  croup  kettle,  the  steam  may  be  delivered  into  the 


■1 


468  THE  LABYNX  AND  TRACHEA 

room  or  directly  over  the  patient.  When  the  latter  method  is  used, 
it  is  well  to  cover  the  bed  of  the  patient  with  a  sheet  arranged  in  the 
form  of  a  tent  and  raised  sufficiently  high  to  permit  a  free  drnilalioii 
of  air,  the  nozzle  of  the  croup  kettle  being  inserted  under  one  ^oi 
the  tent  and  the  water  kept  boiling  (Fig.  463). 

DRY  INHALATIONS 

These  are  useful  in  diseases  of  the  upper  respiratory  tract  for  those 
who  cannot  tolerate  the  steam  inhalations. 

The  Inhaler. — A  special  mask  made  of  woven  metal,  which  accu- 
rately fits  the  mouth  and  which  is  proWded  with  a  sponge  upon  wludi 
the  medication  is  dropped,  is  employed  (Fig.  463). 


\ 


Fig.  463— Inhalation  mask. 

Formulary. — Any  of  the  very  volatile  oils,  such  as  thymol,  men- 
thol, eucalyptol,  etc.,  may  be  employed. 

Technic. — Twenty  or  thirty  drops  (1.25  to  2  c.c.)  of  the  oil  are 
placed  upon  the  sponge  of  the  mask,  and  the  latter  is  placed  over  the 
patient's  face  and  is  secured  by  strings  fastened  back  of  the  head  and 
neck.  The  patient  inhales  through  the  mask  by  means  of  the  mouth, 
and  exhales  through  the  nose.  The  mask  may  be  worn  for  about  half 
an  hour  two  or  three  times  a  day. 

INTUBATION  OF  THE  LARYNX 

Intubation  of  the  larynx,  an  operation  devised  by  O'Dwyer, 
consists  in  the  introduction  of  a  tube  into  the  larynx  for  the  purpose  of 
securing  free  respiration  in  the  presence  of  obstruction  in  the  larynx 
or  upper  portion  of  the  trachea.  It  is  an  operation  which  gives 
prompt  relief  without  the  necessity  of  cutting  and  without  producing 


^^^^^^^p  INTUBATION    OF    THE       LABYNX  469 

any  loss  of  blood  or  shock.  It  is  less  terrifying  to  the  patient 
than  tracheotomy  and  the  after-care  is  not  so  troublesome. 
Anesthesia  is  not  necessary  nor  is  any  previous  preparation  of  the 
patient  required.  Special  instruments,  however,  are  essential,  and 
the  leeding  of  the  patient  is  often  troublesome  and,  while  not  a  diffi- 
cult operation  in  itself,  it  requires  special  training  for  its  skilful  per- 
formance which  is  best  learned  by  practice  upon  the  cadaver. 

Indications. — The  operation  was  originally  devised  for  the  relief 
of  obstruction  to  respiration  in  cases  of  laryngeal  diphtheria  and  has 


'^O.  464. — CDwyer  inlubation 
!•  tube  utd  obturator  separated;  3,  gauge; 
T.  «traclor. 


I.  Tube  with  obturator  in  place; 
ith  gag;  3,  inlroduceri  6,  silk  thread; 


"^w  almost  entirely  supplanted  tracheotomy  in  such  cases.  The 
""mediate  indications  are  dyspnea  accompanied  by  cyanosis,  depres- 
siori  0/  the  suprasternal  and  supraclavicular  spaces  on  Inspiration, 
"'d  sinking  in  of  the  lower  portion  of  the  chest.  Intubation  is  also 
^ployixi  in  laryngeal  stenosis  from  other  causes  for  the  purpose  of 
.producing  gradual  dilatation  of  the  parts,  progressively  larger 
'"ms  being  introduced  and  worn  for  a  few  days  at  a  time. 

Instruments. — The  instruments  refjuired  are  an  O'Dwyer  intuba- 
hon  set  including  seven  metal  or  hard-rubber  tubes,  an  introducer, 
*il  extractor,  a  mouth  gag,  and  a  gauge  indicating  the  size  of  the 
tubes  according  to  the  age  of  the  patient  (Fig.  464).     Although  these 


470  THE  LARYNX  AND  TRACHEA 

mstruments  have  been  modified  and  attempts  have  been  made  to 
improve  upon  them,  those  originally  designed  by  O'Dwyer  give  the 
best  results. 

The  intubation  tube  has  an  expanded  head  prolonged  backward 
in  the  form  of  a  flange  to  prevent  it  from  slipping  through  the  vocal 
cords  and  a  fusiform  bulb  in  the  middle  to  aid  in  keeping  the  tube  in 
position.  In  the  anterior  portion  of  the  head  a  perforation  is  pro- 
vided for  the  attachment  of  a  piece  of  silk  thread.  The  lower  end  of 
the  tube  is  rounded  oflf  and  oval.  Each  tube  is  provided  with  an 
obturator  which  can  be  screwed  on  to  the  introducer.  The  free 
extremity  of  the  obturator  ends  in  a  protuberance  which  projects 
beyond  the  tube  and  prolongs  the  latter  into  a  rounded  extremity  to 
aid  in  its  introduction. 

The  introducer,  or  intubator,  consists  o£  a  handle  in  which  is  set  a 
rod,  to  the  extremity  of  which  the  obturator  may  be  screwed.  A 
sliding  joined  tube  fits  over  this,  which  can  be  pushed  forward  by  a 
small  knob  set  on  the  handle  of  the  instrument,  thereby  detachiag 
the  intubation  tube  from  the  obturator  when  the  former  is  in  proper 
position  in  the  larynx. 

The  extractor,  or  extubator,  is  an  instrument  supplied  with  javrs 
which  fit  into  the  lumen  of  the  tube,  and  when  opened  by  pressure 
upon  a  lever  engage  the  tube  with  sufficient  force  to  permit  its  removaJ 
from  the  larynx. 

Asepsis. — The  instruments  should  be  sterilized  before  use. 

Position  of  the  Patient. — The  child,  with  its  arms  at  its  sides,  »^ 
wrapped  from  chin  to  foot  in  a  sheet  or  blanket  and  is  supported  up(^^«^ 
the  lap  of  a  nurse  in  a  sitting  posture  facing  the  operator  with  itsf( 
held  between  the  nurse's  knees  and  its  head  resting  on  her  rigl 
shoulder.  An  assistant  should  stand  behind  and  grasp  the  child 
head  firmly,  lifting  upward  as  though  holding  the  child  by  thehea* 
thus  extending  the  head  as  far  as  possible  (Fig.  465).  Some  oper; 
tors,  however,  prefer  to  intubate  with  the  patient  in  a  horizont^* 
position  and  with  a  small  sand-bag  placed  under  the  back  of  tt^^ 
neck. 

Technic. — ^A  tube  of  a  size  corresponding  to  the  age  of  the  patie*^ 
is  selected  and  is  properly  threaded  with  a  piece  of  silk  2  or  3  fe^ 
(60  to  90  cm.)  long.     Then,  with  the  obturator  in  place,  the  tube  ^ 
screwed  on  the  introducer  in  such  a  maimer  that  its  projecting 
flange  lies  behind  and  faces  away  from  the  operator.     The  mouth  ga^ 
is  next  inserted  between  the  patient's  jaws  on  the  left  side  and  is  held 
in  place  by  the  assistant  who  supports  the  child's  head.     The  opera- 


DJTDBAnON  OF  THE   LAHYMX 


tor,  with  his  eyes,  nose,  and  mouth  protected  against  possible  infec- 
tion in  diphtheria  cases,  faces  the  patient  and  inserts  bb  left  indez- 


Fic.  465. — Position  o(  child  for  intubation  and  method  of  holijing. 

fiiiger  into  the  mouth,  hooking  up  the  epiglottis  (Fig.  466) .  In  doing 
tl"s  care  should  be  taken  to  keep  the  finger  to  the  left  side  and  out  of 
the  Way  as  much  as  possible.    The  operator  then  takes  the  introducer 


with  the  tube  attached  in  his  right  hand,  holding  it  as  follows:  The 
thumb  pressed  against  the  button  on  the  upper  side  of  the  handle,  the 


472 


THE  LASYNX   AND  TRACHEA 


index-finger  around  the  hook,  on  the  under  surface  of  the  instramcd, 
and  the  loop  of  silk  wound  over  his  little  finger,  as  shown  in  Fig. 
467.     He  then  slowly  introduces  the  tube  into  the  mouth  in  theiM- 


dian  line,  hugging  the  center  of  the  tongue  and  keqiing  the  handletrf 
the  instrument  at  first  well  down  on  the  chest  of  the  patient  (Rg- 
468).    When  the  end  of  the  tube  reaches  the  epiglottis  (Fig.  469),  the 


Fig.  468.- 


Seconrf  slep,  iniroducinR  the  tube 


handle  is  sharply  elevated,  so  that  the  tube  is  brought  into  a  vertiT' 
position  (Fig.  470) ,  If  the  handle  of  the  instrument  is  not  suffiden'* 
elevated,  the  tube  will  point  toward  the  entrance  of  the  esophagi 
which  it  will  be  apt  to  enter  during  the  next  maneuver  (Fig.  471).    / 


INTUBATION    OF    THE    LARYNX 


473 


B  same  time  the  finger  of  the  operator  is  moved  to  the  posterior 
rtion  of  the  larjiix,  resting  on  the  arytenoid  cartilages  to  prevent 
E  tube  from  entering  the  esophagus.  The  tube  is  then  gently 
shed  through  the  chink  of  the  glottis  and  on  into  the  larynx,  guided 
the  operator's  finger.     No  force  whatever  should  be  used. 


<6Q.^TTiird  step  ii 


—  Fourth  step  in  intubation. 


As  soon  as  the  tube  is  in  proper  position,  the  operator's  forefinger 
iaced  on  its  head  helding  it  in  place  while  the  button  on  the  handle 
he  instrument  is  pushed  forward,  thus  disengaging  the  obturator 
n  the  tube  (Fig.  472).  The  intubator  with  the  obturator  attached 
hen  removed,  and  the  tube  is  pushed  well  into  the  larynx  by 


'1.  471. — Showing  a  faulty  position 
e  tube.  Hue  to  the  handle  of  tlxe  in- 
iccr  Bot  being  raised  sutficieDtly  high. 


FtG.  473. — Fifth  step  in  intubation 
witlidrawinR  llie  introducer  while  index- 
finger  holds  the  tube  in  place. 


finger  (Fig.  473).  Not  more  than  five  to  ten  seconds  should  be 
turned  in  introducing  the  tube,  for  while  this  is  being  done  breath- 
is  interfered  with;  if  the  tube  cannot  be  promptly  inserted,  the 
ration  should  be  suspended  and  a  second  attempt  made  after 
wing  the  child  time  to  recover  its  breath. 


476  THE  UUtYNX  AND  TRACHEA 

solid  food.    As  a  rule,  by  having  tlie  patient  lie  with  the  head  lowered, 
fluids  will  pass  along  the  roof  of  the  mouth  to  the  posterior  phaiyt- 
geal  wall,  and  will  enter  the  esophagus,  and,  if  given  slowly,  suffidenl 
food  may  be  administered  in  this  way  (Fig.  476);  or  food  may  te 
administered  by  having  the  patient  suck  up  the  food  through  a 
tube  while  lying  face  downward  upon  the  lap  of  a  nurse.    In  some 
cases,  where  the  patient  refuses  foods,  liquids  may  be  administered 
by  means  of  the  stomach-tube  passed  through  the  mouth  or  by  me: 
of  a  soft-rubber  catheter  passed  into  the  stomach  through  the  nos« 
(page  555}.    Rectal  feeding  may  be  combined  with  the  above      il 
indicated.  ■ 

When  to  Remove  the  Tube. — The  tube  should  always  be    ] 
moved  as  soon  as  possible,  as  its  prolonged  use  may  produce     «xl- 


FiG.  477, — Eitubation, 

ceration  of  the  larynx.  In  cases  of  diphtheria,  where  antitoxin  -^^ 
been  administered,  the  tube  may  be  removed  in  three  to  seven  d^*"-^/ 
depending  to  some  extent  upon  the  age  of  the  patient,  being  lef*^ 
for  longer  intervals  in  very  young  children.  If  the  tube  becoc^*^^ 
occluded  at  any  time,  it  must  be  removed  without  dday,  cleai*'^^'^' 
and  then  reintroduced.  When  the  tube  is  to  be  permanently  *Y^ 
moved,  the  physician,  after  extracting  it,  should  wait  sufficien.  *-  ^ 
long  to  see  that  respiration  does  not  become  impeded  and  nec^^^*" 
sitate  its  reintroduction. 

Technic  of  Eitubation. — The  patient  is  placed  and  held  in   t.i*^ 
same  position  as  for  introduction  of  the  tube.    The  mouth  gag'    ^ 
inserted,  and  the  operator  passes  his  left  index-finger  into  the  mou  ^ 
and  over  the  epiglottis  until  it  rests  on  the  head  of  the  tube.    The 


I 


INTDBATION  OF   THE   LARYNX  47S 

ever,  in  that  it  is  possible  for  the  child  to  remove  the  tube  if  it 

^ts  hold  of  the  string. 

Should  the  tube  be  plat^  in  the  esophagus  by  mistake,  there  will 
be  no  relief  to  the  dy^nea  and  the  cyanosis,  there  will  be  an  absence 
of  cough,  and  the  string  of  ^Ik  will  be  seen  to  gradually  shorten  as  the 
tube  passes  down  the  esophagus.  In  such  a  case,  the  tube  should  be 
rexTi.ove(}  by  pulling  on  the  string,  and,  after  waiting  a  sufficient  time 
for  the  patient  to  recover  from  the  excitement  attending  the  opera- 
tion., it  should  be  reintroduced. 


Fig.  476. — Method  of  feeding  an  intubation  patient  with  the  bead  lowered. 

^Xn  some  instances,  the  tube  may  become  occluded  by  pushing  the 

*^^  membrane  ahead  of  it.     If  this  occurs,  the  tube  should  be 

^^^**.oved  at  once,  and,  if  the  obstructing  membrane  is  not  expelled 

'^'^Tfci  the  larynx  and  cannot  be  extracted  and  suffocation  seems  im- 

^^^**Xent,  tracheotomy  should  be  performed.     Care  should  be  taken 

^t  to  select  too  small  a  tube,  for  it  may  be  expelled  by  coughing  or 

^^y  escape  into  the  trachea, 

Feeding  Intubated  Patients. — The  tube  renders  swallowing  diffi- 
*^^lt,  and  the  patients  are  only  able  to  take  liquid,  or,  at  most,  semi- 


476  THE  LARYNX  ANB  TRACHEA 

solid  food.     As  a  rule,  by  having  the  patient  lie  with  the  head  lovatd, 
fluids  will  pass  along  the  roof  of  the  mouth  to  the  posterior  phuyn- 
geal  wall,  and  will  enter  the  esophagus,  and,  if  given  slowly,  suffident 
food  may  be  administered  in  this  way  (Fig,  476) ;  or  food  may  be 
administered  by  having  the  patient  suck  up  the  food  throng  a. 
tube  while  lying  face  downward  upon  the  lap  of  a  nurse.    In  som.^ 
cases,  where  the  patient  refuses  foods,  liquids  may  be  administotd 
by  means  of  the  stomach-tube  passed  through  the  mouth  or  by  meau-s 
of  a  soft-rubber  catheter  passed  into  the  stomach  through  the  nob-* 
(page  555).    Kectal  feeding  may  be  combined  with  the  above  5J 
indicated.  ■ 

When  to  Remove  the  Tube. — The  tube  should  always  be  r^a- 
moved  as  soon  as  possible,  as  its  prolonged  use  may  produce  im^^ 


Fig.  477. — ExtubatioD. 

ceration  of  the  larynx.  In  cases  of  diphtheria,  where  antitoxin  h  ^^ 
been  administered,  the  tube  may  be  removed  in  three  to  seven  daj*^* 
depending  to  some  extent  upon  the  age  of  the  patient,  being  left  *-" 
for  longer  intervals  in  very  young  children.  If  the  tube  becom^^ 
occluded  at  any  time,  it  must  be  removed  without  delay,  cleaneC^' 
and  then  reintroduced.  When  the  tube  is  to  be  permanently  n?~^ 
moved,  the  physician,  after  extracting  it,  should  wait  sufficiently 
long  to  see  that  respiration  does  not  become  impeded  and  neces- 
sitate its  rein t rod uction. 

Technic  of  Extubation.— The  patient  is  placed  and  held  in  the 
same  position  as  for  introduction  of  the  tube.  The  mouth  gag  is 
insertwl,  and  the  operator  passes  his  left  index-finger  into  the  mouth 
and  over  the  epiglottis  until  it  rests  on  the  head  of  the  tube.     The 


abator,  held  in  the  operator's  right  hand,  is  then  introduced  with 
jaws  closed,  by  the  same  maneuvers  employed  in  introducing  the 
(bator,  until  its  tip  is  (elt  by  the  finger  on  the  tube.  It  is  then 
;fully  guided  into  the  lumen  of  the  tube.  By  pressing  the  lever  on 
of  the  handle,  the  jaws  of  the  instrument  are  separated  and  obtain 
rcure  hold  on  the  tube,  so  that  it  may  be  easily  withdrawn  {Fig. 
).  To  accomplish  this,  the  tube  must  be  lifted  at  first  vertically 
'ard.  The  handle  of  the  instrument  is  then  depressed,  and  the 
B  is  brought  out  by  a  reversal  of  the  movements  of  intubation. 
In  an  emergency,  when  the  tube  becomes  obstructed,  it  may  be 
iible  to  remove  it  by  enucleation,  especially  if  the  tube  be  short. 
5  consists  in  placing  the  thumb  of  the  right  hand  on  the  larynx 
eath  the  end  of  the  tube  while  the  patient's  head  is  extended,  and 
1  a  quick  motion  of  the  head  forward,  at  the  same  time  e.\erting 
'ard  pressure  on  the  larynx,  the  tube  is  expelled  into  the  mouth. 

TRACHEOTOMY 

The  term  tracheotomy  is  generally  used  to  designate  the  operation 
pening  into  the  air-passages  at  some  point  between  the  sternum 

thyroid  cartilage.  To  be  exact,  however,  the  term  should  be 
ted  to  operations  below  the  cricoid  cartilage,  while  above  that 
It,  that  is,  in  the  cricothyroid  space,  the  operation  is  called  laryn- 
>my.  Tracheotomy  is  subdivided  into  the  high  operation  when 
opening  is  made  above  the  isthmus  of  the  thyroid  gland,  and  into 

tracheotomy  when  the  operation  is  performed  below  this  point. 
Indications.' — Tracheotomy  is  indicated  for  the  relief  of  obstru- 

dyspnea,  which  may  be  the  result  of  any  one  of  the  following 
ditions:  The  formation  of  pseudomembrane;  the  presence  of 
ign  bodies;  the  presence  of  growths  within  the  larynx  or  trachea 
sxternal  to  these  structures;  edema  of  the  larynx;  spasm  of  the 
'nx;  rapid  swelling  of  the  tonsils  and  pharynx;  injuries  to  the 
nx  and   trachea,  such  as  contusions,   fractures,  bums,   clcatri- 

stenosis,  etc.  For  the  relief  of  obstruction  from  diphtheritic 
nbranes,  however,  intubation  should,  as  a  rule,  be  the  operation 
hoice,  tracheotomy  being  reserved  for  those  cases  where  intuba- 
1  fails,  as  when  the  membrane  extends  down  low  in  the  trachea, 
»here  the  necessary  instruments  for  intubation  are  not  available, 
tcheotomy  may  also  be  required  for  the  removal  of  foreign  bodies 
in  the  larynx,  trachea,  and  bronchi,  for  the  administration  of 
:heal  anesthe^a  in  operations  upon  the  mouth,  pharynx,  jaws, 


d 


47^  THE  LASYXX  AKD 

or  larynx,  and  as  a.  preliininar>'  to  \aiyngtctoan  aihml^ 
bronchoscopy. 

Choice  of  Operation. — The  choice  betwa  knapHi^l 
tracheotomy,  and  low  tracheotomy  depends  i^ua  At  tti 
obstruction  and  also  upon  the  age  of  the  patient  udtkan^ 
haste.  Of  the  three,  larj-ngotomy  is  the  most  o^aiq 
performed.  It  thus  becomes  the  operation  of  dnitiii 
emergency  where  the  obstruction  is  located  in  the  liiyBali 
there  is  demand  for  haste  in  order  to  avoid  imminnil  irfitrf 
where  the  proper  instruments  and  assistants  are  IicfcB|.  ki 


Fic,  478-— The  location  of  the  incisions  in  laryngotomy  and  trachert 
liickham.) 
a,  Thyruiil  cartilage;  h,  incision  for  laryngotomy;  c  and  r,  brandt 
thyroid  arteries;  J.  cricoid  cartilage;  /.  incision  for  high  tracheotomy;  (, 
h,  incision  tor  low  irachcotomy;  i.  pncumogastric  nerve;  j,  stemo-iu 
k.  interior  th>Toid  veins;  /.  stcrno-lhyroid  muscle. 

however,  a  suitable  operation  to  be  performed  upon  t 
thirteen  years  of  age,  on  iucount  o(  the  small  size  of  the  1 
space,  nor  should  it  be  piTfornied  for  the  relief  of  co 
quiring  the  wearing  of  a  tube  for  any  length  of  time,  or 
the  proximity  of  the  vocal  tords  and  their  liability  to  ii 
tube. 

On  account  of  the  small  number  of  important  vessels  e 
ind  the  greater  ease  with  which  the  trachea  is  reached,  hi 
omy  b  preferable  to  the  low  operation  where  the  locj 


TRACHEOTOMY 


479 


rpermits.  It  is  the  operation  of  choice  for  children  and  in 
a  of  diphtheria  where  a  tube  has  to  be  worn  for  some  time. 
Low  tracheotomy  may  be  required  for  the  removal  of  foreign  bod- 
from  the  bronchi,  for  lower  tracheo-bronchoscopy,  for  the  relief 
hreatened  suffocation  from  occulsion  of  the  trachea  by  tumors  of 
thyroid,  etc.  It  requires  more  skill  in  its  performance  than  does 
high  operation,  as  in  the  lower  portion  of  the  neck  the  trachea  is 
■e  deeply  placed  and  important  structures  at  the  root  of  the  neck 
in  close  proximity. 

[nstrumeDts. — The  instruments  that  should  be  provided  include: 
aJpel,  a  narrow  bistoury,  scissors,  two  sharp  retractors,  two  ten- 


Fic.  47g. — Instruments  for  tracheotomy, 
Scalpd;  3,  curved  bistoury;  3,  scissors;  4,  retractors;  5,  tenoculuni;  6,  artery 
K;  7.  thumb  forceps;  8,  needle-holder;  9,  Trousseau  tracheal  dilator;  10,  tiEicheo- 
tubc;  ti.  catheter;  1 1,  tracheal  forces;  13  needles;  14,  No.  2  catgut. 

a,  artery  clamps,  two  pairs  of  thumb  forceps,  tracheal  forceps,  a 
Usseau  tracheal  dilator,  a  flexible-rubber  catheter,  tracheotomy 
s  and  tape,  a  nee  die- holder,  two  curved  cutting-edge  needles,  and 
2  catgut  for  ligatures  and  sutures  (Fig.  479}.  In  an  emergency, 
Te  delay  would  mean  the  loss  of  the  patient's  life,  the  operation 
■  be  performed  by  the  aid  of  a  pocket-knife  and  two  hairpins  bent 


480  THE  LARYNX  AND  TKACHEA 

in  the  shape  of  a  hook  to  hold  the  trachea  open  until  the  proper  tube 
can  be  obtained. 

Tracheotomy  tubes  of  several  sizes  and  with  different  cun'cs 
should  be  provided  so  that  one  suitable  for  the  individual  case  may  be 
at  hand.    A  silver  tube,  somewhat  flattened  from  side  to  side,  with- 


Fio.  480— Tracheotomy  tube.  Fic   481.— Tracheotomy    tube  iXX^V"' 

vised  from  rubber  tubing. 

out  fenestrae,  and  with  a  movable  inside  tube,  is  preferable  (Fig.  4-^*' 
With  some  tubes  an  obturator  is  supplied  as  an  aid  to  insertioo.  ^' 
an  adult,  a  No.  5  or  6  tube  will  usualy  suffice;  for  a  child  under  ■f*' 
a  No.  2,  tube  should  be  provided;  for  a  child  from  two  to  touM^^' 


Fic.  481. — Position  of  patient  for  laryngotomy  «nd  tracheotomy. 

No.  3 ;  and  for  one  over  four,  a  No.  4.  In  an  emergency  a  tube  m^X 
be  improvised  by  bending  a  piece  of  rubber  tubing  into  the  require^ 
shape,  as  shown  in  Fig.  481.  For  laryngotomy,  a  tube  shorter  thM* 
the  ordinary  tracheotomy  tube,  and  flattened  from  before  backwwc^ 
is  employed. 


TRACHEOTOMY 


■The  instruments  are  sterilized  by  boiling  or.  in  an 
emergency,  by  immersion  in  a  i  to  ao  carbolic  acid  solution.  The 
hands  of  the  operator  and  his  assistants  should  be  prepared  with  the 
same  care  as  for  any  operation. 

Position  of  the  Patient. — This  should  be  such  as  to  bring  the  neck 
into  the  greatest  possible  prominence.  The  patient  is  therefore 
placed  in  a  strong  light  on  a  iirm  flat  table  with  a  cushion  under  his 
shoulders,  thus  allowing  the  head  to  hang  back,  but  not  so  far  as  to 
put  the  trachea  under  tension  or  to  flatten  it  and  impede  respiration 
(F"ig.  482).  In  an  emergency,  the  patient's  head  may  be  simply 
a.llowed  to  hang  over  the  edge  of  the  table  or  a  lounge. 

A  child  should  be  wrapped  in  a  blanket  or  sheet,  with  its  arms  at 
the  sides.  The  legs  should  also  be  secured  and  an  assistant  should  be 
provided  to  hold  the  head  in  proper  position. 

Anesthesia. — In  adults,  local  anesthesia  with  cocain  or  procain 
IS  sufficient.  A  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  pro- 
<^ain  solution  is  employed  for  the  skin,  and  a  0.1  per  cent,  solution 
■  ^^  a  0.5  per  cent,  procain  solution  for  deeper  infiltration.  When 
there  is  occasion  for  great  haste  in  the  presence  of  unconsciousness 
Pr  dyspnea  with  marked  and  increasing  cyanosis,  an  anesthetic  may 
oe  dispensed  with,  as  in  such  cases  the  sense  of  pain  is  much  blunted 
or  abolished. 

In  young  children.  local  anesthesia  is  not  followed  by  good  results, 
*s  the  infiltration  alone  terrifies  the  child  and  produces  struggling, 
'*'hich  adds  to  the  dyspnea.  If  air  enters  the  lungs  at  ail,  chloro- 
*orix  given  slowly  is  the  best  anesthesia,  ether  being  apt  to  irritate 
*he  mucous  membrane  and  produce  lar>-ngeal  spasm,  thus  adding  to 
*-ne  dyspnea. 

Preparations.^ — If  hairy,  the  neck  should  be  shaved.  The  skin  is 
sterilized  by  painting  with  tincture  of  iodin. 

Technic. — 1.  Laryngotomy. — The  th>Toid  and  cricoid  cartilages 

^re  identified,  and,  with  the  larynx  supported  between  the  thumb  and 

,   '"relinger  of  the  operator's  left  hand,  an  incision  about  iH  inches 

U   cm.)  long  is  made  through  the  skin,  exactly  in  the  median  line  of 

"le  neck,  extending  from  the  lower  portion  of  the  thyroid  cartilage  to 

bslow  the  cricoid  cartilage.     The  superficial  fascia,  platysma,  and 

deep  fascia  are  divided,  and  the  sternohyoid  and  sternothyroid  mus- 

des  are  separated  at  the  inner  borders  and  held  apart  by  retractors. 

Tae  connective  tissue  and  veins  underlying  these  structures  are  then 

5^rated,  all  veins  being  clam]ied  or  Ugated  before  division.     The 

fncothyroid  membrane  is  thus  brought  into  view.     The  thyroid 


482  THE   LARYNX  AND  TRACHEA 

cartilage  is  steadied  with  a  tenaculum,  while  the  cricothyKsd  mem- 
brane is  transversely  incised  by  means  of  a  sharp,  oarrow-pdiittd 
bistoury  near  the  upper  border  of  the  cricoid  cartilage,  so  as  to  ivai 
the  cricothyroid  artery,  which  runs  along  the  upper  border  d  the 
space  below  the  thyroid  cartilage  (Fig.  483).  If  the  situation  olthis 
vessel  is  such  that  injury  to  it  or  its  branches  cannot  be  avoided,  it 
should  be  tied  between  two  Kgatures  before  the  membrane  isindsed. 
In  opening  the  membrane,  the  incision  must  be  carried  deep  cdou^ 
to  include  the  mucous  membrane  lining  it,  otherwise  the  laryngotomy 
tube  may  be  pushed  in  between  the  two  structures  and  not  into  the 
larynx  at  all.    The  wound  is  held  apart  with  two  small  retractors  or 


Fic.  483. — Opening  the  cricothyroid  membrane  in  laryngotoiny 
(After  Bickham.) 

a  tracheal  dilator,  and  the  foreign  body  which  may  be  causing  t^* 
obstruction  is  removed  by  means  of  tracheal  forceps.     If  there  is  n*  *' 
sufficient  room  to  remove  the  foreign  body  through  this  incision,  t-''* 
cricoid  cartilage  may  be  cut.    The  laryngotomy  tube  b  then  ca*"*" 
fully  introduced  and  is  secured  in  place  by  tapes  passing  around  t*'* 
patient's  neck,  a  small  square  pad,  spUt  to  its  center,  being  interpos^^ 
between  the  skin  and  the  flange  of  the  tube.     A  stitch  or  two  may  l** 
placed  at  the  upper  and  lower  angles  of  the  wound  to  bring  them  t<^ 
gether,  if  necessary.     Even  where  the  obstruction  is  immediately 
relieved ,  it  is  preferable  in  any  case  to  insert  a  tube  for  a  time  until  the 
tissues  become  more  or  less  adherent,  so  as  to  avoid  subcutaneous 
emphysema. 


TRACHEOTOMY  463 

gh  Tracheotomy. — The  thyroid  cartilage  is  grasped  between 
b  and  forefinger  of  the  left  hand,  so  as  to  steady  the  trachea, 
I  the  right  hand  a  vertical  incision  i}^  to  2  inches  (4  to  5 
;  is  made  exactly  in  the  median  line,  extending  from  the  cri- 
ilage  to  a  little  below  the  isthmus  of  the  thyroid  gland  (Fig. 
he  skin  and  superficial  and  deep  fascia  are  incised,  and  the 
ugxilar  veins  which  are  encountered  in  the  upper  part  of  the 
together  with  any  communicating  branches  of  the  superior 
k^eins,  are  caught  in  forceps  and  ligated.  The  sternohyoid 
lothyroid  muslces  are  thus  exposed,  and  should  be  separated 
ir  inner  borders  and  retracted  to  the  sides.     As  these  muscles 


.  4S4. — Expmsing  Lhe 


hiph  tracheotomy. 


i  apart,  the  isthmus  of  the  thyroid  gland  and  the  deep  cervi- 
;  covering  the  trachea  appear.  This  fascia  is  divided  from 
r  border  of  the  cricoid  cartilage  by  a  transverse  incision 
ownward  at  the  extremities.  The  fascia  is  then  stripped 
trachea  and  retracted  downward,  and  with  it  the  isthmus  of 
jid  gland,  thus  exposing  the  rings  of  the  trachea.  If  the 
ithmus  is  very  large,  two  ligatures  may  be  placed  about  it,  on 
of  the  median  line,  to  control  the  hemorrhage,  and  the  isthmus 
deep  fascia  is  incised  vertically  and  eachhalf  retracted  to  the 
tenaculum  is  then  inserted  beneath  the  cricoid  cartilage,  and 
'  an  assistant  so  as  to  steady  the  trachea.  If  without  a  lube, 
to  apply  retraction  sutures  on  either  side  of  the  trachea 


J 


484 


THE  LARYNX    AND  TRACHEA 


Fic  48;. — Opening  the  trachea  in  high  tracheotomy.     (After  Bkkluun.) 


Fig.  486.— Method  of  inserting  the  tracheotomy  tube. 


TSACHEOTOUY^ 

before  opening  the  latter.  For  this  purpose  a  full  curved  needle, 
threaded  with  fairly  strong  silk,  is  passed  on  each  side  through  the 
membrane  below  the  ring  to  be  cut,  emerging  through  the  membrane 
above.  A  sharp  narrow  bistoury,  with  its  cutting  edge  up,  is  in- 
serted through  the  membrane  below  the  second  ring  of  the  trachea, 
and  the  latter  is  incised  in  the  median  line  as  far  up  as  the  cricoid 
caitOage,  care  being  taken  to  include  the  mucous  membrane  of  the 
trachea  in  this  incision  (Fig.  485).  The  edges  of  the  tracheal  opening 
are  separated  with  tracheal  forceps,  or  the  wound  is  held  open  by 
the  retraction  sutures,  if  they  were  previously  inserted,  and  the 
tracheotomy  tube,  with  its  cannula,  is  carefully  passed  through  the 
open  wound  into  the  trachea  (Fig.  486).     If  there  is  no  great  urgency, 


Fic.  487. — Showing  the  tracheotomy  tube  in  place.     (Stoney.) 

*  oleeding  should  be  arrested  before  the  trachea  is  opened,  but  where 

^■ste  is  important  this  may  be  Omitted  until  the  tube  is  introduced. 

When  the  tube  has  been  properly  placed,  a  pad  of  gauze  is  inter- 

V^tsed  between  the  skin  and  the  flange  of  the  tube,  and  the  latter  is' 

I    securely  held  in  place  iy  tapes  passing  from  each  side  of  the  flange 
irwmd  the  neck  (Fig.  487). 
la  cases  of  diphtheria,  as  soon  as  the  trachea  is  opened  a  large 
inount  of  mucus  and  membrane  is  usually  expelled,  and  it  is  of 
advantage  in  such  cases  not  to  insert  the  tube  at  once,  but  to  hold  the 
tracheal  wound  open  and  allow  the  membrane  to  be  expelled.     What 
is  not  expelled  may  then  be  removed,  if  loose,  by  forceps.     The  dan- 
ger of  infection  from  the  patient's  coughing  bits  of  membrane  from 
_  the  tracheal  opening  into  the  face  of  the  operator  should  be  guarded 


486  THE  LARYNX  AND  TRACHEA 

against  by  the  operator  wearing  a  face  mask  or  by  holding  a  piece  oi 
wet  gauze  over  the  wound. 

3.  Low  Tracheotomy, — The  trachea  is  steadied  with  the  thumb 
and  forefinger  of  the  left  hand,  and  a  vertical  incision  b  carried  from 
the  thyroid  cartilage  to  within  J^  inch  (i  cm.)  of  the  sternal  notch. 
The  skin  and  superficial  and  deep  fascia  are  indsed,  and  the  inferior 
thyroid  veins,  or  other  vessels  that  may  be  in  the  way,  are  ligated  and 
divided.    The  sternohyoid  and  sternothyroid  muscles  are  sqwirated 
in  the  median  line  and  are  retracted  to  each  side.    The  deq>  cervical 
fascia  is  divided  vertically  downward  from  the  lower  border  of  the 
isthmus  of  the  thyroid  gland,  and  is  retracted  laterally,  notching  it 
transversely  on  each  side  if  necessary  to  obtain  more  space.    Care 
must  be  takeii  in  deepening  the  incision  at  the  lower  angle  of  the 
woimd  not  to  injure  the  innominate  vein  which  may  bulge  up  above 


Fig.   488. — Intracasnular  alligator  forceps.      (Fowler.) 

the  sternal  notch.     The  isthmus  of  the  thyroid  gland  is  pulled  well  m^P 
out  of  the  way  by  means  of  a  retractor,  and  while  the  trachea     ^ 
steadied,  an  incision  is  carried  upward  through  two  or  more  of  tf^ 
lowermost  rings  by  means  of  a  narrow  bistoury.     The  edges  of  tt^  . 
tracheal  wound  are  then  retracted,  and  the  tube  is  inserted  arP- 
secured  in  place  as  previously  described. 

After-care. — The  opening  of  the  tube  should  be  covered  with 
piece  of  gauze  moistened  with  normal  salt  solution,  and  the  patiei 
kept  in  a  room  at  a  temperature  of  about  65°  to  70°  (18®  to  21°  Q^^ — ■ 
If  the  operation  is  performed  for  inflanmiatory  conditions,  the  atmo^^ 
phere  should  be  kept  moist  by  the  steam  from  a  croup  kettle  directe^^ 
so  as  to  play  over  the  tracheal  opening  (see  page  465).     At  first,  th^^ 
inner  tube  should  be  removed  every  two  or  three  hours  and  b^^ 
cleansed;  later,  less  frequent  attention  will  be  required.     The  outer  "^ 
tube  should  be  removed  and  cleansed  as  often  as  necessary,  this  being 
done  by  the  surgeon  himself.     Its  reintroduction  will  be  greatly  facili- 
tated by  the  use  of  a  guide.     Any  membrane  or  muqus  that  may 
collect  at  the  mouth  of  the  tube  should  be  promptly  removed.     Secre- 


TRACHEOTOMY  487 

tj'ons  blocking  the  tube  may  be  removed  by  means  of  a  small  catheter 
and  a  suction  syringe.  Membrane  may  be  removed  from  the  interior 
of  the  tube  with  alligator  forceps  (Fig.  4S8)  introduced  through  the 
cannula.  If  this  is  not  possible,  the  tracheotomy  tube  should  be 
withdrawn  and  the  obstruction  removed. 

Removal  of  the  Tube. — In  cases  of  diphtheria  the  tube  may  be 
permanently  removed  as  soon  as  there  is  free  respiration  through  the 
la-r^nx  with  the  tracheal  wound  closed.  This  is  usually  possible  in 
irom  five  days  to  one  week.  When  tracheotomy  is  employed  for 
ttie  removal  of  foreign  bodies,  etc.,  the  tube  should  be  worn  for 
twenty-four  hours  at  least.  This  allows  time  for  the  oozing  to  cease 
and  averts  the  danger  of  blood  entering  the  trachea  and  the  escape  of 
air  into  the  subcutaneous  tissues. 

Complications. — Broncho-pneumonia  is  a  common  complication 
ever  when  not  due  to  an  extension  of  the  diphtheritic  process.  Infec- 
^on  of  the  wound  may  follow  in  diphtheria  cases  and  may  spread  into 
iKe  loose  connective  tissue  of  the  neck,  producing  a  celluHtis;  or  the 
infection  may  work  down  and  cause  septic  pneumonia.  An  improp- 
er')' fitting  tube  frequently  causes  ulceration  of  the  trachea  from 
pressure.  This  complication  should  be  immediately  remedied  by  the 
substitution  of  a  new  tube.  Emphysema  may  occur  if  the  tube  is 
r^oved  too  soon;  it  has  also  been  produced  from  injury  to  the  pos- 
*^r  or  lateral  walls  of  the  trachea.  Hemorrhage  from  congested 
^sins  may  at  times  be  severe;  in  the  majority  of  cases,  however,  the 
"'eeding,  which  may  be  profuse  before  the  trachea  is  opened,  stops 
^ntaneously  as  soon  as  respiration  is  re-established. 


CHAPTER  XVn  I  -e  OS 

\r  inhi 
THE  ESOPHAGUS  IxfiLVi 


Anatomic  Considerations 


rioses 


The  esophagus  extends  from  the  lower  border  of  the  cricoid  cartil- 
age to  about  ^he  level  of  the  ensiform  cartilage  or,  in  other  words, 
from  the  level  of  the  disk  between  the  fifth  and  sixth  cervical  verte- 
brae to  the  tenth  dorsal  vertebra.    Its  entire  length  is  about  lo  indies 
(25  cm.) J  while  the  distance  from  the  upper  incisor  teeth  to  thear- 
diac  end  measures  about  16  inches  (40  cm.).     Antero-posteriorly  the 
esophagus  presents  a  slight  curve  with  the  concavity  forward,  as  H 
follows  the  direction  of  the  spinal  column.    Laterally,  it  has  the  fol- 
lowing curves:  from  its  starting  point  it  turns  slightly  to  the  leC't^ 
projecting  as  much  as  ^^  inch  (i  cm.)  to  the  left  of  the  trachea;  i*^ 
then  descends  in  front  of  the  spine,  at  first  behind  the  arch  of 
aorta  and  then  lying  to  the  right  of  the  aorta,  finally  curving  in  froim^ 
and  a  little  to  the  left,  of  the  aorta  to  pass  through  the  diaphrag:*^*^ 
(Fig.  489).     In  its  course,  the  esophagus  has  in  front  of  its  upper  po^ 
tion  the  trachea;  while  below  it  is  crossed  by  the  left  bronchus  and 
arch  of  the  aorta.     The  pericardium  and  the  left  vagus  nerve 
lie  in  front.     Posteriorly,  it  rests  upon  the  spinal  column  and  the  th« 
racic  duct;  about  3  inches  (7  cm.)  from  the  diaphragm  it  crosses 
aorta.    On  either  side  it  is  in  relation  with  the  pleura. 

The  esophagus  measures  about  ^^  inch  (19  mm.)  in  diametei 
but  a  number  of  constrictions  in  its  caliber  have  been  described, 
most  marked  being  as  follows:  (i)  at  its  commencement,  6  inch< 
(15  cm.)  from  the  incisor  teeth;  (2)  at  a  point  10  inches  (25  cm. 
from  the  incisor  teeth,  where  it  is  crossed  by  the  left  bronchus;  an 
(3)  at  a  point  16  inches  (40  cm.)  from  the  incisor  teeth,  where 
passes  through  the  diaphragm  (Fig.  490).    At  these  points  the 
of  the  tube  measures  about  ^i  inch  (i  cm.).     The  measurement 
curves,  and  constrictions  of  the  esophagus  are  important  to  rememl 
in  the  passage  of  instruments  and  with  reference  to  the  lodgment 
foreign  bodies. 

Diagnostic  Methods 

The  methods  available  for  examination  of  the  esophagus  include: 
(i)  auscultation,  (2)  percussion,  (3)  external  palpation,  (4)  instru- 


00 


AUSCULTATION  489 

il  examination,  (5)  inspection  through  the  esophagoscope,  and 
e  use  of  the  X-rays.  The  first  three  of  these  methods  are  of 
imited  clinical  value,  while  the  use  of  the  esophagoscope  is  of 
fu]  value  excqjt  in  the  hands  of  an  expert,  so  that  in  the  major- 
cases  we  have  to  rely  upon  the  use  of  bougies  and  sounds  or  the 


Fig.  489,  Fig.  490. 

489, — The  course  and  relations  of  the  esophagus  viewed  from  behiqd. 
490. — The  normal  nairowings  of   the  esophagus.     (Eisendrath.)     i,   At  It* 
I    with    the    phuTUX;    2,    opposite    the    bifurcation    of    the    bronchi;   3,  at 

in  examination  of  other  regions,  a  careful  history  of  the  case 
[  precede  any  local  examination. 

AUSCULTATION 
^ultation  is  performed  by  listening  with  a  stethoscope  over  the 
:  of  the  esophagus  while  the  patient  swallows  liquids.     The 


490  THE   ESOPHAGUS 

usual  points  for  auscultation  are  upon  the  left  side  of  the  spine  oppo- 
site the  ninth  or  tenth  dorsal  vertebra,  or  just  to  the  left  of  the  cni- 
form.     Normally,  duiing  the  passage  of  liquids  down  the  tube  two 
sounds  are  heard :  one  directly  after  the  patient  swallows  and  the 
other  six  or  seven  seconds  later,  as  the  food  is  forced  into  the  stomadi 
through  the  cardia.     If  stenosis  exists  at  the  cardia  or  a  stricture  be 
present  at  some  point  higher  up,  this  second  sound  will  be  absent  or 
delayed;  in  paralysis  of  the  esophagus  it  will  likewise  be  absent.   A.t: 
times  it  may  also  be  possible  to  recognize  by  auscultation  the  stop>- 
page  of  the  fluid  when  it  reaches  the  point  of  stricture. 

PERCUSSION 

Percussion  may  reveal  the  presence  of  large  tumors,  dilatations,  oi" 
diverticula.  In  the  latter  condition,  dulness  may  be  present  only 
after  eating  and  be  absent  when  the  sac  is  empty.  A  tympanitic 
note  will  be  obtained  when  the  diverticulum   sac  contains  ga-^- 

PALPATION 

External  palpation  is  extremely  limited  in  usefulness,  as  it  is  onl3^ 
applicable  to  the  cervical  portion  of  the  esophagus.  By  means  ^^^* 
palpation  one  may  be  able  to  discover  hard  foreign  bodies,  tumor^» 
enlarged  glands,  enlargements  of  the  thyroid,  as  well  as  any  pressu^"^ 
tenderness  along  the  esophagus.  Diverticula  full  of  food  may  be  thi 
distinguished  and  mapped  out,  and  not  infrequently  it  is  possible 
empty  the  diverticulum  sac  of  its  contents  by  pressure. 

By  internal  palpation  with  the  index-finger,  foreign  bodies  lodj 
in  the  entrance  of  the  esophagus  and  strictures,  new  growths,  eic^  ' '' 
at  the  same  location  may  be  recognized. 

EXAMINATION  BY  SOUNDS  AND  BOUGIES 

The  sound  and  bougie  are  employed  for  diagnostic  as  well  as  thera- 
peutic purposes.     By  their  use  valuable  information  may  be  obtained 
as  to  the  location  of  foreign  bodies,  strictures,  diverticula,  etc.;  fur- 
thermore, the  degree  of  a  stenosis  may  be  accurately  determined. 
The  passage  of  esophageal  instruments  is  not  difficult     Gentleness 
only  should  be  employed  in  manipulation,  however,  since,  if  due  care 
is  not  exercised  in  this  direction,  a  false  passage  may  be  readily  made 
through  the  esophagus  into  the  mediastinum;  especially  is  such  an 


EXAMINATION  BY  SOUNDS   AND  BOUGIES  491 

accident  possible  if  the  coats  of  the  esophagus  are  already  weakened 
by  disease. 

Before  any  attenipt  is  made  to  pass  instruments,  a  thorough  phys- 
ical examination — including  the  vascular  system — should  be  made, 
la  the  presence  of  aortic  aneurysm,  recent  hemorrhage  from  the  esoph- 
agusor  stomach,  acute  inflammation  of  the  esophagus,  and  after  recent 


Fig.  491. — Cylindrical  esophageal  sound. 

ulceration,  the  use  of  esophageal  instnmients  is  contraindicated. 

ii  cases  of  advanced  pulmonary  or  cardiac  disease  and  cirrhosis  of  the 

iver,  instruments,  if  used,  should  be  employed  with  gieat  caution. 

Instruments. — For  ordinary  examination,  graduated  esophageal 

^ugies  and  bougies  k  boule  are  employed.    These  instruments  vary 

^  length  from  24  to  32  inches  (60  to  80  cm.).    The  best  bougies  are 


Fig.  492. — Conical  esophageal  sound. 

^^Uow  and  are  made  of  a  gum-elastic  material,  so  that  when  warmed 
^^^yr  become  flexible  and  capable  of  being  bent  to  any  desired  shape. 

'Xhey  may  be  obtained  cylindrical  (Fig.  491)  or  conical  (Fig.  492) 
^     ^orm.     In  their  stead,  however,  a  thick  rubber  stomach-tube  is 

-n  utilized. 

The  bougie  k  boule  is  an  essential  instrument  if  the  length  of  a 

crture  is  to  be  estimated.     It  consists  of  a  flexible  whalebone  shaft. 


Fig.  493. — Olivary  bougies  k  boule  for  the  esophagus. 

tJie  end  of  which  metal  or  ivory  olive-shaped  tips  of  different  sizes 
;ir  be  screwed  (Fig.  493).    The  shaft  should  be  marked  off  in  an 
or  centimetric  scale. 
In  cases  of  very  tight  stricture  filiform  bougies  of  whalebone  or 
en  material  may  be  employed  to  determine  whether  the  stricture 
■^    permeable.     They  may  be  introduced  into  the  stricture  through 


k 


493  THE   ESOPHAGUS 

a  hollow  bougie  which  is  first  passed  to  the  face  of  the  stricture,  a 
they  may  be  inserted  through  an  esophagoscope. 

Asepsis. — Rubber  bougies  and  tubes  may  be  sterilized  by  baling. 
The  gum-elastic  instnmients,  unless  of  the  very  best  material,  m 
ruined  by  boiling  or  by  the  use  of  strong  antiseptics.  They  nuybe 
rendered  sufficiently  aseptic  by  immersion  in  a  saturated  soludoo  d 
boracic  acid,  after  first  thoroughly  washing  with  soe^  and  vata. 
The  hands  of  the  operator  should  also  be  clean. 

Position. — The  patient  is  seated  in  a  chair  with  the  head  tHrowa 
back  against  the  back  of  the  chair,  and  with  the  r-hin  raised  suf- 
ficiently to  make  the  passage  between  the  mouth  and  the  esophagus 
as  straight  a  hne  as  possible.    The  surgeon  stands  in  front  of  the 


Fig.  49<(.— Shows  the  first  step  in  introducins  an  esophageal  bougie. 

patient,  while,  if  desu-ed    an  assistant  may  steady  the  head  froc* 
behind.    In  the  case  of  a  child   it  will  be  necessary  to  confine  itJ 
arms,  either  having  them  held  by  a  nurse  or  by  mcludmg  them  in  s 
sheet  wrapped  about  the  child's  body. 

Anesthesia. — In  an  adult  general  anesthesia  is  only  necessary  ic^ 
exceptional  cases,  but  the  pharynx  and  larynx,  if  very  irritable  or  sea^ 
sitive,  may  be  brushed  over  with  a  5  orio  per  cent,  solution  of  cocaii^ 

Teclinic. — The  patient  is  seated  in  the  proper  position  with 
towel  about  the  neck  for  protection,  and  is  given  a  basin  to  catcrr-- 
vomitus  or  saliva.     A  soft,  flexible  sound  is  passed  as  follows:  tfc»ff 
bougie,  moistened  with  water  and  held  in  the  operator's  right  hand  as 
one  would  a  pen,  is  passed  into  the  patient's  open  mouth  back  to  the 


EXAMINATION  BY   SOUNDS   AND  BOUGIES 


493 


pharynx.  The  patient  is  then  requested  to  swallow  and  the  instru- 
ment is  thus  advanced,  partly  by  the  act  of  swallowing  and  partly  by 
the  operator,  until  an  obstruction  is  reached  or  the  sound  enters  the 
stomach  (Fig.  494). 

Sometimes  when  a  rather  inflexible  bougie  is  employed  or  when 
the  tongue  is  thiclc  or  the  pharynx  is  swollen,  some  difficulty  may  be 
encountered  in  entering  the  esophageal  opening.  Under  such  con- 
ditions the  operator  passes  the  index-finger  of  his  left  hand  into  the 
patient's  widely  opened  mouth  to  a  point  well  back  of  the  tongue  and 


495, — Introduction  oE  an  esophogeiil  bougie  with  the  bnger  holding  the  tongue 
and  epiglottis  forward 

''•"a.-ws  the  latter  forward,  and  with  it  the  larynx,  so  that  the  esophagus 

**'^y  be  more  easily  entered  fFig.  495).     The  bougie  is  then  passed 

**    the  finger  as  a  guide  straight  back  in  the  median  line  to  the 

P**afynx,  and,  hugging  the  posterior  wall  of  the  pharynx,  it  is  pushed 

^atliiy,  but  gently,  backward  and  downward  into  the  esophagus, 

^*^  thence  into  the  stomach,  unless  some  obstruction  be  encountered. 

The  patient  should  be  instructed  to  breathe  deeply  during  the 

^^^sage  of  the  bougie,  even  if  gagging  is  produced,  and  he  should  be 

^^gtioned  not  to  bite  the  examiner's  finger  or  the  tube.    There  will 


i 


494  1^^    ESOPHAGUS 

usually  be  gagging  and  some  attempts  to  vomit  as  the  tube  is  inserted, 
but,  unless  very  distressing,  they  may  be  disregarded.  The  patient's 
head,  however,  should  be  bent  forward  over  a  basin  as  soon  as  the 
tube  is  well  within  the  esophagus  to  receive  any  vomitus,  mucus,  or 
saliva  (Fig.  496.) 

If  dyspnea  and  cough  are  induced,  the  instrument  has  probata 
entered  thelarynx.  To  settle  this  point,  the  patient  should  be  told  to 
phonate  "ee";  if  he  can  do  so,  one  may  be  sure  the  bougie  is  not  ia 
the  larynx.  If  the  passage  of  the  tube  becomes  impeded  at  any  point, 
the  tube  should  be  slightly  withdrawn  and  then  again  pushed  gentler 
onward,  when,  unless  a  stenosis  exists,  it  will  advance  witIlo^B.-^ 
difficulty.    The  points  of  normal  constriction  at  which  a  bougie  na.^^ 


Fig.  496  ^Shons  second  step  n  introduanR  an  esoph^eal  bougie 

be  arrested  without  any  diseased  condition  being  present  should,  how-"^ 
ever,  be  kept  in  mind.  They  are:  (i)  6  inches  (15  cm.)  from  tfa^ 
upper  incisor  teeth;  (2)  10  inches  (25  cm.)  from  the  incisors;  and  {3)" 
16  inches  {40  cm.)  from  the  incisors  (see  Fig.  490).  If  a  large  tube* 
can  be  passed  into  the  stomach,  the  existence  of  a  stenosis  may  be 
ruled  out,  while  if  the  tube  passes  very  easily  without  any  sense  of 
resistance,  atony  or  paralysis  of  the  canal  is  presumable. 

Any  evidences  of  pain,  however,  produced  by  the  bougie  in  its 
descent  should  be  carefully  noted,  as  pointing  to  possible  inflamma- 
tion, ulceration,  or  malignancy.  When  the  bougie  meets  a  real 
obstruction  the  cause  should,  if  possible,  be  learned;  that  is,  whether 
due  to  spasm,  an  organic  stricture,  a  diverticulum,  a  new  growth,  or  a 
foreign  body.     No  force  should  be  employed  in  attempting  to  over- 


i  BV   SOUNDS    .. 


the  obstruction,  but  the  bougie  should  simply  be  held  firmly  in 
place  for  several  minutes  or  be  slightly  withdrawn  when,  if  a  spasm 
were  the  cause,  it  can  be  advanced  as  relaxation  takes  place.  A  spas- 
modic stricture  will  always  disappear  if  the  patient  is  placed  under  the 
influence  of  a  genaral  anesthetic.  If  the  obstruction  does  not  yield, 
the  bougie  is  removed  and  a  smaller  one  Is  Inserted ;  and,  if  necessary, 
smaller  sizes  are  successively  introduced  until  one  is  found  that  will 
pass  completely  through  the  stenosed  area  into  the  stomach.  In  this 
way  the  degree  of  stenosis  is  ascertained.     It  is  quite  important  in 


Fig.  497.  Fig.  498. 

^KS.  jgj, — Method   of   estimating  the  length   of  an   esophageal 
*»*"«»«  i  boule  al  the  face  of  the  slriclure. 

Fto.  4g8, — Method   of  cstimBting   the  length   of  an   esophageal 
""■de  i  boiile  is  withdravra  until  its  base  is  arrested  at  the  distal  end  of  the 


'"^^ing  the  examination  to  insert  the  bougie  into  the  stomach,  as, 
"t^erwise,  a  second  stricture  below  the  lirst  may  be  overlooked. 
To  determine  the  length  of  a  stricture,  a  large  olive-tipped  sound 
i*"iserted  until  it  reaches  the  face  of  the  stricture  (Fig.  497),  and  the 
distance  of  the  stenosis  from  the  upper  incisor  teeth  is  estimated  from 
ths  markings  on  the  shaft  of  the  instrument.  The  bougie  is  then 
withdrawn  and  a  size  that  will  just  pass  is  inserted  well  through  the 
stricture.  Upon  withdrawing  the  instrument,  the  base  of  the  bulb 
catches  tn  the  lower  rim  of  the  constriction  (Fig.  498),  and  the  dis- 
lADce  of  this  point  from  the  mouth  is  also  estimated.     By  subtracting 


45)6  THE   ESOPHAGUS 

the  first  of  these  measurements  from  the  second,  the  length  i 
tracture  is  readily  determined. 

It  is  often  possible  for  a  practised  hand  to  detennine  1 
tency  of  an  obstruction  from  the  sensation  imparted  by  coi 
the  tip  of  the  instrument.  By  means  of  a  metal-tipped 
boule  the  consistency  of  hard  foreign  bodies,  such  as  te 
bone,  etc.,  may  be  readily  recognized,  and  at  times  a  dist 
may  be  distinguised  when  the  two  come  in  contact. 

If  the  bougie  has  entered  a  diverticulum,  it  will  be  { 
move  its  end  freely  in  different  directions,  and,  if  the  diver 


499- 


Fjc.  . 

sound    pa&!^ing     the    opening   of    a    diverticu 


Fic.  499,— 
Cumprecht.) 

Fic,  500.^ — Shows  the  case  with   which  a.  sound  will  enter  a  div-erti 
the  latter  is  full.     (Alter  Gumprccht.) 

Fig.  SOI. — Shows  the  ease  with  which  a  sound  follon's  the  esnphag 
diverticulum  is  empty.     (After  Cumprecht.) 

located  high  up,  the  end  of  the  bougie  may  often  be  felt  in 
Again,  by  withdrawing  the  instrument  somewhat  so  as  to 
the  tip,  and  by  changing  its  direction  (Fig.  499),  it  can  fret 
passed  by  the  diverticulum  into  the  stomach.  A  bougie  w: 
apt  to  enter  a  diverticulum  if  the  sac  be  full  (Fig,  500)  and  j 
stomach  when  the  sac  is  empty  (Fig,  501),  This  in 
obstruction  to  the  passage  of  a  bougie  is  characteristic  ( 
ticulum,  and  is  a  point  in  the  differential  diagnosis  fron 
Another  method  of  differentiating  between  a  stenoas  ar 
ticulum  has  been  devised  by  Plummer.     It  is  carried^  out 


EXAMINATION  BY    SOUNDS    AND   BOUGIES  497 

The  patient  is  instructed  to  swallow  with  a.  little  water  before  bed- 
time 3  yards  (270  cm.)  of  button-hole  sillt  and  in  the  morning  to 
swallow  3  yards  (270  cm.)  more  at  the  rate  of  a  foot  (30  cm.)  an  hour. 
By  the  afternoon  of  the  same  day,  if  there  is  an  opening  in  the  stric- 
ture or  diverticulum,  the  thread  will  have  been  carried  into  the  stom- 
ach and  intestines  a  sufficient  distance  to  withstand  moderate  trac- 
tion without  being  withdrawn.  A  whalebone  bougie  with  an  olive 
tip,  through  which  is  an  opening  sufficiently  large  to  accommodate 
tte  thread,  is  then  passed  down  the  esophagus  on  the  thread,  which 
is  tield  loosely,  until  an  obstruction  is  encountered.     If  this  obstruc- 


FlG.  501. 
*^ic.  501. — Esophageal  sound  passtd  uvcr  a  "-walloiurd  thrtad 
t^ter  Plummer.) 

^10.  s*3.^Sound  lifted  oul  of  the  diverticuli 


Pluo 


=r-) 


by  lightening  the  thread.     (Alter 


K»ii  be  due  to  stricture,  the  bougie  will  not  change  its  level  when  the 
tliTead  is  made  taut,  but,  if  the  sound  is  in  a  diverticulum  (Fig.  502), 
llie  bougie  will  be  elevated  to  the  level  of  the  opening  into  the  esoph- 
*?Us  (Fig.  503),  The  depth  of  the  diverticulum  may  be  readily 
ll^taiiiined  by  the  distance  the  bougie  is  elevated  when  the  thread  is 
taut 
-The  bougie  should  always  be  examined  after  its  withdrawal  for 
;presence  of  blood  or  pus  which  may  be  found  adhering  to  its  sur- 
face or  Up,  With  the  hollow  bougie  provided  with  a  lateral  opening 
near  its  tip,  fragments  of  tissue  sufficiently  large  for  examination  may 


498  THE   ESOPHAGUS 

be  brought  away  by  the  instrument,  which  when  placed  under  the 
microscope  may  confirm  a  diagnosis  of  possible  malignaiicy. 

ESOPHAGOSCOPY 

Esophagoscopy,  a  method  devised  by  Mikulicz,  consists  in  di- 
rect inspection  of  the  interior  of  the  esophagus  by  the  aid  of  a  bng 
endoscopic  tube  illuminated  by  electricity.  By  the  use  of  theesopb- 
goscope  in  the  hands  of  an  expert,  much  valuable  information  may 
be  obtained;  foreign  bodies  may  be  located  and  removed;  ulcers, 
new  growths,  strictures,  the  openings  of  diverticula,  etc.,  may  be 
directly  inspected;  and  fragments  of  tissue  may  be  removed  for  exami- 
nation. Still,  the  discomfort  of  such  an  examination  for  the  patient 
and  the  experience  and  skill  required  in  the  use  of  the  instrument  on 
the  part  of  the  examiner  will  not  allow  it  to  supplant  the  ordinary 
methods  of  examination  as  a  routine. 

In  the  passage  of  the  esophagoscope  the  same  care  should  be 
observed  as  in  the  passage  of  any  esophageal  instrument.  The  con- 
traindications to  its  use  are  practically  the  same  as  those  mentioned 
for  the  sound  or  bougie,  viz.,  aortic  aneurysm,  recent  hemonhage 
from  the  esophagus,  advanced  pulmonary  or  cardiac  disease,  etc. 

Instruments. — Von  Mikulicz's  instruments  (Fig.  504)  are  cylin- 
drical tubes  about  ^5  to  ^2  i^^ch  (10  to  13  mm.)  in  diameter,  bevelled 
at  the  end  and  supplied  with  an  obturator  to  aid  in  their  introduc- 
tion.  On  the  outside,  the  tubes  are  marked  off  in  a  centimetnc 
scale.  They  are  made  in  different  lengths,  according  to  the  depth  to 
which  it  is  wished  to  pass  the  instrument.  The  illumination  is  sup- 
plied by  a  panelectroscope  at  the  proximal  end  of  the  instrument 
Among  other  instruments  of  this  type  may  be  mentioned  those  of 
Killian  and  Briinings. 

Other  tubes,  such  as  Jackson's  (Fig.  505)  or  Einhom's,  for 
instance,  are  provided  with  illumination  at  the  distal  end  of  the 
instrument.  These  will  be  found  easier  to  manage,  as  with  the  for* 
mer  it  is  difficult  to  direct  the  light  properly  on  account  of  the 
length  of  the  tube.  To  examine  the  entire  length  of  the  esophagu^j 
Jackson  uses,  for  adults,  a  tube  about  21  inches  (53  cm.)  long  and 
%  inch  (10  mm.)  thick,  and  for  children,  a  tube  18  inches  (45  cmJ 
long  and  J^5  inch  (7  mm.)  thick.  In  addition  to  the  esophagi 
scope,  a  Sajous  applicator,  swabs  on  holders,  various  shaped  forceps 
for  removing  foreign  bodies  or  sections  of  tissues  for  examination,  etc, 
are  required. 


ESOPHAGOSCOPy 


499 


Asepsis. — The  tubes  and  accessory  instruments  may  be  sterilized 
boiling  and  the  lights  by  immersion  in  alcohol. 
Preparation  of  Patient. — The  patient's  stomach  should  be  empty, 
avoid  regurgitation  of  its  contents.     Where  there  is  a  marked 


Fig.  504. — Von   Mikulicz  s 


of  inslruments   (or   esopbagoscopy.     (Gottstein   i 
Kfen's  Surgery.) 


atation  of  the  esophagus,  a  preliminary  lavage  (see  page  502}  may 
necessary.  The  clothing  should  be  loosened  from  about  the 
tient's  neck,  and  chest  and  any  plates  or  artificial  teeth  shouid  be 
Eoved  from  the  mouth. 


^3= 


-CJEI 


^^^^  Fig.  505. — Jactson's  esophagoscopc. 

Position    of    Patient. — Some   operators    perform   esopbagoscopy 

h  the  patient  sitting  up;  others,  with  the  patient  on  a  table  in  a 


THE   ESOPHAGUS 


right  lateral  position,  with  the  head  supported  and  controlled  by  an 
assistant.  This  latter  posture,  or  that  known  as  Rose's  postuie, 
viz.,  the  patient  recumbent  with  the  head  hanging  over  the  end  of  i 


Fic.  506. — The  position  of  the  palient  and  assistant  for  esophsgoscopy.  ■ 
(After  Jackson.) 

table,  supported  by  an  assistant,  who  raises,  lowers,  or  turns  the  he^ 
at  will  (Fig.  506),  is  preferable. 

Anesthesia. — General  anesthesia  may  be  required  in  childre" 
For  adults,  painting  the  pharynx,  larynx,  and  entrance  of  the  esoph^ 


Fig.  507. — Shows  the  method  of  holding  the  esophagoscope.     (After  Jackson.) 


gus  with  a  10  per  cent,  solution  of  cocain  by  means  of  a  cotton  swal 
held  in  a  Sajous  applicator  some  minutes  before  the  introduction  o 
the  tube  will  suffice.     This  may  be  very  effectually  done  through  i 


ESOPHAGOSCOPY 


sot 


short  split-tube  gpatula,  such  as  is  used  in  direct  laryngoscopy  (see 

f'g-  45°)  ■ 

Tedinic. — The  seat  of  trouble  should  have  been  previously  deter- 
mined by  means  of  a  bougie,  and  if  the  operator  possesses  tubes  of 
different  lengths  this  will  enable  him  to  select  one  of  the  proper  length. 
The  tube  is  lubricated,  the  patient's  mouth  is  well  opened,  and,  with 


Pic.  50S. — First  step  in  esophagoscopy,  the  left  iode^'finger  guiding  the 
into  ihe  tsophngus.     (After  Jackson.) 

the  index-fmger  of  the  left  hand,  the  base  of  the  tongue  is  drawn 
forward  (Fig.  508).  The  operator  then  introduces  the  tube,  with  the 
obturator  inserted  in  place,  backward  to  the  posterior  part  of  the 
pharynx  and  then  downward,  the  assistant  at  the  same  time  extending 
the  patient's  head  so  as  to  bring  the  mouth  and  esophagus  nearly 
"*  the  same  straight  line.     The  patient  is  directed  to  aid  the  passage 


***  tie  tube  by  swallowing.  As  soon  as  the  esophagus  has  been  well 
entered,  the  obturator  is  removed,  the  illumination  is  turned  on,  and 

_  ">e  tube  is  gently  pushed  on  into  the  canal  by  direct  sight,  the  sur- 
KCon  standing  or  being  seated  at  the  head  of  the  table  (Fig.  509). 
^nder  direct  inspection  the  direction  of  the  esophagus  can  be  dis-' 
linguished  and  the  lube  advanced  accordingly,  care  being  taken  to 


502  THE  ESOPHAGUS 

avoid  compression  of  the  trachea  by  a  faulty  direction  of  the  end  of 
the  tube.  In  the  cervical  portion,  the  walls  of  the  esophagus  lie  in 
apposition,  the  canal  being  represented  by  a  slit  extending  from  side 
to  side.  Below  the  level  of  the  sternum  the  canal  is  open.  The 
appearance  of  the  esophageal  mucous  membrane  differs  from  that  of 
the  trachea  in  that  it  has  not  the  deep  red  tint  of  the  latter,  but 
appears  pale  red  or  slightly  pink.  Any  mucus  or  regurgitated  matter 
from  the  stomach  that  blocks  the  end  of  the  tube  may  be  removed  by 
means  of  swabs  upon  long  applicators  or  by  the  aspirating  apparatus 
with  which  some  of  the  tubes  are  supplied.  In  this  maimer  the  whok 
interior  of  the  canal  down  to  the  cardia  may  be  minutely  inspected, 
and  diseased  areas  treated  by  local  applications  if  desired.  Follow- 
ing the  operation,  if  there  is  pain  or  difficulty  in  swallowing,  cracked 
ice  in  small  quantities  may  be  administered. 

SKIAGRAPHY 

The  X-rays  are  useful  in  locating  bones,  coins,  and  other  imper- 
vious foreign  bodies.  By  having  the  patient  first  swallow  bismuth  or 
similar  metallic  substances,  which  oflfer  resistance  to  the  penetration 
of  the  X-rays  and  are  capable  of  casting  a  shadow,  the  presence  of 
a  diverticulum,  constrictions,  or  dilatations  is  readily  recognized, 
and  the  size  and  shape  may  be  outlined.  For  this  purpose,  a  mixture 
of  bismuth  subcarbonate,  one  part  to  two  of  mucilage  of  acacia,  milt, 
or  gruel  is  employed.  The  bismuth  forms  a  coating  in  the  gullet 
and  the  outline  of  the  tube  is  thus  represented  upon  the  skiagraph  by 
a  dark  shadow. 

Tlierapeutic  Measures 

LAVAGE  OF  THE  ESOPHAGUS 

Lavage  of  the  esophagus  is  employed  chiefly  for  the  purpose  of 
removing  collections  of  mucus  and  stagnated  or  decomposing  food 
particles  which  have  become  arrested  in  a  diverticulum  sac  or  in  a 
dilated  area  above  a  stenosis.  In  cancer  of  the  esophagus  it  is  fre- 
quently employed  to  remove  foul  and  decomposed  products  of  the 
ulceration,  and  gives  much  relief  to  the  patient. 

Apparatus. — An  ordinary  stomach-tube,  about  a  No.  20  American 
in  size  and  30  inches  (75  cm.)  long,  provided  with  two  lateral  windows 
near  the  tip,  and  fitted  with  a  small  glass  funnel  at  its  proximal  end, 
forms  the  necessary  apparatus  (Fig.  510).     More  elaborate  apparatus 


LAVAGE   OF   THE  ESOPHAGUS 


Fig.  51a. — App&ratus  foi  esophageal  lavage. 
a  the  tip  of  the  tube;  b.  glass  funnel;  c,  mark  to  indicate  the  dblance 
from  the  teeth  to  the  stomach. 


Fio,  sti. — Boas'  apparatus  for  esophageal  lavage.     (After  Gumprecht.) 


S04  THE   ESOPHAGUS 

has  been  devised  for  esophageal  lavage,  such  as,  for  example,  Boas' 
tube  (Fig.  511),  which  is  provided  with  an  inflatable  rubber  balloon 
for  closing  the  lower  end  of  the  esophagus,  thus  preventing  solution 
passing  the  cardia;  but  the  simple  apparatus  described  above  will 
answer  in  the  majority  of  cases. 

Asepsis. — The  tube  and  funnel  should  be  sterilized  by  boiling 
before  use. 

Solution. — For  simple  lavage  sterile  water  is  sufficient.  Solutions. 
with  an  antiseptic  or  astringent  action  are  also  sometimes  employed  - 

Temperature. — The  solution  should  be  introduced  warm,  i.«.,  a.^ 
a  temperature  of  about  100°  F.  (38°  C). 

Frequency. — In  some  cases  the  lavage  will  be  required  as  fre- 
quently as  every  day;  in  other  cases  once  every  other  day  is  suffident. 
It  should  preferably  be  performed  before  the  first  meal  of  the  day- 

Position  of  the  Patient — The  patient  should  sit  in  a  chair,  or 
else  should  sit  up  in  bed  with  the  head  thrown  back  and  the  diin 
elevated.     The  operators  stands  in  front. 

Technic. — The  patient  is  protected  by  a  sheet  or  a  towel  fastened 
about  his  neck,  and  is  given  a  basin  to  hold  for  the  purpose  of  receiv- 
ing any  vomitus  that  may  be  expelled  during  the  passage  of  th^ 
tube.     He  then  opens  his  mouth  widely,  and  the  operator  slowl>' 
inserts  the  stomach- tube,  moistened  with  water  down  to  the  seat  of 
the  dilatation,  being  careful  at  first  to  keep  the  tip  of  the  instrumen.'t' 
close  to  the  posterior  wall  of  the  pharynx  to  prevent  its  enterin 
the  larynx.     The  funnel  end  is  then  raised  and  through  it  from  2 1 
2  1/2  ounces  (60  to  75  c.c.)  of  warm  water  are  poured  into  tL 
esophagus.     The  funnel  end  is  then  lowered  and  the  contents  ar 
drained  off.     By  alternately  pouring  in  solution  and  draining  it  Oj 
the  esophagus  may  be  thoroughly  cleansed  and  all  particles  of  foo^3> 
or  mucus  removed. 

THE  DILATATION  OF  ESOPHAGEAL  STRICTURES  BY 

BOUGIES 

The  treatment  of  an  esophageal  stricture  comprises  dilatation 
by  means  of  bougies,  internal  esophagotomy,  external  esophagotomy, 
and,  when  the  stricture  is  impassable,  gastrostomy.  Gradual  dila- 
tation by  bougies  is  most  frequently  employed  and,  generally 
speaking,  is  the  best  form  of  treatment,  as  by  this  means  the  majority 
of  strictures  may  be  in  time  dilated.  The  tendency,  however,  is  for 
the  stricture  to  reform  after  dilatation  unless  a  bougie  be  passed  at 


DILATATION    OF    ESOPHAGEAL    STRICTLTIES 


505 


ervals  during  the  remainder  of  the  patient's  life.  When  the 
icture  involves  the  greater  part  of  the  canal,  dilatation  is  fre- 
ently  unsuccessful.  Dilatation  is  con- 
indicated  in  very  recent  bums  of  the 
iphagus.  Moderate  and  carefully  per- 
med dilatation,  however,  is  not  contra- 
ticated  by  carcinoma. 

Strictures  may  be  located  in  any  part 
the  esophagus,  but  the  majority  are  situ- 
■d  near  the  points  of  normal  constriction 

the  canal  (Fig.  512).  They  are  usually 
gle,  but  may  be  multiple;  and  they  also 
rj-  in  form  and  shape,  being  valve-like, 
Qular,  semicircular,  or  tortuous.  The 
rtion  of  the  canal  immediately  above  a 
ht  stricture  dilates  from  the  acfumula- 
n  of  food;  especially  is  this  the  case  if 
:  stricture  is  low  in  the  canal,  and  as  a 
ult  inflammation  or  suppuration  may 
vt\op.  In  such  cases  there  is  great 
nger  of  perforating  the  walls  of  the  eso- 
agus  unless  extreme  gentleness  in  mani- 
Ution  is  observed. 

The  danger  of  passing  a  bougie  through 

aneurysmal  sac  should  also  be  kept  in 
nd,  and  to  avoid  such  an  accident  a 
■eful  physical  examination  should  be  ^o^i)„!!^'' 
ide  in  every  case  before  inserting  any 
>pbageal  instrument.  By  such  examina- 
n  the  discovery  of  other  growths  within  ^°'""  ^""^  °^  "-^^  pharynx  and 
,  J-      ■■  1      ■  beginning   of   the  esophagus; 

5  neck_  or  mediastmum  producing  com-  ,_  ^^^^^^^  ^^^^  ^^J^^  ^^ 

ssion  is  often  possible.     It  is  next  neces-  tumors  of  ihe  neck;  3.  stenosis 
7  to   determine   by  means  of  a  bougie  due  to  aneurysm  of  ihc  arch 
:IocaUon,  the  degree,  the  approximate  "f  the  aoru;  4,  stenosis  as  the 
'  °       '  '^'^  result  01  caustic  or  lye  burns; 

igtn,  and,  if  possible,   the  character  of  j_  stenosis  as  result  of  carci- 
i  stricture  before  any  attempts  at  dilata-  noma  of  lower  end  ot  the  eso- 

n  are  made.  P"""^'  ""^  '^"'^   ""^  °* 

.  ,  stomach. 

Instruments. — Flexible  bougies  of  woven 

Ltmal  impregnated  with  elastic  gum,  which  become  soft  when 

iced  in  warm  water  and   rigid  when  placed  in  cold  water,  are 

lerally  employed.     The  bougies  vary  in  size  from  1-^2  to  ^i  inch 


Fig.  513.— The  most  fre- 
if  stricture  of  the 
(Eisendrath.) 
A,  Aorta,  D.  Diaphragm. 
,  Stenosis  from  c. 


J 


5o6 


THE   ESOPHAGUS 


(2  to  14  mm.).  In  a  normal  esophagus,  a  bougie  ^^  to  ^  inch  (ij 
to  14  mm.)  in  diameter  will  pass  the  narrow  portions  without 
difficulty. 

For  strictures  of  fair  size,  say  the  size  of  a  lead  pencil,  cylindrical 
bougies  (Fig.  513)  may  be  employed;  for  smaller  strictures  the  con- 
ical (Fig.  514)  or  bulbous  instnunents  (Fig.  515)  are  used. 


Fig.  513. — Cylindrical  esophageal  bougie. 

In  the  dilatation  of  very  tight  strictures  catgut  strings,  flodblc 
whalebone,  or  linen  filiforms  similar  to  the  urethral  filifonns  are 
sometimes  employed.  They  are  inserted  by  the  aid  of  the  esopha- 
goscope  or  through  a  special  hollow  sound. 

Other  more  complicated  instruments  are  sometimes  used,  such 
as  Schreiber's  and  Billroth's  sounds.     The  former  (Fig.  516)  consists 


Fig.  514. — Conical  esophageal  bougie. 

of  a  hollow  bougie  with  a  rubber  bag  on  the  dilating  end,  which  is 
capable  of  being  distended  with  fluid  forced  in  through  the  distal 
end  of  the  instrument.     Billroth's  sound  consists  of  a  cloth  sound 
filled  with  mercury.     These  instruments,  however,  possess  no  ad- 
vantages over  the  ordinary  flexible  bougie. 


l''ir,.  515. — Bulbous  esophageal  bougie. 

Asepsis. — The  gum-elastic  bougies  may  be  sterilized  in  formalixi 
vapor  or  by  immersion  in  a  saturated  boracic  acid  solution. 

Preparation  of  Patient. — In  cases  of  marked  dilatation  of  tb^ 
canal  above  the  stenosis  full  of  stagnant  food  and  mucus,  preliini- 
nary  esophageal  lavage  (page  502),  is  indicated. 

Rapidity  of  Dilatation. — The  stretching  should  be  done  gradually- 
Rapid  dilatation  or  divulsion  is  dangerous  and  inadvisable. 


i 


A. 


DILATATION    OF    KSOPIL\GEAL    STRICTURES 


507 


Frequency. — As  a  rule,  the  bougies  may  be  inserted  everj^  second 
:  third  day.  If  the  bougies  be  employed  too  frequently,  irritation 
I  the  seat  of  stricture  is  produced  and  the  condition  is  made  worse 
istead  of  improved.  After  full  dilatation  has  been  reached,  the 
tervals  between  treatments  may  be  stretched  to  a  week,  and  then 
■adually  to  a  month.  The  patient  should  not  bL-  permitted  to  go 
nger  than  this,  however,  without  the  passage  of  a  bougie,  as  con- 
actJon  is  extremely  liable  to  develop.     At  any  signs  of  recurrence 

the  trouble,  more  frequent  treatments  are  necessary. 

Position  of  Patient. — The  patient  should  be  seated  in  a  chair  with 
e  head  thrown  well  back  and  with  the  chin  raised. 

Anesthesia. — Though  not  absolutely  necessary,  preliminary  co- 
inization  of  the  pharynx  and  larynx  with  a  10  per  cent,  solution 
cocain  renders  the  operation  easier. 

Technic— A  bougie  of  a  size  that  will  enter  the  stricture  is 
osen.     This  is  determined  from  the  examination  of  the  stricture 


KZisgr 


Fig.  516. — Schreiber's  esophageal  sound,     (Gottst 


1  Kten's  Surgery.) 


cviously  made.  The  bougie  Is  softened  in  warm  water  and  bent  to 
gentle  curve  near  its  tip.  The  operator,  standing  in  front  of  the 
Ltient,  inserts  the  bougie  Into  the  patient's  mouth  to  the  posterior 
aJl  of  the  pharynx,  and,  keeping  It  close  to  this  latter  structure,  it 
slowly  advanced  into  the  esophagus  (see  Fig,  494).  If  difficulty 
«ncountered  in  entering  the  esophagus,  the  tongue  may  be  drawn 
rward  by  the  left  index-finger,  as  shown  In  Fig.  495. 

When  the  stricture  is  reached  care  must  be  taken  not  to  use  any 
rce  in  attempting  to  pass  it,  as  a  false  passage  may  be  made  or  the 
slrument  may  simply  be  doubled  upon  itself.  By  gently  with- 
'awing  and  then  advancing  the  instrument,  and  by  moving  its  tip 
'  different  directions,  the  opening  will  be  entered  if  the  particular 
istrument  is  of  sufficiently  small  caliber.  When  the  instrument  is 
5«  within  the  stricture  the  operator  is  acquainted  with  the  fact 
y  the  tight  grasp  upon  the  bougie  exerted  by  the  stricture.  The 
^ugie  should  be  slowly  passed  entirely  through  the  constriction,  and 
*«uld  be  allowed  to  remain  in  place  from  five  to  ten  minutes  before 
is  withdrawn.  At  the  next  sitting,  the  same  size  bougie  is  again 
'smed,  and,  if  the  stricture  seems  very  tight,  this  same  instrument 


* 


5o8  THE   ESOPHAGUS 

may  be  passed  on  two  or  more  occasions  before  a  larger  one  is  em- 
ployed. When  there  is  more  than  one  stricture,  no  attempt  should 
be  made  to  dilate  the  lower  ones  imtil  dilatation  of  the  upper  is 
secured. 

Very  tight  strictures  may  be  dilated  by  means  of  a  thread  passed 


Fig.  517. — Von   Hacker *s   method  of  introducing   thin  catgut  bougies.   (Gott- 
stein  in  Keen's  Surgery.)     a,  b,  c,  Into  the  stricture;  b\  through  a  wide  hollow  bougie  (f^ 

through  the  stricture  as  a  guide,  over  which  are  passed  small  olivary 
bougies  or  conical  sounds  (see  page  497) ,  by  means  of  filiform  bougies 
inserted  through  an  esophagoscope,  or  by  von  Hacker's  method  of 
inserting  catgut  strings.  In  the  latter  procedure  a  hollow  sound 
made  especially  for  inserting  catgut  strands  is  passed  down  as  far  as 
the  face  of  the  stricture,  and  through  this  the  catgut  strands  are 
insinuated  into  the  opening  one  after  another  in  a  manner  similar  to 
the  method  used  for  tight  urethral  strictures  (Fig.  517).  They 
are  left  in  place  fifteen  to  thirty  minutes,  and,  as  the  gut  swells,  the 
contracture  is  stretched.  As  soon  as  sufiicient  dilatation  for  the 
passage  of  a  small  bougie  has  been  thus  produced,  bougies  of  a  con- 
ical shape  may  be  substituted. 

INTUBATION  OF  THE  ESOPHAGUS 

This  consists  in  the  insertion  of  a  tube  into  a  stenosed  esophagus 
which  is  left  in  place  continuously  for  varying  periods  at  a  time.   B 


INTITBATION    OF    THE    ESOPHAGUS 


509 


s  3  method  of  treatment  used  in  cancer  of  the  esophagus  when  the 
)atieQt  is  unable  to  swallow  food,  and  sometimes  as  a  means  of  dilat- 
ng  elastic  strictures  which  are  dilatable,  but  rapidly  contract  after 
he  withdrawal  of  a  bougie. 

Long  tubes  inserted  into  the  stomach  through  the  mouth  or  nose 
T  short  tubes  which  can  be  passed  through  the  stenosed  area  by  the 
id  of  a  guide  are  employed.  The  use  of  the  short  tubes  is  preferable 
nd  is  far  more  agreeable  to  the  patient,  as  with  them  it  is  pos- 
ible  for  the  patient  to  swallow  saliva  and  to  take  food  in  the  natural 
'ay,  the  ability  to  taste  food  being  also  preserved  by  the  patient. 
'hey  are,  however,  more  difficult  to  insert  than  are  the  long  tubes, 
nother  disadvantage  of  the  short  tubfe  is  that  if  it  becomes  blocked 
may  have  to  be  removed  for  cleansing.  If  the  obstruction  is 
tuated  very  near  the  entrance  of  the  esophagus,  the  use  of  short 
ibes  is  usually  impracticable,  as  the  expanded  end  of  the  tube 


itubalion  of  the  esophagus. 

s  on  the  larynx  and  produces  laryngeal  irritation  and  spasm. 
*>  such  cases  long  tubes  are  indicated.  Long  tubes  are  also  indi- 
cted in  the  later  stages  of  carcinoma  of  the  esophagus,  with  a  fistu- 
*Us  opening  between  the  esophagus  and  air-passages,  when  it  is 
Pessary  to  prevent  any  food  from  passing  through  the  esophagus  in 
^<ler  to  avoid  danger  of  lung  complications. 

Instruments.^ — When  long  tubes  are  indicated,  an  ordinary  hollow 
i^lindrical  esophageal  tube  (see  Fig.  491)  or  a  rubber  stomach-tube 

appropriate  size  may  be  employed.  For  the  purpose  of  feeding 
>«  patient,  a  glass  funnel  that  will  fit  into  the  proximal  end  of  the 
ibe  will  also  be  required. 

Short  tubes  of  gum  elastic  and  hard  rubber  have  been  devised 
^  Symonds,  von  Leyden,  and  others.  Symonds'  tubes  (Fig.  518) 
"«  about  6  inches  (15  cm.)  long,  and  may  be  obtained  in  sizes  of 
*Jying  caliber.  The  lower  end  of  the  tube  has  a  terminal  or  a 
tcral  opening,  while  the  upper  extremity  ends  in  a  funnel-s 


I 


5IO  THE   ESOPHAGUS 

expansion,  which  rests  upon  the  superior  surface  of  the  stricture  or 
growth  and  prevents  the  tube  from  slipping  down  the  esophagus;  to 
this  expanded  end  silk  threads  are  secured,  as  shown  in  Fig.  518,  for 
the  purpose  of  extracting  the  tube.  A  special  whalebone  guide  for 
inserting  the  tube  is  also  required  (Fig.  519). 

Asepsis. — Gum-elastic  instnmients  are  sterilized  by  formalin 
vapor  or  by  immersion  in  a  saturated  solution  of  boracic  add. 
Rubber  tubes,  however,  may  be  boiled.  Before  reinserting  the  same 
tube,  it  should  be  thoroughly  washed  with  soap  and  water  and 
resterilized. 

Duration  of  the  Intubation. — For  dilating  a  stricture  the  tube  is 
left  in  place  twenty-fom  to  forty-eight  hours,  and,  if  it  has  then  b^ 
come  loosened  through  stretching  of  the  contracture,  it  is  removed 
and  a  larger  one  is  inserted  and  allowed  to  remain  in  place  for  the 
same  length  of  time.  This  process  is  repeated  until  full  dilatation 
has  been  obtained. 


Fig.  519. — Symonds*  tube  on  introducer. 

In  cancer  of  the  esophagus  the  tube  is  worn  continuously  except 
when  it  is  removed  once  every  ten  days  for  cleansing.  A  long  tube, 
however,  may  be  left  in  place  permanently,  as  it  can  be  kept  clean  by 
syringing  down  its  interior. 

Position  of  Patient. — The  patient  is  placed  in  the  same  position 
as  for  the  passage  of  any  esophageal  instrument,  viz.,  sitting  upright, 
the  head  thrown  well  back,  and  the  chin  elevated. 

Anesthesia. — As  an  aid  in  the  introduction  of  the  tube  the  phar- 
ynx and  larynx  may  be  sprayed  with  a  10  per  cent,  solution  of  cocain. 

Technic.  i.  Long  Tubes, — The  site  of  the  stenosis  is  previously 
determined  by  means  of  a  bougie,  and  a  tube  that  will  comfortably 
pass  is  selected.  The  patient  widely  opens  his  mouth  and  the  opera- 
tor gently  inserts  the  tube  in  the  manner  already  described  for  the 
passage  of  an  esophageal  bougie  (page  492).  The  tube  is  passed  into 
the  stomach,  and  the  proximal  end,  which  is  brought  out  of  a  comer  of 
the  mouth,  is  fitted  with  a  cork  and  is  secured  to  the  ear  by  a  piece 


INTUBATION  OF  THE  ESOPHAGUS 


■  of  silk.  It  will  be  necessary  for  the  patient  to  remain  in  a  recum- 
bent position  with  the  head  to  one  side  to  allow  saliva  which  collects 
to  escape,  as  this  is  prevented  from  passing  down  the  canal. 


Fic.  520. — ShoM'-i  long  esophageal  tube  passed  through  the 


ng  the  method  of  inlroducing  Symonds'  short  tube. 

Instead  of  passing  the  tube  through  the  mouth  it  may  be  in- 
*rted  through  the  nostril  (Fig.  520).     The  free  end,  corked  as  above, 
Is  tien  secured  In  place  by  means  of  adhesive  plaster. 
2.  Short  Tubes. — A  tube  of  the  proper  size  is  selected  and  placed 


512  THE   ESOPHAGUS 

upon  the  introducer,  being  prevented  from  falling  off  by  the  silk 
threads  which  are  grasped  by  the  operator  with  the  same  hand  he 
employs  in  introducing  the  tube.  The  patient's  tongue  is  then  drawn 
well  forward  and  the  tube  is  passed  down  the  esophagus  and  is  in- 
serted through  the  stricture  by  means  of  the  introducer,  following  the 
same  steps  as  for  the  passage  of  a  bougie  (Fig.  521).  When  the  tube 
is  in  proper  position  the  tension  on  the  threads  is  relaxed  and  the 
introducer  is  gently  disengaged  from  the  tube  and  removed.  The 
threads  are  then  brought  out  of  a  corner  of  the  mouth  and  are  secured 
to  the  ear  or  face  with  adhesive  plaster.  If  any  of  the  patient's 
teeth  are  missing  the  threads  should  be  made  to  emerge  from  the 
mouth  through  such  a  space  so  as  to  avoid  being  cut  by  the  teeth. 

Should  the  tube  become  blocked,  it  may  be  possible  to  remove 
the  obstruction  by  passing  a  very  small  bougie  down  through  it; 
otherwise  the  tube  will  have  to  be  removed  and  cleaned.  With- 
drawal of  the  tube  is  effected  by  making  gentle  traction  upon  the 
threads  secured  to  its  proximal  end. 

Feeding. — ^While  the  tube  is  in  place  the  patient  is  kept  upon  a 
fluid  diet,  such  as  milk,  broth,  eggs  beaten  in  milk,  etc.     With  the 
short  tubes  food  may  be  administered  by  mouth,  but  when  the  long 
tubes  are  employed  thq  nourishment  is  introduced  through  a  funnd 
inserted  in  the  proximal  end  of  the  tube.     Between  feedings  the  end 
of  the  tube  may  be  closed  by  means  of  a  cork. 


CHAPTER  XViri 
THE  STOMACH 


Anatomic  -Considerations 


The  stomach  may  be  described  as  a  hollow,  inverted,  pear-shaped 
oiijan,  the  greater  part  of  which  lies  in  the  epigastric  and  left  hypo- 
fiondriac  regions,  about  one-sixth  of  the  organ  extending  beyond  the 
n^ht  of  the  median  line.  When  empty  it  lies  deep  In  the  abdomen 
10  front  of  the  pancreas,  being  covered  by  the  liver  and  diaphragm 


FiC.  s>^- — The  norma!  position  «f  the  stomach. 

™  about  two-thirds  of  its  area  and  by  the  abdominal  wall  over  the 
Wnaiuing  one-third.  The  space  in  which  the  stomach  comes  in 
contact  with  the  anterior  abdominal  wall  is  triangular  in  shape, 
bounded  on  the  right  by  the  lower  border  of  the  liver,  on  the  left 
hy  Ihe  eighth,  ninth,  and  tenth  costal  cartilages,  and  below  by  the 
transverse  colon. 

The  upper  limit  of  the  stomach,  the  fundus,  reaches  the  level  of 
the  lower  border  of  the  fifth  rib  in  the  mammary  line,  being  in  rela- 


514  THE   STOMACH 

lion  with  the  diaphragm  above  and  the  concave  surface  of  the  ^leen 
to  the  left.  The  lower  limit  or  greater  curvature  extends  to  thelevd 
of  a  line  connecting  the  lowest  portions  of  the  ninth  or  tenth  ribs  or 
to  within  2  inches  (5  cm.)  of  the  umbilicus.  In  contraction  or  dila- 
tation of  the  organ,  however,  this  normal  position  of  the  greater  cur- 
vature may  be  modified  to  a  marked  degree.  The  cardiac  or  superior 
opening  lies  about  3^^  inch  (i  cm.)  to  the  left  of  the  median  line,  at 
the  level  of  the  eleventh  dorsal  vertebra,  or  anteriorly  at  the  level  of 
the  junction  of  the  sterniun  and  seventh  costal  cartilage.  It  is 
situated  about  4  J^  inches  (11  cm.)  posterior  to  the  anterior  abdom- 
inal wall.  The  pyloric  opening  is  situated  in  front  of,  but  on  a  lower 
plane  than,  the  cardiac  opening,  l3dng  to  the  right  of  the  median  line 
and  covered  by  the  right  lobe  of  the  liver.  It  is  on  a  level  with  the 
upper  border  of  the  body  of  the  first  limibar  vertebra  or  anteriorly 
on  a  level  with  a  point  2  or  3  inches  (5  to  7.5  cm.)  below  the  stemoxi- 
phoid  joint.  The  long  axis  of  the  undistended  stomach  lies  in  more 
of  a  vertical  than  a  horizontal  plane  with  the  lesser  curvature  di- 
rected principally  to  the  right  and  the  greater  curvature  to  the  left 
When  distended,  however,  the  organ  changes  its  position  somewhat; 
the  greater  curvature  is  tilted  to  the  front  so  that  the  upper  surface 
looks  upward  and  the  lower  downward;  at  the  same  time  the  pyioros 
moves  2  inches  (5  cm.)  or  more  to  the  right. 

The  capacity  of  the  stomach  is  subject  to  wide  variations.  The 
average  is  about  2}^  pints  (1200  cc).  When  the  stomach  ia 
empty,  the  longest  diameter  measures  7  34  to  8  inches  (18  to  20 
cm.)  and^  the  transverse  diameter  2%  to  334  inches  (7  to  8  cm.)- 
When  the  organ  is  filled,  the  longest  diameter  is  increased  to  10  or  12 
inches  (25  or  30  cm.)  and  the  widest  point  of  the  transverse  diameter 
to  334  or  4  inches  (8  or  10  cm.). 

Diagnostic  Methods 

In  the  diagnosis  of  stomach  diseases  a  history  of  the  previous  al^^ 
the  present  condition  of  the  patient  should  be  carefully  taken  and  ^ 
general  physical  examination  should  be  made  before  the  examinati^^^ 
of  the  stomach  itself  is  undertaken.  In  obtaining  the  patient  ^ 
history,  in  addition  to  the  usual  questions  common  to  all  historic^^ 
inquiry  should  be  directed  especially  to  the  following  points:  th^ 
general  condition  of  the  health,  the  appetite,  any  loss  of  weight,  the 
date  and  manner  of  onset  of  the  symptoms,  pain,  sensation  of  pressure 
or  distention,  nausea,  vomiting,  vomiting  of  blood,  etc.     Of  special 


DIAGNOSTIC  METHODS  515 

diagnostic  importance  is  a  history  of  gastric  pain,  vomiting,  or  the 
vomiting  of  blood. 

As  to  pain,  one  should  ascertain  its  character,  its  location,  whether 
diffuse  or  circumscribed  in  area,  and  especially  the  time  of  its  onset 
in  relation  to  the  taking  of  food  and  the  length  of  time  it  persists 
after  meals.  A  simple  feeling  of  pressure  or  fulness,  however,  should 
not  be  confounded  with  pain.  Patients  often  confuse  the  two.  It 
is  also  important  to  determine  whether  the  pain  is  present  at  all 
times  or  only  at  certain  stated  periods  and  whether  any  special 
variety  of  food  has  an  influence.  Pain  complained  of  when  the 
stomach  is  empty  is  probably  due  to  hyperchlorhydria,  in  which 
case  it  is  relieved  by  eating.  On  the  other  hand,  the  pain  of  an  ulcer 
or  cancer  comes  on  after  eating,  and  the  seat  of  pain  is  usually  local- 
ized. In  ulcer  it  is  severe,  comes  on  soon  after  eating,  and  is  often 
completely  relieved  by  vomiting.  Its  origin  is  often  located  by  the 
patient  in  the  back  in  the  region  of  the  lower  dorsal  vertebrae  on  the 
left  side.  In  cancer  the  pain  is  not,  as  a  rule,  so  severe  as  that  of 
ulcer  nor  does  it  come  on  so  soon  after  eating,  and  it  is  not  so  uni- 
formly relieved  by  vomiting. 

With  a  history  of  nausea  and  vomiting,  the  examiner  should  in- 
quire into  the  relation  of  these  symptoms  to  the  taking  of  food,  the 
frequency  of  occurrence,  the  character  and  the  quantity  of  vomitus, 
and  whether  the  patient  is  relieved  by  vomiting.  This  all  has  an  im- 
portant bearing  upon  the  case.  Nausea,  as  a  rule,  but  not  always, 
precedes  vomiting.  In  certain  conditions,  especially  when  of  nervous 
origin,  nausea  may  be  present  when  the  stomach  is  empty.  The 
time  of  vomiting  is  also  quite  important.  In  gastric*ulcer  the  vomit- 
ing usually  takes  place  soon  after  feeding,  that  is,  within  an  hour  or 
so;  and,  as  already  pointed  out,  its  occurrence  usually  relieves  the 
pain  complained  of.  In  cancer  of  the  stomach,  vomiting  may  not 
appear  until  late  in  the  disease  and,  as  a  rule,  the  attacks  of  vomiting 
do  not  come  on  at  such  short  intervals  after  feeding  as  in  the  case  of 
ulcer.  In  dilatation,  on  the  other  hand,  vomiting  occurs  at  com- 
paratively long  intervals,  and  the  amount  brought  up  is  correspond- 
ingly large.  Blood  in  the  vomitus  is  always  of  diagnostic  importance. 
A  profuse  hermorrhage  from  the  stomach  generally  signifies  an  ulcer, 
while  the  constant  vomiting  of  blood-streaked  material  points  more 
toward  cancer;  especially  is  this  true  if  the  vomited  matter  has  a 
foul  odor. 

It  has  been  possible  here  to  point  out  the  importance  and  the 
significance  of  but  a  few  symptoms,  and  for  further  details  the  reader 


5l6  *  THE   STOMACH 

* 

is  referred  to  works  on  diagnosis  where  these  will  be  found  fufly 
discussed.  The  writer  simply  wishes  to  emphasize  the  importance 
of  a  careful  history  and  to  point  out  in  a  general  way  the  lines  of 
questioning. 

A  general  physical  exmination  should  never  be  n^lected  even 
though  the  patient  refers  his  symptoms  to  the  stomach  alone,  for 
secondary  disturbances  of  the  functions  of  the  stomach  are  present 
in  a  great  variety  of  diseases.    This  examination  should  include  the 
mouth,  the  tongue,  the  chest,  the  abdomen,  an  analysis  of  the  urine, 
an  examination  of  the  blood,  etc.    When  all  possible  information  Iuls 
been  obtained  from  these  sources,  a  special  examination  of  tke 
stomach  itself  should  be  made,  for  which  the  following  methods  ar^ 
available:  (i)  inspection;  (2)  palpation;  (3)  percussion;  (4)  auscultat— 
tion;  (5)  inflation;  (6)  examination  of  the  gastric  secretion;  (7)  tests 
for  determining  the  motor  and  absorptive  power  of  the  stomach;  (S) 
transillumination;  (9)  gastroscopy;  and  (10)  skiagraphy. 

INSPECTION 

Abdominal  inspection  in  thin  individuals  may  at  times  gi^**^^ 
valuable  information,  but  in  stout  persons  the  method  is  of  verT^ 
Kmited  use.    In  favorable  cases  it  may  be  possible  by  this  meaK^^s 
to  determine  the  size  and  position  of  the  stomach  by  tracing  tfc»e 
shadow  which  represents  the  outline  of  the  greater  curvature.  1^^" 
spection  is  greatly  aided  by  a  preliminary  inflation  of  the  organ  (pa^* 
5 24) .     When  thus  distended  the  stomach  becomes  separated  from  tt** 
surrounding  organs  and  its  contour  is  more  easily  made  out.    At  tb* 
same  time  abnormal  positions  or  new  growths  may  be  better  reco^' 
nized. 

Position  of  Patient. — The  patient  is  placed  upon  a  firm  flat  tabl^» 
with  his  head  directed  toward  the  source  of  light,  so  that  the  rays  wil* 
fall  from  the  head  toward  the  feet.  The  light  should  be  so  regulat^^ 
by  adjustment  of  the  window  shades  that  it  enters  on  a  plane  only  ^ 
little  above  the  patient. 

Technic. — The  examiner  takes  his  stand  near  the  patient's  fe^^ 
and,  by  moving  from  side  to  side,  is  enabled  to  make  out  the  stomal* 
outlines  from  the  shadows  cast  by  the  inequalities  of  the  abodmio-^ 
wall  produced  by  the  stomach  beneath  (Fig.  523).  At  times  tum^^*^ 
of  the  body  of  the  stomach  or  of  the  pylorus  may  be  observed  elev^-j 
ing  the  abdominal  walls,  and,  if  the  growth  be  movable,  a  change  ^ 
its  position  may  be  noted  when  the  stomach  is  full  and  when  i^ 


INSPECTION  517 

empty.  If  there  be  obstnictioti  of  the  pylorus  with  dilatation  and 
hypertrophy  of  the  walls,  peristaltic  movements  of  the  stomach  may 
be  observed  after  taking  food.     These  waves  may  be  seen  extending 


Fig.  514- — Showing  the  shape  oi:  (t)  A  dilated  stomach,  (2)  an  hour-glass  stomach, 

(3)  the  stomach  in  gastroptosis. 

toward  the  pylorus  from  under  the  ribs  in  the  left  upper  quadrant  to 
the  right  lower  quadrant.  Peristalsis  may  be  excited  by  tapping  the 
abdomen  or  by  the  application  of  cold.    A  dilated  stomach  may  be 


5l8  THE    STOUACH 

detemuDed  from  the  great  bulging  in  the  epigastrium  and  by  trac- 
ing the  greater  curvature  to  a  point  considerably  below  the  umbili- 
cus, and  at  times  an  hour-glass  contraction  may  be  recogimed  (Fig. 
524).  In  gastroptosis  the  epigastrium  will  be  retracted,  and  the 
lesser  curvature  may  be  seen  represented  by  a  groove  extending  from 
the  umbilicus  to  the  ribs  upon  the  left  and  above.  Depres^onoftbe 
epigastrium  will  also  be  seen  in  stenosis  of  the  cardia. 

PALPATION 

Palpation  is  by  far  the  most  reliable  of  the  methods  of  phymal 
examination.    The  stomach  should,  when  possible,  be  palpated  both 


Method  of  palpating  the  stomach. 


before  and  after  taking  food,  as  tumors  of  the  posterior  wall  are  often 
capable  of  being  felt  only  when  the  stomach  is  empty.  The  large 
intestine  should  be  emptied  by  an  enema,  if  necessary,  so  as  to  avoid 
mistaking  feces  for  new  growths.  The  examination  should  be  cartiw 
out  systematically,  and  of  course  it  must  not  be  limited  to  the  stom- 
ach alone  but  all  the  other  abdominal  organs  should  be  palpated 
as  well. 

Position  of  Patient. — The  patient  lies  recumbent  with  the  abdom- 
inal muscles  as  relaxed  as  possible.     If  it  is  necessary  to  obtain 


PALPATION  519 

ater  relaxation  than  is  possible  by  this  posture,  the  knees  should  be 
[wn  up  and  the  head  and  thorax  should  be  slightly  raised  upon  a 
ow.  Where  there  is  considerable  rigidity  of  the  abdominal  muscles 
n  fat  individuals,  relaxation  may  be  secured  by  placing  the  patient 
I  warm  bath. 

Technic. — The  examination  should  be  performed  in  a  warm 
m  and  the  physician's  hands  should  be  warmed  to  avoid  the 
scular  spasm  produced  by  cold  hands.  The  patient  isinstructed 
teep  his  mouth  open  and  to  breathe  regularly  and  deeply  to  induce 
fullest  amount  of  relaxation.  The  examiner  sits  or  stands  beside 
patient  arid  places  both  hands  flat  upon  the  abdomen,  with  the 


--  526. — PaJpalinR 


the  finfiera  of  Ihi;  two  hands. 


ttis  down  and  the  fingers  slightly  flexed,  and  palpates  with  the 
>er-tips.  Only  gentle  manipulations  should  be  employed^  as 
erwise  spasm  of  the  abdominal  muscles  will  be  induced  and  the 
i  of  the  examiner  will  be  defeated. 

When  it  is  desired  to  perform  deep  palpation  for  the  recognition 
deep-seated  tumors,  one  hand  is  superimposed  upon  the  other, 
-  upper  hand  making  the  pressure  and  the  lower  one  performing  the 
Ipation  (Fig.  525).  Deep  palpation  is  greatly  aided  by  hav-ing  the 
■tient  breathe  deeply;  it  then  becomes  possible  for  the  palpating 
M  to  follow  the  receding  abdominal  walls  with  expiration. 

la  palpation  tumors,  one  hand  is  used  to  fix  the  growth  and  the 


520 


THE   STOMACH 


Other  outlines  its  size  and  determines  its  consistency,  fixity,  or 
mobility,  and  the  presence  or  absence  of  pulsation,  tenderness  upon 
pressure,  etc.  (Fig.  526). 

The  examiner  should  first  determine  the  size  and  position  of  the 
stomach.  Inflation  (page  524)  is  a  great  aid  to  palpation,  asitk 
usually  impossible  to  palpate  the  outline  of  an  empty  organ.  An- 
other method  of  determining  the  size  or  the  position  of  the  stomach 
is  by  means  of  a  long  soft-rubber  stomach- tube  passed  into  the  organ 
to  such  an  extent  that  it  lies  along  the  greater  curvature.  Thfc 
greater  curvature  and  the  pylorus  may  thus  be  outlined  by  palpatinf 
the  tube  through  the  abdominal  walls.    All  parts  of  the  organ  are 


ue 


UU^raffiyi 


tSite  cf  teiuUmmss 
mleer  of  the  duodtm^ 


Uleerif^timmtk, 


Fig.  527. — Points  of  pressure  tenderness  in  ulcer  of  the  stomach.     (Mayo  Robsonin 

Keen's  Surgery.) 


next  carefully  palpated  with  the  purpose  of  determining  the  presence 
or  absence  of  new  growths,  painful  spots,  etc.  Txmiors  of  the 
pylorus  and  the  greater  curvature  are  readily  palpable.  The  former 
are  usually  situated  to  the  right  of  the  median  line,  between  the 
xiphoid  and  the  umbilicus,  but  they  have  a  wide  range  of  motion 
unless  adherent.  Tumors  of  the  lesser  curvature  lie  to  the  left  of 
the  median  line,  thus  differentiating  them  from  those  of  the  gall- 
bladder. They  are  less  freely  movable  than  those  of  the  pylorus. 
Tumors  of  the  cardia  are  seldom  palpable.  Changing  the  position 
of  the  patient  to  a  lateral  one  is  often  of  service  in  rendering  a  growth 
more  accessible  to  the  examiner.     The  knee-chest  posture  is  also  of 


PERCUSSION 

value,  as  deep-seated  movable  tumors  then  fall  forward  toward  the 
anterior  abdominal  wall. 

Eliciting  tender  spots  on  palpation  is  frequently  a  diagnostic  aid. 
In   organic  diseases,  such  as  ulcer,  cancer,  gastritis,  etc,  pain  is 
spontaneous  and  is  increased  upon  pressure,  while  in  nervous  condi- 
tions it  is  generally  diminished  or  relieved  by  pressure.     In  gastritis 
and  nervous  affections  the  pain  is  diffuse,  while  in  ulcer  and  cancer 
it   is  usually  localized  to  a  small  circumscribed  area.     The  most 
common  points  of  tenderness  for  ulcer  are  between  the  left  costal 
margin  and  the  mid-line  (Fig.  527);  points  of  pressure  tenderness  are 
aiso  at  times  found  i  to  2  inches  (2.5  to  5  cm.)  to  the  left  of  the  spine, 
in    the  neighborhood  of  the  twelfth  dorsal  vertebra  (Fig,  528).     In 


^<i-  s)S. — Points  of  pressure  tenderness  found  posteriorly  in  ulcer  ot  the  stomach. 
(Mayo  Robson  in  Keen's  Surgery.) 

"ttections  of  the  gall-bladder  similar  tender  points  will  be  frequently 
'ound  more  to  the  right  of  the  spinal  column. 

PERCUSSION 

Only  the  greater  curvature  and  the  portion  of  the  anterior  surface 
*■'  the  stomach  in  contact  with  the  anterior  abdominal  wall  are  access- 
't>le  for  percussion,  consequently  the  chief  use  of  this  method  is  to 
^^termine  the  shape  and  size  of  the  stomach.  Percussion  of  the 
'^mach,  even  under  the  most  favorable  conditions,  is  unreliable,  on 
Account  of  the  proximity  of  other  air-containing  organs.     The  chief 


5" 


THE  STOMACH 


source  of  error  is  the  resonance  of  the  transverse  colon,  which  auiyhe 
confused  with  that  of  the  stomach.  To  avoid  this  the  stomach  mi; 
be  distended  with  gas  and  the  colon  with  fluid,  or  the  colon  may  be 
inflated  and  the  patient  may  drink  one  or  more  glasses  of  wat«.  In 
dther  case  a  contrast  between  the  tympany  of  the  one  and  the  dubea 
of  the  other  will  be  obtained  on  percussion.  The  pMx:usdon  note 
over  the  stomach  is  a  high-pitched  metallic  tympany,  but  it  will  vay 
much,  depending  upon  whether  the  stomach  is  empty,  whether  it  h 
full  of  food,  or  simply  contains  air.     Percussion  should  be  perfomud 


Fig.  5J9. — ^Pcrcussion  of  the  stomach. 

when  the  stomach  contains  some  air;  under  inflation  of  theorgM 
percussion  furnishes  even  more  valuable  results. 

Position  of  the  Patient. — The  patient  should  lie  in  the  recumboit 
posture. 

Technic — The  palmar  surface  of  the  middle  finger  of  the  left  hand 
is  laid  upon  the  area  it  is  intended  to  percuss  and  is  hdd  finely 
against  the  surface,  while  with  the  flexed  middle  finger  of  the  ri^^ 
hand  a  number  of  sharp  taps  or  blows  are  struck  (Fig,  529).  Th^ 
force  of  the  percussion  should,  as  a  rule,  be  very  light,  but,  if  it  "^ 
desired  to  make  out  a  deeply  placed  growth,  firm  heavy  percusao" 
will  be  required.     The  same  is  true  when  the  abdominal  walls  a" 


AUSCULTATION  523 

thick.  Having  outlined  the  stomach  with  the  patient  recum- 
,  the  percussion  should  be  performed  with  the  patient  upright 
etermine  if  the  organ  sinks  down  from  its  normal  position. 


AUSCULTATION 

ly  listening  to  sounds  produced  within  the  esophagus  during  the 
lowing  of  fluids  and  to  sounds  originating  within  the  stomach 
f,  certain  information  of  diagnostic  importance  may  be  obtained. 
Jie  first  method  it  is  possible  to  determine  whether  there  be  an 
ruction  of  the  cardia  or  not.  It  is  carried  out  as  follows: 
The  operator  hstens  with  his  stethoscope  placed  over  the  esopha- 

that  is,  to  the  left  of  the  ensiform  cartilage  or  to  the  left  of  the 
ai  column  opposite  the  ninth  or  tenth  dorsal  vertebra  while  the 
ent  is  swallowing  fluids.  Two  sounds  are  thus  heard:  first,  a 
ting  sound  that  immediately  follows  the  act  of  swallowing,  and 
cond  sound,  more  rattling  in  character,  known  as  the  "degluti- 

murmur, "  which  is  heard  six  or  seven  seconds  (sometimes  as 
:h  as  twelve  seconds)  later;  it  represents  the  passing  of  food 
'Ugh  the  cardiac  orifice  into  the  stomach.  If  this  second  sound 
instantly  absent,  more  or  less  complete  occlusion  of  the  cardi'a 
resumable. 

rhe  succussion  or  splashing  sounds  that  originate  in  the  stomach 
f  are  of  greater  diagnostic  importance.  In  order  to  obtain  these 
ids  the  stomach  must  contain  air  and  be  partly  filled  with  fluid. 

patient  lies  recumbent  and  the  operator  listens  with  his  ear  near 
abdomen  while  he  taps  the  abdominal  wall  in  the  region  of  the 
lach  with  his  finger-tips.  Succussion  sounds  may  also  be  elicited 
moving  the  patient  quickly  from  side  to  side.  These  sounds 
lid  be  differentiated  from  other  gurgling  sounds  which  are  heard 
n  the  stomach  contains  only  air  or  is  empty.  Succussion  in 
J  is  of  no  diagnostic  importance,  for  it  may  be  heard  in  a  normal 
oach  containing  a  quantity  of  fluid.  It  is  pathological,  however, 
itained  w/te?i  Ike  stomach  should  normally  be  empty,  that  is,  in  the 
ning  before  breakfast,  three  hours  after  a  test  breakfast,  or  seven 
rs  after  a  test  dinner.  It  then  indicates  a  condition  of  atony  or 
aeot  motility.  When  succussion  is  heard  over  an  abnormally 
e  area,  or  beyond  the  normal  boundaries  of  the  organ,  it  indicates 
lation  or  gastroptosis.  The  outlines  of  the  stomach  may  be 
iped  out  with  considerable  accuracy  by  tapping  first  from  above 
award,  and  then  from  side  to  side,  the  examiner  listening  the 


^ 

4 


i 


524  THE   STOMACH 

while  with  a  stethoscope  placed  over  the  stomach  and  noting  wkre 
the  splashing  sounds  stop. 

INFLATION  OF  THE  STOMACH 

The  stomach  may  be  inflated  for  diagnostic  purposes  to  deter- 
mine its  size,  shape,  and  position,  and  to  establish  the  presence  or 
absence  of  tumors.  It  is  of  great  aid  to  inspection,  palpation,  or 
percussion. 

The  inflation  may  be  performed  by  means  of  effervescent  soh- 
tions  giving  off  carbonic  acid  gas  or  by  means  of  air  introduced 
into  the  stomach  through  a  tube.  Inflation  by  the  latter  method  is 
safer,  as  it  is  under  the  direct  control  of  the  operator  and  may  be 
stopped  at  any  moment  if  desired;  furthermore,  the  distention  may  be 
immediately  relieved  if  necessary.  On  the  other  hand,  distention  by 
means  of  carbonic  acid  gas  is  of  great  advantage  in  nervous  individ- 
uals who  fear  the  stomach-tube.  It  is  not  always  satisfactory,  how- 
ever, as  the  dosage  may  not  be  large  enough  to  generate  suflScientgas 
in  a  capacious  stomach  or,  if  too  much  gas  is  formed,  it  mayproduce 
pain  and  vomiting.  With  either  method  some  caution  must  be 
observed  and  the  inflation  must  be  immediately  stopped  if  pain  be 
produced.  Inflation  is  contraindicated  in  recent  hemorrhage  of  the 
stomach,  in  suspected  gastric  ulcer,  in  advanced  cardiac  disease,  and 
in  advanced  arterial  disease. 

Under  distention  the  stomach  is  raised  from  the  neighboring 
organs  and  its  limits  thus  become  more  dearly  outlined,  so  that  con- 
ditions of  dilatation,  gastroptosis,  and  hour-glass  contractions  may  be 
distinguished  and  timiors  may  be  rendered  more  pronounced.  Be 
fore  performing  inflation  in  the  case  of  suspected  gastric  tumor,  the 
abdomen  should  be  carefully  examined  ai^d  the  exact  situation  of  the 
growth  noted;  by  then  noting  the  position  of  the  growth  after  infla- 
tion it  may  be  determined  whether  the  growth  is  connected  with  the 
stomach  and  whether  it  is  fixed  by  adhesions  or  is  movable.  Fre- 
quently under  inflation  it  is  possible  to  determine  by  sight  and  by 
palpation  the  direct  continuity  between  the  stomach  and  the  tumor. 
Tumors  of  the  pylorus  and  of  the  anterior  stomach  wall  become  more 
prominent,  while  those  of  the  posterior  wall  become  less  so  when  the 
stomach  is  inflated.  Tumors  of  the  pylorus  generally  move  down- 
ward and  to  the  right  under  inflation.  Tumors  of  the  lesser  curva" 
ture  near  the  cardia  are  displaced  to  the  right  under  the  liver.  At 
the  same  time  spurious  tumors  due  to  spasm  disappear. 


INTLATION   OF   THE   STOMACH 


525 


ppaT&tus. — For  inflation  with  carbonic  acid  gas  no  apparatus  is 
Ired.     A  stomach-tube  should  be  at  hand,  however,  for  the  pur- 
of  relieving  the  patient  of  distention  from  gas  if  necessary. 
o  inflate  with  air  an  ordinary  stomach-tube,  30  inches  {75  cm.) 

of  soft  rubber,  to  the  proximal  end  of  which  a  double  cautery 

or  a  Davidson  syringe  is  attached,  will  be  required  (Fig.  530). 

sepsis. — The  tube  should  be  sterilized  by  boiling. 

ositioa  of  the  Patient.- — If  desired,  the  tube  may  be  passed  with 

latient  sitting  up,  but  the  inflation  and  the  examination  should 

.fried  out  with  the  patient  recumbent  and  with  the  chest  and 

men  well  exposed  to  view. 

Bchnlc.     I.  By  Carbonic  Acid  Gas. — The  patient  is  given  i 

(4  gm.)  of  bicarbonate  of  soda  dissolved  in  3  ounces  (90  c.c.) 


Flo.  530. — Slomach-tubt  and  Davidson  syringe  for  inflating  the  stomach. 


iter,  and  then  a  little  less  than  i  dram  (4  gm.)  of  tartaric  acid 
Ived  in  3  ounces  (go  c.c.)  of  water.  As  the  two  solutions  come 
ntact,  carbonic  acid  gas  is  generated  and  the  stomach  is  thereby 
nded.     In  dilatation  of  the  stomach,  however,  it  may  be  neces- 

to  give  a  second  dose  to  obtain  suflicient  distention  for  the  pur- 

of  mapping  out  the  outlines  of  the  organ. 

.  By  Air.— To  inflate  a  stomach  successfully  with  air  through  a 

it  is  essential  that  the  patient  be  accustomed  to  the  passage  of 
stomach-tube — the  tube  should  certainly  have  been  passed  at 

once  previously.  The  tube  is  inserted  as  follows:  The  patient 
itructed  to  open  the  mouth,  and  the  tube,  moistened  with  water, 


i 


526  THE   STOHiACH 

is  passed  along  the  roof  of  the  mouth  to  the  pharynx.  From  thb 
pomt  it  is  advanced  partly  by  swallowing  efforts  on  the  part  of  the 
patient  and  partly  by  the  operator  who  pushes  it  on  until  it  has 
passed  a  sufficient  distance  to  be  carried  beyond  the  cardia.  By 
alternately  compressing  and  relaxing  the  inflation  bulb  the  stomach  b 
then  gently  pumped  up  with  air  until  it  is  sufficiently  distended  for 
the  purposes  of  the  examination.  In  the  case  of  an  insuffidency  of 
the  pylorus  it  may  be  impossible  to  distend  the  stomach,  the  gas 
being  expelled  on  into  the  small  gut.  This  will  be  evidenced  by  a 
generalized  swelling  of  the  abdomen,  instead  of  a  distention  localized 
in  the  region  of  the  stomach. 

As  soon  as  the  examination  is  completed,  the  inflation  bulb  is 
removed  from  the  end  of  the  tube  and  the  air  is  allowed  to  escape 
so  as  to  avoid  the  disagreeable  distention.  The  abdomen  may  be 
kneaded  to  facilitate  the  escape  of  the  air. 

EXAMINATION  OF  THE  STOMACH  CONTENTS 

The  contents  of  the  stomach  may  be  removed  for  purposes  of 
diagnosis  when  it  is  desired  to  examine  the  gastric  secretion  chanic- 
ally  and  to  test  the  motor  functions  of  the  stomach.  Such  examina- 
tion often  gives  results  of  both  diagnostic  and  prognostic  vahc, 
but,  while  gastric  analysis  is  of  great  importance,  the  infomali^ 
obtained  by  such  examination  must  not  be  relied  upon  to  the  exd^ 
of  other  methods  of  diagnosis,  as  it  is  by  no  means  final.  In  all  cases 
the  history  and  the  results  of  the  physical  examination  should  be 
given  due  consideration. 

To  test  the  digestive  power  of  the  stomach  it  is  necessary  to 
examine  the  contents  at  the  height  of  digestion.    In  other  cases,  as 
when  hypersecretion'  or  disturbance  of  the  motor  power  of  the 
stomach  is  suspected,  the  contents  of  the  fasting  stomach  should  be 
examined.     Normally,  the  stomach  should  be  empty  of  food  within 
eight  hours  after  a  full  meal.    According  to  Rehfuss,  after  an  >1* 
night  fast  the  residuum  in  the  stomach  averages  between  30  ana 
50  c.c.  (i  and  1%  ounces)  in  amount.    It  is  thin  and  opalescent,  and 
contains  bile  in  about  50  per  cent,  of  the  cases.     It  has  an  aveiap 
total  acidity  of  30  and  an  average  free  acidity  of  18.    If,  therefore, 
the  contents  of  the  stomach,  removed  in  the  morning  before  any 
food  has  been  taken  since  the  evening  before,  show  the  presence  of 
food  or  if  a  considerable  quantity  of  fluid  containing  free  hydro- 
chloric acid  is  obtained,  it  points  in  the  former  case  to  motor  insui- 
ficiency  and  in  the  latter  to  hypersecretion. 


EXAMINATION    OF    THE    STOM.4CH   CONTENTS  527 

Test  Meals. — To  obtain  results  from  which  comparisons  may  be 
bwn  the  patient  should  be  given  on  an  empty  stomach  a  meal  of  a 
leSnite  composition  and  the  contents  of  the  stomach  should  be  re- 
loved  after  a  definite  lapse  of  time.  For  this  purpose  either  a  test 
re&kfast  or  a  mid-day  test  dinner  is  employed. 

The  Ewald-Boas  test  breakfast  consists  of  one  or  two  rolls^ — be- 
»een35  and  70  gm.  {1  and  23'^  ounces),  a  cup  of  tea  without  sugar  or 
lilk,  or  300  to  400  c.c.  (10  to  14  ounces)  of  water.  This  is  given 
pon  an  empty  stomach  in  the  morning  and  removed  in  one  hour. 

The  Riegei  test  dinner  consists  of  a  large  plate  of  meat  sou]) — - 
M  C.C.  (about  14  ounces),  a  large  portion  of  beefsteak  or  other  meat, 
eiglxing  150  to  aoo  c.c.  (5  to  7  ounces),  mashed  potatoes-—  50  gm. 
■li  ounces),  and  a  roll  35  gm.  {i  oimce).  The  contents  of  the 
omacb  are  removed  and  examined  three  or  four  hours  later. 

Examination  of  the  Stomach  Contents.— The  object  of  a  gastric 
laJysis  is  twofold;  First,  to  determine  the  presence  or  absence  of 
tnstitueats  which  are  normally  present,  and,  second,  to  ascertain 
hether  other  substances  exist  which  should  normally  be  absent, 
ormally,  the  gastric  contents  one  hour  after  a  test  breakfast  con- 
st of  from  I  to  2^i  ounces  {30  to  70  c.c.)  of  acid  material  which 
Ma  filtration  yields  a  clear  yellow  or  yellowish-brown  fluid.  Upon 
lalysis  this  contains  a  total  acidity  of  40  to  60  (0.15  to  0.21 
:r  cent.),  free  hydrochloric  acid  25  to  50  (o.i  to  0.2  per  cent.}, 
;psin,  rennin,  albumoses,  peptones,  maltose,  achroddextrin,  and 
■ythrodextrin. 

The  technic  of  gastric  analysis  will  be  found  in  works  upon  clinical 
boratory  methods.  Such  examinations,  however,  should  be  made 
ong  the  following  lines: 

1.  Macroscopical  examination,  noting  the  quantity,  character, 
ior,  reaction,  etc. 

2.  Microscopical  examination. 

3.  Chemical  Examination. — This  should  include  tests  to  deter- 
line  the  presence  or  absence  of  free  hydrochloric  acid  and  of  com- 
bed hydrochloric  acid,  the  degree  of  total  acidity,  the  presence  of 
£tic  acid,  the  presence  of  volatile  acids,  the  presence  of  soluble 
bumin,  the  products  of  digestion,  the  presence  of  rennin  and  pepsin, 
td  the  character  of  the  carbohydrates. 

The  Significance  of  Variations  in  the  Composition  of  the  Gastric 
icretion.  Hypcrchlorhydrta. — Free  hydrochloric  acid  is  found  in 
cess  in  the  early  stages  of  chronic  gastritis,  in  gastric  neuroses,  in 
stric   ulcer,   and  in   hypersecretion.     It  points   strongly   against 


J 


5X8  TEE   STOMACH 

cancer  except  in  cases  where  an  ulcer  is  undergoing  malignant 
change. 

Hypochlorhydria. — A  diminished  secretion  of  hydrochloric  add 
occurs  in  the  late  stages  of  chronic  gastritis,  in  gastric  oeuiose,  in 
gastric  atrophy,  in  dilatation  of  the  stomach,  in  the  early  stages  of 
gastric  cancer,  and  sometimes  in  ulcer  when  associated  with  cfarouc 
gastritis  or  a  cachectic  condition.  It  is  also  diminished  in  fevai, 
wasting  diseases,  pernicious  anemia,  chlorosis,  neurasthenia,  ctc^ 

XnacA/wAydrta.—Hydrochloric  acid  is  absent  when  the  seaetiog 
glands  have  been  destroyed,  as  in  atrophic  catarrh  and  in  canca  d 
the  stomach.  A  diagnosis  of  cancer,  however,  cannot  be  made  on 
this  alone;  the  hydrochloric  acid  must  be  constantly  absent  and 
other  corroborative  facts  must  be  present. 


Fio.  531. — Stomach-tube  and  funnel  for  expressing  the  stomach  contents  *• 
Showing  the  lateral  fenestra;  b,  funDel;  c,  mark  to  indicate  the  distance  fm" ''' 
Dcisor  teeth  to  the  stomach. 

Hyperacidity,  or  an  increase  in  the  total  acidity,  may  be  the  rtsu* 
of  excessive  output  of  hydrochloric  acid  or  it  may  be  caused  ^ 
organic  acids  (lactic,  butyric,  and  acetic). 

Hypoacidity,  or  a  diminished  total  acidity,  denotes  a  defidencj' i" 
the  amount  of  hydrochloric  acid,  the  significance  of  which  has  be* 
mentioned  above. 

Lactic  acid  is  the  result  of  bacterial  fermentation.  It  is  founds 
appreciable  amounts  only  when  hydrochloric  acid  is  absent  and  * 
general  signifies  insufficiency  of  the  motor  power  and  stagnation  w 
the  stomach  contents,  as  is  found  in  dilatation,  obstruction  of  the 
pylorus,  and  cancer.  The  presence  of  lactic  acid  alone  is  not  dia(- 
nostic  of  cancer,  as  small  amounts  may  be  found  after  a  meat  iftt 


EXAMINATION*    OF    THE    STOMACH   CONTENTS 


529 


and  may  also  be  present  in  other  pathological  conditions,  nor  does  its 
absence  prove  the  nonexistence  of  cancer.  When,  however,  it  is 
found  in  considerable  amount  and  is  associated  with  an  absence  of 
hydrochloric  acid  and  with  deficient  motility,  it  is  strongly  sugges- 
tive of  cancer,  especially  if  the  Boas-Oppler  bacillus  is  also  present. 
Pepsin  and  rcnnin  are  only  absent  when  profound  organic  changes 
have  resulted  in  an  almost  complete  destruction  of  the  gastric 
mucous  membrane  as  the  result  of  chronic  inflammation,  severe 
atrophy,  etc.  The  presence  or  absence  of  these  ferments  is  thus  of 
importance  in  the  diagnosis  between  an  organic  change  and  a 
functional   ondttion. 

Extraction  of  the  Stomach  Contents. — The  stomach  contents 
may  be  removed  through  a  stomach-tube  either  by  the  aspiration  or 
expression  method.  The  expression  method  answers  in  the  great 
majority  of  cases,  but  it  may  fail  where  the  contents  of  the  stomach 
are  not  fluid  enough  to  flow  through  the  tube.  The  use  of  the 
stomach-tube  is  contralndicated  in  the  presence  of  aortic  aneurysm, 
in  patients  liable  to  cerebral  hemorrhage,  or  in  those  who  have  recently 
offered  from  gastric  or  pulmonary  hemorrhages,  in  those  who  are 


^^^  weak,  in  those  suffering  from  severe  pulmonary  or  cardiac 
troubles,  etc. 

Apparatus.— When    the    expression    method    of    removing    the 

^'omach  contents  is  employed  the  following  apparatus  wfll  be  re- 
'luired:  A  soft-rubber  stomach-tube  about  jo  inches  (75  cm.)  long 
"^^  ,'4  of  an  inch  (6  mm.)  in  caliber,  with  two  srpooth-edged  lateral 
^Peoings  and  a  blind  end,  connected  by  a  piece  of  glass  tubing  3  to  4 
^clies  (7,5  to  10  cm.)  long  to  2  feet  {60  cm.)  of  rubber  tubing,  to  the 
^M  of  which  a  glass  funnel  is  attached  (Fig.  531). 

When  aspiration  is  employed,  the  stomach-tube  may  be  connected 
*ith  a  bottle  aspirator,  with  a  stomach-pump,  or  with  a  rubber-bulb 
lorm  of  aspirator,  such  as  Boas'  apparatus  (Fig.  532).  The  bottle- 
*lJ»rator  (Fig.  533)  consists  of  a  large  glass  bottle  supplied  with  a 


530  TH£   STOllACH 

tightly  fitting  rubber  stopper  through  which  two  glass  tubes  past; 
one  of  these  is  connected  with  the  stomach-tube  while  to  the  otlier  i 
Potain  syringe  is  attached,  by  means  of  which  the  air  in  the  bottle 
is  exhausted. 


ff^ifi  yium^ 


Fto.  533- — Bottle  arTanged  for  asfuuting  the  stomach  c 

bottle;  b,  Inbiag  connected  with  &  Potain  aapintori  e,  the  itomach  tube. 


Fig.  534- — Introducing  the  stomach-tube.     First  step,  impaiting  a.  curve  to  tk  cDd 
of  the  tube  for  its  more  easy  passage. 

Asepsis. — The  stomach-tube  should  be  sterilized  before  use. 
Position  of  the  Patient. — The  patient  is  seated  upright  in  a  chair 
or  in  bed. 

Technic. — Artificia!  teeth  or  plates  should  be  removed  from 


Fig.  536.^ — Introducing  the  stomach- tube.    Third  step. 

nx.  The  patient  is  then  requested  to  swallow,  and  the  instni- 
is  thus  advanced  into  the  esophagus,  partly  by  the  swallowing 
1  and  partly  by  the  operator   (Fig.   535).     During  this  ma- 


532 


THE   STOMACH 


neuver  the  patient  is  instructed  to  breathe  regularly  and  deq)ly,  even 
if  a  sense  of  suffocation  is  produced,  and  to  hold  the  head  slightly 
forward  to  allow  the  escape  of  the  saliva  which  collects  in  the  throat 
(Fig.  536).  As  soon  as  the  tube  has  passed  the  entrance  of  the 
esophagus  it  may  be  readily  pushed  on  into  the  stomach  without 
any  difficulty.  The  distance  from  the  incisor  teeth  to  the  cardia  is 
about  16  inches  (40  cm.)  and  to  the  lower  border  of  the  healthy 
stomach  about  22  inches  (55  cm.),  but  in  pathological  conditions,  as 


Fig.  537. — Aspiration  of  the  stomach  contents.     First  step. 

in  dilatation,  for  example,  it  may  be  more.     When  the  tube  has 
introduced  for  the  proper  distance,  the  contents  of  the  organ 
removed,  either  by  expression  or  by  suction  furnished  from  one  of 
forms  of  aspirating  apparatus  described  above. 

Expression  of  the  stomach  contents  is  accomplished  by  pre 
over  the  region  of  the  stomach  while  the  patient  bends  forward 
strains  as  if  at  stool.     The  proximal  end  of  the  tube  is  in  the  m( 
time  lowered  over  a  dish  or  bowl  to  a  point  below  the  level  of  tb^ 
stomach. 


EXAMINATION   OF   THE   STOMACH  CONTENTS 


533 


Aspiration  with  the  Boas  aspirator  is  performed  as  follows:  With 
the  clamp  closed  the  operator  compresses  the  bulb  (Fig.  537)  and 
then  releases  it,  thus  filling  the  bulb  with  the  stomach  contents. 
The  clamp  is  then  opened  and  the  bulb  is  compressed,  causing  the 
contents  to  be  forced  out  into  a  receptacle  (Fig.  538). 

The  Fractional  Method  of  Gastric  Analysis. — In  the  frac- 
tional method  of  gastric  analysis  samples  ofthe  stomach  contents  are 
withdrawn  and  examined  at  frequent  intervals  during  the  whole 


Fig.  538. — AspiratioD  of  the  stomach  contents.     Second  step. 

''cle  of  gastric  digestion.  For  the  purposes  of  this  examination 
■eJifuss  has  devised  a  special  tube  of  small  size,  which  may  be  left 
*■  the  stomach  for  a  considerable  time  without  discomfort  to  the 
•^tient.  Samples  of  the  stomach  contents  are  removed  every  15 
"'inutes  after  the  administration  of  a  test  meal  till  the  close  of  diges- 
^a,  and  the  results  of  the  analyses  are  plotted  in  a  graphic  chart  or 
^^*fve.  In  this  way  the  chemical  composition  of  the  gastric  juice 
«1ring  every  phase  of  gastric  digestion,  and  the  progress  of  digestion 
M  any  time  after  the  ingestion  of  food  may  be  studied.     This  method 


i 


534 


THE  STOMACH 


consumes  more  time  than  the  older  methods  of  gastric  aiiafyss,bBt 
more  exact  iDformation  as  to  the  secretory  and  motor  power  of  the 
stomach  is  thus  obtained -than  is  possible  from  the  customary  sngle 
examination  one  hour  after  a  test  meal. 

ApparatuB. — -The  Rehfuss  tube  is  40  inches  (lOO  cm.)  longandNo. 
10  to  12  French  in  size.  The  proximal  end  is  adapted  to  fit  aiias~ 
pirator,  while  to  the  distal  end  is  fitted  a  metal  tip  heavy  enough  tj«3 
cause  it  to  gravitate  to  the  bottom  of  the  stomach.  The  tip  is  prc*. 
vided  with  slots  of  the  same  size  as  the  tubing  so  that  any  malai^ 
which  enters  the  tip  will  pass  through  the  tube.  A  glass  syringt  i 
employed  for  aspirating  (Fig.  539). 


I'lg-  539-— The  Rehfuss  tube  for  fractional  gastric  snalyNa. 

Asepsis.— The  apparatus  should  be  sterilized  by  boiling. 

Position  of  the  Patient, — The  patient  is  seated  upright  in  a  chan 
or  in  bed. 

Technic. — The  patient  is  given  an  Ewald  test  meal  (2  slices  o' 
bread  or  toast  and  2  glasses  of  water)  on  a  fasting  stomach  after  re- 
moval of  the  residium.  The  tube  is  inserted  in  the  following  mann*'' 
The  patient  is  directed  to  open  his  mouth,  and  the  tip  of  the  tul*' 
lubricated  with  glycerin,  is  placed  back  of  the  tongue  in  the  phai)""" 
by  the  examiner.  The  tube  is  then  carried  into  the  stomach  by  tw 
patient  swallowing.  In  this  he  may  be  aided  by  swallowing  * 
little  water  if  any  difficulty  is  met  in  getting  the  tube  down.  AlW' 
22  to  24  inches  (55  to  60  cm.)  of  tubing  is  passed.     From  iM '"  ^'' 


EXAMINATION    OF    THE    STOM.\CH   CONTENTS  535 

US  (5  to  10  c.c.)  of  the  stomach  contents  are  then  removed  at  15 
ute  intervals,  or  30  minute  intervals  if  digestion  is  very  slow, 
J  the  end  of  digestion,  that  is,  until  aspiration  shows  no  further 
I  particles.  The  specimens  are  collected  in  separate  containers 
are  labelled  and  later  examined,  and  the  results  are  tabulated  in  a 

c. 

ITariations  in  Curves  in  Health  and  Disease.— There  is  no  one 

1  of  secretory  curve  common  to  all  normal  stomachs,     Rehfuss, 

jeim.  and  Hawk  {Journal  American  Medical  Association,  Sept. 

1914)  describe  three  normal  types  of  curve: 

:.  The  Isosecretory  Type.— -The  curve  shows  a  steady  rise,  reach- 

1  high  point  of  60  for  total  acidity  and  40  for  free  acidity.     The 

.  point  is  maintained  for  from  )  2  to  i  hour  and  then  gradually 

ines.     Food  residue  disappears  in  2  to  2I.2  hours. 

!.  The  Hypersecretory  Type. — There  is  a  rapid  rise  of  the  curve, 

hing  a  high  point  of  70  to  100  for  acidity.     The  curve  shows  a 

slow  or  no  decline  in  the  usual  time.  Food  remnants  disappear 
to  2,^2  hours,  but  the  gastric  secretion  often  continues  for  half  an 

■  or  longer. 

;.  The    Hyposecretory    Type. — This    type   is   rare.     The    curve 

ly  rises,  reaching  a  high  point  of  40  to  50  for  acidity.    Digestion 

implete  in  2  to  zj-a  hours. 

iome  of  the  variations  in  the  curves  in  disease  are,  according  to 

n  (iV.  Y.  Medical  Journal,  Jan.  18,  1919),  as  follows; 

Ji  Gastric  ulcer  the  ascent  of  the  curve  is  rapid  and  its  height  is 

hed  within  an  hour  or  slightly  after.     The  high  point  for  total 

ity  is  between  :oo  and  no  and  for  free  acidity  between  60  and 

The  decline  is  gradual  or  sudden.     Blood  may  be  present, 
ri  Duodenal  ulcer  the  curve  shows  a  gradual  ascent.     The  height 
le  curve  is  not  reached  until  2}'2  hours  when  the  stomach  begins 
npty.     The  high  point  for  total  acidity  reaching  no  or  over  and 
ree  acidity  between  90  and  100, 

tn  Gastric  carcinoma  with  obstruction  the  total  acidity  may  be 
rial  or  slightly  above  normal,  while  the  free  acidity  is  entirely 
nt  or  rises  to  10  or  15  after  an  hour.     Blood  and  lactic  acid  are 

found.  In  carcinoma  of  the  cardia  with  no  obstruction,  both  the 
1  and  free  acidity  are  subnormal. 

Cahn  points  out  that  reflex  irritation  due  to  gall-stones,  appendi- 
,  colitis,  or  renal  colic  may  produce  a  marked  influence  upon  the 
ric  cur\-c,  and  results  similar  to  those  observed  in  duodenal  ulcer 

■  be  obtained. 


I 


536  THE   STOMACH 

TEST  OF  THE  MOTOR  FUNCTION  OF  THE  STOMACH 

By  the  motor  power  of  the  stomach  is  meant  the  ability  of  that 
organ  to  propel  its  contents  into  the  intestine.     When  this  functioa 
is  deficient,  as  from  obstruction  of  the  pylorus  due  to  cancer,  ulcer, 
etc.,  or  from  impairment  of  the  gastric  musculature,  food  accumu- 
lates in  the  stomach  and  dilatation  finally  results.     Early  recogni- 
tion of  perversion  of  the  motor  power  is  thus  of  great  importance. 
There  are  a  number  of  tests  for  determining  the  motor  function  of  the 
stomach,  among  which  are  the  following: 

Leu  he's  Test. — This  consists  in  giving  the  patient  a  test  meal 
composed  of  a  plate  of  soup,  a  beefsteak,  and  a  roll.  If  the  stomach 
is  empty  seven  hours  later  and  nothing  can  be  removed  by  lavage, 
the  motor  power  is  normal;  on  the  other  hand,  if  food  remains  in  the 
stomach  longer,  the  motor  power  is  deficient,  the  degree  of  impair- 
ment being  indicated  by  the  quantity  and  the  character  of  the  food 
remaining. 

Ewald^s  Test. — This  consists  in  administeiing  salol  to  a  patient 
after  a  meal  and  noting  the  length  of  time  before  salicylic  add  ap- 
pears in  the  urine.     Salol  is  unaffected  by  the  gastric  juice,  but  fe 
split  into  salicylic  acid  and  carbolic  acid  in  the  intestine.    In  pc^' 
forming  this  test  the  bladder  is  first  emptied;  the  patient  is  then  givc^ 
15  grains  (i  gm.)  of  salol  in  two  gelatin-coated  capsules  and  is  it^'^ 
structed  to  urinate  at  intervals  of  half  an  hour  for  two  hours  and  tO 
preserve  the  specimens  separately;  these  are  later  tested  with  neutral 
ferric  chlorid  solution  for  the  presence  of  salicylic  acid.    In  the  prc^^ 
ence  of  salicylic  acid  the  test  gives  a  violet-blue  color.    In  norm^ 
cases  the  salicylic  acid  should  be  recognized  in  the  urine  in  from  thirty 
to  seventy-five  minutes.    Delay  in  its  appearance  indicates  defidetJ^^ 
motor  power. 

lodipin  Test — This  drug  is  unaltered  by  the  gastric  juice,  but 
the  intestine  it  is  split  up  and  iodin  is  absorbed  and  eliminated 
the  saliva.     Fifteen  grains  (i  gm.)  of  iodipin  are  administe  ed 
gelatin-coated  capsules  in  the  morning  with  breakfast  and  the  saliv^^ 
is  then  tested  with  starch-paper  and  nitric  acid  for  iocUn  every  fifte^^"* 
minutes.     In  a  normal  case  the  iodin  is  recognized  in  the  saliv^""^ 
within  about  an  hour. 

TEST  OF  THE  ABSORPTION  POWER  OF  THE  STOMACH 

The  usual  method  of  determining  this  is  by  the  test  of  PenzoN 
and  F'aber.     It  is  performed  as  follows:  3  grains  (0.2  gm.)  of  chen^^^'- 


^^^^^^^r      TRANS LLLU]>tl NATION    OF    THE    STOMACH  537 

cally  pure  potassium  iodid  are  given  In  a  gelatin-coated  capsule  on 
on  empty  stomach,  and  the  urine  or  the  saliva  is  then  tested  with 
h-paper  and  fuming  nitric  acid  every  few  minutes  for  iodin.  Its 
mce  is  indicated  by  a  blue  or  a  violet  reaction,  Iodin  should 
rittmally  be  detected  in  the  saliva  and  urine  in  from  six  and  a  half 
to  fifteen  minutes  after  the  ingestion  of  the  iodid  of  potassium,  while 
its  appearance  is  considerably  delayed  if  the  absorption  power  is 
interfered  with. 

TRANSILLUMINATION   OF   THE    STOMACH,    OR   GASTRO- 
DIAPHANY 

A  method  introduced  by  Einhorn.  which  consists  of  transillumi- 
nating  the  stomach  by  means  of  a  small  electric  light  fastened  to  the 
end  of  a  rubber  tube.  By  this  method  of  diagnosis  the  position  and 
size  of  the  stomach  may  be  determined,  and  the  presence  and  posi- 
tion of  a  growth  or  a  thickening  of  the  anterior  wall  of  the  stomach 
nay  be  recognized  from  the  lack  of  transparency.  It  is  of  value  in 
Ae  diagnosis  of  dilatation  and  in  the  differentiation  of  this  condi- 
ion  from  gastroptosis.  In  the  former  the  illuminated  area  is  larger 
liaii  normal,  while  in  the  latter  it  is  small  and  situated  low  down. 
''"a.nsillumination,  however,  is  not  used  as  a  routine,  since  it  is 
orrjplicated  and  requires  special  apparatus,  furthermore,  there  are 
ifTipler  methods  of  determining  the  size  and  position  of  the  organ. 
'le  advantage  of  the  method  is  that  the  organ  is  seen  in  its  natural 
audition,  whereas  under  inflation  it  is  apt  to  be  stretched  beyond 
te  normal.  To  employ  the  method  successfully  it  is  necessary  that 
l^e  patient  be  accustomed  to  the  insertion  of  the  stomach  tube, 
'l^lierwise  retching  and  vomiting  will  interfere  with  the  examination. 

Apparatus. — Einhom's  gastrodiaphane  consists  of  a  small  Edi- 
**'n.  incandescent  lamp  attached  to  the  distal  end  of  a  soft-rubber 
sumach-tube.  The  wires  which  convey  the  electricity  to  the  lamp 
pa-ss  down  inside  the  tube  while  at  the  proximal  end  are  two  screws 
tor  attaching  the  wires  leading  from  the  battery.  A  six  to  eight 
•"V-cell  battery  furnishes  the  necessary  power. 

Lynch  has  modified  Einhom's  gastrodiaphane  by  employing  a 
longer  tube — 53  inches  (135  cm.)  long^ — sufliciently  long  to  pass 
^ough  the  pylorus — and  by  supplying  it  with  an  inner  auxiliary 
^^e  through  which  the  stomach  may  be  inflated  with  air  or  water 
'*"  the  contents  of  stomach  or  duodenum  may  be  aspirated  (Fig.  540). 

Asepsis. — The  instrument  should  be  sterilized  before  use. 


538  THE   ST01£ACH 

PoBition  of  the  Patient. — The  examination  is  performed  withthe 
patient  in  the  erect  position. 

Technic. — Transillumination  must  be  performed  upon  an  mp^ 
stomach;  if  necessary,  the  stomach  should  be  first  emptied  by  meau 
of  the  stomach-tube.  The  patient  is  then  given  two  glasses  of  wata 
to  drink  to  prevent  overheating  the  stomach  from  the  lamp.  The 
tube  is  moistened  with  water  and  is  carefully  guided  into  the  phar- 
ynx and  the  patient  is  instructed  to  swallow,  the  descent  of  the  tube 
being  aided  by  the  operator  who  pushes  it  on  as  soon  as  it  is  wdl 
within  the  esophagus.  When  the  lamp  is  within  the  stomach,  the 
illumination  is  turned  on  and  the  room  is  darkened,  while  the  results 


Fic.  540, — Lynch's  gastrodiaphane.     (Lynch.) 

of  the  transillumination  are  noted.  A  bright  lununous  areaviUbt 
noted  on  the  anterior  abdominal  wall  which  corresponds  in  si*  to 
the  outlines  of  the  stomach.  In  the  case  of  a  tumor  of  the  antefi* 
stomach  wall,  even  if  too  small  to  be  felt,  a  dark  patch  will  appearin 
the  illuminated  area. 

Variation  in  Technic. — In  order  to  increase  the  brilliancy  of  iht 
transillumination,  Kemp  advocates  the  introduction  of  fluorescfflit 
media  into  the  stomach  preliminary  to  the  passage  of  the  gastroda- 
phane.  It  is  claimed  for  this  method  that  it  is  possible  to  perfom 
a  satisfactory  transillumination  even  when  the  abdominal  walls  »« 
very  thick. 

Two  media  are  employed:  Bisulphate  of  quinin  and  fiuorescon. 
The  former,  which  gives  a  pale  violet  fluorescence,  is  administwrf 
in  the  proportion  of  bisulphate  of  quinin  gr.  x  (0.65  gm.)  to  1  [W"' 
(500  c.c.)  of  water  with  the  addition  of  5  tijp  (0.30  c.c.)  of  dilnt* 


^^^^^^H  CASTROSCOPY  539 

J^lioric  or  sulphuric  acid  to  increase  the  acidity  and  so  intensify 

fluorescence. 

Fluorescein,  which  gives  a  green  fluorescence,  is  administered  as 
,ows:  The  patient  is  given  S  ounces  (236  c.c.)  of  water  to  drink 
which  is  dissolved  15  grains  (i  gm.)  of  sodium  bicarbonate  to 
ider  alkaline  the  acid  stomach  contents,  A  second  drink  is  then 
en,  consisting  of  8  ounces  of  water  (236  c.c.)  in  which  are  mixed 

ta  J-i  grain  (0.008  to  0.016  gm.)  of  fluorescein,  1  dram  (4  c.c.) 
glycerin,  and  15  grains  (i  gm.)  of  bicarbonate   of  soda.     After 

administration  of  the  fluorescent  medium  the  lamp  is  introduced 
[  the  ejcamination  is  proceeded  with  as  above. 

GASTROSCOPY 
Gastroscopy  consists  in  the  insertion  into  the  stomach  of  a  stiff 
al  tube,  illuminated  by  electricity,  through  which  the  interior  of 

organ  is  inspected.  This  method  of  examination  was  inaugu- 
d  by  Mikulicz  in  1881,  but,  on  account  of  its  limited  value  and 

technical  difTiculties  in  the  use  of  the  older  instruments,  it  never 
le  into  general  use.  Later,  in  1890,  Rosenheim  devised  a  gastro- 
>e  on  similar  principles.  Both  these  instruments  were  made  with 
iDis  on  the  principle  of  the  cystoscope,  but  the  fact  that  they  were 
ited  bhndly  and  not  under  the  sight  of  the  operator  proved  a 
ous  drawback.  Chevalier  Jackson,  in  1906,  designed  a  gastro- 
pe  on  entirely  different  principles  employing  large  tubes  with 

illumination  at  the  distal  end,  similar  to  those  used  in  direct 
cheo-bronchoscopy  and  esophagoscopy,  and  he  thus  made  it  pos- 
le  to  explore  a  considerable  portion  of  the  stomach  by  direct 
ion.  As  a  rule,  from  two-thirds  to  three-fourths  of  the  stomach, 
luding  the  pylorus,  is  available  for  examination  with  this  form 
lutrument,  depending  upon  the  range  of  lateral  motion  of  the  hiatus 
phagei.     A  stomach  which  occupies  a  vertical  position  presents 

largest  area  for  exploration  while  the  more  horizontally  the  or- 
I  k  placed  the  less  of  it  will  be  available  for  examination.  Further- 
re,  under  direct  view  gastroscopy  lesions  may  be  palpated  by 
Ins  of  a  probe  passed  through  the  instrument,  applications  may 
made  to  diseased  areas,  foreign  bodies  may  be  removed,  and  sec- 
is  of  tumors  may  be  excised  for  microscopical  examination.  A 
her  advance  in  gastroscopy  was  made  in  i9iobyHillinconjunc- 

with  Herschell,  who  combined  a  direct  and  indirect  view  esopha- 
istroscope  and  added  to  the  instrument  a  tap  for  inflating  the 
lach  with  air. 


n 


540  THE   STOMACH 

Gastroscopy,  however,  cannot  supplant  other  methods  of  diagno- 
sis. It  necessitates  that  the  patient  submit  to  a  general  anesthetic 
and  requires  such  experience  and  dexterity  on  the  part  of  the  operator 
for  its  proper  performance  as  to  place  it  outside  the  domain  of  any 
but  experts.  According  to  Jackson,  gastroscopy  is  without  danger 
other  than  that  from  the  anesthesia.  At  the  same  time,  the  opera- 
tion  requires  great  skill  which  is  best  obtained  by  practising  upon  the 
cadaver.  He  considers  the  operation  unadvisable  under  the  follow- 
ing conditions:  "In  the  profound  cachexia  of  the  last  stages  of  malig- 
nancy; in  the  profound  anemia  of  inanition  from  known  or  unknown 
causes;  cardiac,  pericardiac,  or  major  vascular  lesions;  general  or 
local,  acute  or  chronic  conditions  associated  with  either  dyspnea  or 
dropsical  effusions;  the  late  stages  of  organic  diseases,  as  dnhosk 
of  the  liver,  etc."  Diseases  of  the  esophagus  may,  of  course,  inter- 
fere with  or  render  gastroscopy  out  of  the  question. 


Fig.  541. — ^Jackson's  gastroscope. 

Apparatus. — Jackson's  gastroscope  (Fig.  541)  consists  of  a  cylin- 
drical tube  about  32  inches  (80  cm.)  long  with  a  lumen  2/5  indi 
(10  mm.)  in  diameter,  and  with  a  thickened  distal  end.  In  the  wall 
of  the  instrument  are  two  small  accessory  tubes;  one  through  whidi 
the  illuminating  apparatus  is  inserted  and  the  other  for  the  purpose 
of  aspirating  fluids  that  may  interfere  with  the  examination.  To  the 
proximal  end  of  this  latter  tube  an  aspirating  apparatus  is  attached. 
The  instrument  is  also  provided  with  an  obturator  having  a  conical 
tip  to  facilitate  its  insertion. 

The  Hill-Herschell  esophagogastroscope  (Fig.  542)  for  combined 
direct  and  indirect  gastroscopy  consists  of  a  direct  view  tube  with  the 
illumination  supplied  at  the  proximal  end  from  a  Briinings  hand 
lamp  and  an  indirect  view  periscopic  tube  with  a  terminal  lamp, 
which  can  be  passed  through  the  direct  view  tube.  The  direct  view 
tube  is  supplied  with  a  cap  containing  a  plain  glass  window  and  a 
tap  through  which  air  can  be  forced  for  the  purpose  of  inflation.   A 


GASTROSCOPY 


541 


second  cap,  also  with  an  inflating  tap  and  with  a  rubber-lined  opening 
ior  the  passage  of  the  indirect  view  tube,  is  provided.  Both  caps 
are  fastened  to  the  proximal  end  of  the  tube  by  means  of  a  bayonet 
joint. 

Asepsis. — The  tube  may  be  boiled  and  the  light-carrying  appara- 
tus may  be  sterilized  by  immersion  in  a  i  to  20  carbolic  acid  solution^ 
.  followed  by  rinsing  in  alcohol,  or  alcohol  alone  may  be  employed. 

1 


a  be 

Fig.  542. — Hill-Herschell  esophagogastroscope.  a,  Direct  view  esophagoscope 
with  Brtinings  lamp;  6,  indirect  view  periscope;  c,  shows  instrument  assembled  for 
gastroscopy. 

Preparations. — These  should  include  the  ordinary  preparations 
for  a  general  anesthetic;  that  is,  the  patient  is  given  a  cathartic  the 
night  before  the  operation  and  food  is  withheld  for  a  period  of  twelve 
hours  before  the  operation  (see  also  page  18).  It  is  essential  that 
the  stomach  be  empty  when  gastroscopy  is  performed,  and,  if  neces- 
sary, lavage  of  the  stomach  should  be  practised  three  or  four  hours 
previous  to  the  operation.  In  dilatation  with  atony  preliminary 
lavage  is  a  necessity. 


542 


THE   STOMACH 


Position  of  the  Patient. — The  patient  is  placed  in  the  recumbent 
posture  with  the  shoulders  brought  4  to  6  inches  (10  to  15  cm.)  over 
the  edge  of  the  table  and  the  head  supported  by  an  assistant  seated 


H^r^i 


Fig.  543. — Position  of  patient  for  gastroscopy.     (After  Jackson.) 

at  the  head  of  the  table  and  to  the  right,  after  the  manner  shown  in 
the  accompanying  illustration  (Fig.  543).  This  assistant  also  con- 
trols the  mouth  gag.    Jackson  recommends  that^  as  soon  as  the  tube 


Fig.  544. — Method  of  inserting  the  gastroscope.     (After  Jackson.) 

is  passed,  the  head  of  the  table  be  raised  a  distance  of  about  12 
inches  (30  cm.). 

Anesthesia. — General  narcosis  with  ether  is  employed.    Unless 
the  patient  is  deeply  anesthetized,  retching  will  take  place,  which 


GASTROSCOPY 


543 


II  not  only  interfere  with  the  examination,  but  may  make  the  pro- 
iure  a  dangerous  one. 

Technic- — i.  Direct  View  Gaslroscopy. — The  mouth  gag  is  in- 
■ted  and  the  operator  introduces  the  left  forefinger  into  the  patient's 
»uth  to  the  base  of  the  tongue  or  behind  the  epiglottis  and  draws 
;  tongue  downward.  The  gastroscope,  well  lubricated,  and  held  in 
:  operator's  right  hand,  is  then  introduced,  following  the  fore- 
ger,  aheady  in  the  patient's  mouth,  as  a  guide  (Fig.  544).  At 
s  stage  the  assistant  who  controls  the  patient's  head  should  bend 
r  patient's  neck  well  backward  so  as  to  bring  the  mouth  and 
phagus  in  as  straight  a  line  as  possible.  As  soon  as  the  instru- 
Dt  has  been  passed  beyond  the  entrance  of  the  esophagus,  the 
urator  is  withdrawn  and  the  light  is  turned  on.     The  instrument 


PlE  S*S- — Sho«-ing  Lhe  head  and  neck  of  patient  drawn  tci  the  right  to  allow 
instromenl  to  pass  tlirough  the  hiaiui  and  abdominal  esophagus.     (After  Jackson.) 

massed  the  rest  of  the  way  entirely  by  sight,  care  being  taken  to 
nd  compressing  the  trachea  by  the  point  of  the  instrument.  To 
is  the  hiatus  at  the  diaphragm,  the  instrument  is  rotated  in  such  a 
y  that  the  long  axis  of  a  cross  section  of  the  tube  corresponds  to 
It  of  the  hiatus  (this  extends  from  behind  and  the  right  to  the  front 
d  the  left).  To  pass  the  abdominal  esophagus  as  it  bends  to  the 
t,  the  head  and  neck  of  the  patient  are  turned  to  the  right  (Fig. 
S).  When  the  tube  has  entered  the  stomach,  the  interior  of  the 
gan  should  be  systematically  explored  according  to  the  technic 
scribed  by  Jackson,'  which  the  writer  takes  the  liberty  of  quoting: 

'Jackson.     Trpcheo  bronchoscopy,  Esophagoscopy,  and   Gastroscopy,   page   149. 


{ 


544  1^^   STOMACH 

"There  are  two  plans  of  exploration,  both  of  which  should  be 
carried  out.  First,  the  gastroscope  should  be  passed  downcarefuDy 
and  gently  to  the  greater  curvature,  inspecting  the  anterior  and  pos- 
terior walls.  At  times  these  walls  do  not  seem  to  be  fully  coBapscd 
ahead  of  the  tube,  and  one  will  have  to  be  examined  first,  that  the 
other.  Then  the  tube  is  withdrawn,  inclined  slightly  laterally  in  the 
same  plane,  then  pushed  gently  downward  again  in  a  new  series  d 
folds.  This  is  repeated  until  the  extreme  pyloric  limit  is  reached. 
To  reach  this  limit  the  head  and  neck  of  the  patient  are  moved  to  the 
left,  with  the  tube  below  the  cardia  (Fig.  546). 

"After  the  whole  possible  range  has  been  covered  in  this  way 
we  proceed  to  the  second  plan.     The  tube  is  passed  down  until  the 


Fig.  546. — Showing  ihe  patient's  head  and  neck  turned  to  the  left  to  kUow  the  instru- 
ment to  reach  the  pyloric  end.     (After  Jackson.) 

extremity  touches  the  wall  of  the  greater  curvature,  in  the  extreme 
left  of  the  possible  field.  Then  the  tube  is  moved  slowly  along  the 
greater  curvature,  but  not  in  too  close  contact  therewith,  until  the 
extreme  right  is  reached.  Withdrawing  the  tube  a  centimeter  or  two, 
the  field  is  slowly  swept  again  in  the  same  plane,  but  at  a  higher 
level,  and  so  on,  upward  to  the  cardia.  Next  the  left  fingers  of  one 
skilled  in  abdominal  palpation  are  called  upon  to  manipulate  the 
unexplored  portions  over  the  front  of  the  tube.  This  is  sometimes 
better  accomplished  by  turning  the  patient  on  his  side,  first  on  one 
side,  then  on  the  other.  During  all  these  manipulations  the  tube 
must  be  withdrawn  within  the  esophagus;  when  the  stomach  is  w 
its  new  position,  the  gastroscope  is  again  pushed  downward  and  th* 


>.   547' — The  passage  of  the  outer  tube  of  the  Hill- Hcrschell  esophagogaslroscope 
I  the  esophagus  under  direct  vision.     (Mayo  Kobson  in  Keen's  Surgery.) 
.  348. — Method  of  i«rforminK  indirect  view  gaslroscopy  with  the  Hill-Her- 
istruDieiit.     (Mayo  Robson  in  Keen's  Surgery.) 

istroscope  is  passed  on  down  until  the  greater  curvature  is 
Qtered,  and  the  distance  from  the  teeth  is  again  taken.  The 
■nee  between  this  and  the  first  measurement  gives  the  vertical 
ter  of  the  stomach  at  this  point.  Care  must  be  used  that  the 
rements  are  not  rendered  inaccurate  by  pushing  the  greater 
:ure  downward,  wliich  is  exceedingly  easy  to  do  without  know- 


H 


546  THE   STOMACH 

ing  it  if  the  sense  of  touch  is  relied  upon  to  determine  when  the  lower 
wall  is  reached.     If  the  downward  progress  of  the  gastroscope  is 
watched  through  the  upper  orifice  it  is  easy  to  see  when  the  wall  at 
the  greater  curvature  is  touched.    Having  taken  our  measuranents, 
we  then  place  the  obturator  externally  parallel  to  the  tube  within  ani 
indicate  to  the  abdominal  manipulator  the  exact  position  of  the  lower 
end  of  the  tube,  which  he  can  then  mark  on  the  skin,  giving  thus  with, 
absolute  accuracy  the  exact  location  of  the  greater  curvature  of  tke 
empty  stomach  at  that  point.     Care  must  be  taken,  of  course,  U> 
resterilize  the  obturator  should  it  touch  anything  unclean." 

2.  Combined  Direct  and  Indirect  View  Gastroscopy, — ^The  outer 
direct  view  tube  is  passed  into  the  stomach  under  the  sight  of  the 
operator  (Fig.  547)  in  the  manner  previously  described  for  the  pass- 
age of  Jackson's  gastroscope  (page  543).  With  the  tube  in  the  stom- 
ach the  cardiac  region  may  be  examined  by  direct  vision  under  in- 
flation. The  optical  window  and  the  hand  lamp  are  then  removed,! 
handle  taking  the  place  of  the  lamp  and  the  perforated  cap  the  place 
of  the  glass  window.  The  indirect  view  tube  is  now  passed  throu^ 
the  perforated  cap  and  outer  tube,  being  careful  to  begin  the  infla- 
tion before  it  enters  the  stomach  so  that  the  window  of  the  peri- 
scope will  not  be  soiled  from  contact  with  the  mucous  membrane. 
The  pylorus  is  first  located  (Fig.  548)  and  from  this  as  a  starting  point 
the  remainder  of  the  stomach  is  inspected  in  detail,  slowly  withdraw- 
ing and  turning  the  gastroscope  so  that  all  portions  are  brought  to 
view.  The  region  of  the  cardia,  however,  can  only  be  inspected  by 
direct  view. 

SKIAGRAPHY 

The  X-ray  is  useful  in  locating  foreign  bodies  impermeable  to  the 
rays  and  in  determining  the  size,  position,  and  peristaltic  move- 
ments of  the  organ.  By  inserting  a  long  soft  stomach-tube,  which  is 
filled  with  bismuth  or  shot,  in  the  stomach  along  the  greater  curva- 
ture and  then  taking  an  X-ray  while  the  patient  is  in  the  erect  posi- 
tion, the  outline  of  the  stomach  and  position  of  the  pylorus  have  been 
mapped  out.  Another  method  of  determining  the  size  and  position 
of  the  stomach  is  to  have  the  patient  swallow  keratin-coated  capsules 
of  bismuth  or  to  give  the  patient  on  an  empty  stomach  a  pint  {yx>  c.c.) 
of  milk,  kumiss,  mucilage  of  acacia,  or  gruel  into  which  two  ounces 
(60  gm.)  of  bismuth  subcarbonate  or  the  oxychlorid  of  bismuth  is 
suspended  by  a  thorough  mixing.  These  may  be  administered 
shortly  before  the  skiagraph  is  taken.     Pictures  should  be  taken  with 


LAVAGE   OF  THE   STOMACH  547 

patient  recumbent  and  in  the  erect  posture.  A  normal  stomach 
should  show  an  absence  of  bismuth  in  from  three  to  six  hours  after 
the  ingestion  of  the  bismuth  meal. 

EXPLORATORY  LAPAROTOMY 

An  exploratory  laparotomy  is  the  most  valuable  of  all  the  methods 
of  diagnosis  in  diseases  of  the  stomach,  and  in  many  cases  it  is  the 
o^y  method  by  which  a  correct  diagnosis  can  be  arrived  at.     It  is 
^^  operation  that  only  requires  a  small  incision  and  which,  if  properly 
^Tried  out,  is  without  danger  to  the  patient.     The  ease  and  slight 
risk  with  which  it  may  be  performed  are,  however,  apt  to  lead  to 
*    Neglect  of  other  simpler  methods  of  diagnosis  and  result  in  its  em- 
ployment in  far  too  radical  a  manner.     It  is  only  justifiable  where  a 
careful  trial  of  other  means  has  failed  to  establish  a  diagnosis.    Thus, 
for  example,  in  cases  where  a  cancerous  growth  is  strongly  suspected 
but  its  presence  cannot  be  verified,  or  where  a  palpable  tumor  of  the 
stomach  is  present,  and  there  is  a  question  as  to  its  character  and 
whether  it  can  be  removed  or  not,  an  exploratory  incision  is  certainly 
a  justifiable  procedure  and  its  prompt  performance  is  clearly  indi- 
cated, since  an  early  recognition  of  the  trouble  furnishes  the  only  hope 
of  cure.    The  surgeon  must  be  convinced,  however,  that  he  can  ac- 
complish something  for  the  relief  of  the  patient -before  it  is  attempted, 
and  he  must  be  prepared  to  carry  out  any  operative  procedure  that 
seems  indicated.    To  perform  an  exploratory  laparotomy  simply  for 
the  purpose  of  making  a  correct  diagnosis  in  an  individual  who  is 
manifestly  not  fit  for  a  severe  operation  or  upon  whom  it  is  evident 
that  the  performance  of  a  gastroenterostomy  would  give  scarcely 
any  hope  for  relief  of  his  symptoms  is  unjustifiable. 

Therapeutic  Measures 

LAVAGE  OF  THE  STOMACH 

Lavage  consists  in  washing  out  the  stomach  by  introducing  water 
or  other  fluids  through  a  stomach-tube  or  catheter  and  then  siphon- 
ing it  oflf.  It  is  a  most  useful  therapeutic  procedure  and,  if  per- 
formed with  proper  precautions,  is  without  danger. 

Indications. — Gastric  lavage  may  be  required  for  the  following 
purposes:  (i)  To  remove  poison  and  drugs  from  the  stomach.  (2) 
To  remove  mucus,  undigested  and  fermenting  food  from  a  dilated  or 


548  THE   STOMACH 

atonic  stomach  when  the  stomach  is  unable  to  empty  itself  of  its 
contents  after  eight  or  ten  hours     In  such  conditions  la vage  is  espe- 
cially valuable,  as  it  cleanses  the  mucous  membrane  in  preparation 
for  fresh  food  and  thus  promotes  the  appetite;  at  the  same  time  the 
stomach  is  toned  and  strengthened.     (3)  To  withdraw  the  irritating 
material  from  the  stomach  in  acute  gastric  indigestion,  especially 
in  infants.     (4)  For  the  purpose  of  cleansing  the  stomach  in  prepara- 
tion for  gastric  operations.     (5)  In  intestinal  obstruction  and  per- 
itonitis with  fecal  vomiting  for  the  purpose  of  diminishing  the  vomit- 
ing and  at  the  same  time  removing  toxic  material  from  the  digestive 
tract;  and  as  a  preliminary  to  operation  in  such  cases  where  it  k  im- 
portant to  have  the  stomach  empty  to  avoid  the  danger  of  vomited 
matter  entering  the  air-passages.     (6)  Finally,  lavage  may  be  cnx- 
ployed  when  it  is  desired  to  bring  medicated  solutions  in  contact 
with  the  gastric  mucous  membrane,  though  a  more  efficacious  method 
is  by  means  of  the  stomach  douche. 

The  contraindications  to  lavage  are  practically  the  same  as  thos* 
given  against  the  use  of  the  stomach-tube  for  diagnostic  purposes, 
viz.,  in  the  presence  of  recent  gastric  hemorrhage,  in  acute  inflamm^' 
tion  of  the  stomach,  in  aortic  aneurysm,  in  advanced  uncompensated 
valvular  heart  lesions,  etc.  In  cases  of  marked  general  arterio- 
sclerosis and  in  general  weakness  or  prostration  it  should  be  used 
with  caution. 

Apparatus. — The  employment  of  a  stomach-pump  is  not  advis^ 
able  on  account  of  the  danger  of  injuring  the  mucous  lining  of  tl:*^ 
stomach;  instead,  an  ordinary  siphonage  apparatus  should  be  enc"-' 
ployed.     This  consists  of  a  soft-rubber  stomach-tube  joined  \>^ 
means  of  3  to  4  inches  (7.5  to  10  cm.)  of  glass  tubing  to  a  piece  c^* 
rubber  tubing  2  to  3  feet  (60  to  90  cm.)  long,  to  the  free  end  of  whic^^^ 
a  glass  funnel  having  a  capacity  of  about  a  pint  (500  c.c.)  is  fitted 
(see   Fig.    531).     The   stomach-tube   should   be   about   30  inch^?^ 
(75  c.c.)  long,  }4:  to  >2  an  inch  (6  to  12  mm.)  in  diameter,  aa^^ 
should  be  provided  preferably  with  a  closed  tip  and  with  two  later^^ 
openings  of  fairly  large  size  so  as  to  give  passage  to  solid  particl^^^ 
of  food  (Fig.  549).     These  openings  should  be  situated  as  close  t 
the  tip  as  possible.     The  tube  should  also  have  a  mark  indicating 
the  distance  from  the  upper  incisor  teeth  to  the  stomach,  so  that  th 
operator  may  know  when  he  has  passed  it  a  sufficient  distance. 

For  an  infant  the  following  apparatus  may  be  employed:  A  sof 
rubber  catheter,  16  American  (24  French)  in  size,  provided  with  ^ 
large  lateral  eye  and  joined  by  a  glass  connection  to  2  feet  (60  cm.^  ^ 


jDbing,  to  the  Iree  end  of  which  an  8-ounce  (250  c.c.) 
is  attached.     In  addition,  a  mouth  gag  may  be  required. 

' — The  whole  apparatus  should  be  sterilized  by  boiling  or 

6n  in  an  antiseptic  solution  and  then  rinsed  in  water  be- 
After  use  it  should  be  thoroughly  cleansed,  care  being 

jt  that  particles  of  food  are  not  left  adher- 

interior  of  the  tube,  especially  about  the 

lows. 

IS   Employed. — For    cleansing    purposes 

warm  water  is  generally  employed.     To 

tnach  of  niucus,  alkaline  mineral  waters, 

1  or  Vichy,  or  Carlsbad  salt,  i  dr.  (4  gm.) 
(1000  c.c.)  of  water,  or  sodium  bicarbo- 

;  per  cent.),  may  be  employed. 

ature. — The  solution  should  be  of  a  tem- 

frora  90°  to  100°  F.  (32"  to  38°  C), 

f. — The  stomach  should  not  be  overdis- 

t  solution,  about  a  pint  (500  c.c.)  being 

at  a  time.    The  washing-out  process  is 

nued,  however,  until  the  contents  of  the 

turn  clear,  provided  the  patient's  con- 
tits   it.     In  some  cases  the  process  must 

[  ten  or  twelve  times  before  this  is  at- 

^  Lavage.— When  employed  to  remove 

ood  from  a  dilated  stomach,  lavage  may 
ed  either  in  the  morning  before  the  first 

night,  three  or  four  hours  after  the  last 

former  time  is  preferable,  as  the  stomach 

en  aU  possible  opportunity  for  assimila-     "it"  ii  closed  end 

•^  ,  .  1  ■         ■  1         ""d    lateral    len- 

contents  and   no  nourishment  is  with-     estn. 

'Some  cases,  however,  when  the  distress 
he  flatulency  is  such  as  to  interfere  with  the  night's  rest, 
■age  is  indicated.  In  very  severe  cases  it  may  be  neces- 
b  out  the  stomach  twice  a  day,  night  and  morning. 
of  Patient. — The  patient  sits  in  a  chair  facing  the  opera- 
e  head  slightly  bent  forward.  If  the  patient's  condition 
I  this  is  not  advisable,  the  operation  may  be  performed 
sient  semiupright  in  bed,  A  child  should  be  supported 
position  upon  the  lap  of  a  nurse  with  its  head  held  for- 


55° 


THE  STOMACH 


ward  by  an  assistant  so  as  to  allow  saliva  and  vomitus  to  escape 
from  the  mouth. 

Anesthesia. — In  case  gagging  is  excessive,  the  pharynx  msy  be 
sprayed  or  painted  with  a  5  per  cent,  solution  of  cocain.  This  is 
rarely  necessary,  however,  after  the  first  passage  of  the  tube. 

Technic. — Plates  or  artificial  teeth  should  be  removed  from  the 
patient's  mouth  and  an  apron  or  large  towel  should  be  fastened 
about  the  neck  and  allowed  to  hang  over  the  chest  and  lap  for  protec- 
tion.   The  patient  should  be  given  a  small  bowl  to  catch  any  vomitui 


Fig.  550.— Showing  ihe  method  of  washing  out  the  stoitiach.     (After  Boston.) 


or  saliva  that  may  escape  from  the  mouth.  The  tube  is  then  well 
moistened  with  water  to  facilitate  its  passage.  Oily  lubricants 
should  be  avoided  on  account  of  the  disagreeable  taste.  As  a  rule, 
with  a  soft  tube  it  is  unnecessary  to  hold  the  base  of  the  tongue 
forward  or  to  guide  the  tube  in  place  by  the  fingers.  The  tube  is 
simply  passed  along  the  roof  of  the  patient's  mouth  until  the  phao""* 
is  reached,  when  the  patient  is  instructed  to  swallow  and  the  instni- 


LAVAGE   OP   THE   STOMACH 


551 


ment,  grasped  by  the  pharyngeal  muscles,  is  carried  on  into  the 
esophagus  (see  Fig,  535).  At  first  there  may  be  some  irritation  and 
gagging,  but  by  having  the  patient  breathe  in  deeply  and  regularly 
this  rapidly  subsides.  When  a  patient  becomes  accustomed  to  Qie 
passage  of  the  tube  there  is  very  little  if  any  discomfort  produced. 

As  soon  as  the  tube  enters  the  esophagus  it  is  rapidly  pushed  on 
into  the  stomach.  Frequently  when  the  tube  enters  the  stomach  the 
contents  immediately  escape  into  the  funnel;  if  not,  the  funnel 
should  be  lowered  and  the  contents  drained  off.    To  accomplish  this 


Fio.  SS'' — Showing  the  passage  of  a  stomach-tube  through  the  nose  in  periorming 
gastric  lavage  upon  infants. 

it  may  be  necessary,  however,  to  apply  some  slight  pressure  over  the 
epigastrium,  after  the  method  employed  in  expressing  a  test-meal 
(see  page  532). 

Having  removed  the  contents  of  the  stomach,  or  being  sure  that 
it  is  empty,  the  tube  is  pinched  close  to  the  patient's  mouth,  and  the 
funnel  is  elevated  slightly  and  filled  with  about  a  pint  (500  c.c.)  of 
solution  (Fig.  550),  The  compression  is  then  removed  from  the 
tube  and  almost  the  entire  contents  of  the  funnel  is  allowed  to  slowly 
run  into  the  stomach,  enough  solution  being  kept  in  the  funnel,  how- 
ever, to  start  the  siphonage.    The  funnel  is  then  lowered  and  the 


552  THE   STOMACH 

contents  of  the  stomach  are  siphoned  back  into  the  funnel  and  dis- 
carded, care  being  taken  to  see  that  approximately  the  same  quantity 
returns  as  was  introduced.  The  process  of  lavage  is  continued  by 
afternately  pouring  solution  into  the  stomach  through  the  funnd 
and  then  removing  the  solution  by  siphonage.  In  order  to  reach  all 
portions  of  the  stomach  and  more  thoroughly  cleanse  the  mucous 
membrane,  it  is  well  to  have  the  patient's  position  changed  during 
the  lavage;  for  example,  after  one  or  more  washings  in  the  upright  po- 
sition have  the  patient  lie  down  and  then  roll  first  to  one  side  and  then 
to  the  other. 

At  the  completion  of  the  lavage  the  tube  is  removed  as  follows: 
A  small  quantity  of  fluid  is  allowed  to  remain  in  the  funnel  and,  as 
the  tube  is  slowly  withdrawn,  this  is  permitted  to  flow  back  into  the 
stomach  until  the  end  of  the  tube  is  in  the  esophagus.  The  tube  is 
then  tightly  pinched  to  prevent  the  solution  from  escaping  as  the 
tube  is  withdrawn  over  the  larynx  and  through  the  mouth.  The 
important  point  is  that  the  tube  should  not  be  removed  from  the 
stomach  empty,  as  portions  of  mucous  membrane  may  be  drawn  into 
the  fenestras  of  the  tube  and  be  lacerated  or  otherwise  injured. 

Variation  in  Technic. — In  insane  individuals  or  imruly  children 
who  try  to  prevent  the  passage  of  the  tube  by  refusing  to  open  the 
mouth  or  by  bitting  the  instrument,  the  tube  may  be  passed  through 
a  nostril  (Fig.  551).  As  a  rule,  this  method  of  introduction  is  not 
diflScult,  as  the  tube  hugs  the  posterior  wall  of  the  pharynx  and  read- 
ily enters  the  esophagus.  A  smaller-size  tube,  however,  is  required, 
and  care  should  be  taken  to  see  that  it  is  well  lubricated. 

THE  STOMACH  DOUCHE 

Gastric  douching  consists  in  irrigating  the  stomach  by  means  of 
solutions  introduced  under  pressure.  The  fluid  is  preferably  intro- 
duced through  a  tube  provided  with  many  small  lateral  openings,  so 
that  all  portions  of  the  mucous  lining  of  the  stomach  are  irrigated  by 
the  solution  which  flows  out  in  fine  streams  with  considerable  force. 
Either  plain  water  or  medicated  solutions  are  employed  in  the  douche. 

The  stomach  douche  is  useful  in  slight  degrees  of  motor  insuffi- 
ciency for  the  purpose  of  stimulating  peristalsis  and  secretion.  It  is 
also  employed  in  neuroses  affecting  the  sensory  apparatus  of  the 
stomach. 

Apparatus. — A  glass  funnel  with  a  capacity  of  i  pint  (500  cc), 
a  piece  of  rubber  tubing  2  to  3  feet  (60  to  90  cm.)  long,  a  glass  con- 


I  tube  3  to  4  inches  (7.5  to  10  cm.)  long,  and  a  stomach-tube 
30  inches  (75  cm.)  long,  with  a  large  number  of  side  openings 

t^T  inch  (i  to  a  mm.)  in  diameter  and  a  terminal  opening 
}-i  inch  (3  to  4  ram.)  in  diameter,  should  be  provided  (Fig. 

The  large  opening  in  the  end  of  the  tube  is  necessary  in 
to  drain  the  solution  quickly  out  of  the  stomach  and  at  the 
ime  remove  any  solid  particles, 

ihom  has  devised  a  douche  apparatus  which  consists  of  a 
■  lube  26  inches  (65  cm.)  long  and  ?8' inch  (9  mm,)  in  diameter, 


~A.n  enlarged  view  of  b  stomach* 
douche  tube. 


— Linhnrn's  apparatus  for  ffv- 
ing  a  stomach  douche. 


lating  at  the  stomach  end  in  a  hard-rubber  cap  with  numerous 
lenings  and  a  large  end  opening  (Fig.  553).  Within  the  tip  of 
ip  lies  a  freely  movable  aluminum  ball  which  is  prevented  by 
tjssbars  from  entering  the  main  portion  of  the  tube.  This  ball 
ver  the  terminal  opening  as  the  solution  flows  into  the  stomach 
luses  the  fluid  to  flow  out  through  the  small  openings.  When 
rrent  is  reversed,  the  ball  is  driven  upward  and  the  solution  is 
i  off  through  the  large  opening. 


554  THE   STOMACH 

Asepsis. — The  apparatus  should  be  boiled  or  immersed  in  an  anti- 
septic solution  and  then  rinsed  off  before  use,  and  should  be  thor- 
oughly cleansed  after  use. 

Solutions. — Plain  boiled  water  is  usually  employed.  For  the 
removal  of  mucus,  alkaline  solutioAS,  as  sodium  bicarbonate  (i  to  5 
per  cent.),  Carlsbad  salt  i  dr.  (4  gm.)  to  i  quart  (1000  ex.)  of  water, 
etc.,  are  used.  As  antiseptics  and  antifermentatives  are  the  follow- 
ing: salicylic  add  (0.3  per  cent.),  sodium  salicylate  (0.5  to  i  per 
cent.),  boric  add  (2  to  3  per  cent.),  sodium  benzoate  (i  to 3  percent), 
resordn  ( i  to  3  per  cent.),  creolin  (0.5  per  cent.),  lysol  (0.2  to 0.5 per 
cent.) ,  etc.  A  solution  of  silver  nitrate  in  the  strength  of  o.i  to  0.2 
per  cent,  is  sometimes  employed  as  an  astringent  to  diminish  sensa- 
tion and  salt  solution  (0.4  per  cent.)  to  increase  gastric  secretion. 
Chloroform  water  has  been  recommended  as  an  anodyne  in  gastralgia. 

Temperature. — As  a  general  rule,  the  solution  should  be  employed 
warm — at  a  temperature  of  90°  to  100°  F.  (32°  to  38°  C).  Occasion- 
ally, however,  the  alternate  use  of  a  warm  and  a  cold  douche  is  found 
beneficial. 

Time  for  Douching. — The  douche  should  be  employed  only  when 
the  stomach  is  empty.  The  most  effective  time  for  its  use  is  earl)  in 
the  morning  or  three  or  four  hours  after  the  first  meal. 

Amotmt  of  Pressure. — To  be  most  effective  the  solution  should  be 
introduced  under  considerable  pressure.  The  fimnel  end  is  cons^ 
quently  raised  3  feet  (90  cm.)  or  more,  as  the  solution  is  flowing. 

Position  of  the  Patient. — The  douching  may  be  performed  with 
the  patient  sitting  upright  in  a  chair  or  in  bed,  but  in  order  to  bring 
the  solution  into  contact  with  all  portions  of  the  organ  this  position 
may  be  altered  from  time  to  time  with  advantage;  that  is,  changing 
from  the  upright  to  the  recumbent  and  first  upon  one  side  and  then 
upon  the  other. 

Anesthesia. — In  the  presence  of  excessive  irritation  or  gagging  the 
pharynx  may  be  sprayed  with  a  5  per  cent,  solution  of  cocabasa 
preliminary  to  the  passage  of  the  tube. 

Technic. — The  patient  is  given  a  small  bowl  to  receive  any  vom- 
ited matter  or  an  excessive  flow  of  saliva  and  his  chest  and  lap  arc 
protected  by  an  apron.  The  tub6  is  then  moistened  with  warm  water 
and  is  inserted  into  the  patient's  mouth,  being  kept  in  close  contact 
with  the  roof  of  the  mouth  until  the  pharynx  is  reached.  From 
this  point  on  the  tube  is  advanced  partly  by  the  action  of  the  pharj''*" 
geal  muscles  as  the  patient  swallows,  aided  by  the  operator  who 
gently  pushes  it  onward.     The  tube  is  inserted  only  a  suflident  dis- 


THE   STOMACH  DOUCHE  555 

tance  to  bring  the  perforated  tip  within  the  cardia  (Fig.  554),  which 
is  detennined  by  a  mark  placed  upon  the  tube  for  that  purpose.  The 
funnel  end  is  then  raised  and  a  pint  (500  c.c.)  of  solution  is  poured 
into  the  iunnel,  the  tube  being  pinched  until  the  funnel  is  filled;  the 
solution  is  then  allowed  to  flow  into  the  stomach,  the  funnel  end  being 
elevated  high  enough  to  obtain  the  necessary  pressure. 

To  remove  the  solution,  the  tube  is  pinched  while  there  is  still 
some  liquid  in  it  and  is  inserted  some  4  to  6  inches  (10  to  15  cm.) 
further  into  the  stomach,  so  that  its  end  will  lie  in  the  fluid  contents, 
.The  funnel  end  is  then  lowered,  the  compression  of  the  tube  released, 
and  the  fluid  withdrawn  by  siphonage. 

The  stomach  should  first  be  thoroughly  washed  out  in  the  above 
manner  with  lukewarm  water,  using  several  pints  for  the  purpose. 


Fio.  SS4- — ShowinR  the  mechanism  of  the  stomach  douche.     {After  Gumprecht.) 


The  medicated  solution  is  then  introduced  in  the  same  manner,  but 
should  be  allowed  to  remain  only  from  a  half  minute  to  a  minute.  It 
is  then  siphoned  off,  and  the  stomach  is  again  douched  out  with  warm 
water.  The  tube  is  then  removed,  care  being  taken  to  compress  it 
between  the  thumb  and  forefinger  to  prevent  the  fluid  dripping  from 
it  into  the  larynx  as  it  is  withdrawn. 

GAVAGE 

Gavage  consists  in  introducing  food  into  the  stomach  by  means  of 
the  stomach-tube.  The  tube  may  be  passed  through  the  mouth  or 
through  the  nose.  The  latter  method  may  be  necessary  in  the 
case  of  infants  and  .when  the  patient  struggles  against  the  passage 
of  the  tube  and  tries  to  bite  the  instrument. 

This  method  of  feeding  may  be  employed  after  intubation  and 
tracheotomy,  in  certain  operations  about  the  mouth  and  throat,  in 


556 


THE   STOMACH 


cerebral  diseases,  when  the  patient  is  unconscious^  and  in  acute  dis- 
eases such  as  diphtheria,  scarlet  fever,  typhoid  fever,  etc.,  when  the 
patient  will  not  take  nourishment.     It  is  especially  valuable  in  pliai- 
yngeal  paralysis  when  the  patient  cannot  swallow  food  or  liqmds. 
It  is  a  method  frequently  employed  in  feeding  premature  infants,  or 
children  suffering  from  malnutrition,  to  whom  otherwise  it  would  be  a 
difficult  matter  to  give  sufficient  food. 

Apparatus. — The  same  sort  of  apparatus  as  is  employed  for  gastric 
lavage  will  be  required,  viz.,  a  soft  stomach-tube  30  inches  (75  cm.) 
long,  2  feet  (60  cm.)  of  rubber  tubing  joined  to  the  stomach-tube  by  a 


Fig.  555. — Apparatus  for  nasal  gavage. 

glass  connecting  tube  3  or  4  inches  (7.5  to  10  cm.)  long,  and  a  glass 
funnel  with  a  capacity  of  about  i  pint  (500  c.c.)  (see  Fig.  531).  If 
it  is  intended  to  employ  the  apparatus  for  nasal  feeding,  a  tube  of 
smaller  caliber  than  that  ordinarily  used  will  be  required.  For 
young  children  a  No.  10  American  (16  French)  catheter  should  take 
the  place  of  the  stomach-tube  (Fig.  555). 

Asepsis. — Strict  asepsis  should  be  observed  in  the  care  of  the 
apparatus.  Before  use,  it  should  be  boiled  or  immersed  in  an  anti- 
septic solution  followed  by  a  thorough  rinsing  off  with  water,  and 
after  use  it  should  be  thoroughly  cleansed.  In  contagious  cases,  as 
diphtheria,  for  example,  the  apparatus  should  always  be  boiled. 


5S8  THE   STOMACH 

The  Food. — The  material  employed  for  feeding  will,  of  aHnsCi 
vary  according  to  the  indications  in  the  individual  case.  Wbeo  the 
digestive  power  of  the  stomach  is  impaired  predigested  food  sbould 
be  employed.  The  intervals  between  the  feedings  of  a  child  should 
be  somewhat  increased  when  gavage  is  employed. 

Position  of  Patient.— The  child  should  be  held  flat  on  its  bad 
across  the  nurse's  knees  with  the  head  slightly  elevated.   Its  uins 


Fig.  558, — Gavage.     Third  step,  showing  the  tube  being  compressed  as  it  is  rtBUi™ 
to  prevent  leakage. 

and  legs  may  be  confined  by  wrapping  it  in  a  sheet  from  the  chin  U» 
the  knees. 

Technic. — The  tube  or  catheter  is  moistened  in  warm  water  iiw 
is  passed  into  the  mouth  to  the  base  of  the  tongue  and  then  gently 
down  the  esophagus  to  the  desired  depth  (Fig.  556).  In  an  infants 
birth  the  distance  from  the  alveolus  to  the  cardia  is  6H  vif^^  ^' 
cm.);  at  two  years  it  is  9  inches  (23  cm.);  at  ten  years  it  is  iiincf"* 
(28  cm.),  and  in  an  adult  it  is  about  16  inches  (40  an.).  After u* 
tube  has  been  inserted  to  the  proper  depth,  the  funnel  is  eIe\-atdaM 


DUODENAL    FEEDING  559 

quired  amount  of  food  introduced  (Fig.  557).  The  tube  is  then 
)•  withdrawn,  pinching  it  the  while^  so  as  to  prevent  any  drip- 
\i  food  into  the  pharynx  and  larynx  (Fig.  558)-  The  patient 
I  be  kept  quietly  in  the  recumbent  position  for  some  time  after 
troduction  of  the  food.  In  cases  complicated  by  gastroenteri- 
;.,  a  preliminary  lavage  of  the  stomach  with  warm  water,  just 
giving  the  food,  is  often  advisable.  It  removes  mucus  and  any 
smnants  of  a  previous  feeding,  cleanses  the  mucous  membrane, 
the  same  time  stimulates  it  to  a  better  absorption  of  the  freshly 
uced  food. 

DUODENAL  FEEDING 
lodenal  feeding  consists  in  the  administration  of  food  through  a. 
tube  introduced  into  the  duodenum   through  the  stomach. 


55Q. — Einhorn's  duodenal  pump,  a,  Metal  capsule,  lower  half  provided 
nterous  holes,  the  upper  half  conununicating  with  tube  b;  i,  ]i,  m,  marks  of 
u  ^  56,  lit  ~  70  cm.  from  capsule;  c,  rubber  band  with  sillc  attached  to  end  of 
■hich  can  be  placed  over  the  ear  of  the  patient;  d,  three-way  atop-cock;  t,  c61- 

connectiiig  tube;/,  aspirating  syringe.     (Kemp.) 

lethod  of  feeding  is  sometimes  employed  in  conditions  where  it 
red  to  keep  the  stomach  empty  and  at  rest,  as  in  gastric  and 
lal  ulcer  and  gastric  dilatation  not  due  to  organic  obstruction. 
also  been  employed  in  cases  where  difficulty  is  found  in  admin- 
g  the  proper  amount  of  nourishment,  as  in  nervous  vomiting, 
miting  of  pregnancy,  and  in  infants  who  do  not  retain  the  food 
[jy  gavage. 

laratus. — A  number  of  duodenal  tubes  have  been  devised  that 
:  used  for  feeding  purposes.  That  of  Einhorn  consists  of  a 
French  tube  to  the  distal  end  of  which  is  attached  an  elongated 
ited  brass  capsule  weighing  48  grs.  (3  gm.).  The  exterior  of 
be  has  markings  at  40  cm.  (16  Ins.),  56  cm.  (22  ins.),  70  cm. 
..),  and  80  cm.  (33  ins.)  from  the  distal  end  to  indicate  the  po- 
jf  the  capsule  after  it  has  been  swallowed.  A  three-way  stop- 
od  a  glass  syringe  complete  the  outfit  (Fig.  559). 


n 


560  THE   5XOHACH 

Palefiki  has  modined  Einhom's  tube  by  employing  a  heavier  (10; 
grs.  ^6.5  gm.; ;  and  shorter  perforated  gold  plated  lead  baflL  whidiitis 
claimed  will  pass  into  the  duodenum  more  rapidly. 

For  infants  Hess  has  discarded  the  lead  ball  and  cmpknis  a  No. 
14  to  1 5  French  soft  Xelaton  catheter  with  a  large  eye.  The  extobr 
of  the  catheter  has  markings  at  20  cm.  (S  ins.),  25  cm.  (10  ins.), and 
30  cm.  ^12  ins. J  from  the  eye- 
Preparation  of  the  Food. — Milk  and  eggs  are  the  foods  used. 
Where  the  patient  cannot  tolerate  milk,  barley  water  is  substituted. 
Einhom  gives  the  following  mixture:  milk  7  to  8  ozs.  (200  to  250 cc), 
one  egg.  and  a  tablespoonful  of  lactose.  If  the  latter  produces  dtar- 
rhea,  it  is  omitted.  The  egg  is  beaten  in  the  milk  and  the  mixtme  is 
strained  before  it  is  administered. 

Temperature  of  the  Food. — ^The  food  should  be  given  at  a  tenqier- 
ature  of  100  F.  (^8  C.)- 

Frequency  of  Feedings. — Eight  feedings  are  given  a  day  at  2-lioiir 
intervals. 

Position  of  Patient — The  patient  is  seated  in  a  chair  with  the 
head  thro^i^Ti  back. 

Technic. — The  operator  places  the  bulb  in  the  patient's  ope^^ 
mouth  and  instructs  him  to  swallow  it.     WTien  the  40  cm.  (16  in-) 
mark  is  at  the  patient's  teeth,  the  metal  ball  should  be  at  the  caidi^ 
and  at  this  stage  of  the  operation  the  patient  is  given  a  glass  of  water 
to  drink  and  is  instructed  to  lie  down  on  his  right  side  to  favor  bjT 
gra\'ity  the  passage  of  the  ball  toward  the  pylorus.     The  tube  is  tbc^ 
slowly  pushed  onward,  and  when  the  56  cm.  (22  ins.)  mark  isattb^ 
teeth  the  bulb  should  be  at  the  pylorus.     From  this  point  the  tube  i^ 
left  to  work  its  way  into  the  duodenum,  which  is  indicated  whentb^ 
70  cm.  (28  in.)  mark  is  at  the  teeth.     From  time  to  time  test  aspir-' 
ations  are  made  to  determine  more  certainly  the  position  of  the  tubc^ 
that  is,  whether  it  is  in  the  stomach  or  duodenum.     K  in  the  stomachf 
secretion  will  be  obtained  and  will  be  of  an  acid  reaction  whUe  fro*'' 
the  duodenum  but  little  secretion  can  be  withdrawn  and  it  will  be 
neutral  or  alkaline  in  reaction.     In  a  normal  case  it  requires  froin 
2  to  3  hours  for  the  ball  to  pass  through  the  pylorus  and  a  consider- 
able longer  time  in  the  presence  of  pyloric  spasm,  gastroptosis,  or 
gastrcctasis. 

With  the  bulb  in  the  duodenum,  the  food,  properly  heated  and 
strained,  is  drawn  into  the  syringe  and  is  then  slowly  injected.  After 
each  feeding  a  small  quantity  of  fluid  is  forced  through  the  tube  and 
then  some  air,  in  order  to  cleanse  the  tube  and  bulb  and  prevent  them 


MASSAGE   OF   THE   STOMACH  56 1 

bom  becoming  clogged.    The  tube  is  left  in  place  during  the  course 

of  treatment,  being  fastened  to  the  patient's  ear,  and,  if  it  does 

not  produce  an  annoying  irritation  of  the  pharynx,  it  may  be  left  in 

place  from  lo  to  12  days.     During  the  time  the  tube  is  worn,  the 

patient's  teeth  and  mouth  should  be  frequently  cleansed  with  a 

moutli  wash. 

MASSAGE  OF  THE  STOMACH 

^Cassage  systematically  and  properly  performed  is  a  valuable 
therapeutic  procedure  in  certain  diseases  of  the  stomach.  It  is 
applied  to  this  organ  with  the  same  object  in  view  as  when  used  upon 
other  muscular  organs;  that  is,  to  strengthen  weak  and  atonic  mus- 
cular walls  with  imparled  contractile  power.  Massage  also  aids  in 
the  propulsion  of  the  stomach  contents  into  the  intestine.  It  is  thus 
employed  with  success,  chiefly  in  cases  of  simple  atony  and  of  atonic 
dilatation,  and  to  a  lesser  degree  in  dilatation,  due  to  pyloric  stenosis. 
Massage  is  advised  by  some  in  gastroptosis  for  the  purpose  of  strength- 
ening the  relaxed  ligamentous  supports.  Finally,  it  is  supposed  to 
stimulate  the  normal  secretions  of  the  stomach,  and  is  recommended 
by  some  authorities  in  cases  with  impaired  gastric  secretion  and  in 
iiervous  dyspepsia. 

Before  recommending  massage  an  exact  diagnosis  is  essential, 
^^assage  is  contraindicated  in  acute  inflammation  of  the  stomach,  in 
J^^ent  gastric  ulcers,  in  hemorrhage  from  the  stomach,  in  great  disten- 
"^on  of  the  stomach  from  gas,  and  in  inflammation  of  the  peritoneum. 
The  massage  should  be  performed  by  one  thoroughly  familiar  with 
"^^  technic.  • 

Time  for  Massage. — This  will  depend  upon  the  purpose  of  the 
treatment.  When  employed  simply  for  the  purpose  of  toning  up  and 
^^recigthening  the  stomach  wall,  massage  is  best  performed  early  in 
^*^^  morning  when  the  stomach  is  empty.  In  cases  of  dilatation, 
l^owever,  the  object  is  to  propel  the  contents  of  the  stomach  into  the 
intestines,  and  the  massage  is  then  performed  upon  a  full  or  partly 
^l  stomach.  The  best  time  for  this,  as  a  rule,  is  six  to  seven  hours 
^^^^r  the  principal  meal  of  the  day. 

5'requency. — The  massage,  to  be  of  any  value,  should  be  per- 
^^n:ied  every  day. 

Duration. — During  the  first  treatments  the  manipulations  should 
^^  of  short  duration — about  two  to  three  minutes  at  a  sitting — and 
*^^ter,  as  the  patient  becomes  more  accustomed  to  the  treatment,  the 
^^^ting  may  be  extended  to  periods  of  five  to  ten  minutes. 

36 


56a  THE  STOMACH 

Position  of  the  Patient. — The  patient  lies  upon  his  back  vith  ]a 
head  slightly  raised  and  the  legs  flexed  so  as  to  relax  the  abdomiul 
muscles. 

Technic. — Stroking  movements  (effleurage)  and  kneading  ^)4tris- 
sage)  are  the  manipulations  most  employed.     In  perfonning  efflenr- 


Fic.  560. — Stroking  mas&age  applied  to  the  stomach.     (After  Gut.) 

age  the  operator  places  his  left  hand  upon  the  right  hypochondriu 
region  for  the  purpose  of  counterpressure  and  with  his  right  haad,!!* 
fingers  of  which  are  outstretched,  he  performs  stroking  movemaiti 
from  the  fundus  toward  the  pylorus;  i.e.,  from  left  to  right  (Fig.  560)' 


Fig.  561. — Kneading  massage  applied  to  the  stomach. 


Kneading  of  the  stomach  may  alternate  with  these  stroking  mo^**" 
ments  to  advantage.  In  these  manipulations  large  folds  of  thf 
abdominal  wall,  including  the  stomach,  are  picked  up  between  "* 
thumb  and  four  fingers  of  the  two  hands  by  deep  handgrasps  and  art 


ELFCIROTHERAPY   IN   DISEASES   OF   THE   STOMACH  563 

eaded  by  alternately  squeezing  and  relaxing  the  fingers  (Fig.  561). 
e  force  used  in  the  various  movements  of  massage  will  depend  upon 

sensitiveness  of  the  patient,  the  thickness  of  the  abdominal  walls, 
I  the  rigidity  of  the  muscles.  The  manipulations,  howeve?',  should 
er  produce  pain  or  be  disagreeable  to  the  patient. 
To  accelerate  the  passage  of  the  stomach  contents  into  the  intes- 
■s,  the  fundus  of  the  stomach  and  contents  are  grasped  through 
abdominal  walls  between  the  thumb  and  lingers  of  the  right  hand 

by  propulsive  movements  directed  backward  an  attempt  is  made 
hrow  the  contents  of  the  stomach  toward  the  pylorus. 

SLECTROTHERAPY  IN  DISEASES  OF  THE  STOMACH 

Electricity  has  undoubted  beneficial  effects  upon  certain  diseases 
he  stomach,  although  the  manner  in  which  the  electric  current 
■  is  not  well  understood,  and  the  experimental  evidence  of  its  value 
oth  contradictory  and  in  some  cases  not  in  accord  with  the  results 
lined  clinically.  It  seems  probable,  however,  that  electricity 
■eases  the  motor  activity,  stimulates  the  secretion  of  the  gastric 
e,  and  increases  the  absorption  power  of  the  stomach.  According 
:Iinical  experience,  at  any  rate,  its  use  is  followed  by  favorable 
ilts  in  simple  atony,  dilatation  from  atony,  hypochlorhydria, 
vous  anorexia,  nervous  vomiting,  paresthesia,  hyperesthesia,  and 
tralgias. 

Both  the  faradic  and  the  galvanic  currents  are  employed  and  they 
y  be  used  percutaneously  or  intraventricularly.  As  to  the  choice 
:urrent  and  the  method  of  its  application,  authorities  again  dis- 
ee.  The  majority,  however,  advise  the  use  of  the  faradic  currents 
en  the  motor  functions  are  diseased  and  the  galvanic  in  neuroses 
d  in  cases  where  the  secretory  apparatus  is  at  fault.  The  intra ven- 
cular  method  seems  more  desirable  when  the  necessary  apparatus 
It  hand,  as  the  stomach  is  thus  directly  treated.  External  appU- 
tion  of  electricity,  on  the  other  hand,  is  simpler  to  carry  out  and  is 
ess  disagreeable  method  for  the  patient. 

Apparatus. — For  the  percutaneous  application  there  will  be 
juired  two  curved  flat  electrodes  of  about  9  square  inches'  surface 
»  to  600  sq,  cm.  )  (Fig.  562).  For  intrastomachic  application  a 
^ial  gastric  electrode,  such  as  Bardet's,  Stockton's,  or  Wegele's, 
erted  within  a  stomach-tube,  may  be  employed  or  Einhorn's  deglu- 
le  electrode  may  be  used.  The  latter  (Fig.  563)  consists  of  a  hard- 
)ber  shell,  shaped  like  an  egg,  with  numerous  small  perforations 


( 


564  THE   STOMACH 

piercing  its  surface,  and  within  this  capsule  is  a  button  of  copper  or 
brass.  A  small  rubber  tube  M5  inch  (i  mm.)  in  diameter  carries 
fine  wires  leading  from  the  button  to  the  instrument.  A  curved  plate 
electrode  is  connected  with  the  other  pole  of  the  battery. 


Fic.  sO', — Large  flat  sponge  tleclrode. 

Duration  of  Application. — Each  treatment  should  consume  about 
ten  minutes. 

Frequency. — At  first  treatments  are  employed  daily;  altertwooi 
three  weeks,  twice  weekly;  and,  finally,  applications  are  maderi 
weekly  intervals  until  the  treatments  are  discontinued. 


• 


deglulible  electiwde. 


Strength  of  Current.— For  galvanism  from  15  to  20  ma.  are  of"" 
narily  used.  With  the  faradic  current  it  is  not  possible  to  measn" 
exactly  its  strength;  the  current  should  be  sufficient,  however,"' 
produce  strong  and  visible  contractions  of  the  abdominal  wall  ai"* 
back  muscles  without  causing  pain. 


ELECTROTHERAPY    IN   DISEASES    OF    THE    STOMACH  565 

Position  of  Patient. — The  patient  should  be  in  the  recumbent 
u'tion  with  the  head  slightly  elevated  and  the  legs  flexed  so  as  to 
ix  the  abdominal  muscles. 

Technic. — i.  Percutaneous  Applkalion. — ^The  two  electrodes  are 
1  moistened  and  the  negative  pole  is  placed  over  the  region  of  the 
arus,  the  positive  over  the  spine  in  the  region  of  the  seventh  or 
ith  dorsal  vertebra.     The  negative  electrode  may  be  held  station- 

for  short  periods  or  may  be  moved  about  over  the  parts  with 
tion  during  the  treatment.  Either  the  faradic  or  the  galvanic 
rent  may  be  employed. 

2,  Inlraslomachic  Application. — The  treatment  should  be  given  on 
anpty  stomach,  preferably  one  or  two  hours  after  a  light  breakfast. 
Lccessary,  the  stomach  should  be  emptied  by  means  of  a  stomach- 
e.  Wien  an  electrode,  such  as  Wegele's  or  Stockton's,  is  em- 
y-ed,  it  is  introduced  in  the  same  manner  as  a  stomach-tube.  One 
wo  glasses  of  water  are  then  introduced  into  the  stomach  through 

tube  or,  if  Einhorn's  electrode  is  used,  before  the  electrode  is 
llowed.  In  introducing  this  latter  the  patient  should  be  re- 
sted to  open  the  mouth  widely  and  the  electrode  is  placed  well 
k  in  the  patient's  mouth  and  the  patient  is  then  instructed  to 
Jlow.  If  there  is  any  difficulty  in  accomplishing  this,  drinking  a 
is  of  water  will  be  of  material  assistance. 

The  gastric  electrode  b  connected  with  the  negative  pole  of  the 
tery,  the  positive  pole  is  connected  to  a  plate  electrode.  This 
rtrode  is  applied  for  part  of  the  seance  over  the  region  of  the  stora- 
,  held  in  one  place  for  a  few  moments  at  a  time.  A  smaller 
nge  electrode  is  then  substituted  and  is  moved  about  over  the 
ion  of  the  stomach  from  left  to  right  for  several  minutes,  and  is 
n  shifted  to  the  spine  in  the  region  of  the  seventh  or  eighth  dorsal 
tebra  where  it  is  allowed  to  remain  a  minute  or  more,  and  finally 
s  applied  once  more  to  the  epigastrium  over  which  it  is  gently 
ved  for  a  minute  or  so.  The  current  is  then  gradually  decreased 
ithe  gastric  electrode  removed. 


CHAPTER  XIX 


THE  COLON  AND  RECTUM 

Anatomic  Considerations 

m 

The  Colon. — The  colon  is  that  portion  of  the  alimentary  canal 
l5dng  between  the  small  intestine  and  the  rectum.  It  is  5  to  6  ft 
(150  to  180  cm.)  long  and  in  its  widest  portion,  the  ceoun,  measaies 
33^  inches  (8  cm.)  in  diameter.  The  average  capacity  of  the  cokrn 
in  infants  is  i  pint  (500  c.c),  at  2  years  2}^  pints  (1.25  liters),  and  in 
adults  9  pints  (4.5  liters). 


Fig.  564. — The  course  and  |)osition  of  the  colon. 


It  is  divided  into  the  cecum,  ascending  colon,  transverse  colon, 
descending  colon,  and  sigmoid  colon. 

The  cecum,  lying  in  the  right  iliac  fossa  below  the  ileocecal  vaht» 
is  ^I'i  inches  (8  cm.)  broad  and  2  J^  inches  (6  cm.)  long.  It  is  usually 
completely  covered  by  peritoneum.  From  its  inner  and  posterior 
portion  is  given  oflf  the  vermiform  appendix,  a  small  blind  tube 
with  an  average  length  of  33^^  inches  (8  cm.).     The  ileum  opens  into 

566 


ANATOMIC   CONSmEEATIONS  567 

cum  at  a  point  just  above  the  origin  of  the  appendix.     Regurgi- 

of  fluids  and  gases  Into  the  small  intestine  is  prevented  by  the 

:al  valve,  a  slit-like  opening  at  right  angles  to  the  long  axis  of 

'Wel. 

e  ascending  colon  is  8  inches  (20  cm.)  long.     It  extends  ver- 

up  the  right  side  of  the  abdomen  from  the  cecum  to  the  infe- 
rface  of  the  liver  to  the  right  of  the  gall-bladder,  where  it  turns 

left  as  the  hepatic  flexure.     It  passes  in  front  of  the  posterior 

linal  muscles  and  the  lower  pole  of  the  kidney,  and  is  bound  to 

■mer  by  connective  tissue.     Anteriorly  and  laterally  it  is  cov- 

y  peritoneum. 

s  transverse  colon  is  about  20  inches  (51  cm.)  in  length.     It  ex- 

rom  the  hepatic  flexure  across  the  abdomen  below  the  liver  and 

r  curvature  of  the  stomach,  with  a  slight  downward  curve  at 

iter,  to  the  spleen,  where  it  turns  downward  as  the  splenic 

.    The  transverse  colon  is  the  most  movable  portion  of  the 

;ut,  being  fastened  to  the  posterior  abdominal  wall  by  a  long 

.cry. 

!  descending  colofi  is  8J^  inches  (21  cm.)  long.     It  extends  down 

t  side  of  the  abdomen  from  the  splenic  flexure  to  the  sigmoid, 

n  front  of  the  left  kidney  and  posterior  abdominal  muscles. 

jrly  and  laterally  it  is  covered  by  peritoneum. 

t  sigmoid  colon  Is  the  narrowest  portion  of  the  large  gut.     It  is 

lyj^  inches  (44  cm.)  long  and  extends  from  the  left  iliac  crest 

i-shaped  curve  to  the  third  sacral  vertebra.     In  the  first  por- 

its  course  it  passes  downward  almost  to  Poupart's  ligament, 
ims  from  the  left  to  the  right  to  enter  the  pelvic  cavity  near  the 
,e,  and  passing  to  the  right  side,  it  turns  upward  as  far  as  the 
nargin  of  the  right  iliac  fossa.     From  this  point  it  makes  a 

turn  and  passes  downward,  backward,  and  inward  to  become 
lous  with  the  rectum.  The  sigmoid  is  very  movable,  having 
)lete  peritoneal  covering  and  mesosigmoid.  At  the  junction 
e  rectum  the  gut  exhibits  a  marked  narrowing  from  an  increase 
muscular  fibers,  known  as  the  sphincter  of  O'Beirne. 
!  Rectum. — The  rectum  commences  at  the  sigmoid  flexure, 
e  the  third  sacra!  vertebra,  and  descends  in  the  middle  line  of 
mm  and  coccyx.  As  it  descends  it  forms  a  curve  with  the 
ity  forward  until  it  reaches  a  point  about  i  inch  (2.5  cm.) 
he  tip  of  the  coccyx  where  it  turns,  forming  a  sharp  angle  and 
continued  downward  and  backward  through  the  thickness  ot 
vie  floor  as  the  anal  canal  (Fig,  565).    The  antero-posttrior 


568  THE  COLON  AND  BECTUU 

curves  of  the  rectum  are  distinct  and  a  knowledge  of  their  diitctioB 
is  important  for  the  proper  introduction  of  the  finger  or  instrumeob 
in  making  an  examination.  There  are  also  two  slight  lateral  ciuvo, 
first  to  the  right  and  then  to  the  left,  but  of  less  practical  importance. 

For  purposes  of  description  the  rectum  may  be  divided  into  the 
rectum  proper  and  the  anal  canal. 

The  rectum  proper  extends  from  the  middle  of  the  third  sacnl 
vertebra  to  the  upper  border  of  the  internal  sphincter  muscle,  or  to 
about  the  level  of  the  apex  of  the  prostate  gland,  and  measures  j  to 
4  inches  (7.5  to  10  cm.)  in  length.     This  portion  of  the  rectum  is 


Fig.  565.— Sagittal 


sacculated  in  form,  exhibiting  three  pouches  or  dilatations,  of  wUdi 
the  lowest  and  largest,  called  the  ampulla,  measures  in  some  ciscs 
nearly  10  inches  (25  cm.)  in  circumference.  The  constrictions  1*" 
tween  which  lie  these  dilatations  are  produced  by  an  infolding  of  tbe 
coats  of  the  bowel  in  the  formation  of  the  so-caUed  rectal  valves.  I" 
the  male,  the  rectum  is  in  relation  anteriorly  with  the  recto-veskal 
pouch,  the  trigone  of  the  bladder,  the  seminal  vesicles,  and  the  pn*- 
tate  gland,  while  in  the  female,  the  vagina  and  the  recto-vagiMl 
pouch  with  the  small  intestine  therein  contained  lie  anteriorly. 

The  anal  canal  is  about  i3^  to  2  inches  (4  to  5  cm.)  long,  ft 
extends  downward  and  backward,  terminating  at  the  surface  of  ll* 
body  as  the  anus.  This  portion  of  the  rectum  has  no  peritoneal 
covering.     It  is  embraced  by  the  internal  sphincter  muscle  and  B 


.  Fig.    566.— The   reclal   valves  a^ 
n  through  the  proctoscope.    (Aftei 


ANATOMIC   CONSIDERATIONS  569 

d  by  the  levatores  ani  muscles.     At  the  anus  the  skin  is  dark 
color  and  puckered  up  into  radiating  folds.     The  anal  canal 

tion  anteriorly  in  the  male  with  the  bulb  and  membranous 

)f  the  urethra;  and  in  the  fe- 

■  perineal  body  separates  it 
lower  end  of  the  vagina. 

rectum  is  lined  with  a  dark 

icular     mucous    membrane. 

thrown  into  a  series  of  folrU.    i 

t   important   of   which   are 

s  Houston's  valves,  or  the 

lives.       These   are   three- 

2s    two    or  four — seimlun;ir 

)rojecting     like     transverse 

nto  the  cavity  of  the  bowel 

is  distended.     According  to 

.1   arrangement  the  inferior     ^^'■■^ 

ects  from  the  left  wall  of  the 

t  a  point  about  2  inches  (5  cm.)  above  the  anal  orifice;  the 

nd  most  constantly  present  one  projects  from  the  right 

.  point  situated  3  inches  (7.5  cm.)  from  the  anus,  while  the 
superior  fold  projects  from  the  left  wall 
near  the  third  sacral  vertebra,  or  at  a 
point  about  i  inch  (2.5  cm.)  above  the 
middle  fold  (Fig.  566).  These  valves 
are  attached  to  the  walls  of  the  rectum 
for  a  distance  of  from  1^  to  Ij  its  cir- 
cumference and  protrude  into  its  cavity 
to  varying  degrees.  Their  function 
seems  to  be  to  assist  the  sphincters  and 
to  serve  to  support  the  fecal  mass. 
They  may  be  the  cause  of  difficulty  in 
makmg  digital  examinations  and  they 
may  act  as  obstacles  to  the  passage  of 
a  rectal  tube. 

In  the  anal  canal  the  mucous  mem- 
brane is  thrown  into  a  series  of  longi- 
tudinal folds,  five  to  twelve  in  number, 
called  the  columns  of  Morgagni.     They 

t  Ja   inch   (i   cm.)  in  length,  and  are  prolonged  upward 
radiating  folds  about  the  anus.     Stretched  between  these 


57©  THE  COLON  AND  RECTUM 

columns  at  their  inferior  ends  are  semilunar  folds  of  mucous  mem- 
brane forming  pouches  that  open  upward,  known  as  the  valves  of 
Morgagni  (Fig.  567). 

Diagnostic  Methods 

Assuming  that  the  usual  lines  of  inquiry  common  to  all  histories 
have  been  followed  and  it  having  been  ascertained  whether  there  is  a 
past  record  of  syphilis,  gonorrhea,  dysentery,  typhoid  fever,  appen- 
dicitis, peritonitis,  pelvic  inflammation,  gall-stones,  etc.,  which  might 
result  in  adhesions,  ulceration,  stricture,  or  tumor,  inquiry  is  then 
directed  to  special  symptoms. 

In  the  presence  of  pain,  its  location,  whether  in  the  abdomen, 
rectimi,  pelvis,  or  neck  of  the  bladder,  its  character,  whether  sudden 
in  onset,  acute  and  cutting,  or  a  dull  ache;  and  the  time  of  day  it  is 
felt,  that  is,  before  or  after  stools  or  with  every  stool,  will  often  fur- 
nish a  clue  as  to  the  cause.    Pain  in  the  upper  part  of  the  abdomen 
is  suggestive  of  gastric,  duodenal,  or  gall-bladder  affections.    Pain  in 
the  right  iliac  fossa  may  be  due  to  appendicitis  or  to  involvement  d 
the  cecum.    Pain  situated  in  the  central  portion  of  the  abdomen  is 
frequently  caused  by  colic  from  gas,,  or  mechanical  obstruction, 
though  not  infrequently  early  in  appendicitis  the  pain  is  in  this  local- 
ity.    Colic  is  characterized  by  short,  sharp  pains  coming  on  suddenly 
and  often  shifting  in  location;  furthermore,  the  passage  of  gas  or  feces 
usually  gives  relief.     Constant  or  prolonged  pain  is  more  apt  to 
signify  some  organic  lesion.     Frequently  in  place  of  pain  patients 
will  complain  of  more  or  less  discomfort  or  tenesmus  in  the  anus  or 
rectum.     It  is  a  frequent  symptom  in  dysentery  and  in  many  other 
affections  of  the  rectum. 

If  abdominal  distention  is  complained  of,  it  should  be  ascertained 
whether  it  is  general  or  localized  and  whether  there  is  any  passage 
of  gas  from  the  bowels,  and,  if  so,  whether  it  relieves  the  condition. 
A  total  absence  of  flatus  with  obstinate  constipation  suggests  ob- 
structon. 

Finally,  the  habitual  state  of  the  bowels  should  be  determined, 
that  is,  whether  they  are  normal,  constipated,  or  loose,  or  whether 
constipation  and  diarrhea  are  alternately  present.  The  examiner 
should  also  inquire  as  to  the  color,  odor,  and  character  of  the  move- 
ments, whether  soft  or  hard,  large  or  small,  and  whether  they  contain 
mucus,  pus,  or  blood.  The  amount  and  contour  will  vary  much  in 
health  as  well  as  in  disease,  depending  upon  the  form  of  food  taken, 
the  quantity  of  water  imbibed,  etc. 


INSPECTION  571 

When  all  possible  information  has  been  obtained  from  a  history 
and  general  physical  examination,  a  local  examination  is  made  to 
determine  more  accurately  the  cause  of  the  symptoms  complained  of 
and  the  proper  line  of  treatment  to  pursue.  Especially  is  it  import- 
aat  to  make  a  systematic  examination  in  the  presence  of  rectal 
symptoms.  On  account  of  the  close  relation  and  anatomic  prox- 
imity of  other  pelvic  organs,  as  the  uterus,  tubes,  and  ovaries  in  the 
female  and  the  bladder,  urethra,  prostate,  and  seminal  vesicles  in  the 
male,  it  is  necessary  to  be  able  to  differentiate  between  many  affec- 
tions the  symptoms  of  which  may  reflexly  simulate  an  abnormal 
Condition  of  the  rectum.  It  is  not  uncommon  for  a  stricture  of  the 
Urethra,  an  enlarged  prostate,  a  stone  in  the  bladder,  or  a  displace- 
ment of  the  uterus,  for  example,  to  produce  a  set  of  symptoms  which 
|>oint  to  the  rectum  as  their  seat. 

The  methods  available  for  examination  of  the  colon  and  rectum 
include  abdominal  inspection,  palpation,  and  percussion,  ausculta- 
tion, inflation  of  the  colon,  skiagrapy,  rectal  inspection  and  palpa- 
tion, proctoscopy,  examination  by  sounds  and  bougies,  examination 
by  the  probe,  lavage  of  the  bowel,  and  examination  of  the  feces. 

/.  Abdominal  Examination 
INSPECTION 

In  a  thin  individual  it  is  often  possible  to  make  a  diagnosis  of 
ptosis,  timiors,  or  constrictions  of  the  colon  from  the  appearance  and 
shape  of  the  abdomen.  Abdominal  inspection  is  of  but  very  limited 
use  in  stout  individuals. 

Position. — The  patient  lies  with  the  body  synmietrically  placed 
upon  a  firm  flat  table  with  the  light  falling  obliquely  from  the  head 
toward  the  foot  (see  Fig.  523).  It  is  of  advantage  when  examining 
for  ptosis  to  have  the  patient  also  assume  the  erect  positon. 

Technic. — The  patient's  abdomen  being  fully  exposed,  inspection 
is  performed  from  the  side  and  from  the  foot  of  the  table  (see  Fig. 
523).  The  examiner  notes  first  the  general  appearance  of  the  abdo- 
men, whether  distended  or  flat  and  whether  the  abdominal  walls  are 
well  developed  and  capable  of  supporting  the  contents.  In  entero- 
ptosis  the  upper  part  of  the  abdomen  is  concave  and  more  or  less  of  a 
"pot-belly"  is  evident  with  a  sulcus  between  the  two  recti  above  the 
umbilicus.  This  characteristic  appearance  is  accentuated  with  the 
patient  in  the  erect  position — the  abdomen  appears  more  pendulous 


572  THE  COLON  AND  RECTUM 

and  the  abdominal  contents  may  project  like  a  hernia  through  the 
space  between  the  two  recti.  The  examiner  then  makes  more  careful 
inspection  for  the  presence  of  hernia,  visible  swelling,  or  tumor.  A 
tumor  may  produce  sufficient  bulging  of  the  part  affected  to  be  recog- 
nized by  inspection.  Likewise,  if  the  individual  is  thin,  in  the  pres- 
ence of  stenosis  of  the  bowel  it  may  be  possible  to  recognize  disten- 
tion of  the  portion  of  the  bowel  proximal  to  the  seat  of  obstruction 
and  the  strong  peristaltic  waves.  Inflation  of  the  bowel  (see  page 
573)  is  of  considerable  value  in  making  more  prominent  a  tumor  or 
the  seat  of  an  obstruction. 

PALPATION 

The  cecum  and  parts  of  the  ascending,  transverse,  descending, 
sigmoid  colon  are  accessible  for  palpation,  depending  upon  the  stout- 
ness of  the  individual.  It  is  thus  possible  to  recognize  local  tender- 
ness, thickening  of  the  gut,  and  a  tumor,  and,  in  the  presence  of  the 
latter,  its  size,  mobility,  and  consistency. 

Preparations  of  the  Patient. — When  feasible,  the  patient's  bovds 
should  be  emptied  by  a  cathartic  given  the  night  before. 

Position. — The  examination  is  performed  with  the  patient  in  the 
dorsal  position  upon  a  flat  table  with  the  knees  flexed  and  a  smaD 
pillow  beneath  the  head  and  shoulders  to  secure  relaxation  of  the 
abdominal  muscles.  Shifting  the  patient  from  side  to  side  will  oft» 
furnish  more  complete  information  in  the  presence  of  a  tumor  or  othff 
mass. 

Technic. — The  examiner  stations  himself  by  the  side  of  the  pa- 
tient and  places  his  right  hand,  well  warmed,  flat  upon  the  patient's 
abdomen,  at  first  performing  gentle  circular  palpation  over  all  parts. 
Gradually  deeper  palpation  may  be  employed,  but  sudden  poking  » 
any  region  should  be  carefully  avoided.  In  performing  deep  palp** 
tion  reinforcing  one  hand  with  the  other  is  of  great  aid.  Tender 
spK)ts,  rigidity  of  the  muscles,  and  the  presence  of  masses  should  be 
looked  for.  Tenderness  suggests  inflammation  or  ulceration  of  the 
bowel.  In  eliciting  tenderness  it  is  well  to  watch  the  patient's  face, 
as  this  is  often  a  better  guide  than  questions  as  to  his  sensations. 
Rigidity  of  one  or  both  recti  is  of  diagnostic  importance  signifying 
some  local  peritoneal  irritation  in  the  first  instance  and  general  peri- 
tonitis if  both  recti  are  involved.  A  rigid  right  rectus  is  not  uncom- 
mon, however,  in  right-sided  pneumonia  and  pleurisy.  The  sensa- 
tion a  mass  gives  to  the  palpating  hand  is  frequently  a  guide  to  its 
character.     Thus,  a  cancerous  growth  is  generally  hard  to  the  touch, 


INFLATION   OF   THE   COLON  573 

cannot  be  indented,  and  is  frequently  uneven;  a  benign  growth  is 
generally  smooth;  a  fecal  impaction  is  movable,  has  a  doughy  feel, 
and  can  be  indented  with  the  fingers.  In  intussusception  the  mass  is 
smooth  and  has  the  characteristic  sausage  shape.  Often  more  valu- 
able information  as  to  the  source  and  mobility  of  a  mass  may  be 
elicited  by  changing  the  position  of  the  patient  from  time  to  time  and 
by  inflation  of  the  bowel  (see  below). 

PERCUSSION 

The  chief  use  of  percussion  is  to  confirm  the  results  obtained  by 

palpation.    The  percussion  note  over  the  empty  colon  is  tympanitic 

^Hd  of  a  higher  pitch  and  less  volume  than  over  the  stomach,  and 

over  the  small  intestine  the  note  is  of  a  still  higher  pitch  and  less 

Volume.    When  the  bowel  contains  fluid  or  fecal  matter  or  in  the 

presence  of  a  solid  tumor  the  percussion  note  is  flat.    Percussion  is 

thus  of  value  in  differentiating  between  the  empty  intestine  and  a 

solid  tumor,  and,  in  the  presence  of  the  latter,  in  determining  its  size 

and  shape.    By  first  inflating  the  bowel  with  air  or  fluid  it  is  possible 

to  trace  its  course  and  thus  recognize  the  presence  and  degree  of 

ptosis.    This  method  is  also  of  value  in  locating  the  seat  of  a  stricture 

of  the  bowel  by  the  contrast  between  the  percussion  note  obtained 

over  the  inflated  portion  and  that  over  the  empty  bowel. 

AUSCULTATION 

Auscultation  is  of  but  little  diagnostic  importance  in  diseases  of 
the  large  bowel.  Various  splashing,  gurgling,  and  whistling  sounds 
are  to  be  heard  normally  in  the  intestines  and  are  due  to  the  move- 
ments of  gas  and  fluids.  In  chronic  obstruction  of  the  large  bowel 
gurgling  sounds  are  also  to  be  heard  in  the  region  of  the  obstruction, 
and,  if  they  are  always  heard  in  the  same  location,  they  are  of  con- 
siderable diagnostic  importance.  An  entire  absence  of  intestinal 
sounds  would  suggest  intestinal  paresis.  By  injecting  into  the  bowel 
small  quantities  of  fluid  (about  a  pint  (500  c.c.))  it  is  possible  to  map 
out  the  course  of  the  bowel  by  the  splashing  sounds  heard  on  auscul- 
tation. This  procedure  may  be  employed  to  advantage  in  cases  of 
suspected  ptosis. 

INFLATION  OF  THE  COLON 

This  procedure  is  performed  both  as  a  diagnostic  and  as  a  thera- 
peutic measure  (for  the  latter  see  page  616).     The  bowel  may  be 


574  THE  COLON  AND  RECTUM 

inflated  either  by  means  of  air  or  fluids.  For  diagnostic  purposes, 
however,  air  is  preferable,  as  there  is  thus  produced  a  contrast  oa 
percussion  between  the  tympany  of  the  air-distended  bowd  and  tht 
flatness  of  a  tumor.  It  has  the  disadvantage,  however,  that  tht 
amount  injected  caimot  be  measured  as  can  flidds,  and  consequoitly 
the  degree  of  distention  is  not  so  well  regulated. 

The  colon  may  be  distended  as  far  as  the  cecum,  provided  there 
be  no  obstruction  and  the  inflation  be  slowly  and  carefully  performed. 
When  thus  distended,  the  bowel  is  raised  from  the  surrounding  parts 
and  is  caused  to  stand  out  against  the  abdominal  wall  so  that  it  may 
be  readily  mapped  out  by  palpation  and  by  percussion,  and  its  size, 
shape,  position,  and  mobility  may  be  determined.  It  thus  it 
comes  possible  to  locate  the  seat  of  a  stricture  or  an  obstruction  by 
noting  the  limits  of  the  distended  area — the  part  below  the  seat  of 
stenosis  becomes  prominent,  while  the  portion  of  the  bowel  above  wiB 
be  but  slightly  distended  or  not  at  all  so,  depending  upon  the  degree 
of  occlusion.  Under  inflation,  timiors  of  the  large  bowel  are  made 
more  prominent  and  it  is  frequently  possible  to  recognize  that  a 
growth  is  located  in  or  is  in  connection  with  the  colon  by  tracing  the 
distended  bowel  directly  into  the  tumor  mass.  Finally,  inflation  is 
also  of  great  aid  in  determining  the  probable  seat  of  other  abdominal 
tumors,  the  distention  of  the  bowel  causes  a  change  in  the  position 
of  the  timior,  displacing  it  in  the  direction  of  the  normal  position 
of  the  organ  from  which  it  takes  origin,  so  that  tympany  is  obtained 
where  there  was  originally  dulness;  for  example,  a  tumor  of  the 
stomach  is  pushed  upward;  a  tumor  of  the  gall-bladder  and  Bveris 
pushed  upward  and  forward,  a  tumor  of  the  pancreas  becomes  less 
noticeable;  a  tumor  of  the  kidney  is  pushed  upward  toward  the 
normal  position  of  the  kidney  and  lies  behind  the  distended  colon; 
a  tumor  of  the  spleen  will  lie  in  front  of  the  colon  and  the  growth 
will  become  more  readily  palpable  from  being  pushed  forward,  etc.» 
etc. 

Apparatus. — The  injection  of  fluids  is  effected  by  means  of  a  foun- 
tain syringe  or  a  graduated  glass  irrigating  jar  as^  a  reservoir,  and 
a  rectal  tube  attached  to  the  reservoir  by  about  6  feet  (i8o  cm.)  of 
rubber  tubing  J^  to  %  inch  (6  to  9  mm.)  in  diameter. 

For  the  injection  of  air  a  special  inflation  apparatus  may  be  em- 
ployed, but  a  rectal  tube  attached  to  a  Davidson  syringe,  cautery 
bulb  (Fig.  568),  hand  bellows,  or  bicycle  pump  will  answer  equally 
well.  The  pumping  apparatus  may  be  dispensed  with  if  oxyff^ 
or  carbonic  gas  is  used.     In  the  case  of  the  former  the  rectal  tube 


INTLATION   OF   THE  COLON  575 

is  simply  attached  to  the  oxygen  tank  (Fig.  569),  while,  if  the  latter 
gas  be  employed,  the  tube  is  attached  to  a  syphon  of  carbonic,  and 
the  latter  is  inverted  so  that  the  gas  escapes  without  the  water 
following. 


Fio.  568. — Rectal  tube  and  cautery  bulb  for  inflating  the  colon. 

Media  for  Inflation. — Of  fluids,  warm  normal  salt  solution  (dr.  i 
(4  gm.)  of  salt  to  a  pint  (500  c.c.)  of  water)  is  best.  Air,  oxygen,  or 
carbonic  acid  gas  may  be  used  when  gaseous  disteation  is  desired. 

Amount  Injected. — When  inflating  with  gas  there  is  no  way  to 
determine  accurately  the  amount  of  gas  injected,  and  the  patient's 


Fic,  369- — Inflation  of  the  colon  with  oxygen. 


sensations  and  the  degree  of  distention  of  the  bowel  must  be  the 
guide.  Never  inject  sufficient  to  cause  pain,  and  care  must  be  taken 
not  to  endanger  the  gut. 

As  much  as  3  quarts  (3  liters)  of  fluid  may  be  injected  with  safety. 


576  THE  COLON  AND  RECTUM 

Rapidity. — Fluid  or  gas  should  be  injected  slowly  and  steadily; 
rapid  distention  of  the  bowel  is  to  be  avoided.  From  fifteen  minutes 
to  half  an  h6ur  should  be  consumed  in  performing  the  operation.  If 
the  reservoir  be  not  elevated  above  3  feet  (90  cm.),  the  fluid  will  not 
enter  the  bowel  too  rapidly. 

Position  of  Patient. — The  tube  may  be  inserted  with  the  patient 
upon  his  side,  but  as  soon  as  the  inflation  is  begun  the  dorsal  position 
should  be  assumed. 

Technic. — If  there  is  an  accumulation  of  fecal  matter  in  the 
bowels,  a  simple  enema  should  be  given  and  an  evacuation  produced 
before  attempting  the  operation.  The  rectal  tube  is  then  well  lubri- 
cated with  vaselin  and  is  inserted  4  or  5  inches  (10  to  12  cm.)  within 
the  rectum.  If  fluid  is  employed,  the  reservoir  is  then  elevated  be- 
tween 2  and  3  feet  (60  to  90  cm.)  and  the  solution  is  allowed  to  distend 
the  bowel  slowly,  cotton  being  tightly  packed  about  the  anus  and  the 
buttocks  being  held  in  close  apposition  to  prevent  leakage.  As  the 
rectum  becomes  distended  there  will  be  some  spasm  and  an  almost 
irresistible  desire  on  the  part  of  the  patient  to  expel  the  fluid,  but  if 
the  flow  be  temporarily  stopped,  or  the  reservoir  lowered,  and  time  be 
given  for  the  fluid  to  pass  upward,  this  feeling  soon  passes  off  and  the 
inflation  may  be  then  continued.  When  the  colon  has  been  suffi- 
ciently distended  and  the  purposes  of  the  examination  are  accom- 
plished, the  fluid  is  allowed  to  escape  from  the  bowel  through  the 
tube. 

The  technic  of  introducing  gas  is  practically  identical  with  the 
above,  great  care  being  taken,  however,  not  to  force  the  gas  in  too 
rapidly  or  in  excess,  and  at  the  completion  of  the  examination  to  draw 
off  as  much  of  it  as  possible,  so  as  to  avoid  unpleasant  distention.  Its 
escape  may  be  aided  by  inserting  two  fingers  into  the  rectum  and 
holding  the  anus  open. 

SKIAGRAPHY 

The  X-rays  are  of  value  in  recognizing  the  presence  of  foreign 
bodies  in  the  intestinal  tract,  and  for  determining  the  position  of  the 
colon  and  the  seat  of  strictures,  dilatations,  angulations,  or  adhesions 
that  may  be  causing  obstruction.  For  recognizing  the  latter  condi- 
tions a  preliminary  rectal  injection  of  a  bismuth  mixture  or  the  inges- 
tion of  a  bismuth  meal  is  essential.  When  the  bismuth  is  given  by 
mouth,  its  passage  may  be  traced  through  the  intestinal  tract  by 
means  of  repeated  X-rays,  and  valuable  information  as  to  the  motil- 
ity of  the  intestinal  contents  may  be  secured. 


SKIAGRAPHY  577 

In  preparation  for  an  X-ray  examination  of  the  large  intestine, 
the  patient  is  given  a  purge  for  two  nights  before  and  an  enema  on 
the  day  of  the  examination  to  thoroughly  empty  the  colon.  Two 
oimces  (60  gms.)  of  bismuth  subcarbonate  are  mixed  with  a  little 
starch  in  2  quarts  (2  liters)  of  warm  water  and  are  injected  into  the 
bowel  with  the  patient  in  the  Sims  position  with  the  hips  elevated,  or 
while  in  the  kjnee-chest  position,  and  a  radiograph  is  immediately 
taken;  or,  the  patient  may  be  given  by  mouth  an  ounce  (30  gms.)  of 
bismuth  subcarbonate  or  oxychlorid  in  12  ounces  (360  gms.)  of  milk 
or  koumiss,  and  the  radiograph  be  taken  at  the  end  of  24  hours  when 
all  the  bismuth  should  be  in  the  large  bowel.  A  second  picture 
should  be  taken  at  the  end  of  48  hours  in  order  to  judge  of  the  motility 
of  the  bowel.  Exposures  should  be  made  with  the  patient  in  the  re- 
cumbent and  in  the  upright  posture 

//.  Internal  Examination 

Preparation  of  the  Patient. — In  order  to  make  a  satisfactory 
examination  of  the  rectum  the  latter  should  be  emptied  of  its  con- 
tents by  means  of  a  cathartic  given  the  night  before  or  by  an  enema 
administered  just  before  the  examination  is  begun.  In  some  cases, 
however,  more  useful  information  as  to  the  usual  condition  of  the 
rectum  may  be  obtained  by  making  a  preliminary  examination  of  the 
patient  in  just  the  condition  he  presents  himself.  The  presence  of 
blood,  pus,  or  mucus  will  thus  be  revealed,  of  which  there  would  often 
be  no  trace  after  a  cleansing  enema.  If  necessary,  an  enema  may 
then  be  given  and  a  more  complete  examination  may  be  made  later. 
The  bladder  should  likewise  be  evacuated,  and  tight  clothing,  such  as 
bands,  belts,  or  corsets,  which  tend  to  force  the  intestines  into  the 
pelvis,  should  be  loosened. 

Position  of  the  Patient. — Four  positions  are  employed  for  rectal 
examinations,  each  of  which  has  its  own  advantages  under  special 
conditions.  These  are:  (i)  the  Sims,  (2)  the  lithotomy,  (3)  the  knee- 
chest,  and  (4)  the  squatting  posture. 

The  SimSy  or  left  lateral  position,  is  obtained  by  placing  the  pa- 
tient upon  the  left  side  with  the  left  side  of  the  face,  the  left  shoulder, 
and  the  left  breast  resting  upon  a  flat  pillow.  The  left  arm  lies  be- 
hind the  back  and  the  thighs  are  well  flexed  upon  the  body  with  the 
right  knee  drawn  up  nearer  the  body  than  the  left.  The  buttocks  lie 
near  the  edge  of  the  table  and  are  elevated  upon  a  hard  pillow  (Fig. 

570).     This  position  will  be  found  most  useful  for  routine  examina- 
37 


578  THE  COLON  AND  KZCTUU 

tions,  and  probably  will  be  found  less  objectionable  to  the  patient 
than  the  lithotomy  or  knee-chest  positions. 

The  lithotomy  position  is  secured  by  placing  the  patient  flat  on  the 
back  and  flexing  the  thighs  upon  the  abdomen  and  the  1^  upon  (he 


Fig.  57o.^The  Sims  posldi 


thighs.  The  buttocks,  which  are  elevated  upon  a  hard  flat  pillow, 
project  over  the  end  of  the  table  (Fig.  571).  In  very  stout  iDifi- 
viduals  this  position  will  permit  of  a  more  satisfactory  eiamiiutioQ 
than  will  the  Sims. 

The  knee-chest  position  is  obtained  by  having  the  patient  kneel 
upon  a  table  with  the  thighs  at  right  angles  to  the  legs  with  the  body 


Fic.  S7t. — The  lithotomy  position. 


well  flexed  upon  the  thighs,  the  chest  resting  upon  a  pillow  pUc^^ 
upon  the  same  level  as  the  knees  (Fig.  572).  The  knee-chest  poatic^ 
favors  displacement  of  the  coils  of  intestine  upward,  thus  allowing  tt^ 
rectum  to  be  distended  by  the  entrance  of  air  upon  the  insertion  of 


PALPATION 


579 


speculum  or  proctoscope.  The  mucous  membrane  of  the  rectum, 
which  in  the  dorsal  position  lies  in  folds,  becomes  expanded,  and  thus 
a  more  thorough  inspection  of  all  portions  of  the  canal  is  possible. 
The  squaring  posture  is  only  suitable  for  digital  examination. 
The  patient  assumes  an  attitude  similar  to  that  taken  while  at  stool. 
Portions  of  the  rectum  may  be  thus  palpated  which  in  the  Sims  or  the 
dorsal  position  would  be  out  of  reach  of  the  examiner's  finger.  By  a 
slight  straining  effort  protrusions  or  moderate  degrees  of  prolapse  will 
be  revealed. 


ifliiiiliiiiiiiiiiiiiiiiiiiiiiMiiiiiiiiiiiipiiiiMiwiwniipifiimiP 


Fig.  572. — The  knee-chest  position. 


INSPECTION 


The  anus  is  first  inspected.  The  presence  of  discharges  from  the 
rectum,  excoriations,  eczema,  thickening  of  the  epidermis,  scars, 
ulcerations,  fistulous  openings,  condylomata,  the  swelling  of  an 
abscess,  and  external  hemorrhoids  are  carefully  looked  for.  Then, 
by  separating  the  buttocks  and  placing  the  thumbs  on  either  side  of 
the  anus  and  drawing  it  apart  while  the  patient  strains  slightly, 
inspection  of  the  anal  canal  for  at  least  an  inch  (2.5  cm.)  will  be 
possible  (Fig.  573).  Slight  degrees  of  prolapse,  fissures,  ulcers., 
•hemorrhoids,  and  polypi  or  other  growths  may  be  readily  demon- 
strated in  this  way. 

PALPATION 

Palpation  of  the  rectum  may  be  performed  by  means  of  the  finger 
or  by  the  whole  hand.     With  the  index-finger  one  may  examine  the 


580  THE  COLON  AND  RECTUM 

anus,  the  anal  canal,  and  the  ampulla  of  the  rectum.    The  fiist  4 
inches  (10  cm.)  of  the  rectum  may  be  thus  explored. 

Introduction  of  the  whole  hand  into  the  rectum,  as  advocated  by 
Simon,  for  the  purpose  of  palpation  of  portions  of  the  canal  out  of 
reach  of  the  finger,  may  be  practised  if  the  hand  is  moderately  small. 
Tuttle  states  that  a  hand  requiring  a  kid  glove  larger  than  ^H  should 
never  be  introduced  into  the  rectum  except  in  a  life  or  death  emer- 
gency, 'Manual  palpation  is  rarely  required,  being  only  necessary  for 
examining  tumors  high  up  that  caimot  be  inspected  by  means  of  a 
speculum  or  a  proctoscope.  In  addition,  it  is  a  serious  procedure,  as 
there  b  danger  of  rupture  or  undue  distention  of  the  bowel  in  careless 
hands. 


— Inspection  of  the  anus,     (.\shton.) 


Anesthesia. — General  anesthesia  will  be  required  for  palpation  by 
the  whole  hand,  as  complete  dilatation  of  the  rectum  is  essential- 

Technic. — i.  By  the  Finger.— No  anesthesia  will  be  required. 
The  direction  of  the  rectum,  which  is  at  first  slightly  forward  from  tht 
anus,  then  back  into  the  hollow  of  the  sacrum,  then  to  the  right,  arid 
finally  to  the  left  toward  the  sigmoid  flexure,  should  be  kept  clearly  i" 
mind.  The  index-finger  of  the  right  hand  is  covered  with  a  rubber 
finger  cot.  If,  however,  it  is  desired  to  preserve  the  tactile  sense  of 
the  finger,  a  covering  is  dispensed  with,  in  which  case  soap  should  be 
forced  under  the  nail.  The  finger  is  well  lubricated  with  sterile  vase- 
lin  or  with  one  of  the  preparations  of  Irish  moss  made  (or  thef»f' 
pose  and  is  then  introduced  slowly  and  with  a  rotary  motion,  tl* 
patient  being  requested  to  strain  gently  to  facilitate  its  passage 


PALPATION 


through  the  sphincter.  Roughness  in  inserting  the  finger  or  disre- 
gard of  the  natural  direction  of  the  canal  will  be  liable  to  cause  spasm 
of  the  sphincter  and  give  the  patient  such  pain  that  a  thorough 
examination  will  be  impossible. 


Fig.  574.— Palpation  ot  the  rectum.     (Gant.) 

As  the  finger  passes  through  the  anal  canal  the  condition  of  the 
sphincter  should  be  noted,  the  examiner  observing  whether  it  is 
closed,  rigid,  and  resisting,  or  loose  and  patulous.  When  the  internal 
sphincter  has  been  passed,  the  finger  is  swept  lightly  over  the  mucous 


Fig.  S7S' — Method  of  dilating  the 


finger  of  each  hand. 


membrane,  palpating  the  rectal  wall  in  ail  directions.  The  size  and 
sensitiveness  of  the  rectum  is  thus  ascertained.  The  eyamining 
finger  will  readily  detect  the  presence  of  impacted  feces,  polypi,  large 
hemorrhoids,  malignant  growths,  ulcerations,  fissures,  and  strictures 


583.  THE  COLON  AND  RECTUU 

if  a  systematic  examination  is  made.  In  the  male,  enhigantnt, 
induration,  degrees  of  sensitiveness,  or  softness  of  the  prostate  should 
be  carefuUy  noted,  and  likewise  information  regarding  the  condltioa 
of  the  seminal  vesicles  and  bladder  should  be  obtained.  A  vesical 
caJcuIus  may  frequently  be  dbcovered  by  such  examination.  Id  the 
female,  the  uterus,  tubes,  ovaries,  and  broad  ligaments  are  caxtMj 
examined  for  displacements  or  signs  of  inflammation.  Finally,  the 
coccyx  should  not  be  overlooked,  as  this  bone  may  be  responsible  lor 
considerable  rectal  disturbance. 

If  pus,  blood,  or  mucus  be  present  in  the  bowel  there  will  be  aa 
escape  of  the  material  from  the  anus  when  the  finger  is  withdravnot 
the  finger  will  come  away  coated.     In  all  cases  it  is  important  to  nolc 


Fig.  576. — :Method  of  dilating  the 


the  odor  of  the  examining  finger  upon  its  withdrawal.  The  foul  oc^ 
of  cancer  is  characteristic  and  will  not  be  mistaken  for  anythK-^ 
else  once  it  is  recognized. 

2.  Sy  the  Whole  Ha»<i.— Stretching  of  the  sphincters  is  co**' 
menced  by  introducing  into  the  anus  the  two  forefingers  with  the  p^-^ 
mar  surfaces  out,  and  separating  them  slowly  and  gently  in  all  dire^' 
tions,  care  being  taken  to  avoid  injury  to  the  mucous  membrane  i^ 
possible  (Fig.  575).    As  soon  as  a  little  dilatation  has  been  secure"' 
two  and  then  three  fingers  of  each  hand  may  be  introduced,  carrj-ioS 
them  to  a  point  well  above  the  internal  sphincter.    The  fingers  are 
then  gradually  separated  until  sufficient  dilatation  is  obtained  to  al- 
low the  hand  to  pass  (Fig.  576).     The  hand  is  then  well  lubricate" 
and,  with  the  fingers  formed  in  the  shape  of  a  cone,  it  is  gradually 
introduced  past  the  sphincter  muscles  until  it  enters  the  dilated  t^' 
puUa.     From  this  point  on  only  two  fingers  should  be  used  in  palp*' 


EXAMINATION  BY   THE   SPECULUM   OR  PROCTOSCOPE  583 

tion,  and  great  care  and  gentleness  are  necessary  to  prevent  injury,  as 
the  canal  gradually  narrows  down. 


EXAMINATION  BY  THE  SPECULUM  OR  PROCTOSCOPE 

By  the  aid  of  suitable  specula  and  reflected  light,  the  whole  inner 
surface  of  the  rectum  up  to  the  sigmoid  flexure  may  be  inspected. 
The  openings  of  glands  and  the  condition  of  the  valves  and  any  altera- 
tion in  color  or  unevenness  of  the  surface  of  the  mucous  membrane 
are  noted.  Ulcers,  polypi,  new  growths,  malignant  disease,  stric- 
tures, the  internal  openings  of  fistulous  tracts,  hemorrhoids,  and 
congestion  or  inflammation  of  the  rectal  mucosa  may  be  distin- 
guished by  the  experienced  examiner. 


Fig.  577. — The  Sims  rectal  speculum.     (Hirst.) 

Instruments. — The  ordinary  rectal  specula  are  made  in  various 
shapes  and  styles,  such  as  the  Sims  (Fig.  577),  the  bivalve,  the  duck- 
bill (Fig.  578),  the  fenestrated-blade  (Fig.  579),  the  conical,  etc. 
These  are  all  useful  instruments  for  inspection  of  the  lower  4  or  5 
inches  (10  to  12  cm.)  of  the  bowel,  but  their  usefulness  is  limited  to 
that  region. 

For  examination  of  points  higher  up  Kelly  has  devised  tubular 
specula  (Fig.  580)  which  permit  a  thorough  inspection  of  the  entire 
rectum  and  the  sigmoid  flexure.  This  set  of  instruments  consists  of: 
(i)  a  sphincteroscope,  (2)  a  long  and  (3)  a  short  proctoscope,  and 
(4)  a  sigmoidoscope.  The  sphincteroscope  is  short  and  slightly 
conical;  the  diameter  of  the  lower  end  of  the  tube  is  i  inch  (2.5  cm.) 
and  of  the  upper  end  ij^i  inches  (3  cm.).  The  cylinder  of  the  short 
proctoscope  is  5^^^  inches  (14  cm.)  long,  and  %  inch  (22  mm.)  in 


584  TEE  COLON  AND  RECTnlf 

diameter.  The  long  proctoscope  is  8  inches  (20  cm.)  long  and  of  die 
same  diameter  as  the  short  proctoscope,  and  the  sigmoidoscope  b  of 
like  diameter  and  14  inches  (35  cm.)  long.  Each  speculum  conasts 
of  a  cylindrical  metal  tube,  at  the  outer  end  of  which  is  a  funnd- 
shaped  rim  about  2  inches  (s  cm.)  in  diameter  to  which  a  handle  it 
attached.  A  blunt  obturator  is  provided  to  facilitate  the  intiodiK' 
tion  of  the  instrument  into  the  bowel.  Illumination  is  secured  fum 
an  electric  light  held  close  to  the  sacrum,  which  is  reflected  by  a  hesd 
mirror  into  the  speculum,  or  else  an  electric  head  light  or  the  direct 
sunlight  may  be  employed. 


Fig.  579- — Fenestrated- blade    rectJj 
speculum. 

Murphy  has  modified  Kelly's  instrument  in  such  a  way  that  the 
specula  telescope,  the  proctoscope  fitting  into  the  sphincteroscope, 
etc.  This  does  away  with  the  necessity  of  withdrawing  and  insertiif 
a  speculum  through  the  anus  each  time  a  smaller  size  is  used,  TV 
sphincteroscope  is  used  first,  and  into  this  the  next  smaller  sizes 
passed  without  withdrawing  the  original  instrument,  until  all  h*i 
been  introduced  in  succession. 

The  pneumatic  proctoscope,  such  as  Tuttle's  modificatioD  ' 
Law's  instrument  (Fig.  581),  is  not  dependent  upon  atmosphi 
pressure  as  a  means  of  dilatation,  this  being  accomplished  by  a  gxt 


( 


EXAMINATION  BY  THE   SPECULUM   OB   PROCTOSCOPE  585 

inflation  apparatus  connected  with  the  instrument.  Tuttle's  procto- 
sa>pe  consists  of  a  long  cylinder,  to  the  circumference  of  which  is 
£tted  a  small  metallic  tube  closed  at  its  distal  extremity  by  a  flint- 


»=- 


3=^ 


—Kelly's  set  of  tubular  specula.     1,  Swab  and  holder;  2 

3,  loDg  proctoscope;  4,  short  proctoscope;  5,  sphineteroscope.  ■ 


Fic.  581.— Tuttle's  pneumatic  proctoscope.  1,  Proctoscope  with  obturator 
removed;  i,  obturator;  3,  handle;  4,  air-tight  plug  with  glass  window;  ;,  inflating 
apparatus. 

glass  bulb.     An  electric  light  fitted  upon  a  long  metallic  stem  is  car- 
ried through  the  small  accessory  cylinder  to  the  end  of  the  speculum. 


586  THE  COLON  AND   HECTUM" 

An  obturator  fits  into  the  distal  end  of  the  large  cylinder  tn  fadlitate 
the  introduction  of  the  instrument.  In  addition,  there  is  an  aiF 
tight-fitting  plug  containing  either  a  plain  glass  window  or  a  kis 
focused  to  the  length  of  the  instrument  to  be  inserted  in  the  piocto- 


FiG.  582. — Method  of  holding  the  proctoscope. 

scope  when  the  obturator  is  removed.  This  plug  is  in  connectkni 
with  an  inflating  apparatus.  An  adjustable  handle  is  supplied  vitl 
the  instrument.  These  specula  vary  in  length  from  4  to  14  inckn 
(10  to  35  cm.).  Tuttle  recommends  a  4-  and  a  lo-inch  (loaodij 
cm.)  tube  for  ordinary  use.     The  light  is  furnished  by  a  fourorasii 


Fic.  5 83 .^Proctoscopy.    First  step,  method  of  inserting  the  instrument. 

dry-cell  battery.  In  using  the  specula  and  proctoscope  longdresang 
forceps  and  cotton  balls  with  which  to  swab  out  the  bowel  willb* 
required. 

Asepsis! — The  specula  may  be  sterilized  by  boiling  or  by  ini" 
mersion  in  a  i  to  20  carbolic  add  solution.     In  case  the  latter  B 


EXAMINATION  BY   THE   SPECULUM   OH   PHOCTOSCOPE  587 

-employed,  the  instrunKDt  should  be  rinsed  off  with  alcohol  or  sterile 
vater  before  use. 

PositioD  of  the  Patient. — The  patient  should  be  placed  in  the 
knee-chest  jwation,  so  that  the  rectum  will  balloon  up  upon  the 
entrance  of  air  through  the  instrument. 


—Proctoscopy.    Secood  step,  showing  tbe  direction  of  the  instrumeDt  i: 

passing  through  the  anus.  ' 


Fio.  585. — Proctoscopy 


Third  step,  showing   the  direction  < 
enteriug  the  ampulla. 


the  instrument  i 


L  rule,  unless  the 


Anesthesia. — An  anesthesia  is  not  required,  as  a 
patient  is  eitremely  hyperesthetic. 

Technic. — i.  With  the  Kelly  Instrument.— Tbe  instrument  should 
always  be  wanned  and  lubricated  with  sterile  vaselin  before  its 
introduction.  In  using  the  sphincteroscope  the  handle  of  the  instru- 
ment is  grasped  in  the  right  hand  with  the  right  thumb  pressii^ 


588  THE  COLON  AKD  JtECTDU 

against  the  obturator,  as  shown  in  Fig.  582.  The  buttocks  are  thn 
drawn  apart,  and  with  the  end  of  the  obturator  held  gainst  the  cantl 
orifice  (Fig,  583),  the  patient  strains  slightly  and  the  speculum  is 
slowly  pushed  into  the  bowel  in  a  direction  downward  and  fonranl 
(Fig.  584)  until  the  funnel-shaped  rim  prevents  its  further  progress. 
The  obturator  is  then  removed,  allowing  air  to  pass  in  and  distecd 
the  bowel.  The  light  is  reflected  into  the  instrument  in  such  a  ny 
as  to  thoroughly  illuminate  the  interior,  and,  as  the  instrument  is 
slowly  withdrawn,  the  whole  of  the  anal  canal  is  carefully  inspected 


—Proctoscopy. 


The  proctoscope  is  inserted  in  precisely  the  same  manner,  fc^^ 
pushing  the  instrument  in  a  direction  downward  and  forward  [H- 
584)  and  then  upward  toward  the  sacral  hollow  (Fig.  585).  As  soon 
as  the  tube  enters  the  ampulla,  the  obturator  should  be  withdraw 
allowing  air  to  enter  and  expand  the  bowel.  The  light  is  then  thrown 
into  the  instrument  and  the  ampulla  is  inspected.  From  this  point 
the  instrument  is  advanced  past  the  valves  entirely  by  sight.  Some 
difiiculty  may  be  experienced  in  following  the  direction  of  the  canal 
from  a  valve  or  fold  of  mucous  membrane  occluding  the  end  of  the 
instrument.  In  such  acasethedistalendof  theinstrumentshouldbe 
gently  moved  from  side  to  side  until  the  opening  of  the  canal  b  found- 
In  this  manner  the  whole  interior  of  the  rectum  may  be  inspected' 
As  the  instrument  is  withdrawn,  the  condition  and  character  of  the 


f  EXAMINATION    BY    THE    SPECUHru    ( 


PROCTOSCOPE  589 

lucous  membrane  as  it  falls  over  the  end  of  the  instrument  is  noted 
Fig.  587). 


■  587. — Shotring^  the  method  at  performing  proctoscopy  by  the  aid  of  a  bead  n 
and  an  electric  light. 


In  istioduciog  the  sigmoidoscope  it  is  to  be  remembered  that  the 
per  portion  of  the  canal  gradually  turns  to  the  left,  hence  the  point 


'0.  588. — Showing  the  method  oE  inserting  Tullle's  instrument  with  the  finger  in 
the  rectum  and  the  auxiliary  tube  pressing  against  it. 

f  the  instrument  is  turned  in  that  direction  as  it  slowly  ascends  the 
owel. 


I 


590  THE  COLON  AND  RECTUM 

2.  With  TutUe^s  Proctoscope. — The  proctoscope,  wanned  and 
well  lubricated,  is  introduced  in  much  the  same  manneras  is  Kelly's 
instrument.  To  avoid  causing  the  patient  any  discomfort  from  the 
presence  of  the  auxiliary  tube,  however,  it  is  well  to  insert  the  index- 
finger -of  the  left  hand  into  the  bowel  first  and  than  to  introduce  the 
instrument  with  the  end  of  the  auxiliary  tube  pressed  against  the 
finger  (Fig.  588),  as  the  tube  enters  the  bowel  the  finger  is  withdrawn. 
When  the  internal  sphincter  has  been  passed,  the  obturator  is  with- 
drawn and  the  plug  containing  the  glass  lens  is  substituted.  This 
makes  the  instrument  air-tight.  Very  slight  pressure  upon  the  bulb 
of  the  inflating  apparatus  distends  and  straightens  out  the  canal  as 
the  instrument  is  advanced.  Should  the  lamp  become  obscured  by 
feces  or  mucus,  the  plug  is  removed  from  the  instrument  and,  with- 
out removing  the  instrument,  the  glass  is  wiped  off  with  a  cotton 
wipe  held  in  long  dressing  forceps.  At  the  completion  of  the  exami- 
nation the  cap  at  the  end  of  the  tube  is  withdrawn  and  the  air  is 
allowed  to  escape  from  the  bowel  before  the  instrument  is  removed. 

EXAMINATION  BY  SOUNDS  AND  BOUGIES 

The  employment  of  the  rectal  sound  or  bougie  for  the  diagnosis 
of  stricture  has  been  superseded  to  a  large  extent  by  the  use  of  the 
proctoscope.  The  bougie,  furthermore,  is  not  a  very  reliable  in- 
strument, as  strictures  that  do  not  exist  may  be  imagined  to  be  pre- 
sent from  the  point  of  the  instrument  catching  in  the  folds  of  lnu^ 
ous  membrane  or  in  a  diverticulum,  or  from  being  arrested  by  fecal 
matter,  the  promontory  of  the  sacrum,  a  retroverted  uterus,  or  an 
enlarged  prostate.  Again,  the  instrument  may  bend  or  curve 
upon  itself. 

Instruments. — There  are  many  varieties  of  sounds  and  bougies 
made  for  diagnostic  purposes,  but  the  only  instrument  that  should  be 
employed  is  a  soft-rubber  one,  the  Wales  bougie  (Fig.  589)  being  a 
type.  Metal  or  hard-rubber  sounds  are  dangerous,  even  in  the 
hands  of  an  expert,  unless  they  are  inserted  by  the  aid  of  a  procto- 
scope, as  they  may  easily  be  pushed  through  the  rectal  wall  into  the 
peritoneal  cavity,  especially  if  the  rectum  is  weakened  by  some 
pathological  condition.  The  Wales  bougie  is  made  of  soft  rubber 
in  different  sizes,  and  in  length  measures  about  12  to  14  inches  {39 
to  35  cm.).  It  is  perforated  by  a  canal  running  through  its  center 
for  the  purpose  of  allowing  fluid  to  be  injected  into  the  bowel  to 
aid  in  its  passage.  In  using  this  instrument  a  Davidson  syringe 
should  be  provided. 


A 


EXAMINATION  BY   SOUNDS   AND  BOUGIES 


591 


Technic. — The  bougie,  well  lubricated,  is  gently  inserted  into 
the  bowel  until  its  further  progress  is  impeded  by  some  obstruction. 
The  Davidson  syringe  is  then  attached  and  a  stream  of  warm  water 
or  oil  is  forced  through  the  instrument  for  the  purpose  of  dislodging 
any  fecal  matter  or  folds  of  mucous  membrane  that  may  be  interfer- 
ing with  its  passage.  In  this  way  the  whole  length  of  the  bowel 
may  be  explored  without  danger,  and  the  instrument  may  be  passed 
into  the  sigmoid  provided  no  stricture  exists. 


Fig.  589. — Wales'  bougies. 


EXAMINATION  BY  THE  BOUGIE  A  BOTTLE 

The  rectal  bougie  k  boule  is  made  use  of  in  diagnosis  to  deter- 
mine the  size  and  length  of  a  stricture. 

Instruments. — The  bougie  k  boule  consists  of  a  flexible  wire  or 
rubber  shaft  with  a  handle  to  the  extremity  of  which  acorn-tips  of 
various  sizes  may  be  screwed  (Fig.  590).  The  bougie  k  boule  is  used 
to  best  advantage  in  connection  with  a  cylindrical  speculum  or  a 
proctoscope. 


O 


Fig.  590. — Rectal  bougie  k  boule. 


Technic. — A  speculum  is  introduced  into  the  anus  and  is  carried 
up  to  the  seat  of  the  stricture  so  that  a  clear  view  of  its  opening  may 
be  secured.  The  examiner  begins  by  selecting  a  large  bougie  and 
passing  it  through  the  speculum  to  the  opening  in  the  stricture  (Fig. 
591).  If  it  is  found  to  be  too  large  to  enter  the  stricture,  smaller 
instruments  are  selected  until  one  is  found  that  will  just  pass  through 
the  contracture.  This  is  inserted  entirely  through  the  stricture, 
using  gentleness  only  in  manipulation,  and  as  it  is  withdrawn  its 


S92  THE  COLON  AND  RECTUM 

base  catches  the  distal  opening  of  the  stricture  (Fig.  591).  Fim 
this  examination  the  exact  length  and  size  of  the  contracture  ma]' be 
readily  ascertained. 


Fic.  591.  Fig.  s9»- 

Ftc.  591. — Method   of   estimating   the  length  of  a  rectal  stricture,  the  Imp ' 

boule  at  the  face  of  the  stricture. 

Fic.  S9J— Method  of  estimating  the  length  of  a  rectal  stricture.   Tte  I*** 

k  boule  is  withdrawn  until  its  base  is  arrested  at  the  distal  end  of  the  striclurt. 


EXAMINATION  BY  THE  PROBE 

Probing  has  but  little  utility  in  the  diagnosis  of  rectal  (fct** 
except  as  a  means  of  determining  the  situation  and  course  of  a  recto- 
vaginal or  ischiorectal  fistula. 

Instruments.^ — A  silver  probe  8  or  10  inches  (20  to  2$  cm.)  W 
with  a  flat  handle  is  employed  (Fig.  593).     The  probe  should  beflO" 


Fig.  593.— Rectal  probe. 

ible  that  it  may  be  bent  in  any  direction  if  desired.  When  exanun"'? 
for  a  recto- vaginal  fistula  a  Sims  speculum  will  be  required  in  addiW 
to  expose  the  fistulous  opening  in  the  vagina. 

TechniC' — The  index-finger  of  the  left  hand,  well  lubricatedT " 
first  introduced  into  the  rectum.     The  probe,  grasped  in  the  rig"' 


LAVAGE   OF   THE  BOWEL 


593 


hand,  is  then  passed  through  the  external  opening  in  the  supposed 
direction  of  the  fistulous  tract.  The  tract  of  the  sinus  is  thus  slowly 
explored,  removing  the  probe  and  bending  it  so  as  to  alter  its  shape  to 
correspond  with  the  direction  of  the  sinus  if  necessary.  The  internal 
finger  at  once  recognizes  the  tip  of  the  probe  as  it  enters  the  rectum 
(Fig.  594). 


Fig.  594. — Showing  the  method  of  probini;  an  ischiorectal  fistula.     (Ashton.) 


LAVAGE  OF  THE  BOWEL 

As  a  diagnostic  measure,  irrigation  of  the  howcl  is  sometimes 
employed  for  the  purpose  of  securing  samples  of  the  contents  for 
examination.  The  presence  of  blood,  pus,  ameba',  tumor  fragments, 
etc.,  in  the  material  thus  obtained,  will  often  lead  to  the  recognition 
of  ulcerative  or  suppurative  processes  or  malignant  conditions  which 
from  their  location  high  up  in  the  bowel  might  otherwise  escape 
notice. 

Apparatus. — There  will  be  required  a  rectal  tube  connected  with 
a  glass  funnel  by  about  3  feet  {90  cm.)  of  rubber  tubing. 

Position  of  the  Patient. — Irrigation  may  be  performed  with  the 
patient  in  the  dorsal  position  or  lying  upon  the  left  side  with  the 
knees  drawn  up. 

Technic. — The  tube,  properly  lubricated,  is  inserted  into  the  rec- 
tum a  short  distance,  and  about  a  pint  (500  c.c.)  of  warm  boiled 
water  is  slowly  allowed  to  run  into  the  bowel  through  the  funnel, 
which  is  elevated  i  to  2  feet  (30  to  90  cm.)  above  the  level  of  the 
patient.    As  soon  as  any  discomfort  is  felt  by  the  patient,  the  funnel 


594  THE  COLON  AND  RECTUM 

is  lowered  and  the  contents  of  the  bowel  are  syphoned  off  and  pre- 
served for  examination. 


EXAMINATION  OF  THE  FECES 

Examination  of  the  stools  is  of  distinct  diagnostic  value  in  many 
of  the  diseases  of  the  digestive  tract.  Besides  furnishing  information 
as  to  the  functional  activity  of  the  various  organs  associated  with  tlic 
process  of  digestion  and  absorption  of  food,  it  is  a  valuable  aid  in 
the  recognition  of  those  diseases  of  the  rectum  and  large  intestine 
which  are  due  to  infection  by  parasites  and  bacteria.  Wthout 
attempting  to  enter  into  the  technic  of  such  examination,  the  details 
of  which  will  be  found  fully  described  in  manuals  on  clinical  labora- 
tory methods,  the  lines  along  which  the  investigation  should  be 
conducted  may  be  briefly  referred  to.  There  are  four  methods  of 
examination  available:  macroscopical,  microscopical,  chemical,  and 
bacteriological. 

Macroscopical  examination. — The  amount,  color,  odor,  consist- 
ency, and  form  of  the  stool  and  the  presence  or  absence  of  mucus, 
blood,  or  pus  should  be  carefully  noted. 

Microscopical  examination  is  made  for  the  purpK)se  of  detecting 
intestinal  parasites  or  their  ova,  fat  globules,  undigested  meat  fibers, 
blood,  pus,  or  tumor  fragments. 

Bacteriological  examination  will  identify  pathogenic  bacteria  if 
present. 

Chemical  examination  should  include  tests  for  mucin,  albumin, 
carbohydrates,  fat,  blood,  bile  pigments,  etc. 

Therapeutic  Measures 

ENEMATA  AND  ENTEROCLYSIS 

Hydrotherapy  of  the  lower  bowel  may  be  carried  out  by  means  of 
enemata  or  by  enteroclysis.  These  two  measures  are  often  unneces- 
sarily confused  and,  while  in  general  they  are  employed  for  the  rdio 
of  much  the  same  conditions,  yet  in  practical  application  they  ^ 
quite  distinct.  By  an  enema  is  understood  the  introduction  into  the 
bowel  of  clysters  of  fluid  to  be  retained  some  little  time  at  least.  Th« 
quantity  of  fluid  so  injected  is  usually  small  in  amount,  rarely  ex- 
ceeding I  to  2  pints  (500  to  1000  C.C.).  Enteroclysis,  on  the  other 
hand,  is  an  irrigation  of  the  lower  bowel,  the  fluid  returning  almost 


ENEMATA   AND   ENTEROCLYSIS 


595 


rapidly  as  it  is  introduced.     In  this  procedure,  large  quantities 

fluid  are  made  use  of- — frequently  several  gallons  at  an  irrigation, 
le  enema  and  the  irrigation  may  be  administered  either  low  or 
;h,  according  to  whether  the  fluid  is  introduced  a  few  inches  up 
e  rectum  or  high  in  the  colon. 

Enemata. — Encmata  may  be  of  several  kinds,  according  to  the 
rpose  for  which  they  are  employed.  They  may  be  designed 
nply  to  secure  an  action  of  the  bowels  in  ordinary  constipation  or  to 
iload  the  bowel  of  long-standing  fecal  accumulations  or  impactions 
id  at  the  same  time  relieve  the  accompanying  tympanites.  These 
e  known  as  purgative  enemata.  Such  injections  owe  their  action  to 
.e  stimulating  effects  upon  intestinal  peristalsis  and  to  the  softening 
oduced  in  the  hardened  fecal  matter.  In  the  treatment  of  consti- 
ition,  however,  the  use  of  enemata  should  be  restricted  as  much  as 
ssible;  they  should  not  be  advised  for  long-continued  use,  as  they 
aduaUy  lose  their  potency,  and  constantly  increasing  quantities  are 
cessary  to  produce  an  effect.  For  the  local  effects  in  colitis,  dysen- 
ty,  catarrhal  and  ulcerative  conditions  of  the  rectum  and  colon, 
lall  enemata  of  antiseptic,  astringent,  or  sedative  solutions  to  be 
lained  some  httle  time  are  administered  after  each  movement  or 
lowing  a  cleansing  irrigation.  While  used  mainly  for  purgative 
d  cleansing  effects,  enemata  have  other  valuable  uses  in  thera- 
jtics.  Rectal  injections  of  saline  solution  are  made  use  of  in  the 
atment  of  shock,  hemorrhage,  sepsis,  etc.  (see  Saline  Infusions, 
607).  Rectal  enemata  are  likewise  employed  as  a  means  of  intro- 
:iig  fluids  and  nutriment  into  the  bowel  (see  Rectal  Feeding, 
613)  and  for  the  administration  of  drugs  which  affect  the  general 
>tem  after  absorption. 

In  employing  the  rectum  as  an  avenue  tor  the  administration  of 
igs,  however,  certain  facts  are  to  be  kept  in  mind.  The  drug 
)uld  always  be  given  in  such  a  state  that  the  active  principle  is  in  an 
ieous  solution  or  else  is  capable  of  being  dissolved  in  the  fluids  of 
!  rectum.  It  should  also  be  remembered  that,  while  the  absorption 
wer  of  the  rectum  may  be  great,  drugs  are  taken  up  but  slowly  and 
i  rapid  effect  is  desired,  this  method  should  not  be  employed.  As  a 
e,  unless  the  drug  is  very  powerful  and  is  capable  of  being  rapidly 
sorbed,  the  dose  is  twice  the  amount  given  by  mouth. 

Apparatus. — The  simpler  the  apparatus,  provided  it  is  efficient, 
i  better.  A  fountain  syringe  or  a  glass  irrigating  Jar,  capable  of 
l(Kng  a  quart  (100c  c.c.)  of  solution,  will  be  required  as  a  reservoir. 
It  in  an  emergency  a  large  funnel  will  answer.     A  rubber  tubing 


596 


THE  COLON   AND   RECTUM 


about  3^  to  ^  inch  (6  to  g  mm.)  in  diameter  and  at  least  6  feet 
(i8o  cm.)  long  is  connected  with  the  outlet  of  the  reservoir,  and  to  the 
free  end  an  appropriate  nozzle  is  attached  (Fig.  595).  For  low 
enemata  the  ordinary  hard-rubber  rectal  nozzle  provided  with  every 
douche-bag  will  answer,  but  if  the  injection  is  to  be  given  high  iq)  in 
the  bowel  a  flexible-rubber  rectal  tube  about  20  inches  (50  cm.)  long 
will  be  more  convenient.  The  tube  should  be  smooth  and  from  % 
to  J^  inch  (9  to  12  mm.)  in  diameter.  A  very  simple  apparatus 
consists  of  a  long  colon  tube  and  a  funnel  (Fig.  596) . 


Fig.  595. — Fountain   syringe   and   nozzle     Fig.  596. — Colon  tube  and  fun^t-' 
for  giving  a  low  enema. 


Rectal  tubes  are  made  with  the  openings  at  the  side,  or  with 
opening  at  the  end  (Fig.  597).  The  latter  are  better,  as  the  fluid  m  ^ 
be  injected  directly  through  the  tube  for  the  purpose  of  dislodgL* 
any  feces  or  folds  of  mucous  membrane  that  may  obstruct  the  p^ 
sage  of  the  tube.  In  addition,  a  bed-pan  or  a  douche-pan  should  t 
provided. 

Formulary. — For  simple  cleansing  purposes  or  to  produce  ^ 
evacuation  in  mild  cases  of  costiveness  an  enema  consisting  of  nono^ 
salt  solution  (dr.  i  (4  gm.)  of  salt  to  i  pint  (500  c.c.)  of  warm  water; 
or  the  soap-suds  enema,  made  by  adding  to  i  quart  (1000  c.c.)   ^* 


ENEMATA  AND   ENTEROCLYSIS  597 

>t  water  sufficient  castile  soap  scrapings  to  make  suds,  may  be  used, 
he  continued  use  of  the  latter  is  not  advisable,  however,  as  some 
ritation  may  be  caused  by  the  lye  which  is  apt  to  result  in  proctitis 

skin  eruptions. 

In  habitual  constipation  the  injection  of  from  2  to  6  ounces  (60  to 
k>  c.c.)  of  warm  sweet  oil  into  the  bowel  or  the  use  of  the  flax-seed 
lema  will  often  give  good  results.  The  latter  is  prepared  by  adding 
ounce  (30  gm.)  of  flax-seed  to  i  pint  (500  c.c.)  of  cold  water  and 
len  boiling  the  mixture  for  ten  minutes.  The  resulting  muci- 
ginous  mixture  is  strained  and  injected  while  warm.  Another 
xkI  enema  consists  of  equal  parts  of  milk  and  molasses.  When 
more  profound  effect  is  desired  there  are  a  number  of  drugs  that 


frr^'vrrrw^r^^^ in , 

iiiiiif"""^' iiiiiiih— iiiiiiitii[i7rr~~'~'  — ,. . .....  ..  ■•  '  "■'  ■■■'J 

WMfOlffttflllffriffMfillflilfll """"* 


Fig.  597. — Rectal  tubes. 

^y  be  incorporated  in  the  enema.     Of  these  may  be  mentioned 
ive  oil,  castor  oil,  glycerin,  ox  gall,  turpentine,  magnesium  sulphate, 

arlsbad  salt,  etc.     The  following  combinations  of  the  above  will 
i  found  useful : 

^  Olive  oil  or  castor  oil,  oz.  ii  (60  c.c.) 

Warm  soapy  water,  oz.  iv  (120  c.c.) 

I^  Glycerin,  oz.  i  (30  c.c.) 

Olive  oil,  oz.  iii  (90  c.c.) 

Warm  soapy  water,  oz.  iv  (120  c.c.) 

I^  Ox  gaU,  dr.  ii  (8  gm.) 

Warm  water,  O  i  (500  c.c.) 

I^  Ox  gaU,  dr.  ii  (8  gm.) 

Glycerin,  oz.  iv  (120  c.c.) 

Warm  water,  O   i  (500  c.c.) 

I^  Magnesium  sulphate,  oz.  i  (30  gm.) 

Glycerin,  oz.  ii  (60  c.c.) 

Warm  water,  oz.  iii  (qo  c.c.) 

I^  White  of  egg  (beaten), 

Oil  of  turpentine,  dr.  i  (4  c.c.) 

Olive  oil,  oz.  i  (30  c.c.) 

Warm  water,  O   i  (500  c.c.) 


598  THE  COLON  AND  RECTUM 

I^  Magnesium  sulphate,  oz.  ii  (60  gm.) 

Oil  of  turpentine,  dr.  ii  (8  ex.) 

Glycerin,  oz.  ii  (60  cc.) 

Warm  water,  oz.  iv(i20C.c) 

For  the  relief  of  tympanites  a  turpentine  enema  or  an  enema  con- 
sisting of  3  ounces  (90  c.c.)  of  milk  of  asafetida  may  be  used.  For 
irritability  of  the  rectum  the  use  of  a  small  flaxseed  enema  or  the 
starch-water  enema,  to  which  10  to  2o1ITt  (0.6  to  1.25  c.c.)  of  laudanum 
are  added,  will  often  give  great  relief.  The  starch-water  enema  is 
prepared  by  mixing  an  ounce  (30  gm.)  of  starch  and  sufficient  cold 
water  to  form  a  thick  paste;  enough  boiling  water  is  then  added  to 
dilute  this  mixture  to  the  consistency  of  mucilage. 

Temperature. — The  enema  should  be  given  warm — at  a  tempera- 
ture of  about  100®  F.  (38°  C.) — unless  contraindicated. 

Rapidity  of  Flow. — The  solution  should  always  be  injected  slowly 
to  avoid  discomfort  and  spasm  from  a  sudden  distention  of  the  bowel. 
The  reservoir  is  consequently  elevated  2  to  3  feet  (60  to  90  cm.) 
above  the  patient. 

Quantity. — To  stimulate  peristalsis  and  produce  an  evacuation 
of  the  bowels  a  bulk  of  liquid  sufficiently  large  to  distend  the  walls  of 
the  intestine  should  be  injected.  For  this  purpose  between  i  pint 
(500  c.c.)  and  i  quart  (1000  c.c.)  of  fluid  is  made  use  of  at  one  injec- 
tion. Enemata  to  be  permanently  retained  for  absorption,  such  as 
those  containing  drugs  or  nutriment,  should  be  small  in  amount,  as  a 
rule  containing  only  2  to  3  ounces  (60  to  90  c.c.)  of  fluid. 

Position  of  the  Patient. — The  dorsal,  the  Sims,  or  the  knee-chest 
position  may  be  utilized.  When  employing  the  dorsal  or  the  Sims 
position  the  hips  should  be  elevated  upon  a  hard  pillow;  especially 
is  this  necessary  if  the  enema  is  to  be  injected  high  into  the  bowel- 
Infants  can  be  best  controlled  lying  on  the  back  upon  the  atten- 
dant's lap. 

Technic. — The  tube  is  first  well  lubricated  with  vaselin,  and  any 
air  is  expelled.  The  left  hand  then  separates  the  buttocks,  and, 
while  the  patient  strains  slightly  to  relax  the  sphincter,  the  tube  is 
inserted  into  the  anus,  guided  by  the  right  hand  in  which  it  is  held*^ 
a  distance  of  about  2  inches  (5  cm.)  from  its  extremity,  the  operator 
using  a  slight  boring  motion,  and  bearing  in  mind  that  the  direction 
of  the  anal  canal  with  the  patient  recumbent  is  upward  and  slightly 
forward.  Having  traversed  the  anal  canal,  the  tube  enters  the  rec- 
tum proper,  and  is  then  slowly  advanced  in  an  upward  and  slightly 
backward  direction.     From  this  point  some  difficulty  may  be  met 


ENEMATA    AJJD    ENTEROCLYSIS  599 

with  in  passing  the  tube,  as  it  often  doubles  upon  itself  from  the 
point  catching  in  a  fold  of  mucous  membrane  or  one  of  the  valves 
or  from  being  obstructed  by  feces.  Withdrawing  the  tube  slightly 
and  advancing  it  will  often  suffice  to  free  it;  in  other  cases  allowing 
the  fluid  to  flow  as  the  tube  is  advanced  displaces  or  removes  any  ob- 
struction and  at  the  same  time  causes  the  tube  to  straighten  out.  In 
this  manner  the  tube  may  be  passed  into  the  colon,  if  desired,  without 
causing  the  patient  any  great  discomfort,  provided  gentleness  and  no 
force  be  employed. 

When  the  tube  is  introduced  to  the  desired  height,  th^  reservior  is 
elevated  a  distance  of  2  or  3  feet  (60  to  go  cm.),  and  its  contents  are 
aUowed  to  enter  the  bowel  slowly  (Fig.  598),    The  patient  is  apt  to 


Fig.  598, — Method  ot  giving  a  low 


■Complain  of  fulness  in  the  rectum  as  the  fluid  enters  and  distends  it, 
out,  by  temporarily  stopping  the  flow,  this  feeling  soon  passes  off, 
and,  as  the  rectum  becomes  tolerant  to  the  pressure,  more  fluid  can 
oe  injected.  When  the  desired  amount  has  been  introduced,  the 
flow  is  shut.off  by  pinching  the  tube,  which  is  then  withdrawn.  The 
Patient  is  directed  to  hold  the  enema  for  live  or  ten  minutes  if  possible 
before  using  the  bed-pan. 

Enteroclysis.- — Like  enemata,  irrigations  are  used  mainly  for 
<^Ieansing  purposes,  to  remove  putrefying  material  or  toxins  from  the 
l>owels,  and  to  bring  medicated  fluids  into  contact  with  diseased 
Hiucous  membrane.  Large  irrigations  are  not  advised,  however,  in 
the  treatment  of  habitual  constipation,  the  use  of  small  enemata  is 
Just  as  efficacious,  and  there  is  less  danger  of  producing  atony  of  the 
bowel  than  where  it  is  continually  overloaded  and  distended  with 
large  quantities  of  fluid.  In  the  treatment  of  intestinal  toxemia  by 
diteioclysis,  the  bowels  are  thoroughly  cleansed  and  absorption  of 


6oO  THE  COLON  AND  RECTUM 

the  toxins  from  the  decomposing  contents  is  prevented.  At  the  same 
time,  more  or  less  fluid  is  absorbed,  the  activity  of  the  skin,  kidneys, 
and  liver  is  consequently  stimulated  and  general  absorption  and 
autointoxication  are  greatly  lessened.  For  the  same  reasons  entero- 
clysis  has  a  wide  field  of  usefulness  in  the  treatment  of  renal  insuffi- 
ciency, uremia,  toxemia,  general  septic  conditions,  etc.,  produdng 
marked  diuresis,  and  not  only  diluting  the  toxins  in  circulation,  but 
favoring  their  elimination. 

Enteroclysis  with  hot  normal  salt  solution,  through  the  stimu- 
lating effect  on  the  circulation  and  the  elevation  of  bodily  tempera- 
ture, produces  marked  and  beneficial  results  in  shock  due  to  whatever 
cause  (see  Saline  Rectal  Infusions,  page  607). 

In  proctitis  and  in  catarrhal,  dysenteric,  and  ulcerative  conditions 
of  the  large  bowel  irrigations  are  employed  for  cleansing  purposes, 
removing  foreign  substances,  mucus,  and  pus,  and  thus  rendering 
bacteria  less  active;  they  also  serve  as  a  means  of  bringing  medicinal 
agents  in  contact  with  the  diseased  surfaces.  For  the  local  effect 
upon  diseases  of  the  rectum  or  adjacent  organs  irrigations  are  used 
either  hot  or  cold;  for  example,  in  the  treatment  of  internal  hemor- 
rhoids or  hemorrhage  from  ulcers  situated  in  the  rectum  or  lower 
bowel.  Such  irrigations  are  likewise  employed  in  genitourinary  and 
gynecological  practice  for  the  treatment  of  congestion  and  inflam- 
mation located  in  the  bladder,  prostate,  and  deep  urethra,  or  the 
uterus  and  its  appendages. 

Apparatus. — The  reservoir  for  the  solution  may  be  either  a 
quart-glass  irrigating  jar  or  a  fountain  syringe,  attached  to  which 
is  about  6  feet  (180  cm.)  of  rubber  tubing  3^  to  ^4  iiich  (6  to  9 
mm.)  in  diameter.  Irrigating  tubes  are  made  in  two  styles:  a  single- 
flow  tube,  in  which  the  fluid  enters  and  escapes  through  the  same 
opening,  and  a  double-current  tube,  in  which  the  inflow  enters  and 
the  outflow  escapes  through  different  compartments. 

In  irrigating  with  a  single  tube,  it  will  prove  most  satisfactor)' 
to  use  a  colon  tube  about  20  inches  (50  cm.)  long  and  ^  to  h 
inch  (9  to  12  mm.)  in  diameter,  with  the  opening  at  the  end.  With 
this  form  of  tube  fluid  may  be  deposited  high  in  the  colon  or  low  in 
the  rectum  at  will.  For  infants,  a  catheter,  16  to  18  French,  mayl>e 
used.  The  irrigating  tube  is  connected  to  the  end  of  the  rubber  tub- 
ing of  the  irrigator  by  a  T-shaped  glass  tube,  to  the  long  arm  01 
which  is  attached  a  short  piece  of  rubber  tubing  closed  by  a  clip 
(Fig.  599).  The  solution  is  passed  into  the  bowel  with  this  clip 
closed,  and  when  it  is  to  be  drawn  off  the  inflow  of  solution  is  temp^ 


ENEMATA   AND   ENTEROCLYSIS 


6oi 


rarily  stopped  by  pinching  the  tubing  between  the  glass  connection 
and  the  irrigator,  the  clip  is  opened,  and  the  fluid  returns  through  the 
same  tube  and  escapes  through  the  long  arm  of  the  T-tube  into  a 
waste-pail  ready  for  that  purpose.  The  same  thing  may  be  very 
simply  accomplished  with  a  long  colon  tube  and  a  funnel  (see  Fig. 
596).     The  solution  is  forced  in  through  the  funnel,  and,  when 


Fig.  599. — Apparatus  for  enteroclysis. 

sufficient  has  entered  the  bowel,  the  funnel  is  depressed  and  the  fluid 
allowed  to  escape. 

With  a  double-flow  tube  irrigations  may  be  carried  out  far  more 
conveniently,  especially  when  several  gallons  of  fluid  are  used  at  each 
irrigation.  A  very  efficient  double-flow  apparatus,  especially  for 
high  irrigating,  may  be  improvised  by  passing  a  moderate-sized 


Fig.  600. — Kemp's  return-flow  irrigator. 

single-flow  tube  high  into  the  bowel,  alongside  of  which  is  inserted  a 
second  tube  of  larger  caliber  to  carry  off  the  return  flow.  There  are 
any  number  of  excellent  double-flow  irrigators  on  the  market,  of 
which  Bodenhamer's,  Kemp's  (Fig.  600),  or  Tuttle's  tubes  are  sat- 
isfactory models.  These  instruments  are  made  of  hard  rubber  so 
that  they  may  be  readily  sterilized.     Tuttle's  irrigator  (Fig.  601) 


6o2  THE  COLON  AND  RECTUM 

consists  of  a  cylinder  enclosing  a  smaller  tube  which  opens  at  the  end 
of  the  irrigator.  This  smaller  tube  conducts  the  fluid  into  the  bowcL 
The  outside  cylinder  has  numerous  openings  in  its  sides  to  carry  off 
the  outflow.  It  ends  in  a  discharge  tube  to  which  a  long  piece  of 
rubber  tubing  is  attached  to  carry  off  the  waste. 

A  bath-thermometer,  a  douche-pan  or  a  bed-pan,  a  slop-pail, 
and  rubber  sheeting  to  protect  the  bed  complete  the  necessary 
equipment. 

Solutions  for  Irrigation. — In  the  great  majority  of  cases,  unless  a 
specific  action  is  required  from  direct  contact  of  remedies  with  the 
surface  of  the  intestine,  normal  salt  solution  (dr.  i  (4  gm.)  of  salt  to 
a  pint  (500  c.c.)  of  warm  water)  is  used.  For  cleansing  purposes 
and  to  aid  in  the  expulsion  of  flatus,  5  to  15  TTt  (a3  to  i  c.c.)  of  oleum 
cinnamomi  or  oleum  menthae  piperitae  may  be  added  to  each  pintof 
solution. 


Fig.  601. — ^Tuttle's  retum-flow  irrigator. 

The  following  solutions  will  be  found  useful  in  catarrhal  or  ulcera- 
tive conditions  of  the  lower  bowel,  according  to  whether  a  soothing, 
antiseptic,  stimulating,  or  astringent  action  is  desired:  aqueous 
extract  of  krameria,  i  to  20;  fluid  extract  of  hydrastis,  i  to  50;  fluid 
extract  of  hamamelis,  i  to  50;  boric  acid,  i  to  20;  hydrogen  peroxi<i, 
I  to  10;  thymol,  i  to  50;  carbolic  acid,  i  to  500;  bichlorid  of  mercury, 
I  to  10,000;  permanganate  of  potash,  i  to  500;  salicylic  add,  i  to 
500;  quinin,  i  to  1000;  argyrol,  i  to  1000;  tannic  acid,  i  to  S^oi 
silver  nitrate,  i  to  2000,  etc.  In  using  the  more  powerful  and  pois- 
onous drugs,  such  as  carbolic  acid  and  bichlorid  of  mercury,  for  in- 
stance, any  excess  of  solution  remaining  in  the  bowel  at  the  compl^ 
tion  of  the  irrigation  should  be  drained  off  before  withdrawing  the 
tube. 

Temperature. — This  will  depend  upon  the  condition  for  which  the 
irrigation  is  employed  and  upon  the  action  desired.  For  simpk 
cleansing  purposes  and  in  the  treatment  of  colitis  and  dysentery  the 
irrigation  should  enter  the  bowel  at  a  temperature  of  100®  to  105"  F. 
isS""  to  41^  C).  Hot  irrigations  (110°  to  115"^  F.  (43*^  to46°C.))are 
indicated  when  the  stimulating  action  of  heat  is  desired,  or  for  the 


I 


ENEMATA   AND   ENTEROCLYSIS  603 

<liiiretic  efiFect  and  to  increase  the  eliminative  action  of  the  skin,  and 
for  the  efiFect  of  heat  upon  inflammations  of  neighboring  organs. 

Cold  enteroclysis  (65°  to  70®  F.  (18°  to  21°  C.))  has  a  beneficial 
action  upon  the  whole  intestinal  tract,  toning  up  the  mucous  mem- 
brane and  stimulating  the  muscular  tissue,  and  so  increasing  peri- 
stalsis. This  is  indicated  in  the  treatment  of  internal  hemorrhoids, 
inflammatory  conditions  of  the  rectum,  prostate,  deep  urethra,  etc. 
In  hemorrhage  from  the  bowel,  very  cold  (50°  F.  (10°  C.))  or  very 
hot  (120°  F.  (49°  C.))  irrigations  are  used.  It  should  not  be  for- 
gotten, however,  that  prolonged  enteroclysis  with  very  hot  or  very 
cold  fluid  will  cause  a  rise  or  lowering  of  the  bodily  temperature 
amounting  to  several  degrees. 

Rapidity  of  Flow. — The  fluid  should  enter  the  bowel  with  com- 
parative slowness,  to  avoid  exciting  peristalsis  and  to  allow  the  fluid 
to  be  well  distributed  over  the  intestinal  wall.  Elevation  of  the 
reservoir  2  to  3  feet  (60  to  90  cm.)  for  a  low  irrigation  and  3  to  4  feet 
(90  to  120  cm.)  for  the  high  will  give  the  proper  flow. 

Quantity. — A  continuous  irrigaton  of  from  ten  minutes  to  one- 
half  an  hour  or  more  at  a  time  gives  the  best  results  in  septic  condi- 
tions, toxemias,  inflammations  in  the  organs  adjacent  to  the  bowel, 
«tc.  Several  gallons  of  solution  are  needed  for  such  an  irrigation. 
On  an  average,  from  i  to  i3^  pints  (500  to  750  c.c.)  of  solution  in 
high  enteroclysis,  and  from  2  to  8  ounces  (60  to  240  c.c.)  in  the  low 
irrigation  are  kept  in  the  bowel  continuously.  For  cleansing  pur- 
poses, and  in  the  treatment  of  diseases  involving  the  mucous  mem- 
brane of  the  bowel,  the  irrigation  is  continued  until  the  solution 
returns  dear. 

Position  of  the  Patient. — Enteroclysis  may  be  performed  with 
the  patient  (i)  in  the  dorsal  position,  with  hips  elevated;  (2)  in  the 
Sims,  or  left  lateral  prone  position;  and  (3)  in  the  knee-chest  posture. 

When  it  is  desired  to  irrigate  the  whole  colon,  the  position 
of  the  patient  may  be  altered  to  advantage  from  time  to  time  in 
order  to  allow  the  force  of  gravity  to  act  upon  the  fluid  and  permit 
it  to  reach  all  portions  of  the  colon.  Elevation  of  the  patient's 
hips  causes  the  fluid  to  gravitate  toward  the  transverse  colon,  and 
thence  along  this  portion  of  the  bowel  to  the  ascending  colon  if  the 
patient  is  shifted  from  the  left  side  to  the  right. 

Technic. — The  apparatus  is  properly  connected  and  the  reservoir 
is  filled  with  the  solution,  first  allowing  a  little  to  escape  from  the 
nozzle  to  expel  any  air  and  to  see  that  everything  works  properly. 
Practically  the  same  steps  are  followed  in  inserting  the  tube  for 


6o4  THE  COLON  AND  RECTUM 

enteroclysis  as  were  detailed  for  giving  an  enema.  The  tube,  vd 
lubricated  with  vaselin  or  oil,  is  grasped  in  the  fingers  of  the  li^t 
hand  not  far  from  its  extremity,  while  the  left  hand  separates  the 
patient's  buttocks  The  patient  is  instructed  to  strain  sufficient^  to 
relax  the  sphincter,  and  the  tube  is  Inserted  at  first  upward  and 
forward  for  a  distance  of  2  to  3  inches  (5  to  7.5  cm.)  and  then  upvaid 
and  slightly  backward  toward  the  sacrum.  There  is  very  little 
difficulty  in  passing  a  rectal  tube  or  an  irrigating  nozzle  the  necessaiy 
distance  for  a  low  irrigation,  if  the  normal  direction  of  thebovdis 


Fig.  6o3.— Showing  one  method  of  irrigating  the  bowel  with  a  single  mbt 


followed,  a  well-oiled  tube  almost  sUpping  in  of  its  own  accord*' 
times.  To  pass  a  flexible  tube  the  remainder  of  the  way  into  tie 
sigmoid  is  not  so  simple,  as  it  is  not  possible  to  guide  the  tube  afto 
it  gets  3  or  4  inches  (7.5  or  10  cm.)  into  the  bowel,  and  it  has  to  pr»c- 
tically  find  its  own  way  along.  It  will  be  found  a  distinct  aid,  bw- 
ever,  in  accomplishing  this  if  the  solution  is  allowed  to  flow  gently'* 
soon  as  the  anal  canal  is  passed.  This  tends  to  make  the  tube 
stiffer  and  at  the  same  time  it  straightens  out  the  folds  of  mucous 
membrane  and  carries  the  valves  out  of  the  way,  which  might  othO' 


ENEMATA    AND    ENTEROCLYSIS  605 

wise  form  obstructions.  When  the  tube  has  been  inserted  to  the 
desired  distance,  the  reservoir  is  raised  3  or  4  feet  (90  or  no  cm.), 
and  the  washing-out  process  begins. 

In  performing  enteroclysis  with  a  single  tube,  i  to  i'-'2  quarts 
[i  to  1.5  liters)  of  solution — depending  upon  the  capacity  and  toler- 
mce  of  the  individual — are  allowed  to  flow  into  the  bowel  before  the 
fluid  is  permitted  to  return.  If  the  fluid  enters  the  bowel  slowly  and 
the  desire  on  the  part  of  the  patient  to  expel  it  be  resisted  a  few 


J'lc.  603,^ — Showing   the  method  of   irrigalinic  the  bouel   by  j 
colon  tube 


moments  until  it  passes  well  into  the  colon,  no  great  difficulty  will  be 
encountered.  To  withdraw  the  fluid,  the  outlet  placed  in  the  tube 
leading  from  the  reservoir  is  opened  (Fig.  6oz),  or,  if  a  funnel  con- 
stitutes the  reservoir,  this  is  simply  lowered  below  the  level  of  the 
patient,  and  the  solution  escapes  through  the  same  tube  by  which 
it  entered  (Fig.  603).  This  process  of  lavage  is  repeated  until  the 
fluid  returns  clear. 


n 


6o6  THE  COLON  AND  KECTUli. 

The  colon  may  be  more  thoroughly  irrigated,  as  already  mcD- 
tioned,  by  altering  the  patient's  position  as  follows:  With  the  patiot 
in  the  Sims  position,  for  instance,  and  with  the  hips  elevated,  tbc 
descending  colon  is  first  thoroughly  washed  out.  About  i>^  to  i 
pints  (750  to  1000  c.c.)  of  solution  are  then  retained,  and  the  patiat 
is  gradually  rolled  to  the  dorsal  position  and  then  to  the  right  side. 
This' permits  the  fluid  to  pass  from  the  descending  colon  to  the  trans- 
verse and  ascending  colon.     To  allow  the  solution  to  gravitate  dawii 


Fro.  604. — Showing  the  method  of  imgaLmg  the  bowel  by  means  of  a  return** 
irrigator 

the  ascending  colon  to  the  caput  coli,  the  patient's  shoulders  tit 
raised  slightly  higher  than  his  hips  The  process  is  then  exactly 
reversed:  the  shoulders  are  first  lowered,  the  patient  then  rolls  to  the 
dorsal  position,  and  finally  to  the  left  side  again. 

In  using  the  double-flow  style  of  irrigator,  the  outflow  tube  is 
compressed  until  a  pint  (500  c,c.)  or  more  of  solution  runs  into  the 
bowel  (Fig.  605),  when  it  is  released,  the  solution  still  contbuingW 
flow  in.  In  this  way  a  current  is  soon  established,  and  the  descending 
colon  and  rectum  are  thoroughly  washed  out.     During  the  irrigatio'i 


SALINE    RECTAL   INFUSIONS  607 

the  reservoir  should  not  be  allowed  to  become  empty,  the  supply- 
being  replenished  as  often  as  necessary.  In  withdrawing  an  irrigator 
or  a  tube  with  openings  upon  the  side,  care  should  be  taken  to  rotate 
the  instrimient  slightly  to  prevent  the  mucous  membrane  from  being 
caught  in  the  fenestrae. 

SALINE  RECTAL  INFUSIONS 

The  value  of  saline  infusions  in  the  treatment  of  hemorrhage  and 
in  the  prevention  and  relief  of  surgical  shock  has  already  been  con- 
sidered in  Chapter  V.  The  rectal  infusion,  being  a  somewhat  slower 
and  less  effective  method  of  introducing  salt  solution  into  the  circu- 
lation than  either  the  intravenous  or  the  subcutaneous  methods,  is 
used  with  greater  success  in  the  milder  forms  of  shock  and  hemor- 
rhage, and  in  the  severe  cases  as  an  adjunct  to  intravenous  infusion 
or  hypodermoclysis.  It  has,  however,  the  distinct  advantage  of 
simplicity  over  the  other  two  methods,  requiring  no  preparation  of 
the  patient  and  but  the  crudest  form  of  apparatus;  hence  its  value 
as  an  emergency  measure.  In  septic  conditions,  toxemias,  renal 
insufficiency,  uremia,  etc.,  the  fluid  thus  introduced  into  the  bowel 
is  rapidly  absorbed,  and  the  skin,  kidneys,  and  liver  are  stimulated 
to  increased  activity,  with  the  rapid  elimination  of  poisonous  prod- 
ucts as  a  result.  Rectal  infusions  are  also  indicated  when  it  is 
desirable  to  increase  the  quantity  of  fluid  in  the  tissues,  as,  for 
example,  in  cases  where  large  quantities  of  fluid  are  lost  from  purg- 
ing, as  in  dysentery  or  cholera.  It  is,  furthermore,  a  most  valuable 
means  of  relieving  the  thirst  so  frequently  complained  of  after 
abdominal  operations. 

Apparatus. — The  equipment  will  not  differ  from  that  used  in 
giving  an  ordinary  enema.  There  will  be  required  a  thermometer; 
a  graduated  glass  irrigating  jar  or  fountain  syringe;  6  feet  (i8o  cm.) 
of  rubber  tubing,  about  K  to  %  inch  (6  to  9  mm.)  in  diameter; 
and  a  rectal  tube,  20  inches  (50  cm.)  long  and  ^  to  3^  inch  (9  to 
12  mm.)  in  diameter.  In  an  emergency,  a  large  funnel  will  answer 
as  a  reservoir,  and  a  large  long  soft-rubber  catheter  will  take  the 
place  of  the  rectal  tube. 

Solution. — Normal  salt  solution,  (dr.  i  (4  gm.)  of  salt  to  a  pint 
(500  c.c.)  of  water)  is  used.'  For  a  stimulating  effect,  whisky  or 
brandy,  oz.  ss.  to  oz.  i  (15  to  30  c.c.)  may  be  added.  In  surgical 
shock  3oTTl  (2  c.c.)  of  a  i  to  1000  solution  of  adrenalin  chlorid  may 
be  added  to  the  enema  for  the  purpose  of  raising  blood-pressure. 


6o8  THE  COLON  AND  RECTUM 

Temperature. — The  solution  should  enter  the  bowel  at  a  tem- 
perature of  iio°  to  115°  F.  (43°  to  46°  C).  As  there  is  but  little 
loss  of  heat  on  account  of  the  rapidity  of  the  flow,  the  solution  in  the 
reservoir  should  be  at  the  same  temperature  at  which  it  is  desired 
to  have  it  enter  the  bowel,  or  not  more  than  one  or  two  degrees 
higher. 

Rapidity  of  Flow. — The  fluid  should  be  introduced  slowly  and  not 
with  such  rapidity  as  to  excite  intestinal  spasm.  With  this  in  view, 
the  reservoir  is  held  not  over  3  to  4  feet  (90  to  120  cm.)  above  the 
patient. 

Quantity. — Small  amounts  are  more  apt  to  be  retained  by  the 
bowel.  From  3^^  pint  (250  c.c.)  to  a  quart  (1000  c.c.)  may  be  given 
at  a  single  injection. 

Position  of  the  Patient — The  infusion  may  be  given  preferably 
with  the  patient  in  the  Sims  position  with  the  hips  raised  or  else 
in  the  knee-chest  position.  If  it  is  not  expedient  to  move  the  patient 
about,  the  dorsal  position  with  the  hips  elevated  and  with  the  knees 
drawn  up  may  be  substituted. 

Technic. — The  reservoir  is  filled  with  the  required  amount  of 
solution  of  the  proper  temperature,  and  a  thermometer  is  placed 
in  it  that  the  temperature  may  be  kept  uniform.  The  rectal  tube 
should  be  well  lubricated  with  vaselin  or  oil.  Some  of  the  solution 
is  allowed  to  escape  from  the  tube  to  expel  any  air  or  cold  fluid.  The 
flow  is  then  shut  off  and  the  tube  is  grasped  in  the  fingers  of  the 
right  hand  about  2  inches  (5  cm.)  from  its  extremity  while  the  left 
hand  separates  the  buttocks.  As  the  patient  strains  slightly, 
relaxing  the  sphincter,  the  tube  is  gently  inserted  into  the  rectum. 
In  doing  this  the  normal  direction  of  the  bowel  with  the  patient  in 
the  dorsal  posture — first  upward  and  forward,  and  then  upward 
and  backward — must  be  kept  in  the  mind  of  the  operator.  \\Tien 
the  internal  sphincter  is  passed,  the  solution  is  again  allowed  to 
flow  gently,  in  order  to  displace  any  feces,  folds  of  mucous  membrane, 
etc.,  that  might  act  as  an  obstruction,  and  the  tube  is  pushed  on  into 
the  bowel  for  a  distance  of  at  least  8  to  10  inches  (20  to  25  cm.)- 
The  reservoir  is  then  raised  from  3  to  4  feet  (90  to  120  cm.),  and  the 
required  amount  of  solution  is  introduced.  If  it  is  injected  slowly 
and  the  tube  is  passed  high  up,  no  diflSculty  will  be  foimd  in  intro- 
ducing and  having  retained  often  as  much  as  a  quart  (icxx)  c.c.)  <rf 
solution.  At  the  completion  of  the  operation  the  tube  is  withdrawn 
and  the  patient  is  instructed  to  remain  quiet  in  the  recumbent 
position. 


CONTINUOUS   PROCTOCLYSIS 


609 


CONTINUOUS  PROCTOCLYSIS 

By  this  method  a  continuous  stream  of  saline  solution  is  instilled 
into  the  rectum  at  very  low  pressure.  Given  slowly,  so  as  not  to 
irritate  the  rectum,  enormous  quantities  of  salt  solution  may  be  thus 
absorbed.  It  was  originally  employed  by  Murphy  in  the  treatment 
of  septic  peritonitis  in  conjunction  with  free  abdominal  drainage^ 
on  the  theory  that  the  large  quantity  of  fluid  absorbed  reverses  the 
l)rmph  currents,  so  that,  instead  of  absorption  taking  place  from  the 
peritoneal  surface,  the  lymphatics  pour  out  fluid  and  wash  out  the 


Fig.  605. — A  very  simple  apparatus  for  continuous  proctoclysis. 


peritoneum,  as  it  were.  At  the  same  time,  stimulation  of  the  heart 
and  kidneys  results,  and  with  the  latter  an  increased  elimination  of 
toxins  and  septic  material.  While  employed  mainly  in  cases  of 
peritonitis,  where  the  results  have  certainly  been  marvelous,  con- 
tinuous proctoclysis  will  be  found  an  excellent  means  of  infusing 
salt  solution  in  any  septic  condition  or  general  toxemia,  shock, 
uremia,  etc. 

Apparatus. — ^A  glass  reservoir  or  a  fountain  syringe  with  a  capac- 
ity of  at  least  2  quarts  (2  liters),  3  to  4  feet  (90  to  120  cm.)  of  rubber 

tubing  yito%  oi  an  inch  (6  to  9  mm.)  in  diameter,  and  a  vaginal 
39 


6io 


THE   COLON   AND   KECTUM 


nozzle  of  hard  rubber  with  iiumeroi)s  openings  on  the  sides,  bat 
at  an  angle  of  35  degrees  about  2  inches  (5  cm.)  from  the  t^  (Ilg. 
605)  forms  the  simplest  apparatus.  A  soft-rubber  catheter  may  be 
used  in  place  of  the  hard  nozzle,  If  desired.  Hot-water  bags  or  hot- 
water  cans,  which  surround  the  reservoir  and  prevent  the  solutkffl 
from  cooling,  should  also  be  provided.  An  indiciW, 
placed  in  the  outflow  tube  to  show  the  rate  of  Aov, 
is  a  great  convenience.  A  simple  one  is  described 
by  Dewitt  {Surgery,  Gynecology  and  Obstetrics,  Febn- 
ary,  1911).  The  plunger  is  removed  from  a  frindi 
(15  cm.)  metal-topped  glass  syringe  and  the  metal 
top  is  perforated  with  from  2  to  4  holes  for  the  es- 
cape of  gas,  and  through  the  opening  for  the  plunger 
is  inserted  a  glass  medicine  dropper.  The  Uf^ 
end  of  the  dropper  is  cormected  with  the  temiff 
by  a  short  piece  of  rubber  tubing  carrying  a  scot 
damp  (Fig.  606),  while  the  tip  of  the  syringe  is  at- 
tached to  the  rectal  tubing.  By  means  of  this 
simple  device  the  rate  of  flow  may  be  observed  and 
an  outlet  is  pro^'ided  for  flatus. 

Saxon  has  devised  an  apparatus  especially  fV 
proctoclysis  (Fig.  607),  consisting  of  a  oqipo 
bucket,  inside  of  which  is  placed  a  glass  reservoiEv 
the  salt  solution.  Between  the  copper  bucketaod 
reservoir  is  provided  a  space  of  aj-a  inches  (6  d"-) 
for  hot  water.  A  thermometer  is  placed  in  th* 
tubing  which  leads  from  the  reservoir,  and  avoit 
pipe  for  the  escape  of  £atus  is  also  provided. 

A  very  simple  apparatus  is  described  by  Ivosffl 
{Journal  of  the  American  Medical  Association,}'^ 
12,  1909)  in  which  the  solution  is  kept  at  the  re- 
toclysis.  (Cran-  quired  temperature  by  means  of  an  8-candIe-powff 
?ri^T"*  ^^^  electric  lamp.  The  mechanism  is  sufficienUy  dear 
from  the  accompanying  illustration  (F^.  608). 
There  are  a  number  of  more  elaborate  forms  of  apparatus  m«ter 
however,  in  which  the  heat  is  furnished  by  a  thermolite  warmer  or 
by  electricity. 

Solutions. — Normal  salt  solution  (dr.  i  (4  gm.)  of  salt  to  a  [»»' 
(500  c.c.)  of  water),  glucose  solution,  or  plain  boiled  tap  water  maybe 
used.  The  latter  has  been  employed  to  a  great  extent  in  the  last  fe» 
years,  as  it  has  been  found  that  the  large  bowel  tolerates  warm  w*'*' 


Fig.  606.— 
Modification  of 
Dewitt 's  appli- 
ance for  regulat- 
ing the  flow  of 
solution  in  proc- 


CONTINUOUS   PROCTOCLYSIS 


6ll 


as  well  as  it  does  saline  solutions;  furthermore,  thirst  is  more  quickly 
and  effectively  relieved. 

Glucose  may  be  used  in  a  watery  solution  in  the  strength  of  2 
drams  {7.5  gm.)  to  the  quart  (liter).  Solutions  of  glucose  are  espe- 
cially valuable  as  not  only  are  fluids  thus  supplied,  but  the  patient 
also  receives  a  certain  amount  of  carbohydrate  food. 

Temperature. — The  solution  should  beat  a  temperature  of  about 
100°  to  iog°  F.  (38°  to  41°  C.)  as  it  enters  the  rectum,  and  it  must 
therefore  be  at  a  temperature  of  from  120°  to  130°  F.  (49°  to  54°  C.) 


Fig.  607. 

Fic.  607. — Saion's  apparatus 

Fig.  fioS. — Ivcrsen's  apparatus  for 

electric  bulb;  b,  cock;  c,  Y-ihaped  glas 


proctoclysis, 
proctoclysis,    a,  Eight-candle-power 
iienl  lube  for  the  Escape  of  gss. 


in  the  reservoir.  The  solution  must  be  kept  at  a  uniform  degree 
of  heat  by  either  constantly  replenishing  with  hot  solution  or  by 
surrounding  the  reservoir  with  hot-water  bags,  unless  one  of  the 
special  heating  devices  is  employed. 

Rapidity  of  Flow. — The  salt  solution  just  trickles  into  the  bowel, 
not  much  faster  than  it  is  absorbed,  at  about  the  rate  of  30  to  lao 
drops  a  minute.  In  this  way  Ja  to  ij-a  pints  {250  to  750  c.c.)  will 
flow  into  the  rectum  in  about  an  hour.  The  reservoir  should  be 
elevated  only  from  4  to  18  inches  (10  to  45  cm.)  above  the  level  of 
the  rectum,  depending  upon  the  rate  of  absorption,  and  the  elevation 


6l2  THE  COLON  AND  RECTUM 

of  the  reservoir  must  be  so  regulated  that  no  accumulation  of  fli^^ 
occurs  in  the  bowel. 

Quantity. — The  instillation  is  practically  continuous,  and  tt»* 
quantity  of  fluid  introduced  is  limited  only  by  the  absorbing  pcrw^s 
of  the  rectum.  From  6  to  15  quarts  (6  to  15  liters)  may  be  absorb^^ 
in  twenty-four  hours.  Murphy  has  given  as  much  as  30  piiM~  ' 
(15  liters)  in  twenty-four  hours  to  a  child  of  eleven.  It  was  all  tr^- 
tained.  Monroe,  however,  sounds  a  note  of  warning  against  ov^^ 
use  of  this  method,  claiming  that  it  is  possible  for  a  patient  to  ab< 
more  fluid  than  can  be  elminated,  shown  by  an  overfull  pulse, 
cough,  and  by  rfiles  from  edema  of  the  lungs. 


Fig.  609. — ShoBing  the  method  of  administenng  continuous  proctoclysis.  (K*'^ 
and  Noble.)  □,  Adhesive  strap  fastening  the  tubing  to  the  thigh  ;b,  vaginal  hokIe  I*^ 
at  aJi  angle  of  35  degrees. 

Tectmic. — The  reservoir  is  filled  with  solution  and  suffideDt 
fluid  is  allowed  to  escape  to  expel  any  air  from  the  tubing.  TlJ* 
right-angled  noozle,  well-lubricated,  is  introduced  into  the  rectitf'^ 
just  beyond  the  sphincter  muscle,  so  that  the  angle  fits  closely  to 
the  anus,  and  is  secured  in  place  by  adhesive  plaster  passing  to  tb* 
thigh  (Fig.  6og),  The  reservoir  is  then  raised  about  6  inches  (<5 
cm.) — just  sufficiently  high  to  overcome  the  intraabdominal  pressure 
and  allow  the  fluid  to  trickle  into  the  bowel.  Forceps  or  otkermaf^ 
of  constriction  should  not  be  applied  lo  the  tube  to  regulaie  the  pr^'' 
unless  the  apparatus  be  provided  with  an  accessory  vent  to  carry 
off  the  flatus,  as  they  interfere  with  the  free  expulsion  of  gas  thronS" 


NUTRIENT   ENEMATA  613 

the  tube  or  the  return  of  fluid  to  the  reservoir  should  the  patient 
strain  or  vomit.  The  injection  may  be  stopped  every  few  hours 
if  the  pulse  becomes  too  full  or  the  rectum  irritable;  in  such  cases 
the  tube  is  not  disturbed.  Murphy  advises  that  the  tube  should 
not  be  removed  except  for  defecation,  as  the  constant  reinsertion 
will  prove  irritating  to  the  rectum.  It  is  rarely  necessary  to  con- 
tinue the  proctoclysis  for  more  than  three  or  four  days.  Exact 
technic  and  almost  constant  attention  on  the  part  of  the  nurse  are 
necessary  to  gain  success  with  this  method. 

NUTRIENT  ENEMATA 

The  nutrient  enema  is  employed  in  cases  when  feeding  by  the 
natural  way  is  undesirable  or  impracticable.  Rectal  feeding  has  its 
time  limitations,  however.  The  capacity  of 
the  rectum^is  small  and  absorption  is  consider- 
ably slower  than  by  the  natural  way,  so  that 
only  about  a  quarter  of  the  amount  of  nour- 
ishment necessary  for  sustenance  can  be  given 
in  this  way.  As  a  temporary  expedient  or  as 
an  adjunct  to  natural  feeding  it  is  most  use- 
ful, but  for  permanent  feeding  it  is  quite  im- 
practicable. If  it  alone  is  depended  upon  for 
nourishment,  life  can  rarely  be  prolonged  for 
more  than  four  to  six  weeks,  though  it  is  true 
that  certain  exceptional  cases  have  been  re- 
ported where  patients  have  lived  exclusively 
upon  rectal  feeding  for  longer  periods. 

Indications. — i.  In  cases  where  some  im- 
pediment to  the  passage  of  food  exists,  as  eso- 
phageal stricture,  new  growths  encroaching 
upon  the  esophagus,  and  in  pyloric  or  duode- 
nal stenosis.  2.  In  incessant  and  uncontroU-  Fig.  610.— Funnel 
able  vomitmg.     3.  In  any  condition  where  it  ^".^.  ^^^f'^  ^^^^  ^^^  *^- 

_     ,     ,  _  •         ,        ,.  ministenng  nutnent  ene- 

is  desu-able  to  give  the  alimentary  tract  a  rest,  ^^^^^ 

as  in  acute  inflammation  or  ulceration  of  the 

upper  part  of  the  alimentary  canal,  acute  gastritis,  gastric  ulcer, 

typhoid  fever,  and  lesions  of  the  small  intestine.     4.  As  an  adjunct 

to  natural  feeding  in  any  condition  when  the  patient  cannot  receive 

sufiicient  nourishment  by  mouth. 


6 14 


THE   COLON  AND  RECTUM 


Apparatus. — ^A  large  glass  funnel,  2  to  3  feet  (60  to  90  cm.)  d 
rubber  tubing  J^  to  %  of  an  inch  (6  to  9  mm.)  in  diameter,  and  a 
plain  rectal  tube  20  inches  (50  cm.)  long,  No.  35  French  in  size  (Fig. 
'610)  make  a  simple  and  very  effective  apparatus,  and  one  that  can 
be  easily  cleaned.  If  desired,  a  hard-rubber  syringe  with  a  capacity 
of  from  4  to  6  ounces  (120  to  180  c.c.)  (Fig.  611)  or  a  Davidson 
syringe  attached  directly  to  the  rectal  tube  may  be  used.  In  children 
a  No.  18  to  20  French  ordinary  rubber  catheter  is  substituted  for 
the  rectal  tube. 

Asepsis. — The  tube  should  be  boiled  before  using,  and  it  must  be 
carefully  cleaned  after  each  injection.     Syringes,  if  employed,  should 


Fig.  611. — Colon  tube  and  syringe  for  administering  nutrient  enemata.     (Ashtoo.) 

likewise  be  very  thoroughly  cleansed  with  soap  and  water  every  time 
they  are  used. 

Material  Employed  for  Feeding. — Whatever  the  form  of  nourish- 
ment used,  it  must  be  free  from  all  irritating  properties  and  should 
be  small  in  bulk,  or  it  will  be  immediately  expelled.  As  the  lower 
bowel  secretes  no  digestive  ferments,  the  substances  injected  must  be 
of  such  a  nature  that  they  are  readily  absorbed,  otherwise  the  enema 
acts  as  a  foreign  body  and  proves  irritating  to  the  bowel.  The 
food  should  always  be  fluid  in  character  and,  as  far  as  is  possible, 
predigested.  As  a  general  thing,  starches  and  fats  are  to  be  avoided. 
Combinations  of  pancreatinized  meat  extracts,  peptonized  milk,  and 
egg  albumen  will  be  found  to  be  most  readily  taken  up  by  the  bowel 
The  addition  of  a  small  quantity  of  salt  to  each  egg  aids  in  its  absorp- 


NUTRIENT   ENEMATA  615 

tion.  Alcohol  in  the  form  of  red  wine,  brandy,  or  whisky  may  be 
incorporated  in  the  enema  when  a  stimulating  effect  is  desired.  A 
good  stimulating  enema  consists  of  brandy  oz.  ii  (60  c.c),  ammonium 
carbonate  gr.  xx  (1.3  gm.),  and  beef  tea  q.s.  ad  oz.  viii  (240  c.c).  A 
pint  (500  c.c.)  of  black  coffee  alone  has  also  a  marked  stimulating 
effect. 

One  of  the  most  easily  absorbed  foods  which  is  not  irritating  to  the 
bowel  is  glucose.     It  may  be  used  in  a  10  to  15  per  cent,  solution 

The  following  formulae  (Ashton)  will  be  found  very  useful.  In 
continued  rectal  feeding  it  is  well  to  use  them  in  rotation. 

(i)  Beef  juice  oz.  iii  (90  c.c),  and  liquor  pancreatis  dr.  ii  (8  c.c). 

(2)  One  raw  egg;  salt,  gr.  xv  (i  gm.);  brandy  or  whisky  oz.  ss. 
(15  c.c);  and  peptonized  milk  oz.  iii  (90  cc). 

(3)  One  egg;  liquor  pancreatis  dr.  ii  (8  cc);  and  beef  juice  oz. 
iii  (90  c.c). 

(4)  One  raw  egg,  and  peptonized  milk  oz.  iii  (90  c.c). 

(5)  Salt,  gr.  XV  (i  gm.) ;  beef  juice  oz.  i  (30  c.c) ,  and  peptonized 
milk  oz.  iii  (90  cc). 

(6)  Yolk  of  one  raw  egg;  brandy  or  whisky  dr.  vi  (24  c.c);  liquor 
pancreatis  dr.  ii  (8  c.c);  and  beef- tea  oz.  iii  (90  c.c). 

Temperature. — Giye  the  injection  at  a  temperature  near  that  of 
the  body,  about  95°  F.  (35°  C.) — never  cold  or  very  hot — as  peris- 
talsis may  be  excited  and  the  rectum  will  probably  reject  the  feeding. 

Quantity. — ^Only  a  small  amount  of  food  should  be  injected  at  one 
time,  usually  i  to  6  ounces  (30  to  180  c.c),  depending  on  the  retain- 
ing capacity  of  the  rectum  and  whether  the  patient  is  a  child  or  an 
adult.    Large  quantities  are  liable  to  be  expelled  by  the  bowel. 

Frequency  of  Feedings. — This  will  depend  upon  the  quantity  taken 
at  one  time.    A  patient  who  can  retain  as  much  as  6  ounces  (180  c.c.) 

» 

need  only  be  fed  every  six  hours.  Cases  where  but  small  amounts  are 
retained  will  require  three-  to  four-hour  interval  feedings. 

Care  of  the  Rectum. — ^A  cleansing  enema,  consisting  of  salt  dr. 
ii  (8  gm.)  to  a  quart  (1000  c.c.)  of  lukewarm  water  or,  if  there  is  much 
mucus  present,  sodium  bicarbonate  dr.  i  (4  gm.)  to  a  quart  (1000  cc.) 
of  warm  water,  is  given  each  morning  at  least  an  hour  before  the  first 
feeding.  This  serves  to  wash  out  of  the  bowel  any  particles  of  waste 
matter  or  mucus;  it  furthermore  cleanses  the  mucous  membrane  and 
prepares  it  for  more  thorough  absorption  by  stimulating  the 
circulation. 

Position  of  the  Patient. — In  giving  any  retained  enema  the  patient 
should  preferably  be  in  the  Sims  position  with  the  hips  elevated  or  in 


6l6  THE  COLON  AND  RECTUM 

the  knee-chest  position.    If  it  is  inexpedient  to  move  the  patient,  the 
dorsal  position  with  hips  elevated  and  knees  drawn  up  will  suffice. 

Technic. — The  tube  is  well  lubricated  with  sterile  vaselm  or  with 
sweet  oil  to  facilitate  its  passage  and  to  avoid  irritating  the  rectum. 
The  tube  is  slowly  and  gently  introduced,  according  to  the  direc- 
tions already  given  for  the  introduction  of  the  enema  or  enterodysis 
tube  (see  page  598),  well  into  the  bowel  for  a  distance  of  10  to  12 
inches  (25  to  30  cm.),  so  as  to  prevent  expulsion  of  the  food  and  fur- 
nish an  extensive  surface  for  absorption.  To  avoid  injecting  air, 
the  tube  and  the  reservoir  of  the  syringe  are  filled  with  the  material 
to  be  injected  before  the  tube  is  inserted  into  the  lectum.  The  fluid 
must  be  injected  very  slowly.  When  the  proper  amoimt  is  intra" 
duced,  the  tube  is  carefully  removed  and  the  patient  is  instructed  to 
remain  quietly  in  the  recumbent  position  with  the  lips  elevated  for 
at  least  half  an  hour,  to  lessen  the  chances  of  the  food  being  expelled. 
In  cases  of  marked  irritability  of  the  rectum,  5  to  10  KU  (0.3  to  0.6 
c.c.)  of  the  tincture  of  opium  may  be  added  to  the  enema. 

INJECTIONS  OF  FLUID  OR  AIR  INTO  THE  BOWEL  Df 

INTUSSUSCEPTION 

Tlie  slow  injection  of  bland  fluids  or  air  into  the  bowel  maybe 
employed  for  its  mechanical  effect  in  overcoming  an  obstruction  due 
to  intussusception.  Success  from  either  method,  however,  depends 
largely  upon  an  early  diagnosis  of  the  condition,  for  disinvagination 
becomes  more  difficult  in  direct  proportion  to  the  length  of  time  which 
has  elapsed  from  the  onset  of  the  symptoms.  After  the  first  tweniH 
four  hours  of  an  attack,  attempts  at  reductuni  by  means  of  kydrostaiic 
or  gaseous  pressure  are  not  justifiable,  as  tight  adhesions,  which  render 
reduction  impossible,  or  strangulation  and  partial  necrosis  of  the  gut 
with  the  added  danger  of  rupture  may  be  present.  The  greatest 
objection  to  this  method  of  treatment  lies  in  the  fact  that  in  many 
cases  it  is  impossible  to  tell  immediately  whether  the  invagination  has 
been  reduced,  and  the  success  of  the  procedure  can  only  be  deter- 
mined by  allowing  the  patient  to  come  out  of  the  anesthetic  and 
carefully  observing  the  symptoms. 

Not  more  than  fifteen  minutes  to  a  half  hour  should  be  consumed 
in  attempts  at  relief  by  these  nonoperative  measures.  In  all  cases 
preparations  for  operation  should  be  made  beforehand  so  that,  should 
reduction  fail,  an  immediate  laparotomy  can  be  performed.  Treat- 
ment by  injections  is,  of  course,  only  applicable  when  the  intussus- 


INJECTIONS    OF   FLUID   OR   AIR   INTO   THE   BOWEL  6l^ 

ception  occurs  in  the  large  bowel,  on  account  of  the  obstruction  by  the 
ileo-cecal  valve  to  the  passage  of  fluid  or  gas  into  the  small  intestine. 

Treatment  by  Injection  of  Fluid. — Apparatus. — ^A  fountain 
syringe  or  a  graduated  glass  irrigating  jar  as  a  reservoir  and  a  rectal 
nozzle  or  a  large  catheter,  attached  to  the  reservoir  by  6  feet  (i8o  cm.) 
of  rubber  tubing  3^  to  %  inch  (6  to  9  mm.)  in  diameter,  should  be 
provided.  ^ 

Solutions  Employed. — Normal  salt  solution — salt  dr.  i  (4  gm.) 
to  a  pint  (500  c.c.)  of  water — thin  gruel  or  nulk  and  water  may 
be  used. 

Temperature. — ^As  the  relaxing  effect  of  heat  is  desirable,  the 
solution  should  be  at  a  temperature  of  about  105°  F.  (41°  C.)  as  it 
enters  the  bowel. 

Quantity. — The  capacity  of  the  colon  varies  from  10  ounces 
(300  c.c.)  in  a  child  of  five  months  to  a  pint  (500  c.c.)  or  more  in  a 
child  a  year  old.  Not  more  than  iH  pints  (750  c.c.)  of  solution 
should  be  injected  into  the  bowel  of  a  child  under  one  year.  In  an 
adult,  the  rectum  and  colon  hold  as  much  as  9  pints  (4.5  liters)  with- 
out undue  distention. 

Rate  of  Flow. — The  fluid  should  enter  the  bowel  in  a  gradual, 
steady,  continuous  flow.  From  ten  to  fifteen  minutes  are  consumed 
in  injecting  the  given  quantity  of  solution. 

Amount  of  Pressure. — Starting  with  the  reservoir  elevated  about 
3  feet  (90  cm.),  which  gives  a  pressure  of  less  than  2  pounds,  the 
height  may  be  slowly  increased  to  4  or  5  feet  (120  or  150  cm.)  if  neces- 
sary. A  greater  pressure  than  obtained  at  the  latter  elevation  is  not 
advisable  for  fear  of  rupturing  the  bowel.  This  danger  should  be 
'constantly  borne  in  mind. 

Position  of  the  Patient. — The  patient  should  be  in  the  dorsal  posi- 
tion, with  the  hips  elevated. 

Anesthesia. — ^Anesthesia  with  ether  to  the  full  surgical  extent  to 
produce  muscular  relaxation  is  necessary. 

Technic. — The  nozzle  or  catheter  is  well  lubricated  with  oil  or 
vaselin,  and  any  air  is  expelled  from  the  tube.  The  nozzle  is  then 
inserted  into  the  rectum  for  several  inches,  and  the  reservoir  is  ele- 
vated about  3  feet  (90  cm.)  and  the  solution  is  allowed  to  flow  slowly 
into  the  bowel.  Escape  of  the  fluid  along  the  side  of  the  tube  is 
prevented  by  tightly  packed  cotton  about  the  anus  and  pressing  the 
buttocks  firmly  together.  While  the  solution  is  flowing,  the  abdomen 
may  be  very  gently  kneaded  or  the  child  may  be  inverted  several  times. 
Diminution  of  the  pressure  necessary  to  inject  the  fluid  indicates  that 


6l8  THE  COLON  AND  RECTUM 

disinvagination  or  else  a  rupture  of  the  bowel  has  occurred,  and  the 
injection  should  be  immediately  stopped. 

After  a  thorough  trial  by  injection,  if  in  doubt  as  to  the  result,  the 
solution  is  allowed  to  escape  and  the  patient  is  examined.  If  there 
were  present  at  the  outset  a  distinct  tumor,  the  success  of  the  proce- 
dure will  be  denoted  by  its  disappearance.  A  tumor  still  present  and 
retaining  its  fyll  size  will,  of  course,  signify  a  failure,  and  an  immediate 
laparotomy  should  be  performed  while  the  patient  is  still  under  the 
anesthetic. 

Treatment  by  Inflation  with  Air.— In  employing  air  to  distend 
the  bowel  the  pressure  cannot  be  so  well  regulated  as  with  fluid,  and, 
furthermore,  the  weight  of  the  column  of  water,  which  in  some  cases 
seems  to  be  an  important  factor,  is  lacking. 

Apparatus. — A  rectal  tube  or  a  catheter  of  appropriate  size  and  an 
ordinary  bellows  or  a  Davidson  syringe  will  be  required.  In  order  to 
permit  the  escape  of  air  the  moment  it  is  desired,  a  T-tube  of  glass 
may  be  inserted  between  the  rectal  tube  and  the  inflation  apparatus. 
One  limb  of  the  T-tube  is  inserted  into  the  rectal  tube,  the  other  into 
the  tube  leading  from  the  inflator,  while  to  the  third  limb  a  short 
piece  of  rubber  tubing  is  attached  which 'can  be  opened  or  shut  by  a 
clip. 

Gases  Used.- — Ordinary  air,  oxygen,  or  carbonic  acid  gas  may  be 
employed. 

Pressure. — The  air  should  be  injected  very  slowly.  The  best 
guide  as  to  the  amount  to  be  introduced  and  the  pressure  is  the  dis- 
tention produced  along  the  colon  and  in  the  abdomen. 

Anesthesia. — A  general  anesthetic  should  be  employed  to  insure 
extreme  relaxation. 

Technic. — The  tube  or  catheter  is  introduced  well  into  the  rectum 
and  the  inflating  apparatus  is  connected.  The  air  is  very  gently  and 
slowly  pumped  in,  while  an  assistant  compresses  the  buttocks  to  p^^ 
vent  its  escape.  Gentle  abdominal  massage  or  inversion  of  the 
patient  may  be  tried  while  the  inflation  is  progressing.  Reduction 
may  be  indicated  by  rumbling  sounds  or  a  gush  of  liquid  fecal  matter 

DILATATION   OF  RECTAL   STRICTURES  BY  THE  BOUGB 

The  surgical  treatment  of  rectal  strictures  consists  of:  (i)Gradual 
dilatation;  (2)  proctotomy;  (3)  excision;  (4)  entero-anastomosis; 
and  (5)  colostomy.  Treatment  by  dilatation,  though  not  often  cura- 
tive, is  a  most  valuable  palliative  measure.      By  means  of  gradual 


DILATATION   OF   RECTAL    STRICTURES   BY   THE  BOUGIE         619 

dilatation,  the  lumen  of  a  stricture  may  be  so  much  increased  in  size 
tliat  the  patient  is  relieved  of  his  obstructive  symptons  and  may  be 
kept  comfortable  for  years,  provided  the  dilatation  be  maintained  by 
the  occasional  passage  of  a  bougie. 

Exact  information  as  to  the  site,  caliber,  length,  and  thickness  of 
the  constriction  should  be  previously  obtained  by  means  of  a  digital 
examination,  if  within  4  inches  (10  cm.)  of  the  anus,  or  if  seated 
higher  up,  by  the  use  of  the  proctoscope  and  bougie,  as  already 
described,  before  any  attempt  at  dilatation  is  made.  The  majority  of 
strictures  are  situated  within  3  inches  (7.5  cm.)  of  the  anus,  though 
they  may  be  located  at  any  point  higher  up,  or  within  the  anus  itself. 
The  stricture  may  consist  of  a  ring-like  constriction,  or  a  narrowing  of 
the  canal  for  a  distance  of  i  inch  (2.5  cm.)  or  more,  or  it  may  be  tor- 
tuous in  shape.  The  bowel  above  the  stricture  is  often  markedly 
dilated  and  the  rectal  walls  may  be  so  thinned  that  rupture  of  the  gut 
readily  occurs  upon  the  use  of  slight  force.  At  the  seat  of  stricture  the 
mucous  membrane  is  often  ulcerated  or  replaced  by  dense  scar  tissue. 

Instruments. — The  instrument  employed  for  dilatation  should  be 
a  soft-rubber  bougie  with  a  conical  tip,  such  as  the  Wales  instrument 


Fig.  612. — Wales' bougies. 

(Fig.  612).  Metal  dilators  and  those  of  rigid  material  should  be 
avoided  as  dangerous. 

Asepsis. — The  bougies  are  to  be  sterilized  before  using,  and  the 
bowels  should  be  well  cleaned  out,  the  rectum  being  irrigated  with 
normal  salt  solution  both  before  and  after  each  treatment. 

Rapidity  of  Dilatation. — The  stricture  should  be  stretched  gradu- 
ally. Dilatation  ought  not  to  be  performed  rapidly  or  by  divulsion. 
Such  methods  are  extremely  dangerous,  as,  apart  from  the  shock,  on 
account  of  the  laceration  of  the  tissues  there  is  great  risk  of  hemor- 
rhage and  septic  infection. 

Frequency. — This  depends  upon  the  amount  of  tenderness  and 
irritation  as  the  result  of  the  manipulations.  If  the  bougies  are 
passed  at  too  frequent  intervals,  irritation  and  inflammation  are 


630  THE   COLON  AND  RECTUU 

produced  which  induce  the  very  condition  it  is  intended  to  cfflRcL 
As  a  rule,  the  stretching  should  not  take  place  oftener  than  encf 
other  day.     In  some  cases,  the  lapse  of  two  or  three  days  Itetwea 


Fig,  613. — Method  of  insertiiig  a  bougie  into  a  stricture  through  apiocloMf*- 


Fic.  614.— Showing  a  bougie  passed  through  a 


each  treatment  is  necessary,  for  the  bougie  ought  not  to  be  reuiB*' 
duced  until  all  signs  of  the  discomfort  it  has  produced  have  entJW 
passed  off.    Later,  when  full  dilatation  has  been  reached,  an  bter* 


COLONIC  MASSAGE  621, 

up  to  a  month  may  elapse  between  each  treatment,  if  it  is  found  that 
there  is  no  tendency  for  the  contraction  to  recur  in  the  interval. 

Position  of  the  Patient. — The  patient  is  to  be  in  the  Sims  position, 
"with  the  knee  well  drawn  up,  or  in  the  knee-chest  position  if  a  procto- 
scope is  to  be  used. 

Technic. — The  bougie  is  well  lubricated  and,  guided  by  the  right 
index-finger,  is  made  to  enter  the  orifice  of  the  constriction;  or, 
better  still,  it  is  inserted  accurately  into  the  stricture  under  the  guid- 
ance of  the  eye  through  a  proctoscope  introduced  to  the  seat  of 
stricture  (Fig.  613),  as  recommended  by  Tuttle.  The  advantages  of 
this  method  are  obvious.  The  greatest  gentleness  must  be  observed 
in  inserting  the  bougies,  and  under  no  circumstances  should  the 
tissues  be  lacerated.  The  first  instrument  should  be  of  such  a  size 
that  it  enters  the  stricture  with  ease.  The  next  one,  a  size  larger,  is 
left  in  place  for  a  few  moments,  and  then  a  third  instrument  is 
inserted  if  it  can  be  done  without  pain  to  the  patient.  The  procto- 
scope is  then  withdrawn  and  the  bougie  is  left  in  situ  ten  to  fifteen 
minutes. 

Following  the  treatment,  an  irrigation  of  hot  normal  salt  solu- 
tion is  given,  and  the  patient  is  kept  quiet  for  a  quarter  to  a  half-hour. 
At  the  subsequent  sittings,  it  is  well  to  conmience  with  an  instrument 
a  size  smaller  than  the  largest  one  used  at  the  previous  sitting.  An 
increase  in  the  dilatation  is  attempted  at  each  sitting. 

COLONIC  MASSAGE 

Abdominal  massage  is  indicated  for  the  relief  of  chronic  consti- 
pation and  its  accompanying  symptoms  the  result  of  atony  of  the 
intestines,  in  which  class  of  cases,  if  properly  carried  out,  it  is  a  most 
valuable  therapeutic  measure,  tending  to  strengthen  the  muscles  of 
the  abdomen  and  bowel  and  the  tone  of  the  nervous  system,  as  well 
as  to  stimulate  the  secretory  function  of  the  colon  and  to  increase  the 
peristaltic  action.  To  be  of  value,  however,  it  should  be  performed 
by  one  trained  for  such  work.  Massage  is  contraindicated  during 
menstruation  and  in  pregnancy,  and,  of  course,  in  the  presence  of  such 
pathological  conditions  as  gastric  or  intestinal  ulcers,  intestinal 
obstruction,  appendicitis,  hemorrhage  from  the  bowel,  inflammation 
of  the  peritoneum,  etc. 

Time  for  Massage. — The  best  time  for  massage  is  early  in  the 
morning  before  breakfast.  In  cases  where  this  is  not  possible,  care 
should  be  observed  that  it  is  not  given  until  at  least  one  hour  has 
elapsed  since  the  last  meal. 


THE   COLON   AND   RECTUM 


Fig.  616— Showing  the  method  of  kneading  the  colon.     (Bandler.) 


AUTO-MASSAGE  623 

ation. — Each  treatment  should  consume  from  five  to  fifteen 

;.     The  treatments  should  be  persisted  in  until  the  regularity 

itools  is  re-established,  to  effect  which  may  require  several 

■r  months. 

[uency. — Treatments  should  be  given  daily. 

larations. — The  bladder  and,  if  possible,  the  rectum  should  be 


tion  of  the  Patient. ^ — The  patient  lies  in  the  dorsal  position 
e  shoulders  and  knees  slightly  elevated,  so  as  to  secure  aa 

?lax3tion  as  possible. 

mic^The  masseur  stands  upon  the  patient's  left  side  and 
lis  manipulations  by  making  light  circular  movements  (effleur- 
irting  at  the  cecum  and  following  the  course  of  the  ascending, 
rsc,  and  descending  colon.  The  small  intestine  and  the  rest 
bdomen  are  similarly  manipulated.  Then  deep  pressure  and 
ig  movements  (petrissage)  are  substituted.  In  these  move- 
.hc  whole  colon  is  manipulated  in  the  first  instance  by  per- 
:  zigzag  movements  while  making  deep  pressure  with  one 
iperimposed  upon  the  other  (Fig.  615),  and,  in  the  second 
;,  by  raising  up  deep  handgrasps  of  the  abdominal  muscles 
■  intestines  and  kneading  them  by  alternately  compressing 
xing  the  fingers  (Fig.  616).  In  performing  ihi'se  deeper  man- 
ns  one  will  be  governed  as  to  the  amount  of  force  that  may  be 
!d  by  the  sensitiveness  of  the  patient.  Care  should  be  taken 
;  manipulations  be  not  too  vigorous,  lest  some  injury  to  the 
result. 

AUTO -MASSAGE 

sage  may  be  very  effectually  carried  out  by  the  patient  him- 
rolling  a  ball  over  the  abdomen,  beignning  at  the  cecum  and 


the  abdomen. 


g  the  course  of  the  colon  up  the  right  side,  then  across  the 
a,  and  down  the  left  side  in  the  direction  of  the  descending 


1 


624  '^'Hi;   COLON   AND   RECTUM 


colon.  A  cannon  ball  or  a  wooden  ball  filled  with  shot  wdgldngjto 
5  pounds  (1.4  to  2.2  K.),  covered  with  chamois  or  flannel  {Fig.  617), 
may  be  used  for  this  purpose. 

THE  APPLICATIOK  OF  ELECTRICITY  TO  THE  RECTUM  AMD 
COLON 

Electricity  is  of  value  in  conjunction  with  the  abdominal  mis- 
sage  in  all  form  of  constipation,  but  especially  so  in  the  atonic  va- 
riety. Under  the  stimulating  action  of  the  electric  currenl.the 
nerves,  muscles,  and  glandular  structures  connected  with  the  bowel 
are  favorably  influenced,  so  that  the  peristaltic  action  and  thesecrt- 
tion  of  mucus  are  increased,  at  the  same  time,  the  contracting  power 
of  the  voluntary  muscles  of  the  abdomen  is  strengthened. 


Both  the  faradic  and  the  galvanic  currents  are  employed,  tl^ 
former  being  generally  preferred  for  atonic  constipation  and  ic'c*"" 
nal  paresis  and  the  galvanic  for  spastic  constipation  and  paiw"' 
neuroses.     They  may  be  applied  percutaneously  or  internally- 

Apparatus,— For  the  percutaneous  applications  a  large  "St 
sponge  electrode  (Fig.  618)  and  a  small  sponge  electrode  (Fig-'5'9' 
will  be  required.  When  it  is  desired  to  make  internal  appiical""'^ 
a  special  irrigating  rectal  electrode,  such  as  Boas*  (Fig.  6W  "^ 
Kemp's,  and  a  flat  abdominal  sponge  will  be  required. 


APPLICATION   OF   ELECTRICITY  TO   THE   RECTUM  AND   COLON      625 

Strength  of  Cttrrent. — As  there  is  no  means  of  estimating  the 
strength  of  the  faradic  current,  the  sensations  of  the  patient  should 
be  the  guide,  the  current  being  strong  enough  to  cause  muscular  con- 
tractions but  no  pain.  For  galvanism,  from  10  to  15  ma.  of  current 
are  ordinarily  required. 

Duration  of  Application. — Each  treatment  should  consume  from 
ten  to  fifteen  minutes. 

Frequency. — At  first  applications  are  made  daily,  then  every 
other  day,  and,  as  the  conditions  improve,  once  or  twice  a  week. 


Fig.  619. — Small  sponge  electrode.        Fig.  620. — Boas'  rectal  electrode. 
(Bandler.)  (Handler.) 

Time  of  Application. — Treatments  are  given  with  best  results  at 
night,  just  before  the  patient  retires. 

Position  of  Patient. — The  patient  should  be  in  the  recmnbent 
position,  with  the  head  slightly  elevated  and  the  legs  flexed,  so  as  to 
relax  the  abdominal  muscles. 

Technic. — i.  Percutaneous  Application, — The  positive  pole  is  at- 
tached to  a  large  flat  electrode,  and  the  latter,  well  moistened,  is 
placed  over  the  spinal  column.    The  negative  electrode  is  then 

40 


626  THE  COLON  AND  RECTUM 

applied  to  the  abdomen  for  a  few  minutes  at  a  time,  fiist  over  the 
cecum,  then  along  the  course  of  the  transverse  colon,  and  finally 
along  the  descending  colon.  This  is  supplemented  by  drcular 
motions  with  the  negative  electrode  over  the  same  regions.  Finally, 
the  entire  abdomen  is  similarly  treated. 

2.  Rectal  Application. — An  irrgating  electrode  attached  to  the 
negative  pole  of  the  battery  is  inserted  in  the  rectum  and  the  positive 
electrode  is  placed  over  the  spine  or  abdomen.     When  the  current  is 
turned  on,  saline  solution  is  allowed  to  flow  slowly  through  the  rectal 
electrode,  carrying  the  current  to  all  portions  of  the  colon. 


CHAPTER  XX 

THE  URETHRA  AND  PROSTATE 

Anatomic  Consideralions 

I  The  Mate  Urethra. — The  urethra  is  a  closed  canal,  composed  of 
erectile  and  muscular  tissue,  and  lined  by  mucous  membrane,  extend- 
ing from  the  bladder  to  the  external  urinary  meatus.  Its  entire 
length  is  from  6J-2  to  9  inches  (16  to  23  cm.),  depending  upon  the 


FlC.  631. — Section  of  penis,  bladder,  etc.  (Testut.)  i,  SymphysU  pubis-,  a,  pre- 
vesical space;  3,  abdominal  wall;  4,  bladder;  5,  urachus;  6,  seminal  vesicle  and  vu 
detelens;  7,  prostate;  8,  plexus  of  Santorini;  9,  sphincter  vesica;  10,  suspensory  ligament 
ol  penis;  11.  penis  in  flaccid  condition;  11,  penis  in  state  of  erection;  13,  glans  penis; 
U>  bulb  of  urethra;  15,  cui'de-sac  of  bulb,  a.  Prostatic  urethra;  b,  membranous 
ra;  (.  spongy  urethra. 

1  of  the  penis.     For  purposes  of  description  it  is  divided  into 

e  following  portions,  corresponding  to  the  parts  through  which  it 

S:  (i)  The  spongy  portion,  or  pars  cavernosa,  (a)  the  membran- 

»  portion,  or  pars  membranosa,  and  (3)  the  prostatic  portion,  or 


638  THE   URETHRA   AND   PROSTATE 

pars  prostatica  (Fig.  621).  Clinically  and  for  all  practical  purposes, 
however,  it  may  be  divided  into  the  anterior  urethra,  that  portion 
lying  in  front  of  the  anterior  layer  of  the  triangular  ligament;  and 
ihe  posterior  urethra,  the  portion  lying  behind  the  anterior  layer  a£ 
the  triangular  ligament 

The  Spongy  Urethra. — It  extends  the  entire  length  of  the  corpus 
spongiosum  opening  externally  upon  the  glans  penis  as  a  vertical  slitL, 
the  meatus.  The  spongy  urethra  measures  on  the  average  about  ^ 
inches  (15  cm.).  The  lumen  of  this  portion  of  the  urethra  is  not  of 
the  same  size  throughout,  but  presents  two  fusiform  dilatations,  on.^ 
at  the  bulb,  the  bulbous  urethra,  and  the  other  within  the  glans,  th.^ 
fossa  navicularis. 

The  mucous  membrane  is  pale  pink  in  color  and  has  opening  upon 
its  surface  a  number  of  glands  and  crypts.  In  the  floor  of  the  bulbous 
portion  the  ducts  of  Cowper's  glands  open  side  by  side.    Scattered  all 


Fig.  622. — The  interior  of  the  urethra,  i,  Meatus;  i,  fossa  navkularis;  j,  uKth'*' 
glands;  4,  orifices  of  Cowper's  glands;  5,  Copwer's  glands;  6,  ejaculatory  ducts;  7  nnO* 
pocularis;  8,  verumontanum, 

through  the  mucous  membrane  of  the  urethra  are  the  urethral  glantJ* 
or  glands  of  Littr6.  Upon  the  roof,  the  mucous  membrane  is  studde** 
with  small  crypts  or  diverticula,  the  lacunae.  The  orifices  of  ibes^ 
lacunae  open  toward  the  meatus  forming  little  pockets  into  whic** 
instruments  may  find  their  way  and  be  arrested  in  their  passage- 
One  of  these,  the  lacuna  magna,  is  especially  liable  to  interfere  wit** 
the  passage  of  instruments.  It  lies  in  the  roof  of  the  fossa  navicular»* 
about  I  inch  (2.5  cm.)  from  the  meatus.  These  mucous  glands  ao^ 
lacunae  are  Uable  to  infection  and  may  become  the  seat  of  small  gonor- 
rheal abscesses. 

The  Membranous  Urethra. — It  is  that  portion  of  the  urettr» 
lying  between  the  two  layers  of  the  triangular  ligament,  and  extend* 
from  the  apex  of  the  prostate  gland  to  the  bulb  of  the  spongy  portioB- 
It  measures  about  H  inch  (i  cm,)  in  length.  The  membranous  ure- 
thra is  the  most  fixed,  as  well  as  the  least  distensible  of  all  segments  of 
the  urethra.     In  its  course  it  pierces  both  layers  of  the  triangular  liga- 


ANATOMIC   CONSIDERATIONS  629 

ment  and  receives  prolongations  from  these  structures,  and  is  also 
surrounded  by  the  compressor  urethras  muscle.  Spasm  of  this  muscle 
IS  a  frequent  hindrance  to  catheterization  and  the  passage  of  sounds. 
Embedded  in  the  fibers  of  the  compressor  urethras  and  on  either  side 
of  the  membranous  urethra  lie  the  glands  of  Cowper,  the  ducts  from 
which  open  in  the  anterior  portion  of  the  bulbous  urethra. 

The  mucous  membrane  lining  this  portion  of  the  canal  is  darker 
in  color  and  much  more  sensitive  than  that  in  the  spongy  portion. 

Prostatic  Urethra. — It  measures  ^  to  i^i  inches  (2  to  3  cm.) 
in  length  and  extends  from  the  internal  urethral  orifice  to  the  poste- 
rior layer  of  the  triangular  ligament,  traversing  the  prostate  gland 
from  base  to  apex.  In  the  presence  of  hypertrophy  of  the  prostate, 
the  caliber  of  this  portion  of  the  canal  may  become  obstructed  or 
deformed. 

The  floor  of  the  prostatic  urethra  is  encroached  upon  by  a  fusiform 
swelling,  the  verumontanum  or  caput  gallinaginis.  At  the  front  and 
most  prominent  part  of  the  verumontanum  is  seen  the  slit-like  open- 
ing of  the  sinus  pocularis,  a  blind  pouch  or  diverticulum,  usually  J^  to 
yi  inch  (6  to  8  mm.)  in  length,  which  runs  up  in  the  substance  of  the 
prostate  beneath  the  middle  lobe.  It  is  regarded  as  homologous  with 
the  uterus  in  the  female.  Within  the  sinus  pocularis  or  upon  its 
margins  are  the  slit-like  openings  of  the  ejaculatory  ducts.  On  each 
side  of  the  verumontanum  is  a  depression,  the  prostatic  sinus  into 
which  the  openings  of  the  prostatic  ducts  empty. 

The  Caliber  of  the  Urethra. .  — The  caliber  of  the  urethra  varies 
greatly.  While  the  average  diameter  is  0.3  inch  (7.5  mm.)  or  27 
French  scale,  the  individual  urethra  is  not  of  the  same  uniform  cali- 
ber from  end  to  end,  there  being  a  number  of  constricted  and  dilated 
portions.  The  wide  parts  are:  (i)  The  pars  prostatica,  (2)  the  bulb- 
ous urethra,  and  (3)  the  fossa  navicularis.  The  narrow  portions 
are:  (i)  The  meatus,  (2)  the  penoscrotal  junction,  (3)  the  membran- 
ous xirethra,  and  (4)  the  internal  prostatic  opening  Of  these  the 
meatus  is  the  narrowest,  and  in  a  normal  individual  an  instrument 
that  will  pass  the  meatus  should  pass  the  other  narrow  points. 

Normally,  the  walls  of  the  urethra  are  in  contact  and  on  cross 
section  the  canal  appears  as  a  mere  slit.  In  the  prostatic  portion, 
from  the  projection  of  the  verumontanum,  it  has  the  appearance  of  a 
half  moon,  in  the  membranous  portion  it  is  star-shaped;  in  the  cav- 
ernous portion,  it  appears  as  a  transverse  slit;  in  the  glans,  as  a  verti- 
cal slit. 


630  THE   URETHRA   AND   PROSTATE 

Curves  of  die  Urethra. — The  anterior  urethra  is  freely  movsble 
and  may  be  made  to  assume  any  curve.  The  posterior  urethra  ii 
fixed,  however,  between  the  suspensory  ligament  of  the  penis  and  the 
internal  vesical  opening,  and  its  natural  curves  are  important  to  boi 
in  mind  in  the  passage  of  instruments.  In  the  prostatic  portion  tlie 
direction  of  the  urethra  is  downward;  in  the  membranous,  downwaid 
and  forward;  and  in  the  spongy  portion,  forward  and  slightly  upwaid 
for  2  inches  (5  cm.},  and  then  sharply  downward.  Thus  two  curvs 
are  formed:  (i)  concave  forward,  and  (2)  concave  downward.  The 
latter  may  be  straightened  or  obliterated  by  lifting  up  the  penis,  but 
the  first  is  fixed  and  can  only  be  straightened  by  using  some  force,  h 
children  and  in  thin  individuals,  the  fixed  curve  is  much  shaipa, 
while  in  large,  stout  men  it  becomes  Battened.  A  distended  bladds 
or  an  enlarged  prostate  lengthens  it. 


•  KT 


Fig.  623. — The  prostate  gland  and  seminal  vesicles. 

The  Prostate  Gland. — The  prostate  is  a  sexual  organ  composed 
of  glandular,  muscular,  and  fibrous  tissue,  lying  in  front  of  the  neck  of 
the  bladder.  It  is  pierced  above  by  the  urethra  and  below  by  the 
ejaculatory  ducts.  In  shape  it  resembles  an  irregular  truncated  cone, 
the  apex  of  which  rests  against  the  posterior  layer  of  the  triangular 
ligament  while  the  base  is  directed  toward  the  bladder.  In  size  it 
measures  about  iM  inches  (4  cm.)  transversely,  i,^  inches  (3  cm.) 
vertically,  and  %  inch  (2  cm,)  longitudinally.  It  weighs  4  to  6 
drams  (16  to  24  gm.).    The  size  of  the  prostate  is  not  constant,  how- 


DIAGNOSTIC  METHODS  63 1 

ever,  varying  greatly  in  different  individuals  and  depending  upon  the 
age  of  the  patient.  In  a  child,  the  gland  is  only  rudimentary,  not 
reaching  the  full  size  until  about  the  twenty-fifth  year.  During  the 
later  years  of  life,  it  often  becomes  hypertrophied,  not  infrequently 
enlarging  to  over  twice  its  original  size. 

The  prostate  consists  of  two  lateral  lobes  which  bulge  posteriorly 
and  a  so-called  middle  lobe.  The  latter  is  that  portion  of  the  gland 
which  lies  between  the  two  ejaculatory  ducts  directly  posterior  to  the 
beginning  of  the  urethra.  If  enlarged,  as  occurs  when  the  gland  is  the 
seat  of  senile  hypertrophy,  the  median  lobe  forms  a  projection  which 
may  cause  urinary  obstruction  and  interfere  with  the  passage  of 
instruments.  The  two  lateral  lobes  meet  and  become  continuous  in 
front  and  behind  the  urethra.  The  tissue  formmg  this  union  in  front 
is  spoken  of  as  the  anterior  commissure  and  the  portion  behind  as  the 
posterior  commissure  or  isthmus  (pars  intermedia). 

The  Female  Urethra. — It  extends  from  the  neck  of  the  bladder 
to  the  external  urinary  meatus,  curving  downward  and  a  little  for- 
ward. The  female  urethra  measures  ij^'i  to  1}^  inches  (3  to  4  cm.)  in 
length  and  3^  inch  (6  mm.)  in  diameter,  but,  as  it  is  not  surrounded 
by  resisting  structures,  it  is  possible  to  so  dilate  it  as  to  admit  the 
fiinger.  It  lies  in  front  of,  and  is  very  closely  associated  with,  the 
anterior  wall  of  the  vagina  through  which  it  may  be  readily  palpated. 

Its  walls,  composed  of  muscular,  erectile,  and  mucous  tissue,  are 
normally  in  contact,  presenting  a  stellate  appearance  on  cross  section. 
The  mucous  membrane  is  pale  in  color  and  is  thrown  into  a  series  of 
longitudinal  folds,  one  of  which,  on  the  upper  half  of  the  posterior 
wall,  is  quite  marked  and  corresponds  to  the  verumontanum  in  the 
male.  The  compressor  urethras  muscle  surrounds  it,  between  the 
layers  of  the  triangular  ligament. 

Close  to  the  posterior  margin  of  the  external  urethral  orifice  on 
either  side  of  the  mid-line  are  the  tubes  of  Skene.  As  in  the  male,  the 
external  meatus  is  the  narrowest  portion.  It  appears  as  a  vertical 
slit,  yi  to  yi  inch  (5  to  6  mm.)  in  length,  about  i  inch  (2.5  cm.) 
posterior  to  the  base  of  the  clitoris. 

Diagnostic  Methods 

In  the  examination  of  the  urethra  some  definite  system  should  be 
followed.  The  first  step  consists  in  taking  a  careful  history  of  the 
case.  This  should  embrace  the  family  history,  a  history  of  past  ail- 
ments, and  the  patient^s  description  of  the  present  trouble,  its  onset. 


632  THE   URETHRA   AND   PROSTATE 

duration,  etc.  While  in  some  cases  of  urethral  disease  exhaustive 
questioning  of  the  patient  is  superfluous,  it  will  be  found  that  an  exact 
history  will  often  be  of  the  greatest  aid  in  arriving  at  a  correct 
diagnosis. 

The  examiner  should  then  take  up  more  in  detail  the  synq>toms 
complained  of  by  the  patient.  It  should  be  ascertained  whether  tlie 
patient  has  or  has  had  a  urethral  discharge,  and,  if  so,  its  character; 
whether  it  is  sufficient  to  stain  or  stiffen  the  linen,  or  whether  it  sim- 
ply glues  the  lips  of  the  meatus  together;  whether  it  occurs  only  with 
the  first  urine  passed,  or  in  the  intervals  as  well;  whether  there  is  any 
discharge  with  defecation;  also  whether  defecation  is  accompanied  by 
pain  about  the  prostate  or  rectum.  It  is  important  to  inquire  into 
the  act  of  urination,  ascertaining  whether  the  passage  of  urine  causes 
any  pain,  and,  if  so,  its  character,  and  whether  the  pain  is  present  it 
the  beginning  or  end  of  the  act;  also  whether  there  is  an  increased  fit- 
quency  in  urination.  The  patient  should  be  questioned  as  to  the 
character  of  the  stream  of  urine,  its  force  and  caliber;  whether  there  is 
any  dribbling;  whether  the  stream  is  interrupted  or  suddenly  sto{q)ed, 
such  as  would  be  the  case  with  enlargement  of  the  prostate  or  m  the 
presence  of  a  vesical  calculus.  The  character  of  the  urine  passed 
should  also  be  inquired  into;  whether  the  presence  of  blood  has  been 
noted,  and  whether  shreds  are  present,  and  their  character.  Mae 
exact  information  upon  these  latter  points,  however,  will  be  obtained 
after  a  complete  examination  of  the  urine. 

Having  questioned  the  patient  along  the  lines  above  indicated, 
secretions  and  discharges,  if  present,  should  be  collected  for  examina- 
tion (see  pages  283,  295),  and  then  the  actual  examination  of  the 
urethra  and  prostate  may  be  taken  up.  The  methods  available  fa 
this  include:  (i)  glass  tests  and  injection  tests  for  the  purpose  of  lo- 
cating the  seat  of  the  discharge,  (2)  inspection,  (3)  palpation,  and  (4) 
instrumental  examination.  Tlte  use  of  instruments ^  however,  shotM 
not  be  undertaken  if  there  is  an  active  discharge  from  the  urethra  for 
fear  of  aggravating  the  inflammation  and  producing  such  complica- 
tions as  abscess,  stricture,  etc.  It  is  far  better  to  postpone  such  ex- 
ploration until  the  severity  of  the  inflammation  and  the  dischaise 
have  been  reduced  by  the  use  of  injections  or  irrigations. 

GLASS  TESTS 

« 

A  number  of  tests  have  been  employed  for  the  purpK)se  of  deter- 
mining whether  the  seat  of  the  pus  has  its  origin  in  the  anterior  or 


GLASS   TESTS  633 

posterior  urethra.    The  simplest  of  these  are  known  as  the  two-glass 
test  and  the  five-glass  test. 

The  Two-glass  Test. — It  is  performed  as  follows :  The  patient  is 
instructed  to  hold  his  urine  for  three  or  four  hours,  and  upK)n  present- 
ing himself  for  examination  he  is  told  to  urinate  into  two  glasses  or 
graduates.  He  should  pass  about  2  ounces  (60  c.c.)  into  the  first 
glass  and  the  remainder  into  the  second.  If  the  contents  of  the  first 
glass,  in  which  are  collected  the  washings  from  both  the  anterior  and 
posterior  urethra,  contains  pus  or  shreds  revealed  by  holding  the  glass 
before  a  strong  light  and  the  contents  of  the  second  glass  is  clear,  it 
may  be  inferred  that  the  anterior  urethra  is  involved,  but  the  pos- 
terior urethra,  if  at  all,  only  slightly  so.  If,  on  the  other  hand,  the 
contents  of  both  glasses  are  cloudy  or  contains  shreds,  it  shows  that 
there  is  sufficient  secretion  from  the  posterior  urethra  to  have  escaped 
into  the  bladder  and  discolored  its  contents,  or  that  the  secretion  come 
from  the  bladder  itself,  the  ureters,  or  kidneys.  In  the  former,  case, 
the  contents  of  the  first  glass  is  more  turbid  than  that  in  the  second 
glass;  while  in  the  latter  conditions  there  is  but  little  difference 
between  the  two  specimens. 

Another  method  and  one  that  is  more  certain  in  differentiating 
between  an  anterior  and  posterior  urethritis,  consists  in  first  thor- 
oughly irrigating  the  anterior  urethra  with  a  warm  boric  acid  or 
normal  salt  solution  by  means  of  a  catheter  introduced  as  far  as  the 
bulb,  and  then  having  the  patient  urinate  into  two  glasses.  If  the 
contents  of  both  glasses  are  clear,  we  may  be  sure  the  posterior  ure- 
thra is  free.  Pus  or  shreds  appearing  in  the  second  glass  indicate  a 
posterior  urethritis,  or  that  they  come  from  the  bladder  or  beyond. 

The  Wolbarst  Five-glass  Test. — This  is  more  reliable  than  the 
the  two-glass  test  in  determining  the  source  of  shreds  or  pus.  The 
technic  is  as  follows:  The  patient  presents  himself  with  a  full  bladder, 
having  held  his  urine  for  4  or  5  hours.  The  meatus  is  thoroughly 
washed  off  to  remove  any  adherent  secretion,  and  the  anterior  ure- 
thra is  irrigated  by  means  of  a  hand  syringe  with  sterile  water. 
Th^e  washings  are  collected  in  the  first  glass  and  represent  the  con- 
tents of  the  anterior  urethra.  Further  irrigation  of  the  anterior 
urethra  is  performed  until  it  is  certain  that  the  urethra  is  clean  as  far 
back  as  the  cut-off  muscle,  and  these  washings  are  collected  in  glass 
two,  or  the  control  anterior  urethral  glass.  A  soft  sterile  catheter  is 
next  introduced  into  the  bladder  and  a  sample  of  its  contents  is 
drawn  off  into  a  third  glass.  This  represents  the  bladder  urine.  If 
this  specimen  proves  to  be  clear  and  free  from  shreds,  the  catheter  is 


634  ^H£  URETHRA  AND  PROSTATE 

removed  and  the  patient  is  instructed  to  void  an  ounce  or  two  (30  to 
60  c.c.)  of  urine  into  a  fourth  glass.  This  glass  represents  the  con- 
tents of  the  posterior  urethra  and,  if  it  contains  shreds  or  pus,  it  is 
evident  they  originate  in  the  posterior  urethra  as  the  anterior  urethra 
and  bladder  are  clean.  If  it  should  be  found,  however,  that  the  con- 
tents of  the  second  glass  is  not  clear,  that  is,  if  the  bladder  urine  is 
cloudy,  the  catheter  is  left  in  place  and  the  bladder  is  emptied  and  is 
then  washed  out  with  sterile  water,  allowing  from  4  to  6  ounces  (120 
to  180  c.c.)  of  clear  solution  to  remain.  The  catheter  is  then  removed 
and  the  test  is  carried  out  as  before  for  the  fourth  glass.  The  pros- 
tate is  next  thoroughly  massaged  and  the  patient  then  voids  the 
urine  or  solution  containing  pus  expressed  from  the  prostate  and 
seminal  vesicles  into  a  fifth  glass.  If  desired,  the  right  and  left 
seminal  vesicles  may  be  massaged  and  their  contents  collected  in 
similar  manner  in  a  sixth  and  seventh  glass  as  is  done  in  the  seven 
glass  test  of  Pedersen. 

INJECTION  TEST 

For  the  purpose  of  diflFerentiating  between  an  anterior  and  a  pos-  ' 
terior  urethritis,  the  anterior  urethra  may  be  injected  With  a  solution 
that  will  color  the  shreds  in  that  portion  of  the  canal.  A  i  per  cent. 
solution  of  methylene  blue  is  employed.  By  means  of  a  blunt- 
pointed  urethral  syringe  the  anterior  urethra  is  filled  with  the  methy- 
lene blue  and  the  patient  is  instructed  to  hold  the  solution  in  the  ure- 
thra for  about  a  minute.  The  solution  is  then  allowed  to  escape. 
If  upon  urination  the  shreds  appear  blue,  they  come  from  the  ante- 
rior urethra;  unstained  shreds  from  the  posterior  urethra.  A  micro- 
scopical examination  may  be  necessary,  however,  to  determine 
whether  the  shreds  remain  unstained.  In  making  this  test  it  is 
essential  that  the  patient  should  not  have  urinated  for  some  time 
previously. 

INSPECTION 

In  the  Male. — In  the  male,  inspection  of  the  urethra  without 
the  aid  of  instruments  is  limited  to  the  meatus  and  the  exterior  of  the 
canal  as  far  as  the  peno-scrotal  junction.  Swelling,  signs  of  inflam- 
mation, new  growths,  etc.,  which  present  externally  may  thus  te 
recognized.  While  comparatively  limited  in  scope,  inspection  should 
never  be  neglected,  but  should  form  part  of  the  routine  examination. 

Position  of  Patient. — The  patient  may  stand  or  lie  flat  upon  a 
table. 


INSPECTION  63s 

Tedinic. — The  penis  is  elevated  so  as  to  bring  its  under  surface  to 
view  and  any  abnormalities  are  noted.  Tiie  presence  or  absence  of  a 
discharge  should  also  be  determined.  By  stripping  the  urethra  from 
the  scrotum  forward  by  means  of  the  index-finger  applied  externally, 
the  presence  of  any  discharge  may  be  demonstrated.  If  present, 
some  should  be  deposited  upon  a  shde,  and  later  should  be  stained  and 
examined  for  gonococd. 

In  the  Female. — In  the  female,  the  mouth  and  the  vaginal  sur- 
.  face  of  the  canal  in  its  entire  course  may  be  inspected. 

Position  of  Patient. — The  patient  should  be  placed  in  the  dorsal 
position. 

Technie. — The  operator,  sitting  in  front,  separates  the  labia  and 
notes  the  condition  of  the  meatus  and  searches  for  signs  of  inflamma- 


FlG.   614. — Method  of  stnpping 
charge  from  the  urethra      (A&hton.) 


Fic.   615. — Method   of    inspecting    the 

urethml  orifice  in  the  female. 

(Ash  ton.) 


tion,  the  presence  of  new  growths,  eversion  of  the  mucous  membrane, 
discharges,  etc.  The  presence  of  the  latter  may  be  more  readily  dem- 
onstrated by  stripping  the  canal  from  the  bladder  forward  by  means 
of  a  finger  passed  into  the  vagina  (Fig.  624).  The  mouth  of  the  ure- 
thra may  be  eitposed  by  drawing  the  lips  apart  by  means  of  the 
fingers,  one  placed  on  each  side  as  shown  in  Fig.  625.  In  tiiis  manner 
the  orifices  of  Skene's  glands  may  be  exposed.  Finally,  the  index- 
finger  or  a  speculum  is  passed  into  the  vagina  and  its  posterior  wall  is 
depressedj  so  that  the  whole  extent  of  the  vaginal  surface  of  the  ure- 
thra is  exposed.  In  this  manner  tumors,  dilatations,  cysts,  saccula- 
tions, etc^,  will  be  noted. 


636 


THE   URETHRA   AND   PROSTATE 

PALPATION 


In  the  Male. — ^Like  inspection,  palpation  of  the  urethra  is  of 
limited  value,  especially  in  the  male.  By  it,  however,  changes  in  the 
consistency,  sensitiveness,  and  form  of  the  canal  may  be  recogniad. 


Fid.  6z6. — External  pialpation  of  the  uiethia. 

Position  of  Patient. — The  urethra  may  be  palpated  with  the 
patient  standing  or  in  the  dorsal  position.     To  palpate  the  prost^ 


Fig.  637. — Showing  the  method  of  palpating  the  prostate  gland. 


the  patient  should  be  placed  in  the  knee-chest  position,  or  should 
'  bend  over  with  the  hands  resting  upon  achairand  the  thighs  sq)anteil' 


PALPATION  637 

Technic. — In  palpating  the  urethra  the  penis  should  be  grasped 
just  behind  the  glans  between  the  thumb  and  the  forefinger  ol  the  left 
hand,  and,  while  putting  the  organ  on  the  stretch,  the  penile  portion 
of  the  urethra  is  palpated  between  the  thumb  and  the  forefinger  of  the 
right  hand  (Fg  626).  It  should  be  noted  whether  the  urethra  is 
dastic,  as  it  normally  is,  or  whether  it  is  hard,  indurated,  or  nodular. 
An  inflamed  urethra  will  be  painful  to  the  touch  and  will  feel  tense 
and  swollen.  A  urethral  abscess  appears  as  a  painful  swelling  bulg- 
ing the  wall  of  the  canal.  A  cancerous  growth  will  be  hard,  nodular, 
and  adherent.    By  inserting  a  sound  and  then  palpating  the  urethra 


Tig.  6a8. — Combined    rectal    and    instrumental   examination   of  the  proitate  gland. 


upon  it  more  valuable  information  may  be  obtained,  as  changes  in  the 
consistency  of  the  canal  will  be  accentuated. 

To  palpate  the  membranous  urethra  and  prostate  a  rectal  exami- 
nation will  be  necessary.  For  this  the  bladder  should  preferably 
contain  a  Uttle  urine.  The  operator,  standing  upon  the  patient's  left, 
inserts  his  right  forefinger,  protected  by  a  finger  cot  and  well  lubri- 
cated, into  the  bowel  (see  Palpation  of  the  Rectum,  page  579). 
After  passing  the  sphincter,  the  examining  finger  comes  in  contact 
with  the  membranous  urethra  for  a  space  of  3^  inch  (i  cm.),  and  then 
the  prostate  gland  is  reached.  Normally,  the  latter  is  not  very  dis- 
tinctly felt,  but  in  the  presence  of  hypertrophy  it  readily  is,  and  some- 
times it  is  so  enlarged  that  it  may  be  palpated  bimanually.  Points 
of  tenderness,  softening,  painful  swellings-,  or  a  general  enlargement 


638  THE  URETHRA  AND  PROSTATE 

should  be  looked  for  and  any  difference  between  the  two  lobes,  should 
be  noted.  The  condition  of  the  seminal  vesicles  should  likewise  be 
investigated.  They  lie  above  each  lobe  of  the  prostate  extending 
upward  and  outward,  but  are  not  palpable,  unless  enlarged  or 
thickened  by  disease. 

If  desired,  the  seminal  vesicles  and  prostate  may  at  this  time  be 
massaged  for  the  purpose  of  obtaining  their  secretions  for  examina- 
tion. This  is  done  by  carrying  the  finger  up  over  each  seminal  ves- 
icle in  turn  and,  while  making  firm  pressure,  canying  the  finger 
downward  over  the  lobe  of  the  prostate  toward  its  base.  The  massage 
will  force  the  discharge  into  the  urethra  and  it  may  then  be  coDectcd 
upK)n  a  clean  slide  by  stripping  the  urethra  from  behind  forward. 

At  times  a  combined  examination  with  the  finger  in  the  rectum 
and  an  instrument  in  the  urethra  will  be  of  assistance  in  exploring  the 
prostate.  A  bladder  sound  or  other  metallic  instrument  is  intro- 
duced into  the  bladder,  and;  by  engaging  the  prostate  between  it  and 
the  examining  finger  (Fig.  628),  the  extent  of  hypertrophy  as  well  as 
the  amount  of  induration  may  be  ascertained. 

In  the  Female. — In  the  female,  the  entire  canal  may  be  ex- 
plored by  palpation  through  the  vagina  and  valuable  informatioD 
is  thus  often  obtained 

Position  of  Patient. — The  patient  is  placed  in  the  dorsal  position. 

Technic. — The  examiner,  sitting  in  front,  separates  the  labia  with 
the  fingers  of  his  left  hand,  while  he  palpates  with  his  right  index- 
finger.  The  meatus  is  first  examined  by  pressing  with  the  examining 
finger,  placed  just  outside  the  vaginal  outlet,  up  against  thesjnnph)'sis. 
Then  by  means  of  the  index-finger  in  the  vagina  the  whole  length  of 
the  urethra  may  be  explored  by  tracing  the  course  of  the  canal  back  as 
far  as  the  bladder.  By  rolling  the  urethra  with  the  index-finger  from 
side  to  side  and  exerting  pressure  upward  upon  the  canal  with  the 
inferior  and  posterior  surfaces  of  the  symphysis  as  points  of  counter- 
pressure,  changes  as  to  sensitiveness,  consistency,  or  form  of  the  canal 
may  be  readily  recognized. 

EXAMINATION  BY  SOUNDS  AND  BOUGIES 

Having  obtained  all  the  informaton  pK)ssible  by  the  means  al- 
ready detailed,  an  instrumental  exploration  of  the  urethra,  prcvii^ 
the  latter  is  not  the  seat  of  an  acute  inflammation  j  for  the  purpose  01 
determining  the  presence  or  absence  of  strictures  is.  the  next  step- 
While  such  symptoms  as  a  gleety  discharge,  dribbling  at  the  end  01 


EXAMINATION  BY   SOUNDS   AND  BOUGIES 


639 


urination,  malformation  in  the  shape  of  the  stream,  difficulty  in  start- 
ing the  stream,  retention  of  urine,  etc.,  may  point  strongly  to  the 
presence  of  a  stricture,  they  are  by  no  means  infallible,  and  it  is  only 
by  a  careful  local  examination  of  the  urethra  that  the  diagnosis  of 


Fig.  629. — Blunt  steel  sound. 

Stricture  can  be  absolutely  made.  For  the  purpose  of  simply  locating 
a  stricture  and  determining  its  size,  sounds  and  bougies  are  employed, 
while  for  determining  the  length  of  the  contracture  the  bulbous 
bougie  or  bougie  k  boule  is  necessary. 


Fig.  630. — Flexible  urethral  bougie. 

In  inserting  an  instrument  into  the  urethra,  the  utmost  gentleness 
is  required.  The  instrument  should  be  passed  slowly  so  that,  if  an 
obstruction  is  suddenly  encountered,  there  will  be  no  danger  of  pro- 
ducing injury  to  the  canal ;  even  the  slightest  force  should  always  be 


Fig.  631. — Filiform  bougies. 

atfoided.  It  is  only  by  cultivating  a  delicate  touch  and  keeping  in 
mind  the  anatomical  variations  in  the  urethra  that  painless  manipu- 
lation of  urethral  instruments  is  possible.     In  making  such  an  exam- 


Fig.  632. — Female  sound.     (Ashton.) 


ination  it  should  be  remembered  that  the  passage  of  an  instrument 
for  the  first  time  may  result  in  a  severe  chill,  and  a  rise  of  tempera- 
ture.    To  prevent  this,  it  is  well  to  terminate  the  examination  with  an 


540  THE   URETERA   AND   PROSTATE 

instillation  of  i  to  1500  nitrate  of  silver  to  lessen  the  urethral  conges- 
tion. After  one  exploration  the  urethra  should  be  given  a  rest  for  a 
few  days,  as  not  infrequently  the  irritation  produced  aggravates  a 
chronic  urethral  discharge. 

Instruments. — Blunt  steel  sounds  of  the  proper  curve  (Fig.  629) 
are  preferable  for  the  exploration  of  strictures  of  large  caliber.  There 
is  considerable  risk  of  injuring  the  urethra  iriien 
a  rigid  steel  instrument  of  a  size  smaller  than  i; 
French  is  used,  and  it  is  safer  for  those  not  esped- 
ally  skilled  in  the  manipulation  of  urethral  in- 
struments to  employ  woven-^lk  olivary  bougies 
(Fig.  630)  in  examining  small  strictures.  A  srt 
of  these  instruments  from  the  smallest  size  made 
up  to  No.  20  French  should,  therefore,  be  at 
hand.  The  best  are  made  in  France.  For  finding 
the  channel  through  very  tight  strictures  whal^ 
bone  filiform  bougies  (Fig.  631)  are  necessary. 
They  are  provided  with  small  bulbous  points  from 
which  they  taper  for  an  inch  (2.5  cm.)  or  so  until 
the  full  size  of  the  shaft  is  reached.  To  fadiiUte 
the  entrance  of  these  instruments  into  tortuous 
canals  the  tips  may  be  softened  in  hot  water  and 
then  bent  into  various  shapes,  as  curves,  spirals, 
angles,  etc.  For  diagnostic  purposes  the  filiforms 
should  be  about  12  inches  long  (30  cm,).  For  ei- 
ploring  the  female  urethra  a  slightly  curved  steel 
sound  is  employed  (Fig.  632). 

Asepsis. — Metal  instruments  are  boiled  for 
five  minutes  in  a  i  per  cent,  soda  solution.  The 
best  makes  of  the  silk-elastic  instruments  may 
also  be  boiled,  but  some  of  the  others  will  notlast 
long  if  so  treated,  and  it  is  safer  to  sterilize  tbcm 
in  formalin  vapor  for  twenty-four  hours  and  tho 
rinse  well  in  sterile  water  before  using.  A  special  apparatus  (Fig- 
633)  is  required  for  this,  however.  It  consists  of  a  glass  cj-Iin'I^ 
about  16  inches  (40  cm.)  long  with  a  perforated  plate  near  the  top 
for  holding  the  catheters  and  in  the  base  a  receptacle  for  fonnali" 
tablets.  In  its  absence  the  instrument  may  be  soaked  in  a  i  to » 
carbolic  acid  solution  followed  by  immersion  in  a  saturated  boW 
acid  solution  and  rinsing  in  sterile  water.     Whale-bone  bougies  toi)' 


Fig.  633. — For- 
malin sterilizer  for 
urethral     instru- 

a.  Top;  6,  rack 
for  catheters;  e, 
lainer  for  formalin. 


EXAMINATION  BY   SOUKD5  AMD  BOUGIES  641 

be  boiled,  though  they  will  not  stand  prolonged  boiling.  The  ex- 
aminer's hands  should  be  as  carefully  cleansed  as  for  any  operation.' 

The  glans  penis  should  be  first  washed  with  soap  and  water,  then 
with  a  I  to  5000  bichiorid  solution  followed  by  sterile  water.  The 
ur.ethra  is  irrigated  with  a  warm  saturated  solution  of  boric  acid  or 
with  a  I  to  5000  solution  of  potassium  [}ermanganate  both  before 
and  after  the  examination. 

Position  of  the  Patient. — The  patient  should  lie  in  the  dorsal 
position  with  his  shoulders  slightly  raised  and  thighs  flexed  and 
jotated  somewhat  outward,  and  near  that  side  of  the  table  upon 
which  the  operator  stands.  The  operator  takes  his  place  just  above 
the  patient's  hips,  facing  the  patient's  body,  upon  whichever  side 
of  the  table  is  most  convenient  for  him — generally  the  left  side  is 
chosen. 

Technic. — In  beginning  the  examination  the  largest  instrument 
that  wili  pass  the  meatus  should  be  introduced.    As  the  meatus  is  the 


lag  a  urethral  sound. 


narrowest  portion  of  the  urethra,  any  instrument  that  can  be  intro<- 
duced  through  it  will  pass  along  the  entire  canal,  unless  some  con- 
traction is  present.  Should  the  meatus  be  abnormally  small,  it  may 
be  enlarged  by  an  incision  (see  page  679).  The  operator  grasps  the 
penis  behind  the  corona  between  the  ring  and  the  middle  fingers  of  the 
left  hand  and  with  the  thumb  and  index-fingers  of  the  same  hand  he 
retracts  the  foreskin  and  separates  the  lips  of  the  meatus.  The  sound , 
warmed  and  well  lubricated  with  one  of  the  Irish-moss  preparations, 
is  grasped  lightly  between  the  fingers  of  the  right  hand,  and  is  gently 
introduced  into  the  meatus.    As  the  point  of  the  instrument  is  in- 


643  THE   UlLETHKA   AND   PROSTATE 

serted  in  the  meatus  the  handle  should  lie  parallel  to  the  abdomuu] 
wall  and  In  line  with  the  fold  of  the  groin  (Fig.  634) .  Fnnn  this  posi- 
tion the  handle  is  gradually  sw^t  to  the  center  line  (Fig.  635),aiidtl)e 


Fic.  636. — Third  step  in  inserting  a  urethral  sound. 

instrument  is  further  introduced  with  its  point  first  hugging  thew* 
of  the  urethra  and  then  gently  following  the  roof  of  the  canal  thnW 
the  rest  of  its  course  into  the  bladder.    The  instrument  is  t**" 


EXAMINATION   BY    SOUNDS    AND   BOUGIES  643 

[shed  onward  and  downward,  the  penis  being  drawn  over  it  until  the 
lint  of  the  sound  is  deep  in  the  bulbous  urethra  (Fig.  636).  The 
ndle  is  next  gradually  raised  to  a  perpendicular  and  is  then  de- 


638. — Showing  false  passage  of  sound  from  depressing  the  handle  o[  the  instrument 


issed,  thus  permitting  the  point  of  the  instrument  to  follow  the 
ed  curve  of  the  urethra  beneath   the  pubic  arch  {Fig.  637). 

Care  must  be  taken,  however,  not  to  raise  the  handle  of  the  instru- 
*lt  too  soon,  that  is  before  the  beak  has  entered  well  into  the  bulb- 


1 


($44  1^^    mtZTESA   AND   PROSTATE 

ous  uretha,  as  otherwise  its  point  will  be  made  to  lodge  gainst  & 
upper  part  of  the  anterior  layer  of  the  triangular  ligament  instodof 
entering  the  membranous  portion  (Fig.  638).    Again,  the  sound  mijr 


Fia.  639. — Showing  the  tip  of  the  sound  caught  in  the  bulb  a 
triangular  ligament. 


Fig.  640,— Method  of  lifling  up  the  tip  of  the  sound  obstructed  by  the  lowtf  P*"" 
of  the  triangular  ligament. 

fail  to  enter  the  mcnibranous  uretha  from  the  point  lodging  in  "" 
bulbous  urethra  against  the  lower  portion  of  the  triangular  ligafflfl'' 


EXAMINATION  BY   SOUNDS  AND  BOUGIES  645 

(Fig.  639).  This  may  be  avoided  by  depressing  the  handle  and  at  the 
same  time  by  lifting  up  on  the  point  of  the  instrument  with  the  fin- 
gers inserted  behind  the  scrotum  so  as  to  press  against  the  perineum 
(Fig.  640). 

Having  passed  the  beak,  of  the  sound  into  the  membranous 
urethra  it  is  then  made  to  traverse  the  remainder  of  the  canal  and  to 
enter  the  bladder  by  sweeping  the  handle  forward  and  downward 
between  the  thighs  (Fig.  641),  provided,  of  course,  that  no  obstruc- 
tion has  been  encountered.  While  this  is  being  done  the  free  hand 
should  make  pressure  over  the  pubes  in  order  to  relax  the  suspensory 
ligament  of  the  penis. 

By  rotating  the  sound  about  its  own  axis  it  can  readily  be  ascer- 
tained whether  the  beak  has  entered  the  bladder  or  is  still  in  the 


Fio.  641. — Final  step  in  mserting  a  uiethtal  sound. 

prostatic  urethra.  Furthermore,  by  sweeping  the  beak  of  the  instru- 
ment about  the  vesical  neck  any  irregularity  or  disproportion  between 
the  two  lobes  of  the  prostate  will  be  noticed. 

If  an  obstruction  is  metin  any  portion  of  the  canal,  the  instrument 
sliould  be  slightly  withdrawn,  and  the  penis  put  on  the  stretch,  so  as 
to  straighten  out  any  folds  of  mucous  membrane  in  which  the  point 
of  the  instrument  may  have  caught.  If  it  then  fails  to  pass,  the 
obstruction  is  due  either  to  spasm  or  to  an  organic  stricture.  When 
the  seat  of  obstruction  is  in  front  of  the  bulbous  urethra,  spasm  may 
be  ruled  out,  but  an  obstruction  at  the  bulbo-membranous  junction  or 
in  the  membranous  urethra,  on  the  other  hand,  is  often  caused  by 
To  determine  this,  the  instrument  is  not  withdrawn,  but 


646  "^^^^   USETHSA   AKD   PSOSTATE 

should  be  kept  firmly  and  gently  pressed  against  the  face  of  the  ob- 
struction for  a  few  moments,  when,  if  spasm  were  the  cause,  it  wOlm 
time  subside  so  that  the  instrument  can  be  readily  passed  into  the 
bladder.  Furthermore,  upon  attempting  to-  withdraw  the  instn- 
rnent,  that  characteristic  grasping  of  the  instrument  such  as  is  found 
in  the  presence  of  a  tight  organic  stricture  will  be  absent.  When  an 
obstruction  is  met  deeper  than  6^  inches  (16  cm.)  from  the  mcs- 
tus,  or  in  the  prostatic  urethra,  stricture  may  be  ruled  out;  such  u 
obstruction  may  be  due  to  an  enlarged  prostate,  a  stone,  or  spasm  of 
the  internal  sphincter. 


Fig.  64a. — Showing  the  method  of  passing  a  filiForm  bougie  thiougb  a  snull  ttrictve 
by  first  iitling  the  canal  with  filiforms. 

In  this  way  the  presence  of  a  stricture  is  determined  and  its  <iis- 
tance  from  the  meatus  is  readily  estimated.  To  ascertain  its  caliba 
is  the  next  thing.  When  the  examining  instrument  encounters  tie 
stricture  no  force  should  be  used  in  attempting  to  make  it  pass; 
instead,  that  particular  instrument  is  withdrawn,  and  smaller  siies 
inserted  in  succession,  substituting  flexible  bougies  for  steel  instru- 
ments below  a  No.  15  French,  until  an  instrument  is  found  that  will 
readily  pass.  If  even  the  smallest-size  bougies  will  not  pass,  filiforms 
should  be  used.  As  a  general  rule,  no  attempt  should  be  made  to  pest 
a  filiform  on  the  same  day  that  other  exploration  lias  been  attempted,  for 
iifter  repeated  attempts  have  been  made  to  pass  an  instnmient,  the 
opening  in  the  stricture  becomes  distorted  from  pressure  of  the  sounds 
or  bougies,  and  for  a  time  is  impassable  even  to  a  filiform.    In  using 


EXAMINATION  BY   THE  BOUGIE  X  BOULE  647 

filiforms  it  should  be  remembered  that,  owmg  to  their  small  size,  they 
are  liable  to  be  obstructed  from  being  caught  in  folds  of  mucous  mem- 
brane or  in  the  orifices  of  the  glands  and  ducts  so  abundant  through- 
out the  urethra,  and  it  is  very  easy  to  make  a  false  passage  with  one  of 
these  instruments  if  undue  force  is  used.  If  a  filiform  catches  in  a 
pocket  or  fold  of  mucous  membrane,  it  should  be  withdrawn  slightly, 
and  then  gently  advanced,  or  it  may  be  gently  rotated  as  it  is  ad- 
vanced. Sometimes  the  passage  of  a  filiform  will  be  greatly  facili- 
tated by  injecting  sufficent  sterile  oil  through  the  meatus  alongside 
the  filiform  to  thoroughly  distend  the  canal,  and  then,  while  keeping 
the  lips  of  the  meatus  closed,  the  instrument  is  gently  advanced. 

When  once  an  instrument  has  entered  the  stricture  there  can  be 
no  doubt  of  this  fact  from  the  tightness  with  which  it  is  grasped  by 
the  stricture,  a  sensation,  which,  once  recognized,  will  not  be  for- 
gotten. Should  the  operator  be  unable  to  find  the  opening  with  a 
single  filiform,  the  canal  may  be  filled  with  them  and,  by  fiirst  ad- 
vancing one  and  then  another,  it  will  usually  be  pK)ssible  to  make  one 
engage  in  the  stricture  (Fig.  642).  Failing  by  this  maneuver,  a 
urethroscope  may  be  introduced  down  to  the  face  of  the  stricture 
and  through  it  the  instrument  may  be  passed  under  direct  vision. 

After  such  exploration  the  urethra  should  be  irrigated  with  warm 
normal  salt  solution  or  with  a  warm  saturated  solution  pf  boric  acid. 

EXAMINATION  BY  THE  BOUGIE  X  BOULE 

The  bougie  k  boule  or  bulbous  bougie  is  employed  for  the  purpose 
of  determining  the  size  and  length  of  a  stricture.  The  usefulness  of 
this  instrument  is  limited  to  the  anterior  urethra,  as,  if  passed  into 
the  membranous  portion,  the  compressor  urethrae  muscle  is  liable  to 
contract  about  the  bulb  of  the  instrument  and  give  a  sensation  of 
stricture.  Furthermore,  when  the  canal  is  the  seat  of  more  than 
one  stricture,  it  is  frqeuently  impossible  with  the  bougie  k  boule  to 
detect  the  deeper  ones,  as  those  in  the  anterior  portion  of  the  canal 
may  be  so  tight  that  the  passage  of  an  instrument  sufliciently  large 
to  detect  the  deeper  ones  is  out  of  the  question. 

Instruments. — The  bulbous  bougie  consists  of  a  flexible  shaft,  upon 
the  end  of  which  is  mounted  an  acorn-shaped  tip.  The  head  of  the 
instrument  should  be  short  and  should  join  the  shaft  at  rather  an 
abrupt  angle.  They  are  made  of  metal  or  of  woven  material  with 
a  rubber  head  (Fig.  643).  The  latter  are  preferable  as  being  less 
rigid.     These  instruments  are  made  in  sizes  from  5  to  40. 


648  THE   UBETHRA   AND   PKOSTAXE 

Asepsis. — The  proper  sterilization  of  these  instruments  lias  al- 
ready been  described  in  detail  (page  640).  The  hands  of  the  t^wi- 
tor  are  to  be  thoroughly  cleaned.  The  glans  penis  should  be  washed 
ofiF  with  soap  and  water,  and  then  wiped  with  a  swab  wet  with  a  i  to 
5000  bichlorid  of  mercury  solution,  followed  by  sterile  water.    Tie 


O- 


< 


Fic.  643. — Urethral  bougies  A  boule. 

urethra  should  be  irrigated  with  a  i  to  5000  potassium  permanganate 
solution,  or  a  saturated  solution  of  boric  acid  both  before  and  afttf 
examination. 


Fig,  644 — 


Position  of  Patient. — The  patient  lies  upon  a  firm  table  in  the 
dorsal  position.  The  operator  stands  upon  the  side  most  convenient 
for  him,  facing  the  patient's  body  and  just  above  his  hips. 

Technic, — As  large  an  instrument  as  will  pass  the  meatus  k 
chosen.  The  operator  grasps  the  penis  behind  the  corona  betweoi 
the  middle  and  ring  Angers  of  the  left  hand,  and  with  the  thumb 


EXAMINATION    BY    THE    BOUGIE    X    BOULE 


649 


and  forefinger  of  the  same  hand  retracts  the  foreskin  and  opens  the 
meatus.  The  bougie,  well  lubricated  and  held  lightly  between  the 
thumb  and  first  two  fingers  of  the  right  hand,  is  introduced  until  an 
obstruction  is  met  (Fig.  644).  The  distance  of  the  obstruction  from 
the  meatus  is  measured  upon  the  shaft  and  the  instrument  is  with- 
drawn. Successively  smaller  sizes  are  introduced  until  a  size  that  will 
pass  the  stricture  is  reached.  From  this  the  size  of  the  stricture  is 
determined.  The  instrument  is  passed  entirely  through  the  stricture, 
and  is  then  withdrawn  until  resistance  caused  by  the  shoulder  of  the 
instrument  striking  the  distal  face  of  the  stricture  is  felt  (Fig.  645). 


Fic.  645.— Method  of  est 
the  bougie  i  bouie  withdrawi 


LtinR  the  length  of  a  urethral  stricture.     The  base  oi 
3til  in  contact  with  tht.  distal  end  of  the  si 


The  shaft  is  then  grasped  at  the  meatus  as  a  guide,  and  the  instrument 
is  removed.  The  distance  from  the  meatus  to  the  shoulder  is  then 
measured,  and  subtracting  the  previous  measurement  from  this  gives 
the  length  of  the  stricture.  In  this  way  the  entire  anterior  urethra 
to  the  bulbo- membranous  junction  may  be  explored  and  strictures, 
if  present,  calibrated. 

In  exploring  the  deep  urethra  the  shaft  of  the  instrument,  if  of 
wire,  should  be  bent  to  correspond  to  the  normal  curve  of  the  canal. 
It  is  then  introduced  in  the  same  manner  as  a  sound  (see  page  641). 
As  abeady  mentioned,  spasmodic  contraction  of  the  compressor 
urethra  muscle  may  simulate  stricture.  After  removal  of  the  bougie 
the  urethra  should  be  irrigated  with  boric  acid  solution. 


650  THE    URETHRA  AND  PROSTATE 

URETHROMETRT 

It  is  a  method  of  measuring  the  caliber  of  the  anterior  urethra  by 
means  of  a  si>ecial  instrument,  the  urethrometer.  This  instrument 
has  an  advantage  over  a  sound  or  bougie  in  that  it  can  be  introduced 
through  a  narrow  meatus  and  strictures  of  large  caliber  can  be  d^ 
tected  and  measured.  At  the  same  time,  several  strictures  may  be 
examined  by  one  insertion  of  the  instrument.  The  method  is,  how- 
ever, more  irritating  to  the  urethral  mucous  membrane  than  the  use 
of  a  sound  or  bougie,  and  is  it  only  applicable  to  the  anterior  urethra. 
In  inexperienced  hands  it  is  often  an  unreliable  method  of  examina- 
tion, as  strictures  that  do  not  exist  may  be  imagined  to  be  present, 
which  turn  out  to  be  the  normal  constrictions  of  the  canal. 

Instruments. — The  urethrometer  of  Otis  (Fig.  646)  consists  of  a 
small  straight  cannula  marked  off  in  inches  and  half -inches,  ending  in 
a  series  of  short  metallic  arms  hinged  upon  themselves,  and  upon  the 
shaft  of  the  instrument,  which  may  be  enlarged  into  a  bulb-like  shs^ 


•Fig.  646. — Otis'  urethrometer.     d,  Instrument  open;  6,  instrument  dosed;  c,  rubber 

stall  to  cover  the  end  of  instrument. 

of  any  size — from  16  to  45  French — by  turning  a  thumb-screw  at  the 
proximal  end  of  the  instrument.  A  dial  and  indicator  show  the 
extent  of  expansion.  A  thin  rubber  stall  is  drawn  over  the  end  of 
the  instrument  when  closed,  for  the  purpose  of  protecting  the  urethra. 

Asepsis. — The  urethrometer  is  boiled  in  a  i  i>er  cent,  solution  o^ 
carbonate  of  soda.     The  external  genitals  are  thoroughly  cleanse4> 
and  the  urethra  is  irrigated  with  a  mild  antiseptic  solution.    TVj^ 
operator's  hands  are  sterilized  in  the  usual  way. 

Position  of  Patient. — The  patient  is  placed  in  the  dorsal  reca^" 
bent  posture. 

Technic. — The   closed   instrument,   warmed  and  lubricated, 
introduced  through  the  meatus  and  is  passed  as  far  as  the  bult^ 
membranous  junction.     The  bulb  is  then  expanded  by  turning  '^ 
thumb-screw  upon  the  proximal  end  of  the  instrument  until  the 
tient  feels  a  fulness  in  the  perineum.     This  indicates  the  normal 
of  that  portion  of  the  urethra.     The  instrument  is  then  slowly  wi^ 


ESTIMATION  OF  THE  LENGTH  OF  THE  URETHRA      65 1 

drawn  until  an  obstruction  is  met,  when  the  instrument  is  screwed 
down  until  it  is  of  sufficiently  small  size  to  pass  and  is  then  again  en- 
larged and  drawn  forward.  In  this  way  the  entire  anterior  urethra 
may  be  measured,  and  strictures  located  and  calibrated.  It  should 
be  remembered  when  emplo)dng  this  instrument  that  the  urethra  is 
not  of  uniform  caliber,  but  normally  is  the  seat  of  dilatations  and 
constrictions.  Thus,  the  bulbous  urethra  is  the  widest  and  most 
distensible  portion,  and  the  meatus  the  most  contracted.  More  or 
less  constriction  of  the  canal  is  also  encountered  at  the  peno-scrotal 
junction. 

At  the  completion  of  the  operation  the  canal  is  irrigated  with  an 
antiseptic  solution. 

ESTIMATION  OF  THE  LENGTH  OF  THE  URETHRA 

This  procedure  is  of  value  in  determining  whether  the  prostate  is 
enlarged.  For  practical  purposes  the  length  of  the  urethra  is  the 
distance  it  is  necessary  to  pass  a  catheter  from  the  meatus  before 
urine  begins  to  flow.  This  may  vary  from  63^  to  9  inches  (16  to  22 
cm.),  but  on  the  average  it  is  7^^  to  83^  inches  (19  to  21  cm.).  A 
marked  increase  beyond  the  normal  in  the  urethral  length  indicates 
that  the  prostatic  urethra  is  lengthened  and  that  the  prostate  is 
therefore  enlarged. 

Instruments. — ^An  ordinary  silk  gum-elastic  catheter  or  a  catheter 
marked  off  in  inches  (Fig.  647)  may  be  employed. 

Asepsis. — The  catheter  is  boiled  or  immersed  in  a  i  to  20  carbolic 
add  solution  followed  by  rinsing  in  sterile  water.     The  external 


EiG.  647. — Cathether  marked  off  in  inches. 

genitals  are  thoroughly  cleansed  and  the  urethra  is  irrigated  with  a 
vpSld  antiseptic  solution.  The  operator's  hands  are  also  thoroughly 
cleansed. 

Position  of  Patient. — The  dorsal  position  is  employed. 

Technic. — The  catheter,  well  lubricated,  is  introduced  into  the 
bladder  until  urine  begins  to  flow.  It  is  then  withdrawn  until  the 
flow  just  stops  and  the  point  where  the  catheter  protrudes  from 
the  meatus  is  noted.  The  distance  from  this  mark  to  the  eye  of  the 
catheter  represents  the  length  of  the  urethra.     If  the  catheter  passes 


652  THE  URETHRA  AND  PROSTATE 

without  obstruction  and  urine  begins  to  flow  when  the  eye  of  the 
catheter  is  a  distance  of  from  7H  to  8}^  inches  (19  to  21  cm.) 
from  the  meatus,  we  may  conclude  that  the  prostate  is  not  enlar^ 
On  the  other  hand,  a  marked  increase  in  the  distance  the  catheter 
has  to  travel  indicates  an  increase  in  the  length  of  the  prostatic 
urethra. 

URETHROSCOPY 

It  consists  in  direct  inspection  of  the  interior  of  the  urethra 
through  a  metal  tube  by  the  aid  of  suitable  illumination.  While  m 
the  routine  examination  of  the  urethra  direct  inspection  is  not  al- 
ways necessary,  the  urethroscope  becomes  a  valuable  instrument  for 


Fig.  648. — Instruments  for  urethroscopy,     i,  Chetwood's  tubes;  2,  tube  with 

in  place;  3,  applicator. 

the  diagnosis  of  conditions  in  which  tl;e  pathological  changes  are 
slight  and  of  such  a  character  as  not  to  be  detected  by  means  of  the 
sound  or  bougie.  Lesions  of  the  mucous  membrane  may  be  th^s 
accurately  located  and  their  character  definitely  determined.  Fur- 
thermore, by  means  of  the  urethroscope,  it  is  possible  to  make  local 
applications  directly  to  diseased  areas  or  to  remove  calculi,  foreign 
bodies,  polypi,  etc.  (see  page  673).  The  instrument  is  also  som^ 
times  of  value  in  the  treatment  of  strictures,  as  by  its  aid  it  is  poss^ 
ble  to  discover  the  opening  of  a  very  tight  or  eccentrically  plac^ 
stricture  and  insert  a  filiform  under  direct  vision. 


URETHROSCOPY  653 

To  successfully  employ  the  urethroscope  care  and  gentleness  in 
manipulation  are  absolutely  essential  and  the  operator  must  have  had 
considerable  experience  in  its  use  and  must  be  familiar  with  the 
normal  appearance  of  the  different  portions  of  the  urethra  in  order  to 
properly  interpret  the  findings.  If  strictures  exist  or  the  caliber  of 
the  canal  is  below  12  French,  preliminary  dilatation  by  means  of 
sounds  should  be  carried  out.  In  acute  gonorrhea  the  use  of  the 
urethroscope  b  contraindicated. 

Apparatus. — The  urethroscope  consists  of  a  metal  tube  supplied 
with  an  obturator  to  aid  in  its  introduction  and  an  electric  light  for 
illuminating  its  interior.  The  tubes  for  use  in  the  anterior  ure- 
thra are  straight  and  are  4  to  5  inches  (lo  to  la  cm.)  long,  while  those 
for  the  posterior  urethra  are  5  to  6  inches  (la  to  15  cm.)  long;  a 


(T 


^ 


Fig.  649. — Swioliiinie'B  urelhroscopc  (or  examining  the  posterior  urethra. 

straight  tube  may  be  used  in  the  posterior  urethra  or  the  tube  may 
be  obtained  with  the  distal  end  slightly  curved  to  facilitate  its  intro- 
duction, as  the  Swinburne  urethroscope  (Fig.  649)  or  the  Goldschmidt 
instrument.  The  caliber  of  the  tubes  is  from  22  to  32  French.  The 
illumination  is  furnished  through  a  two-  or  four-volt  lamp  from  a 
(our-  to  six-dry-cell  battery.  In  the  Chctwood  instrument,  the 
iUumination  is  supplied  by  means  of  a  delicate  cold  lamp  at  the 
distal  end  of  the  instrument,  while  in  the  Otis  urethroscope  the 
h'ght  is  placed  at  the  pro.\imal  end  of  the  instrument.  In  their 
stead,  a  head  light  and  Klotz  tube  (Fig.  650)  may  be  employed. 

In  addition  to  the  urethroscope  long  slender  applicators  wrapped 
with  cotton  are  necessary. 

Asepsis. — The  tube  and  applicators  should  be  boiled  for  five 
r^iinutes  in  a  I  per  cent,  soda  solution,  while  the  lamp  may  be  im- 
'oersed  in  a  I  to  lo  carbolic  acid  solution  and  then  in  alcohol.  The 
operator's  hands  should,  of  course,  be  sterile.  The  glans  penis  is 
"^sfied  with  soap  and  water,  and  is  then  wiped  with  a  1  to  5000 
'*U:hlorid  of  mercury  solution.     The  urethra  is  to  be  irrigated  with 


6S4 


THE    UKETBRA  AND   PROSTATE 


a  warm  saturated  solution  of  boric  acid  or  i  to  5000  potassium 
permanganate  solution. 

Position  of  Patient. — The  patient  should  be  upon  a  flat  table  in 
the  recumbent  position  for  anterior  urethroscopy  and  in  the  litho- 
tomy position  for  examination  of  the  posterior  urethra. 


»^^l1^»g>g^g»i^*l>  — *»  ■■iHi   M^^»^  ^^^m 


Fig.  650. — Klotz's  urethral  tube 


Anesthesia. — Cocain  is  not  to  be  used  if  it  can  be  avoided,  as  it 
alters  the  appearance  of  the  mucous  membrane  somewhat  and  by 
deadening  sensibility  it  conceals  valuable  information  as  to  the  con- 
dition of  the  canal.  Hyperesthesia  of  the  urethra,  if  present,  may  be 
lessened  to  a  considerable  degree  by  the  passage  of  a  full-sized  sound 
once  or  twice  before  the  intended  examination. 


Fio.  651. — Method  of  inserting  the  urethroscop)e. 

Technic. — A  tube  as  large  as  will  pass  through  the  meatus  should 
be  used,  as  very  little  information  is  obtained  by  insp>ection  through 
a  small  tube.  If  the  meatus  is  abnormally  small,  it  should  be  cut 
(see  page  679).  The  patient  voids  his  urine  just  before  the  ex- 
amination is  begun.  Before  proceeding  with  the  examination,  the 
patient  is  instructed   to  tell  the  operator  if  any  particular  sensi- 


UHETHROSCOPV  655 

tive  spot  is  encountered  while  the  instnimeiit  is  being  passed.  The 
penis  is  held  vertically  upward  in  the  lingers  of  the  left  hand,  and 
the  tube,  well  warmed  and  lubricated,  and  with  the  obturator  in 
place,  is  inserted  through  the  meatus  (Fig,  651),  and  thence  onward 
until  it  meets  an  obstruction  or  reaches  the  bulbous  urethra,  pro- 
vided the  anterior  portion  of  the  canal  only  is  to  be  examined. 
If  the  prostatic  urethra  is  to  be  inspected,  the  tube  is  inserted  all 
the  way  into  the  bladder.     This  is  accomplished  by  turning  the 


..  651. — showing  the  method  of  examining  the 
throscope. 


relhra  through  the  u 


instrument  down  between  the  thighs  to  an  almost  horizontal  posi- 
tion as  soon  as  its  point  reaches  the  bulbous  urethra  and,  at  the 
same  time,  making  gentle  upward  pressure  upon  the  point  of  the 
instrument  by  means  of  the  fingers  on  the  perineum.  In  this  way' 
the  point  of  the  instrument  is  made  to  pass  through  the  opening 
in  the  triangular  ligament.  The  tube  is  then  gently  pushed  on  into 
the  bladder.  Inserting  a  straight  tube  into  the  posterior  urethra  is 
generally  painful  and  it  may  not  be  possible  without  employing 
local  anesthesia;  introduction  of  the  curved  urethroscope  is  much 
less  disagreeable  for  the  patient. 


656  THE   UKETHBA   AND   PROSTATE 

As  soon  as  the  instrument  is  inserted  to  the  de^red  depth,  the 
obturator  is  removed,  the  light  is  turned  on,  and,  as  the  tube  k 
slowly  withdrawn,  the  different  portions  of  the  mucous  membrane 
are  inspected  as  they  appear  in  the  end  of  the  tirethroscope  (Fig. 
652).  If  a  clear  view  of  the  mucous  membrane  is  interfered  with 
by  blood  or  secretion  collecting  in  the  end  of  the  tube,  long  appli- 
cators covered  with  cotton  should  be  inserted  through  the  instru- 
ment and  the  mucous  membrane  mopped  dry;  care  should  be  takcD 
not  to  push  the  tube  back  in  the  canal  after  the  examination  hts 
once  begun  without  inserting  the  obturator,  as  the  edges  of  the  tube 
might  cause  damage  to  the  parts. 

Before  one  can  become  competent  in  recognizing  patholo^ 
conditions  it  is  necessary  that  the  examiner  should  be  &cquaiat(d 


Fic.  654.-1 
upper   jK)rliun   of   the   prostatic  urethra.         middle  porlion  of  the  p 
(After  Stern.)  (After  Stem.) 

with  .the  normal  appearance  and  color  of  the  urethral  mucous  mO"- 
branc.  Beginning  at  the  posterior  urethra  in  a  normal  case  the 
central  figure  a])i)cars  as  a  cone,  the  mucous  membrane,  which  B 
of  a  dark  red  color,  being  thrown  into  longitudinal  folds.  As  the 
instrument  is  withdrawn,  the  verumontanum  comes  to  view  in  [l* 
form  of  a  semilunar  cur\'e  with  the  convexity  upward  (Fig.  Sjj) 
and  the  mucous  membrane  appears  of  a  bright  red  color.  By  ^btly 
changing  the  position  of  the  instrument,  it  is  possible  to  obtain* 
view  of  the  sinus  pocularis  and  openings  of  the  ejaculatory  ducB 
(Fig.  654).  Upon  the  further  withdrawal  of  the  instrument,  thf 
ridge  of  the  verumontanum  becomes  gradually  less  marked  and  t« 
mucous  membrari'j  takes  on  a  paler  hue.  In  the  membranous 
urethra   the   central   figure  appears  as  a  cone  with  a  central  ^°^ 


imETHROscopv  657" 

'  the  mucous  membrane  extending  out  in  radiating  folds  (Fig.  655). 
I  In  the  bulbous  urethra  the  centra!  figure  changes  to  a  vertical  slit 
L  with  the  mucous  membrane  bulging  on  each  side  (Fig.  656).  In 
I  this  portion  of  the  canal  the  mucous  tnembrane  is  still  paler  in  color. 


..ni.1.-  of  the  mem 
(After  Stem.) 


Fto  656, — ^The  ftppcaiaoce  of  the  bul- 
bous urethra.     (After  Stem.) 


The  central  figure  then  gradually  changes  from  a  vertical  slit  to  a 
triangular  opening  (Fig.  657),  and  at  the  penoscrotal  junction  it 
takes  the  form  of  a  transverse  slit  with  radiating  folds  extending  to 
the  periphery   (Fig.   (i$&).     In  the  pendulous  urethra  the  central 


Fic.  657,— The  appearance  of  the 
perineal  poition  of  the  spongy  urethra. 
(After  Stern.) 


Fig,  658.— The  appearance  <rf  the 

urethra    at    the    penoscrotal    Junction. 
(After  Stern.) 


figure  again  becomes  cone-shaped  (Fig.  659)  and,  finally,  at  the 
meatus  it  appears  as  a  vertical  slit,  the  color  of  the  mucous  membrane 
changing  from  a  pale  pink  to  a  purplish  hue. 

In  examining  the  urethra  through  the  urethroscope  it  should  be 


6S8  THE   URETHRA   AND   PROSTATE 

£r5t  ascertained  whether  the  normal  elasticity  of  the  canal  is  im- 
paired or  not.  This  is  accomplished  by  noting  the  central  figure  as 
the  tube  is  withdrawn.  In  chronic  inflammatory  conditions  the 
urethra  becomes  more  or  less  rigid  and  does  not  immediately  collq« 
over  the  end  of  the  urethroscope  as  it  is  withdrawn;  instead,  the  coiw- 
like  central  figure  often  becomes  elongated  or  else  distorted  from 
being  contracted  at  certain  points,  if  the  inflammation  is  a  localized 
one,  and,  in  addition,  the  whole  mucous  membrane  in  such  ca«s 
not  infrequently  becomes  of  a  paler  hue  than  normal.  Changes  in 
the  appearance  of  the  mucous  membrane  should  also  be  noted,  h 
chronic  urethritis  there  will  at  times  be  found  localised  coi^ested 
areas,  granular  patches  which  frequently  bleed,   and  superficial 


Fig.  659. — The  appearance  of  the  pendulous  urethra.    (Af  tei  Stem.) 


ulcerations  covered  with  secretion.  Inflamed  lacunae  appear  as  red 
openings  upon  the  surface  of  the  mucous  membrane  from  which  will 
frequently  be  seen  exuding  drops  of  pus.  Retention  cysts,  polypi, 
etc.,  are  readily  diagnosed  by  this  means.  If,  during  the  examina- 
tion, it  is  desired  to  more  closely  study  the  condition  of  the  mucous 
membrane  at  any  particular  spot  this  may  be  accomplished  bj' 
pushing  that  part  into  the  field  by  digital  compression  upon  the 
urethra  below  the  end  of  the  urethroscope. 

After  removal  of  the  tube  the  anterior  urethra  should  be  im- 
gatcd  with  a  warm  saturated  boric  acid  or  normal  salt  solution,  and. 
if  the  instrument  has  been  passed  into  the  deep  urethra,  the  bladder 
should  also  be  irrigated. 

URETHROSCOPY  IN  THE  FEMALE 
The  female  urethra  being  shorter  and  capable  of  greater  dis- 
tention than  that  of  the  male  lends  itself  more  readily  to  examinalion 
by  the  urethroscope. 


URETHROSCOPY  JN  THE  FEMALE  659 

Instruments. — Short  male  endoscopic  tudes  or  a  regular  female 
uretliroscope  may  be  employed.  They  may  be  obtained  with  the 
light  at  the  distal  end  or,  as  in  the  Kelly  tubes  (Fig.  660),  with  the 
light  reflected  from  a  head  mirror.  The  female  urethroscope  should 
be  about  3  inches  (7,5  cm.)  long.  The  tubes  vary  in  size  anywhere 
from  34  to  36  French 


A  Kelly  cone-shaped  urethral  dilator  {Fig.  661)  should  be  pro- 
vided for  dilating  the  meatus.  Applicators  or  alligator-jawed  forceps 
and  absorbent  cotton  will  also  be  required. 

Asepsis. — The  tub^s,  applicators,  etc.,  may  be  boiled  for  five 
minutes  in  a  I  per  cent,  soda  solution.  The  lamp  is  sterilized  by 
immersion  in  a  r  to  20  carboiic  acid  solution  and  then  rinsed  off  in 


Fig.  661. — Kelly's  cone-shaped  urethral  dilator.     (Ashton.) 

alcohol.  The  vulva  and  the  external  urethral  orifice  are  sterilized 
by  washing  with  tincture  of  green  soap  and  water,  next  with  a  i  to 
5000  bichlorid  of  mercury  solution,  and  finally  with  sterile  water. 

Position  of  Patient. — The  dorsal  posture  is  employed. 

Anesthesia. — If  the  urethra  is  hyperesthetic,  a  small  pledget  of 
cotton  saturated  with  a  2  per  cent,  solution  of  cocain  is  placed  in 
the  mouth  of  the  urethra  for  a  short  time  before  the  operation. 


66o  TSE   URETHRA  AKD   FSOSTATE 

Technic. — The  urine  is  voided  before  the  ezanunation  b^u. 
If  necessary,  the  meatus  is  dilated  sufficiently  to  admit  a  good-azol 
tube  by  means  of  a  Kelly  dilator  (Fig.  663).     The  instrument,  Tith 


Fic.  66a. — Showing  the  method  of  dilating  tlie  urethra.    (Asbton.) 


the  obturator  in  place  and  well  lubricated,  is  then  inserted  into  tk 
mouth  of  the  urethra  and  is  carefully  passed  into  the  bladder  (E^ 
663).    The  obturator  is  next  removed  and  the  lighting  appatabuii 


Flo.  663. — Itilro<iuctii)n  of  the  urethroscope  Pio,  664. — Showing  the  melbod  <i 

into  the  female  urethra.     (Ashton.)  inspecting  the  female  urethra  thmifk 

the  urethroscope.     (AshtOD.) 

properly  adjusted.  The  instrument  is  then  gradually  mthdrawn 
while  the  examiner  notes  the  condition  of  the  mucous  membrane  as 
it  falls  over  the  end  of  the  tube  (Fig.  664). 


HAND   INJECTIONS   FOR   THE   URETHRA  66 1 

At  the  internal  urethral  orifice  there  appears  through  the  urethro- 
scope a  large  opening  surrounded  by  a  narrow  ring  of  mucous  mem- 
brane. As  the  instrument  is  withdrawn  the  central  figure  becomes 
first  more  oval  and  then  lower  down  appears  as  a  transverse  slit  with 
the  mucous  membrane  thrown  into  folds  that  radiate  to  the  pe- 
riphery. Finally,  at  the  external  orifice  the  central  figure  appears 
as  a  vertical  slit,  while  the  mucous  membrane  appears  thrown  into 
a  number  of  radiating  folds.  A  posterior  fold  is  especially  marked 
in  the  upper  portion  of  the  canal;  it  is  a  continuation  of  the  trigone. 

The  points  to  be  noted  in  the  examination  have  been  sufficiently 
dealt  with  under  the  technic  of  male  urethroscopy  and  will  not  be 
repeated  here. 

Therapeutic  Measures 

HAND  INJECTIONS  FOR  THE  URETHRA 

The  injection  of  solutions  into  the  anterior  urethra  by  means  of  a 
small  hand  syringe  is  employed  either  for  simple  cleansing  purp>oses 
in  preparation  for  the  passage  of  urethral  instruments  or  for  the 
purpose  of  treating  anterior  urethritis.  The  efficiency  of  injections 
in  limiting  acute  gonorrhea  is  a  question  and  it  is  doubtful  if  they 
have  much  effect  outside  of  removing  the  irritating  discharges  and 
cleansing  the  mucous  membrane.  They  may,  however,  be  pre- 
scribed in  the  acute  stages  in  the  form  of  mild  antiseptic  solutions 
to  be  used  by  the  patient  himself  as  an  adjunct  to  irrigations  carried 
out  by  the  physician.  In  the  declining  stages  of  the  disease  or  when 
the  condition  becomes  chronic,  astringent  injections  are  of  un- 
doubted value  in  reducing  the  congestion  and  thus  drying  up  the 
thin  discharge  that  remains. 

When  injections  are  employed,  certain  precautions  should  be 
observed.  In  the  first  place,  mild  solutions  are  preferable  to  very 
strong  ones,  as  being  less  irritating  to  the  mucous  membrane. 
They  should  not  be  strong  enough  to  cause  more  than  temporary 
pain  or  stinging,  otherwise  they  are  likely  to  do  more  harm  than 
good.  In  the  second  place,  the  greatest  gentleness  in  making  the 
injection  is  necessary  to  avoid  injuring  the  urethral  mucous  mem- 
brane. Furthermore,  while  it  is  desirable  that  the  solution  should 
be  brought  into  contact  with  all  the  folds  and  depressions  of  the 
mucous  membrane,  it  is  important  that  the  fluid  should  not  be  in- 
jected into  the  bladder,  which,  however,  rarely  happens,  as  the 
cut-off  muscle  interposes  a  barrier.     If  it  should  occur,  infective 


662 


THE  URETBRA  AND   PROSTATE 


material  will  necessarily  be  carried  back  into  the  deep  urethra  with 
a  good  chance  of  starting  up  a  posterior  urethritis  and  q>ididymit]s. 
For  this  reason,  only  a  small  quantity  of  fluid  should  be  injected  at 
a  time  and  that  without  force.  Used  with  these  precautions,  in- 
jections may  be  safely  employed  by  the  patient  himself  when  desirei 
The  Syringe. — ^The  best  form  of  instrument  for  injections  is  a 
hand  syringe  with  a  capacity  of  about  2  ^^  drams  (10  c.  c).  It 
should  be  preferably  of  glass  so  that  it  can  be  sterilized  by  boiling. 
The  nozzle  should  be  cone-shaped  (Fig.  665)  that  it  may  fit  into  the 
meatus,  and  it  should  be  seen  that  it  is  perfectly  smooth.  Before 
using,  the  syringe  should  be  tested  to  see  that  the  piston  move 
easily  and  without  any  jerks.  A  basin  should  also  be  provided 
to  receive  the  solution  that  flows  back  from  the  urethra. 


Fig.  66$. — Urethral  syringe. 

Solutions  Employed. — Many  solutions  with  soothing,  astringent, 
or  antiseptic  properties  are  employed,  a  few  of  which  are  given: 


Sedative  Injections 


Q.  Fl.  ext.  Hydrastis, 
Aquae  destil., 

Q    Morph.  sulph.j 
CocainsD, 
Muc.  acaciae, 
Aquae  destil. 


TTlxx-xxx  (1.2-2  c.c) 
5i  (30  C.C.) 
gr.  viii  (0.5  gm.) 
gr.  iv  (0.26  gm.) 
8i  (30  c.c.) 
q.s.ad  5ii  (60  c.c.) 


Astringent  Injections 


I^.  Zinci  sulphatis, 

Aquae  destil. 
Q   Zinci  sulphocarbolatis 

Aquae  destil., 
I^.  Plumbi  acetatis, 

Aquae  destil., 
I^.  Zinci  acetatis. 

Aquae  rosae, 

Antiseptic  Injections 

I^.  Sol.  protargol, 

I^.  Sol.  argyrol, 

I^.  Sol.  potass,  pcrmanganat., 

IJ.  Sol.  bichlorid  of  mercury, 


gr.  iv-viii  (0.26-0.5  gm.) 

5iv  (120  c.c.) 

gr.  vi-xii  (0.4-0.8  gm.) 

5iv  (120  c.c.) 

gr.  iv-xii  (0.26-0.8  gm.) 

5iv  (120  c.c.) 

gr.  i-xv  (0.065-1  gm.) 

8i  (30  c.c.) 


0.25  to  I  per  cent. 
5  to  10% 
1-5000  to  3000 
1-30,000 


HAND   INJECTIONS   FOS  THE   URETHRA 


663 


Temperature. — ^The  solution  shotUd  be  used  at  about  the  tem- 
perature of  the  body. 

Quantity. — Only  sufficient  quantity  of  the  solution  to  distend 
the  anterior  urethra  should  be  injected  at  a  time.  At  first  about 
3i  (4  C.C.)  should  be  used;  later  this  maybe  increased  toSiii  (12  c.c). 

Frequency. — The  injections  may  be  employed  three  to  six  times 
daily,  depending  upon  the  severity  of  the  case.  As  the  symptoms 
improve  they  may  be  given  less  frequently.  It  should  be  remem- 
bered, however,  that  in  some  cases  after  a  time  the  continued  use 
of  injections  may  prevent  a  discharge  from  entirely  disappearing, 
aiid  it  is  necessary  to  stop  them  entirely  for  a  week  or  more  before 
a  cure  is  obtained. 


Fig.  666.— Method  of  giving  i.  ureChrat  injection. 

Position  of  Patient. — Injections  may  be  given  with  the  patient 
lying  recumbent  or  sitting  upon  the  edge  of  a  chair. 

Preparation. — The  glatis  penis  and  the  lips  of  the  meatus  should 
be  washed  off  with  a  i  to  5000  solution  of  bichlorid  of  mercury. 

Technic — The  patient  urinates  immediately  before  the  injection 
is  given  so  as  to  wash  out  as  much  of  the  discharge  as  possible  and 
also  that  he  may  not  have  to  urinate  soon  afterward,  thus  allowing 
the  solution  to  remain  in  contact  with  the  urethra  the  maximum 
length  of  time.  The  syringe  is  then  filled  with  from  i  to  20  drams 
(4  to  8  C.C.)  of  solution,  and  any  air  is  expelled  by  depressing  the 
piston  while  the  tip  is  elevated.  The  penis  is  held  back  of  the  corona 
between  the  thumb  and  forefinger  of  the  left  hand,  while  with  the 


664  THE   URETHRA   AND   PROSTATE 

right  hand  the  nozzle  of  the  syringe  is  inserted  into  the  me&tns, 
far  enough  to  completely  occlude  the  meatus  and  prevent  leakage, 
and  the  solution  is  gently  injected  into  the  urethra  and  immediatdy 
allowed  to  escape.  A  second  syringeful  of  solution  is  then  injected 
into  the  urethra  until  the  latter  is  well  distended  (Fig.  666).  The 
syringe  is  then  removed  and  the  meatus  is  held  together  for  from  thne 
to  five  minutes  so  as  to  keep  the  solution  in  contact  with  the  mucous 
membrane  (Fig.  667).  The  solution  is  then  allowed  to  run  out  into 
the  receptacle  provided  for  the  purpose. 


Fic.  667. — Second  step  in  injection  of  the  urethra,  holding  the  solution  in  the  urethn. 


IRRIGATIONS  OF  THE  URETHRA 

Irrigation  of  the  urethra  is  accomplished  by  flushing  out  the 
canal  with  copious  quantities  of  mild  antiseptic  solutions.  It  is  a 
method  employed  extensively  in  the  treatment  of  acute  gonorrhea. 
To  be  efEective  large  quantities  of  fluid  must  be  used,  and  the  urethra 
must  be  so  distended  that  the  solution  comes  in  contact  with  all 
recesses  and  folds  in  the  mucous  membrane. 

It  is    claimed  that  under  the  irrigation  method  of  treatmeof. 
properly  employed,  the  intensity  of  the  symptoms  is  much  lessened 
and  the  duration  of  the  attack  shortened.    On  the  other  bind, 
many  authorities  oppose  this  form  of  treatment  on  the  ground  that 
it  increases  the  dangers  of  prostatic  infection  and  that  the  virulence 
of  the  infection  is  increased.     If  gentleness  is  observed  and  the  pre- 


IRRIGATIONS    OF    THE    URETHRA  665 

caution  is  taken  not  to  give  the  anterior  injection  under  too  great 
pressure,  that  is,  not  to  force  the  solution  into  the  bladder,  as  is  so 
frequently  done,  the  danger  of  complications  is  slight.     It  is  not  a 


Fig.  668. — Valentine  irrigad 


thral  irrigating  nozzle. 


method  of  treatment,  however,  that  can  be  placed  in  the  hands  of 
the  patient,  but  it  should  always  be  carried  out  by  the  physician. 
Both  the  anterior  and  the  posterior  urethra  may  be  irrigated. 


Fifi.  66g, — Chetwood's  alternating  cut-off. 


Apparatus. — An  irrigating  reservoir  that  can  be  raised  or  lowered 
to  any  desired  height  at  will,  such  as  Valentine's,  a  Chelwood  two- 
way  blunt  glass  urethral  nozzle,  a  waste-pail,  and  two  pieces  of  rub- 


666  THE   URETHJRA   AND   PROSTATE 

ber  tubing,  one  about  8  feet  (240  cm.)  long  for  connecting  the  inflow 
with  the  irrigator  and  another,  a  sh<»:t  piece,  leading  from  the  oat- 
flow  tube  to  the  waste-pail,  are  required  for  anterior  inigatioDs. 
While  not  absolutely  necessary,  an  alternating  irrigating  clamp 
(Fig.  669)  is  a  convenience. 

For  irrigating  the  posterior  urethra  a  No.  12  to  18  French  soft- 
rubber  catheter  with  a  smooth  beveled  eye,  and  a  large  glass  syringe 
(Fig.  670)  should  be  provided. 


Fig.  670. — Syringe  and  catheter  for  irrigating  the  posterior  urethra. 


Solutions. — Mild  antiseptic  solutions  are  employed.  Those  most 
frequently  used  are: 

Permanganate  of  potash,  x-6000  to  i-iooo 

Bichlorid  of  mercury,  1-30,000  to  1-10,000 

Silver  nitrate,  1-15,000  to  1-2000 

Temperature. — The  solutions  should  be  used  at  about  the  body 
temperature. 

Quantity. — About  a  quart  (i  liter)  of  solution  should  be  used  in 
an  anterior  irrigation. 

For  posterior  irrigations  from  4  to  12  ounces  (120  to  360  c.c.)oi 
solution  are  employed. 

Frequency. — Early  in  the  disease,  when  the  discharge  is  free,  two 
daily  irrigations  give  the  best  results.  Later,  one  irrigation  a  day  is 
suflScient. 

Height  of  Reservoir. — The  reservoir  should  not  be  raised  abov'C 
4  feet  (120  cm.).  Such  an  elevation  will  give  all  the  necessary  dis- 
tention of  the  urethra  without  forcing  the  solution  beyond  the  an- 
terior urethra.  If  it  produces  pain,  the  pressure  should  be  reduced 
by  lowering  the  reservoir  or  partially  pinching  off  the  inflow  tube. 

Position  of  Patient. — For  anterior  irrigations  the  patient  may 
stand  or  be  seated  upon  the  edge  of  a  chair,  while  for  a  postenor 
irrigation  the  patient  should  be  in  the  dorsal  position. 

Preparation  of  Patient. — For  protecting  the  clothes  the  patient 
may  wear  a  rubber  apron  in  which  is  provided  an  opening  for  tte 


(Fig.  671).     The  glans  penis  and  lips  of  the  meatus  should  be 
ed  off  with  a  i  to  5000  bichlorid  of  mercury  solution, 
echoic.     1,  Anterior  Irrigations. — The   patient   should   empty 
ladder  before  each  treatment.     The  operator  holds  the  penis 


inger  of  the  right  hand,  inserts  the  glass  nozzle  into  the  meatus. 
ten  releases  the  inflow  tube,  at  the  same  time  closing  the  out- 


Fig.  673. — Pint  step  in  irrigating  the  posterior  urethra.    Cathe 
the  bladder  until  urine  begLu  to  flow. 


INSTILLATIONS  669 

same  time  shutting  or  opening  the  outflow,  the  urethra  is  alternately 
distended  with  solution  and  emptied  without  the  necessity  of  remov- 
ing the  nozzle.  This  alternate  filling  and  emptying  of  the  urethra 
is  much  easier  to  perform  with  the  scissor-like  clamp  of  Chetwood 
than  with  the  fingers.  It  takes  about  five  minutes  to  thus  irrigate 
the  urethra  with  i  quart  (i  liter)  of  solution. 

2.  Posterior  Irrigations. — The  anterior  urethra  is  first  irrigated 
as  just  described.  A  No.  12  to  1 8  French  catheter,  well  lubricated 
with  one  of  the  Irish-moss  preparations,  is  then  inserted  into  the 
urethra  with  the  eye  upward  until  urine  just  escapes  (Fig.  673). 
After  the  bladder  is  emptied,  the  catheter  is  withdrawn  i  inch 
(2.5  cm.)  until  its  point  lies  in  the  prostatic  urethra  and  from  4  to 
12  ounces  (120  to  360  c.c.)  of  the  antisepic  solution  are  gently  in- 
jected (Fig.  674).  The  posterior  urethra  is  thus  washed  backward 
toward  the  bladder.  The  catheter  is  then  removed  and  the  patient 
is  instructed  to  void  the  contents  of  his  bladder,  thus  giving  a  final 
washing  from  behind  forward  to  both  posterior  and  anterior  urethrse. 

INSTILLATIONS 

Instillations  are  employed  when  it  is  desired  to  medicate  the 
urethra  with  small  quantities  of  strong  solutions.  They  are  lin- 
dicated  in  chronic  gonorrhea,  but  should  not  be  used  in  acute  cases; 
they  are  specially  useful  in  chronic  posterior  urethritis.  Instila- 
tions  are  also  valuable  in  the  treatment  of  sexual  neurasthenia  when 
inflammatory  lesions  are  present  in  the  posterior  urethra.  The  ob- 
ject of  such  injections  is  to  induce  a  hyperemia  of  the  tissues  with 
the  hope  that  it  will  be  followed  by  absorption  of  the  old  as  well  as 
the  new  products  of  inflammation  and  by  a  return  to  normal.  It 
is  a  method  that  may  be  applied  to  the  anterior  or  posterior  urethra. 
Instillations  should  not  be  employed  in  cases  where  injections  or 
irrigations  of  weak  solutions  are  followed  by  irritation,  and  they 
should  likewise  be  avoided  in  posterior  urethritis  when  the  prostate 
and  seminal  vesicles  are  the  seat  of  an  acute  inflammation. 

The  Syringe. — While  the  instillation  may  be  given  by  means  of  a 
flexible  catheter  and  small  syringe,  a  special  instrument,  such  as 
Keyes'  modification  of  the  Ultzmann  syringe  (Fig.  675),  will  be 
found  more  satisfactory.  The  latter  consists  of  a  long  curved 
nozzle  of  German  silver,  provided  with  a  central  opening,  to  the 
proximal  end  of  which  is  attached  a  large  hypodermic  syringe  with 
the  piston  graduated  in  minims. 


670  THE   URETHIELA.   AND   PROSTAIX 

Asepsis. — The  syringe  sliould  be  sterilized  by  boiling  for  five 
minutes  in  a  i  per  cent,  solution  of  sodium  carbonate.  The  ^ans 
penis  and  meatus  are  then  washed  with  warm  water  and  soap, 
followed  by  a  I  to  5000  bichlorid  of  mercury  solution. 

Solutions  Employed. — In  using  instillations  it  is  well  to  start  with 
a  weak  solution,  employing  it  till  the  urethra  becomes  tolerant,  aod 
then  to  gradually  increase  the  strength.  The  solutions  most  fre- 
quently made  use  of  are: 


Silver  nitrate  0.5    to  2    percent. 

Thallin  sulphate,  3        to  10  per  cent. 

Copper  sulphate,  i        to  4   per  cent. 

Argyrol,  10       to  20  per  cent. 

Protargol,  0.25  to  xo  per  cent. 

2        to  xo  per  cent. 


Ichthyol, 


Fig.  675. — Keyes-Ultzmann  instillation  83ninge. 

Temperature. — The  solution  should  be  given  at  about  the  tem- 
perature of  the  body — say  100°  F.  (38^  C.) . 

Quantity. — Ten  or  twenty  minims  (0.6  to  i.25  c.c.)  of  solution  are 
injected  at  a  time. 

Frequency. — Instillations  may  be  given  at  from  forty-eight-  to 
seventy-two-hour  intervals.  As  a  general  rule,  a  second  injection  is 
not  to  be  given  until  all  irritation  from  the  first  has  subsided. 

Position  of  the  Patient. — The  patient  should  be  lying  down  upon  a 
bed  or  table. 

Technic.  i.  Posterior  Instillations, — The  patient  should  \'oid 
his  urine  previous  to  the  instillation,  and  the  anterior  urethra  is 
first  cleansed  by  an  injection  of  weak  antiseptic  solution.  The 
syringe,  filled  with  the  desired  amount  of  solution,  and  with  the 
nozzle  well  lubricated  with  some  nonoily  lubricant,  as  one  of  the 
Irish-moss  preparations,  is  carefully  introduced  in  the  same  manner 
as  one  would  pass  a  sound  (page  641)  until  its  point  lies  behind  the 
compressor  urethras  muscle  in  the  membranous  urethra  (Fig.  676). 
This  will  be  at  a  distance  of  about  5}^  to  6  inches  (14  to  15  cm.) 
from  the  meatus  or  roughly  when  the  shaft  of  the  instrument  is  at 


INSTILLATIONS  '  67I 

an  angle  of  45  degrees  with  the  horizon.  From  5  to  20  drops  (0.3 
to  1.25  c.c.)  of  solution  are  then  slowly  injected.  Care  must  be 
taken  in  withdrawing  the  nozzle  of  the  instrument  not  to  permit 
any  solution  to  drip  from  the  point  along  the  anterior  urethra.  To 
avoid  this,  the  piston  of  the  syringe  should  be  withdrawn  slightly 
before  the  nozzle  is  removed. 

Generally  there  is'  considerable  burning  upon  urination  following 
a  posterior  instillation  and  at  times  there  may  be  pain  and  tenesmus 
and  some  discharge  during  the  first  twenty-four  hours.  As  a  rule, 
these  symptoms  subside  within  six  to  twenty-four  hours.     If  the 


Fig.  67b. — 5howing  the  syringe  in  position  for  deep  urethral  instillation. 

reaction  is  severe,  however,  the  patient  should  remain  quietly  in  bed 
and  an  opium  suppository  should  be  introduced  into  the  rectum  and 
heat  applied  to  the  perineum. 

2,  Anterior  Inslillalions. — In  giving  an  anterior  instillation  the 
same  preparations  are  followed  as  for  a  posterior  instillation.  The 
nozzle  of  the  instrument,  well  lubricated,  is  then  carefully  intro- 
duced as  far  as  the  bulb  of  the  urethra  and  about  20  drops  {1.25 
c,c.)  of  solution  are  injected.  The  solution  follows  the  instrument 
as  it  is  withdrawn,  medicating  the  whole  anterior  urethra.  A  piece 
of  cotton  should  be  placed  over  the  glans  and  worn  for  a  few  hours 


672  THE   URETHRA  AND   PROSTATE 

to  prevent  any  excess  of  solution  escaping  from  the  meatus  and 
soiling  the  patient's  clothing.  The  cotton  may  be  readily  secured 
in  place  by  means  of  a  loose-fitting  elastic  band  placed  behind  the 
corona. 


APPLICATION  OF  OINTMENTS  TO  THE  URETHRA 

Astringent  and  stimulating  ointments  are  at  times  employed  in 
the  treatment  of  chronic  urethritis  instead  of  instillations.  They 
are  considered  by  some  authorities  more  efficient  than  the  use  of 
drugs  in  solution,  as  being  more  penetrating  and  more  lasting  in 
effect. 

Instruments. — Ointments  may  be  applied  to  the  whole  urethra, 
in  which  case  an  ordinary  sound  or  a  cupped  sound  (Fig.  677)  is. 
employed  or  they  may  be  brought  into  contact  with  any  particular 
area  by  means  of  Tomasoli's  or  some  other  form  of  ointment  syringe 
(Fig.  678).  This  latter  instrument  consists  of  a  hollow  curved 
catheter-like  nozzle  and  a  plunger  for  forcing  the  ointment  out  at 
the  end. 

Formulary. — Uima's  ointment  for  use  with  sounds  consists  of: 

I^.  01.  cocse,  J^ui  (90  c.c) 

Cerae  flav.,  Sss  (2  gm.) 

Argent,  nitratis,  gr.  xv  (i  gm.) 

Bals.  peruvianiy  5ss  (2  c.c)  M. 


Fig.  677. — Cupj>ed  sound. 

The  mixture  is  melted  over  a  hot-water  bath  and  the  sound  is  then 
dipped  into  it  and  the  ointment  is  permitted  to  solidify  by  cooling. 
Finger's  Ointment  consists  of: 

I^.  Argent,  nitratis  or  cu.  sulphatis,  gr.  xv  (i  gm.) 

01.  olivce,  5>ss  (5.6  c.c) 

Lanolin,  3ui  (90  c.c.)  M. 

Another  consists  of: 

I^.  Pot.  iodidi.,  5s8  (2  gm.) 

lodi.  pur.,  gr.  v  (0.3  gm.) 

01.  oliva;,  5ss  (2  c.c.) 

Lanolin,  5i  (30  ex.)     M. 


XTRETHROSCOPE   IN   1"HE   TREATMENT   OF   URETHRAL   DISEASES       673 

Preparations. — The  patient's  bladder  should  be  empty.  The 
glans  penis  and  meatus  are  washed  with  soap  and  water,  followed  by 
a  I  to  5000  bichlorid  of  mercury  solution. 

Technic— When  a  sound  is  employed,  as  large  a  one  as  will 
comfortably  pass  the  meatus  is  coated  with  the  ointment,  or  if  a 
cupped  sound  is  used,  the  depressions  are  filled  with  the  ointment, 
and  it  is  passed  through  the  urethra  and  is  left  in  place  about  five 
minutes.  The  ointment  melts  and  thus  medicates  the  entire  urethral 
mucous  membrane. 


r 


i4=«(^j 


Fic.  678.— Uteltral  oii 


In  employing  a  special  ointment  carrier  the  instrument  is  partly 
filled  with  the  ointment  and,  after  being  well  lubricated,  it  Is  passed 
as  far  as  the  diseased  area.  The  piston  is  then  inserted  and  is  pushed 
through  the  instrument  forcing  the  ointment  out  the  end  into  the 
urethra. 

THE  URETHROSCOPE  IN  THE  TREATMENT  OF 
URETHRAL  DISEASES 

By  means  of  the  urethroscope  or  an  open  wire  speculum  (Fig. 
679)  lesions  in  the  urethra  may  be  accurately  located  and  efforts  at 


treatment  can  be  thus  focused  on  the  exact  seat  of  the  disease. 

scopic  treatment  is  thus  of  great  value   in   the  presence  of 

ted  lesions  of  the  urethra  which,  resisting  the  ordinary  methods 

^treatment  by  irrigations,  instillations,  etc.,  are  often  the  cause  of 

persistent  gleety  discharge.     For  example,  through  the  urethro- 

^'^pe  and  by  the  aid  of  suitable  instruments,  strong  applications 

I  ***ay  be  made  to  granular  patches,  erosions,  and  ulcerations;  sup- 


674  ^I^^   UKETHRA   AND   PROSTATE 

purating  glands  or  follicles  may  be  incised  and  small  growths  may  be 
removed  from  the  canal  under  direct  vision. 

The  technic  of  using  the  urethroscope  has  previously  been  fuDy 
described  (page  652)  so  that  the  application  of  the  instruniait  to 


\ 


Fig.  S80. — Urethra]  probe. 


the  treatment  of  various  urethral  conditions  will  simply  be  outliocd 
in  a  general  way.  As  has  been  already  emphasized  in  previn 
pages,  it  is  essential  that  one  should  be  familiar  with  the  noimal  tf- 


—Method  ol  making  appli< 


the  urethra  through  the  uretbm^ 


pearance  of  the  urethra  before  attempts  to  employ  the  instrument 

for  treatment  are  made.     Furthermore,  the  greatest  gentleness  m 

manipulation  is  necessary  to  avoid  injury  to  parts  already  diseaseo. 

In  the  treatment  of  congested  and  granular  patches,  erosions, 


STHROSCOPE   IN   THE   TREATMENT   OP   URETHRAL   DISEASES        675 

i  ulcerations,  local  applications  of  silver  nitrate  or  copper  sulphate 
y  be  used  by  means  of  cotton-wrapped  probes  through  the 
throscope  previously  passed  to  the  seat  of  the  disease  (Fig,  681). 
this  way  strong  solutions  of  these  drugs — 30  to  60  gr.  (2  to  4 
.)  to  the  ounce  (30  c.c.) — which  would  be  extremely  irritating  if 


^(^  Fig.  682 — Urethral  Suiife. 

ilied  to  the  whole  mucous  membrane,  may  be  applied.  If  the 
jased  areas  are  numerous  and  extensive  the  strength  of  the  appli- 
ions  should  be  somewhat  weaker — say  5  to  10  gr.  (0.3  to  0.6  gm.) 
the  ounce  (30  c.c).  When  using  the  stronger  solutions,  care 
uld  be  taken  to  make  the  application  exactly  to  the  diseased  area 


Fig.  OSs-^Kollmann's  urethral  syringe. 

i  not  to  leave  any  excess  of  solution  to  run  over  the  healthy  mucous 
mbrane.  Such  applications  should  not  be  made  too  frequently — 
t  oftener  than  once  a  week — as  usually  an  acute  urethritis,  often 
Mmpanied  by  a  bloody  discharge,  is  set  up.  This,  as  a  rule, 
bsides  in  twenty*four  to  forty-eight  hours. 


^K  Fig.  684. — Urethral  curet. 

Areas  of  induration  may  be  incised  through  the  urethroscope  by 
(ansof  a  urethral  knife  (Fig.  682).  Two  or  3  drops  of  a  4  per  cent. 
Itition  of  cocain  with  adrenalin  chlorid  should  be  applied  to  the 
leased  area  by  means  of  a  cotton-wrapped  probe,  and  the  incision 
ly  then  be  made  without  pain.     In  the  same  manner  abscesses 


J 


676  THE   TTKETSRA   AND  PROSTATA 

of  Little's  glands  or  inflamed  follicles  may  be  opened,  A  discharg- 
ing crypt  or  follicle  may  be  injected  every  few  days  with  a  few  drops 
of  a  peroxid  of  hydrogen  solution  by  means  of  KoUmann's  syringe  and 
cannula  (Fig.  683).  Polyps  and  papillomata  may  be  removed  by  a 
urethral  curet  (Fig.  684)  or  by  caustics.  If  pedunculated,  a  wire 
snare  (Fig.  685)  or  the  galvanocautery  snare  may  be  employed.  In 


Fig.  685. — ^Urethral  snare. 

any  case  the  area'  of  operation  should  be  first  cocainized  in  the  manner 
above  described. 


THE  DIRECT  APPLICATION  OF  COLD  TO  THE 
URETHRA  BY  THE  PSYCHROPHORE 

In  the  treatment  of  spermatorrhea  and  sexual  neurasthenia  where 
the  urethra  is  congested  or  hyperesthetic  the  direct  application  of 
cold  to  the  deep  urethra  by  means  of  the  cold-water  sound  or  psy- 
chrophore  is  often  of  value.  An  ordinary  cold  sound  is  also  employed 
in  treating  such  conditions,  but  is  not  so  effective,  as  the  instrument 
soon  becomes  warm  from  contact  with  the  urethra.  With  the  psy- 
chrophore  it  is  possible  to  keep  a  continuous  cold  application  in  the 
urethra  as  long  as  is  desired. 

Apparatus. — The  psychrophore  is  a  double-current  closed  sound 
within  the  outer  sheath  of  which  are  two  canals,  one  for  the  inflow 
of  cold  water  and  the  other  for  the  outflow,  which  communicate 
near  the  terminal  end  of  the  instrument,  thus  permitting  that  portiot^ 
of  the  instrument  to  be  kept  cold.     The  inflow  canal  is  connected 
with  a  rubber  tube  leading  from  a  douche  bag  or  irrigating  j^ 
(Fig.  686). 

Temperature. — The  temperature  of  the  water  should  be  abot^ 
50®  to  40°  F.  (10°  to  5^  C.)  to  start  with.  As  the  urethra  grows  mo^ 
tolerant  the  temperature  ijiay  be  lowered. 

Duration  of  Treatments. — The  sound  should  be  left  in  place  fo^ 
from  five  to  ten  minutes  at  a  sitting. 


PROSTATIC   MASSAGE 


Frequency. — Treatments  may  be  given  daily  or  on  alternate 
days. 

Technic. — An  instrument  as  large  as  the  normal  caliber  of  the 
urethra  should  be  used.  It  is  well  lubricated  and  gently  inserted  in 
the  same  manner  as  a  sound  (page  641)  until  the  curved  portion  lies 
in  the  membranous  and  prostatic  portions  of  the  urethra.  The  tub- 
ing from  the  reservoir  is  then  coimected  with  the  inflow  canal  and 
a  current  of  cold  water  is  allowed  to  pass  through  the  instrument, 
escaping  from  the  outflow  canal  into  a  basin  provided  for  the  purpose. 
In  this  way  the  hyperesthetic  urethra  is  exposed  to  the  mechanical 
effect  of  the  sound  and  the  sedative  action  of  cold. 


Fig.  686. — Apparatus  for  applying  cold 


PROSTATIC  MASSAGE 


Massage  of  the  prostate  gland  by  means  of  the  finger  in  the  rec- 
tum is  frequently  employe'd,  and  with  good  results,  in  the  treat- 
ment of  chronic  prostatitis  in  which  the  inflammation  extends  deep 
^  the  gland  tissue.  The  object  is  to  express  from  the  prostate  into 
'"e  posterior  urethra  as  much  as  possible  of  the  purulent  contents 
°'  tie  gland  and  to  cause  absorption  of  the  products  of  inflammation 
''"oiai  indurated  areas.  It  is  also  used  for  the  purpose  of  emptying 
^e  distended  seminal  vesicles  and  hastening  resolution.  It  should 
****t  be  employed  in  acute  prostatitis  or  acute  vesiculitis,  and  care 
^«oui(j  be  taken  not  to  perform  the  massage  too  vigorously,  other- 


678  XBE   UHETHKA   AND   PKOSTATE 


wise  the  tissues  will  be  bruised  and  the  inflammation  will  be  qpi 
vat«d. 


^0.  687. — Position  of  the  patient  and  method  of  iotroducmg  the  finga  inlo  th 
rectum  in  prostatic  n 


Fic.  688. — Showing  the  method  of  massaging  tlie  prostate. 


Duration  of  Treatment. — The  massage  should  be  carried  out  fa 
two  or  three  minutes  at  a  sitting. 


MEATOTOMY  679 

Frequency. — Unless  followed  by  irritation,  treatments  may  be 
given  once  every  four  or  five  days. 

Position  of  Patient. — The  operation  may  be  performed  with  the 
patient  bending  forward  over  a  chair  or  in  the  knee-chest  position. 

Technic. — If  possible,  the  patient's  bladder  should  be  full.  The 
operator  wears  a  rubber  glove  on  the  right  hand  or  a  finger  cot  on  his 
right  index-finger  and,  after  lubricating  the  index-finger,  introduces 
it  into  the  rectum  (Fig.  687),  canying  the  finger  high  up  on  one  side 
over  the  seminal  vesicle.  Firm  but  gentle  pressure  is  then  made 
with  the  finger  over  the  seminal  vesicle  and  the  finger  is  slowly 
drawn  down  over  the  vesicle  toward  its  duct  and  also  over  the  cor- 
responding lobe  of  the  prostate  (Fig.  688).  This  procedure  is  then 
repeated  upon  the  opposite  side,  and  finally  over  the  central  portion 
of  the  gland.  All  portions  of  the  gland  are  thus  massaged,  but 
special  attention  should  be  paid  to  those  portions  that  are  enlarged 
or  diseased. 

After  completing  the  massage  the  patient  urinates,  thus  empty- 
ing the  bladder  of  pus  and  d6bris  expressed  by  the  massage. 

MEATOTOMY 

Meatotomy  consists  in  dividing  a  narrow  meatus.  It  may  be 
required  as  a  preliminary  to  the  passage  of  large  instnunents  into 
the  urethra  or  bladder  and  in  the  presence  of  urethral  inflammation, 
when  the  size  of  the  meatus  is  such  that  free  drainage  is  interfered 
with.     If  properly  performed,  it  is  an  operation  without  danger. 

Instruments. — The  incision  is  best  made  with  an  Otis  meatome 
(Fig.  689)  or  with  an  ordinary  blunt-pointed  straight  bistoury. 

Location  of  Incision. — The  meatus  should  be  cut  exactly  in  the 
median  line  upon  the  floor  of  the  urethra. 


Fig.  689. — Otis*  meatome. 

Preparations. — The  glans  penis  and  meatus  shoidd  be  washed 
with  soap  and  water  followed  by  a  i  to  5000  solution  of  bichlorid  of 
mercury.  The  anterior  urethra  should  be  irrigated  with  a  saturated 
boric  acid  solution. 

Anesthesia. — To  render  the  operation  painless  the  line  of  pro- 
posed incision  is  infiltrated  with  a  o.i  per  cent,  solution  of  cocain 
or  a  0.5  per  cent,  procain  solution  introduced  through  the  frenum  or, 


68o  THE   URETHRA  AND    PROSTATE 

if  desired,  by  the  topical  application  of  a  weak  cocain  solution  (see 
page  87). 

Technic. — The  operator  retracts  the  foreskin  and,  steadying  the 
penis  between  the  thumb  and  forefinger  of  his  left  hand,  inserts  the 
knife,  with  the  cutting-edge  down,  into  the  urethra  for  a  distance  of 
I  J'^  inches  (4  cm.).  The  meatus  is  then  incised  exactly  in  the  mid- 
line by  drawing  the  knife  out.  To  allow  for  subsequent  contraction 
it  is  well  to  incise  the  canal  to  a  size  larger  than  is  desired  to  perma- 
nently maintain  it — a  meatus  that  will  give  passage  to  a  No.  30  F. 
sound  is  sufficiently  enlarged.  If  it  is  found  upon  inserting  an  in- 
strument that  the  constriction  has  not  been  entirely  cut,  any  remain- 
ing bands  should  be  divided. 

At  first  there  may  be  some  hemorrhage  from  the  incision,  but 
this  can  usually  be  controlled  by  inserting  a  plug  of  gauze  for  an  inch 
(2.5  cm.)  or  so  within  the  meatus.  Should  the  bleeding  be  severe, 
the  incision  should  be  grasped  between  the  thumb  and  forefinger 
placed  on  either  side  of  the  frenum  and  should  be  compressed  until 
the  hemorrhage  stops. 

The  After-Treatment. — This  consists  in  passing  a  full-sized 
straight  sound  through  the  meatus,  at  first  daily  and  then  every 
second  day  for  a  week  or  ten  days,  otherwise  the  narrowing  is  apt 
to  reform.  When  meatotomy  is  performed  as  a  preliminary  to 
instrumental  examination,  the  exploration  may  be  performed  at 
the  same  sitting. 

THE    TREATMENT    OF    STRICTURES    BY  INSTRUMENTAL 

DILATATION 

The  methods  of  treatment  applicable  to  organic  stricture  of  tk 
urethra  include  gradual  dilatation,  continuous  dilatation,  and  cut- 
ting the  stricture  either  from  within  — internal  urethrotomy— or 
from  without — external  urethrotomy.  Two  other  methods,  namely, 
divulsion  and  electrolysis,  which  are  sometimes  described  in  text- 
books, are  now  practically  obsolete.  Divulsion  is  so  dangerous  tbt 
it  has  been  abandoned,  while  electrolysis  is  an  operation  that  is  of 
doubtful  benefit  and  has  never  found  much  favor. 

Intermittent  dilatation  of  strictures  by  the  passage  of  instru- 
ments of  increasing  size  should  be  the  method  of  choice  when  pos- 
sible, as,  if  properly  performed,  it  is  without  danger.  It  is,  of  coursc» 
only  applicable  to  strictures  which  are  permeable,  but  a  large  pro- 
portion of  such  may  be  successfully  treated  by  this  method.   K^ 


THE    TREATMENT   OF   STRICTURES  68 1 

especially  suited  to  those  strictures  which  are  fairly  recent,  soft,  and 
dilatable.  For  old  strictures  with  considerable  scar  tissue  forma- 
tion, which  are  rigid  and  unyielding,  attempts  at  dilatation  are  apt 
to  fail,  so,  if  after  a  fair  trial  of  the  method  in  these  cases  it  does  not 
give  results,  more  radical  means  of  treatment  should  be  substituted. 
Again,  intermittent  dilatation  is  not  apt  to  be  successful  when  ap- 
plied to  the  so-called  resilient  strictures;  these,  while  dilatable,  are 
so  elastic  that  they  recontract  between  treatments,  and  little,  if 
any,  advance  is  made  beyond  a  certain  point.  Strictures  which  are 
irritable,  that  is,  those  in  which  attempts  at  dilatation  are  followed 
by  pain  and  spasm  resulting  in  retention  of  urine,  those  in  which  the 
passage  of  instruments  is  followed  by  chills  and  fever,  those  compli- 
cated by  numerous  false  passages  and  suppurating  fistidous  tracts, 
and  all  strictures  near  the  meatus  should  be  cut.  For  strictures 
complicated  by  cystitis,  intermittent  dilatation  is,  likewise,  im- 
desirable  on  account  of  the  dangers  of  pyelonephritis,  these  require 
cutting  of  the  stricture  and  free  drainage  of  the  bladder. 

Before  making  any  attempt  to  treat  strictures,  the  number  of 
strictures,  their  exact  location,  their  size,  and  their  extent  should  be 
determined  by  instrumental  exploration  of  the  urethra,  and  sufficient 
time  for  the  tissues  to  react — at  least  seventy-two  hours — should 
elapse  after  such  an  examination  before  the  dilatation  is  begun. 
Strictures  may  occur  at  any  point  in  the  canal  except  in  the  prostatic 
urethra,  but  the  most  frequent  sites  are:  (i)  in  the  region  of  the 
bulbomembranous  junction,  (2)  within  23^^  inches  (6  cm.)  of  the 
meatus,  and  (3)  near  the  penoscrotal  junction.  They  may  be  single 
or  multiple,  and  in  shape  annular  or  tortuous.  The  opening  is 
seldom  situated  in  the  center  of  the  stricture,  but  generally  lies  to  one 
side  of  the  median  line  of  the  urethra. 

All  strictures  have  a  tendency  to  contract  and  in  time  cause 
more  or  less  impediment  to  the  urinary  flow  with  serious  results  to 
the  whole  urinary  tract.  The  urethra  immediately  behind  the 
stricture  is  the  first  to  feel  the  effects  of  this  obstruction  and  the 
canal  at  this  point  becomes  more  or  less  dilated  and  the  mucous  mem- 
brane is  thinned  out.  Urine  collects  in  this  dilated  portion  and  de- 
composes, with  the  result  that  an  inflammation  is  set  up  accompanied 
by  a  gleety  discharge.  This  may  in  time  go  on  to  ulceration  and 
extravasation  of  urine  with  the  formation  of  false  passages  and  fis- 
tulas. The  effect  of  the  urinary  obstruction  is  also  felt  upon  the 
bladder.  It  first  hypertrophies  and  may  later  become  thinned  and 
dilated,  and  it  is  not  uncommonly  the  seat  of  cystitis.     In  time 


682  THE   URETHRA   AND   PROSTATE 

inflammation  and  dilatation  of  the  ureters  and  kidney  follow,  re- 
sulting in  pyelitis  and  pyelonephritis. 

Mention  is  made  of  these  complications  because  their  presence, 
or  absence,  and  severity,  if  present,  are  of  direct  practical  impor- 
tance in  determining  the  method  of  treatment  to  pursue.    If  should 
further  be  borne  in  mind  that  the  stricture  itself  is  usually  congested 
and  the  mucous  membrane  is  softened  and  inflamed,  so  that  in  per- 
forming  dilatation  the  greatest  care  and  gentleness  are  necessary  to  avoid 
lacerating  and  contusing  the  already  irritated  tissues.    Roughness  or 
carelessness  in  introducing  the  instrument  can  do  only  harm.    The 
beneficial  effects  of  dilatation  depend  not  only  upon  the  mechanical 
distention  to  which  the  urethra  is  subjected,  but  also  upon  the 
simple  presence  of  the  instrument  which  stimulates  the  tissues  to  a 
mild  reactionary  hyperemia,  which  is  accompanied  by  softening 
and  absorption  of  the  scar  tissue.     If  more  than  this  is  done,  that  is, 
if  the  tissues  are  so  irritated  that  an  inflammation  is  induced,  the 
value  of  the  treatment  is  lost  and  the  original  trouble  is  simj^ 
aggravated. 

Instruments. — ^^For  strictures  above  No.  15  French  conical  sted 
sounds  of  proper  curve  are  employed.     These  may  be  of  the  style 


Fig.  690. — Conical  steel  sound. 


shown  in  Fig.  690,  or  those  with  a  double  taper  (Fig.  691)  may  be 
used.  The  latter  instcimient  has  a  slight  advantage  in  that,  the 
shaft  being  smaller  than  the  shoulder,  dilatation  of  the  deeper  parts 
is  effected  without  unduly  stretching  the  meatus.     For  strictures 


Fig.  691. — Double-taper  steel  sound. 


in  the  pendulous  urethra  in  front  of  the  bulb  a  straight  conical  sound 
(Fig.  692)  may  be  employed;  such  an  instrument  should  not  be  used, 
however,  in  the  deep  urethra. 

Kollmann  dilators  are  used  in  preferance  to  sounds  by  some 


THE     TREATMENT    OF    STRICTURES  683 

operators.     They  are  made  on  the  principle  of  the  Otis  urethrometer 
with  four  blades  regulated  by  a  thumb-screw  at  the  proximal  end 


Fig.  6g3. — Straight  steelsound. 

of  the  instrument.     A  dial  and  indicator  show  the  extent  to  which  the 
blades   are   separated.     Two   styles   of   dilators   are  generally  em- 


c  6<)3. — KoUmann's  straight  dilator.  Fig.  694.  —  Kollmann'a  curved   dil»- 

tor  for  the  posterior  urethra  with  irrigat- 
inf;  attachment. 

ployed — a  straight  one  for  the  anterior  urethra  (Fig.  693)  and  a 
I  ggyed  instrument  (Fig.  694)  for  the  posterior  urethra.     Some  are 


684 


THE  URETHRA  AND  PROSTATE 


supplied  with  attachments  for  irrigating  the  urethra.  A  rubber 
sheath  is  provided  with  these  instruments  to  be  drawn  over  the 
blades  (Fig.  695)  and  so  avoid  injuring  the  urethral  mucous  mem- 
brane when  the  instrument  is  being  closed.  This  is  not  used,  how- 
ever, with  the  irrigating  dilators.  When  closed  the  instrument 
measures  20  French  and  may  be  expanded  to  45  French.    On  account 


Fig.  695. — Rubber  sheath  in  position. 

of  their  small  size,  they  may  be  used  for  dilating  strictures  in  the 
presence  of  a  narrow  meatus  without  first  cutting  the  latter. 

With  small  steel  instrurnents  there  is  a  considerable  chance  of 
making  a  false  passage  and  always  the  danger  of  inflicting  trauma- 
tism, so  that  for  strictures  of  a  smaller  size  than  No.  15  French,  soft 


Fig.  696. — Flexible  urethral  bougie. 

instruments  should  be  employed.  Flexible  olivary  bougies  (Fig. 
696)  are  the  best  in  this  class  of  cases,  as  they  find  their  way  through 
the  stricture  with  greater  ease  and  there  is  less  danger  of  making  a 
false  passage.  They  are  made  of  woven  material  covered  with 
rubber  and  the  best  are  of  French  make. 


Fig.  697. — Gouley  tunneled  sound  and  filiform. 

For  dilating  tight  strictures  whalebone  filiform  bougies  and  tun- 
neled sounds  (Fig.  697)  should  be  provided.  The  filiforms  shouM 
be  at  least  18  inches  (45  cm.)  long  and  of  such  size  that  the  tunneled 
sounds  will  slip  easily  over  them.  Care  should  be  taken  not  to  use 
rough  or  split  filiforms.  In  fact,  any  instrument,  no  matter  what  the 
variety,  must  be  perfectly  smooth  and  sound;  imperfect  instruments 
should  be  discarded  as  unsafe. 


THE    TREATMENT    OF    STRICTURES  685 

Asepsis. — The  strictest  asepsis  should  be  observed  in  regard  to 
the  instruments  used.  Metal  instruments  should  be  boiled  for  five 
minutes  in  a  i  per  cent,  solution  of  sodium  carbonate.  Filiforms 
and  the  newer  gum-elastic  instruments  will  stand  moderate  boiling. 
They  may  also  be  sterilized  by  formaldehyd  vapor,  after  which  they 
should  be  well  rinsed  in  sterile  water;  or  they  can  be  immersed  first  in 
a  t  to  20  carbolic  solution  and  then  in  a  saturated  solution  of  boric 
acid. 

The  glans  and  meatus  should  be  washed  with  soap  and  water 
followed  by  a  i  to  5000  bichlorid  of  mercury  solution.  The  urethra  is 
irrigated  both  before  and  after  each  treatment  with  a  saturated  solu- 
tion of  boric  acid  or  a  i  to  5000  permanganate  of  potash  solution,  and, 
if  the  bladder  is  infected,  it  should  likewise  be  irrigated,  provided  the 
stricture  is  sufficiently  large  to  admit  a  catheter. 

The  same  regard  to  cleanliness  should  also  apply  to  the  operator's 
hands. 

Rapidity  of  Dilatation.— This  can  only  be  determined  by  a  study 
of  the  individual  case.  It  is  important,  however,  not  to  do  too  much 
dilating  at  a  time.  It  should  not  be  carried  to  a  point  where  discom- 
fort or  pain  is  caused.  If  the  stretching  is  too  rapid,  it  practically 
amounts  to  divulsion  with  its  attendant  risks  of  inflammation  and 
sepsis.  Furthermore,  tearing  of  the  stricture  results  in  new  formation 
of  tissue  which  in  turn  contracts.  In  the  case  of  tight  strictures  the 
introduction  of  a  second  instrument  after  the  first  is  sufficient.  In 
other  cases  the  dilatation  may  be  carried  further,  using  three  or  four 
instruments  in  all. 

Frequency  of  Treatment. — After  the  passage  of  an  instrument  a 
reactionary  hyperemia  sets  in  and  this  should  be  given  time  to  subside 
before  instruments  are  reintroduced.  A  lapse  of  three  to  seven  days 
should,  therefore,  occur  between  treatments — on  an  average  an  inter- 
val of  about  five  days.  One  will  be  guided,  however,  partly  by  the 
amount  of  contraction  that  takes  place  between  treatments  and  also 
by  the  toleration  of  the  urethra.  Instruments  should  never  be  passed 
so  frequently  as  to  produce  irritation.  Very  contractile  strictures 
require  the  frequent  passage  of  sounds,  while  for  those  that  are  easily 
dilated  and  do  not  readily  reform  longer  intervals  may  be  allowed. 
After  the  stricture  has  been  stretched  to  28  or  30  French,  the  inter- 
k'als  between  the  treatments  may  be  increased,  at  first  to  once  a  week, 
-hen  once  or  twice  a  month,  and  finally  to  several  times  a  year. 

Extent  of  Dilatation. — There  is  no  fixed  rule  to  be  followed  as  to 
i»e  extent  to  which  a  stricture  is  to  be  dilated.     Various  scales  have 


686  TKC   UKETHRA   AND   PKOSTATE 

been  devised  for  determining  the  approximate  size  of  the  tuethia 
from  comparison  with  the  circumference  of  the  penis',  but  tbey  an 
not  accurate.  As  a  general  rule,  dilatation  of  the  stricture  to  the 
size  of  the  meatus,  provided  it  is  of  normal  caliber,  is  suffident 

Position  of  Patient.' — The  patient  should  be  in  the  dorsal  portion 
with  his  shoulders  slightly  raised  and  thighs  a  little  flexed  and  rotated 
outward.  The  operator  takes  his  place  just  above  the  patient's 
hips  and  facing  toward  the  patient's  body,  upon  whichever  »(ie  is 
most  convenient  for  him. 

Anesthesia. — ^Local  anesthesia  is  only  necessary  where  the  patient 
is  nervous  and  the  urethra  hyperesthetic,  or  upon  the  first  passage 
of  a  sound  after  urethrotomy,  as  properly  introduced  instruments 
should  cause  little  or  no  pain.    In  such  cases  the  urethra  is  well 


Fic.  698. — First  step  in  passing  a  sound. 

distended  with  a  0.2  per  cent,  solution  of  cocain  and  adrenalin  solu- 
tion and  the  solution  is  confined  in  the  urethra  for  fifteen  minutes  by 
holding  the  meatus  closed. 

Technic.     i.  Large  Slrictures. — Under  this  heading  will  be  con- 
sidered strictures  above  15  French  in  size. 

With  Sounds.— A  sound  of  a  size  that  will  easily  pass  through  the 
stricture — determined  by  previous  exploration— is  warmed,  well 
lubricated  with  lubrichondrin  or  other  Irish-moss  preparation,  and 
is  very  gently  introduced  in  the  following  manner:  The  operator 
grasps  the  penis  behind  the  corona  between  the  ring-  and  midd/e 
fingers  of  the  left  hand  and  with  the  thumb  and  index-fingers  of  the 
same  hand  he  retracts  the  foreskin  and  separates  the  lips  of  the  mea- 
tus.    The  sound  is  grasped  lightly  between  the  thumb  and  first  W> 


THE   TREATMENT   OF   STRICTURES  687 

fingers  of  the  right  hand  and  is  carefully  inserted  into  the  urethra. 
At  this  stage  the  handle  of  the  instrument  should  be  parallel  to  the 
abdominal  wall  and  in  line  with  the  folds  of  the  groin  (Fig.  698).     As 


Fig.  700.— Third  step  in  passing  a  sound, 
the  sound  is  pushed  onward  and  downward,  the  handle  of  the  instru- 
ment is  gradually  swept  to  the  center  line  (Fig.  699)  and  is  then  slowly 
raised  to  a  perpendicular  so  that  its  beak  passes  beneath  the  pubic 


1 


688  THE   UBETHRA   AND   PKOSTATE 

arch  (Fig.  700)  into  the  membranous  urethra.  Unless  the  stricture 
be  in  the  deep  urethra,  it  is  not  necessary  to  insert  the  sound  mto  the 
bladder — the  instrument  should  simply  be  passed  through  the  stric- 
ture. To  insert  the  instrument  the  full  distance,  the  handle  is 
brought  forward  and  downward  between  the  thighs  (Fig.  701). 
When  the  point  of  the  sound  reaches  the  stricture,  the  utmost 
gentleness  in  manipulation  should  be  used  in  engaging  it  io  the 
stricture,  and  no  attempt  to  enforce  the  instrument  along  should  be 
made,  until  it  is  certain  that  its  point  has  entered  the  opening  in  the 
stricture.     Having  passed  the  sound  entirely  through  the  stricture, 


Fig.  701.- — Fourth  step  in  passing  a,  sound. 


it  is  removed  by  a  reversal  of  these  steps  and  a  second  one  is  intro- 
duced. If  this  causes  pain  or  spasm,  it  is  immediately  withdrawn, 
and  no  immediate  further  attempt  to  dilate  is  made.  If,  however, 
the  urethra  tolerates  the  second  instrument,  a  third  one  may  be 
introduced. 

At  the  next  sitting  the  dilatation  is  begun  by  inserting  a  sound  oik 
size  larger  than  the  first  instrument  used  at  the  previous  treatment,     1 
and  the  dilatation  is  increased  one  or  two  sizes  as  before.     In  this  vaj 
the  treatments  are  continued  until  the  desired  degree  of  dilatation  a    ' 
obtained. 

The  passage  of  the  sound  will  cause  more  or  less  smarting,  but  * 
is  only  transitory.  At  times  a  few  drops  of  blood  may  follow  tks 
removal  of  the  instrument.     The  next  act  of  urination  is  apt  to    ■** 


THE    TREATMENT    OF    STRICTURES  689 

painful,  and  not  infrequently  the  gleety  discharge  is  increased  for 
twenty-four  or  forty-eight  hours.  The  patient  should  be  warned  of 
these  symptoms  beforehand. 

With  the  Kallmann  Dilator. — The  rubber  sheath  is  drawn  over  the 
instrument.  The  dilator,  closed  and  well  lubricated,  is  then  intro- 
duced to  the  seat  of  constriction  and  dilatation  of  the  canal  is  then 
produced  to  any  desired  extent  by  turning  the  thumb-screw  at  the 
end  of  the  instrument.  The  stretching  must  be  performed  very 
gradually  and  with  great  care,  as  these  instruments  are  so  powerful 
that  severe  trauma  may  be  caused  by  a  too  rapid  dilatation.  If  the 
patient  complains  of  pain,  or  if  an  undue  amount  of  resistance  is  felt, 
the  dilatation  should  be  stopped.  Having  effected  the  desired 
amount  of  dilatation,   the  instrument  is  left  in  place  for  several 


Flc  701. — Method  of  inserting  a  flexible  bougie  througli  a  urelliral  stricture. 

moments  before  it  is  closed  and  removed.     At  subsequent  treatments 
the  dilatation  is  increased  one  or  two  numbers  each  time, 

1.  Stnall   Strktures. — For   small    strictures,    that    is,    below    15 
French,  soft  bougies  are  employed.     A  bougie  of  a  size  that  will  read- 
ily enter  the  stricture  is  selected.     The  penis  is  held  straight  up  and 
upon  the  stretch  in  the  fmgers  of  the  left  hand  after  the  manner  de- 
scribed above,  and  the  bougie,  well  lubricated,  is  carefully  passed 
■aight  down  to  the  seat  of  obstruction  (Fig.  702),  provided  the 
Itter  is  in  the  anterior  urethra.     An  instrument  can  thus  be  readily 
I. passed  straight  as  far  as  the  bulbomembranous  junction,  but  here  it 
**  apt  to  be  obstructed.     To  pass  this  point  and  enter  the  deep  ure- 
"*ra,  the  bougie  should  be  introduced  bent  as  much  as  possible  to 


i 


690  THS   USETHKA   AND   FKOSTATE 

the  shape  of  a  curved  sound,  and,  when  the  point  reaches  the  bulb, 
slight  pressure  should  be  made  with  the  fingers  on  the  perineum  (see  . 
Fig.  640).  When  the  instrument  strikes  the  face  of  the  obstructkn, 
gentle  attempts  are  made  to  engage  its  point  in  the  stricture.  This 
accomplished,  the  instrument  is  pushed  on  entirely  through  the 
stricture,  and  the  dilatation  is  proceeded  with  in  the  same  manna  u 
when  using  sounds.  Steel  instruments  may  be  substituted  for  the 
bougies  when  the  dilatation  has  been  carried  as  high  as  15  French 
3.  PUiform  Strictures. — In  the  beginning  of  the  treatment  fA  1 
filiform  stricture  it  often  requires  the  greatest  perseverance  and  sUU 
to  enter  the  bladder,  as  frequently  the  stricture  is  of  such  small  caliber 


Fig.  703. — Method  of   passing  a  filiform  bougie  through  a  stricture  by  fint  Shf 
the  canal  with  filiforms. 

or  the  opening  is  so  situated  that  it  is  extremely  difficult  to  engap 
even  a  fine  filiform.  Once,  however,  the  filiform  is  inserted,  the  main 
difficulty  is  surmounted.  In  introducing  filiforms  the  same  method 
is  employed  as  for  straight  bougies.  The  penis,  grasped  in  the  fingers 
of  the  operator's  left  hand,  is  put  upon  the  stretch  and  the  filiform, 
well  lubricated,  is  inserted  along  the  floor  of  the  canal.  If  the  point 
of  the  instrument  is  obstructed. by  a  fold  of  mucous  membrane  or  tht 
opening  of  some  lacuna,  it  should  be  withdrawn  shghtly  and  tbta 
slowly  reinserted.  When  the  face  of  the  stricture — the  location  d 
which  has  been  previously  determined — obstructs  the  further  ad- 
vance of  the  filiform  the  instrument  should  be  slowly  rotated  making 
attempts  to  engage  its  point  in  the  stricture,  the  while,  but  without 
using  any  force.     Sometimes  by  distending  the  canal  with  wanQ 


THE   TREATMENT   OF   STRICTURES  691 

sterile  oil  it  is  possible  to  enter  the  fiUform  in  the  opening  of  the 
stricture.  Failing  with  one  filiform,  a  second  may  be  inserted  beside 
the  first  one  and  the  same  manipulation  is  carried  out  as  with  the  first. 
If  still  unsuccessful,  additional  fiUforms  are  inserted  until  the  ure- 
thra contains  six  or  seven  of  them.  Then  gentle  attempts  are  made 
to  pass  each  in  turn,  and  usually  one  will  finally  slip  into  the  opening 
(Fig,  703),  whence  it  can  be  readily  passed  into  the  bladder.  If, 
after  a  fair  trial,  it  is  impossible  to  insert  an  instrument,  it  is  better  to 
give  up  the  attempt  for  the  time  being,  and  try  again  a  few  days 
later.  Sometimes  upon  a  second  or  third  trial  the  opening  will  be 
readily  located.  Gentle  manipulation  combined  with  perseverance 
will  result  in  success  in  the  great  majority  of  cases,  but,  if  it  is  impos- 


Fic.  704. — Method  of  passing  a  Lunneled  sound 

wble  to  pass  the  instrument  by  these  means,  a  urethroscope  may  be 
introduced  as  far  as  the  obstruction  and  the  filiform  inserted  by 
direct  sight. 

Having  finally  passed  a  filiform,  the  smallest  size  tunneled  sound 
should  be  inserted  over  it  as  a  guide  fFig.  704).  If  there  has  been 
much  manipulation  in  passing  the  filiform,  the  operator's  efforts  had 
best  stop  at  this,  or,  at  the  most,  a  second  sound  is  introduced.  At 
the  next  sitting  the  filiform  is  again  inserted  and  the  dilatation  in- 
creased by  inserting  larger  instruments  over  it  as  a  guide.  After 
some  dilatation  has  been  thus  obtained,  soft  bougies  may  be  sub- 
stituted for  the  fihforms  and  tunneled  sounds,  and  the  treatments 
may  be  carried  out  as  outlined  above. 


692  THE   UKETHKA   AND   PROSTATE 

Accidents  and  Complications  Attending  Dilatation. — ^There  are 
several  troublesome  as  well  as  serious  complications  that  may  follow 
the  passage  of  urethral  instruments. 

Shock. — In  some  cases,  in  spite  of  the  utmost  gentleness  in  ma- 
nipulation, the  passage  of  a  sound  produces  sufficient  shock  to  cause 
the  patient  to  faint  or  collapse.  It  is  more  likely  to  occur  in  patients 
upon  whom  an  instrument  is  passed  for  the  first  time,  especially  if 
they  are  of  a  distinctly  nervous  type  and  look  upon  the  operation 
with  fear  and  apprehension. 

Much  may  be  done  in  preventing  such  a  complication  when  the 
nervous  element  is  in  evidence  by  avoiding  pain  through  the  use  of 
local  anesthesia.  Should  fainting  occur,  the  patient's  head  is  to  be 
immediately  lowered  and  stimulants  administered  if  necessary. 

Urethral  Chill  and  Fever, — ^A  form  of  urinary  septicemia  spoken  of 
as  urethral  chill  and  fever  is  liable  to  follow  urethral  instnmientation. 
It  may  be  the  result  of  absorption  of  toxic  elements  which  are  present 
in  the  urine,  in  the  urethra,  or  are  introduced  from  without  w&l  the 
instrument,  or  it  may  be  the  result  of  shock  to  the  kidne}rs.  The 
condition  may  be  of  a  mild  type — in  which  case  a  few  hours  after 
the  passage  of  the  instrument  the  patient  is  seized  with  a  chill  frf- 
lowed  by  fever,  more  or  less  prostration,  and  within  twenty-four 
hours  recovery — or  it  may  be  severe  and  progressive  and  eventually 
result  in  the  death  of  the  patient. 

Preventive  treatment,  which  is  of  the  greatest  importance,  should 
consist  in  rigid  asepsis,  gentle  manipulation  of  urethral  instruments, 
and  antiseptic  irrigations  or  instillations  after  any  instrument  has 
been  used.  Actual  treatment  comprises  rest  in  bed,  quinin  in  5-  or 
lo-grain  (0.3  to  0.6  gm.)  doses,  and  the  administration  of  genito- 
urinary antiseptics.  In  the  presence  of  urinary  suppression,  hot 
baths  or  hot  packs  and  stimulants  are  indicated. 

Inflammation  of-  the  Urethra,  Prostate,  or  Bladder, — Inflammation 
of  the  stricture,  prostatitis,  or  cystitis  may  follow  as  a  result  of  injury 
to  the  urethra  or  vesical  neck  from  rough  or  careless  introduction  of 
instruments  or  from  failure  to  pay  due  regard  to  cleanliness.  The 
inflammation  may  extend,  in  addition,  from  the  urethra  down  the 
ejaculatory  ducts  and  set  up  an  epididymitis.  In  the  presence  of 
such  complications,  attempts  at  dilatation  should  cease  until  the 
acute  period  is  passed  and  appropriate  treatment  shoidd  be  directed 
to  the  cure  of  the  complication. 

Hemorrhage, — At  times  considerable  hemorrhage  may  result  from 
the  passage  of  instruments.     This,  as  a  rule,  indicates  a  false  passage 


THE    TREATMENT    OF    STRICTURES  693 

or  an  attempt  at  too  great  a  degree  of  dilatation  at  one  sitting. 
Bleeding  may  occur,  however,  in  some  cases  where  the  urethra  is 
markedly  congested  with  scarcely  any  injury  to  the  tissues.  The 
bleeding  usually  stops  of  its  own  accord.  If  excessive,  the  patient 
should  be  kept  quietly  in  bed  and  cold  applications  should  be  applied 
to  the  perineum. 

False  Passage. — Another  accident  that  may  result  from  the  use  of 
urethral  instruments  is  the  formation  of  a  false  passage  by  forcing 
the  instrument  through  the  urethral  wall  into  the  surrounding  tissues. 
It  is  more  liable  to  happen  when  using  rigid  instruments  of  small  size 
and  probably  occurs  more  frequently  than  Is  recognized.  When  a 
false  passage  is  made,  there  will  generally  be  free  hemorrhage  at  the 
time  or  upon  withdrawal  of  the  instrument,  and  the  patient  will  com- 
plain of  severe  pain  and  may  show  signs  of  shock.  At  the  same  time, 
the  operator,  while  conscious  that  the  instrument  has  passed  the 
obstruction,  will  recognize  that  the  point  is  not  in  the  urethra  from 
the  direction  of  the  handle.  In  such  a  case,  if  an  examination  is 
made  by  the  rectum,  the  point  of  the  instrument  will  be  found  in  the 
perineum  near  the  rectal  wall.  Furthermore,  the  instrument,  if  it  be 
a  rigid  curved  one,  cannot  be  rotated  about  its  own  axis  as  would  be 
the  case  were  its  point  in  the  bladder. 

Following  such  an  accident,  if  the  patient  can  urinate,  the  treat- 
ment should  be  expectant  in  the  main;  that  is,  he  should  be  put  to  bed 
and  given  urinary  antiseptics  and  carefully  watched.  Should  extra- 
vasation of  urine  occur  or  an  abscess  develop,  prompt  and  free 
drainage  should  be  established  and  perineal  urethrotomy  should  be 
performed. 

CONTINUOUS  DILATATIOH 

Continuous  dilatation  consists  in  inserting  a  filiform  or  small 
bougie  through  a  stricture  and  leaving  it  in  place  for  twenty-four  or 
forty-eight  hours.  By  the  end  of  this  period  more  or  less  absorption 
of  the  stricture  has  taken  place,  so  that  there  is  some  dilatation,  and 
a  larger  instrument  may  then  be  inserted.  It  is  a  method  that  may 
be  sometimes  employed  for  securing  dilatation  of  tight  strictures  not 
amenable  to  gradual  dilatation,  and  is  worthy  of  trial  in  such  cases 
before  resorting  to  a  radical  cutting  operation.  The  method  has  its 
objections,  however,  in  that  it  is  necessary  to  keep  the  patient  under 
constant  observation  and  in  bed;  furthermore,  irritation  from  the 
instiument  in  the  urethra  is  apt  to  cause  urethritis  which  may  in  turn 


4 


694  "^^^^   UKETHSA   AND   PROSTATE 

lead  to  cystitis.  Tlie  method  is  contraindicated  in  the  presence  of 
cystitis  or  if  renal  complications  exist. 

Instruments. — Filiform  (see  Fig.  631)  or  soft  bougies  (see  Fig.  630) 
may  be  employed. 

Asepsis. — Rigid  asepsis  is,  of  course,  imperative.  The  instm- 
ments  are  to  be  sterilized  as  already  described  (page  640).  Thepemi 
and  meatus  are  washed  with  soap  and  water,  followed  by  a  i  to  5000 
bichlorid  of  mercury  solution.  The  urethra  should  be  irrigated  witit 
a  I  to  5000  permanganate  of  potash  or  saturated  boric  add  solutica, 
and  the  bladder  should  be  likewise  irrigated  with  boric  add  solutiw, 
if  possible,  upon  changing  the  instruments. 

Technic. — The  instrument  is  passed  through  the  stricture  aftd 
the  method  already  described  for  intermittent  dilatation  (page  689), 


Fio.  705. — Showing  the  method  of  securing  1  bougie  or  catheter  in  the  oiethim.    (AIM 
EincUIr,  Polyclinic  Journal,  July,  190S.} 

and  is  then  securely  fastened  in  place.  There  are  several  methods  of 
doing  this,  but  the  following  is  the  simplest  and  most  effectiw. 
Four  pieces  of  adhesive,  each  about  4  inches  (12  cm.)  long  and  ^  inch 
(6  mm.)  wide  are  secured  to  the  bougie  (which  for  a  space  of  an  iDch 
(2.5  cm.)  in  front  of  the  meatus  has  been  thoroughly  dried  and  from 
which  all  grease  has  been  removed)  in  such  a  way  that  one  strip  lits 
upon  the  dorsum,  one  on  the  ventral  surface,  and  one  on  either  lateral 
surface  of  the  penis.  When  a  foreskin  is  present,  it  is  drawn  down 
over  the  glans  and  each  strip  is  carried  over  it  and  caused  to  adhere  to 
the  penis.  An  additional  strip  of  adhesive  i  inch  (2.5  cm.)  wide 
is  placed  horizontally  about  the  penis  just  behind  the  corona  cova- 
ing  the  four  small  strips  (Fig.  705)  This  strip  should  not  entirely 
encircle  the  penis,  thus  avoiding  any  danger  of  constricting  it 
Where  there  is  no  foreskin,  a  piece  of  gauze  should  be  interposed  l»- 
tween  the  glans  and  the  small  strips.  A  liberal  sterile  gauze  dressing 
is  then  wrapped  about  the  penis  and  the  protruding  instrument,  and 
the  whole  is  supported  by  means  of  a  T-bandage.  The  urine  escapes 
■  along  the  side  of  the  bougie  into  the  gauze,  which  should  be  chan^ 
when  saturated.     Within  twenty-four  or  forty-eight  hours  the  bou^ 


CONTINTJOUS   DILATATION  695 

is  removed,  and  the  stricture  will  be  found  sufficiently  stretched  to 
permit  the  easy  introduction  of  a  larger  instrument.  This  is  left  in 
for  the  same  length  of  time,  and  upon  its  removal  gradual  dilatation 

maybebegun.  .      -  .  . 

When  there  is  retention  of  urme,  the  filiform  is  passed  as  before, 
a  tunneled  catheter  is  passed  over  it  as  a  guide  into  the  bladder 
(page  690),  and  the  urine  is  drawn  off.  The  bladder  is  then  irrigated 
and  the  catheter  removed,  but  the  filiform  is  secured  in  place  as  de- 
scribed above.  Usually  urine  will  begin  to  pass  along  the  bougie  in 
a  short  while,  but  if  not  it  may  be  withdrawn  as  often  as  necessary 
by  means  of  a  tunneled  catheter. 


CHAPTER  XXI 
THE  BLADDER 

Anatomic  Considerations 

The  bladder  is  a  musculomembranous  reservoir  for  the  receptkn 
of  urine,  lying  behind  the  pubes  and  in  front  of  the  rectum  in  tk 
male  and  the  uterus  in  the  female.  The  bladder  may  be  described 
as  having  (i)  a  summit,  or  apex;  (2)  a  base,  or  fundus,  which  rests 
upon  the  rectum  and  into  which  open  the  ureters;  (3)  a  body,  01 
middle  portion;  and  (4)  a  neck,  or  constricted  portion,  opening  into 
the  urethra.     It  has  an  average  physiological  capacity  of  from  6  to 


Fig.  706. — Showing  the  space  above  the  pubes  through  which  it  is  possible  to  enlirtle 
bladder  without  opening  into  the  peritODCum. 

9  ounces  (iSo  to  270  c.c),  and  a  normal  maximum  capacity  of  n 
ounces  (720  c.c),  but,  under  certain  pathological  conditions,  it  may 
become  enormously  distended  without  rupture.  Its  shape  and  poa- 
tion  depend  to  a  certain  extent  upon  whether  it  is  empty  or  fnU- 
When  empty,  it  lies  well  behind  the  pubes,  and  upon  median  secdw 
appears  triangular  in  outline;  when  partially  filled,  it  beconxs 
rounded  in  outline;  and,  when  completely  distended,  it  becomesovil 
and  rises  partly  from  the  pelvis  into  the  abdominal  cavity. 


ANATOSnC   CONSmERATIOMS  697 

The  peritoneum  partially  covers  the  anterior  surface  and  sides 
of  the  bladder,  and  entirely  covers  the  superior  surface,  extending 
posteriorly  as  far  as  the  level  of  a  transverse  line  passed  between  the 
upper  limits  of  the  seminal  vesicles,  whence  it  is  reflected  to  the 
rectum  in  the  male,  while  in  the  female  it  is  reflected  to  the  uterus. 
When  the  bladder  becomes  distended,  the  peritoneum  is  carried  from 
the  anterior  abdominal  wall  with  it,  so  that  in  retention  of  urine 
with  distention  it  becomes  possible  to  empty  the  viscus  by  passing 
an  aspirator  into  it  above  the  pubes  without  fear  of  entering  the 
peritoneal  cavity  (Fig.  706). 


Fig.  707. — The  interior  o{  the  bladder,     i,  Trigone;  a,  orifice  of  ureter;  3,  muscular 
layer;  4,  mucous  membrane;  5,  iuteruieteric  line;  6,  prostate  gland. 

Beneath  the  peritoneal  coat  lies  the  muscular  layer.  It  consists 
of  three  coats:  external,  middle,  and  internal.  The  external  is  com- 
posed of  fibers  arranged  longitudinally  and  in  thick  bundles  over  the 
anterior  and  posterior  surfaces,  but  forming  a  comparatively  thin 
layer  at  the  sides.  The  fibers  of  the  middle  coat  have  a  circular 
arrangement.  They  are  thickest  at  the  neck  where  they  form  the 
internal  vesical  sphincter.  The  internal  layer  is  thinner  than  either 
of  the  others.  Some  of  its  libers  are  arranged  longitudinally  and 
others  circularly. 

The  mucous  coat  is  composed  of  stratified  pavement  epithelium. 


698  THE  BLADDER 

It  is  of  a  pale  salmon  color.  When  the  bladder  is  distended,  the 
mucous  membrane  forms  a  smooth  lining  for  the  interior,  but  is 
thrown  up  into  thick  folds  when  the  viscus  is  empty,  except  over  the 
portion  known  as  the  trigone  where  it  is  always  smooth.  Tic 
mucous  membrane  of  the  bladder  is  comparatively  insensitive  to 
touch  when  in  a  normal  condition,  as  it  has  a  scant  nerve  supply,  the 
most  sensitive  portion  being  over  the  trigone.  The  trigone  is  a 
smooth  triangular  space  at  the  base  of  the  bladder,  the  apex  of  whid 
corresponds  to  the  opening  of  the  urethra  and  the  base  to  a  line 
passing  between  the  orifices  of  the  two  ureters  (Fig.  707). 

The  ureters  pierce  the  bladder  wall  obliquely  and  appear  upon  the 
mucous  membrane  as  round  openings  or  oval  slits  directed  forward 
and  inward.  These  orifices  are  from  i  to  i)^  inches  (2.5  to  4  cm.) 
apart  and  about  i  inch  (2.5  cm.)  from  the  beginning  of  theurethia. 

Diagnostic  Methods 

When  examining  a  case  of  suspected  bladder  disease  the  symp- 
toms complained  of  should  first  receive  careful  attention.  In  additkn 
to  the  usual  questions,  information  bearing  upon  the  act  of  uiinatkn 
should  be  sought,  ascertaining  whether  there  is  frequency  of  mini" 
tion,  whether  there  is  urgency,  whether  the  act  is  difficult,  irbxAis 
pain  is  present  and,  if  so,  its  relation  to  the  passage  of  urine,  ^diethff 
the  force  or  caliber  of  the  stream  is  changed,  etc.,  etc. 

Frequency  of  urination  is  common  in  all  bladder  a£Fections  where 
the  mucous  membrane  is  inflamed.  It  is  also  a  S3rmptom  of  vesical 
stone,  tumor,  foreign  body,  or  an  enlarged  prostate.  In  the  presence 
of  stone  this  symptom  is  more  marked  when  the  patient  is  up  and 
about  or  after  exertion,  while  in  the  case  of  an  enlarged  prostate  it  is 
more  pronounced  at  night.  Frequent  micturition  may,  however, 
occur  when  the  bladder  is  healthy,  as  in  diabetes,  in  hysteria,  in  those 
who  drink  large  quantities  of  water,  in  those  whose  urine  contains 
excessive  amounts  of  uric  acid  or  oxalates,  etc. 

Urgency  of  micturition,  or  the  feeling  of  being  compelled  to  pass 
urine  the  instant  the  desire  is  felt,  points  strongly  to  inflammation  of 
the  bladder  or  the  prostate.  Inflammation  or  irritation  of  the  ure- 
thra may  also  cause  it.  It  is,  however,  sometimes  observed  as  the 
result  of  certain  mental  emotions,  as  fright  or  apprehension,  or  mental 
suggestions,  such  as  the  sound  of  running  water.  Irritating  urine  and 
diseases  of  the  nervous  system  are  also  causes. 

With  a  history  of  painful  micturition,  it  is  important  to  determine 
the  seat  of  the  pain  and  the  exact  relation  it  bears  to  the  act  of  urina- 


EXAMINATION   OF   THE   URINE  699 

tion.  Pain  from  prostatitis  is  generally  felt  in  the  perineum  or  rec- 
tum, pain  in  bladder  disease  is  felt  over  the  pubes,  in  kidney  disease  in 
the  loins.  A  vesical  calculus,  however,  will  frequently  cause  pain  in 
the  head  of  the  penis.  Pain  at  the  beginning  of  urination,  as  a  rule, 
points  to  some  obstruction  to  the  outflow  of  urine  or  to  inflammation 
of  the  urethra,  or  it  may  be  the  result  of  very  irritating  urine.  If  it 
occurs  during  micturition,  it  may  be  caused  by  inflammation  of  the 
urethra,  prostate,  or  bladder  wall.  Pain  at  the  end  of  urination 
occurs  when  a  vesical  calculus  is  present  or  when  there  is  inflamma- 
tion involving  the  neck  of  the  bladder  or  the  prostate.  In  acute 
prostatitis  pain  is  also  present  upon  defecation.  When  pain  is  pres- 
ent in  the  intervals  between  the  acts  of  urination,  it  may  be  caused  by 
a  vesical  calculus,  tumors,  or  prostatic  abscess.  When  such  pain 
is  increased  upon  exertion  and  entirely  relieved  by  rest  in  the  dor^ 
position,  it  is  believed  by  some  writers  to  be  pathognomonic  of  ves- 
ical calculus. 

Difficuty  of  urination,  as  a  rule,  indicates  stricture  of  the  urethra 
or  an  enlarged  prostate.  Changes  in  the  caliber  of  the  stream  gener- 
ally point  to  stricture.  In  the  presence  of  enlarged  prostate,  disease 
of  the  bladder  wall,  and  in  some  nervous  affections,  the  force  of  the 
stream  may  be  greatly  diminished,  so  much  so  as  to  amount  to  a  mere 
dribbling.  A  vesical  calculus  may  at  times  cause  a  sudden  stoppage 
of  the  stream,  and  this  is  frequently  accompanied  by  sharp  pain. 

While  a  complete  history  should  always  be  obtained,  at  the  same 
time  too  much  importance  should  not  be  placed  upon  symptoma- 
tology in  the  diagnosis  of  vesical  affections.  The  symptoms  are  often 
deceptive,  as  they  may  be  common  to  diseases  involving  the  bladder, 
kidneys,  or  urethra.  Even  when  they  clearly  point  to  the  bladder 
as  their  seat  of  origin,  they  are  sometimes  of  but  little  value  in  dif" 
ferentiating  between  the  various  morbid  conditions  that  may  affect 
this  organ.  An  accurate  diagnosis  can  only  be  arrived  at  by  a  physical 
examination  along  the  lines  detailed  below. 

The  methods  available  for  examination  of  the  bladder  include 
urinalysis,  inspection,  percussion,  palpation,  sounding,  cystoscopy, 
tests  of  the  capacity,  the  sufficiency,  and  the  absorption  power  of  the 
bladder,  and  the  X-rays. 

EXAMINATION  OF  THE  URINE 

A  complete  chemical,  microscopical,  and  bacteriological  examina- 
tion of  the  urine  should  be  made  in  all  cases  of  suspected  disease  of 


i 


700  THE  BLADDER 

the  bladder  or  kidneys.  The  proper  method  of  collecting  the  sped- 
men  for  such  examination  has  been  previously  described  (page  305), 
but  it  is  outside  the  province  of  this  work  to  describe  urinalysis;  for 
this  the  reader  is  referred  to  some  of  the  numerous  works  devoted  to 
the  subject.  The  diagnostic  significance  of  modifications  in  the  nor- 
mal condition  of  the  urine  as  far  as  applies  to  vesical  and  renal  disease 
will,  however,  be  briefly  considered. 

The  quantity  of  urine  passed  normally  by  a  healthy  adult  amounts 
on  an  average  to  50  ounces  (1500  c.c.)  in  twenty-four  hours,  but  this 
may  be  greatly  modified  even  in  health,  depending  upK)n  the  seasonoi 
the  year,  the  quantity  of  water  imbibed,  the  amount  of  exercise  taken, 
the  condition  of  the  nervous  system,  etc.,  etc.  In  certain  diseases,  as 
fevers,  in  affections  accompanied  by  night-sweats  or  diarrhea,  chronic 
parenchymatous  and  acute  nephritis,  in  blockage  of  a  ureter  by  an 
impacted  stone  or  by  a  twist,  in  shock,  hemorrhage,  etc.,  the  outpat 
of  urine  may  be  greatly  decreased  (oliguria).  On  the  other  hand,  an 
increased  quantity  of  urine  (polyuria)  will  be  found  in  hysteria,  m 
the  presence  of  interstitial  changes  in  the  kidney,  from  the  use  of 
diuretics,  in  diabetes,  in  renal  tuberculosis,  in  pyelitis,  etc 

In  bladder  affections  the  daily  output  of  urine  generally  remains 
unchanged  and,  in  the  presence  of  marked  changes  in  this  req)ect, 
involvement  of  the  kidneys  or  some  constitutional  disease  may  be 
implied. 

The  specific  gravity  of  the  urine  for  a  normal  individual  is  fixed  at 
1.018  to  1.025  ^t  ^0°  F.  (16°  C).  The  specific  gravity  is  dosdy 
related  to  the  amount  of  solids  excreted,  so  to  be  of  value  the  test 
should  be  applied  to  a  mixture  of  the  urine  voided  during  twenty-four 
hours. 

In  diseases  of  the  bladder  the  specific  gravity  is  unaffected,  but  in 
renal  disease  it  may  be  markedly  changed.  A  low  specific  gravity 
and  an  increased  output  of  urine,  when  the  bladder  is  diseased,  points 
strongly  to  pyelitis  or  pyelonephritis. 

TIte  odor  of  urine  is  faintly  aromatic,  the  more  marked  the  greater 
the  proportion  of  solids.  The  taking  of  such  drugs  as  copaiU, 
cubebs,  turpentine,  and  sandalwood  modify  this  characteristic  odor. 
In  diabetic  coma  the  odor  of  the  urine  resembles  that  of  chloroform 
from  the  presence  of  acetone  and  diacetic  acid.  Urine  that  has 
undergone  ammoniacal  decomposition,  as  is  frequently  the  case  in 
chronic  cystitis,  has  the  characteristic  and  offensive  odor  of  stak 
urine.  Urine  coming  from  a  bladder  which  communicates  with  the 
rectum  by  a  rectovesical  fistula  has  an  odor  of  skatol.     In  the  pres- 


EXAMINATION   OF   THE    URINE  701 

ence  of  ulcerations  within  the  bladder,  especially  ulcerating  tumors, 
the  urine  will  be  foul-smelling  and  may  even  have  a  distinct  odor  of 
putrefaction. 

The  color  of  the  urine  is  a  light  or  dark  amber  depending  upon  the 
concentration.  The  presence  of  blood  gives  the  urine  a  bright  red  or 
reddish  black  hue,  depending  upon  whether  the  hemorrhage  is  recent 
or  old.  Bile  gives  a  dark  yellow  or  brownish  color  with  a  greenish 
tinge.  In  chyluria  the  urine  appears  milky.  Fevers  render  the  urine 
darker  than  normal.  Various  drugs  may  also  modify  the  color,  thus 
senna,  rhubarb,  and  santonin  may  color  the  urine  a  golden-yellow 
»r  deep  red  hue,  methylene  blue  gives  a  greenish-blue  color,  and 
poisoning  from  carbolic  acid,  chlorate  of  potash,  or  creosote  makes 
the  urine  smoky  or  black. 

Transparency. — Normal  urine  should  be  clear  and  transparent 
when  voided.  In  bladder  diseases  the  urine  is,  as  a  rule,  turbid. 
Turbidity  may  be  caused  by  urates,  phosphates,  blood,  pus,  epithe- 
lium, chyle,  or  bacteria.  The  turbidity  caused  by  urates  disappears 
upon  heating  the  urine,  that  due  to  phosphates  clears  up  upon  the 
addition  of  one  or  two  drops  of  acetic  acid. 

In  bacteriuria,  as  is  seen  after  the  passage  of  unclean  instruments, 
the  turbidity  is  slight  and  remains  unchanged  upon  standing,  upon 
the  application  of  heat,  or  in  the  presence  of  acetic  acid.  The 
condition  is  recognized  by  the  aid  of  the  microscope. 

The  turbidity  produced  by  pus  is  increased  upon  heating  the  urine, 
and  does  not  disappear  upon  the  addition  of  an  acid.  Furthermore, 
upoi]  allowing  such  a  specimen  to  stand  a  few  hours,  it  will  be  found 
that  the  pus  settles  to  the  bottom  leaving  the  rest  of  the  fluid  clear. 
A  simple  test  for  the  presence  of  pus  is  to  add  a  little  solution  of 
potassium  hydrate  to  the  suspected  specimen;  in  the  presence  of  pus 
a  gelatinous  precipitate  is  formed. 

The  reaction  oj  urine  is  normally  slightly  acid.  The  acidity  is 
increased  in  fevers,  gout,  iithemia,  rheumatism,  chronic  Brights  dis- 
ease, etc.,  and  upon  a  diet  composed  chiefly  of  proteids.  A  vegetable 
diet  and  large  quantities  of  fluids  render  the  urine  neutral  or  alkaline. 

In  diseases  of  the  bladder  the  urine  may  be  acid  or  alkaline,  thus 
in  acute  cystitis  the  urine  is  usually  acid.  In  chronic  cystitis  it  may 
be  either  acid  or  alkaline,  always  the  latter  in  the  presence  of  ammoni- 
Bcal  fermenation,  but  when  due  to  the  gonococcus,  tubercle  bacillus, 
or  colon  bacillus  it  is  acid.  In  uncomplicated  cases  of  pyelitis  and 
pyelonephritis  the  urine  also  has  an  acid  reaction. 


i 


702  THE  BLADDER 

Albuminuria, — ^Albumin  in  the  urine  is  not  to  be  considered  an 
invariable  sign  of  kidney  disease.  It  may  result  from  a  number  of 
local  causes,  such  as  blood,  pus,  prostatic  secretion,  etc.,  due  to  an 
inflammation  involving  the  kidney  pelvis,  ureter,  bladder,  prostate, 
or  urethra,  without  the  existence  of  organic  disease  of  the  kidney. 
Furthermore,  a  transient  albuminuria  is  not  infrequently  the  result 
of  the  diet,  the  amount  of  excerdse  taken,  nervous  shocks,  toxins  in 
the  blood,  etc.  So  that  it  becomes  of  the  greatest  importance  to 
decide  whether  an  albuminuria  is  of  renal  origin  or  is  the  result  of 
other  pathological  conditions,  and  sometimes  this  is  a  difficult  matter. 
The  two  may  exist  together. 

Hematuria, — Blood  in  the  urine  may  have  its  source  in  any  part  of 
the  genitourinary  tract,  as  the  urethra,  prostate,  bladder,  ureters,  or 
kidneys.  While  it  is  not  always  possible  to  determine  the  source  of 
the  hemorrhage  from  an  examination  of  the  urine,  there  are  certain 
characteristic  differences  in  hemorrhages  from  Jthese  different  regions. 

Urethral  hemorrhage  may  arise  from  acute  urethritis  or  inflamed 
strictures,  or  may  follow  traumatism  to  the  canal,  the  passage  of  in- 
struments, etc.  In  urethral  hemorrhage,  if  the  source  is  from  in  front 
of  the  compressor  urethrae  muscle,  the  blood  appears  independently 
of  urination,  and  may  escape  from  the  meatus  freely,  in  drops,  or  m 
the  form  of  long  clots.  If  from  the  posterior  urethra,  the  blood  finds 
its  way  backward  into  the  bladder  and  when  of  considerable  quantity, 
uniformly  discolors  the  urine.  If,  however,  the  posterior  hemonhage 
is  slight,  the  first  and  last  portions  of  the  urine  passed  may  be  blood- 
tinged  while  the  intermediary  portion  will  be  clear. 

Vesical  hemorrhage  may  follow  the  sudden  and  complete  emptying 
of  the  bladder  in  retention,  or  it  may  be  due  to  trauma,  the  passage 
of  instruments,  varicosities,  stone,  inflammation,  ulcer,  tuberculosis, 
tumors,  etc.  The  urine  in  a  recent  vesical  hemorrhage  may  be 
comparatively  clear  at  first,  or  only  slightly  discolored,  becoming 
more  so  as  the  bladder  is  emptied,  until  it  finally  has  a  bright  red  color 
or  consists  of  almost  pure  blood.  It  may  contain  large  clots  which 
have  no  definite  shape,  and,  if  long  retained,  they  appear  black  and 
tarry.     The  reaction  of  the  urine  is  generally  alkaline. 

Renal  hematuria  may  be  due  to  inflammation,  congestion,  trauma, 
stone,  tuberculosis,  tumors,  the  use  of  strong  diuretics,  etc.,  etc.  The 
blood  will  be  thoroughly  mixed  with  the  urine,  imparting  to  the  latter 
a  smoky  tint  or  deep  red-brown  color.  It  will  be  found  that  the  cor- 
puscles are  greatly  changed  and  without  coloring  matter,  often 
appearing  as  mere  shadows,  but  in  cases  of  ruptured  kidney  or  in 


EXAMINATION    OF    THE    URINE 


703 


severe  renal  hemorrhage  from  other  cause,  they  may  remain  unaltered 
and  the  urine  will  be  much  Ughter  in  color.  The  urine  during  renal 
hemorrhage  and  just  after  is  generally  acid  in  reaction  unless  the 
bleeding  has  been  severe  or  pus  is  present.  Large  clots  are  seldom 
formed  unless  the  blood  coagulates  after  reaching  the  bladder,  but 
there  may  be  found  casts  of  the  kidney  tubules  or  cylindrical- 
shaped  dots  from  the  ureters. 

A  more  positive  diagnosis  between  hematuria  of  renal  origin  and 
that  of  the  bladder  may  be  made  by  introducing  a  catheter  and  thor- 
oughly washing  out  the  bladder  with  a  warm  normal  salt  solution, 
being  careful  to  wash  out  all  the  clots.  If  the  blood  is  of  renal  origin, 
the  last  washings  will  consist  of  clear  fluid  and  will  remain  clear  until 
more  blood  flows  from  the  ureters.  If,  on  the  other  hand,  the  bleed- 
ing arises  from  the  bladder,  it  will  be  found  impossible  to  completely 
free  the  fluid  from  blood. 
!  By  means  of  a  cystoscopic  examinatioQ.  (page  713)  the  bladder 
may  be  excluded  as  the  source  of  the  blood  if  it  is  found  free  from 
disease,  or  it  may  be  possible  to  see  blood  escaping  from  one  or  other 
ureter.     (See  also  the  absorption  test,  page  713.) 

Pyuria. — Pus  in'the  urine  is  a  common  accompaniment  of  bladder 
diseases  and  also  those  affecting  the  urethra  and  kidneys.  Pyuria  is 
a  symptom  of  suppuration  or  catarrh  in  the  genitourinary  tract,  thus 
it  will  be  found  in  pyonephritis,  pyelitis,  tuberculosis,  cystitis,  ure- 
thritis, etc.  It  is  characterized  by  cloudy  urine  in  which  a  thick 
yellow  sediment  settles  upon  standing. 

A  differential  diagnosis  between  urethral  pus  and  bladder  pus  may 
be  made  by  having  the  patient  void  his  urine  in  two  glasses  (page  633). 
If  the  urethra  is  the  source,  the  first  glass  of  urine  will  be  found  cloudy 
and  the  contents  of  the  second  glass  clear  or  nearly  so.  When  the 
bladder  is  affected  the  contents  of  both  glasses  will  be  equally  cloudy. 

In  deciding  between  vesical  and  renal  pyuria,  it  should  be  borne  in 
mind  that  in  the  former  condition  the  amount  of  albumin  will  be 
slight  and  there  will  be  no  renal  casts,  but  bladder  epithelium  will  be 
found,  while  in  urine  containing  pus  from  the  kidney  albumin  will  be 
found  in  a  greater  proportion  than  can  be  accounted  for  by  the 
amount  of  pus,  and  casts  may  be  present.  The.use  of  the  catheter  or 
cystoscope  will,  however,  furnish  more  exact  evidence  as  to  the  source 
of  the  pyuria. 

To  apply  the  first  test,  the  bladder  is  thoroughly  washed  with  a 

warm  normal  salt  or  boric  acid  solution  through  a  catheter  until  the 

.  Siud  returns  clear.     The  catheter  is  then  clamped  and  allowed  to 


4 


704  I'HE  BLADDER 

remain  in  place  ten  or  fifteen  minutes,  and  what  urine  has  CDteied^ 
bladder  in  the  meantime  is  drawn  off.  If  this  last  specimen  is  ^ain 
turbid  we  may  conclude  that  the  pus  comes  from  the  kidneys. 

On  cystoscopic  examination,  if  the  bladder  be  found  free  from 
disease,  this  evidence  points  to  the  kidney  as  the  source  of  pus.  The 
diagnosis  may  be  made  absolute  if  pus  is  seen  exuding  from  the  Die- 
ters or  a  sample  of  urine  obtained  by  ureteral  catheterization  on- 
tains  pus. 

INSPECTION 

Inspection  of  the  bladder  without  the  aid  of  instruments  is  ex- 
tremely limited  in  value.     By  inspection  of  the  abdomen,  it  is  poasi- 


FiG.  708.— Vaginal  inspection  of  the  bladder.     (Ashtoa.) 

ble  to  recognize  a  distention  of  the  bladder,  and,  in  the  female,  by 
means  of  a  vaginal  inspection,  some  information  as  to  the  condition 
of  the  floor  of  the  bladder  may  be  gained. 

Position  of  Patient-^For  ordinary  abdominal  inspection  tif 
patient  lies  flat  on  the  back  with  the  body  uncovered  from  the  uit 
bilious  to  the  knees,  and  with  the  legs  extended  in  the  same  pUnf 
the  body. 

For  inspection  through  the  vagina  the  patient  should  be  in  t« 
dorsal  posture. 

Technic.  i.  Abdominal  Inspection. — The  examiner  takes  » 
position  upon  one  side  of  the  patient  and  carefully  notes  any  danf 
in   the   size  or  shape  of  the  hypogastrium.     A  distended  bW"* 


PALPATION  705 

appears  as  an  ovoid  tumor  with  the  narrow  end  down,  situated  above 
the  symphysis  generally  in  the  median  line. 

2.  Vaginal  Inspection.— The  examiner  sits  facing  the  vulva,  and, 
by  retracting  the  perineum  with  the  index-finger  of  the  left  hand 
introduced  within  the  vagina  (Fig.  70S),  the  anterior  vaginal  wall 
is  exposed  for  inspection.  In  this  way  a  displacement  of  the 
bladder,  protrusion  from  distention,  or  a  vesicovaginal  fistula  may 
be  recognized, 

PERCUSSION 

Percussion  of  the  bladder  is  chiefly  of  use  in  determining  the 
presence  or  absence  of  distention.  The  percussion  note  over  the 
hypogastrium  is  normally  tympanitic.  When  the  bladder  becomes 
distended  with  fluid,  there  will  be  a  fluctuating  tumor  above  the 
symphysis  which  gives  aflat  percussion  note  and  tympany  at  the  sides. 
If,  however,  coils  of  intestine  fill  the  space  between  the  bladder  and 
the  abdominal  wall,  as  is  sometimes  the  case  where  the  intestines 
become  adherent  as  the  result  of  pelvic  peritonitis,  percusion  will 
furnish  but  imperfect  information,  as  a  tympanitic  note  may  be  ob- 
tained and  yet  the  bladder  be  distended.  Any  doubt  as  to  the  pres- 
ence of  distention  should  be  immediately  settled  by  passing  a  catheter 
into  the  bladder. 

PALPATION 

In  the  case  of  thin  individuals  with  relaxed  abdominal  wails  pal- 
pation will  often  give  valuable  information,  but  in  fat  or  very  muscu- 
lar patients  it  is  of  limited  use.  The  palpation  may  be  performed 
abdominally  or  bimanually.  The  latter  method  yields  the  most 
valuable  information.  Distention,  large  foreign  bodies,  calculi,  or 
tumors,  and  tender  areas  may  be  thus  recognized,  and  an  idea  as  to 
the  thickness  and  sensibility  of  the  bladder  walls  may  be  obtained. 
It  is  an  especially  useful  method  to  employ  in  examining  the  bladders 
of  children. 

Digital  palpation  of  the  bladder  by  means  of  a  finger  introduced 
through  a  perineal  or  suprapubic  wound  or  through  the  urethra  in  the 
'diale  are  methods  now  rarely  employed  for  diagnosis  alone,  aswe 
Oave  other  equally  efficient  and  more  simple  means  of  examination. 
Position  of  Patient. — For  abdominal  palpation  the  patient  should 
°e  in  the  dorsal  posture  with  the  thighs  flexed  and  the  body  uncovered 
"Om  the  umbilicus  down.  This  or  the  knee-chest  posture  may  be 
^lUployed  for  bimanual  examination. 


■jo5  THE  BLADDER 

Anesthesia. — In  stout  individuals  or  those  with  rigid  abdominal 
walls,  it  may  be  impossible  to  make  a  satisfactory  bimanual  examina- 
tion without  the  aid  of  general  anesthesia. 


Fig.  709. — Abdominal  palpation  of  a  distended  bladder. 


Technic.     i.  Abdominal  Palpation. — ^The  examiner  stands  qm 
the  left  side  of  the  patient,  and,  placing  his  right  hand  flat  upon  tbc 


of  the  bladder. 


abdomen  just  above  the  pubes,  gently  palpates  the  hypogastric  re^on 
by  means  of  his  finger  tips.    In  thin  individuals,  if  distention  is 


SOUNDING  707 

present,  a  fluctuating  tumor  will  be  recognized.  By  requesting  the 
patient  to  breathe  deeply  with  the  mouth  open  and  at  the  same  time 
pressing  the  ulnar  border  of  the  hand  deeply  toward  the  pelvis,  it  is 
often  possible  to  -outline  the  swelling  of  a  distended  bladder  more 
distinctly  (Fig.  709).  Such  manipulation  will  frequently  cause  the 
patient  to  evince  a  desire  to  uriniate. 

2.  Bitnanudl  PcUpaHon. — The  bladder  should  be  first  emptied. 
The  index-finger  of  the  right  hand  or  the  index  and  middle  fingers,  if 
possible,  are  introduced  into  the  rectum  in  the  male  or  the  vagina 
in  the  female,  after  first  being  well  lubricated.  The  four  fingers  of 
the  left  hand  are  then  placed  above  the  symphysis,  and,  while  they 
make  counter  pressure  toward  the  base  of  the  bladder,  the  entire 
idscus  is  palpated  bimanually  (Fig.  710). 

SOUNDING 

Palpation  of  the  interior  of  the  bladder  by  means  of  a  suitable 
sound  is  a  method  of  exploration  employed  in  cases  of  suspected 
stone,  foreign  bodies,  or  tumors.  The  sound  is  also  of  value  in 
testing  the  sensitiveness  of  the  bladder  walls  and  in  estimating  the 


Fig.  711. — Thomp6on  stone  searcher. 

amoimt  of  intravesical  enlargement  of  the  prostate  .(page  637)  and  in 
the  diagnosis  of  cystocele  in  the  female. 

While  soimding  is  a  fairly  reliable  method  in  searching  for  a  stone,* 
there  are  certain  difficulties  and  sources  of  error  that  should  be  borne 
in  mind.  A  stone  may  be  encrusted  with  blood  and  mucus  and  so  be 
missed  entirely,  or  it  may  be  encysted  with  only  such  a  small  por- 
tion exposed  that  it  may  be  difficult  to  reach  it,  or  it  may  lie  behind 
an  enlarged  middle  lobe  of  the  prostate.  Very  small  stones  may  like- 
wise be  missed  or  they  may  be  so  light  that  slight  shock  imparted 
by  contact  of  the  instrument  is  unnoticed.  A  tumor,  or  a  contracted 
thick  bladder  wall  encrusted  with  lime  salts  or  phosphates  may  give 
a  sensation  that  is  confused  with  the  click  of  a  stone. 

Instruments. — For  sounding  the  male  bladder  a  Thompson  metal- 
fic  searcher  (Fig.  711)  is  employed.  This  instrument  has  a  fairly 
large  beak,  flattened  from  side  to  side,  which  joins  the  shaft  at  an 


708  THE   BLADDER 

angle  of  120  degrees.  The  shaft  should  be  slender — 12  to  15  French 
scale — so  it  can  be  readily  moved  back  and  forth  or  rotated  from 
side  to  side  within  the  urethra.  The  handle  of  the  instrument  b 
supplied  with  a  guide  which  indicates  the.  direction  of  the  beak. 

Asepsis. — The  sound  is  boiled  for  five  minutes  in  a  i  per  cent 
sodium  carbonate  solution.  The  external  genitals  are  cleansed  with 
soap  and  water  followed  by  a  i  to  5000  bichlorid  of  mercury  solution. 
The  hands  of  the  operator  should  be  sterilized  in  the  usual  way. 
The  urethra  should  be  irrigated  with  a  saturated  solution  of  boric 
acid  or  a  I  to  5000  permanganate  of  potassium  solution.  The  blad- 
der is  emptied  and  irrigated  with  boric  acid  solution. 

Position  of  Patient. — The  patient  should  be  in  a  recumbent  posi- 
tion with  the  hips  raised  several  inches  higher  than  the  head  and  the 
thighs  extended  flat. 

Preparations  of  the  Patient. — The  rectum  should  be  empty. 
About  4  ounces  (120  c.c.)  in  an  adult  and  2  ounces  (60  c.c.)  in  a  child 
of  a  saturated  boric  acid  solution  or  a  normal  salt  solution  should 
be  introduced  into  the  bladder  so  as  to  permit  easy  movement  of 
the  searcher  and  to  prevent  the  stone  from  being  concealed  in  the 
folds  of  mucous  membrane. 

Anesthesia. — As  a  rule,  no  anesthesia  is  necessary.  In  sensi- 
tive cases  the  instillation  of  a  few  drops  of  a  2  per  cent,  solution  of 
cocain  into  the  posterior  urethra  will  suffice,  or  the  bladder  may  be 
filled  with  5  ounces  (150  c.c.)  of  a  warni  o.i  per  cent,  solution  of 
cocain  to  which  is  added  20  drops  (1.25  c.c.)  of  adrenalin  chlorid. 
This  is  to  be  retained  fifteen  to  twenty  minutes.  If  the  bladder  is 
extremely  irritable  and  the  patient  nervous,  a  general  anesthetk 
may  be  administered.  In  children  a  general  anesthetic  is  usually 
necessary. 

Technic. — The  instrument  is  well  lubricated  with  lubrichondrin 
or  one  of  the  other  Irish-moss  preparations  and  is  introduced  in  tte 
same  manner  as  a  sound  (page  641).     When  the  beak  of  the  instru- 
ment reaches  the  triangular  ligament,  the  fingers  «f  the  left  hand  are 
applied  to  the  perineum  and  assist  in  guiding  the  point  into  the  open- 
ing.    The  handle  of  the  sound  is  then  brought  down  between  the 
thighs  and  the  instrument  is  at  the  same  time  gently  pushed  into 
the  bladder.     As  the  instrument  traverses  the  fixed  curve  of  the 
urethra,  pressure  should  be  made  over  the  region  of  the  pubes  to 
relax  the  suspensory  ligament  of  the  penis  (see  Fig.  637).    To  ^ 
sure  the  point  is  within  the  bladder,  the  instrument  should  be  intro- 
duced a  distance  of  about  8  inches  (20  cm.). 


\ 


SOUNDING  709 

A  systematic  examination  of  the  entire  bladder  is  then  per- 
formed. The  instrument,  being  held  lightly  between  the  thumb 
and  the  forefinger  of  the  right  hand,  is  first  inserted  to  the  full  length, 
and  is  then  slowly  withdrawn,  rotating  the  beak  from  side  to  side, 
so  that  the  point  of  the  sound  is  brought  into  contact  with  every  por- 
tion of  the  bladder  wall.  In  this  way  any  thickness  or  rigidity  of 
the  bladder  wall,  as  is  found  in  hypertrophy,  chronic  inflammatory 
conditions,  and  in  the  presence  of  firm  growths,  may  be  recognized. 
In  the  same  manner  the  sensitiveness  of  the  organ  may  be  tested. 
Normally,  the  bladder  has  but  little  sensation  to  touch  except  in  the 
region  of  the  trigone.     In  cases  of  posterior  urethritis  this  region  may 


Fig.  71J. — Palpation  of  a  stone  lodged  above  the  vesical  openings. 

be  markedly  hyperesthetic.  Local  areas  of  increased  sensitiveness 
point  to  ulceration  or  new  growths,  while  in  cases  of  cystitis  the  entire 
bladder  will  be  sensitive. 

In  examining  for  suspected  stone  the  search  should  be  carried  out 
in  the  same  systematic  manner,  carrying  the  instrument  to  the  fun- 
dus first  and  then  tapping  each  lateral  wall  in  succession  as  the  in- 
strument is  withdrawn  to  the  vesical  neck.  The  upper  wall  of  the 
bladder  is  then  palpated  by  depressing  the  handle  of  the  instrument 
Well  down  between  the  thighs,  and  as  an  aid  the  bladder  wall  may  be 
•depressed  toward  the  instrument  by  means  of  the  free  hand  placed 
above  the  pubes.  In  this  way  a  stone  located  above  the  vesical  open- 
"ig  may  be  located  {Fig.  712).  The  beak  of  the  sound  is  then  rotated 
^d  turned  downward.  In  doing  this,  if  the  point  catches  in  the 
*^Ucous  membrane,  the  handle  should  be  depressed  so  as  to  lift  the 
^^t  clear  of  the  floor.     The  posterior  prostatic  region  is  then  ex- 


yio 


THE  BLADDER 


plored.  Should  the  prostate  be  enlarged,  the  handle  of  the  instni- 
ment  should  be  raised,  somewhat,  and,  with  a  finger  in  the  rectom, 
it  will  be  possible  to  bring  a  stone,  if  one  is  present,  within  reach  of 
the  instrument  (Fig.  713). 

When  the  sound  strikes  a  stone,  the  examiner  will  recognize  the 
fact  by  a  distinct  click  that  may  sometimes  be  heard  as  well  as  IdL 
Some  idea  as  to  the  consistency  of  the  stone  may  be  gained  from  tbc 
sharpness  of  the  ring;  a  high-pitched  metaUic  dick  generally  indi- 
cates a  hard  stone  (oxalate),  while  a  dull  low-pitched  sound  would 
indicate  a  soft  stone  (urate).     It  is  also  possible  todetermine  whether 


e  lodged  behind  the  prostate  with  the  aid  of  *  {b|b 
in  the  rectum. 


a  stone  is  rough  or  smooth  from  the  sensation  imparted  as  the  beat 
of  the  instrument  is  drawn  over  its  surface.  If  possible  it  should 
be  ascertained  whether  a  stone  is  movable  or  fixed  by  attempting  to 
dislodge  it  with  the  beak  of  the  instrument  or  by  changing  the  posi- 
tion of  the  patient,  that  isj  after  the  stone  is  located,  the  sound  is 
withdrawn  and  the  patient  is  put  in  the  knee-chest  posture,  on  re- 
suming the  dorsal  position,  the  instrument  is  again  inserted  and  any 
change  in  the  position  of  the  stone  is  noted. 

To  determine  the  size  of  the  stone,  the  beak  of  the  instnimentis 
carried  to  the  posterior  surface  and  the  position  of  the  meatus  is 
marked  on  the  shaft.  The  instrument  is  then  slowly  withdrawn, 
tapping  the  stone  the  while,  until  the  anterior  border  is  reached  and 
the  relation  of  the  meatus  to  the  shaft  is  again  noted.     Subtracting 


TEST  OP  THE  BLADDER  CAPACITY  71I 

the  latter  measurement  from  the  hrst  one  gives  approximately  the 
length  of  the  stone  in  its  antero-posterior  diameter.  The  transverse 
diameter  may  be  likewise  estimated  by  tapping  the  stone  from  side 
to  side. 

At  the  completion  of  the  operation  the  instrument  is  removed  by 
a  reversal  of  the  steps  taken  in  its  insertion,  and  the  bladder  is 
irrigated  with  a  warm  saturated  solution  of  boric  acid,  followed  by  a 
deep  urethral  instillation  of  i  to  1500  silver  nitrate  solution. 

TEST  OF  THE  BLADDER  CAPACITY 

By  distending  the  bladder  with  fluid  its  capacity  is  readily  esti- 
mated, and  from  this  it  may  be  determined  whether  the  bladder  is 


Fig.  7x4. — Catheter  and  syringe  for  estimating  the  bladder  capacity. 

normal,  atonic,  or  contracted.  If  large  quantities  of  solution  can  be 
injected  without  inducing  contractions,  it  may  be  inferred  that  atony 
or  paralysis  exists,  but  if,  on  the  other  hand,  the  bladder  is  in  an  in- 
flamed condition  or  is  contracted,  it  will  often  not  be  possible  to 
inject  more  than  an  ounce  (30  c.c.)  or  so  without  the  patient  com- 
plaining of  distention. 

This  test  is  also  useful  in  the  diagnosis  of  a  ruptured  bladder. 
By  injecting  a  definite  amount  of  solution  into  the  bladder  and  noting 
the  quantity  that  returns,  the  presence  or  absence  of  rupture  may  be 
readily  recognized.  In  performing  this  test,  however,  it  is  neces- 
sary to  inject  6  to  8  ounces  (180  to  250  .c.)  of  fluid,  as  small  amounts 
may  give  misleading  results. 

Apparatus. — An  ordinary  soft-rubber  catheter  for  the  male  or  a 
glass  catheter  for  the  female  and  a  large  syringe,  such  as  a  Janet  or 
Record  (Fig.  714),  are  required. 

Asepsis. — The  apparatus  is  sterilized  by  boiling  and  the  exami- 
ner's hands  are  to  be  thoroughly  cleansed.  The  external  genitals 
are  washed  with  soap  and  water,  followed  by  a  i  to  5000  solution 
of  bichlorid  of  mercury,  and  the  urethra  is  irrigated  with  a  satu- 


712 


THE  BLADDER 


rated  solution  of  boric  acid  or  a  i  to  5000  solution  of  potas^iuQ 
permanganate. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  posidon 
upon  a  flat  table. 

Technic. — The  catheter,  well  lubricated,  is  introduced  into  the 
bladder  and  all  the  urine  is  drawn  off.  The  syringe  is  then  filled 
with  a  warm  (100°  F.  (38°  C.))  saturated  solution  of  boric  add  o 
normal  salt  solution,  and  the  solution  is  slowly  injected  into  tk 
bladder  (Fig.  715).  As  soon  as  the  patient  complains  of  distentica, 
the  injection  is  stopped  and  the  quantity  of  fluid  that  has  entered 
.  the  bladder  is  estimated.    The  syringe  is  then  disconnected  froo 


Fio.  71J. — Method  of  distending  the  bladder  wjth 


the  catheter  and  the  fluid  is  allowed  to  escape  from  the  bladder 
through  the  catheter. 


ESTIMATION  OF  RESIDUAL  URINE 

Normally,  with  micturition  the  bladder  empties  itself  almost 
completely,  but,  if  the  evacuation  of  urine  is  interfered  with  by 
obstruction  from  a  stricture  or  an  enlarged  prostate  or  from  the  cra- 
dition  of  the  bladder  itself,  as,  for  example,  in  atony,  cystocele,  etc., 
the  evacuation  will  be  incomplete  and  more  or  less  residual  urine 
will  remain.  The  amount  of  residual  urine  often  has  a  bearing  upon 
the  prognosis  as  well  as  the  treatment  to  be  pursued  in  a  given  case, 
and  its  estimation  is  thus  of  some  importance. 

Apparatus. — All  that  is  required  is  a  Mercier  catheter  with  a 
coud£  curve  and  a  glass  graduate. 

Asepsis. — The  catheter  is  sterilized  by  formalin  vapor  or  by 
immersion  in  a  i  to  20  carbolic  acid  solution  followed  by  rinsing  in 


CYSTOSCOPY  713 

sterile  water.  The  external  genitals  are  cleansed  in  the  usual  way, 
and  the  urethra  is  irrigated  with  a  mild  antiseptic  solution.  The 
hands  of  the  operator  should  likewise  be  sterile. 

Technic.^The  patient  is  instructed  to  empty  his  bladder  as 
completely  as  possible  while  in  the  upright  position.  He  is  then 
placed  in  the  dorsal  position.  The  catheter,  well  lubricated,  is  in- 
troduced into  the  bladder,  and  any  urine  that  remains  is  drawn  off 
into  the  graduate  and  is  measured.  This  may  amount  to  from  i 
dram  (4  c.c.)  to  several  ounces.  If  there  is  more  than  2  ounces 
(60  c.c.)  of  residual  urine,  it  is  certain  that  some  interference  with 
the  voluntary  evacuation  of  the  bladder  exists.  Observation  of  the 
flow  of  urine  from  the  catheter  may  also  furnish  valuable  information. 
If  the  urine  is  expelled  in  a  strong  gush,  it  indicates  that  the  muscu- 
lar structure  of  the  bladder  is  competent,  while,  if  it  simply  escapes 
by  gravity,  an  atonic  condition  is  probably  present. 

THE  ABSORPTION  TEST 

A  test  sometimes  employed  to  determine  whether  blood  in  the 
urine  has  its  source  in  the  bladder  consists  in  injecting  a  solution  of 
iodid  of  potassium  into  the  bladder  and  later  testing  the  saliva  for 
iodin.  Ordinarily  there  will  be  no  absorption  from  the  healthy 
bladder,  but,  if  raw  or  ulcerated  surfaces  are  present,  absorption  of 
the  iodid  of  potassium  is  quite  rapid  and  iodin  will  be  eliminated  in 
the  saliva. 

Apparatus. — There  will  be  required  an  ordinary  soft-rubber  irri- 
gating catheter,  a  Janet  syringe,  and  a  test-tube. 

Asepsis.— The  usual  aseptic  precautions  employed  when  intro- 
ducing an  instrument  into  the  bladder  should  be  observed. 

Techoic. — The  patient  first  empties  his  bladder.  The  soft 
Catheter  is  then  introduced  and  the  bladder  is  well  irrigated  with  nor- 
mal salt  solution.  From  2  to  3  ounces  (60  to  90  c.c)  of  a  i  per  cent. 
Solution  of  potassium  iodid  are  then  injected  into  the  bladder  and  the 
catheter  is  removed.  At  the  end  of  ten  or  fifteen  minutes  some  of 
the  patient's  saliva  is  collected  in  a  test-tube  and  is  tested  for  iodin. 
This  is  readily  done  by  adding  a  few  drops  of  a  dilute  solution  of 
cooked  starch  and  stirring  with  a  glass  rod  dipped  in  fuming  nitric 
Scid.     If  iodin  is  present  in  the  saliva,  the  mixture  will  turn  blue. 

CYSTOSCOPY 
Cystoscopy  is  the  inspection  of  the  interior  of  the  bladder  by  the 
*i<i  (^  an  instrument  especially  devised  for  the  purpose,  the  cysto- 


714  THE   BLADDER 

scope.  It  is  a  method  of  examination  that  may  be  of  the  greatest 
value  when  employed  by  an  expert,  but  it  is  of  limited  use  in  the 
hands  of  the  inexperienced,  for  it  is  absolutely  essential  that  the 
examiner  be  familiar  with  the  appearance  of  the  normal  bladder  be- 
fore he  can  recognize  and  correctly  interpret  pathological  conditions, 
and  this  can  only  be  leamed-by  practical  experience. 

By  a  cystoscopic  examination  properly  carried  out  it  is  possible 
to  obtain  an  accurate  picture  of  the  interior  of  the  bladder  and  to 
study  the  appearance  of  the  ureteral  orifices  as  well  as  the  conditum 
of  the  urine  that  escapes  from  themj  that  is,  whether  it  contains  pus 
or  blood.  Cystoscopy  thus  becomes  of  service  not  only  for  diagnosis 
of  obscure  vesical  aflFections  that  may  escape  recognition  by  other 
means,  but  also  in  the  diagnosis  between  a  possible  vesical  and  kidney 
lesion. 

The  method  has,  however,  certain  limitations.  It  cannot  be 
employed  with  success  in  the  presence  of  marked  hypertrophy  of  the 
prostate,  when  the  bladder  is  greatly  contracted,  or  when  there  is 
an  active  vesical  hemorrhage  going  on  which  obscures  the  view.  It 
is  contraindicated  in  the  presence  of  acute  urethritis,  acute  prosta- 
titis, epididymitis,  or  acute  cystitis.  The  urethra  must,  as  a  rule, 
be  of  a  caliber  of  22  to  24  French,  and,  if  the  meatus  is  narrow,  it 
must  be  first  cut,  or,  if  strictures  are  present,  they  must  be  sufr 
ciently  dilated  before  the  instrument  can  be  introduced. 

Instruments. — Cystoscopes  are  of  two  types,  the  direct  view,  in 
which  the  light  is  on  the  convex  side  of  the  beak  and  the  eye  looks 
down  a  straight  tube  through  a  window  in  the  distal  end,  and  the 
indirect  view,  in  which  the  light  is  placed  on  the  concave  side  and  the 
image  is  reflected  at  right  angles  to  the  eye-piece,  thus  giving  an 
inverted  picture.  Some  of  the  newer  indirect  view  instruments, 
however,  give  an  upright  picture. 

For  the  simple  examination  of  the  bladder  the  use  of  an  indirect 
view  cystoscope  gives  the  best  results,  as  with  such  an  instrument  the 
I  .  roof,  floor,  and  walls  of  the  bladder — excepting  a  part  of  the  posterior 

!  wall — may  be  readily  inspected.     The  examination  may  be  satisfac- 

[  torily  performed  either  by  means  of  a  special  exploring  cystoscope,. 

such  as  the  Nitze,  Otis,  Schapira,*etc.,  or  by  means  of  one  of  the 
ureter-catheterizing  cystoscopes  to  be  described  later  on  (see  page 
759).  The  exploring  cystoscope  has  an  advantage  over  the  cathe- 
terizing  instruments,  however,  in  that  its  shaft  being  small  the  exam- 
ination is  less  painful. 

The  Nitze  instrument  (Fig.  716)  is  the  oldest  type  of  the  indirect 


CYSTOSCOPY 


7^5 


or  right-angled  view  cystoscope.  It  consists  essentially  of  a  metal 
tube  9  inches  (23  cm.)  long  and  from  15  to  24  French  scale  in  size, 
having  at  the  distal  end  a  short  beak  fitted  with  a  small  electric  lamp 
and  on  the  concave  side  of  the  instrument  at  the  point  where  the  beak 
joins  the  shaft  a  lens,  beneath  which  is  placed  a  prism.  From  the 
prism  the  image  is  reflected  at  right  angles  through  a  series  of  lenses 
to  the  eye-piece,  A  small  knob  soldered  on  the  circumference  of  the 
eye-piece  indicates  the  position  of  the  cystoscopic  window.  The 
instrument  is  fitted  with  two-way  stopcocks  for  irrigation  should  the 
lens  become  cloudy.  Space  does  not  permit  a  description  of  the 
many  modifications  of  the  Nitze  instrument,  each  of  which  has  ad- 
vantages of  its  own. 

The  illumination  for  cystoscopcs  may  be  furnished  from  a  six- 
or  eight-cell  battery  or  from  the  street  current  provided  a  controller  is 
employed. 


%, 


Fic.  716. — Nitze's  cystoscopea. 


Additional  instruments  required  are  a  Janet  syringe,  holding 
from  3  to  4  ounces  (90  to  1 20  c.c.) ,  or  an  irrigating  jar,  and  a  catheter. 

Asepsis.— Formalin  vapor  may  be  employed  or  the  instrument 
may  be  immersed  in  a  i  to  20  carbolic  acid  solution  for  ten  minutes 
followed  by  rinsing  in  alcohol  and  then  sterile  water.  The  external 
genitals  should  be  cleaned  with  soap  and  water  followed  by  a  i  to 
5000  bichlorid  solution.  The  e,xaminer's  hands  are  to  be  likewise 
sterilized. 

Position  of  the  Patient. — The  examination  is  performed  with  the 
patient  in  the  lithotomy  position  and  with  his  buttocks  close  to  the 
edge  of  the  table  or,  as  preferred  by  some  operators,  in  the  semi- 
recumbent  posture.  The  best  form  of  table  to  use  is  one  provided 
■with  uprights  which  are  surmounted  with  double  inclined  rests  about 
15  inches  (37  cm.)  above  the  level  of  the  table  for  the  support  of  the 
patient's  thighs  and  knees  (Fig.  717).     It  is  a  great  convenience  to 


7l6  THE   BLADDER 

have  a  table  provided  with  a  wheel  within  reach  of  the  operator,  by 
turning  which  it  may  be  raised  or  lowered  at  will. 

Anesthesia.— Local  anesthesia  of  the  urethra  is  generally  neces- 
sary, though  in  exceptional  cases  cystoscopy  may  be  performed  witt 
out  anesthesia.  The  instillation  into  the  deep  urethra  of  a  few  dn^ 
of  a  z  per  cent,  solution  of  cocain  may  be  sufficient.  A  sensitivt 
bladder  may  be  rendered  anesthetic  by  first  emptying  it  and  then 
filling  it  with  5  ounces  (150  c.c.)  of  a  warm  o.i  per  cent,  solution  of 
cocain  to  which  is  added  20  drops  (i.2$  c.c.)  of  adrenalin  and  having 


Fio.  717.^— Table  witli  BicrhoS's  leg  supports  for  cystoscopy.     (Greene  and  Brooks.) 


the  whole  amount  retained  for  fifteen  to  twenty  minutes.  Guyon's 
method  of  obtaining  local  anesthesia  consists  in  injecting  into  the 
rectum  three-quarters  of  an  hour  beforehand  a  mixture  containing: 

Antipyrin,  gr.  xiv  (o.g  gm.) 

Laudanum,  ntx  (0.6  c.c.) 

Water,  5iU  (90  c.c.) 

In  some  adult  cases,  where  the  urethra,  bladder,  or  prostate  are 
extremely  sensitive,  and  in  children  general  anesthesia  may  be 
required. 

Preparations. — The  bladder  should  first  be  emptied  and  should 
then  be  thoroughly  irrigated  with  a  saturated  solution  of  boric  add 
by  means  of  a  catheter  and  Janet  syringe  until  the  fluid  returns  dear, 
as  a  satisfactory  L'xamination  can  be  made  only  in  a  clean  bladder.    If 


CYSTOSCOPY  717 

an  irrigating  cystoscope  is  employed,  the  irrigation  may  be  performed 
through  the  sheath  of  the  instrument.  Four  to  6  ounces  (120  to 
180  c.c.)  of  a  saturated  solution  of  boric  acid  or  normal  salt  solution 
are  then  injected  into  the  bladder  and  allowed  to  remain  so  as  to 
smooth  out  the  folds  of  mucous  membrane  and  furnish  space  for  the 
cystoscope  to  be  moved  about. 

If  there  is  bleeding  from  the  bladder  sufficient  to  interfere  with    ' 
the  .examination,  a  solution  of  i  to  3000  adrenalin  chlorid  may  be 
injected  through  the  catheter  and  allowed  to  remain  for  about  ten  or 
fifteen  minutes,  when  it  is  drawn  off  and  the  bladder  is  distended. 

I  Pre.  : 
Everything  that  will  be  required  during  the  examination  should 
be  placed  near  at  hand,  and  the  cystoscope  light  should  be  tested 
I     under  water  before  the  instrument  is  introduced. 

Teclmic. — The  instrument  after  being  thoroughly  tested,  is  lubri- 
cated with  glycerin  or  lubrichondrin  and  is  gently  passed  into  the 
I     bladder  in  the  same  manner  one  would  pass  a  sound.     Great  care 
'     should  be  talcen  not  to  use  any  force  in  introducing  the  instrument. 
If  there  is  any  difficulty  in  making  the  beak  enter  the  opening  in  the 
triangular  ligament,  pressure  applied  on  the  perineum  by  the  fingers 
!     of  the  free  hand  will  assist  in  its  passage  into  the  membranous  urethra 
(see  Fig.  640).     As  soon  as  the  instrument  has  entered  the  bladder,  it 
'     can  be  freely  moved  about. 

The  operator  then  takes  his  seat  with  his  eyes  on  a  level  with  the 
ocular  end  of  the  instrument,  the  light  is  turned  on,  and  the  interior  of 


—Position  of  the  c>'stoscope  for  inspection  of  the  roof  ot  the  bladder. 


4 


7l8  THE  BLADDER 

the  bladder  is  systematically  inspected,  care  being  taken  not  to  touch 
the  mucous  membrane  with  the  light.  It  should  be  remembered  that 
in  using  a  prism  form  of  indirect  view  cystoscope  the  image  will  be 
reversed,  as  in  the  laryngoscope.  The  instrument  being  introduced 
with  its  beak  turned  up,  the  roof  of  the  bladder  will  first  come  into 
view  (Fig.  718).  In  order  to  see  as  much  of  this  portion  of  the  blad- 
der as  possible,  the  instrument  should  be  rotated  first  in  one  directiin 
and  then  in  the  other  and  then  pushed  farther  in,  repeating  thoe 
movements  until  the  entire  roof  has  been  inspected.  By  depressing 
or  elevating  the  shaft  a  more  complete  view  of  the  anterior  or  post^ 
rior  wall  is  obtained.  The  beak  of  the  instrument  is  then  rotated  90 
that  it  faces  toward  the  floor  of  the  bladder  (Fig.  719),  and  the  instni- 


FiG.  719. — Position  of  the  cystoscope  for  inspeclJOD  of  the  floor  of  the  bladda. 


ment  is  withdrawn  until  the  prostate  appears  as  a  clear  dark  red  cres- 
cent. If  hypertrophied,  it  will  appear  deformed  in  the  picture,  and 
the  degree  of  its  enlargement  and  its  location  may  be  recognized. 
The  instrument  is  next  pushed  slowly  backward  in  the  median  line 
as  far  as  the  fundus,  the  examiner  carefully  inspecting  the  floor  of  the 
bladder  as  the  instrument  is  advanced.  By  slightly  rotating  thf 
instrument  first  to  one  side  and  then  to  the  other  a  large  extent  of  the 
floor  may  be  viewed. 

The  mucous  membrane  normally  has  a  salmon  or  grayish-pii» 
tint  and  is  smooth  and  glossy  with  the  superficial  vessels  standing 
out  here  and  there.  Wheo  acutely  inflamed,  it  becomes  a  dark  red 
color  and  has  a  velvety  appearance  and  there  is  a  general  hyperema 
so  that  the  small  blood-vessels  disappear.  In  chronic  inflammation 
the  mucous  membrane  may  take  on  a  grayish  tint  and  the  foWJ 


CYSTOSCOPY   IN   THE   FEMALE  719 

appear  much  thickened.     This  region  should  be  carefully  examined 
for  small  stone,  tuberculous  ulcers,  and  new  growths. 

Having  inspected  the  floor,  the  instrument  is  turned  45  degrees  to 
one  side  and  is  gradually  withdrawn  from  the  fundus.  In  this  way 
the  opening  of  the  ureter  on  that  side  will  come  to  view  as  an  oblique 
slit  or  as  a  small  dimple  (Fig.  720)  in  a  prominent  papilla,  and,  if  it  is 
watched,  it  will  be  seen  to  emit  a  gush  of  urine  every  ten  to  fifteen 
seconds.  If  not  immediately  found,  the  interureteric  line,  which  runs 
transversely  across  the  central  field  between  the  two  ureters,  should 
be  identified  and,  by  tracing  this  to  one  side  or  the  other,  the  ureteral 
orifice  may  be  located.  The  appearance  of  the  ureteral  orifice  should 
be  carefully  inspected  for  signs  of  ulceration,  erosions,  or  inflamma- 
tion which  might  indicate  a  diseased  kidney  on  that  side,  and  likewise 
the  character  of  the  urine  which  escapes  should  be  noted,  i.e.,  whether 
clear,  purulent,  or  bloody. 

Fig.  710. — Appearance  of  Che  ureteral  orifices. 

The  lateral  wall  is  carefully  inspected  as  far  as  the  vesical  neck. 
The  instrument  is  then  rotated  90  degrees  to  obtain  a  view  of  the 
opposite  side  and  it,  including  the  ureter  of  that  side,  are  examined 
while  the  instrument  is  slowly  passed  to  the  fundus  again.  Follow- 
ing some  such  scheme,  the  entire  bladder  may  be  inspected  except 
a  portion  of  the  posterior  wall  which  is  invisible  with  an  indirect  ^iew 
instrument.  During  the  examination  it  is  well  to  shut  off  the  light 
at  intervals  so  as  to  allow  the  instrument  to  cool. 

At  the  end  of  the  examination  the  light  is  turned  off  and  the 
instrument  is  carefully  withdrawn,  taking  care  to  see  that  the  beak  is 
again  turned  up  before  this  is  done.  The  patient's  bladder  is  then 
emptied  and  irrigated  with  boric  acid  solution. 

CYSTOSCOPY  IN  THE  FEMALE 

Hie  examination  of  the  female  bladder  may  be  periormed  by 
Usbg  an  ordinary  male  cystoscope  or  a  somewhat  shorter  female 


738  THE  BLADDEK 

Position  of  Pfttient — The  patient  should  be  in  the  dorsal  po^tioD. 

Preparation  of  Patient. — The  bladder  should  be  empty.  The 
external  genitals  are  washed  with  soap  and  water  followed  by  a  i  to 
5000  bichlorid  of  mercury  solution,  and  the  urethra  is  irrigated  with  a 
boric  acid  or  i  to  5000  potassium  permanganate  solution. 

Technic. — i.  Single  Catheter  Method. — The  catheter,  well  lubri- 
cated, is  gently  passed  into  the  bladder,  and  any  residual  urine  is 


Fig.  731. — Irrigation  of  the  bladder  with  a  double-flow  catheter. 

allowed  to  escape.  The  funnel  is  filled  with  from  3  to  6  ounces  (90 
to  180  c.c.)  of  the  solution,  and  the  tubing  leading  from  the  funnel  is 
attached  to  the  catheter,  first  taking  care  to  see  that  air  er  any  cold 
solution  is  expelled  from  the  tube.  The  funnel  is  then  raised  2  or  3 
feet  (60  to  90  cm)  above  the  patient  and  the  solution  is  permitted  10 
slowly  flow  into  and  distend  the  bladder.  As  soon  as  the  patient 
complains  of  the  distention,  the  flow  is  shut  off.  After  allowing  the 
solution  to  remain  in  the  bladder  a  few  moments,  the  funnel  is  low- 
ered below  the  level  of  the  bladder  and  the  fluid  is  allowed  to  escape 


AUTO-IRRIGATIONS  729 

into  the  waste-pail  (Fig.  730).  The  funnel  is  then  refilled  and  the 
process  repeated  untD  the  fluid  returns  clear. 

In  performing  the  irrigation  care  must  be  observed  not  to  overdis- 
tend  the  bladder.  Just  how  much  can  be  injected  al  a  time  depends 
upon  the  individal  case,  but  it  should  not  be  sufficient  to  cause  any 
pain.  Entrance  of  air  into  the  bladder  should  also  be  guarded 
against. 

a.  Double-fiow  Catheter  Method. — The  technic  varies  a  little  from 
that  just  described.  The  catheter  is  passed  into  the  bladder  and  the 
irrigating  tubing  is  attached  to  the  inflow  tube  of  the  catheter.  The 
reservoir,  filled  with  the  entire  amount  of  fluid  to  be  used  during  the 
irrigation,  is  then  raised  2  to  3  feet  (60  to  90  cm.)  above  the  bladder 
and  the  solution  is  allowed  to  flow.  As  fast  as  it  enters  the  bladder,  it 
is  carried  off  again  through  the  outflow  tube  (Fig.  731);  but,  by 
occasionally  compressing  the  outflow  tube,  the  bladder  may  be  more 
or  less  completely  filled  before  the  fluid  is  permitted  to  escape. 

AUTO -IRRIGATIONS 

While  it  is  not  advisable  to  allow  a  patient  to  irrigate  his  own 
bladder  in  the  presence  of  a  severe  cystitis,  auto-irrigation  may  be 
safely  performed  for  the  purpose  of  keeping  the  bladder  clean  by  those 
who  are  compelled  to  lead  a  catheter  life  The  patient  should,  how- 
ever, be  carefully  instructed  how  to  sterilize  the  catheter,  his  hands, 
etc.,  ttnd  in  the  proper  method  of  performing  the  irrigation,  and  he 
should  be  fully  warned  of  the  dangers  of  neglecting  to  follow  the 
strictest  rules  of  cleanliness. 

Apparatus. — A  douche  bag  with  a  capacity  of  i  quart  (1  liter),  4 
feet  (120  cm.)  of  rubber  tubing,  a  T-shaped  glass  tube,  a  soft-rubber 
catheter,  and  a  waste-pai!  comprise  the  necessary  outfit.  The 
T-shaped  glass  connection  is  placed  between  the  catheter  and  the 
tubing  of  the  reservoir  and  to  its  long  arm  is  attached  another  piece 
of  tubing  that  leads  to  the  waste-pail,  A  shut-off  clip  is  placed  on  the 
tube  leading  from  the  irrigator  and  another  upon  the  waste  tube 
(Fg-  752). 

Solution  Used. — It  is  better  not  to  entrust  the  patient  with  strong 
antiseptic  solutions;  instead  a  saturated  (4  per  cent.)  solution  of  boric 
acid  should  be  used.  It  is  prepared  by  dissolving  about  5  teaspoon- 
iuts  (20  gm.)  of  boric  acid  crystals  in  i  pint  (500  c.c.)  of  hot  water. 

Position  of  Patient. — The  irrigation  is  most  conveniently  given 
^th  the  patient  sitting  in  a  chair  and  with  the  waste-pail  on  the  floor 
between  the  legs. 


i 


720 


THE  BLADDER 


instrument.  Such  examination,  which  is  less  difficult  than  in  the 
male  on  account  of  the  short  length  of  the  urethra,  requires  no  sepa- 
rate description,  as  the  technic  differs  in  no  essential  way  from  the 
method  used  in  the  male.     Another  method  of  vesical  inspection  b 


Fig.  721  — Instruments  for  cystoscopy  in  the  female,  i,  Electric-lighted  open- 
tube  cystoscope;  2,  urethral  dilator;  3,  urine  evacuator;  4,  aUigator- jawed  foroq«;  St 
ureteral  searcher. 


Fig.  722. — Kelly's  open-tube  cystoscope. 

by  means  of  Kelly's  open  straight  tubes  and  atmospheric  distention 
of  the  bladder. 

Instruments. — For  cystoscopy  according  to  Kelly's  method  there 
will  be  required:  Kelly's  specula,  or  some  of  their  modifications, 
an  electric  head  light  or  head  mirror,  a  Kelly  dilator  to  stretch  the 


ii 


CYSTOSCOPY    IN    THE    FEMALE 


721 


external  urethral  orifice,  a  urine  evacuator  to  draw  off  residual  urine, 
alligator  forceps  for  holding  cotton  swabs,  and  a  ureteral  probe  for 
probing  the  mucous  membrane  or  locating  the  ureteral  orifices 

(Fig.  731). 

The  specula  consist  of  cylindrical  tubes  3  3-^  inches  (8  cm.)  long, 
of  equal  length  throughout,  and  in  sizes  of  from  1.^  inch  (5  mm.) 
in  diameter  up  to  ;J^  inch  (20  mm.).  Those  below  No.  12  are  gen- 
erally employed  for  diagnostic  purposes.  The  tubes  are  of  German 
silver  or  nickel-plated,  each  having  a  conical  expansion  at  the  ocular 
end  to  which  is  fastened  a  strong  handle  (Fig.  722)  Each  tube  is 
supplied  with  an  obturator  having  a  conical  end-piece.     The  illumi- 


FiG.  713. — Enlarged  view  ot  an  electric-lighted  open-tube  cystoscope. 


nation  is  furnished  by  reflected  light  or  from  an  electric  head  light, 
the  latter  being  preferable.  These  specula,  however,  may  be  ob- 
tained furnished  with  an  electric  light  at  the  distal  end  (Fig.  723),  an 
instrument  which  simplifies  the  operation  for  one  not  accustomed  to 
the  use  of  a  head  light. 

The  urethral  dilator  is  a  cone-shaped  metallic  instrument  which 
gradually  increases  in  size  from  the  point  until  at  the  base  it  meas- 
ures 1^5  inch  (16  mm.)  in  diameter.  The  instrument  is  graduated 
so  that  the  examiner  can  determine  the  required  amount  of  dilatation. 

The  urine  evacuator  is  necessary  for  the  purpose  of  removing  the 
urine  that  collects  in  the  floor  of  the  bladder  which  would  otherwise 


f  33  THE  BLADDER 

interfere  with  the  examination.  It  counts  of  a  suction  bulb  at- 
tached by  m^ans  of  a  long  delicate  rubber  tube  to  a  small  perforated 
glass  bulb.  In  the  Luys'  open  tube  cystoscope  an  a^irating  tube  is 
incorporated  in  the  instrument. 

Asepsis. — All  the  instruments  with  the  exception  of  the  light  car- 
rier may  be  boiled  for  five  minutes  in  a  i  per  cenL  soda  solution. 
The  latter  may  be  sterilized  by  immersion  in  a  i  to  30  carbolic  add 
solution  followed  by  rinsing  in  sterile  water.  The  operator's  hands 
should  be  carefully  sterilized  and  the  external  genitals  and  mouth 
of  the  urethra  should  be  cleansed  with  soap  and  water,  followed  by 
a  I  to  5000  solution  of  bichlorid  of  mercury. 


Fw.  714.— Method  ot  dilating  the  urethra      (Asbton.) 


Position  of  Patient. — Two  positions  are  employed,  the  dorsal  and 
the  knee-chest.  In  the  dorsal  position  the  patient  lies  with  the  head 
and  thorax  resting  on  the  table  and  the  hips  elevated  8  to  10  inches 
(20  to  30  cm.)  upon  cushions  so  as  to  raise  the  pelvis  and  permit  the 
bladder  to  distend  with  air  when  the  cystoscope  is  introduced. 
While  the  dorsal  posture  is  the  least  wearing  on  the  patient,  it  is  not 
suited  for  stout  persons.  In  such  cases,  the  knee-chest  posture,  with 
the  knees  separated  10  or  12  inches  (25  or  30  cm.),  is  more  suitable. 

Preparations  of  Patient. — Before  the  patient  is  placed  upon  the 
table  the  rectum  and  bladder  should  be  emptied. 

Anesthesia. — ^Local  anesthesia  is  generally  sufficient  except  in 
very  nervous  women.  A  pledget  of  cotton  saturated  with  a  a  per 
cent,  solution  of  cocain  introduced  upon  an  applicator  within  the 


CYSTOSCOPY  IN  THE  fEllALE  733 

meatus  and  aUowed  to  remain  for  five  minutes  will  anesthetize  the 
urethra  sufficiently  to  allow  it  to  be  dilated. 

Technic. — As  a  rule,  it  is  first  necessary  to  dilate  the  urethral 


— Metliod  of  holding  tbe  open-tube  cystoscope  during  it 
the  bladder. 


intioductlon  into 


orifice;  the  rest  of  the  canal,  being  very  dilatable,  is  easily  stretched 
by  the  cystoscope  in  its  passage.  The  dilator  is  lubricated  with  one 
of  the  Irish-moss  preparations  and  is  introduced  into  the  urethra  with 
a  slight  boring  motion  until  the  required  amount  of  dilatation  b 


Flo.  716. — Inspection  of  the  female,  bladder  through  an  open-tube  cyitoacope. 

reached  (Fig.  724).  Dilatation  to  about  No.  12  on  the  dilator  is 
generally  sufficient.  A  speculum  of  a  size  from  7  to  10,  depending 
upon  the  age  of  the  patient,  is  then  selected.     It  should  be  grasped  in 


734  ^^^^  BLADDEK 

Tedinic. — Having  tested  the  cystoscope  and  the  high  frequen( 
current,  the  cystoscope,  well  lubricated  and  with  the  electrode : 
one  of  the  catheter  chambers  is  introduced  into  the  bladder  (seep»i 
717).  The  end  of  the  wire  to  be  introduced  into  the  tumor,  sfaou 
have  been  previously  cut  off  flush  with  the  insulation.  The  turn 
is  located  and  the  electrode  is  inserted  into  it  as  near  the  base 


FiO-  73S- — Destruction  of  vesical  growth  by  means  of  the  high  freqnenc;  dBtti 
(Aftei  Oudin.} 

possible  (Fig.  735).  The  current  is  then  turned  on  for  15  to  30 ae 
onds  and  a  rapid  blanching  of  the  tissues  at  the  point  of  outi 
occurs.  The  wire  is  then  allowed  to  cool  and  is  reinserted  in 
another  portion  of  the  tumor  and  the  dessication  continued  until  t 
whole  mass  has  been  treated.  At  subsequent  treatments  portions 
the  growth  that  remain  viable  are  similarly  dealt  with.  When  t 
entire  mass  has  sloughed  away  the  base  is  likewise  treated. 

CATHETERIZATION  OF  THE  BLADDER 

Catheterization  of  the  bladder  is  indicated  in  all  cases  of  comple 
retention  of  urine  and  in  some  cases  of  partial  retentioD,  as,  f 
example,  in  prostatic  hypertrophy  when  the  residual  urine  amoun 
to  more  than  2  ounces  (60  c.c).  Retention  may  be  the  result 
obstructon  from  stricture,  spasm  of  the  compressor  urethra  musd 
hypertrophy  or  congestion  of  the  prostate,  clots  of  blood,  cald 
foreign  bodies  or  tumors  in  the  bladder  or  urethra,  perineal  absco 
traumatism,  etc.,  etc.,  and  as  the  result  of  defective  expulsion  pow 
of  the  bladder  through  impairment  of  the  nervous  mechanism,  «' 
hysteria,  certain  diseases  of  the  brain  and  spinal  cord,  shock,  fevei 


IRRIGATIONS  Jaj 

SKIAGRAPHY 

The  X-rays  are  sometiraes  used  in  locating  a  vesical  stone  which, 
from  being  buried  in  a  pocket  or  being  situated  behind  the  prostate, 
may  escape  detection  by  other  means.  The  success  of  the  skiagraph 
depends  to  a  large  extent  upon  the  composition  of  the  calculus.  Oxa- 
late and  phosphate  stones  cast  a  dense  shadow,  but  those  composed 
of  urates  and  uric  acid  cast  very  faint  shadows,  and  so  may  be 
missed  entirely.  The  bony  walls  of  the  pelvis  may  likewise  interfere 
and  give  a  negative  result.  To  secure  a  satisfactory  radiograph  it 
is  essential  that  the  bowels  be  emptied  by  a  purge  administered  the 
night  before  followed  by  an  enema  in  the  morning. 

By  injecting  into  the  bladder  a  solution  of  bismuth  or  one  of  the 
silver  salts  and  taking  a  radiograph  immediately,  much  valuable 
information  as  to  the  size  and  position  of  the  bladder  and  the  presence 
or  absence  of  diverticula,  sacculations,  tumors,  or  obstruction  at  the 
vesical  neck  may  be  obtained. 

Bismuth  is  used  in  a  lo  per  cent,  watery  solution.  Of  the  silver 
salts,  collargoi  in  2  to  10  per  cent,  solution  and  argyrol  in  !$  per  cent. 
solution  are  generally  employed.  Eight  ounces  (250  c.c.)  of  solu- 
tion will  be  sufficient. 

»  Therapeutic  Measures 

IRRIGATIONS 

Irrigation  of  the  bladder  may  be  employed  either  for  simple 
cleansing  purposes,  as  is  required  in  preparation  for  an  instrumental 
examination  or  operative  procedure,  or  to  produce  a  local  effect  upon 
the  mucous  membrane.  Irrigations  are  thus  of  the  greatest  value  in 
the  treatment  of  various  inflammatory  affections  of  the  bladder.  In 
acute  cystitis,  however,  on  account  of  the  distention  produced,  they 
often  increase  the  pain  and  may  aggravate  the  trouble.  They  should 
be  employed,  however,  in  acute  cases  if  the  bladder  docs  not  com- 
pletely empty  itself  and  there  is  decomposition  of  urine.  Irrigations 
are  also  contraindicated  where  the  bladder  cannot  hold  more  than  i 
ounce  (30  c.c.)  of  fluid  without  exciting  a  desire  to  urinate;  in  such 
cases,  instillations  should  be  substituted. 

There  are  two  methods  of  performing  vesical  irrigation;  {i)'by 
injecting  the  fluid  in  sufficient  quantity  to  distend  the  bladder  and 
having  it  retained  a  short  time  before  allowing  it  to  escape,  and  (3) 
by  using  a  double-flow  catheter  which  allows  the  fluid  to  escape  as  fast 


736 


THE  BLADDER 


In  the  presence  of  strictures  a  gum  elastic  olivary  catheter  (Fig. 
738)  and  a  set  of  Grouley's  tunneled  catheters  and  filiforms  (Fig.  739) 
will  be  required.  In  place  of  the  latter  a  whip  catheter  (Fig.  740) 
may  be  employed.  This  consists  of  a  flexible  gum  elastic  catheter 
tapering  off  for  several  inches  into  a  filiform. 


Fig.  738. — Gum-elastic  olivary  catheter. 


Fig.  739. — Gouleys  tunneled  catheter  and  filifonn. 


Fig.  740. — Whip  catheter. 

The  best  form  of  catheter  to  use  when  the  prostate  is  enlarged  is  a 
Mercier  coud6  catheter  (Fig.  741).  The  slight  angle  at  the  end  of  this 
instrument  permits  it  to  override  an  obstruction.  Guyon's  mandrin 
coud6  catheter  (Fig.  742)  and  a  long-curved  prostatic  catheter 
(Fig.  743)  should  also  be  provided.  The  caliber  of  the  insruments 
for  this  class  of  cases  should  be  fairly  small,  say  from  15  to  18  French. 


CATHETERIZATION    OF    THE    BLADDER  737 

Asepsis. — The  greatest  care  should  be  taken  to  avoid  infection  of 
the  bladder.  Metal  and  rubber  catheters,  as  weU  as  the  better  make 
gum  elastic  instruments  are  boiled  for  five  minutes.     Instruments 


<^ 


^^= 


Fig.  741. — Catheters  with  a  coudf  and  bicoudfi  curve. 

that  will  not  stand  boiling  are  sterilized  by  formaUn  vapor  (page  640) 
or  by  immersion  in  a  i  to  20  carbolic  acid  solution  followed  by  rinsing 
in  sterile  water.  The  operator's  hands  are  to  be  sterilized  as  care- 
fully as  for  any  operation. 


Fig.  74J. — Guyon' 


coud£  catheter. 


Quantity  of  Drine  Withdrawn. — -Except  when  the  distention  is 
sUght  and  of  short  duration,  the  bladder  should  not  be  emptied  com- 
pletely at  the  first  catheterization.  As  the  result  of  long-standing 
vesical  distention  there  occurs  a  dilatation  of  the  ureters  and  renal 


ILJ     KJ' 


Fig.  743.^Silver  prostatic  catheter. 


pelvis  with  changes  in  the  kidney  structure,  and  a  sudden  evacuation 
of  the  urine  is  apt  to  be  followed  by  suppression  of  urine,  or  hemor- 
rhage from  the  vesical  mucous  membrane  or  kidneys  may  result  from 


738  THE  BLADDEK 

the  sudden  relief  of  pressure  upon  the  distended  v&ns.  Tbadwe, 
not  more  than  8  ounces  (240  c.c.)  of  urine  should  be  withdrawn  at  the 
first  catheterization,  gradually  increa^ng  the  amount  at  subseqiuat 
catheterizations. 


Fig.  745. — Showing  sott-rubber  catheter  passed  into  the  bladder. 


Frequency. — As  a  rule,  in  complete  retention  the  bladder  requi"* 
emptying  every  four  to  eight  hours.  When  the  catheter  is  emplo)t^ 
for  withdrawing  the  residual  urine  of  prostatic  hypertrophy  ^ 
frequency  will  depend  upon  the  amount  of  residual  urine.    Thus,  i* 


CATHETERIZATION  OF  THE  BLADDER 


739 


this  amounts  to  from  2  to  4  ounces  (60  to  120  c.c),  one  daily  catoeteri- 
ation  before  the  patient  retires  in  the  evening  will  suffice,  if  it 
amounts  to  from  4  to  6  ounces  (120  to  180  cc),  the  catheter  should 
be  used  twice  a  day,  i.e.,  in  the  evening  and  morning,  larger  quanti- 
ties of  residual  urine  demand  that  the  bladder  be  emptied  three  or 
four  times  a  day. 

Position  of  Patient. — Catheterization  should  be  performed  with 
the  patient  in  the  dorsal  position  with  his  shoulders  slightly  raised 
and  thighs  somewhat  flexed  and  rotated  slightly  outward. 


Flo.  746. — Showing 


]  ordinary  catheter  obstructed  by  a 
the  prostate  gland. 


enlarged  middle  lobe  of 


Preparation  of  Patient. — The  glans  penis  and  meatus  should  be 
washed  with  soap  and  water,  followed  by  a  i  to  5000  bichlorid  of 
mercury  solution  and  then  sterile  water.  The  urethra  is  irrigated 
with  a  warm  saturated  solution  of  boric  add  or  a  i  to  5000  solution 
of  potassium  permanganate. 

Techuic. — i.  In  Cases  Uncomplicated  by  Siriciure  or  Enlarged 
Prostate. — ^A  full-sized  soft-rubber  catheter  is  tried  first.  It  is  well 
lubricated  and,  while,  the  penis  is  held  upright,  is  slowly  fed  into  the 
urethra  a  little  at  a  time  (Fig.  744).  If  the  catheter  becomes  ob- 
_«tructed,  the  penis  should  be  put  upon  the  stretch  to  obUterate  any 
wrinkles  in  the  mucous  membrane,  and  the  instrument  is  again 
-  advanced  as  before  or  by  rotating  it  while  the  attempt  is  made  to 
make  it  pass.     In  this  way  a  soft  instrument  can  usually  be  made  to 


740  THE  BLADDER 

enter  the  bladder  when  the  retention  is  simply  due  to  defective  eq 
sive  power.  In  withdrawing  a  catheter  the  instrument  should 
compressed  between  the  thumb  and  forefinger,  or  the  tip  of  the  fii 
should  be  placed  over  the  opening  at  the  prcudmal  end  to  pren 
the  urine  which  remains  in  the  catheter  from  dripping  out  and  wet^ 
the  patient's  clothes. 

In  cases  of  spasmodic  stricture,  failing  in  attempts  to  pass  a 
instrument,  a  full-sized  metal  catheter  should  be  resorted  to.  E 
a  catheter  is  passed  precisely  as  one  would  a  sound  (see  page  6 


Fig.  747. — Showing  a  coud£  catheter  passhig  the  obsUuctiou. 

When  the  point  of  the  instrument  has  been  introduced  as  far  as 
obstruction,  it  should  be  held  pressing  steadily  against  the  face 
the  stricture  for  a  few  minutes  until  the  sp>asm  passes  off,  wher 
may  be  easily  slipped  into  the  bladder. 

2.  In  llie  Presence  of  Stricture. — In  dealing  with  a  retention  dut 
stricture  a  small  soft-rubber  catheter  should  be  given  first  trial. 
unsuccessful,  attempts  may  be  made  to  pass  an  olivary  poin 
catheter.  If  this  fails,  a  fiUform  should  be  introduced  through  1 
stricture  (see  page  690)  and  a  Gouley  tunneled  catheter  passed  o' 
this  as  a  guide,  or,  in  its  stead,  a  whip  catheter  may  be  employ 
Should  the  stricture  be  of  such  small  caliber  that  it  is  only  possi 
to  insert  a  filiform,  the  latter  should  be  left  in  place  to  act  as  a  ca| 
lary  drain,  taking  care,  however,  to  fasten  it  in  such  a  way  thai 
cannot  slip  out  (page  694).     In  this  way  the  bladder  will  empty 


^~  CATHETERIZATION   IN   THE   FEMALE  74I 

self  in  a  few  hours,  and,  by  the  end  of  twenty-four  hours,  sufficient 
dilatation  will  usually  have  taken  place  to  allow  the  passage  of  a 
tunneled  catheter.  Failing  to  pass  even  a  filiform  the  bladder  should 
be  aspirated  (page  746). 

3.  In  the  Preseme  oj  Prostatic  Bypertropky.- — A  soft  flexible  cath- 
eter should  be  tried  and  then  a  coud6  catheter.  The  latter  will  often 
succeed  where  a  soft  catheter  fails  because  the  bend  of  the  tip  of  this 
instrument  keeps  the  point  in  contact  with  the  upper  wall  of  the  ure- 
thra and  thus  permits  it  to  more  easily  override  a  median  prostatic 
enlargement  (Fig.  747}.  Sometimes,  if  an  ordinary  coud^  catheter 
will  not  pass,  an  elbowed  catheter  with  a  stylet  can  be  made  to  do  so. 
With  this  instrument  it  is  possible  to  elevate  the  point  more  sharply, 
when  obstructed,  by  withdrawing  the  mandarin  a  little,  so  that  the 
point  of  the  instrument  passes  upward  over  the  obstruction  into  the 
bladder. 

After  repeated  and  unsuccessful  efforts  with  the  above  instrument 
a  metal  prostatic  catheter  should  be  tried  before  resorting  to  aspira- 
tion. Great  gentleness  should  be  employed  in  its  introduction  to 
avoid  making  a  false  passage.  Sometimes  assistance  in  guiding  its 
point  may  be  derived  from  placing  a  finger  in  the  rectum, 

CATHETERIZATION  IN  THE  FEMALE 

Catheterization  of  the  female  bladder  is  a  simple  procedure.  It 
should  always  be  done,  however,  by  direct  sight;  the  old  method  of 
passing  a  catheter  by  touch  carries  with  it  the  great  risk  of  infection, 


^H  F:c.  748.— Glass  female  catheter.     (Ashton.) 

Instruments. — A  glass  female  catheter,  5  inches  (13  cm.)  long  and 
1/5  of  an  inch  (5  mm.)  In  diameter  with  a  gentle  curve  in  opposite 
directions  at  both  ends  (Fig.  748),  is  the  best  instrument  to  employ. 

Asepsis. — The  catheter  is  boiled  for  five  minutes  and  the  opera- 
tor's hands  are  carefully  scrubbed  in  soap  and  water,  followed  by 
immersion  in  an  antiseptic  solution. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position 
with  the  thighs  flexed  and  the  legs  well  separated. 

Pieparations  of  Patient.- — The  external  genitals  and  meatus  are 
cleansed  with  soap  and  water  followed  by  a  i  to  5000  bichlorid  of 
mercury  solution. 


y42  THE  BLADDEH 

Technic. — The  operator  separates  the  labia  with  the  thumb  and 
forefinger  of  the  left  hand  so  as  to  expose  the  meatus.  The  catheter, 
held  near  the  proximal  end  in  the  fingers  of  the  right  hand,  is  then 


the  femkle.    (Aihton.) 


Fig.    7  so. ^Showing  the  method  ot  preventing  urine  dripping  from  the  oUiW"* 
it  is  withdrawn.     (Ashton.) 

introduced  through  the  urethra  into  the  bladder  (Fig.  749).  ^"' 
the  bladder  has  been  emptied,  the  forefinger  is  first  placed  over  the 
proximal  end  of  the  catheter  to  prevent  the  escape  of  the  urine  it 
contains  (Fig.  750)  and  the  instrument  is  then  withdrawn. 


CONTINUOUS  CATHETERIZATION 


743 


CONTINUOUS  CATHETERIZATION 

A  catheter  may  be  introduced  into  the  bladder  and  left  in  place  in 
cases  where  drainage  of  the  bladder  for  a  brief  period  is  desired.  It 
may  be  employed  in  chronic  cystitis  accompanied  by  the  presence  of 
large  amounts  of  pus,  frequent  urination,  and  tenesmus,  in  vesical 


=d 


Fig.  751. — ^The  Pezzer  retention  catheter. 

hemorrhage,  and  in  cases  of  obstruction  from  an  enlarged  prostate 
where  the  constant  introduction  of  a  catheter  causes  spasm  or  hemor- 
rhage, or  where  catheterization  is  difficult.  The  bladder  is  thus  put 
at  rest  and  at  the  same  time  is  kept  constantly  emptied,  the  bene- 
ficial eflPects  of  which  are  shown  by  a  rapid  decrease  of  the  inflamma- 


^^ 


Fig.  752. — The  MaUcot  retention  catheter. 

tion  and  congestion,  decline  of  the  fever,  and  relief  of  the  pain  and 
tenesmus.  Continuous  catheterization  is  also  indicated  in  wounds  of 
the  urethra  or  after  certain  operations  upon  the  urethra  when  it  is  de- 
sirable to  prevent  the  contact  of  infected  urine  with  raw  surfaces. 


MorimmtlU 


Fig.  753. — Stylet  in  place  in  Mal6cot  catheter,    a,  Mandarin  pushed  forward;  6, 

mandarin  withdrawn. 


At  first;  when  the  catheter  is  inserted,  there  may  be  a  feeling  of 
weight  in  the  perineum,  but  this  soon  passes  ofiF.  In  some  instances  a 
mechanical  urethritis  is  set  up  which  may  persist  until  the  instrument 
is  removed  and,  if  neglected,  urethral  abscess  or  extension  of  the 
infection  backward  into  the  bladder  may  result. 


744  "^^^  BLASDES 

Instrumeats. — A  plain  soft-rubber  catheter  of  about  i8  French 
with  the  eye  near  the  end  or  the  retention  catheters  of  Pezzer  or 
Mal&:ot  may  be  employed.  The  Pezzer  catheter  (Fig.  751)  has  1 
flange  to  rest  against  the  vesical  neck,  while  the  Mal£cot  instrumtnt 
(Fig.  752)  has  wings  on  either  side.  When  introduced  over  a  sty\A 
(Fig.  753),  these  projections  are  made  to  disappear,  but  rafipm 
when  the  stylet  is  removed. 

Duration. — This  will  depend  upon  the  toleration  of  the  uiethii. 
In  some  cases,  continuous  drainage  may  be  kept  up  for  over  tm 
weeks,  without  the  catheter  causing  much  irritation;  in  othas,  the 


Fio.  754.— Showing  the  method  of  Bccuring  a  catheter  in  the  bladder.    {Aftn  Siid 
Polyclinic  Journal,  July,  1908.) 


presence  of  an  instrument  in  the  bladder  produces  so  much  initation 
and  vesical  spasm  that  it  cannot  be  used  at  all. 

Preparation  of  Patient. — The  glans  penis  and  meatus  are  washed 
with  soap  and  water  followed  by  a  i  to  5000  solution  of  bicblord  of 
mercury,  and  the  urethra  is  thoroughly  irrigated  with  a  mild  anti- 
septic solution. 

Asepsis. — The  catheter  should  be  thoroughly  sterilized  by  boifing 
or  by  formalin  vapor  and,  if  the  latter  method  is  employed,  care  must 
be  taken  to  remove  all  trace  of  the  formalin  by  thoroughly  riosiog  the 
catheter  in  sterile  water.  The  operator's  hands  should  likewise  be 
perfectly  sterile. 

Technic. — i.  Sy  the  Ordinary  Catheter. — If  an  ordinary  rubber 
catheter  is  employed,  it  is  well  lubricated  and  is  then  introduced  in 
the  usual  way  until  its  eye  lies  just  within  the  bladder.  It  is  quite 
important  that  the  point  of  the  catheter  be  not  introduced  too  fu, 
for,  if  so,  it  will  not  only  fail  to  drain  the  bladder  properly,  but  wfll 
irritate  the  vesical  floor.  To  insure  that  the  instrument  is  properly 
placed,  it  should  first  be  introduced  into  the  bladder  until  the  urine 
flows  freely  and  then  slowly  withdrawn  until  the  flow  just  stops, 
when  it  is  pushed  into  the  bladder  again,  this  time  for  a  distance  of 
J-i  inch  (6  mm.).     It  is  then  secured  in  place  as  follows: 


CONTINUOUS    CATHETERIZATION 


745 


The  portion  of  the  catheter  protruding  from  the  meatus  is  thor- 
oughly dried  and  all  grease  is  removed.  Then  four  pieces  of  adhesive 
plaster,  each  about  4  inches  {10  cm.)  long  and  }i  inch  (6  mm.)  wide, 
are  secured  to  the  catheter  at  the  point  it  emerges  from  the  meatus  in 
such  a  way  that  one  strip  lies  upon  the  dorsum,  one  on  the  ventral 
surface,  and  one  on  either  side  of  the  penis.  Each  strip  is  carried 
back  over  the  foreskin  and  is  made  to  adhere  to  the  body  of  the  penis. 
An  additional  strip  of  adhesive  i  inch  {2.5  cm.)  wide  is  placed  hori- 
zontally about  the  penis  back  of  the  corona,  covering  the  four  small 
strips  (Fig.  754).  Care  should  be  taken,  however,  not  to  have  this 
strip  entirely  encircle  the  penis.  The  penis  is  then  wrapped  in  sterile 
gauze  and  is  supported  over  one  groin  by  a  T-bandage.    If  upon 


k 


Fio.  755. — Malfcot  reten^on  catheter  in  place  in  the  bladder. 


inspection  it  is  found  that  the  urine  escapes  freely,  the  free  end  of  the 
catheter  is  finally  connected  with  a  drainage-tube  which  conducts 
the  urine  to  a  receptacle  at  the  side  of  the  bed.  The  receptacle 
should  be  half-full  of  some  antiseptic  solution. 

If  the  retained  catheter  is  employed  in  a  case  of  long-standing 
retention  where  it  is  dangerous  to  empty  the  bladder  at  once,  an 
intermittent  form  of  drainage  may  be  employed  by  discarding  the 
drainage-tube  and  simply  inserting  a  plug  in  the  end  of  the  catheter, 
which  is  removed  at  definite  intervals  and  an  increasing  quantity  of 
the  urine  drawn  off  each  time  until  it  is  considered  safe  to  empty  the 
bladder  completely,  when  the  above  method  is  used. 

2.  By  ike  Self-retaining  Catheter. — In  inserting  a  special  self-re- 
taining catheter,  a  stylet  curved  to  the  shape  of  a  sound  is  introduced 
within  the  instrument  so  as  to  obliterate  the  projecting  collar  or 
wings  (see  Fig.  753).     When  the  catheter  is  in  place,  the  stylet  is 


746  THE  BLADDER 

withdrawn,  thus  allowing  the  bladder  end  of  the  catheter  to  expand 
again  so  .that  the  catheter  is  retained  in  place  unless  some  force  is 
used  in  withdrawing  it  (Fig.  755).  In  spite  of  this,  however,  it  is 
safer  to  fix  the  catheter  in  place  by  the  method  above  described, 
after  first  withdrawing  it  until  the  resistance  shows  that  the  terminal 
enlargement  is  at  the  vesical  neck. 

After-care. — The  catheter  rapidly  becomes  encrusted  with  lime 
salts,  blood,  or  pus  and  should,  therefore,  be  changed  every  two  or 
three  days  to  permit  of  its  being  cleansed.  At  this  time  the  urethra 
and  bladder  should  be  thoroughly  irrigated  with  a  mild  antiseptic 
solution  and  the  catheter  thoroughly  sterilized  before  it  is  reinserted. 
In  the  presence  of  pus  or  blood  the  bladder  may  be  irrigated  throu^ 
the  catheter  as  frequently  as  seems  indicated. 

If  urethritis  develops,  the  urethra  should  be  irrigated  once  or 
twice  daily  with  a  saturated  solution  of  boric  acid.  This  may  be 
accomplished  by  withdrawing  the  catheter  until  its  extremity*lies 
in  front  of  the  bulbous  urethra  and  then  flushing  out  the  urethra 
from  behind  through  the  instrument  by  means  of  an  irrigating  appa- 
ratus. The  catheter  is  then  pushed  back  to  its  original  position. 
Constant  watch  should  be  kept  lest  ulceration  of  the  urethral  wall 
develop  at  the  penoscrotal  junction  from  pressure  of  the  catheter. 
To  avoid  this,  the  penis  should  be  supported  in  such  a  position  that 
the  sharp  angle  formed  at  the  penoscrotal  junction  when  the  organ 
hangs  vertically  is  obliterated. 

ASPIRATION  OF  THE  BLADDER 

Suprapubic  aspiration  of  the  bladder  is  indicated  as  a  temporary 
expedient  when  there  is  complete  retention  of  urine  and  catheteriza- 
tion is  impossible  from  the  presence  of  a  tight  stricture,  prostatic 
enlargement,  or  from  any  other  cause.  The  operation  is  easily 
performed  and,  if  properly  done,  is  a  safe  procedure.  At  times  after 
a  single  aspiration  the  congestion  is  so  much  lessened  that  within  a 
few  hours  it  becomes  possible  to  pass  a  catheter,  or  the  patient  voids 
spontaneously,  but,  if  necessary,  the  bladder  may  be  emptied  several 
times  a  day  for  several  days  by  this  method  without  danger. 

Where  a  permanent  drainage  for  some  time  is  desired,  suprapubic 
puncture  by  means  of  a  trocar  and  cannula  may  be  performed. 
Puncture  through  the  perineum  or  rectum,  on  the  other  hand,  should 
be  avoided  as  unsafe. 

Instruments. — For  temporary  relief  an  aspirating  needle  and 
syringe  should  be  employed.     The  needle  should  be  fairly  fine  and 


ASPIRATION    OF    THE    BLADDER 


747 


about  3  inches  (7.5  cm.)  long.  The  Potain  aspirator  (Fig.  756)  is 
the  best  to  use.  This  instrument  has  akeady  been  described. (page 
340)- 

When  a  trocar  and  cannula  are  used,  a  curved  instrument  with 
the  convtxity  of  the  curve  upmost  should  be  obtained.  A  scalpel  to 
nick  the  skin  is  also  required. 

Asepsis.— The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  sodium  carbonate  solution  and  the  operator's  hands  are  sterilized 
in  the  usual  way  as  for  any  operation. 

Site  of  Puncture. — The  puncture  is  made  in  the  median  line  about 
}i  inch  (i  cm.)  above  the  pubes.     The  extraperitoneal  space  above 


Fio.  7sfi. — ^Polaio  aspirator. 

the  pubic  bone  is  increased  when  the  bladder  is  distended  and  a  needle 
or  trocar  may  be  inserted  here  without  danger  of  entering  the  perito- 
neum. When  a  number  of  punctures  are  made,  the  site  may  be 
changed  a  little  each  time. 

Position  of  Patient.^ — The  operation  may  be  performed  with  the 
patient  recumbent  or  sitting  partly  up. 

Preparations  of  Patient.^ — The  pubes  should  he  shaved  and  then 
painted  with  tincture  of  iodin. 

Anesthesia. — Sufficient  anesthesia  is  obtained  by  freezing  the 
surface  tissues  with  ethyl  chlorid  or  salt  and  ice  to  render  the  opera- 
tion painless. 

Technic. — i.  By  the  Aspirator.— "VYss  suprapubic  region  is  first 
carefully  percussed  to  make  sure  that  there  are  no  coils  of  intestine 
lying  in  front  of  the  bladder.     The  aspirator  is  assembled,  tested,  and 


1 


748  THE  BLADDER 

the  air  in  the  bottle  exhausted.  A  small  nick  is  then  made  in  the 
skin  at  the  spot  chosen  for  the  puncture  and  the  needle,  held  in  the 
right  hand  with  the  index-finger  placed  on  its  shaft  as  a  guide,  is 
introduced  through  the  tissues,  directed  downward  and  backward, 
until  a  lessened  resistance  signifies  that  the  bladder  has  been  entered 
This  will  usually  be  when  the  needle  has  entered  from  i^i  to  2}i 
inches  (4  to  6  cm.),  depending  upon  the  thickness  of  the  abdominal 
wall.  The  aspirator  is  then  attached  and  the  vacuum  is  extended  to 
the  needle-point  by  opening  the  inflow  cock.  If  no  urine  is  with- 
drawn, the  needle  is  introduced  still  further  until  fluid  is  reached. 
The  contents  of  the  bladder  are  then  partly  or  completely  emptied, 
depending  upon  the  duration  of  the  retention  and  the  amount  of  the 
distention  (see  page  737). 

In  removing  the  needle,  care  should  be  taken  to  keep  up  the  suc- 
tion until  the  needle  is  completely  withdrawn,  otherwise  some  urine 
may  escape  from  the  tip  of  the  needle  as  it  traverses  the  prevesical 
space  and  cause  an  infection.  The  site  of  the  puncture  is  finally 
covered  with  a  piece  of  sterile  gauze  held  in  place  by  adhesive  plaster. 

2.  By  the  Trocar  and  Cannula. — A  small  nick  is  made  in  the  skia 
as  before  at  the  chosen  site  and  through  this  the  trocar  and  cannula 
with  the  convexity  up  is  inserted  into  the  bladder,  care  being  taken  to 
guard  against  the  instrument  entering  too  deeply  by  placing  the 
index-finger  on  the  shaft  of  the  instrument  as  a  guide.  The  trocar  is 
then  removed  and  the  cannula  is  secured  in  place  for  permanent 
drainage  by  means  of  tapes.  A  rubber  drainage-tube  leading  to  a 
receptacle  half  filled  with  an  antiseptic  solution  is  fastened  to  the 
cannula. 

The  bladder,  if  it  contains  much  pus,  may  be  irrigated  through  the 
cannula  once  or  twice  daily.  The  cannula  should  be  removed  and 
sterilized  every  few  days.  To  do  this  a  small  catheter  is  passed 
through  the  lumen  of  the  cannula  into  the  bladder  where  it  is  main- 
tained while  the  catheter  is  being  cleansed.  The  cannula  is  then 
easily  reintroduced  over  the  catheter  as  a  guide. 

The  permanent  cannula  should  be  removed  as  soon  as  it  is  possible 
to  pass  a  catheter  through  the  urethra  without  difficulty.  The  sinus 
remaining  is  allowed  to  close  by  granulation. 


H 


CHAPTER  XXII 


THE  KIDNEYS  AND  URETERS 

Anatomic  Considerations 

The  Kidneys. — The  kidneys  are  two  bean-shaped  organs,  each 
measuring  on  an  average  from  4  to  4?-^  inches  (10  to  12  cm.)  in 
length  and  2}'^  inches  (6  cm.)  in  breadth.  They  lie  deeply  situated 
in  the  abdominal  cavity  on  each  side  of  the  vertebral  column  behind 
the  peritoneum,  embedded  in  a  loose  layer  of  areolar  tissue,  the  peri- 
renal fat,  resting  upon  the  diaphragm,  the  quadratus  lumborum, 


Fig.   757. — The  position  of  the  kidneys  and 


from  behind. 


and  psoas  muscles.  Surrounding  the  perirenal  fat  is  a  layer  of  fascia, 
Complete  except  along  the  inner  border  of  the  kidney  and  at  its  lower 
pole,  which  is  firmly  attached  to  the  spine  and  diaphragm,  and  serves 
to  anchor  the  kidney  in  place. 

The  position  of  the  kidneys  from  behind  corresponds  to  the  space 
between  the  upper  border  of  the  twelfth  dorsal  vertebra  and  the  first 
and  second,  or  third,  lumbar  vertebrie.  The  right  kidney  generally 
lies  about  )-^  to  3-2  inch  (8  to  12  mm.)  lower  than  the  left  on  account 


7SO 


THE   KIDNEYS  AND  tHLETERS 


of  the  position  of  the  liver  above  it,  the  upper  extremity  of  the  right 
kidney  usually  reaching  to  the  level  of  the  lower  border  of  the 
eleventh  rib  and  that  of  the  left  to  the  upper  border  of  the  eleventb 
rib.  The  inferior  pole  of  the  kidney,  on  the  right,  reaches  to  within 
I  }4  inches  (4  cm.)  and,  on  the  left,  to  within  3  inches  (5  cm.)  of  the 
crest  of  the  ilium.  During  deep  inspiration  or  when  the  patient 
stands  erect  the  kidney  will  descend  to  a  somewhat  lower  level 
The  long  axis  of  the  kidney  is  directed  obliquely  downward  and  out- 
ward, so  that  the  superior  poles  lie  from  H  to  i  inch  (i  to  a.5  cm.) 
nearer  the  median  line  than  the  lower  poles. 


Fio.  758. — The  kidneys  and 


from  the  front. 


Anteriorly,  the  position  of  the  kidney  may  be  mapped  out  by  pass- 
ing a  horizontal  line  through  the  umbilicus  and  a  vertical  line  from 
the  middle  of  Poupart's  ligament  to  the  costal  border  perpendicular 
to  the  horizontal  line — the  former  passes  just  below  the  lower  poles 
of  the  kidneys,  while  the  latter  cuts  the  long  axis  of  the  kidney  at  the 
junction  of  its  middle  and  outer  thirds.  If  the  kidney  lies  to  the 
outer  side  of  the  vertical  line  or  below  the  horizontal  umbilical  Hw, 
it  is  indicative  of  enlargement  or  a  displacement. 

Relations  of  Kidneys. — Behind,  the  kidneys  are  in  relation  with 
the  diaphragm,  quadratus  lumborum,  psoas  muscles,  and  with  the 
last   dorsal,    iliohypogastric,    and   ilioinguinal    nerves.    The  do* 


ANATOJflC   CONSIDERATIONS  751 

relations  of  these  nerves  account  tor  the  referred  pains  sometimes 
encountered  in  diseases  of  the  kidneys. 

In  front  of  the  right  kidney  are  the  under  surface  of  the  right  lobe 
of  the  liver,  the  second  portion  of  the  duodenum,  the  ascending  colon, 
and  the  hepatic  flexure.  The  left  kidney  is  in  relation  in  front  with 
the  spleen,  the  fundus  of  the  stomach,  the  tail  of  the  pancreas,  the 
splenic  vessels,  and  the  descending  colon. 

Ureters. — The  ureters  are  two  in  number,  one  for  each  kidney. 
They  measure  about  12  inches  (30  cm.)  in  length  and  have  a  caliber 
equal  to  that  of  a  goo^e  quill.  The  ureter  begins  at  the  neck  of  the 
renal  pelvis  opposite  the  lower  pole  of  the  kidney  and  passes  down  on 
the  psoas  muscle  behind  the  peritoneum  to  the  brim  of  the  pelvis. 
A  line  drawn  on  the  abdominal  wall  vertically  upward  from  the  junc- 
tion of  the  middle  and  inner  thirds  of  Poupart's  ligament  roughly 
represents  the  course  of  the  ureter  from  the  kidney  to  the  pelvic 
brim. 

The  ureter  in  the  male,  after  crossing  the  pelvic  brim  and  the 
common  iliac  vessels,  passes  downward  and  backward  in  front  of  the 
sacroiliac  joint  and  enters  the  parietal  attachment  of  the  posterior 
false  ligament  of  the  bladder.  It  then  passes  forward  and  inward  to 
the  base  of  the  bladder  which  it  enters  just  above  the  seminal  vesicle, 
first  passing  under  the  vas  deferens. 

The  ureter  in  the  female,  after  crossing  the  pelvic  brim  and  iliac 
vessels,  passes  downward  and  backward  along  the  lateral  wall  of  the 
pelvis  as  in  the  male.  It  then  enters  the  base  of  the  broad  ligament 
and  passes  down  parallel  with  the  cervix  and  upper  portion  of  the 
vagina,  at  a  distance  of  about  3>^  inch  (i  cm.)  external  to  the  cervix 
and  posteriorly  to  the  uterine  artery.  After  crossing  the  upper  third 
of  the  vagina  the  ureter  enters  the  bladder  opposite  the  middle  of  the 
vagina.  The  pelvic  portion  of  the  ureter  in  the  female  is  thus  readily 
palpated  through  the  vagina  or  rectum. 

The  ureters  enter  the  bladder  ij-i  to  2  inches  (4  to  5  cm.)  apart 
and,  after  passing  obliquely  forward  and  inward  for  a  distance  of  ^ 
of  an  inch  (2  cm.)  through  the  bladder  wall,  they  appear  on  the 
mucous  membrane  about  i)^  inches  (3  cm.)  apart  and  the  same  dis- 
tance posterior  to  the  internal  urethral  orifice.  Through  this  oblique 
insertion  of  the  ureters  into  the  bladder  regurgitation  of  urine  when 
the  bladder  is  distended  is  effectually  guarded  against. 

The  ureters  are  composed  of  three  coats,  an  outer  fibrous,  a  middle 
or  muscular,  and  an  internal  or  mucous.  Normally  the  walls  are 
Collapsed  and  lie  in  contact.     The  lumen  of  the  ureter  presents  three 


4 


752  THE  KIDNEYS  AND   X7RETERS 

constrictions  and  two  intermediate  dilated  portions.  The  constric- 
tions are:  First,  about  23^  inches  (6  cm.)  from  the  hilum  of  the 
kidney,  second,  at  the  point  where  the  ureter  crosses  the  pelvic 
brim,  and,  third,  at  its  entrance  into  the  bladder. 

Diagnostic  Methods 

In  suspected  disease  of  the  kidney  or  ureter  a  careful  history  of  the 
past  ailments  and  present  symptoms  should  first  be  obtained.  Fre- 
quently pain  will  be  the  only  symptom  complained  of.  In  such  case 
its  exact  location  should  be  determined;  that^is,  whether  limited  to 
the  loin  or  radiating  along  the  course  of  the  ureter,  and  whether 
unilateral  or  bilateral.  Severe  attacks  of  pain  radiating  from  theloin 
down  toward  the  bladder,  testicle,  and  thigh  are  strongly  suspicious 
of  calculus.  The  character  of  the  pain  should  also  be  ascertained; 
whether  it  is  dull  or  aching,  or  paroxysmal  and  lancinating,  and 
whether  continuous  or  periodic.  Periodic  attacks  of  sharp  pain 
accompanied  by  a  considerable  diminution  in  the  amount  of  urine 
secreted,  followed  by  relief  of  the  pain  and  an  abimdant  flow  of  urine 
are  characteristic  symptoms  of  hydronephrosis  due  to  a  movable 
kidney.  The  patient  should  also  be  questioned  as  to  the  character 
of  his  urine,  i.e.,  whether  bloody,  etc.,  supplemented  by  inquiry  as  to 
special  points  along  the  lines  mentioned  in  the  sections  upon  the 
urethra  and  bladder.  This  is  followed  by  a  thorough  physical 
examination. 

The  methods  available  for  examination  of  the  kidneys  and  ureters 
include  inspection,  palpation,  percussion,  urinalysis,  c)rstoscopic 
examination,  ureteral  catheterization,  pyelometry,  segregation  of 
urine,  determination  of  the  functional  capacity  of  the  kidneys, 
skiagraphy,  and  exploratory  incision. 

INSPECTION 

On  account  of  the  deep  situation  of  the  kidney  in  the  abdomen, 
insp>ection  gives  no  information  if  the  kidney  is  normal.  When,  how- 
ever, the  kidney  is  greatly  enlarged  it  may  produce  a  visible  swelling 
in  the  loin  or  protrude  anteriorly  and  cause  a  bulging  of  the  lower 
ribs  upon  the  side  affected. 

Inspection  should  be  performed  from  in  front  with  the  patient 
lying  flat  on  the  back,  and  also  from  behind  and  laterally  with  the 
patient  standing  and  bending  forward,  so  as  to  make  any  bulging 
more  prominent  through  relaxation  of  the  abdominal  muscles. 


PALPATION   OF   THE   KIDNEYS 


PALPATION  OF  THE  KIDNEYS 

Palpation  is  by  far  the  most  valuable  of  the  methods  of  physical 
diagnosis  for  determining  the  presence  of  enlargement  or  displace- 
ments of  the  kidney.  While  the  normal  kidney  can  seldom  be  felt, 
unless  the  individual  is  very  thin  and  the  abtlominal  wall  is  lax,  and 
then  it  is  ony  possible  to  palpate  the  lower  pole  of  the  kidney,  an 
increase  in  the  size  of  the  organ  or  undue  mobility  is  readily  recog- 
nized. By  palpation  it  is  also  possible  to  determine  the  sensitiveness 
of  the  kidney  and  in  the  presence  of  a  tumor,  its  characteristics — 
namely,  its  size,  shape,  and  whether  soft,  hard,  or  fluctuating. 

Palpation  is  sometimes  performed  with  one  hand,  so  placed  that 
the  fingers  press  in  the  loin  while  the  thumb  lies  on  the  abdomen 
beneath  the  costal  arch,  but  a  more  satisfactory  method  is  the 
bimanual. 


Fic.  7S9.^Palpation  of  the  kidney  with  tlie  patient  in  the  dorsal  position. 


Position  of  Patient.-^The  patient  should  lie  flat  on  the  back  with 
the  head  and  shoulders  elevated  upon  a  small  pillow  and  the  lower 
extremities  flexed  so  as  to  thoroughly  relax  the  abdominal  walls. 
Sometimes  in  cases  of  movable  kidney  additional  information  may  be 
elicited  by  palpating  with  the  patient  standing,  his  body  bent  forward 
from  the  hjps,  and  with  his  hands  resting  on  the  arm  of  a  chair  for 
support;  or  else  the  patient  may  assume  the  lateral  position,  lying  on 
the  sound  side,  and  with  the  thighs  slightly  flexed  {Fig.  760}. 

Preparations  of  Patient. — Care  should  be  taken  to  have  the  colon 
empty  at  the  time  of  the  examination;  if  necessary  a  cathartic  should 


754  THE   KIDNEYS  AND   TJHETEBS 

be  administered  the  night  before  for  this  purpose.  All  clothing  tfut 
is  likely  to  interfere  with  the  examination  should  be  removed. 

Anesthesia. — If  palpation  is  diflicult  through  rigidity  of  the  ab- 
dominal muscles  or  from  increased  sensitiveness,  a  general  anesthetic 
may  be  required  in  order  to  make  a  satisfactory  examination. 

Technic. — The  examiner  should  stand  upon  the  side  he  wishes  to 
examine.  When  palpating  the  right  kidney  the  fingers  of  the  left 
hand  are  placed  under  the  loin  just  below  the  last  rib  and  the  rj^ 
hand  is  placed  flat  on  the  abdomen  below  the  costal  arch  (Fig,  759); 


Flo.  760. — Palpation  of  theVidney  with  the  patient  on  the  side. 


to  palpate  the  left  kidney  the  position  of  the  hands  is  reversed.  The 
patient  is  instructed  to  breathe  deeply  but  quietly,  and  any  manipula- 
tions should  be  gentle  in  character  to  avoid  inciting  muscular  cod- 
traction.  The  kidney  descends  during  inspiration  and,  if  at  tlustime 
forward  pressure  is  made  with  the  hand  under  the  loin  andthehand 
upon  the  abdomen  is  pressed  backward  under  the  ribs,  the  kidney, 
if  enlarged,  will  be  felt.  If  the  kidney  is  displaced,  it  may  be  cau^t 
between  the  two  hands  as  it  descends  during  deep  respiration  and 
may  be  prevented  from  returning  to  its  former  position.  In  the 
presence  of  a  tumor,  the  size,  shape,  and  consistence  of  the  growth 
should  be  determined  and  its  sensitiveness  ascertained.  Palpation 
of  the  normal  kidney  causes  a  peculiar  sensation  which  has  been 
likened  to  pressure  on  the  testicle;  actual  pain  will  be  elicited,  how- 
ever in  the  presence  of  some  tumors,  kidney  calculus,  or  pus 
formation. 

Tumors  of  the  colon,  gall-bladder,  pylorus,  spleen,  or  a  peduncu- 
lated ovarian  or  uterine  growth  may  be  mistaken  for  a  renal  tumor 
or  a  movable  kidney.     The  symptoms  complained  of  and  the  relation 


PALPATION   OF    TlIE    URETERS  755 

of  the  colon  to  the  tumor,  however,  will  usually  settle  the  diagnosis. 
The  colon  .lies  in  front  or  to  the  inner  side  of  the  kidney  and,  if  neces- 
sary, it  should  be  inflated  to  more  accurately  map  it  out. 

At  times  the  so-called  "ballottement  of  the  kidney"  may  be 
obtained  if  the  kidney  is  freely  movable.  To  elicit  this  sign  sudden 
sharp  pressure  is  applied  to  the  loin  by  the  posterior  hand,  when,  if 
movable  or  enlarged,  the  kidney  will  be  driven  forward  with  a  slight 
impact  against  the  hand  on  the  abdomen  in  front. 

PALPATION  OF  THE  URETERS 

'  The  ureters  may  be  palpated  through  the  abdominal  wall,  through 

the  vagina,  or  through  the  rectum.     Abdominal  palpation  is  only  of 
ji     value  if  the  patient  is  thin  and  the  abdominal  walls  lax,  and  then  it  is 
I     only  possible  to  palpate  the  ureter  if  thickened  or  if  it  contains  a 
I     calculus.     In  some  cases,  however,  if  inflamed  and  painful,  the  ureter 
I      may  be  traced  from  the  kidney  pelvis  to  the  pelvic  brim  from  the 
pain  elicited  on  palpation.     Through  the  vagina  it  is  possible  to 
palpate  the  ureter  from  the  base  of  the  broad  ligament  to  its  entrance 
into  the  bladder.     Calcuh,  thickening,  or  inflammation  of  this  por- 
tion of  the  ureter  is  thus  readily  recognized.     In  the  male  by  rectal 
I      examination  the  ureter  may  be  palpated  in  its  course  from  the  pelvis 
to  the  bladder. 

Positions  of  Patient. — For  abdominal  palpation  the  patient 
I  should  He  flat  on  the  back  with  the  head  and  shoulders  slightly  ele- 
'      vated  and  the  thighs  flexed. 

I  Vaginal  or  rectal  palpation  is  performed  in  the  dorsal  position 

with  the  thighs  flexed. 

Preparations  of  Patient. — The  bladder  and  bowels  should  be 
empty  at  the  time  of  examination. 

Technic— I.  Abdominal  Palpation.— The  examiner  stands  on  the 
side  to  be  palpated  and  first  locates  the  promontory  of  the  sacrum  by 
deep  palpation  with  the  examining  hand.  The  ureter  crosses  the 
pelvic  brim  at  a  point  about  i}i  inches  (3  cm.)  to  the  side  of  the 
promontory  and  a  little  below  it.  A  thickened  ureter  may  be 
palpated  at  this  point  if  the  patient  has  thin,  relaxed  abdominal  mus- 
cles. Beginning  at  this  point,  the  ureter  may  be  traced  upward  along 
its  course  by  making  deep  pressure  along  the  outer  border  of  the 
rectus  muscle  (Fig.  761).  If  the  ureter  is  inflamed,  palpation  will 
elicit  pain.  On  the  right  side  such  pain  must  be  differentiated 
from  that  of  cholecystitis  or  appendicitis. 


756  THE   KIDNEYS  AKD   USETESS 

2.  Vaginal  Palpation. — The  right  hand  is  emplojred  to  pa^te 
the  right  ureter  and  the  left  hand  for  palpation  of  the  left  ureter. 
The  index-finger  is  inserted  in  the  vagina  and  is  carried  to  the  vaginai 


Fio.  761. — Vaginal  palpstioD  of  the 


fornix  corresponding  to  the  ureter  to  be  palpated.  From  this  point 
it  is  pushed  upward  and  outward  toward  the  pelvic  wall,  and  a  careful 
search  is  made  for  the  ureter  which  will  be  recognized  as  a  flat  cord 


PERCUSSION 


7S7 


pas^g  forward  and  inward  from  the  pelvic  wall  around  the  cervix  to 
the  bladder  (Fig.  762).  Sometimes,  by  means  of  a  bimanual  exam- 
ination, with  the  external  hand  placed  on  the  abdominal  wall  and 
exerting  downward  pressure  the  ureter  may  be  more  satisfactorily 
examined. 

3.  Rectal  Palpation. — The  right  hand  palpates  the  right  ureter 
and  vice  versa.  The  index-finger  well  lubricated  is  inserted  into  the 
rectum  and  is  carried  upward  a  little  higher  than  the  level  of  the  base 
of  the  seminal  vesicle.  The  finger  is  then  turned  toward  the  lateral 
wall  of  the  pelvis  and  the  ureter  is  sought  by  moving  the  finger 
backward  and  forward.  It  will  be  recognized  as  a  flat  cord-like 
structure  passing  at  first  downward  along  the  side  of  the  pelvis  and 


Fic.   j6j. — Palpation  of  the  ureter  per  rectum. 


then  forward.  It  may  be  traced  as  far  as  the  bladder  and  will  be 
recognized  passing  forward  and  inward  from  the  pelvic  wall  to  the 
base  ol  the  bladder,  where  it  will  be  felt  a  little  above  the  seminal 
vesicle. 


PERCUSSION 

Percussion  of  the  kidney  is  of  slight  value  unless  the  organ  is 
greatly  enlarged.  At  best  it  is  difficult  on  account  of  the  thick  layer 
of  muscles  in  the  dorsal  and  lumbar  regions  and  the  depth  of  the 
kidney  from  the  anterior  abdominal  wall.  In  fat  individuals  the 
<ii&cultics  are   increased  in  proportion.     Percussion  is  important. 


758  THE   KIDNEYS  AND   USETESS 

however,  for  the  purpose  of  showing  the  position  of  the  colon  in 
relation  to  a  tumor  occupying  the  region  of  the  kidney  and  m 
differentiating  growths  of  the  kidney  from  the  ^leen  and  liver. 

Position  of  Patient. — To  percuss  from  behind  the  patient  should 
lie  face  downward  with  a  firm  cushion  or  several  pillows  under  the 
abdomen  to  make  the  lumbar  region  more  prominent  (Fig.  764). 

For  anterior  percussion  the  patient  lies  in  the  dorsal  posture  mth 
the  legs  extended. 

Preparations  of  Patient. — The  colon  must  be  emptied  so  as  not  to 
obscure  the  results. 

Technic. — It  is  necessary  to  employ  very  strong  percussion  to  out- 
line the  organ,  but  in  fat  individuals  even  this  may  yield  unsatis- 
factory results.  In  a  normal  case  the  kidney  dulaess  will  be  found 
to  extend  about  2  inches  (5  cm.)  below  the  last  rib,  merging  above 


Fig.  764. — PoaitioD  of  the  patient  for  percussion  of  the  kidneys  from  bdiiiid. 

into  that  of  the  liver  or  spleen.  In  a  large  renal  growth  percusawi 
will  give  dulness  extending  outward  and  downward  beyond  the  nor- 
mal limits,  with  colon  resonance  in  front  or  internal  to  the  tumor. 

Tumors  of  the  spleen  or  liver  may  give  much  the  same  area  of 
dulness,  but  the  colon  resonance  will  be  behind.  Inflation  of  the 
colon  {page  573)  may  be  necessary  before  its  position  can  be  accur- 
ately determined. 

URINALYSIS 

The  examination  of  the  urine  is  of  the  greatest  importance.  I' 
should  comprise  a  complete  physical,  chemical,  microscopical,  awi 
bacteriological  analysis.  Abnormality  may  be  due  to  general  dis- 
eases, rcnai  diseases,  or  to  lesions  in  the  lower  genitourinary  tract, 
so  that  it  is  not  sufficient  to  simply  recognize  a  departure  from  the 
normal,  but  the  seat  of  the  trouble,  i.e.,  whether  in  the  bladder,  ureter, 
or  kidney,  must  be  determined  and,  if  the  ureters  or  kidneys  ai* 


CATHETEHiaNG  THE  UKETERS  759 

affected,  which  side  is  involved  as  well.  For  this  purpose  the  cysto- 
scope  and  ureteral  catheter  are  of  the  greatest  aid.  Other  methods 
for  determining  the  source  of  abnormal  urinary  constituents  have 
already  been  described  (see  page  699) . 


U^  CYSTOSCOPY  (See  page  713) 

^^T'  CATHETERIZIHG  THE  URETERS 

The  use  of  the  ureteral  catheter  is  of  the  greatest  diagnostic  aid  in 
diseases  of  the  kidney  or  ureter,. as  it  is  possible  by  this  means  to 
collect  urine  separately  from  each  kidney  for  analysis  uncontami- 
nated  by  contact  with  the  bladder  or  urethra,  and  to  explore  the 
entire  length  of  Ihe  ureter  from  the  bladder  to  the  kidney  pelvis. 
This  method  of  examination  is  thus  of  value  in  determining  whether 
both  kidneys  are  present,  in  estimating  the  functional  capacity  of 
either  kidney,  and  in  the  presence  of  blood  or  pus  in  the  urine  in 
determining  whether  its  source  is  the  kidney  or  the  ureter  and  from 
which  side  it  comes.  It  is  also  of  the  greatest  aid  in  recognizing 
stricture  or  calculus  of  the  ureter,  hydroureter,  hydronephrosis,  etc. 

Ureteral  catheterization  has  certain  drawbacks  that  should  be 
mentioned.  Under  the  most  favorable  conditions  it  requires  con- 
siderable skill  to  catheterize  the  ureters,  and  in  some  cases,  compli- 
cated by  the  presence  of  tight  urethral  strictures,  enlargement  of  the 
prostate,  tumors,  or  thickening  of  the  bladder  mucous  membrane  it 
may  be  impossible,  Then  there  is  always  present  the  danger  of 
carryng  infection  from  the  bladder  into  a  healthy  ureter  or  kidney. 
With  proper  aseptic  precautions  in  performing  the  operation,  how- 
ever, this  danger  may  be  disregarded. 


Fic.  765. — Bransford  Lewis  eysloscopc, 

Instnimects. — Catheterizing  cystoscopes,  like  the  exploring  cysto- 
scopes,  are  of  two  types,  the  direct  view  and  the  indirect  view. 

The  direct  view  cystoscope  of  which  th?  Brenner,  Brown, 
Bransford  Lewis,  Eisner,  etc.,  instruments  are  t>'pes,  are  arranged 
*ith  the  light  either  on  the  convex  side  of  the  beak,  or  with  a  window 
both  on  the  convexity  and  concavity  so  that  the  light  is  shed  in  both 


4 


760  THE   KIDNEYS  AND  URETERS 

directions,  and  are  provided  with  a  straight  observation  teleso^ 
having  a  window  at  the  distal  end.  The  catheter  chambers  aie 
placed  on  the  under  surface  of  the  telescope  so  that  the  catheters 
protrude  at  the  lower  part  of  the  field  of  vision  in  a  straight  line. 
An  obturator  takes  the  place  of  the  telescope  when  the  instrument  is 
being  inserted  into  the  bladder. 

The  indirect  catheterizing  cystoscope,  such  as  the  Nitze,  Casper, 
Albarran,  Bierhoff,  Buerger,  etc.,  have  the  light  upon  the  concave  side 
of  the  beak,  while  the  image  is  reflected  at  right  angles,  by  means  of  a 
prism,  to  the  eye-piece  at  the  proximal  end.  The  catheter  chamben 
are  enclosed  wJthin  the  sheath  of  the  instrument  lying  above  the 
telescope.  A  small  movable  tongue  or  finger,  which  can  be  raised  or 
lowered  by  means  of  a  screw  at  the  ocular  end  of  the  instrument,  is 
provided  for  the  purpose  of  changing  the  angle  of  the  catheters  as 
they  emerge  from  the  instrument.  Irrigating  cocks  are  provided 
with  both  styles  of  cystoscope. 

Instruments  may  also  be  obtained  with  which  it  is  possible  to 
employ  either  the  direct  or  indirect  methods  of  observation  and 
catheterization,  as  McCarthy's  composite    cystoscope,  which  has 


CO 


BB 


Fig.  766. — The  Bierhoff  cystoscope.  a,  Showing  the  instrument  with  the  tete- 
scope  in  position  for  catheterization ;  6,  showing  the  telescope  rotated  within  the  shetth 
to  facilitate  removal  of  the  instrument. 

both  indirect  and  direct  view  telescopes  and  an  indirect  double 
catheterizing  attachment,  and  the  universal  cystoscopes  of  Tilden 
Brown  and  Bransford  Lewis,  which  combine  in  one  instrument  direct 
and  indirect  observation  and  double  catheterization  by  either  the 
direct  or  indirect  method. 

While  the  choice  of  the  type  of  instrument  must  rest  with  the 
individual  operator,  there  is  no  doubt  that  in  the  majority  of  cases  it 
is  easier  to  catheterize  with  the  direct  view  instrument,  exceptions 
being  the  presence  of  intra  vesicular  hypertrophy  of  the  prostate  and 
a  trabeculated  bladder,  in  which  class  of  cases  the  indirect  vieir 
instrument  is  essential;  on  the  other  hand,  it  is  far  easier  to  locate 
the  ureteral  orifices  by  indirect  view. 


CATHETERIZING   THE   URETERS  761 

The  catheters,  which  are  of  sitk  elastic  material  about  24  inches 
(60  cm.)  long  and  5  to  7  French  in  size,  should  be  of  different  colors 
to  differentiate  them.  The  distal  end  is  either  blunt  or  olive  pointed. 
Before  using,  it  should  be  seen  that  the  catheters  are  smooth  and  the 
eyes  perfect;  the  patency  of  the  catheters  should  also  be  tested  by 
injecting  water  through  them.  They  are  best  kept  at  full  length  in 
glass  tubes  plugged  with  cotton  at  either  end. 

For  the  purpose  of  recognizing  calculi  the  end  of  the  catheter  may 
be  dipped  in  melted  wax  (2  parts  of  dental  wax  and  i  part  of  olive  oil) 
and  allowed  to  harden  in  the  air  (Fig.  767).  On  coming  in  contact 
with  a  stone  scratch  marks  will  be  produced  on  the  wax  tip.  The 
wax  catheters  can  only  be  used,  however,  with  the  direct  view  instru- 
ment and  to  avoid  scratching  the-  wax  they  should  be  threaded 
through  the  instrument  from  the  vesical  end  backward. 


^^^H  Fic.  767. — Wan-tipped  ureteral  catheter. 

In  addition  to  the  ureteral  catheters  an  irrigating  jar  or  a  Janet 
syringe  holding  3  to  4  ounces  (90  to  120  c.c.)  of  solution  and  a  soft- 
rubber  catheter  should  be  provided  for  irrigating  the  bladder. 

Illumination  for  the  cystoscope  may  be  obtained  from  a  six-  or 
eight-cell  battery  or  from  the  street  current  provided  a  controller  is 
employed . 

Asepsis. — The  cystoscope  should  be  well  cleaned  with  tincture  of 
green  soap  and  water  and  is  then  placed  in  a  i  to  20  carbolic  acid 
solution  or  95  per  cent,  alcohol,  or  it  may  be  sterilized  by  formalin. 
Before  using,  it  should  be  rinsed  ofT  in  a  saturated  solution  of  boric 
acid.  The  catheters  are  sterilized  by  formalin  vapor  or  by  boiling 
for  one  or  two  minutes  in  plain  water,  care  being  taken  to  wrap 
them  separately  in  gauze  to  prevent  their  sticking  together  and  to 
place  them  at  full  length  in  the  sterilizer.  The  examiner's  hands 
are  carefully  sterilized  in  the  usual  way. 

Position  of  Patient.^ The  patient  may  be  in  the  lithotomy  posi- 
tion with  the  buttocks  close  to  the  edge  of  the  table,  or  as  preferred 
by  some  operators  in  a  semirecumbent  posture.  The  table  should  be 
provided  with  uprights  which  are  surmounted  with  double  inclined 
rests  for  the  thighs  and  knees,     (See  Fig.  717.) 

Anesthesia. — If  any  anesthesia  is  necessary,  local  anesthesia 
usually  suffices.     It  may  be  obtained  by  the  instillation  into  the  deep 


4 


762  THE   KIDNEYS  AND   URETEKS 

urethra  of  a  small  quantity  of  a  3  per  cent,  solution  of  cocdn  or  by 
fijling  the  empty  bladder  with  5  ounces  (150  c.c.)  of  a  warm  0.1  per 
cent,  solution  of  cocain  to  which  is  added  30  drops  (1.25  c.c)  of 
adrenalin.  This  must  be  retained  for  at  least  fifteen  to  twatjr 
minutes.  Guyon's  method  may  also  be  employed  (see  page  716). 
In  some  few  cases  it  may  be  necessary  to  employ  general  anesthesia; 
for  children  general  anesthesia  should  always  be  used. 

Preparations  of  Patient. — The  external  genitals  should  be 
cleansed  with  soap  and  water  followed  by  a  i  to  5000  bichlorid  of 
mercury  solution  The  bladder  is  then  emptied  and  thoroughly  ini- 
gated  with  a  saturated  solution  of  boric  add  by  means  of  a  cathela 
and  a  large  syringe  or  through  the  sheath  of  the  cystoscope  if  tbe 
instrument  is  supplied  with  an  irrigating  cock,  until  the  fluid  retums 
clear.  Four  to  6  ounces  (120  to  180  c.c.)  of  a  saturated  boric  add  or 
normal  salt  solution  are  then  injected  into  the  bladder  and  allowed 
to  remain  for  the  purpose  of  distention. 


Fig.  768. — Catheterization  by  the  direct  method,  showing  the  cystoscope  ts  introdocwl 
and  with  the  vesical  end  deflected  toward  the  ureter. 

If  hemorrhage  from  the  bladder  is  sufhcient  to  interfere  with  the 
operation,  a  i  to  3000  adrenalin  chlorid  or  1  to  15,000  silver  nitrate 
solution  should  be  injected  through  the  catheter  and  allowed  to 
remain  in  the  bladder  for  ten  to  fifteen  minutes  before  it  is  distended. 

Technic. — i.  Direct  Cathelerizalion. — The  cystoscope  and  catlw- 
ters  having  been  thoroughly  tested,  the  instrument,  well  lubricated 
with  glycerin  or  lubrichondrin  and  with  the  obturator  in  place,  is 
introduced  into  the  bladder.    The  obturator  is  then  removed  and  the 


CATHETERIZING    THE    XIRETERS  763 

catheterizing  telescope  is  inserted  in  its  place,  after  which  the  light 
is  turned  on  and  the  ureteral  orifices  are  sought  for.  They  are  lo- 
cated at  the  upper  angles  of  the  trigone  about  ?i  inch  (2  cm.)  from 
the  median  line  and  i  inch  (2.5  cm.)  from  the  internal  opening  of  the 
urethra.  By  first  locating  the  apex  of  the  prostate  and  then  pushing 
the  instrument  in  about  i  inch  (2.5  cm.)  the  intcrureteric  line  which 
passes  between  the  two  ureters,  forming  the  base  of  the  trigone,  will 
come  to  view  and  if  this  is  traced  to  one  side  or  the  other  the  orifice 
of  the  ureter  will  be  recognized  in  the  lateral  angle  of  the  trigone.  It 
may  appear  either  as  a  slit  or  as  a  dimple  on  the  apex  of  a  papilla,  and, 
if  carefully  watched,  urine  will  be  seen  coming  from  it  in  intermittent 
spurts.  It  may  be  extremely  difficult  to  locate  the  ureter,  but  a 
careful  search  will  usually  reveal  it.  In  all  manipulations  of  the 
cystoscope  it  is  of  the  utmost  importance  to  employ  extreme  gen- 
tleness, otherwise  bleeding  will  supervene  and  interfere  with  the 
examination. 


—  Calhelprization  by  the  direct   method,  showing  the  heel  of  the  cystoscope 
brought  close  to  the  mouth  of  the  ureter. 


With  the  direct  view  cystoscope  the  instrument  is  not  rotated 
about  an  axis,  but  the  beak  is  kept  constantly  pointing  upward  while 
the  vesical  end  is  turned  from  one  side  to  the  other  or  up  and  down 
as  the  case  may  be  (Fig.  768).  The  mouth  of  the  ureter  having  been 
located,  the  heel  of  the  cystoscope  is  brought  close  to  it  (Fig.  769)  and 
an  attempt  is  made  to  engage  the  catheter  in  its  liunen.     The  cath- 


764  "^^^^   KIDNEYS   AND   TTKETEKS 

eter  is  then  slowly  and  gently  threaded  up  the  ureter  to  the  desired 
distance  (Fig.  770).  If  the  purpose  of  the  catheterization  is  simfdy 
to  withdraw  urine  from  the  ureter,  the  catheter  is  introduced  3  (1)4 
inches  (7.5  to  10  cm.);  in  exploring  the  ureter  for  stone  or  stricture, 
or  to  determine  whether  pus  has  its  origin  in  the  ureter  or  kidney 
pelvis,  the  catheter  should  be  passed  as  far  as  the  renal  pelvis— 13  to 
15  inches  (32  to  37  cm.).  If  less  than  11  inches  (27  cm.)  of  catbettr 
can  be  inserted,  an  obstruction  must  be  inferred  (Braasch).  Tie 
other  ureter  is  located  and  catheterized  in  the  same  manner. 


— CalhelerJEation  by  the  direct  method,  showing  the  catheter  enloii*'" 


The  light  is  then  extinguished  and  the  catheterizing  attachment  b 
first  carefully  removed  and  then  the  sheath,  keeping  the  catheters  u 
position  in  the  ureter  by  threading  them  through  the  instrument  as 
it  is  withdrawn.  Unless  the  catheters  are  of  different  colors,  the;- 
should  be  labeled  "left"  or  "right"  in  order  to  distinguish  then. 
The  first  urine  that  flows  is  discarded  and  the  ends  of  the  cathettts 
are  then  wiped  off  and  inserted  into  sterile  bottles  plugged  m^ 
cotton,  A  catheter  may  become  plugged  with  mucus,  blood  dots, 
or  pus.  If  so  about  15  TTl  {i  c.c.)  normal  salt  solution  may  be  in- 
jected through  it  by  means  of  a  syringe. 

From  2  to  4  ounces  {60  to  t20  c.c.)  of  urine  are,  as  a  rule,  suffi- 
cient for  examination.  While  the  urine  is  being  collected,  the 
patient's  legs  should  be  released  from  the  crutches  holding  them  uid 


CATHETERIZING    THE    URETERS  765 

should  be  allowed  to  assume  as  comfortable  a  position  as  possible, 
the  completion  of  the  operation  the  catheters  are  carefully  re- 
ived and  the  bladder  is  irrigated  with  a  saturated  solution  of  boric 
d. 


.  773. — CatheterUation   by  Ihe  indirect  method,  the  catheter  being  pushed  into 
the  instrument  until  its  tip  posses  alightly  beyond  the  ureteral  orifice. 

2.  Indirect  Cathelerizalion.— The  instrument,  well  lubricated,  is 
reduced  into  the  bladder  and  is  then  rotated  completely  around  so 
it  its  beak  looks  posteriorly.     The  prostate  is  thus  located  and  by 


i 


^66  THE   KIDNEYS  AMD  UKETEBS 

rotating  the  instrument  through  an  angle  of  30  to  45  degrees  the  lat- 
eral ridge  of  the  trigone  may  be  traced  running  backward  at  an  angle 


Fio.  773. — Catheterization  by  the  iadifect  method,  shoiring  the  tip  of  the  otirtB 
being  deflected  toward'the  UTeteral  orifice  by  elevating  the  directoT. 


Fig.  774. — Catheterization  by  the  indiiect  method,  showing  the  catheter  insottdi 
the  ureter. 

from  the  prostate.     At  the  point  of  the  junction  of  this  ndge  with  ih 
interureteric  line  will  be  found  the  ureteral  orifice.     It  should  b 


CATHETERIZING   THE   URETERS  767 

remembered  that  with  this  form  of  instrument  the  image  will  appear 
inverted,  that  is,  the  prostate  will  appear  at  the  upper  portion  of  the 
field  instead  of  at  the  lower.  Having  located  the  ureteral  orifice  the 
instrument  is  brought  close  to  it  (Fig.  771)  and  the  catheter  is  pushed 
gently  forward  until  its  tip  passes  shghtly  beyond  it  (Fig.  772).  The 
small  director  is  then  elevated  shghtly  (Fig.  773)  and  the  catheter  is 
again  pushed  forward.  If  it  misses  the  orifice,  the  catheter  is  with- 
drawn a  little  and  a  second  attempt  made  to  introduce  it.  By 
pushing  the  catheter  forward  a  little  or  withdrawing  it  and  changing 
its  angle  of  deflection  shghtly,  it  is  finally  introduced  into  the  ureter 
(Fig.   774).     The  other  ureter  is  then  located  and  the  catheter  is 


Fig,  77S.  Fig.  ??6. 

Fig.  775.^Removal  of  the  sheath.  First  step,  showing  the  telescope  removed 
and  the  catheters  lying  loosely  in  the  sheath.  {After  Buerger,  Annals  of  Surgery, 
Feb,,  ,9og.) 

Fig.  776. — Removal  of  the  sheath.  Second  step,  showing  the  ocular  end  de- 
piessed  and  carried  to  the  left  until  clear  of  the  catheters.  (After  Buerger,  Annals  of 
Surt*ry,  Feb.,  igog.) 

introduced  in  the  same  way.  The  catheterizing  telescope  is  then 
carefully  removed,  first  turning  tite  defieclor  down  and  extinguishing 
the  lamp.  It  is  sometimes  a  difficult  matter  to  remove  the  sheath  of 
the  cystoscope  and  still  leave  the  catheters  in  place  when  using  this 
form  of  instrument.  The  following  manipulations,  however,  de- 
scribed by  Buerger  (Annals  af  Surgery,  February,  1909),  simplify 
this  portion  of  the  operation : 

"After  having  introduced  the  catheters  a  little  higher  than  we 
■would  if  the  instrument  were  to  remain  in  the  bladder,  and  after 


768  THE   XIDNEVS  AND  WRZrEKS 

removal  of  the  telescope,  the  following  movements  should  beamed 
out :  first,  the  ocular  is  depressed  and  carried  a  little  to  the  lef t,  tknt 
separating  the  beak  from  the  line  of  the  catheters  (Fig.  776) ;  senod, 
the  whole  instrument  is  rotated  to  the  right  on  its  longitudinal  ub 
through  an  arc  of  190  degrees,  retaining  the  relative  po«ti(ni  just 
described,  thus  making  the  beak  point  upward  (Fig.  777);tluid 
(still  in  the  same  plane,  with  the  ocular  a  little  to  theleft),tbeoailu 
is  raised  and  brought  back  to  the  median  line  in  order  to  bring  tk 
convexity  of  the  beak  against  the  trigone  of  the  bladder  (  Fig.  778); 
and  fourth,  the  sheath  is  removed,  its  inferior  aspect  being  mideto 
hug  the  posterior  wall  of  the  urethra." 

Removal  of  the  Bierhoff  instrument  is  comparatively  ^i)q)le,H 
it  is  arranged  so  that  the  telescope  may  be  rotated  within  thesbeatli 
until  the  beak  points  upward  without  disturbing  the  cathetas(sct 
Fig.  766). 


Fig.  777-  Fic.  778. 

Fio.  777.— Removal  of  the  shealh.  Third  step,  showing  the  beak  being  nm' 
upward.     (After  Buerger.  Annals  of  Surgery,  Feb.,  1909.) 

Fid.  778, — Removal  of  the  sheath.  Final  step,  the  beak  in  position  for  aasei 
of  the  sheath.     (.After  Buerger,  Annals  of  Surgery,  Feb.,  1909.) 


URETERAL  CATHETERIZATIOH  IN  THE  FEHA1£ 

Ureteral  catheterization  in  the  female  has  the  same  fidd  <^ 
usefulness  as  when  applied  to  the  male  (see  page  759).  In  additi* 
catheters  are  often  inserted  into  the  ureters  as  a  guide  to  their  po* 
tion  so  as  to  avoid  injuring  them  in  difficult  pelvic  operations.  Cithf 
terization  may  be  performed,  as  in  the  male,  by  means  of  one • 


URETERAL   CATHETERIZATION   IN   THE   FEMALE  769 

the  catheterizing  cystoscopes,  the  method  of  performing  which  re- 
quires no  further  explanation  than  that  given  above,  or  by  means  of 
open  tubes  under  air  distention  after  the  method  of  Kelly.  This 
latter  method  requires  separate  description. 

Instnimeats.— The  ordinary  Kelly  speculum  with  illumination 
furnished  by  reflected  light  or  some  of  the  modifications  of  Kelly's 
tubes  with  the  light  at  the  distal  end  may  be  employed.  The  latter 
are  preferable. 

In  addition  there  will  be  required  a  cone-shaped  urethral  dilator, 
alligator-jaw-shaped  forceps,  a  residual  urine  evacuator,  Kelly's 
ureteral  se.archer,  silk  flexible  catheters,  a  metallic  catheter,  and 
hard-rubber  flexible  sounds  (Fig.  779). 


Fic.  779. — Instrumenta  for  catheterizing  the  ureters  in  the  female,  i,  Open-tube 
cystoscopc;  t,  Kelly  urethral  dilator;  3,  residual  urine  evacuator;  4,  alligator-jawed 
forceps;  5,  ureteral  searcliei;  6,  metal  ureteral  catheter;  ;,  flenible  ureteral  cathetecB 
with  stylets;  8,  ureteral  bougies. 

The  cystoscope,  alligator-jaw  forceps,  urethral  dilator,  and 
searcher  have  been  previously  described  (page  720). 

The  flexible  silk  catheters  are  made  in  two  lengths:  la  inches 
(30  cm.)  long  for  ordinary  ureteral  catheterization  and  ao  inches 
(50  cm.)  long  for  catheterization  of  the  kidney  pelvis.  The  tips 
are  blunt  or  olivary  and  have  an  ova!  eye  about  ?^^  inch  (2  cm.) 
from  the  distal  end.  They  may  be  obtained  in  sizes  running  from 
Ke  to  M  inch  (1.5  to  3  mm.)  in  diameter.  A  wire  stylet  is  in- 
troduced within  the  catheter  to  furnish  it  with  the  necessary  stiff- 


770 


;   KIDNEYS   AND   IJH] 


ness  for  passage  into  the  ureter,  or  forcep 
780),  may  be  employed  for  this  purpose, 
a  calculus  the  ends  of  the  catheters  may  be  ■ 
Metal  catheters  are  12  inches  (30  cm.)  h 
in  diameter  and  are  supplied  with  three  e 
point  which  is  conical  in  shape  and  sli{ 
employed  when  a  stricture  low  down  in  the 
passage  or  a  flexible  catheter. 


FlO,  780. — Ashton'a  forceps  for  guiding  the  cathett 

Solid,  flexible,  hard-rubber  bougies  are  t 
ureters  or  dilating  strictures.  They  are  20 
H2  inch  (2  mm.)  in  diameter.  When  war 
and  in  this  state  may  be  passed  the  entire  lei 
danger.  For  the  purpose  of  locating  a  stou' 
(Fig.  781). 


Fig.  7B1. — Wwtipped  bougie. 

Asepsis.' — Great  care  should  be  takei 
details.  The  operator's  hands  should  be 
precautions  should  be  taken  not  to  allow 
touch  the  table  or  patient's  body  during  tl 
instruments  and  hard-rubber  bougies  are  st 
minutes  in  a  i  per  cent,  soda  solution.  ' 
sterilized  by  immersion  in  a  i  to  20  solutioi 
by  rinsing  in  alcohol.  Silk  catheters  ai 
vapor  or  are  boiled  for  not  over  two  minul 
then  placed  in  cold  sterile  water  to  make 
be  taken  when  boiling  the  catheters  to  pli 
at  full  length  and  to  wrap  them  separatel 
their  surfaces  from  becoming  glued  togeth 

After  use  the  catheters  should  be  thorc 
outside  with  warm  water  and  tincture  of 
away  at  full  length  in  a  glass  receptacle. 

Position  of  the  Patient. — As  for  cystc 
employed,  namely,  the  dorsal  elevated  ant 


UltETESAL  CATHETERIZATION  IX  THE  FEXALE  JJX 

former  the  patient  lies  with  the  head  and  thorax  resdng  oa  tht  table 
and  the  hips  elevated  8  to  12  inches  (20  to  30  cm.r  upon,  a  crs^fLDoa  so 
as  to  raise  the  pelvis  sufficiently  to  allow  the  bladder  to  disteod  with  air 
when  the  cystoscope  is  in  place.  If  the  bladder  does  not  iniiate  with 
the  patient  in  the  dorsal  position,  the  knee-chest  posture  is  ezE^iIoyed. 
The  latter  position  is  usually  necessary  in  stout  people. 

Preparations  of  Patient — It  should  be  seen  that  the  rectum  and 
bladder  are  empty  before  beginning  the  examination.  The  external 
genitals  are  then  washed  with  soap  and  water  followed  by  a  i  to 
5000  solution  of  bichlorid  of  mercury,  and  the  bladder  is  irrigated  with 
a  warm  saturated  solution  of  boric  acid  until  the  fluid  returns  ckcar. 
The  solution  is  then  all  drained  off  before  the  cystoscope  is  inserted. 

Anesthesia. — ^Local  anesthesia,  obtained  by  inserting  into  the 
meatus  a  small  pledget  of  cotton  saturated  with  a  2  per  cent,  sohi- 
tion  of  cocain  and  allowing  it  to  remain  for  five  minutes,  is  generally 
sufficient.  In  extremely  nervous  patients  general  anesthesia  may  be 
required. 

Technic. — The  urethra  is  first  dilated  and  the  cystoscope  is  intro- 
duced in  the  manner  already  described  (page  723).  The  obturator  is 
then  removed,  when,  if  the  patient  is  in  the  proper  position,  air  rushes 
in  and  distends  the  bladder.  The  light  is  then  adjusted  and  a  seardi 
is  made  for  the  ureteral  orifices.  In  doing  this  it  is  well  to  first  with- 
draw the  instrument  until  the  mucous  membrane  of  the  internal 
urethral  orifice  begins  to  close  over  the  end  of  the  instrument,  and 
then  to  advance  it  J^  to  ^  inch  (i  to  2  cm.)  turned  either  to  the 
right  or  left  about  30  degrees  from  the  center  line  along  the  dark 
lateral  ridge  of  the  trigone.  The  distal  end  of  the  instrument  is  then 
brought  close  to  the  base  of  the  bladder  by  raising  the  handle  of  the 
cystoscope  if  the  patient  is  in  the  dorsal  position,  or  depressing  the 
handle  if  the  knee-chest  position  is  used.  By  moving  the  instrument 
carefully  about,  the  mouth  of  the  ureter  will  be  located  somewhere 
near  the  end  of  the  cystoscope.  It  may  appear  as  a  small  slit,  a 
distinct  hole,  or  a  dark  point  in  the  bladder  mucous  membrane. 
If  it  is  not  readily  found,  the  speculum  should  be  directed  toward  its 
normal  location  and  a  careful  search  made  for  it  with  a  ureteral 
searcher  in  the  folds  of  mucous  membrane. 

Having  located  the  orifice,  the  end  of  the  cystoscope  is  brought 
close  to  it  and  the  catheter  is  introduced.  Metal  catheters  or  sounds 
are  not  difficult  to  introduce.  They  should  be  well  lubricated  and, 
while  the  cystoscope  is  maintained  in  position  with  the  left  hand,  they 
are  guided  by  means  of  the  right  hand  into  the  ureteral  orifice. 


77a 


THE    KIDNEYS    AND   UKETEBS 


Flexible  catheters  may  be  introduced  in  two  ways,  rfther  by  the 
use  of  a  stylet  togive  them  stiffness  or  by  the  aid  of  a  specially  made 
forcepSj  such  as  Ashton's  (see  Fig.  780).  By  the  former  method  the 
catheter,  well  lubricated,  with  the  stylet  in  place,  is  gently  inserted  m 
the  same  manner  as  a  metal  catheter  into  the  mouth  of  the  ureter 
(Fig.  782).  The  stylet  is  then  withdrawn  and  the  catheter  is  pushed 
on  until  it  has  entered  the  desired  distance.  For  ordinary  purposes 
of  catheterization  this  will  be  3  or  4  inches  (7.5  to  10  cm.).    In  intro- 


Fic.  78J.— Calhcti 


ducing  these  flexible  catheters  care  must  be  observed  that  the  portion 
outside  the  cystoscope  does  not  become  contaminated  by  touching  the 
patient  or  the  table. 

If  it  is  desired  to  catheterize  both  ureters,  the  mouth  of  the  other 
one  is  then  located  and  the  catheter  introduced  in  the  same  manner. 
The  cystoscope  is  then  withdrawn  and  the  catheters  are  labeled  right 
and  left  to  distinguish  them.  After  wiping  the  ends  of  the  catheters, 
they  arc  placed  in  two  small  sterile  bottles  plugged  with  sterile  cotton, 
and  about  2  to  4  drams  (8  to  15  c.c.)  of  urine  are  collected  from  each 
kidney  (Fig.  783}. 


URETERAL    CATHETERIZATION    IN    THE    FEMALE 


Variation  in  Technic. — The     following     method,    devised  by 
Kelly,  for  collecting  urine  from  one  kidney  without  using  a  catheter 


from  each  kiduEy.     (Ashton.) 


Fig.  784.^Kelly's  method  of  coltecting  urine  frnm  a  kidney  withoi 
(After  Kelly.) 


is  sometimes  employed  when  it  Is  undesirable  to  introduce  a  catheter 
into  the  ureter  for  fear  of  carrying  in  infection  from  the  bladder  or 


774  THE  KIDNEYS  AND  URETERS 

from  other  causes.  Briefly,  it  consists  in  placing  the  patient  in  the 
knee-chest  posture,  introducing  into  the  bladder  a  speculum  with  the 
end  cut  on  the  slant,  and  exposing  to  view  the  ureteral  orifice  from 
which  it  is  desired  to  obtain  a  specimen  of  urine.  The  orifice  of  the 
ureter  is  then  wiped  clean  and  the  speculum  is  held  close  against  the 
bladder  wall  so  that  the  urine  escapes  into  the  speculum  whence  it  is 
collected  by  means  of  a  small  glass  graduate  (Fig.  784).  In  this  way 
often  in  a  short  time  sufficient  urine  may  be  collected  for  purposes  of 
examination. 

PYELOMETRY 

By  distending  the  renal  pelvis  with  fluid  its  capacity  may  be  meas- 
ured, and  from  this  it  may  be  determined  whether  the  pehis  is 
normal,  contracted,  or  dilated.  The  test  is  based  upon  the  fact  that 
if  the  kidney  pelvis  is  overdistended  an  artificial  renal  colic  is  pro- 
duced. A  normal  pelvis  will  hold  from  i3^  to  4  drams  (5  to  15 
c.c.)  of  fluid  without  pain.  According  to  Braasch  if  the  renal  pelvis 
has  a  capacity  of  less  than  50  lU  (3  c.c.)  it  indicates  irritability  or  a 
contraction  generally  due  to  stone,  tumor,  acute  or  chronic  pyelitis, 
or  spasm;  a  pelvis  allowing  distention  up  to  i  ounce  (30  c.c.)  maybe 
found  in  neurotic  subjects,  the  condition  being  explained  by  the  pres- 
ence of  a  hysterical  anesthesia;  while  a  capacity  of  10  drams  (40 
c.c.)  and  over  indicates  hydronephrosis. 

Instruments. — A  direct  or  indirect  catheterizing  cystoscope, 
ureteral  catheters,  a  catheter  and  syringe  for  irrigating  the  bladder,  a 
small  syringe  with  a  capacity  of  2^  drams  (10  c.c.)  with  a  nozzle 
that  will  fit  the  end  of  the  ureteral  catheter,  as  the  Record  syringe, 
and  a  glass  measuring  graduate  will  be  required. 

Asepsis. — See  under  ureteral  catheterization  (pages  761,  770). 

Solution  Used. — A  2  per  cent,  boric  acid  solution,  colored  with  a 
drop  or  two  of  methylene  blue,  is  employed. 

Temperature. — The  solution  should  be  at  a  temperature  of  about 
100°  F.  (sS""  C). 

Position  of  Patient. — Same  as  for  ureteral  catheterization  fpages 
761,  770). 

Anesthesia. — (Sec  pages  761,  771). 

Preparation  of  Patient. — Same  as  for  ureteral  catheterization 
(pages  762,  771). 

Technic. — A  catheter  of  sufficient  size  to  occlude  the  ureter  and 
prevent  the  escape  of  the  solution  beside  it  is  introduced  into  the 
ureter  of  the  afifected  side  as  far  as  the  pelvis  (see  ureteral  catheteriza- 


SEGREGATION   OF   URINE  775 

tion,  pages  762,  771).  The  colored  solution  is  then  injected  into 
the  catheter  while  the  operator  notices  through  the  cystoscope  if  any 
of  it  leaks  back  into  the  bladder;  if  not,  the  injection  is  slowly  con- 
tinued until  colicky  pain  is  produced  in  the  region  of  the  kidney, 
showing  that  the  pel\-is  Is  distended.  The  quantity  injected  indi- 
cates the  capacity  of  the  pelvis. 

SEGREGATION  OF  URINE 

Special  instruments,  known  as  segregators,  which  separate  the 
bladder  into  two  halves  through  the  formation  of  an  artiticial  dam, 
may  be  employed  to  collect  the  urine  separately  from  the  kidneys 
when  a  catheter  cannot  be  passed  into  the  ureter  or  ureteral  catheter- 
ization is  contraindicated.  They  are  easier  to  employ  than  the 
ureteral  catheter  and  with  their  use  there  is  no  danger  of  carrying  infec- 
tion into  the  ureters,  but,  on  the  other  hand,  they  are  not  so  accurate, 
as  an  incomplete  watershed  may  be  formed  allowing  the  urine  from 
the  two  sides  to  mingle,  and  the  introduction  of  the  instruments  may 
incite  vesical  bleeding  and  give  misleading  results.  Again,  if  the 
bladder  is  diseased,  the  urine  obtained  is,  of  course,  contaminated  and 
it  is  not  possible  to  determine  whether  the  source  of  blood  or  pus  is 
the  bladder,  ureter,  or  kidney.  If  the  bladder  is  very  irritable  or 
bleeds  easily,  as  is  the  case  in  the  presence  of  acute  cystitis,  vesical 
calculus,  tumors,  and  prostatic  hypertrophy,  a  segregator  should  not 
be  used.  In  healthy  bladders,  however,  segregation  properly  per- 
formed is  fairly  reliable. 

Instruments. — There  are  several  types  of  urine  separators  among 
which  may  be  mentioned  the  instruments  of  Harris  and  Luys. 

The  Harris  segregator  (Fig.  785)  consists  of  two  catheters  having 
a  common  sheath  except  at  the  distal  and  proximal  ends.  The  intra- 
vesical ends  when  in  contact  form  a  cylinder  with  a  double  curve  and 
are  supplied  with  numerous  small  eyes  which  lead  to  the  interior  of 
the  catheter.  The  extravcsical  portion  ends  in  curved  metal  tubes  to 
which  are  connected  by  means  of  pieces  of  rubber  tubing  two  aspirat- 
ing bottles.  A  long  lever,  connected  to  the  shaft  of  the  instrument  by 
means  of  a  fulcrum  and  spring,  which  is  inserted  into  the  rectum  or 
vagina  for  the  purpose  of  raising  up  the  bladder  wall  in  the  mid-line 
in  the  form  of  a  dam,  is  also  provided. 

Luys'  instrument  (Fig.  786)  consists  of  two  catheter  tubes  sepa- 
rated by  a  metal  partition,  the  vesical  end  of  which  has  a  B6niqu6 
form  of  curve.     On  the  concave  side  of  the  intravesical  portion  is  a 


i 


776  THE  KIDNEYS  AND  URETERS 

small  chain  covered  with  a  thin  India-rubber  membrane,  so  arranged 
that,  after  the  instrument  is  within  the  badder,  by  turning  a  tiumb- 
screw  at  the  proximal  end  of  the  instrument  the  rubber  membraneis 
made  to_partition  the  badder  into  two  halves.     Near  the  pronmal 


Fig,  785.— The  Harris  segregator.     (Ashton.) 


end  are  two  discharge  tubes  which  empty  into  small  bottles.  In 
males  this  instrument  causes  less  discomfort  than  does  the  Hanis 
segregator. 

Asepsis. — The  instruments  and  the  bottles  for  collecting  the 
urine  should  be  sterilized  by  boiling  for  five  minutes,  and  the  oper- 
ator's hands  are  cleansed  as  for  any  operation. 


K^ 


—The  Luj's  segregat< 


Position  of  Patient. — In  using  the  Harris  instrument  the  patient 
lies  flat  on  the  back  with  the  feet,  hips,  and  head  on  a  level  and  with 
the  thighs  flexed. 

The  same  position  is  employed  in  inserting  the  Luys  instrument, 
but,  when  the  instrument  is  in  the  bladder,  the  patient  is  elevated 
to  a  semi-sitting  position. 


SEGREGATION   OF   URltiZ  .  "J-jy 

Preparations  of  Patient. — The  rectum  should  be  empty.  The 
external  genitals  are  cleansed  with  soap  and  water  followed  by  a  i 
to  5000  solution  of  bichJorid  of  mercury.  The  urethra  is  irrigated 
with  a  I  to  5000  solution  of  potassium  permanganate.  The  bladder 
is  emptied  by  means  of  a  catheter  and  is  then  irrigated  with  a  satu- 
rated solution  of  boric  acid  or  sterile  water.  About  5  ounces  (150 
C.C.)  of  solution  is  left  in  place  when  using  the  Harris  instrument  to 
permit  manipulation  of  the  instrument,  less  distention  being  neces- 
sary with  the  Luys  instrument. 

Anesthesia. — Local  anesthesia  may  be  required  if  the  urethra  or 
bladder  are  hj-peresthetic. 

Technic. —  i.  Barris'  Method. — The  instrument,  closed  so  the 
catheters  form  a  continuous  tube,  is  well  lubricated  and  is  introduced 


Fig.  787— Scgregi 


IS  of  the  Harris  segrcgator.     First  step,  instru- 
1   Q  the  bladder.     (Ashtoo.) 


into  the  bladder  until  its  beak  lies  just  within  the  vesical  neck  (Fig. 
787).  The  proximal  ends  are  then  rotated  outward  so  that  the  ves- 
ical ends  are  made  to  lie  on  either  side  of  the  ureteral  orifices  and  are 
fixed  in  this  position  by  the  small  spring  at  the  proximal  end  of  the 
instrument  (Fig.  78S).  The  !ung  lever,  well  lubricated,  is  then  in- 
troduced into  the  rectum  of  the  male  or  the  vagina  of  the  female  and' 
b  secured  by  a  damp  to  the  sheath  of  the  catheters.  By  means  of  a 
spiral  spring  the  rectal  or  vagina!  end  is  forced  upward  causing  a 
longitudinal  ridge  of  bladder  wall  to  be  formed  in  Ihe  mid-line  be- 
tween the  two  ureteral  orifices  with  the  end  of  each  catheter  lying  at 
the  bottom  of  the  correspondng  compartment  of  the  bladder.  The 
fluid  left  in  the  badder  is  then  allowed  to  escape  from  each  catheter 
until  it  has  all  been  drained  off.     The  aspirating  apparatus  is  then 


J 


778  THE   KIDNEYS  AND   UREXERS 

attached  and  the  urine  is  genUy  sucked  out  of  the  viscus  from  tune  to 
time  by  means  of  the  suction  bulb  and  is  collected  in  two  sterile 
bottles  (Fig.  789).    The  instrument  must  be  left  in  place  about  half 


Fig.  7SS. — Segreg&tion  of  uHne  by  means  of  the  Harris  seKTeg&tor. 
vesical  ends  of  the  instrument  separated.     (Ashtoii.) 


Fic.  7 89. ^Segregation  of  urine  by  means  of  the  Harris  segregator.      Third  siepi 
the  instrument  in  place,      (.\shton.) 

an  hour  to  collect  sufficient  urine  for  examination.     Care  must  be 
taken  to  avoid  too  vigorous  aspiration  or  hemorrhage  will  be  incited. 
At  the  completion  of  the  operation  the  lever  is  detached,  the  cath- 
eters are  folded  back  in  place,  and  the  instrument  is  carefully  re- 


TESTS   OF   KIDNEY  FUNCTION 


779 


moved,  following  which  the  bladder  is  irrigated  with  a  saturated 
solution  of  boric  acid. 

2,  Luys'  Method — The  rubber  dam  is  first  carefully  examined  to 
see  if  it  is  intact.  The  instrument,  well  lubricated,  is  then  introduced 
in  the  same  manner  one  would  insert  a  sound,  dqiressing  the  handle 
well  between  the  thighs  as  soon  as  the  tip  enters  the  prosta.tic  urethra 
so  as  to  carry  the  curved  portion  into  the  bladder.  As  soon'as  the 
instrument  is  well  within  the  bladder,  the  patient  is  raised  to  a  semi- 
sitting posture  and  the  diaphragm  is  raised,  carefully  keeping  the 
instrument  exactly  in  the  median  line.  The  handle  of  the  instrument 
b  then  elevated  until  resistance  shows  that  the  intravesical  portion  is 
in  contact  with  the  base  of  the  bladder.    This  should  be  confirmed 


Fig.  7go.— Showing  the  method  of  using  the  Luys  segregator. 


by  vaginal  or  rectal  palpation.  After  all  solution  has  been  drained 
from  the  bladder,  the  urine,  as  it  trickles  into  the  bladder,  b  carried 
off  by  a  catheter  on  each  side  and  is  collected  in  the  small  tubes  at  the 
proximal  ends  of  the  instrument  (Fig.  790). 

At  the  completion  of  the  operation  the  diaphragm  is  lowered  and 
the  instrument  is  withdrawn.  This  is  followed  by  a  vesical  irrigation 
of  boric  acid. 

TESTS  OF  KIDNEY  FUNCTION 


The  function  of  the  kidney  is  to  maintain  the  normal  concentra- 
tion of  the  fluids  of  the  body  by  eliminating  in  the  urine  waste  prod- 
ucts of  metabolism  which,  if  accumulated  in  the  blood  and  tissues, 
would  produce  serious  results.  Numerous  tests  for  determining  the 
functional  efficiency  of  the  kidneys  have  been  devised  which  are 


780  THE   KIDNEYS  AND  URETERS 

based  on  the  principles  that  under  conditions  of  impaired  renal 
activity,  the  urine  will  contain  a  smaller  amount  of  its  normal  con- 
stituents or  will  be  less  able  to  artificially  eliminate  certain  foreign 
substances,  while  the  blood  will  show  a  concentration  of  substances 
normally  excreted  in  adequate  amounts.  These  tests  may  be  thus 
divided  into  three  classes:  (i)  Tests  of  excretion,  (2)  tests  of  reten- 
tion, and  (3)  a  combination  of  tests  of  excretion  and  retention. 

From  a  medical  standpoint  tests  of  kidney  function  are  of  diag- 
nostic value  in  determining  the  kidney  activity  in  acute  and  chronic 
nephritis,  uremia,  cardiopathies,  arteriosclerosis,  and  myocardial 
insufficiency.  They  are  also  of  considerable  prognostic  importance 
as  by  repeated  tests  it  is  possible  to  determine  whether  a  disease  i 
progressive,  stationary,  or  responding  to  treatment. 

In  surgery,  in  addition  to  being  a  means  of  estimating  operativi 
risks  by  showing  whether  the  two  kidneys  are  properly  performin| 
their  functions,  functional  tests  are  of  great  importance  when  th 
removal  of  one  kidney  is  contemplated  in  determining  the  activit] 
of  each  kidney.  But,  although  they  demonstrate  which  kidney  i 
fimctionating  best,  they  are  not  infallible  and  do  not  absolutd; 
prove  that  a  particular  kidney  is  capable  of  doing  sufficient  excretor 
work  after  removal  of  its  mate. 

The  Elimination  of  Substances  Normally  Present  in  the  Urine  as  a 

Index  of  Renal  Functiofi 

Urinalysis. — While  urinalysis  is  of  great  importance  in  the  dia{ 
nosis  of  diseases  of  the  kidneys  and  urinary  organs,  estimation  of  th 
specific  gravity  and  the  amount  of  water,  nitrogen,  and  salts  excrete 
by  the  kidneys  is  not  sufficient  by  itself  in  determining  the  fun( 
tional  capacity  of  the  kidneys,  as  the  quantity  of  these  substances ; 
markedly  influenced  by  the  intake  of  fluids  and  food,  by  exercise,  b 
the  condition  of  the  nervous  system,  and  by  the  condition  of  oth< 
organs.  It  is  of  little  use  unless  combined  with  a  chemic 
examination  of  the  blood,  or  unless  the  intake  and  ti 
loss  through  other  channels  is  determined  as  well.  In  other  word 
it  must  be  combined  with  a  study  of  body  metabolism.  The  mos 
that  can  be  assumed  from  an  ordinary  urinalysis  is  that,  if  the  elimi 
nation  of  the  constituents  of  the  urine  are  constantly  normal,  th' 
kidney  function  is  probably  not  deficient,  while  if  there  is  mud 
variation  from  the  normal  and  this  is  constantly  present,  the  kidne] 
function  is  likely  to  be  impaired.     Thus,  as  a  test  of  kidney  function 


■,i  li 


TESTS   OF   KIDNEY  FUNCTION  781 

urinalysis  alone  has  only  the  value  of  contributory  evidence  and  it  is 
necessary  to  employ  other  tests  to  corroborate  the .  findings  and 
determine  the  extent  of  deficiency,  if  present. 

Experimental  Polyuria  Test. — ^A  method  of  estimating  the 
fimctional  activity  of  the  kidneys  is  by  the  response  to  the  ingestion 
of  an  increased  amount  of  fluid,  known  as  the  experimental  polyuria 
test,  devised  by  Albarran,  which  consists  essentially  in  obtaining  the 
urine  from  each  kidney  when  the  patient  is  dry  and  comparing  the 
two  specimens  and  then  having  the  patient  drink  a  large  quantity  of 
water  and  noting  the  effect  upon  the  activity  of  the  two  kidneys. 

The  test  is  based  upon  the  following  laws:  First,  a  diseased  kidney 
has  a  mofe  uniform  function  than  a  healthy  one,  and  the  more 
extensively  its  parenchyma  is  destroyed  the  less  will  its  function  vary 
from  time  to  time;  second,  when  one  kidney  alone  is  diseased  or  is 
more  diseased  than  the  other,  if  the  urinary  function  is  disturbed,  its 
function  is  less  modified  than  the  other.  In  other  words,  if  an 
increased  excretory  demand  is  placed  upon  the  kidneys  through  the 
ingestion  of  large  quantities  of  water  and  the  urine  is  collected  sepa- 
rately, the  less  diseased  organ  should  show  a  greater  increase  in  activ- 
ity, manifested  by  the  excretion  of  a  larger  total  amount  of  fluid  and 
solids,  though  the  percentage  of  solids  will  be  diminished,  while  the 
diseased  kidney  will  show  a  relatively  small  or  no  increase  in  activity. 
The  test  thus  becomes  of  value  not  only  in  examining  the  renal 
function  of  both  kidneys  but  also  in  determining  which  kidney  is 
functionating  best  and  the  power  of  each  to  accommodate  itself  to 
increased  demands  for  excretory  work. 

Technic. — The  patient  should  not  have  eaten  anything  for  four 
hoiirs  or  taken  any  liquids  for  three  hours.  A  single  catheter  is 
placed  in  one  ureter  and  the  urine  from  the  other  side  is  collected  by 
means  of  a  small  catheter  passed  into  the  bladder.  The  urine  which 
flows  for  the  first  ten  or  fifteen  minutes  is  discarded  in  order  to  permit 
the  reflex  polyuria  or  oliguria  which  may  follow  the  introduction  of 
the  ureteral  catheter  to  subside,  and  the  urine  that  then  flows  is 
collected  for  half  an  hour.  This  is  saved  for  comparison  with  speci- 
mens taken  after  the  administration  of  the  fluid.  At  the  end  of  half 
an  hour  the  patient  is  given  two  to  three  glasses  (300  to  400  c.c.)  of 
mineral  water  and  the  urine  is  collected  separately  and  examined  at 
half  hour  intervals  for  one  and  a  half  hours.  For  estimating  the  total 
function,  ureteral  catheterization  is  not  necessary,  the  urine  being 
collected  by  voiding.  Not  only  is  the  total  quantity  of  urine  noted, 
but  the  specimens  are  tested  as  to  the  freezing-point,  quantity  and 


782  THE   KIDNEYS  AND   URETERS 

percentage  of  urea  and  sodium  chlorid,  and,  if  phloridzin  has  be< 
given,  the  amount  of  sugar  is  estimated. 

Normally  the  polyuria  appears  within  the  first  half  hour,  reachii 
its  maximum  during  the  third  half  hour,  and  then  rapidly  decliiu 
The  total  amoimt  of  solids  remains  constant  or  increases,  while  t 
the  percentage  sinks  in  proportion  to  the  polyuria. 

If  the  functional  activity  of  the  kidney  is  impaired,  there  is ; 
polyuria  or  it  is  delayed  and  the  content  of  solids  is  unaffected. 

Test  Meal  for  Kidney  Function. — This  fimctional  test  i 
originally  suggested  by  Hedinger  and  Schlayer  in  1914  and  was  lai 
more  fully  elaborated  by  Mosenthal  {Archives  of  Internal  Medici 
Nov.,  191 5).  It  is  a  composite  test  for  substances  normally  elii 
nated  in  the  urine,  the  specific  gravity,  salt,  nitrogen,  and  wa 
excretion  being  determined  in  2  hourly  periods  during  the  day  a 
for  a  12  hour  period  at  night.  The  test  has  come  into  quite  gene 
use  and  is  of  recognized  value  in  the  study  of  renal  function  and 
the  diagnosis  of  various  forms  of  kidney  and  cardiac  diseases,  a 
dropsical  conditions. 

Technic. — The  directions  for  the  test  meal  are  contained  in  t 
following  form  (Mosenthal) : 

DIET 
Test  Meals  For  Kidney  Functign 
For Date     


All  food  is  to  be  salt-free  food  from  the  diet  kitchen. 

Salt  for  each  meal  is  to  be  furnished  in  weighed  amoimts.  0 
capsule  of  salt  containing  2.3  gm.  sodium  chloride,  is  furnished  wi 
each  meal.  The  salt  which  is  not  consumed  is  returned  to  the  la 
oratory,  where  it  is  weighed,  and  the  actual  amount  of  salt  tak 
calculated. 

All  food  or  fluid  not  taken  must  be  weighed  or  measured  aft 
meals,  and  charted  in  the  spaces  below. 

Allow  no  food  or  fluid  of  any  kind  except  at  meal  time^. 

Note  any  mishaps  or  irregularities  that  occur  in  giving  the  dii 
or  collecting  the  specimens. 

Breakfast,  8  a.  m. 

Boiled  oatmeal,  100  gm. 
Sugar,  1-2  teaspoonfuls. 
Milk,  30  c.c. 


TESTS   OF   KIDNEY  FUNCTION 


783 


Two  slices  bread  (30  gm.  each). 

Butter,  20  gm. 

Coffee,  160  c.c. 

Sugar,  I  teaspoonful.   -  200  c.c. 

Milk,  40  c.c. 

\l\[kj  200  C.C. 

Water,  200  c.a 

Dinner,  12  Noon 

3Icat  soup,  180  c.c. 

Bec&teak,  100  gm. 

Potato  (baked,  mashed  or  boiled),  130  gm. 

Ckeen  vegetables,  as  desired. 

Two  slices  bread  (30  gm.  each). 

Batter,  20  gm. 

Tea,  rSo  c.c. 

Sugar,  I  tea^x)onful.  h  200  c.c. 

Vrlk  20  c 

Water.  250  c.c. 

Fuddmg  (tapioca  or  rice),  no  gm. 

Supper,  5  p.  m. 

Ywn  egg^r  cooked  any  style. 
Two  iiices  bread  (30  gm.  each). 
BiiWdBT,  20  gm. 
TToaL  rSo  c.c. 
idipur.  I  tea^xwnfuL 

HEik,  20  cc 

ffrait  stewed  or  fresh),  i  portion. 

Wafflr,  300  c.c- 


200  c.c. 


i  .^  3C. — So  food  or  fluid  is  to  be  given  during  the  night  or  until 
S'f'  ::«ck  the  next  morning  (after  voiding),  when  the  regular  diet  is 


Stlxxent  is  to  empty  the  bladder  at  8  a.  m.  and  at  the  end  of  each 
jKiiaL  JLA  indicated  below.  The  siH^cimenn  are  tu  bt?  coll(*cted  for 
iifai-:hilawing  periods  in  properly  luhelled  bottles: 

/^  k.   it-ca  A.  M..   10  A.   M.-I2   N.,    12   N.    2   l\  Mm  2  l».  M.    4  P.  M., 

J43?.?i:-n  p.  it,  6  p.  M.-8  p.  M.,  8  I*.  M.-8  a.  m. 

ITie  :ibove  diet  contains  upproxiiniitcly  1.^4  gm.  of  nitrogen, 
rSf5^gn.  'ji  salt,  and  1760  c.c.  of  lluidn  and  a  lonsidrnililr  amount  of 


784  THE   KIDNEYS   AND  URETERS 

purin  material  in  the  meat,  soup,  tea,  and  coflfee.  These  all  act  ai 
diuretics  and  the  test  depends  upon  the  manner  in  which  the  kidnej 
responds  to  these  stimuli.  Mosenthal  emphasizes  that  the  urb 
must  be  collected  pimctually  every  2  hours,  that  no  solid  food  oi 
fluid  be  taken  between  meals,  and  that  the  12  hour  night  spedmei 
be  completed  before  the  breakfast  is  touched.  The  quantity  ani 
specific  gravity  of  each  specimen  is  determined.  Originally  the  tota 
and  percentage  content  of  salt  and  nitrogen  of  each  specimen  wa 
also  estimated,  but  it  is  now  considered  sufficient  if  this  is  limite< 
to  the  total  day  and  night  specimens. 

Mosenthal  gives  at  length  the  responses  and  the  test  in  healt 
and  disease,  which  may  be  summarized  as  follows:  In  normal  ii 
dividuals  the  urine  will  show  variations  in  the  specific  gravity  in  tl 
2  hour  specimens  of  nine  points  or  more  from  the  highest  to  tl 
lowest.  The  quantity  of  water,  salt,  and  nitrogen  eliminated  a] 
proximately  balances  the  intake.^  The  night  urine  is  of  high  spedi 
gravity  (1018  or  more),  is  high  in  its  percentage  of  nitrogen  (aboi 
I  per  cent.),  and  small  in  amount  (400  c.c.  or  less),  regardless  of  tl 
amount  of  fluid  taken  or  the  quantity  of  urine  voided  during  the  da; 

When  the  functional  activity  of  the  kidney  is  diminished,  tl 
night  urine  usually  shows  the  effects  first,  the  quantity  increasinj 
the  specific  gravity  being  lowered,  and  the  concentration  of  nitroge 
diminishing.  More  marked  impairment  of  fimction  is  characterize 
by  a  decided  lowering  and  fixation  of  the  specific  gravity,  a  dimii 
ished  output  of  salt  and  nitrogen,  a  tendency  to  total  polyuria,  an 
a  night  urine  showing  an  increase  in  volume,  low  specific  gravit] 
and  low  concentration  of  nitrogen.  Fixation  of  the  specific  gra\it 
in  additon  to  occurring  in  nephritis,  may  be  an  indication  of  in 
paired  renal  function  secondary  to  extrarenal  conditions,  as  pyelitis 
cystitis  with  prostatic  hypertrophy,  hydronephrosis,  pyonephrosis 
polycystic  kidneys,  renal  congestion  due  to  cardiac  diseases,  diabetes 
and  anemias. 

The  Elimination  in  the  Urine  of  Foreign  Substances  as  an  Index  0 

Renal  Function 

The  Phloridzin  Test. — This  test  depends  upon  the  property  0 
the  healthy  kidneys  to  form  sugar  from  phoridzin.     The  bladder  i 

^  The  quantity  of  urine  excreted  will  be  about  400  c.c.  less  than  the  fluid  intake,  th 
loss  occurring  through  the  skin,  lungs,  and  intestines.  Ninety  per  cent,  of  the  nitroge 
intake  should  be  eliminated,  the  balance  being  lost  in  the  feces.  Sodium  chloride  1 
excreted  entirely  in  the  urine,  except  in  diarrhoea  (Mosenthal). 


TESTS   OF   KTONEY   FUNCTION  785 

first  emptied  and  then  iblTl  (i  c.c.)  of  an  aqueous  solution  of  phlo- 
ridzin  containing  0.005  ^o  °-°i  g™-  (approximately  }  i^  to  ^^  gr.)  of 
the  drug  is  injected  into  the  buttock.  If  the  kidneys  are  healthy, 
glycosuria  should  appear  within  fifteen  minutes  to  half  an  hour  after 
the  administration  of  the  phloridzin  and  should  persist  for  about  two 
to  four  hours.  Delay  in  its  appearance  or  the  excretion  of  only  small 
amounts  of  sugar  points  to  renal  insufficiency,  while  an  entire  ab-  ■ 
sence  of  sugar  indicates  that  the  kidneys  are  seriously  affected.  If 
the  functional  activity  of  each  kidney  is  to  be  determined,  a  catheter 
is  placed  in  each  ureter  and  the  relative  proportion  of  sugar  in  the 
separate  specimens  of  urine  thus  obtained  is  estimated. 

Methylene-blue  and  Indigo-carmin  Test. — Another  method 
of  testing  the  functional  activity  oi  the  kidneys  is  to  inject  drugs, 
such  as  methylene  blue  or  indigo-carmin,  which  color  the  urine  after 
entering  the  circulation.  For  this  purpose  the  bladder  is  emptied  and 
i&Wi  (i  c.c.)  of  a  5  per  cent,  solution  of  methylene  blue  or  5  drams 
(20  c.c.)  of  a  0.4  per  cent,  solution  of  indigo-carmin  is  injected  intra- 
muscularly. If  the  kidneys  are  normal,  upon  cystoscopic  examina- 
tion within  half  an  hour  after  administration  of  the  methylene  blue 
and  within  nine  to  twelve  minutes  after  the  administration  of  the 
indigo-carmin.  stained  urine  will  be  seen  escaping  from  the  ureteral 
orifices.  On  account  of  the  slow  elimination  of  methylene  blue, 
requiring  observations  over  a  long  period  ol  time,  this  test  has  not  the 
same  value  as  the  indigc-carmin. 

It  is  claimed  for  these  tests  that  if  the  coloring  of  the  urine  is  de- 
layed or  its  intensity  lessened  it  tends  to  show  that  there  is  some  im- 
pairment of  the  renal  function. 

The  Phenolsulphonephthalein  Test. — Tn  1910  Rowntree  and 
Geraghty  proposed  a  new  colorimetric  test  for  estimating  the  renal 
function  by  using  phenolsulphonephthalein.  As  this  drug  is  very 
rapidly  and  almost  exclusively  eliminated  from  the  body  by  the 
kidneys,  the  test  is  one  of  the  most  delicate  and  reliable  for  determin- 
ing the  functional  efficiency  of  the  kidneys.  When  the  kidney  func- 
tion is  not  impaired,  the  drug  is  present  in  the  urine  within  five  to 
ten  minutes  after  a  subcutaneous  injection,  from  40  to  60  per  cent,  of 
it  being  excreted  within  the  first  hour  and  from  20  to  sg  per  cent, 
during  the  second  hour.  After  an  intramuscular  injection,  the  drug 
appears  in  the  urine  in  about  the  same  time  as  after  a  subcutaneous 
injection,  but  from  5  to  10  per  cent,  more  is  eliminated  during  the 
first  hour.  Following  an  intravenous  injection,  the  drug  appears  in 
the  urine  in  from  three  to  five  minutes,  and  from  35  to  45  per  cent,  of 


4 


786  THE   KIDNEYS  AND  URETERS 

it  is  eliminated  within  the  first  half  hour  and  63  to  80  per  cent, 
the  first  hour. 

The  quantity  of  the  drug  eliminated  during  a  given  time  in 
the  excretory  capacity  of  the  kidneys,  that  is,  in  impaired 
activity  the  appearance  of  the  drug  in  the  urine  will  be  dela> 
the  quantity  will  be  diminished  according  to  the  amount  of 
involvement  present.  It  is  thus  a  valuable  test  in  cardi 
cases  in  determining  the  degree  of  kidney  impairment  and 
diagnosis  of  uremia  from  conditions  that  may  simulate  it. 
types  of  nephritis  the  elimination  of  phthalein  is  decreas 
surgical  work  the  test  is  of  great  value  as  in  addition  to  fur 
information  as  to  the  functional  capacity  of  the  two  kidne 
possible  to  determine  the  amount  of  work  performed  by  eacl 

Technic. — Twenty  minutes  to  half  an  hour  before  making 
the  patient  is  given  two  or  three  glasses  (300-400  c.c.)  of  ¥ 
order  to  assure  a  free  urinary  secretion.  Under  the  usual 
precautions  the  patient  is  catheterized,  the  catheter  being  lef 
empty  bladder.  Sixteen  minims  (i  c.c.)  of  the  standard  '< 
solution  of  phenolsulphonephthalein  containing  0.006  gm.  (a 
mately  J^o  g^O  of  the  drug  is  then  injected  subcutaneously 
muscularly,  or  intravenously^  and  the  time  of  injection  is 
The  urine  is  allowed  to  flow  into  a  test-tube  containing  a  drop 
per  cent,  solution  of  sodium  hydroxid  and  the  time  of  the  fir 
pinkish  tinge  is  noted.  The  catheter  is  now  withdrawn,  the 
being  required  to  urinate  into  a  receptacle  at  the  end  of  an  ho 
the  first  appearance  of  the  drug  and  in  a  second  receptacle 
end  of  the  second  hour.  In  the  presence  of  urinary  obstruct] 
catheter  is  left  in  the  bladder,  the  hourly  specimens  being  sep 
collected.  Twenty-five  per  cent,  solution  of  sodium  hydroxic 
added  to  the  urine  in  sufficient  quantity  to  render  it  strongly  i 
and  bring  out  the  characteristic  color — a  brilliant  purple  red. 

To  determine  the  amount  of  dye  present  a  Duboscq  colorin 

a  modified  Hellige  hemoglobinometer  is  employed.     The  s 

containing  the  urine  is  diluted  with  sufficient  distilled  water  to 

y  tj{  quart  (i  liter)  and,  after  thoroughly  mixing,  a  small  filtered  po 

j  compared  with  a  standard  in  the  colorimeter.     A  simpler  am 

accurate  method  is  to  prepare  a  series  of  standard  solutions  : 
tubes  containing  5,  10,  15,  20  p>er  cent.,  etc.,  of  the  drug  up  to 

1  Rountrcc  and  Gcraghty  (Journal  of  American  Medical  Association^  Sept 
advocate  for  general  use  the  intramuscular  injection  in  the  lumbar  muscles. 


1 


I  . 


/■■/: 

/.■/ 


/  I 


TESTS    OF    KIDNEY    FUNCTION  787 

cent.,  and  then  selecting  the  standard  tube  which  matches  the  color 
of  the  diluted  urinary  specimen. 

To  determine  the  functional  efficiency  of  each  kidney,  the  ureters 
are  catheterized  and,  as  soon  as  the  urine  flows  freely,  the  drug  is 
injected.  The  time  of  injection  is  recorded  and  the  collection  of  urine 
from  each  side  is  continued  for  one  hour  fiom  the  time  of  the  first 
appearance  of  the  drug.  If  the  drug  is  given  intravenously  the  urine 
need  only  be  collected  for  fitteen  minutes  after  the  appearance  of 
the  drug.  The  quantity  excreted  in  each  specimen  is  then  estimated 
as  described  above. 

Tke  Concentration  in  the  Blood  of  Substances  Normally  Excreted  in 
the  Urine  as  an  Index  of  Renal  Function 

Blood  Chemistry.— The  estimation  of  the  retention  in  the  blood 
of  certain  nitrogenous  products  of  metabolism  is  the  basis  of  a  number 
of  tests  of  kidney  function.  The  most  important  determinations 
from  the  standpoint  of  renal  function  are  the  total  non-protein 
nitrogen,  urea,  uric  acid,  and  creatinin.  Through  the  failure  on  the 
part  of  the  kidney  to  eliminate  these  nitrogenous  products  which  are 
present  in  the  blood  in  a  constant  amount  in  health,  they  are  retained 
and  accumulate  in  the  blood.  An  estimation  of  the  concentration 
of  these  substances  in  the  blood,  therefore,  gives  a  fairly  reliable 
indication  of  the  renal  efiiciency,  and  it  becomes  of  still  greater  value 
if  combined  with  a  simultaneous  examination  of  the  urine.  Tests 
of  retention  are  also  of  the  greatest  help  in  prognosis  and  in  furnish- 
ing a  guide  as  to  the  necessity  for  a  restricted  protein  diet  in  nephritis. 

Retention  tests  require  the  collection  of  from  H  to  2J-2  drams 
(j  to  10  c.c.)  of  blood  from  the  patient,  the  technic  of  which  will  be 
found  described  on  page  302.  For  the  details  of  the  actual  quantita- 
tive estimations,  the  reader  is  referred  to  works  on  laboratory  technic 
or  clinical  chemistry.  It  will  be  only  possible  here  to  refer  to  the 
normal  concentration  of  these  substances  in  the  blood  and  the  sig- 
nificance of  variations. 

Non-protein  Nitrogen  in  the  Blood. — The  normal  content  is  from 
22  to  30  mg.  per  100  c.c.  of  blood.  In  health  approximately  50  per 
cent,  of  this  is  represented  by  blood  urea.  Non-protein  nitrogen  is 
markedly  influenced  by  the  quantity  and  quality  of  the  food  taken, 
and  on  a  full  meal  with  meat  diet  Tileston  and  Comfort  found  an 
average  rise  of  4.7  mg. 

A  concentration  above  30  mg.  per  100  c.c.  of  blood  may  be  re- 
garded as  indicating  some  degree  of  renal  impairment.     Tileston 


788  THE  KIDNEYS  AND  URETERS 

and  Comfort  (Archives  of  Internal  Medicine^  Nov.,  1914),  from  obser- 
vation of  a  large  series  of  cases,  draw  the  following  conclusions:  A 
rise  of  non-protein  nitrogen  of  from  30  to  35  mg.  per  100  c.c.  of 
blood  indicates  slight  impairment  of  kidney  function,  from  35  to  50 
mg.  considerable,  and  from  50  to  100  mg.  a  very  marked  impairment, 
while  100  mg.  or  over  is  of  dangerous  significance.  They  only  en- 
countered a  concentration  of  over  100  mg.  in  two  conditions  besides 
uremia,  /.«.,  acute  intestinal  obstruction  and  profound  anemia  from 
hemolysis.  In  disease  from  32  to  85  per  cent,  of  the  increase  is 
accounted  for  by  urea. 

Urea  in  the  Blood. — In  health,  blood  urea  is  present  in  from  11  to 
15  mg.  per  100  c.c.  of  blood,  forming  about  50  per  cent,  of  the  non- 
protein nitrogen.  It  is  very  markedly  affected  by  a  high  protein 
diet,  on  a  full  meal  with  meat  diet  the  rise  averaging  2.5  mg.  (Tileston 
and  Comfort).  With  deficient  elimination  it  accumulates  in  the 
blood  and  the  greater  the  amount  of  concentration  the  more  serious 
is  the  prognosis.  A  concentration  of  urea  above  15  mg.  per  100  c.c 
of  blood  may  be  taken  as  indicative  of  retention.  From  15  to  50  mg. 
per  100  c.c.  of  blood  are  met  in  moderate  degrees  of  impairment, 
and  in  the  presence  of  from  100  to  200  mg.  the  prognosis  is  serious. 

Urea  and  non-protein  nitrogen  parallel  each  other  to  such  an 
extent  that  frequently  the  estimation  of  only  one  is  made. 

Uric  Acid  and  Creatinin  in  the  Blood. — In  health  uric  add  is  pres- 
ent in  from  2  to  3  mg.  per  100  c.c.  of  blood,  and  creatinin  in  from  i  to 
1.5  mg.  per  100  c.c.  of  blood.  Creatinin  on  a  meat-free  diet  is  en- 
tirely of  endogenous  origin  and,  for  this  reason,  it  is  considered  by 
many  as  a  more  reliable  indication  of  renal  insufficiency  than  blood 
urea.  A  rise  of  creatinin  to  3.5  mg.  per  100  c.c.  of  blood  is  of  danger- 
ous significance,  while  5  mg.  usually  means  a  fatal  result  in  a  short 
time. 

In  studies  of  renal  function  in  nephritis  by  Chase  and  Myers 
{Journal  of  the  American  Medical  Association,  Sept.  23,  1916),  it  was 
observed  that  high  uric  acid  estimations  were  frequently  found 
without  any  other  retention,  while  creatinin  appeared  to  be  retained 
only  in  the  last  stages  of  the  disease.  They  found  that  normally 
creatinin  is  the  most  readily,  and  uric  acid  the  least  readily,  elimi- 
nated by  the  kidney,  urea  being  intermediate,  and  that  therefore 
uric  acid  retention  should  constitute  one  of  the  early  signs  of  incipient 
interstitial  nephritis,  while  a  considerable  creatinin  retention  should 
indicate  a  grave  functional  impairment  of  the  kidney  and  should  be  a 
valuable  prognostic  sign. 


TESTS   OF    KIDNEV   FUNCTION  789 

Ambard's  Coefficient  and  the  McLean  Index  of  Urea  Excretioa.— 

The  relation  between  the  concentration  of  urea  in  the  blood  and  urea 
excreted  by  the  kidneys  as  expressed  by  Ambard's  constant  or  the 
McLean  index  is  considered  of  more  value  in  determining  slight 
degrees  of  renal  impairment  and  as  an  indication  of  prognosis  than 
the  estimation  of  blood  urea  or  non-protein  nitrogen.  Kidney  im- 
pairment may  be  thus  indicated  in  cases  that  show  normal  ranges 
in  the  blood  of  nitrogenous  products. 

Ambard  found  that  when  the  kidneys  are  normal  certain  laws 
govern  the  relationship  between  the  urea  content  of  the  blood  and 
urine.     His  conclusions,  known  as  Ambard's  laws,  are  as  follows: 

1.  When  the  concentration  of  urea  in  the  urine  is  constant,  the 
rate  of  excretion  varies  directly  as  the  square  of  concentration  of 
urea  in  the  blood. 

2.  When  the  concentration  of  urea  in  the  blood  remains  constant, 
the  rate  of  excretion  varies  inversely  as  the  square  root  of  the  con- 
centration in  the  urine. 

3.  That  other  factors  being  the  same,  the  rate  of  excretion  varies 
directly  with  the  weight  of  the  individual. 

He  demonstrated  a  constant  ratio  between  the  concentration  of 
urea  in  the  blood  and  the  rate  of  excretion  in  the  urine.  This  numer- 
ical constant,  known  as  Ambard's  Coefficient,  is  determined  by  the 
following  mathematical  formula: 


i'r 


Constant  {A') 


^^F1^ 


'5 


Ur  =  Grams  of  urea  per  liter  of  blood. 

D  —  Grams  of  urea  excreted  per  24  hoursl 
Wt  =  Weight  of  individual  in  kilograms. 

C  =  Grams  of  urea  per  liter  of  urine. 

25  grams  per  liter  is  taken  as  the  standard  concentration  of  urea 
in  the  urine  and  70  kg.  as  the  standard  weight. 

The  normal  value  of  the  Coefficient  is  between  0.07  and  o,og. 
In  impaired  function  with  inability  of  the  kidney  to  eliminate  in 
proportion  to  the  concentration  of  urea  in  the  blood  there  is  a  rise  in 
the  constant  in  proportion  to  the  degree  of  renal  insufficiency.  Val- 
ues of  from  0.09  to  0.12  indicate  slight  impairment,  0.13  to  o.z  a 
moderate  degree  of  impairment,  and  above  0.2  severe  renal 
impairment. 

McLean  modified  the  above  by  using  a  formula  adapted  from 


790  THE   KIDNEYS   AND   I7]t£:TERS 

Ambard's  laws  which  he  has  termed  the  index  of  urea  excretion. 
It  is  determined  by  the  following  formula: 

Index  (/)  ^^'  ^  ^'^^ 

^  ^   Wt  X  (Ur)« 

An  index  of  loo,  corresponding  to  a  value  for  Ambard's  Coeffi- 
cient of  0.08,  is  the  standard  normal  index.  Variations  are  expressed 
in  terms  of  the  normal.  Thus  an  index  of  50  equals  the  rate  of  excre- 
tion of  50  per  cent,  of  normal  under  conditions  of  concentration  in 
the  blood  and  urine.  An  index  below  80  is  considered  abnormal 
and  one  below  50  in  renal  disease  is  an  evidence  of  marked  kidney 
impairment. 

These  tests  are  not  available  for  use  in  general  practice,  as  they 
require  very  accurate  collections  of  urine  and  time  measurements, 
and  the  services  of  an  expert  chemist  to  carry  out  the  various  estima" 
tions.  For  the  technic  the  reader  is  referred  to  works  on  laboratory 
methods. 

Cryoscopy  of  the  Blood  and  Urine. — Cryoscopy  is  the  determina- 
tion of  the  treezing-point  of  a  liquid  compared  to  that  of  distilled 
water.  The  underlying  principle  of  this  test  is  that  fluids  containing 
a  small  amount  of  solid  material  give  a  high  freezing-point  whik 
liquids  with  greater  concentration  freeze  at  a  lower  temperature. 
Applied  to  the  blood  and  urine,  cryoscopy  is  valuable  in  determin- 
ing the  renal  activity  of  the  kidneys  and  in  some  cases  may  be  of 
prognostic  value  when  renal  impairment  exists.  For  example,  if  the 
kidneys  are  doing  an  insufficient  amount  of  excretory  work,  there 
will  be  an  accumlation  of  solid  material  in  the  blood  which  will, 
therefore,  freeze  at  a  lower  temperature  than  normal,  and  at  the 
same  time  the  urine  in  such  a  case,  through  impairment  of  the 
power  of  the  kidneys  to  eliminate  properly,  will  give  a  higher 
freezing-point  than  normal. 

The  freezing-point  of  normal  blood  is  0.56°  C.  below  that  of  dis- 
tilled water.  In  weakened  anemic  individuals,  however,  it  may  rise 
to  —0.55°  C.  or  even  as  high  as  —0.53°  C.  or  —0.52®  C.  If  cryo- 
scopy of  the  blood  gives  a  freezing-point  below  —0.56°  C,  it  is 
regarded  as  indicating  some  impairment  of  the  renal  function  with 
retention  of  waste  products  in  the  blood.  According  to  Kummell,  if 
the  freezing-point  of  blood  falls  to  —0.60°  C.  it  indicates  such  a  de- 
gree of  renal  impairment  that  nephrectomy  is  contraindicated. 

Cryoscopy  of  the  urine  is  of  less  value  than  when  the  test  is  ap- 
plied to  the  blood.     Healthy  urine  freezes  at  —0.9°  C.  to  —2°  C,  and 


SKIAGRAPHY  791 

if  the  freezing-point  is  higher  than  — o.g°  C.  it  is  considered  to  be  in- 
dicative of  insufficient  activity.  Cryoscopy  of  urine  collected 
separately  from  each  kidney  by  ureteral  catheterization  will  give 
more  information  than  when  the  test  is  applied  to  the  bulk  of  urine. 

To  carry  out  this  test  3}-i  drams  (lo  c.c.)  of  blood  and  urine  are 
required.  For  comparative  examination  the  two  should  be  collected 
at  the  same  time,  the  former  by  venous  puncture  (page  302)  and  the 
latter  by  ureteral  catheterization  (page  759}. 

For  the  technic  of  cryoscopy,  which  requires  a  considerable 
amount  of  skill  to  properly  carry  out,  the  reader  is  referred  to  some  of 
!  manuals  on  clinical  laboratory  methods. 


the  m; 

I 


SKIAGRAPHY 


*The  X-ray  is  of  the  greatest  aid  in  the  diagnosis  of  ureteral  and 
renal  calculi.  A  good  picture  will  give  positive  information  as  to  the 
position  of  a  calculus,  that  is,  whether  it  is  located  in  the  ureter  or 
kidney  and  will  demonstrate  the  number  and  size,  as  well  as  the 
position  of  the  kidneys.  In  order  to  interpret  the  results  of  the  X-ray 
correctly  the  plate  should  show  the  following  anatomic  landmarks. 
The  eleventh  and  twelfth  ribs,  the  transverse  processes  of  the  verte- 
brae, the  crests  of  the  ilia,  and  the  psoas  muscle.  If  these  points  are 
shown,  the  position  of  a  calculus  may  be  determined  with  accuracy. 
The  shadows  cast  by  tumors,  fecal  concretions,  calcified  retroperit- 
oneal glands,  buried  sutures  which  have  become  calcified,  phleboliths, 
foreign  bodies  in  the  intestines,  the  thickened  tip  of  an  appendix,  etc., 
are  sometimes  wrongly  interpreted  as  calculi.  Such  errors  may  be 
avoided  if  a  catheter  filled  with  a  30  per  cent,  bismuth  paste  or  a 
catheter  in  which  a  lead  wire  stylet  has  been  placed  is  inserted  into 
the  ureter  and  renal  pelvis,  and  an  X-ray  is  then  taken.  The  shadow 
of  a  calculus  will  be  shown  to  be  in  close  relation  to  that  produced  by 
the  wire  in  the  ureter.  Thus,  while  a  positive  picture  can  usually  be 
taken  as  proof  of  the  presence  of  a  calculus,  this  cannot  always  be 
said  of  the  negative  evidence  furnished  by  an  X-ray.  It  must  be 
remembered  that  great  thickness  of  the  abdominal  wall  may  interfere 
with  the  success  of  a  picture  and  that  the  chemical  composition  of  the 
stODe  is  also  an  important  element,  for  while  oxalate  and  phosphate 
stones  give  a  deep  shadow,  those  composed  of  uric  acid  furnish  but 
faint  shadows  and  may  escape  recognition.  In  all  cases  to  obtain  a. 
successful  picture  it  is  absolutely  essential  that  the  stomach  be  empty 
and  the  bowels  be  thoroughly  cleared  by  a  purge  given  the  night 
before  and  an  enema  the  morning  of  the  examination. 


792  THE  .KIDNEYS   AND   URETERS 

Pyelography. — ^This  consists  in  the  injection  of  an  opaque  fluid 
into  the  ureter  and  renal  pelvis  followed  by  an  immediate  radiograph. 
This  method  of  diagnosis  is  of  the  greatest  value  in  demonstrating  the 
extent  and  character  of  dilatations  of  the  renal  pelvis  and  ureter, 
distortions  of  the  pelvis  by  tumors  or  stones  and  of  the  ureter  by  the 
presence  of  stones  or  strictures. 

A  lo  to  15  per  cent,  solution  of  collargol,  a  50  per  cent,  solution 
of  argyrol,  a  5  per  cent,  silver  iodid  emulsion,  and  a  10  per  cent 
thorium  nitrate  solution  are  among  those  frequently  employed. 
The  catheter  is  inserted  into  the  renal  pelvis  and  the  contents  are  al- 
lowed to  run  oflf.    A  quantity  of  the  warmed  opaque  solution  suffi- 
cient to  distend  the  renal  pelvis  is  then  allowed  to  slowly  flow  in  under 
the  force  of  gravity;  it  should  not  be  injected  with  a  syringe,  as  it 
has  been  shown  that  collargol  solution  injected  even  under  moderate 
pressure  may  pass  up  the  tubules  into  the  kidney  tissue  producing 
infarcts.    The  quantity  of  fluid  used  will  depend  upon  the  size  of  the 
pelvis  previously  determined  by  pyelometry  (see  page  774)  or  by  the 
production  of  pain  when  the  pelvis  is  distended.    To  study  the 
ureter  the  catheter  is  partly  withdrawn  so  that  the  ureter  may  be 
filled  up  and  distended  by  the  solution.    The  catheter  is  then 
plugged  to  prevent  the  escape  of  the  solution  and  the  opposite  side 
is  similarly  injected,  a  radiograph  being  taken  inmiediately.    The 
plugs  are  finally  removed  from  the  catheters  and  the  solution  is 
allowed  to  drain  off.    To  aid  in  removing  the  solution  it  is  well  to 
induce  a  polyuria  by  giving  the  patient  a  glass  of  water  to  drink  at 
the  completion  of  the  operation. 

EXPLORATORY  INCISION 

In  cases  of  contemplated  nephrectomy  where  other  means  of 
diagnosis  fail  to  give  satisfactory  results,  an  exploratory  operation 
will  determine  the  exact  condition  of  the  second  kidney.  The  kidney 
requiring  removal  is  first  exposed  and  thoroughly  explored.  If  its 
removal  seems  indicated,  it  is  replaced  for  the  time  being  and  the 
kidney  supposed  to  be  healthy  is  then  cut  down  upon  by  a  lumbar 
incision,  the  capsule  is  incised,  and  the  organ  is  palpated  and  if  neces- 
sary inspected.  If  it  is  found  to  be  healthy,  the  wound  is  closed  and 
the  other  kidney  may  then  be  removed.  Should,  however,  such 
exploration  reveal  serious  disease  of  the  second  kidney,  nephrectomy 
is  contraindicated. 


MEDICATION    OF    THE    RENAL    PELVIS    AND    URETERS  793 

Therapeutic  Measures 

MEDICATION  OF  THE  RENAL  PELVIS  AND  IJRETERS 

Lavage  of  the  kidney  pelvis  and  ureter  has  been  employed  with 
considerable  success  in  treating  subacute  and  chronic  affections  of 
the  kidney  pelvis  and  ureter.  The  procedure  is  not  difficult  for  one 
skilled  in  the  passage  of  the  ureteral  catheter,  and  properly  performed 
seems  to  be  without  danger.  It  is  not  a  suitable  method  of  treat- 
ment, however,  in  acute  infections,  and  in  chronic  cases,  even, 
other  measures  should  be  hrst  given  a  trial. 


Fio.  791.^ — Medication  of  the  renal  pelvis. 

Instruments. — In  addition  to  the  apparatus  necessary  for  ureteral 
catheterization  (see  pages  759,  769)  there  will  be  required  a  glass 
syringe, with  a  capacity  of  zH  drams  (10  c.c.) , supplied  with  ablunt 
nozzle  sufficiently  small  to  fit  into  the  end  of  the  catheter. 

Asepsis. — The  same  precautions  against  infection  should  be 
observed  as  detailed  under  ureteral  catheterization  (pages  761,  770). 

Solutions  Used. — Sterile  water,  a  saturated  solution  of  boric  acid, 
silver  nitrate  in  the  strength  of  i  to  8000  increased  in  strength  up  to 
I  to  2000,  protargol  i  to  500  to  2  per  cent.,  argyrol  2  to  5  per  cent., 
collargol  4  per  cent.,  bichlorid  of  mercury  i  to  150,000  to  1  to  16,000 
may  be  employed.     Too  strong  solutions  will  result  in  colic. 

For  the  purpose  of  aiding  the  passage  of  an  impacted  calculus 
injections  of  sterile  olive  oil  have  been  employed. 


794  THE   KIDNEYS   AND   URETERS 

Temperature. — The  solution  should  be  at  a  temperature  of.  loo* 
F.  (38°  C). 

Quantity. — One  to  2  drams  (about  5  to  10  c.c.)  of  solution  arc 
generally  injected  at  a  time.  If  large  amoimts  are  employed,  over- 
distention  of  the  renal  pelvis  will  result  with  consequent  colic. 

Frequency. — The  treatments  may  be  applied  once  Or  twice  a 
week. 

Position  of  Patient. — Same  as  for  ureteral  catheterization  (pages 
(761,  770). 

Anesthesia. — (See  pages  761,  771.) 

Preparations  of  Patient. — The  same  as  for  ureteral  catheteriza- 
tion (pages  762,  771). 

Technic. — The  catheter  is  inserted  into  the  renal  pelvis  as  pre- 
viously described  (pages  762,  771).  Any  fluid  or  pus  collection  is 
then  allowed  to  drain  off,  and  the  tip  of  the  syringe,  charged  with  th( 
solution,  is  introduced  into  the  end  of  the  catheter  and  i  or  2  dranu 
(about  5  to  10  c.c.)  of  solution  are  injected.  Care  must  be  taken  U 
see  that  the  syringe  contains  no  air  and  the  injection  must  be  givei 
very  slowly  and  evenly  to  avoid  a  sudden  distention  of  the  kidney  pel 
vis.  The  syringe  is  then  disconnected,  the  patient  is  raised  to  J 
semiupright  position,  and  the  solution  is  allowed  to  escape;  if  J 
small  catheter  is  employed,  the  solution  may,  however,  escape  besid 
it  into  the  bladder.  This  washing-out  process  may  be  repeate( 
until  the  solution  returns  clear.  The  syringe  is  again  counecte( 
with  the  catheter*  which  is  slowly  withdrawn,  the  solution  bein^ 
injected  the  while  so  as  to  medicate  the  entire  ureter.  At  the  com 
pletion  of  the  operation  the  bladder  is  irrigated. 

To  aid  the  passage  of  a  ureteral  calculus  by  the  injection  of  olivt 
oil,  the  following  technic  is  employed:  a  ureteral  catheter  is  passed 
beyond  the  stone  if  possible,  and,  if  not,  up  to  it,  and  a  few  drops  oi 
sterile  olive  oil  are  injected.  This  acts  as  a  lubricant  and  the  stone 
is  often  readily  passed  as  a  result. 

THE  DILATATION  OF  URETERAL  STRICTURES 

The  gradual  dilatation  of  ureteral  strictures  may  be  performed  by 
suitable  bougies,  introduced  with  the  aid  of  the  cystoscope.  While  it 
is  doubtful  if  a  permanent  cure  can  be  obtained  in  many  cases  by  this 
method,  as  such  strictures,  like  those  of  the  urethra,  rectum,  etc.,  tend 
to  recontract  in  the  majority  of  cases,  the  patient  is  greatly  benefited 
for  the  time  being  through  relief  of  the  distention  of  the  ureter  and 


THE    DILATATION    OF    URETERAL    STEICTUKES 


79S 


kidney  pelvis  caused  by  the  obstruction.  The  majority  of  strictures 
are  located  near  the  ureteral  orifices,  and  these  are  most  readily  di- 
lated, though  the  method  may  be  applied  with  success  to  strictures 
in  any  part  of  the  canal. 

lustruments.' — Dilatation  may  be  effected  by  means  of  flexible 
whalebone  bougies,  flexible  catheters  or,  if  the  stricture  is  near  the 
vesical  end,  by  metal  catheters.  These  instruments  as  well  as  the 
cystoscopes  have  been  already  described  (pages  759,  769). 

Asepsis. — (See  pages  761,  770.) 


Fig.  793. — ShowinR  the  method  of  ililating  a  ureteral 
(After  Kell)'  and  Noble.) 


catments  are  employed  every  two  or 
5  for  ureteral  catheterization  (pages 


Frequency  of  Dilatation.- 

thrce  days. 

Position  of  Patient. — San 
761.  770). 

Preparations. — (See  pages  762,  771.) 

Anesthesia.- — (See  pages  761,  771.) 

Technic. — The  ureteral  orifice  is  located  as  already  described  and 
the  dilator  is  introduced  into  the  ureter  in  the  same  maimer  as  the 
ureteral  catheter  (pages  762,  771).  Choosing  an  instrument  that  the 
stricture  will  readily  admit,  it  is  passed  completely  through  the  stric- 
ture and  is  left  in  place  for  a  few  moments  and  then  a  larger  size  is 
inserted.  At  the  next  treatment  the  stricture  is  dilated  one  or  two 
sizes  more  until  finally  it  is  stretched  sufficiently  to  admit  a  No.  5  or 
6  catheter  with  ease.  Following  each  treatment  lavage  of  the  kidney 
pelvis  and  ureter  may  be  practised  as  described  above. 


CHAPTER  XXm 
THE  FEMALE  GEITERATIV] 

Analomic  ConsitUratii 

The  Vagina. — The  vagina  is  a  muscul 
tending  from  the  uterus  to  the  vulva,  lying 
urethra  in  front  and  the  rectum  behind.  W 
posture  it  is  directed  downward  and  forward 
with  the  horizon.  The  anterior  wall,  which 
rior  wall,  due  to  the  position  of  the  cervix,  n 
(5  to  6  cm.)  in  length,  whilethe  posterior 
inches  (7.5  to  9  cm.).  Normally  the  walls 
distended  the  vagina  becomes  conical  in  sha 
below.  That  portion  surrounding  the  cervi 
roof  or  fornix.  It  is  divided  for  description 
rior  fornix,  in  which  is  normally  felt  the  bo 
tenor  fornix,  th'e  deepest  portion,  which  is 
cul-de-sac  of  Douglas;  and  the  lateral  forni 

Relations. — Anteriorly,  in  its  lower  pwrt 
tion  with  the  urethra  and  in  its  upper  half  wi 
the  bladder.  Posteriorly,  it  is  in  relation  i 
its  lower  quarter,  in  its  upper  quarter  with  t 
and  between  the  two  with  the  rectum. 

Structure. — It  consists  of  a  mucous,  m 
tissue  coat.  The  mucous  membrane,  whic 
riety,  exhibits  on  the  anterior  and  posterio 
or  rugte,  which  extend  out  transversely  from 
are  more  distinct  on  the  anterior  wall. 

The  muscular  coat  is  arranged  in  two  laj 
and  an  outer  circular. 

The  connective- tissue  coat  is  a  thin  fibn 
few  smooth  muscle  fibers.  In  its  meshes  th 
plexus  of  veins. 

The  Uterus  and  Appendages. — The  ut 

low  pear-shaped  organ  lying  in  the  pelvis 

the  rectum.     It  measures  about  3  inches  (7, 

(s  cm.)  in  breadth,  and  i  inch  (2.5  cm.)  in 

796 


ANATOMIC    CONSIDERATIONS 


797 


Externally,  it  is  flattened  from  before  backward,  and  at  the  point 
where  the  peritoneum  is  reflected  from  the  uterus  to  the  bladder  there 
appears  a  constriction,  the  isthmus,  which  corresponds  with  the  posi- 
tion of  the  internal  os  and  divides  the  uterus  into  two  portions.  The 
portion  lying  below  the  isthmus  is  the  cervix,  that  part  between  the 
isthmus  and  a  line  joining  the  entrance  of  the  tubes  is  known  as  the 
body,  while  the  portion  above  the  plane  of  the  entrance  of  the  tubes  is 
known  as  the  fundus.  The  cervix  in  turn  is  also  divided  into  three 
portions:  an  infravaginal  portion,  below  the  attachment  of  the  ante- 
rior vaginal  wall;  a  supravaginal  portion,  above  the  attachment  of  the 
posterior  vaginal  wall;  and  an  intermediate  portion,  lying  between 
the  two. 


The  interior  of  the  uterus  measures  about  a  1/2  inches  fficm.)  in 
length  and  is  divided  into  two  portions  by  the  internal  os.  That 
portion  of  the  canal  above  this  point  is  triangular  in  shape  with  the 
base  upward  and  with  the  walls  normally  in  contact.  In  the  cervical 
portion  the  canal  is  fusiform  in  shape.  The  uterus  opens  into  the 
vagina  through  the  e.\ternal  os,  a  transverse  aperture  having  an  ante- 
rior and  a  posterior  lip,  while  above  it  connects  with  the  peritoneal 
cavity  through  the  Fallopian  tubes. 

Position  of  Uterus. — NormaUy  the  uterus  lies  in  a  slightly  ante- 
flexed  position  with  the  fundus  pointing  toward  the  umbilicus  (Fig. 
793).  Its  position,  however,  is  modified  from  time  to  time  by  the 
neighboring  organs.  Thus  a  distended  bladder  will  push  it  toward 
the  sacrum,  while  a  full  rectum  pushes  it  forward. 


798  THE  FEMALE  GENERATIVE  OHGANS 

Structure. — The  uterus  is  made  up  of  a  mucous,  muscular,  and  i 
peritoneal  coat.  The  mucous  membrane  of  the  body  of  the  uterus  i 
smooth  and  pale  in  color,  with  the  mouths  of  numerous  tubular  gland 
opening  upon  its  surface.  The  lining  epithelium  is  of  the  dliatec 
variety  having  a  motion  from  within  outward. 

In  the  cervix  it  is  firmer  in  structure  and  is  thrown  into  numerou 
folds,  the  arbor  vitae.  These  are  arranged  in  the  form  of  a  mediai 
ridge  on  the  anterior  and  posterior  waUs,  from  which  branch  second 
ary  ridges  in  an  upward  and  outward  direction.  Between  the 
ridges  are  located  the  openings  of  tubular  and  racemose  glands,  t 
the  upper  portion  of  the  cervix  the  mucous  membrane  is  the  same  a 
that  found  in  the  body  of  the  uterus  and  below  it  is  similar  to  that  i 
the  vagina. 

Extending  out  from  either  superior  angle  of  the  uterus  are  the  ti 
Fallopian  tubes.  They  measure  3  to  5  inches  (7.5  to  12.5.  cm.)  i 
length  and  lie  in  the  free  borders  of  the  broad  ligaments  between  tl 
ovaries  behind  and  the  round  ligaments  in  front.  They  are  line 
with  ciliated  epithelium  having  a  direction  toward  the  uterus.  The 
external  apertures,  the  fimbriated  extremities,  open  into  the  peri 
oneal  cavity  near  the  ovary.  Internally,  each  tube  opens  into  tl 
uterine  cavity  at  its  superior  angle. 

The  ovaries,  two  in  number,  lie  on  either  side  of  the  uterus,  aboi 
on  a  level  with  the  pelvic  brim,  near  the  abdominal  extremities  of  tl 
tubes.  Each  ovary  measures  i  1/2  inches  (4  cm.)  in  length,  3/4  inc 
(2  cm.)  in  breadth,  and  1/3  to  1/2  inch  (0.8  to  i  cm.)  in  thicknes! 

• 
Diagnostic  Methods 

In  making  a  gynecological  examination  the  investigation  shouli 
comprise  an  inquiry  into  the  patient's  general  condition  as  well  asai 
examination  of  the  pelvic  organs.  A  clear  and  concise  historj'  of  th 
subjective  symptoms  should  be  the  first  step  in  every  case.  It  i 
preferable  to  allow  the  patient  to  first  detail  her  own  symptoms  and  t 
supplement  this  by  inquiry  as  to  essential  points.  In  doing  this  it  i 
well  to  follow  a  routine  system  in  order  to  avoid  omitting  some  impoi 
tant  point  that  may  have  direct  bearing  upon  the  case,  and  also  tha 
the  examiner  may  have  a  complete  record  for  future  reference. 

In  addition  to  the  usual  questions  commonly  asked  in  obtaining  J 
history,  special  information  should  be  sought  in  regard  to  the  follow 
ing  points.  First  the  menstrual  history  should  be  inquired  into,  ascer 
taining  the  age  at  which  menstruation  began,  the  precautions  taker 


DIAGNOSTIC   METHODS  799 

during  menstruation,  the  interval  between  the  periods,  the  regularity 
of  the  periods,  the  duration  of  the  flow,  and  its  character,  whether 
painful,  whether  accompanied  by  the  passage  of  clots,  and  whether 
scanty  or  profuse.  The  latter  is  especially  important,  as  excessive 
menstrual  bleeding  points  to  the  presence  of  some  pathological 
condition. 

With  a  history  of  painful  menstruation  the  time  the  pain  begins 
and  ceases  in  relation  to  menstruation  should  be  ascertained.  It 
should  also  be  found  out  whether  there  has  been  any  bleeding  be- 
tween the  periods.  If  the  menopause  has  occurred,  its  date  and  the 
presence  or  absence  of  any  bleeding  since  are  to  be  noted.  If  the 
patient  is  married,  certain  data  relating  to  child-bearing  should  be 
sought,  comprising  the  number  of  children,  the  dates  of  their  births, 
a  history  of  the  labors,  whether  easy,  difficult,  or  instrumental  and 
whether  they  were  followed  by  a  long  and  protracted  convalescence. 

With  a  history  of  abortions  or  miscarriages  the  period  of  preg- 
nancy at  which  they  occurred  and  their  probable  cause  should  be 
ascertained.  At  times  it  is  also  important  to  know  something  of  the 
marital  relations,  that  is,  the  frequency  of  coitus,  whether  the  act  is 
painful  and  whether  measures  to  prevent  conception  have  been  em- 
ployed, and,  if  so.the  methods  used. 

The  patient  is  next  questioned  as  to  the  presence  or  absence  of  a 
vaginal  discharge.  If  present,  its  character  should  be  inquired  into, 
whether  foul,  blood-tinged,  or  having  the  characteristics  of  an  ordi- 
nary leucorrhea.  The  quantity  of  discharge  is  also  to  be  noted,  and 
whether  it  is  always  present  or  only  occurs  midway  between  the 
monthly  periods. 

Pain  is  another  frequent  and  important  complaint  upon  which  full 
information  should  be  sought.  The  character  and  situation  of  the 
pain  should  always  be  determined.  The  pain  complained  of  may  be 
in  the  form  of  a  headache,  a  bearing-down  feeling,  backache,  or  its 
situation  may  be  referred  to  some  part  of  the  pelvis,  the  coccyx,  or  the 
inguinal  region.  Inguinal  pain  generally  points  to  some  disease  of 
the  uterine  appendages  or  ligaments;  on  the  other  hand,  backache  is 
found  as  an  accompaniment  of  a  number  of  conditions,  such  as 
chronic  constipation,  uterine  displacements,  pelvic  tumors,  etc.,  while 
pain  in  the  coccyx  is  often  a  symptom  of  neurasthenia.  It  should 
also  be  ascertained  if  the  pain  is  modified  by  menstruation,  and  if  so, 
whether  it  is  worse  before  the  flow  begins,  during  the  flow,  or  after- 
ward, also  whether  it  is  affected  by  exercise,  any  sudden  jolt  or  jar, 
or  by  coitus. 


H 


8CX>  THE  FEMALE  GENERATIVE  ORGANS 

Finally,  since  many  gynecological  patients  have  in  addition  t 
their  pelvic  troubles  other  disorders,  the  general  sjrmptoms  and  th 
functions  of  other  organs  should  be  similarly  inquired  into.  Thu 
the  patient  should  be  questioned  as  to  her  appetite,  loss  of  wdghl 
nausea  and  vomiting,  and  if  the  latter  is  present,  its  character  an 
relation  to  the  taking  of  food,  the  condition  of  the  bowels,  and  whethc 
she  sleeps  well  or  suffers  from  nervousness,  hysteria,  palpitation  of  th 
heart,  hot  flashes,  etc.,  etc. 

The  methods  available  for  such  examination  include  abdomin^ 
inspection,  palpation,  percussion,  auscultation,  and  mensuradoi 
internal  examination  by  inspection  and  palpation,  the  use  of  specul 
and  the  uterine  sound,  digital  exploration  of  the  uterus,  test  excisioi 
test  curettage,  and  exploratory  incision. 

Preparation  of  Patient. — Certain  preparation  of  the  patient 
essential  for  a  thorough  examination,  otherwise  the  results  will  I 
unsatisfactory.  If  an  anesthetic  is  to  be  given,  the  prei>arations  f( 
such,  previously  detailed  (page  i8),  should  be  carried  out.  In  an 
case,  the  bowels  should  be  thoroughly  evacuated  by  means  of  a  mil 
purgative  taken  the  day  before,  followed  by  an  enema  on  the  momii 
of  the  examination.  The  bladder  is  emptied  spontaneously  juj 
before  the  patient  presents  herself  for  examination. 

A  suitable  examining-table  should  be  provided,  and  the  simple 
it  is  the  better.  It  should  be  about  3  feet  (90  cm.)  high,  strong  i 
construction,  provided  with  adjustable  foot-rests,  and  capable  ( 
being  lengthened  so  that  the  patient  may  be  placed  up>on  it  in  th 
horizontal  position.  A  small  step,  to  aid  the  patient  in  mounting 
is  also  necessary.  A  second  small  table  should  be  placed  near  a 
hand,  upon  which  are  placed  solutions,  instruments,  etc.,  that  may  b 
required  during  the  examination. 

When  it  is  necessary  to  make  a  vaginal  examination  in  th 
patient's  home,  an  ordinary  kitchen  table  or  the  bed  may  be  utilizec 
In  the  latter  case  the  patient  is  placed  lengthwise  across  the  bed,  wit 
an  ironing-board  covered  by  several  thicknesses  of  a  sheet  placed  0: 
the  mattress  under  the  patient's  hips,  and  with  the  patient's  lee 
supported  on  two  chairs  (Fig.  794). 

With  the  patient  in  the  desired  position  upon  the  table  it  shoul 
be  seen  that  the  corsets  and  any  constricting  bands  are  removed  froi 
about  the  waist  and  that  the  patient  is  so  covered  by  sheets  that  onl; 
the  region  to  be  examined  is  exposed.  For  an  abdominal  examina 
tion  two  sheets  are  employed,  one  draped  over  the  pehac  region  an< 
lower  part  of  the  abdomen  and  the  other  over  the  upper  abdomen 


GVNECOIOGICAL   POSTURES 


8oz 


For  a  vaginal  examination  the  sheet  is  thrown  over  the  lower  extrem- 
ities and  is  then  separated  so  as  to  expose  the  vulva.  If  the  examiner 
is  provided  with  a  nurse,  these  details  may  be  left  to  her.  While  a 
nurse  is  not  absolutely  necessary,  it  is  always  preferable  to  have  some 
woman  present  at  the  examination,  not  only  for  the  greater  comfort 
of  the  patient,  but  for  the  protection  of  the  physician  against  malici- 
ous charges  at  the  hands  of  unscrupulous  females. 


Fig.  794. — Position  of  the  patient  for 


upon  a  bed.     (.\shtan.) 


Gynecological  Postures, — In  examining  tht  female  pelvic  organs 
a  number  of  postures  are  available.  These  include  the  dorsal,  the 
Sims,  the  knee-chest,  the  erect,  and  the  squatting  positions. 

The  dorsal  position,  which  is  the  best  for  digital  or  bimanual 
examinations,  is  obtained  by  placing  the  patient,  facing  the  light,  flat 
on  the  back,  with  the  hips  near  the  edge  of  the  table  and  with  the 
feet  supported  upon  the  foot-rests  (Fig.  795). 

Tiic  Sims  position  is  obtained  by  placing  the  patient  upon  her 
left  side,  with  the  left  side  of  the  face,  the  left  shoulder,  and  left 
breast  resting  upon  a  flat  pillow.  The  left  arm  lies  behind  th-e  back, 
the  thighs  are  well  flexed  upon  the  body,  and  the  right  knee  is  drawn 
up  nearer  the  body  than  the  left  (see  Fig.  57°)-  ^  this  position  an 
excellent  view  may  be  obtained  of  the  vaginal  fornices,  the  anterior 
vaginal  walls,  and  the  cervix,  but  it  is  not  satisfactory  for  a  digital 


I     vagmai 

I 


THE  lEMALE   GENERATIVE  ORGANS 


examination,  as  the  pelvic  organs  are  more  difficult  to  leach 
with  the  patient  in  the  dorsal  posture. 

The  knee-chest  position  is  obtained  by  having  the  patient 


Fig.  796. — Examination  with  the  patient  standing  ccect.     (Asht< 


Upon  a  table,  with  the  thighs  at  right  angles  to  the  legs,  the 
resting  upon  a  pillow  placed  upon  the  same  level  as  the  knee 
Fig.  572).     In  this  posture  the  intestines  gravitate  toward  th 


INSPECTION  803 

phragm,  and  the  vagina  becomes  distended  so  that  the  numerous 
folds  of  mucous  membrane  are  spread  out  smoothly. 

The  Erect  Posture. — The  patient,  with  her  clothes  elevated  and  a 
sheet  fastened  about  her  hips,  stands  with  one  foot  on  the  floor  and 
the  other  resting  upon  a  stool  6  to  8  inches  (15  to  20  cm.)  high.  The 
examiner  kneels  in  front  of  the  patient  and  passing  his  hand  beneath 
the  sheet,  makes  a  digital  examination  of  the  vaginal  outlet  and  the 
uterus  (Fig.  796).  In  this  position  a  prolapse  of  the  uterus  or  a  re- 
laxation of  the  vaginal  outlet  is  more  readily  recognized  than  in  the 
dorsal  posture. 

The  squatting  posture  is  sometimes  useful  in  ascertaining  the  degree 
of  a  uterine  prolapse  and  the  relaxation  of  the  vaginal  walls.  The 
patient  takes  the  same  position  as  when  at  stool  and,  by  a  slight 
straining  effort,  any  tendency  to  prolapse  is  readily  made  visible  to 
the  examiner. 

Asepsis. — In  all  gynecological  examinations  every  precaution 
must  be  taken  to  avoid  infecting  a  patient  as  well  as  to  prevent  infec- 
tion of  the  examiner  by  the  patient.  All  instruments  that  are  used 
are  boiled  for  five  minutes  in  a  i  per  cent,  soda  solution,  and  no  instru- 
ment should  be  used  on  more  than  one  patient  without  resterilization. 
The  examiner's  hands  are  sterilized  by  a  thorough  scrubbing  with 
tincture  of  green  soap  and  water,  following  by  immersion  in  an  anti- 
septic solution.  The  examiner  should  also  see  that  his  finger-nails 
are  cut  short  to  avoid  hurting  the  patient. 

If  the  patient  is  suspected  of  having  syphilis  or  gonorrhea,  or  in 
the  presence  of  a  septic  discharge,  the  examiner  should  protect 
himself  by  wearing  rubber  gloves  previously  sterilized.  In  the 
majority  of  cases  it  is  sufljcient  to  wipe  off  the  vulva  with  a  swab 
soaked  in  a  1  to  2000  bichlorid  solution,  but  where  a  profuse  or  foul 
discharge  is  present  a  vaginal  douche  may  be  required.  When  it  is 
desired  to  obtain  a  specimen  of  a  discharge  for  examination,  antisep- 
tic solutions  or  douches  should  be  omitted  until  this  has  been  done. 

I  /.  Examinalion  of  the  Abdomen 

mSPECTION 

From  the  appearance  of  the  skin,  the  shape  of  the  abdomen,  and 
the  effect  of  respiration  upon  a  tumor  valuable  information  may  be 
obtained. 

Positioii  of  Patient. — The  patient  should  lie  with  the  body  sym- 
metrically  placed  upon  a  firm  flat  table  in  the  horizontal  position. 


904  THE   FEUAXE  GENEKA.TIVE 

■  Technic. — With  the  patient's  abdomen 
light  falling  obliquely  upon  the  abdomen, 
first  from  the  side  and  then  from  the  foot  c 
The  color  of  the  skin  of  the  abdomen,  tl 
strife,  eruptions,  scars,  edema,  and  dilated  ■ 
abdominal  walls,  whether  rigid  or  lax,  and 
of  the  abdomen  should  aU  be  noted. 

In  enlargement  of  the  abdomen  due  to 
of  the  abdominal  wall  usually  hangs  down 
In  ascites  the  abdomen  is  more  or  less 
bulge  outward.  In  the  presence  of  pregnai 
enlargement  is  smooth  and  regular,  in  tl 
men  being  symmetrically  enlarged,  while  a 
if  small,  may  distend  one  side  only.  Fibre 
irregular  and  nodular  growths.  If  a  tum< 
ence  or  absence  of  mobility  with  respirat 
dominal  walls  move  over  the  growth  should 
weakened  condition  of  the  recti  muscles  oi 
should  also  be  sought  by  having  the  patiet 

PALPATIOIT 

Palpation  of  the  abdomen  is  the  most  s: 
of  abdominal  examination  and  should  fori 
gynecological  examination.  By  it  the  pre 
fluctuation,  or  local  tenderness  that  might 
simply  to  a  vaginal  examination  may  be  re< 
ence  of  an  enlargement,  its  situation,  ori 
consistency  may  be  determined. 

Position  of  Patient. — The  patient  lies  i 
the  shoulders  slightly  elevated  and  the  t 
secure  thorough  relaxation. 

Technic. — The  examiner  first  thorou 
Then,  taking  his  place  upon  one  side  of  the 
palpates  all  portions  of  the  abdomen.  In 
hand— usually  the  right — is  placed  upon  t 
ward,  and  firm  but  gentle  pressure  is  made 
finger  tips  should  be  avoided  as  it  incites 
Local  or  general  rigidity  of  the  abdominal 
the  presence  of  a  tumor  are  thus  ascertain! 

To  differentiate  obesity  from  intraabdo: 


PALPATION  805^ 

are  employed  and  make  deep  pressure  from  the  sides  toward  the 
mid-line,  at  the  same  time  lifting  upward  on  the  abdominal  walls 
(Fig.  797).     The  situation,  origin,  size,  or  mobility  of  a  tumor  is 


Fig.  7Q7.  —Showing  the  method  of  estimating  the  thickness  o(  the  abdominal  walls.    ' 

determined  by  making  deep  pressure  with  both  hands  in  all  direc- 
tions about  the  mass  (Fig,  798).  An  enlarged  uterus  is  mapped  out 
in  the  same  manner.     In  examining  the  lateral  regions  of  the  abdo- 


Flc,   798.^Bimanual  palpation  of  an  abdominal  tumor.     (Ashlon.) 

men  bimanual  palpation  is  often  of  service,  one  hand  being  placed 
under  the  flank  and  making  forward  pressure  while  the  other  hand 
palpates  the  antero-lateral  surface  of  the  abdomen. 


8o6 


THE  FEMALE  GENEBATIVE  ORGANS 


I' 

J   I 

1 


Fluid  collections  axe  recogpized  by  a  thrill  or  wave  produce 
placing  one  hand  with  the  palm  flat  on  one  side  of  the  abdomei 
tapping  the  abdomen  from  the  opposite  side  with  the  fingers  c 
other  hand.  To  avoid  confusing  a  wave  produced  by  tapping 
abdomen  with  that  of  fluid  the  examiner  should  have  an  assi 
place  the  ulnar  edge  of  his  hand  firmly  on  the  summit  of  the  i 
men  while  the  tapping  is  performed  (Fig.  799).  In  the  case  ( 
the  wave  is  then  absent. 


Fig.  799. — Mehod  of  differentiating  between  a  wave  produced  when  tap|nn| 

abdomen  and  one  containing  fluid.     (Ashton.) 


PERCUSSION 

Abdominal  percussion  is  valuable  when  employed  as  an  ad 
to   inspection   and   palpation  in  differentiating  between  tym 
ascites,   cystic  and  solid  tumors,  and  in  determining  the  siz 
shape  of  a  tumor,  and  its  origin.     To  avoid  errors,  the  large 
tine  should  be  emptied  by  an  enema  before  the  examination. 

Position  of  Patient. — Percussion  is  performed,  first,  wit 
patient  lying  on  the  back  and,  then,  turned  upon  the  side. 

Technic. — The  examiner  places  the  palmar  surface  of  the  n 
finger  of  the  left  hand  firmly  upon  the  area  to  be  percussed 
using  the  tip  of  the  middle  finger  of  the  right  hand,  bent  at  a 
angle,  as  a  plexor,  strikes  quick,  sharp  blows  (see  Fig.  529). 
normal  resonance  of  the  abdomen  is  tympanitic  except  in  the  re 
of  the  liver  and  spleen  where  it  is  dull.  Fecal  masses,  cystic  and 
tumors,  and  fluid  collections  give  dulness  on  i>ercussion.     ^ 


II 


If 


PERCUSSION  807 

distended  intestines  overlie  a  growth,  however,  the  note  will  be  tym- 
panitic, and  it  will  be  necessary  to  employ  deep  and  strong  percus- 
sion to  bring  out  the  dulness.     By  carefully  percussing  around  the 


I 


,TYN/lPANy^ 


Fig.  800. — Showing  the  area  ot  dulnesa  and  tympany  ii 
recumbent.     (Ashton.) 


a  when  the  patient  ii 


margins  of  a  tumor  and  noting  where  tympanitic  resonance  is  absent, 
it  is  often  possible  to  determine  the  origin  of  the  growth. 

In  the  presence  of  ascites  with  the  patient  in  the  dorsal  position, 
dulness  will  be  elicited  in  the  flanks,  while  the  center  of  the  abdomen 


^yMPANV^ 


I 


Fig.  801. — Showing  the 


when  the  patient 


will  be  tympanitic,  as  the  intestines  float  to  the  highest  point  {Fig. 
800).  With  a  change  in  the  patient's  position  the  fluid  gravitates  to 
the  lowest  point  and  the  location  of  the  duhiess  and  tympany  is  like- 
wise changed  (Fig.  801).  On  the  other  hand,  the  area  of  dulness  due 
to  tumors  is  not  affected  by  changes  in  the  patient's  position. 


THE  FEICALE   GENEKA.TIVE   ORGAITS 


ATJSCULTATIOIT 

Auscultation  is  of  limited  use  except  in  the  differential  diagii' 
between  pregnancy  and  other  tumors.  In  the  former  case  the  fi 
heart  sounds  and  the  funic  souffle  settle  the  diagno^.  Much  inq 
tance  cannot  be  attached  to  the  uterine  bruit,  however,  in  the 
Bence  of  other  signs  pointing  to  pregnancy,  as  it  is  also  heard  in  Is 
fibroid  tumors.  In  some  cases  of  peritonitis  it  may  be  possibb 
hear  a  friction  note, 

MENSUKATTOK 

Mensuration  of  the  abdomen  is  useful  in  determining  whether 
abdomen  is  symmetrically  enlarged  or  not,  in  noting  any  increas 
ascites,  and  in  recording  the  rapidity  of  enlargement  in  a  tumoi 

Position  of  Patient. — The  measurements  are  taken  with 
patient  in  the  horizontal  recumbent  position. 


Fig,  8oa. — Showing  the 


Technic.^ — An  ordinary  tape  measure  is  employed  and  the  fol 
ing  measurements  are  taken:  (i)  the  circumference  of  the  abdc 
at  the  level  of  the  umbilicus,  (2)  the  distance  from  the  ensiform  c 
lage  to  the  pubes,  (3)  the  distance  from  the  umbilicus  to  each  ant 
superior  spine,  (4)  the  distance  between  the  two  anterior  sup 
spines,  and  (5)  the  distance  from  the  anterior  superior  spines  t( 
pubes  (Fig.  802).  To  have  any  value  for  purposes  of  con^>ar 
these  measurements  should  be  taken  from  the  same  points 
time  and  with  the  patient  in  exactly  the  same  position. 


INSPECTION 

//.  ExaminaH&n  of  (lie  Pelvic  Organs 

INSPECTION 


809 


A  careful  inspection  of  the  external  genitals  and  the  vaginal 
orifice  should  always  be  made  as  a  routine  before  a  digital  examina- 
tion, otherwise  lesions  involving  the  vulva  £ind  neighboring  parts 
may  escape  notice.  Inflammations,  new  growths,  the  presence  of 
abnormal  secretions,  prolapse  of  the  anterior  or  posterior  vaginal 
walls,  lacerations  of  the  perineum,  and  many  other  pathological  con- 
ditions are  readily  recognized  by  inspection. 


Fio.  803. — Insi)ectioa  of  the  vapnal  outlet.     (Bandler.) 


[      Position   of   Patient.— Inspection    is   performed   with    the  pa- 
tient in  the  dorsal  posture  with  the  feet  toward  the  light, 

Technic. — The  examiner  sits  or  stands  facing  the  vulva  and  be- 
gins his  inspection  without  disturbing  the  relation  of  the  parts.  He 
should  first  note  the  general  appearance  of  the  vulva,  whether  the 
labia  are  closed  or  in  apposition,  and  whether  the  vulva  is  the  seat  of 


SlO  THE  FEMALE  GENERATIVE   ORGANS 

infianunation,  ulcerations,  warts,  swelling,  edema,  varicosttes,  e 
tions,  or  excoriations,  the  latter  a  frequent  accompaniment  of  a 
cliarge.  If  a  discharge  is  present,  its  color,  quantity,  and  o 
characteristics  should  be  noted. 

The  labia  are  next  separated  with  the  fingers  of  the  left  hand, 
the  entrance  to  the  vagina  is  inspected  (Fig.  803),  noticing  the  < 
of  the  mucous  membrane,  the  presence  or  absence  of  the  hymen, 
condition  of  the  openings  of  the  ducts  of  Bartholin  and  the  orifii 
the  urethra,  and  the  presence  or  absence  of  lacerations,  cysto 
or  rectocele.  By  instructing  the  patient  to  bear  down  or  si 
slightly,  a  prolapse  of  the  anterior  or  posterior  vaginal  walls  b  n 


FtG.  804. — Method  of  exposbg  the 'anterior  and  posterior  vaginal  walk  for  in^ 

(Ashton.) 


more  evident.  The  hood  of  the  clitoris  should  also  be  retracted 
an  examination  made  for  adhesions  or  concretions  that  may  b( 
cause  of  nervous  symptoms.  By  retracting  the  perineum  with 
fingers  inserted  in  the  vagina,  as  shown  in  Fig.  804,  the  lower  po 
of  the  anterior  and  posterior  vaginal  walls  may  be  brought  to  1 

EXAMINATION  OF  DISCHARGES 

If  an  abnormal  discharge  is  present,  specimens  should  be  obu 
at  this  time  for  later  microscopical  or  bacteriological  examina 
The  importance  of  such  an  examination  cannot  be  too  stro 
emphasized.  The  tecimic  for  collecting  and  preparing  the  s; 
mens  has  been  previously  detailed  at  length  in  Chapter  XI, 


DIGITAL    PALPATION 


DIGITAL  PALPATION 

Palpation  by  means  of  the  linger  is  employed  to  obtain  more 
complete  information  as  to  abnormal  conditions  of  the  vulva  or 
vaginal  outlet  discovered  on  inspection,  and  to  determine  the  condi- 
tion of  the  vagina,  vaginal  fornices,  and  the  cervix.  For  a  satis- 
factory examination  of  the  other  pelvic  organs,  bimanual  palpation 
is  necessary. 

Asepsis. — All  the  aseptic  precautions  previously  detailed  (page 
803)  should  be  observed. 


Fig.  805. — The  diagnosis  of  a  cystocele  by  the  aid  of  a  bladder  sound.     (Ashton.) 

Position  of  Patient, — The  dorsal  position  is  ordinarily  employed, 
but  the  erect  posture  ^\t11  be  found  useful  in  estimating  the  degree 
of  a  uterine  prolapse. 

Preparations.' — (See  page  800.) 

Technic. — The  examiner  first  palpates  between  the  thumb  and 
forefinger  of  the  right  hand  any  abnormal  conditions,  such  as  swell- 
ings, new  growths,  etc.,  about  the  vulva  and  the  vaginal  outlet,  and 
also  the  glands  of  Bartholin  for  signs  of  inflammation  or  thickening. 

The  labia  are  then  separatfd  between  the  thumb  and  index- 
finger  of  the  right  hand,  and  the  index-finger  of  the  left  hand,  well 
lubricated,  is  introduced  into  the  vagina.  The  condition  of  the 
vagina  is  then  investigated,  noting  the  presence  or  absence  of 
congenital  malformations,  its  sensitiveness,  its  temperature,  and 
whether  the  vaginal  walls  have  their  normal  roughness  or  are  smooth 


i 


Fig.  806. — Mtthod  of  estimating  the  thickness  of  the  penDenm- 


BIMANUAL  PALPATION  813 

finger  in  the  vagina  (Fig.  805),  acystocele,  if  present,  may  be  more 
readily  recognized.  The  posterior  vaginal  wall  is  likewise  examined 
by  rotating  the  examining  finger,  palmar  surface  back,  and,  by 
placing  the.  thumb  of  the  same  hand  near  the  rectum,  the  perineum 
may  be  grasped  between  the  two  fingers  and  its  firmness  and  thick- 
ness estimated  (Fig.  806).  The  vaginal  fornices  on  all  sides  of  the 
cervix  are  next  palpated,  noting  their  depth,  any  rigidity,  indura- 
tion, or  tenderness. 

If  the  uterus  is  in  a  normal  position,  it  will  be  possible  to  feel  its 
body  through  the  anterior  fornix,  while,  if  retroverted,  the  latter  will 
be  felt  in  the  posterior  fornix.  The  condition  of  the  uterus  is  more 
satisfactorily  made  out,  however,  by  bimanual  palpation. 

Finally,  the  cervix  is  palpated  (Fig.  807),  noting  especiaUy  its 
size,  whether  closed  or  open,  whether  hard  or  soft,  its  mobility,  and 
its  position,  that  is,  whether  pointing  backward  toward  the  sacrum, 
as  in  retroflexion  of  the  uterus,  or  pointing  forward  toward  the  sym- 
physis, as  is'found  when  the  uterus  is  retroverted  or  anteflexed.  The 
presence  or  absence  of  lacerations,  erosions,  cysts,  etc.,  should  also  be 
determined. 

BIMANUAL  PALPATION 

Bimanual  palpation  by  means  of  the  fingers  of  one  hand  in  the 
vagina  or  rectum  and  the  fingers  of  the  other  hand  making  counter- 
pressure  above  the  symphysis  is  the  most  valuable  method  for  in- 
vestigating the  condition  of  the  pelvic  organs.  By  it  one  may  map 
out  the  size  and  shape  of  the  uterus  and  determine  its  consistency, 
position,  mobility,  and  the  presence  or  absence  of  new  growths.  The 
tubes,  ovaries,  broad  ligaments,  etc.,  may  likewise  be  palpated  and 
their  condition  ascertained. 

Vagino-abdominal  palpation  is  the  most  satisfactory  and  the 
more  generally  employed  method.  It  should  be  supplemented  by 
recto-abdominal  palpation,  however,  in  any  doubtful  cases.  The 
latter  method  is  especially  useful  in  exploring  the  posterior  surface 
of  the  uterus  and  the  appendages  in  cases  of  posterior  displacement 
of  the  uterus,  as  these  structures  may  then  be  more  readily  reached 
from  the  rectum  than  from  the  vagina.  Recto-abdominal  palpa- 
tion is  also  indicated  in  children,  in  the  unmarried,  and  in  cases 
where  the  vagina  is  unduly  sensitive  or  obstructed  by  tumors  or  an 
imperforate  hymen. 

To  perform  a  successful  bimanual  examination  it  is  necessary 
that  the  abdominal  walls  be  thin,  relaxed,  and  free  from  tenderness 


8l4  THE  FEMALE  GENERATIVE  ORGANS 

upon  pressure,  and  that  the  vagina  be  sufficiently  large  to  admit 
the  fingers  of  the  examining  hand.  In  the  case  of  individuals  with 
very  muscular,  fat,  or  rigid  abdominal  walls  or  a  small  viagina  the 
examination  is  usually  unsatisfactory  without  an  anesthetic.  In 
any  case,  the  examination  must  be  performed  with  the  utmost 
gentleness.  Rough  manipulations  accomplish  nothing  and  are  cap- 
able of  causing  great  harm,  especially  in  cases  where  the  pelvis 
contains  a  tube  filled  with  pus,  a  thin- walled  cyst,  an  ectopic  preg- 
nancy, etc. 

Asepsis. — For  the  necessary  precautions  against  infection  see 
page  803. 

Position  of  Patient. — Bimanual  palpation  is  most  satisfactorily 
performed  with  the  patient  in  the  dorsal  position. 

Preparations. — (See  page  800.) 

Anesthesia. — General  anesthesia  is  not  often  required  in  indi- 
.  viduals  with  thin  and  relaxed  abdominal  walls,  but  in  muscular,  fat, 
or  nervous  individuals  or  where  the  parts  are  tender  and  sensitive 
an  anesthetic  may  be  necessary  to  secure  relaxation.  A  general 
anesthetic  should  also  be  employed  if  any  doubt  remains  as  to  the 
conditions  found  after  an  ordinary  bimanual  examination,  and  in 
all  cases  where  it  is  necessary  to  make  a  vaginal  examination  upon 
virgins. 

Technic. — i.  Vagino-abdominal. — The  examiner  stands  facing 
the  patient  a  little  to  one  side  or  the  other  depending  upon  which 
hand  he  palpates  with.  The  labia  are  then  separated  between  the 
thumb  and  forefinger  of  one  hand  and  the  index-finger  of  the  other 
hand,  or  the  index-  and  middle  fingers  if  the  parts  are  sufficiently 
relaxed  to  admit  them,  are  well  lubricated  and  are  inserted  into  the 
vagina,  while  the  fingers  of  the  free  hand  are  placed  on  the  abdomen 
above  the  pubes.  The  external  hand  is  used  to  steady  or  depress  the 
organs  while  the  internal  hand  does  the  palpating.  As  a  rule  the 
left  hand  is  employed  to  palpate  with,  being  the  smaller  of  the  two  and 
possessing  greater  tactile  sensibility,  but  the  examiner  should  be 
equally  proficient  with  either  hand.  The  last  two  fingers  of  the 
internal  hand  should  be  folded  back  upon  the  palm,  as  shown  in  Fig. 
808,  so  as  to  in  vagina  te  the  pelvic  floor  and  thereby  permit  the 
greatest  possible  penetration.  The  palmar  surfaces  of  the  fingers  of 
the  internal  hand  are  brought  in  contact  with  the  cervix  and  its  con- 
dition and  position  are  first  determined.  With  the  internal  fingers 
in  contact  with  the  cervix  and  exerting  upward  pressure  the  external 
hand  locates  the  fundus  of  the  uterus  and  makes  gentle  pressure  from 


BIMANUAL  PALPATION  815 

above.  The  length,  sensitiveness,  consistency,  and  position  of  the 
uterus  are  thus  determined,  and  likewise  the  mobility  by  making  a 
series  of  gentle  pushes  from  above  and  below  (Fig.  809), 


Fic  808. — Method  of  inserting  the  examining  fingers  in  bimanual  palpation.     Small 
figure  shows  tbe  method  of  holding  the  fingers. 


Fio.  809.— Method  ot  determining  the  Fit,  8io— Method  of  estimating  the 
length     and     mobility     of     the     uterus,  thicknesa  of  the  uterus.      (Ashton.) 

(AshtoD.) 

By  placing  the  internal  fingers  in  front  of  the  cervix  and  the  fingers 
of  the  external  hand  behind  the  fundus  the  thickness  of  the  uterus 
may  be  estimated  (Fig.  810).  If  the  fundus  is  pressed  well  forward 
by  the  external  hand,  the  anterior  and  lateral  surfaces  may  be  pal- 


8l6  THE    TEMALE    GENERATIVE    ORGANS 

pated  and  any  irregularity  of  the  surfaces  which  might  be  caused  by 
fibroids  or  other  growths  is  noted.  By  carrying  the  fingers  of  lie 
internal  hand  posterior  to  the  cervix  and  pressing  the  fundus  bad- 
ward  the  posterior  surface  is  in  like  manner  explored.    ^Mien  tbe 


Fig.  8u. — Diagnosis  of  an  anlefleTion  of  the  uterus  hybimflnual  pa.lp(itioo.    (Ashlon.) 


Fg    8 

I  — D  agnosia    ot    a    poiterior 

Fig.  813.— Shows    the    meiiwi  i 

displflceme 

palpating  the  body  o(  the  ultnis  »  > 

palpat  on 

(Ashton  ) 

posterior  displacement.     (Ashwo.) 

fundus  is  not  found  in  its  normal  position,  it  should  be  sought  f* 
anteriorly  near  the  symphysis,  or  posteriorly.  To  palpate  for  ante- 
rior displacements,  the  internal  finger  is  carried  up  in  (ronl  of  ll* 


BIMANUAL  PALPATION  817 

cervix  into  the  anterior  fomiit,  while  the  external  hand  exerts  pres- 
sure downward  behind  the  symphysis.  If  anteflexed,  the  fundus  will 
be  readily  felt  between  the  fingers  of  the  external  and  internal  hands 
(Fig.  811),  while  in  posterior  displacements  the  opposed  fingers  may 
be  brought  together  as  shown  in  Fig.  812.  In  such  case  the  fundus 
should  then  be  sought  posteriorly  by  carrying  the  internal  finger 
up  into  the  posterior  cul-de-sac  while  external  pressure  is  made  by 
the  external  hand  from  above  (Fig.  813). 

A  posterior  flexion  will  be  readily  differentiated  from  a  version  by 
the  bend  or  angle  on  the  posterior  aspect  of  the  uterus  (Fig.  814). 


Fig.  814. — Diagnosis  of  a  posterior  fleriou  of  the  uterus  by  bimanual  palpation. 
(AsbtoD.) 

In  the  presence  of  a  posterior  displacement  it  should  be  determined 
whether  the  uterus  is  mobile  or  fixed  through  adhesions  by  passing 
the  internal  fingers  high  up  posteriorly  and  by  the  aid  of  the  external 
hand  attempting  to  lift  the  uterus  up. 

After  thoroughly  examining  the  uterus  the  condition  of  the  broad 
and  uterosacral  ligaments  should  be  ascertained.  By  carrying  the 
fingers  up  beside  the  cer\Tx  into  the  lateral  fornices  and  making 
counter-pressure  from  above  the  condition  of  the  broad  ligaments 
may  be  determined,  and  any  pain  on  pressure,  thickening,  or  indura- 
tion noted.  Palpation  of  the  uterosacral  ligaments  through  the  p(js- 
terior  fornix  may  be  performed  in  like  manner. 

The  tubes  and  ovaries  should  als*^  be  examined  with  reference  to 
their  sze,  shape,  consistency,  sensitiveness,  jxtsition,  and  mobility. 


8j8         the  feuale  generahvx  organs 

It  is  of  advantage  to  use  the  right  hand  in  palpating  the  rif^t  ade 
and  the  left  hand  for  the  left  side.  The  examining  fingers  are  in- 
serted well  up  in  the  lateral  fornix  beside  the  cervix  in  an  upward  and 
backward  direction,  while  the  external  hand  makes  deep  pressuie 
downward  through  the  abdominal  wall  on  the  corresponding  side. 
By  altering  the  position  of  the  fingers  of  the  two  hands  from  time  to 
time  the  ovary  and  tube  are  finally  grasped  between  the  opposed 
fingers  (Fig.  815).  Except  where  the  abdominal  walls  are  extremely 
thin  and  the  vagina  is  relaxed,  the  normal  tube  cannot  be  felt,  bul, 


Fio,  815. — EiaminatioD  of  the  uteiitie  apipendages  by  bimanual  palpation.    (Ashlm.) 


when  enlarged,  it  may  be  readily  recognized  as  a  club-shaped  mass 
gradually  narrowing  down  as  it  approaches  the  uterus.  The  nor- 
mal ovaries,  however,  are  generally  palpable  as  small,  oval  masses, 
somewhat  tender  upon  pressure,  on  each  side  of  the  uterus.  When, 
as  the  result  of  chronic  inflammation,  extensive  adhesive  formatjon 
has  taken  place  the  tubes  and  ovaries  are  often  matted  together  into 
irregular  masses,  and  it  may  not  be  possible  to  map  them  out  sepa- 
rately. Having  examined  one  side  of  the  pelvis,  the  same  procedure 
is  repeated  upon  the  other  side. 

2.  Reclo-abdominal. — The  examiner  stands  facing  the  patient  and 
inserts  the  well-lubricated  index-finger  of  the  left  hand  high  into  the 
rectum.    At  the  same  time  the  external  hand  placed  on  the  abdomeo 


BIMANUAL    PALPATION  819 


bove  the  symphysis  makes  counter-pressure,  while  the  uterus  and 
ppendages  are  carefully  palpated  (Ftg.  8i6).     Care  must  be  taken, 


I 


Fio.  816. — Recto-abdominal  palpation  of  Ihc  uterus.     (Ashton.) 


I 


IG.  Si  7. — Recto-abdominal  palpation  of  the  uterus  with  the  latter  drawn  toward  tbe 
vaginal  outlet  b>  means  of  a  tenaculum      (Ashton.) 

owever,  not  to  exert  too  much  force  with  the  fingers  in  the  rectum 
)r  fear  of  lacerating  or  otherwise  injuring  the  bowel. 


820  THE  FEUALE  GENERATIVE  ORGANS 

By  drawing  the  uterus  well  down  by  means  of  a  pair  of  bullet 
forceps  caught  in  the  cervix,  and  then  performing  recto-abdominal 
palpation,  a  much  more  complete  examination  is  possible  (Fig.  817). 
This  method,  however,  should  never  be  attempted  when  the  utenB 
is  fixed  by  adhesions  or  the  appendages  are  inflamed.  As  a  rale, 
general  anesthesia  is  necessary.  Care  should  always  be  taken  to 
replace  the  uterus  in  its  normal  position  at  the  completion  of  sudi 
an  examination. 

EXAMINATION  BY  SPECULA 

By  means  of  suitable  specula  the  mucous  membrane  of  the  endie 
vagina  and  cervix  may  be  directly  inspected.  The  use  of  specula 
furnishes  little  information  outside  of  the  color  and  condition  of  tbe 


Fig.  818.— Goodell's  vaginal  speculum.     (Ashtan.) 


mucous  membrane  and  the  origin  of  a  discharge,  which  is  not  as 
readily  obtainable  by  digital  palpation.  For  gynecological  treat- 
ment and  operative  procedures,  however,  specula  are  indispensable. 


Fic.  819, — Trivalve  vaginal  speculi 


Instruments. — Numerous  specula  have  been  devised,  such  as  the 
bivalve  (Fig,  818),  the  trivalve  (Fig.  819),  the  cylindrical,  the  Sims 
(Fig,  820),  Simon's,  the  self-retaining  weighted  speculum,  etc.,  etc. 


EXAMINAnON  BY   SPECUL*. 


For  diagnostic  purposes  the  bivalve  and  the  Sims  specula  are  prob- 
ably most  commonly  employed.  To  prevent  the  anterior  vaginal 
wall  from  obscuring  the  view  when  using  the  Sims  speculum  a  vag- 
inal depressor  is  also  required  (Fig,  821).    A  sponge  holder  (Fig. 


Fig.  830. — Sima'  vagina]  specuhii 


822)  and  cotton  wipes  should  be  provided  for  removing  secretions. 

Asepsis. — The  speculum  should  be  sterilized  by  boiling  for  five 
minutes  in  a  i  per  cent,  soda  solution  and  the  operator's  hands  are 
sterilized  in  the  usual  way. 

Position  of  Patient. — When  the  bivalve  or  trivalve  speculum  is 


Flc.  B21. — Vaginal  deptessor.     (Ashton.) 

employed  the  patient  should  be  in  the  dorsal  position.  In  using  the 
perineal  retractors,  such  as  the  Sims,  the  left  lateral,  or  the  knee- 
chest  position  may  be  employed. 

Preparations    of    Patient.— (See  page  800.) 


Fio.  822, — Sponge  holder  and  swab. 

Tectmic. — i.  With  the  Bivalve  Speculum.— The  examiner  stands 
or  sits  facing  the  vulva.  Then,  with  the  labia  well  separated  be- 
tween the  index-  and  middle  fingers  of  the  left  hand,  the  speculum, 
warmed  and  well  lubricated,  is  inserted  into  the  vagina  with  its 


THE  FEMALE  GENERATIVE  OBGANS 


blades  parallel  to  the  vulva  opening  (Fig.  823).     The  speculum  is 
introduced  about  2  inches  (5  cm.)  and  is  then  rotated  so  that  tlx 


null  UJNii- 

FiG.  824. — Method  ot  exposing  the  lateral  walls  of  the  \  agina  by  means  of  the  bivilw 
speculum.     (Ash  ton.) 

blades  lie  parallel  with  the  anterior  and  posterior  vaginal  walls.  By 
widely  separating  the  blades  (Fig.  824)  a  view  of  the  cervix  and  the 
lateral  walls  of  the  vagina  is  obtained.     For  inspection  of  the  ante- 


EXAMINATION  BY   SPECULA  823 

nor  and  posterior  vaginal  walls  the  blades  of  the  speculum  are  turned 
so  that  they  lie  parallel  with  the  outlet  of  the  vulva  and  they  are 
then  ofiened  (Fig.  825).     The  condition  of  the  entire  vagina!  mucous 


■■■||  ■illii  V 

Fic.  Sas- — Method  of   expc!  ng  the  anterior  and  posterior  v^jinal  walls  by  n 
n  b  val  e  sf  eculum      (Aahton.) 


Fic.  8;6. — Shows  the  method  of  inserting  Sims'  speculuc 


membrane  may  be  thus  ascertained,  and  inflammatory  conditions, 
a  fistulous  opening,  new  growths,  etc.,  will  be  readily  recognized  i£ 
present.     If  a  discharge  is  present,  its  origin  should  be  determined. 


THE  FEUALE  GENEKATIVi;  ORGANS 


blades  parallel  to  the  vulva  opening  (Fig.  823).     The  speculum  is 
introduced  about  i  inches  (5  cm.)  and  is  then  rotated  so  that  the 


Fic.  834.— Method  of  exposing  the  lateral  walls  of  the  \  agina  by  means  ot  the  Wv*!" 
speculum.     (Asbton.) 

blades  lie  parallel  with  the  anterior  and  posterior  vaginal  walls.  By 
■widely  separating  the  blades  (Fig,  824)  a  view  of  the  cervix  and  the 
lateral  walls  of  the  vagina  is  obtained.     For  inspection  of  the  aDt^ 


EXAMINATION  BY    SPECULA  823 

rior  and  posterior  vaginal  walls  the  blades  of  the  speculum  are  turned 
so  that  they  lie  parallel  with  the  outlet  of  the  vulva  and  they  are 
then  opened  (Fig.  825).    The  condition  of  the  entire  vaginal  mucous 


Wiiliiiiltiiiiiiiiiiiiiiiiup  iiii  1  Nil  111  Hill  ipiiTir- 
Fio.  Saj. — Method  o£  nposmg  the  antenor  aod  postenor  vagmal  walls  by  meana  of 
a  bivalve  speculum.     (Ashlon.) 


Fig.  H26. — Shows  the  method  of  inserting  Sims'  specului 


membrane  may  be  thus  ascertained,  and  inflammatory  conditions, 
a  fistulous  opening,  new  growths,  etc.,  will  be  readily  recognized  i£ 
present.     If  a  discharge  is  present,  its  origin  should  be  determined. 


824  THE  FEMALE  GENERATIVE  ORGANS 


Fig.  817. — Showing  the  Sims  speculum  in  place.    (Ashtoa.) 


SOUNDISG   THE    UTERUS  8*5 

The  cervix  is  then  inspected,  noting  its  size  and  shape  and 
whether  it  is  lacerated  or  is  the  seat  of  inflammation,  erosions,  c>"sts, 
or  new  growths,  and  whether  a  dbcbarge  issues  from  the  external  os. 
D  secretions  obstruct  the  ^^ew,  they  should  be  carefully  wiped  away 
by  means  of  cotton  wipes  held  by  a  sponge  holder.  In  some  cases, 
where  the  vagina  is  verj'  long  and  narrow,  a  dear  \-iew  of  thecervix 
can  only  be  obtained  bydrawing  it  down  into  the  vagina  bymeans  of 
a  tenaculum  or  bullet  forceps. 

2.  Witblfie  Sims  Speculum. — The  shaft  of  the  speculum  is  grasped 
in  the  operator's  right  hand  while  with  the  left  hand  the  upper 
buttock  is  raised  so  that  the  vulva  id  well  separated.  The  blade  of 
the  speculum,  which  has  been  previously  warmed  and  lubricated, 
is  then  inserted  into  f  he  vagina  parallel  with  the  cleft  of  the  \-iJva 
(Fig.  826).  The  blade  is  then  rotated  so  that  it  lies  parallel  with  the 
anterior  and  posterior  vaginal  walls  and  is  further  introduced  until 
its  distal  end  lies  back  of  thecervix.  By  making  traction  backward 
and  outward  the  perineum  is  retracted  so  that  an  excellent  view  of 
the  anterior  vaginal  wall  and  cervix  is  obtained  (Fig.Saj).  Should 
the  anterior  vaginal  wall  obstruct  the  view,  it  may  be  drawn  outof 
the  way  by  means  of  the  vaginal  retractor  as  shown  in  Fig.  82S. 

SOUNDING  THE  UTERUS 
The  uterine  sound,  which  was  formerly  employed  to  a  greates- 
tent  in  gynecological  diagnosis  is,  now  seldom  used,  as  little  informa- 
tion is  gained  by  its  use.  ouside  of  determining  the  length,  size,  and 
consistency  of  the  uterine  cavity,  that  is  not  as  readily  obtainable 
by  other  and  less  dangerous  means.  The  unskilled  use  of  the  uterine 
sound  has  often  led  to  the  introduction  of  septic  material  into  the 
uterus  carried  from  the  vagina  or  cer\'ix,  as  well  as  to  the  infliction 
of  serious  injury  upon  the  uterine  mucous  membrane  and  even  per- 
foration of  that  organ.  To  avoid  these  risks  the  position  of  the 
uterus  should  be  ascertained  before  an  attempt  is  made  to  introduce 
the  sound,  and,  during  the  attempt,  only  gentle  manipulations  of 
the  instrument  should  be  made;  it  should  never  be  used  as  a  means  of 
righting  a  displaced  uterus.  The  sound  should  never  be  introduced 
by  touch  alone,  but  always  with  the  cervix  clearly  exposed  bj'  means 
of  a  speculum,  and  in  every  case  the  date  of  the  last  menstruation 
should  be  ascertained  beforehand  so  as  not  to  interrupt  a  possible 
pregnancy.  Its  use  is  contraindicated  if  the  uterus  is  infected  or  is 
the  seat  of  a  malignant  disease,  or  if  the  uterine  appendages  are 
involved  in  a  suppurative  disease. 


826 


THE  FEMALE  GENERATIVE  ORGANS 


Instruments. — The  operator  will  require  a  vaginal  speculum,  a 
pair  of  bullet  forceps,  cotton  wipes,  a  sponge  holder,  and  a  uterine 
sound  (Fig.  829). 

The  sound  is  made  of  flexible  metal,  about  12  inches  (30  cm.) 
long  and  from  1/12  to  1/8  inch  (2  to  3  mm.)  thick,  with  a  bulbous 
tip.  The  shaft  is  marked  off  in  inches,  and  2  1/2  inches  (6  cm.)  from 
the  distal  end  is  a  small  protuberance  to  indicate  the  normal  depth 
of  the  uterus. 

Asepsis. — The  introduction  of  a  soimd  or  any  instrument  into  the 
uterus  should  be  regarded  as  a  surgical  operation  and  should  be  car- 
ried out  with  every  aseptic  detail.    All  the  instruments  should  be 


Fig.  829. — 


Instruments  for  sounding  the  uterus,     i,  Ganigues'  weighted  speculttm; 
2,  dressing  forceps;  3,  tenaculum;  4  uterine  sound. 


boiled  for  five  minutes  in  a  i  per  cent,  soda  solution.  The  external 
genitals  should  be  thoroughly  cleansed  with  soap  and  water  followed 
by  a  I  to  2000  bichlorid  solution  and  the  vagina  should  be  douched 
with  some  antiseptic.  The  operator's  hands  are  cleansed  as  thor- 
oughly as  for  any  operation. 

Position  of  Patient.— The  patient  should  be  in  the  lithotomy 
position. 

Technic. — The  operator  sits  facing  the  vulva  and,  after  separating 

the  labia,  introduces  the  speculum.     The  anterior  lip  of  the  cervix 

is  then  seized  by  means  of  bullet  forceps  and,  after  being  pulled  down 

•into  view,  is  thoroughly  wiped  off  with  a  cotton  swab  soaked  in  a 


DIGITAL    PALPATION    OF    THE    UTERINE    CAVITY  827 

I  to  2000  bichlorid  solution.  The  sound  with  its  distal  3  inches  (7.5 
cm.)  bent  in  a  slight  forward  curve  is  grasped  lightly  between  the 
thumb  and  forefinger  of  the  right  hand  and  is  introduced  Into  the 
external  os,  being  careful  not  to  touch  anyportion  of  the  vagina.  By 
gently  depressing  its  handle  the  sound  should  readily  glide  up  the 
canal  to  the  fundus.  If  the  point  is  arrested  by  catching  in  a  fold  of 
mucous  membrane  or  at  the  internal  os,  gentle  manipulation  will 
usually  result  in  its  passage — force  should  never  be  employed. 


Fig.  830. — Showing  the  method  of  estimBling  the  length  of  the  uterus  by  means  of 
[he  uterine  sound. 

Sometimes,  when  the  cervix  is  bent  forward,  the  sound  may  be 
more  readily  passed  if  it  is  started  with  the  concavity  of  its  curve 
turned  backward  and,  as  soon  as  it  becomes  arrested,  rotating  it  for- 
ward. When  the  tip  of  the  instrument  reaches  the  fundus,  the  opera- 
tor's right  index-finger  should  be  moved  along  the  shaft  of  the  instru- 
ment until  it  comes  in  contact  with  the  cervLx  for  the  purpose  of  in- 
dicating the  depth  of  the  canal  when  the  instrument  is  removed 
_(Fig.  830). 


^  DIGITAL  PALPATION  OF  THE  UTERINE  CAVITY 

Digital  exploration  of  the  interior  of  the  uterus  is  occasionally 
required  in  the  diagnosis  of  intrauterine  growths  or  retained  prod- 


838  THE   FEltALE   GENERATIVE   OBGAMS 

ucts  of  conception  which  are  not  revealed  by  other  methods  of 
examination.  With  the  finger  in  the  cavity  of  the  uterus  it  is  possible 
to  determine  whether  the  uterus  is  empty  or  not,  the  length  and 
direction  of  the  canat,  and  the  thickness,  consistency,  and  other 
characteristics  of  the  endometrium. 

D^tal  erploration  necessitates  a  thorough  preliminary  dilata- 
tion of  the  cervix,  except  in  puerperal  cases,  and  should,  therefore, 
be  considered  in  the  same  light  as  a  surgical  operation.  It  should 
not  be  attempted  until  the  possibility  of  pregnancy  has  been  excluded 
by  determimng  the  date  of  the  last  menstruation  and  by  a.  careful 
examination. 


Fic.  831. — Digital  exploration  of  the  uterine  cavity,     (AshtdD.) 


Instruments. — Instruments  for  dilating  the  cervix  are  required. 
These  include  a  vaginal  speculum,  a  pair  of  dilators,  sponge  holders, 
and  two  bullet  forceps.     (See  Fig.  883.) 

Asepsis. — Strict  aseptic  precautions  should  be  observed.  The 
external  genitals  are  washed  with  soap  and  water,  followed  by  a 
I  to  2000  bichlorid  of  mercury  solution.  The  vagina  is  cleansed 
with  soap  and  water  by  means  of  a  sponge  on  a  holder  and  is  then 
douched  with  an  antiseptic  solution.  The  instruments  are  boile<i 
for  five  minutes  in  a  i  per  cent,  soda  solution  and  the  operator's 
hands  are  prepared  with  the  same  care  as  for  any  operation. 

Position  of  Patient. — The  lithotomy  position  is  employed. 


EXPLORATORY    INCISION  83() 

Anesthesia.— General  anesthesia  is  required  except  in  postpartum 

cases. 

Tecbnic. — The  cervix  is  first  dilated  sufficiently  to  admit  the 
operator's  finger  (see  page  864).  The  index-finger  of  the  right  hand 
or,  where  possible,  as  in  postpartum  cases,  the  index-  and  middle 
fingers  are  then  passed  into  the  uterus,  while,  vnth  the  left  hand  on 
the  abdomen,  the  operator  presses  down  upon  the  fundus  uteri,  so 
as  to  bring  the  uterus  within  reach  of  the  interhal  fingers  (Fig.  831), 
The  interior  of  the  uterus  is  then  systematically  explored  by  the  in- 
ternal fingers. 


Fig.  83 3. ^Instruments  for  an  exploratory  vaginal  scclion  i.  Garrigues'  weighted 
speculum;  2,  sponge  holder;  3,  tenaculum;  4,  thumb  forceps;  5,  sharp-pointed  scissors; 
6,  artery  damps;  7,  needle  holder;  8,  needles;  q.  No,  3  catgut. 

THE  EXAMINATION  OF  SECTIONS  AND  SCRAPINGS  FROM 
THE  UTERUS 

To  determine  the  nature  of  a  suspicious  growth  a  portion  should 
be  excised  for  examination.  The  method  of  doing  this  has  already 
been  described  (page  307).  Where  the  interior  of  the  uterus  is  the 
seat  of  suspected  disease,  scrapings  from  the  endometrium  for  ex- 
amination should  be  collected  by  a  thorough  curettage  (see  page  868) , 


EXPLORATORY  INCISIOH 

Direct  palpation  of  the  pelvic  structures  is  sometimes  required  in 
the  diagnosis  of  obscure  pelvic  conditions.  It  may  be  accomplished 
by  means  of  an  abdominal  incision  or  through  a  small  opening  made 
in  the  cul-de-sac  of  Douglas.     The  latter  method  b  preferable,  as  it 


gxO  THE   FEICALE   GENEKATIVZ   OKGANS 

is  not  a  dangerous  operation,  and  the  recovery  of  the  patient  is  more 
rapid  than  when  an  abdominal  section  is  performed.  The  operator 
should  be  prepared,  however,  to  perform  any  operative  procedures, 
such  as  draining  a  pus  sac,  removing  suppurating  tubes,  or  caning 
the  abdomen,  if  the  findings  indicate  it. 

Instruments. — There  will  be  required  a  weighted  vaginal  specu- 
lum, sponge  holders,  bullet  forceps,  toothed  thumb  forceps,  sliaq>- 


pointed  curved  scissors,  artery  clamps,  curved  cutting-edged  needles, 
a  needle  holder,  and  No.  2  catgut  (Fig.  832). 

Asepsis. — The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.  The  external  genitals  are  scrubbed  with  soap 
and  water  followed  by  a  r  to  2000  bichlorid  solution,  and  the  vagina 
is  cleansed  by  first  washing  with  soap  and  water  and  then  by  means 
of  an  antiseptic  douche.  The  operator's  hands  are  sterilized  in  the 
usual  way. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
position. 

Preparation  of  Patient. — The  patient  is  prepared  for  general 
anesthesia  {see  page  18)  and  the  bowels  and  bladder  should  be  empty 
at  the  time  of  operation. 


832  .  THE  FEBiALE   GENERATIVE   ORGANS 

Anesthesia. — General  anesthesia  is  employed. 

Technic. — The  vaginal  speculum  is  placed  in  the  vagina  and  the 
posterior  lip  of  the  cervix  is  seized  in  bullet  forceps  which  are  given 
to  an  assistant  to  hold.  The  operator  then  picks  up  the  posterior 
vaginal  wall  by  means  of  thumb  forceps  at  a  point  in  the  mid-line, 
just  back  of  where  it  is  reflected  from  the  cervix,  and  with  a  pair  of 
scissors  makes  a  transverse  incision  about  i  inch  (2.5  cm.)  long 
through  the  vaginal  wall  (Fig  833).  The  vaginal  wall  posterior  to 
the  incision  is  then  separated  by  blunt  dissection  from  the  under- 
lying peritoneum  for  a  short  space  (Fig.  834).  The  peritoneum  thus 
exposed  is  then  picked  up  and  a  transverse  opening,  sufficiently 
large  to  admit  the  fingers,  is  made  in  it.  Through  this  opening  the 
pelvic  structures  may  be  thoroughly  palpated  by  the  finger  (Fig. 
835),  and  if  desired  the  appendages  may  be  brought  down  to  view 
and  inspected. 

At  the  completion  of  the  operation  the  opening  in  the  peritoneum 
and  that  in  the  vaginal  wall  are  closed  by  a  few  catgut  sutures. 


Therapeutic  Measures 
VAGINAL  IRRIGATIONS 

Vaginal  irrigation,  or  douching,  may  be  employed  for  simple 
cleansing  purposes,  as  in  leucorrhea  or  in  preparation  for  operatic 
procedures;  for  the  purpose  of  bringing  soothing,  astringent,  or  anti- 
septic solutions  in  contact  with  diseased  vaginal  or  cervical  mucous 
membrane ;  and  as  a  means  of  applying  heat  to  the  pelvic  organs  to 
relieve  congestion  or  inflammation,  to  hasten  involution  after  labor, 
to  control  uterine  hemorrhage,  etc.  In  pregnancy  and  during 
menstruation  douches  should  be  used  with  caution. 

Apparatus. — There  will  be  required  a  large  glass  irrigating  jar  or 
douche  bag,  a  bath  thermometer,  6  feet  (180  cm.)  of  rubber  tubing, 
1/4  inch  (6  mm.)  in  diameter,  leading  from  the  reservoir  to  the 
douche  nozzle,  a  glass  vaginal  douche  nozzle,  and  a  douche  pan 
with  a  spout  to  which  is  attached  a  piece  of  rubber  tubing  sufficiently 
long  to  convey  the  waste  fluid  to  a  slop  pail  (Fig.  836). 

The  douche  nozzle  should  preferably  be  of  glass  wilfumt  ony 
curve  and  having  perforations  on  t/ie  sideSy  but  with  none  at  the  end 
(Fig.  837).  With  such  an  instrument  there  is  little  danger  of  the 
solution  entering  the  uterus  in  cases  of  a  patulous  cervix. 


VAGINAL   IRRIGATIONS  833 

Asepsis.- — The  greatest  care  should  be  taken  against  infection 
especially  in  puerperal  cases.  The  apparatus  should,  therefore,  be 
boiled  for  five  minutes  in  plain  water  and  the  thermometer  should  be 
sterilized  by  immersion  in  a  i  to  500  bichlorid  of  mercury  solution, 
after  which  it  is  rinsed  in  sterile  water.     The  attendant's  hands 


Fir,,  836,— Apparatus  for  vaginal  douching. 


should  be  cleansed  in  the  usual  way  and  the  external  genitals  should 
be  washed  with  soap  and  water  followed  by  a  i  to  sooo  bichlorid 
solution.  When  the  patient  administers  the  douches  herself,  the 
dangers  of  infection  and  the  proper  means  of  avoiding  it  should  be 
carefully  explained  to  her. 


:=3) 


Fig,  837. — Enlarged  view  ot  a  glass  vaginal  douche  nozzle. 


Solutions  Used.— Among  the  many  solutions  used  for  vaginal 
injection  are  the  following:  Plain  sterile  water;  normal  salt  solu- 
tion— salt  3i  (4  gm.)  to  the  pint  (500  c,c.)  of  boiled  water;  boric 
add  2  per  cent,;  thymol  i  to  1000;  lysol  i  per  cent.;  creolin  1  per 
cent,;  tannic  acid  3i  (4  gm.)  to  the  quart  (liter);  alum  acetate  3i 
(4  gm,)  to  the  quart  (liter) ;  permanganate  of  potash  i  to  2cxx>; 
bichlorid  of  mercury  i  to  5000;  carbolic  acid  i  per  cent.,  etc.     The 


834  "^^^  FEMALE   GENERATIVE   ORGANS 

use  of  poisonous  drugs,  such  as  the  latter  two,  should  be  fottoived  by  t 
douche  of  sterile  water  or  saline  to  avoid  any  danger  of  absorption. 

Temperature. — Ordinarily  the  irrigation  is  given  at  a  tempera- 
ture of  100"  to  105"  F.  (38"  to  41°  C).  When  the  stimulating  and 
vascular  constricting  effect  of  heat  is  de^ed,  however,  the  temp- 
erature should  be  from  115*  to  120"  F.  (46°  to  49"  C.)- 

Quantity. — ^At  least  i  gallon  (4  liters)  of  solution  should  be  used 
at  a  time.  If  it  is  desired  to  obtain  a  prolonged  effect  from  the  heat, 
several  gallons  may  be  used  over  a  period  of  fifteen  to  thirty  minutes. 


Pio.  838. — Showing  the 


{b)  method  of  sJving  «  vagiul 


Height  of  Elevation.— This  is  important,  since,  if  the  reservoir  is 
elevated  too  high,  the  pressure  will  be  so  great  that  solution  may  be 
forced  into  the  uterus.  An  elevation  of  3  to  3  feet  {60  to  90  cm.)  is 
amply  sufficient. 

Frequency. — This  will  depend  upon  the  purposes  of  the  douche 
from  once  a  day  to  three  or  more  times  daily. 

Position  of  Patient — The  patient  lies  in  bed  on  a  douche  pan  in 
the  dorsal  position,  with  the  knees  flexed,  or  else  recumbe&t  in  a  bath 
tub.  The  douche  should  not  be  taken  with  the  patient  silting  on  Ih 
toikt. 

Technic. — The  labia  are  widely  separated  with  the  finger  of  the 
left  hand  and  with  the  right  hand  the  nozzle  is  introduced  into  the 
vagina,  first,  however,  allowing  the  solution  to  flow  in  order  to  expel 


LOCAL    APPLICATIONS    TO    THE   VAGINA   AND    CERVIX  835 

any  air  or  cold  fluid.  The  desired  amount  of  solution  is  then  per- 
mitted to  enter  the  vagina  which  balloons  up  under  the  influence  of 
the  distention  and  thus  allows  the  solution  to  come  in  contact  with 
its  entire  surface  (Fig.  838). 

In  cases  of  a  relaxed  vagina,  it  is  necessary  to  compress  the  vaginal 
outlet  about  the  douche  tube  in  order  to  obtain  this  distention. 
This  procedure  should,  however,  be  used  with  caution  in  puerperal 
cases,  for,  if  the  intravaginal  pressure  be  too  great,  some  of  the 
solution  will  necessarily  be  forced  into  the  uterus.  -  During  the  irri- 
gation care  must  be  taken  to  protect  the  patient's  body  from  cold 
by  suitable  covering. 


LOCAL  APPLICATIONS  TO  THE  VAGINA  AND  CERVIX 

Local  applications  are  employed  in  treating  inflammations  of  the 
vagina  and  the  vaginal  portion  of  the  cervix.  They  may  be  made  by 
means  of  cotton-tipped  applicators  or  by  tampons  (see  page  837). 


I 


Ftc.  839. — Instruments   For   making   local   applications   to   the   vagina,     i,    Bivalve 
speculum;  2,  applicator. 

The  former  method  should  be  employed  when  it  is  desired  to  medi- 
cate localized  areas  of  inflammation  or  ulceration  or  to  employ 
strong  solutions. 

Instruments. — There  will  be  required  a  bivalve  vaginal  speculum 
and  a  metal  applicator  or  a  pair  of  dressing  forceps  (Fig.  839), 

Asepsis. — The  instruments  are  boiled  in  a  i  per  cent,  soda  solu- 
tion for  five  minutes  and  the  external  genitals  are  cleansed  with  soap 
and  water  followed  by  a  i  to  2000  bicblorid  of  mercury  solution. 
The  operator's  hands  should  likewise  be  clean. 

Solutions  Used. — Tincture  of  iodin,  silver  nitrate  gr.  xx  to  xxx 
(1.3  to  2  gm.)  to  the  ounce  (30  c.c),  argyrol  50  per  cent.,  copper 
sulphate  gr.  v  to  xx  (0.3  to  T.3  gm.)  to  the  ounce  (30  c.c),  zinc  sul- 
phate gr.  V  to  XX  (0.3  to  1.3  gm.)  to  the  ounce  (30  c.c),  etc.,'are 
among  the  solutions  generally  employed. 


n 


836 


THE   FEllALE   GENERATIVE 


Frequency. — Applications  may  be  made 
Position  of  Patient. — The  patient  shoul 
the  dorsal  position. 

Technic. — The  diseased  area  is  exposed 
and,  after  removing  any  mucus  or  secretiot 
to  medicate  is  wiped  dry.  Anapplicator  or 
with  cotton  is  then  dipped  in  the  solution  i 
thoroughly  nibbed  over  the  diseased  area, 
vaginal  tampon  is  inserted  and  allowed  to  ] 
twenty-four  hours. 

APPLICATION  OF  POWDERS  T< 

Powders  are  sometimes  employed  with  e 
in  the  treatment  of  chronic  vaginitis,  espec 
are  present. 


Instruments. — A  vaginal  speculum,  ( 
powder  blower  are  required  (Fig,  840). 

Formulary. — Soothing  or  astringent  po\ 
zinc  oxid,  bismuth  subnitrate,  calomel,  tanr 
nin,  acetanilid,  alone  or  in  combination,  an 


VAGINAL   TAMPONS  83/ 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  posture. 

Tectmic. — The  vagina  is  first  well  cleansed  with  a  douche.  A 
speculum  is  then  inserted  and,  by  means  of  a  cotton  swab  held  in  a 
dressing  forceps,  the  mucous  membrane  is  thoroughly  dried.  The 
entire  inflamed  surface  is  then  coated  with  the  desired  powder  ap- 
plied by  means  of  the  powder  blower,  A  light  tampon  is  finally 
inserted  and  is  left  in  place  for  twenty-four  hours. 

VAGINAL  TAMPONS 
Vaginal  tampons  are  used  for  a  variety  of  purposes,  namely,  to 
bring  medication  in  contact  with  the  vagina  or  the  cervix  in  the  treat- 


FiG.   841 . —Showing  the  melhod  of  making  a  cotton  vagina!  tampon. 
(KeUy  and  Noble.) 

ment  of  inflammations  involving  these  structures,  to  protect  and 
keep  separated  inflamed  or  ulcerated  vaginal  walls,  to  apply  glycerin 


gig  THE   FEMALE   GENEKATTVE   ORGANS 

for  its  depleting  effect  upon  the  uterus  and  pelvi9  organs,  to  support 
a  prolapsed  ovary,  for  the  purpose  of  stretching  adhesions  or  sup- 
porting the  uterus  hy  distention  of  the  vagina  and  fomices,  and  alone 
or  in  combination  with  the  uterine  pack  to  control  hemorrhage  from 
the  uterus. 

Tampons  should  not  be  left  in  place  more  than  twenty-four 
hours,  as  they  tend  to  become  foul  and  offensive,  and  strings  should 
aways  be  attached  so  that  they  may  be  removed  by  the  patient 
The  patient  should,  of  course,  be  informed  of  the  exact  number  of 
tampons  inserted. 

Instruments. — Bivalve  and  Sims'  specula  and  dressing  forceps 
are  required. 

The  Tampon. — Tampons  are  made  of  absorbent  cotton,  lambs' 
wool,  or  gauze.     For  carrying  medication  absorbent  cotton  is  prefer- 


A'aginal  tampons  in  positioi 


able,  while  for  purposes  of  support  lambs'  wool  or  gauze,  having 
more  body,  are  best. 

The  cotton  tampon  is  made  by  cutting  a  flat  layer  of  absorbent 
cotton  into  an  oblong  shape,  placing  a  heavy  silk  string  about  14 
inches  {^^  cm.)  long,  across  one  end  as  shown  in  Fig.  S41,  and  rolling 
th^  cotton  about  the  string.  On  tying  the  string  the  two  ends  of  the 
cotton  roll  are  brought  together  and,  at  the  same  time,  the  string  is 
buried  in  and  securely  fastened  to  the  cotton. 

Lambs'  wool  tampons  may  be  made  in  the  same  manner  or  a  silk 
string  may  be  simply  tied  to  the  center  of  a  wad  of  the  wool. 

A  gauze  tampon  should  consist  of  a  single  piece  of  gauze  3  fE*t 
(90  cm.)  or  more  long,  depending  on  the  capacity  of  the  vagina  and 


VAGINAL    TAMPONS  839 

the  fimmess  with  which  it  is  lo  be  packed,  and  folded  to  a  width  of 
about  2  inches  (5  cm.)- 

The  Medicated  Tampon.— The  tampon  is  made  as  above  de- 
scribed and  is  then  saturated  with  the  desired  medication.  For  this 
purpose  the  following  drugs  are  employed:  Ichthyol  and  glycerin  25 
per  cent.,  boroglycerid,  glycerite  of  tannic  acid  20  per  cent.,  argyrol 
10  to  25  per  cent.,  protargol  2  per  cent.,  etc.  When  indicated,  the 
tampon  may  be  covered  with  some  of  the  powders  mentioned  on  page 
836  in  place  of  these  solutions. 

Asepsis.— The  instruments  should  be  boOed  and  the  tampons 
thoroughly  sterilized.     The  external  genitals  are  washed  with  soap 


I 


Fig    843. — Shows  Ihe  method  of  packing    the  vagina  with  iht  patient  in  the  Sims 

and  water  followed  by  a  i  to  2000  bichlorid  of  mercury  solution.  The 
oj)erator's  hands  are  cleansed  in  the  usual  way. 

Position  of  Patient.- — For  inserting  the  medicated  tampon  the 
patient  may  be  in  the  dorsal  posture,  but,  when  it  is  desired  to  thor- 
oughly pack  the  vaginal  vault  for  the  purposes  of  support  and  to  con- 
trol hemorrhage,  the  Sims  or  the  knee-chest  posture  is  preferable. 

Preparations  of  Patient — The  bladder  and  bowels  should  be 
empty.  Any  clots  or  secretions  are  wiped  from  the  vagina  and  the 
entire  vagina  is  then  swabbed  out  with  a  i  to  2000  bichlorid  of  mer- 
cury solution. 


1 


840  THE  FEMALE  GENERATIVE  ORGANS 

Technic. — For  applying  a  medicated  tampon  a  bivalve  speculum 
is  inserted  and  the  tampon,  soaked  in  the  medicament,  is  carried  in 
dressing  forceps  to  the  desired  spot.  A  wool  tamj>on  is  then  inserted 
to  retain  the  first  one  in  position  and,  while  the  tampons  are  held 
securely  in  place  by  means  of  the  dressing  forceps,  the  sp>eculum  is 
removed,  care  being  taken  that  the  strings  attached  to  the  tampons 
are  left  hanging  from  the  vagina  (Fig.  842). 

The  tampon  is  to  be  removed  by  the  patient  within  twenty-four 
hours,  at  which  time  a  cleansing  douche  should  be  taken. 

To  thoroughly  pack  the  vagina,  as  is  necessary,  for  example,  for 
the  control  of  hemorrhage,  the  patient  being  in  the  Sims  or  the  knee- 
chest  posture,  a  Sims  speculum  is  inserted  and  the  posterior  vaginal 
wall  is  put  upon  the  stretch.  Then,  by  means  of  a  pair  of  dressing 
forceps,  the  entire  vagina  is  thoroughly  tamponed  with  a  strip  of 
gauze,  beginning  with  the  posterior  vaginal  fornix,  then  filling  the 
lateral  and  anterior  fornices,  and,  as  the  rest  of  the  vagina  is  packed, 
gradually  withdrawing  the  speculum  (Fig.  843).  A  T-bandage  is 
then  applied  to  retain  the  pack  in  place.  Such  a  pack  properly 
inserted  will  control  any  ordinary  hemorrhage  from  a  nonpuerperal 
uterus,  but  in  severe  hemorrhages  and  in  postpartum  cases  the 
uterus  also  should  be  tamponed  (page  847). 

Removal  of  the  packing  in  twelve  or  twenty-four  hours  should  be 
followed  by  a  cleansing  douche. 

THE  INTRAUTERINE  DOUCHE 

Uterine  douches  are  employed  in  the  treatment  of  septic  conditions 
affecting  the  uterus,  to  control  hemorrhage,  andfor  cleansing  the  uterus 
after  curettage  and  other  intrauterine  operations.  Certain  precau- 
tions in  their  use  are  necessary.  They  should  always  be  given 
fby  the  physician  himself  and  the  same  care  and  attention  to 
cleanliness  should  be  observed  as  in  any  operative  procedure.  It  is 
absolutely  essential  that  a  free  and  unimpeded  return  of  the  solntion 
be  provided  by  having  the  cervix  well  dilated  or  by  employing  a 
return-flow  irrigating  nozzle,  otherwise  there  is  danger  of  overdis- 
tention  of  the  uterus  with  resulting  shock  or  of  the  fluid  being  forced 
into  the  tubes.  Furthermore,  the  use  of  poisonous  drugs y  such  as  car- 
bolic acid  or  bichlorid  of  mercury,  should  always  be  followed  by  an  in" 
trauterine  irrigation  of  sterile  water  or  of  normcU  scUt  solution. 

Apparatus. — There  will  be  required  a  glass  irrigating  jar  or  a  large 
douche  bag,  a  thermometer,  6  feet  (180  cm.)  of  rubber  tubing,  }i 


THE   INTRAUTERINE   DOUCHE  84 1 

mch  (6  mm.)  in  diameter,  connecting  the  reservoir  and  the  douche 
nozzle,  a  douche  pan  with  a  spout  to  which  is  attached  a  piece  of  rub- 
ber tubing  sufficiently  long  to  convey  the  returning  fluid  to  a  waste 
pail  (see  Fig.  836). 

There  are  several  forms  of  intrauterine  douche  nozzles.     When 
the  cervix  is  widely  dilated,  as  in  postpartum  cases,  a  curved  glass 


Fig.  844.-0135 


e  douche  nozzle. 


nozzle  with  the  openings  upon  the  sides,  such  as  the  Chamberlain 
tube  (Fig.  844),  is  sufficient. 

In  other  cases  it  is  necessary  to  employ  some  form  of  return-flow 
nozzle.     The  Fritsch-Bozeman  nozzle  (Fig.  845)  is  the  safest  of  these. 


Fig.  845. — Fritsch-Boieini 


(Bandler.) 


It  consists  of  an  outer  tube  fenestrated  near  the  tip,  with  a  second 
opening  upon  the  under  surface  of  the  instrument  near  its  lower  end 
for  the  return  flow.  Inside  this  outer  lube  is  a  smaller  inflow  tube. 
This  instrument  requires  some  dilatation  of  the  cervix,  however, 


Fic.  846.— Return -fiow  dilnling  catheter.     (Ashton.) 

before  it  can  be  introduced  and  where  this  is  lacking  a  smaller  instru- 
ment, such  as  Talley's  intrauterine  catheter  (Fig.  846),  may  be  em- 
ployed. The  latter  consists  of  a  curved  metal  catheter  with  two 
heavy  wires  on  its  under  surface,  which  may  be  expanded  or  closed  by 
turning  a  small  thumb-screw.  The  catheter  is  introduced  into  the 
uterus  with  the  wires  lying  close  to  the  catheter  and,  when  in  the 


^ 


842 


IHE  FEMALE  GENERATIVE  .ORGANS 


uterus,  the  wires  are  expanded^  thereby  dilating  the  cervix  suffi- 
ciently to  permit  a  return  of  the  injected  solution. 

Instruments. — In  addition  to  the  above  apparatus  a  vaginal 
speculum,  a  sponge  holder,  and  a  pair  of  bullet  forceps  are  required 
(Fig.  847). 

Asepsis. — ^The  apparatus  and  instruments  should  be  sterilized  by 
boiling  and  the  thermometer  by  inmiersion  in  a  i  to  500  bichlorid  of 
mercury  solution  followed  by  rinsing  in  sterile  water.  The  external 
genitals  are  first  washed  with  soap  and  water  and  then  with  a  i  to 
2000  bichlorid  of  mercury  solution.     The  vagina  is  cleansed  by  means 


Fig.  847. — Instruments  for  intrauterine  douching,     i,  Garrigues'  weighted  speculum; 

2,  sponge  holder;  3,  tenaculum. 


of  a  I  to  5000  bichlorid  of  mercury  douche,  followed  by  sterile  water. 
The  operator's  hands  are  sterilized  in  the  usual  way. 

Solutions  Used. — Plain  sterile  water,  normal  salt  solution — salt 
5i  (4  gm.)  to  the  pint  (500  c.c.)  of  water,  i  to  10,000  to  i  to  5000 
bichlorid  of  mercury,  50  per  cent,  alcohol,  0.5  per  cent,  solution  of 
lysol,  0.5  per  cent,  solution  of  creolin,  silver  nitrate  i  to  1000,  etc, 
etc.,  are  among  the  solutions  employed. 

Temperattu-es. — Ordinarily  the  temperature  of  the  solution  is 
about  105°  F.  (41°  C.) .  Where  the  stimulating  and  constricting  effect 
of  heat  is  desired,  the  temperature  of  the  solution  should  be  115°  to 
120°  F.  (46^^  t0  49°  C.). 

Quantity. — About  i  quart  (i  liter)  of  solution  is  used  at  a  time. 


THE  intrauter:ne  douche  843 

Rapidity  of  Flow, — The  fluid  should  not  be  allowed  to  enter  the 
uterus  more  rapidly  than  it  can  escape,  otherwise  there  is  danger  of  its 


Fig.  S48. — Inserting  the  douche  nozzle  when  the 


well  dilated. 


being  forced  into  the  tubes.    Therefore,  the  reservoir  should  not  be 
elevated  more  than  2  feet  (60 cm.). 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position. 


I 


r~^ 


Fig.  845. — Method  ol  giving 

Teconic,^ — If  the  cervix  is  well  dilated  so  that  the  entrance  of  the 
douche  nozzle  is  not  interfered  with,  the  latter  may  be  inserted  by 
touch  alone,  as  follows :     One  or  two  fingers  of  the  left  hand  are  passed 


844  ''^^^  FEUALE   GENERATIVE   OSGANS 

into  the  vagina  and  the  external  os  is  thus  located.  The  douche 
nozzle,  with  the  solution  flowing  so  as  to  avoid  injecting  any  air,  is 
then  inserted  into  the  uterus  by  the  right  hand,  being  guided  through 
the  cervix  by  the  fingers  of  the  left  band  (Fig.  848).  The  noz^eis 
then  gently  passed  to  the  fundus  of  the  uterus  and  the  cavity  is  tbor- 
ougly  irrigated.  The  return  flow  must  be  carefully  watched  to  see 
that  it  is  not  obstructed.  It  is  well  to  place  the  left  hand  exter- 
nally over  the  fundus  uteri  in  puerperal  cases  to  prevent  any  possible 
over  distention  of  the  uterus  and  opening  up  of  the  sinuses  (Fig.  849). 


douche  wiih  a  Teiuni-flo» 


To  introduce  the  douche  nozzle  by  sight,  the  posterior  vaginal 
wall  is  retracted  by  means  of  a  speculum,  and,  if  the  cervii  is  not 
readily  accessible,  it  is  drawn  down  into  the  vagina  by  means  of  bullet 
forceps  caught  in  its  anterior  lip.  The  cervix  is  then  wiped  off  by 
means  of  a  swab  on  a  sponge  holder  wet  with  a  i  to  2000  bichloridof 
mercury  solution,  and  a  return-flow  nozzle  is  inserted  by  direct 
sight,  taking  care  to  have  the  solution  first  flowing  (Fig.  850).  In 
inserting  the  nozzle  extreme  gentleness  should  be  used  to  avoid  in- 
juring the  tissues  or  possibly  perforating  the  uterus.  The  latter 
accident  has  happened  frequently  enough  to  warrant  this  caution. 

INTRAUTERINE  APPLICATIONS 
The  application  of  drugs  with  an  astringent  or  caustic  action  to 
the  mucous  membrane  of  the  uterus  is  employed  in  the  treatment  of 


INTRAUTERINE    APPLICATIONS  84S 

endometritis  alone  or  in  conjunction  with  curettage.  The  best  re- 
sults are  obtained,  however,  when  intrauterine  apphcations  are  used 
after  a  preliminary  curettage. 

The  indiscriminate  employment  of  intrauterine  applications 
often  do  more  harm  than  good.  They  should  only  be  employed  In 
cases  where  thorough  asepsis  can  be  obtained,  and  then  only  with 
the  cervix  sufficiently  dilated  to  allow  thorough  subsequent  drainage. 
The  procedure,  therefore,  is  one  that  rises  to  the  dignity  of  an  opera- 
tion and  should  not  be  attempted  as  a  part  of  the  of&ce  treatment, 


Fig.  851. — iBstnimenls  tor  making  intrauterine  applications,     i,  Garriguea  weighted 
speculum;  :,  sponge  holder;  j,  tenaculum;  4,  applicator. 

The  position  and  size  of  the  uterus  and  the  condition  of  the  other 
pelvic  organs  must  be  determined  by  bimanual  examination  before- 
hand. In  the  presence  of  adnexal  involvement  or  other  complica- 
tions intrauterine  apphcations  are  con  train  dicated. 

Isstruments. — There  should  be  provided  a  vaginal  speculum, 
spoi^e  holders,  bullet  forceps,  and  two  uterine  applicators  (Fig,  851). 

Asepsis.— The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.  The  external  genitals  are  washed  with  soap  and 
water  followed  by  a  i  to  2000  bichlorid  solution.  The  vagina  is 
douched  with  a  i  to  5000  bichlorid  of  mercury  solution  followed  by 
sterile  water.  The  operator's  hands  are  likewise  sterilized  as  for  any 
operation. 

Solutions  Used. — Sulphate  of  zinc  5  to  10  per  cent.,  chlorid  of 
zinc  5  to  10  per  cent,,  silver  nitrate  5  to  10  per  cent.,  perchlorid  of 


846  THE  FEMAXE  GENERATIVE  ORGANS 

iron  5  per  cent.,  ichthyol  5  to  10  per  cent.,  tincture  of  iodin  50  per 
cent.,  Churchill's  solution  of  iodin,  pure  carbolic  acid,  etc,  etc.,  may 
be  employed. 

PositioQ  of  Patient — The  patient  is  placed  in  the  dorsal  poation. 

Technic. — ^The  vaginal  speculum  is  -inserted  and  the  cervix  b 
drawn  down  into  view  by  means  of  bullet  forceps  which  seize  the 
anterior  lip.    Any  secretion  or  collection  of  mucus  is  then  wiped  away 


Fig.  853. — Shows  the  method  of  making 


appUution. 


from  the  external  os  by  means  of  a  swab  soaked  in  a  i  to  aooo  bi- 
chlorid  solution,  and  the  cervix  is  dilated  if  necessary  (see  page  864). 
A  small  thin  layer  of  dry  cotton  is  then  securely  wound  round  an 
applicator,  taking  care  that  the  tip  of  the  instrument  is  well  covered. 
The  swab  thus  fashioned  is  to  be  of  such  size  that  it  will  readily  pass 
the  cervix.  The  applicator  is  curved  to  the  shape  of  the  canal  and  is 
passed  into  the  uterus  for  the  purpose  of  removing  any  secretions  and 
thus  allow  the  solution  to  come  in  contact  with  all  portions  of  the 
mucous  membrane.  A  second  applicator,  similarly  wrapped  with 
cotton,  is  dipped  in  the  solution.  Any  excess  of  fluid  is  squeezed 
from  the  cotton  and  the  appUcadon  is  then  made  to  the  interior  of  the 
uterus,  carrying  the  cotton-tipped  applicator  weU  up  to  the  fundus 
and  moving  the  instrument  about  in  the  cavity  (Fig.  852).  A  vaginal 
tampon  is  finally  inserted,  which  is  removed  in  twenty-four  houis. 
The  patient  should  remain  quiet  for  a  day  or  two,  and,  if  a  strong 
caustic  has  been  employed,  she  should  be  warned  that  at  first  there 
will  be  an  increased  discharge. 


TAMPONING   THE   UTERDS 


847 


TAMPOHIHG  THE  UTERUS 

Tamponage  of  the  uterus  may  be  required  to  control  severe  uter- 
ine hemorrhage,  to  secure  dilatation  of  the  cervix  for  the  expulsion  of 
the  uterine  contents  or  in  preparation  for  intrauterine  manipulations, 
and  to  aid  in  the  separation  of  retained  products  of  conception.  The 
technic  of  tamponing  the  uterus  for  the  control  of  hemorrhage  is 


Fro.  853. — InitnunenU  for  tamponing  the  uterus,     t,  Ganigues'  speculum;  a,  sponge 
bolder!  3,  tenaculum;  4,  uterine  dressing  forceps;  5,  uterine  packer. 


something  with  which  every  physican  should  be  familiar,  as  occasions 
may  arise  when  the  operation  is  demanded  without  delay  as  a  life- 
saving  measure;  at  the  same  time  it  should  be  regarded  as  a  surgical 
procedure  and  one  that  should  always  be  performed  under  thorough 
aseptic  precautions.  The  position  and  size  of  the  uterus  should  be 
ascertained  by  bimanual  examination  beforehand,  otherwise  the 
uterus  may  be  injured  in  attempting  to  insert  the  packing. 

Instniments,— A  Simon  or  a  Garrigues  speculum,  sponge  holders, 
two  bullet  forceps,  a  pair  of  uterine  dressing  forceps,  or  a  cannula  and 
packer  are  required  (Fig.  853).  In  the  majority  of  cases  a  pair  of 
curved  dressing  forceps  may  be  employed  for  inserting  the  packing, 
but,  where  the  cervix  is  not  well  dilated,  a  special  packer,  such  as  is 
shown  in  Fig.  854,  by  means  of  which  the  packing  is  pumped  into  the 
uterus  through  the  cannula,  is  more  convenient. 

Packing  Material. — The  most  satisfactory  material  to  employ 
for  packing  is  sterilized  gauze.     This  should  be  folded  into  strips  3 


n 


848  THE   FEMALE   GENERATIVE   ORGANS 

inches  (5  cm.)  wide  for  use  when  the  cervix  is  well  dilated  and  into 
strips  J-^  inch  (i  cm.)  wide  for  an  incompletely  dilated  cervix. 
Care  should  be  taken  to  see  that  the  strips  are  so  folded  that  no 


ij    j      CJ 


o 


Fig.  854. — Showing  the  cannula  and  plunger  of  the  u 


e  packer  sep4nted. 


frayed  edges  are  exposed.     The  gauze  is  best  kept  in  long  str^ 
packed  In  sterile  glass  tubes. 

Asepsis. — The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.    The  patient's  external  genitals  are  washed  with 


.  855. — Method  of  tamponing  the  uterus  with  a  long  strip  of  gauze  inserted  b; 
means  of  dressing  forceps. 


soap  and  water,  followed  by  a  i  to  2000  bichlorid  solution  and  the 
vagina  is  first  cleansed  with  soap  and  water  and  then  douched  withi 
1  to  5000  solution  of  bichlorid  of  mercury.  The  operator's  hands  are 
sterilized  as  for  any  operation. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
position. 

Preparations  of  Patient. — The  patient's  bladder  and  bowels 
should  be  empty. 


TAMPONING   THE   UTERUS  849 

Tochnic. — Any  clots  are  first  wiped  out  of  the  vagina.  The  cer- 
vix is  exposed  by  means  of  the  speculum  and  the  anterior  and  pos- 
terior lips  are  seized  in  bullet  forceps  which  are  given  to  an  assistant 
to  hold.  A  strip  of  gauze  is  then  seized  In  dressing  forceps  iti  such  a 
way  that  the  gauze  falls  over  the  end  of  the  forceps  so  as  to  avoid 
inflicting  any  injury  upon  the  tissues  and  is  carried  to  the  fundus. 
Successive  sections  of  the  gauze  are  inserted  in  the  same  manner  until 
the  cavity  is  filled  (Fig.  855).  Whenever  possible,  a  single  strip  of 
gauze  should  be  employed.     While  inserting  the  gauze  the  operator's 


Fig.  856.— Method  ot  using  the 

free  hand  should  be  kept  upon  the  abdomen  in  order  to  control  the 
uteruSj  and  care  should  be  taken  that  the  gauze  does  not  come  in 
contact  with  anything  that  is  not  sterile.  The  end  or  ends  of  the 
gauze,  if  more  than  one  strip  is  used,  should  be  left  projecting  into 
the  vagina,  so  that  it  may  be  easily  found,  when  the  gauze  is  to  be 
removed,  which  should  be  within  twenty-four  hours  of  its  insertion. 

In  cases  of  severe  hemorrhage  the  vagina  also  should  be  packed 
(see  page  837),  taking  care,  however,  to  tie  the  vaginal  strip  to  that 
within  the  uterus  or  else  to  bring  the  ends  of  both  vaginal  and  uterine 
strips  to  the  vaginal  outlet.  Upon  removal  of  the  gauze  a  vaginal 
douche  should  be  given. 

In  tamponing  the  uterus  by  means  of  the  special  packer  shown  in 
Fig.  854,  the  cervix  is  exposed  as  before  and  is  drawn  down  by  means 
of  bullet  forceps.     The  cannula  is  then  inserted  into  the  uterus  and  a 


850  THE  FEMALE  GENERATIVE  ORGANS 

narrow  strip  of  gauze  is  caught  on  the  sharpened  end  of  the  piston  and 
is  carried  into  the  uterus  by  a  pumping  motion  of  the  piston  (Fig. 
856). 

BIER'S  HYPEREMIC  TREATMENT  IN  GYNECOLOGY 

Passive  hyperemia  by  means  of  special  forms  of  suction  cups 
applied  to  the  cervix  uteri  has  been  employed  with  good  results  m 
cases  of  puerperal  and  other  forms  of  infection  of  the  cervix  and 
uterus,  in  ulcerations  of  the  cervix,  in  chronic  metritis,  and  in  amenor- 
rhea. The  use  of  cups  is  contraindicated,  however,  if  the  adneza  are 
inflamed. 

In  dysmenorrhea  there  have  been  numerous  favorable  reports 
from,  the  application  of  large  suction  cups  to  the  breast  once  or  twice 
a  day  for  periods  of  fifteen  to  thirty  minutes,  beginning  a  few  days 
before  the  date  of  expected  menstruation  and  continuing  the  treat- 
ments till  the  end.  Pelvic  exudates  have  also  been  treated  with 
success  by  means  of  hot-air  boxes  in  which  the  pelvis  and  hips  rest. 

The  apparatus  for  obtaining  active  and  passive  hyperemia,  as 
well  as  the  method  of  its  use,  have  been  previously  described  in 
Chapter  X. 

PELVIC  MASSAGE 

Pelvic  massage  after  the  method  of  Brandt  has  been  employed  for 
the  purpose  of  hastening  the  absorption  of  pelvic  exudates  through 
stimulation  of  the  circulation  and  lymph  currents,  to  stretch  or  sepa- 
rate old  adhesions,  to  stimulate  contractions  in  the  uterus,  and  to 
strengthen  and  tone  up  weakened  or  thickened  pelvic  ligaments.  In 
certain  selected  cases  this  method  of  treatment  has  value.  Fdvk 
massage  must  never  he  employed^  however^  in  the  presence  of  acute 
inflammation  or  with  pus  collections  in  the  tubes  or  pelvis ^  so  that  the 
diagnosis  must  be  carefully  made  in  every  case  before  it  can  be  safely 
attempted,  and  then  it  should  only  be  performed  by  the  physician 
himself.    In  individuals  with  erotic  tendencies  it  should  be  avoided. 

Duration  of  Treatments. — The  massage  is  p>erformed  for  about  ten 
minutes  at  a  sitting. 

Frequency. — Treatments  are  given  daily. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  posture. 

Preparations. — The  bladder  and  bowels  should  be  emptied  before- 
hand and  the  clothing  should  be  loosened  from  the  abdomen 

Technic. — Under  all  aseptic  precautions  two  fingers  of  the  left 
hand  are  introduced  into  the  vagina  and  are  carried  up  to  the  part  to 


PELVIC    MASSAGE  851 

te  massaged.     Then,  by  means  of  the  right  hand  placed  on  the  abdo- 
men,  at  first  gentle  circular  movements  and  then  deep  pressure 


Fig.  85 7. ^Showing  the  position  o£  the  bands  in  commencing  pelvic  masssge- 


FiG.  SjS. — laatnimenta  for  scarification  of  the  1 
holder;  3,  tenaculum;  4,  nan 


rvii.     I,  Bivalve  specului 
w-h laded  bistoury. 


manipulations  are  made  over  the  diseased  part,  which,  at  the  same 
time,  is  raised  and  fixed  within  reach  of  the  external  hand  by  the 


853  THE   FEMALE   GENERATIVE   OSGAKS 

internal  fingers.  The  manipulations  should  be  begun  each  time 
over  the  periphery  of  the  diseased  part  and  should  always  be  made 
with  the  greatest  care  and  with  the  absence  of  any  approach  to 
roughness. 

When  employed  for  the  purpose  of  gradually  stretching  adhesions 
or  contracted  ligaments,  gentle  intermittent  traction  is  applied  to  the 
uterus  through  the  internal  and  external  hands  in  a  direction  oppoate 
to  the  point  of  the  fixation  (Fig,  857),  By  thus  gradually  stretching 
the  adhesions  and  through  the  stimulating  effect  of  the  manipulations 
the  fibrous  tissue  is  gradually  absorbed  and  the  muscular  and  elastic 
tissues  become  regenerated.  Such  manipulations  are  especially  use- 
ful when  used  in  conjunction  with  hot  douches  and  tampons  in  gradu- 
ally replacing  a  utems  bound  down  by  adhesions. 

SCARIFICATION  OF  THE  CERVIX 

The  withdrawal  of  blood  from  the  cervbc  is  a  valuable  therapeutic 
measure  in  cases  of  chronic  congestion  of  the  uterus  and  pelvic  organs. 


F       8s()  — M    hod  of  scarifying  the  cervix  by  punclures.     (Ashton.) 
F  G   860  ^Sca   fica   on  of    he  cervix,  showing  the  method  ot  making  the  super&i:d 
ncisions.     (Ashton.) 

It  is  also  employed  with  good  results  for  the  relief  of  the  pain  and  colic 
of  delayed  menstruation  due  to  pelvic  congestion. 

Instruments. — A  vaginal  speculum,  sponge  holders,  bullet  forceps, 
and  a  narrow-bladed  bistoury  are  required  (Fig.  858). 

Asepsis. — All  aseptic  precautions  should  be  observed.  The 
instruments  are  to  be  boiled  for  five  minutes  in  a  1  per  cent,  soda  solu- 


PESSARY  THERAPY  853 

tion,  and  the  hands  of  the  operator  are  prepared  as  for  any  operation. 
The  external  genitals  are  cleansed  with  soap  and  water,  followed 
by  a  I  to  2000  bichlorid  solution,  and  the  vagina  is  douched. 

Position  of  Patient. — -The  patient  should  be  in  the  dorsal  posture. 

Technic. — The  ccr\Tx  is  exposed  by  the  speculum  and,  after  being 
mopped  off  by  means  of  a  wipe  moistened  in  a  i  to  2000  bichlorid 
solution,  is  seized  by  the  bullet  forceps  and  is  drawn  well  down  to- 
ward the  vaginal  outlet.  Numerous  punctures  are  then  made  by 
means  of  the  point  of  the  bistoury  to  the  depth  of  J-^  to  y^  inch 
(6  to  12  mm.)  around  the  circumference  of  the  cervix  (Fig.  859),  or, 
instead  of  punctures,  cross  cuts  may  be  employed  (Fig.  860).  In 
this  way  from  H  ounce  (15  c.c.)  to  2  ounces  (60  c.c.)  of  blood  msiy 
be  withdrawn.  A  tampon  of  ichthyol  and  glycerin  or  tannin  and 
glycerin  is  then  inserted  into  the  upper  portion  of  the  vagina,  to  be 
removed  within  twleve  hours. 

PESSARY  THERAPY 

Pessaries  are  employed  for  the  purpose  of  maintaining  a  retrodis- 
placed  or  prolapsed  uterus  in  place  and  to  support  a  cystocele.  In 
the  case  of  a  prolapse  of  the  uterus  or  a  cystocele  a  pessary  is  only  of 
value  as  a  palliative  measure  where  operative  relief  is  refused  or  is 
imdesirable  on  account  of  the  age  or  condition  of  the  patient.  In  a 
certain  proportion  of  retrodisplacements,  however,  a  properly  fitted 
pessary  will  in  time  produce  a  cure,  the  most  favorable  cases  being 
those  in  which  the  displacement  is  only  of  short  duration  as,  for 
example,  after  confinement.  The  only  cases  of  displacement  in  which 
pessary  therapy  is  suitable  are  those  where  the  pelvic  floor  has  suffi- 
cient tonicity  to  give  support  to  the  pessary  and  where  the  displace- 
ment is  not  complicated  by  pelvic  lesions.  Their  use  is  contraindi- 
cated  in  the  presence  of  considerable  enlargement  or  a  prolapse  of  the 
ovary,  hydrosalpinx,  pyosalpinx,  or  new  growths,  and  where  the 
uterus  is  bound  down  by  adhesions.  Some  cases  of  adhesions,  how- 
ever, under  appropriate  treatment  by  medicated  tampons,  hot 
douching,  etc.,  may  be  so  stretched,  or  even  be  made  to  disappear, 
that  later  a  pessary  may  be  satisfactorily  employed. 

Pessaries  are  not  designed  as  a  means  of  replacing  a  uterus,  but 
simply  to  hold  the  organ  suspended  in  proper  position  after  it  has 
been  replaced.  This  it  does  by  distending  the  vaginal  walls,  and  not 
through  any  force  exerted  by  the  instrument  upon  the  uterus  itself. 
Every  pessary  should  be  fitted  to  the  individual  case,  and  it  is  here 


L 


854  I^B  FEMALE   GENEKAXIVE   ORGANS 

that  the  experience  of  the  physician  counts  for  much.  When  properly 
fitted,  the  pessary  should  never  cause  any  pain  or  even  make  the  patient 
conscious  of  its  presence,  and  it  may  be  worn  for  years,  with  certain 


ring  (d)  pessary  with  external  support.     (Ashton.) 


precautions  as  to  cleanliness,  to  be  mentioned  later,  without  harm. 
On  the  other  hand,  an  ill-fitting  pessary  or  one  employed  in  a  case 
not  suitable  for  such  treatment  is  distinctly  harmful.  It  should, 
therefore,  always  be  impressed  upon  the  patient  that  if  theieastpain 


PESSAKY    THERAPY  855 

or  an  undue  amount  of  leucorrhca  results  from  the  insertion  of  the 
pessary,  she  should  report  to  the  physician  immediately,  or  else 
remove  the  pessary  herself. 

Pessaries. — Pessaries  are  made  of  hard  rubber  in  a  great  variety 
of  shapes.  For  retrodisplaccmcnts  the  most  commonly  employed  is 
the  Hodge-Smith  (Fig.  86i),  If,  however,  the  pelvic  floor  is  relaxed, 
a  Hodge  pessary  (Fig.  862)  is  preferable,  as  its  wide  lower  bar  renders 
it  less  liable  to  slip  out.  This  type  of  pessary  acts  in  such  a  way 
that  the  force  is  exerted  upon  the  posterior  cul-de-sac  and  the 
utcrosacral  ligaments,  so  that  the  cervix  is  pulled  backward  and  the 
uterus  is  thus  tipped  forward. 

Ring  pessaries  (Fig.  86^)  are  also  employed  in  rctrodisplaccments 
where  there  is  not  sufficient  support  for  the  ordinary  pessary.  They 
act  by  so  distending  the  vagina  in  all  directions  that  the  uterus  is 
supported  by  the  lower  vaginal  structures.  The  ring  should  be 
smooth  and  fairly  thick,  at  least  f^  inch  (6  ram.),  so  as  to  avoid  any 
danger  of  its  eroding  through  the  vaginal  walls.  The  ring  pessary 
is  also  employed  for  retaining  a  prolapsed  uterus  in  place;  but  in 
many  cases  of  prolapse,  the  perineum  is  so  relaxed  that  the  pessary 
immediately  slips  out,  and  some  sort  of  pessary  held  in  place  by  an 
abdominal  support,  such  as  is  shown  in  Fig.  866,  will  be  necessary. 

For  supporting  a  cystocele  Gehrung's  anteversion  pessary  (Fig, 
864)  or  Skene's  pessary  (Fig.  S65)  is  often  used  with  success. 

As  previously  stated  the  pessary  should  be  fitted  to  each  individual 
case.  The  shape  of  the  pessary  may  be  readily  changed  by  first 
coating  the  instrument  with  oil  or  vaselin  and  then  softening  it  by  the 
heat  of  an  alcohol  lamp.  When  it  has  been  moulded  to  the  desired 
shape  it  is  hardened  again  by  immersion  in  cold  water.  The  ten- 
dency is  to  employ  too  large  a  ]>e5sary,  which  is  dangerous,  as  it  may 
exert  undue  pressure  upon  the  vaginal  wall  and  produce  excoriations, 
or  in  time  even  ulcerate  through.  On  the  other  hand,  if  the  pessary  is 
too  small,  it  will  not  remain  in  place.  The  safest  plan  is  to  measure 
the  vagina  in  each  case  and  shape  the  pessary  accordingly.  The 
depth  of  the  vagina  is  determined  by  carrying  two  fingers  as  high  as 
possible  into  the  posterior  cul-de-sac  and  measuring  the  distance  from 
the  inferior  border  of  the  symphysis,  while  the  width  is  estimated  by 
noting  the  distance  to  which  the  two  fingers  in  the  vagina  may  be 
separated.  About  y^  inch  (i  cm.)  should  be  deducted  from  the 
former  measurement  for  the  correct  length  of  the  pessary. 

Asepsis. — The  ring  pessary  may  be  sterilized  by  boiling,  but  the 
others,  if  so  treated,  lose  their  shape;  prolonged  immersion  in  some 


J 


$56  THE  PEHALE  GENERATIVE:  ORGANS 

antiseptic  solution,  such  as  i  to  500  bichlorid  of  mercury,  shoiild  be 
employed  instead.     Instruments  that  may  be  required  are  boiled 
and  the  hands  of  the  operator  are  sterilized  in  the  usual  manner. 
Positioa  of  Patient. — For  inserting  the  pessary  the  patient  is  ordi- 


Fic.  867.— First  step  ir 


■eplacing 


narily  placed  in  the  dorsal  posture,  though  in  some  cases  the  knee- 
chest  position  may  be  used  to  better  advantage. 

Preparations  of  Patient. — The  bladder  and  bowels  should  be 
empty,  and  the  clothing  well  loosened. 


Fig.  868.^ — Second  step  in  replacing  a  retroverted  uterus,     (.^shton.) 


Technic. — i.  Replacement  of  the  Retroverted  Uterus. — There  are 
two  methods  of  replacement:  (i)  By  bimanual  manipulation,  and 
(2)  with  the  patient  in  the  knee-chest  posture  The  former  method 
is  usually  effective  if  the  abdominal  walls  are  not  thick  and  rigid  and 


PESSARY  THESAPV  857 

the  vagina  is  suESciently  roomy.  It  is  performed  as  follows:  Two 
fingers  of  the  left  hand  are  introduced  into  the  vagina  and  are  carried 
up  into   the  posterior  cul-de-sac  where  they  exert  pressure  in  an 


Fig.  S69. — Third  slep  in  replacing  a.  rctroverted  uterus.     (Ashton.) 


upward  and  forward  direction  upon  the  body  of  the  uterus  (Fig,  867). 
As  the  uterus  is  thus  elevated,  the  right  hand  is  placed  upon  the 
abdomen,  and  an  attempt  is  made  to  hook  the  fingers  behind  the  fun- 


Fio.  870. — Second  method  of  repli 


dus  (Fig.  868) ,  The  fundus  is  then  pulled  forward  by  the  fingers  of 
the  external  hand  while  the  internal  fingers  are  shifted  to  the  an- 
terior fornix,  where  they  make  backward  pressure  upon  the  cervix 


85S  THE    FEMALE    GENER-VTIVE    ORG.\NS 

and  the  lower  segment  of  the  uterus  (Fig,  S69).  Sometimes,  how- 
ever, it  is  not  possible  to  raise  the  fundus  past  the  promontoiy  by 
this  method.     In  such  a  case  the  anterior  lip  of  the  cervix  should  be 


Fig.  87a.— Second  method  of  replacing  a  retroverted  u 
Noble.) 


Third  step..    (KeUyii 


wm 


grasped  in  bullet  forceps,  and  the  whole  uterus  is  then  pulled  downJ 
toward  the  vaginal  outlet  (Fig,  870).     At  the  same  time  the  index- 
finger  of  the  left  hand  covered  with  a  glove  is  inserted  into  the  rectum. 


PESSARY    TH£K.\PY  859 

aixi  the  fnndos  ts  dn-ated  past  the  pramoDtorr  (Fig.  871).  The 
corixis  then  ptialtcd  backward  (F%.  S;^).  tb<r  bullet  forceps  are  re- 
moved, and  rcpoaticKi  ^  oxmpleted  himannally  as  described  above. 
If  these  manqxilatioiis  fail,  the  potimt  sbouM  be  placed  in  the 
knee-dkcst  postare  and  the  poGterior  va^nal  wall  retracted  by  means 
of  a  Sims  w  Smoo  qiecahim.  This  freqnentl}'  results  in  the  uterus 
falling  forward  through  the  effect  of  graii'ity.  If  it  does  not,  the  cer- 
vix should  be  grafted  with  bnDet  forceps  and  puUed  upn-ard  and  out- 
ward toward  the  %-a^oal  outlet,  while  the  fundus  is  pushed  forward 
by  means  of  a  pair  of  dressing  forceps  armed  with  a  pledget  of 
cotton  carried  up  into   the  posterior  cuJ-de-sac   (Fig.  873).     The 


Fic.  873. — Replacement  of  a  posterior  uterine  dbplacenieDl  in  the  knec<heat 
position.  Showing  the  cervii  drawn  forward  and  Ihe  fundus  sninpng  clear  of  the 
promontory.     lUusuaUon  o  shows  the  fundus  pushed  anteriorly  by  direct  pnasurc^ 

(.\shton.) 


patient  is  then  slowly  and  carefully  turned  to  the  dorsal  position, 
and  a  bimanual  examination  is  made  to  determine  if  the  uterus  is 
still  in  position  before  a  pessary  is  inserted. 

In  all  manipulations  toward  replaccvienl  of  a  ulerus,  the  utmost 
gentleness  sfiould  be  employed.  If  the  patient  is  very  sensitive  or  the 
abdominal  walls  rigid,  it  is  preferable  to  give  a  general  anesthetic 
rather  than  employ  force. 


i 


860  THE  FEUALE  GENERATIVE  ORGANS 

2,  Introduction  of  Pessaries. — To  insert  the  ordinary  retroversioo 
pessary,  the  left  index-finger  b  carried  into  the  vagina  and  the  vagina] 


Fig.  S74  — First  step  m   ntroduc  ng 


wall  is  retracted,  while  with  the  right  hand,  the  pessary  is  introduced 
atfirst  obliquely  (Fig.  874),  and  then  turned  so  that  it  lies  transversely 


Fig.   875. — Showing  the  pessary  in  the  vagina  with  the  posterior  bar  in  contact  with 
the  cervix.     (Ashton.) 

in  the  vagina  (Fig.  875).     The  index-finger  of  the  left  hand  is  then 
shifted  so  that  it  lies  under  the  anterior  bar  with  its  tip  resting  upon 


PESSARV   THEEAPV 


86i 


the  posterior  bar  (Fig.  876).  The  posterior  bar  is  then  pressed  down- 
ward and  backward  until  it  lies  behind  the  cervix  (Fig.  877).  After 
the  pessary  has  been  introduced,  the  patient  is  examined  while  in  the 
erect  position  to  see  if  it  fits  properly.     A  properly  fitting  pessary 


Fio   876. — Second   step   in   iatroducing   a  retroversion   pessary,   depressing   the 
posterior  bat  and  inserlin?  it  behind  the  cervix.     (Ashton.) 

Fro.  877. — Showing  the  retroversion  pessary  in  place-     (Ashton.) 


Fig.  878. — First  step 

should  hold  the  uterus  in  place  and  at  the  same  time  should  not  be 
so  tight  that  the  examining  finger  cannot  be  passed  between  the 
vaginal  walls  and  the  pessary  on  all  sides. 


863 


THE  FEMALE  GENERATIVE  OBGANS 


The  ring  pessary  is  introduced  in  much  the  same  way,  that  is,  the 
left  index-finger  retracts  the  posterioi  vaginal  wall  while  with  tlie 
fingers  of  the  right  hand  the  pessary  is  introduced  obliquely  into  the 
v^ina  (Fig.  878).    It  is  then  turned  transversely  and  is  manipulated 


Fic.  880.-— Showing  Skene's  pessary 


by  the  internal  fingers  until  it  lies  In  proper  position  with  its  opening 
surrounding  the  cervix  (Fig,  879). 

Skene's  cystocele  pessary  is  introduced  into  the  vagina  in  the  same 
manner  as  the  retroversion  pessary,  with  the  posterior  bar  l>'ing 
behind  the  cervix,  and  the  broad  anterior  bar  supporting  the  bladder 
(Fig.  880). 


PESSARY   THERAPY  863 

Gehnmg's  cystocele  pessary  is  more  difficult  to  introduce.  The 
following  methed  is  employed:  The  pessary  is  placed  upon  a  table  in 
such  away  that  it  rests  upon  its  inferior  arch,  with  the  two  curves, 


■Firet  step  in  iaUodudng  Gehning's  pessary, 

right  and  left,  facing  toward  the  operator,  who  then  grasps  the  curve 
L  between  the  thumb  and  forefinger  of  the  right  hand,  and  inserts 
curve  R  into  the  right  side  of  the  vagina  (Fig.  881)  and  then  curve  L 


Fic  88j. — Gehning'a  pessary  in  position. 

into  the  left  side.  The  pessary  is  then  manipulated  into  such  posi- 
tion, that  the  superior  arch  lies  up  in  front  of  the  uterus,  the  inferior 
arch  under  the  pubic  arch,  and  the  two  curves  R  and  L  on  the  pos- 
terior vaginal  wall  (Fig.  882). 


864  THE  FEMALE  GENERATIVE  ORGANS 

After-care. — Within  three  or  four  days  after  introductdon  of  the 
pessary,  the  vagina  is  inspected  to  determine  whether  there  is  any 
erosion  from  undue  pressure  of  the  pessary.  The  patient  is  then 
ined  once  every  month  or  six  weeks,  at  which  time  the  pessarj-  is 
'ed  and  well  cleansed  before  re-insertion  and  the  vagina  is 
examined  for  signs  of  ulceration,  which,  if  present,  necessitate  the 
removal  of  the  pessary  and  the  substitution  of  medicated  tampons 
imtil  healing  has  been  effected.  Once  a  week  and  after  each  men- 
strual period  the  patient  should  take  a  warm  boric  acid  or  soapsuds 
douche  for  cleansing  purposes,  while,  if  there  is  irritation  from  the 
presence  of  the  pessary,  a  daily  douche  should  be  administered.  In 
cases  where  the  displacement  is  accompanied  by  considerable  uterine 
congestion  and  enlargement,  a  hot  vaginal  douche  should  be  given 
night  and  morning  (sec  page  832).  In  all  cases  the  physician  should 
impress  upon  the  patient  the  necessity  of  reporting  if  at  any  time  the 
pessary  causes  any  pain  or  discomfort. 


DILATATION  OF  THE  CERVIX 

Dilatation  of  the  cervix,  while  a  small  operation,  is  one  of  con- 
siderable importance,  as  it  forms  a  part  of  many  gynecological  pro- 


FiG.  8S3 —Instruments  for  dilating  the  cecvit.  i,  Garrigues'  speculum;  i,  sponge 
holder;  3,  tenaculum;  4,  uterine  sound;  5,  GoodeU  dUators;  6,  Fritsch-BozemaD  return' 
flow  irrigator. 

cedures.     Thus  it  may  be  required  as  a  preliminary  to  exploration  of 
the  interior  of  the  uterus,  intrauterine  irrigations  and  apphcations, 


DILATATION  OF  THE  CER\TX  865 

curettage,  and  to  secure  sufficient  dilatation  for  the  extraction  of 
retained  secundines  following  an  incomplete  abortion.  Dilatation 
of  the  cervix  is  also  employed  for  the  cure  of  dysmenorrhea  and  ster- 
ility dependent  upon  cervical  stenosis.  The  operation  should  always 
be  performed  under  all  aseptic  precautions  and  after  the  position  of 
the  uterus  and  the  condition  of  the  appendages  have  been  first  deter- 
mined by  bimanual  examination.  Pelvic  peritonitis,  pelvic  abscess, 
pyosalpiiix,  etc.,  are  contraindications  to  dilatation,  unless  the  pro- 
cedure is  to  be  immediately  followed  by  operative  treatment  of  these 
conditions. 

There  are  two  methods  of  performing  dilatation:  (i)  Gradual 
dilatation  by  means  of  sponge,  laminaria,  or  tupelo  tents,  and  (2) 
rapid  dilatation.  The  former  method,  besides  being  painful,  is  no 
longer  looked  upon  with  favor  on  account  of  the  dangers  of  infection 
and  will  not  be  described. 


Fic,  884. — Hegar'a  graduated  dilators.     (Baodler.) 

Instruments. — A  self-retaining  speculum,  a  sponge  holder,  two 
bullet  forceps,  a  uterine  sound,  two  pairs  of  Goodell's  dilators  (a 
small  and  a  large  size),  and  a  Fritsch-Bozcman  return-flow  irrigator 
are  required  (Fig.  883).  Some  operators  prefer  to  employ  graduated 
sound  dilators,  such  as  Hanks'  or  Hegar's  (Fig.  884),  in  place  of  the 
glove  stretcher  form  of  dilator,  as  producing  less  laceration  of  the 
ceivical  tissue. 

Asepsis.^The  instruments  are  boiled  in  a  i  per  cent,  soda  solu- 
tion for  five  minutes  and  the  operator's  hands  are  thoroughly 
cleansed. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
posture. 

Anesthesia.— While  the  operation  may  be  performed  under  local 
anesthesia  by  infiltrating  the  cervical  tissue  with  a  o.z  per  cent. 
solution  of  cocain  or  a  i  per  cent,  procain  solution,  and  inserting  a 
pledget  of  cotton  saturated  with  a  4  per  cent,  solution  of  cocain  into 
the  cervical  canal,  general  anesthesia  will  be  found  preferable  in  the 
majority  of  cases. 


866 


THE  FEliALE  GENERATIVE   OBGANS 


Preparatioqs  of  Patient — The  bladder  and  bowels  are  to  be 
empty.  The  hair  is  shaved  or  closely  cut  from  the  labia  and  the 
external  genitals  are  washed  with  soap  and  water  followed  by  a  i  to 
2000  bichlorid  solution.  The  vagina  is  then  washed  with  soap  and 
water  by  the  aid  of  a  swab  on  a  sponge  holder  and  this  is  followed  by  a 
douche  of  I  to  5000  bichlorid. 

Technic. — The  speculum  is  introduced  into  the  vagina  and  the 
anterior  cervical  lip  is  seized  by  bullet  forceps  and  is  drawn  toward 


Fio.  885.— First  step 


1  dilatation  of  the  1 

down  by  a  tenaculum. 


iposcd   and  dn 


the  vaginal  orifice  (Fig.  885).  The  cervix  is  then  swabbed  with  a 
I  to  2000  bichlorid  solution.  A  sound  is  next  introduced  for  the  pur- 
pose of  determining  the  direction  of  the  uterine  canal,  and  this  is 
important  in  order  to  avoid  perforating  or  otherwise  injuring  the 
uterus  with  the  dilators  in  case  of  a  retrodisplacement  or  a  sharp  ante- 
flexion. The  small  size  Goodell  dilator  is  then  inserted  into  the  cer- 
vix, carefully  manipulating  it  past  any  obstruction  from  the  internal 
OS,  but  above  all  avoiding  the  use  of  any  force.  With  the  instrument 
through  the  internal  os  the  dilators  are  gradually  expanded,  first  in 
one  direction  and  then,  after  rotation  of  the  instrument,  in  another. 


DILATATION   OF  THE   CERVIX  867 

until  a  moderate  amount  of  dilatation  has  been  obtained,  wnen  the 
large  size  dilator  may  be  substituted.  The  dilatation  is  thus  con- 
tinued, the  operator  being  guided  as  to  the  force  he  may  exert  by  the 
amount  of  resistance  offered  by  the  cervix,  until  the  cervix  has  been 
sufficiently  stretched  for  the  purposes  of  the  operation. 

At  the  completion  of  the  operation  the  uterus  is  irrigated  through 

a  Fritsch-Bozeman  double-flow  tube.     Following  the  operation  the 

I  patient  should  remain  in  bed  three  to  four  days  during  which  time  a 


I 


FlO.  BS6. — Second  step  in  dilatation  of  the    cervix.     Shows  the  metliod  of  dilating 
bj  means  of  Goodell's  dilators. 

daily  vaginal  douche  of  warm  4  per  cent,  boracic  add  solution  or  ster- 
ile water  is  given. 

Dilatation  by  means  of  the  Hegar  style  of  dilator  is  comparatively 
simple.  The  cervix  is  exposed  and  drawn  down  as  above,  and  then, 
beginning  with  the  small  ones,  successive  larger  sizes  of  the  dilators 
are  inserted  into  the  cervix  (Fig.  887),  lubricating  each  sound  with 
sterile  vaselin  before  Its  introduction.  In  using  the  smaller  sized 
sound  great  care  must  be  observed  against  making  a  false  passage  in 
case  any  obstruction  is  offered  by  the  internal  os. 


th  I 

ed 

J 


THE  PBUALE  GEKERATIVE  OKGANS 


Wben  dilatation  is  performed  for  sterility  due  to  steaosis,  some 
operators  follow  the  operation  by  introducing  into  the  cervix  a  hard- 
rubber  stem,  such  as  is  shown  in  Hg.  888,  for  the  purpose  of  maintain- 
ing  the  dilatation.    The  stem  is  from  22  to  25  French  in  ^ze  and  is 


Fig.  8S7. — Showing  the  method  of  diUting  the  cervix  by  means  of  the  graduated 
dilators  of  Hegar. 

provided  with,  a  groove  upon  its  lateral  wall  for  the  escape  of  dis- 
charges. It  has  this  objection,  however,  that  it  is  liable  to  irritate  the 
cervical  lining. 


pessary.     ( Handler.) 


CURETTAGE 

Curettage,  or  the  scraping  of  the  inner  lining  of  the  uterine  cavity 
may  be  performed  for  the  purpose  of  removing  diseased  mucosa  in 
chronic  endometritis,  for  the  purpose  of  obtaining  tissue  for  subse- 
quent microscopic  examination  in  suspected  cancer  of  the  uterus,  and 
as  a  preliminary  to  repair  of  the  cervix  and  operations  upon  the  uter- 
ine appendages.  In  puerperal  cases  the  operation  is  indicated  for  the 
removal  of  pieces  of  decidua  or  placenta  retained  after  labor  or  follow- 
ing incomplete  abortions. 


Cl-KETTAGE  869 

The  operation  is  contraindicated  in  cancer  of  the  uterus  except  to 
obtain  tissue  for  examination  and  as  a  preliminary  to  a  radical  opera- 
tion and  likewise  in  pelvic  peritonitis,  pyosalpinx,  pelvic  celluliUs, 
ectopic  pregnancy,  etc.,  unless  as  a  preliminary  to  a  laparotomy. 
Curettage  is  dangerous  in  the  presence  of  submucous  fibroids,  as 
sloughing  of  the  growths  may  result  through  injury  from  the  curet. 
In  streptococcus  infections  of  the  uterus,  the  operation,  if  performed 
at  all,  should  be  done  with  caution,  as  new  channels  for  infection  are 


Fig.  889, — Inslnimenls  for  curcilige.     1,  Garrigu 

■s'  weighted  speculum;  2  sponge 

holder;  3,  tenacula;  4,  ulecinc  sound;  5.  Goodell  dilal 

rs;  6,  Fritsch-Ilozemita  nozzle; 

7,  Sima'  curets:  8,  Martin's  cureti  9,  blunt  curet;  i 

,  pl&cental  Forceps;  11,  uterine 

dressing  forceps. 

» 


opened  up  by  the  curet  a  nd  extension  of  the  process  to  the  deeper 
tissues  is  liable  to  follow. 

A  ci(rettage  should  always  be  performed  under  the  strictest  asep- 
sis and  with  care  and  gentleness,  as  a  false  passage  may  easily  be 
made  through  the  wall  of  the  uterus  with  the  curet  or  dilator;  espe- 
cially is  this  liable  to  happen  in  septic  conditions  and  in  puerperal 
cases  where  the  uterine  wal!  is  soft.  The  position  of  the  uterus  and 
the  condition  of  the  adnexa  should  be  ascertained  beforehand  by 
means  of  a  bimanual  examination. 

Instruments. — A  Simon  or  a  Garrigues  self-retaining  speculum, 
sponge  holders,  two  bullet  forceps,  a  uterine  sound,  a  pair  of  large  and 
small  Goodel!  dilators,  Sims'  curets,  a  Martin  curet,  a  large  blunt 


I 


(870  THE  FEMALE  GENERATIVE  ORGANS 

■Curet,  placental  forceps,  uterine  dressing  forceps,  and  3  Fritsch- 
Bozeman  return-flow  irrigator  will  be  required  (Fig.  889). 

Asepsis. — All  the  instruments  are  boiled  for  Ave  niinutes  in  a  i  per 
^ent.  soda  solution,  and  the  operator's  hands  are  sterilized  as  for  any 
operation. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
■posture. 

Anesthesia. — General  anesthesia  is  necessary. 


Fig.  890. — Dilatation  and  cureltage  ot  the  uterus.  Illustration  a  shows  the 
endometrium  being  removed  with  Sims'  ciiret;  illuslTation  b  shows  the  mucous  meio- 
brane  on  the  fundus  being  removed  with  Martin's  curet.     (AshtOQ.) 

Preparations  of  Patient. — The  bladder  and  bowels  are  to  be 
empty.  The  hair  is  shaved  or  cut  from  the  labia  and  the  external 
genitals  are  washed  with  soap  and  water  followed  by  a  i  to  2000 
bichlorid  solution.  The  vagina  is  first  thoroughly  cleansed  with 
soap  and  water  by  means  of  a  swab  on  a  sponge  holder  sind  is  then 
thoroughly  douched  with  a  1  to  5000  bichlorid  of  mercury  solution. 
Technic. — i.  Nonpuerperal  Cases. — The  cervix  is  exposed  by 
means  of  the  speculum  and  the  anterior  or  both  the  anterior  and 
posterior  lips  are  caught  by  means  of  bullet  forceps  and  are  drawn 
well  down  toward  the  vulva.  The  cervix  is  then  wiped  with  a  swab 
soaked  in  a  i  to  2000  bichlorid  solution  and,  after  first  determining 
'  the  direction  of  the  canal,  the  cervix  is  dilated  in  the  manner  de- 
Scribed  on  page  866.    The  entire  uterus  is  then  thoroughly  scraped 


CURETTAGE  87 1 

■with  a  shaip  curet  of  the  largest  size  that  will  pass  through  the  cer- 
\-ix.  This  should  be  done  in  a  systematic  manner — for  example,  be- 
ginning with  the  anterior  wall,  the  curet  is  carried  to  the  fundus  and 
is  then  withdrawn  along  the  front  wall  and  out  of  the  uterus  in  one 
sweep.  Any  adherent  tissue  is  wiped  off  the  curet  and  the  instru- 
ment is  reinserted  and  withdrawn  over  another  section  of  the  an- 
terior wall.  The  process  is  repeated  until  the  entire  anterior  wall  has 
been  scraped,  and  then  the  two  side  walls  and  the  posterior  wall  are 
similarly  dealt  with,     A  Martin  curet  is  then  substituted  for  the 


Fig.  8gi.— Shows   Iht 


:  cavity  bdng  swabbed  1: 
(Ashton.) 


th   pure  carbolic   acid. 


Sims  instrument  and  the  fundus  is  well  scraped.  The  cavity  is  then 
irrigated  with  sterile  water  or  normal  salt  solution  by  means  of  the 
return-flow  catheter  in  order  to  remove  any  dfibris  or  loose  shreds  of 
tissue,  and  a  light  packing  is  inserted  for  a  few  moments  to  dry  the 
cavity.  The  packing  is  then  removed  and  the  uterine  cavity  is 
swabbed  with  pure  carbolic  acid  introduced  by  means  of  a  cotton  swab 
on  dressing  forceps  (Fig.  8gi).  In  doing  this  care  must  be  taken  not  to 
touch  the  vagina  with  the  carbolic  acid  and  to  remove  any  excess  of 
acid  from  the  swab  before  inserting  it  in  the  cervix.  The  vagina  is 
then  cleansed,  the  bullet  forceps  are  removed  from  the  cervix,  and  a 
light  vaginal  tampon  is  placed  in  contact  with  the  cervix.  The 
vulva  is  finally  covered  with  a  gauze  pad. 

2.  Puerperal  Cases.- — Unless  the  cervix  b  already  dilated,  it  should 
be  stretched  sufficiently  to  admit  one  or,  if  possible,  two  fingers.     The 


I 


872  THE   FEMALE    GENERATIVE   ORGANS 

operator  then  inserts  the  index-  and  middle-fingers  or,  if  this  is  not 
possible,  the  index-finger  of  the  right  hand  into  the  uterus  and,  while 
counter  pressure  is  made  over  the  fundus  with  the  left  hand,  he  thor- 
oughly explores  the  cavity  and  separates  any  retained  material  by 
means  of  the  internal  fingers  (Fig.  892).  ■  Large  pieces  of  tissue  thus 
loosened  may  be  then  removed  by  means  of  placental  forceps.  The 
cavity  of  the  uterus  is  then  irrigated  with  normal  salt  solution  or  with 
sterile  water  and  is  lightly  scraped  with  a  large  dull  curet.  In  doing 
this  great  care  and  gentleness  are  necessary  to  avoid  perforating  the 


Fig.  892. — Digital  currettage  of  Ihi 


(Asbton.) 


uterus.  Sharp  curets  should  never  be  employed  in  puerperal  cases. 
After  a  final  exploration  with  the  finger,  the  cavity  is  again  irrigated 
and  the  operation  is  concluded  by  cleansing  the  vagina  and  covering 
the  vulva  with  a  sterile  gauze  pad  secured  in  place  by  a  T^-bandage. 
Only  in  cases  where  the  operaUon  is  accompanied  by  severe  bleeding 
or  where  it  is  desired  to  introduce  contraction  in  a  flabby  organ  is  it 
necessary  to  pack  the  uterus  (see  page  847) .  If  this  is  done,  the  pack- 
ing should  be  removed  in  twenty-four  hours. 

After-care, — The  vagina  should  be  douched  daily  with  a  i  to  5000 
warm  bichlorid  solution  followed  by  sterile  water  or  normal  salt  so- 
lution. In  cases  of  curettage  for  simple  endometritis  the  patient  may 
be  allowed  out  of  bed  within  a  week,  in  other  cases  the  duration  of 
the  stay  in  bed  will  depend  upon  the  condition  of  the  patient. 


INDEX 


Abdomen,  aspiration  of,  350 
auscultation  of,  808 
auto-massage  of,  623 
inspection  of,  516,  803 
local  anesthesia  in  operations  on,  102 
mensuration  of,  808 
palpation  of,  518,  804 
percussion  of,  806 
Abdominal  examination  of  rectum  and 
colon,  571 
inspection  of  bladder,  704 
massage,  621 
palpation  of  bladder,  706 
of  ureters,  755 
Abscess-  cavities,  bismuth  paste  for,  276 
collection    of    discharges    from,    for 
bacteriological  examination,  294 
Absorption  power  of  stomach    Penzoldt 
and  Faber  test,  536 
test  of,  536 
test  of  bladder,  713 
Accessory  sinuses,  anatomy  of,  361 
lavage  of,  389 

passive  hyperemia  in  diseases  of,  396 
skiagraphy  of,  378 
Accidental  pneumothorax,  following  arti- 
ficial pneumothorax,  276 
Accidents    during    anesthesia    and    their 

treatment,  65 
A.  C.  E.  general  anesthetic  mixture,  50 
Active  hyperemia,  267 
Acupuncture,  184 

vaccination  by,  222 
Administration      of      antimeningococcus 
serum  in  meningococcus  meningitis, 

336 
of  antiserum  in  cerebrospinal  menin- 
gitis, 336 

in  poliomyelitis,  337 
of  antitetanic  serum  in  tetanus,  337 
of  arsphenamin,  206 

by  rectum,  213 

intravenous,  206,  209 
of  arsphenaminized  scrum,  338 
of  chloroform,  drop  method,  36 

vapor  method,  39 
of  diphtheria  antitoxin,  214 
of  drugs  by  rectum,  595 
of  ether,  closed  method,  32 

drop  method,  30 

semiopen  method,  32 

vapor  method,  33 
of  ethyl  chlorid,  49 
of  general  anesthetics,  17 


Adnunistration  of  neoarsphenamin,  211 
intramuscular,.  213 
intravenous,  215 
by  rectum,  213 
of  neosalvarsan,  211 
of  nitrous  oxid,  42 
and  ether,  45 
of  salvarsan,  206 
of    salvarsanized    serum    in    cerebral 

syphilis.  338 
of  serum  in  poliomyelitis,  337 
After-effects  of  general  anesthetics,  72 
After-treatment  of  cases  of  general  anes- 
thesia, 74 
Agglutination    tests    in    transfusion    of 

blood,  140 
Air,  hot,  active  hyperemia  by,  267 
inflation  of   bowel   ^nth,   in  intussus- 
ception, 618 
of  colon  with,  574 
of  stomach  with,  524,  525 
injections  of,  in  intussusception,  616, 
618 
Albarran^s  cystoscope,  760 
Albumin  in  urine,  702 
•  Albuminous  expectoration  after  aspiration 

of  chest,  347 
Albuminuria,  702 

Alcohol  for  injections  of  fifth  nerve,  225 
Alligator  forceps,  intracannular,  486 
Alligator-jawed  forceps,  Kelly's,  769 
Allis*  ether  inhaler,  26,  27 
Allport's  ear  syringe,  423 
Alton's  method  for  preparation  of  paraf- 

fine  tubes,  154 
Ambard's  coefficient  in  urea  excretion,  789 
Anachlorhydria,  528 
Anal  canal,  anatomy  of,  568 
Analysis,   gastric,   fractional  method  of, 

533 
Anesthesia,  Bier's  venous,  no 
chloroform,  34 

apparatus,  36 

suitable  cases,  35 
epidural,  122 
ether,  24 

apparatus,  26 

suitable  cases,  25 
ethyl  chlorid,  47 
apparatus,  48 
suitable  cases,  48 
general  accidents  during,  65 

A.  C.  E.  mixture  for,  50 

administration  of,  17 


873 


874 

Anesthesia,  general,  after-effects,  71 
after-treatment  following,  74 
anesthol  for,  50 
asnhyiiatioQ  from,  66 
Billroth  mixlure  for,  50 
cardiac  paralyaia  during,  70 
care  of  bowels  before,  18 

of  patient,  as 
C.  E.'miiture  for,  50 
delayed  poisoning  from,  73 
diet  before,  iS 
drugs  used  for,  17 
duration  of,  33 

physical  examination  before,  ig 

postoperative  paralyses  foiloiring,  73 

precautions  in,  18 

preliminary  use  of  drugs,  19 

preparation  of  mouth,  19 
of  patient  for,  18 

renal  complications  of,  73 

respiratory  complications  of,  73 
paralysis  during,  70 

Schldch's  mixture  for,  50 

stages  of,  31 

Vienna  mixture  for,  50 
infiltration,  S8 
insuEBation,  intratracheal,  51 
intravenous  general,  58 
intubatioD,  51 
local,  76 

advantages,  77 

B-eucain  in,  83 

by  freezing,  86 

by  surface  application  of  anesthetic 
drugs,  87 

cocain  in,  Si 

conduction  of  operation  under,  85 

disadvantages,  77 

drugs  employed  tor,  81 

ethyl  chlorid  in,  87 

in  abdominal  operations,  102 

in  hernia  operations,  103 

in  operations  on  anus,  106 
on  bladder,  88 
on  eye,  87 

on  head,  95 

on  inflamed  tissues,  loq 

on  larynx,  87 

on  lower  extremity,  106 
on  lower  jaw,  96 
on  mouth,  96 

onn^.'s? 
on  penis,  105 


Anestheua, 
quiniu 

lumbar, 
nitrous  0 

ap 
appi 

oil-ether 
parasacr 

tracheal. 
Anesthetic, 

Anesthetics 
local,  76 
Aneslhetifil 
Anesthol,  : 
Ankle-joint 
Anoci-assoi 
Anterior  cr 
nares,  35 

rhinosco] 

tibial  ne^ 

Antimeninj 

Antitetani< 

tetanus, 
Antitoxin, 

after-e 

compli 

reducti 

syringe, 

Antrum  of 

Anus,  dilat 

palpatio! 
Applicatior 

intrautei 


:alp,  95 


1,106 


•OS 


on  thorax,  98 

on  upper  extremity,  99 

on  urethra,  87,  105 
methods  of  producing,  So 
preparation  of  patient  for,  84 


of  • 


VW 


Applicator 

Arsphenam 

by  reel 


1                                                                                              INDEX                                                                   875                       ^1 

of,  in  cerebral  syphilis,  338  ' 

disc  barges    and    secretions                    ^H 

from    nose    and   accessory                    ^H 

Artery  to  vein  transfusion,  143 

sinuses,  394                                                ^H 

Artificial  leech.  195,  100 

from  serous  cavities,  394                              ^H 

from  urethra.  295                                            ^H 

respiration,  68,  69 

from  uterus,  296                                              ■ 

sera  for  infusions,  i6q 

from  vafiina.  296                                             ^M 

gum  acacia  solutions,  170 

of  wounds  in  Carrel-Dakin  treatment,                    ^H 

Hare's  formula  for,  :69 

Locke's  formula  for,  170 

Ball,  cannon,  for  auto-massage,  634                              ^H 

Ringer's  formula  for,  169 

Balloltemeni  of  kidney.  755                                          ^H 

S/umano's  formula  for.  170 

Bandage,  elastic,  for  passive  hyperemia,                    ^H 

Arytenoid  cartilages,  anatomy  of,  437 

^1 

Bardet's  stomach  electrode,  563                                     ^H 

Ashlon's  forcepa,  770 

Barker's  solution  for  spinal  anesthesia,  1 16                    ^M 

Asphyjdation  during  general  anesthesia, 

Beck's  bismuth  paste  formula:,  277                                ^H 

66 

syringe  for  bismuth  paste  injections,  377                  ^M 

Aspirating  bulb,  Bgas',  519 

needle,  339 

Bellocq's  cannula,  39S                                                      ^H 

syringe  and  needles,  313 

Bennett's  ether  inhaler,  ig                                             ^^M 

trocar,  340 

gas  and  ether  apparatus,  45                                      ^^M 

Aspiratiiin.  339 

nitrous  oxid  inhaler.  41                                   ^^^H 

of  abdomen  in  ascites,  350 

Bermingham  nasal  douche.  380                      ^^^^^M 

of  bladder.  746 

B-eucain  as  local  anesthetic,  S3                      ^^^^^1 

of  pericardium,  347 

Bicoudi!  catheter,  737                                       ^^^^^H 

of  peritoneal  cavity,  350 

Bierhofl's  cystoscope,  760                                  ^^^^^B 

of  pleura.  339 

Bier's  active  hyperemia,  367                                         ^^M 

of  stomach  contents,  519,  533 

cannula  for  venous  anesthesia,  ito,  iii                    ^H 

of  tunica  vaginalis,  354 

passive  hyperemia,  250                                                ^H 

Aspirator  bottle  for  stomach  contents,  530 

by  constrictins  bands,  255                                   ^H 

Connell's  heat  vacuum,  34s 

by  cups.  26]                                                           ^H 

Dieulafoy,  340,  341.  34a 

in  diseases  of  nose  and  accessory                    ^H 

Potam,  340,  341,  747 

.  sinuses,  396                                                  H 

aectetion,  Jackson's,  455 

in  gynecology,  850                                               ^H 

syphonage,  343 

of  head,  259                                        ^^^^^H 

Atomizer,  Davidson,  384 

359                                          ^^^^^^H 

De  Vilbiss,  384 

of  scrotum,  j6i                                     ^^^^^^H 

Bteam,  4^6 

shoulder,  26a                                    ^^^^^H 

Whitall  Talum.  3«4 

of  testicles,  356,  261                             ^^^^^^H 

Atropin  as  preliminary  to  general  anes- 

venous anesthesia,  no                                    ^^^^^H 

thesia,  19 

Billroth's  esophageal  sound,  506                                     ^H 

Aural  speculum,  Boucheron's,  408 

general  anesthetic  mixture,  50                                      ^| 

electric-lighted,  409 

Bimanual  palpation  of  bladder,  707                            .    ^M 

Grubcfs.  40M 

of  pelvic  organs,  813                                                  ^H 

Toynbee's,  408 

Stethoscope,  417 

tachian  tube,  423                                                            ^1 

Auricular  nerve,  great,  blocking  of,  95 

Bismuth  paste.  Beck's  formula,  277                               ^1 

Auriculotemporal  nerve,  blocking  of,  95 

for  diagnosis  and  treatment  of  fistu-                     ^U 

Auscultation  of  abdomen,  808 

lous  tracts,  276                                                        ^H 

of  colon,  573 

injections,  syringe  for,  277                                         ^| 

of  stomach,  S13 

Bistoury.  184                                                                       ^1 

Auscultatory     method     of     determining 

Bivalve  rectal  speculum,  583                                           ^M 
vaginal  speculum,  S30,  S21                              ^^^^^1 

blood-pressure,  13a 

Aulo-imgatiun  of  bladder,  729 

Bladder,  absorption  test,  713                           ^^^^H 

Auto-massaRe,  6)3 

anatomy  of,  696                                             ^^^^^H 

cannon  ball  for,  623 

aspiration                                                         ^^^^H 

Auloscopy,  450 

auto-irrigations  of ,  739                                  ^^^^^^^| 

calculus  in,  ar-ray  in  detection  of,  735            ^^^^^B 

Babcock's     formula:    tot    solutions    for 

capacity  of,  696                                                     ^H 

spinal  anesthesia,  116 

test  of,  711                                                             -     ■ 

catheterization  of,  734                                                   ^H 

blood  for,  30a 

after-care,  746                                                             ^H 

of  discharges  and  secretions  for,  190 

in  presence  of  prostatic  hypertrophy,                     ^1 

from  abscess  cavity,  194 

741                                                                         ■ 

from  eyes,  295 

of  stricture,  740                                                     ^M 

876 


INDEX 


Bladder,coiitinuous  catheterization  of,  743 
cystoscopic  examination  of,  in  female, 

719 
m  male,  713 

examination  of,  698 

female,  catheterization  of,  741 

inflammation  of,  after  passage  of  ure- 
thral instruments,  692 

inspection  of,  704 

instillations  of,  730 

irrigations  of,  725 

local  anesthesia  in  operations  on,  88 

palpation  of,  705 

papilloma  of,  fulguration  of,  by  high 
frequency  currents,  732 

percussion  of,  705 

skiagraphy  of,  725 

sounding  of,  707 

stone  in,  Thompson's  searcher  for,  707 

tumors,   fulguration   of,   by   high   fre- 
quency currents,  732 
Blake's  ear  syringe,  424 
Bleeding,  185 
Blocking,  nerve,  9^ 

of  anterior  crural  nerve,  106 
tibial  nerve,  108 

of  auriculo-temporal  nerve,  95 

of  brachial  plexus,  99 

of  branches  of  trifacial  nerve,  97 

of  cervical  plexus,  100 

of  digital  nerves,  102 

of  dorsal  nerves,  105 

of  external  cutaneous  nerve,  106 

of  frontal  nerve,  95 

of  genitocrural  nerve,  103 

of  great  auricular  nerve,  95 
occipital  nerve,  95 

of  iliohypogastric  nerve,  103 

of  ilioinguinal  nerve,  103 

of  inferior  dental  nerve,  96,  97 

of  infraorbital  nerves,  96 

of  intercostal  nerves,  98 

of  lingual  nerve,  96 

of  lumbar  nerves,  103 

of  meatal  nerve,  96 

of  median  nerve  at  wrist,  loi 
in  arm,  100 

of  musculospiral  nerves,  100 

of  posterior  tibial  nerve,  108 

of  radial  nerve,  loi 

of  sciatic  nerves,  106 

of  small  occipital  nerve,  95 

of  superior  laryngeal  nerve,  98 

of  supraorbital  nerve,  95 

of  temporomalar  nerve,  95 

of  thoracic  nerves,  103 

of  ulnar  nerve,  at  wrist,  loi 
in  arm,  100 
Blood  chemistry,  787 

collection    of,    for    bacteriological   ex- 
amination, 302 
for  microscopical  examination,  297 

concentration  in,  of  substances  nor- 
mally excreted  in  urine,  as  index  of 
renal  function,  787 

creatinin  in,  788 


Blood,  cryoscopy  of,    for  determination 
of  kidney  nmction,  790 
expectoration    of,   after   aspiration  of 

chest,  347 
groups  for  transfusion,  method  of  de- 
termining, 141 
Moss'  classification,  141 
in  urine,  702 

non-protein  nitrogen  in,  787 
serum,  human,  injection  of,  137,  164 
^  Welch's  apparatus  for  collecting,  165 
significance  of,  in  vomitus,  515 
smear,  for  microscopical  examination, 

method  of  making,  298 
tests  for  functional  capacity  of  kidneys, 

787 
by  cryoscopy,  790 

creatinin  in,  788 
non-protein  nitrogen  in,  787 
urea  in,  788 
uric  acid  in,  788 
transfusion  of,   137.    Sec  also   Trans- 
fusion of  blood. 
urea  in,  788 
uric  acid  in,  788 
washing,  187 
Blood-pressure,  determination  of,  127 
auscultatory  method,  132 
diastolic,  127 
normal,  128 
systolic,  127 

variations  of,  in  disease,  134 
in  health,  128 
Blower,  powder,  388 
Blunt  curet,  869 

Boas'  apparatus  for  esophageal  lavage,  503 
aspirating  bulb,  529 
rectal  electrode,  624,  625 
Bodenhamer's  irrigator,  601 
Bodine's  formula  for  cocain  and  salt  solu- 
tion, 82 
Bougies  k  boule,  examination  of  rectum 

by,  591 
of  urethra  by,  647 
urethral,  648 
dilatation  of  esophageal  strictures  by, 

504 
of  rectal  strictures  by,  618 
esophageal,  491,  506 
Eustachian,  430,  431 

medicated,  431 
examination  of  esophagus  by,  490 
of  rectum  by,  590 
of  urethra  by,  638,  647 
urethral,  639,  684 
Wales',  590,  591,  619 
wax- tipped,  770 
Boucheron's  aural  speculum,  408 
Bowel,  lavage  t)f,  593 
Brachial  plexus,  blocking  of,  99 
Braun's  novocain  solutions,  84 
Breathing  tube,  phar>Tigeal,  52 
Brenner's  cystoscope,  759 
Brewer's  method  of  transfusion  of  blood, 
148 
transfusion  tubes,  148 


^^^^^^^^^^^^H                                                 877           ^M 

^^TSn^c^^a^n^,  454 

Catheter,  gum-elastic.  736                                ^^^^^^| 

Kiman's,754 

737                                     ^^^^^M 

Brovfn'scyatoscope,  759 

intrauterine,  Talley's,  841                             ^^^^^^H 

Buerger's  cystoscope,  760 

743                                                    ^^^H 

Bulb,  Hspiraling,  Boas',  519 

Peuer,  743                                                      ^^^^^M 

form  of  cupping  glass,  194 

727                                              ^^^H 

73$                                                        ^^^H 

C*LCt7Li  in  bladder,  Thompson's  searcher 

soft-rubber!  735                                              ^^^^^| 

for,  707 

in  kidneys,  skiagraphy  of,  791 

ureteral,  wax-tipped,  761 

ureteral,  skiagraphy  of,  791 

whip.  736 

Cancer,  gastric,  secretory  curve  in,  535 

Catheterization,   continuous   of   bladder. 

Cannun  ball  for  aulo-massnge,  623 

743 

Cannula  and  pluriKer  of  uterine  packer. 

for  inflation  of  middle  ear,  419 

848 

of  Eustachian  lube,  419 

and  trocar  for  aspirating,  350 

Biimafont  or  Kramer  method,  4*3 

BeUocq'a,  398 

X^wenbcrg  melhod,  420 

Bier's,  for  venous  aneslheua,  110,  iii 

of  female  bladder,  741 

Brewer's  transfusion,  148 

of  male  bladder,  734 

Crile's  transfusion,  144 

in  presence  of  prostatic  hypertro- 

phy, 74' 

of  stricture.  740 

Sou  they 's,  193 

of  ureters,  direct  view  method,  76a 

Trendelenburg's  tracheal,  57 

in  female,  768 

Capacity  of  bladder,  696 

in  male,  739 

test  of,  711 

indirect  view  method,  765 

of  kidney  pelvis,  774 

Caustics,  application  of,  to  ear,  417 

o(  renal  pelvis,  774 

to  larynx,  463 

Carbonic   acid  gas,  inflation  of  stomach 

to  nose,  386 

with,  534,  sis_ 

to  uterus,  844 

C.  E.  genera!  anesthetic  mixture,  50 

Cecum,  anatomy  of,  566 

Carrel     apparatus     for     instillation     of 

Cerebral  syphilis,  administration  of  sal- 

wounds,  1^7,  138,  239 

varsanizeil  serum  in,  338 

lubes  for  disinfection  of  wounds.  340 

Cerebrospinal  fluid,  normal,  and  its  patho- 

Canel-Dakin    technic     for     sleriliiing 

logical  variations,  335 

wounds,  J34 

meningitis,  administration  of  antiserum 

apparatus  for,  237-141 

in,  336 

bacteriological    examination    of 

Cervical  plexus,  blocking  of,  loo 

wound  in,  .47 

Cervix,  collection  of  discharges  from,  tor 

cleansing  of  wound  10,  24^ 

microscopical  examination,  285 

Daufresne's  method  for  prepara- 

dilatation of,  864 

tion  of  solution  for,  235 

dfibridcment  in,  343,  Hi 

local  applications  lo,  835 

dressing  wound,  346 

scarification  of,  852 

dressings  for,  241 

in  penetrating  wounds,  944 

841 

in  perforating  wounds.  246 

Chapin's  urine  collector,  305 

in  superficial  wounds,  243 

Chetwood's  alternating  cut-off,  665 

instillation    tubes,   arrangement 

urethral  irrigating  nozzle,  665 

Of,  343-246 

Chill,  urethral,  69 j 

instillations  in,  34* 

solution  for,  235-137 

drop  method,  36 

technic,  342 

vapor  method,  39 

Carrel's  method  of  sterilizing  wounds,  IM 

anesthesia,  34 

of  transfusion  0/  blood,  143 

apparatus,  36 

Cartilage,  arytenoid,  anatomy  of.  437 

suitable  cases,  35 

cricoid,  anatomy  of,  436 

delayed  poisoning  from,  73 

thyroid,  anatomy  of,  436 

dropper,  a  7 

Casper's  cystoscope,  760 

Catheter  and  syringe,  Eustachian,  4^9 

inhalers,  36,  37 

Chromic  add  method  of  fusiag,  on  probe, 

bicoud^,  737 

387 

coudS,  737 

Clamp,  Crile's,  144 

Eustachian,  43S 

Citrate  melhod  of  blood  transfusion,  156 

female,  741 

solution    tor    transfusion    of    dtrated 

Gouley's  tunneled,  736 

blood,  157 

878 


INDEX 


Citrated  blood,  transfusion  of,  156 
Closed  method  of  administering  ether,  32 
Clover  ether  inhaler,  28 
Coakley's  transilluminator,  376 
Cocain  as  local  anesthetic,  81 
Bodine's  formula  for,  82 
in  spinal  anesthesia,  115 
morphin  preliminary  to,  85 
•solutions,  preparation  of,  81 
sterilization  of,  82 
Coefficient,  Ambard's,  789 
Cold,  direct  application  of,  to  urethra  by 
psychrophore,  676 
enteroclysis,  603 
local  anesthesia  by,  86 
Collection  and  preservation  of  pathologi- 
cal material,  279 
of  blood  for  bacteriological  examination, 
302 
for  microscopical  examination,  297 
of  discharges  and  secretions  for  bac- 
teriological       examination, 
290 
from  abscess  cavity,  294 
from  eyes,  295 

from   nose   and  accessory  si- 
nuses, 294 
from  serous  cavities,  294 
from  urethra,  295 
from  uterus,  296 
from  vagina,  296 
of  feces,  307 
of  gastric  contents,  306 
of  sputum,  304 
of  urine,  305 
Colon,  anatomy  of,  566 
application  of  electricity  to,  624 
ascending,  anatomy  of,  567 
auscultation  of,  573 
descending,  anatomy  of,  567 
inflation  of,  573 

for  diagnostic  purix)ses,  573 
irrigation  of,  594,  599 
massage  of,  621 
palpation  of,  572 
percussion  of,  573 
sigmoid,  anatomy  of,  567 
skiagraphy  of,  576 
transverse,  anatomy  of,  567 
Colonic  anesthesia,  oil-ether,  64 

massage,  621 
Color  of  urine,  701 
Columns  of  Morgagni,  569 
Concentration  in  blood  of  substances  nor- 
mally excreted  in  urine  as  index  of  renal 
function,  787 
Connell's  heat  vacuum  aspirator,  342 

pharyngeal  breathing  tube,  68 
Constipation,  electrotherapy  in,  624 
Continuous    catheterization    of    bladder, 

.743  . 
dilatation  of  urethral  strictures,  693 
proctoclysis,  609 

Creatinin  in  blood,  test  for  kidney  func- 
tion, 788 

Crib  arranged  for  steam  inhalations,  467 


Cricoid  cartilage,  anatomy  of,  436 
Crile's  anoci-association,  77 
clamps,  144 

method  of  blood  transfusion,  143,  145 
of  intraarterial  infusion,  178 
of  intubation  anesthesia,  51 
transfusion  cannula,  144 
Croup  kettle,  466 

Crural  nerve,  anterior,  blocking  of,  106 
Cryoscopy  of  blood  and  urine,  test  for 

kidney  function,  790 
Culture,  smear,  method  of  making,  290 

stab,  method  of  making,  289 

streak,  method  of  making,  28S,  289 

tubes,  inoculation  of,  method,  287 
Cupped  sound,  672 
Cupping,  194 

dry,  196 

glass,  194 

wet,  197 
Cups  for  abstracting  blood,  195 

for  passive  hyperemia,  262 

pessary,  854. 

suction,  for  passive  hyperemia,  263 
Curet,  blunt,  869 

Martin's,  869 

Sims',  869 

urethral,  675 
CuretUge,  868 

nonpuer|>eral  cases,  870 

puerperal  cases,  871 
Curtis  and  David  apparatus  for  trans- 
fusion, 154 
Curves,  secretory,  of  stomach,  535 
Cutaneous  nerve,  external,  blocking,  zo6 
Cystoscope,  Albarran's,  760 

Bierhoflf's,  760 

Brenner's,  759 

Brown's,  759 

Buerger's,  760 

Casper's,  760 

direct  view,  714 

electric-lighted,  721 

Eisner's,  759 

indirect  view,  714 

Kelly's,  720 

Lewis',  732,  759 

Nitze's,  714,  715,  760 

Otis',  714 

Schapiras',  714 
Cystoscopic  treatment,  731 
Cystoscopy  in  female,  719 

in  male,  713 

Dakin-Carrel  technic  for  disinfection  of 

wounds.    See  Carrel-Dakin. 
Dakin's  hypochlorite  solution,  234 
solution,  preparation  of,  by  Daufresnc's 
method,  235 
properties  of,  235 
test  of  alkalinity  of,  237 
titration  of,  237 
Daufresne's  method  of  preparing  Dakin's 

solution,  235 
David  and  Curtis   apparatus  for  trans- 
fusion, 154 


INDEX 


879 


Davidson's  atomizer,  384  ' 

syringe  and  stomach  tube  for  inflating 
stomach,  525 

Dawbam's   method   of   intraarterial   in- 
fusion, 179 

Death  from  chloroform  anesthesia,  34 
sudden,  after  aspiration  of  chest,  347 

Deglutition  murmur,  523 

Dench*s  vap>orizer,  428 

Dental  nerve,  inferior,  blocking  of,  96,  97 

Depressor,  tongue,  Kirstein's,  448 
va^nal,  821 

Debridement  in  preparation  of  wounds  for 
disinfection   by   Carrel-Dakin  technic, 
242,  243 

De  Vilbiss  atomizer,  384 

Dewitt's  apimratus  for  regulating  flow  in 
proctoclysis,  610 

Diastolic  blood-pressure,  127 

Dieulafoy  aspirator,  ^40,  341,  342 

Digital  nerves,  blockmg  of,  102 
palpation  of  cervix,  812 
of  nasopharynx,  375 
of  pelvic  organs,  81 1 
of  uterine  cavity,  827 

Dilatation  of  anus,  581,  582 
of  cervix,  864 
of  esophageal    strictures  by    bougies, 

504 
of  rectal  strictures  by  bougie,  618 
of  rectum,  581,  582 
of  ureteral  strictures,  794 
continuous,  680,  693 
Dilator,  Hegar's,  865 
Kelly's,  urethral,  659 
Kollmann's  curved,  683 
straight,  683 
Diphtheria  antitoxin,  administration  of, 
214 
after-effects  of,  216 
complications  following,  218 
reduction  in  mortality  rate  by,  218 
Direct   and    indirect    view    gastroscopy, 
combined,  546 
application  of  cold  to  urethra  by  psy- 
chrophore,  676 
to  nose,  386, 
laryngoscopv,  447 
palpation  of  pelvic  organs,  exploratory 

incision  for,  829 
tracheo-bronchoscopy,  453 
transfusion,  143 
view  gastroscopy,  543 
method  of  ca&eterization  of  ureters, 
762 
Discharges,  collection  of,  for  bacteriologi- 
cal examination,  290 
vaginal,  examination  of,  810 
Disinfection  of  wounds  by  Carrel-Dakin 
technic,    234.    See   also   Carrel-Dakin, 
Dorsal  nerves,  blocking  of,  105 
position  for  gynecological  examination, 
801 
Double-flow  catheter,  727 
Douche,  Bermingham's  nasal,  380 
hot-air,  268,  269 


Douche,  intrauterine,  840 
nozzle,  841 
nasal,  379 
stomach,  552 

Einhom's,  553 
vaginal,  832 
nozzle,  833 
Drainage  in  edema  of  lower  extremities, 

192 
Drop   method   of  administering   chloro- 
form, 36 
ether,  30 
Drugs,  administration  of,  by  rectum,  595 
as  preliminary  to  general  anesthesia,  19 
employed  for  local  anesthesia,  81 
hypodermic  injection  of,  201 
intramuscular  injection  of,  201  ^ 

used  for  general  anesthesia,  17 
Drum  membrane,  anatomy  of,  464 
determination  of  mobility  of,  41Z 
incision  of,  432 
massage  of,  432 
Dry  cupping,  196 
inhalations,  468 
Duck-bill  rectal  speculum,  583,  584 
Duodenal  feeding,  559 
pump,  Einhom's,  559 
ulcer,  secretory  curve  in,  535 

Eah,  anatomy  of,  401 
application  of  caustics  to,  427 
examination  of,  405 
inflation  of,  4x5 
inspection  of,  407 
instillations  for,  425 
speculum,  Boucheron's,  408 

electric-lighted,  409 

Gruber's,  408 

Toyn bee's,  408 
syringe,  423 

AUport's,  423 

Blake's,  424 

syringing,  423  .  ,     ^  :      , 

Ekielmann's    modification    of    Galton's  ' 

whistle,  4x4 
Edema,  acupuncture  for,  184  . 

of  glottis,  scarification  in,  191  ^ 

of  lower  extremities,  drainage  in,  192 
Effusions,     pleural,    following    artificial 

pneumothorax,  276 
Einhom's  duodenal  pump,  559 

esophagoscope,  498 

gastrodiaphane,  537 

stomach  douche,  553 
electrode,  563,  564 
Elastic  bandage  for  passive  hyperemia, 
256 

garter  for  producing  obstructive  hypere- 
mia of  neck,  256 
Elbow-joint,   exploratory    puncture    of, 

327 
Electric  head  light,  365 

Electric-lighted  cystoscope,  721 

speculum,  409 
Electricity,  application  of,  to  rectum  and 

colon,  624 


88o 


INDEX 


Electrode,  Boas'  lectal,  624,  625 

Einhom's,  564 

large  flat  sponge,  624 

small  sponge,  625 
Electrotherapy  in  constipation,  624 

in  diseases  of  stomach,  563 

in  tumors  of  bladder,  732 
Elimination  in  urine  of  foreign  substances 
as  index  of  renal  function,  784 

of  substances  normally  present  in  urine 
as  index  of  renal  function,  780 
Elsberg's  method  of  transfusion  of  blood, 
148 

transfusion  cannula,  149 
Eisner's  cystoscope,  759 
Embolism,  gas,  following  artificial  pneu- 
mothorax, 275 
Emphysema,  subcutaneous,  following  arti- 
ficial pneumothorax,  276 
Endoneural  infiltration,  93 
Enema ta,  594 

drugs  administered  by,  595 

nutrient,  613 

purgative,  595 
Enteroclysis,  594,  599 

cold,  603 

hot,  603 

with  double  tube,  601 

with  single  tube,  600 
Epidermic  puncture,  vaccination  by,  222 
Epidural  anesthesia,  122 
Epiglottis,  anatomy,  of,  436 

method    of    drawing    forward    during 
anesthesia,  67 
Epsom  salts  for  spinal  anesthesia,  116 
Erect  position  for  gynecologic  examina- 
tion, 803 
Esmarch  elastic  bandage  for  obstructive 
hyperemia,  256 

mask,  26 
Esophageal  bougies,  491,  506 
k  boule,  491 

lavage,  502 

sounds,  491,  506 
Billroth's,  506 
Schrciber's,  506,  507 

strictures,  dilatation  of,  504 

tube,  Symond's,  509,  510 
Esophagogastroscope,  Hill-Herschell,  540, 

541 
Esophagosrope,  Einhorn's,  498 

Jackson's,  498,  499 

Mikulicz's,  498,  499 
Esophagoscopy,  498 
Esophagus,  anatomy  of,  488 

auscultation  of,  489 

dilatation  of  strictures  of,  504 

examination  of,  by  sounds  and  bougies, 
490 

intubation  of,  508 

lavage  of,  502 

normal  constrictions  of,  488 

palpation  of,  490 

percussion  of,  490 

skiagraphy  of,  502 
Estimation  of  residual  urine,  712 


Ether,  administration  of,  closed  method, 
32 
drop  method,  30 
semiopen  method,  32 
vapor  method,  33 
anesthesia,  24 
apparatus,  26 
suitable  cases,  25 
bed,  75 
Ethmoidal  sinuses,  anatomy  of,  362 
Ethyl  chlorid,  adininistration  of,  49 
anesthesia,  47 
apparatus,  48 
suitable  cases,  48 
as  local  anesthetic,  87 
inhalers,  48 
spray  tube,  86 
tube,  47 
Eucain  B,  83 

Eustachian  bougie,  430,  431 
catheter,  428 

and  syringe,  429 
tube,  anatomy  of,  404 
catheterization  of,  419 
inflation  of,  by  catheter,  419 
Politzer's  method,  417 
Valsalva's  method,  416 
medication  of,  429 
Ewald-Boas  test  breakfast,  527 
Ewald's  test  of  motor  power  of  stomach, 

S36 
Examination  of  discharges,  810 
Ex|>ectoration,  albuminous,  after  aspira- 
tion of  chest,  347 
of  blood  after  aspiration  of  chest,  347 
Experimental   polyuria   test  for   kidney 

function,  781 
Exploratory  incision  for  inspecting  kid- 
neys, 792 
for  palpation  of  peKnc  organs,  829 
laparotomy,  547 
puncture,  311 
of  ankle-joint,  329 
of  elbow-joint,  327 
of  hip-joint,  327 
of  jomts,  326 
of  kidneys,  325 
of  knee-joint,  328 
of  liver,  322 
of  lung,  317 
of  pericardium,  318 
of  peritoneal  cavity,  321 
of  pleuia,  312 
of  shoulder- joint,  326 
of  spleen,  324 
of  wrist- joint,  327 
Expression  of  stomach  contents,  529,  532 
External  cutaneous    nerve,    blocking  of, 

106 
Extraction  of  stomach  contents  for  ex- 
amination, 529,  533 
Extremities,  local  anesthesia  in  operations 
on,  99,  106 
lower,  edema  of,  drainage  in,  iq2 
Extubation,  476 
Extubator,  0'Dw>'er's,  469 


INDEX                                                                   88 1                        ^M 

Eyes,  collection  of  discharges  from,  for 

Functional  capacity  of  kidneys,   delei^ 

bacteriological      eiamination, 

mination  of,  779 

395 

by  Ambard's  coefiBdent,  789 

tor    microscopical    eiamination, 

333   _     _ 

by  cryoscopy,  790 

local  anesthesia  in  operalJons  on,  S7 

by  McLean  index,  789 
by  urinalysis,  780 
experimeDtal  polyuria  test  for, 

F\BER  and  Peneoldt  test  for  absorption 

power  of  stomacli,  536 

781              "^ 

Face,  local  anesthesia  for  operations  on.  q6 

indigo-earmin  test  for,  785 
methylene-blue  lest  for,  785 

Fallopian  tubes,  anatomy  of,  79S 

palpation  of.  St^ 

False  passage  from  urethral  instrumenta- 

for. 785 

tion,  693    _ 

phloridzin  test  for,  784 

test  meals  for.  781 

chemical  Mamination  of,  594 

Fusing  chromic  acid  on  probe,  387 

collection  of,  for  examination,  30; 

examination  of.  594 

Galton's    whistle,    Edelmann's    modifi- 

macroscopical  eiatni nation,  594 

microscopical  eiamination,  594 

Garrigues'  weighted  speculum,  S26 

Feeding  by  gavage,  555 

Gas  embolism  following  artificial  pneumo- 

by  rectum,  613 

.    thorax,  37s 

duodenal,   559 

injection  of,  into  pleural  cavity,  370 

during  esophageal  intubation,  512 

Gastric  analysis,  fractional  method  of,  533 

intubation  cases,  475 

object,  537 

Fenestra ted-blade   rectal  speculum,   583, 

carcinoma,  secretory  curve  in,  535 

584 

Fever,  urethral,  69J 

306 

Fifth  nerve,  anatomy  of,  335,  336 

extraction  of,  for  examination,   519, 

first  division  of,  injection  of,  33S 

douching,  553 

injections  of,  tor  tic  douloureux,  125 

for  trifacial  neuralgia,  335 

juice,  composition  of,  537 

second  di\-ision   of,  injections  of,  339 

lavage,  547 

third  division  of,  injections  of,  330 

secretion,  composition  of,   EigniiicBnce 

Filiform  bougies,  urethral.  639.  684 

of  variations  in,  537 

Finger  palpation  of  rectum.  5R0 

ulcer,  secretory  curve  in,  535                          

Fingers,  local  anesthesia  in  operations  on, 

Lynch's,                                                            J^^^^H 

Finger's  ointment,  671 

Gastrodiaphany,  537                                          ^^^^^^^^1 

Fistulous  tracts,  bismuth  paste  for  diagno- 

GastroacDpe, Jackson's,  540                           ^^^^^^M 

sis  and  treatment  of,  176 

Mikulicz's,  539                                                   ^^^^^H 

Five  glass  test,  633 

Rosenheim's,  539                                                           ^H 

Floyd  needle  for  artibcial  pneumothorax, 

Gaslroscopv,  5^9                                                          ^M 
combined    direct   and     indirect    view,                       ^M 

273 

Fluids,   injection   of,   in  intussusception, 

546                                                                                 ■ 

616,  617 

direct  view,  543                                                        ^H 

Forceps,    Ashlon's,  for  guiding  urethral 

Jackson's  technic,  543                                              ^H 

catheter,  770 

Gavage,  555                                                                         ^M 

intracannular  alligator,  4S6 

Gehning's  pessary,  854                                                ^H 

Kelly's  alligator-jawed,  769 

General  anesthesia,   17.    See  also  Ana-                      ^M 

placental.  869 

Ihesia,  gentrat.                                                                 ^^M 

uterine  dressing.  Sfig 

Foreign  substances  eliminated  in  urine. 

^M 

as  index  of  renal  function,  7S4 

Genilocrural  nerve,  blocking  of,  103                   ^^^^^M 

Formalin    sterilizer   for   urethral    instru- 

Glass tests,  632                                                   ^^^^H 

ments,  640 

633                                                         ^^^^^^1 

Fractional  method  of  gastric  analysis,  533 

633                                         ^^^^H 

Freezing,  local  anesthesia  by,  Sb 

Glottis,  scarification  of,  191                              ^^^^H 

Ftitsch-Bozeman  douche  nozzle,  841 

Glucose  in  acidosis,  613                                    ^^^^^B 

Frontal  nerve,  blocking  of,  95 

in  continuous  proctoclysis,  610                                   ^^1 

sinus,  anatomy  of,  361 

in  nutrient  enemata,  615                                                ^H 

lavage  of,  394 

Goodell's  vaginal  speculum,  Ria                                      ^H 

transillumination  of,  376.  377 

Gouley's  sound,  684                                                            ^H 

FulguraUon  of  vesical  growths  by  high 

tunneled  catheter,  73^                                                   ^H 

frequency  current,  733 

Goyanes'  method  of  arterial  anesthesia,                     ^H 

Function,  kidney,  tests  of,  779 

1 

ir4                                                                                     ^M 

882 


INDEX 


Gravity  method  of  administering  serum 

by  lumbar  puncture,  337 
Great  auricular  nerve,  blocking  of,  95 

occipital  nerve,  blocking  of,  95  . 
Gruber's  aural  speculum,  408 
Gum  acacia  solutions,  infusion  of,  170 
Guyon*s  catheter,  737 
Gwathmey's  gas  and  ether  apparatus,  46 

nitrous  oxid  gas  and  oxygen  inhaler,  43 

oil-ether  colonic  anesthesia,  64 

vapor  apparatus,  28,  30 
Gynecologic  examinations,  798 
Gynecological  positions,  801 

Hand  injections  for  urethra,  661 
Hare's  formula  for  artificial  serum  for  in- 
fusions, 169 
Harris'  method  of  segregation  of  urine,  777 

segregator,  775 
Hartmann's  tuning  forks,  414 

vaporizer,  428 
Hays'   pharyngoscope  for  inspection   of 

nasopharynx,  370 
Head  lamp,  electric,  365 

light,  Kirstein's,  448 

local  anesthesia  in  operations  on,  95 

passive  hyperemia  of,  259 
Hearing  tests,  413 
Heart,  massage  of,  71 
Heat  vacuum  aspirator,  Connell's,  342 
Hegar's  dilators,  865 
Hematuria,  702 
Hemolysis,  tests  for,  in  blood  transfusion, 

.    139 

Hemorrhage  after  passage  of  urethral,  in- 
struments, 692 
control  of,  tam{>oning  nose  for,  397 

Hernia,  local  anesthesia  in  operations  for, 
103 

Hewitt's  nitrous  oxid  gas  and  oxygen  in- 
haler, 42 

High    frequency     current     in     vesical 
growths,  732 
tracheotomy,  478,  483 

Highmore,  antrum  of,  anatomy  of,  361 

Hill-Herschell  esophagogastroscope,  540, 

541 
Hip-joint,  explorator>'  puncture  of,  327 
Hodge  pessary,  854 
Hodge-Smith  pessary,  854 
Hoecht  method  for  injection  of  sciatic 

nerve,  232 
Hot  enteroclysis,  603 
Hot-air,  active  hyperemia  by,  267 

boxes  for  active  hyperemia,  268 

douches  for  active  hyperemia,  268,  269 
Houston's  valves,  569 
Hydrocele,  aspiration  and   mjection  of, 

354 
Hydrotherapy  of  rectum,  594 
Hyperacidity,  528 
Hyperchlorhydria,  527 
Hyperemia,  active,  267 
passive,  250 

by  constricting  bands,  255 
by  cups,  261 


Hyperemia,  passive,  in  diseases  of  nose 
and  accessory  sinuses,  396 

in  gynecology,  850 

of  head  and  neck,  259 

of  scrotum,  261 

of  shoulder,  260 

of  testicles,  256,  261 
Hypersecretory  curve,  535 
Hypoacidity,  528 
Hypochlorhydria,  J28 
Hypodermic  injection  of  drugs,  201 

syringe,  201,  202 
Hypodermoclysis,  180 
Hyposecretory  curve,  535 

Iliohypogastric  nerve,  blocking  of,  103 
Ilioinguinal  nerve,  blocking  of,  103 
Illumination  for  rhinoscopy,  363 
Incision,  exploratory,  for  inspecting  kid- 
neys, 792 
for  palpating  pelvic  organs,  829 
in  laryngotomy,  478 
in  tracheotomy,  478 
of  drum  membrane,  432 
of  membrana  tympani,  432 
Index,  Mcl^ean,  789 
Indigo-carmin  test  for  functional  capacity 

of  kidneys,  785 
Indirect    and    direct     view    gastro5cq)y 
combined,  546 
transfusion,  149 
by  citrate  method,  156 
by  Kimpton-Brown  method,  155 
by  Lindeman  method,  150 
by  paraffined  tubes,  153 
by  syringe  method  of  Lindeman,  150 
of  Unger,  152 
view    method    of     catheterization  of 
ureters,  765 
Infantile     paralysis,     administration     of 

antiserum  in,  337 
Inferior  dental  nerv^e,  blocking  of,  96,  97 
Infiltration  anesthesia,  88 
endoneural,  93 
of  large  nerve  trunk,  94 
of  skin,  91,  92 
perineural,  93 
Infiltrator,  Matas',  89 

Morrow's,  90 
Inflamed  tissues,  operations  on  under  local 

anesthesia,  109 
Inflation  in  intussusception,  616 
of  colon  for  diagnostic  purposes,  573 
of  middle  ear,  415,  428 

Politzer's  method,  417 
through  catheter,  419 
Valsalva's  method,  416 
with  medicated  vapors,  428 
of  stomach,  524 
by  air,  524,  525 
by  carbonic  acid  gas,  524,  525 
Infraorbital  nerve,  blocking  of,  96 
Infusions,  intraarterial,  177 
intravenous,  170 
of  gum  acacia  solutions,  170 
of  physiological  salt  solution,  167 


INDEX 


883 


Infusions,  rectal,  607 

saline,  607 
subcutaneous,  180 
Inhalations,  dry,  468 
mask,  468 
steam,  465 
Inhaler,  Allis*  ether,  27 
Bennett's  ether,  29 

gas  and  ether,  45 

nitrous  oxid,  41 
care  of,  30 
Clover's  ether,  28 
Esmarch's  chloroform,  26 
Gwathmey's  gas  and  ether,  46 

nitrous  oxid  gas  and  oxygen,  43 

vapor,  30 
Hewitt's  nitrous  oxid  gas  and  oxygen, 

42 

Junker's  chloroform,  36 

Schimmelbusch  chloroform,  27,  48 
steam,  466 

Ware's  ethyl  chlorid,  48 
Injection,  hand,  for  urethra,  661 

hypodermic,  of  drugs,  201 

intramuscular,  of  drugs,  201 
of  neoarsphenamin,  213 

intravenous,  of  arsphenamin,  206,  209 
of  neoarsphenamin,  213 

of   bismuth    paste    for   diagnosis   and 
treatment  of  fistulous  tracts,  276 

of  fifth  nerve  for  neuralgia,  225 

of  first  division  of  fifth  ner\'e,  228 

of  fluid  or  air  into  bowel  in  intussuscep- 
tion, 616 

of  gas  into  pleural  cavity,  270 

of  human  blood  serum,  137,  164 

of  sciatic  nerve,  231 

of  second  division  of  fifth  ner\'e,  229 

of    solutions   into    Eustachian   tubes, 

429 

of  third  division  of  fifth  nerve,  230 

test  for  urethral  pus,  634 
Inoculating  culture  tubes,  method,  287 
Inspection  of  abdomen,  516,  803 

of  anus,  571,  579 

of  bladder,  704 

of  ear,  407 

of  external  genitals,  809 

of  kidneys,  752 

by  exploratory  incision,  792 

of  larynx,  440 

of   nasopharynx   by   Hays'   pharyngo- 
scope, 370 

of  nose,  363 

of  rectum,  579 

of  stomach,  516 

of  trachea,  440 

of  urethra,'634,  635,  652,  658 

of  vaginal  orifice,  809 
Instillation     syringe,      Kcycs-Ultzmann, 
669-670,  731 

tubes,  for  Carrcl-Dakin  disinfection  of 
wounds,  238-240 
Instillations  for  bladder,  730 

for  ear,  425 

of  urethra,  669 


Instrumental  dilatation  of  urethral  stric- 
tures, 680 
continuous,  693 
Insufflation  anesthesia,  intratracheal,  52 
Insufflations  for  larynx,  465 

for  nose,  388 
Insufflator,  laryngeal,  464 

nasal,  388 

Sajous',  389 
Intercostal  ner\'es,  blocking  of,  98 
Internal  examination  of  rectum,  577 
Intraarterial  infusion,  Crile's  method,  178 
Dawbam's  method,  179 
of  salt  solution,  177 
Intracannular  alligator  forceps,  486 
Intramuscular  injection  of  drugs,  201 

of  neoarsphenamin,  213 
Intrastomachic  application  of  electricity 

to  stomach,  565 
Intratracheal  insufflation  anesthesia,   52 
Intrauterine  applications,  844 

douche,  840 
nozzle,  841 

stem  pessary,  868 
Intravenous    administration    of   neoars- 
phenamin, 213 

anesthesia,  apparatus  for,  58,  59 

general  anesthesia,  58 

infusion  of  salt  solution,  170 

injection  of  arsphenamin,  206,  209 
of  neoarsphenamin,  213 
Intubated  patients,  feeding,  475 
Intubation  anesthesia,  51 

O'Dwyer  instruments  for,  467 

of  esophagus,  508 

of  lar>'nx,  468 

tube  and  introducer,  469,  472 
Intussusception,  injections  of  fluid  or  air 

into  bowel  in,  616 
lodipin  test  of  motor  power  of  stomach, 

Irrigating  nozzle,   urethral,  Chetwood's, 

66s 
Irrigations  of  bladder,  725 

of  bowel,  593 

of  rectum,  594,  599 

of  urethra,  664 

stomach,  552 

vaginal,  832 
Irrigator,  Bodenhamer's,  601 

double-flow  rectal,  601 

Kemp's,  601 

return-flow,  601,  602 

Tuttle's,  601,  602 

urethral,  Valentine's,  665 
Isosecretory  curve,  535 
Isotonic   preserving   fluid   for   red   cells, 

preparation  of,  162 
Iversen's  apparatus  for  proctoclysis,  610 

611 

Jackson's  bronchoscope  454 
direct  view  laryngoscope,  55 
esophagoscope,  498,  499 
gastroscopc,  540 
laryngoscope,  447 


884 


INDEX 


Jackson's  secretion  aspirator,  455 
separable  speculum  for  p>assing  broncho- 
scope, 455 
technic  of  gastroscopy,  543 
Janeway's  sphygmomanometer,  130,  131 
JaW,  lower,  local  anesthesia  in  operations 
on,  96 
method    of    holding    forward    during 
anesthesia,  67 
Joint,  exploratory  puncture  of,  326 
Junker's  chloroform  inhaler,  36 

Kaliski's  transfusion  needle,  158 
Kelly's  cystoscope,  720 
method  of  collecting  urine  from  ureter 

without  ureteral  catheter,  773 
rectal  speculum,  583,  585 
urethral  dilator,  659 
tube-speculum,  659 
Kemp's  irrigator,  601 
Kettle,  croup,  466 
Keyes-Ultzmann      instillation      syringe, 

669-670,  731 
Kidneys,  anatomy  of,  749 
ballottement  of,  755 
exploratory  puncture  of,  325 
function  of,  tests  of,  779 
functional  capacity  of,  determination, 
blood  tests  for,  787 
by  cryoscopy,  790 
experimental  p>olyuria  test  for, 

781 
indigo-carmin  test  for,  785 

methylene-blue  test  for,  785 

phenolsulphonephthalein  test  for, 

78s 
phloridzin  test  for,  784 

test  meals  for,  782 
inspection  of,  752 

by  exploratory  incision,  792 
palpation  of,  753 
pelvis,  capacity  of,  774 
lavage  of,  793 
medication  of,  793 
percussion  of,  757  • 

position  of,  749 
pyelography  of,  792 
relations  of,  750 
skiagraphy  of,  791 
Killian's  bronchoscope,  454 
laryngoscope,  451 
method  of  laryngoscopy,  450 
Kimpton-Brown  method  of  blood  trans- 
fusion, 155 
transfusion  tubes,  153 
Kirstein's  head  light,  448 

tongue  depressor,  448 
Klotz's  urethral  tube,  654 
Knee-chest  position,  578 

for  gynecologic  examination,  802 
Knee-joint,    exploratory     puncture    of, 

.328 

Knife,  urethral,  675 
KoUmann's  curved  dilator,  683 

straij^ht  dilator,  683 

urethral  syringe,  675 


Kramer  or  Binnafont  method  for  cathe- 
terizing  Eustachian  tube,  423 

KulenkampfiF's  method  of  blocking  bra- 
chial plexus,  99 

Lactic  acid  in  stomach  contents,  528 
Lamp,  head,  electric,  365 
Laparotomy,  exploratory,  547 
Laryngeal  insufflator,  464 

knife,  protected,  191 

nerve,  superior,  blocking  of,  98 

probe,  460 

spray,  461 
Laryngoscope,  Jackson's,  55,  447    > 

Killian's,  451 
Laryngoscopy,  440 

direct,  447 

suspension,  450,  452 
Laryngotomy,  477,  478,  481 
Larynx,  anatomy  of,  436 

application  of  caustics  to,  462 

direct  applications  for,  462 

dry  inhalations  for,  468 

examination  of,  439 

inspection  of,  440 

insufflations  for,  465 

intubation  of,  468 

local  anesthesia  in  operations  on,  87 

palpation  of,  by  probe,  460 

scarification  of,  192 

skiagraphy  of,  460 

spraying  of,  461 

steam  inhalations  for,  465 
Lavage  of  accessor>'  sinuses,  389 

of  bowel,  593 

of  esophagus,  502 

of  frontal  sinus,  394 

of  maxillar>'  sinus,  390 

of  sphenoidal  sinus,  395 

of  stomach,  547 

of  ureters  and  renal  peh-is,  793 
Leech,  artificial,  199,  200 

varieties,  198 
Leeching,  197 
Leube's  test  of  motor  power  of  stomach, 

536 
Levy  and   Baudouin   needle  and   stylet, 

227 
Lewis'  operating  cystoscope,  732 

universal  cystoscope,  759 
Limb,  scarification  of,  192 
Lindeman's  syringe  method  for  indirect 
transfusion  of  blood,  150 

transfusion  cannula,  151 
Lingual  nerve,  blocking  of,  96 
Lips,  local  anesthesia  in  operations  on,  96 
Lithotomy  position  in  rectal  examination, 

Liver,  exploratory  puncture  of,  322 
Local  anesthesia,  76.    See  also  A  tu-sthcsia, 
local. 

applications  to  vagina  and  cervix,  835 
Locke's  formula  for  artificial   serum   for 

infusions,  170 
Locomotor  ataxia,  arsphenamin  in,  206 
Low  tracheotomy,  479,  486 


^^^^^^^Hpip                                                      885         H 

LO  wen  berg     method     for    cathetcrizbiE 

Method  of  coUecIing  blood  for  bacterio- 

Kustachian luhe,  410 

logical  examinaUon,  301 

Lower  extremities,  edema  of,  drainage  in, 

feces,  307 

191 

gastric  contents,  306 

local  anesthesia  in  operations  on,  106 

sputum,  304 

urine,  305 

96 

of  determining  blood  groups,  141 

tracheo-btonchoscopy,  459 

of  inoculation  of  culture  tubes,  287 

Luer's  hypodermic  syringe,  s*l 

of   making   biood   smears,   for   micro- 

Lumbar anesthesia,  1 15 

scopical  examination,  398 

ner\-es,  blocking  of,  103 

amear  culture,  190 

puncture,  329 

preparations  for  microscopical  ex- 

as means  of  administering  therapeutic 

amination,  279 

sera,  336 

stab  culture,  2S9 

vertebra,  anatomy  of,  3sg,  330 

streak  culture,  288,  189 

Lumbard'a  glass  nasal  tubes  for  anesthe- 

Methylene-blue    test   for   functional   ca- 

sia, 19 

pacity  of  kidneys,  785 

Lung,  crploratory  puncture  of,  317 

collection  of.  J97 

tuberculous,     artificial     pneumothorax 

for,    270 

Luy's  method  of  segregation  of  urine,  779 

.smear   preparation    for.    method   of 

making,  279 

segregator.  775 

Middleear.  inflation  of,  415,428 

Lynch's  gastrodiaphane,  537,  538 

with  medicated  vapors,  428 

modification  of  Kiilian's  book  spatula, 

4S= 

gastroscope.  S3g 

Mixture.  aneatheUc,  49 

Morgagni's  columns,  569 
valves,  S70 

MaKcol  retention  rnthcler,  743 

to  general  anesthesia,  19 

27J 

■     Martin's  curet,  869 

to  spinal  anesthesia,  119 
Morrow  s  infiltrator,  90 

Mask,  inhalation.  468 

Massage,  abdominal.  611 

MorUlily  rate,  reducUon  of,  by  diphtheria 

auto-,  of  abdomen,  623 

antitoxin,  21S 

colonic,  611 

Mosenthal'a  test  meal  for  kidney  func- 

of ear-drum,  432 

tion,  jBj 

of  membrana  tympani,  431 

Moss'  classification  of  blood  groups  tor 

of  prostate,  638,  677 

transfusion,  140 

of  stomach,  561 

Motor  functions  of  stomach,  test  of,  536 

pelvic,  850 
Malas'  massive  infiltrator,  89 

Mouth,  collection  of  discharges  from  for 

microscopical  examjnalion,  3S1 

Mamillary  sinus,  anatomy  of,  361 

local  anesthesia  in  operations  on,  96 

lavage  of,  390 

Murphy's  proctoscope,  584 

transillumination  of,  376,  37B 

McLean  index  in  urea  excretion,  789 

18s 

Meals,  test,  for  kidney  function,  782 

Musculospiral  nerves,  blocking  of,  100 

Meatome,  Otis',  679 

Myles'  nasal  speculum,  36(1 

Meatotomy,  679 

Median  nerve,  at  wrial,  blocking  of,  101 

Nahes,  anterior,  35B                                      ^^^^^H 

in  arm,  blocking  of,  100 

^^^^m 

Medicated  bougie,  431 

posterior.                                                   ^^^^M 

tampon,  839 

digital  palpation  of,  37J                     ^^^^^^M 

Medication  by  rectum,  595 

inspeclLon        367                                ^^^^^1 

of  Eustachian  tubes.  4)9 

Nasal  i^ouche,  379                                         ^^^^^H 

of  renal  pelvis  and  ureters,  793 

fierminghum's,  jHo                                            ^H 

Meltzcr  and  Aucr's  method  of  intratra- 

douching, 379                                                           ^M 

cheal  insufflation  aneslheeta,  51 

hemorrhage,  tamponing  for,  397                          ^^H 

Membrana  tymjiani,  anatomy  of,  404 

probe,  373                                                    ^^^^M 

determination  of  mobility  of,  411 

speculum,  Myles,  366                          ^^^^^H 

incision  of,  433 

383                                                 ^^^^^H 

massage  of,  43* 

38Z                                             i^^^^^H 

Membranous  urethra,  anatomy  of,  6^8 

tubes,  Lumbard's,  vg                              ^^^^^^H 

Meningitis,    meningococcus,    adminislra- 

syringing,  3S2                                                      ^^M 

Nasopharynx,  digital  palpation  of,  37s                    H 
inspection  of,  by  Hays'  pharyngoscope^              ■ 

Mental  nerve,  blacking  of,  96 

J 

886 


INDEX 


Neck,  local  anesthesia  in  operations  on,  97 

passive  hyperemia  of,  259 
Needle,  aspirating,  339 
Floyd,  for  artificial  pneumothorax,  273 
hypK>dermoclysis,  181 
Ksuiski's  transfusion,  158 
Neoarsphenamin,  administration  of,  211 
by  rectum,  213 
intramuscular,  213 
intravenous,  213 
preparation  of  solution,  212 
Neosalvarsan.    See  Neoarsphenamin, 
Nerve  blocking,  93 
Neuralgia,    trifacial,    injections   of    fifth 

nerve  for,  225 
Neuritis,  acupuncture  in,  185 
New   York   Board   of   Health   antitoxin 
syringe,  216 
vaccination  outfit,  220 
Nitrogen,  non-protein,  in  blood,  test  for 

kidney  function,  787 
Nitrous  oxid,  administration  of,  42 
and  ether,  administration  of,  46 
anesthesia,  45 

apparatus,  45 
inhaler,  45,  46 
and  oxj'gen  inhaler,  42,  43 
anesthesia,  39 
apparatus,  4t 
suitable  cases,  40 
inhaler,  41 
Nitze's  cystoscope,  714,  715,  760 
Non-protein  nitrogen  in  blood,  test  for 

"kidney  function,  787 
Normal  cerebrospinal  fluid  and  its  patho- 
logical variations,  335 
systolic  blood -pressure,  128 
Nose,  anatomy  of,  358 
and  accessory  sinuses,  collection  of  dis- 
charges from,  for  bacteriological  ex- 
amination, 294 
application  of  caustics  to,  386 
collection  of  discharges  from,  for  micro- 
scopical examination,  282 
douching,  379 
examination  of,  363 
inspection  of,  363 
insufflations  for,  388 
lavage  of,  389 

local  anesthesia  in  operations  on,  87 
palpation  of,  373 
by  probe,  373 
passive  hyperemia  in  diseases  of,  396 
probing  of,  373 
spraying,  383 
syringing,  382 
tamponing,  397 
Novocain.    See  also  Procain. 
Braun's  formula  for,  84 
in  spinal  anesthesia,  116 
Nutrient  enemata,  613 

Occipital  nerve,  great,  blocking  of,  95 

small,  blocking  of,  95 
Odor  of  urine,  700 
O'Dwyer  intubation  instruments,  469 


Gil-ether  colonic  anesthesia,  64 
Ointment,  application  of,  to  urethra,  672 

Finger's,  672 

syringe,  673 

Unna's,  672 
Ossicles  of  ear,  403 
Otis'  cystoscope,  714 

meatome,  679 

urethrometer,  650 
Otoscope,  Siegle's,  412 
Otoscopy,  407 
Ovaries,  anatomy  of,  798 

palpation  of,  817 

Palate  retractor.  White's.  370 
Palpation,  bimanual,  of  pelvic  organs,  813 

digital,  of  nasopharynx,  375 
of  pelvic  organs,  8n 
of  uterine  cavity,  827 

of  abdomen,  518,  804 

of  anus,  572 

of  bladder,  705 

of  colon,  572 

of  esophagus,  490 

of  Fallopian  tubes,  817 

of  kidneys,  753 

of  larynx  by  probe,  460 

of  nose  by  probe,  373 

of  ovaries,  817 

of  pelvic  organs,  exploratoiy  incision 
for,  829 

of  prostate,  636 

of  rectum,  572,  579 
by  whole  hand,  582 

of  stomach,  518 

of  ureters,  755 

of  urethra,  636,  638 

of  uterus,  813 
Papilloma  of  bladder,  destruction  by  high 

frequency  currents,  732 
Paracentesis  of  abdomen,  350 

pericardii,  347 

thoracis,  339 
Paraffine  tubes,  Alton's,  method  of  pre- 
paring, 154 
for  indirect  transfusion  of  blood,  153 
Paralysis,  anesthetic,  postoperative,  73 

cardiac,  during  general  anesthesia.    70 

infantile,  administration   of  serum    in 

337 
respirator>%  during  general   anesthesia 

70 
Parasacral  anesthesia,  125 
Paresis,  arsphenamin  in,  206 
Passive  hyperemia,  250 

by  constricting  bands,  255 

by  suction  cups,  261 

in   diseases   of   nose   and   accessory 
sinuses,  396 

in  gynecology,  850 

of  head  and  neck,  259 

of  scrotum,  261 

of  shoulder,  260 

of  testicles,  256,  261 
Paste,  bismuth,  in  diagnosis  and  treat- 
ment of  fistulous  tracts,  276 


Pathological     material,     collection     and 
preservation  of,  179 
variulion^     of     normal     cerebrospinal 
fluid,  33S 
Pelvic  massage,  850 
organs,  anatomy  of,  7q6 
digital  palpation  of,  811 
examination  of,  »cq 
palpation  of,  exploratory  incision  for, 


839  _ 


o-abdOminal    palpatiol 


,    ».3, 


vagino-abdominal  paJpation  of,  S13, 
S14 
Pelvis,  renal,  capacity  of,  J74 
lavage  of,  753 
medication  of,  703 
Penis.  local  anesthesia  in  operations  on, 

105 
Penzoldt  and  Faber   test  of  absorption 

powei  of  stomach,  536 
Pepsin  in  stomach  contents,  529 
Percussion  of  abdomen,  806 
of  bladder,  705 
ol  esophagus,  490 
of  kidneys,  757 

Percutaneous    application    of   electritiiy 
to  colon,  635 
to  stomach,  565 
Pericardicentesis,  347 
Pericardium,  aspiration  of,  347 

exploratory  puncture  of,  318 
Perineural  infiltration,  93 
Peritoneal  ca\-ity,  aspiration  of,  350 

exploratory  puncture  of,  331 
Pessary,  cup,  854 

Gehrung's,  854 

Hodge,  854 

Hodge-Smith,  854 

intrauterine  stem,  R63 

introduction  of,  860 

ring,  854 

Skene's,  S54 

therapy,  853 
Pezzer  catheter,  743 
Pharyngeal  breathing  tube,  51 
Pharyngoscope,  Hays',  for  inspection  of 

nasopharynx,  370 
Phacynx,   collection   of  discharges  from, 
lot  microscopical  esamination,  iSi 

inspection  of,  370 
Phenolsulphonephthalein    test    for    func- 
tional capacity  of  kidneys,  785 
Phlebotomy,  185 
Phloridzin  test  for  functional  capacity  of 

kidneys,  784 
Physiological  salt  solution,  infusion  of,  167 
Platinum  needles  for  cultures.  1S7 
Pleura,  aspiration  of,  339 

exploratory  puncture  of,  311 

injections  of  gas  into,  370 
Pleural      effusions      I0I  lowing      artificial 
pneumothorax,  376 

shock  following  a rliQcial  pneumothorax. 


U 


373 


Pleurocentesis.  339 

Pneumatic  otoscojK,  Siegle's,  41^ 
Pneumothorax,  accidental,  following  arti- 
ficial pneumothorax,  376   ' 
after  aspiration  of  chest,  347 
artificial,   production   of,  370 
Poisoning,  delayed  chloroform.  73 
Poliomyelitis,     administration     of     anti- 
serum in,  337 
Politzer's  method  of  inflation  of  middle 

Polyuria,    experimental,    test,    for   func- 
tional capacity  of  kidneys,  781 
Position,    dorsal,    for    gynecological    ex- 
amination. So  I 
erect,  for  gynecologic  examination,  803 
for  aspiration  of  pleura,  345,  346 
gynecological,  Soi 
knee-chest,  578 

for  gynecologic  1         '       '         ~ 
lithotomy,  578 
Sims,  for  gynecologic  e 
squatting,  579 
for  gynecologic  examination,  S03 
Posterior  nares,  358 

digital  palpation  of,  375 
inspection  of,  367 
rhinoscopy,  367 
tibial  nerve,  blocking  of,  108 
Postoperative  anesthetic  paralyses,  73 
Potain  aspirator,  340,  341,  747 
Powder  blower,  388 

laryngeal,  464 
Powders,  application  of,  to  larynx,  4GJ 
to  nose.  388 
to  vagina,  S3  6 
Preservation  and  collection  of  patholog- 

ical  material,  379 
Preserved  red  cells,  transfusion  of,  161 
Probe,  examination  of  rectum  by,  SB' 
(using  chromic  acid  on,  3S7 
laryngeal,  460 
nasal,  373 
palpation  of  larynx  by,  460 

of  nose  by.  373 
urethral,  674 
Probing  laryns,  460 
'.  373 

.  ^  irasacri.  .    . . 

n  sacral  anestbcs 

in  spina!  anesthesia,  116 
Proctoclysis,  coniinuous,  609 

Iversen's  apparatus,  61a,  611 

Saxon's  apparatus,  bio,  61 1 
Proctoscope,  examination  of  r 
583 

Tuttlc's,  s8s 
Proctoscopy  with  Kelly's  instrument,  587 

with  Tuttle'a  instrument,  590 
Prostate,  637 

anatomy  of,  630 

inflammation  of,  after  passage  of  urelh- 

massage  of,  638,  677 
palpation  of,  £36 


1  by. 


888 


INDEX 


Prostatic  catheter,  silver,  737 
hypertrophy,  catheterization  in,  741 
urethra,  anatomy  of,  629 
Psychrophore,  676,  677 
direct  application  of  cold  to  urethra  by, 
676 
Pulmonary  tuberculosis,  artificial  pneu- 
mothorax in,  270 
Pump,  Einhom's  duodenal,  559 
Punch,  skin,  for  removal  of  superficial 

growths,  309 
Puncture,  epidermic,  vaccination  by,  222 
exploratory,  311 
of  ankle-joint,  329 
of  elbow- joint,  327 
of  hip- joint,  327 
of  joints,  326 
of  kidneys,  325 
of  knee-joint,  328 
of  liver,  322 
of  lung,  317 
of  pericardium,  318 
of  |>eritoneal  cavity,  321 
of  pleura,  312 
of  shoulder- joint,  326 
of.  spleen,  324 
of  wrist- joint,  327 
for  parasacral  anesthesia,  126 
for  sacral  anesthesia,  1 24 
for  spinal  anesthesia,  117 
lumbar,  329 
as  means  of  administering  therapeutic 
sera,  336 
spinal,  3  29.     See  also  Lumbar  puncture. 
venous,  method  of  making,  302 
Purgative  enemata,  595 
Pus  in  urine,  703 
Pyelography  of  kidneys,  792 

of  ureters,  792 
Pyelometry,  774 
Pynchon's  vaporizer,  428 
Pyuria,  703 

Quantity  of  urine  passed  in  twenty-four 

hours,  700 
Quinin   and   urea   hydrochlorid   as   local 

anesthetic,  84 

Radial  nerve,  blocking  of,  loi 
Ransohoflf's  method  of  arterial  anesthesia, 

114. 
Reaction  of  urine,  701 

Rectal    administration    of    arsphenamin, 

213 

of  neoarsphenamin,  213 
anesthesia,  61 

application  of  electricity  to  colon,  626 
bougie  k  boule,  591 
electrode,  Boas',  624,  625 
feeding,  613 
inflation,  616 

infusion  of  salt  solution,  607 
irrigations,  594,  599 
irrigator,  Bodenhamer's,  601 

Kemp's,  601 

Tuttle's,  601,  602 


Rectal  palpation  of  ureter,  757 
probe,  592 
speculum,  bivalve,  583 

duckbill,  583,  584 

fenestrated-blaule,  583,  5S4 

KeUy's,  583,  585 

Murphy's,  584 

Sims\  583 

Tuttle's,  58s 
strictures,  dilatation  of,  by  bougie,  618 

surgical  treatment  of,  618 
tubes,  597 
valves,  569 
Recto-abdominal     palpation     of     pelvic 

organs,  813,  818 
Rectum,  abdominal  examination  of,  571 
administration    of    arsphenamin    and 
neoarsphenamin  by,  213 

of  drugs  by,  595 
anatomy  of,  567 
and  anus,  local  anesthesia  in  operations 

on,  106 
application  of  electricity  to,  624 
dilation  of,  581,  58a 
examination   of,  by   bougie    k  boule* 

SQi 

by  bougies,  590 

by  probe,  592 

by  proctoscope,  583 

by  sounds,  590 

by  speculum,  583 

feeding  by,  613 
hydrotherapy  of,  594 
inflation  of,  with  air,  618 

with  fluid,  617 
inspection  of,  571,  579 
internal  examination,  577 
irrigations  of,  594,  599 
lavage  of,  593 
medication  by,  595 
palpation  of,  572,  579 

by  finger,  580 

by  whole  hand,  582 
proper,  anatomy  of,  568 
skiagraphy  of,  576 
strictures  of,  dilatation  of,  by  bougie,. 

618 
Red  blood  corpuscles,   preserved,   trans- 
fusion of,  161 
Rehfuss  tube  for  fractional  gastric  anal- 
ysis, 534 
Relapsing  fever,  arsphenamin  in,  207 
Removal  of  fragments  of  tissue  for  exami- 
nation, 307 
Renal  complications  of  general  anesthesia. 

73 
hematuria,  702 

Rennin  in  stomach  contents,  529 
Replacement  of  retroverted  uterus,  856 
Residual  urine,  estimation,  712 
Respiratory  c6mplications  of  general  anes- 
thesia, 73 
paralysis  during  general  anesthesia,  70 
Retractor,  White's  palate,  370 
Retroverted  uterus,  replacement  of,  856 
Revaccination,  224 


INBEX 


889 


Rhinoscopy,  363 
anterior,  366 
posterior,  367 
Riegel's  test  dinner,  527 
Ring  pessar>')  854 
Ringer's  formula  for  artificial  serum  for 

infusions,  169 
Rinne*s  test  of  hearing,  415 
Riva-Rocci  sphygmomanometer,  129 
Robertson's  apparatus  for  collecting  blood 
for  preser\'ed  red  cells  transfusion « 
162 
for  syphoning  off  supernatant  fluid, 

163 
method  of  transfusing   preserved   red 
cells,  162-164 
Robinson's  apparatus  for  artificial  pneu- 
mothorax, 272 
Rogers'  sphygmomanometer,  131 
Rosenheim's  gastroscope,  539 

Sacral  anesthesia,  122 

Sacrum,  anatomy  of,  122,  125 

Sajous'  applicator  and  mouth-gag,  449 

insufflator,  389 
Saline  solution,  infusion  of,  167 
intraarterial  infusion  of,  177 
intravenous  infusion  of,  170 
rectal  infusions  of,  607 
subcutaneous  infusion  of,  180 
Salvarsan.     See  Arsphrnamin. 
Salvarsanized  serum,  administration  of,  in 

cerebral  syphilis,  338 
Saxon's  apparatus  for  proctoclysis,  610, 

611 
Scalp,  local  anesthesia  in  o|>erations  on, 

95 
Scarification,  190 

of  cervix,  852 

of  glottis,  191 

of  larynx,  192 

of  limb,  IQ2 

of  tonsil,  191 

vaccination  by,  221 
Schapira  cystoscope,  714 
Schimmelbusch  mask,  26,  27,  48 
Schleich's  general  anesthetic  mixture,  50 
Schreiber's   esophageal    sound,  506,  507 
Sciatic  nerve,  blocking  of,  106 

injections  of,  231 
Sciatica,  injections  for,  231 
Scoop  powder  blower,  388 
Scopolamin-morphin  anesthesia,  65 
Scrotum,  aspiration  of,  356 

local  anesthesia  in  operations  on,  105 

passive  hyperemia  of,  261 
Secretions,  collecting  for  bacteriological 

examinations,  290 
Secretory  curves  of  stomach,  535 

variations  in,  in  health  and  disease 

535 
Segregation  of  urine,  775 

Harris^  method,  777 

Luy's  method,  779 

Segregator,  Harris',  775 

Luy's,  775 


Semiopen  method  of  administering  ether 

32 
Sera,  artificial  for  infusions,  169 
Serous  cavities,  collection  of  discharges 
from,  for  bacteriological  examination 
294 
Serum,  arsphenaminized,  338 
blood,  human,  injection  of,  137,  164 
salvarsanized,  338 

Welch's  apparatus  for  collecting,  165 
Shock  after  passage  of  urethral  instru- 
ments, 692 
pleural,  275 
Shoulder,  passive  h>'pcremia  of,  260 
Shoulder-joint,   exploratory  puncture  of, 

326 
Siegle's  pneumatic  otoscope,  412 
Silver  catheter,  735 
Sims'  curet,  869 
position,  577 

for  gynecological  examination,  801 
rectal  speculum,  583 
vaginal  speculum,  821 
Sinus,  ethmoidal,  anatomy  of,  362 
frontal,  anatomy  of,  362 
lavage  of,  394 

transillumination  of,  376,  377 
maxillar>',  anatomy  of,  361 
lavage,  390 

transillumination  of,  376,  378 
sphenoidal,  anatomy  of,  362 
lavage  of,  395 
Sinuses,  accessory,  lavage  of,  389 

passive  hyperemia  in  diseases  of,  396 
skiagraphy  of,  378 
tuberculous,  bismuth  paste  for,  276 
Skene's  i>essary,  854 
Skiagraphy  of  accessory  sinuses,  378 
of  bladder,  725 
of  esophagus,  502 
of  intestines,  576 
of  kidneys,  791 
of  larynx,  460 
of  rectum,  576 
of  stomach,  546 
Small  occipital  nerve,  blocking  of,  95 
Smear,  blood,  for  microscopical  examina- 
tion, method  of  making,  298 
culture,  method  of  making,  290 
preparation  for  microscopical  examina- 
tion, 279 
from  cervix,  285 
from  eyes,  282 

from  mouth  and  pharynx,  281 
from  nose,  282 
from  urethra,  283 
from  uterus,  286 
from  vagina,  285 
Snare,  urethral,  676 

Sodium  citrate  method  of  blood  trans- 
fusion, 156 
Solution,  Dakin's.     See  Dakin's  solution. 
Sounding  of  bladder,  707 
urethra,  638 
uterus,  825 
Sounds,  cupped,  672 


890 


INDEX 


Sounds,  esophageal,  491,  506 

Billrotn's,  506 

Schreiber's,  506,  507 
examination  of  esophagus  by,  490 

of  rectum  by,  590 

of  urethra  by,  638 
Gouley's,  684 
urethral,  639 
Southey's  trocars  and  cannula,  193 
Specific  gravity  of  urine,  700 
Specula,  bladder,  Kelly's,  720 

ear,  Boucheron's,  408 
,        electric-lighted,  409 

Gruber's,  408 

Toynbee's,  408 
examination  of  pelvic  organs  by,  820 

ot  rectum  by,  583 
nasal,  Myles',  366 
rectal,  bivalve,  583 

duck-bill,  583,  584 

fenestrated-blade,  58^,  584 

Kelly's,  583,  585 

Murphy's,  584 

Sims',  583 

Tuttle's,  585 
Sims'  rectal,  583 
urethral",  673 

Kelly's,  659 
vaginal,  bivalve,  820,  821 

Goodell's,  820 

Sims',  821 

trivalve,  820 
weighted,  Garrigues',  826 
Sphenoidal  sinuses,  anatomy  of,  362 

lavage  of,  395 
Sphygmomanometer,     Janeway's,      130, 

,131 

Riva-Rocci,  129 

Rogers',  131 

Stanton's,  130 
Sphygmomanometr>',  127 
Spinal  anesthesia,  115 

canal,  puncture  of,  329 
Spleen,  exploratory  puncture  of,  324 
Sponge  holder  and  swab,  821 
Spong>'  urethra,  anatomy  of,  628 
Spray,  laryngeal,  461 

nasal,  383 
Spra>'ing,  nasal,  sSs 

of  larynx,  461 
Sputum  bottles,  305 

collection  of,  for  examination,  304 
Squatting  position,  579 

for  gynecologic  examination,  803 
Stab  culture,  method  of  making,  289 
Stanton's  sphygmomanometer,  130 
Steam  atomizer,  466 

inhalations,  465 

inhaler,  466 
Sterilization  of  cocain  solutions,  82 

of  salt  solutions,  169 

of  wounds  by  Carrel  method,  234 
Sterilizer,  formalin,   for  urethral  instru- 
ments, 640 
Stethoscope,  aural,  417 
Stockton's  stomach  electrode,  563 


Stomach,  absorption  power  of,  Penzoldt 
and  Faber  test,  536 
anatomy  of,  513 
auscultation  of,  523 
capacity  of,  514 
contents,  analysis  of,  fractional  method, 

533 
comp>osition  of,  527 

curves  of,  535 
examination,  526,  527 
extraction  of,  529 
aspiration  method,  529,  533 
expression  method,  529,  532^ 
lactic  acid  in,  528 
pepsin  in,  529 
rennin  in,  529 
douche,  552 

Einhom's,  553 
douching,  552 
electrode,  Bardet's,  563 
Einhom's,  563 
Stockton's,  563 
Wegele's,  563 
electrotherapy  in  diseases  of,  563 
exploratory  laparotomy  of,  547 
inflation  of,  524 
by  air,  524,  525 
by  carbonic  acid  gas,  524,  525 
inspection  of,  516 
irrigation  of,  552 
lavage  of,  547 
massage  of,  561 

motor  power  of,  Ewald's  test,  536 
iooipin  test,  536 
Leube's  test,  536 
tests  for,  536 
palpation  of,  518 
percussion  of,  521 
secretory  curves  of,  535 
skiagraphy  of,  546 
splashing  sounds  in,  523 
succussion  sounds  in,  523 
transillumination  of,  537 
tube  and  Davidson  syringe  for  inflating 
stomach,  525 
Rehfuss,  534 
washing  out,  547 
:c-ray  examination  of,  546 
Stools.     See  Feces. 
Stovain  in  spinal  anesthesia,  116 
Streak  culture,  method  of  making,  2SS,  2S9 
Strictures  of  bladder,  catheterization  in, 
740 
of  esophagus,  dilatation  of,  by  bougies, 

504 
of  rectum,  dilatation  of,  by  bougie,  61S 
of  urethra,  dilatation  of,  680 

continuous,  693 
ureteral,  dilatation  of,  794 
urethral,  determining  size  and  length  of, 
647,  648 
Stylet  needle  for  spinal  puncture,  330 
Subcutaneous  drainage  in  edema,  192 
emphysema  following  artificial  pneunx^ 

thorax,  276 
infusion  of  salt  solution,  180 


INDEX 


891 


Suction  cups  for  passive  hyperemia,  263 
Sudden   death  after  aspiration  of  chest, 

347 
Superior  laryngeal  nerve,  blocking  of,  98 
Supraorbital  nerve,  blocking  of,  95 
Suspension  laryngoscopy,  450,  45a 
Swab  and  sponge  holder,  821 
Swinburne's  urethroscope,  653 
Symond's  esophageal  tube,  509,  510 
Syphilis,  arsphenamin  in,  206 

cerebral,  administration  of  salvarsan- 
ized  serum  in,  338 
Syphonage  aspirator,  343 
Syringe,  antitoxin,  215 

Davidson,  525 

ear,  423 

AUport's,  423 
Blake's,  424 

Eustachian,  429 

for  bismuth  paste  injections,  277 

hypodermic,  201,  202 

instillation,  Keyes-Ultzmann,  669-670, 

731 
method  of  Lindeman  for  indirect  trans- 
fusion of  blood,  150 
of  Unger  for   transfusion   of  blood, 

nasal,  382 

ointment,  673 

transfusion,  Unger's  instrument  for,  152 

urethral,  662 
RoUmann's,  675 
Syringing  of  ear,  423 
Systolic  blood-pressure,  127 

normal,  128 
Szumann's   formula   for  artificial   serum 

for  infusions,  1 70 

Talley's  intrauterine  catheter,  841 
Tampon,  838 
medicated,  839 
vaginal,  837 
Tamponing  nose  for  control  of  hemor- 
rhage, 397 
uterus,  847 
Temporal  nerve,  blocking  of,  95 
Test,  absorption,  of  bladder,  713 
blood,  for  functional  capacity  of  kid- 
neys, 787 
breakfast,  Kwald-Boas,  527 
dinner,  Riegel,  527 

Ewald's  of  motor  power  of  stomach,  536 
experimental  polyuria,  for  kidney  func- 
tion, 781 
five-glass  for  urethral  pus,  633 
for  agglutination  of  blood,  140 
for  hearing,  413 
for  hemolysis  of  blood,  139 
indigo-carmin  for  kidney  function,  785 
iodipin,  for  motor  power  of   stomach, 

536 
Leube's,  of  motor  power  of  stomach,  536 
meal,  Mosenthal's,  for  kidney  function, 

782 
methylene-blue  for  functional  capacity 
of  kidneys,  785 


Test  of  absorption  power  of  stomach,  536 
of  acuteness  of  hearing,  413 
of  bladder  capacity   711 
of  kidney  function,  770 
of  motor  power  of  stomach,  536 
Penzoldt-  and    Faber    for    absorption 

power  of  stomach,  536 
phenolsulphonephthalein,  for  functional 

capacity  of  kidneys,  785 
phloridzin,  for  functional  capacity  of 

kidneys,  784 
Rinne's,  of  hearing,  415 
two-glass  for  urethral  pus,  633 
voice,  for  hearing,  413 
watch,  for  hearing,  413 
Weber's,  of  hearing,  415 
Testicles,     obstructive     hyperemia     of, 

method  of  producing,  261 
Tetanus,    administration    of    antitetanic 

serum  in,  337 
Therapeutic   scfta,    lumbar   puncture   as 

means  of  administering,  336 
Thompson's  stone  searcher,  707 
Thoracentesis,  339  . 
Thoracic  nerve,  blocking  of,  103 

local  anesthesia  in  operations  on,  98 
Thyroid  cartilage,  anatomy  of,  436 
Tibial  nerve,  anterior,  blocking  of,  108 

jjosterior,  blocking  of,  108 
Tic  douloureux,  injections  of  fifth  nerve 

for,  225 
Tissues  for  examination,  removal  of,  307 
inflamed,    operations    on,    under  local 
anesthesia,  109 
Titration  of  Dakin's  solution,  237 
Tongue  depressor,  Kirstein's,  448 
Tonsil,  scarification  of,  191 
Towel  cone,  28 

Toxic  effects  following  injections  of  bis- 
muth paste,  277 
Toyn bee's  aural  speculum,  408 
Trachea,  anatomy  of,  438 
examination  of,  439 
inspection  of,  440 
Tracheal  anesthesia,  56 
Tracheo-bronchoscopy,  direct,  453 
lower,  459 
uppr,  458 
Tracheoscopy,  440 
Tracheotomy,  477 
high,  478,  483 
low,  479,  486 
tube,  480 
Transfusion  cannula,  Brewer's,  148 
Crile's,  144 
Elsberg's,  149 
Lindeman 's,  151 
needle,  Kaliski's,  158 
of  blood,  137 

agglutination  reactions  in,  140 
artery  to  vein,  143 
Brewer's  method,  148 
citrate  method,  156 
contraindications,  138 
Crile's  method,  143,  145 
direct,  143 


892 


INDEX 


Transfusion  of  blood,  Elsberg's  method, 

indications,  138 

indirect,  149 

by  paraffined  tubes,  153 

by  syringe  method  of  Lindeman, 

150 
Kimpton-Brown  method,  155 
Moss*  classification  of  groups  for,  140 
position  of  donor  and  recipient,  144 . 
preserved  red  cells,  161 
quantity  transfused,  142 
rapidity  of  flow,  143 
repetition  of,  143 
selection  of  donor,  139 
syringe  method,  of  Unger,  152 
tests  for  hemolysis  in,  139 
variations  in  technic,  148 
of  preserved  red  cells,  161 
Robertson's    apparatus    for    collecting 
blood  for  preserved  red  cells,  162 
for  syphoning  off  supernatant  fluid, 
163 
syringe,  Unger's  instrument  for,  152 
tube,  David  and  Curtis,  154 

Kimpton-Brown,  153 
U.    S.    Army   apparatus    for   citrated 
blood,  157,  159 
Transillumination  of  frontal  sinus,  376, 

377 

of  maxillary  sinus,  376,  378 

of  stomach,  537 
Transilluminator,  Coakley's,  376 
Transparency  of  urine,  701 
Trendelenburg  tracheal  cannula,  57 
Trifacial  nerve,  anatomy  of,  225,  226 
branches,  blocking  of,  97 

neuralgia,  injections  of  fifth  nerve  for, 
225 
Trivalve  vaginal  speculum,  820 
Trocar  and  cannula  for  aspirating,  350 

and     syringe    for    aspirating    and    in- 
jecting hydrocele,  355 

aspirating,  340 

Southey's,  193 
Tropacocain  in  spinal  anesthesia,  116 
Tubes,  Carrel,  for  wound  disinfection,  240 

culture,  inoculation  of,  method,  287 

David  and  Curtis  transfusion,  154 

esophageal,  Symond's,  509,  510 

ethyl  chlorid,  47 

for  esophageal  lavage,  Boas',  503 

intubation,  469,  472 

Kimpton-Brown  transfusion,  153 

Klotz's  urethral,  654 

paraffine,  Alton's  method  of  preparing, 

154 
pharyngeal  breathing,  52 
rectal,  597 

Rehfuss  stomach,  534 
speculum,  urethral,  Kelly's,  659 
stomach,  525 

Rehfuss,  534 
stomach-douche,  553 
tracheotomy,  480 
urethral,  Klotz's,  654 


Tuberculous  lung,  artificial  pneumothorax 
for,  270 

sinuses,    bismuth  paste,  for  diagnosis 
and  treatment  ot,  376 
Tunica  vaginalis,  aspiration  of,  354 
Tuning  forks,  Hartmann's,  414 
Tuttle's  irrigator,  601,  602 

proctoscope,  585 

rectal  speculum,  585 
Two-glass  test,  633 

Ulcer,  duodenal,  secretory  curve  in,  535 

gastric,  secretory  curve  in,  535 
Ulnar  nerve  at  wrist,  blocking  of,  loi 

in  arm,  blocking  of,  100 
Unger's    instrument    for    syringe    trans- 
fusion, 153 
method  of  blood  transfusion,  152 
Unna's  ointment,  672 
Upper    extremity,    local    anesthesia    in 
operations  on,  99 
tracheo-bronchoscopy,  458 
Urea     excretion,     Ambard's     coefficient 
and  McLean  index  in,  789 
in  blood,  test  for  kidney  function,  788 
Ureteral  calculi,  skiagraphy  of,  791 
catheter,  wax- tipped,  761 
catheterization,  direct  view  method,  762 
in  female,  768 
in  male,  759 

indirect  view  method,  765 
medication,  793 
palpation,  755 
strictures,  dilatation  of,  794 
Ureters,  anatomy  of,  751 
catheterization  of,  direct  view  method, 
762 
in  female.  768 
in  male,  759 

indirect  view  method,  765 
lavage  of,  793 
medication  of,  793 
palpation  of,  755 
pyelography  of,  792 
Urethra,  627 
anatomy  of,  627,  631 
application  of  cold  to,  by  psychrophore, 
676 
of  ointments  to,  672 
caliber  of,  629 

collection  of  discharges  from,  for  bac- 
teriological examination,  295 
for  microscopical  examination,  283 
curves  of,  630 
dilatation  of,  complications  following, 

692 
estimation  of  length,  651 
examination  of,  631 
by  bougie  k  boule,  647 
by  sounds  and  bougies,  638 
glass  tests,  632 
hand  injections  for,  661 
injection  test  for  pus,  634 
inspection  of,  634,  635,  652,  658 
instillations  of,  669 
irrigations  of,  664 


INDEX 


893 


Urethra,  local  anesthesia  in  operations  on, 
87.  105 
membranous,  anatomy  of,  628 
palpation  of,  636,  638 
prostatic,  anatomy  of,  629 
spongy,  anatomy  of,  628 
strictures  of,  dilatation  of,  680 
continuous,  693 
Urethral  bougie,  639,  684 
k  boule,  647,  648 
chill,  692 
curet,  675 
dilator,  Kelly's,  659 

Kollmann's,  curved,  683 
straight,  683 
diseases,  urethroscope  in  treatment  of, 

673 
fever,  692 

filiforms,  639,  684 

inspection,  634 

instillations,  669 

irrigating  nozzle,  Chetwood's,  665 

irrigations,  664 

knife,  675 

mucous  membrane,  normal  appearance 

of,  656,  657 
ointment  syringe,  673 
probe,  674 
pus,  determination  of,  glass  tests  for,  63  2 

injection  for,  634 
snare,  676 
sound,  blunt,  639 
conical,  682 
cupped,  672 
double -taper,  682 
straight,  683 
speculum,  673 
strictures,  dilatation  of,  680 
continuous,  693 
estimation   of   size  and    length   of, 
647.  648 
syringe,  662 

Kollmann's,  675 
tube,  Klotz's,  654 
tube-speculum,  Kelly's,  659 
Urethritis  after  passage  of  urethral  sound, 

692 
Urethrometer,  Otis',  650 
Urethrometry,  650 
Urethroscope,  653 
female,  659 

in  treatment  of  urethral  diseases,  673 
Swinburne's,  653 
Urethroscopy  in  female,  658 

in  male,  652 
Uric  acid  in  blood,  test  for  kidney  func- 
tion, 788 
Urinalysis,  758 
as  test  of  kidney  function,  780 
in  bladder  disease,  699 
in  kidney  disease,  699,  758 
Urine,  albumin  in,  702 
blood  in,  702 

collection  of,  for  examination,  305 
from  infants,  306 
in  presence  of  incontinence,  306 


Urine,  color  of,  701 
cryoscopy  of,  for  determination  of  func- 
tional capacity  of  kidneys,  790 
elimination  of  foreign  substances  in,  as 
index  of  renal  function,  784 
of  substances  normally  present  in,  as 
index  of  renal  function,  780 
examination  of,  699,  758 
odor  of,  700 
pus  in,  703 
quantity    of,    passed    in    twenty-four 

hours,  700 
reaction  of,  701 
residua),  estimation  of,  712 
segregation  of,  775 
Harris*  method,  777 
Luy's  method,  779 
specific  gravity  of,  700 
substances  normally  excreted  in,  con- 
centrated in  blood,  as  index  of  renal 
function,  787 
transparency  of,  701 
U.  S.  Army  apparatus  for  transfusion  of 

citrated  blood,  157,  159 
Uterine  cannula  and  plunger,  849 
douche,  840 
nozzle,  841 

Chamberlain's,  841 
Fritsch-Bozeman,  841 
Talley's,  841 
packer,  848,  849 
Uterus,  anatomy  of,  796 
collection  of  discharges  from,  for  bac- 
teriological examination,  296 
for     microscopical      examination, 
286 
curettage  of,  868 
digital  palpation  of,  827 
douching,  840 
palpation  of,  813 
position  of,  797 

retrovcrted,  replacement  of,  856 
scrapings  from,  examination  of,  829 
sections  from,  examination  of,  829 
sounding  of,  825 
tam]3oning,  847 

Vaccination,  219 

by  acupuncture,  222 

by  epidermic  puncture,  222 

by  scarification,  221 

shield,  222 
Vacuum,      heat,     aspirator,     Connell's, 

342 
Vagina,  anatomy  of,  796 
application  of  jwwders  to,  836 
bimanual  palpation  of,  813 
collection  of  discharges  from,  for  bac- 
teriological examination,  296 
for  microscopical  examination,  285 
digital  palpation  of,  81 1 
douching  of,  832 
examination  by  specula,  820 
inspection  of,  809 
local  applications  to,  835 
relaUons  of,  796 


894 


INDEX 


Vaginal  depressor,  821 
discharges,  examination  of,  8zo 
douche,  832 

nozzle,  833 
inspection  of  bladder,  705 
irrigations,  832 
palpation  of  ureters,  756 
speculum,  bivalve,  820,  8az 
Goodeirs,  820 
Sim's,  821 
trivalve,  820 
tampons,  837 
medicated,  839 
Vagino-abdominal    palpation    of    pelvic 

organs,  813,  814 
Valentine's  irrigator,  665 
Valsalva's  method  of  inflation  of  middle 

ear,  416 
Valves  of  Morgagni,  570 

rectal,  569 
Vapor  method  of  administering   chloro- 
form, 39 
ether,  33 
Vaporizer,  Bench's,  428 
Hartman's,  428 
Pynchon's,  428 
Venesection,  185 
Venous  anesthesia,  no 

puncture,  method  of  making,  302 
Vertebrae,  lumbar,  anatomy  of,  330 
Vesical  growths,  fulguration  of,  by  high 

frequency  currents,  732 
Vienna  general  anesthetic  mixture,  50 
Vincent's  apparatus  for  blood  transfusion, 

154 
method  of  determining  blood  groups, 
141 
Voice  test  for  hearing,  413 
Vomiting  after  anesthesia,  72 
Von  Hacker's  method  of  dilating  esopha- 
geal strictures,  507 
von  Mikulicz's  esophagoscope,  498,  499 

Wales'  bougies,  590,  591,  619 
Ware's  ethyl  chlorid  inhaler,  48 


Washing  out  stomach,  547 

Watch  test  for  hearing,  413 

Wax- tipped  bougie,  770 
ureteral  catheter,  761 

Weber's  test  of  hearing,  415 

Wegele's  stomach  electrode.  563 

Weighted  speculum,  Garrigues',  826 

Welch's  apparatus  for  collecting   blood 
serum,  165 

Wet  cupping,  197 

Whip  catheter,  736 

Whistle,  Galton's,  Edelmann's  modifica- 
tion. 414 

Whitall  Tatum  atomizer,  384 

White's  palate  retractor,  370 

Wolbarst  five-glass  test,  633 

Wounds,    sterilizing    by    Carrel-Dakin 
technic,  234 
apparatus  for,  237-241 
■    bacteriologic  examination  in,  247 
cleansing  of  wound.  242 
debridement  in,  242,  243 
dressing  wound,  246 
dressings  for,  241 
in  penetrating  ivounds,  244 
in  {>erforating  wounds,  246 
in  superficial  wounds,  243 
instillation   tubes,   arrangement 

of,  243-246 
instillations  in,  242 
solutions  for,  235-237 
technic,  242 

Wrist- joint,  exploratory  puncture  of,  327 

X-KAY  examinadon  of  accessory  sinuses, 
378 
of  bladder,  725 
of  esophagus,  50a 
of  intestines,  576 
of  kidneys,  791 
of  larynx,  460 
of  rectum,  576 
of  stomach,  546 

Yaws,  arsphenamin  in,  207 


11841*0 


Gift 

San  Francisco  Coimty  Medical 
Society