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it^^a*!® 




Jilt 



BOOKS 



BY 



ALBERT S. MORROW. M. D. 



Diagnostic and Thefapeutic Technic 

Octavo of 775 pages, with 815 line- 
drawings. Cloth, 1 5. 00 net. 



Immediate Gire of the Injured 

i2mo of 355 pages, with 242 illus- 
trations. Cloth, $2.50 net. 
The New {2d) Edition 



DIAGNOSTIC 



AND 



THERAPEUTIC TECHNIC 



A Manual of Practical Procedures 
Employed in Diagnosis and Treatment 



BY 

ALBERT S. MORROW. A. B.. M. D. 

ADJUNCT PROFESSOR OF SURGERY IN THE NEW YORK POLY- 
CLINIC; ATTENDING SURGEON TO THE WORKHOUSE HOSPITAL, 
AND TO THE NEW YORK CITY HOME FOR THE AGED AND INFIRM 



WITH 815 ILLUSTRATIONS, MOSTLY ORIGINAL 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1912 



Copyright, iQii, hy W. B. S;iimders Company 



Reprinted January. 1912 



PRINTED IN AMERtOA 



PREM OF 

W B. SAUNOERt COMPANY 

PHILADELPHIA 



To my Father 

Prince A. Morrow, M. D, 

this book 
is affectionately dedicated 



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 9. 

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. 

7 



r>r\P^ 






8 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 who 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 Administsation op 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 44 

Ethyl chlorid anesthesia 46 

Anesthetic mixtures 49 

Intubation anesthesia 50 

Anesthesia through a tracheal opening 52 

Rectal anesthesia 53 

Scopolamin-morphin anesthesia 55 

Accidents during anesthesia and their treatment 56 

After-efiFects of anesthetics 62 

After-treatment of cases of general anesthesia . . « 64 

CHAPTER II. 

Local Anesthesia 66 

Advantages and disadvantages of local anesthesia 67 

Methods of producing local anesthesia 70 

Preparations of the patient for local anesthesia 70 

Drugs employed for local anesthesia 71 

Preparation of the anesthetic solution 72 

Conduction of an operation under local anesthesia 73 

Local anesthesia by cold 75 

Surface application of anesthetic drugs 75 

Infiltration anesthesia 76 

Endo- and perineural infiltration 81 

Practical application of infiltration, endo- and perineural methods of anesthesia 

to special localities 83 

Bier's venous anesthesia 95 

Arterial anesthesia 98 

Spinal anesthesia 99 

CHAPTER in. 

Sphygmomanometry 106 

Normal blood pressure 106 

O 



lO CONTENTS. 



PACE 



Instniments for estimating blood pressure 107 

Technic of estimating blood pressure no 

Variations of blood pressure in disease in 

CHAPTER IV. 

Transfusion of Blood 114 

Indications and contraindications 115 

Hemolysis 116 

Methods of performing transfusion 116 

Selection of the donor 118 

Technic by Crile's method 119 

Brewer's method 122 

Hartweirs method 122 

Levin's method 123 

Elsberg's method 123 

Technic by Carrel's suture 124 

CHAPTER V. 

Infusions of Physiological Salt Solution 127 

Indications 127 

Preparation of normal salt solution 128 

Artificial sera for infusions 129 

Intravenous infusion 130 

Intraarterial infusion 137 

Hypodermoc lysis 140 

Rectal infusion 143 

CHAPTER VI. 

Hypodermic and Intramuscular Injection of Drugs i44 

Administration of Diphtheria Antitoxin 149 

Vaccination 153 

Acupuncture 159 

Venesection 161 

Scarification 166 

SubcutaiJeous Drainage for Edema 168 

Cupping 170 

Leeching 174 

CHAPTER VII. 

Bier's Hyperemic Treatment 177 

Passive hyperemia 177 

Effects of hyperemia 178 

Indications 180 

General principles underlying hyperemic treatment 181 

Passive hyperemia by means of constricting bands 183 

Passive hj'peremia by means of suction cups 188 

Active hyperemia 194 



CONTENTS. 1 1 

CHAPTER Vni. 

PAGB 

Collection and Preservation op Pathological Material 199 

Method of making smear preparations for microscopical examination 199 

Method of inoculating culture tubes 207 

Collection of discharges and secretions for bacteriological examination .... 210 

Collection of blood for microscopical examination 217 

Collection of blood for bacteriological examination 222 

Collection of sputum 224 

Collection of urine 224 

Collection of stomach contents 226 

Collection of feces 226 

Removal of a fragment of solid tissue for examination 226 

CHAPTER DC. 

Exploratory Punctures 230 

Exploratory punctures in general 230 

Exploratory puncture of the pleura 233 

Exploratory puncture of the lung 4 237 

Exploratory puncture of the pericardium 238 

Exploratory puncture of the peritoneal cavity 240 

Exploratory puncture of the liver 241 

Exploratory puncture of the spleen 242 

Exploratory puncture of the kidneys 243 

Ejcploratory puncture of joints 244 

Spinal puncture 246 

Spinal puncture as a means of administering antitoxic sera 253 

CHAPTER X. 

Aspirations 254 

Aspiration of the pleural caWty 254 

.Aspiration of the pericardium 263 

•Aspiration of the abdomen for ascites 265 

.Aspiration of the tunica vaginalis 270 

Aspiration of the bladder 272 

CHAPTER XI. 

The Nose and Accessory Sinuses 273 

.Anatomic considerations 273 

Diagnostic methods 278 

Rhinoscopy 278 

Inspection of the nasopharynx by means of Hays' pharj'ngoscope 286 

Palpation by the probe * 288 

Digital palpation of the nasopharj'nx 291 

Transillumination of the accessor^' sinuses 292 

Skiagraphy 294 

Therapeutic measures 294 



12 CONTENTS. 

PAGB 

Nasal douching 294 

The nasal syringe 297 

The nasal spray 299 

Direct application of remedies 301 

Insufflations 303 

Lavage of the accessory sinuses 305 

Passive hyperemia in diseases of the nose and accessory sinuses 311 

Tamponing the nose for the control of hemorrhage 312 



CHAPTER XII. 

The Ear 317 

Anatomic considerations 317 

Diagnostic methods 321 

Direct inspection 323 

Otoscopy 324 

Determination of the mobility of the drum membrane 328 

Hearing tests 329 

Inflation of the middle ear for diagnosis 332 

Therapeutic measures 339 

The ear syringe 339 

Instillations 342 

Application of caustics 344 

Inflation of the middle ear for therapeutic purposes 345 

Inflation with medicated vapors 345 

Injection of solutions into the Eustachian tubes 346 

The Eustachian bougie 347 

Massage of the drum membrane 348 

Incision of the drum membrane 349 



CHAPTER XIII. 

The Larynx and Trachea 353 

Anatomic considerations 353 

Diagnostic methods 357 

Laryngoscopy and tracheoscopy 357 

Direct laryngoscopy 364 

Autoscopy 367 

Direct tracheo- bronchoscopy 367 

Palpation by the probe 374 

Skiagraphy 375 

Therapeutic measures 375 

The laryngeal spray 375 

Direct application of remedies 377 

Insufflations 379 

Steam inhalations 380 

Dry inhalations 383 

Intubation 383 

Tracheotomy 392 



CONTENTS. 1 3 

CHAPTER XIV. 

PAGB 

Tbe Esophagus 403 

Anatomic con^derations 403 

Diagnostic methods 404 

Auscultation 405 

Percussion 405 

Palpation 405 

Examination by sounds and bougies 405 

Esophagoscopy 412 

Skiagraphy 416 

Therapeutic measures 416 

Lavage of the esophagus 416 

Dilatation of esophageal strictures by the bougie 418 

Intubation of the esophagus 423 

CHAPTER XV. 

The Sto&iach 427 

Anatomic considerations 427 

Diagnostic methods 428 

Inspection 430 

Palpation 432 

Percussion 435 

Auscultation 436 

Inflation of the stomach 437 

Extraction of stomach contents for examination 440 

Test of motor function 447 

Test of absorption power 448 

Gastrodiaphany 448 

Gastroscopy 450 

Skiagraphy 456 

Exploratory laparotomy 456 

Therapeutic measures 457 

Lavage of the stomach 457 

The stomach douche 462 

Gavage 465 

Massage 468 

Electrotherapy 470 

CHAPTER X\^I. 

The Rectum and Colon 474 

Anatomic considerations 474 

Diagnostic methods 477 

Inspection 479 

Palpation by the fmger 480 

Mp.nual palpation 482 

Examination by the speculum or proctoscope 483 

Examination by sounds and bougies 490 

Examination by the bougie ^ boule 491 

Examination by the probe 492 

Inflation of the colon 493 



14 CONTENTS. 

PAGB 

Therapeutic measures 4g6 

Enemata 4g6 

Enteroclysis ^oi 

Saline rectal infusion 508 

Continuous proctoclysis 510 

Nutrient enemata 514 

Injection of fluids or air into the bowel in intussusception 517 

Dilatation of rectal strictures by the bougie 519 

Colonic massage 522 

Auto-massage 524 

Application of electricity to the rectum and colon 524 

CHAPTER XVII. 

The Urethba and Prostate , 527 

Anatomic considerations 527 

Diagnostic methods 531 

Glass tests for locating urethral pus 532 

Injection test for locating urethral pus 534 

Inspection 534 

Palpation 535 

Examination by sounds and bougies 538 

Examination by the bougie h boule 546 

Urethrometry 549 

Estimation of the urethral length . 550 

Urethroscopy in the male 551 

Urethroscopy in the female 558 

Therapeutic measures 560 

Urethral injections 560 

Irrigations of the urethra 564 

Instillations 568 

Application of ointments 571 

Urethroscopic treatment 572 

Direct application of cold to the urethra 575 

Prostatic massage 576 

Meatotomy ^ 578 

Treatment of strictures by gradual dilatation 579 

Treatment of strictures by continuous dilatation 590 

CHAPTER XVin. 

TBe Bladder 593 

Anatomic considerations 593 

Diagnostic methods 595 

Urinalysis 596 

Inspection 601 

Percussion 601 

Palpation 602 

Sounding for stone 604 

Test of bladder capacity ' 607 

Estimation of residual urine 609 

Test for absorption from the bladder 609 



CONTENTS. IS 

PAGE 

Cystoscopy in the male 6io 

Cystoscopy in the female 615 

Skiagraphy 620 

Therapeutic measures 620 

Irrigations ; 620 

Auto-irrigations 624 

Instillations 626 

Cystoscopic treatment 627 

Catheterization in the male 628 

Catheterization in the female 635 

Continuous catheterization 636 

Aspiration of the bladder 639 

CHAPTER XrX. 

The Kidneys and Ureters 642 

Anatomic considerations 642 

Diagnostic methods 645 

Inspection 645 

Palpation of the kidney 646 

Palpation of the ureters 648 

Percussion 650 

Urinalysis 651 

Catheterization of the ureters in the male 652 

Catheterization of the ureters in the female 661 

Segregation of urine 667 

Determination of the functional capacity of the kidneys 671 

Skiagraphy 674 

Exploratory' incision 675 

Therapeutic measures 675 

Medication of the renal pelvis and ureters 675 

Dilatation of ureteral strictures 677 

CHAPTER XX. 

The Female Generative Organs 679 

Anatomic considerations 679 

Diagnostic methods 681 

I. Examination of the abdomen. 

Inspection 686 

Palpation 6S7 

Percussion 689 

Auscultation 691 

Mensuration 691 

n. Examination of the pelvic organs. 

Inspection 692 

Examination of discharges 693 

Digital palpation 694 

Bimanual palpation 6g6 

Examination by means of specula 7^3 

Sounding the uterus 7^8 

Digital palpation of the uterine cavity 7^° 



l6 CONTENTS. 

PAGE 

Examination of sections and scrapings from the uterus 712 

Elzploratory vaginal incision 712 

Therapeutic measures 715 

Vaginal irrigations 715 

Local applications to the vagina and cervix 718 

Application of powders to the vagina 719 

Vaginal tampons 719 

Intrauterine douche • 723 

Intrauterine applications 727 

Tamponing the uterus 729 

Bier*s hyperemic treatment in gjrnecology 732 

Pelvic massage 733 

Scarification of the cervix 734 

Pessary therapy 735 

Dilatation of the cervix 746 

Curettage 751 

Index 757 



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 condition. 
Anesthetics are divided into general and local. General anesthetics are 
inhaled as gaseous vapors and enter the circulation through the alveoli 
of the lungs, whence they are carried to all the tissues and organs of the 
body, including the central nervous system, producing loss of conscious- 
ness, abolition of pain, and muscular relaxation. The drugs most 
used for this purpose are ether, chloroform, nitrous oxid gas, and 
ethyl chlorid administered separately, in sequence, or in combination 
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 any 
general anesthetic the patient is brought practically to the border-line 
between life and death, and, in many cases, the life of the patient de- 
pends, in the first place, upon the selection of the anesthetic, and, in the 
second place, 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 sepa- 
rately, and the anesthetic chosen that is best suited to that particular 
case. According to statistics, the mortality following the administra- 
tion of the diflferent anesthetics is about as follows: 

Nitrous oxid, i in 100,000 

Ether, i in 16,000 

Ethyl chlorid, i in 4,500 

Chloroform, i in 3,000 

Statistics, however, are not of absolute value as a guide. The 
production of narcosis with the same anesthetic under all conditions^ 

17 



l8 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

even though the particular agent chosen were absolutely safe, would 
certainly be unjustifiable. An 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. 
Fiu'thermore, in estimating the relative safety of the different anes- 
thetics, one must consider not only the immediate dangers that may 
arise, but also the more remote toxic eflFects 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 anesthetic, but in considering each 
agent an attempt will be made to indicate the cases for which it is best 
suited. 

Preparations for Anesthesia and Precautions. — Certain precautions 
are necessary before the administration of a general anesthetic. Ex- 
perience 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 possi- 
ble condition. In other cases where only a light anesthesia — as with 
nitrous oxid — is required, but little preparation will be necessary. 

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

Diet. — The diet for twenty-four hours before the operation should 
be of an easily digestible character, and should be taken in small 
amounts to prevent overloading the alimentary canal. If the opera- 
tion 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 breakfast may be taken, not later than 8 a. m. A feeling of faint- 
ness 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 
never 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 opera- 
tion, vomiting is almost sure to occur, adding not only to the danger 
of the anesthetic, but to the subsequent distress of the patient. In some 



PREPARATION OF THE PATIENT FOR ANESTHESIA. 1 9 

cases of special gravity on account of shock or marked feebleness, a 
nutrient enema, with the addition of whisky or brandy, may be given 
half an hour before the anesthesia is commenced. 

In an emergency, lavage of the stomach may be carried out 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 contents 
of the stomach suddenly pouring out under the relaxation. of the anes- 
thetic. To avoid imdue excitement and possible collapse, the lavage 
may be performed, if desired, just as the patient is under complete 
anesthesia. 

Preparation of the Mouth, 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 teeth results in a very foul and septic 
condition, necessitating systematic treatment for several days before 
administration of the anesthetic is safe. 

The Use of Morphin. — A good night's rest does much to fortify the 
patient and put him in the best possible condition for the operation. 
With some patients simply a rub-down with alcohol at bedtime 
suffices to induce sleep; in others, especially if nervous, the administra- 
tion of trional or the bromids is indicated. Many surgeons administer 
morphin hypodermically before anesthesia. In some cases this is of 
advantage, shortening the stage of excitement and necessitating less of 
the anesthetic to maintain insensibility, 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 overnarcosis; furthermore, it delays the awakening 
from the anesthesia. In children or the very old it must be used with 
caution. Any condition producing embarrassed or obstructed respira- 
tion is a contraindication as is, of course, any idiosyncrasy against the 
drug. It should not be given to very weak subjects or to those in 
stupor. 

Physical Examination. — A thorough physical examination should 
be made in all cases as a routine preliminary to general anesthesia, for 
exact knowledge as to the state of health is essential to an intelligent 



20 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

selection of the anesthetic and its safe administration. Such an exami- 
nation has a good moral eflFect upon the patient, and, if assurance can 
be given that nothing abnormal can be discovered, it does much to 
allay the natural fear and timidity of a nervous individual. This 
examination should be made, when possible, before the day of operation, 
so that, if the condition of the patient demands it, the operation may be 
postponed without subjecting the patient to imnecessary preparations. 
In the presence of acute bronchitis or coryza, a postponement of the 
anesthesia 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-four 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 especially important A 
normal adult male will pass 250 to 450 gr. (16 to 29 gm.), and females 
less. If the quantity eliminated falls much below this normal minimum, 
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 anes- 
thetic (Fowler). If albumin be present, the dangers of a general 
anesthetic are increased, especially with ether. In the presence of 
large quantities of albumin and casts the operation should be postponed 
or local anesthesia substituted. With sugar in the urine, the chances 
of diabetic coma developing should always be carefully considered. 
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 administered for 
several days, and, where there is not time for this, nitroglycerin should 
be given by hypodermic before the anesthetic is begun. In the pres- 
ence of hypotension, cardiac stimulants for several days previous to the 
operation are indicated. 

Care of the Patient. — ^The comfort of the patient while on the operat- 
ing table should be seen to by the anesthetist. 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 condemned. 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 



PREFAKATION OF THE PATIENT FOK ANESTHESIA. 21 

to the operating-room is not to be advised if it can be avoided. The 
lifting around of the padent 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 sufficientiy upon 
a small pillow to allow freedom in breathing, answers in the majori^ of 
cases. Ether and nitrous oxid are sometimes given with the patient's 
head and trunk elevated, but under no circumstances should chloro- 
form be given with the patient sitting up or semiupright, 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. 




.^The anesthetist's supplies. 
1, Pus basin; 2, mouth wipes on artery clamps; 3, mouth wedge; 4. tongue forceps; 5 
c syringe. 



mouth gag; 6, hypoder 



Before administering the anesthetic, anything that interferes with 
or obstructs the respiration in ihe 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 anesthesia. 
The mouth should be examined, and false teeth, obturators, plates, 
chewing gum, tobacco, etc, should be removed lest ihey fall back into 
the larynx and cause choking. It is always well to have a third 
person present in case help is needed, and in the case of a female 
patient this is very necessary, as erotic dreams may lead to damaging 
accusations against the anesthetist. 



22 THE ADlilNISTRATIOK OF GENEKAL ANESTHETICS. 

The Anesthetist's Supplies. — Besides the apparatus necessary for 
the actual administration of the anesthetic, the anesthetist should be 
provided with the following: a mouth gag, a wedge or screw -shaped 
piece of hard rubber to force the jaws apart, tongue forceps, a hypo- 
dermic syringe in good working order, with whisky, camphor, adrenalin, 
atropin,and strychnin at hand in case of need, a number of small 
mouth wipes with an artery clamp as a holder, and a small pus basin 
(Fig. i). A cylinder of oxygen should be ready for use, and an in- 
fusion set and tracheotomy tube should be accessible, if required. 




-Arrangement of the operating- table aJid the anesthetist's supplies 



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 of it when he leaves the table. 

Stages of Anestiiesia. — Anesthesia from most of the general anes- 
thetic agents passes through four stages, as follows: (i) The initial, or 
stage of irritation; (a) ihe stage of excileinent; (3) the stage of surgical 
anesthesia; and (4) the stage of coming out. With some anesthetics 
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 ihe drug employed and the technic of its administration. 

The Initial Stage. — The inhalation of an anesthetic produces irrita- 
tion of the mucous membrane of the respiratory tract and a profuse 



STAGES OF ANESTHESIA. 23 

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 to tear off 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 charac- 
teristic 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 Excitement — ^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 entirely 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 
trunk and extremities occur. The eyes are often rolled from side to 
side. WTiile 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 pupils contract but still 
react slowly to light, and the conjunctival reflex disappears. The 
skin becomes cool, pale, and moist. Total insensibility is now pro- 
duced, 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 



24 THE ADBilNISTRATION OF GENERAL ANESTHETICS. 

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 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 administered to keep the pupils 
midway between contraction and dilatation, with a response to Ught 
at all times. 

Stage of 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 be- 
comes slower and less audible, and there is frequent sighing. The 
conjunctival reflex reappears, the pupillary reflex becomes active, and 
the patient frequently rolls the eyes about. Frequent swallowing oc- 
curs, followed by retching. Vomiting of frothy and often bile-stained 
mucus occurs in many 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 or cautery, nor should it be used near an 
X-ray tube; cases have been reported where combustion has taken 
place when ether was used in an X-ray room. An artificial light held 
well above it is safe, however, as the ether fumes tend to sink downward. 
It is explosive if ignited when mixed with air. Only the purest ether 
should be used for anesthetic purposes, and it should be kept in her- 
metically sealed tin cans, as exposure to light and air cause it to decom- 
pose 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 



ETHER ANESTHESU. 25 

coughing. Lesions of the lungs axe 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 stimulant, 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 
being improved immediately 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, especially upon the respiratory centers. 
Chloroform, on the other hand, is a depressant in any dose. It is 
estimated that ether is about five times as safe as is chloroform, and, 
as it is less rapid in its action, danger signs can be recognized and 
proper treatment instituted with more chances of success than with 
the latter. Upon the kidneys it acts as an irritant, and prolonged 
anesthesia often results in postoperative albuminuria. Ether produces 
a distinct leukocytosis, a slight diminution of the hemoglobin, and a 
marked decrease in the coagulation-time of the blood (Hamburger and 
Ewing). 

Owing to its low boiling-point and volatility, ether is very rapidly 
eliminated from the lungs, and it is necessary to give it in a more or 
less concentrated form, thus diflFering from the administration of chloro- 
form. The administration of ether is rendered safer if preliminary 
anesthesia is induced by some quick anesthetic, as nitrous oxid or ethyl 
chlorid; furthermore, oxygen and ether is a safer mixture than air and 
ether. The oxygen may be administered by passing the oxygen tube 
under the mask, or, in the closed inhalers, the tube may be attached 
directly to the ether bag. 

Suitable Cases. — When a general anesthetic is necessary and the 
operation is not suited to nitrous oxid anesthesia, ether is preferable 
to chloroform unless direct contraindications to its use are present. 
In the hands of an expert, many of the dangers attributed to chloro- 
form are absent, but it must be remembered 'that under the same 
conditions ether 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 anemia ether is preferable to chloroform, as it has a 
less marked effect upon the hemoglobin. If the patient's hemo- 
globin is below 30 per cent., however, any general anesthetic is 
contraindicated (Da Costa). In heart disease, if the compen- 
sation is good, ether is safe, but with broken compensation or 



26 



THE ADMINISTRATION OF GENERAL ANESTHETICS. 



when there is high arterial tension and degenerative changes in the 
blood-vessels, it is contraindicated on account of the danger from over- 
stimulatioQ. In myocardial disease 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 
advanced Bright's disease. In patients over sixty years old, ether, 
as a rule, is to be avoided, as they are very likely to be afflicted 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 sali%^ that breathing is seriously 
interfered with. 




Fig. 3. — The Esmarch mask. 



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. It should never be 
administered in operations about the mouth or face requiring the 
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 
forms of inhalers are used, according to which method is 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 



ETHER ANESTHESIA. 



chloroform bottle (Fig. 5) may be used for the dropping, or a very con- 
venient dropper can be improvised by cutting a groove in both sides 
of the cork of the ether can — one to admit air and the other to allow the 
escape of the ether. 





— The Schimmelbusch mask. Flo. 5. — Chlorofonn dropper. 



The Allis 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 cufE and cover- 
ing 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 Bennett (Fig. 9), the Gwathmey, thePedersen,eic. These 
consist essentially of a metal face-piece surrounded by an inflatable 
rubber rim, an ether chamber filled with gauze, and a closed rubber 



28 THE ADUINISTKATION OF GENERAL ANESTHETICS. 

bag into and out of which the patient breathes. They are also pro- 
vided with suitable openings for the entrance of air.' With such 
inhalers, the temperature of the ether vapor is raised by the expired 
air, thus adding to the value and safety of the anesthetic. 




Fig. 7.— Towel cone. 

To obtain the benefit of the warm vapor without the disadvantages 
of the closed inhalers, 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 vapor can be delivered through a small tube 




Fio 8.— The Clover ether inhaler. 

passed into the mouth without interfering with the operation. There 
are a number of inhalers for this purpose, of which Gwathmey's 
apparatus is a type. Gwathmey's vapor apparatus (Fig. 10), as de- 
scribed by him (Journal of American Medical Association, October 27, 

' Space does not pennii a detailed descripi 
OS a desciiption of the mechanism and full ii 



ETHEK ANESTHESIA, 



29 



1906), consists of two six-ounce (178 c.c.) bottles, one for chlorofonn 
and one for ether. Both bottles are placed in a tin vessel containing 
thermolite. This "thermolite warmer," if placed in boiling water for 
three minutes, will remain warm for over one and a half hours. If the 
heat is to be continued, this can be accomplished by simply taking the 




Fig. 9.— The Bennett ether tnhalet. 

stoppers out, thus exposing the thermolite to the atmosphere. The 
liquid then begins to recrystaliize, and on turning to a soUd form gives 
o£f 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 stopper, and representing 




.— -Gwathmey s vapor apparatus 



three degrees of vapor strength. The small switches at the lop of each 
bottle are so arranged that chloroform or ether, combined or separately, 
can be given, and in any strength desired. In addition, by simply 
turning a small lever, without removing the mask, the patient receives 
pure air or a mixture of oxygen and air. By compressing the hand 



30 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

bulb, air or oxygen is forced into the apparatus and the warmed ether or 
chlorofonn vapor is carried to the patient by the efferent tube. 

Inhalers, whatever the variety, should alwa)'s be properly 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 ao solution of 
carbolic 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. 

Administration. — Drop Method. — The usual precautions ah-eady 
detailed having been observed, and the eyes of the patient being pro- 




Showing the adminisl ration of ether by the dnDp method. 



tected by a folded piece of gauze, the anesthetist starts the anesthetic by 
placing the mask over the mouth with the request that the patient 
breathe naturally and regularly. As soon as several breaths have been 
taken, a few drops of ether arc poured on 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 lessened for the time being. In from five to six min- 
utes the stage of excitement and struggling begins, and the ether should 
then be dropped more rapidly. It should never, however, be poured 
on suddenly in large amounts, as this simply irritates the respiratory 
tract and produces laryngeal spasm, causing the patient to cough. 



ETHER ANESTHESIA. 3I 

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. As 
soon as the patient is thoroughly anesthetized, just sufficient ether 
should be given to keep him thoroughly under its effects. 

During the anesthesia the breathing should be carefully watched, 
together with the pulse and the eye reflexes. Under the stimulation 
of the ether, the respirations are increased in frequency and depth, 
and are rather noisy in character on account of the increased amount 
of mucus and saUva that collects in the throat. Irregular rapid respira- 
tion approaching a gasping type is unsafe. The breathing should 
not be allowed to become giu"gling 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. 12). 




Fig. 12. — Proper method of holding the jaw forward. 

This prevents the relaxed epiglottis from being pushed back by the 
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 by 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 so as to allow the mucus and saliva to flow out 
through the comer 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 reapplied, 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 



32 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

dilate and remain so without responding to light in the absence of the 
conjunctival reflex, it is a sign of ovemarcosis. 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 of it 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 (59 to 118 c.c.) should suffice for an hour; with 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 does 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 accustomed 
to the apparatus, ether is slowly turned on during an inspiration 
by gradually revolving the drum of the ether chamber (Fig. 13). If 
cough or signs of irritation occur, the amount of ether should be cut 
down. Care should always be taken not to push the anesthetic too 
fast. Since the patient breathes back and forth the air in the rubber 
bag, it should be seen that the bag is kept about two-thirds full — it 
should never be allowed to become empty. Usually with a closed 
inhaler anesthesia can be produced in from four to six minutes. On 
accoimt of rebreathing the same air, some duskiness of countenance is to 
be expected, but this may be regulated by admitting more air or by 
administering oxygen. A distinct livid color should not be allowed to 
persist with either a closed or an open inhaler. Such a condition is a 
sign of poor administration of the anesthetic, or else the particular 
anesthetic used is not suited to the case. 

Anesthesia by the closed method, besides being more rapid, reduces 
considerably the amount of ether used. Recovery from the effects of 



ETHEB ANESTHESIA. 



33 



the anesthesia is more prompt, and the after effects, as nausea and 
vomiting, are greatly diminished. Furthermore, the ether vapor 
inhaled from the bag, being warm, is safer, more effective, and less 
apt to produce irritation of the respiratory tract. 

Vapor Method, — It is preferable to start the anesthesia by some 
of the quick methods, as nitrous oiid gas followed by ether, or by 
ethyl chlorid followed by ether, and, when the patient is well under 
its influence, the ether vapor is substituted. The vapor method may, 
however, be used from the beginning, if desired, starting with a 
medium percentage of vapor, and then working to the highest. When 




Fig. ij. — Showing Ihe administration of ether with a closed inlialer. 



completely under, a medium or low percentage of vapor is used, accord- 
ing to the case and 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, without 
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. 



34 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

CHLOROFORM ANESTHESIA. 

Chloroform is a clear, colorless, heavy, volatile liquid with a sweet- 
ish taste and characteristic odor. When used for anesthetic purposes, 
it should be absolutely pure and neutral to litmus. Under the in- 
fluence of heat or light, it decomposes into hydrochloric acid, chlorin, 
etc., hence it should always be kept in well-stopped, 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 to a 
marked degree blood pressure through vasomotor depression. 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 without premonitory 
signs. Vasomotor paralysis causing dilatation of the vessels and capil- 
laries and fatal syncope is the primary cause, though the inhibitory 
action of the drug upon the heart itself may contribute. Respiratory 
failure is not common as a primary complication, but is secondary to 
the failure of the vasomotor centers. Many of the deaths from chloro- 
form occur early in its administration when, during the stage of ex- 
citement and struggling, more of the drug is inhaled than is expected, 
or it is pushed too rapidly in an attempt to overcome the struggling. 
With a trained and watchful assistant as an 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. It is considered less dangerous in warm climates 
than in cold ones. 

Chloroform is the strongest anesthetic we possess, and should al- 
ways be administered well diluted with air. A stronger vapor than 
2 per cent, is a dangerous dose. In this respect it differs from nitrous 
oxid and ether, in the use of which a well-saturated vapor is required. 
A 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 postoperatire vomiting are less frequent. 



CHLOROFORM ANESTHESIA, 35 

Chloroform should always be administered warm. This can be 
accomplished by using some one of the warm vapor inhalers, or by 
simply placing the bottle containing the drug in warm water (loo® F.) 
every few moments. 

Chloroform should never be given with the head very high, or with 
the patient sitting up, on account of the danger of s)aicope; this pre- 
caution should also be borne in mind when lifting or moving persons 
under the influence of chloroform. As a rule, the recovery from 
chloroform anesthesia is quicker than from ether, though the vomiting 
may last longer. 

Suitable Cases. — Chloroform is generally preferred to ether in 
yoimg children and in those over sixty years of age who are free from 
myocardial disease, for the reason that it causes less irritation of the 
mucous membrane lining the respiratory tract. It is preferred to 
ether for patients with advanced Bright's disease who are free from 
myocardial trouble, in obstructive conditions of the larynx or trachea, 
and for those whose lungs are involved by such conditions as tuber- 
culosis, asthma, bronchitis, etc. 

In heart disease with broken compensation and dyspnea, in 
aneurysm, and in cases of marked degeneration and weakening of 
the blood-vessels, chloroform is better than ether on account of the 
milder preliminary stages. In cases of myocarditis and of fatty de- 
generation it is dangerous and some other drug should be employed. 

In parturition it is safer than in health, because only a partial 
action is required, and fright and apprehension which may be the 
cause of some of the fatalities are absent. When, however, deep sur- 
gical anesthesia is required in such cases, ether is indicated. 

Chloroform should be avoided as an anesthetic in hemorrhage or 
shock, on account of its depressant effect upon the circulation; and like- 
wise in anemia, as it decreases hemoglobin and actually produces 
anemia. In cerebral surgery, chloroform is preferred by many sur- 
geons, and also in operations about the face and mquth, after induction 
of complete narcosis by some other method, as it causes but little cough 
and flow of saliva, and the anesthesia can be maintained with but a 
small amount of anesthetic. 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 incomplete anesthesia, chloroform is contraindicated. 
In ophthalmic operations, where the condition of the pupil cannot 
be ascertained, ether is preferred to chloroform. 

Apparatus. — Chloroform should never be administered in a closed 



36 THE ADUINISTKATION OF GENERAL ANESTHETICS. 

inhaler. Either the open drop method, with a free mixture of air, or 
the warm vapor method should be used. For the former, a handker- 
chief, the coraer of a towel (Fig. 14), or a piece of gauze will suffice, 
but a mask, such as Skinner's, Esmarch's (see Fig. 3), or Schimmel- 
busch'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 




Fic. 14— Chk 



which the flow can be accurately regulated, and a receptacle for warm 
water will be required. 

Different forms of apparatus for accurately estimating the strength 
of vapor, as Junker's (Fig. 15), Braun's, Gwathmey's (see Fig. 10), etc., 
are often used. These are supplied with a tracheal tube and are 
especially useful in operations about the mouth or throat. By squeez- 
ii^ the bulb, air is forced through the warmed chloroform, and a 




Junker's chlorofonn inhaler. 



vapor containing a definite mixture of chloroform and air is adminis- 
tered. By attaching the bulb to a tube connected with an oxygen 
cylinder, oxygen may be readily administered instead of air. 

The same care as to the cleanliness of the chloroform mask should 
be observed as would be with ether inhalers. After each anesthesia 
the metal framework should be boiled and Ihen recovered. 



CHLOSOFOBU ANESTHESIA. 



37 



AdminifltratioiL — The usual precautions already considered should 
be observed, and 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 chloroform 4 or 5 
inches (10 to 13 cm.) from the face (Fig. 16) and the patient is told to 
breathe naturally and regularly. As soon as the patient grows accus- 
tomed to the vapor, the chloroform is dropped steadily at a rate of 
10 to 30 drops (0.60 to 1.90 C.C.) a minute, and the mask is brought 




— Showp-ing the method of adminisiering chlorofonn (first step). 



nearer the face, being careful, however, not to touch the skin with por- 
tions of the mask wet with chloroform (Fig. 17). 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 never be pushed, otherwise, when the patient 
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 diminished, as it should also if the patient's 



38 THE ADUINISTRATION OF GENERAL ANESTHETICS. 

breathing becomes embarrassed. The jaw must be kept well forward 
if there is the slightest impediment from the tongue to free respiration. 
When the. patient is fully anesthetized, only small quantities of the 
anesthetic should be administered, just sufficient to keep him under. 

With chloroform anesthesia, we have practically the same stages as 
with ether, but they succeed each other more rapidly, and a dangerous 
condition of anesthesia is often quickly produced unless proper care be 
taken. The stage of excitement is less marked and shorter than with 




Fig. 17. — Showing the method of admiiiutering chlorofonn (second step). 



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 sensi- 
tive to light; conjunctival reflex just abolished; full muscular rela^ca- 
tion; and a good color without blueness of the iips or cheeks. The 
latter is an indication for a weaker vapor and more air or oxygen. 
With the ordinary chloroform mask, o^^gen 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 close watch should be 
kept over the respirations, the pulse, the condition of the eye reflexes, 
and the general appearance of the patient. It is only by the constant 



NITROUS OXID ANESTHESU. 39 

and undivided attention of the anesthetist that the safety of the patient 
can be guaranteed. The slightest alteration in the respirations 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 dilatation 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 (p. 33), and will not be repeated 
here. With chloroform, it is an especially valuable method to employ, 
as the warm vapor can be administered in a definite 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 marked anesthetic properties, though the 
anesthesia is not so profound as that of 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 time. 
It is the safest of all the general anesthetics, i in 100,000 being the gen- 
erally accepted death rate. No deaths have been reported from nitrous 
oxid when administered with oxygen. By heating the nitrous oxid 
and oxygen, the anesthetic is made even safer than when it is adminis- 
tered in the usual way (Gwathmey). 

Anesthesia from nitrous oxid alone cannot be maintained for more 
than fifty or sixty seconds without air, on account of the development 
of symptoms of asphyxiation. Used with the proper admixture of 
air or oxygen, however, an anesthesia for an hour or more may be 
safely maintained. According to Hewitt, mixtures containing 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 children. 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 uncon- 
sciousness in from one to two minutes, and is the most agreeable of the 



40 THE ADMINISTRATION OF GENERAL ANESTHETICS, 

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 prevent asphyxial symptoms, and ad- 
ministered by an expert, the scope of nitrous oxid may be greatly 
broadened, and 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 muscu- 
lar relaxation, and for breaking up adhesions in ankylosed joints. 
When local anesthesia is contraindicated, it becomes the anesthetic 
of choice for abscess, felon, empyema, benign timiors, strangulated 
hernia, varicocele, minor amputations, exploratory Operations, etc. 
Bevan and others have employed it extensively with success in opera- 
tions 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 complete 
relaxation is often 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 children, the 
mask and formidable appearing apparatus frequently cause so much 
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 with 
goiter, enlarged tonsils, or adenoids. In operations about the rectum 
and perineum, it is sometimes not very satisfactory, as the patient may 
stiffen up or straighten out the limbs, thus interfering with the operator. 
The same may be said of its use in alcoholics, or strong, robust, or fat 
individuals, though, according to Gwathmey, by preliminary medica- 
tion with morphin alone, or with morphin and chloretone, or mor- 
phin 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 Hewitt's 
Gwathmey's, Bennett's (Fig. i8), etc. In general, these consist of 
a metal mask with a pneumatic rubber rim that fits the face 
accurately so as to preclude air, a gas chamber with inspiratory 
and expiratory valves or openings, and, attached to the gas chamber, 



NITROUS OXID ANESTHESIA. 4I 

a rubber balloon connected by rubber tubing with the nitrous oxid 
cylinder. With such apparatus, air may be admitted through the open- 
ings provided for that purpose or the inhaler may be removed eveiy 
two to five inspirations, allowing the patient to get a supply of pure 




and oxygen inhaler. 



air. Oxygen may likewise be administered by passing the oxygen 
tube under the rim of the mask. 

When a definite amount of oxygen is to be given, a special appara- 
tus, as that of Hewitt (Fig. 19) or Gwathmey (Fig. 20), is essential. 



43 



THE ADIONISTEATION OF GENERAL ANESTHETICS. 



In the latter, the gas is warmed by passing through a metal coil sur- 
rounded by hot water and any desired combinadon of nitrous oxid 
gas and oxygen may be obtained by reguladng special switches, which 
axe provided with indicators showing the exact strength of the vapor 
which the patient receives. 

As with all inhalers, the metal parts should be boiled and the rubbers 
sterilized in a solution of i to 20 carbolic acid after use. Before using, 
the apparatus should always be tested to see that it works properly. 




Fro. 10. — Gwathmey'a 



s oxid gas and oxygen inhaler 



Administration. — In giving pure nitrous oxid, the apparatus is 
properly connected with the supply cylinder, and the rubber balloon 
is about three-fourths filled with gas. In turning the gas on it should 
be done slowly, as, at times, when suddenly released, it escapes from 
the cylinder 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 no air can be drawn in around the rubber rim. The 
expiratory valve is opened and the patient is told to breathe regularly. 
After two or three breaths of air, during which the patient becomes 
accustomed to the apparatus, the gas is allowed to enter the mask by 
opemng the proper stopcock. The patient thus breathes in pure 



NITROUS OXID ANESTHESIA. 



43 



nitrous oxid and expires nitrous oxid and air, so that lie constantly 
receives more nitrous ozid into the lungs. 

The first few inspirations of pure 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 a 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 anesthetic cannot be continued beyond this point 
without danger of asphyxiation. If the mask is removed, there is still a 




period of surgical anesthesia, lasting about a minute. This is soon 
followed by a reactionary redness or blush about the face, and a return 
to normal breathing. By reapplying the mask before the patient 
entirely comes out, and administering more nitrous oxid, the anesthesia 
may be prolonged nearly an hour, provided sufficient air is admitted 
to avoid extreme cyanosis, stertor, and muscular twitchings, and yet 
not so much as to keep the patient insufficiently anesthelized. This 
may be accomplished by allowing two lo five breaths of nitrous oxid 
to one of air, or the air may be administered in combination with the 
nitrous oxid through the opening provided on the inhaler for that pur- 
pose. A slight duskiness of the countenance, moderate snoring, and 
regular respiration should be aimed at. 



44 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

Administered with oxygen, the freedom from symptoms of as- 
phyxia is complete. 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 (2 to 3 per cent.) it may be increased to from 5 to 
10 per cent., or more, depending upon the case. Enough oxygen should 
always be given to prevent cyanosis without detracting from the anes- 
thetic effects of the nitrous oxid. 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. 
Recovery is rapid and is usually unaccompanied by any impleasant 
after-effects. 

NITROUS 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 anesthesia as 
are ordinarily encountered when straight ether is administered from the 
start. A combination of gas and ether carries a patient into a stage of 
surgical anesthesia very rapidly — ^usually in about one to three 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 is safer than ether given alone by the 
open or semiopen inhalers, probably because the stage of excitement 
is absent, and, in the second place, 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. 22), Gwathmey's (Fig. 23), 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 
have an ether chamber containing gauze upon which the ether is poured. 



NITEOUS OXID A2ro ETHER SEQUENCE. 



45 



They are arranged so tliat gas is first administered in the usual way, 
and then by slowly revolving a drum the ether chamber is gradually 
opened, the quantity of gas at the same time being correspondingly 
diminished, until finally the patient receives full strength ether vapor. 




Fic 13. — The Bennett gas and elher apparati 



In the Bennett apparatus the gas bag is removed as soon as the patient 
is well under the nitrous oxid, and a second bag is substituted; with the 
Gwathmey inhaler, this is improved upon, and but one bag is used for 




Fig 3j — Gwathmei s gas and ether apparatus. 

both gas and ether. As with all apparatus ha\-ing mechanism likely 
to get out of order, the inhalers should always be tested before using. 
The same inhaler should never be taken from one person (o another 
without sterilization. 



46 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

Administration. — ^The apparatus is properly connected and the 
gauze in the ether chamber is well satm^ted with ether. The mask is 
applied to the face so that it fits snugly, and the patient is instructed 
to breathe naturally. As soon as it is seen that the patient is breathing 
properly, the expiratory valve is opened and the nitrous oxid is turned 
on. After a few breaths the expiratory valve is closed and the patient 
breathes the gas back and forth, gradually going imder its influence, 
which is denoted by duskiness of color, irregular snoring respiration, 
and muscular twitching. 

The addition of ether vapor is now commenced by rotating the ether 
chamber slowly. A small amount of ether is administered at first, and 
this is gradually increased until the patient is getting the full strength 
of ether. During this period, if symptoms of asph)rxia from the gas 
appear, small quantities of air should be admitted from time to time 
through the air valve, but not in such amount as to allow the patient 
to come out. As soon as anesthesia is well established, which usually 
takes less than two minutes, the gas is discontinued and the adminis- 
tration of the ether is proceeded with in the usual way when using a 
closed cone. 

In giving a combination of gas and ether, care must be taken to 
turn the ether on rather slowly at first. If the patient commences to 
cough and hold his breath, the ether should be turned on less rapidly, or 
entirely stopped, until regular breathing is again established. If 
administered properly, the patient goes under the anesthetic with sur- 
prising quickness, without any discomfort or struggling, and, after 
anesthesia is once established, but little anesthetic is required to main- 
tain it. Some duskiness of countenance and cyanosis are to be expected 
from the nitrous oxid, and the constant rebreathing of the same vapor, 
but this may be controlled by a careful regulation of the air valves. 

ETHYL CHLORID ANESTHESIA. 

Ethyl chlorid is a colorless, very volatile and inflammable liquid. 
If pure, it has an ethereal odor, and should not be acid to litmus. For 
general anesthetic purposes the purest quality of the drug should be 
used, and only that labelled "for general anesthesia." This can be 
obtained in containers furnished with a spring stopcock, which permits 
the drug to be administered in a fine stream in any desired quantity 
(Fig. 24), or in hermetically sealed glass tubes containing about i 1/2 
drams (5 c.c.) of the drug. The latter is best suited for the closed 
inhalers, the whole amount being emptied into the inhaler at once. 



ETHYL CHLOBU) ANESTHESIA. 47 

Ethyl chlorid is decomposed by light and air, hence it should be kept 
in a dark place and La tightly stopped tubes. 

When inhaled, it is very rapidly absorbed and is quickly eliminated, 
anesthesia being produced in from thirty seconds to a minute or so, 
and lasting two to three minutes after the withdrawal of the anesthetic. 
Recovery is not quite so rapid as with nitrous oxid, and after effects, 
such as headache, nausea, vomiting, and dizziness are not at all uncom- 
mon. It is not nearly so safe as nitrous oxid, nor so pleasant an anes- 



FiG. 24.- — Ethyl chlorid tube. 

thetic to take. It has the advantage, however, of not producing cya- 
nosis, and the anesthetic effects are more prolonged; furthermore, it 
can be administered without special apparatus. It stimulates both 
the heart and respiration, increasing the rate and the depth of the latter, 
but it lowers blood pressure through dilatadon of the peripheral vessels. 
Suitable Cases. — Ethyl chlorid is employed mainly for brief opera- 
tions or for examinations not requiring full muscular relaxation, and as 
a preliminary to ether to get the patient under rapidly without strug- 




FiG. 25. — Showing the Schiramelbusch mask covered wiih game and oil silk for the ad- 
minislmtion of ethyl chlond 

gling and excitement. It acts especially well in children or infants on 
account of its rapidity of action It should never be immediately 
followed by chloroform, as both are circulatory depressants. Its use 
is contraindicated when there is any respiratory obstruction. 

Apparattis. — Owing to its great volatility, ethyl chiorid is most 
satisfactorily given by means of a closed inhaler, though the semi- 
open method may be employed, and is preferred by many as being 
safer. For the latter, one may employ an Esmarch or Schimmelbusch 



48 THE ADUINISTKATION OF GENERAL ANESTHETICS. 

mask, over the gauze of which is placed some impervious material, 
as oil silk or rubber tissue, with only a small opening through which the 
drug is sprayed (Fig. 25) ; or an AJlis inhaler may be used, leaving only 
a small opening in the top Any of the ordinary closed inhalers can be 
utilized for administenng ethyl chlorid by simply spraying the drug 
into the ether bag 

There are a number of special inhalers, however, devised especially 
for this drug and similar anesthetics. Ware's inhaler (Fig. 26) con- 
sists of a pliable rubber mouth-piece, to the 
top of which is fitted a metal 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 bal- 
loon. The balloon is attached to the 
mouth-piece by a T-shaped chamber which 
IS provided with a valve and a small open- 
ing through which the anesthetic may be 
sprayed. 

nu. 30. — ware s eiDvi cniona .j... . ■• i.- . i, 

j^jjjiigj Admmistration. — In administenng ethyl 

chlorid by the closed method, the inhaler 
is placed over the patient's face during expiration in order to fill the 
bag, and, as soon as the patient is breathing regularly, from about 
I to I 1/2 dr. (3 to 5 c.c.) of ethyl chlorid are sprayed into the 
bag, or, if a special inhaler is used, into the opening proWded for the 
purpose. If the face-piece be tightly applied, so as to prevent the en- 
trance of air, signs of anesthesia appear in from thirty seconds to one 
minute. As soon as anesthesia is produced, the patient should be 
allowed to have air. 

Full anesthesia is characterized by rapid and slightly stertorous 
breathing, dilated pupils, absence of conjunctival reflexes, 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 with, 
or else ether is substituted. Should the patient recover too rapidly, more 
anesthetic should be given, provided a plentiful supply of air is al- 
lowed. By an interrupted administration of ethyl chlorid — that is, 
first securing deep narcosis and then giving air— a light anesthesia may 
be maintained for some time, though at times muscular relaxation is 




ANESTHETIC MIXTURES. 49 

not obtained and the patient is apt to remain partly conscious. 
Danger 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 
drug will be necessary, and somewhat more time will be consumed in 
getting the patient under than with the closed method. The mask is 
placed over the face, air being excluded as far as possible by surround- 
ing it with a towel, and the drug is simply sprayed upon the inhaler in a 
steady stream until anesthesia is produced. 

AIIESTHETIC MIXTURES. 

The addition of ether, alcohol, and other drugs to chloroform has 
been extensively practised for the purpose of modifying the action and 
avoiding the dangers of the latter. There are a large number of such 
mixtures, varying both in composition and in the relative proportion 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. 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. 
4 



50 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

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 
dangerous drug they contain. 

Suitable Cases. — When nitrous oxid or ether are considered inad- 
visable, a mixture of chloroform and ether is the next choice. Thus 
in children and in persons over sixty, in the fat and plethoric, in cases 
suffering from 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 operations 
mixtures are most useful. Being agreeable to take, they are often 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, pre\iously described (see page 36), 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 recum- 
bent position. The inhalation is begun gradually with the admixture 
of plenty of air. Small quantities of the anesthetic frequently 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 stimulant action 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 ANESTHESIA. 

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 



INTUBATION ANESTHESIA. 



51 



Crile's method, will be found of great semce. The advantages are 
that the anesthetist and inhaler are removed from the seat of operation 
so that they in no way interfere with the operator, and the anesthetic 
can be administered continuously, as it is not necessary to delay or stop 
the operation eveiy little while 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 coughing or 
vomiting up of blood that may have collected in 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 




Fio. 27. — Showing the melhcKl u! 



nR Ihe jiharyiut for inluhn- 



(20 cm.) long, preferably cut al ihcir distal ends ai an acuie angle, and 
furnished with side openings. The upper ends of the tubes are 
connected to the two arms of a Y-shaped glass lube, to the long arm 
of which isaltached by means of a ihird piece of rubber tubing a funnel 
lighlly 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, arc carefully 
passed through the narcs and down to the epiglottis with their ]>ointed 
ends directed downward and forward. The tongue is then drawn well 
forward and the whole pharynx is hrmly packed with a single piece of 



52 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

gauze in such a way that the packing does not obstruct the lateral 
fenestrae or ends of the tubes (Fig. 27). Care 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. 

Anesthesia Through a Tracheal Opening. — In some operations 
upon the tongue, larynx, or pharynx it becomes necessary to administer 
the anesthetic through an opening in the trachea. 

Apparatus. — For this purpose a Hahn or Trendelenburg cannula 
is employed. These instruments consist essentially of a metal funnel. 




Fig. 28. — The Trendelenburg apparatus for tracheal anesthesia. 

covered or filled with gauze upon which the anesthetic is dropped, and 
connected with a special tracheotomy tube by means of a piece of tub- 
ing. The tracheal tube of the Hahn apparatus is 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 with the Trendelenburg instru- 
ment (Fig. 28) by surrounding the lower portion of the cannula with a 
delicate air bag, which, as soon as the tube is in place, is gently inflated 
by compressing an inflating bulb supplied with the apparatus. 

Technic. — A preliminary tracheotomy is first performed (see page 
392). The tracheal tube is then introduced into the opening, care 
being taken to see that the tamponage is effective, so as to prevent 
blood from entering the trachea. The tube to convey the anesthetic 
vapor from the funnel is then attached to the tracheal cannula, and the 



RECTAL ANESTHESIA. 53 

anesthetic is administered by dropping chloroform on the gauze of the 
inhaler. 

Rectal Anesthesia. — It consists in producing narcosis by means of 
warm ether vapor slowly forced into the rectum. This method was 
employed in 1847 by Roux. Later, in 1884, it was taken up by 
Mollifere and in this country by Dr. Weir and Dr. Bull, but it never 
came into general use. In the early cases colicky pains, diarrhea, 
bloody stools, and painful distention of the intestine were frequently 
observed. These s)rmptoms, no doubt, were in many instances due 
to faulty methods of administering the anesthetic, and with the im- 
proved technic of Cunningham the method has given better results. 




Fio. 39. — Showing the tracheal cannula 



Though it cannot be said to be free from risks, rectal anesthesia has 
a definite place among the methods of anesthetizing at our disposal. 
Its greatest field of usefulness is in cases of extreme pulmonary or bron- 
chial 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 ether. While 
it is true that the greater part of the ether is eliminated from the lungs, 
the direct irritation of concentrated vapor is overcome, as is shown 
by the absence of the bronchial secretion, cough, etc. It has the ad- 
vantage of requiring but little ether to induce and maintain anesthe- 
sia, and there is practically no stage of excitement or postoperative 
nausea and vomiting. On the other hand, the induction of narcosis is 
slow, and, in some cases where the absorptive power of the rectum is 
very limited, enough of the drug is not taken into the system to keep the 
patient under, so that other means of anesthetizing must be utilized. 



54 THE ADMINISTKATION OF GENERAL ANESTHETICS, 

It is not a suitable method to employ in abdominal operations on ac- 
count of the distention produced, nor should it be used if the intestines 
are inflamed or the walls of the intestines weakened. 

Apparatus. — The necessary apparatus consists of the following: 
A wash bottle to hold the ether, about 8 inches (20 cm.) high and 4 
inches (10 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 efiferent tube is connected a piece of rubber tubing leading 
to a plain rectal tube, a glass bulb being interposed between the rectal 




Fic. 30. — Apparatus for rectal anesthesia. 

tube and the rubber tubing to catch any condensed ether vapor and 
prevent it from entering the rectum. 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 90° F. , but not much above, as the ether 
will boil at about 95° F. A' thermometer should be provided for the 
purpose of regulating the temperature. By compressing the cautery 
bulb air is forced into ihe ether through the long tube and leaves the 
apparatus saturated with warm ether vapor. 

Preparation of the Patient. — A thorough cleansing of the bowels is 
absolutely necessary, otherwise absorption cannot take place and the 



SCOPOLAMIN-MORPHIN ANESTHESIA. 55 

first essential of the anesthesia is defeated. A cathartic is given to the 
patient the night before the operation, and on the morning of tlie 
operation a colonic irrigation, followed by an ordinary soapsuds enema 
an hour before the operation, complete the preparations. 

Technic. — The patient lies upon the table with one thigh elevated 
upon a sand-bag so as to aflford 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 about 8 to lo 
inches (20 to 25 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 forefinger should be 
inserted alongside the tube into the bowel to permit the gases already 
present to escape, otherwise the absorption of the vapor is interfered 
with; on complaints of distention, the superfluous vapor must, like- 
wise, be allowed to escape. 

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 finally 
slightly stertorous, and the patient then passes into complete surgical 
narcosis, generally without the preliminary stage of excitement. The 
time necessary for this varies from five to fifteen minutes, according to 
the patient and the absorption power of the boweh The anesthetic can- 
not be pushed, however, for the more the bowel is distended beyond a 
certain point the less is the absorption. As soon as anesthesia is com- 
plete it may be maintained by gently squeezing the bulb every minute 
or so. The same signs as to the depth of anesthesia, condition of the 
patient, etc., should guide the anesthetist as in the administration of 
pulmonary anesthesia, and the same precautions about keeping the 
tongue and the jaw forward should be observed. At the completion 
of the anesthesia, the rectal tube is disconnected from the apparatus, 
and, by gentle abdominal massage of the colon, the vapor remaining 
unabsorbed is forced out. This should be followed by a cleansing 
enema. 

ScopoIamin»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 pro- 
duce anesthesia. From the number of deaths reported from this 
combination when used in large enough quantities to produce anesthe- 
sia unaided, it would appear to be a very dangerous form of anesthesia, 
and up to the present time it has a higher death percentage than chloro- 



56 THE ADmNISTRATION OF GENERAL ANESTHETICS. 

form 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. i/ioo 
(0.00065 gm.) and morphin, gr. 1/6 to 1/4 (0.0108 to 0.0162 gm.) 
by h)rpodermic, one hour to two hours before operation. This com- 
bination 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 pulmonary edema. In the 
young and the aged hyoscin and morphin should be used with great 
caution. 

ACCIDENTS DURING ANESTHESIA AND THEIR TREATHENT. 

The accidents and dangers that may arise during the administra- 
tion of anesthetics are connected with the respiratory or circulatory 
systems and include asph)rxiation, respiratory paralysis, and cardiac 
paralysis. Theoretically, the dangers of nitrous oxid, ether, and ethyl 
chlorid are those to be expected from failure of the respiratory centers, 
while the accidents from chloroform narcosis are primarily those occur- 
ring as the result of the depressing effects of the drug upon the circula- 
tion. Practically, however, in severe cases failure of the respiratory 
centers 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 proper 
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 



ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT. 57 

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 dangerous, state of narcosis. 

Asphyxiation. — ^Asphyxiation indicates that there is some inter- 
ference with the amoimt of oxygen the patient is receiving. 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 pro- 
gressively 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 
** forgetfuliiess to breathe," falling back of the tongue and epiglottis, 
obstruction to the air passages by blood, mucus, saliva, or foreign 
bodies, partial or complete occlusion of the nose from deformities of the 
bones and nasal growths, or from collapse and falling in of the ate nasi 
during inspiration under deep narcosis. 

Treatment. — Cyanosis due to coughing or struggling may be over- 
come by simply removing the inhaler and permitting the patient 
to get a breath of fresh air. When the position of the patient is re- 
sponsible, it should be corrected without delay. If the cyanosis be due 
to obstruction or partial occlusion of the nares, the mouth should be 
kept sufficiently open by means of a mouth-gag to permit the entrance 
of the necessary amount of air. "Forgetting to breathe" is 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 momentary compression 
of the sternum is frequently all that is necessary. Failing by these 
means, the jaws should be held apart and rhythmic traction exerted 
upon the tongue to excite a reflex inspiration. 

Obstruction caused by the falling back of the tongue and epiglottis 
is corrected by properly holding the lower jaw forward (Fig. 31), or by 
traction upon the tongue by means of tongue forceps or a silk 
ligature. The most effective means for overcoming obstruction from 
this cause is to pass the index finger into the mouth over the base of 
the tongue and hook it forward together with the epiglottis (Fig. 32). 

When the asphyxial symptoms are due to obstruction by collec- 



58 THE ADMINISTRATION OF GENEKAL ASESTHETICS. 

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 
cleaned. Solid bodies may be removed by the finger or forceps. 
If this is not possible, tracheotomy (page 392) should be perfonned 
without hesitation. 




Fig 31. — Method ot holding Ihe jaw forward. 



In any case of asphyxia, if the cyanosis is severe and grows progress- 
ively worse in spite of the above line of treatment, the anesthetic and the 
operation should be discontinued while artificial respiration, combined 
with inhalations of oxygen, is carried out. This is most effectively 
performed by a combination of the Sylvester and Howard methods. 
Any of the methods of ardficial respiration are useless, however, as 
long as there is any obstruction in the air passages, and these should 
always be first cleared out, as previously directed. 




Fig. 32. — Showing the melhod ()f drawing-the tongue and epiglottis forward. 



Artificial respiration is carried out as follows: The footof theoperat- 
ing-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 



ACCIDENTS DDKING ANESTHESIA AND THEIS TREATMENT. 



59 



above the bead (Fig. $^). This thoroughly expands the chest and 
produces an inspiration. The arms are maintained in this positioa 
for a second or two, to allow the air to thoroughly expand the lungs. 
Expiration is produced by the reversal of the above maneuver, bring- 




Fig. 3^. — Artificial respnradon (inspiration). Note the as^stant's hands ready to make 
anintetptessure over the lower portion of the chest. 




Pic. 34- — Artificial respiration (eipiratii 
against the chest while the 



The operator hnngs the paiieni s , 
makes counterpressure 






ing the arms downward with firm pressure against the chest wall, 
while at the same time an assistant, with palmsof the hands outstretched 
over the margins of the ribs and epigastrium, presses upward toward 
the diaphragm (Fig. 34). This counterpressure prevents the effects 



6o THE 



ixz^an^ii 



cc 'Jut grpcajGry 't».ii^ ^i^^ ^cns Ibec ipatr lae: <*a»|Aii*f™ and abdomi- 
nal Tscera. Atjc arnrttT scmmt or so. ihe assEiant suddenly 
reieaaes :fK lower porior ct ±e d&csc azad ai die same dme 
deTarSoQ. oc ±e ars&s s uizx persarmed. H&t m t yimi ents produdng 
arrfnrTaJ rcs^xrar^oc vry^Hff be Tia*-V is sear as possbfe to die rate of 
nnrnial rcsocr^^Gii. czrtaizlj ax o*R=r immr w doaes a minate. As an 
^Tzncz :o ±e a^bo?^. fordbie fpiamriinn oc dfet spmnmr ani may be 
perirjcssufi z*-jc ±e: pcrpose oc eufv-r g rrriri OKpcradon. 

A faTocLbte response jo treanseirr s Arraicrd fa^ a gndial return 
oc :^ zarzral coior. a: 5rsc Dcebue gasps aad:!xxis«i€iiscratianpts at 
respcradoc a=ii a return oc ±e pdse a: :be vcisz. li. after five or ten 
mirrrf^ ±ere 5^ 3»> respoctse ^ the rearmeai. dae prognosis is exceed- 
oisfr bad. b^ir ±e ar=5csal respcrarSac sbocjd be p o bfeted in for at least 
lalf as. z«xx. IXeairfi^ from aspciyssa akxie d^amg anesdicsia can be 
zxrtritsrjui in rzearix aH cases br coQawiue die scnesdoos and the tzeat- 
nienr ab^yye descrEbed. 

Respiratory Ratfalrsis. — ^Tlus is a more doiocs conditioD. In the 
ir^ scales oc anescbesa h may be d:2e to a spajsn of the glottis, dia- 
parzzrr.. and respiratorr m*.2§cles rhroc^ redex irritatioQ £nom over- 
srfm-^aiioc. oc ±.e nasal bcarEches of the trigemfnal nerve, when large 
ct^andtxs oc ether are soddenhr pocred ::poQ the inhaler or the strength 
oc^edmz is too rapidly increased. The pat5enr suddenly stops breath- 
fsir and becomes cyaaosed, but the puptHary reactioa remains and the 
p».:Lse Is usually good : and. if artificial resptration be prompdy performed, 
tie d^zL^er is overcome. 

When the condition occurs in the later simcs, after deep narcosis, 
ft h the result of too much anesthetic, psrodudng paralysis of the 
medullary centers, and is a more dangerous coodidon. The pupils 
suddenly dilate and fai! to respond to light, and the ocmiunctival reflex 
'A lost; the respirations become progressi\eIy weaker and more super- 
ncial. znd nnally stop. The heart also ceases to beat after a few 
seconds, the patient has an ashen-gray look, and lies in a state of ex- 
treme relaxatJon. 

TreatmenC^^This is a condition revjuiring prompt and energetic 
treatment. The anesthetic and ±e x>peration should be immediately 
stopped and every effort made :o reW^n? the patient. It should be seen 
that there is no impediment to the free entrance of air into the respira- 
v>ry passages, and then the foot of the table should be ele%-ated upon a 
stool, while artificial respiration is performed after the manner above 
described Daae ^8^ 

Cardiac Paralysis. — Syncope may occur during anesthesia from 



ACXIDENTS DURING ANESTHESIA AND THEIR TREATMENT. 6 1 

chloroform or ether, but is more apt to be produced from the former. 
It is the most serious of all the anesthetic accidents. From the fact that 
a great proportion of the deaths from chloroform anesthesia occur in 
the early stages, when only a small quantity of the anesthetic has been 
given, it has been contended that fright, producing vasomotor paraly- 
sis, is the cause. There is no doubt that fright or struggling 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 over-dosage. 

When circulatory paralysis occurs, the pulse first becomes weak and 
irregular, and then feeble and fluttering; the skin becomes pallid, 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 examination reveals a heart 
dilated and overcharged with blood, and general dilatation of the 
capillaries and veins, especially in the abdomen, so that the patient 
has practically bled into his own vessels, and nearly all the blood is 
^^^thdrawn from the cerebral centers. 

Treatment. — The treatment of such a condition should consist in 
artificial respiration and in adopting means to overcome the cerebral 
anemia and to empty the engorged heart. In the presence of signs 
pointing to syncope, the treatment should be instituted promptly, 
without waiting for cessation of respiration. The foot of the table 
should be immediately elevated to an angle of 45 degrees, so that the 
patient is in an exaggerated Trendelenburg position. Children may 
be inverted by simply holding them by the heels. Combined with 
position, compression of the limbs and abdomen by means of bandages 
may be employed to force the blood from the dilated capillaries and 
splanchnic areas. Artificial respiration and oxygen inhalations 
should be employed from the start, as already described. Massage 
of the heart for the purpose of emptying it of the engorged blood should 
also be practised. 

External cardiac massage can be readily carried out with the hand 
placed over the precordium by elevating and depressing the wrist- joint at 
about the rate of the normal beat. In abdominal operations the heart 



62 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

may be massaged by grasping it between the thumb and forefinger, 
through the relaxed diaphragm, and alternately compressing and 
relaxing it twenty to forty times a minute. Direct cardiac massage 
can be practised through an incision in the fourth intercostal space 
and opening the pericardium. This operation 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 2on]^ (o. 30 to i . 25 c.c.) injected into a 
vein, camphorated oil, 20TrL (1.25 c.c), whisky, 2ottl (1.25 c.c), etc., 
may be tried with better chances of success. An intravenous infusion 
of hot salt solution, combined with 15 to 3017^ (0.92 to 1.9 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 infusion of adrenalin in salt solution 
injected toward the heart (see page 137) 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 complication. 
The best way to avoid it is by careful preparation of the patient before 
anesthesia and a skilful administration of the anesthetic. In some 
cases, however, it occurs in spite of all that can be done, and may be 
persistent. That from chloroform is usually more severe and more 
diflicult 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. 
(0.97 to 1.3 gm.) of bicarbonate of soda in a glass of warm water 
is also recommended. Cerium oxalate, gr. v (0.324 gm.), bismuth 
subnitrate, gr. v (0.324 gm.), acetanilid in i gr. (0.065 gm.) doses 
every one -half hour until 8 gr. (0.52 gm.) have been taken, morphin, 
or small doses [1/12 gr. (0.0054 gm.)] of cocain every half hour 
up to I gr. (0.065 gJ^O ^^y be used in the more troublesome cases. If 
the condition becomes persistent and severe, lavage of the stomach 



THE AFTER-EFFECTS OF ANESTHESIA. 63 

(see page 457) should be carried out and repeated as often as neces- 
sary. In fact, it is the best means of preventing vomiting in any case, 
and some surgeons employ it as a routine, having it performed 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, bronchitis, 
bronchopneumonia, and lobar pneumonia. They should be treated 
along the lines ordinarily followed in such cases. Lung complications 
are especially liable to follow anesthesia where a diseased condition 
is already present, as in those suflFering from bronchitis, emphysema, 
or tuberculosis, 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- 
ratus employed for administering the anesthetic should not be carried 
from one patient to another without sterilization, .and due care should 
be observed while administering the anesthetic to prevent aspiration 
of fluids or vomitus. As a further precautionary measure, the patient 
should always be carefully protected against chilling, both during the 
anesthesia and while he is being removed to his bed. 

Renal Complications. — Temporary albuminuria and casts are not 
uncommon after both ether and chloroform, and, if a diseased condi- 
tion of the kidneys be present beforehand, it is much aggravated,though 
of the two drugs chloroform exerts a less irritant action. Scanty 
excretion of urine with actual suppression and hematuria are occasion- 
ally seen. Such a condition should be treated by mild diuretics, cathar- 
tics, and saline rectal irrigations. Glycosuria has been observed as 
a complication after nitrous oxid anesthesia. 

Postoperative Anesthetic Paralyses. — These are mostly per- 
ipheral from pressure upon some nerve during the period of unconscious- 
ness, though paralysis of central origin may take place as the result of 
cerebral embolism or hemorrhage, especially in those with high 
arterial tension and degenerative changes in the blood-vessels. Per- 
ipheral paralysis may affect the arm, leg, or face. Injury to the musculo- 
spiral nerve from pressure by the edge of the table if the arm is allowed 
to hang down, and injury to the brachial plexus from pressure between 
the clavicle and first rib, or by the head of the humerus when the arms 
are fastened above the head are the most frequent lesions. 

Delayed Poisoning. — Certain of the late deaths occurring after 
anesthesia, that were formerly supposed to be due to sepsis, shock, fat 
embolism, etc., are now known to be due to an acid intoxication. This 
condition, variously designated as cholemia, acidosis, acetonuria, and 



64 THE ADMINISTRATION OF GENERAL ANESTHETICS. 

acid intoxication, most frequently follows chloroform narcosis and 
especially among children. The symptoms do not appear until the 
patient has recovered from the anesthesia, developing 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, convulsions, 
and coma. In some the temperature is exceedingly high (up to 108 
degrees), 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 solu- 
tion by rectum, by hypodermoclysis, or intravenously in the severer 
ones, seems the most valuable remedy in this condition. For intra- 
venous injection i 1/2 ounces (47 gm.) of bicarbonate of soda is 
dissolved in i quart (liter) of normal salt solution [salt 3ii (7-8 gm.) 
to the quart (946 c.c.) of water], and 1/2 pint (236 c.c.) is admin- 
istered every three or four hours until the entire amount is injected. 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 
blankets. During the process of mo\ang, care should be taken not to 
elevate the head or chest. The recovery room should be well venti- 
lated, 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, which are to be removed, however, when the patient 
is received, unless there is some special indication for their use, as in 
shock or collapse. If used, hot-water bags should always be covered 
with flannel and care should be taken to see that they are not hot enough 
to bum the patient. 

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 



THE AFTEK-TILEATMENT OF CASES OF GENERAL ANESTHESIA. 65 

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 can be practised if the patient is conscious, and 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. De- 




FiG. 35.— The ether bed. 



lirious patients should be gently restrained, but not tied in bed. In- 
halations of oxygen or vinegar, and washing the patient's face in cold 
water, are of aid in arousing to consciousness. 

The patient should not be allowed to sit up for at least six hours. 
Small quantities of warm water or cracked ice are given in the first 
few hours, but no food is allowed within six hours. In cases of 
collapse, or in patients who are very weak, nutrient or stimulating 
enemata may be given to sustain the patient until food can be taken. 
The first food taken by mouth should be liquid in character, con- 
sisting of broth, beef tea, or soup. If this is retained, other articles 
of soft diet should be added, until the ordinary diet is being taken. 
It is important to have the urine examined for several days after 
anesthesia, and after the use of chloroform special reference should 
be paid 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 anesthesia, but usage 
has so perpetuated the term "local anesthesia" that it will be employed 
in these pages. The introduction of cocain by Roller, in 1884, first 
made possible local anesthesia as it is employed at the present time, 
compression 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 previously. A further impetus 
was given to the development of local anesthesia by the discovery that 
infiltration with cocain, or similar anesthetic agents, into or around a 
nerve trunk in any part of its course effectually blocTted the sensation 
in the region supplied by that particular nerve, peripheral 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 the last few 
years 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 now performed under general narcosis could be as 
satisfactorily carried out under local anesthesia intelligently used. 

In the choice between local and general anesthesia in any given 
case, the question to be decided is whether under local anesthesia pain 
sensibility can be entirely abolished and, at the same time, suflScient 
muscular relaxation be obtained to insure the proper performance of 
the necessary procedures contemplated. If these conditions can be 
satisfactorily obtained, and if the operator possess the necessary ex- 
perience 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 un- 
pleasant after-effects of general narcosis, and to obtain a less disturbed 
and more rapid recovery, regardless of whether the particular operation 
be classified as a major or a minor one. 

66 



ADVANTAGES AND DISADVANTAGES OF LOCAL ANESTHESIA. 67 

Advantages and Disadvantages of Local Anesthesia. — ^There are, 
however, certain advantages in local anesthesia that should not be lost 
sight of. Most important is the absolute safety to the life of the 
patient when this form of anesthesia is employed with proper precau- 
tions. With the substitution of the weak for the old-time strong solu- 
tions, and with a knowledge of the limit of the amount of cocain that 
can be safely used, the dangers of cocain poisoning may be disregarded. 

Again, under local anesthesia, shock is lessened, and the depression 
observed after the use of general narcosis is absent to a marked degree, 
so that local anesthesia becomes the method of choice when an anes- 
thetic is required for those in collapse or with lowered vitality. This is 
especially true when the nerve-blocking method is employed, for it is 
well known that cocain injected into a nerve effectuaUy blocks the 
passage of all shock-producing impulses along that particular nerve. 
As Crile puts it: "As no impulses of any kind can pass either 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 established that the injec- 
tion of cocain into nerve trunks supplying a given region of operation is 
frequently performed for the purpose of preventing shock even where 
general anesthesia is employed, as, for example, the preliminary block- 
ing of the sciatic nerve in hip amputations. 

Under local anesthesia the postoperative blood changes and the 
kidney, heart, and lung complications are all avoided, while the 
unpleasant after effects that pertain to general anesthesia are reduced 
to a miminum. The avoidance of vomiting is especially important 
for the proper healing of the wounds, and the prevention of such com- 
plications as hernia recurrence. 

Under local anesthesia the most favorable conditions for primary 
union are present, for, as gentleness in handling tissues is essential 
for the successful employment of this method of anesthesia, the 
minimum amount of trauma is inflicted upon the tissues. 

Another advantage connected with an operation under local anes- 
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 ha\ing 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 



68 LOCAL ANESTHESIA. 

contraindication, depending upon the control the operator has over 
his patient. 

There is no doubt that it requires more time to operate under local 
than under general anesthesia, and that it necessitates the possession 
of patience and tact upon the part of the operator. 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 procedure that will prevent cocain and 
the local analgesics from gaining ascendency in the crowded amphi- 
theaters of popular teachers where quick and brilliant work is expected 
by an impatient audience." This inconvenience to which the operator 
is subjected, coupled with the general imfamiliarity 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 precedures, such as the 
incision of an abscess, exploratory puncture, removing small cysts, 
amputating toes or fingers, performing circumcisions, etc., major opera- 
tions of any magnitude and extent may be performed, provided the 
region is capable of being anesthetized by infiltration or nerve blocking. 

For the removal of practically all benign growths and isolated glands, 
local anesthesia is quite sufficient. Th)rroidectomy is now largely 
done under infiltration anesthesia, with perfect success; and the 
avoidance of a general anesthetic in this operation has, in a great 
measure, contributed to the reduction in the mortality. In the exten- 
sive dissection necessary for the removal of malignant growths or long 
chains of matted glands, however, local anesthesia is not indicated, as 
the limits of the disease are not well defined when the tissues are swollen 
by the infiltrated fluid. 

Amputations of any of the limbs may be performed if the large 
sensory nerves are properly blocked. By means of a preliminary co- 
cainization of the sciatic and anterior crural nerves, amputation of the 
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 
procedures and rib resections, may be painlessly performed if the perios- 
teum as well as the more superficial tissues are rendered insensible by 
proper infiltration. Thus fractures of the lower jaw, the clavicle, the 
olecranon, and the patella can readily be operated upon by local 
methods. The latter operation lends itself especially to local anesthesia 



SUITABLE CASES FOR LOCAL ANESTHESIA. 69 

on account of the superficial position of the bone and the scarcity of 
sensory nerves in that region. 

For the majority of abdominal operations local anesthesia is not 
satisfactory. We know that the abdominal organs are insensible to 
pain, but the parietal peritoneum is most sensitive, especially if in- 
flamed. Exploratory operations and procedures, such as colostomy, 
gastrostomy, gastrotomy, simple drainage of the gall-bladder, supra- 
pubic cystotomy, suture of the intestines following typhoid perforation, 
etc., requiring but little intraabdominal manipulation, can be readily 
performed without a general anesthetic; but when extensive manip- 
ulation is required, with the separation of adhesions necessitating more 
or less dragging upon the mesentery, local anesthesia is contraindicated. 
Furthermore, in abdominal surgery complete muscular relaxation is 
often required to secure the necessary wide retraction, and this cannot 
be obtained with local anesthesia. 

Local anesthesia is ideal in the operations for inguinal hernia on 
account of the superficial position of the structures involved and the 
definite position and course of the sensory nerve trunks supplying the 
region of operation. Other forms of hernia can be operated upon 
by employing infiltration alone, but not with the entire satisfaction 
obtained in the inguinal variety. For strangulated hernia of any 
variety, local anesthesia should always be the choice. The additional 
strain of general anesthesia upon these patients frequently produces 
much more depression than they can bear, and, as there is no 
need for haste, abundance of time, if necessary, may be taken in 
attempts at restoration of gut of doubtful vitality, without adding a 
particle to the shock of the operation. 

Tracheotomy, the ligation of blood-vessels, the repair of the per- 
ineum and cervix, etc., and any of the operations about the scrotum, 
as those for castration, varicocele, or hydrocele, are all amenable to 
local anesthesia. Operations about the rectum have been performed 
quite extensively by some operators under local anesthesia, but for 
most of these operations a thorough stretching of the sphincter ani is 
essential, and this cannot be performed painlessly by this method; 
for this reason it is unsuitable in the majority of cases. However, 
simple operative procedures, such as those for fissure, external and 
thrombotic hemorrhoids, and straight uncomplicated fistulae are 
within the scope of local anesthesia. 

By a skilful use of local anesthesia in the hands of one thoroughly 
familiar with the technic of infiltration, nerve blocking, etc., this 
list may be considerably enlarged. Furthermore, it should not be 



70 LOCAL ANESTHESIA. 

forgotten that even in many operations too painful for cocain alone, 
the major portion of the operation may be performed under local 
anesthesia, and then nitrous oxid gas or a small quantity of ether may 
be administered to tide the patient o\'er the more painful procedures, 
thus avoiding a prolonged general narcosis. 

Those cases in which local anesthesia is impracticable have been 
already indicated in a general way. In addition, for young children, 
for those who are greatly excited or hysterical, and for insane or 
delirious indi\iduals, local anesthesia is generally contraindicated, 
or at best it is very unsatisfactory on account of the diflSculty of obtain- 
ing the necessary quietude. 

Methods of Producing Local Anesthesia. — ^At the present time two 
methods of producing local anesthesia are recognized: (i) The use 
of agents which freeze the tissues, and (2) the use of chemical anes- 
thetics 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 
largely have to rely. 

The methods of employing chemical anesthetics may be in turn 
divided into two classes: (i) Where the drug is used in such a way 
that the endings of the sensory nerves are paralyzed (terminal an- 
esthesia); and (2) where the drug k brought in contact with a 
nerve trunk in some part of its course, thereby blocking the sensory 
conductivity of that particular nerve and rendering the area sup- 
plied 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 anes- 
thesia), though by this latter method a mixture of terminal and regional 
anesthesia is often produced; while regional anesthesia may be pro- 
duced by the injection of analgesics into a nerve trunk (endo- 
neural infiltration), aboul a nerve trunk (perineural infiltration), 
or into the subarachnoid space (spinal anesthesia). 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 trunks 
and nerve endings. This method of anesthesia is a combination of 
terminal and regional anesthesia. 

Preparation of the Patient. — The usual preparation of the bowels, 
etc., recommended as preliminary to a general anesthesia, is ad\isable. 
There is no need for the patient to fast, however, and a light meal of 
eggs, coflfee, milk, toast, etc., may be allowed, unless the character of the 



DRUGS EMPLOYED FOR LOCAL ANESTHESIA. . *J1 

operation 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 precautions should 
be taken as for general anesthesia (see page i8). Apprehensive antici- 
pation on the part of the patient should be prevented as far as possible 
by reassurances and by a good night's sleep before the operation. 

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 
allays nervousness on the part of the patient; it somewhat deadens 
sensibility; and it is the physiological antidote for cocain poisoning. 
It may be given hypodermically in the dose of i/6 to 1/4 gr. (0.0108- 
0.0162 gm.) a half hour before operation. In some cases, where the 
I>atient is especially nervous or unusual difficulties are expected, 
morphin 1/4 gr. (0.0162 gm.) combined with i/ioogr. (0.00065 gm.) 
of hyoscin may be administered hypodermically two hours before 
operation. 

Drugs Employed for Local Anesthesia. — Local anesthetics are drugs 
which, even in weak solution, when brought into contact with sensory 
nerves temporarily paralyze them. Of the many local anesthetics 
cocain was the first employed and holds the most important place, 
having successfully stood the test of time. When applied to the un- 
broken 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 complete insensibility in the whole distribution of the nerve 
peripheral to the point of injection. 

The toxicity of cocain 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 injected into the tissues with safety depends upon the strength of the 
solution as well as the method of injection. To be well within the 
limits of safety, not more than 3/4 gr. (0.0486 gm.) of cocain should 
be allowed to remain unconfined in the tissues, nor should this amount 
be exceeded when applied to mucus membranes from which rapid 
absorption takes place. With the weaker cocain solutions (0.2 to o. i 
per cent.) it is rarely necessary to exceed this amount, even in extensive 
operations. Of course, when a large proportion of the solution escapes, 
or when the circulation is impeded by constriction, a larger amount may 
be used with safety. 

In the early history of its development cocain was used in solutions 



72 LOCAL ANESTHESIA. 

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 eflfects, a number of drugs, as eucain B, 
tropacocain, stovain, alypin, novocain, acoin, nirvanin, orthoform, 
anesthesin, etc., which are less toxic but have about the same action as 
cocain, have been introduced as substitutes. Of these, eucain B, 
tropacocain, and novocain are probably most frequently used. These 
newer preparations are preferred by many operators to cocain, and they 
have the advantage that their solutions can be sterilized by boiling. 
Weak solutions of cocain, however, used with proper precautions, the 
writer has always found to be eflScient as well as perfectly safe. 

Preparation of the Solution. — Solutions of cocain should always 
be freshly prepared at the time of operation, as it is well known that 
cocain solutions are prone to decompose, and in a short time such a 
solution becomes capable of producing suppuration. A solution 
isotonic with the fluids of the body, as normal salt solution, is the best 
medium for dissolving the cocain. Such a solution, producing 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 eflScient 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 formula, each tube 
containing 2 4/5 gr. (o. 18 gm.) of sodium chlorid and 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 approximately a i to 500 solution 
of cocain in normal salt solution. 

Solutions of cocain used in the following strength will be found 
amply strong for the purpose for which they are recommended. For 
anesthetizing the skin and for perineural injections, a i to 500 (1/5 of 
I per cent.) solution; for deeper infiltration, a i to 1000 (i/ioof i per 
cent.) solution; for massive infiltration, a i to 3000 (1/30 of i per cent.) 
solution; and for endoneural injections, 10 to 3orr[ (o. 6 to i . 90 c.c.) of 
a I to 200 (1/2 of I per cent.) solution are employed. Schleich has 
three solutions containing a combination of cocain, morphin, and 
sodium chlorid: 

* Parke, Davis & Co., and Squibbs. 



THE CONDUCTION OF THE OPERATION. 



73 





No. I, strong. 


No. 2, medium. 


No. 3, weak. 


Cocain hydrochlor- 


gr. 3 (0.195 gm.) 


gr.ii/2(o.o97gm.) 


gr. 1/6 (0.0108 gm.) 


ate. 








Morphin hydrochlor- 


gr. 2/5 (0.026 gm) 


gr. 2/5 (0.026 gm.) 


gr. 2/5 (0.026 gm.) 


ate. 








Chlorid of sodium, 


gr. 3 (0.195 gm.) 


gr. 3 (0.195 gm.) 


gr. 3 (0.195 gm.) 


Distilled sterilized 


02. 3 2/5 (100 c.c.) 


02. 3 2/5 (100 c.c.) 


oz. 3 2/5 (100 c.c.) 


water. 









The strong solution is used for the skin, perineural injections, 
etc. An ounce (30 c.c.) may be used without risk. Of the medium 
strength solution, used for ordinary infiltration of the tissues below 
the skin, two ounces (^59 c.c.) may be used; while as much as twenty 
ounces (591 c.c.) of the weaker solution, which is employed for massive 
infiltration of large areas, may be safely injected. Tablets according 
to the Schleich formulse 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- 
longing the anesthetic effects. At the same time, by preventing 
capillary oozing, it gives a much drier field of operation. With its use 
there is some danger of secondary hemorrhage if the large blood- 
vessels are not properly secured, since, owing to its styptic action, even 
arteries of some size may be prevented from bleeding at the time and 
so be overlooked. It is a good rule, therefore, to at least clamp any 
v^essel that bleeds, however slightly, when using adrenalin. From five 
to ten 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 Conduction of the Operation. — It may not be out of place at this 
time to say a few words about the proper conduction of an operation 
under local anesthesia. The successful and satisfactory employment 
of local anesthesia depends upon an intelligent appreciation of its 
limitations, upon the experience and skill of the operator, and upon an 
accurate knowledge of the sensory nerv-e supply in any given region 



74 LOCAL ANESTHESIA. 

These are essential. Much also depends upon the temperament of 
the operator and upon his method of operating. For this reason, 
with some operators, the use of local anesthesia will be impossible; 
with others, it will necessitate a radical change in their operative 
technic. A nervous fidgety operator, in a hurry to get through his 
work, will never find much to encourage him in attempts to employ 
local anesthesia in major surgery. 

It is important, in the first place, to make the patient as comfortable 
as possible upon the operating-table. Operations under local anesthe- 
sia consume considerable time, and it is a hardship to keep a con- 
scious patient upon the ordinary hard-topped operating-table for an 
hour or more. Several thicknesses of blanket, an air mattress, or a 
layer of soft pillows placed upon the table, will add much to the 
patient's comfort, as well as to the peace of mind of the operator. 
The patient should always be recumbent, and a comfortable, relaxed 
attitude should be assumed, with the arms folded over the chest or 
clasped above the head. While washing the patient in preparation 
for the operation, it should be borne in mind that the patient is con- 
scious and great gentleness should be employed in the process. Care 
should also be taken not to soak the patient with large quantities of 
solution and leave him lying in a chilly pool fpr the remainder of the 
operation. 

With very nervous individuals, it is well to keep the instruments 
covered from view 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 under local anesthesia. Rough manipula- 
tions, or tearing of the tissues, or unnecessary pulling with retractors^ 
by an awkward assistant, 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, and renders the chances of completing the operation 
without the aid of a general anesthetic very small. Rough wiping 
of the wound is likewise 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 trivial details is responsible 
for many of the failures with local anesthesia, and often results in 
condemnation of the method, though the fault lies with the operator. 



THE SURFACE APPLICATION OF ANESTHETIC DRUGS. 75 

THE PRODUCTION OF LOCAL ANESTHESIA BY COLD. 

The anesthetic properties of intense cold have long been recog- 
nized and utilized in minor surgery. The tissues may readily be frozen 
suflSciently for anesthetic purposes by the application of salt and ice, 
or by spraying the part with some rapidly evaporating chemical, such 
as ether, rhigoline, or ethyl chlorid. The tissues as a result become 
blanched, and a superficial anesthesia is produced, which persists 
but a few minutes. This form of anesthesia has a very small field of 
usefulness, and is only suitable for small 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 question. 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 applied to the tissues of poorly 
nourished individuals. 

Ethyl chlorid is now used almost exclusively for the purpose of 
freezing, and is both quick and effective. It is obtained in glass tubes 
^th one end drawn out to a fine point 
and furnished with a spring tip (Fig. 
36) or with a screw cap. The method 
of application is extremely simple. 

_,, , . - 1111. Fig. 36. — Ethyl chlond spray tube. 

The tube is uncovered and held m- 

verted 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 
nose; 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 tissues, such as 
the removal of polypi or small tumors, and opening of infections may 
thus be performed. 

For operations about the eye, a drop or two of a 2 to 4 per cent, solu- 




76 LOCAL ANESTHESIA, 

tion of cocain is instilled into the eye every ten minutes until three or 
four drops have been given. 

Local anesthesia of the nasal mucous membrane may be produced 
by applying a 4 per cent, solution of cocain upon swabs of cotton di- 
rectly to the part to be anesthetized. Spraying the solution into the 
nostrils is not so desirable, as the solution is liable to nm down into the 
pharynx through the posterior nares and produce a very unpleasant 
sensation 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 
may be employed after the cocainization. 

In the larynx cocain may be applied more freely without danger 
than 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 urethra may be sufficiently anesthetized by fidling it with a o. 2 
per cent, cocain and adrenalin solution, introduced by means of an 
instillation syringe or catheter. The solution should be confined in the 
urethra for at least fifteen minutes, by holding the meatus closed. 

For the bladder, a o.i per cent, cocain and adrenalin solution is 
sufficient. Five ounces (150 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, combined 
with minute quantities of morphin, cocain, and carbolic acid. From his 
v/ork 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 trunks. 
The resulting anesthesia is partly due to the direct action of the drug 



INFIXTfiATION ANESTHESIA. 



77 



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 indefinitely prolonged if the circulation be kept stationary 
by some form of constriction applied to the part, centrally to the seat 




Ftc. 37.— Apparatus toe iofilttation. 
I, Medicine glasses tor cocain solulions; 2, ampule ot sterile cocain and salt crystals; 
3, dropper for adrenalin; 4, syringe armed with a short needle; 5, long fine needle for deep 
infiltration. 

of injection, or by incorporating in the fluid infiltrated vasoconstrictor 
drugs like adrenalin. With the infiltration method of anesthesia it is 
absolutely necessary to thoroughly edematize or literally pack the 
tissues with the anesthesic fluid, for, without this, the weak solution 
employed would be worthless. 




Apparatus. — For the purposes of ordinary infiltration the 6on| 
(3.75 c.c.) or the 10 c.c. (2 3/4 dram) sub-Q syringe is the best. 
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 operation, and are to be kept filled 



78 



LOCAL ANESTHESIA. 



in readiness, so that the infiltration can be carried on rapidly without 
waiting to recharge the same syringe. The needles should be sharp and 
fine, with a very short bevel, and they should fit the syringe without any 
leakage at the joint. It will be convenient to have a short needle, i 
inch (2 . 5 cm.) long, for skin infiltration, and a second one, 2 to 2 1/2 
inches (5 to 6 cm.) long, for deeper infiltrations. 

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. 38) 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 for the introduction of 
air, and one for the escape of the fluid. 
A rubber inflating apparatus is at- 
tached 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 aCir, and the 
bulb and tubing are removed. Infil- 
tration is performed by inverting the 
apparatus and opening the outflow 
stopcock. Several needles of different 
lengths, shai>es, and sizes are pro\ided 
with this instrument. The author 
uses an infiltrator made on much the 
same principles as the Matas inslru- 
menl. It consists of a long graduated 
glass cylinder capable of holding 10 
ounces (300 c.c), with an oudet at 
the K^ttom and a ruWxT siopjvr fastened in the top by a clamp. A 
'MwaW j^lass tulx^ connected with an intlating bulb passes through this 
stopjvr (,Fig, 30^1. The reser\*oir is almost filled with the solution, 
lca\ing alxnit one t^uartor for air sj\ice, and the instrument is 
chanjcil with sutVuicnt air to cause the iluid to flow through the 
nciMlc in a stn^nj; sin\-^m. 

Technic. In all caM^ whcn^ an ojttonsive or ai all prolonged 
ojvraTion is ot>ntomplait\i. unless oi^ntraindicaied, morphin, gr. 
3 4 ^o.oif^^ sni.\ should Ik given hy]xxlcrmicilly half an hour before 




l'"^a. j?o. — ITw Author's A]>]>Anitus for 
mAsMNT inhltniion. 



lilFILTKATION ANESTHESIA. 



79 



Operation. For the skin infiltratioD, a warm 0.2 per cent, solution 
of cocain in normal salt solution is used. The syringe is filled with 
solution and the needle is shown to the patient with an explanation of 
just what is intended to be done. This is necessary in order to avoid 




Fia. 40. — Showing Ihe method of infiltraling the skin. The needle is inserted in such & 
way thai, with the injection of a few drops of solution, a wheal the size of a ten- 
cent piece is produced. 

an often unexpected shock from the first prick of the needle. The 
needle, fuld 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 Just below the skin surface A few drops of solution 




— Showing 



;dgc of the wheal. 



are injected and the skin becomes blanched and raised into a wheal 
about the size of a ten-cent piece (Fig. 40). The needle is then 
reinserted into the edge of the wheal and more solution injected in the 
same manner, until the entire line of the proposed incision is one 



8o LOCAL ANESTBESLl. 

coDlinuous wheal (Fig. 41). 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 in- 
filtrated, using a longer and somewhat larger needle. For this purpose 
a I to 1000 solution for ordinary cases and a i to 3000 to 1 to loooo solu- 
tion for massive infiltration of large areas is used. The needle is in- 
serted into the line of the skin cocainization, and the solution is injected 
in all directions from the point, so as to practically surround the area of 
proposed incision with anesthetic solution. Special care is taken to 
thoroughly infiltrate known sensitive regions, as, for instance, in the 




Fig. 41. — Showing the diieciions in which ihe needle should be inserted in masdve infil- 
Iration of deep struciures. 

operation for inguinal hernia about the external ring where the main 
nerve trunks break up into their terminal filaments. In the case of an 
operation uf>on a circumscribed growth, the infiltration b carried out 
in such a way as to completely encircle the diseased area and isolate it 
from nerve communication with the surrounding parts. In like 
manner fascia, muscles, down to or including the periosteum, may be 
infiltrated in a mass, after the method of Matas (Fig. 42), or each 
structure separately as they are 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 
taken to infiltrate fascia, muscle, and tendon sheaths, periosteum, and 
joint capsules, and when operating upon joints to cocainize the syn- 
ovial membranes by a preliminary instillation of weak cocain solution 
into the joint before operation. With proper infiltration the whole 
field is thoroughly edcmatized and is changed into a tumor-like mass 
that is perfectly anesthetic. 

While the infiltration method is carried out without any attempt 
to specially cocainize nerve trunks, they should nevertheless be injected 



ENDO- AND PERINEURAL INFILTRATION. 8 1 

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 infiltra- 
tion (Fig. 43). In such a case, where large quantities of solution are 




Fig. 43. — ^Showing the application of a constricting band to the finger in order to prolong 

and intensify the anesthesia. 

used and remain in the tissues when the operation is completed, it is a 
wise precaution to loosen the constriction gradually 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 

nerve and produce anesthesia in the entire area of its distribution has 

made possible many operations of magnitude, such as those for hernia, 

amputations, etc. Successful nerve blocking presupposes an accurate 

knowledge of the course and distribution of the sensory nerves. It 

may be performed at a distance from the seat of operation by injecting 

the cocain solution around the nerve, or by cutting down and exposing 

the nerv^e before injection; or the cocainization may be performed by 

separately injecting each nerve as it is exposed during the course of the 

operation. The action of the cocain is intensified and indefinitely 

prolonged by arresting the circulation in the injected and anesthetized 

nerv^e trunks by means of elastic constriction, as already spoken of 

under infiltration, and to a lesser degree by the addition of adrenalin to 

the analgesic solution. 
6 



82 LOCAL ANESTHESIA. 

The perineural method of infiltration is more suited to regions sup- 
plied by the smaller superficial nerves and to the smaller extremities, as 
the fingers and toes. For anesthetizing the larger nerve trunks with thick 
sheaths, direct injection of the nerves as they are exposed in the field of 
operation, or at some point along the course of the nerve central to the 
seat of operation, will give more certain results. When a region is 
supplied by several nerves, each will have to be separately isolated and 
blocked. 

Apparatus. — ^The ordinary 6on]^ (3-75 c.c.) or lo c.c. (2 3/4 dr.) 
"Sub-Q'' syringe, with a fairly long needle will be found most sat- 
isfactory. 

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 nerv-e can be reached with the hypo- 




FiG. 44. — Mcthcxl 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 jwint of injection. 

dermic needle is infiltrated as already described, and through this area 
the needle is inserted toward the known location of the particular nerve 
to be anesthetized. The syringe is charged with a o. 2 per cent, solu- 
tion of cocain, and from 15 to 20 drops (0.92 to 1.9 c.c.) are injected 
into the tissues surrounding the nerve. The solution is allowed to be- 
come diffused, and then, if the nerve be in an extremity, the part is ex- 
sanguinated by elevation and an elastic constriction is applied centrally 
to intensify and prolong the anesthesia. In a few moments the entire 
region supplied by the blocked nerve becomes insensible. It may hap- 
pen that, in regions where constriction is inapplicable, the anesthesia 
may not be sufficiently prolonged, and it will be necessary to repeat the 
injection more than once to maintain the anesthesia. 



ENDO- AND PERINEURAL INFILTRATION. 83 

In the endoneural method of anesthesia, 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 o. 5 per cent, solution of 
cocain as they are exposed. When the injection 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 with a 
0.5 per cent, solution of cocain, the fluid being injected into all por- 
tions of the nerve so that an entire transverse section is thoroughly 
blocked (Fig. 44). Other nerves supplying the region of operation are 
similarly dealt with. The part is then exsanguinated by elevation and 
the elastic constriction is applied centrally to the point of injection. 
In a short time all sensation below the seat of injection becomes be- 
numbed, 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 exclusion 
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 the 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 capabili- 
ties of each. 

The Head. — Operations upon the scalp, such as wound suture, the 
removal of tumors, cysts, etc., and even procedures requiring incision 
of the periosteum and opening into the brain, may be performed pain- 
lessly under a combination of infiltration and perineural anesthesia. 
An accurate knowledge of the nerve supply of the region is essential, 
however. 

Briefly, the scalp has the following nerve supply (Fig. 45). The 
small occipital and great occipital nerves together supply the whole 
posterior part of the scalp as far forward as the vertex. The great 
auricular nerve supplies the mastoid region, as docs also the small 
occipital. The parietal portion of the scalp receives its supply from the 
auriculotemporal and a branch of the temporomalar. The supra- 
trochlear branch of the frontal nerv^e supplies the integument of the 
lower part of the forehead on either side of the median line. The 
supraorbital supplies the cranium over the frontal and parietal bones. 



04 LOCAL ANESTHESU. 

Blocking these nerves by cross strips of infiltration at the points where 
they penetrate the muscular fascia and become subcutaneous (Tig. 46), ' 
or performing a thorough circumscribed infiltration around the area 
of 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 tourniquet 
passed around the forehead above the ears and over the occipital 
protuberance will be found most useful as an aid to anesthesia. 




Fig. 45. Fig. 46. 

Fic. 45. — The superficial nerves of the scalp and face. 1, Supratrochlear nerve; i, 
Bupiaorbital nerve; 3, lemporal branch [of Ihe temporomalar nerve; 4, auriculolemporal 
nerve; 5, great auricular nerve; 6, small occipital nerve; 7, great occipital nerve; 
8, infratrochlcar nerve; q, infraorbital ner\'e; 10, nasal ncrie; 11, menial nerve. 

Fic. 46. — Sho«-ing the aroa of ancalheaa after blocking the supratrochlear, supra- 
orbital, and mental nerves. The dots indicate the points for infiltration. 

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, 46). In like manner the 
upper lip may be anesthetized by cocainization of the infraorbital 
nenes. The inferior dental ner\e 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 



ENDO- AND FESINECRAL INMLTRATION. 85 

of the last molar tooth. The lower jaw may be thus anesthetized 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 be performed. Infiltration alone, 
however, is often sufficient in the smaller operations about the lips 
and mouth. 

The Neck. — Operations about the neck for the removal of benign 
growths, isolated freely movable glands, or for the ligation of vessels 
are performed by infiltration of the lines of incision combined with 




Fig. 48. 

Fig. 47- — The auperfitial cervical plexus. Tlie clotted lines intiici 
the steinomastoid muscle. 

Fig. 4S. — Showing the area of anesthesia alter blocking the superficial < 
plexus. The dots indicate the points for infiltrating. 



massive infillralion of the surrounding tissues. As already mentioned, 
thyroidectomy and tracheotomy may be carried out by following the 
same principles. In superficial operations upon the anterior and 
posterior triangles, perineural blocking by a cross strip of infiltration, 
or direct injection of the superficial branches of the cervical plexus 
as they escape from the posterior border of the sternomasloid muscle 
at or about its middle will be of great aid (Fig. 48). Operations 
upon the larynx may be performed under infiltration anesthesia com- 
bined with blocking of the superior laryngeal ner\e at the tip of the 
greater cornu of the hyoid bone - 



86 LOCAL ANESTHESU. 

The Thorax. — Exploratory punctures, aspiration of the pericardium 
and pleura, rib resection for empyema, and the removal of benign 
growths from the breast may all be satisfactorily carried out under 
infiltration. In the operation of rib resection the infiltration should be 
carried out layer by layer, including the periosteum. Perineiu^l 
blocking of the intercostal nerves as they pass between the intercostal 
muscles in the upper portion of the intercostal space, or endoneural 
injection of each nerve as it is exposed , will assist in rendering the opera- 
tion painless where more than one rib is to be resected. After the 
periosteum over the rib is incised and reflected, the rib may be exsected 
without pain. The parietal pleura, like the peritoneum, is very sensi- 
tive and requires infiltration before incision. 

The Upper Extremity. — Almost any operation may be performed 
in this region under a skilful use of local anesthesia. Exposing the 
brachial plexus under infiltration anesthesia above the clavicle (Fig. 
49) and blocking each branch separately by direct injection with a 
0.5 per cent, solution of cocain destroys all sensation in the area below 




Fig. 49. — Exposure of the brachial plexus (or infiltration. 

I, External jugular vein; a, tmnsverealis colU artery; 3, scalenus anlicus muscle; 4, fifth 

cervical toot; 5, sixth cervical root; 6, seventh cervical root; 7, clavicle. 

the point of injection, and amputations or other operations may be 
performed at any level below the seat of injection. 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 nerves. 

Operations upon the forearmrequireblockingof the median, ulnar, 
and musculospiral nerves. This may be done by directly injecting 
all three nerves after exposure under infiltradon anesthesia in the upper 
portion of the arm or by separately exposing and blocking eachnerve 
just above the elbow. In following the latter method, the median nerve 



EKDO- AND PERINEURAL INFILTRATION. 87 

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 mus- 





Fic. 50. — Exposuie of the musculospiral and medinn m 
culo^piral nerve; 3, median nerve. 

Fig- si. — Exposure of the ulnar nerve just above Ihe internal condyle. 

culospiral, between the biceps tendon and the supinator longus muscle. 
Blocking each nerve with a o. 5 per cent, solution of cocain produces 
complete insensibility of the extremity beiow the point of injection 
excepting the skin and subcutaneous tissues of the upper central 




bj-d 



i^ular strips 



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 sensi- 
bility in this region (Fig. 52). 



88 



LOCAL ANESTHESIA. 



Just above the wrist, the median, ulnar, and radial nerves are 
available for perineural injection. The median is reached by introduc- 
ing the needle to the ulnar side of the tendon of the palmaris longus and 
inserting it obliquely for a distance of 1/2 to 3/4 inch (i to 2 cm.) 
in the direction of the radius. The ulnar nerve may be anesthetized 
perineurally a little above the head of the ulna by inserting the needle 
to a depth of about 4/5 inch (2 cm.) between the ulna and the tendon of 
the flexor carpi ulnaris. The radial nerve and its branches are best 
caught by a cross strip of subcutaneous infiltration just above the 




Fig. 53. — Cross-section of the forearm above the wrist showing the direction of the needle 
for perineural infiltration of the ulnar and median ner\'es. (After Braun.) 

I, Interosseus nerve; 2, radial nerve; 3, radial artery; 4, median nerve; 5, ulnar nerve; 
6, areas of skin infiltration; 7, flexor carpi ulnaris tendon; 8, paknaris longus tendon; 9, 
flexor carpi radialis tendon. 



Styloid process of the radius (Fig. 53). Perineural injection alone for 
operations upon the wrist is not satisfactory, as this region is also sup- 
plied by small branches given off from these nerv-es higher up. A 
circular strip of subcutaneous infiltration above the wrist, however, 
will render the anesthesia complete (see Fig. 52). In thin individuals, 
massive circular infiltration alone is generally 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 finger (Fig. 54) . Through 
these points the needle is inserted toward each of the four digital nerves, 
and the anesthetic solution injected (Fig. 55). All ner\'e conmiunica- 
tion is thus blocked and the finger may be incised, amputated, etc., 
without pain. By injecting in the known location of the digital nerves 
as they pass between the metacarpal bones, the bases of the fingers and 
even the metacarpals may be anesthetized. 



ENDO- AND PERINEURAL INFILTRATION. 89 

. The Abdomen. — ^The abdomea may be opened in any region by 
simple in&ltratioQ, combined with endoneural injection of nerves as 
they are exposed. The skin, the subcutaneous tissues, the fasciic, the 




Fio, 54, — Pdnts for inserting the needle in perineural infiltration of Ihe digital nerves. 

muscular layers, and the periosteum should be separately infiltrated, 
layer by layer. The limitations of local anesthesia in abdominal 
surgery have already been considered (page 69) and will not be re- 
iterated here. 




Fio. 55. — Cross- section of the finger shotting the direction of the needle for perineural 

infiltration of the digital nerves. (After Braun.) 

I, EJrtensor tendons; 2, bone; 3, flexor tendons; 4, areas of skin infjltration. 

Hernia. — While operations for hemia of any variety may be 
carried out under local anesthesia, the inguinal will be found especially 
suited to this method of anesthesia, the umbilical and femoral varieties 
less so. 



90 



LOCAL ANESTHESIA. 



For inguinal hemia a combination of infiltration and endoneural 
injection is possible on account of the anatomical arrangement of the 
inguinal region, which is supplied by three fairly large nerve trunks 
having a rather constant course — namely, the iliohypt^astric, the 
ilioinguinal, and the genitocrural. The iliohypogastric will be 
found in the upper angle of the hernial incision after reflecting the 
aponeurosis of the external obUque, usually running downward and 
inward on a line drawn from about the anterior-superior spine to a 




Fic. s6. — Showing ihe nerve supply o( the inguinal region. (After Gushing.) 
I, Iliohypogastric nerve; 3. ilioinguinal nerve; 3, conjoined tendon; 
muscle; 5, aponeurods of the external oblique incised and edges reflected. 



point an inch (2.5 cm.) above the external ring. The ilioinguinal 
will usually be found in the line of incision just beneath the aponeurosis 
of the external oblique, and on a lower level than the iliohypogastric, 
running downward in the long axis of the hemia (Fig. 56). It may 
even 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 which 
event its place is taken by the genitocrural. The genitocrural will be 
found after reflecting the aponeurosis of the external oblique lying 
among the structures of the cord, and frequently it lies behind the cord. 
Infiltration anesthesia is employed until the aponeurosis of the external 
oblique is reflected, when the above nerves are separately blocked. 
In performing the in6itration, especial care should be taken to inject 
plenty of solution in the region of the external ring where the nerves 
break up into their terminal filaments. After the nen^es are properly 



ENDO- AND PEKINEURAI. INFILTRATION. 



91 



blocked, the remainder of the operation may be painlessly performed 
without the use of additional cocain, 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- 
nation of infiltration and endoneural injection. If this latter method 
is employed, the incision is placed so as to expose in addition the exter- 
nal abdominal ring. The aponeurosis of the external oblique is thus 
exposed and is incised for a short distance, so that the ilioinguinal 
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. 




Fig. S7' — Shon-Cng the melhod 0/ infilirating about [he cord in operations upon ihe testicle. 

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. 

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 
escapes from the external ring (Fig. 57}, combined with infiltration 
along the site of incision. 

Penis and Urethra. — Circumcision may be performed by infiltrating 
the skin and mucous membranes along the lines of proposed incision, 



92 LOCAL ANESTHESIA. 

being careful to infiltrate the frenum thoroughly. More extensive 
operations upon the pendulus portion may be performed by subcu- 
taneous infiltration of a ring about the base of the penis, carefully 
injecting the solution around each of the dorsal nerves. External 
urethrotomy may be performed imder infiltration combined with 
topical anesthesia of the mucous membrane (see page 76). 

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 amount of 
anesthetic solution into the base of the growth is suflScient. 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, 



\-/ 



.1 




Fig. 58. — Points for injection in infiltration about the anus. 

and at the sides (Fig. 58) — 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. — Exposure under infiltration anesthesia and 
blocking of the anterior crural, the external cutaneous, and the sciatic 
nerves, combined with a circular strip of 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 external cutaneous nerve^ may be reached 

^ Nystroem describes {CentraWlatt f. Chintrgie^ 190Q) a method of skin-grafting under 
local anesthesia by taking the grafts from the outer side of the thigh after obtaining anes- 
thesia in this region by pcrincurally infiltrating the external cutaneous nerve at the inner 
side of the anterior superior spine. 



EHDO- AND PESUtEDRAL INFILTRATION. 



93 



for injection by an incision so placed as to expose the nerve as it 
emerges from under the anterior superior spine (Fig. 59). The anterior 
crural nerve may be exposed by an incision placed about 1/3 inch (i 




Fig. sg.— Exposure of the anienor crural and external cutaneous nerves for Injectkm. 
I, Anterior crural nerve; a, external cutaneous nerve; 3, femoral artery; 4, femoral vdo. 

cm.) external to the center of Poupart's ligament. The nerve will be 
foimd just external to the femoral artery. The sciatic may be exposed 
at the lower border of the gluteus maximus muscle, or at the upper bor- 




FlC, 60. — Exposure of the sciatic nerve in the upper part of the Ihigh for injection. 
I, Gluteus maidmus muscle; 2, biceps muscle; 3. semilendinosus muscle; 4, sciatic nerve. 

der of the popliteal space. In the former case, an incision 3 to 4 inches 
(7 . 6 to 10 cm.) long is made between the tuberosity of the ischium and 
the great trochanter, with its center over the lower margin of the gluteus 



94 



lOCAL ANESTHESIA. 



maximus muscles. By retracting the gluteus maxiraus upward and 
the ham-string muscles inward, the nerve will be found lying under the 
outer edge of the biceps muscle (Fig. 60). In the upper portion of the 




Fig. 61. — Exposure of the internal saphenous nerve for injection. 
I, Iniemal saphenous nerve; i, internal saphenous vein. 

popliteal space the nerve may be exposed by a vertical incision in the 
mid-line; it will be found lying between the biceps and semimembran- 
osus muscles. It should be injected before it divides, or else both the 



Fig. 61. — Cross-section o£ the leg above the ankle-joint, showing the direction ot the needle 
for perineural inlilttalion of the posterior tibial nerve. (After Braun.) 
1. Posterior tibial nerve; i, external saphenous nerve; .;, area of skin infiltration; 4, 
musculocutaneous nerve; 5, anterior tibial nerve; 6, tendo achillis; 7, peronei muscles; 8, 
flexor longus hallucis; o. extensor longus cligiiorum; 10, extensor longus hallucis: 11, 
tibialis amicus; 12, tibialis posticus; 13, flexor longus digilorum. 

iniemal and external popliteal nerves are to be blocked. In operations 
below the tuljcrcle of the tibia, it is unnecessary to block the anterior 
crural and external cutaneous; blocking of the sciatic in the popliteal 



bier's venous anesthesia. 95 

space and of the external saphenous as it passes to the inner and pos- 
terior aspect of the knee-joint is sufficient (Fig. 6i). 

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 the 
tendo achillis direcdy forward almost to the posterior surface of the 
tibia (Fig. 62). The anterior tibial may be likewise perineurally 
injected by inserting the needle on the dorsum of the ankle between the 
tendons of the tibialis anticus and the extensor longus hallucis and the 
innermost tendon of the extensor longus digitorum. By a circular 
strip of subcutaneous infiltration, the remainder of the sensory 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. 

BIER'S VENOUS ANESTHESIA. 

Quite recently Bier has developed an innovation in the production 
of local anesthesia in extremities, termed venous anesthesia. It con- 
sists essentially in rendering the limb bloodless and, after isolating the 
field of operation from the circulation by means of tourniquets 
applied above and below the area to be anesthetized, injecting the 
anesthetic solution into one of the veins between the two tourniquets. 
WTiat is termed "direct anesthesia" rapidly develops between the 
two bandages; while somewhat later, after the anesthetic solution 
has had time to act upon and paralyze the nerve trunks within the 
isolated area, the anesthesia extends to the entire limb beyond the 
bandage. This is termed "indirect anesthesia." 

Venous anesthesia, of course, is applicable only to the extremities, 
and 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 operations upon bones, muscles, tendons, etc. According 
to its originator, diabetic gangrene and arteriosclerosis are contra- 
indications to its use. 

WTiile this method of anesthesia is too new to have received a 
thorough trial in the hands of different operators, it has been thoroughly 



96 LOCAL ANESTHESU. 

tested by its originator and by him 15 considered to be far ahead of the 
other methods for producing local anesthesia. Bier reports (Berliner 
klinische Wochensckriff, March 19, 1909) 134 operations wider 
venous anesthesia, including amputations, arthrotomies, bone suture, 




Fig. 63. — Cannula and syringe for injecting the solution in venous anesthesia. 



extirpation of varicose veins, etc., and of this total in 115 cases the 
anesthesia was perfect, in fourteen satisfactory, and in five unsatis- 
factory. Of the latter, however, three were operations upon children. 
In four cases in which the writer has employed this method the anes- 
thesia was all that could be desired. 




Fig. 64. — Inslrumenls for venous anesthesia, 

I, Scalpel: 3, blunl-poinled scissors; ,;, thumb forceps; 4, aneur}-sm needle; 5, needle 

holder; 6, curved needles; 7, No. 2 plain catgut. 

Apparatus. — An infusion cannula, a S3'ringe, such as the Sub-Q 
or the Janet, with a capacity of about 3 ounces {89 cc.) and 
supplied with a short hea\7 piece of rubber tubing for connection with 
the cannula (Fig. 63), a hemostat to clamp the rubber tubing, and 



biek's venous anesthesia. 



97 



three rubber bandages, each aj inches (6 cm.) wide and 6 feet (i8o cm.) 
long, will be required. 

Instnunents. — Instruments necessaiy for an ordinary infusion are 
required; namely, a scalpel, mouse-toothed thumb forceps, a pair of 
blunt-pointed scissors, an aneurysm needle, needle holder, two curved 
needles with a cutting-edge, and No. 2 plain catgut (Fig. 64). 

Sohition. — Bier employs a 0.5 per cent, solution of novocain in 
normiil salt solution. 

Quanti^ Used.— From 20 to 60 c.c. {5 1/2 drams to 2 ounces) of 
solution are ordinarily injected, depending upon the extent of the area 
to be anesthetized. The quantity employed should not, however, 
exceed 2 3/4 ounces (80 c.c). 

Site of Injection. — ^For the arm, the basilic vein and for the leg 
the internal saphenous vein is usually chosen, though any of their 
tributaries sufficiently large for the purpose will answer. 

Preparations. — The site of injection is carefully cleansed with soap 
and water, followed by a i to 2000 solution of bichlorid of mercury 
and then sterile water. The instruments are boiled, and the operator's 
hands cleansed as for any operation. 

Technic. — The limb is first elevated and rendered bloodless 
by the application of an Esmarch bandage applied from the extremity 




FiC. 65, — Bier's venous anesthesia Showing the application of the bandages and the 
sue of injec(lon-f 

of the limb up to a point well above the site of injection. Some care 
should be taken to apply this bandage properiy as it is necessary that 
the veins be thoroughly emptied. Two tourniquets are then applied, 
one at a point above the operative field and the other below, by 
WTapping soft rubber bandages about the limb in broad bands so as 
not to cause the patient any unnecessary discomfort. The first 
bandage is then removed, Under infiltration anesthesia with a 0.2 
per cent, solution of cocain, one of ihe main subcutaneous veins or 
one of its large tributaries is exposed in the proximal part of the 
isolated area (Fig. 65). The vein is opened by cutting with scissors, 
and the cannula is secured in its distal end. The syringe, filled with 



98 LOCAL ANESTHESIA* 

the solution, is then attached to the cannula and the desired quantity 
of the anesthetic is injected under considerable pressure toward the 
periphery/ i.e.y against the valves of the veins, escape of the anesthetic 
solution being prevented by clamping the rubber tubing with a hemo- 
stat. In this way the anesthetic solution is distributed through the 
tissues between the two tourniquets and is brought in contact with the 
nerve trunks and nerve endings of the whole area, producing com- 
plete anesthesia of all the tissues. 

Direct anesthesia follows between the bandages in three to five 
minutes, and indirect anesthesia beyond the distal bandage is ob- 
served in six to twenty minutes. As a rule, some motor paralysis 
occurs in the anesthetized area, but it soon disappears after removal 
of the bandages. While a large portion of the anesthetic solution 
escapes from the wound during the operation, it is advisable at the 
completion of the operation, before suturing the wound, to gradually 
loosen the distal tourniquet, but not the central one, so as to permit 
the veins to fill up and force out the anesthetic solution. As an 
added precaution, when large amounts of solution have been employed, 
the veins may be thoroughly washed out with saline solution through 
the same cannula used to inject the anesthetic. 

Variations in Technic. — Following Bier's lead, others have in- 
jected local anesthetics into the arterial system instead of into a vein. 
Thus Goyanes {CentraJblait fur Chirurgie, 1909, Vol. XXVI) describes 
a method of regional anesthesia by the injection of the anesthetic 
solution into an artery. The solution is injected 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 
espedally 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 

* Bier in a later communication (Edinburg Medical Journal, Aug., 1910) states that he 
has lately made the injection centrally, opening the vein close to the distal bandage. 



SPINAL ANESTHESIA. 99 

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 diflFused 
through the capillary walls into the surrounding tissues so that little, 
if any, solution is returned to the general circulation. The writer 
has had no experience with the arterial method. 

SPINAL ANESTHESIA. 

This form of anesthesia is produced by injecting weak solutions of 
cocain or allied drugs into the subarachnoid space. Cocainization 
of the spinal cord was first suggested by Corning in 1885. Bier, in 
1899, improved upon the method and made it practicable for surgical 
purposes. 

The enthusiasm with which spinal anesthesia was first received 
has, however, proved unwarranted by practical results. The mor- 
tality is higher than from ether or chloroform, and it is not absolutely 
certain that permanent harm to the cord may not result. Certainly, 
cases have been reported which would suggest such a possibility. 
In a certain percentage of the cases anesthesia does not develop or is 
incomplete, and at times most unpleasant symptoms accompany 
the anesthesia; headache, nausea, vomiting, sweating, chills, rise of 
temperature, or collapse are by no means rare. Spinal anesthesia has 
a place in surgery, without doubt, but it should be reserved for those 
exceptional cases in which general anesthesia is contraindicated or 
other methods of local anesthesia are impracticable. 

Injections have been made in all portions of the cord, but for 
practical surgical purposes they are now limited to the lumbar region. 
The danger of inducing respiratory paralysis is too great to warrant 
the introduction of cocain into the higher regions of the cord. 

Solutions Used. — All the various local anesthetics have been used. 
Cocain may be used in a 2 per cent, solution in normal salt solution, 10 
to 40 TT[ (0.6 to 2.50 c.c.) of such a solution, containing between 
1/5 and I gr. (0.01296 and 0.065 gm.) of cocain, are injected. The 



lOO LOCAL ANESTHESIA. 

addition of a few drops of a i to looo solution of adrenalin chlorid to the 
cocain is said to be of great benefit, preventing the effusion of the 
anesthetic to the brain, and many of the unpleasant after-effects. 

Eucain B is safer than the cocam, but it is not so effective. Its 
solution can be boiled. 

Stovain is also less toxic and is very highly recommended by 
many authorities. A 5 per cent, solution is used, the dose being 3/4 to 
I gr. (0.0486 to 0.065 8™-)- 

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 3/4 to i 1/2 gr. 
(0.0486 100,0974) gro-)* 

Tropacocain is another substitute for cocain, frequently used, and the 
anesthesia is more lasting. At the present time, it is the anesthetic most 
frequently employed for spinal anesthesia. It is given in a dose of from 
1/2 to I gr. (0.0334 to 0.065 fi^) ill a 5 percent, solution. 




Fic. 66. — Apparatus for siunal anesthemft. 
I, Elhyl chlorid; a, medidne glasses, one for Tcceiving the spinal fluid and the other 
for the anesthetic solution; 3, ampule containing steiile cocain and sail crystals; 4, scalpel; 
5, syringe and trocar. 

The injection of a solution of Epsom salt has lately been advocated 
by Meltzer, Haubold, and others. Sixteen minims (i c.c.) of a 25 
per cent, solution are given for every 25 pounds 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 
hours. It is claimed that overdosage endangers life from respiratory 
paralysis. 

Apparatus. — A special stylet needle and an appropriate syringe with 
capacity of about 1 1/3 drams (5 c.c.) should be provided. The needle 



SPINAL ANESTHESIA. 



lOI 



should be 1/25 of an inch (i mm.) in diameter, and about 3 3/4 inches 
(9. 5 cm.) long. 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 needle be not too long — the more transversely it is ground the 
better. With a short-pointed needle the liability of injecting only a 
portion of the solution into the canal and part outside the sub- 
arachnoid space is quite remote. In addition, a scalpel for making 
the preliminary puncture and sterilized medicine glasses for holding 
the solution to be injected should be provided (Fig. 66). 

Location of the Puncture. — Any of the spaces between the second 
lumbar and the first sacral vertebrae is available for the puncture, but 
the usual site is between the third and fourth, or the fourth and fifth lum- 
bar vertebrae (Fig. 67). The spaces may be identified by counting down 
from the seventh cervical vertebra. If this is difficult on account of 




Fig. 67. — Points for injecting the anesthetic solution in spinal anesthesia. 



excess of fat, the fourth lumbar spinous process may be readily located, 
and from it the other vertebrae, by passing a line between the highest 
points of the iliac crests. Such a line passes through the tip of the 
spinous process of the fourth lumbar vertebra (Fig. 68). A point on 
either side of the spinal column half an inch (i cm.) from the median 
line is chosen, and starting from this point the needle is passed upward 
and inward toward the median line between the spinous processes. The 
average space available for the puncture between the bones in the lum- 
bar portion of the cord is 18/25 to 4/5 inch (18 to 20 mm.) in the 
transverse, and 2/5 to 3/5 inch (10 to 15 mm.) in the vertical diameter. 



I02 



LOCAL ANESTHESIA. 



PreparatioiL — ^The operation should be performed with the greatest 
aseptic care. The needle and syringe should always be boiled, the 
solution injected must be sterile, and the operator's hands and site of 




Fig. 68. — Showing the method of locating the fourth spinous process by passing a line 

through the highest points of the iliac crests. 

operation should be prepared with all the care that would be obsen'ed 
in any operation. 

Position of the Patient. — The body of the patient is curved well 
forward so as to widen the intervertebral spaces as much as possible. 




Fig. 69. — Sitting position for spinal puncture. 

For this purpose the patient sits up, leaning well forward, with his back 
to the operator (Fig. 69), or else lies upon one side with the back in the 
form of an arch (Fig. 70). 



SPINAL ANESTHESIA. 



103 



Technic. — ^The spot chosen for the puncture is anesthetized with 
ethyl chlorid or a few drops of cocain, and a small puncture is made 
in the skin with a scalpel (Fig. 71), to lessen the dangers of carrying in 
infection with the needle. The operator places his finger as a guide 




Fig. 70. — Lateral portion for spinal puncture. 

between the two spinous processes bounding the space for the puncture, 
and inserts the needle upward and inward toward the median line until 
it enters the subarachnoid space (Fig. 72). Lessened resistance, fol- 
lowed by the escape of the fluid from the needle, determines when this 





Fig. 71. 

Fig. 71. — Spinal anesthesia. 
Fig. 72. — Spinal anesthesia. 



Fig. 72. 

First step, nicking the skin at the site of puncture. 
Second step, inserting the needle . 



is accomplished. The distance necessary to be traversed varies from 
I to I 1/2 inches (3 to 4 cm.) in a child, 2 1/2 to 3 inches (6 to 8 cm.) 
in an adult. In inserting the needle, if it strikes bone, it should be 
withdrawn slightly and its direction changed. A quantity of cerebro- 



LOCAL aiq:sthesia. 



spinal fluid, corresponding to the amount of anesthetic to be injected, 
should be allowed to escape before the analgesic solution is introduced 
(Fig. 74). This will vary from 10 to 400^^ {0.6 to 2. 50 cc), according 




Fig, 74. Fig, 75. 

Fig. 74,— Spinal anesthesia. Third step, allowing the cerebrospinal fluid to escape. 
Fio. 75- — Spinal anesthesia. Fourth step, injecting (he anesthetic solution. 

to the strength of the solution to be used. Some operators prefer to 
dissolve the analgesic agent in the cerebrospinal fluid withdrawn and 
reinject the solution thus formed. The solution should always be 



SPINAL ANESTHESIA. IO5 

slowly introduced (Fig. 75). The needle is then withdrawn and the 
puncture sealed with collodion and cotton, or is dressed with a piece of 
gauze held in place by adhesive plaster. As soon as the injection is 
completed the patient lies down. The anesthetic solution thus mixes 
with the cerebrospinal fluid in the subarachnoid space and has a 
chance to act upon the intradural nerve trunks and roots. 

In from ten to fifteen minutes loss of sensation, often accompanied 
by muscular paral}rsis, takes place. The anesthesia becomes marked 
first in the anal and perineal regions, and then in the lower extremities, 
being limited above, as a rule, to a zone not higher than the waist 
line. With a successful injection, any operation about the lower ex- 
tremities, the anus, perineum, or pelvis may be readily performed. 
The anesthesia thus obtained persists for two hours or longer* 



CHAPTER IIL 
SPHTGMOMANOMETRY. 

Sphygmomanometry is the instrumental estimation of arterial 
blood pressure. The determination of blood pressure has become a 
subject of such practical importance that both ph}rsicians and surgeons 
should be familiar with the technic. In certain cases it is often of the 
greatest value in making a diagnosis, as well as in the prognosis and as a 
guide to the treatment. It is especially valuable in surgical work in 
determining the fitness of a subject for anesthesia (see also page 20) 
and during an operation in revealing impending danger from shock or 
weakening heart. For the latter purposes it should be employed as a 
routine in all serious operations likely to be attended by shock or con- 
siderable hemorrhage. 

The instrument employed for estimating blood pressure consists 
essentially of a hollow rubber band for compression of an artery, con- 
nected with a mercury manometer and inflating bulb. The amount 
of pressure necessary to obliterate the pulse distal to the point of 
constriction measured in millimeters of mercury represents the blood 
pressure. This is far more accurate than the usual method of palpating 
the pulse. Both systolic and disastolic pressure should be taken 
when it is possible, but of the two the determination of the systolic 
pressure is of most importance, as pathological conditions affect it 
more than the diastolic. 

The average normal systolic pressure obtained with the wide (12 cm.) 
armlet, according to Janeway, is as follows: 

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

For children over two years, 90-110 mm. of mercury 

For adults, 100-130 mm. of mercury 

In females the pressure is about 10 mm. less than in males. After 
middle life the pressure generally reads higher — often as high as 145 nmi. 
A systolic pressure between 145 and 90 mm. in an adult may, therefore, 
be considered within the limits of health. If, on repeated examinations, 
the pressure registers above or below these limits, it should be viewed 
with suspicion. A pressure above 200 mm. is considered very high 
and below 70 mm. very low, while below 45 to 40 mm. the pulse can 

106 



SPHYGMOMANOMETRY. IO7 

rarely be recognized. The diastolic pressure normally registers 25 to 
40 mm. less than the systolic. If the difference between the two is 
less than 20 mm. or more than 50 nmi., it indicates, in the first instance, 
an abnormally small pulse and, in the latter case, an abnormally large 
pulse. 

As blood pressure is dependent upon the quantity and velocity of 
the blood entering the circulation with the contraction of the left 
ventricle, and on the resistance in the peripheral arteries, it can be 
readily seen that it may be subject to considerable variation in health 
and may be modified by many circumstances. Anything which 
increases one or other of these factors will raise the blood pressure and 
vice versa. Thus a recent meal, fear, anxiety, self-consciousness, 
mental application, pain, drugs which act upon the vascular system, 
such as camphor, caffein, strychnin, digitalis, adrenalin, etc., increase 
blood pressure. Smoking likewise increases it if it has a stimulating 
effect, but causes it to fall if it depresses. Exercise has the same effect, 
that is, it increases pressure unless it is carried to exhaustion, when the 
pressure falls. The posture of the individual also modifies the pressure 
reading, it being 10 to 15 mm. higher with the person standing than 
when Ipng down. Likewise, the pressure is generally higher in the 
afternoon. The size of the encircling band is also important, the nar- 
row bands giving a higher reading than the broad ones. Furthermore, 
as the estimation of pressure depends on the tactile sense of the indi- 
vidual palpating the pulse, the pressure readings in the same patient 
will vary somewhat with different observers. Therefore, to avoid 
these sources of error and obtain readings of value for comparison, the 
determination of pressure should always be made by the same observer, 
under the same conditions, at the same time of day, with the patient 
in the same position, and at rest mentally and physically, and employ- 
ing the same size armlet. 

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

The Riva Rocci sphygmomanometer (Fig. 76), as modified by 
Cook, consists of a portable manometer with a jointed tube and scale 
reading up to 320 mm. The armlet Consists of a rubber bag 4 1/2 
inches (n . 5 cm.) wide by 16 inches (40 cm.) long, covered with canvas, 
and supplied with hooks and eyes for fastening it in place. A Richard- 
son double inflating bulb is connected with the armlet, and also with the 
manometer by means of a glass T-tube and rubber tubing. A second 
glass T-tube is inserted in the rubber tubing near the manometer, to 



io8 



SPHYGHOUANOUETRY. 



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. 77) consists of a rubber compression arm- 
let 4 1/2 inches (11.5 cm.) wide by 16 inches (40 cm.) long, inclosed 
in a cuff of leather or thick canvas reinforced by tin strips. In the 
center of the cuff is cemented a glass tube 1/4 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 




FlO, 76. — The Siva, Rocci Sphygmomanometer. 



T-shapwd metal tube, one arm of which is connected with the armlet 
and the other with the inHating apparatus, which consists of a double 
inflating bulb. At the top of the metal cistern is a screw valve for the 
gradual release of pressure, and on the arm connected with the inflat- 
ing apparatus is a stopcock to shut off the inflation. 

Janeway's instrument (Fig. 78) 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 
inflation. The armlet is a closed rubber bag measuring 4 3/4 inches 
(12 cm.) in width and 18 inches (45 cm.) in length, inclosed in a leather 



SFHYGMOUANOUETKY. 109 

cuff that is ^stened to the limb by means of two straps. A stopcock 
coDtaining a needle valve for the release of pressure is interposed be- 
tween the cistern and inflating bag. The instrument is unassembled 
for packing in its case as follows; The scale is sUd down and 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 is plugged 
by a small cork "A" and the other end is closed automatically when the 




Fig. 77. — Slanlon's Sphygmomanometer. 

lid is shut by a block which compresses the rubber " B. " The inflation 
bulb is removed, and, as the box shuts, the stopcock slips under a spring 
"C." 

By means of the Stanton and Janeway instruments both systolic 
and diastolic pressure may be estimated, but for practical purpose 
determination of the systolic pressure is sufficient. Whatever fonn of 
instrument is employed, a wide armlet (4 i/a to 4 3/4 inches (ir.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. 



no SFHYGMOUANOHETSY. 

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 cuS 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 one and that the mercury is at the zero point. The in- 
flating bulb is then properly connected with the armlet 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 until 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 ri^laxing the reservoir bulb. 

Stanton's Instriiment.^Thc armlet is buckled in place and is con- 
nected 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 arm- 
let is slowly inflated until the pressure causes the pulse to disappear. 



SPHYGMOMANOMETRY. Ill 

The inflation cock "A" is then closed and valve "B" is gradually 
opened until the pulse just reappears. The height o£ the mercuiy 
when this occurs represents the systolic pressure. The pressure is 
further slowly reduced a few millimeters at a time, and, as the mercury 
falls, its column oscillates up and down, increasing in size until a maxi- 
mum is reached and then diminishing. The base-line of the maxi- 
mum oscillations represents the diastolic pressure, which is normally 
25 to 40 mm. below the systolic pressure. 




Fig. 79. — Technic ot spbygmomanometry with the Stanton i: 



Janeway's Inslrumenl.— The armlet is properly secured about the 
limb as described above and the scale is so adjusted that the level of 
the two columns of mercury is at zero. With the fingers on the 
radial pulse the armlet is gradually inflated by compressing the bulb 
until 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 pulse. 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 desired. The diastolic pressure is oblained 
in the same manner as described under the technic with the Stanton 
sphygmomanometer. 

Variations of Blood Pressure in Disease.' — Pain of all kinds causes 

'For a complete eiposiiion of ihia phase ot the subject the reader is referred to 
Janeway's "Clinical Study of Blood Pressure." 



112 SPHYGMOMANOMETRY. 

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 peritonitis, etc., the blood pressure is 
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 cachectic conditions, as cancer, tuberculosis, 
etc., are as a rule accompanied by low pressure. In tuberculosis, if 
the pressure is normal or increased, it is looked upon as a good prog- 
nostic sign. 

In infectious diseases low pressure is the rule. In typhoid fever a 
rapid 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 Affections. — Acute nephritis may or may not produce eleva- 
tion of pressure. The same is true of chronic parenchymatous nephri- 
tis, but in the chronic interstitial variety high pressure is the rule. 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 
may not be elevated; in fact, the results of blood pressure observations 
in this class of cases are too varied to be of value. In primary myo- 
carditis the blood pressure is low, but when secondary to arterial or 
kidney disease it may be high. In arteriosclerosis the pressure is 
generally elevated, especially with hypertrophy of the left ventricle. 
Arteriosclerosis may exist, however, without elevation of pressure, and, 
if cardiac muscle insufi&ciency be present, the pressure may be below 
the normal. 

Acute Peritonitis, — In the early stages, the pressure is abnormally 
high. A sharp rise may precede all other symptoms in the beginning 
of peritonitis from typhoid, appendicular, or other forms of perfora- 
tion. 

Head or Brain Injuries, — Blood pressure is increased in compres- 
sion of the brain from depressed bone, extra- or subdural clots, abscess, 
tumors, fracture of the base, apoplexy, etc., in proportion to the degree 
of intracranial tension. In acute compression from hemorrhage a high 
and rising blood pressure indicates an increase in the bleeding and a 
progressive failure of the circulation in the medulla. When the paraly- 
tic stage of compression appears, the pressure falls. Low pressure is 
also found in concussion of the brain. 



SPHYGMOMANOMETRY. II3 

Hemorrhage. — ^The loss of considerable blood results in a rapid fall 
of pressure. 

In shock and collapse 2l fall in blood pressure is uniformly present. 
According to Crile, in shock, the fall in pressure is gradual, while the 
term " collapse'* should be limited to those conditions in which there 
is a sudden fall in blood pressure due to hemorrhage, injuries of the 
vasomotor centers, or to cardiac failure. 

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

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

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



CHAPTER IV. 
TRANSFUSION. 

The term transfusion is applied to the transference 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 all 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, 
and Den)rs, in 1667, published their results that the operation was 
used to any great extent. After this, it was employed for such a 
variety of purposes and so extra vagent were the claims of its exponents 
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 occurring 
after childbirth. 

The transfusion was either performed directly by means of glass 
cannulas tied in the blood-vessels and joined by rubber tubing, or else 
indirecdy, the blood being drawn from the donor, and, after first being 
defibrinated by whipping, the serum resulting was injected into the 
veins of the recipient. Frequently the blood of dissimilar species, such 
as sheep's blood, was employed. There were many accidents resulting 
from the use of alien blood, and from the employment of transfusion 
in an improper class of cases, to say nothing of the dangers of infection 
and of embolism to which the patient was exposed by the methods used, 
so that the results were variable and uncertain, and in some cases even 
fatal. 

As the subject became more thoroughly studied and better imder- 
stood, it was recognized that the blood of dissimilar species, through its 
faculty for breaking up the red blood-corpuscles, was impracticable and 
dangerous for the purpose of introduction into the human circulation, 
and that direct transfusion from artery to vein only was permissible. 
Furthermore, it was contended by many 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, the uncertainty of blood-vessel anastomo- 

114 



TRANSFUSION. II5 

sis 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 usefulness of the operation, and it became less 
and less used. Finally, with the introductions of infusions of normal 
salt solution as a substitute, transfusion practically became extinct. 

During the past ten years, largely through the work of Carrel, Crile, 
and others in this coimtry, transfusion has been revived, and with the 
development of improved methods of blood-vessel anastomosis it has 
become a practical operation, the value of which in certain cases even 
outside of hemorrhage and shock seems to be well established, both 
experimentally and clinically. 

Indicatioiis and Contraindications. — ^The principal indication for 
transfusion is severe hemorrhage. Crile has shown that if performed 
early enough it is a specific remedy. Experimentally he has success- 
fully treated every degree of hemorrhage; dogs were even bled to the 
last drop that would flow and were then successfully transfused. 
Transfusion is also indicated in pathologic hemorrhage, where the 
coagulability of the blood is deficient, as in hemophilia, cholemia, and 
hemorrhage from the bowels, etc. In these cases the condition of the 
padent has been at least improved by the operation and in most cases 
the hemorrhage has been controlled. Some of the reported cases were 
transfused more than once before permanent improvement was noted. 
For shock, according to Crile, transfusion is the best form of treat- 
ment we now possess. It exerts far greater influence on blood pressure 
than does saline solution. Both will raise blood pressure, but the latter 
will not maintain the rise in pressure. Transfusion, on the other hand, 
frequently raises the blood pressure above normal and will sustain it 
at a high level for a number of hours. 

In 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. 

At present the value of transfusion in many other conditions, such 
as tuberculosis, chronic suppuration, acute infectious diseases, etc., 
is still undetermined, and we are not as yet fully informed as to what 
diseases contraindicate its use. There have been cases reported of 
fatal hemolysis after transfusion in pernicious anemia and in obscure 
blood diseases, which indicate that in some diseases at least transfusion 
of the blood of similar species even is accompanied by danger. Until 
we possess greater knowledge of the subject, caution should be observed 
against the indiscriminate employment of transfusion. 



ri6 



TRANSFUSION. 



Tests for hemolysis should be made upon the donor and the recip- 
ient whenever possible. Hemolysis between the donor's corpuscles and 
the patient's serum is not necessarily harmful, but if it' is found that 
there b reversed hemolysis, that is, if the donor's serum hemolyses the 
patient's corpuscles, another donor should be chosen. These tests, 
however, require twenty-four hours, so that in an emergency they 
are not available. Theoretically, agglutination of the red corpuscles 
and precipitadon may also occur; though, according to Crile, in practice 
these changes may be disregarded. 

Methods of Performing 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, 




Fjo. 80. — Instruments for Iransfu^on. 

I, Scalpel; a, thumb forceps; 3, blunt-pmnted scissors; 4, 
fine lissue forceps; 6, Crile clamps; 7, small pair of curved scissc 
needles tlireaded vrilh 6ne strands of silk. 



mosquito hemostats; j, 
jis; 8, Crile cannuke; q, 



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 draw- 
ing the artery over this venous cuff. By this method the intinwe of the 
vessels are brought into apposition and there is no foreign substance in 
contact with the stream of blood, thus lessening the chance of throm- 
bosis. Anastomosis by direct suture, while it brings about the same 
result, is difficult to perform except by one accustomed to blood-vessel 
suture. In addition, there is frequently a contraction of the vessels 
at the point of suture, and thrombosis is more likely to occur. The 



TRANSFUSION. 



117 



Operator intending to perform transfusion should, however, be familiar 
with both methods. 

Instruments. — There will be required a scalpel, an ordinary pair 
of blunt-pointed scissors, a small pair of curved scissors, thumb forceps, 
very fine tissue forceps, two small Crile clamps, mosquito hemostats, 
and transfusion cannulas. If direct suture is employed, instead of the 



1 

Z 




Fig. 81. — Enlarged view of Crile's clamps. (After Fbwler.) 
I, Clamp without rubbers; 2, rubber tubes to fit on jaws of (^amps; 3, clamp applied 

to artery. 

Crile tubes, there will be needed several No. 16 cambric needles and fine 
strands of silk (Fig. 80). The silk should be thoroughly impregnated 
with vaselin and should be threaded into the needles before the opera- 
tion is begun. 

The tube devised by Crile is of German silver and is provided with 
a small handle and with two grooves upon the outer surface of the 
cannula portion into which fit the ligatures holding the vein and artery 




s^ 



Fig. 82. 



Fig. 83. 

Fig. 82. — Enlarged view of Crile's cannula. 
Fig. 83. — Buerger's cannula. 



in place (Fig. 82). At least four sizes of these tubes should be at 
hand, and the largest size that can be used without injury to the arterial 
coats by undue stretching should be employed. 

To avoid the necessity of ha\ing several sizes of cannulae and to 
furnish an instrument that can be more easily manipulated, Buerger 
has devised a cannula which is supplied with a long handle and is made 



ii8 



TRANSFUSION. 



with a slit in the circumference of the tube so that it is possible to alter 
the diameter of the cannula to fit the individual vessels (Fig. 83). 

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 thoroughly washed with green soap and water, 
followed by a I to 2000 solution of bichlorid of mercury, and then by 
sterile water. 

Selection of the Donor. — If possible, a yoimg vigorous adult should 
be selected to supply the blood. The subject should preferably be 
from among the relatives of the patient — a close blood relation, as a 
brother or sister, if possible. It is essential that the donor chosen be 
free from any constitutional or other disease, and a thorough physical 
examination, preceded by careful questioning, should be made to 
determine his fitness. 







y 






OperaTinff lahle 
1 ilecipient' 


/ 






©, ( 









Operating Table 
Z J?onor 













Fig. 84. — Arrangement of the operating-tables for a transfusion. (After Crile.) 

I, Table for recipient; 2, table for donor; 3, table for arms of recipient and donor; 4 and 

5, stools for operator and assistant; 6, instrument table; 7, table for dressings, etc . 



Position of the Donor and Recipient. — ^The donor should lie upon 
an operating-table of such make that will permit his head to be quickly 
lowered if he becomes faint while the operation is in progress. The re- 
cipient is placed upon a second table, with the head turned in the 
opposite direction. Both tables should be provided with cushions or a 
layer of pillows, so that the patients will be comfortable during the 
operation. Between the two operating-tables is placed a small square 
table upon which the arms of the donor and recipient rest during the 



TRANSFUSION. II9 

operation. The operator is seated upon a stool in front of this table, 
and his assistant opposite. 

Anesthesia* — ^The operation is performed under local anesthesia, 
emplo)ring a 0.2 per cent, solution of cocain for the skin and a o.i 
per cent, solution for deeper infiltration. 

Quantity Transfused. — It is impossible to estimate the exact amount 
of blood transfused and the guides should be the condition of the donor 
and the recipient; the amount should also vary according to the condi- 
tion for which the transfusion is performed. Twenty to forty-five 
minutes' flow in a good anastomosis is usually sufficient. As soon as 
the donor shows signs of loss of blood — vindicated by a gradual pallor 
about the nose and ears, deepening of the lines of expression; sighing or 
irregular respiration, etc. — the transfusion must be inmiediately stopped. 
If it is carried too far, the donor goes into a state of collapse, and a 
condition is produced in him similar to that for the relief of which the 
operation was performed. Furthermore, transfusion of excessive 
amounts of blood may cause serious damage to the viscera of the 
recipient, and even death. Acute dilatation of the heart, manifested 
by dyspnea, cyanosis, cough, and pain over the precordium is the most 
frequent sequel to overtransfusion. Should such a complication 
ensue, the transfusion must be inmiediately stopped, and appropriate 
treatment be instituted. 

Rapidity of Flow. — The rate with which the blood flows from the 
donor to the recipient should be carefully gauged, for fear of over- 
charging the heart and producing an acute cardiac dilatation. This 
may be determined by noting the strength of the pulsation in the veins. 
If too strong, the flow may be regulated by partially compressing 
the lumen of the artery by means of the fingers. 

Technic by Crile's Method.^The radial artery of the donor and 
any of the superficial veins about the elbow of the recipient are chosen 
for making the anastomosis — in a child the popliteal vein may be 
utilized. Both the donor and the recipient are given 1/4 gr. (0.0162 gm.) 
of morphin hypodermically half an hour before the operation unless it 
is contraindicated. 

The area of incision is infiltrated with cocain, and about i 1/2 
inches (4 cm.) of the radial artery is exposed and dissected free. 
Any branches are avoided if possible; if they cannot be avoided, they 
may be tied off with fine silk and cut close to the trunk. A Crile 
clamp is gently 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 



I20 



TRANSFUSION. 



compress the vessel and shut oflF the 
the artery is then ligated and the ^ 
o\^r the end of the vessel 
The field of operation i^ 



^. 







.^^^^ 



Fig. 85. — ^Transfusion by Crile's method. First step, ex^ 



Crile's clamps applied. ^^ 




^ ^-* 



.^ . 



hot saline solution. The vein of the recipient chosei. 
the same manner, and about i 1/2 inches (4 cm.) of it 
surrounding tissues. The distal end of the vein is ligau 
proximal end is applied a Crile clamp (Fig. 85), or a narrow p 




Fig. 86. 



Fig. 87. 



Fig. 88. 



Fig. 86. — Transfusion by Crile's method. (After Crile). Second step, drawing the 
vein through the cannula. 

Fig. 87. — ^Transfusion by Crile's method. (After Crile.) Third step, method of 
cuffing back the vein. 

Fig. 88. — Transfusion by Crile's method. (After Crile.) Fourth step, showing the 
vein cuffed back over the cannula and the method of drauing the artery ovtt the vein. 

fastened as descril^ed above. The vessel is divided and the ad\'entitia 
is snipped off after pulling it out over the end of the vessel. A Crile 
cannula of appropriate size, held in an artery clamp, is pushed o\*er 
the vein. A suture inserted in the edge of the vein, as shown in Fig. 86, 



TRANSFUSION. 



121 



aids in drawing the latter through the cannula. The projecting 
portion of the vein is seized by three mosquito clamps and is turned 
back as a cuflf (Fig. 87), and is tied in the second groove of the cannula. 
The forearms of the donor and the recipient are then placed so that 
the hand of the donor is directed toward the elbow of the recipient. 
The cuflfed portion of the vein is lubricated with sterile vaselin, three 
mosquito forceps are applied to the edges of the artery, and it is grad- 
ually drawn down over the cuffed vein (Fig. 88) 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 clamp upon the artery is 
then very gradually opened, allowing the blood to flow into the vein of 
the recipent (Fig. 89). At the completion 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 
observed. The vessels to be anastomosed must be handled with the 





Fig. 89. — ^Transfusion by Crile's method. Fifth step, showing the anastomosis completed. 



greatest care. They should never be bruised with artery clamps or 
picked up with toothed forceps. Some difficulty may be experienced 
from retraction of the vessels when they are cut. This may be over- 
come to a great extent by keeping them constantly moistened with hot 
saline solution. In the case of a contracted artery, Crile advises that it 
be dilated by gently inserting a fine pair of closed artery 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. 



122 TRANSFUSION. 

Variations in Technic. — Brewer has simplified Crile's method 
of making an anastomosis by emplo}dng long glass tubes lined with 
parafl&n (Fig. 90). These tubes are about 2 1/2 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 slighdy bulbous, 
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 paraffin, shaken out, and allowed to cool. The vein and 
artery are exposed and isolated in the usual way and two Crile clamps 
are applied as shown in Fig. 85. The artery is drawn over one end of 
the tube and is secured by a ligature. A longitudinal or a transverse 



:^ 



a 



^ 



C: 



c= 



Fig. 90. — Brewer's glass tubes lined with paraffin for transfusion. 

cut is made in the wall of the vein (see Fig. 104) , and, after loosening the 
arterial clamp sufficiently to permit the tube to fill with blood, the distal 
end of the tube is quickly inserted into the vein in the manner shown in 
Fig. 106, and is secured in place by a ligature. The clamps are then 
removed and the blood is allowed to flow. 

It is claimed that the length of these tubes and the ease with which 
they are inserted into the vessels render the operation considerably 
less difficult. 

Hartwell {Journal of the American Medical Association, Jan. 23, 
1909) has devised a method of transfusion without the use of a cannula 
by simply inserting the artery into the vein. He describes the method 
as follows: " The artery and vein are dissected out, temporarily clamped 
and divided in the usual manner, with the usual care in securing the 
small branches. The adventitia is removed from each, but a small 
coil of it is left curled up on the outside of the artery about i 1/2 inches 
(4 cm.) from the cut proximal end. Three guiding sutures of fine silk 
are then passed by means of a fine needle — an ordinary intestinal 
needle and zero silk are sufficiently fine — at intervals of 120 degrees 



TRANSFUSION. 1 23 

in the circumference of the cut end of the vein. The end of the artery 
is greased with melted sterilized petrolatum. The mouth of the vein 
is drawn open with the sutures, and the artery is passed directly into it 
for a distance of an inch (2 . 5 cm.). One of the guiding sutures is then 
I)assed through the rolled up adventitia on the artery, to hold the two 
vessels in contact, and the greater or less amount of superfluous cir- 
cumference of the vein is clamped or sutured so as simply to approxi- 
mate the artery but not to constrict it. The obstructing clamps are 
removed, and the blood current is allowed to flow." 




Fig. 91. — Levin's transfusion clamp. 

Levin {Annals of Surgery , March, 1909) describes a clamp form of 
transfusion cannula. This instrument (Fig. 91) is made in the form of 
an artery clamp with a small cannula attached to the tip of each blade. 
Upon the free edge of each cannula are placed four small pin points, 
and upon the outer surface are four grooves into which the pins fit when 
the two cannulae are in contact. 

To perform an anastomosis with this instrument the two halves of 
the instrument are separated. The cut vein is passed through one 




^ 



Fig. 92. — Elsberg's transfusion cannula. 

cannula and its wail is hooked on the pins. The artery is treated in 
a similar manner, and then both halves of the instrument are united 
and clamped. 

Elsberg {Journal of the American Medical Association, March 
13, 1909) describes a very practical cannula that does away with the 
necessity for the Crile clamps. His method of performing the anasto- 
mosis differs from the Crile method in several points. "The cannula 
(Fig. 92) is built on the principle of a monkey wrench, and can be en- 
larged or narrowed to any size desired by means of a screw at its end. 



124 TRANSFUSION. 

The smallest lumen obtainable is about equal to that of the smallest 
Crile cannula, and the largest greater than the lumen of any radial 
artery. The instrument is cone-shaped at its tip, a short distance 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 tip." 

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 
1/2 inch (i cm.) from the end of the cannula, and three fine 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 
by drawing upon 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. 103). The 
vein is opened by means of a small transverse slit in the same manner 
as for an intravenous infusion (see Fig. 104), and the cannula with the 
cuffed artery is inserted into the vein and tied securely in place by means 
of the loose ligature. The cannula is then screwed open and the blood 
is allowed to flow, the rapidity of flow being controlled by the extent to 
which the cannula is opened. 

Technic by Carrel's Suture. — Under local anesthesia the radial 
artery of the donor and the median basilic vein of the recipient are 
dissected free for a distance of i 1/2 inches (4 cm.), and any small 
branches are tied off with fine silk close to the main trunk. A small 
Crile clamp is applied to the proximal portion of the artery as near as 
possible to the upper limit of the incision, and the distal end of the 
vessel is tied off. The artery is then cut close to the distal ligature 
and the adventitia is drawn down over the end of the vessel and trimmed 
off. The field of operation is then covered by a pad moistened in 
saline solution, while the attention of the operator is directed to pre- 
paring the vein. The extreme distal end of the vein is tied off with a 
ligature, a Crile clamp is applied to the proximal portion, and the 
vessel is severed close to the distal ligature (see Fig. 85). The end of the 
vein is then trimmed of its adventitia, as was the artery. The arms of 
the donor and the recipient are placed near together upon a small table, 
so that the vessels may be brought together without tension, the hand 
of the donor pointing toward the elbow of the recipient. The ends of 
the two vessels are then sutured together as follows: 



TRANSFUSION. 



"5 



The needle, threaded with a fine strand of silk impregnated with 
vaselin, is passed through the wall of the artery from without in and 
through the wall of the vein (Fig. 93), and the two ends of the suture 
are tied and left long, to serve as a traction stitch. Two other sutures 





Fig. 93. 

Fig. 93. — Transfusion by Carrers suture, 
method of inserting the three traction sutures. 

Fig. 94. — ^Transfusion by Carrel's suture, 
traction sutures in place. 



Fig. 94. 
(After Carrel.) First step, showing the 

(After Carrel.) Second step, the three 



are similarly placed at such points that the circumference of the vessels 
is divided into three equal parts (Fig. 94). Two of these traction sutures 
are made taut, and the portion of the vessels between them is readily 
sutured. A continuous stitch is employed for this, the stitches being 





Fig. 95. 

Fig. 95. — Transfusion by Carrel's suture, 
method of suturing the artery and vein. 

Fig. 96. — Transfusion by Carrel's suture. 
tomosis completed. 



Fig. 96. 
(After Carrel.) Third step, showing the 

(After Carrel.) Fourth step, the anas- 



placed near the edges of the vessels and close together to prevent leakage 
(Fig. 95). Before performing this suturing a clamp should be attached 
to the third traction stitch and should be allowed to hang from below 
so as to open the lumen of the vessel and thus avoid including other por- 



126 TRANSFUSION. 

dons of the intima in the suture. As soon as one-third of the vessek 
is united, the next two traction stitches are made taut and another third 
is sutured, the clamp being also shifted to the under stay. The remain- 
ing third is united in precisely the same manner, thus completing the 
suturing around the entire circumference of the two vessels (Fig. 96). 
The clamp upon the vein is removed first, and then the arterial clamp is 
slowly unscrewed, allowing the blood to gradually flow from one vessel 
into the other. If the sutures are properly applied, there should be but 
little, if any, leakage at the line of union. 



CHAPTER V. 
INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 

The administration of physiological salt solution was originally intro- 
duced as a substitute for transfusion of blood in the treatment of hemor- 
rhage on account of the numerous risks that attended the latter opera- 
tion as formerly performed, and the difficulty of obtaining a suitable 
donor when most needed. The technic of transfusion has, however, 
been wonderfully perfected, and it can now be said to be an operation 
without danger if employed with proper precautions; but, notwith- 
standing the fact that it can never supplant transfusion in the point 
of effectiveness, as no media have been foimd as satisfactory as blood, 
the infusion of salt solution is, and will be, employed in preference to 
transfusion in the great majority of cases. This may be readily under- 
stood when we consider that the methods of administering salt solution 
can be carried out on short notice, that they require but little prepara- 
tion, that they are marked by simplicity in technic, and that they are 
within the reach of all; on the other hand, transfusion becomes a 
formidable operation in comparison. 

Salt solution may be introduced into the circulation through a vein 
(intravenous infusion), through an artery (intraarterial infusion), 
through the subcutaneous tissues (hypodermoclysis), and by way of 
the bowel (rectal infusion). Whichever route be chosen, the saline infu- 
sion is a most valuable and potent therapeutic procedure. 

Indications. — The use of physiological salt solution is indicated in 
the following conditions : 

(i) In collapse following severe hemorrhage to replace the 
circulating fluid, thus giving the heart a volume of fluid to contract 
upon and raising blood pressure. Salt solution, however, cannot 
replace the constituents of the blood, and in the severest grades of 
hemorrhage, when the number of oxygen-carrying red cells falls below 
a certain point, the injection of fluids into the circulation will not avail; 
only the transfusion of blood can avert a fatal issue in such cases. 

(2) In the prophylaxis and treatment of mild surgical shock, for the 
purpose of restoring heat to the body and raising arterial tension. As 
shown by Crile, however, in severe shock, unless due to hemorrhage, 
the rise of blood pressure is so temporary that the first benefits derived 

127 



128 INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 

from the infusion are not maintained. In such cases, the combination 
with the salt solution of drugs which raise blood pressure, such as 
adrenalin chlorid, is followed by more marked and beneficial results. 
For a single infusion, lo to 3orrL (o. 6 to i . 9 c.c.) of the i to 1000 solution 
of adrenalin chlorid may be added to a pint (473. 11 c.c.) of salt solu- 
tion, or the adrenalin may be administered by thrusting a hypodermic 
needle into the rubber tubing near the cannula and injecting the drug 
as the salt 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 rapid 
elimination of impurities from the body by causing diuresis, saline 
infusion is indicated in suppression of urine, uremia, diabetic coma, 
eclampsia, septicemia, various forms of toxemia, and in poisoning 
from carbonic acid gas, illuminating gas, etc. 

(5) For the purpose of relieving postoperative thirst. 

The administration of saline solution is contraindicated in advanced 
dropsy, pulmonary edema, or marked cardiac insufficiency. 

Preparation of the Solution. — To be exact, normal physiological 
salt solution that is isotonic with the blood, consists of nine pkrts 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 o. 7 per cent. — roughly, i dram (3.9 gm.) of chemically pure sodium 
chlorid to a pint (473.11 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 cor- 
puscles. It is the opinion of Mummery that symptoms, such as 
chills and sweating, which are sometimes seen after intravenous infu- 
sions, are due to the incorrect chemical composition of the fluid em- 
ployed. Carelessness in this respect, as well as disregard of the proper 
temperature of the solution, are withoi^t 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 is 
to have a sterilized and very concentrated solution put up in hermetically 
sealed tubes, in such a strength that the contents of one tube emptied 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 1 29 

into a quart (946 ex.) of sterile water gives a normal salt solution (Fig. 
97). 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 tempera- 
ture.'* A more convenient method of bringing the solution to the 




"STFRTTTZrD"- 
SALT SOLUTION 

iifitiifilttHlitB 




Fig. 97. — ^A tube of concentrated sterile salt solution. 

required temperature when needed for use is to have very hot and 
cold salt solutions at hand in separate flasks. The solution may be 
quickly heated by placing the flasks, surrounded by water to their 
necks, in a sterilizer or a deep basin, and bringing the water to the 
boiling-point. Some of the cold solution is poured into the reservoir 
first, and sufficient of the hot solution is then added to bring the con- 
tents of the reser\'oir to the proper temperature. 

Other Solutions Employed. — 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: 



Hare's formula: 




(Approximately.) 


Calcium chlorid, 


0.25 gm. 


gr. iv. 


Potassium chlorid, 


.10 gm. 


gr. I 1/2 


Sodium chlorid, 


9 gm. 


dr. 2 1/4 


Distilled water, 


1000 c.c. 


qt. i. 


Ringer's formula: 






Potassium chlorid, 


0.2 gm. 


gr. iii. 


Sodium bicarbonate, 


0.2 gm. 


gr. iii. 


Sodium chlorid, 


9 gm- 


dr. 2 1/4 


Distilled water. 


1000 c.c. 


qt. i. 



* Fowler. "The Operating-room and the Patient." 
9 



I30 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 



Locke^ s formula: 








Calcium chlorid, 


0.2 


gm. 


gr. m. 


Potassium chlorid, 


O.I 


gm. 


gr. I i/a 


Sodium bicarbonate, 


O.I 


gm. 


gr. I 1/2 


Glucose, 


I 


gm. 


gr. XV 


Sodium chlorid. 


9 


gm. 


dr. 2 1/4 


Distilled water, 


lOOO 


c.c. 


qt. i. 


Szumann's formula: 








Sodium chlorid, 


6 


gm. 


, dr. I 1/2 


Sodium carbonate, 


I 


gm. 


gr. XV. 


Distilled water. 


lOOO 


c.c. 


qt. i 


H ayem^s formula: 








Sodium chlorid. 


5 


gm. 


dr. I 1/4 


Sodium sulphate, 


I 


gm. 


gr. XV. 


Distilled water. 


lOOO 


c.c. 


qt. L 



INTRAVENOUS INFUSION. 

The introduction of salt solution directly into a vein assures us of 
its immediate entrance into the circulation and the certainty of its 




Fig. 98. — Ap])aratus for giving an intravenous infusion. (Ashton.) 

absorption. The intravenous method is thus indicated in any of the 
conditions previously mentioned where there is necessity for great haste 
and a prompt response to the treatment. The advantages of this 
method of infusion are pointed out by Matas as being almost unrestricted 
in possibilities in regard to quantity, comparatively muqh less painful 



INTHAVENOUS INFUSION. 



131 



than the subcutaneous method, and requiring the simplest and most 
readily improvised apparatus. In addition, if properly given, there is 
absolute freedom from danger. 

Apparatus. — There should be provided a thermometer, a graduated 
glass irrigating jar, about 6 feet {180 cm.) of rubber tubing, 1/4 inch 
(6 mm.) in diameter, and a blunt-pointed metal infusion cannula 
(Fig. 98). In addition, a constrictor for the arm, a gauze compress, 
and a bandage will be required. 

In an emergency, a fountain syringe or a large funnel will answer 
for the reservoir, and the glass tube of a medicine dropper will take the 
place of a cannula. 




Fig. 99. — Instruments foi 



its; ,;, thumb forceps; 4, aneurysm needle; 5, needle 
rved needles; 7, No, 2 plain catgut. 



Instruments. — The operator will require a scalpel, a pair of blunt- 
pointed scissors, mouse-toothed thumb forceps, an aneurysm needle, a 
needle holder, two curved-needles with a cutting edge, and No. 2 plain 
catgut (Fig. 99). 

Asepsis. — Strict asepsis should be observed. The instruments and 
apparatus should be boiled, the thermometer should be immersed in a 
I to 500 solution of bichlorid of mercury for ten minutes, and then rinsed 
in sterile water, and the operator's hands and patient's skin should be 
as carefully scrubbed as for any operation. 

Temperature of Solution. — Most operators advise tiiat the solution 



132 INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 

be administered at a temperature of a few degrees above that of normal 
blood, i,e,, at about 105° F. The stimulating effect of heat upon the 
circulation, however, should not be lost sight of, and, when such an 
action is desired, the solution may be used at a temperature of 115® to 
118° F. without harmful effects. It should be borne in mind that there 
will be some loss of heat while the solution is flowing from the reservoir. 
For this reason, the fluid in the reservoir should be kept at a temperature 
of from 2® to 3° higher than the temperature at which it is wished to 
give the infusion. 

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 continu- 
ously. By watching the thermometer and adding hot solution 
from time to time, as that in the reservoir cools, a uniform tempera- 
ture may be maintained. 

Rapidity of Flow. — The speed of the flow can be regulated by raising 
or lowering the reservoir, or compressing the rubber tube. The speed 
of flow should be at about the rate of one pint (473 . 1 1 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 dilatation of the 
heart may be produced by disregard of this caution. Furthermore, 
if the solution enters the circulation too rapidly, the fluid that 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 ap- 
pear, 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 enormous quantities. The average amount administered at a 
time varies from one pint (473 . 1 1 c.c.) to three pints (1419 c.c), dep>end- 
ing on the case, but larger quantities may be required in cases of sev^ere 
hemorrhage, or after venesection. The operator will be guided as to 
the requisite quantity chiefly by the return of the pulse, the increase 
in its volume, and by the improvement in the color of the patient's 
skin. In severe cases it may be advisable to repeat the infusion two 
or three times within twenty-four hours rather than to infuse an 
enormous quantity at one time. 

Site of Operation. — One of the most prominent veins at the bend 
of the elbow is usually chosen (Fig. 100), preferably the median basilic 



INTEAVENOUS INFUSION. 133 

which runs across the bend of the elbow from without inward.' At 
times a vein exposed in the course of an operation may be conveniently 
utilized. 

Preparation of the Patient — All clothing should be removed from 
the area selected for the infusion, and that about the axilla loosened 
if the arm is chosen for the infusion. The bend of the elbow is shaved, 
if necessary, and is scrubbed with warm water and soap, then washed 




Fio. 100. — The superficial veins of Ihe forearm. (Ashton.) 

vnlh bichlorid of mercury (i to 2000), and finally is rinsed with sterile 
water. A sterile bandage is tightly wrapped above the elbow to com- 
press the veins and make ihem more prominent (Fig. loi). If the 
circulation is very feeble, even this expedient may fail to make the veins 
stand out conspicuously. 

Anesthesia. — Anesthesia of the skin is obtained by infiltration at 
the site of incision with a o. 2 per cent, solution of cocain freshly pre- 
pared, or by freezing with ethyl chlorid or a piece of ice dipped in salt. 

' Dawbam advises that the infuaon be performed through the internal saphenous 
vein at a point anywhere above (he ankle, claiming (i) that it is as large or larger (han the 
veins at the bend of the elbow; (i) that there are no important structures near by to be 
injured by a careless operator; {3) (hat the scar is unobjectionable; and (4) that the asas- 
tants performing the operation will usually interfere less with the operating surgeon than if 



134 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 



Technic. — With the forearm supmated, a transverse incision is made 
over the median basilic vein (Fig. 102). The vein is dissected from its 




Fig. ioi. — Showing the application of the bandage to the arm to constrict the veins 

(Ashton.) 




Fig. 102. — Intravenous saline infusion. (Ashton.) First step, showing the vein exposed by 

a small incision. 



bed for a distance of i to i 1/2 inches (2.5 to 4 cm.), and is raised from 
the wound while two catgut ligatures are passed beneath it by means 



INTRAVENOnS INFUSION. 



of an aneiuTsm 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 b placed high up around the portion 
of the vein nearest the heart, ready to be tied (Fig. 103). A portion of 




Fic 103. — Intravenous saline infuuon. Second step, showing the distat end of the 
van tied and ft second ligature being passed under the proiiina.1 end of the vrin. 





saline infusion. Third step, showing the method of inrising 
saline infu»on. (Ashlon,) Fourth step, showing the cannula 



the vein. 

Fig. ioj. — Intra 
being inserted into i> 



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 upward is made with scissors through 
half the vein, exposmg its lumen (Fig. 104). The solution is firstallowed 



136 INFUSIONS OF PHYSIOLOGICAL SAXT SOLUTION. 

to flow through the cannula 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, 105) 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 at the end of the operation (Fig. 106). The bandage is 
now removed from above the elbow, and the saline solution is allowed 
to enter the circulation, the reservoir being raised 2 to 6 feet (60 to 
180 cm.) above the patient. During the infusion the temperature of 
the solution must be kept uniform, the thermometer in the reservoir 
being constantly watched, and care must be taken to replenish the fiuid 
in the reservoir before it has all escaped, otherwise air will enter the vein 
when a fresh supply is added. 

When suf&cient solution has been introduced, the ligature about 
the cannula is loosened, and the latter is withdrawn. With this same 



\ 




\\ 



!\ 



\V. 



// 



Fig. 106. Fig. 107. 

Fic. 106,— Intravenous saline infusion. Fifth step, showing the cannula tied in place. 
Fig. 107.— Intravenous saline infusion, (.\shton). Sixth step, showing the infusion 
cannula removed and ihc proximal end of the vein ligated. 

ligature the proximal end of the vein may be then tied off (Fig. 107). 
The edges of the skin wound are united with several 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 wilhout 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- 



INTRAARTERIAL INFUSION. I37 

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, especially 
if the subject is very fat, places a limitation upon the field of usefulness 
of this method. 

mXRAARTERIAL INFUSION. 

Saline solution may be injected into the artery instead of intra- 
venously, if desired. The solution may be injected either into the 
distal end of the vessel, or into the proximal end against the blood 
current. The advantages claimed by its advocates for this method of 
infusion over the venous route is that the fluid, by being first driven to 
the capillaries, is sent to the heart more gradually and is more evenly 
mixed with the circulating blood than when the entire volume of solu- 
tion enters a vein, and, as a result, there is less disturbance produced 
in the circulation. Infusion against the blood current has, in addition, 
it is claimed, a stimulating effect upon the heart. 

These alleged advantages of arterial infusion, however, seem to be 
overbalanced by the accidents that may follow employment of this 
method, there having been reported a number of cases in which 
sloughing about the area of infusion resulted, in some even necessitat- 

» 

ing amputation of the hand, so that for ordinary purposes saline 
solution introduced through a vein should be the method of 
choice. 

Crile and DoUey {Journal of Experimental Medicine, Dec, 1906), 
however, have shown that the infusion of normal salt solution and 
adrenalin into an artery against the blood current in suspended ani- 
mation from the effects of anesthesia or other causes is the most effect- 
ive 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 pres- 
sure, and that before a material rise can be effected by the action of the 
adrenalin upon the arteries it is necessary for the solution to pass 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 accu- 
mulation 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 shown that it is possible by this 
method to resuscitate animals that were apparently dead. 



138 INFDSIONS OF PHYSIOLOGICAL SALT SOLUTION. 

Apparatus. — The same apparatus described on page 131 for intra- 
venous infusion, or an infusion cannula attached to a large glass 
funnel by a piece of rubber tubing, may be employed. In addition, 
a hypodermic syringe will be required. 

Site of Infusion. — The carotid artery or one of its large branches is 
chosen for the injection as being the most direct route to the coronary 
arteries. 

Technic. — Ciile (Am. Jour, of Med. Sciences, April, 1909) gives 
the following technic for employing arterial infusion in humans for 
purposes of resuscitation. "The patient, in the prone position, is 
subjected at once to rapid rhythmic pressure upon the chest, with one 




Fig. 108. — Showing the method of infumng salt and adrenaliit solution into the carotid 
artery. (After Da CosU.) 

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 saline, 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 30 ri (0.92 to 1.90 c.c.) are at once injected. Repeat the injec- 
tion in a minute, if needed. Synchronously with the injection of the 
adrenalin, the rhythmic pressure on the thorax is brought to a maximum. 
The resulting artificial circulation distributes the adrenalin that spreads 



INTRAARTERIAL INFUSION. 



139 



its stimulating contact with the arteries, bringing a wave of powerful 
contraction and producing a rising arterial, hence 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 
still further the blood-pressure-raising adrenalin, causing a further 
and vigorous rise in blood pressure, possibly even doubling the 
normal." . . . "Just as soon as the heart-beat is established, 
the cannula should be withdrawn, first, because it is no longer needed, 
and, second, the rising blood pressure will drive a current of blood into 
the tube and funnel." 

Dawbam's Emergency Method of Intraarterial Infusion.— 
This consists in injecting saline solution into the circulation through a 




Fig. 109. — Apparatus for infusing salt solution into an artery in Dawbarn's emergency 

method. 



hypodermic, or a long fine aspirating needle, inserted into the common 
femoral artery. Dawbam recommends it as an emergency method in 
the absence of cannula and instruments necessary for intravenous 
infusion, or where the superficial veins are small and very difficult to 
locate. 

Apparatus. — ^A h)rpodermic needle, or a long fine aspirating needle, 
and an ordinary Davidson syringe (Fig. 109) are all that are required. 

Technic. — The femoral artery is first carefully defined just below 
Poupart's ligament. The aspirating needle is then forced by a slow 
rotary movement directly into the artery, entering it at right angles. 
As soon as the needle enters the vessel, bright red blood will fill its 
lumen. The rubber tubing of the syringe, which has been previously 
fiJled with saline fluid, is then slipped over the base of the needle and 
is firmly secured in place by tying. The fluid is then steadily pumped 



I40 INFUSIONS OF PHYSIOLOGICAl SALT SOLUTION. 

from a basin directly into the arterial circulation (Fig. no). Accord- 
ing to Dawbam, it requires about half an hour to inject a pint of solu- 
tion by this method. If a fountain syringe is used instead of a David- 
son syringe, it must be held at least 6 feet (i8o cm.) above the patient 
to secure the necessary pressure, otherwise the blood will be forced 
ba.ck up the tube. 




Fig. iio. — Showing the method of infusing salt solution into the femoral artery. 

HYPODERMOCLYSIS. 

The subcutaneous method of infusion does not permit as rapid an 
introduction of lai^e quantities of solution as the intravenous, on ac- 
count of the slowness with which the solution is absorbed. It is indi- 
cated in the same conditions as venous infusions, when urgeocy is 
not of prime importance. It is also frequently used as ao 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 impossible. 

Apparatus. — There will be required a thermometer, a graduated 
gla^s, irrigating jar, 6 feet (i8o cm.) of rubber tubing, 1/4 inch 
(6 mm.) in diameter, and an aspirating needle of fair size (Fig, iii). 
When it is desired to introduce the fluid into both bresists at once, two 
needles fastened to the rubber tubing by meajis of a Y-shaped glass 
connection, as shown in Fig. 112, may be employed. In an emergency, 
a glass funnel or a foimtain syringe, to which is attached an ordinary 
hypodermic needle by several feet of rubber tubing, may be utilized. 

Asepsis. — The necessary apparatus should be boiled, the seat of 
injection thoroughly scrubbed, and the operator's hands carefully 



HYPODERMOCLYSIS. I4I 

cleansed. Tlie thermometer is sterilized by immersion in a i to 500 
bicblorid solution for ten minutes, followed by rinsing in sterile water 
Temperature of the Solution. — The solution should enter the body 
at about 110° F. When using a large aspirating needle the fluid in the 
reservoir should be kept at a constant temperature of about 3 degrees 




for pving hypodermoclysis, (Ashton 



higher. If a hj^podcrmic needle be employed, about 5 degrees should 
be allowed for cooling. 

Rapidity of Flow. — As the fluid is taken up with but comparative 
slowness from the subcutaneous tissues, tKe injection is given less rapidly 
than by the intravenous method. With a fair-sized needle about a 




-Showing two needles arranged for hypodermoclysi: 



pint {473.11 c,c.) of fluid may be injected in from twenty to thirty 
minutes, the reservoir being held from 3 to 4 feet {90 to 120 cm.) above 
the patient. When a hypodermic needle is employed, Ihe 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. 



142 INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 

Quantity Given. — Injections of small quantities of solution, re- 
peated several times, give better results than a single large injection. 
As a rule, from 8 to i6 ounces (236 to 473.11 c.c.) of solution are 
introduced at a single injection, and repeated in a few hours, if neces- 
sary. According to Hildebrand, it is not safe to introduce a larger 
quantity of solution in fifteen minutes than i dram (3.75 c.c.) to each 
pound (453 gm.) of body weight. If this ratio is exceeded, the fluid 
accumulates and the tissues become water-logged, as the kidneys do 
not secrete rapidly enough to carry it off. Furthermore, very large 
quantities of solution should not be injected into one area, 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 be in 
a region free from large blood-vessels and nerves and where there is an 
abundance of loose connective tissue. The usual sites are: (i) imder 




Fig. 113. — Sites for hypodermoclysis. 

the mammary glands; (2) in the subcutaneous tissue between the crest 
of the ilium and the last rib; (3) in the subcutaneous tissue in the 
axillary space; (4) in the subcutaneous tissue on the inner surfaces of 
the thighs (Fig. 113). 

Anesthesia. — The point of skin puncture may be anesthetized by 
the injection of a drop or two of a o. 2 per cent, solution of cocain, or by 
freezing with ethyl chlorid or salt and ice. 

Technic. — The reservoir is raised from 3 to 4 feet (90 to 120 cm.) 
above the patient, and some of the fluid is allowed to escape from the 
needle, to expel any air or cold solution. With the solution still 
flowing, the operator, using steady pressure, inserts the needle obliquely 
well into the subcutaneous tissue. As the solution enters, a swelling 
appears in the subcutaneous tissues which, however, slowly subsides as 
the fluid is absorbed (Fig. 114). If, as soon as the tissues in one area 
become distended, the needle be partly withdrawn and its direction be 



HYPODEKMOCLYSIS. I43 

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 temperature of 




11 

Fig. J14, — Giving hypodennocly^s under Ihe left breast. (Astiton.) 

the solution is to be kept uniform, and sufficient solution must be in 
the reservoir at all times to prevent air from entering 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 cotton 
and collodion. 

RECTAL INFUSION. (See page 508.) 



CHAPTER VL 

HYPODERMIC AND INTRAMUSCULAR INJECTIONS, AD- 
MINISTRATION OF DIPHTHERIA ANTITOXIN, VACCINA- 
TION, ACUPUNCTURE, VENESECTION, SCARIFICATION, 
SUBCUTANEOUS DRAINAGE FOR EDEMA, CUPPING, AND 

LEECHING. 

THE HYPODERMIC AND INTRAMUSCULAR INJECTION OF 

DRUGS. 

Drugs may be administered by injection into the subcutaneous or 
muscular tissues when a rapid effect is desired, or when for any reason 
medication by the mouth is undesirable or is contraindicated. The 
injection of soluble, nonirritating substances is made into the sub- 
cutaneous 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 promptness 
of the effects 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 upon the 
functional activity of the gastrointestinal tract. 

The Hypodermic Syringe. — The ordinary hypodermic syringe 
consists of a glass barrel protected by a metal case and furnished with 



Fig. 115. — Ordinary glass and metal h>'podermic syringe. 

a leather-covered piston (Fig. 115). Such syringes, however, are 
difficult to keep clean and, if they are frequently boiled, the leather 
packing soon dries out and becomes insufficient unless carefully at- 
tended to. Syringes of solid metal (Fig. 116) or those consisting of a 
glass barrel and solid glass piston, as the Luer (Fig. 117), or with an 
asbestos-covered piston, as the "Sub-Q,'' will be found preferable, and 
may be easily cleaned and repeatedly boiled without harm. A syringe 
with a capacity of 3onx (i . 9 c.c.) is amply large for ordinary use. 

144 . 



INJECTION OF DRUGS. 



I4S 



The needles should be as fine as possible (28 to 27 gauge) and very 
sharp, and for injection beneath the skin they should be about i inch 
(2.5 cm.) in length. For the administration of liquids of a heavy 
consistency a needle of somewhat larger caliber will be required. For 
intramuscular injections, the needle should be i 1/2 to 2 inches (4 to 
5 cm.) long, and, if one of the insoluble preparations of mercury is 
employed, the caliber of the needle should be correspondingly large. 
To prevent the needles rusting and the lumen becoming plugged, they 
should be first well cleaned out with water after using, followed by 





Fig. 116. — All metal hypodermic syringe. 

alcohol and ether to remove any remaining fluid from the interior that 
might cause rusting, and, finally, they should be put away with a fine 
wire inserted in the lumen. 

Preparation of the Solution. — ^The drugs most frequently used for 
hypodermic medication are morphin, atropin, strychnin, hyoscin, 
pilocarpin, caffein, cocain, apomorphin, quinin, mercury, digitalis, 
ergotin, nitroglycerin, adrenalin, alcohol, ether, etc. As the majority 
of these are either very powerful or poisonous, the dose should be 
accurately measured in every case. 

The solution employed for the injection should always be sterile 




Fig. 117. — Luer's hypodermic syringe. 

and preferably freshly prepared. The strength of the solution is also 
important, for, if too concentrated, it may prove irritating, while, if 
greatly diluted, the bulk of solution necessary for the injection becomes 
objectionable. Most of the drugs for hypodermic use may be obtained 
in the form of soluble tablets which are dissolved in 5 to lon]^ (o . 30 to 
0.60 c.c.) of boiled water when required for use. Sterile solutions of 
the drugs, however, may be obtained in hermetically sealed glass 
ampullae, each containing sufficient for one dose. The solution must 
be as nearly neutral as possible; irritating solutions or strongly alcoholic 
10 



146 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC 



preparations should be avoided on account of the danger of subsequent 
sloughing at the seat of injection. When whisky or brandy is em- 
ployed, 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 al- 
bolene or benzoinol. 

Sites for Injection. — ^For ordinary injections the least sensitive por- 
tions of the body provided with plenty of cellular tissue are selected, 




Fig. 118. — Sites for hypodermic injections. 

the spot chosen, of course, being distant from the immediate neighbor- 
hood of large blood-vessels or nerves, bony prominences, or inflamed 
areas. The common sites are the outer surfaces of the arm, forearm, 
thighs, or the buttocks. 

For deep intramuscular injections of drugs not rapidly absorbed 
the gluteal region is usually chosen (Fig. 118). 

Asepsis. — The strictest regard as to cleanliness should always 
be observed. The needle and syringe should be boiled or at least 
immersed in some antiseptic solution before use, and the skin at the 
site of the injection should be washed with soap and water or rubbed 
clean with a piece of cotton or gauze saturated with alcohol 



INJECTION OF DRUGS. 14? 

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 between the thumb and fore- 
finger of the left hand, while with the right hand the needle is quickly 
thrust at an angle of 45 degrees into the subcutaneous tissues at the 




Ftc. 119. — Showing the method of giving a hypodermic injecdi 



base of this fold (Fig. 119). If the needle is sharp and it be quickly 
plunged through the skin, but httle, if any, pain will be experienced. 
The solution should be injected slowly to avoid too sudden distention of 
the tissues. When the required 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 difiEuse the 
solution. 




FlO. 110.— Deep intramuscular injection. First step, inserting the needle. 



In giving a deep intramuscular injection, the skin over the chosen 
site is held tense by the fingers of the left hand, and the needle is 
steadily forced through the skin and subcutaneous tissues directly into 
the glutei muscles up to its hilt (Fig. 120). As soon as the needle 



148 HYPODERMIC AND INTRAUUSCULAK INJECTIONS, ETC 

is in place, it is advisable to remove the syringe and observe whether 
there is any flow of blood from the needle (Fig. lai); if so, anew puncture 




Fio. III. — Deep inlnniuscular injection. Second step, showing the lyriiige removed and 

inspection of the needle for the Sow of blood. 

should be made. Observance of this precaution will obviate injecting 
the solution into the blood current should the needle point penetrate 
some vein. The solution is then injected slowly (Fig. 122), and at the 




liar injection. Third step, injecting the solution. 



completion of the operation the site of puncture is sealed with coUodioil 
or by means of a small piece of adhesive plaster. 



THE ADIONISTSATION OF DIPHTHERIA ANTITOXIN. I49 

THE ADMINISTRATION OF DIPHTHERIA ANTITOXIN. 

Antitoxin is now almost universally used in the treatment of diph- 
theria, and its administration is a procedure with which all physicians 
should be familiar. It has enormously reduced the mortaUty from 
this disease, and, if the serum is of reliable quality, its use is without 
danger. The diphtheria bacilli are not killed by the antitoxin, but 
the toxins are neutralized and a condition is produced in the blood 
which inhibits the growth of the bacilli so that they gradually disappear. 

The Serum. — As the serum is liable to be contaminated it should 
always be obtained from an unquestionable source. Antitoxin of 
the greatest concentration, that is, containing as little serum and as 
many units^ of antitoxin as is possible, should be used in preference, as 
smaller amoimts at a dose will be required and joint pains, skin erup- 
tions, etc. — symptoms which are now considered to be due to the horse 
serum and not the antitoxin — will be avoided. 

Dosage. — There is no definite rule for fixing the dose. It is known 
how much antitoxin is required to neutralize a given amount of toxin, 
but in practice there is no method of estimating the latter in any given 
case. Conclusions drawn from experience and clinical studies give 
the only practical guides. The dose should always be large, however, 
for the serum is harmless and it is better to administer too much than 
not enough. The average dose advised by the New York Health 
Department is 5000 units, repeated the following day if the condition 
of the patient has not improved. According to Holt " for a child over 
two years, an initial dose for a severe attack, including all laryngeal 
cases, should not be less than 4000 to 5000 units; and the dose should be 
repeated in six or eight hours provided no improvement is seen. 
Children under two years should receive from 2000 to 3000 units. 
Cases of exceptional severity where the injection is given late should 
receive from 8000 to 10,000 units, to be repeated in from six to eight 
hours if the progress of the disease is unfavorable. Mild cases should 
receive from 2000 to 3000 units as an initial dose, a second being rarely 
required." 

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 (2000 units) may be administered. 
The immunity thus furnished is not permanent, however, lasting only 
three or four weeks. 

* The strength of the serum is measured in units, a unit being the amount of antitoxin 
necessary to neutralize in a guinea-pig 100 fatal doses of diphtheria. 



150 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

Time of Administration. — ^Antitoxin should be given as soon as a 
clinical diagnosis is made, not waiting for a bacteriological examination. 
There are no contraindications to its use in the presence of lu-gent 
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 give the best results. 
This is well shown by the following table of the cases injected in 1902-4, 
prepared by the New York Health Department: 



Day. 


No. cases. 


Case fatality. 


Percentage. 


I 


623 


10 


1.6 


2 


1689 


53 


31 


3 and 4 


187 1 


127 


6.7 


5 and over 


455 


82 


18 



The Syringe. — The simpler the syringe, the better. The syringe 
should have a capacity of about i 1/2 to 2 3/4 drams (5 to 10 c.c). 
Glass syringes with asbestos packing or those with the solid glass piston, 




Fig. 123. — The record antitoxin syringe. 

as the Luer, are most easily sterilized. The record syringe (Fig. 123) 
is also an excellent instrument. A moderately fine needle or the small- 
est through which the serum will flow is preferable to one of very large 
caliber. In charging the syringe it is better to remove the piston and 




.^j\m 



edddffiSE 




^ 



Fig. 124. — The New York Board of Health Antitoxin Syringe. The syring? comes 
sterilized and already loaded with antitoxin and, upon inserting the needle into the distal 
end, is ready for use. 

pour the antitoxin into the syringe, as it is difficult to draw it up 
through the needle. The piston is then inserted and, with the syringe 
elevated, any air is expelled. Many of the manufacturers at the present 
time supply a syringe already sterilized and filled with antitoxin (Fig. 
124). The advantages of this in the saving of time are obvious. 



THE ADMINISTRATION OF DIPHTHERIA ANTITOXIN. iqi 

Site of Injection. — ^The subcutaneous tissues of the outer aspect 
of the thigh, of the back part of the axilla near the angle of the scapula, 
or of the upper portion of the abdomen are usually chosen for the 
injection (Fig. 125). 

Asepsis. — The syringe and needles should always 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 carefully 
prepared by first washing with a little soap and warm water, followed 
by a I to 2000 solution of bichlorid of mercury, and then wiping the 
surface with alcohol and ether. 




Fig. 125.— Sites for antitoxin injection. 

Technic. — In order to prevent any undue excitement, the injection 
should be made with the patient in such a position that he cannot see 
what is going on; in children this is especially necessary. Care must 
be taken to expel any air from the syringe by elevating its point and 
depressing the piston a little. A fold of the skin from the area pre- 
viously sterilized is then raised up between the thumb and forefinger 
of the left hand, and, with the right hand, the needle is quickly plunged 
into the subcutaneous tissue (Fig. 126). If done quickly with a sharp- 
pointed needle, preliminary local anesthesia of the skin is unnecessary. 
The serum is then injected very slowly and the swelling produced is 
not massaged, being allowed to subside as the serum is absorbed. 
After withdrawal of the needle the puncture is sealed with collodion and 
cotton. Following the injection there may be a slight reaction consist- 
ing of some redness, edema, and pain at the site of puncture, but these 
usually subside in a short time. 

Effects of Antitoxin. — In favorable cases a prompt and marked im- 
provement in the local and general symptoms follows the use of antitoxin. 
In a few hours the pseudomembrane begins to lose its dirty color and 
becomes blanched and somewhat swollen. Within twelve to twenty- 
four hours the membrane loosens at the edges and rolls up, becoming 
detached in a mass, or in small pieces. This seems to take place more 
rapidly about the tonsils than elsewhere. The usual time for restora- 



£$2 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

tion to the normal condition in the throat is twenty-four hours to three 
or four days. Sometimes the membrane, after disappearing, forms 
again; such cases should promptly receive more antitoxin. 

In nasal diphtheria similar effects are observed, each irrigation 
bringing away small or large pieces of detached membrane. The 
nasal discharge and swelling soon diminish, and at the same time the 
mouth breathing ceases. 




Fig. 126. — Showing the method of injecting diphtheria antitoxin in the subcutaneous tissue 

of the axilla. 



In laryngeal diphtheria antitoxin prevents the extension of the mem- 
brane into the trachea and bronchi in the majority of cases, and since 
its introduction it has been necessary to operate upon a much smaller 
proportion of cases than formerly. 

The effects upon the constitutional symptoms are likewise impress- 
ive. In favorable cases the general condition of the patient improves 
noticeably -vvdthin twelve to twenty-four hours. The constitutional 
symptoms of toxemia disappear, the color and general appearance are 
altered, and the appetite begins to improve. The temperature may 
rise I or 2 degrees in the first four or five hours after 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 in two or three days. The 
persistence of fever is an indication for a second dose of antitoxin. 

The reduction in the mortality rate since the introduction of and- 



VACCINAnON. 



153 



toxin is well shown in the following table {Fig. 127) prepared by the 
New York Department of Health, the small reduction shown in the 
first three years of its use being explained by the fact that sufficiently 
large doses of antitoxin were not used at first and that the serum used 
later was more efficient. 

Complications. — In a certain percentage of cases skin eruptions 
develop after several days. These may be erythematous, scarlatifonn, 
morbiliform, or urticarial in character. Urticaria is said to follow in 



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^ "_ ^ I 


, ^ I 


^-\.„'''-':s ^, i 









Fig. 197. — Chart prepared by the New York Board of Health, showing ihe reduction in the 
mortality from diphlhetia since the introduction of anlitoxin. 

about 30 per ceni. of the cases and usually comes on from ihe eighth 
to the fourteenth day. It frequently develops upon the buttocks, ab- 
domen, and chest and may be the cause of great discomfort and annoy- 
ance to the patient. Infection and cellulitis may result from the injec- 
tion if due regard to asepsis is not obser\ed. 

Painful condirions in the large joints, as the hips, knees, wrists, and 
shoulders, occur in a small proportion of the cases. These symptoms, 
however, are not due to the antitoxin, but are caused by the horse 
serum, and depend upon the susceptibility of the patient to the serum. 



VACCINATION. 

Vaccination is the inoculation with the vaccine or virus of cowpox 
for the purpose of inducing that disease in man and thereby affording 
partial or permanent protection against smallpox. 

The immunity rendered by vaccination is not claimed to be invari- 



154 HYPODERMIC AND INTBAMUSCULAR INJECTIONS, ETC, 

ably complete. In a great majority of cases, though, a successful inocu- 
lation grants a person immimity to smallpox for a nimiber of years, 
though the effects may in time wear off and the individual again become 
susceptible. The mortality in such cases, however, is very low com- 
pared with the mortality in those who have never been vaccinated. 
According to Osier, in the former it is 6 to 8 per cent, and in the unvac- 
cinated not less than 35 per cent. 

The nature of the protection thus afforded is not absolutely imder- 
stood, but the results of vaccination are imquestionable and admirably 
attest its eflSciency. Localities in which vaccination is systematically 
carried out develop fewer cases and present the lowest death rate from 
smallpox. In Germany, since 1874, compulsory vaccination and 
revaccination have been enforced and since then there have been no 
epidemics of smallpox in that country. On the other hand, the results 
of disregard to the value of vaccination are well illustrated by the mor- 
tality rate of smallpox in European countries between 1893 and 1897, 
inclusive, quoted by Schamberg {New York MedicalJournal, Jan. 16, 
1909) from the Imperial Board of Health reports of the German Empire. 
He says: "We are startled to note in this period there died in the 
Russian Empire, including Asiatic Russia, 275,502 persons from small- 
pox, Spain lost over 23,000 lives, Hungary over 12,000, Austria and 
Italy over 1 1 ,000. In Germany the number of smallpox deaths dur- 
ing this period was only 287, representing one death to every 1,000,000 
of population a year." These statistics are certainly con\dncing. 
Compulsory vaccination and revaccination are without doubt the most 
efficient means for the prevention of smallpox. Where this is not 
possible, as in this country, physicians should take it upon themselves 
to see that every child coming under their care is properly vaccinated. 

The Virus. — The virus should always be obtained from a reliable 
source. That from the calf is to be used by preference. Humanized 
lymph should never be employed except upon imperative occasions 
when bovine lymph is not procurable. 

The virus is obtained under rigid aseptic precautions by curetting 
the pustule from a calf and making an emulsion of it with glycerin. 
This is then collected in capillary tubes and is hermetically sealed until 
used. The lymph should not be distributed until it has been tested for 
tetanus and other })athogenic germs, and an autopsy has been performed 
upon the calf to make certain it was free from disease. The lymph may 
also be obtained spread upon ivor>' or celluloid points, but they are not 
preferable to the capillary tubes as there is danger of the \irus being 
contaminated by handling. 



VACCINATION. 1$$ 

lime for Vaccination. — In choosing the time for vaccination the 
age and the general heahh of the individual should be taken into 
consideration. As a general rule, unless contraindicated, the child 
should be three to six months old before vaccination. The operation 
should be avoided if possible in dentition; and, in children who are 
delicate or suffering from malnutrition, syphilis, or skin eruptions, 
it should be postponed until the child is in good condition. The best 
season is in the early fall or spring when there is less danger of epidemics 
of contagious diseases, such as scarlet fever, measles, diphtheria, 
whooping-cough, etc. Upon exposure to smallpox, whether the indi- 
\'idual is in infancy or in old age, he should always be inmiediately 
vaccinated. 

Instruments. — ^A sharp-pointed scalpel or a lancet is as useful an 
instrument as can be found for performing the scarification. Sharp 


















 ' 


1 -s-'-'^"'--- — ■'"" --T^- 




==— -^==^=" 
















6 l-^ 







Fig. 128. — New York Department of Health vaccination outfit. 

I. Instruments in case; 2, rubber tube for blowing the virus out of the tube; 3, tube 
containing \irus; 4, needle for scarification; 5, stick for spreading the virus. 

needles may also be employed and, as they are cheap, the same needle 
need not be used for more than one case. Special scarificators are 
made, but they have no advantages over a lancet or a needle. If the 
vaccine points are used, no scarificator is necessary. 

The New York Department of Health supplies with each capillary 
tube of vaccine virus, a needle, a flat tooth pick for spreading the virus, 
and a piece of small rubber tubing which fits over one end of the 
capillary tube and is used to blow the vaccine out of the tube (Fig. 128). 

Site of Vaccination. — The vaccination is performed either upon 
the arm or leg. As a rule, the arm is preferred as a site, especially in 
children who are running about, as being more easily kept at rest and 
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 



156 



HYPODERIQC AND INTRAlfDSCDIAS INJECTIOl^, ETC. 



deltoid muscle; in the leg a. spot on the outer aspect at the jiucticm cl 
the middle and upper third is selected. 

Asepsis. — The operation of vaccination should be regarded as an im- 
portant one and, as most of its dangers are due to infection, the opera- 
tor should see that all aseptic precautions are observed. The instru- 
ment employed for scarifying the skin should be carefully sterilized 
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 soap and 
warm water followed by alcohol and ether and is allowed to dry. The 
use of strong disinfectants is not advised as the chances of a successful 
inoculation may be lessened. 

Technic. — Vaccination by the scarification method k generally 
practised in this country. Incision draws too much blood and the 




Fig. 119. — Vaccination. Firsi step, scarifying the 



virus is apt to be washed away. A proper spot is chosen upon the 
arm or leg, and an area 1/8 to 1/4 inch (3 to 6 mm,) in diameter is 
scarified by making a number of scratches at right angles to each other 
in the skin with the point of the instrument just deep enough to draw 
serum, but no blood (Fig. 129). If more than one inoculation is to be 
made, as is frequently done, the areas scarified should be at a distance 
of at least i inch (2.5 cm.) apart. The virus is then deposited upon 
the scarilied area, being rubbed in with some sterile instrument for a 
full minute and allowed to dry (Fig. 131). The site of vaccination is 
finally covered with a piece of sterile gauze held in place with two small 



VACCINATION. 




Fio. 130. — Vaccination. Second step, bbwing the virus out o( the capillar^' tube o 
small piece of wood. 




Fig. 131.— Vaccination. Tliird step. Rubbing the virus into the scarified 



158 HYPODERMIC AND INTRA MUSCUIAB INJECTIONS, ETC. 

Strips of adhesive plaster, or, if desired, a wire shield ^ig. 132) may be 
used, provided it is applied in such a way as not to constrict the arm 
(Fig. 133). After the vesicle has formed, the part should be gently 
washed with sterile water once a day and dressed with fresh gauze 
or covered with a shield to prevent contact with the clothing. 

Course of Vaccination. — Outside of a httle 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 hoius by the 
formation of a small vesicle which by the seventh or eighth day reaches 
its full development. It is usually round, 1/4 to 1/2 inch (6 to 12 mm.) 





Fio. 131. — Vaccination sliieli 



Fic IJ3 —Showing the shield in place. 



in diameter, and full of limpid fluid. The center of the vesicle is 
depressed, while the margins arc ele\'aled and slightly indurated. 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 com- 
mences 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. 

Constitulional symptoms more or less marked accompany the 
eruption. Remilicnt fever of from 101° to 104° begins on the fourth 
day and may persist until the eighth or ninth day, when it drops grad- 
ually to normal. In children irritability, loss of appetite, and rest- 
lessness at night may accompany the fever. The axillary or inguinal 



ACUPUNCTURE. 1 59 

glands become swollen and sore, depending upon whether the arm 
or leg is the seat of inoculation. 

Certain irregular types of vaccination are sometimes met with. In 
rare cases a generalized vaccine eruption with marked fever and 
other severe symptoms may occur. Single vesicles may also be 
produced on other parts of the body distant from the site of inocula- 
tion by autoinoculation from scratching. Sometimes the period of 
incubation is prolonged and the vesicle formation is delayed. 

Complications. — Urticaria, impetigo contagiosa, and rashes resem- 
bling those of scarlet fever or measles have been observed. Erysipelas 
may occur at any time before the sore heals. 

Suppuration and abscess of the axillary or inguinal glands some- 
times follow vaccination. In anemic and unhealthy subjects, if 
infection occurs, cellulitis and deep ulcers may form, followed by 
extensive loss of tissue and large scars. 

Syphilis is no longer feared under modem methods of vaccination; 
the same is true of tuberculosis, and it has been shown in addition 
that the tubercle bacillus is destroyed in glycerinated lymph. Tetanus 
can only follow carelessness and neglect of precautions in preparing the 
lymph. 

Revaccination. — Immunity furnished by vaccination is not per- 
manent, and in all persons revaccination should be performed several 
years after the first vaccination. The New York Health Department 
advises that revaccination be repeated at intervals of not more than 
three years if permanent immunity is to be acquired. The vaccination 
should be as thoroughly carried out as in the first instance. In cases 
of exposure to contagion during the interv^al, revaccination should be 
performed at once. 

ACUPUNCTURE. 

This is a small operation which consists in the insertion of needles 
or other small sharp instruments either into the superficial tissues for 
the purpose of relieving the tension in swollen or edematous areas, or 
directly into muscles or nerves for the relief of the pain of muscular 
rheumatism or of neuritis. 

For the relief of tension, and to furnish an exit for the effusion be- 
neath the skin, acupuncture is frequently employed in edema involving 
the extremities, labia, or scrotum, though, if the tissues are so greatly 
distended that sloughing seems imminent, incisions should be substi- 
tuted for the punctures. In acute epididymitis and similar cases acu- 
puncture is also often used with good results. 



l6o HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

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 nerve stretching, 
etc., are instituted. 

Instruments. — ^To relieve tension the punctures may be made 
with triangular-pointed surgeon's needles or with a very narrow- 
bladed bistoury (Fig. 134). Employed for the relief of the pain of 
muscular rheumatism or neiuitis, half a dozen cylindrical needles 
about 3 or 4 inches (7 . 6 to 10 cm.) long will be required. Long darn- 
ing needles or sharp hat pins will answer very well. 




:> 



Fig. 134. — ^Instniments for acupuncture. 

Asepsis. — ^The skin should be carefully sterilized by washing with 
warm water and soap, followed by a i to 2000 solution of bichlorid of 
mercury; the instruments are to be boiled; and the operator's hands are 
cleansed 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 operation, 
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 
making a single or, when required, numerous deep stabs with the 
needle 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 
saturated with some mild antiseptic, as boric acid. 

WTicn treating muscular rheumatism by this method, several sharp 
round needles are thrust through the skin into the painful parts of the 
affected muscle to a depth of i to i 1/2 inches (2.5 to 3.8 cm.), or 
more, depending on the amount of adipose tissue, and are allowed to 
remain in place five to ten minutes. In remoxing them, care must be 
taken not to break them ofif in the tissues. Not infrequently the relief 
of pain is immediate. 



VENESECTION. l6l 

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 
sciatic there is usually no trouble. The patient's sensations will be a 
guide as to whether the nerve is reached, for, as soon as this occurs, 
a sharp pain will be felt different from that experienced as the needle 
passes through the superficial tissues. The needles when properly 
placed should be left in site about five or ten minutes. 

VENESECTION. 

Venesection, or phlebotomy, is an operation that consists in the 
opening of some superficial vein and the abstraction of blood from the 
general circulation for therapeutic purposes. 

The beneficial effects of bleeding have been recognized from the 
time of Hippocrates. Unfortunately, though, bleeding was formerly 
much overdone, and in the early part of the last century it came to be 
the custom to bleed indiscriminately for almost any sickness. In conse- 
quence of its abuse this valuable operation has lost much of its popu- 
larity and is now but rarely practised. Popular prejudice, furthermore, 
often prevents its employment, so that even in cases where it is of un- 
doubted therapeutic value the practitioner of to-day prefers to put his 
trust in drugs to accomplish the desired effects. In spite of this neglect, 
however, bleeding is a powerful and beneficial therapeutic measure 
when employed in the proper class of cases, and as Hare points out 
*' the indications for venesection are as clear and well defined as are 
the indications for any remedy." 

Indications. — These may be better appreciated by an understanding 
of what venesection accomplishes. In the first place, through the 
mechanical effect upon the circulation of removal of a quantity of 
blood, the tension in the blood-vessels is diminished, and the vascular 
tone becomes more evenly balanced, so that an engorged area, where 
the vessels are relaxed and dilated, is relieved. At the same time the 
speed of the circulating blood in the capillaries is accelerated, and 
stasis is further prevented, and the absorption of exudates hastened. 

Upon the general system venesection also has beneficial effects caus- 
ing a lessened activity of the various functions; the cardiac and respira- 
tory actions become quieter, the temperature is lowered, and cell 
proliferation is less active. 

In general, then, it may be said that venesection is indicated for the 
II 



l63 



HYPODEKHIC AND INTRA MQSCULAK INJECTIONS, ETC. 



relief of congestion in cases of excessive vascular tension evidenced by 
a rapid, strong, full, incompressible pulse, while low arterial tensioa 
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 cyanosis, in pleurisy, 
peritonitis, pulmonary edema, pulmonary hemorrhage, emphysema 
with marked dyspnea and cyanosis, congestion of the brain, cardiac 
valvular disease with engorged right heart, bleeding both lowers vascu- 
lar tension and relieves engorgement. In cases where toxins or other 
deleterious substances are present in the blood, as in eclampsia, uremic 
convulsions, illuminating-gas poisoning, poisoning by hydrogen sulphid, 
prussic acid, etc., bleeding serves the double purpose of reducing arterial 
tension and removing a definite quantity of toxic niaterial. Large 
quantities of blood may be abstracted in such cases, followed by 
transfusion or saline infusion (the so-called "blood washing") with 
unquestionably good results. 




Fig, 135, — Instruments for vi 
I, Glass graduate; 2, ethyl chlorirt; 3, scalpel; 4, stick for patient to grasp; 5, bandages. 

Instruments. — ^Thore will be required a scalpel or bistoury, a sterile 
gauze pad, several bandages, a round object as a stick or roller band- 
age for the patient to grasp, and a large glass graduate (Fig. 135). 

Quantity Withdrawn.^On an average from 6 ounces (180 c.c.) 
to 13 ounces (360 c.c.) may be abstracted from an adult, and from 
I ounce (30 c.c.) to 3 ounces (90 c.c.) from a child, depending on the 
condition and the character of the pulse and upon ihe apf^arance of 
the patient. This amount may be increased, however, if the venesec- 
tion is to be supplemented by transfusion or saline infusion. Under 



VENESECTION. 163 

such conditions 20 ounces (600 c.c.) or more may be removed from an 
adult. 

Site of Operation. — Some one of the large veins in front of the elbow- 
joint is usually selected (Fig. 136), but the internal jugular or internal 
saphenous may be utilized. 

Position of the Patient — The patient should be sitting upright or 
in a semireclining position on a couch, with his head turned away 
from the seat of operation, as the sight of blood may cause faintness. 




Fig. 136. — Superficial veins at ihe foreann. (Ashton.) 



The semiupright position is a safeguard against withdrawing loo 
much blood, as the patient becomes faint sooner than if he were lying 
down. 

Asepsis. — While this is a small operation, at the same time all 
aseptic precautions should be observed. In former times many 
palicnts lost their lives from septic thrombosis. Accordingly, the in- 
struments 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 washed with warm water and soap, then rinsed 
with a I to 2000 solution of bichlorid of mercury, and finally with sterile 
water. 



164 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



Anesthesia. — The area of incision may be anesthetized by infiltrat- 
ing with a few drops of a o. 2 per cent, solution of cocain, or by freezing 
with ethyl chlorid 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 obstruct 
the venous circulation and make the veins stand out prominently 
(Fig. 137). By directing the patient to grasp some object and work 
his fingers while the arm is hanging down, the veins will become even 
more distended. The operator next identifies either the median 




1^ 






1 1 
1 1 

I ! 



\ 



1 



y 



/ i 



Fig. 137. — Vjenesection. First step, showing the application of the bandage to the arm. 

(Ashton.) 

basilic or median cephalic vein, and, compressing it with his left thumb 
placed just below the seat of incision, makes a small cut transversely 
to the long axis of the vein (Fig. 138), which is exposed by dissection 
and a small opening made in its anterior wall (Fig. 139). The thumb 
is then removed and the blood is permitted to escape into a glass grad- 
uate (Fig. 140). 

While cutting down on the vein care must be taken not to disturb 
the relative positions of the skin and vein by drawing on the skin, other- 
wise 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 tissues. If 
the median basilic vein is utilized, the incision into its wall must not 
be made too deeply for fear of wounding the brachial artery. 



VENESECTION. 



i6s 




Fic. 138. — Venesection. Second step, vein exposed and opeia.foi's finger compressing 
the distal portion of the vessel. 

Fig. 139. — Venesectian. Third step, showing incision into vein walls. 




Rc 140. — Venesection. Fourth step, showing the operator's finder removed from the 
vein and the blood being collected in a glass graduate. 



l66 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

When a sufficient quantity of blood has been abstracted, a gauze 
pad is held over the wound by the thumb, and the bandage is re- 
moved from the arm. The incision is then dressed with a sterile 
gauze compress held in place by a bandage. The patient should be 
instructed to carry the arm in a sling for a few days following this 
operation. 

Complications. — ^The most serious complication is a puncture of 
the brachial artery by the incision into the vein producing an arterio- 
venous aneurysm. This may be avoided by carefully cutting down 
upon the vein and not incising skin, superficial tissues, and vein at one 
cut. 

Sometimes a very painful neuralgia is a sequel to the operation, 
probably due to injury to some of the cutaneous nerves of the region. 
If the instruments are clean and proper aseptic precautions are ob- 
served, septic thrombosis is not to be feared. 

SCARIFICATION. 

Scarification consists in making multiple incisions into the tissues 
for the relief of local congestion or tension. By this method of local 
bleeding, engorged blood-vessels are emptied and effusions of serum 
are permitted to escape; thus imdue tension from exudates is relieved, 
and the tendency of the tissues to slough is lessened. 

For the relief of inflammatory conditions of the skin and mucous 
membranes scarification finds its chief application. Thus in inflamed 
ulcers, threatened gangrene from extreme tension, phlegmonous 
erysipelas, etc., prompt relief often follows its use. Scarification may 
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- 
matory affections and edemas of the pharynx, uvula, tonsils, and glottis 
it is often indicated; in involvement of the latter with progressive dysp- 
nea and cyanosis the scarification should be performed without any 
delay. 

Instruments. — An ordinary scalpel or bistoury is all that is necessary. 
A special scarifier (Fig. 141) may be employed, however, if desired. 
This instrument consists of a metal box containing a number of sharp 
blades, which, upon touching a spring, are suddenly forced out in 
such a way as to cut the tissues to which the instrument is applied to 
any desired depth. 



SCARIFICATION. 



167 



For incising the tonsil, glottis, etc., a sharp-pointed curved 
bistoury wrapped with adhesive plaster to within 1/4 inch 




Fig. 141. — ^Automatic scarificator. 

(6 mm.) of its point (Fig. 142) should be employed in the absence 
01 a protected laryngeal knife (Fig. 143). 

Asepsis. — ^The operation must be performed with all the usual 
aseptic precautions. 




Fig. 142. — Knife wrapped with adhesive plaster. 

Anesthesia. — Where extensive incisions are required, as in urinary 
fxtravasalion, for example, nitrous oxid anesthesia will be required. 
In other cases local anesthesia with a o. 2 per cent, solution of cocain 





Fig. 143. — Protected larj-ngcal knife. 

or by freezing, if the nutrition of the parts is unimpaired, will suffice. 
Mucous surfaces may be anesthetized with a 4 per cent, solution of 
cocain sprayed upon or applied directly to the parts. 



l68 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

Technic. — ^The incisions are made in parallel rows over the inflamed 
area, and, according to the indications, they may or may not extend 
through the entire thickness of the skin. They should always be made 
in the long axis of a limb (Fig. 144) and in other regions 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 serum. 




Fig. 144. — Showing the method of scarifying a limb. 

Scarification of the lar3mx should always be performed with the 
aid of laryngoscopy (page 357). When a clear view of the edematous 
parts has been obtained, incisions about 1/4 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 larynx. 
A gargle of hot water or an inhalation of steam is then employed to 
encourage the bleeding and escape of the serum. This often gives 
complete relief in a few hours; if the symptoms are not improved, 
however, or the dyspnea recurs, tracheotomy (page 392) must be 
performed without hesitation. 



DRAINAGE IN EDEMA OF THE LOWER EXTREMITIES. 

There are three operative procedures that may be employed for 
relieving edema of the lower extremities when the tension becomes too 
great, namely, multiple punctures (page 159), incision (page 166), and 
drainage by the trocar and cannula. Of these, the latter is less trouble- 
some, more cleanly, and certainly far more comfortable for the patient. 

From one to four cannulae 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. 



DRAINAGE IN EDEUA OF THE LOWER EXTREMITIES. I69 

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 should, of course, be 
immediately stopped and stimulants administered. 

Apparatus. — Southey's tubes (Fig. 145) or those of Curschmann 
may be employed. The former come in a set consisting of one trocar 
and four cannula. Each cannula has a lateral as well as a distal 
opening. The lumen of the cannula is about 1/25 inch (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. 




Fio. 145. — Southey's trocars and 



Sites of Puncture. — The back or outer sides of the legs are usually 
chosen. 

Asepsis. — Rigid asepsis should be observed to avoid infection. The 
trocar and cannula are boiled, the operator's hands carefully cleansed, 
aod the spot chosen for puncture is first washed with green soap and 
water, then with a solution of bichlorid of mercury (i to 2000), and 
finally with alcohol. 

Techoic. — 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 the 
chosen site. The trocar is then removed and to the free end of the 
cannula is attached a rubber tube filled with some antiseptic solution. 
The dbtal end of the tube is allowed to drain into a basin placed upon 



170 HYPODEBHIC AND INTRA UUSCUIAB INJECTIONS, ETC. 

the floor by the side of the patient's bed (Fig. 146). The canttuk 
should be secured in place by means of adhesive plaster, and sterilized 
dressings should be placed about it. Care should be taken that the 
cannuke are not displaced, and for thb reason, with restless patients, 




Fio. 146. — ShowioK the mcihod of draining an edematous limb with Southey's ainnuk. 
(After Gumprecht.) 

it is better to remove them at night. It is preferable in any case to 
make new punctures than to leave the cannula in place for several 
days. After removal of the cannula, the sites of the punctures should 
be sealed with collodion and cotton. 



cuppmG. 

Cupping niay be either dry or wet according to the method of 
application. Dry cupping produces a local congestion of the super- 
ficial tissues and relieves congestion of the deeper subjacent organs 
by deviating the blood from these parts. Wet cupping, in addilion, 
actually abstracts blood from the tissues. Cupping finds its chief 
application in the relief of congestion of deeply placed organs as the 
brain, spinal cord, lungs, liver, kidneys, etc. 

Apparatus. — Special cupping glasses supplied with a rubber bulb 
(Fig. 147) for exhausting the air are oblainal)le and will be found very 
convenient, but the ordinary cupping glasses in which the vacuum is 
created by igniting a little alcohol smeared over the interior of the cup 



COPPING. 171 

are just as efficient. In an emergency, 2-ounce (59 c.c.) whisky or 
n-ineglasses, or thick tumblers with smooth rounded edges will answer 
equally well. From 8 to 12 cups will be required in dry cupping and 
from 3 to 6 in wet cupping, depending upon the extent of surface to 
which they are to be applied. In addition there should be provided 



Fig. 147. — Bulb form of tupping glass. 

some alcohol, a small stick to the end of which a cotton swab is attached, 
and matches or an alcohol fiame. If wet cupping is to be employed, 
there will also be required a sharp scalpel or lancet (Fig. 148). 

Sites of Application. — Cupping glasses are never to be applied 
directly ovtT inflamed tissues on accoimt of the pain that would result. 




Fig. 148. — Instruments for wet cupping. 
I, Cupfung glasses; 3, swab in alcohol; 3, alcohol lamp; 4 



calpel. 



Xor should they be placed over bony or irregular surfaces on account 
01 the impossibility of excluding air. Where Ihe brain is the 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 con- 



173 



HYPODERMIC AND INTRAMUSCUIAR INJECTIONS, ETC. 



gestion or acute nephritis, to the lumbar regions; in affections ot the 
eye, to the temples; etc. Wet cups, however, are often followed by 
scarring; hence they should not be applied over conspicuous regions or 
upon the shoulders or chests of women. 




Fic. 149. — Cupping. First step, swabbing the 



of Ihe cupping glass with alrohoL 



Technic. — i. Dry Cupping. — Any hair should be first shaved off 
the part and the surface of the skin dampened with warm water so that 
the cups will adhere. To apply cups supplied with an exhausting bulb, 
simply compress the rubber bulb, then place the cup upon the skin, 




Fio. 150. — Cupping. Second step, igniting ihe alcohol in the cupfung glass. 



and release the bulb, A partial vacuum is thus produced and the skin 

and underlying tissues engorged with blood are sucked up into the cup. 

When ordinary cups are employed, the swab, saturated with alcohol, 

is lightly wiped over the interior of each cup (Fig. 149), care being 



CUPPING, 173 

taken not to leave any excess of alcohol that may nti^ down over the 
edges. The alcohol is then ignited (Fig. 150), and the cup is quickly 
and tightly applied to the skin. The contained air is rapidly ex- 
hausted by the flame, and, as the cup cools, a strong vacuum is created, 
which draws up the underlying tissues (Fig. 151) and produces local 
congestion. A number of cups — anywhere from eight to ten — may be 
applied in the same manner over any given region. If the cups are 
air-tight, the flame is extinguished before the patient feels the heat 
from the burning alcohol. When the swelling of the skin and under- 
lying tissues has taken place to such an extent as to replace the ex- 




' 

Fig. 151.— Cupping. Third step, the application of the cups. 

hausted air, the cups become loosened and drop off. If, however, 
it b 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 the glass and 
thus allow air to enter. 

2. Wet Cupping. — By this method a definite amount of blood may 
be removed, each cup being capable of abstracting from i to 3 drams 
(3.75 to 11.25 c-C-)- The cups are first applied to the region as 
already described; then with a scalpel parallel incisions about 1/3 inch 
(8.5 mm.) ap)art are made, care being taken to incise the skin only, 
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 
then immediately applied for the second time. Blood will be drawn 



174 HYPODERMIC AND INTERMUSCULAR INJECTIONS, ETC. 

from the scarified area into the cups until the vacuum is exhausted and 
the cups fall off. If it is desired to withdraw more blood, the cups 
are emptied and, after washing away the clots from the cut surface, 
they are applied again, or hot fomentations may be employed to en- 
courage the bleeding. When sufficient blood has been withdrawn, a 
sterile gauze dressing is applied over the scarified region. 

LEECHING. 

Leeching may be employed for the purpose of abstracting blood 
from contused or congested areas inaccessible to wet cupping. It is 
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 small 
American leech which is capable of withdrawing about a dram (3.75 
c.c.) of blood and the Sweedish leech which will suck from 3 to 4 drams 
(11.25 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. Only 
those coining from clean, uncontaminated water should be used. 

Sites of Application. — It should be remembered that the leech 
produces a triangular cut in the skin which results in a permanent 
scar, hence they should not be placed upon conspicuous portions of the 
body. They should never be applied to regions where there is much 
loose cellular tissue, such as the eyelids, labia, scrotum, or penis, for 
extensive ecchymoses may be the result. As their bite is irritating, 
they should not be applied directly to an inflamed area; instead, they 
are to be applied to the periphery. They should never be allowed to 
take hold of the skin directly over a superficial artery, vein, or nerve. 

Leeches are generally applied to the temples or the back of the 
neck in congestion or inflammation of the brain, to the mastoid and 
in front of the tragus in acute mastoiditis and acute otitis media, to 
the perineum when the scrotum, penis, or labia are the regions affected, 
and to the coccyx for the relief of congested or inflamed hemorrhoids. 

Preparation of the Skin. — To avoid infection the skin over the 
region to which the leech is applied should be washed with soap and 
water. If the part is hairy, it should be first shaved. 

Technic. — The leech is applied to the part and confined under 
a pill-box or wineglass until it takes hold. A special leech-tube or a 
test-tube may be employed for this purpose, in which case the leech 
is placed in the tube tail or large end first and the tube is then inverted 
so that the leech's head comes in contact with the skin. This may 



LEECHING. 175 

be removed as soon as the leech takes hold, but, in employing leeches 
about the orifices of mucous cavities, they should always be confined 
so as to prevent their escaping into the interior. If the leeches are 
removed from the water an hour or so before using, they will take 
hold more readily. Making a puncture of the skin and applying the 
leech to the bleeding spot or rubbing the skin with sweetened water 
or milk will cause the leech to take hold, if it does net seem inclined to 
do so. When once the leech haS begun to draw blood, it should not 
be pulled ofiF — ^it will let go of itself when filled. If it is 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 
the leech bleeding can be encouraged and often an ounce (30 c.c.) or 
more of blood may be withdrawn in this way. After removal of the 
leech 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 became infiltrated with 




Fig. 152. — Artificial leech. 

material excreted from the throat of the leech which prevents coagula- 
tion of the blood. The bleeding can usually be controlled, however, 
by compression or by applying a piece of cotton saturated with some 
styptic, as a solution of i to 1000 adrenalin chlorid, alum, or tannic acid. 
The use of the actual cautery or passing a harelip pin or needle beneath 
the bite and winding a thread about the two 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 employed instead 
of live leeches. It consists of a small cupping apparatus combined 
with a scarifier (Fig. 152). The latter is in the form of a small steel 
cylinder containing a circular lancet propelled by a cord or a spring. 
The skin is first scarified, by drawing upon the cord which cause3 the 



176 



HYPODERMIC AND INTEAMDSCULAR INJECTIONS, ETC. 



lancet to rapidly rotate, as shown in the accompanying illustration (Fig. 
153)1 the blades of the instrument being adjusted so as to cut to the 




Fio. 15J. — AppUcalion of the artificial leech to the mastoid. (After Ballenger.) Fint 
step, showiog (he method of scarifying. 




Fig. 154. — Application of the artificial leech to the mastoid. (After Balienger.) Second 
step, withdrawing blood. 

desired depth. Then the cupping tube is applied and blood abstracted 
by withdrawing the piston and creating a vacuum (Fig. 154). With 
this instrument as much as i ounce (30 c.c.) of blood may be drawn. 



CHAPTER VIT. 

BIER'S HYPEREMIC TREATMENT. 

While the value of artificially producing hyperemia with the definite 
purpose of increasing the inflammatory reaction has only recently 
been recognized, this mode of treating inflammation has been uncon- 
sciously employed for centuries. Hot applications, hot air, poultices, 
counterirritants, scarification, blisters, etc., which were formeriy used 
with the idea that they lessened congestion in deeply inflamed areas 
through the production of a local hyperemia, we now know have no 
such action, but instead cause a marked hyperemia of the deeper as well 
as the superficial structures. 

It is likewise interesting to note that as early as the sixteenth century 
Ambroise Par^ employed artificial congestion in delayed union of 
fracture due to insufficient callus formation. Others later and inde- 
pendently have called attention to the value of hyperemia in similar 
conditions. To Bier, however, belongs the credit of placing treatment 
by hj-peremia upon a logical and scientific basis, and of demonstrating 
its great practical value. 

As is well known, there are two distinct forms of hyperemia, namely, 
active and passive. The former, obtained by means of dry hot air, 
produces a more active flow of arterial blood through the parts, and is 
especially useful for the absorption of the products of chronic, non- 
tuljercular inflammations. The passive, venous, or obstructive form 
of hN-peremia, 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 
obsenations of Farre and Travers who, as far back as 1815, called 
attention to the frequency of phthisis in persons whose lungs were ren- 
dered anemic because of stenosis of the pulmonary orifice, and by 
the reverse of this, namely, the rarity of pulmonary tuberculosis in 
indi\iduals suffering from cardiac conditions tending to produce con- 
12 177 



178 BIER*S HYPEREMIC TREATMENT. 

gestion or hyperemia of the lungs, as later pointed out by Rokitansky. 
Impressed by these observations, Bier conceived the idea of artificially 
producing a hyperemia for the cure of tubercular affections in other 
parts of the body. Encouraged by the results obtained in the treat- 
ment of tubercular affections, he soon extended the use of h)rperemia 
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 de\dsing variously 
shaped glass cups and vacuum apparatus for producing a h)rperemia 
of regions of the body not amenable to the constricting band, though it 
is true Bier had himself employed this method previously and had 
abandoned it. 

Treatment by hyperemia is based on the theory that infliammation 
represents nature's efforts for protection of the body against bacterial 
invasion and in the restoration of a part to a healthy condition. Bier's 
teachings in regard to inflammation take exactly the opposite view 
from what has hitherto been held and taught. Formerly it was the aim 
of treatment to combat in every way possible the phenomena accom- 
panying an inflammation. In the presence of pain, heat, redness, 
and swelling, cold applications, elevation of the part, rest, and immobili- 
zation were advocated for the relief of these symptoms. According 
to Bier, however, the redness, heat, and swelling of an inflammation 
are but the outward signs of the effort on the part of nature to over- 
come noxious influences and produce a cure; and these are to be en- 
couraged as beneficial instead of combated. An attempt was 
accordingly made to artificially reproduce the most e\ident of these 
phenomena, namely, congestion or hyperemia, and thereby 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, 
the 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 most 
striking — the more marked, the earlier the treatment is begun. 

Diminution of Pain. — The prompt relief of pain is one of the most 
remarkable features of the treatment. Accepting the theory that pain 
from an inflammation is due to irritation of the cells and end organs 
by toxins, as well as to the high specific gra\ity of the inflammatory 



PASSIVE HYPEREMIA. 1 79 

exudate, its relief under the influence of hyperemia, which 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 technic is at 
fault. The patient should always be impressed with the necessity of 
reporting any discomfort in the part subjected to the hyperemia, and 
his sensations should be an important guide for the operator. 

Through the prompt decrease of pain and sensitiveness, reflex 
contracture of muscles is avoided and earlier motion in a part is possi- 
ble. This is especially important in infections involving tendon 
sheaths and joints, as with early motion much better functional results 
are possible. Even in an extremely sensitive joint, it is remarkable 
how quickly slight motion may be painlessly practised under hyperemia. 

Bactericidal Action, — It has been shown by experiments upon 
animals as well as by clinical evidence that hyperemia is fatal to bac- 
terial life. Notzel succeeded in fifty-one cases out of sixty-seven in 
counteracting the effects of fatal doses of anthrax and streptococci 
injected into the extremities of rabbits, by first inducing congestion 
in these parts, the same doses later, in the absence of hyperemia, prov- 
ing fatal. Clinical experience also proves that certain forces are brought 
to bear by the hyperemia which either directly or indirectly antagonize 
bacterial growth and either destroy or dilute the toxins. Beginning 
infection, such as a furuncle or a carbuncle, in which redness, tender- 
ness, swelling, and slight infiltration are the only signs present, can 
thus often be made to subside without suppuration, while, if suppura- 
tion has already developed, the infectious process may be prevented 
from extending to the deeper tissues and the clinical course be greatly 
shortened. Accidental soiled wounds, which from experience we have 
every reason to believe will become infected, under the influence of 
hyperemia can often be made to heal without infection, and not infre- 
quently by primary union, and there is no better means than the 
increased secretion induced by the hyperemia for thoroughly flushing 
out and rapidly cleansing these dirty wounds. 

There is considerable difference of opinion as to the agent underly- 
ing this bactericidal action, and several theories have been advanced 
in explanation. Some believe that it is due to an increase in the phago- 
cytes; some consider the carbonic acid of the venous blood to be the 
agent; others offer Wright's theory as to increase of the opsonic index 
as the beneficent factor; and still others claim that the increased 
transudate induced by the hyperemia mechanically flushes out the 
affected part and thereby dilutes the toxins and removes dead bacteria. 



l8o bier's HYPEREmC TREATMENT. 

It is difficult to say which is the exact cause. Bier himself, I believe, 
inclines to the phagocytosis theory. Personally, the writer feels that 
the mechanical flushing of the part by the increased transudate is 
quite an important factor, especially in the presence of open wounds 
or sinuses. 

Limitation of the Pathological Process. — Under hyperemia, necrosis 
of even badly damaged parts is often prevented by the superabundant 
nourishment of the tissues, or, when the infection has advanced to the 
destruction of tissues, the disease process is more promptly localized, 
and a line of demarcation between the healthy and diseased tissues is 
earlier in evidence. Sloughs and sequestra are thus early separated 
and cast off, while in tubercular affections connective tissue replaces 
the tubercular, and the disease gradually dies out. 

Solvent and Absorbent Action, — Both the active and the passive 
forms of hyperemia act as solvents, while the active, in addition, has 
a very marked absorbent action. The products of inflammation, as 
infiltrations, exudates, and plastic changes, are dissolved, so to speak, 
and their absorption is thus favored. Careful application of hyperemia 
thus makes unnecessary many of the operations of resection, etc. This 
is well illustrated in the excellent functional results, with freedom 
from ankylosis and deformity, obtained in tubercular and other 
joint affections. 

Indications. — ^Passive h)rperemia has been recommended for all 
kinds of acute inflammatory processes and many of the chronic ones, 
and the literature of the past few years teems with numerous favorable 
reports of its use, not only in purely surgical affections, but in the 
specialties and in medicine as well. 

The surgical conditions in which it has been found to be especially 
beneficial may be summarized as follows: Acute infections and in- 
flammations, such as furuncles, carbuncles, felons, infected wounds, 
infection of tendon sheaths, lymphangitis, lymphadenitis, mastitis, 
gonorrheal arthritis, and other forms of acute infections of joints, acute 
bone infections, burns; as a prophylactic measure in soiled or dirty 
wounds, compound fractures; in chronic affections, such as tuberculosis 
of bones, joints, glands, tendon sheaths, testicles; delayed union of 
fractures; fistulae; old discharging sinuses; and infected leg ulcers un- 
complicated by varicose veins. Its use is, however, contraindicated 
in lesions complicated by thrombosis of veins. In erysipelas its value 
is doubtful; in fact, erysipelas has been known to develop under pro- 
longed hyperemia in tubercular lesions which were complicated by open 
sinuses. In diabetes, likewise, the results have not always been good. 



PASSIVE HYPEREMIA. l8l 

Passive h)rperemia has also been employed with success in medicine 
for such conditions as acute rheumatism, gout, and pulmonary tuber- 
culosis. For the latter condition Kuhn has devised a mask of thin 
celluloid which by means of an adjustable valve cuts ofiF some of the air 
entering the alveoli and thus induces a suction hyperemia. 

In a host of other affections falling within the domain of rhinology, 
otology, gynecology^ obstetrics, and dermatology, passive hyperemia 
has been recommended and applied with varying degrees of success, 
but further experience and investigation will be necessary before it can 
be stated precisely what are the therapeutic indications and contrain- 
dications of this very valuable method of treatment. 

General Principles Underlying Hyperemic Treatment. — ^As em- 
phasized by the author of this method of treatment, and others, it is 
not a panacea or cure for all troubles. One should recognize that it 
has its limitations. In some of the milder forms of infection, complete 
cure may often be eflfected by hyperemia alone; in other cases, of the 
more severe infections, it forms only a part of the treatment, and opera- 
tive interference should never be delayed when indicated. Pus must 
always be promptly evacuated when presenty and cold abscesses like- 
wise are to be opened. This is accomplished by small incisions or 
punctures, the old-time extensive incisions, which often result in 
unsightly scars and even deformities, being unnecessary under this 
form of treatment. The hemorrhage incident to such incisions should 
be controlled by packing the wound for two to three hours before the 
hyperemia is induced. In an infection of the tendon sheaths, the 
anatomy of the parts should be carefully kept in mind and the incisions 
made accordingly. Small multiple incisions are employed and should 
be so placed as to avoid cutting the transverse palmar ligaments oppo- 
site the finger joints. In the case of infection of a large joint, the pus is 
aspirated and the joint cavity is irrigated through a large trocar; in 
other localities, ordinary surgical principles should be the guide as to 
the incision. The curettages of abscess cavities is avoided, while 
drains and tampons are discarded, as the secretions that are poured 
out under the artificial hyperemia serve to keep the wound open. Cer- 
tain cases of very rapidly extending infection, with acute onset, how- 
ever, require early incision in conjunction with the hyperemia, even 
before softening has occurred. If incisions are not made, the hyper- 
emia may do harm and the local inflammation become worse, for the 
transudate which is induced by the hyperemia, added to the exudate 
already present, has no outlet and may drive the bacteria and their 
toxins into healthy tissue and favor the extension of the infection. 



l82 BIER*S HYPEREMIC TREATB4ENT. 

In inflammations involving joints or tendon sheaths, mild active 
and passive motion is carried out from the first day, in order to obtain 
the best functional results, provided this can be done without producing 
pain. Slight motion is harmless so long as it is painless. For this 
reason, no immobilizing dressing need be applied during the treatment, 
open wounds being merely covered with moist antiseptic gauze. 

In acute infections, the results are often prompt and most striking. 
In favorable cases, the temperature declines, pain is relieved, extension 
to deeper tissues is prevented, and the process rapidly subsides or at 
least the clinical course is much shortened. Swelling and redness are 
temporarily increased, and are to be expected as part of the treatment. 
The discharge from' open wounds is at first most abundant, but this 
likewise rapidly subsides, and with it the edema and redness. 

In chronic lesions of a tubercular nature, the treatment must be 
carried out for months. In the case of joints, the pain and swelling 
slowly diminish, the contour of the joint again becomes distinguishable, 
and mobility gradually increases; secretions from sinuses become serous 
instead of purulent, the sinus taken on a healthy appearance and finally 
closes. In tubercular 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 shoulder can thus usually 
be dispensed with — a sling at most is used — but in knee or foot 
tuberculosis a suitable apparatus should be worn, or the part so immo- 
bilized 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 tubercu- 
losis of joints the following: 

1. Commencing amyloid disease and advanced pulmonary involve- 
ment. 

2. Large abscesses, filling up the whole joint cavity and demanding 
operation. 

3. Faulty position of the joint, such that cure would give a joint 
less 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 this 
method may be ascribed to errors in this direction. It certainly requires 
time and close attention, as well as considerable experience on the 
part of the attendant, to obtain good results; but, if the treatment be 



PASSIVE HVPEREUIA. 183 

properly carried out with perseverance, one will be amply repaid. At" 
first the patient must be carefully watched as, with the use of the elastic 
band, for instance, it may be necessary to remove or reapply the con- 
striction several times in the course of a single treatment in order to 
maintain the proper degree of hyperemia. Intelligent patients may 
later be instructed in carrying out the treatment with either the bandage 
or the cup, and in time they themselves can apply the treatment at 
home, but they should always remain under the supervision of the 
surgeon. 

Hetbods of Produdng Passive Hyperemia. — As already indicated, 
the passive form of hyperemia may be obtained 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 is 
the oldest method of producing an obstructive hyperemia. It is 
especially applicable to affections invohing the extremities, head, and 
neck. The hip-joint is the only one in either of the extremities to 
which the method cannot be satisfactorily applied. There is no 
doubt that the proper application of the band requires more skill than 
does cupping. Exact technic is necessary, and great caution must be 




Fig. 155. — Esmari'h elastic bandage for obstructive hyperemia. 

obser\-ed not to exceed the proper grade of hyperemia, and in tuber- 
cular cases not to lower the vitality of the tissues by too prolonged ob- 
struction. Only a mild hyperemia is necessary to produce results; 
otherwbe, distinct harm is done. For this reason, the bandage should 
be applied by the surgeon himself until an intelligent and compelcnl 
person of the household can be instructed in its proper application. 

Apparatus. — For most cases, a soft, thin elastic bandage, such as 
Esmarch's or Martin's, alxiut 2 1/2 inches (6 cm.) in breadth, is 
employed (Fig. 155). 

For the shoulder-joint and testicles, rubber tubing is used in place 
of a bandage. That used about the shoulder should be of fairly stout 
rubber, and about a foot long (30 cm.) ; while for the scrotum, a catheter 
or a piece of drainage-tube of small size answers. 



184 bier's hyfekeuic tkeatuent. 

To produce h3'peremia of the head and neck, a rubber bandage 
measuring about i 1/4 inches {3 cm.) in width may be used, or a special 
neck-band made for the purpose may be obtained. A garter elastic, 
about I inch (2.5 cm.) in width and provided with hooks and eyes 
so that it may be adjusted to any size, as shown by the accompanying 
illustration (Fig. 156), answers the purpose admirably. 

Site of Application. — The constriction should always be applied 
over healthy tissue and well above the area of infianunation. 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 little 
either up or down the limb. 




Fig. 156. — Elastic garter Cor producing obstructive hyperemia of the Deck. (After Meyei- 
Schmieden.) 



Duration of Application. — In the treatment of acute processes, the 
best results arc obtained from prolonged stasis, namely, from twenty to 
twenly-two hours a day. The bandage is accordingly applied 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 daily constriction may be dimin- 
ished until it is only of from one to two hours. 

For tubercular affections shorter applications are used, the band- 
age being applied once or twice a day from one to four hours at a time. 
In his early work on tubercular affections, Bier first employed short 
periods of hyperemia, and Ihcn prolonged and almost continuous 
hyperemia, but he experienced many failures and bad results with the 
latter. He found that prolonged stasis in this class of cases was apt 
to devitalize the parts and lead lo ihe rapid formation of cold abscess, as 
well as to the development of septic abscess, lymphangitis, adenitis, 
erysipelas, etc., so that he returned to the short applications of from 
one to four hours a day. In cases of acute hot abscess formation, how- 
ever, due to a mixed infection of open sinuses, the application may be 



PASSIVE HYPEKEIOA. 185 

extended to the longer periods — twice, ten or eleven hours — until the 
acute process has subsided. 

Technic. — To apply the bandage, its initial extremity is first wet 
sufficiently to make it adhere to the skin and prevent it from slipping. 
The bandage is wound around the limb with moderate tension six or 
eight times well above the seat of disease, each layer overlapping the 
preceding by about 1/2 inch (i cm.). The bandage is then made 
secure by adhesive plaster or tapes previously sewed to the terminal 
end ^ig. 157). 



Fig. 157. — Showing the melhod o( applying the elastic bandage to the arm. 

The degree of hyperemia is of the utmost importance. The 
object is simply to moderately constrict the veins of a part, without in 
any way interfering with the arterial supply, thereby partly checking 
the reflux of blood and increasing the quantity of venous blood normally 
present. It requires practice and careful attention to detail to apply the 
bandage in such a way that the arteries are not compressed, while at 
the same time the proper venous obstruction is obtained. If the con- 
striction b applied properly, the veins in the part distal to the bandage 
become slightly distended, and the part takes on a bluish-red hue and 
becomes warm to the touch. This degree of hyperemia is essential, 
as the hot hyperemia only has therapeutic value. As already empha- 
sized, the ptdse should never be obliterated. It must at all times be 
distinguished, not even weakened. Furthermore, the application 
of the bandage should never cause pain or annoyance, or hyperesthesia 
of the part. If too great a degree of compression is employed, nutri- 
tional disturbances from the increased stasis injures the tissues and 



i86 bier's hyperemic treatment. 

reduces their natural resistance. In such a case, a white edema is 
produced, or the skin becomes grayish-blue in color, or has a mottled 
red and white appearance, and the part remains cold to the touch. 
Such a condition demands removal of the bandage and its proper 
reapplication. 

For obtaining the proper degree of hjrperemia, it has been suggested 
that a sphygmomanometer, such as the Riva Rocci instrument, for 
example, be employed. The cufif is seciu-ed about the part in the 
same manner as would be done in taking the blood pressure and the 
systolic pressure is estimated. The mercury is then allowed to drop 
about ID mm., which gives the proper tension, after which the tube lead- 
ing to the inflation band is tightly ^lamped. 

In chronic cases it is sometimes very difficult to obtain the prop)er 
amount of hyperemia, and several procedures have been ad\Tsed to 
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 m place for long periods at a time, 
it is advantageous to apply a soft flannel bandage beneath the rubber 
to prevent imdue pressure upon the soft parts, which might produce 
an irritation of the skin, or even atrophy of the muscles. This is 
especially 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 be 
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. 
When the application is only for short periods of a few hours each day, 
the edema becomes absorbed spontaneously in the intervals, but under 
prolonged hyperemia of twenty to twenty-two hours the time for this 
absorption is very short, and it is often not possible to entirely reduce 
it between applications. Elevation of the part upon pillows must con- 
sequently be performed during the intermissions. Massage of the 
region subjected to the pressure of the constriction should also be 
practised in order to guard against pressure atrophy. 

In producing hyperemia of the shoulder- joint, head and neck, or 
testicles, a slight variation in technic, requiring separate description, 
is necessary. 



PASSIVE HYPEREMIA. 187 

Head and Neck. — About the neck a special band, as already 
described, is used. It should be applied about the root of the neck, 
well below the larynx, with only moderate tension. To obtain the 
greatest degree of hyperemia with least constriction, small pieces of 
felt or wadding may be placed under the constricting band on either 
side of the larynx over the great veins (Fig. 158). If properiy applied, 
such a bandage can be worn with entire comfort. It causes a pro- 
nounced edema of the face, particularly about the eyelids. This is no 
contraindication to its use, however. Care should be taken not to 
apply the band too tightly — of course it should never strangulate or 




Fig. 158. — Showing the application of the neck band. 

interfere with eating or swallowing. If throbbing or a feeling of marked 
fullness in the head is complained of, the bandage should be removed 
and reapplied. 

Sfwulder, — A soft bandage or cravat is placed loosely about the 
patient's neck and tied. Through the loop a stout piece of rubber 
tubing about a foot in length is passed as a ligature encircling the 
shoulder-joint, the middle portion being placed in the axilla and the 
two ends passing up — one in front and the other behind the joint — to 
a point above the shoulder, where they are secured by tying or by means 
of a clamp. A second piece of bandage is secured to the tubing in 
front of the joint, and passes across the chest, under the opposite axilla, 
and around the back, where it is secured to the portion of the rubber 
ring behind the joint (Fig. 159). By adjusting the bandage and 
regulating the tightness of the rubber tubing, the proper degree of 
constriction may be obtained. 



i88 bier's hyperemic treatment. 

For anatomical reasons it is not possible to change the location of 
the constrictor at each application, as is done upon the extremities, 
and great care and attention is necessary to avoid pressure necrosis. 
For this reason, it is better to apply the constriction for short periods — 
say three or four hours — ^at a time, repeated several times in the twenty- 
four hours, with correspondingly longer intermissions, in preference 
to the ten or eleven hour applications. 




Fig. 159. — Showing the method of obtaining obstructive hyperemia of the shoulder. 

Scrotum, — Tubercular and other affections of the testicle may be 
treated by placing constriction about the root of the scrotum. A 
small piece of rubber tubing or catheter is wound several times about 
the base of the scrotum over a layer of cotton and is secured in place 
by tying with a piece of tape or cord (Fig. 160). 

Hyperemia by Means of Suction Cups. — Innumerable forms and 
styles of suction cups for producing hyperemia in regions not accessible 
to constriction, as well as large chambers for use upon the extremities 
and large joints, have been de\'ised. The hyperemia produced by these 
de\ices is also a venous one, and is applicable to the same class of cases 
as is obstructive hyperemia by the bandage. As with the use of the 
constricting band, exact technic is necessary, and the importance of 



PASSIVE HYFEKEMIA. 189 

obtaining the proper degree of hyperemia cannot be too strongly 
emphasized. 

When one of the cups is applied to a surface and a vacuum produced, 
the skin and underlying tissues are sucked into the chamber and venous 
sta-sis with a consequent increase in the supply of blood in the skin and 
deeper layers results. Besides producing hyperemia, the mechanical 
effect of the cupping glass is also of distinct advantage. From an 
open discharging wound pus and broken-down tissues are rapidly and 
effectually aspirated. Small sequestra of bone are often quickly 




'■"'■ ifto. — Showing ihe method of producing obstructive hyperemia of the testicles 
(\fler Meyer Schmieden ) 

^Parated and discharged through a sinus under the influence of the 
hyperemia combined with suction. In the presence of tubercular 
^"^uses, daily applications of the suction cups may be employed in con- 
junction with the rubber bandage. 

Apparatus.— Cups suitable for furuncles, styes, carbuncles, breast 
^'iscess, etc., chambers in which are placed the fingers, hands, feel, 
^^^ large joints, as well as apparatus lo be used by ihe gynecologist, 
'"tnopedist, otologist, and other specialists are now manufactured. 
ypes of some of these are shown in the following illustrations (Figs. 
. * to 171). If there is considerable discharge, a type of cup shown 
"^ Fig. 162 will be found most useful. 

In selecting the cup, one should be chosen of sufficiently large di- 

atneter to extend well outside the limits of an acute inflammation, and 

^'^ng edges that are thick and smooth, in order lo avoid undue 

P^^sure upon the skin. In the smaller glasses the suction is obtained 

"If nieans of small rubber bulbs. With the larger apparatus, stronger 



BIES S HYPEKEIOC TSEATMENT. 



suction is required and a special exhausting pump is necessary (Fig. 
172). A further convenience for use with the larger apparatus is a 




F[G. 161. — Cup for sty. 162. Cup for small abscess. 163. Cup for large a 
164. Cup tor gums. 165. Cup f<)r carbuncle. 166. Cups for lon^ls. 167. Bicut'cup. 
168. Cup for ccnlx. i6(). Cup for misc. 170. Finger suction glass. 171. Hand 
suction glass. 



three-way stopcock inserted between the glass chamber and the pump 
to allow admission of air when the negative pressure is too great or is 
to be discontinued. 



PASSIVE HYPEREMIA. 



191 



In addition to these cups and chambers, larger and stronger appa- 
ratus for orthopedic use is made for the purpose of bending stiff 
joints by atmospheric pressure, as shown by Fig. 173. Here the arm is 
drawn firmly in the glass case as the air is exhausted until the hand 
meets the obstacle at the lower end of the chamber, when the wrist 
turns in the direction of least resistance. Other joints of the body can 
be similarly treated by the use of suitable apparatus. Klapp has also 




Fig. 172. — ^Pump for produdng a vaxnium in the larger cups and suction glasses. 

de\-ised metal chambers which are provided with an air pump and a 
hea\7 rubber bag for obtaining motion in a partially ankylosed joint. 
Upon exhausting the air in the apparatus, the rubber bag descends and 
exerts an evenly regulated pressure upon the part to be treated, as shown 
in Fig. 174. 

Asepsis. — In using suction apparatus in the neighborhood of open 
wounds or sinuses, strict asepsis should be observed. To avoid all 




Fig. 17^. — Showing the method of obtaining motion in a stiff wrist by the aid of passive 

hyperemia. 



danger of adding to the infection, the cups should be boiled before used. 
They should be again boiled and well cleaned before being put away. 

Duration of Application. — In the use of cups, brief applications 
often repeated are essential. Accordingly, the cup is applied for five 
niinutes, and is then removed for an interval of two or three minutes, 
lo allow the congestion, edema, and swelling to subside. The cup is 
then again applied for five minutes, and an entirely fresh supply of 



192 biek's hyperemic treatuent. 

blood with bactericidal properties is brought to the part, the entire 
treatment consuming about three-quarters of an hour. 

Technic. — Pus, if present, is always to be evacuated by means of a 



Fig. 174. — Showjog the method of obtaining motion in a stiff ka«e-joiiit by the aid of 

passive hyperemia. 

small 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. Gende pressure is then made on the 




bulb, and the cup is placed over the affected region, care being taken to 
have 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, 



PASSIVE HYPEREMIA. 193 

the cup adheres to the surface and a pronounced hyperemia results 
(Fig, 175), If the appHcation is made over an open infected wound, 
pus will be drawn out, accompanied by some blood. 

The importance of obtaining just the proper degree of hyperemia 
has already been strongly emphasized and is reiterated here. It 
should be remembered that the suction is to be only strong enough to 
slightly decrease the outflowing blood without interfering with the 
inflow, so that the maximum amount of fighting forces is present at 
alt times during the application. The object is to produce a reddish- 
blue color of the part, A disttJKt bluencss or motUing of the skin, or 
complaint of pain on the part of the patient, indicates too great an 
amount of suction and requires withdrawal 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 hyperemia may be more nicely regulated. In this case, the 
cup with the edges well lubricated is simply applied to the affected 
region, and the air is slowly exhausted until the proper degree of hyper- 
emia is induced. If the vacuum is produced too rapidly, it is apt to 
cause some pain. Should it be found that too great a degree of suc- 
tion is produced, the stopcock may be opened slightly and air allowed 
to enter the chamber until the desired degree of congestion is attained. 



Fio. J76. — Showing a suction glass applied (o the hand. 

In the use of the large chambers, such as are employed for the treat- 
ment of a hand or foot, the member to be subjected to hyperemia is 
first coated with soap or vaselin so that the rubber sleeve will more 
easily slip over the skin and at the same time leakage of air may be 
avoided. The patient then thrusts the arm or foot, whichever it may 
be, into the apparatus, and the rubber sleeve is bandaged securely 
about ihe limb with a rubber bandage (Fig. 176). A partial vacuum 
is then produced. This causes the part to be drawn more deeply into 
the apparatus, and some care will be necessary to avoid injuring the 
limb by suddenly drawing it against the closed end of the apparatus. 



194 bier's hyperemic treatment. 

A distinct hyperemia of the whole part within the chamber is thus 
produced, which may be increased or lessened at will by increasing 
or decreasing the amount of air in the apparatus. 

During the intermissions between applications, the congestion 
may be relieved by elevation if the part be an extremity. Discharge or 
secretions from open wounds or sinuses should be removed between 
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 sitting, if a crust has formed 
over 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 serum is withdrawn with 
each application. The swelling diminishes and the part begins 
to regain its normal appearance and dimensions. As the suppuration 
decreases, the treatment may be given e\'ery second day, and finally 
every third day, until recovery is complete. 

ACTIVE HYPEREMIA. 

The» active or arterial form of hyperemia is produced by means of 
dry hot air. Any portion of the body when subjected to heat becomes 
red and hyperemic 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. Hot air 
in a dry form, however, is the most effective means for inducing such 
a hyperemia on account of the high degree of heat that can be borne 
without discomfort. A part may be subjected to the influence of dry 
hot air of a temperature of 212° F. (100° C.) or more without danger 
of producing a burn or other injurious effects. On the other hand, 
moist heat of a temperature of 125° F. (52° C.) is capable of doing 
distinct harm, and is unbearable even for short periods. 

The use of hot air as a therapeutic agent is by no means new, 
and has been employed with var}qng degrees of success for ages, but 
the methods of application were crude and often unsatisfactory. Im- 
provements in the modern baking apparatus have placed this method 
upon a firm basis, and properly applied in certain cases active 
hyperemia becomes a therapeutic agent of distinct value. 



ACTIVE HYPEREMIA. I95 

Indications. — Active hyperemia has a solvent and absorbent action 
upon exudates, infiltrations, adhesions, etc., and a marked analgesic 
effect, causing a sensitive part to become less so or to be entirely re- 
lieved soon after the application is begun. It thus acts favorably in 
chronic rheumatism, chronic arthritis, chronic synovitis, and arthritis 
deformans. It aids greatly in promoting the absorption of edemas and 
of effusions of blood into the soft parts, and in synovial sacs — ^as in 
traumatic synovitis. Other affections in which active hyperemia 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 
itself, 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. 
In a CoUes' fracture, for example, the bones should be properly re- 
duced and within a few days the part should be daily subjected to 
the influence of heat. After ten days the splint may be discarded en- 
tirely, 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. In the case of a fracture of the malleolus, 
much the same line of treatment may be pursued. A plaster splint is 
applied and worn for ten days. This is then cut down and daily 
applications of hot air instituted. In the intervals, the splint is reap- 
plied and worn, held in place by means of bandages. 

While active hyperemia is of distinct therapeutic value, it should 
not be employed to the exclusion of other means of treatment. Inter- 
nal medication should always be carried out when the condition is 
such that it seems indicated, and the hot-air treatment used as an ad- 
junct. In affections of the joints, neuralgias, etc., massage should 
form an important part of the treatment. Too much stress cannot be 
laid on the value of massage when judiciously used in the appropriate 
class of cases. 

Apparatus. — Active hyperemia may be induced either by the use 
of hot-air boxes or hot-air douches. There are many makes of hot-air 
boxes on the market. The simplest are made of cotton-wood carefully 
fitted together and covered with cloth to prevent any leakage 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. Openings for hot air 
are provided on both sides of the box, the one not in use being shut by 



196 bier's HYPEREIUC TREATMENT. 

a slide. Into ono 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. 




Fig. 177. — Apparatus (or applying active liyperemia to the hand and w 
of its application. 



it and the method 



Hot-air douches may also be obtained for use over small areas, as 
along the course of a ner\'e, about the ear, etc. The douche consists 
simply of a long metal movable chimney, underneath which is the 
lamp or gas burner (Fig. 178). 

Temperature. — The degree of heat to which the part is subjected 
may vary from 150° F. to 212° F. {66° C. to 100° C.) or even higher. 
The 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 
heat lowers the sensibility of a part, and great care must be taken not 



ACTIVE HYPEREMIA. 



197 



to bum the patient; the same caution must be observed when applying 
active hyperemia to tissues with lowered resistance. A moderate 
temperature should be employed at the start, and this should be 
increased gradually as tolerance is attained. The temperature is 
regulated by raising the lamp nearer the box or moving it farther away, 
and also by the size of the flame. 

Duration of Applications. — ^The heat should be applied from half 
an hour to an hour daily, or on alternate days. In exceptionally 
stubborn cases it may be applied for the same length of time twice 
daily. 




Fig. 178. — ^The hot-air douche being applied in sciatica. (The nozzel of the apparatus 
should be shown directed more to the posterior surface of the limb.) 



Technic. — The patient assumes a comfortable attitude, either seated 
or lying down, with the apparatus close at hand. The part to be baked 
is then placed in the box and the lid is closed. The lighted lamp is 
placed under the funnel and the temperature is gradually raised until 
a degree of heat is attained that can be comfortably borne by the pa- 
tient. The vent in the top of the apparatus should always be open 
when it is in use, in order to obtain the necessary draught for the flame 
and proper ventilation of the apparatus. When the desired degree of 
temperature has been reached, it should be maintained from half an 
hour to an hour. The light is then extinguished and the temperature 
b allowed to slowly fall before the member is removed. A sudden 



198 bier's hyperemic treatment. 

change of temperature, such as would be occasioned by immediately 
removing the part to the outside atmosphere, is to be avoided. The 
part, when removed from the baking apparatus, is hot and hyperemic 
and remains so for some little time. Immediately following the treat- 
ment, gentle massage and passive motion, if indicated, should be 
practised. 



CHAPTER VIII. 

THE COLLECTION AND PRESERVATION OF PATHOLOGICAL 

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 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 may be found 
in works devoted to the subject — but it is the writer's purpose in this 
section to give brief instructions as to the methods of collecting material 
and the preparation of specimens for subsequent pathological examina- 
tion. This work usually falls to the lot of the practitioner or surgeon 
himself, and often, through faulty technic in the inoculation of a 
culture, in the preparation of slides, or in the coUection^of discharges, 
etc., the results of the pathologist's examination are misleading or 
useless. 

In any case where material is sent to a laboratory for examination, 
each specimen should be clearly labeled with the name of the patient, 
or by a distinguishing number, with the clinical diagnosis, and a short 
clinical history of the case, together with a statement of from what 
part of the body or from what organ the growth, discharge, or what- 
ever it may be, was obtained, should accompany the specimen. If 
chemicals have been employed for preserving the specimen, this 
should also be stated on the slip sent to the pathologist. 

METHOD OF MAKING A SMEAR PREPARATION FOR MICRO- 
SCOPICAL EXAMINATION. 

Equipment. — A number of clean glass slides, sterile swabs, and 
suitable specula for exposing to view, if necessary, deep-seated regions 
from which the discharge may originate, will be required. 

The slides should be absolutely clean and free from grease. Unless 
the slides are very dirty, the following method of cleansing the glass 
will suffice: First wash off the slide with soap and water, then wipe 
with alcohol and ether and rub dry with an old linen or silk cloth; 
finally pass the slide through an alcohol flame. WTien once cleansed, 
care should be taken that the surface of the slide does not come into 



200 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 

contact with the skin, as, if it does, a thin film of grease will be left 
upon the glass. 

The swabs consist of a steel wire or applicator about one extremity 
of which some cotton is wound. They may be obtained sterilized and 
ready for use, or may be easily extemporized as follows: A test-tube 



Fig. 179. — Roughened wire for making a swab. 

and a piece of stiff wire, of a length somewhat longer than that of the 
tube, are obtained. One end of the wire is first roughened with a 
file (Fig. 179) and is then tightly wrapped with a small roll of cotton 
(Fig. 180). The swab is then loosely laid in the test-tube and the 
mouth of the tube is plugged with sterile cotton (Fig. 181), and the 





Fig. 180. — Showing the method of wrapping cotton on the end of a wire. 

whole is sterilized by dry heat. A supply of swabs may be prepared 
in this way and be kept ready for use almost indefinitely. 

Technic. — The slides are arranged upon a towel and the tubes 
containing the sterile swabs are placed near at hand. With the seat of 
the disease well exposed, the swab is removed from the glass container 




Fig. 181. — Sterile swab in a glass test-tube. 



and dipped into the pus or the secretion, care being taken that it touches 
nothing but the material from which the specimen is to be obtained. 
The swab is then rubbed over the surface of one of the glass slides so as 
to spread the material in a thin transparent film (Fig. 182). At least 
two smears should be made from each locality, and each slide should 
be labeled with a distinguishing number. The slides are allowed to 



SMEAR PBEPAKATION FOR UICBOSCOFICAL EXAUINATION. 20I 

dry and are then piled up and secured one upon another, but with 
their surfaces separated by matches or toothpicks, as shown in Fig. 183. 




Fig. i8i. — Method of making a. 



Frwn the Mouth and Pharynx. — Equipment. — Sterile swabs, 
glass slides, and a tongue depressor will be required (Fig. 184). 




Fig. 183, — Glass slides separated by match sticks and held together with rubber bands 
ready for shipmeat lo the laboratory. (Ashton.) 



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 




Fig. 184. — Instrumenis for taking a smear from the pharynx. 
I, Sterile swabs; i, glass slides; j, tongue depressor. 



smear is made. The patient is seated in a good light, with his mouth 
widely opened, and the tongue controlled by the tongue depressor held 



302 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERLU.. 

in the operator's left hand, so that a good view of the 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 contact with the lips or tongue. 
When in contact with the area from which the material is to be ob- 
tained, the swab should be rotated about so as to bring as much of its 
surface in contact with the secretions as possible (Tig, 185). In 
removing the swab the same care against contamination from contact 
with the tongue, etc., should be observed. A thin smear is then 




Fig. i8s- — Showing the mcihod of taking 



from the pharynx. 



made upon a slide in the manner described above, and the swab is 
returned to its container for future inoculation of culture tubes if 
necessary. 

From the Nose. — Equipment. — Swabs, slides, a nasal speculum, 
a head mirror, and an angular pipette (Fig. 186) will be required. 

Tecbnic. — Ordinarily, for microscopical examination, a smear made 
in the usual way from secretions blown from the nose into a clean 
handkerchief is sufficient. If, however, it is desired to obtain a smear 
from any one locality, the secretion should be first removed by means 
of a pipette (page 214), and from this the smear is made. 

From the Eyes. — Equipment. — Slides, a sterile swab, a platinum 
needle, and an alcohol lamp (Fig. 187) will be necessary. 



SIOIAX PSEPAKATION FOR HICROSCOFICAI, EXAMINATION. 



203 



Technic. — There should be no preliminary cleansing of the eyes. 
The platinum needle is first sterilized by passing it through the flame, 
ind when it has cooled the lids are separated, the loop is brought into 




Fic. 1S6. — Instruments for talung a smear from the nose. 
I, Sterile swab; 3, nasal speculum; j, glass slides; 4, angular pipette; 5, head rr 




Fig. iS 7,— Instruments (or taking a smear f 
[, Sterile swab; 1, glass slides; j, alcohol lamp; .1 



contact with the pus and some of it is transferred lo a slide. A smear 
is then made by means of the swab. 

From the Urethra. — Equipment.— Slides and sterile swabs (Fig. 
188) should be provided. 



204 COLLECTION AND PRESEKVATION OF PATHOLOGICAL MATEBIAL. 



Rg. i88. — Inslmments for taking a, 
I, Sierile svrab; 3, 



.r from the luethd 




FlC. 189. — Forcing the discharge out ot the urethra by pressure against the caul with tbt 
tip of the finger izi the vagina. (Ashton.) 



SHEAK FREPAXATION 70S UICKOSCOPICAL EXAMINATION. 205 

X«cluiic. — In a male, the meatus should be cleansed, and a drop of 
ptis is expressed by stripping the urethra with the finger from behind 
foT-^vard. The swab is then dipped in the pus and a thin smear is 
ma-de upon a slide in the usual way. 

In the female, the labia are held apart by an assistant, the index 
finger is inserted in the vagina, and the urethra is stripped from 
behind forward (Fig. 189). The swab is then brought into contact 
wdth the drop of pus that is thus expressed, and a smear is made from 
it in the usual way. 

From the Vagina. — Equipment. — Swabs, slides, and a vaginal 
speculum (Fig. 190) are needed. 




Fic. 190. — Instruments for taking a smear fTOm the vagina. 
I, Sterile swab; 2, gta^ slides; 3, vaginal speculum. 

'^ecbnic. — The labia are separated and the speculum is introduced 

, ^*-s to obtain a good view of the parts. The swab is then introduced 

*^fcout touching the vulva and is rubbed in the discharge, mucous 

*<:;h, or whatever it may be. A smear is then made from the material 

^*-* s obtained. 

From the Cervix. — Equipment. — A long swab, a speculum, two 
*^scula, a sponge holder, and glass slides (Fig. 191) should be 
^^^^-vided. 

Technic. — The speculum is introduced so that the cer%Tx is well 
T^osed to view, and, by means of a tenaculum placed in each lip, the 
*~\TX is drawn as far down as possible. The swab is then passed into 



2o6 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 



the cervical canal (Fig. 192) , but care is taken that it does not enter Ihi 
uterus for fear of carrying infection to what may be a healthy oigai 




Fig. 191. — Instruments tor taking a smear from the utcms. 
:, Sterile swab; a, tenacula; 3, Simon's speculum; 4, glass slides; 5, sponge bolder" 




— Mi-tliori of collecting the 



from a diseased cer\'ix. The swab 
made in the usual way. 



from the uterus, (Ashton.) 
then withdrawn, and a smear i 



METHOD OF INOCULATING CDLTUEE TUBES. 207 

METHOD OF mOGULATmC CULTURE TUBES. 

Bqtiipiiieat. — Culture tubes, sterile swabs, platinum needles, thumb 
foiceps, and an alcohol lamp (Fig. 193) will be required. 

A variety of media are employed for the growth of bacteria, such as 
broih, agar-agar, gelatin, and blood serum, according to the kind of 
bttieria to be cultivated. The culture media are sold in sterile test- 




Fio. 193. — Instruments for making a, culture. 
I, Alcohol lamp; 2, thumb forceps; 3, itenle swabs; 4, culture tubes; $, platinum needle. 

mbes, generally plugged with cotton. When they are to be kept for 
any length of time, the tubes should, in addition, be sealed with rubber 
caps or oiled paper to prevent their contents from drying out, 

The inoculation of the tubes is performed by means of a swab or a 
plaiinum needle. The method of making and sterilizing the former 



Fig. 194. — Platinum needles. 



has been described above. The needle consists of a platinum wire, 
3 to 4 inches (7 . 6 to 10 cm,) long, which is inserted into the end of a 
glass rod 6 to 8 inches (15 to zo cm.) long, which serves as a handle. 
The free end of the wire may be made into the form of a loop or it may 
be simply left straight (Fig. 194), according to whether a streak or a 



20S COLLECTION AND PRESERVATION OF PATHOLOGICAL UATERIAI. 

stab culture is to be made. Before use, the wire should be sterilized 
by passing it back and forth through a flame for a few seconds. 

Technic. — In making a culture the greatest care must be exercised 
as to the asepsis and the avoidance of contamination. The culture 
tubes, platinum needles, etc., are arranged upon a towel within easy 
reach, and the alcohol lamp is lighted. The end of the culture tube 
containing the cotton plug is first passed through the flame, the cotton 
being singed so as to destroy any germs that may be deposited upon it 
(Fig. 195). The culture tube is held between the thumb and forefinger 
of the left hand, with the mouth of the tube pointing downward, if it 




Fig. !•)$. — Singeing the cotton stopper of a cullure lube preparatory to its inoculaticm. 



contains a solid medium, so as to prevent the entrance of any dust. 
A pair of thumb forceps, after being passed through the flame, are 
used to remove the cotton plug which is then transferred to the left 
hand when it is held between the index and second fingers while the 
culture is being made. 

If a streak culture is to be made, a looped pladnum needle is ster- 
ilized by passing it through the flame, including the portion of 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 of 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. 196). The 
platinum needle is again passed through the flame and is then laid 
aside. The tube is finally closed with the cotton plug, first singeing 
the cotton, however, in the flame while held with the thumb forceps. 



lEETHOD OF INOCULATING CUT-TUHE TUBES. 



209 



niien a stab culture is to be made, a straight needle is employed 
instead of a looped one. The technic is precisely the same as for a 
streak culture except that the needle is inserted straight into theculture 
medium and is then withdrawn. 




. 19&.— Method of making a streak culture. (Levy and Klemperer.) 




Fig. 19;.— Showing "a" stab culture, and "6" smear culture. 

A smear culture with a swab is made as follows: The culture tube 
and ihe tube containing the sterile swab are held side by side between 
the thumb and the index finger of the left hand. The cotton plugs 



3IO COLLECTION AND PRESERVATION OF PATHOLOGICAL UATERIAL. 

are removed with sterile forceps, the ends of the tubes and the exposed 
cotton being first singed, as described above. The cotton plugs are 
held between the ring and little finger and the ring and middle fingers 
of the left hand, while, with the right hand, the swab is withdrawn 
from its tube, dipped in the secretion, and is then inserted into the 
culture tube and is rubbed thoroughly over the surface of the culture 
medium (Fig. 198). The swab is then replaced in its container and the 
cotton plug is singed and reinserted into the mouth of the culture tube. 
When a number of cultures are being made, care should be taken to 
immediately number each tube as it is inoculated. 




Fig. icjS. — The method of making 



COLLECTING DISCHARGES AND SECRETIONS FOR BACTERI- 
OLOGICAL EXAHINATIOH. 

When in the absence of culture tubes or for other reasons it is 
necessary to send fluid material to a laboratory for bacteriological 
examination, il is best collected in sterile glass pipets which are 
then hermetically sealed. This insures against leakage as well as 
any chance of contamination during transportation. 

Equipment. — A number of glass pipets, a rubber suction bulb or a 
suction syringe, an alcohol lamp, scissors, and suitable specula {Fig, 
199) will be required. 

The pipets may be easily made from thin glass tubing of an exter- 
nal diameter of about 1/4 inch (6 mm.). The center of a piece of 
such tubing about 6 inches (15 cm.) long is heated over a flame, the 
tube continually being turned the while, until the glass is softened over 



COLLECTING DISCHASGES AND SECRETIONS. 211 

about 1/2 inch (i cm.) of space (Fig, 200). 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 pordon is stretched out into a capil- 




"fia. 199. — Apparatus for collecting dischai^es for bacteriological 

I, Alcohol lamp; 3, scissors; 3, suction syringe; 4, pipets. 

lary tube several Inches long (Fig. 201). The center of this capillary 
lube is again heated in the flame until it melts, and, by drawing upon 
the ends, it parts in the center, leaving two pipets, each with one sealed 




—Healing Ihe glass tube 



Bunsen fiame. (Aahton.) 



.^ CFig. 202). The center of the thick portions of each of these 
V pets is then melted in the same way and is drawn out Into a capillary 



iu\>e 



an inch (2.5 cm.) or more long, so that we have as a result two 



212 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 

pipets each drawn to a point at one end, wide at the other, and between 
the two ends a bulb separated from the wide end by a capillary constric- 
tion (Fig. 203). The pipets are sterilized, after inserting a piece of 



c 



9 



Fig. 201 . — ^The glass tube is shown drawn out at its center. (Ashton.) 

cotton wool in the wide ends, by passing the whole tube through the 
flame until it is hot (Fig. 204), but not so hot as to melt the glass or 




3 



Fig. 202. — Fusing apart the center of the drawn-out portion of the tube. (Ashton.) 

bum the cotton plug. Thus sterilized, the pipets may be kept on 
hand ready for use almost indefinitely. 





Fig. 203. — Making a bulbous pii>et by heating the thick portion and drawing it out to a 

thin tube. (Ashton.) 

The suction for drawing up secretions into the pipets may be 
furnished by the bulb of a medicine dropper, or by attaching a piece 




Fig. 204. — Sterilizing the interior of the bulbous portion (b) and the slender end (a) of the 

pipet; (d) plug of cotton. (Ashton.) 

of rubber tubing to the pipet and applying the lips or a small suction 
syringe to the free end of the rubber tubing. 

Technic. — The pipets are arranged near at hand upon a towel, 
and the alcohol lamp is lighted. The sealed end of the pipet should 



COLLECTING DISCHARGES AND SECRETIONS. 



213 



be cut oflP with scissors (Fig. 205) and should be then rounded off 
in the flame, so as to avoid producing any injury to the tissue (Fig. 206). 





Fig. 



. — ^Snipping off the fused point of the slender end (a) of the pipet with scissors. 

(Ashton.) 



The p>ipet is then slowly passed through the flame so as to sterilize 
the entire outer surface of the tube (Fig. 207). When the tube has 





G. 206. — Rounding off the rough edges of the glass in the flame. (Ashton.) 

cooled, the rubber nipple or tubing is placed upon the large end, 
and the small end is inserted in the discharge or secretion, which is 



Fig. 

then 
rem 




S07. — Sterilizing the outer surface of the slender end (a) of the pipet. (Ashton.) 

drawn up into the pipet by suction. The suction bulb is then 
'ed, and the small end of the pipet is sealed by melting it in 



^<^^^ ^ 



Flo 





^^^8. — Hermetically sealing the secretions in the bulbous portion of the pipet by fusing 

it in the flame at a and c. (Ashton.) 

^ flame. The constricted portion is likewise melted in the flame, 
^ the portion of the pipet containing the cotton wool is removed, 



214 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 

and the remaining end of the pipet is sealed (Fig. 208). In this 
way the discharge is hermetically sealed in small glass tubes (Fig. 209) 
and can be sent to any distance for later bacteriological examination. 
Each tube as it is prepared should be carefully labeled with a dis- 
tinguishing number. 




Fig. 209. — : 



■Showing the bulbous portion of the pipet sealed and containing the secretion* 

(Ashton.) 



From an Abscess Cavity. — Care must be taken that no antiseptic 
irrigating fluid is used before the discharge is obtained. A specimen 
should be obtained free from blood, if possible. To obtain this and to 
avoid contamination as well, the first portion of the pus should be 
allowed to escape; the edges of the incision are then separated while 
the pipet is inserted into the cavity, and a specimen is withdrawn from 
its depths. 




Fig. 210. — Instruments for obtaining secretions from the nose for bacteriological 

examination. 
I, Sterile angular pipet; 2, alcohol lamp; 3, scissors; 4, nasal speculum; 5, head mirror. 



From Serous Cavities. — The method of obtaining fluid from 
serous cavities is described under exploratory punctures (Chapter IX). 

From the Nose and Accessory Sinuses. — ^Equipment. — An an- 
gular pipet will be required, as well as an alcohol lamp, scissors, a 
nasal speculum, suitable illumination, and a head mirror (Fig. 210). 



CQLLECTINC DISCHARGES AND SECRETIONS. 



"5 



The angular pipette may be made by taking a straight pipet 
witli a long capillary tube, heating the latter at a distance of about 
3 inches (7.6 cm.) from its extremity and, when soft, bending it to 
an angle of 135°. The end should be well smoothed off in a flame 
before using. 

Xechnic. — The same general principles as outlined above are 
followed. The patient is seated as for an anterior rhinoscopic ^mi- 
nation (page 281), the nasal speculum is introduced, and the light is 
reflected so that the interior of the nose can be clearly observed. The 
tip of the pipet is then inserted until it comes in contact with the 
discharge, care being taken not to have it touch the mucous membrane 
or the vibrissEB about the vestibule. The point of the instrument 
is mc»ved about in the secretion while suction is exerted, and some of the 
discharge will thus be withdrawn. The pipet is then removed, sealed, 
and properly labeled. 




a pipel from the female urethra. 



From the Eyes. — The technic is not different from that already 
^escribed for collecting discharges from other regions, and no special 
*«rms of pipets are necessary. Any preliminary cleansing of the eyes 
Should, of course, be avoided. 

From the Urethra. — Equipment. — Pipels and the other appara- 
tus necessary for collecting discharges (see Fig, 199} will be required. 



2l6 COLLECTION AND FKESEKVATION OF PATHOLOGICAL UATEKLU- 

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 pipet has been inserted into the canal, the secre- 
tion is sucked into the pipet (Fig. 211). When the discharge is 
scanty, sufficient may be obtained by expressing the pus from the 
posterior portion of the urethra by drawing the finger along the urethra, 
from behind forward. In the female the same method may be em- 
ployed with the index finger in the vagina (see Fig. 189). When 
a specimen has been obtained, the ends of the pipet are sealed and 
the tube is properly labeled. 





Fic. J13. — Instru 
, AJcohol lamp; z 



s far obtaEning secretions from the vagina for bacteriological 

n syringe ; 4, sterile pipeis ; 5, vaginal speculum. 



From the Vagina. — Equipment. — Pipcts, a suction syringe and 
rubber tubing, scissors, an alcohol lamp, and a vaginal speculum 
(Fig. 212) will be required. 

Technic. — The labia are separated and the speculum is introduced 
into the vagina, so that the posterior cul-de-sac is exposed to \iew. The 
distal end of the pipet is then carefully introduced into the discharge, 
and sufficient secretion for the purposes of the examination is withdrawn 
by means of suction. The pipet is then removed, both ends are 
scaled, and the specimen is properly labeled. 

From the Uterus. — Equipment.— Pipets, a suction syringe and 
rubber tubing, scissors, an alcohol lamp, vaginal specula, two tenacula, 
and sponge holders (Fig. 213) will be required. 

Technic. — The speculum is introduced into the vagina and the 
cervix is well exposed to view. Any vaginal secretions are removed by 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION. 217 

mestus of sponges on holders, tenacula are inserted in the anterior and 
posterior lips of the cervix, and the latter is drawn well down. The 
P'I>^t is then inserted into the cervical canal, care being taken not to 
pusli it into the uterus, and the secretion is sucked into it. It is then 
"■■'^-lidrawn, and both ends are sealed. 




® 



A 

cfccfbdbli 



^ics~ 113. — Inslniments for collecting discharges from Ihe uterus for bacteriological 

examination. (Ashlon.) 
'> X*ipets; 3, suction syringe; 3, Simon's speculum; 4, tenacula; 5, scissors; 6, sponge holder; 
7, alcohol lamp. 



COXLECTION OF BLOOD FOR MICROSCOPICAL EXAMUTATION. 

Blood may be examined microscopically either from a fresh 
*I*-^^<imen or from a dried smear. The former procedure is suitable 
^^"^ 1 y when the blood can be examined promptly — say within half an 
"■*^^ "t-ir. A smear is made when the morphology of the cellular elements 
'^ to be studied after being properly stained. 

Equipment. — Slides, cover-glasses, an alcohol lamp, thumb forceps, 
^-'^<d a spear-fwinted needle or a lancet (Fig. 214) are necessary. The 
^*^> "v-er-glasses and slides should be of the best material. The former 
^'^^^uld be very thin and about 7/8 inch (22 mm.) square. Both 
®™-*^^uld be absolutely clean and free from grease; the cleansing may be 
^^^^■"formed after the method described on page 199. 

location of Puncture.— The blood may be withdrawn from a 

P"^"i.<k in the lobe of the ear or in the tip of the linger. The former 

y^^on is preferable, however, as it is not so sensitive as (he finger, and 

*s usually cleaner, so that the chances of infection are less. Further- 

''^^^re, when the puncture is made in the ear, the operalion is removed 



3l8 COLLECTION AND PSESEKVATION OF PATHOLOGICAL llATERIAL. 

from the view of the patient, which is an important consideration in 
the case of children and nervous indiWduals. 

Asepsis. — The site of puncture should be cleaned by first rubbing 




Fig. 314. — Instruments for collecting blood for nucroscopical eiamliULtion. 
I. Thumb forceps; 1, spear-pointed needle; 3, cover^laases; 4, glass slides; 5, alcohol 

it with a wipe wet with alcohol, and then drying it with ether. The 

needle or lancet is sterilized by boiling or passing it through a fiame. 

Technic. — i. Fresh Specimen. — Care should be taken to avoid 

chilling the specimen and exposing it to the aur any longer than is 




FlC. iij. — Malung a fresh blood smear. First step, puncturing the ear. 



necessary; accordingly, everything should be in readiness for the 
examination. The slide is warmed over the alcohol lamp or by rigor- 
ously rubbing it with a piece of linen, and is then laid on a sterile towel. 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION. 



319 



Tlie cover-glass is likewise warmed and placed near at hand. The 
lobe of the ear is grasped between the thumb and forefinger of the 
left liand and with a quick stab the lowest portion of the lobe is punc- 
tured (Fig. 215). The blood should be allowed to flow without pres- 
sure or rubbing, as these produce a hyperemia and the constituents 




Fig, ajfi. — Making a fresh bbod smear. Second step, collecting ihe drop on a cover-glas 



of the blood may be changed in character or the blood cells may be 
deformed. The first drop is wiped away and a second drop is allowed 
'» flow. The cover-glass is then taken up in the thumb forceps and is 
^Pplied by its under surface to the apex of the drop (Fig, 216), but 
's not allowed to touch the skin. The cover-glass is then gently 




a 17. — Making a tresh blood smear. Third step, placing ihe tover-glass holding the 
blood drop on a slide. 

*''^»ed upon the warmed slide (Fig. 217) and the drop of blood is thus 

*^s^ to spread out in a thin circular layer between the slide and the 

/*^^l-glass. If the drop Is not too large, the blood will not spread 

y^^nd the margins of the cover-glass. The cover-glass should not be 

•^^^sed down upon the slide, as this will injure the corpuscles. 



220 COLLECnON AND PRESERVATION OF PATHOLOGICAL MATERIAL, 

2. Dried Specimen. — A puncture is made in the lobe of the ear 
in the manner described above, and, after the first drop of blood has 
been wiped away, the second drop is received upon a slide near one 
end. As quickly as possible the edge of another slide is dipped into the 




Fig. 3tS. — Method of making a dry blood smeai with two slides. 



drop thus collected and is drawn along the surface of the first slide, 
spreading out the drop in a broad thin smear (Fig. 318). To be 
of any value the smear must be spread out evenly and thinly. 

A second method is to employ cover-glasses. Two cover-glasses 
are thoroughly cleansed and are placed conveniently at hand. The 



—Making a dry blood 




ises. Second step, collecting the 



ear is punctured in the way described above (see Fig. 215), and the 
. first drop of blood is removed. One cover-glass is then held by its 
sides between the ihumb and forefinger of the right hand, while the 
second one is grasped by ils sharp angles in the fingers of the left hand. 



COLLECTION OF BLOOD FOR UICKOSCOPICAL EXAMINATION. 231 



The under surface of this first cover is then applied to the apex of the 
drop of blood (Fig. 219), and is quickly placed upon the second glass, 




Fio, 210. — Making a drj- blood smear with two cover-glasses. Third step, the 
nnhod of holi^ng the two cover-glasses prepiaraiory lo placing the one holding the drop 
gpixi ihc second one. 

wiihihe angles of the two not coinciding (Fig. 2ao), so that the drop 
spreads out by its own weight in a thin film between the two covers 




Fio. jii. — Making a drj- blood 
le 110 covers with iheir surfaces ir 
ivtr between Ihcm. 



ir with Iwo cover-glasses. Fourth step, showing 
:t and the drop of blood spread out in a thin 



lllg. 111). If too large a drop is taken the upper cover will simply 
float around upon the lower. The upper cover is finally seized between 




1 dry blood smear with two cover-glas 
method of drawing the two covers a 



Fifth step, showing the 



the thumb and forefinger of the right hand and, still holding the lower 
cover in the left hand, the two covers are slid apart in the same plane 



322 COLLECTION AND PKESERVATION OF PATHOLOGICAL MATERIAL. 

(Fig. 222). Unless too small a drop has been taken, this is readily 
accomplished. The films thus obtained are then allowed to dry, and 
later they may be fixed and properly stained. It is always well to 
make three or four of these smears, as some of the films may be pooriy 
spread, or may be broken in handling. 



THE COLLECTIOR OF BLOOD FOR BACTERIOLOGICAL 
EXAMHTATIOH. 

The best method of securing blood for culture is by a "venous 
puncture. The ordinary method of obtaining blood through a prick 
of the ear or of the finger is worthless for bacteriological purposes on 
account of the small amount of blood obtained and the chances of 
contamination, especially from the skin. If properly performed, a 
venous puncture is harmless and gives the patient but little discomfort. 

Equipment — A glass syringe with a capacity of 2 3/4 drams 
(about 10 cc), a moderately large needle with a sharp point, broth 
and agar-agar culture tube, and a bandage (Fig. 223) are necessary. 




Fio. jij. — Apparatus for collecting blood for bacteriological 



Site of Puncture.— The median cephalic or median basilic vein is 
usually chosen (see Fig. 100), but, if these are not available, the internal 
saphenous vein in the leg or any of the smaller veins about the wrist 
may be made use of. 

Asepsis. — The skin at the site of puncture should be well scrubbed 
with soap and water, followed by a j to 2000 solution of bichlorid of 
mercury. The hands of the operator are as carefully sterilized as for 
any operation, and the instruments are boiled. 

Anesthesia.— In ordinary cases anesthesia is unnecessary. If it 
is necessary to expose the vein by an incision, as in the case of an 



COLLECTION OF BLOOD FOR BACTEKIOLOGICA.L EXAMINATION. 223 

indindual with much fat or whose tissues are edematous, infiltration 
with a 0.2 per cent, solution of cocain is employed. 

Tcchmc. — A bandage is wound about the arm between the seat of 
puDctuie and the heart with sufficient tension to produce a slight venous 
stasis and cause the veins to stand out prominently, but with not enough 
compression to cut off the arterial flow. By gently forcing the blood 
ilong toward the seat of constriction by means of the forefinger or 
thumb, the vein may be made to stand out more prominently. In 
stoul persons, however, it may be necessary to expose the vein by an 
inctdon. 

The needle with the syringe attached is then passed obliquely 
through the skin into the vein in a direction against the blood current 
(Fig. 224), and the blood is gently sucked into the syringe by slowly 




Fic. 314. — Showing the method of making 



withdrawing the piston. If too great an amount of suction is exerted 
ihe wall of the vein will be forcibly collapsed and will act as a valve 
against the further withdrawal of blood. About i 1/2 drams (5 c.c.) 
of blood may be taken from a child, and about 2 3/4 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 vein. 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. This inocu- 
lation should be done immediately and before the blood has time to 
clot in the syringe. 

During the inoculation of the tubes the greatest care should be 
taken to avoid contamination; the needle is removed from the syringe, 
as it is very apt to be contaminated with staphylococci from the skin, 
no matter how carefully the sterilization may have been carried out, 



224 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 

and the inoculation is made through the sterile end of the syringt 
In doing this, the same technic described on page 207 should be 
followed. Inoculations are usually made with i6ni (i c.c.) of blood 
into definite quantities of media. At the completion of the operatioii 
the seat of puncture is sealed with collodion. 

TEE COLLECTION OF SPtTTUH. 

Sputum should be collected in absolutely clean wide-mouth ounce 
glass bottles, provided with a water-tight cork so that there can be no 
leakage (Fig. 225) during transportation. Suitable bottles may be 
obtained from any laboratory or from most drug stores. The 
specimen should be obtained from the sputum coughed up early 
in the morning before any food has been taken, and ii 
should be seen that the material is coughed up from the 
lungs and that it is not simply an accumulation from 
the mouth and pharynx. As an added precaution 
against contamination from particles 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 th.c 
day, or for twenty-four hours, should be preserved. The 
specimen thus collected should be sent to the laboratory' 
promptly, that it may be examined in as fresh a condi- 
tion as possible. 
With infants and young children it may be next to impossible tc 
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 ad\Tses 
(Archives of internal 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 re- 
ceptacle, the first portion as it comes from the meatus being received 
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 




THE COLLECTION OF URINE. 



225 



i.ny operation. The meatus and surrounding parts are then washed 
with an antiseptic solution, and the catheter is gently inserted into the 
blfi-dder without touching the adjacent parts (see also page 628). The 
&jrst portion of the urine is to be discarded, and then from i 1/2 to 
2 ^/4 drams (about 5 to 10 c.c.) are collected in a sterile test-tube, 
wbich is immediately plugged. 

When it is desired to obtain a separate specimen from each kidney, 
itxc: ureters may be catheterized (see page 652) or a urinary separator 
naay be employed (see page 667). 

To obtain a twenty-four-hour specimen, as, for example, when 
it is desired to determine the total daily amount of urine secreted or to 
estimate the total solids, it is necessary to begin and end with an empty 
bladder. The patient is therefore instructed to empty the bladder 
at a certain hour and to discard this specimen. AH 
the urine passed for the following twenty-four hours, 
including that voided at the end of this period, is 
saved in a large clean bottle. For cases of in- 
continence, a retained catheter must be used (see 
P^gc 637), or else a rubber urinal devised for such 
cases may be employed. 

When considerable time must elapse before a 
specimen can be examined, some preservative, such 
as boric acid in the proportion of 5 grains (0.324 
Sm.) to I ounce (30 cc), or formalin in the propor- 
tion of I drop to each 4 ounces (120 c.c.) may be 
added to the specimen. If cultures or inoculations 
are to be made, any preser\-ative should be avoided. 
In the case of infants there are several methods 
'or collecting urine. With male infants, for an 
ordinary examination, the specimen may be collected 
"}' means of a condom which is secured to the 
'""iy by adhesive plaster, and into which the penis 
ana scrotum are passed; or a bottle may be employed, in the neck of 
*"ch the penis is placed. Chapin has devised a urine collector (Fig. 
^^^^ that may be employed for both males and females. A method 
^"^^etimes employed with females is to place absorbent cotton over 
the Vulva, and, after the child has saturated the cotton, to express (he 
"""e into a bottle; or the child may simply be placed upon a rubber 
^"&et from which the urine is collected as often as it is voided. If it 
*^ecessary to obtain an uncontaminated specimen, catheterization 
"^^St be resorted to, employing a small catheter (9 to 11 French). 




226 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL. 

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 442) being all that is required. The specimen should 
be received in a clean glass receptacle. 

For a complete chemical examination and to test the condition of 
the stomach, the gastric contents an hour after a test-meal will be re- 
quired (see page 440). 

THE COLLECTION OF FECES. 

Ordinarily a small amount should be received in a sterilized 
wide-mouth glass jar and the examination made as soon as possible. 

When examining for the ameba, it becomes necessary to collect 
the stools in a clean warm receptacle and to make the examination 
immediately upon a warmed slide, or else to provide some means for 
keeping the specimen warm until the examination can be conveniently 
made. 

THE REMOVAL OF A FRAGMENT OF SOLID TISSUE FOR EX- 
AMINATION. 

The excision of pieces of tissue for microscopical examination 
may be required in cases where it seems probable that a tumor is 
malignant but where the clinical signs and symptoms are not pro- 
nounced enough to make a positive diagnosis. The information thus 
obtained is especially valuable in growths of recent development, as 
in these the evidence of malignancy is often not apparent from a gross 
examination. 

Instrtunents. — In ordinary cases there will be required: a scalpel, 
scissors, a cutaneous punch, artery clamps, plain thumb forceps, 
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 10 
per cent, aqueous solution of formalin (Fig. 227). 

For regions which are not readily accessible, as, for example, the 
female genitals, volsellum forceps and suitable speculae are necessary. 

For collecting material from the interior of the uterus, curettage 
instruments, etc., will be required (see page 751). 

Anesthesia. — As a rule, local anesthesia by infiltration with a 
0.2 per cent, solution of cocain in normal salt solution is sufficient 
For skin tumors, freezing with ethyl chlorid usually suffices. 



K£HOVAL or A FRAGMENT OF SOLID TISSUE. 337 




Fig. JJ7. — Instnimenls for excidng a. fragment of solid tissue for exatnination. 
I, Scalpel; t, curved sharp-poinled scissors; 3, skin punch; 4, Ihumb forcepsi 5, artery 
:Jainpa; 6, retractors; 7, needle bolder; 8, No. 3 catgul; 9, curved cutting-edge needles; 
ii^qiecimen bottle. 




Fic. i2b.~-Exduon of a {nece of tissue from the cervix. (Ashton). 



338 COIXECTION AND PSESEKVATION OF PATHOLOOICAL HATBSUL. 

Asepsis. — The instrumeiits are boiled, the hands of Uie opentor 

are sterilized, and the site of operation is cleaned as for any operatioa. 

Technic. — The line of proposed incision is first cocainized. Tha 




Fic. 919. — Removal of a fragment of a superficial gnnvth with a skia punch. 

with the tissues well retracted so as to expose the growth, a wedg«^~ 
shaped piece of tissue is removed by means of a scalpel from the pord<7KX^ 
of the growth where the pathological changes are most marked or tt*-^ 
tumor is nodular (Fig. 228). The tissue is then transferred to tt".^ 




bottle containing the 10 per cent, formalin solution, and a proper lal^^ 
is applied. Any hemorrhage is then controlled, the incision is close^^^ ' 
and a sterile dressing is finally applied. 



rJ 



REMOVAL OF A FRAGMENT OF SOLID TISSUE. 229 

A fragment of a very superficial tumor 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. 229). The punch is then removed and 
the circular core is seized in thumb forceps and is freed from its 
base by cutting with a pair of curved scissors (Fig. 230). The punch 
may be employed in the same way, if desired, for removal of deeper 
seated growths after first exposing the tumor by an incision. 

WTien tissue is removed by curettage for examination, the uterus 
should be scraped systematically, and, as soon as collected, the frag- 
ments thus obtained should be placed in a bottle containing the 
preser\'ing 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 751. 



I^."- 



CHAPTER IX. 
EXPLORATORY PUNCTURES. 

An exploratory puncture consists in the introduction of a holloi 
needle attached to an aspirating syringe into a diseased region, and 
subsequent aspiration. This comparatively simple operation may 
performed for the purpose of determining the presence or absence o: 
fluid in any particular area, or to obtain a specimen of fluid for \h^ 
purpose of determining its character by subsequent examination. In. 
addition, exploratory punctures are made prior to therapeutic punctures- 
to determine the exact location of the fluid to be evacuated, lit 
deeply-seated processes, as suppuration and fluctuating tumors, inac- 
cessible to other means of diagnosis, this method of exploration often 
gives most valuable information. The liver, the lungs, the pleural 
and pericardial cavities, the spinal canal, and other organs and regions 
difficult of access may thus be tapped and explored with comparative 
safety. 

Apparatus. — ^Aspirating needles and a syringe of appropriate size 
should be provided. It will be found convenient to have an assortment 
of needles of different lengths and diameters. They should measure 
in length 2 1/2 inches (6.3 cm.), 3 inches (7.6 cm.), 3 1/2 inches 
(8.9 cm.), and 4 inches (10 cm.) ; and in diameter 1/50 inch (o. 5 mm.) -» 
1/25 inch (i mm.), 1/18 inch (1.5 mm.), and 1/12 inch (2 mm.) - 
For ordinary use the needle should be at least 3 inches (7.6 cm.) lotv^ 
and about 1/25 inch (i mm.) in diameter, so that it will readily gi^"^ 
passage to fluids of heavy consistency. 

It is preferable to have a syringe with a capacity of from i to ^ 
drams (3 • 75 to 7 . 5 c.c), through an ordinary hypodermic syringe m^-1' 
be employed if the large needles are made to fit. The syringe shou^ "-^ 
be capable of exerting a strong suction, and the joint between it and tt^^ 
needle should be absolutely air- tight. The best form of syringe co^^ 
sists of a solid glass barrel and a tight-fitting piston pro\ided with ^" 
asbestos or rubber packing (Fig. 231). Such a syringe is simple ^^ 
mechanism, easy to clean, and can be readily sterilized by boiling. -^ 
confirmation of the diagnosis of fluid is to be immediately followed by 1^^ 
evacuation, the aspirating apparatus of Potain or Dieulafoy (s<*^ 

230 



EXPLORATORY PDNCTURES. 



231 



page 356) may be used for the exploration, thus sparing the patient a 
subsequent operation. 

Before making a puncture the syringe should always be tested by 
withdrawing the piston with the finger held over the end, to see if it 
win exert proper suction. The syringe should likewise be tested with 




Fic. 331. — As^nrating syringe and needles. 

the needle fitted in place. After use, the syringe should be taken 
apart, and both it and the needle should be thoroughly cleansed. To 
guard against rusting, the lumen of the needle should be cleansed 
with alcohol and ether, and a wire of suitable size inserted. 

In cases where a complete chemical, microscopical, and bac- 
leriological examination is desired, sterilized test-tubes for collecting 



&t 



9Q 



Fm. I] 1.— Apparatus for making sn 
I, Glass slides; 3. 



irs and cultures from fluids removed by ciploraloi 
lerile test-tube; j, culture lubes. 



and transporting the material aspirated, glass slides, and agar-agar 
cuilure tubes (Fig. 232) should be at hand. 

Asepsia. — The strictest regard to asepsis must be observed in mak- 
ing any exploratory puncture, otherwise there is great risk of infection 
"Hi of converting a simple serous exudate inio a purulent one. The 
site chosen for the puncture should be carefully scrubbed with green 



232 EXPLORATORY PUNCTURES. 

soap and warm water, and then cleansed with alcohol followed by a 
I to 2COO solution of bichlorid of mercury. The operator's hands 
should also be thoroughly scrubbed, followed by immersion in an 
antiseptic solution. The needle and syringe should be boiled. 

Anesthesia. — Local anesthesia by freezing with ethyl chlorid or 
salt and ice, or infiltrating with a 0.2 per cent, solution of cocain, will 
be all that is required. In employing freezing as an anesthetic, if the 
patient is poorly nourished or the skin is edematous, care should be 
taken not to freeze the skin too thoroughly, on account of the danger of 
local gangrene. 

Technic. — ^The needle is introduced into the area chosen for the 
puncture at right angles to the skin surface, care being taken to enter 
it away from important vessels or nerves. The needle should be 
inserted very slowly, with strict attention to the amount of resistance 
encountered, so that the moment it enters a cavity the fact will be 
recognized by the operator through the absence of further obstruction 
and by the fact that the point can be freely moved about. When it b 
certain that the needle has entered a cavity, the piston is withdrawn, 
and a specimen of the contained material is aspirated. Should no 
fluid be immediately found, it may be because the needle is too far in 
or has not penetrated to a sufficient depth. In such cases the needle 
may be withdrawn slightly or pushed further in, and a second attempt 
made to withdraw fluid; or it may be necessary to remove the needle 
slightly and alter its direction. If the result is still unsuccessful, the 
needle should be withdrawn entirely, and a new puncture made at some 
contiguous point. 

After the aspiration is completed, the needle is quickly removed 
and the site of puncture is sealed with collodion or is covered with a 
small pad of sterile gauze held in place by a strip of adhesive plaster. 

Examination of the Aspirated Material. — Whenever fluid is detected 
a quantity sufficient for examination should be withdrawn. Fre- 
quently by a gross examination alone of the fluid sufficient information 
may be obtained as to its character. With the naked eye, one can 
often make a diagnosis between a serous, bloody, or purulent fluid, 
by carefully noting the color, clearness, and consistency of the material 
withdrawn. Valuable information can likewise be obtained from the 
odor. 

For more definite and exact information, a chemical, microscopical, 
and bacteriological examination will be necessary. In preparation 
for such an examination a few drops of the liquid should be injected 
into culture tubes, and the remainder placed in a sterilized test-tube, 



EXPLORATORY PUNCTURE OF THE PLEURA. 233 

previously provided, and kept in readiness for this purpose. At 
times the aspirated fluid may be so thick that only a few flakes or 
flocules of purulent matter can be obtained. Such material, or any 
fragments of tissue adhering to the needle point should be carefully 
transferred to a glass slide for later microscopical examination. Even 
specimens from solid growths large enough for microscopical exami- 
nation may at times be obtained by rotating the needle and moving it 
back and forth suflSciently to detach a small fragment, which may 
then be secured by producing a strong vacuum in the syringe and 
very carefully withdrawing the needle. 

The laboratory examination of the fluid, the technic of which may 
be found fully described in manuals on clinical laboratory methods, 
should be made along the following lines and with reference to the 
special points mentioned. 

1. Physical Characteristics. — ^The color, odor, clearness, consist- 
ency, reaction, coagulability and specific gravity of the fluid, and the 
character of the sediment should be noted. 

2. Chemical examination should include tests for albumin, serum 
globulin, sugar, bile, urea, blood, pus, etc. 

3. Microscopical examination is made for the purpose of detecting 
the presence of blood-corpuscles, epithelial cells, hematoidin and 
cholesterin crystals, specific tumor cells or fragments, necrotic tissue, 
ameba, hydatid booklets, ray fungi, etc. 

4. Bacteriological Examination. — Smear preparations are made 
and examined for pathogenic bacteria, while organisms susceptible 
of culture are inoculated upon suitable media and later examined 
microscopically. Thus organisms may be identified which are not 
readily detected by direct examination. 

5. Cystodiagnosis. — By this is understood the determination of 
the cause of an effusion from the relative number and the character 
of its cellular constituents. 

EXPLORATORY PUNCTURE OF THE PLEURA. • 

This is a safe and simple operation employed to confirm the 
diagnosis of a pleural effusion or to ascertain the nature of the fluid. 
The danger of injuring the lung and producing a pneumothorax need 
not be considered if reasonable care be observed in performing the 
puncture. 

Location of the Puncture. — No fixed rule can be laid down, the 
point chosen for the puncture depending upon the physical examina- 



234 



EXPLORATORY PUNCTURES. 



tion. The needle should enter a spot where there is dullness and an 
absence of respiratory sounds, voice, and fremitus, and, at the same 
time, the point of puncture should lie well below the level of the 
effusion. If it is made at too high a level, the point of the needle may 
lacerate the lung; or, if too low, injury to the diaphragm, liver, or spleen 
may result. As a general thing, however, entrance of the needle in 
the sixth interspace in the anterior ajdllary line, in the sixth or seventh 




FiC. 1,13- — Showing the points for inserting the needle in enploratory punctur 
pleura. (Large dots represent points of election.) 



. interspace in the midaxillary line, or the eighth interspace below ihe 
angle of the scapula will reveal the presence of fluid if such exist 

(Fig- 233)- 

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. 234). In uncomplicated cases, an 
upright sitting posture should be assumed, with the arm of the affected 
sideelevated for the purposeof widening the intercostal spaces (Fig. 235), 

Technic. — To avoid injury to the upper intercostal artery the 
needle is inserted near the upper margin of the rib which forms the 
lower boundary of the space chosen for the puncture. The thumb 
and forefinger of the left hand steady the tissues, while the needle is 



EXPLORATORY PONCTDltE OF THE PLEDRA. 235 

»wly and steadily inserted upward and inward, until its point enters 
e pleural sac. From i to i 1/2 inches (about 2.5 to 4 cm.) under 




of the pleura wiih the patient atting uprighi. 



^ic. 1J5.— Eiploralory puncn 

^inary conditions, and more in fat subjects or in those with very 
'^■^k pleura, may be estimated as the thickness of the thoracic wall 



236 



EXPLORATORY PUNCTURES. 



through which the needle will have to pass before entering the pleural 
cavity. The lack of resistance and the mobility of the needle will 
acquaint one of its entrance into a cavity. 

If fluid is not immediately obtained, the direction of the needle 





ai^^s' 



Fig. 236. 



Fig. 237. 



Fig. 236. — Showing the failure to withdraw fluid from the needle bdng inserted too 
far. (After Gumprecht.) 

Fig. 237. — Showing the failure to withdraw fluid from the needle entering the pleura 
at too high a level. (After Gumprecht.) 

may be changed slightly, or it may be entirely withdrawn and inserted 
in other locations before the attempt is abandoned. Failure to with- 
draw fluid may be due to the needle entering the lung (Fig. 237) or to 
the fluid being encapsulated in a space not entered by the aspirating 




Fig. 238. — Showing the failure to withdraw fluid from the point of the needle becoming 

imbedded in a thickened pleura. (After Gumprecht.) 

needle. Again, the point of the needle may become buried in adhe- 
sions or a thickened pleura (Fig. 238), or its caliber may become 
blocked by coagulated material. In addition to determining the pres- 
ence of fluid, any unusual thickness or density of the pleura may be 



EXPLORATORY PUNCTURE OF THE LUNG. 237 

appreciated by the operator through the amount of resistance offered 
to the entrance of the needle. Upon completion of the aspiration, the 
needle is quickly withdrawn, and the site of the puncture is closed with 
collodion and cotton. 



EXPLORATORY PUNCTURE OF THE LUNG. 

Previous to undertaking any operative procedure upon a pulmonary 
canty, such as a tubercular, bronchiectatic, echinococcic, or abscess 
cavity, an exploratory puncture will be of great service, not only as an 
aid to a physical examination in detecting such a cavity, but likewise 
in determining its size and exact location, and its character by an 
examination of the fluid withdrawn. 

There is considerable risk of infecting the pleura or of producing 
a cellulitis if aspiration of a pulmonary cavity without immediate 
drainage be performed, hence the exploratory puncture should only 
be performed on the operating-table with the patient ready to be anes- 
thetized, and with all preparations to incise and drain the cavity com- 
pleted beforehand, in case pus is obtained. 

Location of the Puncture. — This will depend entirely upon the 
approximate situation of the cavity, as determined by the physical 
signs. 

Technic. — A fair-sized aspirating needle, at least 4 inches (10 cm.) 
long, will be required. While the patient holds the breath to limit 
movement of the lungs, the needle is inserted in the direction of the 
supposed cavity, close to the upper margin of the rib, in the same 
manner as already described for exploratory puncture of the pleura 
(page 234). As the needle is slowly advanced, attempts to withdraw 
fluid are made at successive depths. The abscess may be superficial, 
and even adherent to the chest wall where it can be easily reached, 
but more often it will be necessary to insert the needle a distance of 
3 to 4 inches (7.6 to 10 cm.) before the cavity is entered. Failing to 
withdraw pus, the needle should be removed and reinserted at another 
spot. It may even be necessary to make a number of punctures 
before being successful, as the localization of a pulmonary cavdty is at 
times a most difficult matter. When a needle enters a cavity some 
idea of its size may be obtained from the range of motion of the needle 
and from the quantity of secretion withdrawn, though, if there has 
been considerable expectoration previous to the puncture, little or no 
fluid will be obtained, even though the needle enter a cavity. 

When pus is obtained, the needle should be left in place as a 



238 EXPLOKATOKY PUNCTUBES. 

guide for the incision and drainage, and, while the patient is being 
anesthetized, great care should be taken to see that the needle is not 
displaced. 

EXPLORATORY PUnCTURE OF THE PERICARDIUM. 

An exploratory puncture may be required as a means of making a 
positive diagnosis of the presence of fluid within the pericardium or 
for the purpose of choosing a route through which such fluid may be 
reached and evacuated. Puncture of the pericardium should not be 
undertaken lightly, and the dangers of injuring the internal mammary 
vessels or pleura, or of puncturing the thin-walled auricles of the heart, 
should impress upon the operator the necessity of extreme care when 
performing this operation. 

Location of the Puncture. — To eliminate as far as possible the 
dangers of the operation, special sites for puncture have been recom- 



'■?'^. 




FtG. »ji>, — Pnints for puncturing Ihe pericardium. The doited line indicates a dislended 
pericardial sac. 

mended, as follows: (1) In the fourth or fifth interspace, either 
close to the left 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 1/2 inch (i cm.) from the sternal 
margin. (2) In the fourth intercostal space, close to the right of the 
sternum. It is claimed that from this point it is impossible to injure 



EXPLOEATORY PUNCTURE OF THE PERICARDIUM. 239 

the heart, but this avenue of approach is only suitable when the 
amount of fluid is large. (3) Inserting the needle directly upward 
and backward close to the costal margin in the space between the 
«nsiform cartilage and the seventh costal cartilage on the left side. 

<4) When it is possible to outline accurately the shape of the peri- 
crardium and locate the posidon of the apex beat by means of pulsation 
<jr fricdon rubs, the method recommended by Curschman, Romberg, 
IKussmaul, 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. 239). 




Fic. 340. — Showing the method of Inserting the needle in an exploratory puncture of Ihe 
pericardium. 

The selection of one of these sites over the others will be made 
according to the degree of distention of the pericardium and its shape, 
which is determined by outlining the area of dullness. 

Preparatioa of the Patient. — If the patient be a male, the chest 
should be shaved, and, in any case, the skin must be sterilized thor- 
oughly before making the puncture. 

Position of the Patient. — The operation may be performed with 
the patient semirecumbent or in the upright sitting posture. 

Technic. — As already emphasized, all the aseplic precautions enu- 
ttierated under exploratory punctures (page 231) should be carefully 
carried out. The area of dullness is accurately marked out and the 
point for puncture thereby determined upon. The thumb of the left 
hand is placed as a guide upon the lower rib bounding ihe intercostal 
space selected, and the needle point is inserted just above the margin 
of the rib so as to avoid the upper intercostal artery (Fig. 240). The 



240 EXPLORATORY PUNCTURES. 

needle should be introduced slowly and with great care almost in the 
sagittal plane and directed slightly toward the median line. Entrance 
into the pericardial sac is suspected when resistance to the progress 
of the needle is no longer encountered, or when the heart is felt strik- 
ing against the needle point. If fluid is not reached from one location 
the other points of entrance above mentioned may be employed if 
necessary. Should the fluid obtained be purulent in character, 
prompt incision and drainage is indicated. 

When the purpose of the puncture is accomplished, the needle is 
slowly withdrawn, and the point of puncture is sealed with collodion 
and cotton. 

EXPLORATORY PUNCTURE OF THE PERITONEAL CAVITY. 

Aspiration of small quantities of peritoneal fluid and examination 
of the specimen obtained may be required to determine the tjrpe of an 
effusion into the peritoneal cavity — whether it be serous, inflam- 
matory, hemorrhagic, or chylous. Puncture of solid or fluctuating 
masses within the abdomen may likewise be performed as a diagnostic 
measure, but the dangers of producing serious complications through 
puncture of the intestine or other organs, or from leakage of fluid, 
especially if it be purulent, into the peritoneal cavity stamps it as an 
unsafe method except in those cases where the tumor is in close relation 
to the abdominal wall. When the presence of pus is suspected, it is 
not wise to perform an exploratory puncture unless everything is in 
readiness for an inmiediate operation. The comparative safety of an 
exploratory laparotomy and the fact that much more valuable infor- 
mation can be thus obtained render this the operation of choice. 

Location of the Puncture. — ^For puncture of the peritoneal canty, 
a point midway between the umbilicus and the pubes in the median 
line should be chosen for the insertion of the needle. 

Position of the Patient. — The patient either sits upright, in order 
to allow the gravitation of the fluid to the lowest level, or he may be 
propped up in a semireclining position. 

Preparation of the Patient. — The site for puncture should be 
shaved and properly sterilized. The bladder should always be emptied 
just previous to the operation, 

Technic. — The needle is inserted directly backward until the 
resistance of the abdominal wall is no longer felt and the point of the 
needle moves freely within the abdominal cavity. SuSicient fluid is 
withdrawn for examination, and, after removal of the needle, the site 
of entrance is closed with a thin layer of collodion and cotton. 



EXPLORATOEY PUNCTURE OF THE LIVER. 24I 

EXPLORATORY PUHCTURE 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. Exploratory 
puncture should not be performed, however, unless the preparations 
(or an immediate operation, if such be necessary, are completed 
beforehand, for no matter how small the puncture may be, leakage of 
fluid is liable to occur and cause serious damage. 

Location of the Puncture. — This will depend upon the symptoms 
and physical signs in each individual case. If at any one point there • 




FlO. 341. — Points for puncture of the liver. 

be localized pain, tenderness on palpation, peritoneal crepitation, or 
distinct bulging, such spot should be chosen for the puncture. In 
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 
^pula through the tenth interspace (Fig, 241), Puncture may also 
be made anteriorly directly into the area of liver dullness below the 
line of the pleura. 



242 EXPLORATORY PUNCTURES. 

Anesthesia. — The puncture may be made under local anesthesia, 
but if it is likely that a number of punctures will be necessary and an 
operation is to be performed, it is better to give a general anesthetic 
at the start. 

Technic. — The needle is slowly introduced inward and slightly 
upward to its full extent, and suction is attempted. If fluid is not 
obtained, the needle is slowly withdrawn, a vacuum being maintained 
in the syringe in the meantime, so as to withdraw pus in case the point 
of the needle has previously passed through a ca\ity into healthy tissue. 
Near the surface of the liver the direction of the needle is altered, and 
it is inserted again in a diflFerent plane. In this manner a large area 
of the liver may be explored in all directions from one external puncture, 
provided care is exercised not to injure the pleura and lung above, or 
the gall-bladder and intestines below. To avoid lacerating the liver, 
the exploring needle must be allowed to move freely with the liver as 
it rises or descends during respiration. If fluid is not immediately 
found, a number of punctures should be made before the operation 
is abandoned. Failure to draw pus into the s)ninge does not neces- 
sarily signify absence of an abscess, for at times the material forming 
the abscess is so thick that it will not pass into the needle, and only a 
drop or two of pus will be discovered on close examination, clinging 
to the needle point. 

Having located an abscess, the needle should be left in situ as a 
guide, for it is not an uncommon experience, when pus is discovered 
by aspiration and the needle removed, to fail to locate the abscess at a 
subsequent operation. 

EXPLORATORY PUNCTURE OF THE SPLEEN. 

As a. diagnostic measure, puncture of the spleen may be performed 
without danger if the organ is hard, as is found in chronic malaria, 
but in infectious diseases with a large, soft, and friable spleen it is 
an unjustifiable procedure. Laceration of the capsule followed by 
hemorrhage, suppuration in the spleen, and peritonitis have been 
kno^^^l to result. Likewise puncture of the spleen in suspected cases 
of typhoid fever is no longer warranted, since we have other methods 
of diagnosis, such as WidaPs test, which are both safe and adequate. 
When fluctuation has been demonstrated, as in splenic abscess or 
hydatid disease, examination of the fluid obtained by aspiration may 
give conclusive information; but here again, as in exploratory punctures 
of the liver or lungs, preparations for incision ^nd drainage, in case 



EXFLOSATOKY PDNCTOHE OF THE KIDNEYS. 343 

sacii should be necessary, should be completed before the puncture 
is nriade. 

Xocation of Puncture. — The spleen can be reached by inserting 
the needle througli the tenth intercostal space on the left side (Fig. 342). 
If the organ is markedly enlarged, some point below the left costal 
margin, determined by percussion of the spleen, may be chosen. 

Position of the Patient. — The patient may assume either the sitting 
posCure with the left arm elevated and the hand on the opposite 




■Point for puncturing the splee 



stiouldcr, or the recumbent position, depending upon which gives 
^^ niost ready access to the region of operation. 

Technic. — A fine and fairly long aspirating needle should be 

^•^pioyed. The patient is instructed to hold his breath, to lessen the 

^'^Ser of lacerating the organ, and the operator quickly inserts the 

*^«cile at the chosen site and makes ihe aspiralion with as little delay 

^® Possible. The needle is then withdrawn, and the site of puncture 

^'osed with a thin covering of collodion and cotton. 

EXPLORATORY PUHCTURE OF THE KIDNEYS. 

Exploratory aspiration may be employed to delect collections of 
^^^ or other fluids in the region of the kidney. An exploratory incision, 
Owever, and subsequent aspiration after exposure of the mass is a 
^^ more satisfactory method of diagnosis. 



244 EXPLORATORY PUNCTURES. 

Location of the Puncture. — The needle should be introduced at a 
point about 2 1/2 inches (6 cm.) from the median line, to avoid the 
erector spiiue muscles, and a little below the last rib on the left side, 
and, on the right side, between the last rib and the crest of the ilium. 

Position of Patient. — The padent may sit up, with the back bent 
forward, or he may lie partly upon the unaffected side and partly upon 
the abdomen, with the body bent forward in a curve. 




Fig. 14J. — Showing the relations of the kidneys from behind. 



Technic. — A long fine needle should be employed. The needle is 
slowly introduced forward and slightly inward toward the median line, 
frequent tests at aspiration being made as the needle is advanced. 
When fluid is discovered, a sufficient quantity for diagnosis is with- 
drawn, and the site of puncture is sealed with a cotton and collodion 
dressing. 

EXPLORATORY PUHCTURE OF JOINTS. 

This constitutes a most valuable aid in ascertaining the character 
of a joint effusion. The puncture, as in all exploratory punctures, 
should be made under strict aseptic precautions. Care should be 
exercised not lo insert the needle at a point where blood-vessels or 
important nen-es would be encountered and to avoid producing any 
injury to the cartilage of the joint, lest serious complicadons result. 



EXPLORATORY PUNCTURE OF JOINTS. 



245 



The sites for puncture of those joints to which the method is most 
oiitn applied are as follows: 

The Knee-joint. — The needle may be inserted into either side of 
the joint — but preferably in the outer side — beneath the patella at a 



^* ' 











Fig. 344. — ^Points for puncturing the knee-joint. 

point where fluctuation or distention is most in evidence. When the 
swelling is more marked above the patella, the needle may be introduced 
from above downward behind the bone (Fig. 244). 





Fig. 245. — ^Point for puncturing the 
shoulder-joint. 



Fig. 246. — Point for puncturing the 
elbow-joint. 



The Shoulder- joint. — Entrance to the joint may be readily effected 
by introducing the needle through the center of the joint from in front 
(Fig. 245). 

The Elbow-Joint. — The puncture is best made upon the outer 
side of the joint, the needle being inserted to the outer side of the tri- 



346 EXPLORATORY PUNCTURES. 

ceps muscle downward and inward, beneath the olecranon process 
(Fig. 346). 

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 between the anterior margin of the external 
malleolus and the adjoining surface of the tibia (Fig. 347). 




uu^^ 



Fig. 247. — Point for punctunng the Bukle-joint. 



SPINAL OR LUMBAR PUNCTURE. 

Lumbar puncture, an operation first proposed by Quincke for the 
withdrawal of cerebrospinal fluid from the spinal canal, has both diag- 
nostic and therapeutic value. This procedure is of diagnostic impor- 
tance through the information that may be obtained in estimating the 
pressure of the cerebrospinal Huid and determining its characteristics 
by physical, chemical, microscopical, and bacteriological examination. 

Among its therapeutic uses is its employment as a " decompressive 
agent," in cases of meningitis, hydrocephalus, intracranial tumors, 
cerebral abscess, uremia, etc., etc. On account of the continuity of the 
spaces in the brain and spinal column, temporary relief of intracranial 
and interspinal pressure may be obtained in the above cases by the 
withdrawal of small amounts of fluid from the spinal canal. In 
cerebrospinal meningitis, drainage by lumbar puncture is often fol- 
lowed by good results, as not only is the pressure upon the cord and 



SPINAL 08 LUMBAR PUNCTDBE. 347 

cerebral centers lessened, but pus is withdrawn, and the toxicity of the 
spinal fluid is thereby diminished. 

It b in the administration of antitetanic serum and antiserum in 
cerebrospinal meningitis, and the production of spinal anesthesia, 
however, that lumbar puncture finds its chief therapeutic applications. 

Anatomy. — In the lumbar portion of the vertebral column the 




Fig. 348, — Anatomy of the lumbar venebrfe. 

spinous processes do not project downward to such a degree as in 
other portions, and there is a distinct space (about 7/8 inch (22 mm.) 
in ihe transverse and 3/5 inch (15 mm,) in the vertical diameter) 
heiween the vertebral arches filled with ligaments through which a 
needle may be readily passed into the spinal canal (Fig. 248). The" 
spina! cord reaches only to the second lumbar vertebra, so if the punc- 



=»4i-j=3) 



a:flO<=CS^ 



Fio. J49. — Stylet needle tor spinal punciure. 

lure be made below that point, and the introduction of the needle be 
canied out under rigid asepsis the operation is practically harmless. 

The Needle.— The puncture is best made with a special stylet needle 
itvised for the purpose. It should be at leasl 3 1/2 inches (9 cm.) 
long and about 1/25 of an inch (i mm.) in diameter, and the point 
should be short and ground almost squarely across (Fig. 249). In the 



343 EXFLORATOKY PUNCTTXES. 

absence of such a needle, ihe ordiDary aspiradng needle of about the 
same size may be substituted. In addition, a scalpel, a sterilized grad- 
uated test-tube, culture tubes, and an ordinary hydrometer (Fig. 250) 



I 



1> 



s;; 




Fig. 350. — Apparatus for spinal puncture. 
I, SralptI: 1, clhyl chlond lube; 3. small glass graduate; 4, hydrometer; 5, sterile test- 
tube; 6, culture tubes. 

will be required. When it is desired to estimate accurately the cere- 
brospinal pressure, a small mercury manometer will also be required. 
Iiocatioa of the Puncture. — The space between the third and 




fur spinal puncture. 



fourth or that Iwtwccn the fourth and fifth lumbar vertebne b usually 
chosen (Fis- 251). though, if ihc puncture is performed for diagnostic 



SPINAL OR LUMBAR PUNCTURE. 



249 



purposes, it may be made lower — between the fifth lumbar and first 
sacral vertebrae in order to withdraw any sediment that may be present. 




Fig. 252.~Showixig the method of locating the fourth spinous process by passing a line 

through the highest points of the iliac crests. 

A point just below the tip of the spinous process of the vertebra forming 
the upper boundary of the chosen interspace at a distance of about 
i;2 inch (i cm.) to one side of the median line is selected for the 




Fig. 253. — Sitting posture for spinal puncture. 

"isertion of the needle. In children, however, the spinous processes 
Wng short, the needle may be inserted in the median line. 
The spinous processes may be readily identified by counting down 



250 EXPLORATORY PUNCTURES. 

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 transverse line 
between the highest points of the iliac crests with the patient standing 
erect, and it will be found that such a line passes through the tip of 
the spinous process of the fourth lumbar vertebra (Fig. 252). 

Position of the Patient. — The operation may be performed with the 
patient sitting in a chair, with the body bent well forward in the form 
of a curve (Fig. 253), so as to widen the intervertebral spaces as much 
as is possible. If this is impracticable, the patient may lie on his left 
side with his knees drawn up, shoulders forward, and body bent 
forward in an arch (Fig. 254). 




Fig. 254. — Lateral position for spinal puncture. 

Preparations. — ^The site for the puncture should be carefully 
cleansed, and thorough asepsis must be observed during the entire 
operation. The needle should be boiled and the operator's hands 
should be properly sterilized. 

Anesthesia. — With children general anesthesia may be necessary. 
In other cases, local anesthesia with a o. 2 per cent, solution of cocain, 
or by freezing, as for any puncture, will answer all purposes. 

Technic. — ^To avoid carrying in infection, a puncture should be 
made with a scalpel through the skin at the chosen spot (Fig. 255). 
The operator's left thumb or index finger is then placed between the 
two spinous processes as a guide, and the point of the needle is inserted 
on the same level as the finger about 1/2 inch (i cm.) from the median 
line,. in an upward and inward direction (Fig. 256), imtil it enters the 
spinal canal. In a child this will usually occur at a depth of from 
3/4 to I 1/2 inches (about 2 to 4 cm.) and in an adult from 2 1/2 to 3 
inches (about 6 to 7.5 cm.). If the needle strikes bone, it should 
be slightly withdrawn and then reinserted, its direction being changed 
somewhat. 



SPINAL OR LUMBAR PUNCTURE. 



251 



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 



.^Aitbv 




Fig. 255. — Spinal puncture. First step, nick- 
ing the skin at the point of punctr*^ 



ture. 




Fig. 256. — Spinal puncture. Second 
step, inserting the needle. 



Sterile test-tube (Fig. 257). The first few drops are usually blood- 
stained, and, if so, they should be discarded. Not more than i 1/4 
drams (about 5 c.c.) of fluid should be withdrawn from the spinal 




Fig. 257. — Spinal puncture. Third step, collecting the cerebrospinal fluid. 

canal of a child, nor more than 1/2 ounce (15 c.c.) from an adult, at 
one time for diagnostic purposes. When, however, the puncture is 
performed to relieve intracranial pressure, from i ounce to i 1/2 



252 EXPLORATORY PUNCTURES. 

ounce (30 to 45 c.c.) of fluid may be removed, according to the tension, 
and even more if no ill effects are observed. A dry puncture is some- 
times encountered and may be due to the needle not entering the canal, 
to its being plugged, or from the fluid being too thick to flow through 
its lumen. 

Normal Cerebrospinal Fluid and its Pathological Variations. — 
Normally, the cerebrospinal fluid escapes slowly, while in certain 
diseased conditions with increased pressure, as meningitis, tumor of 
the brain, uremia, paresis, hydrocephalus, etc., and in certain infectious 
diseases, it may spurt out. The pressure may be roughly estimated 
by the strength of the flow from the needle, a strong spurt of fluid 
indicating an increased amount of pressure, and very slow-coming 
drops the reverse. It may be more accurately measured by attaching 
to the needle a small mercury manometer by a small rubber tube, 
8 to 16 inches (20 to 40 cm.) long, filled with a i per cent solution of 
carbolic acid. This, of course, is to be done before any of the fluid is 
permitted to escape. According to Sahli, the normal dural pressure in 
the dorsal position is 60 to 100 mm. of water (5 to 7 . 3 mm. of mercury), 
and 200 to 800 mm. of water (15 to 60 mm. of mercury) in certain 
pathological conditions. 

Normal cerebrospinal fluid is colorless and water-like in clearness, 
of alkaline reaction, has a specific gravity of 1003 to 1004,, ^^^ exists 
in but small amounts, varying between 1/2 and 2 ounces (15 and 60 c.c.) 
in adults and in infants between 3 and 6 drams (10 and 20 c.c). In 
certain infectious diseases, meningitis, hydrocephalus, general paresis, 
etc., the amount of cerebrospinal fluid may be greatly increased. It 
contains but little albumin (0.02 to 0.05 per cent.), some chlorids 
(o. 7 per cent.), a copper-reducing body claimed to be sugar, and traces 
of urea (0.035 ^^ 0.04 per cent.). In nephritis and uremia, the urea 
is largely increased and the amount of chlorids may rise slightly; in 
hydrocephalus there may be a slight increase in the urea. In apoplexy, 
meningitis, paresis, hydrocephalus, and brain tumor, the quantity of 
albumin may be markedly increased. A bloody or blood-stained fluid 
will be found in intrameningeal cranial hemorrhages and in injuries 
of the skull extending through the dura, but in injuries outside the 
dura the fluid will be clear; bloody fluid may also occur in meningitis. 
In jaundice it may be greenish-yellow in color. A cloudy, purulent 
fluid indicates inflammation of the meninges, as does a rise in the 
specific gravity, and the appearance of white blood cells on examination. 
In tubercular meningitis, however, the fluid is clear and limpid. It 
is only possible to determine the specific form of infection by bacterio- 



SPINAL OR LUMBAR PUNCTURE. 253 

logical examination. Identification of the diplococcus intracellularis, 
X^neumococcus, streptococcus, or tubercle bacilli will definitely settle 
^he nature of the infection. 

Lumbar Puncture as a Means of Administering Antitoxic 
Sera. — When lumbar puncture is employed for the purpose of adminis- 
"tering sera in tetanus and cerebrospinal meningitis, a fairly large 
syringe, one with a capacity of at least i ounce (30 c.c), is required in 
.a^ddition to the other instruments necessary for spinal puncture. The 
"puncture is made in the manner described above, and a quantity of 
<:erebrospinal fluid equal to the amount of serum to be injected is 
flowed to escape from the canal; the serum is then warmed and is 
slowly injected through the same needle employed for the puncture. 

In cases of tetanus, Rogers {Journal of the American Medical 

Association^ July i, 1905), injects 2 3/4 to 5 1/2 drams (10 to 20 c.c.) 

of antitetanic serum into the nerves of the cauda equina, as well as 

subcutaneously in the neighborhood of the wound, intravenously, and 

into the nerves of the brachial plexus if the site of infection is upon the 

upper extremity, and into the sciatic and anterior crural nerves if the 

wound is in the lower extremity. In making the spinal injection the 

needle is inserted in the space between the second and third lumbar 

vertebrae, so as to strike the cauda equina, and is manipulated back 

and forth with the object of wounding some of the nerves, which is 

manifested by twitching of the legs; 2 3/4 to 5 1/2 drams (10 to 

20 c.c.) of senmi are then injected into and around these injured 

nerves. 

For cases of cerebrospinal meningitis, i to i 1/2 ounces (30 to 
45 c.c.) of serum are injected into the third or fourth lumbar space 
after a like amount of cerebrospinal fluid has been evacuated. Sub- 
sequent injections are given at intervals of twelve to twenty-four hours, 
according to the severity of the case, for three or four days. If after a 
lapse of several days the symptoms return, another series of injections 
is given. In place of a syringe, a glass funnel holding about 5 1/2 
drams (20 c.c.) attached to the needle by rubber tubing may be employed 
for administering the serum, as advised by Koplik. 



CHAPTER X. 
ASPIRATIOITS. 

ASPIRATION OF THE PLEURAL CAVITY. 

Paracentesis thoracis, also spoken of as thoracentesis and pleur 
centesis, consists in the evacuation of fluid from the pleural cavities by 
Aieans of a hollow needle or trocar to which an aspirator is attached. 

Indications. — When the presence of fluid has been made out by 
the physical signs and the diagnosis verified by an exploratory puncture, 
thoracentesis is indicated in sero-fibrinous effusions under the follow- 
ing conditions: 

1. When the fluid is sufl5cient to produce dyspnea, cyanosis, and 
cardiac weakness. 

2. In very large effusions whether or not pressure symptoms are 
present, especially if bilateral. 

3. When the heart is displaced by the presence of fluid. 

4. When the fluid is not absorbed within a week or ten days in 
spite of medical treatment. 

The advantages of early aspiration are that adhesions may be 
prevented and the course of the disease considerably shortened. Long 
continued pressure upon the lung by an effusion may prevent its sub- 
sequent full expansion, and reappearance of the fluid is more apt to 
occur when the operation has been delayed. 

Apparatus, Etc. — Evacuation of the fluid is accomplished by 
means of suction; for this purpose a hollow needle or a trocar con- 
nected with either an aspirator or a syphonage apparatus may be em- 
ployed. In addition, a scalpel or bistoury, and collodion and cotton, 
or a pad of sterile gauze and adhesive plaster for the dressing, should 
be supplied. 

The Aspirating Needle. — WTicther an ordinary aspirating needle 
or trocar and cannula be employed docs not make any material 
difference, though the latter has some advantages. WTiere the trocar 
form of needle is employed the point of the cannula may be moved 
about without danger after the stylet is removed, and, should the 
lumen of the cannula become plugged, the obstacle may be removed 
without the necessity of withdrawing the cannula by simply reinserting 

254 




ASPIRATION OF THE PLEURAL CAVITV. 255 

the Stylet. With an aspirating needle, on the other hand, the unpro- 
lected point of the needle may injure the lung or diaphragm, and, 
furthermore, should the lumen of the needle become blocked, it may be 
necessary to withdraw it entirely in order to clear out the obstruction. 
If an aspirating needle is used, one should be chosen at least 3 inches 
(7.6 cm.) long and from 1/25 inch (i mm.) to 1/12 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 the 
cannula accurately, and the cannula and stylet should gradually 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 the stylet is 
withdrawn, while a lateral opening, for connection with the aspirator, 
is placed at a point distal to this stopcock, so that the stylet may be 
moved back and forth without disturbing the connections (Fig. 258). 




Fig. 258. — Aspirating trocar. 

Aspirators. — The Potain, the Dieulafoy, or the heat vacuum 
apparatus is most commonly employed, though the aspiration may 
t^e satisfactorily made in a large proportion of cases by simple syphon- 
age. . The Dieulafoy instrument is most convenient for evacuating 
small collections of fluid and when it is desirable to be exact in the 
quantity removed, while for large effusions the Potain or the heat 
vacuum apparatus is best. 

The Potain instrument (Fig. 259) consists of an exhausting pump, 
a large glass bottle, a rubber stopper through which passes the long 
arm of a Y-shaped metal tube with a stopcock in each limb, and two 
pieces of heavy rubber tubing, one connecting the needle or trocar 
with one arm of the Y, and the other joining the second arm and the 
exhausting pump. The instrument is assembled by inserting the stop- 
per firmly into the glass receptacle and attaching one end of a piece 
of tubing to the stopcock a and the other to the needle or trocar. By 
means of the second tubing the exhausting syringe is connected with 



256 ASPIRATIONS. 

Stopcock b. The instrument should be carefully tested before using 
to see that all the connections are air-tight. To produce a vacuum, 
stopcock a is closed and stopcock b is opened, when, by pumping 
from thirty to fifty strokes, the lur will be sufficiently exhausted. 




Fic. IS9- — Potain aspiralt 



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 moment fluid is reached it 
will be drawn by suction into the bottle. If the trocar is employed. 




Ftc. »6o.— The Dieulafoy aspitali 



the stylet is not withdrawn until the trocar enters the chest; as this is 
done the stopcock on the cannula is closed, so as to exclude air. 

The Dieulafoy apparatus {Fig. 260) consists of a glass syringe, with 
a capacity of 3 to 4 ounces (89 to 118 c.c), pronded with two outlets, 



ASPIRATION OF THE PLEURAL CAVITY. 257 



. g each furnished with a stopcock, and to which are fitted heavy rubber 

■IJ tubes. To the eztremi^ of one tube a trocar or aspirating needle 

~W isattached, and at a distance of about 4 inches (locm.) from the needle 

W end a piece of glass tubing is inserted as an index. The other piece 

W 0/ tubing leads from stopcock 6 to a basin to carry off the fluid dis- 

' charged from the cylinder. To use the instrument both stopcocks are 

cfosed, and the piston is fully withdrawn and fixed in place by a spring. 

Tills produces the \^£uum. The aspirating needle is then introduced 

tQ the chosen site, and, as soon as theneedle point is buried in the tissues, 

the stopcock a is opened, allowing the vacuum to extend to the 

needle. The needle is then pushed on in until it enters the chest, the 




Fig. 261.— <:onneir3 beat 



V^^^^ence of fluid being first demonstrated as it passes through the glass 
*iex. When the aspirator is filled, stopcock a is closed and stop- 
*^V b opened, and the fluid is discharged from b by driving the 
«*^ton back in place. This process of aspiration may be repeated as 
*~*uen as necessary without removing the needle or disconnecting the 
^pirator. 

A very excellent form of aspirator and one that is frequently 

I employed is the vacuum bottle described by Connell (Medical 

Rtcord, July 4, 1903). It consists of a strong glass bottle with a capac- 
ity of about 5 pints (2.5 liters), having a mouth i inch (2.5 cm.) 



258 ASPIRATIONS. 

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 (11 c.c.) of 95 per cent alcohol are poured into 
the bottle which is so manipulated that its inner surface is entirely 
coated, when the excess of alcohol is poured oflF. The alcohol is then 
ignited, and, as the flame reaches the bottom of the bottle, the cork is 
quickly inserted, the rubber tubing having been previously clamped 
(Fig. 261). A vacuum is thus produced which is amply suflScientto 
aspirate a chest. 

Removal of an effusion by s3rphonage may be readily accomplished 
by means of a very simple apparatus. A piece of heavy tubing about 
3 feet (90 cm.) long, a clamp to close one end of the tubing, a fim- 




FiG. 262. — Syphonage aspirator. 

nel, sterile water or saline solution to fill the tubing, and a receptacle 
to collect the fluid are the necessary requisites. One end of the tubing 
is fastened to the needle or the side outlet of the trocar and the other to 
the glass funnel (Fig. 262). 

Site of Aspiration. — The needle should be inserted at a point where 
the physical signs or an exploratory puncture demonstrate the presence 
of fluid and at the lowest level of the fluid, that its withdrawal may be 
facilitated as far as possible by the action of gravity. The sixth inter- 
costal space in the anterior axillary line, the sixth or seventh space in 
the midaxillary line, and the eighth space below the angle of the 
scapula are the points of election (Fig. 263). 

Quantity Withdrawn.— It is not essential to empty the chest entirely 
at one sitting. The amount of fluid evacuated should be determined 
more by the manner in which the patient bears the operation, the 



ASPIBATION OF : 



; PLEUEAL CAVITY. 



259 



coDdidon of the puke, and signs of impending collapse rather than by 
the quantity of fluid present. In veiy large effusions as much as 3 
pints (1500 c.c.) may be removed, but it is better to withdraw too Jittle 
than too much, for what remains may be evacuated at a subsequent 
period; and it not infrequently happens that spontaneous absorption 
of the effusion follows the removal of even small quantities. 




Fig. i6j. — Sites foi aspiration of the pleura. (The large dots represent the points <A 
election.) 



PositioD of Patient. — The aspiration is preferably performed with 
the patient on a bed so as to avoid the extra exerlion of moving after 
the operation. When possible, an upright sitting position should be 
assumed, with the arm of the affected side raised, and the hand placed 
on some support or on the opposite shoulder to increase the breadth 
between the intercostal spaces (Fig. 264). If this is impracticable, 
the patient may lie near the edge of the bed, upon the back for a lateral 
puncture, or rolled slightly to the opposite side with the arm extended 
over the head for a posterior puncture (see Fig. 234). 

Asepsis. — The skin at the site of operation should be thoroughly 
cleansed with soap and water, followed by alcohol, and then a 1 to 2000 
solution of bichlorid of mercury. The operator's hands should also 
be properly cleansed, and the needle or trocar sterilized by boiling. 

Anesthesia. — Local anesthesia by freezing with ethyl chlorid or 



-.^ v.^i^ips;? 



360 



ASPIRATIONS. 



by iofiltradoQ with a few drops of a 0.2 per cent solutim ct coado 
at the point of puncture will be suffidoit. 

Tedmic. — ^A vacuum is first produced in the asiarator and the 
needle or ttocar attached. A point is then selected in tiie chosen 
interspace at a little distance from the upper margin oi Uie knrer r9> 




Fio. 164. — Position of patient for aspiration of the pleun. 

bounding the space, so as to avoid the upper intercostal artery, and the 
skin is nicked with a scalpel. The thumb and forefinger of the left 
hand are used to steady the tissues overlying the intercostal space, 
while the needle or trocar is introduced with the right hand, the 
forefinger being placed on the needle to guard against its being inserted 




Fio. 365. — Method of holding the 



too deeply (Fig. 265). As soon as the point of the needle enters the 
tissues, the vacuum already present in the aspirator is extended to the 
needle point by opening the proper stopcock, and the needle is steadily 
pushed in until it enters the pleural sac, which will usually be at a 



ASPIBATION OF THE PLEURAL CAVITY. 



361 



depth of less than 2 inches (5 cm.). The fluid should be withdrawn 
rather slowly in order that the structures may have time to adjust 
themselves to the changed conditions in the chest; at least twenty 
minutes to half an hour should be consumed in removing 2 pints 
(1000 cc). 

Should the patient feel faint or suffer from vertigo or dyspnea 
the operation should be temporarily interrupted and the patient's 
head lowered. Complaints of severe pain, persistent cough, or 




Fic. a66.- — Aspi 



pleura with ihe Pot«n apparatus. 



expectoration of blood also demand that the aspiration be discon- 
tinued. 

At the completion of the operation the tissues are pinched up 
around the shaft of the needle which is quickly withdrawn. The 
site of puncture is then dressed with collodion and cotton, or with a 
sterile pad of gauze held in place by adhesive strips. 

In employing the syphonage apparatus the tubing is iirst filled 
wilh sterile solution, and the clamp is placed near the end of the tube 
to prevent the solution escaping. The needle is then introduced inio 
the chest, while the free end of the tube is placed under water in the 
receptacle provided for the collection of the fluid. On removing the 
clamp from the tube the column of water is released and the fluid 
withdrawn by a process of syphonage (Fig. 267). 



a6a 



ABFISATIOKS. 




Coavlkatioat tad Duiiin.— ^^ is not to be f^re 
naiy a8q>tic precatituws aie obaerved. 

P neum^iurax may kiOxm injuiy to the lung by the aspiratmg 
needle or ttocar, or be due to the rupture of adhesions or a caWty when 
aq»tiBioa occurs, <»- to the ratnnce <rf air along the trocar. 

Albmiritums expectonUon has been observed as a sequel to ihe 
sudden withdrawal of large quantities of fluid. The expectoratioa 
OHisisls 6t a yellowish, frothy fliud, and it is accompanied by dyspnea, 
cyanosis, and a weak pulse. This andition usually begins during the ^ 



/) 


j\\ 


^ 


4i^ 


/«a=^ 


1 JL^ 


/' 


\v' 




\W 




k x\ 




\jij/ 


\' 


^ 




^^s^ ^ 


'^'^ 








^^ 






^z^^^^^~ 















Fig. 167. — Aspiration of the pleura by sirplxnage. 



withdrawal of the fluid, or comes on shortly afterward. It is explained 
on the supposition tbftt the rapid withdrawal of fluid suddenly removes 
the pressure from the lung, which as a result becomes congested, and 
transudation into the air cells follows. 

Expectoralion of blood may result from the ruptiu% of small pul- 
monary vessels, from congestion of the lung, or from injury to the lung 
tissue by the aspirating needle. 

Sudden death is unusual, though it may occur, and at times without 
apparent cause. Embolism, cerebral anemia, from the sudden rush 
of blood to the expanding lung, hemorrhage into the pleural cavities 
from injury to the lung, and irritation of the terminations of the 
pneumogastric nerve have been suggested as explanations. 



ASPIRATION OF THE PERICARDIUM. 



263 



The occurrence of these complications may be reduced to a mini- 
mum by the employment of rigid asepsis, the observance of great care 
in the use of the needle or trocar, and the removal of only moderate 
amoimts of fluid without haste. 



ASPIRATION OF THE PERICARDIUIL 

Paracentesis pericardii, or pericardicentesis, consists in the 

evacuation of the contents of the pericardial sac through aspiration 

by means of a needle or a fine trocar attached to a vacuum apparatus. 

Indications. — ^Paracentesis of the pericardium should be performed: 

I. If the effusion is sufficiently large to endanger life through 

profound disturbance in the cardiac action indicated by severe dyspnea, 




Fig. 268. — Points for aspiration of the pericardium. 

small, rapid, and irregular pulse, and cyanosis, the indicatio vitalis, as 
death may result from syncope if the condition be not relieved without 
delay. 

2. When a large effusion does not show any tendency to absorption 
after a prolonged and fair trial of medical means. 

In the presence of a purulent exudate, though temporary relief may 
be obtained by aspiration, the condition is one that should be treated 
by incision and free drainage, just as in empyema. 

Apparatus, Etc. — In tapping the pericardium a Potain or Dieulafoy 



264 ASPIRATIONS. 

aspirator to which is attached a fine needle or trocar and cannula 
may be employed in the same way as used in the pleural cavity; a 
scalpel, collodion and cotton, or gauze and adhesive plaster for the 
purpose of dressings, should also be at hand. 

Site of Aspiration. — ^The point for making the aspiration should be 
determined upon after having first detected the presence of fluid by 
an exploratory puncture (page 238). For the introduction of the 
needle there are four sites recommended: 

1. In the fourth or fifth intercostal space close to the left sternal 
margin, or else i inch (2 . 5 cm.) to the left of it, thus passing either 
internal or external to the internal mammary artery. 

2. In the fourth interspace close to the right of the sternum. 

3. Close to the costal margin in the angle between the ensiform 
cartilage and seventh costal cartilage on the left, inserting the needle 
upward and backward. 

4. In the fifth or sixth left interspace outside the nipple line between 
the apex beat and outer border of dullness (Fig. 268). 

Quantity Withdrawn. — In small effusions the fluid may be removed 
at one sitting; but in large effusions, in order to avoid suddenly remo\*ing 
the extracardial pressure, it is preferable to withdraw not more than 
3 to 4 ounces (89 to 118 c.c.) at the first sitting. This may be followed 
by absorption of the rest of the fluid, as is often the case in pleurisy. 
If there is no improvement at the end of a day or two, however, it will 
be necessary to perform a second tapping. 

Position of Patient. — ^The operation may be performed either with 
the patient recumbent or sitting upright. 

Asapsis. — The greatest regard to aseptic precautions should be 
observed. The area of operation should be shaved, if necessary, and 
the skin sterilized by first washing with soap and water, then with al- 
cohol, followed by the use of a i to 2000 solution of bichlorid of mercury. 
The operator's hands are thoroughly cleansed, and the apparatus to be 
used in the operation is boiled. 

Anesthesia. — Local anesthesia by freezing with ethyl chlorid 
or other freezing agents, or by injecting a few drops of a o. 2 per cent, 
solution of cocain into the skin will be found useful. 

Technic. — A nick is made through the skin with a scalpel at a 
point not far from the upper margin of the rib forming the lower 
boundary of the space pre\iously determined upon for aspiration. 
The tissues are steadied between the thumb and forefinger of the left 
hand, and the needle is held in the right hand, the index finger being 
placed on its shaft as a guide to the proper depth of insertion, as shown 



ASPIRATION FOR ASCITES. 265 

in Fig. 265. The direction of the needle as it is introduced should 
be at first backward, until it enters the thorax, and then slightly inward 
into the pericardium; but if the approach is made in the left seventh 
costox3rphoid angle, the needle is introduced directly upward and 
backward. The introduction of the needle must be performed slowly, 
steadily, and with great care. The vacuum previously produced in the 
aspirator is extended to the needle, by opening the proper valve, as 
soon as the needle point enters the tissues, so that fluid will be with- 
drawn at the earliest possible moment and thus injury to the heart, 
through inserting the needle too deeply, will be avoided. Usually at a 
depth of I 1/2 to 2 inches (3 . 8 cm. to 5 cm.) the pericardium will be 
entered. Care must be taken not to produce too great a vacuum in the 
aspirator lest the fluid be withdrawn too rapidly — it should simply 
trickle into the aspirator. 

As soon as the desired quantity is removed, the aspirating needle 
is quickly withdrawn, and the seat of puncture is occluded with cotton 
and collodion, or else by a pad of sterile gauze held in place by adhesive 
plaster. 

Complications and Dangers. — It should be remembered that 
aspiration of the pericardium is no simple procedure, but is an oper- 
ation attended by danger. Infection of the pericardium, injury to the 
internal mammary vessels, puncture of the pleura, and laceration of the 
coronary artery and the heart itself by the aspirating needle have all 
been observed. Strict attention to asepsis, extreme care in intro- 
ducing the aspirating needle or trocar, and observ^ance of the various 
points in technic that have been emphasized will do much in preventing 
such accidents. 

ASPIRATION FOR ASCITES. 

Paracentesis of the abdomen consists in puncturing the peritoneal 
canty by means of a trocar and cannula and withdrawing the fluid 
therein contained. It is an operation attended by practically no 
risks and can safely be repeated many times in the same individual 
when necessary. 

Indications. — The abdomen may be aspirated in cases of ascites 
when the physical signs show the presence of fluid, and distention 
becomes distressing from pressure upward upon the diaphragm. It 
should also be performed when the fluid reaccumulates after a previous 
tapping and gives rise to pressure symptoms. 

Instruments, Etc. — A straight or slightly curved cannula and trocar 



266 



ASPIRATIONS. 



of fair size — ^about i/8 to 1/4 inch (3 to 6 mm.) in diameter — should 
be used. The trocar is spear-pointed and should fit the cannula per- 
fectly so as to prevent the point of the latter catching in the tissues 
during its introduction (Fig. 269). An excellent form of cannula, and 
one frequently used, contains a lateral opening about 1/8 inch (3 mm.) 
from its end, for the purpose of avoiding stoppage of the escaping 
fluid, should the intestines or omentum obstruct the end opening of 
the instrument. 

If desired, the aspirating apparatus of Potain or Dieulafoy (page 
255) may be used in place of the simple trocar. 




Fig. 269. — ^Trocar and cannula for aspirating the peritoneal cavity. 
I, Trocar and cannula assembled; 2, showing trocar removed from the cannula. 



In addition a scalpel to make a small preliminary iacision, 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. 

Site of Puncture. — ^The selection of a location free from vessels 
and where the abdominal wall is thin is desirable. Usually a point 
in the linea alba midway between the umbilicus and pubes is selected, 
but the puncture may be at a point in the linea semilunaris just outside 
the rectus muscle on a line midway between the umbilicus and the 
anterior superior iliac spine (Fig. 270). Should repeated punctures be 
made, it will be of advantage to change the site a little each time so 
as to avoid entering adhesions which may have been produced by a 
previous puncture. 

Quantity Withdrawn. — Whether all the fluid should be removed 
at once will be determined by the condition of the patient and the 
manner in which he bears the operation. As a general thing there is 
no harm in removing all the fluid, provided it is not evacuated too 
rapidly. 

Position of Patient. — ^The patient should sit upright on the edge 



A5PIBATI0N FOB ASCITES. 



"^. V 



367 




VtG. 270. — Sites for asinntion of the peritoneal cavitjr. 




ftc t;i.— .\ipinUioD of the peritoneal cavity. First step, application of the abdominal 



368 



ASPnCATIONS. 



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 to 
the lowest level of the peritoneal cavity. When the puncture is made 
in the linea semilunaris, the patient should lie upon the side. 

Preparations. — The bladder and bowels should always be empty 
before operation. The abdominal wall is shaved and then scrubbed 
with soap and water, followed by alcohol and a final rinsing with a 
I to 2000 solution of bichlorid of mercury. The operator's hands 
should likewise be sterilized, and the trocar is to be boiled. 




Fig. 373. — Aspiration of the peritoneal cavity. Second step, nicking (he skin al the pcnnt 

of puncture. 

Anesthesia. — Local anesthesia with ethyl chlorid, ether, ice and 
salt, or infiltration with a few drops of a 0.2 per cent, solution of co- 
cain 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, 271) 
and is to be tightened at inte^^-als during the operation, so that uniform 
pressure may be applied while the fluid is flowing off and a sudden 
overfilling of the abdominal vessels with blood prex-ented. With a 
scalpel the skin is incised for a distance of 1/4 inch (6 mm.) at the 
spot chosen for the puncture (Fig. 272), and the trocar is slowly and 
steadily inserted, with the inde:i finger held along the instrument as 



ASPIRATION FOR ASCITES. 



269 



a guide to the depth it is to enter, and to prevent it from being suddenly 
forced in too far (Fig. 273). As soon as it is judged that the peritoneal 
ca\ity has been reached, the trocar is withdrawn and the fluid is per- 
mitted to escape. 

The fluid should be evacuated slowly, and, if it flows too freely, 
it is well to stop the flow at » intervals by placing the finger over the 
end of the trocar, in order to allow the abdominal contents to 
adapt themselves to the changed conditions. If the stream is sud- 
denly stopped by the intestines or omentum occluding the end of 




Fig. 27?.—. 



m- 



-Aspiration of the peritoneal cavity. Third step, showing the method of 

inserting the trocar. 



the instrument, a slight turn of the cannula or a change in its posi- 
tion may be sufficient to relieve the obstruction; if not, it may be neces- 
sary to clear the lumen by passing a sterile probe through it. As the 
fluid is withdrawn, and the distention of the abdomen decreases, 
necessary support is given to the lax abdominal walls by drawing the 
binder tighter. S)mcope may be thus avoided; should it occur, however, 
the escape of the fluid must be temporarily stopped by placing the 
finger over the end of the trocar and the patient's head must be lowered, 
care being taken to see that air does not enter the trocar while this is 
being done. 

When fluid ceases to flow, the cannula is quickly removed and, if a 
large opening has been made by the trocar, the skin may be drawn 



270 ASPISATIQNS. 

together by a subcutaneous stitch and the Ime of indsioa sealed 
with collodion and cotton. If there seems to be a good deal of ooang 
of fluid along the track of the trocar, howeveii a stoile gause dressings 
held in place with rubber adhesive plaster and changed as often as 
necessaiy, will be found more satisfactoiy. After the aspiration the 
patient should be kept in bed for at least t^venty-f our hours. 

ASPmAHOH OF THB TUHICA YAQISiUB. 

This operation is employed in the cure of hydrocde. It consists 
in introducing an aspirating needle or trocar and cannula into the 
tunica ^^ginalis and removing the contained fluid. It may be per- 
formed simply to withdraw the hjrdrodtic fluid or as part of the 
radical cure l^ injection of carbolic add. The fonner is rarely mcne 
than a palliative measure, as the fluid usually prompdy recurs. 

The treatment by a combination of aspiration a|id the injection 
of 95 per cent carbolic add is, however, successful in more than 80 
per cent, of cases (Sevan). It is especially apidicable to hydroceles 
with thin sacs; in the old, chronic cases with thkk sacs it is not (rften 
successful. 

The operation is practically without danger, if perfoimed with 
proper tedmic and care is taken to prevent injury to the structures of 
the cord and the testicle. The latter usually lies posterior to the tumor. 




.. — ^Trocar and syringe for aspirating and injecting a hydzocele. 



Fig. 274, 

though in rare cases it may be in front. Its position should always 
be ascertained first, if possible, by palpation and transillumination. 

Instruments. — ^A medium size trocar and cannula, or a large 
aspirating needle, to which may be attached a small aspirating syringd, 
will be required (Fig. 274). 

Site of Puncture. — The trocar should be introduced at the junction 
of the lower and middle thirds of the anterior surface of the scrotum, 
at a spot where visible blood-vessels are scarce. 

Asepsis. — The usual aseptic precautions should be observed. The 
skin at the site of puncture should be shaved and then washed with 
soap and water, followed by a i to 2000 solution of bichlorid of mercury. 



ASPIKATION OF THE TUNICA VAGINALIS. 



271 



The operator's hands should be prepared as for any operation, and the 
instruments boiled. 

Anesthesia. — ^The spot of intended puncture may be cocainized 




Fig. 375. — Aspirating a hydrocele. Showing the method of grasping the scrotum and the 
trocai being inserted. 

by the injection of a few drops of a o. 2 per cent, solution of cocain 
or frozen by ethyl chlorid. 

Technic. — The operator places his left hand behind the scrotum 
and grasps the neck of the hydrocele between the thumb and forefinger, 




Fig. 176. — Aspirating a hydrocele. Showing the cannula In place. 

thus making the tumor tense by compression. Holding the 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 instrument being 
introduced too deeply, the operator thrusts it into the ttmica vaginalis 



272 ASPIRATIONS. 

in an upward and backward direction (Fig. 275). 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 depressing 
the free end and the trocar is removed (Fig. 276). All the fluid is then 
allowed to escape, and, to nia.ke sure the sac is empty, the aspirator 
may be attached and suction employed. 

The cannula is left in site and from 5 to 30 drops (0.30 to 1.90 c.c.) 
of 95 per cent, (deliquescent) carbolic acid, depending upon the size of 
the hydrocele, are injected through the cannula (Fig. 277). If a 




Fig. 377, — Method of injecting a hydrocele. 



syringe cannot be attached directly to the cannula, the injection may 
be made by means of a hypodermic syringe and a long needle inserted 
through the cannula. The skin is then pinched up around the can- 
nula, which is quickly removed, and the scrotum b manipulated so as 
to smear the acid over the whole interior. The puncture is then finally 
sealed with collodion and cotton. 

The patient should remain in bed twenty-four to forty-eight hours 
after the operation with a. supporting dressing applied to the scrotum. 
Some swelling follows the injection, but it usually subsides in a week 
or ten days. During this lime the patient should wear a well-fitting 
•oBpensory. 

ASPIRATION OF THE BLADDER. 

AspiratioB of the bladder will be considered under the section 
devoted to that organ (see page 639). 



CHAPTER XI. 

THE NOSE AND ACCESSORY SINUSES. 

Anatomic Considerations. 

The Nose. — ^For purposes of description the nose is divided into an 
external and an internal portion. 

The external nose forms a prominence upon the face resembling a 
triangular pyramid, made up chiefly of bone and cartilage and covered 
with muscles and integument. The bony portion, or bridge, is com- 
posed of the nasal portions of the superior maxilla and the two nasal 
bones. The arch forming the forepart of each side of the nose is 
composed of two large lateral cartilages which converge to form the 
ridge and tip. These are supplemented usually by three smaller 
cartilages bound together by connective tissue, which aid in forming 
the wings or alae. 

The interior of the nose is divided by the septum into two chambers, 
or fossae, narrow above and more expanded below. These open 
anteriorly by the anterior nares, two pear-shaped apertures measuring 
about I inch (2.5 cm.) vertically and 1/2 inch (1.2 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 spaces situated in the 
frontal, ethmoid, sphenoid, and superior maxillary bones. The roof 
is formed by the nasal bones, the cribriform plate of the ethmoid, 
and the body of the sphenoid. The floor, concave from side to side, 
is formed by the palatal process of the superior maxilla and the hori- 
zontal process of the palate bones. It separates the nose from the 
mouth. The inner wall, or septum, is formed posteriorly by the perpen- 
dicular plate of the ethmoid and the vomer, and anteriorly by the 
triangular cartilage. The septum is seldom exactly in the median 
line, but is usually more or less deflected, so that it is unusual to find 
the two fossae of equal size. The outer walls of the nose are formed by 
the superior maxillary, the lachrymal, the ethmoid, the palate, and the 
sphenoid bones. They are very irregular, 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. 278). 

18 273 



374 

The sufeHermeohulitahetmcn the superior and middle turbinates.^ 
It is nanow and groove-like, and is the smallest of the ibrc-e. The 
orifices of the postnior ettunoidal cells open upon the upper and 
ftuepart of its outer wall. .' ^ 



Flo. tjS.- 




[After ZuckcrkandL) 



Tht middle meatus lies Jietween the middle and inferior turbinates, 
and is moie capacious than the superior, extending along the posieritf 
two-thirds of the outer wall of ihe nose. Opening into the middle 
meatus on the outer wall is a crescentic slit-like aperture, the hiaius 



Fig. a79.^Showing ihe 
J, Opening of the sphenoidal 




!r wall of the naaal cavhf . 
!, superior meatus; 3, middte meatus; 4, in 



semilunaris. Just above it, and at times partly occluding this o[>ening, 
is a protuberance, the bulla ethmoidalis, which marks the situation of 
the anterior ethmoidal cells. Upon the lateral wall of the middle 
meatus and extending from the hiatus semilunaris upward and fcff- 



ANATOUY. 375 

ward, is a curved groove bounded internally by the uncinate process 
of the ethmoid, known as the infundibulum. From this a closed duct 
leads into the frontal sinus. At the deepest portion of the infundibulum 
near the posterior end, is the opening of the maxillary sinus, and 
behind thb at times is found an accessory opening. The anterior 
ethmoidal cells also open into the infundibulum on the upper part of 
the outer wall or else they communicate with the frontonasal duct. 




Fic. aSo. — Lateral wall of the right nasal cavity showing the orifice of the accessory 
siniues. (After Schultze and Stewart.) The dotted line indicales the outline of the middle 
turtnnate, which has been removed to show the structures beneath. A portion o£ the 
infciior turbinate has also been removed. 

T. Frontal sinus; t, infunditiulum: j, hUtus semilunaris; 4, orifice of the nasal duct; 
5. bulla ethmoidalis; 6, inferior turbinate; 7, accessory orifice of the maxillary sinus; 8, 
orifice of Eustachian tube; 9. fossa of Roscnmiiller; 10, sphenoidal sinus; 11, orifice of the 
sphenoidal sinus; 11, orifice of the middle and posterior ethmoidal cells; 13, orifice of the 
anterior ethmoidal celts. 



From the anatomical relation of these openings, it can be understood 
how readily infection of the maxillary sinus may follow a suppurative 
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. 

The inferior meatus, the largest of the three, lies between the 
inferior turbinate bone and the floor of the nasal cavity, extending 
along the entire length of the outer wall of the nose. The nasal duct, 
leading from the orbit, opens into the inferior meatus at the junction 
of the anterior third with the posterior (wo-thirds. 

The mucous membrane lining ihe nasal ca\ity is continuous 
anteriorly with the integument and also with the mucous membrane 
of the pharynx. Eustachian tubes, and accessory sinuses. In the 
upper portion of the nose the mucous membrane is of the columnar 



376 THE NOSE AND ACCESSORY SINDSE8. 

variety. Id this region it is tlun and doselj bound to the 
and peridumdrium beneath, and contains the endings of the olhctoiy 
nerves. The remainder of the nasal cavi^ is lined with ciliated tpi- 
thelium. Over the inferior turbinates, the lower porti<»i of the middle 
turbinates, and corresponding parts of the septum the muanismemlmiit 
is thick and very vascular, containing numerous diin-walled Tooas 
channels capable of becoming so enormously distended with bkud 
that they may even occlude the nates. On the floor of the noae tbe 
mucous membrane again becomes thinned out 

The Accessory Sinuses. — Hollowed out of the bones surnninding 
the nasal f ossee are four cavities filled with air, known as the mazillu7, 
frontal, ethmoid, and sphenoid sinuses. These accessory iiDuies 




Fig. aSi. — Cross-section of the maxillaiy unuses, showing the close reUtloD ti the v*M 
o( the molar teelh to the Boors of the Onuses. (After Zuckerkandl.) 

are lined with a thin, pale, mucous membrane continuous with that of 
the meatus into which each sinus respectively opens. The function 
of the sinuses is to give resonance to the voice and at the same time 
add to the lightness of the skull. 

The maxillary sinus or antrum of Highmore, lies to the outer side 
of ihe nasal fossa, occupying the greater portion of the superior max- 
illary bone. It is the largest of all the accessory sinuses. In shape 
it resembles a three-sided pyramid, with the apex at the zygomatic 
process of the maxilla, and the base directed toward the nasal caWty. 
The roof of the antrum is \ery thin and forms the floor of the orbit. 
The anterior wall is directed toward the face and corresponds to the 
canine fossa externally. The floor, which is directed toward the 
mouth, is formed by the alveolar mai^n and outer portion of the hard 



ANATOMY. 277 

palate. The roots of the molar teeth almost protrude through the 
floor into the antrum (Fig. 281), being often separated from the cavdty 
by a thin shell of bone, or merely mucous membrane, so that ulceration 
of the teeth may readily lead to infection of the sinus. This ana- 
tomical arrangement is sometimes taken advantage of in draining the 
antrum, a tooth being extracted and the sinus opened through the 
alveolus. 

Ordinarily, the antrum has a capacity of about 4 drams (15 c.c), 
but its size varies greatly, and in the same individual the two sides are 
frequently disproportionate. The antrum communicates with the 
middle meatus by an ostium opening into the infundibulum, and thence 
through the hiatus semilunaris. This aperture cannot be seen until 
the middle turbinate has been removed. In a small percentage of 
cases an accessory ostium is found lying posterior to the main opening. 

The Frontal Sinus. — The frontal sinuses are two air spaces sepa- 
rated from each other by a septum, lying between the tables of the 
frontal bone above the orbits. Each consists of a vertical portion 
passing upward on the forehead and a horizontal portion extending 
backward over the roof of the orbit. Their size is variable and they 
are often unequal through deflection of the septum to one side. Cases 
have been observed with one sinus entirely absent. The floor of the 
sinus forms by its external portion the roof of the orbit, and by its 
inner portion the roof of some of the anterior ethmoidal cells. The 
latter part of the floor is extremely thin, so that suppuration of the 
frontal sinus is liable to extend to the anterior ethmoidal cells. The 
posterior wall separates the sinus from the frontal lobes of the brain 
by an extremely thin plate of bone. The anterior wall is thick and is 
represented externally by the superciliary ridge. In the posterior 
portion of the floor of the sinus is the rounded or oval aperture leading 
into the infundibulum and thence to the middle meatus by means of 
the hiatus semilunaris. 

The ethmoidal cells lie in the lateral masses of the ethmoid bone. 
These cells vary in size and number. They are divided into two sets, 
anterior and posterior. The anterior open into the middle meatus, 
generally by the infundibulum, while the posterior set open into the 
superior meatus. These cells are separated from the cranial cavity 
and orbit by extremely thin plates of bone. 

The sphenoidal cells are situated in the body of the sphenoid bone 
close to the base of the skull. They are quadrilateral in shape and 
variable in size, and like the frontal sinuses they may be asymmetrical 
from deviation of the septum. The anterior wall looks downward and 



278 THE NOSE AND ACCESSORY SINUSES. 

forward and forms a part of the roof of the nasal cavity. The upper 
wall is very thin and separates the sinus from the cranial 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 ca\ities, care- 
ful 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, 
delations, or deformities. The shape of the jaws also should be ob- 
serv'ed; likewise the presence or absence of any prominences or bulging 
in the neighborhood of the accessory sinuses; the presence or absence of 
enlarged cer\ical glands; the presence of excoriations, herpes, or crusts 
about the anterior nares and upper lip, as indications of nasal discharge. 
It should be ascertained whether the patient breathes through the mouth, 
and the patency of the nose should be tested by alternately closing 
each nostril with the finger while the patient breathes through the 
opposite one. The odor of the breath, the presence or absence of 
marked movement of the ate nasi, or any sounds produced during 
nasal breathing, and the character of the voice should also be carefully 
noted. Ha\ing completed this preliminary examination, that of the 
interior of the nose should be proceeded with. 

For a thorough examination of the nasal cavity and accessor)' 
sinuses five methods are available: namely, (i) inspection or rhinos- 
copy; (2) probing; (3) palpation; (4) transillumination; and (5) 
skiagraphy. 

RHINOSCOPY. 

Inspection of the interior of the nose may be performed by anterior 
and by posterior rhinoscoi)y. In anterior rhinoscopy the examination 
is made through the anterior nares with the aid of a suitable speculum 
and a strong light. Posterior rhinoscopy consists in an examination 
of the nose from within the ])har}'nx by the aid of reflected light and a 
rhinosco])ic or small laryngeal mirror. The former is simple and re- 
([uires no great skill, but the latter is by no means an easy procedure 
for one unskilled, and at times requires considerable patience on the 
j)arl of the operator to complete successfully and satisfactorily. 

Illumination. — To obtain a good view of the interior of the nose, it 
is necessary to have the best illumination possible. Strong sunlight 



EHDIOSCOfY. 



279 



may be utilized for anterior rhinoscopy, but it is not suitable for an 
examination of the posterior nares. Gas or electricity are the two 
forms of artificial light most used. With the former, a Welsbach burner 
fitted with a mica chimney over which b placed a Mackenzie condenser 
gives excellent illumination (Fig. 282). Electric light from a frosted 
lamp is also much used and has an advantage in that it does not give 
out much beat. 

Whatever the form of light, it should be so arranged upon a suitable 
bracket that it may be raised, lowered, or turned from side to side 




Fig. 381. — Gas lamp upon an adjustable stand fitted with a Mackeimc condenser. 

without inconvenience to the operator. The light should be placed 
upon the patient's right, somewhat behind him, and about on a level 
with the tip of his ear. 

Many operators prefer an illumination furnished by an electrical 
head light (Fig. 283). Such a light, with the current furnished from 
a small pocket storage battery will be found a great convenience out- 
side the examining room. 

Instruments. — In addition to a suitable light, there will be required: 
a concave head mirror, about 3 1/2 to 4 inches (8.9 to 10 cm.) in di- 
ameter, with a large central eye-hole, and secured to a soft leather head- 



^ tHE NOSE AKD. ACCESSORY SISUSES. 

band by a ball-and-socket joini; a rhinoscopic miiTor i/a inch (i cm.) 
in diameter, set al an angle of loo lo i lo degrees with the shaft, whici 
is curved 'o follow the line of the tongue; a Myles solid-bladc oaal 
apeculum; a Fraenkel tongue depressor; a White palate rctraciorj 
and a nasal applicator with a triangular-tipped shaft fFig. 284). 




Fio. 184.— Inst nimenls for rhinoscopy. 

:, Alcohol lamp; 3. rhinoscopic mirror; 3, White's palate retractor; 4, Myles' n 

apeculum; s, head mirror; 6, nasal applicator; 7, Fraenkel's tongue depresMt 



Asepsis.— Instruments, such as tongue depressors, specula, appli- 
cators, etc., may be sterilized by boiling. The rhinoscopic minors, 
however, which are soon destroyed by boiling, may be sterilized 1^ 



RmNoscopY. 281 

immersion in a solution of i to 20 carbolic acid and then wiped dry 
before using. 

Position of the Patient. — ^The patient is seated upright upon a 
firm, straight-backed chair. The examiner sits, facing the patient, 
upon 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 the 
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. The out- 
line of the anterior nares is then brought into view, and the relative 
size of the two fossae may be appreciated. Care should be taken to 
look for fissures, abrasions, or pimples on the inner surface of the 




Fig. 285. — Myles* speculum in place. 

vestibule of the nose, the pressure of which would make the introduc- 
tion of the speculum painful, without preliminary cocainization. The 
speculum is then introduced with the blades closed, and, upon sliding 
them apart, the necessary amount of dilatation is obtained (Fig. 285). 
The inspection of the cavity should proceed from before backward, 
tlje light being thrown into all recesses. By slightly elevating the tip 
of the nose, the floor of the nose, the inferior turbinate, and the inferior 
meatus are brought to view. In some cases where the nose is very 
broad or the inferior turbinate small or shrunken, it may even be 
possible to see as far back as the posterior wall of the nasopharynx. 
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 atrophied, however, is it 
possible to obtain a view of the apertures leading to the accessory 



aSz THE XOSE AXO JUXX&SO«T SDRSES. 

sinuw5. Tltdng the patjeni's hod sdO further backward ccpoees 1 
to view the upper ponioa of the middle tnriinate sod the nxtf of the I 
Dose. Occzsooa&y the opcsu&g ci the qifaenoidal sinus may be made 
out, but oalj in cacepdcm] ones is it poeeSsh to see tlie supetior 
tnztnnate. 

Bj tfae direct appBcatxKi of coaun or admolm to the mucous 
loembtane irith cotKm ptedgels or hj s|xa]ii]g, the membrane maj be 
made to shiink and a more sadsiactorjr view of the structures vithia 
the nose maj be obtained. This is especially useful where the nasal 
canty b narrow or the turbinates are bypertropbied. 




FiC. 386. — Showing the method of performing anterior itinoaoopj. 

Secretions that may obstruct the view are gently wiped away by 
means of a cotton-wrapped nasal probe or applicator. The appear- 
ance and general condition of the mucous membrane are thus inspected 
and the apparent source of any discharge noted. In general, pus 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 turbinate and sep- 
tum signifies infection of either the sphenoidal or posterior ethmoidal 
cells. To ascertain exactly which sinus is involved, frequently other 
aids to diagnosis, as probing, transillumination, or skiagraphy, must 
be employed. 



KHINOSCOPY. 383 

The attention of the examiner ig 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 
turbinal bodies, the presence of foreign bodies, the presence of new 
growths and their point of attachment, etc., etc., are in a general way 
the conditions to be looked for. 

2. Posterior Rhinoscopy. — The operator adjusts the head mirror 
over his left eye so that the light is thrown upon the patient's mouth 
The patient is instructed to open the mouth, and a tongue depressor 




Fic. J87. — First step-in posterior rhinoscopy, inserting the tongue depressor. 



held between the thumb and the index and middle fingers of the left 
hand, is inserted and passed over the dorsum of the tongue unii! the 
tip of the instrument rests just behind its arch. The tongue is then 
drawn downward and forward into the floor of the mouth {Fig. 287). 
If care be taken not to insert the depressor too far and to avoid pushing 
back on the tongue, gagging will be prevented. A mirror of suitable 
size is then warmed and, with the light reflected upon the posterior 
pharyngeal wall, the mirror is gently introduced into the mouth, lightly 
held between the thumb and forefinger of the right hand with its 
metal surface directed toward the tongue. The mirror should then 
be carefully carried back into the nasopharynx, avoiding the back 



284 THE NOSE AND ACCESSORY SINUSES. 

of the tongue, the palate, and uvula. After the instrument has 
entered the nasopharyngeal space, a clear view of the posterior ends 
of the turbinates and the other postnasal structures will be obtained 
by depressing the handle of the instrument slightly so that the upper 
border of the mirror lies behind the soft palate. At the same time, 
the handle of the mirror should be so held toward the left angle of the 
patient's mouth that illumination is not interfered with (Fig. 288), 
It should be remembered that it is not possible to obtain a view of 
the whole postnasal space at one time, but, on turning the mirror in 




Fig. 188. Fic 389 

Fig. 388. — Showing ihe rhjnoscopic mirror in place 

Fic. 289.^ — Poaierior rhinuscopic image. I Roof of pharynx 3 uvula 3 soft pabte; 
4, opening of Eusiathian lube; 5, superior turbinate; 6, middle turbinate; 7, inferior 
turbinate. 

various directions by rotating its handle, different portions may be 
brought 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 
depending on the size and condition of the pharyngeal tonsil. On 
depressing the handle slowly, the posterior nares may be examined 
in detail from above downward. In the median line is seen the 
septum; on either outer wall from above downward will be seen the 
ridge of the superior turbinate, with the superior meatus lying just 
below as a darkened depression. Below this will be observed the 
middle turbinate as a pinkish-white fusiform body, and, underlying 



BHiNoscopy. 285 

this, the middle meatus. The inferior turbinate appears just below 
this as a grayish-white body. Finally, by turning the mirror to either 
side, the orifices of the Eustachian tubes and the Eustachian cushions 
are brought to view. Care should be taken not to keep the mirror 
in the throat too long or the patient will be tired out; to make a com- 
plete examination, it is better to reinsert it more than once if necessary. 
In some cases it may be almost an im[>ossibility to make a satisfac- 
tory posterior rhinoscoptc examination. This may be from the forma- 
tion 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 mirror, or a 




Fio. 190, — While's palali 



broad soft palate with a long uvula, or it may be due to the presence of 
a growth in the nasopharynx. The most common obstacle, however, 
is the involuntary elevation of the soft palate on the introduclion of 
the mirror, so that the view of the parts above is blocked. Instructing 
the patient to breathe through the nose with the mouth open, or to 
pronounce " en " with a strong nasal sound, often suffices to overcome 
this impediment. In other cases it will be necessary to use a palate 
retractor, such as White's. After applying cocain to the soft palate, 
the wire palate loop of the instrument is passed behind the sofi palate 
and the stem of the instrument so adjusted as to draw ihe palate well 
forward into the desired position. The instrument is maintained in 
position by means of the wire loops which rest within the nose 
(Fig. 290). 



286 THE NOSE AND ACCESSORY SINUSES. 

INSPECTION OF THE NASOPHARYNX BY MEANS OF THE HAYS 

PHARYNGOSCOPE. 

To overcome the difficulties encountered in examining the naso- 
pharynx with a rhinoscopic mirror, Hays has devised an instrument 
made on the plan of an indirect view cystoscope, which he calls the 
the pharyngoscope.^ With this instrument, the use of which 
requires none of the skill necessary for the ordinary posterior 
rhinoscopic examination, it is possible to obtain a clear picture of the 
nasopharynx, posterior nares. Eustachian tubes, as well as the larynx 
without the slightest discomfort to the patient. Furthermore, as the 
various structures are brought to view they may be inspected in a very 
systematic and thorough manner and with the avoidance of any haste, 
as the instrument, once inserted, may be left in place anywhere from 
five to twenty minutes, during which time its position need not be 
changed. 




Fig. 291. — Hays' pharyngoscope. 

Instruments. — All that is required is the pharyngoscope and a six- 
dry-cell battery. The instrument is made in the form of a tongue 
depressor, the horizontal portion of which is flattened in its inner 
two thirds, and in its widest part measures less than 5/8 inch (i . 6 cm.). 
It contains a central tube into which a movable telescope fits and also 
two wire carriers. At the distal end of the instrument are placed two 
lamps, one on each side of the telescope. On the circumference of the 
eye-piece of the telescope is a small metal guide, to indicate the direc- 
tion in which the lens is turned. The length of the horizontal portion 
including the telescope is about 8 inches (20 cm.). The vertical portion 

*HaroId Hays, in the New York M edicalj ournal , April 19, 1909, and the Laryngo^ 
scope, July, 1909. 



INSPECTION OF THE NASOPHARYNX. 287 

or handle of the instrument contains the wires which carry the current 
to the lamps. Near its upper end is placed a switch for turning on or 
off the current (Fig. 291). 

Asepsis, — The instrument must be thoroughly sterilized before use. 
This is accomplished by means of formalin vapor or by immersion in a 
I to 20 carbolic acid solution followed by rinsing in sterile water. It 
will not stand boiling. 

Anesthesia. — As a rule, anesthesia is not necessary. Should, how- 
ever, gagging be induced by the instrument, the posterior phaiyngea] 
wall may be cocainized. 

Technic. — The patient is instructed to open his mouth widely 
and breathe quietly. The instrument is then inserted in the same 




Fig. 191. — Showing the method of inserting the Hays' pharyngoscope (after Hays, Am. 
Jour. Surg., May, 1909). 



a tongue depressor, until its distal end lies about 
1/16 inch (1.5 mm.) from the pharyngeal wail (Fig. 293). The 
instrument is kept steadily in place upon the tongue, and the 
patient is told to close the mouth and breathe through his nose. 
This produces relaxation and consequent widening of the pharynx 
and nasopharynx. The light is then turned on, and the examiner 
inspects the structures as they are separately brought to \iew by 
rotation of the telescope. Thus with the lens pointing upward, as 
shown by the knob on the eye-piece, the pharyngeal vault is brought 
to view, and, by tilting the distal end of the instrument slightly upward, 
the posterior nares are viewed. 



288 THE NOSE AND ACCESSORY SINUSES. 

To inspect the region of the Eustachian tubes the lens is rotated 
to about 30 degrees to one side, when the orifices of the tubes, Rosen- 
miiller's fossa, etc., will be clearly shown. By rotating the lens so 
that it points downward the epiglottis, larynx, and base of the tongue 
are similarly inspected. 




Fig. 19,3. — Showing Ihe pharyngoscope in place with the 
nasal space. 



inspecting the po:t 



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 normally 
present, as well as the presence of abnormal growths, adhesions, 
foreign bodies, and the patency or obstruction of the openings leading to 
the accessory sinuses, may be determined. 

Instniments. — The instruments comprise those necessary for a 
rhinoscopic examination; a nasal applicator; a nasal probe; and a 
sinus probe (Fig. 294). 

The nasal probe should be of silver, fairly stiff, but at the same 
time capable of being bent. It should be about 8 inches (20 cm.) 
long, and set into its handle at an angle of 135°. 

The instrument employed for examination of the sinuses must be of 
pure soft silver and fine in size so that it may be readily bent to any 
curve or be adjusted to the shape of the region through which it has to 
pass. 

Anesthesia. — The nasal mucous membrane is very sensitive and 
manipulations are apt to produce sneezing, so that the parts should 



PALPATION BY THE PROBE. 



289 



be cocainized before the probe is employed. This may be done by 
tpplying a 4 per cent, solution on a small pledget of cotton, allowing 
suflkient time to elapse for the cocain to take eflEect before proceeding 
with the examination. 

Position of Patient. — ^The positions of the patient and operator are 
&e same as for a rhinoscopic examination. 

Technic. — By means of a speculum and reflected light the interior of 
tibc nasal cavity is brought into view and is then systematically explored 
by the probe. Any growths are touched to determine their consistency, 
ind masses that may be hidden beneath the turbinates and otherwise 
escape attention may be rolled into view by means of the probe. The 
condition of the mucous membrane, the presence and depth of ulcer- 




FiG. 294. — Instruments for palpating the interior of the nose. 
I, Xasal applicator; 2, nasal probe; 3, sinus probe; 4, Myles' nasal speculum; 

5, head mirror. 

ations, etc., are ascertained. All recesses should be thoroughly 
examined, and especially the walls of the sinuses should be gently 
paJpated for the presence of dead bone. 

In the presence of symptoms or signs pointing to involvement of 
the sinuses, the sinus probe should be employed to determine their 
condition and the patency of their ostia as a preliminary to irrigation. 
On account of the anatomical arrangement of the parts, probing is 
practically limited to the sphenoidal and frontal sinuses unless the 
middle turbinate is first removed. Before making any exploration of 
these cavities, any visible pus or discharge is wiped away and the nasal 
carity cleansed by syringing. 

To enter the frontal sinus, the distal end of the probe, bent to an 
angle of 135®, is inserted within the middle meatus at the junction of 
the anterior third and posterior two-thirds of the middle turbinate. 
Its tip is made to hug the outer wall of the middle turbinate, and is 

19 



i 



290 



THE K05E AND ACCESSORY SINUSES. 



passed upward a.nd forward through the hiatus and into the infiindib- 
ulum. By depressing the handle of the instrument, its tip will 
traverse the Infundibulunt and pass through the ostium frontale unless 
some obstruction exists. Gentleness should be employed in this 
maneuver, and no attempt should be made to force the instrument if 
any obstruction to its passage exists. 




Fig. 195. — Showing the steps in the passage of a probe into the frontal 



To enter the sphenoidal sinus, the end of the probe is bent to a 
slight curve and is passed into the nose with its convexity upward. 
The lip of the instrument is made to traverse the roof of the nasal 
fossa until it meets the resistance of the anterior sphenoidal wall. 
The probe is then moved gently about in various directions until its 




Fig. 396. — Showing ihe steps in the passage of a probe into Ihe sphen<ndal ^us. 



poini enters the cavity of the sinus, which is then carefully explored. 
In either case, when the probing is employed as a preliminary to 
irrigation, and the particular sinus has been successfully entered by 
the probe, if the shape of the irrigator be made to correspond to that 
of the probe it will be of great help in the mtroduction of the former. 



DIGITAL PALPATION. 



DIGITAL PALPATIOH. 



Palpation of the posterior nares by means of the finger is employed 
to confirm the diagnosis made by posterior rhinoscopy, or to obtain 
information as to the condition of these parts when the latter is not 
possible. No instruments are needed, except in the case of unruly 
children, when a mouth gag may be required. While digital palpation 
is a rather unpleasant procedure for the patient, if performed rapidly 
and skilfully many of the disagreeable factors may be obviated. 

Preparatioa. — ^The hands should always be well scrubbed before 
making such an examination. 

Tecbnic. — It is well to first explain to the patient what is intended 
to be done. The patient is then directed to open the mouth widely. 




—Showing ihe method of palpating the postnasal space with the finger. 



The left hand of the operator supports the patient's head, and at the 
same time with the thumb or index finger of Ihe same hand he forces 
the cheek in between the opened jaws to prevent the examining finger 
from being bitten (Fig. 297). The index finger of the right hand is 
then gently but quickly introduced into the mouth and is hooked around 
the posterior border of the soft palate into the nasopharynx, and the 
parts are palpated. In this way the presence of adenoids, hyper- 
trophies of the fiosterior ends of the turbinates, or other growths are 
readily recognized. 



292 THE NOSE AND ACCESSORY SINUSES. 

TRANSILLUMINATION. 

Transillumination is a valuable aid for determining the condition 
of the frontal or maxillary sinuses. Its use in connection with other 
sinuses is futile. This method of diagnosis becomes possible from the 
fact that the air spaces, when in a healthy state, transmit light through 
their thin walls, which power is diminished when pus is present or the 
mucous membrane lining the cavity is much thickened. 

Transillumination is not an infallible method, by any "*ftnftj the 
chief causes of error being imperfect synmietry of the two sides, due 
either to a difference in the size of the two sinuses or to a vaiiatioa in 
the thickness of the bony walls. Another source of error occurs when 
involvement of both sides of a pair of sinuses exists, and there is there- 
fore nothing upon which to base a comparison. The method is of 
greatest service in the diagnosis of empyema of the antrum and of 
the frontal sinus. In the latter it is not so valuable or nearly so 
reliable an aid as in the former, for the size of the two frontal -sinuses 
and the thickness in the individual bones are apt to vary. 

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 




Fig. 298. — Coakleys* transilluminator. 
a, Apparatus assembled for transillumination of the antrum; h, glait hood for use 
in transillumination of the antrum; c, hood for use in transilluxniiiatkm of tlie froaul 

sinus. 

glass hood for transillumination of the maxillary sinus, and a second 
hood to fit over the lamp in place of the glass one, for use about the 
frontal sinus (Fig. 298). The lamps are of about four or five candle- 
power, the electricity being supplied by a small battery or the street 
current. In employing the latter, a rheostat, by which the amount of 
current may be regulated, will be necessary. 

Technic. — i. Transillumination of the Frantal Sinus. — The patient 
is seated in a dark room. The black hood is drawn over the trans- 
illuminator and the instrument is placed beneath the orbital portion 
of the brow at the nasal side. The light is turned on and the sinus is 
clearly illuminated, the operator noting the effect. The opposite side 



TRANSILLUMINATION. 293 ^^M 

is Dialed in the same manner, and the two are compared as to the ^^H 

intensit)' with which the light is transmitted. ^^^| 

Thrcugh a large isinus in a normal condition the light is Irans- ^^^| 




^1 






i'sa. x(ft- — TraniiUuminaliun ellct F[C, ,ioo.— Transilluminalioti effect ^^J 
tn A nonoal right fruntal sinus. '\a a diseased left frontal »iius. ^^^H 

milted with greater intensity than through a small cavity, or through ^^^k 
One with thickening of the bony walls or the lining membrane, or one ^^^k 
complicated by the presence of pus or a tumor. ^^| 
2. Transiilum illation of llu Antrum. — The patient is seated in a ^^M 
darkened room, any dental plates or obturators th;it mif^ht obstruct 






 






Utt normal case. {After Hamon Smith, sinusili! of the right atiltutn. (After Har 
la K.tcn's Surgery.) mon Smith, in Keen's Surgery.) 

e light having been prenously removed. The electric lamp, cover 
rith the ^ss hood, is then introduced into the mouth, and the patie 


nt 
lie 



294 T^^^ NOSE AND ACCESSORY SINUSES. 

lamp is lighted, the cheeks, up to the infraorbital margins, and both 
pupils are clearly illuminated. If one antrum contains pus or a solid 
tumor, the malar region of that side will appear darker and an absence 
of illumination of the pupil will be noted. The transmission of light 
will also be interfered with in the presence of thickened walls or 
lining mucous membrane. 

SKIAGRAPHY. 

The X-ray gives important information in regard to the frontal, eth- 
moid, and maxillary sinuses, and, when possible, it should be regularly 
employed as one of the aids in diagnosis. To be of any value, however, 
it must be applied by a competent radiographer. It is especially 
valuable in diseases of the frontal sinuses. In a healthy condition, 
the outlines of the sinuses are clear and distinct; while in 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 septum, all of 
which are important points in making a decision as to method of 
operating, should it be necessary. To determine the size of a sinus 
it is necessary to take two plates, one in profile and the other full face. 

Therapeutic Measures, 

NASAL DOUCHING. 

Nasal douching is employed for the purpose of cleansing the nasal 
cavity prior to operative procedures or for the purpose of remoxing 
secretions or crusts preparatory to the application of other remedies. 
It must always be used with due precautions, for there is considerable 
risk where fluid is forced into the nose in bulk that some of it will 
enter the Eustachian tubes and set up an otitis media. For this reason 
only small quantities of solution are employed at a time, and the injec- 
tion should be made without any force. If one side of the nose is 
obstructed, the solution should enter by that nostril and escape from 
the more open one. As a further precaution, any excess of fluid 
remaining after the irrigation should be allowed to flow from the nose 
or be drawn into the mouth and expectorated, but not blown from the 
nose for fear of forcing some into the Eustachian tubes. The patient 
should furthermore be instructed to remain indoors for at least half 
an hour after each irrigation to avoid catching cold. For the patient's 
own use nasal spraying is a safer method to employ, and, if it becomes 



NASAL DOUCHING. 



295 



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 (473.11 cc), fitted with a nasal nozzle, forms a simple and eflFect- 




FiG. 303. — ^Nasal douche apparatus. 

ive douche. There are a number of douches especially made for the 
nose, a convenient type for use with large quantities of solution being 
sho^^Ti in Fig. 303. It consists of a pint bottle to the bottom of which 
is attached a rubber tube fitted with a nasal nozzle. The small glass 




Fig. 304. — The Bermingham nasal douche. 



douche (Fig. 304), known as the "Bermingham douche," is useful 
where the cleansing is to be carried out by the patient. 

Solutions. — ^For ordinary cleansing purposes the solution should 
be alkaline and as unirritating as possible. 




396 THE NOSE AMD ACCESSORY SINUStlS. 

One of the following fonnube may be employed. 

9. Sodii bicmrboiutia, 

SodiiUbonlis, M. dr. i (3.75 c.c) 

Actdi carbolid, r^.xv (o.pacc.) 

Glyceiini, oz. i (30 c.c.) 

AquK, q. 8. ad. Oi (47311 c-c) M. 

If. Sodii tncubonatis, dr. i (3.75 cc) 

Addi salicyiki, gr. x (0.65 gm.) 

Aqiue, q. s. ad. Oi (473.11 c.c) M. 

Q. Sodii bicarbonadi, 
Sodii b^nds, 

Sodii chloridi, ^. 02. i (30 c.c.) M. 
Sig. A teaapoonfiil to a |^t of w&rm water. 

Some of the propmtai; preparations, such as Usterin, bon)I;rplid| 
glycotbymolin, alkalol, etc., will be found of value where an antiaeplic 
action is also desired. Th^ may be used in the proportion oj dL > 
to dr. i (1.9 to 3.75 cc.) to the ounce (30 c.c.) of water. When dim 
is an offensive discharge, the following may be employed. 

I^. Potassii permanganatiB, gr. i-ii (0.06-0.13 gm.) 

Aqiue, ad. oz. i (30 c.c.) M. 

Ten^enttare. — All solutions should be used warm, at a tempera- 
ture of about 100" F. 

Quantity. — For ordinary cleansing purposes or for the removal 
of free secretion from the nose, a few ounces of solution are suffideat. 
When hard crusts are abundant, however, it sometimes requires 1 
pint (473.11 c.c.) of solution, or more, to loosen them and effect their 
removal. 

Rairtdity of Flow. — The solution should be injected with only 
sufficient force to permit its return from the opposite nostril in a slow, 
gentle stream — never under high pressure. Accordingly, the reservoir 
should be raised only 2 to 3 inches (5 to 7 cc.) above the level of the 
nose. 

Technlc, — The patient stands with his head bent slightly (or- 
ward over a basin or sink, with a towel or napkin placed about his 
neck for protection of the clothes. The douche nozzle, held in the 
right hand, is then inserted into one nostril with sufficient firmness to 
prevent the solution from escaping, while with the left hand the reser- 
voir is raised a few inches so that the solution enters the nose in a weak 
stream. The patient is directed to breathe through his mouth and to 
avoid swallowing during the lavage. In this way, when the patient's 
head is bent forward, the fluid does not escape into the pharynx, but 



THE NASAL SYRINGE. 



297 



passes through one nostril back into the nasopharynx and out through 
the other nostril (Fig. 305). When no obstruction exists in either 
^de, half the solution may be injected through one nostril and the 
remainder in the reverse direction through the other. 

With the small glass douche cup the technic is very simple. 
The patient inserts the nozzle of the partially filled instrument into 




shown here.) 



one nostril, holding the finger over the side opening. He then throws 
his head well back and removes his finger from the opening, which 
allows the solution to flow through the nose into the mouth, whence it 
is expectorated. Each nostril in turn may be thus irrigated. 



THE NASAL SYRINGE. 

The nasal syringe is employed mainly for cleansing the nose- 
The solution may be injected either from the front, returning through 
the opposite nostril, after the manner of the nasal douche, or the nose 
may be washed out from behind forward. By the latter method the 



I T THE NOSE AND ACCESSORY SINUSES. 

postnasal space may be more eEfcctually cleansed of sticky secretions 
and mucus than by injecting the solution from the front. The same 
precautions should be observed in using the syringe as have been 
mentioned for the use of the douche. 

Instruments. — A syringe with a capacity of i to 2 ounces (30 lo 




nasal lips. 



59 C.C.), made of metal or hard r 

be supplied with a straight nozzle lor i 

nares, and with one bent up almost at right angles for cleansing the 

postnasal space (Fig. 306), 



will be required. It shoulil 
injection through the anterior 




Fig. 307.— Showing ihc method of syringing the 



Solution. — Any of the cleansing solutions mentioned on page 296 
may be employed. They should always be used waim, 

Technlc. — In employing the nasal syringe much the same tech- 
nic is followed as with the douche, observing due care against 
injecting the solution with too much force, etc. The nozzle of the 



THE NASAL SPRAV. 399 

sjTinge is inserted into one nostril and the patient is directed to keep 
liis head bent well forward over a receptacle and to breathe through 
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 accumu- 
lation 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 is introduced behind the soft palate. The 
patient is then directed to hold his head well forward, the fluid is slowly 
injected and escapes from the anterior nares, flushing out the post- 
nasal space and nose from behind forward (Fig. 307). On account 
of the sensitive condition of the parts in some cases it may be necessary 
to cocainize the pharynx and soft palate before the ^ringing can be 
properly performed. 

THE NASAL SPRAY. 

Sprays or atomizers are utilized either for cleansing purposes or 
for the application of remedies to the nasal mucous membrane when 
it is not necessary to confine the solution to one particular spot. 

Apparatus. — The simplest form of atomizer usually proves most 
satisfactory, and is less liable to getout of order. The Whitall Tatum 




Fig. 308.— Whitall Talum 



{Fig. 308), the Davidson, or the De \'ilbiss (Fig. 309) are all good ato- 
mizers. The latter is especially serviceable, and the spray part, being 
of metal, may be readily sterilized. The instrument should be pro- 
vided with a straight nasal tip as well as with a postnasal tip. The 
air current may be supplied by a rubber compression bulb or by a 




Fig. 310. — Compressed-air atommng apparatus. 



When a mild antiseptic action is desired, the solutions given on 
page 296 or the following may be used: 



H. Acidi carbolici, 




gr.v(o.3Jgm.) 


Glycerin!, 




dr. i (3.7s cc.) 


Aquse, 


q- 


s. ad. oz. i {30 cc.) M. 


R. Resorcini, 




gr.iii(o.i9C.c.) 


Glycerini, 




dr. 1(3- 75".) 


Aq«», 


1- 


. ad. oz. 1 (30 cc.) M. 



THE DIRECT APPLICATION OF REMEDIES. 3OI 

Astringent solutions, for purposes of lessening secretions, include 
such drugs as zinc sulphocarbolate, zinc sulphate, copper sulphate, 
alum, tannic acid, silver nitrate, etc., used in the strength of 5 gr. 
(0.32 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 purpose 
of protecting the parts, the oil being deposited upon the mucous 
membrane in a thin coat. Usually eucalyptol, camphor, menthol, or 
thymol are combined with the oil in the proportion of 2 to 5 gr. (o. 13 
to 0.32 gm.) or more to the ounce (30 c.c.) for the sedative effect, as 
in the following: 

R. Eucalyptol, nx x (0.60 c.c.) 

Menthol, gr. v(o.32gm.) 

Benzoinol, oz. i (30 c.c.) M. 

I^. Thymol, 

Menthol, &a gr. ii (0.13 gm.) 
Albolene, oz. i (30 c.c.) M. 

^. Camphorse. 

Menthol, S^ gr. v (o. 32 gm.) 
Albolene, oz. i (30 c.c.) M. 

When a stimulating action is indicated, the proportion of the above 
drugs may be increased. 

Technic. — ^The tip of the nose is gently raised and the nozzle of the 
spray is inserted into the vestibule. To avoid injuring the 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 line. By 
alternately compressing and relaxing the rubber bulb, the solution 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 end of the 
atomizer. 

For spraying from the posterior nares, the same technic is employed 
as with the postnasal syringe (page 299). 

THE DIRECT APPLICATION OF REMEDIES. 

This method is employed for the application of strong solutions or 
solid caustics, or when it is desired to confine the action of the remedy 
to any particular area. 

Instruments. — ^For the application of solutions, a nasal applicator, 
the tip of which is wound with a thin layer of cotton, is employed. 



THE NOSK AHD ACCESSOKY SINUSES. 




Eta. 311.— Fnring chromic add on K piobe. Pfatrtep,liMlliigfl>ap«il»fcff >l MM ) 




Fio. 3i». 

Fio. 311. — Fusing thromic acid 1 
the crysUls. (Gleason.) 

F'G- 3»3- — Fuwng chromic acid < 
bead. (Gleason.) 

Fig. 314. — Fuang chromic acid ( 





Fig. 313. Fro. 314. 

n a probe. Second step, dipping the hot probe in 

1 a probe. Third siep, heating the ciystafs into a 

1 probe. Showing the finished probe. (Gleason.) 



INSUFFLATIONS. 303 

Solid caustics, as chromic acid, silver nitrate, etc., are best applied 
fused upon a probe or applicator. 

Chromic acid may be prepared for application as follows: The 
probe tip is brought to a red heat over an alcohol flame (Fig. 311) 
gind is then dipped into crystals of the acid (Fig. 312). Upon with- 
drawing the probe a few crystals will be found adhering to its point. 
Phis mass is then heated in the flame until the crystals begin to melt 
(Fig. 313), and, upon cooling, they recrystallize in the form of a bead 
^n the end of the instrument (Fig. 314). 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 appl)dng chromic acid a second cotton-wrapped 
applicator, saturated with a solution of bicarbonate of soda — 30 gr. 
(i .95 gm.) to the ounce (30 c.c.) — should be at hand to neutralize any 
excess of acid. 

Anesthesia. — ^The parts should be cocainized by the application of 
a. 4 per cent, solution of cocain. 

Technic. — ^The mucous membrane is well cleansed, and, when 
using caustics, the area to be treated is rendered as dry as possible to 
prevent the caustic spreading over too large a surface. The appli- 
cation is then made to the diseased spot under guidance of the nasal 
speculum, being careful not to allow the applicator to touch any 
Dther points. If acid is employed, any excess is immediately neutral- 
ized with the strong solution of bicarbonate of soda by means of an 
applicator previously prepared and in readiness. 

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 powdered acacia is usually 
employed as a base, in the proportion of two parts to one of the active 
principle. Nosophen, aristol, europhen, iodoform, iodal, etc., are 
remedies frequently applied in this manner. Morphin and cocain 
in small doses may be combined with these powders when indicated. 

Instruments. — The insufflator shown in Fig. 315 or that shown 
^ Fig. 316 may be used. The former is made on the same principle 
IS a hand spray, but with larger tubes. It, however, requires the 
use of both hands in its manipulation. The latter instrument con- 
sists of a rubber compression bulb to which is fitted a vulcanized 




304 THE NOSE AND ACCESSORY SINUSES. 

rubber tube. Into this latter fits the nasal tip, the proximal end of 
which is made in the form of a scoop for taking up the powder. Wlien 
the instniment b filled, a sudden compression of the bulb forces air 
thnni^ the apparatus, blowing the powder out in front of h. This 



Fio. 315. — Powder blower. 

instrument may be manipulated with one hand, and the quantitf tS 
powder used can be accurately .measured. Insufflattxa are su[q^ 
with straight tips for the anterior nares, and with curved t^ for 
makii^ applications to the posterior nares. 




Fro, 316. — Scoop powdi 



For the patient's use, an insufflator such as Sajous' ^ig. 317) 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 



Fio. 3"7- 



i' powder blower. 



mouthpiece is attached, the other end being rounded off to fit into the 
nostril. 

Teclmlc. — With a suitable powder blower, the application of 
powders is very simple. The instrument being properly filled, the 



LAVAGE OF THE ACCESSORY SINUSES. 305 

tip is inserted into the nostril or up behind the soft palate, accordingly 
as to whether the anterior or the posterior portions of the nose are 
to be medicated, and, with two or three rapid compressions of the bulb, 
the powder 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 
being held with one finger over the opening in the bottom of the 
receptacle to make it air-tight. The mouth-piece is held between the 
lips and, by one or more gentle puffs, the powder is blown out upon the 
parts to be medicated. 

LAVAGE OF THE ACCESSORY SINUSES. 

This procedure is employed as a means of diagnosis and for the 
purpose of removing purulent secretions and for cleansing the mucous 
lining in the treatment of suppuration involving the accessory sinuses. 
It is performed by means of a suitable cannula introduced into the 
sinus through the natural or an artificial opening. Treatment by 
irrigation is most successful in the eariy cases of empyema; in those 
complicated by granulation tissue or dead bone, it is not so satisfactory. 
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 (3.9 gm.) to the 

pint (473.11 c.c.) of boiled water), a saturated solution of boric acid, 

or any of the cleansing solutions mentioned on page 296 may be used. 

Temperature. — All solutions employed in irrigating should be warm 

-^t about 100° F. 

Lavage of the Maxillary Sinus. — It is rarely possible to insert a 
probe or cannula into the maxillary sinus through its normal opening, 
on account of its hidden position and the fact that the opening is 
directed somewhat downward and forward from the infundibulum. If 
an accessory opening be present, however, it may be possible to irrigate 
through it, but in most cases an artificial opening will have to be made 
through the inferior turbinate, or through the alveolus after removal 
of the second bicuspid, or the first or second molar tooth. The former 
approach should be chosen when the teeth are sound and the origin 
of infection is apparently from the nose. When a decayed tooth is the 
source of trouble and the tooth is beyond saring, puncture through 
the alveolus is justifiable. 

Instruments. — ^For irrigating through the inferior meatus, an antrum 

20 




Fio. 3i8. — iDstrumentafor IftTagetrf themsziUuyidniiitluovf^Apniictuieintkii'aii' 

I, Haul ndnor; a, sjptinge; 3, AppScator; 4, Uylea* nud ipecuhun; 5, tutdng to cniDal 
the ■yringe and CMUinla; 6, Hjrietf trocar and cumuli. 




Fig. 319.— Instruments for lavage of ihe antrum through the alveolus. 

I, Syringe; 2, cannula; ,i, tubing to connecl the syringe to the cannula; 4, alveolar drill 

5, drainage-tube; 6, tooth-extracting forceps. 



LAVAGE OF THE ACCESSORY SINUSES. 



307 



trocar and cannula and small syringe will be required. For opening 
through the alveolus, there should be provided suitable tooth-pulling 
forceps, an alveolar drill, a syringe, and a silver or aluminum tube of 
the same caliber as the drill, 1/2 to 3/4 inch (1.3 to 1.9 mm.) long 
and provided with a flange to prevent its slipping into the antrum. 

Anesthesia. — ^For puncture of the antrum through the inferior 
meatus, local anesthesia by the application of a 4 per cent, solution of 
cocain on a pledget of cotton twenty minutes before will be sufficient. 

Nitrous oxid anesthesia should be employed for the extraction of a 
tooth and drilling through the alveolus. 

Technic. — i. Through the Inferior Meatus, — Having obtained a 
good Wew of the interior of the nose by the aid of a speculum and 
reflected light, a point is selected just beneath the inferior turbinate 




Fig. 320. — Showing the method of puncturing the antrum through the inferior meatus. 



and about 1/2 inch (1.2 cm.) behind its anterior extremity, and the 
trocar is introduced, pushing it in an outward, backward, and slightly 
upward direction, through the thin bony wall into the antrum (Fig. 
320). The relation of the sinus to the orbit should be borne in 
mind when making this puncture and care taken not to enter the 
latter; this may happen if the puncture be made through the middle 
meatus (Fig. 321). 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 sinus and appears 
in the middle meatus. During the irrigation the head should be held 
downward over a receptacle, so that the solution will readily escape 
from the nose. 

The sinus should be irrigated daily until the discharge ceases, 
employing stronger or more stimulating solutions if they seem indicated. 
Usually there is no great diflBiculty in reinserting the cannula through 



308 THE NOSE AND ACCESSORY SDJDSES. 

the openin;^ each day, if it is provided with a blunt obturator. The 
parts should be cocainized, however, before each irrigation. 

3. Through the Alveolus. — The puncture is made through the 



Jil!<mt 




Fio. 3».— TnuMTcnB lectkm Uuoni^ Ae nose, aboiri^ mbbuI*. 

<L Kftfwjpg imtruiii through Inficrior ue&tui; wid h^ ^vp'^^^x eotaiiis the ortit duou^ 

the middle meUiu. (Alter Coffin.) 

socket of the second bicuspid or the inner root sodtzit of the fiist cr 
second molar tooth (Fig. 33a). The affected tooth is first Temond, 
and the drill inserted by a boring motion, as fdlows: For the fiist 
molar, in an upward and slightly inward direction, for the second 




A-ing drills ententig the nmrui 

and Stewart). 



the alveolus. (After Schuliw 



molar, in an upward, slightly inward and forward direction; and for 
the second bicuspid, upward, slightly inward, and backward. Unless 
the approximate position of the antrum is kept in mind and the drill 



LAVAGE OF THE ACCESSORY SINUSES. 



309 



inserted accordingly, the cavity may be missed. As soon as the antrum 
has been entered the cavity is irrigated by means of a syringe, the solu- 
tion escaping into the nose through the natural opening. To aid its 
escape, the patient's head should be inclined forward. Finally, a 
metal drainage-tube of the proper size is inserted, through which 
subsequent irrigations may be made. 

The irrigations may be performed once or twice a day, and later 
they may be carried out by the patient himself. When the discharge 
ceases, the irrigations are discontinued for a day or two, and, if there is 
no recurrence of the trouble, the tube is then removed and the opening 
allowed to close. 

Lavage of the Frontal Sinus. — The frontal sinus may be irrigated 
by means of a small cannula introduced through the fronto-nasal duct 




Fig. 333. — Instrument? for lavage o£ (he frontal sinus. 

I, Myles' nasal spetulum; 2, head mirror; 3, syringe; 4, tubing to connect the syringe to 

cannula; 5, sinus probe; 6, nasal applicator; 7, sinus cannula. 



In some cases, where the opening is occluded by the middle turbinate 
or an enlarged bulla ethmoidalis, the middle turbinate will have to 
be removed before the attempt is successful. Another difficulty pre- 
sents itself in the close proximity of the anterior ethmoidal cells, and 
the cannula may enter this group instead of the frontal sinus. 

Instruments. — A head mirror, a speculum, a nasal applicator, a 
sinus probe, a pure soft-silver sinus cannula that may be easily bent to 



THE NOS£ AMD ACCESSORY SINUSES. 



310 

accommodate itself to any curve — such as Hartmann's — and a syringe > 
that can be attached by means of rubber tubing will be required 

CRg. 323)- 





Fio. Aij ^riltfnH^g the ttapi ctf ptiring & f^imni^ Into tlifl fnolil rfrah 



Anegflteda.— A 4 per ceat solution of oocaih should be ^iplied 
to the middle meatus for twenty minutes before operatioQ. 

Tedmlc.— The cannuk, bent at its distal end to an an^ of about 




Fic 325. — Instruments for lavage of the sphenoidal sinus. 

r, Myles' nasal speculum; 2, head mirror; 3, syringe; 4, tubing to connect the syringe to 

cannula; 5, sinus probe; 6, nasal applicator; 7, sinus cannuk. 

135 degrees, is introduced into the middle meatus at the junction of the 
anterior third with the posterior two-thirds. The tip of the cannula 
is passed into the hiatus and then forward and upward into the infim- 



PASSIVE HYPEREMIA. 



3" 



dibulum, and thence still upward and slightly forward into the sinus, 
through the fronto-nasal duct (Fig. 324). The syringe is then attached 
to the cannula and the sinus is gently irrigated with one of the warm 
cleansing solutions previously mentioned. 

Lavage of the Sphenoidal Sinus. — Instruments. — A head mirror, 
a nasal speculum, a nasal applicator, a sinus probe, a sphenoidal 
curved cannula, and a syringe with rubber-tubing attachment will 
be required (Fig. 325). 

Anesthesia. — ^The region is anesthetized with a 4 per cent solution 
ofcocain. 

Technic. — The cannula is passed into the nasal cavity with the con- 
vexity upward. The point of the instrument is inserted between the 
middle turbinate and the septum, and should follow the roof of the nose 
until it meets the resistance of the anterior wall of the sphenoidal sinus. 
By gently moving the instrument up and down and from side to side, its 
tip will eventually be made to enter the sphenoidal opening (Fig. 326). 




Fic. 326. — Showing the steps of passing a cannula into the sphenoidal sinus. 

The depth of the sinus is only about 3/8 inch (1.5 cm.), and care 
^hould be taken not to force the instrument through its thin walls. 
The syringe is attached to the cannula by rubber tubing, and the 
ca\ity thoroughly but gently ' irrigated. During this procedure the 
patient^s head should be bent forward and the mouth opened to pre- 
vent the backward flow of the returning solution. 



PASSIVE HYPEREMIA IN DISEASES OF THE NOSE AND 

ACCESSORY SINUSES. 

The beneficial effects of passive hyperemia in the treatment of 
inflammations have already been discussed in Chapter VII, to which 




31* IHE HOSE AND ACCESSORY SINUSES. 



section the reader is referred for a full consideration of the subject 
and the technic of its application. According to Ballenger,' the 
indications for passive hyperemia in rhinology are; (i) in the first fiw 
days of acute rhinitis; (2) in the first five days of acute sinusitis; (3) 
in the first five dajra of acute inflammation of the pharjTigeal tonsils; 
(4) in acute tubal catarrh; (5) in chronic purulent inflammation of the 



The hyperemia may be obtained by means of a neck-band {as de- 
scribed on page 184) or by a special form of suction apparatus. The 
latter is more efficacious in the presence of a purulent discharge, ilit 
vacuum serving to remove secretions as well as to induce a benendal 
hyperemia; but it must be used with ffoX care not to induce a hannfnl 
degree of hyperemia. The apparatus shown in Fig. 169 or one pro- 
vided with glass tips which fit into the nostrils may be used. Wth 
the apparatus appUed to the nose, the air is sknriy rarefied irtiile tfae 
patient swallows. This causes the soft palate to rise up in appoEOtioc 
with the posterior wall of the pharynx and to close Ihe naao-phaipz 
and nose from the pharynx, and a hyperemia of the mucous membnne 
of naso-pharynx, nose, accessory sinuses, and Eustachian tubes is thus 
induced. 

TAifPOniNG THE NOSE FOR THE COFTROL OF HBHORllHA^ 

Nasal hemorrhage may be the result of trauma or operations or may 
be due to ulcerations, new growths, cardiac disease, certain constitu- 
tional diseases and infections, diseases of the blood, etc. Usually the 
bleeding ceases spontaneously or imder simple treatment which aims 
at lessening the congestion of the nasal mucous membrane and favoring 
the formation 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, 
having the patient remain quietly in an upright position with the head 
erect, at the same time forbidding any attempts at blowing the nose. 

If these simple measures are insufficient, a speculum should be 
introduced and the interior of the nose inspected for the source of the 
hemorrhage. If the bleeding point is within reach, it should be cau- 
terized by touching with the electro-cautery or with silver nitrate; or 
else some styptic solution, as peroxid of hydrogen, a watery solution of 
tannic acid, or a i to 1000 solution of adrenalin chlorid should be 
applied to the part upon a pledget of cotton. It may be impossible 
to locate the bleeding point, or the hemorrhage may continue in spite 

'Batlenget; "Diseases of the Nose, Throat, and Ear." 



TAMPONING THE NOSE FOR THE CONTROL OF HEMORRHAGE. 313 

of such treatment, so that in the presence of a profuse hemorrhage it 
becomes necessary to pack the nose. In the majority of cases tampon- 
age through the anterior nares will be sufficient; in others, the bleeding 
may occur posteriorly and the posterior nares as well will have to be 
packed. 




Fig. 327. — Instruments for tamponing the anterior nares. 
I, Nasal applicator; a, head mirror; 3, narrow strip of gauze; 4, Myles' nasal speculum. 

Instruments, etc. — To pack the nose from the front, a head mirror, 
a nasal speculum, a nasal applicator, and a single narrow strip of 
gauze should be provided (Fig. 327). 

For packing the posterior nares a tampon about i inch (2.5 cm.) 
long and 1/2 inch (i cm.) thick, should be prepared by rolling a 
strip of gauze to the required size, to the center of which a heavy 




Fig. 328. — Catheter for dra^^'ing plug into the posterior nares. 

piece of silk thread is tied, the two ends, which should each be about 
18 inches (45 cm.) long, being left free. For the purpose of adjust- 
ing the tampon in place, a rubber urethral catheter of a size that will 
readily pass through the nose into the mouth (Fig. 328), or an 
instrument especially made for this purpose, known as Bellocq's 



314 




i NOSE AND ACCESSORY SINUSES. 



sound (Fig- 339)1 will be necessary. This latter consists of a curved 
metal cannula containing a concealed steel spring, which is protruded 
into the phaijmz and mouth when the cannula is in place in the n(i», 
and to the end of vriach the tampon Is then attached. 




Flo. 309.— Bdloc^s cannui'a. 



Technic {Antmor Nares). — ^In tamponing the anterior nares a 
speculum is inserted in the nose and a good view of the interior obtained. 
A narrow strip of gauze, saturated with pcroxid of hydrogen, i^ then 
gently carried well back into the nose by means of an applicator, and 
by fordfig in more gatize the whfAe nose is tamponed and the hemor- 




Fic. 330. — ^Showing the method of tamponLng (he anterior nares. 

rhage controlled (Fig. 330). This packing should always be removed 
within forty-eight hours. Only a single strip of gauze should be used, 
as it will be less difficult to remove and there is no danger of leaving 
any behind in the nose. As a further aid in removal, the end of the 
gauze should be left within easy reach. 



XAUPOmNG THE NOSE FOE THE CONTROL OF HEMORSHAGE. 315 

(2) {PosUrioT Nares). — The tampon, as already described, should 
M well lubricated with vaselin and placed near at hand. The Bellocq 
:a[inula is passed along the floor of the nose on the bleeding side until 




cc. 331. — Showing the method of drawing a plug into the posterior nares bjr the aid of 
Bellocq's cannula. 




Fio. 333. — The posterior nasal plug 



its tip appears back of the soft palate. The steel spring is pushed 
tiome and is protruded into the mouth. The tampon is then tied to 
;he end of the carrier by one of the strings (Fig. 331), the spring 



I 316 THE NOSE AND ACCESSORY SINUSES.  






returned within the cannula, and the latter removed from the nose 
and with it the end of the tampon spring. By pulling upon the siring 
assisted by a finger placed in the naso-pharynx, the tampon is drawo 
tightly into the posterior nares (Fig. 332). 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 the string, 
which is left in place for the purpose of removing the pack, is brought 
out through the mouth and loosely fastened to the ear. When an or- 
dinary catheter is employed in place of a special sound, precisely the 
same technic is followed. 

The packing should be removed in twenty-four hours, since, if left 
in longer, it is apt to set up an irritation and may lead to infection of 
the Eustachian tube. To remo\-e the pack, the string tied to the an- 
terior tampon is first cut free. The naso-pharynx should be cleaned 
of blood-clots, and the whole region sprayed with adrenahn chiorid 
to cause the tissues to shrink as much as possible. The posterior plug 
is then removed by gentle traction upon the string. 



CHAPTER XIL 
THE EAR. 

Anatomic Considerations. 

The ear is divided into three portions, the external ear, the middle 
ear, and the internal ear. For the purposes of this work, a con- 
sideration of the anatomy of the external ear and the nuddle ear will 
suffice. 

The external eat comprises the auricle or pmna and the external 
auditory canal. 

The auricle is the irregular shaped mass composed of fibrocartilage, 
covered by perichondrium, connective tissue, and skin, which projects 
from the side of the head. It has the function of collecting sounds 
and reflecting them to the external auditory meatus. The central 




Fic. 333.— The lefl auricle. 

t. Concha: 3, antihcluc; 3, fossa of anlihelix; 4, heltx; 5, fossa of the helix; 6. tragus; 

7, antitragus; S, lobule, 

depressed portion, resembling a shell in form, is called the concha. 
[t is bounded by a rim, the antihelix, which runs at first backward 
ind then upward and forward, finally dividing into two arms. The 
ipace between these two arms is known as the fossa of the antihelix. 
From the front portion of the concha extends a ridge, known as the 
fieiix, at first in a forward and upward direction and then around the 
circumference of the auricle toward the lowest portion. The space 
between the antihelix and the helix is designated the fossa of the helix. 
317 



The small backward projection lying in front of the concha is called the 
ttagus, and the small tubercle at the lowest portion of the antihelii, 
the antitragus. The lobule of the ear is the lowest soft pendulous 
portion of the auricle. 

Tlie exterttal auditory canal extends from the concha to the drum 
membrane. It serves the purpose of conveying sounds collected hj 
the auricle to the drum membrane. The canal measures about 
I I /a inches (4 cm.) in length, the floor being slightly longer than lie 
roof on account of the oblique position of the drum membrane. Its 
outer third is composed of cartilage, a continuation of that forminK 
the auricle, while the inner two-thirds has a bony framework. The 
interior is lined with thin skin, which cootains hair foUicloi anil 




I^c- 334- — Vtoal view of the organ of hearing. (RmmUI.) 



' cerumenous glands, the latter being most abundant at the junctioii 
of the cartilaginous and bony portions. The widest portion of the 
canal is near the external orifice, the narrowest portion near the 
center, and, beyond this, as it nears the drum membrane, the canal 
expands again. The direction of the canal traced from without inward 
is at first upward and forward, then backward, and finally forward 
and downward. By traction, however, in an upward, backward, and 
outward direction upon the auricle the canal may be straightened 
out and its interior viewed. 

The middle ear, or tympanum, is an irregularly shaped cavity 
situated in the petrous portion of the temporal bone, between the 
external and the internal ear. The interior of the cavity is lined with a 



ANATOUY 319 

delicate mucous membrane. Within it lie the chain of ossicles, the 
tympanic muscles, and the chorda tympani nerve. 

The tympanic cavity is bounded above by the roof, consisting of a 
thin plate of bone, the legmen tympani et antri, which separates it 
from the dura; below by the floor which corresponds to the jugular 
fossa; by an outer wall composed of the drum membrane and the 
ring of bone into which it is inserted; by an inner wall which is con- 
tiguous to the labryinth, and presents an oval window closed by the 
stapes and a round window closed by membrane; by an anterior wall 
which 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 
leading into the mastoid antrum, the adilas ad antrum. The cavity 
is practically divided by the chain of ossicles into two portions, an 
upper epitympanic space or attic, and a lower cavity or atrium. 




Fio. 335- — Analomy of the osacles. {Pyle's "Personal Hygi 



The ossicles are three small bones, the malleus or hammer, the 
incus or anvil, and the stapes or stirrup, joined together by movable 
articulations, and forming an osseus chain between the drum mem- 
brane and the labyrinth. They are held in place by the attachment 
of the malleus to the membrana tympani and of the stapes to the 
oval window, and in addition by various ligaments extending between 
them and the bony walls. Their function is to convey sound waves 
from the drum to the labyrinth. 



330 THE EAK. 

The malleus consists of an oval head which extends upward and 
articulates with the incus, a neck, a manubrium or handle which ex- 
tends downward and is embedded in the membrana tympani, a short 
process, which extends outward from the neck to the membrana 
tympani and pushes the latter outward before it, and a long process 
which passes anteriorly into the Glaseriaa fissure. 

The incus is the middle ossicle. It consists of a body which artic- 
ulates with the malleus, a short horizontal process which extends to 
the posterior wall where it is attaxihed by ligaments, and a long process 
which extends downward and outward and then near its tip sharply 
inward to articulate by its orbicular process with the head of the stapes. 

The stapes consists of a broad base or foot-piece which fits into the 
oval window, to the membrane of which it is attached, two crura or legs, 
and a head which articulates with the orbicular process of the incus. 

The membrana tympani, or ear-drum, is a thin elastic membrane 
stretched obliquely downward and inward across the inner end of the 
external auditory canal forming the outer wall of the tympanic cavity. 
The drum membrane is made up of three layers, an outer one of skin, 
a middle of fibrous tissue, and an inner formed by the reflection of 
the mucous membrane of the middle ear. It serves the purpose of 
receiving and transmitting sound waves to the chain of ossicles. 




Fig. 336. — Ouler surface of the right membrana lympani. (Gleason.) 

a, Membrana flacdda; b, posterior fold; e, short process; d, incudostapedial articuls- 

lion; e, malleus handle; /, umbo; g, cone of tight. 

It may be described as elliptical in outline, and of a pearly gray 
color, but at the same time translucent. Its outer surface is concave 
and normally smooth. By the aid of a speculum and suitable illumina- 
tion there will be noted a whitish ridge formed by the handle of the 
malleus, running from a tubercle near the upper and anterior per- 
iphery downward and backward toward the center of the membrane. 
This tubercle represents the short process of the malleus. Where the 
handle of the malleus ends near the center of the membrane is a depres- 
sion, the umbo. Under illumination in the anterior and lower quad- 
rant of the drum will also be noted a triangular area of light (thereflec- 



DIAGNOSTIC METHODS. 32 1 

tion 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 Schrapnell's membrane, or the membrana flaccida, 
and that below as the memBrana tensor. 

The Eustachian tube is a canal about i 1/2 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 pharjmx near the inferior meatus 
of the nose in front of Rosenmiiller's fossa as a crater-like eminence. 
The tube is made up of a framework which in the outer third is bony 
and in the inner two thirds cartilaginous and membranous, and is lined 
with ciliated epithelium which waves in a direction toward the pharjmx. 
The two ends are enlarged, but approaching the juncture of the osseous 
and cartilaginous portions the tube narrows considerably. Normally 
the walls are in apposition, but when the palatal muscles contract, as, 
for example, in the act of swallowing or yawning, 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 mastoid cells. 

Diagnostic Methods. 

A complete examination of the ear should comprise a clinical his- 
tory, an examination of the nasopharynx, and then an investigation 
of the ear itself. 

A history is quite essential, but it need not necessarily be an ex- 
haustive one. It should first be ascertained what symptoms or symp- 
tom the patient complains of, and whether only one ear or both are 
affected. The duration of the trouble is also of importance, as it has 
considerable bearing upon the prognosis in any given case. The 
probable cause of the condition should also be determined as far 
as is possible by careful questioning. Among the many etiological 
factors of ear diseases are severe colds, grippe, some injury, insects, 
acute infectious diseases, syphilis, tuberculosis, etc. The symptoms 
or s)miptom complained of should then be investigated more 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 learned whether the deafness developed slowly or suddenly, 

whether one or both ears are involved, and, if the latter be the case, 

which ear is more affected. The duration of the condition must also 
21 



322 THE EAR. 

be ascertained. Not infrequently in the presence of chronic catarrh 
of the middle ear, the patient, while not actually deaf, will 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 street car 
(paracusis Willisii), or hearing sounds as if repeated twice (paracusis 
duplicata), or, again, in the presence of marked unilateral deafness 
the inability to locate the source of sounds (paracusis localis). 

Tinnitus, or subjective noises, are present in middle-ear diseases as 
Well as affections of the internal ear, in neurasthenic conditions, 
arteriosclerosis, and may follow the taking of certain drugs, as, for 
example, quinin or the salicylates. They may be described by the 
patient as singing, whistling, buzzing, loud and roaring or musical 
in character, or they may resemble voices. When present, it should 
be learned whether they are located in the ear or in the head, whether 
unilateral or bilateral, and whether they are modified by mental or 
physical exertion or by the time of day. As a rule they are worse at 
night, and in some cases they may be entirely absent during the day. 

In the presence of pain or earache, its character, the duration, and 
whether constant or intermittent should be noted. Pain may be the 
result of morbid conditions in the ear or it may be reflex, as, for example, 
from a decayed tooth, or from an inflammation of the pharjmx, tonsils, 
etc. When it suddenly develops in an ear previously healthy it gener- 
ally points to an acute inflammation of the middle ear, while, if, on the 
other hand, it occurs during the course of some chronic affection of the 
ear, a collection of fluid in the middle ear or destruction of bone may 
be suspected. Pressure tenderness is also of diagnostic importance in 
determining the origin of the trouble. Thus, pain caused by traction 
upon the auricle or by pressure on the tragus points to an inflammation 
involving the external auditory canal, tenderness elicited by pressure 
in the depression below the lobule of the ear to middle-ear inflammation, 
and pressure tenderness over the mastoid to involvement of that bone. 

The presence or absence of a discharge is next determined. With 
a history of a discharging ear, the length of time the discharge has 
lasted, the character of the discharge, whether serous, bloody, or puru- 
lent, whether scanty or in large amounts and whether continuous or 
intermittent should be noted. It is also important to ascertain if the 
discharge is accompanied by pain, and the relation the pain and the 
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 



DIRECT INSPECTION. 323 

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 been already described 
in Chapter XI. The parts in the vicinity of the ear should likewise be 
inspected as well as palpated for signs of inflammation, swellings, 
new growths, enlarged glands, or signs of tenderness. Having com- 
pleted these preliminaries, the actual examination of the ear should be 
instituted. 

The examination of the ear comprises (i) direct inspection of the 
external ear, (2) inspection of the external auditory canal and tympanic 
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 bolh 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 examiner 
may be enabled to recognize pathological conditions at the entrance of 
the auditory canal that might otherwise escape attention or be hidden 
from view by the speculum. 

Instruments. — All that is required is suitable illumination. This 
may be furnished by means of an electric head light (see Fig. 283), or 
by means of light reflected upon the part by means of a head mirror. 

Position of Patient. — The patient is seated upon a stool with the 
ear 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 the 
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 
inspected, noting the presence or absence of excoriations from dis- 
charges, eczema, swellings, deformities, new growths, etc. Then by 
means of traction upon the auricle in an upward and backward direc- 
tion, the external auditory canal is straightened out and a view of a 
considerable portion of its interior becomes possible. The examiner 
should note especially the color of the canal for signs of inflammation, 
the presence or absence of swellings, fissures, foreign bodies, new 
growths, etc. 




Otoscoi^ is the inspection of the eztemal aoditny canal tai 
tympanic membnme by ^ aid of a speculum and statable illnipwHitihi 
By thit means parts of the auditory canal and the drum nM^inhm i ^ 
invisible to direct inspection may be viewed in detsili and the presence 
or absence of pathologicat conditions recognized. 

InitnmientB.— There will be required a stroog U^ sudi as is 
obtained from a Welsbach burner covered by a Macfcenzie condenxr, 
mounted upon an adjustable bracket so tiiat it may be laised to 
any desired hdght, a concave head miirorj i/a to 4 inches (8.900. 




^^- 337' — luBtruments for otOKopjr. 
I, Head minor; 3, axawl apeculaij, ear probe; 4, ear cutet; 5, wignlargatforo^; 

6, ear syringe. 

to 10 cm.) in diameter with a central perforation for the eye, three 
sizes of metal aural specula, a fine ear curet, a probe, a pair of 
Politzer angular ear forceps, and an ear syringe (Fig. 339). If desiredi 
in place of reflected light, illumination from an electric head light may 
be substituted. 

For purposes of examination Gruber's specula (Fig. 338) are most 
satisfactory, as they are elliptical in shape upon transverse section thus 
corresponding to a transverse section of the external auditory canal. 
Where, however, operative procedures are indicated a speculum with 
a wide proximal end that will permit the manipulation of instruments, 
such as Boucheron's (Fig. 339) or Toynbee's b preferable. Electric- 
lighted specula' (Fig. 340) are now used to a large extent, and simplify 
the operation considerably. 

Asepsis.— To avoid carrying infection from one patient to another 
the instruments employed in otoscopy should be boiled or immersed 

' Manufactured by the Electro- Surgical Instrument Co. of Rodiester. N. Y., and 
tlie Wappler Co., New York City. 



OTOSCOPY. 



325 



in a I to 20 carbolic acid solution and then rinsed in sterile water be- 
fore use. 

Position of Patient. — ^The patient an^ examiner should be seated^ 
the former with the ear turned toward the examiner. The examiner's 
eyes should be on a level with the patient's ear and in a horizontal 





Fig. 338. — Gnibcr's speculum. 



Fig. 339. — Boucheron's speculum. 



plane with the external auditory canal. 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. 

Technic. — ^The examiner directs the light full upon the external 
auditory meatus and, grasping the auricle between the thumb and index 




Fig. 340. — Electric- lighted speculum. 

finger of the left hand (if the right ear is being examined and vice 
versa), makes traction in an upward, backward, and slightly outward 
direction, to straighten out the auditory canal. In infants, to accom- 
plish this, it is necessary to pull the auricle outward and a little down- 
ward, as the wall of the canal has no bony support at this time and lies 



326 THE EAR. 

collapsed against the side of the head. The speculum is then warmed 
and, grasped by its rim between the thumb and index finger of the 
right hand, it is gently inlxoduced by a slight rotary motion until 
it has passed the junction of the cartilaginous and bony portions of the 
canal. In inserting the instrument, care must be taken to follow the 
long axis of the auditory canal, by watching the parts illuminated at 
the distal end of the speculum until the drum membrane is brought to 
view. With the speculum property in place, the left hand is shifted 
from the auricle to hold the speculum, the right hand being thus left 
free to manipulate any instruments (Fig. 341). 




Fig. 341. — Otoscopy with Ihc reflector and car speculum. The arrows represent course 
of light (GleasOQ.) 

Before examining the drum membrane, the external auditory canal 
should be inspected, noting its color, size and shape, 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 wax require removal before 
ins|>ection is possible. This may be accomplished, as a rule, by gently 
syringing the canal with warm saline solution or a satiu^ted solution of 
boric acid (see page 339). Small masses of wax and flakes may require 
removal by means of the curet, followed by gentle syringing. The 
ear is then thoroughly dried by means of small mops of sterile cotton 
held in angular forceps or wrapped about the tip of a probe. 

The examiner next inspects the drum membrane. It is placed at 
the distal end of the canal, inclining downward and inward at an angle 
of about 45 degrees. The normal drum appears translucent and of a 



OTOSCOPY. 327 

pearly gray color, with its circumference appearing as a white line. 
Extending from above downward and backward in the upper half of 
the drum is seen the handle of the malleus. In the upper and anterior 
portion about 1/25 inch (i mm.) from the superior wall is the short proc- 
ess of the malleus, and running forward and backward above the short 
process are two folds of membrane above which lies Schrapnell's mem- 
brane. Extendmg from the tip of the malleus toward the periphery, 
in the lower and anterior quadrant, will be noted the bright cone 
of reflected light In addition to these landmarks normally to be 




Fic. 341. — The appearance of the dAim membrane as seen thiough the speculi 



observed, if the membrane is very thin and retracted, there may be 
seen the long process of the incus as a whitish line running 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 
translucent, as it normally should be, or thickened and exhibiting local- 
ized opacities. The presence or absence of granulations or perforations 
should also be determined, the latter being evidenced by the greater 
depth of the drum at the point of perforation. Note also if the mem- 
brane is retracted or bulging with fluid. If retracted, the short proc- 
ess of the malleus appears more plainly, the handle is short- 
ened, and the conical folds are deepened. At the same time the 
cone of reflected light will appear altered in shape and displaced. If 
bulging is present, its location should be noted. As a rule, bulging 
occurs in the posterior portion of the membrane, or the entire drum 
may be distended. If it occurs in the upper portion only, involvement 
of the attic is present. By changing the position of the speculum 
slightly all portions of the drum may be viewed in detail. By means 



338 -EBE EAS. 

of a cotton-tipped jsobe, inspecticai may be supplemented by careful 
palpation, if further infonnation as to the conditions found is desinxl. 
In all manipulations of the speculum or instruments great gentleness 
should be observed. 

DBTERMIffATIOir OF THE XOBIUTT OF THE DRUM IIEHBRABE. 

By the aid of a pneumatic otoscope with which the air in the external 
auditoiy canal may be altenutely condensed or rarefied, it is possible 
to determine the degree of mobility possessed by the tnembrana 
^mpani, and thus recognize undue rigidity or laxncss of the drum or 
the existence of intra^mpanic adhesions binding the drum or oaekies 
to the walls of the QrmpanunL 

^poratoi. — Regie's pneumadc otoscope (FI^ 343) cnndits of 
an air-tight chambta:, the prcnimal end of whkh h doied by a fii^ 
glass window or convex lens pkiced at an an^ cS 45 dqrees to die 





I^iC' 343- — Siegle's pneumalic otoscope. 

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 an 
electric light in its interior or illumination may be supplied by an 
electric head light or reflected light from a head mirror. 

Position of Patient. — The patient and the operator occupy the same 
relative positions as employed for an ordinary otoscopic examination 
(see page 325). 

Technic. — Some of the air is expelled from the bag which is held 
in the examiner's right hand, and the instrument is fitted snuglyinto the 
auditory canal in the same manner as an ordinary speculum. A 
small piece of rubber tubing may be slipped over the end of the specu- 



HEASING TESTS. $ag 

lum, if necessary, to insure its fitting the auditory canal more accurately. 
The examiner then observes under good illumination the movement 
of the drum membrane through the window in the otoscope, as he 
relaxes or compresses the bulb. As the air is rarefied, the drum is 
sucked outward and becomes convex in shape. As the air is con- 
densed by compression of the bulb, the drum membrane moves 
inward and becomes more concave. The presence of adhesions will 
be e\'idenced by absence of any mobility at that particular point, while 
other parts of the drum will move freely. Too energetic use of the 
instrument must be avoided for fear of rupturing a weakened drum. 



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 
impaired, but also serve to localize the seat of a lesion, that is, whether 
in the conducting apparatus or in the nervous mechanism. While 



m 



W W NT/ 



\^ 



SY/ 



Rg. 344. — Hartmann's set of tuning-forks varying from laS vs. to 2048 vs. 

there have been a number of hearing tests devised, the following are 
sufficient for all practical purposes: (i) testing the acuteness of hearing 
by means of the watch and voice, (2) testing the perception of high 
and low notes, (3) Weber's, and (4) Rinn^'s test. 



Apparatus. — While it is of advantage to have a complete set i^ 

tuning-forks, the ordinary tests may be carried out with a low loia 
fork (C-2) having thirty-two vibralions per second, a Gallon's whisde 
for high tones, and a C 2 fork having 512 vibrations per second 
for Weber's and Rinn^'s tests. Galton's whistle (Fig. 345) ^vt* 
tones ranging from about 7000 vibrations per second to the highest 
perceptible lone limit. The instrument is provided with a scale and 
1 screw whereby the number o£ Wbrations may be regulated so as lo 

" Tests 




—Gallon's whistle. 



) 



Tests of the Acuteness of Hearing.— r. r/w Waick 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- 
siderably, the distance at which [he particular watch is heard by a 
normal ear must be determined by experience. Each ear is tested 
separately in the following manner: l"he patient is seated in a chair 
with his eyes closed, and with his forefinger closing the ear not under 
examinadon. The examiner first holds the ticking watch close to 
the ear being tested so that the patient can hear it distinctly and ihta 
slowly brings it from a distance beyond the range of hearing power 
toward the ear in a line perpendicular to the auricle until the patient 
again recognizes the ticking. The distance from the ear at which the 
ticking is heard is then accurately measured, and the result is expressed 
in a fraction of inches, the denominator of which represents the number 
of inches at which the particular watch is normally heard and the 
numerator the number of inches it is heard by the ear under examina- 
tion. For example, if the watch is heard at forty inches by the nor- 
mal ear and the patient hears it at ten inches the result is expressed 
as 10/40. 

2. The Voice Test. — The patient is seated in a large room with the 
eyes closed and the ear not under examination plugged with the fore- 
finger. The examiner then repeats words of one syllable or numerals 
in an ordinary voice and also in a whisper at the end of expiration with 
the residual air from various distances, and measures the distance at 



HEARING TESTS. 33I 

which the patient can hear and repeat them correctly. The result is 
expressed in a fraction of feet, the denominator of which represents 
the distance in feet at which the normal ear can hear the voice and 
the numerator the actual distance at which it is heard by the ear 
imder examination. In employing this test it is important that 
the patient does not see the lips of the examiner and that the 
sounds are transmitted to the ear under examination at right angles 
to the auricle. 

Testing the Perception of Different Notes. — ^The normal range 
of hearing in adults for musical notes lies between i6 and 48,000 
vibrations per second. The majority of individuals, however, possess a 
more limited range than this, varying from about 24 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 
test is of diagnostic value in diflEerentiating between disturbance of 
hearing due to aflEections of the conducting and those of the perceptive 
apparatus. Where the conduction apparatus is at fault high tones 
are heard better than low, while in diseases of the perceptive apparatus^ 
the low tones are heard well, but high-tone hearing is lost or diminished. 
It should be remembered, however, that in advancing age the upper 
tone limit is lowered. 

Weber's Test. — It is employed for the purpose of locating the seat 
of unilateral deafness. In this test a C 2 (512 vs.) fork is set vibrating 
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 ear, it is indicative 
of some affection of the conduction apparatus., as middle-ear disease, 
impacted cerumen, or occlusion of the Eustachian tube, while if the 
perceptive apparatus is at fault, it will be heard better in the nor- 
mal ear. 

Rinne's Test, — ^This test depends upon the fact that aerial conduc- 
tion is better than bony conduction. In a normal ear, if a C 2 (512 vs.) 
fork be placed upon the mastoid until the patient no longer hears any 
soimd, and, if the fork is then brought close to the external ear, the 
sound will again be heard. This is known as a positive Rinni. If, 
however, the sound is not heard again when the fork is thus transposed, 
it is known as a negative Rinni, Therefore, in a deaf ear, if we obtain 
a positive Rinn^, it is indicative of a lesion in the perceptive apparatus, 
while if, under the same conditions, the test is negative, it shows that 
bony conduction is increased; i.e., there is some obstruction or disease 
of the conduction apparatus. 



Infiatioii of the middle ear has both diagnostic and therapeutic 
value. As a diagnostic measure it is employed to determine the 
patency of the Eustachian tubes, that is, whether or not an unobstructed 
communication exists between the middle ear and the pharj-nx; for 
the purpose of detecting the presence or absence of an exudate in the 
middle ear, and, if so, the character of the exudate; to detect the pres- 
ence of perforation of the memt»an:i tympani; and to determine the 
mobili^ of the numbrana tympani. The therapeutic uses of inflation 
will be considered later (see page 345). 

Au auscultatory tube is employed in omjunctkn widi fc*fl***«' foe 
the purpose of determioing whether air enters the middle ear and to 
distingiush the character of the soimd i»Ddu(%d which is of AjagnntA- 
importance. Thus, in a normal condition of the Enstacfaiaii tidies 
and tymfianic cavity, air will be heard to enter the middle ear widi a 
soft blowing sound; if the tube be obstructed, the aoand will have a 
more or less whistling character, while, if the obatnicticn is not 
overcome, air will not be heard to enter the middle ear at all and iht 
sound will be distant When the middle ear omtains an exudate^ die 
sound will vary according to the character of the &iM; if it i& &Sa and 
watery, a fine bubbling sound will be heard; if it is thick and iteid^ 
the sound will be a coarse bubbling one. In the presence of a perfcna- 
tion of the membrana tympani, inflation causes a characteristic lussing 
or whistling sound and often secretion will be forced out through the 
perforation into the external auditory canal. By the aid of a specultmi, 
the drum may be inspected and the effect of the inflation upon it noted 
and the mobility determined. 

There are tliree methods by wliich the middle ear may be inflated: 
(i) Valsalva's method, (2) Politzer's method, and (3) catheterization. 
Before practising inflation it is a wise precaution to inspect the ear- 
drum to see if it is sufliciently strong to stand the straJD, as cases 
have been reported where a diseased drum has been ruptured by the 
Politzer bag. 

Position of Patient.— The patient -should be seated upon a chair. 
The examiner is also seated, facing the patient. 

Preparations of Patient. — In ail cases the nose and pharynx should 
be thoroughly cleansed before inflation is performed by means of 
gargling and the use of a nasal spray (page 299). 

Valsalva's Metfiod. — This method of inflation is the simplest of 
the three and at the same time is the least reliable. It is fairly 



INFLATION OF THE MIDDLE EAR. 333 

successful, however, if only a slight obstruction exists. On account 
of the ease with which it can be performed by the patient, it is apt to 
be repeated too frequently, with the risk of producing a flaccid con- 
dition of the drum unless the patient is cautioned against its overuse. 
Apparatus. — There will be required a head mirror and some 
source of illumination, or an electric head light, aural specula, and an 
aiiral stethoscope. The latter instrument (Fig. 346) consists of a piece 
of rubber tubing, about 3 feet (90 cm.) long into the two ends of 
which are fitted hard-rubber ear-pieces — a white one for the ex- 
aminer's ear and a black one to fit into the patient 's ear. 




Fig. 346. — Aural stethoscope. 

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 forced 
through the tubes into the middle ear. As this occurs the patient will 
have a feeling of distention in both ears, and the examiner by means 
of the aural stethoscope will hear the sound of air entering the middle 
ear. If the drum membrane is inspected as the inflation is performed, 
it will be noticed that the membrane moves outward and becomes 
somewhat congested. 

Polltzer's Method. — This is probably the most frequently em- 
ployed method of inflation. 

Apparatus. — There will be required a head mirror and suitable 
illumination or an electric head light, aural specula, an aural stetho- 
scope, and a Politzer air-bag (Fig. 347). The Politzer air-bag consists 
of a soft pear-shaped bag of such size and shape that it can be readily 
compressed in the operator's hand, supplied with a piece of rubber 
tubing about 8 inches (20 cm.) long, to the end of which is attached 
an olive-shaped glass nose-piece. 

Asepsis. — The glass nose-piece should be sterilized by boiling 
before use. 



Teclinic. — ^The patient is first given a small amount of water — 
about a teaspoonful is sufficient—which he is instructed to hold in his 
mouth until told to swallow. The examiner then inserts the nose- 




Fio. 347. — Instruments for Politzer's method of inflation. 
I, Head nurrori a, aural specula; 3, aunt stethoscope; 4, Politzer inflatioii bag. 

piece of the Politzer bag into one nostril for a distance of about 
1/2 inch (i cm.), and compresses both nostrils about it by means of 
the left thumb and forefinger. The patient is then told to swallow, 
and, as the larynx is seen to rise up at the commencement of the act 




Fic. J48. — InSation by Politzer's method. 

of swallowing, the examiner compresses the air-bag with his right 
hand (Fig. 348). The act of swallowing causes the soft palate torise 
upward and shut off the naso-pharynx, and, at the same dme, the 
Eustachian tubes tend to open so that the air is readily forced through 



INFLATION OF THE MIDDLE EAR. 



335 



the tubes into the middle ear. In children crying has the same 
effect as swallowing. 

With the auscultatory tube 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 upper- 
most, while at the same time the opposite ear is closed by the fingers 
pressed against the external auditory meatus. In using Politzer's 
bag care should be taken not to use a great amount of force and thereby 
avoid causing the patient pain. 

Catheterization. — Inflation through an Eustachian catheter is only 
indicated when inflation! by the methods previously mentioned is im- 
possible. . The passage of a catheter into the Eustachian tube is a 
delicate operation requiring skill as well as gentleness of touch for its 
safe and successful performance. If carelessly performed, there is 
danger of injuring the mucous lining of the tube or of making a false 
passage and injecting air into the submucous tissues of the tube, an 




Fig. 349. — Instruments for inflation through an Eustachian catheter. 
I, Head mirror; 2, aural specula; 3, aural stethoscope; 4, Politzer's inflation bag; 

5, Eustachian catheters. 

accident from which deaths from respiratory obstruction have been 
reported. In certain cases it may be impossible to perform catheteriza- 
tion, as, for example, in the presence of marked deviations of the septum, 
considerable narrowing of the nasal fossae, 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 the pharyngeal 
muscles. 

Apparatus. — There will be required a head mirror and suitable 
illumination or an electric head light, aural specula, an aural stetho- 
scope, a Politzer air-bag with an Eustachian catheter tip, and several 



336 THE EAR. 

sizes of Eustachian catheters (Fig. 34(j). The catheter .is a metal 
tube 61/3 inches (16 cm.) Iraig, curved at its distal end. the extrcnit 
tip of which is slightly bulbous, and with an expanded proximal end 
into which the tip of a PditzeT bag may be I'ltted. It should be of 
pure sUv^ so that its curve may be changed to Tit the individual case. 
A ring is placed upon the aide of the instrument near its proximal 
end to indkate the direction of the beak. Three sizes should be pro- 
vided I /35, 1 /i3, 1 /8 inch (i, 3, and 3 mm.) in diameter, respectivelj. 

Asepsis. — ^The catheter should be sterilized by boiling and the 
hands of the operator should be cleansed as for any operatiit 
procedure. 

AnesQiflsUu — la senative individuals the nose mav^ anesthetized 
by means of a small amount of a 4 per cent, solution of cocain applied 
by means of a cotton-tipped probe to &e inferior meatus. 




Technlc. — The operator first inspects the nose by the aid of illumi- 
nation for the presence of deviations of the septum or other pathological 
conditions which might interfere with the passage of the catheter. The 
catheter may then be inserted by one of two methods: 

I. Lowenberg Method. — The proximal end of the lubricated catheter 
is grasped lightly between the thumb and forefinger of the right hand, 
while by means of the thumb of the left hand, the tip of the patient's 
nose is elevated so as to straighten out the canal. The beak of the 



INFIATION OF THE UIDDLE EAS. 



337 



instrument is then introduced within the anterior nares, the shaft of 
the instrument being in an almost vertical position (Fig. 350). The 
catheter is then elevated to a horizontal position^ and, with the tip 
kept constantly in contact with the floor of the nose, it is gently pushed 




Fia. 351. — Catheleriziiig the Eustachian tube. Second step, catheter being passed along 
the floor of the nose. 




Fig. 353. — Showing the different positions uf the beak of the catheter ii 

the oH&ce of the Eustachian tube. {After Barnhill and Wales.) 

inward until the beak comes in contact with the posterior wall of the 
pharynx (Fig, 351). 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 



338 THE EAR. 

the nasal septum (Fig. 352). The beak is then rotated downward and 
outward through an angle of a little more than 180 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 Eustachian tube (Fig. 353). In all these manipu- 
lations care should be taken to employ the greatest gentleness. The 
entrance of the catheter into the tube will be recognized by the fact 
that the tip is firmly fixed and cannot be rotated. The catheter is 




Fig. 35J. — Calhcteriiing the Eustachian lube. Third step, showing the poalion of ihe 
guide when the catheter tip is entering the orifice of the tube. 

now held in place by the thumb and forefinger of the left hand, the 
other fingers resting upon the bridge of the nose, and, with the nozzle 
of the air-bag fitted into the proximal end of the catheter, inflation b 
performed by compressing the bag in the fingers of the right hand 
(Fig- 354)- While this is done the examiner notes the sound produced 
by means of the auscultation tube. 

In removing the catheter it is first rotated until its back points 
downward and is then gently withdrawn by a reversal of the move- 
ments employed in its insertion. 

2. Binnafonl or Kramer Melkod. — The instrument is introduced in 
the same manner as described under the Lowcnberg method until the 
beak is in contact with the posterior pharyngeal wall. The beak is 
then related outward through more than an angle of 90 degrees which 
causes its tip to rest in Roscnmiillcr's fossa. The catheter is then with- 



TH£ EAR SYKINGE. 



339 



drawn until Its dp is felt to slip over the bulgingposteriorlip of the Eusta- 
chian mouth when its tip will be at the pharyngeal orifice of the tube. 
The distance it is necessary to withdraw the catheter to accomplish 
this varies usually between 1/4 to 3/8 inch (6 to 9 nun.)- The 
catheter is then rotated until the guide ring points to the outer 
canthus of the eye and the tip slips into the tube. With the catheter 
in position inflation is performed as described above. 




FtG. 354. — Inflalion through an Eustachi 



Therapeutic Measures. 
THE EAR SYRINGE. 

Syringing of the ear is employed for the purpose of removing 
foreign bodies or cerumenous masses from the external auditory canal 
and to keep the ear free from purulent material which collects after 
perforation or incision of the drum membrane. In using an ear syringe 
one must always employ extreme gentleness and solutions of the proper 
temperature, otherwise the procedure is not only rendered painful, 
but is capable of causing harm. Especially is it necessary to avoid 
forcible injections in cases where the tympanum is exposed through 
destruction of a considerable portion of the drum membrane. 

The Syringe. — The syringe should be simple in construction and of 
such material that it may be easily sterilized, and should have a capacity 
of I or 2 ounces (30 to 59 cc). It should be provided with a blunt 
conical nozzle — the ordinary olive-shaped tip is not to be commended, as 
it interferes with a free return flow. A syringe with a long-pointed 




nozzle, such as is sliown in Ilg. 356 will often be found more effica- 
cious in removing foreign bodies than the ordinary- s>Tinge. 

For irrigating the internal ear through a perforation In the attic, a 




Fio. 3SS.--Allport'» nr spiaga. 



Buuuicr syringe, such as Blake's (Fig. 357), with a captd^ of i /a ibam 
(1.9 C.C.), provided with specially bent tips, is used. ThoewiUbe 




Fig. 356. — Metal ear syringe with a small nozzle. 



required, in addition, suitable illumination, aural specula, and an auru 
applicator. 




Fio. 357. — Blake's tympanic syringe. 

Asepds. — The syringe and nozzle should be sterilized by boiling 
before being used, and the solution used should be sterile. 

Solutions Used-^Normal salt solution {3i (3-90 gm.) of salt to a 



THE EAB SYRINGE. 34I 

pint {473.11 c,c.) of boiled water), a saturated solution of boric acid, 
a solution of bJchlorid of mercury, i to 5000 to i to 2000, are among 
those frequently employed. 

Temperature. — The solution should be injected warm — at about a 
temperature of 100" F. Cold solution should never be used, as it is 
apt to cause vertigo or fainting. 

Quantity. — For the purpose of removing foreign bodies or wax, i 
or I syringefuls of solution are usually sufficient. When syringing is 
employed in cases of otorrhea, much larger quantities are necessary, 
as much as 1/4 to i pint (118 to 473 c.c.) being required at a time. 

Frequency. — ^This will depend upon the virulence of the infection 
and the amount of discharge When the latter is very profuse, 
syrin^g may be indicated three or four times a day or oftener. 




'"^- j;S,— Washing impacted cerumen from canal. Showing how lo hold auricle lo 
slr^ghten the canal and where to direct the stream of water. (Gleason.) 

Position of Patient. — The patient is seated with the head held erect. 

Technic. — ^The patient's clothing is protected by means of a towel 
secured about the neck and by having him hold a small glass basin 
below the auricle to receive the returning fluid. The operator 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 hand he then introduces the nozzle of the 
sjTinge into the external canal in such a way that the tip of the syringe 
rests against the superior wall of the canal, so that the solution, as it is 
injected, will pass along the upper wall and wash out purulent matter or 



foreign material below (Tig. 358). The solution is then injected with 
only a small amount of force in suflicient rjuantities for tlie purpose of 
the operation. Should dizziness or syncope supervene, the operation 
should be immediately stopped. * 

At the completion of the syringing all moisture is removed by means 
of a cotton-tipped probe and, in the presence of a discharge, a strip of 
sterile gauze is lightly placed in the external canal. 

In cases where it is necessary to cleanse out the attic through a per- 
foration, the drum is exiwsed by the aid of a speculum and good illumi- 
Dation, and Blake's angular cannula is inserted through the perforation 
under direct vision. The cavity is then carefully cleansed by gentle 
syringing. 



t 



mSTILLAnONS. 

In some cases of otorrhea where the discharge has become scanty, 
the long continued use of douches often seems to keep up an imiation 
and a persistence of the discharge. In these cases the instillation of 
astringent solutions for the purpose of promoting healthy granulatioos 




— [nslnimenls for lympamc instil lalion. 
TOr; 3, aural specula; 3, glass insLlllalor. 



may be substituted. The solutions may be thus applied to the 
external auditory canal to affect the lining of the canal or membrana 
tympani or to the tympanic cavity through a perforation when the 
latter contains unhealthy granulation tissue. 



INSTILLATIONS. 343 

Instruments. — To instil a solution into the external auditory canal* 
an ordinary glass medicine dropper may be employed. For tympanic 
instillations a pipet glass dropper with a small curved tip, a head 
minor and illumination, and an aural speculum will be required 
(Fig. 359). 

Asepsis. — The instruments should always be sterilized before use. 

Solutions. — Solutions of silver nitrate 5 to 20 per cent., copper 
sulphate 5 per cent., zinc sulphate 5 per cent., alcohol 25 to 95 per cent, 
may be used. 

Temperature. — ^The solutions should always be warm — at about 
ioo°F. 

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 re- 
moved by means of a cotton-tipped probe. The operator then 




Fig. 360. — Showing nozzle of a pipet inserted for a tympanic Inslillation. 

Straightens out the external auditory canal by grasping 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 in- 
stils 5 to 10 drops (0.30 to 0.60 c.c.) of the desired solution into the audi- 
tory canal. This is retained for from fi\e 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. 

In making intratympanic instillations the auditory canal is first 
cleansed and the drum is exposed by means of a speculum. The point 
of the pipet is then carefully inserted through the perforation and a 
few drops of weak solution arc injected (Fig. 360). 




APOACATIGK OF CATJSTICS. 



The applicati(Hi of chemical caustics to the car may be required 
tor the purpose of destroying granulations or small polypi. The most 
frequently employed agents for this purpose are chromic acid or silver 
nitrate. Th^ are applied fused upon the tip of a delicate ear probe. 
Ja pinVing such applications vith strong chemicals great care must be 
taken that the caustic only comes in contact with the area to be treated. 
They should, therefore, only be applied by the aid of a speculum and 
good illuminadon. 

Instnmunte. — ^There vill be required a, head nUrror and m somce 
of strong light, aural specula, a delicate ainal fnobe, and an anni 
applicatco' (F^. 361). 




Fig. j6i. — Instrumenis for applying caustics to the ear. 
[, Head mError; 3, aural specula; j, aural probe; 4, applicator. 



The method by which the acid or silver nitrate is fused upon the 
probe has been previously described (see page 303), 

Position of the Patient. — The patient and the operator are seated 
in the same relative positions as for an ordinary otoscopic examination. 

Tecbnic. — With the speculum inserted in the ear and the parts well 
illuminated, the site of the intended application is cleansed and then 
thoroughly dried by means of cotton wrapped upon the end of an aural 
applicator. This is very important, for if any fluid be in the ear the 
caustic will spread to other parts as soon as it is applied. The caustic 
is then carefully applied to the area it is desired to destroy. 



INFLATION WITH MEDICATED VAPORS. 



345 



INFLATION OF THE MIDDLE EAR. 

The value of inflation in diagnosis has been previously considered 
(see page 332). As a therapeutic measure it is employed in tubal and 
middle-ear disease with occlusion of the tube for the purpose of re- 
storing the normal tension between the drum membrane, ossicles, and 
the internal ear. The circulation is thus improved and hyperemia and 
infiltration of the tubal and tympanic mucous membrane is diminished. 
At the same time morbid secretions are removed from the Eustachian 
tube and tympanic cavity, and newly formed adhesions are broken 
down. 

The methods by which inflation may be performed and the technic 
will be found described on page 332. 

INFLATION WITH MEDICATED VAPORS. 

In certain cases of subacute or chronic nonsuppurative otitis media, 
inflation with medicated vapors is often employed to better advantage 
than plain air. The vapor of drugs having either a sedative or stimu- 




FlG. 362. — Dench's vaporizer and Eustachian catheter. 

lating action may be used. In this way all the benefits of inflation 
plus the sedative or stimulating effect of the vapor upon the mucous 
membrane are obtained. 

Apparatus. — A vaporizer, in which the air current passes over the 
volatile drug it is desired to employ, attached to an Eustachian catheter, 
forms the necessary apparatus. There are a number of convenient 
vaporizers, such as Hartmann's, Pynchon's, or Dench's (Fig. 362). 
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. 

Formulary. — Vapors of menthol, camphor, eucalyptol, iodin, 
turpentine, chloroform, and ether alone or in combination are most 
frequently employed. 



346 



THE EAR. 



Preparation of Patient.— Same as for catheterization (see page 33;), 
Position of Patient.^Same as for catheterization (see page ii2). 
Technic. — -The Eustachian catheter is passed by one of the methods 
described on pages 336 and 338 and wilh.atl the precautions detailed 
therein. Inflation with air is then performed in order to first force out 
from the tube any collection of mucus or secretion and thus permit tht 
medicated vapor to come in contact with the mucous membrane. The 
medicated vapor is then blown into the tympanic cavity in the same 
manner, after attaching the vaporizer to the catheter. 



THE INJECTION OF SOLUTIONS INTO THE EUSTACHIAH 
TUBES. 

Du*ect medication of the Eustachian tubes may be used to advanlage 
in the treatment of middle-ear catarrh for the purpose of lessening ihe 
swelling of the mucous membrane, and to diminish secretions, therebj 
rendering the tulies more permeable. Weak astringent solutions are 
generally employed ior this purpose, injected through an Eustachian 
catheter. 

Apparatus. — There will be required an Eustachian catheter, a 
small syringe, graduated in drops, and provided with a tip that will fit 
into the proximal end of the catheter (Fig. 363), and a Politzer air-bag. 




Fig. 363. — Eustachian catheter and syringe for medicatian d the Eustachian tubes. 

Asepsis. — The catheter and syringe should be boiled, and the 
solution employed should be a sterile one. 

Solutions Used. — lodid of potassium 5 gr. (0.32 gm.) to the ounce 
{30C.C.), silver nitrate zto 5 gr. (0.13 to o. 32 gm.) to the ounce (30C.C.), 
sulphate of zinc i gr. (0.065 g™) ^^ the ounce (30 c.c), 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 (o . 30 to o . 60 cc.) of the selected 
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. 



THE EUSTACHIAN BOUGIE. 347 

Preparation of fhe Patient. — Same as for catheterization (see 
page 332). 

Position of Patient — Same as for catheterization (see page 332). 

Technic. — ^The catheter is introduced into the tube by one of the 
methods described on pages 336 and 338 and the ear is inflated by the 
Politzer bag to empty it of secretion. The small syringe is then charged 
with the warmed solution, and the desired amount is slowly injected 
through the catheter. The air-bag is then substituted for the syringe 
and the solution is blown into the tube. 

THE EUSTACHIAN BOUGIE. 

Eustachian bougies are employed in overcoming tubal obstructions 
which will not yield to inflation and for the purpose of dilating tubal 
strictures. In the latter condition, however, the use of the Eustachian 
bougie is rarely curative if the stricture is composed of dense connective 
tissue. 

The bougie is passed into the tube through a catheter, and it 
should always be inserted with the greatest care and gendeness, as it 
is a very easy matter to injure the mucous membrane with the result 
that, if inflation be immediately performed, air may be forced imder 
the mucous membrane through the tear and cause emphysema. It 
is, therefore, advisable to wait a day or two after passing the bougie 






Fig. 364. — Instruments for dilatation of the Eustachian tubes. 
I. Eustachian catheters; 2, Eustachian bougies; 3, Politzcr's inflation bag. 

before inflation is attempted. Care must also be observed not to pass 
the bougie a greater distance than the length of the tube; that is, not 
more than i 1/4 inches (3 cm.) beyond the tip of the catheter. 

Instruments. — ^There will be required an Eustachian catheter, 
Eustachian bougies, and a Politzer air-bag (Fig. 364). The bougies 
are made of silkworm gut or whalebone, with tips conical or bulbous 
in shape, and varying in diameter from 1/64 to 1/25 inch (0.4 mm. 
to I mm.). The catheter used to guide the bougie into the tube 
should be somewhat shorter than ordinary with a longer curved beak. 



348 THE EAR. 

Asepsis. — The catheter and bougies should be thoroughly sterilized 
before use. 

Frequency. — Bougies should not be inserted more frequently than 
two or three times a week in order to permit the reaction from one 
insertion to subside before another is attempted. 

Preparations of Patient. — Same as for catheterization (see page 332). 

Position of Patient. — Same as for catheterization (see page 332). 

Technic. — The bougie is lubricated and is introduced within the 
catheter until the tip is level with the distal end of the catheter (Fig. 
365). The catheter, with the bougie in place, is then introduced into 
the tube in the manner described on page 336. The bougie is then 
carefully passed into the tube for not more than i 1/4 inches (3 cm.) 
which can be accomplished in a normal tube without difficulty. If 



r 




Fig. 365. — Showing the bougie inserted in the catheter ready to be passed into the 

Eustachian tube. 

the bougie passes into the Eustachian tube, the patient will complain 
of some pain in the ear, neck, or occiput, whereas, if it doubles back 
into the pharynx, discomfort will be felt in that region. When re- 
sistance is encountered, the bougie should be pushed forward slowly 
and with great caution, occasionally rotating the bougie; forcible 
ynanipulatians must always be avoided for fear of injuring the mucous 
membrane. Having successfully overcome the obstruction, the bougie 
is left m situ for live to ten minutes. At the next sitting a larger-sized 
bougie is employed. 

The Medicated Bougie. — A medicated bougie, obtained by dipping 
a silkworm-gut bougie in some astringent solution, such as silver 
nitrate, before its passage, often has more pronounced and more pro- 
longed elTect than the plain bougie in overcoming a stenosis due to 
congestion or inflammation of the mucous membrane. The medicated 
])()ugie is introduced in the same manner as an ordinar}^ bougie, and 
should be allowed to remain in ])lace about fifteen to twenty minutes 
to obtain a j)rolonged action of the astringent. 

MASSAGE OF THE MEMBRANA TYMPANI. 

Massage of the ear-drum is ])erformed by alternately rarefying and 
condensing the air in the external auditory meatus. This produces 



INCISION OF THE MEMBRANA TYMPANI. 349 

an increased mobility in the membrane tympani and ossicles with the 
result that adhesive processes between the drum membrane and inner 
wall of the tympanum are avoided or broken up when formed and 
likewise ankylosis of the ossicular chain is prevented. The method, 
therefore, has greatest value in adhesive forms of middle-ear disease; 
in acute conditions its use is contraindicated. In all cases an accu- 
rate diagnosis is the first essential, otherwise massage may result in 
harm. It should be avoided in all cases of relaxed drum or where 
portions of the membrane are atrophic. In the latter condition the 
atrophied weakened portion will move under the influence of suction 
while the rest of the drum will be unaffected. 

Apparatus. — ^The massage is performed with the Siegle type of in- 
strument (see Fig. 343), by means of which the drum membrane may 
be observed and the effect of the massage noted. 

Duration. — ^The massage may be applied for one to two minutes at a 
sitting. 

Frequency* — ^Treatments should be given two to three times a week, 
but only so long as improvement in distance hearing takes place. 

Technic. — ^The otoscope is introduced into the ear in the manner 
described on page 328, and the air is alternately rarefied and condensed 
by relaxation or compression of the bulb. The amount of pressure 
used should be regulated by noting the effect upon the membrane and 
ossicles. If the procedure causes pain, the pressure should be promptly 
reduced. 

mCISION OF THE MEMBRANA TYMPANI. 

Incision of the drum membrane should always be promptly per- 
formed in otitis media when the drum is bulging, for the purpose of 
establishing drainage for the exudate and to thereby prevent necrosis 
of the membrana tympani and tympanic contents. It is also indicated 
in acute cases in which, while the membrane is not actually bulging, 
it shows marked hyperemia and infiltration and the patient suffers from 
severe pain and exhibits constitutional symptoms of a severe infection. 
Especially in infants is early incision required under such conditions. 
If incision is delayed until bulging occurs, extensive destructive changes 
may have occurred and the process may rapidly extend to the mastoid 
antrum or to the cranial cavity. Finally early incision is always indi- 
cated if in the course of middle-ear disease there are signs of mastoid 
involvement or of meningitis. 

The extent of incision is of importance. Simple puncture, or 
paracentesis, is to be avoided; instead, the incision should be of suflS- 



350 THE EAR. 

cienf size to afford free drainage for the products of suppuration, 
varying according to the age of the individual, from 1/4 to 3/8 indi 

(6 to 9 mm.) in length. 

Instrumenfs.^There will be required a head mirror and source 
of illumination or an electric head light, aural specula, a sharp para- 
centesis knife (straight or angular), and an ear syringe {Fig. 366). 

Asepsis.^The instruments should be sterilized by boiling, and the 
operator's hands cleansed as thoroughly as for any operation. 




Fic. j66. — Instruments for indsing the drum membrane:, 
r; a, aurat specula; 3, Angular paracenteds knife j 4, AUport's ear qninge. 



Preparations of Patient — The external auditory canal should be 
thoroughly cleansed by syringing with warm saturated boradc add 
solution or with a i to 5000 bichlorid of mercury solution. 

Anesthesia. — The operation is quite painful. In children general 
anesthesia by chloroform is indicated, while in adults nitrous ozid gas 
or some form of local anesthesia may be used. Local anesthesia, by 
means of a solution of cocain applied to the unbroken membrane, is not 
satisfactory, as the cocain is not absorbed. Instead, the following 
mixture may be employed: 



R. Cocain hydrochlorate 
Alcohol, 



r. vi (0.4 gm.) 

5i(3-75c.c.) 



INCISION OF THE UEUBRANA TYMFANI. 



351 



A small amount of this solution is instilled into the external auditory 
canal and is allowed to remain for fifteen minutes. It must be used 
with great care if a perforation be present, as it will thus enter the 
tjrmpanic cavity where absorption is rapid and toxic symptoms may 
result. 

Technic. — The drum is exposed by means of a speculum under 
good illumination, and the external canal is thoroughly dried. The 
knife is then inserted through the membrane in the postero-inferior 
quadrant, and the posterior quadrant of the drum is incised in a 
curve upward to the tympanic vault (Fig. 367). In doing this, the knife 




Fic. 367. — Inciuon of Ihe membrana tyiapani in acule otitis media involving the tower 
portion of the lympaaic cavity. (Dench.) 

should only be inserted through the drum membrane, so as to avoid 
injuring the inner tympanic wall which lies distant only i/i 2 to 1/6 inch 
(2 to 4 mm.). Of course, if there is any localized bulging, the incision 
should be so placed as to relieve it. When the tympanic vault alone 
is involved, the knife is entered in the posterior quadrant opposite the 
short process of the malleus and the incision is carried upward through 
Scrapnell's membrane. The knife is then turned backward, and, as it 
is withdrawn, the tissues of the posterior wall of the auditory canal are 
incised down to the bone for a distance of about 1/8 inch (3 mm.) 
from the drum (Fig. 368). In this way tension in the tympanic vault 
and mastoid is relieved. 



The ear is then carefully cleansed by syringing and after being wd'l 
dried, is Jooseiy packed with gauze. 

After-treatment. — The ear should be syringed with a warm i 
5000 bichlorid of mercury solution as often as secretion collects. At I 
I first, this will necessitate syringing every Iwo or three hours. As Ae.-^ 
discharge decreases, longer intervals may elapse. 




Fig. 36$. — Imjaon of the membrana tympani in acute otitis med 
portion of the tympanic cavity (Dench). 



CHAPTER XIII. 
THE LARYNX AND TRACHEA. 

Anatomic Considerations. 

The Larynx is that portion of the upper air passages extending 
between the base of the tongue and the trachea. It lies in the median 
line of the neck, opposite the fourth, fifth, and sixth cervical vertebrae. 
Anteriorly, it is practically subcutaneous; posteriorly, it forms part of 
the anterior boundary of the pharynx; while on either side of it lie the 
great vessels of the neck. Above, it is broad and triangular in shape, 
while below jt is narrow and cylindrical. 

The framework consists of a number of cartilages held together by 
ligaments; it is lined with mucous membrane, and is capable of being 
moved by muscles which change the relative positions of the cartilages 
and thus modify the approximation of the vocal cords during respira- 
tion and phonation. The most important of these cartilages are the 
thyroid, the epiglottis, the cricoid, and the two arytenoids. 

The thyroid cartilage is the largest of all, and consists of two 
broad lateral alae joined in front at an acute angle. Above, it is joined 
to the hyoid bone by the thyrohyoid membrane, and, below, to the cricoid 
cartilage by the cricothyroid membrane. The space between the 
thyroid and cricoid cartilages in an adult measures about half an inch 
(i cm.) in height, and an opening made through this space gives easy 
access to the larynx below the vocal cords. 

The epiglottis is a leaf-shaped piece of elastic cartilage i 1/3 inches 
(3.5 cm.) long, guarding the superior entrance of the larynx. It is 
attached by its stalk to the upper and posterior aspect of the angle 
between the thyroid alae and to the hyoid bone by ligaments. It lies 
directly behind the tongue, and in swallowing it is pushed backward 
by the bolus of food, closing more or less completely the laryngeal 
opening and thereby preventing the entrance of food into the larynx. 

The cricoid cartilage is a small, nearly semicircular cartilage 
forming the lower part of the cavity of the larynx. It is narrow in 
front, but becomes broadened and high posteriorly. Upon its superior 
border on either side it supports the arytenoid cartilages. 

The arytenoid cartilages^ two in number, are irregularly pyramidal 
in shape and rest by their bases on the superior border of the cricoid 

23 353 



354 



THE LARYNX AND TRACHEA. 



cartilage. They rotate upon a vertical axis and also more lalemllr. 
Through these movements the vocal cords are approximated or drawn 
apart. 

The Interior of the LaryiUE. — The superior opening is wide and 
semicircular in front where it is bounded by the epiglottis. The sides 
are formed by the arytenoepigtottic 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 narrowed 





1 



Fio. 369. — Anterior view of the iaiyni. (After Deaver.) 
I, Epiglottis; 2, lesser cornu of hyoid bone; 3, greatei comu of hyoid bone; 4, thTRi- 
hyoid membrajie; 5, thyroid cajlilage; 6, cricothTToid membnuiei 7, cricoid cutitege; 
8, trachea. 

behind. More or less distinct nodular prominences formed by the 
cuneiform and comiculate cartilages are recogruzed on these folds. 
The cavity of the larynx extends from the sui>erior aperture to the 
lower border of the cricoid cartilage. It is divided into two portions by 
the vocal cords — above, into the supraglottic region, and, below, into 
the subglottic region. The vocal cords consist of two delicate bands 
of elastic tissue enclosed in thin layers of mucous membrane having a 
whitish appearance. They are attached anteriorly to the thyroid 
cartilage and posteriorly to the arytenoids. They measure about 
3/4 inch {2 cm.) in length in the male, and 1/2 inch {1.2 cm.) in 
the female. Between the two cords is a long narrow chink, the 
glottis. Above and parallel to the vocal cords are two second 
folds of mucous membrane enclosing ligamentous tissue, attached 
to the thyroid cartilage in front and to the two arytenoids behind, 



ANATOMY. 355 

commonly called the false vocal cords. Lying between the vocal 
cords and these two bands are two oblong fossae, the ventricles 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 bron- 
chi. It is of the columnar ciliated variety, excepting where it covers 
the vocal cords and the space above the vocal cords, in which regions 
it is of the stratified vanety It contams many mucous glands, espe- 
cially numerous upon the epiglottis. 




Fig 370 — The mtenor of the laiynx. 

r, Epiglotlis; i, Ihyroid cartilage 3 \entncle of lanni 4, cricoid cartilage; 5, false 
vocal cords 6 vocal cords 7 6rst ring of trachea. 

The trachea is a cylindrical tube, composed of cartilages and 
membrane, extending from the cricoid cartilage, at the level of the 
sixth cervical vertebra, to a point opposite the fourth dorsal, where it 
divides into a right and left bronchus. It is from 4 to 4 3/4 inches 
(ro to 12 cm.) long in males, and from 3 2/3 to 4 1/2 inches {g to 11 cm.) 
long in females. Its transverse diameter measures on an average 4/5 of 
an inch {2 cm.) in males, and less in females. In a child of from two 
to four years, the transverse diameter measures 1/3 of an inch (8 mm.) ; 
in a child under eighteen months, it measures 1/4 of an inch (6 mm.). 

The framework of the trachea is composed of from sixteen to nine- 
teen rings of hyaline cartilage, incomplete behind, each measuring 
1/12 to 1/5 of an inch (2 to 5 mm.) in breadth. The narrow space 
between these rings is filled with an elasdc fibroQs membrane which 



356 THE LARYNX AND TRACHE.\. 

Splits into two layers to enclose each cartilage, and also sen'es locom- 
pleie the tube posteriorly. Internally, the trachea is lined with a 
smooth raucous membrane of the ciliated variety, continuous abocc 
with that of the larynji and below with that of the bronchi. It conuins 
an abundance of lymphoid tissue and mucous glands. 

The trachea lies in a mass of loose fat which permits free motion 
upward, downward, and horizontally. In its upper part it lies com- 
paratively superficial, but becomes more deeply placed as it approaches 



I 




Pig. 371. — Anaiomy of the trachea and its relatione. 

the thorax. The isthmus of the thyroid glahd lies opposite the second 
and third rings; below this the following structures will be met from 
above downward: the inferior thyroid veins, the arteria thyroidea ima 
(if present), the sternohyoid and sternothyroid muscles, the cer\ical 
fascia, an anastomosis of the anterior jugular veins; and in the thorax, 
the remains of the thymus gland, the left innominate vein, the arch of 
the aorta, and the innominate and the left common carotid arteries. 
Behind lies the esophagus. Laterally, the trachea is in relation with 
the common carotid arteries, the lateral lobes of the thyroid, the 



LARYNGOSCOPY AND TRACHEOSCOPY. 357 

inferior thyroid arteries, and the recurrent laryngeal nerves. These 
relations are important to bear in mind in performing tracheotomy. 

Diagnostic Methods. 

The diagnostic methods employed in connection with the larynx 
and trachea consist in (i) inspection by means of a laryngeal mirror, 
(2) direct inspection through endoscopic tubes, (3) palpation by the 
probe or finger, and (4) skiagraphy. 

As a preliminary to the actual local examination, attention should 
first be given to the general condition of the patient, and the history 
of other aflFections that may have a bearing upon the condition should 
be inquired into. This is important, for, while the symptoms of 
processes involving this portion of the respiratory tract are charac- 
teristic (consisting of cough, dyspnea, aphonia or dysphonia, dysphagia, 
etc.), and as a rule clearly indicate the seat of the trouble, it should be 
borne in mind that many of these symptoms are secondary to other 
conditions, such as gout, diphtheria, rheumatism, diabetes, nephritis, 
tuberculosis, syphilis, diseases of the nervous system, etc. Thus it 
becomes of the utmost importance to examine other organs as well by 
a thorough physical examination and not to limit the investigation to 
the affected region alone. 

Having completed this portion of the examination, external inspec- 
tion and palpation of the parts should be performed. In this way the 
presence of inflammation, swellings, new growths, enlarged glands, 
fractures of the cartilages, etc., may be determined, and the mobility 
or fixation of the parts during swallowing and respiration may be noted. 

LARYNGOSCOPY AND TRACHEOSCOPY. 

By this method the interior of the larynx and trachea are inspected 
by means of a laryngoscopic mirror and reflected light. The technic 
is not difficult, and, if properly carried out, a satisfactory inspection of 
the tissues may be made as far as the true vocal cords, and under favor- 
able conditions the region beyond the glottis as far as the subdivision 
of the trachea may also be explored, and foreign bodies or pathological 
conditions recognized. Such examination is best made before a meal, 
as otherwise retching and vomiting may be induced. 

Instruments and Apparatus. — Requisites for an ordinary laryngo- 
scopic examination are: a good strong light, such as is obtained from 
a Welsbach burner covered by a Mackenzie condenser. It should be 
placed upon a suitable bracket, that it may be raised or lowered to any 



THE WRYNX AND TRACHEA. 

desired height (see Fig. aSi). A concave head mirror, 3 1/2 lo 4 
inches (9 to 10 cm.) in diameter with a central perforation for ihe eye; 
laryngeal mirrors of three sizes, 1/2, i, and 1 1/2 inches (1.2, 3.5, and 
3.7 cm.) in diameter, that they may be adapted to the size of the 
individual fauces; and an alcohol lamp (Fig. 372) complete the 
necessary equipment. 

Asepsis. — The laryngeal mirrors should be sterilized by immereioo 
in a I to 20 solution of carbolic acid, then rinsed o£E in sterile water and 
dried before use. 




Fig. 371. — Instrumeots tor laiyngoscopy. 
T, Laryngeal minors; 3, head mirrori j, alcohol U 



Position of Patient and Examiner. — To obtain the best results, Ae 
examination should be performed in a partially darkened room. The 
patient sits in a straight-backed chair with the head raised and inclined 
slightly backward. The light is located upon the patient's right, 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 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 length of the mirror. 

Anesthesia. — Ordinarily, cocainization of the parts is unnecessary, 
but, where the mucous membrane of the pharynx is very sensitive, 
brushing a 4 per cent, solution of cocain over the posterior pharyngeal 
wall and soft palate may be required before a satisfactory examination 



LARYNGOSCOPY AND TRACHEOSCOPY. 359 

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. 




Fic. 373. — Laiyngoscopy. Flist step, showing Che method of grasping the tongue. 

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 operator's left hand (Fig. 373). 
Light traction is made outward and slightly upward rather than 




Fig. 374. — Laryngoscopy. Second step, heating the 



downward, so as to avoid forcing the under surface of the tongue 
against the lower incisor teeth. The laryngeal mirror is then warmed 
to avoid condensation of moisture upon its reflecting surface, by 



360 THE LARYNX AND TKACHEA. 

holding it a little distance over a flame for a few seconds (Fig. 374), 
care being taken to lest the temperature of the mirror before introducing 
it into the mouth; this is determined by bringing the back of the mirror 
in contact with the back of the operator's hand. To introduce the 




Fig. 375- — Showing the method of holding the minor. 

mirror, it should be held lightly between the thumb and forefinger of 
the right hand with its reflecting surface downward {Fig. 375), and 
should be made to follow the curve of the hard palate until its back 
touches the uvula and soft palate. It is then pushed upward and 
backward, raising the uvula as far out of the way as possible. Care 




Fig. J76. — Laryngoscopy. Third step, showing the mirrot being introduced and also 
the iclative portion of the patient and examiner and the position of the light. 

must be taken in performing this maneu\'er to avoid touching the 
base of the tongue, and, when the mirror is in position, to keep it held 
steadily in place so as not to excite gagging or retching. Should this 
accident occur, the mirror must be removed and sufficient time must be 



LAKYMGOSCOPY AND TRACHEOSCOPY. 361 

allowed to elapse for the patient to recover his breath and the irritability 
to subside before it is reintroduced. As soon as the instrument is in 
proper position, the handle is moved to one side of the patient's mouth 
so as to be well out of the line of vision. The mirror is then slowly 
and gently turned until a view of the base of the tongue b obtained, 
and any abnormalities of the oi^an are noted; it is then rotated in 
such a manner that its face looks downward and the larynx is brought 
to \iew {Fig. 377). 




Fio. 377. — Laryngosccpy. Fourth step, showing the 



(J. M. Anders.) 



It should be remembered that the laryngeal image will be in- 
verted — that is, the structures of the front part of the larynx appear 
on the upper part of the mirror, and vice versa ; the right and left sides 
of the laryngeal image, of course, correspond to the same sides of the 
patient. In a normal case, the following are noted: at the upper part 
of the picture, the saddle-shaped epiglottis of a yellowish color traversed 
by its pink blood-vessels; extending backward across the mirror back 
of the epiglottis are a pair of pearly-while bands, the vocal cords; 
parallel to the vocal cords, but lying anteriorly and outside, are a 
second pair of bands with a reddish hue, the ventricular bands, or 
false vocal cords; between the vocal cords and the ventricular bands 



I 



362 THE LARYNX AND TRACHEA. 

may be obser\'ed the ventricles of the larjTix, brought into better viewif 
the head is tilled to the side; where the \'ocal cords terminate at the 
lower part of the image are to be seen the arytenoid cartilages, and 
between ihem the interarytenoid space; extending from either side of 
this notch to join the epiglottis are the aryepiglottic folds, with the iwo 
prominences marking the site of the cartilages of Wrisberg and Saa- 





FlG. J78. 

Fio. 378. — The laryngoscopic ima^e. j. Epiglottis; 2, fafse vocal coids; 3, w 
cords; 4, glossoepiglollic fossa; 5. inletaryli-noid space; 6. cartibge of Sanlomd 
and Iht location of the arytenoid cartilage; 7. cartilage of Wrisberg. 

Fio. 3;g. — The larynx during gentle respiration. 

torini, the latter lying on top of the arytenoid cartilages; on either side 
of the image will be noted the glossoepiglollic fossse. 

To make a complete examination, the larynx should be inspected 
during quiet respiration, deep respiration, and phcaiatiotL During 
respiradon the vocal cords are seen to move with each expiration to- 
ward the median line, and away from the median line with inspiration 





Flo, 380. — The laiynz in phonalion. Fig. 381. — The laiynz during deep respintion. 



{Fig- 379)- By requesting the patient to say "ee" or "he," a view is 
obtained of the larynx with the cords almost in apposition and the 
interarytenoid space obliterated (Fig. 380). During deep respiration 
the cords are widely separated, and a ^^ew is obtained of the anterior 
wall of the region below the vocal cords (Fig. 381). There will be 



LARYNGOSCOPY AND TRACHEOSCOPY. 363 

seen the broad yellow cricoid cartilage and the yellowish cartilaginous 
rings of the anterior wall of the trachea with the intervening red mem- 
branous portion. By tilting and carefully adjusting the mirror, the 
bifurcation of the trachea and the openings of the two bronchi may be 
brought into view. To obtain the most favorable position for inspec- 
tion of the trachea, the patient's neck should be held straight and the 
chin extended somewhat forward. The mirror will also require a 
different adjustment, being held more horizontally than for laryngo- 
scopy, and the surgeon should be seated lower. 

The diseases that may affect this portion of the respiratory tract 
are not different from what one would find in other regions com- 
posed of the same tissues. The examiner should accordingly first 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 exuda- 
tions, foreign bodies, and any structural changes, such as ulcerations, 
swellings, abscesses, edema, new growths, malformations, and dislo- 
cations of the arytenoid cartilages, 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, and separate equally with inspiration. Only by 
such tests may paralysis of the cords be recognized. The whole 
examination should be made as rapidly as possible, not more than 
half a minute or so being consumed, so as to avoid tiring the patient 
and inducing an irritable state of the parts. Since often only a glimpse 
of the parts may be thus obtained, it may be necessary to make more 
than one inspection before the whole examination is completed in a 
satisfactory manner. 

_ • 

Difficulties in Laryngoscopy. — It is sometimes a difficult matter 
for a beginner to inspect the parts, owing to faulty technic or to struc- 
tural peculiarities of the parts. A view of the larynx may be missed 
entirely through an improper adjustment of the light, faulty position 
of the patient's head, or holding the mirror at a wrong angle. Clumsy 
and hasty introduction of the mirror, the use of a mirror too hot or 
too cold, or rough traction on the tongue, all militate against success. 
In some cases an excessive irritability of the pharynx precludes a 
successful examination without preliminary cocainization of the 
neighboring parts. In other cases the presence of enlarged tonsils 
may prevent a good view of the parts. If such a condition is present, 
a small oval mirror should be substituted. A large pendulous epiglottis 



364 THE LARYNX AND TRACHEA. 

is not infrequently a cause of difficulty. By placing the mirror close 
to the posterior pharyngeal wall and holding it more nearly vertical 
than usual, with the 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 be employed to 
hold the tongue forward, and if necessary a mouth-gag may be inserted 
between the teeth. A small laryngeal mirror is then introduced, and 
the examination is made in the usual way. If 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 
light, 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- 




FiG. 382. — Jackson's self-illuminated tube spatula for direct laryngoscopy. 

more, foreign bodies and new growths may be removed, and applica- 
tions made to diseased areas under direct \ision. The method may 
be employed in young children in whom ordinary laryngoscopy is diffi- 
cult, and it may also be performed upon a patient under general anes- 
thesia. It is, however, more uncomfortable for the conscious patient 
than ordinary laryngoscopy. 



DIRECT LARYNGOSCOPY. 365 

Instnuneiits. — A tubular spatula, self-illuminated, such as Jackson's 
(Fig. 382) , or with the illumination furnished from an electric head light, 
as Killian's, is generally employed. Kirstein uses a tongue depressor 
of special shape (Fig. 383) and an electric head light (Fig. 384). In 
addition a mouth-gag and a Sajous applicator are required (Fig. 385). 



Fig. 383. — Kirstdn's tongue depressor. 



B. — The tubes and tongue depressor may be boiled, while 
the light-carrying apparatus in the setf-itluminating tube is sterilized 
by immersion in alcohol. 

Position of the Patient. — The patient is seated on a low stool with 
the upper part of the body bent slightly forward and with the head 




Fio. 384 



head light. 



raised and thrown back so that a direct view from above downward is 
possible. An assistant stands or sits behind, supporting the patient's 
head, and holding the mouth-gag in proper position. The operator 
stands in front. 

A child should be seated upon the lap of a nurse, who encircles its 



366 THE LARYNX AND TRACHEA. 

body with her arms, confining the child's arms closely to its sides and 
clasping its legs between her knees. The child's head rests upon the 
nurse's shoulder, being held in the proper position from behind by 
an assistant. 

Anesthesia. — Cocainization of the parts is usually necessary to 
avoid unpleasant gagging and retching. This is accomplished by the 
application to the larynx and neighboring parts of a 4 per cent, solution 
of cocain by means of a cotton swab held by a Sajous applicator. 
This should be performed by the aid of a laryngeal mirror. If opera- 
tive procedures are required, the application of 20 per cent, solution 
of cocain should follow the preliminary cocainization. In young 
children the examination may be carried out under general anesthesia. 




Fig. 385. — Sajous' applicator and mouth-gag. 

Technic. — The operation should, when possible, be performed when 
the stomach is empty, as, otherwise, retching may result in regurgi- 
tation of the stomach contents. The parts having been cocainized, 
with the patient seated in the proper position, a mouth-gag is inserted 
in one side of the mouth and is held in place by the assistant who sup- 
ports the head. With the lamp at the end of the instrument properly 
lighted, if a self-illuminating spatula is employed, or with the head 
lamp lit and adjusted so as to throw the light into the mouth, if a non- 
illuminated tube is used, the tubular speculum is introduced past the 
base of the tongue until the epiglottis appears. 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 the handle of the instru- 
ment in an upward and backward direction (Fig. 386). 

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 \iewed in detail. The points espe- 
cially to be noted in such examination have already been referred to 
under laryngoscopy. By the aid of these tubes, applications may 



DIRECT TRACHEO-BRONCHOSCOPY. 



367 



also be made, if desired, to diseased areas, and growths may be removed 
by means of delicate instruments of special design. 

In the method designated by Kirstein as autoscopy, the patient is 
placed in the same position as above, the mouth is illuminated from the 
electric head light, and the special tongue depressor is gently introduced 
behmd the tongue until its tip rests between the epiglottis and the base 
of the tongue. By elevating the handle of the instrument, the base 




Fig. 386.— Direct laryngoscopy with Jackson's self-illuminated spatula. (Modified from 

(Ballenger.) 
«<, Electric cord supplying lamp of speculum-; 6, conduit for light carrying tube; c, 
shows the tip of the tube holding the epiglottis forward; d, conduit for removing secretions, 
etc., by aspiration during the examination. 

of the tongue is drawn downward and forward, and the epiglottis is 
raised, so that a groove is formed along the back of the tongue. With 
the head light properly adjusted the operator looks down this groove 
and inspects the larynx. The posterior walls of the larynx and tra- 
chea are clearly viewed by this method, but the anterior parts are not 
seen so well as with the laryngoscopic mirror. 



DIRECT TRACHEO-BRONCHOSCOPY. 

In 1897 Killian devised long endoscopic tubes that could be intro- 
duced through the mouth or through a tracheotomy wound, with 
which the trachea and bronchi may be examined by the aid of illumina- 



1 




1 




c 


- 


a 




a 


» 


o 


 ." — 


T 




ti 




ol 


-f-'> 


z\ 


« • •• 




u- •*- 








• 



T 

the s 
tation 
wilh I 
in one 
ports ti 
lighted, 
lamp lit 
illumina; 
base of t: 
point abo 
which 18 tl 
of th- 















^— — — - -"^ -LJL*.. ...C* 

- — » • .. 

"■ » _ — - • v_ _   • 

-.w..t»* a.-.-. ..■...•..^. 

'viIT" •"•1.:*" 1 '" »~''" *rf**"'t**^* *" -I-"- . .1,1' 

•:• ::- •. : :::- ..r ' ." -^cope. h»>'vc'vr. rt;J:v? 
i. ;•■ [;♦• <)7.:y o: -vr ice in ?he h^inii :: ^: :c- 
;;. un^Kilud hanc^ it beroni' • 1 :-"-rv. 



Tn.nifu.tm.cr.n'.^-coijy throujrh a tracheotomy wound ii thesir::^: 

of the !"»' nitf.in/J au'i. a> larmier tulxjs may Ix^ emp;«jye<: :hin in ihe 

ipper ou^fc'J-n.. 1* i- 'Jtit'n of value for the removal of foreiin: b(.icit- 

iH» lar^ to »it- extracted by uppnT tracheo-br-^nchoscopy. Uppi:r 

nihei>-bronch'iscopy. however, should l^? :r.e TjeraLion of choice 



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nir iflJff 



DIRECT TRACHEO-BRONCHOSCOPY. 



369 



inches (45 cm.) long for adults, and one 1/5 inch (5 mm.) in diameter by 
8 inches (20 cm.) long for children. 

In Killian's instruments (Fig. 387) illumination is supplied from 
an electric head light. In the Jackson tubes (Fig. 388) the illumina- 
tion is supplied by a small electric light at the end of the instrument. 







Fig. 388. — Jackson's bronchoscope. 

These latter are somewhat easier to use than KiKian's instruments. 
In addition, the Jackson instruments are provided with a conduit to 
which is attached a suction apparatus and exhaust pump, for the pur- 
pose of removing secretions that may collect and obscure the view 
(Fig. 389). For inserting these instruments, a special split tube (Fig. 
390), resembling that used in direct laryngoscopy, is supplied, which 




Fig. 389. — Jackson's secretion aspirator. 

is removed in two halves after the bronchoscope has entered the glottis. 
A portable battery with rubber-covered cords, a mouth-gag, a 
Sajous applicator, 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 
24 



THE LARYNX AND TRACHEA. 



(see page 394} arc required. The operator should also be prodded 
wilh a number of extra lamps lo replace those that may bum out. 
Asepsis. — Strict asepsis in all details is absolutely ncccssa:y. The 




Fra. 390. — Jackson's separable speculum tor pasang the bronchosoope. The hiadlt. 

ab, for use when the patient is in a sdtiing postuiE; c shows the amngement of tbchnp 

at the distal end. 

tubes and accessory instruments are boiled, the lighting apparatus is 
sterilized by 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 off with bichlorid solulion. The hands of the operator 




Fig. 391. — Accessory 



: heo-bttinchoscopy . 



and assistants should be as thoroughly cleansed as for any operation. 
On account of the danger of sepsis from the mouth, the patient's 
teeth should be brushed and the mouth well cleansed with an antiseptic 
wash before passing the instruments. A tube employed in the upper 



DIRECT TKACHEO-BRONCHOSCOPY, 



371 



operation should not be used for lower bronchoscopy without 
resterilization. 

Preparation of the Patient. — If general anesthesia is to be employed, 
the patient should be prepared according to the usual method (page 
18). In any case, the operation should be performed on an empty 
stomach. For lower tracheo-bronchoscopy, the neck, if hairy, should 
be shaved and sterilized by washing with green soap and warm water, 
followed by a I to 2000 bichlorid of mercury solution. 




Fig. 392. — The {wsition of the patient and the assistant for upper tracheo-bronchoscopy. 

(After Jackson.) 



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 extended 
backward as far as possible and the tongue projected forward. An 
assistant holds the head from behind and steadies the mouth-gag, 
while the operator stands in front. When a general anesthetic is 
employed, and in all cases of lower bronchoscopy, the patient should 
be in the dorsal position on a table, the front of which is slightly ele- 
vated, with the head hanging over the edge of the table, in which 
position it is supported by an assistant who takes care of the mouth-gag, 
as shown in Fig. 392. 



DIKECT TRACHEOBRONCHOSCOPY. 373 

passed through the glottis until it enters the trachea. The split tube 
is then separated and removed. As the bronchoscope is advanced, 
the mucous membrane in front should be anesthetized by means of a 
ao per cent, solution of cocain applied with cotton swabs on a long 
applicator. The instrument is thus slowly passed to the bifurcation 
of the trachea, and the parts are examined in detail as the tube 
advances. 

To enter the r^ht bronchus, the instrument should be turned 
toward the left angle of the patient's mouth, and toward the right 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 
secondary and even the third division of the bronchi may be inspected 
by one especially skilled in this work. 

During the examination, secretions or blood may be removed by 
means of cotton wrapped on long applicators or by the special aspirat- 
ing apparatus supplied with the instrument, the manipulation of which 



Fig. 394. — Lower bronchoscopy, (Modified from Ballenger.) 

is entrusted to an assistant. In this way the entire mucous membrane 
lining the trachea may be examined, foreign bodies located and 
removed, and lesions treated by direct application. 

2. Lower Tracheo-bronchoscopy. — Low tracheotomy is first per- 
formed as described on page 400. After all the bleeding has been 
controlled, a Trousseau dilator is inserted and the tracheal wound is 
held open. The mucous membrane of the trachea is then cocainized 
with a 20 per cent, solution of cocain. A short bronchoscope, with 
the illumination turned on, is then introduced, and the instrument 
is advanced under the guidance of the operator's eye, which is applied 
at the end of the instrument. As soon as the bifurcation of the trachea 
is reached, the tube may be directed into either bronchus by gentle 



374 



THE LAHYNX AND TRACHEA. 



tnanipulalion. The patienl's head is turned sideways, and, if Ihe riKKt 
bronchus is to be entered, the tube is inserted on the left side of the 
head; if the lefl bronchus is lo be examined, the lube is inserled at 
the right side of the head. The bronchi should be cocainized, as before, 
in advance of the instrument with cocain applied upon long applicalurs 
Ihrough the inslrumcnt, and the examination proceeded with as abo^. 
The after-treatment of the patient consists in inserting a Iracheol- 
omy tube which is worn for several days. After the remo%"aJ of this 
tulie, the wound should 1^ carefully prolecled by a gauze dressing and 
cleansed daily, being allowed to heal from the bottom up. 

PALPATION BY THE PROBE. 

Palpation by the probe is of value in determining the con^taicy 
and extent of new growths, the depth and size of ulcerations, the 





J 



Fic. 395. — Instruments for probing the laiyui. 
I, Laiyngeal piobe; 2, laryngeal mirror; 3, alcohol lamp; 4, head mirrDT. 

presence of necrosed cartilage, and the sensibility of the mucous 
membrane. 

Instruments. — A laryngeal mirror, an alcohol lamp, a head light, 
and a laryngeal probe are necessary {Fig. 395). 

Asepsis. — The probe should be boiled and the laryngeal mirror 



PALPATION BY THE PROBE. 375 

sterilized by immersion in a i to 20 solution of carbolic acid, then 
rinsed off in sterile water and dried before use. 

Position of Patient. — ^The patient is in the sitme position as for ordi- 
nary laryngoscopy. 

Anesthesia. — ^The larynx should be cocainized by spra)ring or by 
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 warmed and inserted in such a 
position that a good view of the larynx is obtained. The probe is 
held in the operator's right hand 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 pos- 
terior pharyngeal wall (see Fig. 396). It is then brought into the 
natural position, with the laryngeal portion vertical and the handle in 
the mid-line, the point of the instrument lying in the pharynx behind 
the epiglottis. By raising the handle of the instrument, the point is 
then brought forward over the arytenoids. By directing the point of 
the probe, guided by the image in the mirror, the diseased areas are 
then explored (see Fig. 397). In performing this manipulation, it 
must be remembered that the image in the mirror is reversed, so that 
movements of the instruments will likewise appear reversed, and that 
the distance between the arytenoids and the vocal cords is much 
greater than appears in the image. 

In introducing any lar3mgeal instrument, such as applicators, 
brushes, forceps, etc., of the same shape as the laryngeal probe, that 
is, with long handles and a laryngeal piece at right angles, or nearly so, 
with the handle, the same technic should be employed; otherwise, if 
the instrument is introduced into the mouth with the laryngeal end 
held vertically, it is usually impossible to insert the laryngeal portion 
between the palate and base of the tongue. 

SKIAGRAPHY. 

Skiagraphy is employed as an adjunct to other diagnostic measures 
for locating metal and other foreign bodies which are impenetrable 
to the rays, and also for localizing certain growths of greater density 
than the surrounding tissues. 

Therapeutic Measures. 

THE LARYNGEAL SPRAY. 

The laryngeal spray is employed for the purpose of cleansing and 
for medication. Cleansing of the larynx is frequently required for 



374 



THE LARYNX AND TRACHEA, 



manipulation. The patient's head is turned sideways, and, if the rirfit 
bronchus is to Ix; entered, the tube is inserted on the left side of ihe 
head; if the left bronchus is to be examined, the tube is inserted a! 
the right side of the head. The bronchi should Iw cocainized, as Ijetore, 
in advance of the instrument with cocain applied upon long applicalon 
through the instrument, and the examinalion proceeded with as above. 
The after-treatment of the patient consists in inserting a tracheol- 
omy tube which is worn for several days. After the remo%-aI of this 
lube, the wound should be carefully protected by a gauze dressing and 
cleansed daily, being allowed lo heal from the bottom up. 

PALPATION BY THE PROBE. 

Palpation by ihe probe is of value in dclermining the consistenn- 
and extent of new growths, the depth and size o{ ulcerations, the . 




J 



Fic. 395. — tnsimmenls for probing Ihe laiyn*- 
I, Laiyngeal probe; i, laryngeal minor; 3, alcohol lamp; 4, head nurror. 

presence of necrosed cartilage, and the sensibility of the mucous 
membrane. 

Instruments. — A laryngeal mirror, an alcohol lamp, a head light, 
and a laryngeal probe are necessary (Fig. 395). 

Asepsis. — The probe should be boiled and the laryngeal mirror 



PALPATION BY THE PROBE. 375 

sterilized by immersion in a i to 20 solution of carbolic acid, then 
rinsed off in sterile water and dried before use. 

Position of Patient. — ^The patient is in the sitme position as for ordi- 
nary lar3mgoscopy. 

Anesthesia. — The larynx should be cocainized by spra)dng or by 
the application of a 10 per cent, solution of cocain. 

Technic. — The tongue is protruded and held by the patient with a 
cloth, and the laryngeal mirror is warmed and inserted in such a 
position that a good view of the larynx is obtained. The probe is 
held in the operator's right hand 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 pos- 
terior pharyngeal wall (see Fig. 396). It is then brought into the 
natural position, with the laryngeal portion vertical and the handle in 
the mid-line, the point of the instrument lying in the pharynx behind 
the epiglottis. By raising the handle of the instrument, the point is 
then brought forward over the arytenoids. By directing the point of 
the probe, guided by the image in the mirror, the diseased areas are 
then explored (see Fig. 397). In performing this manipulation, it 
must be remembered that the image in the mirror is reversed, so that 
movements of the instruments will likewise appear reversed, and that 
the distance between the arytenoids and the vocal cords is much 
greater than appears in the image. 

In introducing any laryngeal instrument, such as applicators, 
brushes, forceps, etc., of the same shape as the laryngeal probe, that 
is, with long handles and a laryngeal piece at right angles, or nearly so, 
with the handle, the same technic should be employed; otherwise, if 
the instrument is introduced into the mouth with the laryngeal end 
held vertically, it is usually impossible to insert the laryngeal portion 
between the palate and base of the tongue. 

SKIAGRAPHY. 

Skiagraphy is employed as an adjunct to other diagnostic measures 
for locating metal and other foreign bodies which are impenetrable 
to the rays, and also for localizing certain growths of greater density 
than the surrounding tissues. 

Therapeutic Measures. 

THE LARYNGEAL SPRAY. 

The laryngeal spray is employed for the purpose of cleansing and 
for medication. Cleansing of the larynx is frequently required for 



376 THE lARYNX AND TRACHEA. 

the removal of purulent secretions the result of syphilitic or tubwrular 
ulcerations, and to soften and wash away the crusts which are often 
an accompaniment of felid laryngitis. Whenever possible, spraj-ing 
of the larynx should be done by the surgeon himself, as it can thus 
be performed by ihe aid of direct Wsion in a thorough manner. If this 
is not possible, the patient must be very carefully instructed in the use 
of the instrument. 

Medication of the laiyni may be required in the treatment of acute 
and chronic inflammations, ulcerations, etc., and according to llie 
indications of the individual case, remedies with an antiseptic, astrin- 
gent, sedative, slimulaling, or caustic action are employed. These 
may be used in the form of watery or oily solutions. The great 
sensitiveness of the larj'ngeal mucous membrane should be kept in 
mind in making any topical application, and the use of very iirilaling 
drugs should be avoided. 

Instruments. — It is important to select a spray that will not expel 
the solution in such a powerful stream as lo produce irritation and 
possibly add lo the local inflammation. The Davidson, the Whilall 
Tatum (see Fig. 308), and the De Vilbiss atomizers (see Fig. 309) are 
simple and verj' efficient instruments. They should be provided wiih 
a laryngeal nozzle, which turns downward. The air current may be 
supplied by a rubber compression bulb or by means of a compressed- 
air apparatus (see Fig. .^oi). 

A head mirror, a laryngeal mirror, and proper illuminati<»i will 
also be required when the spraying is to be done by the operator 
under direct vision. 

Solutions. — For cleansing purposes, the alkaline solutions recom- 
mended on page 296 for use in the nose may be employed. For 
topical applications to the larynx, the formula of antiseptic, astrin- 
gent, sedative, and stimulating solutions given on page 300, for use 
in the nose, may be employed according to the indications. 

Temperature. — The solutions should always be used warm, at 
a temperature of about 100° F. 

Anesthesia. — When the parts are very sensitive, preliminary spray- 
ing with a 10 per cent, solution of cocain may be required. 

Technic. — The patient is directed to open his mouth widely and 
to protrude his tongue, which he may hold forward with the fingers of 
his right 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 uiio the 
mouth, and with the aid of the mirror passes it behind the epiglotds and 



THE DIRECT APPLICATION OF REMEDIES. 377 

depresses the tip so that it points toward the diseased area. When 
the nozzle is in proper position, the mirror is removed and the bulb 
of the spray is sharply compressed, the patient being instructed to 
phonate while this is being done. The spray is then immediately 
removed, as the patient will cough and want to expectorate. When 
performed for cleansing purposes, the spraying should be repeated 
several times until the larynx is well washed out. Each time the patient 
coughs, mucus, purulent secretion, and crusts, which have been softened 
and separated by the spray, will be expelled. 

When the sprapng is carried out by the patient, the mouth is widely 
opened and the tongue protruded as before. The spray nozzle, held 
in the patient's right hand, is then introduced well back of the tongue, 
with the tip directed downward and forward over the larynx, and, 
while the patient phonates, the bulb is sharply compressed. In em- 
plo)ring oily preparations, the patient should take an inspiration at 
the moment of compressing the bulb, so as to aid in drawing the solu- 
tion into the larynx. Until the patient becomes skilled in the intro- 
duction of the spray, it is well for him to perform the operation stand- 
ing in front of a mirror. 

THE DIRECT APPLICATION OF REMEDIES. 

This method is indicated when it is desired to apply remedies to 
some particular spot, especially when strong stimulants or caustics 
are used. Liquids may be applied by means of swabs or brushes. 
Solid caustics should be fused on a probe. The application should 
be made with the aid of a laryngeal mirror, and great care must be 
taken to avoid bruising the tissues or causing trauma. 

Instruments. — For the application of liquids, a camel's-hair 
brush, mounted on a wire which is bent at right angles about 2 1/2 to 
3 inches (6 to 7 cm.) from the end and inserted into a handle, a Sajous 
applicator (see Fig. 385), or an ordinary laryngeal applicator wrapped 
with cotton may be employed. In making use of the latter, care 
should be taken that the cotton is wrapped tightly about the end of the 
instrument, so that there is no danger of its falling off and slipping into 
the larynx. 

Solid caustics, as silver nitrate and chromic acid, may be applied 
fused on the end of a laryngeal probe, as described on page 303. 

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. 



THE LARYNX AND TRACHEA. 



Tecbnic. — The laryngeal mirror is warmed and introduced by 
the operator's left hand, so as to obtain a clear view of the parts to be 
medicated. If secretioii or mucus be present, the parts should be first 




Fig. 396. — Method of insetting Uryngeat applicator. 




Fig. 397. — Shows the method of making direct applications to the larynx by the kid (>f the 

laryngeal mirrur. 

cleansed by spraying. The applicator is then dipped in the solution 
to be applied, and any excess of fluid is removed to prevent it from 
running into the trachea. This precaution is especially necessary when 



INSDFFLATIONS. 



379 



img strong solutions or caustics. The instrument, held in the opera- 
tor's right hand, is then introduced into the mouth, with the cun'ed 
surface held first horizontally (Fig. 396), and then, as soon as the tip 
0! the instrument reaches the pharynx, turned to a vertical position. 
The applicator is then guided to the desired spot by the aid of the laryn- 
geal mirror (Fig, 397). 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 
eicess of acid being immediately neutralized by the application of a 
solution of bicarbonate of soda, gr, xxx (1.95 gm.) to the ounce 
(JO c.c), A dusting powder may finally be applied to the cauterized 
area. 

raSDTFLATIOHS. 
Powders may be applied to the larynx by means of a special in- 
sufflator. They are of use chiefly in cases of ulceration, where a seda- 
tive or antiseptic action is desired. A combination of nosophen, 




Fig. 3g8. — Instrumenu for applying powders to the larynx. 
1. Powder blower; a, laryngeal mjrcor; 3, alcohol lamp; 4, head mirror. 

anslol, europhen, iodoform, etc., with finely powdered starch, stearate 
of zinc, or powdered acacia as a base, are usually employed in ihe pro- 
portion of one part of the active principle to two parts of the base. 






THE LARYNX AND TRACHEA. 

Small amounts of morphin or cocain may also be combined wifll the 
base and applied, when indicated, for the relief of pain- 
Instruments. — A laryngeal powder blower, a head light, a laryngeal 
mirror, an alcohol lamp, and suitable illumination are necessary, 
The insufflator shown in Fig. 398 is very convenient, as with h the: 
amount of powder may be accurately measured, and the instrument 
may be manipulated with one hand. 

Technic. — The larynsea! mirror is warmed and properly inserted 
into the pharynx, so that a good view of the parts to be medicated is 
obtained. The insufflator, filled with the desired amount of powder, 
is inserted in the mouth and carried back to the larynx under the guid- 
ance of the image in the mirror. When in proper position, a sudden 
compression on the bulb forces out the powder and deposits it on the 
diseased surface. If it is desired to carry the powder deep into the 
larynx, the patient should be requested to phonate at the moment of 
compressing the bulb. 



STSAM mHALA-nONS. 



am cuiigi 



By means of steam inhalations the active principle of certain d 
that are readily volatilized by heat may be brought into contact with 
the mucous membrane of the rcspiratorj- tract and carried beyond the 
larynx to the trachea and brcnuhi. The- elTccI of the s^team itself is 
also valuable, for it acts as an anodyne upon inflamed mucous mem- 
branes by supplying moisture and so relieving the heat and dryness of 
congestion. In the latter stages of an inflammation the steam, fur- 
thermore, dilutes and assists in removing secretions. Steam inhala- 
tions are thus of great value in congestion and edema of the larynx, 
croup, membranous laryngitis, and bronchitis. They are especially 
serviceable in softening the thick tenacious secretion of chronic 
laryngitis. 

The Inhalers. — When it is simply intended to convey the vapor to 
the vicinity of the patient, a croup ketde with a long spout, such as 
shown in Fig. 399, is most convenient. For direct inhalation, more 
or less elaborate forms of apparatus are manufactm^ (Fig. 400}, bul 
a coffee-pot with a funnel of heavy paper placed in the top makes a 
simple and efficient inhaler (Fig. 401). 

Formulary.— Sedative, stimulating, or antiseptic drugs are the onei 
usually employed for inhalation. These include tincture of benzoin 
compound in the strength of i 3 (3.75 c.c.) to the pint (473.11 cc); 
creosote, 5 to 10 n^ (0.30 to 0.60 c.C;) to the pint (473.11 cc); 



STEAM INHALATIONS. 



381 




Fig, 399.— Croup kettle. 





Fig. 401. — Steam inhaler impro- 
vised from a cofiee-pol. 



THE L--U(VNX AND TRACHEA. 

ol. cubeba;, 5 n\ (0,30 cc.) lo the pint (473.11 c.c); spirits cam- 
phori, 5 TT^ (0,30 c.c.) lo the pint {473.11 c.c); ol. pinus sylvestris, 
5 try (0.30 c.c.) to the pint (473.11 c.c), etc 

Temperature. — When directly inhaled, the vapor should not be of a 
higher temperature than 150° F. If used at too high a temperature, 
irritation of the mucous membrane may be produced and there is 
I danger of the steam scalding the face. 

I Technic— Into an inhaler a pint (473.11 c.c.) of nearly boiling ' 

I water is placed and the proper quantity of the drug is added. The 




Fig. 403. — Crib arranged for steam 



(After Eerier.) 



patient then places his nose over the cone and inhales the escapii^ 
vapor, taking about six to eight breaths a minute. The inhalitioa 
should not be continued for more than five or ten minutes at a time- 
It may be employed three or four times daily. The treatment should 
be carried out in a warm room, i.e., at a temperature of about 68°F-j 
and care should be taken to protect the padent from draughts. As 
the steam relaxes the mucous membrane and renders the palienl 
susceptible to cold, he should not be allowed out of doors' for se\'eral 
hours afterward. 

In using the croup kettle, the steam may be delivered into the room 
or durectly 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 fonn 
of a tent and raised sufficiently high to permit a free circulation of air, 



DBY INHALATIONS. 383 

the nozzle of the croup kettle being inserted under one side of the tent 
and the water kept boUing (Fig. 402). 

DRY HIHALATIOHS. 

These are useful in diseases of the upper respiratory tract for those 
who cannot tolerate the steam inhalations. The method has an 
advantage over steam inhalations in that the patient does not have to . 
remain in the house afterward. 

The Inhaler. — A special mask made of woven metal, which accu- 
rately fits the mouth and which is provided with a sponge upon which 
the medication is dropped, is employed (Fig 403). 




Fio 403 — Inhalation mask 

Formulary. — Any of the ^ ery ^ olatile oils, such as thymol, menthol, 
ftucalyptol, etc., may be employed. 

Teclinic. — Twenty or thirty drops (1.20 to 1.80 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 fasted back of the head and 
beck. 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. 

mTUBATION OF THE LARYNX. 

Intubation of the larynx is an operation devised by O'Dwyer 
■which consists in the introduction of a tube into the larynx for the 
purpose of permitting 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 pro- 
ducing any loss of blood or shock. It is less terrifying to the patient 



384 



THE Lt\KVNX AND TRACHEA. 



than the tracheotomy and the after-care is not so troublesome. 
Anesthesia is not required nor is any previous preparation of the 
patient necessary. Sfiecial instruments, however, are necessary, and 
ihe feeding of the patient is often troublesome and, while nol a diffi- 
cult operation in itself, it requires special training for its skilful per- 
formance which is best learned by practice upon Ihe cadaver. 

Indications. — The operation was originally devised for the relief 
of obstruction to respiration in cases of laryngeal diphtheria and 
has now almost entirely supplanted iTacheotomy in such cases. The 
immediate indications are dyspnea accompanied by cyanosis, depres- 




FiG. 404. — O'Dwyer intubation insiminenia. 

I, Tube H'ith obturator in place; 1, tube and obturator separaled; 3, gsuge; 4, mouth 

gag; 5, introducer; 6, silk thnad; 7, extractor. 

sion of the suprasternal and supraclavicular spaces on inspiration, 
and sinking in of the lower portion of the chest. Intubation is also 
employed in laryngeal stenosis from other causes for the purpose of 
producing gradual dilatation of the parts, progressively increasing 
sizes of tubes being introduced and worn for a few days at a time. 

Instruments. — The instruments required are an O'Dwyer intuba- 
tion set including seven metal or hard-rubber tubes, an introducer, 
an extractor, a mouth gag, and a gauge indicating the size of the tubes, 
according to the age of the patient (Fig. 404). Although these instni- 



INTUBATION OF THE LARYNX. 385 

ments 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 provided 
for the attachment of a piece of silk thread. The lower end of the 
tube is rounded off 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 of 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 detaching the 
intubation tube from the obturator when the former is in proper posi- 
tion in the larynx. 

The extractor, or extubator, is an instrument supplied with jaws 
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 removal 
from the larynx. 

Position of the Patient. — The child, with its arms at its sides, is 
wrapped from chin to foot in a sheet or blanket and is supported upon 
the lap of a nurse in a sitting posture facing the operator with its feet 
held between the nurse's knees and its head resting on her right 
shoulder. An assistant should stand behind and grasp the child 's head 
firmly, lifting upward as though holding the child by the head, thus 
extending the child's head as far as possible. Some operators, how- 
ever, prefer to intubate with the patient in a horizontal position and 
with a small sand-bag placed under the back of the neck. 

Technic. — A tube of a size corresponding to the age of the patient 
is selected and is properly threaded with a piece of silk 2 or 3 feet 
(60 to 90 cm.) long. Then, with the obturator in place, the tube is 
screwed on the introducer in such a manner that its projecting flange 
lies behind and faces away from the operator. The mouth gag 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 operator, 
with his eyes, nose, and mouth protected against possible infection 
in diphtheria cases, faces the patient and inserts his left index-finger 
into the mouth, hooking up the epiglottis (Fig. 406). In doing this 
care should be taken to keep the finger to the left side and out of the 
25 



386 THE LARYNX AND TRACHEA. 

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, ihe 
index-finger around the hook on the under surface of the instrument. 




Fig. 406.^1 niutm ion. First step, stiowing the method of drawing the epiglottis forward. 



and the loop of silk wound over his little finger, as shown in Fig. 
407. He then slowly introduces the tube into the mouth in the median 
line, hugging the center of the tongue and keeping the handle of the 
instrument at first well down on the chest of the patient (Fig. 408). 



INTOBATION OF THE lAKYNX. 387 

When the end of the tube reaches the epiglottis (Fig. 409), the handle 
is sharply elevated, so that the tube is brought into a vertical position 
(Fig. 410). If the handle of the instrument is not sufficiently elevated, 




ibe tube will point toward the entrance of the esophagus which it will 
beapi to enter during the next maneuvers (Fig. 41 1). At the same time 
the finger of the operator is moved to the posterior portion of the 
larjni, resting on the arytenoid cartilages to prevent the tube from 




Fio. (oS.— Intubation Second step, introducing tlie lube into the palienl's mouth. 



entering the esophagus. The tube is then gently pushed through the 
chink of the glottis and on into the larynx, guided by the operator's 
finger. No force whatever should be used. 




As soon as the lube is in proper position, the operator's forefinj^ 
d on its head holding it in place while the button on the handle 
of the instrument is pushed forward, thus disengaging the obturaior 
from the tube (Fig. 412). The intubator with the obturator altadieij 




—Third step 



Fourth step in intulwiiun. 



is then removed, and the tube is pushed well into the larjiut by the 
finger (Fig. 413). Not more than five to ten seconds should be con- 
sumed in introducing the tube, for while this is being done breathing 
is interfered with; if the tube cannot be promptly inserted, the opcraliM 




Fig. 411. — Showing a faulty posiiion of 
ihe lube, due to the handle of ihc intro- 
ducer not being raised sufliciently high. 



Fig. 4".— Fifth step in btubaiKin. 
withdrau-ing the introducer whilt ''* 
index'&ngcr holds the tut>e in place 



should be suspended and a second attempt made after allowing tlw 
child time to recover its breath. 

If the tube is properly placed, there may be at first some cough, 
but the breathing rapidly becomes easier, and the cyanosis is quicUy 
relieved. After the tube is in position, it is well to wait for ten or 



INTOBATION OF THE LARYNX. 389 

fifteen minutes, to make sure that there is no obstruction to free respira- 
tion. When certain that the tube is properly placed in the larynx, the 
mouth gag is reinserted, and one strand of silk is cut near the angle of 
the mouth, and the string is withdrawn, the forefinger being placed on 




Frc. 413. — Sixth step in intubation, 1 

showing the index-fitter pushing the lube 
veil into the larynx. 

the tube to maintain it in position (Tig. 415). Some operators prefer 
to leave the string attached for the removal of the tube in case of 
sudden emergency. If this is done, the siring should be brought out 
the comer of the mouth, hooked over the ear, and secured by adhesive 




Flo. 415. — Una] step in intubation, removing the stnng from the tube 



plaster. This method has the disadvantage, however, of furnishing a 
chance for the child to remove the tube if it gets hold of the string. 

Should the tube be placed in the esophagus by mistake, there will 
be no relief to the dyspnea and the cyanosis, there will be an absence 



390 THE LARYNX AND TRACHEA. 

of cough, and the string of silk will be seen to gradually shortea as the 
tube passes down the esophagus. In such a case, the tube should be 
removed by pulling on the string, and, after waiting a sufficient time 
for the patient to recover from the excitement attending the operation, 
it should be reintroduced. 

In some instances, the tube may become occluded by pushing the 
false membrane ahead of it. If this occurs, the tube should be removed 
at once, and, if the obstrucdng membrane is not expelled from the 
larynx and cannot be extracted and suffocation seems imminent. 




'Method of feeding an inlubation patient with the head bwcred. 



tracheotomy should be performed. Care should be taken not to 
select loo small a tube, for it may be expelled by coughing or may escape 
into the trachea. 

Feeding Intubated Patients. — The tube renders swallowing difficult, 
and (he patients are only able to take liquid or, at most, semisolid food. 
As a rule, by having the patient lie with the head lowered, fluids 
will pass along the roof of the mouth to the posterior pharyngeal wall, 
and will enter the esophagus, and, if given slowly, sufficient food may 
be administered in this way (Fig. 416) ; or food may be administered 



INTUBATION OF THE LAEYNX. 



391 



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 food, liquids may be administered by means of the 
stomach-tube passed through the mouth or by means of a soft-rubber 
catheter passed into the stomach through the nose (page 465), though 
by the continued use of the latter method there is danger of producing 
infection of the middle ear.* Rectal feeding may be combined with 
the above if indicated. 

When to Remove the Tube. — The tube should always be removed as 
soon as possible, as its prolonged use may produce ulceration of the 
larynx. In cases of diphtheria, where antitoxin has been administered, 
the tube may be removed in three to seven days, depending to some 
extent upon the age of the patient, being left m for longer intervals in 




Fig. 417.— Enubalion. 



very young children. If the tube becomes occluded at any time, it 
must be removed without delay, cleaned, and then reintroduced. 
When the tube is to be permanently removed, the physician, after 
extracting it, should wait sufficiently long to see that respiration does 
not become impeded and necessitate its reintroduciion. 

Technic of Eztubation. — The patient is placed and held in the 
same position as for introduction of the tube. The mouth gag is 
inserted, 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 
extubator, held in the operator's right hand, is then introduced with 
its jaws closed, by the same maneuvers employed in introducing the 
intubator, until its tip is felt by the finger on the tube. It is then 
carefully guided into the lumen of the tube. By pressing the lever on 



392 THE LARYNX AND TRACHEA. 

top of the handle, the jaws of the instrument are separated and obtain 
a secure hold on the tube, so that it may be easily withdrawn (Fig. 417). 
To accomplish this, the tube must be lifted at first vertically upward. 
The handle of the instrument is then depressed, and the tube is brought 
out by a reversal of the movements of intubation. 

In an emergency, when the tube becomes obstructed, it may be 
possible to remove it by enucleation, especially if the tube be short. 
This consists in placing the thumb of the right hand on the larynx 
beneath the end of the tube while the patient's head is extended, and 
with a quick motion of the head forward, at the same time exerting 
upward pressure on the larynx, the tube is expelled into the mouth. 

TRACHEOTOMY. 

The term tracheotomy is generally used to designate the opening 
into the air-passages at some point between the sternum and th}Toid 
cartilage. To be exact, however, the term should be limited to opera- 
tions below the cricoid cartilage, while above that point, that is, in the 
cricothyroid space, the operation is called laryngotomy. Tracheotomy 
is subdivided into the high operation when the opening is made above 
the isthmus of the thyroid gland, and into low tracheotomy when the 
operation is performed below this point. 

Indications. — Opening into the air-passages is indicated for the 
relief of obstructive dyspnea, which may be the result of any one of 
the following conditions: The formation of pseudomembrane ; the 
presence of foreign bodies; the presence of growths within the larynx 
or trachea or external to these structures; edema of the larynx; spasm 
of the larynx; rapid swelling of the tonsils and pharynx; injuries to 
the larynx and trachea, such as contusions, fractures, bums, cicatricial 
stenosis, etc. For the relief of obstruction from diphtheritic mem- 
branes, however, intubation should, as a rule, be the operation of 
choice, tracheotomy being reserved for those cases where intubation 
fails, as when the membrane extends down low in the trachea, and 
where the attending physician does not possess the necessary skill for 
intubation, or where the necessary instruments for intubation are not 
available. Tracheotomy may also be required for the removal of 
foreign bodies from the larynx, trachea, and bronchi, for the adminis- 
tration of tracheal anesthesia in operations upon the mouth, pharynx, 
jaws, or larynx, and as a preliminary to laryngectomy and lower 
tracheo-bronchoscopy. 

Choice of Operation. — The choice between laryngotomy, high 



TaACHEOTOMV. 



39i 



tracheotomy, and low tracheotomy depends upon the seat of the 
obstruction and also upon the age of the patient and the necessity for 
haste. Of the three, laryngotomy is the most easily and rapidly 
performed. It thus becomes the operation of choice in a sudden 
emergency where the obstruction is located in the larynx and where 
there is demand for haste in order to avoid imminent suffocation or 
where the proper instruments and assistants are lacking. It is not, 
however, a suitable operation to be performed upon those imder 
thirteen yeare of age, on account of the small size of the cricothyroid 
space, nor should it be performed for the relief of conditions requiring 
the wearing of a tube for any length of time, on account of the proximity 
of the vocal cords and their liabili^ to injury by the tube. 




Fic. 4i8.^The location ot the intisions in laryngotomy and tracheolomy, (After Bickham.) 
a, Thyroid cartilage; ft, incision (or laryngotoray; c and e, branches of superior thyroid 
arteries; d, cricoid cartilage;/, incision for high tracheoloroy; g, thyroid gland; A, incision 
for low tracheotomy; i, pneumogastric nerve; ;', slemo-mastoid muscle; k, interior thyroid 
veins; /, stemo-thyroid muscle. 

On account of the small number of important vessels encountered, 
and the greater ease with which the trachea is reached, high tracheot- 
omy is preferable to the low operation where the location of the trouble 
permits. It is the operation of choice for children and in cases of 
diphtheria where a tube has to be worn for some time. 

Low tracheotomy may be required for the removal of foreign 
bodies from the bronchi, for lower tracheo-bronchoscopy, for the relief 
of threatened suffocation from occlusion of the trachea by tumors of 



the thyroid, etc, II requires more skill in its performance than does 
the high operation, as in the lower portion of the neck the trachea L' 
more deeply placed and important structures at the root of the neck 
are in close proKimity. 

lastruments. — The instruments that should be provided incliuie; 
a scalpel, a narrow bistoury, scissors, two sharp retractors, two ten- 
acula, artery clapips, two pair of thumb forceps, tracheal forceps, a 
Trousseau tracheal dilator, a flexible-nibber catheter, tracheolomy 





Fic. 4ig. — Instrtiments tor tracheolomy, 
I, Scalpel; z, curved bistoury; 3, scissors; 4, retractors; 5, tenaculum; 6, arteiy clunps; 
7, thumb forceps; S, needle- holder; 9, Trousseau tracheal dilator; id, tracbeotomy tube; 
II, catheter; 13, tracheal forceps; ij, oeedles; 14, No. 3 catgut. 

tubes and tape, a needle-holder, two curved cutting-edge needles, and 
No. 2 catgut for ligatures and sutures (Fig. 419). In an emergency, 
where delay would mean the loss of the patient's life, the operation 
may be performed by the aid of a pocket-knife and two hairpins bent 
in the shape of a hook to hold the trachea open until the proper tube 
can be obiained. 

Tracheolomy tubes of several sizes and with different curves should 
be provided so that one suitable for the individual case may be at hand. 
A silver tube, somewhat flattened from side to side, without fenestra, 



TRACHEOTOMY. 395 

and with a movable inside tube, is preferable (Fig. 420). With some 
tubes an obturator is supplied as an aid to insertion. For an adult, 
a No, 5 or 6 tube will usually suffice; for a child under two, a No. 2 
tube should be provided; for a child ttom two to four, a No. 3; and 
for one over four, a No. 4. In an emergency a tube may be improvised 




Fio. 4ao. — Tncheatomy 
tube. 



Fig. 411. — Tracheoloiny tube improvised 
from rubber tubing. 



by bending a piece of rubber tubing into the required shape, as shown 
in Fig. 421. For laryngotomy, a tube shorter than the ordinary tra- 
cheotomy tube, and flattened from before backward, is employed. 

Position of the Patient. — ^This should be such as to bring the neck 
into the greatest possible prominence. The patient is therefore 




Fig. 431. — Posilion of patient tor laiTngotomy and tracheotomy. 



placed in a strong light on a firm 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 
(Fig. 422). In an emergency, the patient's head may be simply 
allowed to hang over the edge of the table or a lounge. 



396 THE LARYNX AND TRACHEA. 

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 is sufficient. 
A o. 2 per cent, solution is employed for the skin, and a o. i per cent, 
solution for deeper infiltration. When there is occasion for great 
haste in the presence of unconsciousness or dyspnea with marked and 
increasing cyanosis, an anesthetic may be 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, 
as the infiltration alone terrifies the child and produces struggling, 
which adds to the dyspnea. If air enters the lungs at all, chloroform 
given slowly is the best anesthesia, ether being apt to irritate the 
mucous membrane and produce laryngeal spasm, thus adding to the 
dyspnea. 

Preparations. — If hairy, the neck should be shaved. The skin is 
sterilized by washing with soap and water followed by the use of a 
I to 2000 solution of bichlorid of mercury. The instruments are steril- 
ized by boiling or, in an emergency, by immersion in a i to 20 carbolic 
acid solution. The hands of the operator and his assistants should 
be prepared with the same care as for any operation. 

Technic. — i. Laryngotomy. — The thyroid and cricoid cartilages 
are identified, and, with the larynx supported between the thumb and 
forefinger of the operator's left hand, an incision about i 1/2 inches (4 
cm.) long is made through the skin, exactly in the median line of the 
neck, extending from the lower portion of the thyroid cartilage to below 
the cricoid cartilage. The superficial fascia, platysma, and deep 
fascia are divided, and the sternohyoid and sternothyroid muscles 
are separated at their inner borders and held apart by retractors. 
The connective tissue and veins underlying these structures are then 
separated, all veins being clamped or ligated before division. The 
cricothyroid membrane is thus brought into Wew. The thyroid 
cartilage is firmly steadied with a tenaculum, while the cricothyroid 
membrane is transversely incised by means of a sharp, narrow-pointed 
bistoury near the upper border of the cricoid cartilage, so as to avoid 
the cricothyroid artery, which runs along the upper border of the space 
below the thyroid cartilage (Fig. 423). If the situation of this vessel 
is such that injury to it or its branches cannot be avoided, it should be 
tied between two ligatures before the membrane is incised. In open- 
ing the membrane, the incision must be carried deep enough to include 
the mucous membrane lining it, otherwise the laryngotomy lube may 



TRACHEOTOMY, 397 

!ie fjushed in between the two structures and not into the larynx at 
II_ The wound is held apart with two small retractors or a tracheal 
ilsm, tor, and the foreign body which may be causing the obstruction 
:K~<«moved by means of tracheal forceps. If there is not sufficient 
d^isn to remove the foreign body through this incision, the cricoid 
kilage may be cut. The laryngotomy tube is then carefully intro- 
=:ed and is secured in place by tapes passing around the patient's neck, 
>>inall square pad, split to its center, being interposed between the 
■n and the flange of the tube. A stitch or two may be placed at the 




Flo. 413. — Opening ihe crirothyroid membrane in laryngotomy. (After Bickham.) 



upper and lower angles of the wound to bring them together, if neces- 
sary. Even where the obstruction is immediately relieved, it is pref- 
erable in any case to insert a tube for a time until the tissues are 
more or less adherent, so as to avoid subcutaneous emphysema, 

2. High Tracheotomy. — The thyroid cartilage is grasped between 
the thumb and forefinger of the left hand, so as to steady the trachea, 
and with the right hand a vertical incision i 1/2 to 2 inches (4 to 5 cm.) 
long is made exactly in the median line, extending from the cricoid 
cartilage to a little below the isthmus of the thyroid gland (Fig. 424). 
The skin and superficial and deep fascia are incised, and the anterior 
jugular veins which are encountered in the upper part of the incision, 
together with any communicating branches of the superior thyroid 
veins, are caught in forceps and ligated. The sternohyoid and sterno- 
thyroid muscles are thus exposed, and should be separated along their 



398 THE LARYNX AND TKACHEA. 

inner borders and retracted to each side. As these muscles are pulled 
apart, the isthmus of the thyroid gland and the deep cervical fascia 
covering the trachea appear. This fascia is then divided from the 
lower border of the cricoid cartilage by a transverse incision cur\-ed 
downward at the extremities. The fascia k then stripped from the 
trachea and retracted downward, and with it the isthmus of the thyroid 
gland, thus exposing the rings of the trachea. If the thyroid isthmus 
is very large, two ligatures may be placed about it, on each side of 
the median Ime, to control the hemorrhage, and the isthmus with the 
deep fascia is incised vertically and retracted to each side. A tenacu- 




FiG, 414. — Eipoaing the Irachea io high tracheolomy. 

lum is then inserted beneath the cricoid cartilage, and is held by an 
assistant so as to steady the trachea. If without a tube, it is well to 
apply retraction sutures on either side of the trachea before opening 
the latter. For this purpose a full cuned 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 inserted through the mem- 
brane below the second ring of ihe trachea, and the latter is incised in 
the median line as far up as the cricoid cartilage, care being taken to 
include the mucous membrane of the trachea in this incision (Fig. 425). 
The edges of the tracheal opening are separated with tracheal forceps, 
or the wound is held open by the retraction sutures, if they were pre- 
viously inserted, and the tracheotomy tube, with its cannula, is 



THACHEOTOICY. 




. 43$. — Opening the trachea in Iiigh Iracbeotomy. (After Biclclum.) 




Fio. 4j6. — Method of inserting the tracheotomy tube. 



400 THE LARYNX AND TRACHEA. 

carefully passed through the open wound into the trachea (Fig. 426). 
If there is no great urgency, all bleeding should be arrested before the 
trachea is opened, but where haste is important this may be omitted 
until the tube is introduced. 

When the tube has been properly placed, a pad of gauze is inter- 
posed between the skin and the flange of the tube, and the latter is 
securely held in place by tapes passing from each side of the flange 
around the neck (Fig. 427). 

In cases of diphtheria, as soon as the trachea is opened a large 
amoimt of mucus and membrane is usually expelled, and it is of advan- 




FiG. 427. — Showing the tracheotomy tube in place. (Stoney.) 

tage in such cases not to insert the tube at once, but to hold the tra- 
chea! wound open and allow the membrane to be expelled. What is 
not expelled may then be removed, if loose, by forceps. The danger of 
infection from the patient's coughing bits of membrane from the tra- 
cheal opening into the face of the operator should be guarded against 
by holding a piece of 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 is carried from 
the thyroid cartilage to within 1/2 inch (i cm.) of the sternal notch. 
The skin and superficial and deep fascia, are incised, and the inferior 
thyroid veins, or other vessels that may be in the way, are ligated and 
divided. The sternohyoid and sternothyroid muscles are separated 
in the median line and are retracted to each side. The deep cervical 
fascia is divided vertically downward from the lower border of the 
isthmus of the thyroid gland, and is retracted laterally, notching it 



TRACHEOTOMY* 4OI 

transversely on each side if necessary to obtain more space. Care 
must be taken in deepening the incision at the lower angle of the wound 
not to injure the innominate vein which may bulge up above the 
sternal notch. The isthmus of the th)rroid gland is pulled well up out 
of the way by means of a retractor, and while the trachea is steadied, 
an incision is carried upward through two or more of the lowermost 
rings by means of a narrow bistoury. The edges of the tracheal 
wound are then retracted, and the tube is inserted and secured in place 
as previously described. 

Difficulties of Tracheotomy. — In cases where the patient is fat, or 
the neck short and swollen so that it is difficult to identify the land- 
marks, the operator may miss the trachea entirely through failure to 
make the incision exactly in the median line or from pulling the 
trachea aside with the retractors. Again, he may fail to place the 
tube within the trachea, through not carrying the incision through the 
mucous membrane. In some cases the patient may cease breathing 
with the first rush of air on opening the trachea. This is usually 
only temporary, and natural breathing soon recommences; if it should 
not, simple pressure on the sternum suffices to start it up. If the ces- 
sation of respiration occurs in the early stage of the operation, the 
trachea should be immediately opened and artificial respiration per- 
formed (see page 58). Sometimes free respiration may be impeded 
by the end of the tube coming in contact with the wall of the trachea. 
Any difficulty in introducing the cannula into the trachea may be 
avoided by making a sufficiently large opening and by steadying the 
trachea with hooks or retraction sutures. 

After-care* — ^The opening of the tube should be covered with a piece 
of gauze moistened with normal salt solution, and the patient kept in a 
room at a temperature of about 65° to 70°. If the operation is per- 
formed for inflammatory conditions, the atmosphere should be kept 
moist by the steam from a croup kettle directed so as to play over the 
tracheal opening (see page 380). At first, the inner tube should be 
removed every two or three hours and be 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 facilitated by the use of a guide. 
Any membrane or mucus that may collect at the mouth of the tube 
should be promptly removed. Secretions blocking the tube may be 
removed by means of a small catheter and a suction syringe. Mem- 
brane may be removed from the interior of the tube with alligator 
forceps (Fig. 428) introduced through the cannula. If this is not 

2t 



402 THE LARYNX AND TRACHEA. 

possible, the tracheotomy tube should be withdrawn and the obstruc- 
tion removed. 

Removal of the Tube. — In cases of diphtheria the tube may be 
permanently removed as soon as there is free respiration through the 
larynx with the tracheal wound closed. This is usually possible in 
from five days to one week. When tracheotomy is employed for 
the 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. 




Fig. 428. — Intracannular alligator forceps. (Fowler.) 

Complications. — Broncho-pneumonia is a common complication 
even when not due to an extension of the diphtheritic process. Infec- 
tion of the wound may follow in diphtheria cases and may spread into 
the loose connective tissue of the neck, producing a cellulitis; or the 
infection may work down and cause septic pneumonia. An improperly 
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 removed too soon ; 
it has also been produced from injury to the posterior or lateral walls of 
the trachea. Hemorrhage from congested veins may at times be 
severe; in the majority of cases, however, the bleeding, which may be 
profuse before the trachea is opened, stops spontaneously as soon as 
respiration is re-established. 



CHAPTER XIV. 
THE ESOPHAGUS. 

Anatomic Considerations. 

The esophagus extends from the lower border of the cricoid cartilage 
to about the level of the ensiform cartilage or, in other words, from 
the level of the disk between the fifth and sixth cervical vertebrae to 
the tenth dorsal vertebra. Its entire length is about lo inches (25 cm.), 
while the distance from the upper incisor teeth to the cardiac end 
measures about 16 inches (40 cm.). Antero-posteriorly the esophagus 
presents a slight curve with the concavity forward, as it follows the 
direction of the spinal column. Laterally, it has the following curves: 
from its starting point it turns slightly to the left, projecting as much as 
1/2 mch (i cm.) to the left of the trachea; it then descends in front 
of the spine, at first behind the arch of the aorta and then lying to the 
right of the aorta, finally curving in front of, and a little to the left of, 
the aorta to pass through the diaphragm (Fig. 429). In its course, 
the esophagus has in front of its upper portion the trachea; while 
below it is crossed by the left bronchus and the arch of the aorta. 
The pericardium and the left vagus nerve also lie in front. Posteriorly, 
it rests upon the spinal column and the thoracic duct; about 3 
indies (7 cm.) from the diaphragm it crosses the aorta. On either 
side it is in relation with the pleura. 

The esophagus measures about 3/4 inch (19 mm.) in diameter, 
but a number of constrictions in its caliber have been described, 
the most marked being as follows: (i) at its commencement, 6 
inches (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; and 
(3) at a point 16 inches (40 cm.) from the incisor teeth, where it passes 
through the diaphragm (Fig. 430). At these points the caliber of the 
tube measures about 1/2 inch (i cm.). The measurements, curves, 
and constrictions of the esophagus are important to remember in the 
passage of instruments and with reference to the lodgment of foreign 
bodies. 

403 



404 THE ESOFHAGOS. 

Diagnostic Methods. 
The methods available for examination of the esophagus include: 
(i) auscultation, (2) percussion, {3) external palpation, {4) instrumental 
examination, (5) inspection through the esophagoscope, and (5) the 
use of the X-rays. The first three of these methods are of very limited 




F[C. 419.^ — The course and relations of the esophagus viewed from behind. 
Fig. 430, — The normal narrowings of the esophagus. (Eisendrath.) I, At its junc- 
n with the pharyni; a, oppoale the bifurcation of the bronchi; 3, at the diaphragm. 



clinical value, while the use of the esophagoscope is of doubtful value 
except in the hands of an expert, so that in the majority of cases we 
have to rely upon the use of bougies and sounds or the X-rays, 

As in examination of other regions, a careful history of the case 
should precede any local examination. 



EXAMINATION BY SOUNDS AND BOUGIES. 405 

AUSCULTATION. 

Ausculation is performed by listening with a stethoscope over the 
course of the esophagus while the patient swallows liquids. . The usual 
points for auscultation are upon the left side of the spine opposite the 
ninth or tenth dorsal vertebra, or just to the left of the ensiform. 
Normally, during 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 stomach 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. At times 
it may also be possible to recognize by auscultation the stoppage of the 
fluid when it reaches the point of stricture. 

PERCUSSION. 

Percussion may reveal the presence of large tumors, dilatations, or 
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 gas. 

PALPATION. 

External palpation is extremely limited in usefulness, as it is only 
applicable to the cervical portion of the esophagus. By means of 
palpation one may be able to discover hard foreign bodies, tumors, 
enlarged glands, enlargements of the thyroid, as well as any pressure 
tenderness along the esophagus. Diverticula full of food may be thus 
distinguished and mapped out, and not infrequently it is possible to 
empty the diverticulum sac of its contents by pressure. 

By internal palpation with the index-finger, foreign bodies lodged 
in the entrance of the esophagus and strictures, new growths, etc., 
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 diflScult. Gentleness only 
should be employed in manipulation, however, since, if due care is not 



4o6 



THE ESOPHAGUS. 



exercised in this direction, false passages- may be readily made through 
the esophagus into the mediastinum; especially is such an accident 
possible if the coats of the esophagus arc already weakened by disease. 
Before any attempt is made to pass instruments, a thorough phys- 
ical examination — including the vascular system — should be made. 
In the presence of aortic aneurysm, recent hemorrhage from the esopha- 




Fig. 431. — Cylindrical esophageal sound. 

gus or Stomach, acute inflammation of the esophagus, and after recent 
ulceration, the use of esophageal instruments is contraindicated. In 
cases of advanced pulmonary or cardiac disease and cirrhosis of the 
liver, instruments, if used, should be employed with great caution. 

Instruments. — For ordinary examination, graduated esophageal 
bougies and bougies h. boule are employed. These instruments vary 




Fig. 432. — Conical esophageal sound. 

in length from 24 to 32 inches (60 to 80 cm.). The best bougies are 
hollow and are made of a gum-elastic material, so that when warmed 
they become flexible and capable of being bent to any desired shape. 
They may be obtained cylindrical (Fig. 431) or conical (Fig. 432) in 
form. In their stead, however, a thick rubber stomach-tube is often 
utilized. 



Fig. 433. — Olivary bougies a boule for the esophagus. 

The bougie k boule is an essential instrument if the length of a 
stricture is to be estimated. It consists of a flexible whalebone shaft, 
to the end of which metal or ivor>' olive-shaped tips of different sizes 
may be screwed (Fig. 433). The shaft should be marked off in an 
inch or centimetric scale. 

In cases of very tight stricture filiform bougies of whalebone or 



£XA11IMATI0N BY SOUNDS AND BOUGIES. 407 

woven material may be employed to determine whether the stricture 
is at all pomeable. They may be introduced into the stricture through 
a hollow bougie which is first passed to the face of the stricture, or 
they may be inserted through an esophagoscope. 

Aaepais. — Rubber bougies and tubes may be sterilized by boiling. 
The gum-elastic instruments, unless of the very best material, are 
niined by boiling or by the use of strong antiseptics. They may be 
rendered sufficiently aseptic by immersion in a saturated solutioQ of 
boracic acid, after first thoroughly washing with soap and water. The 
hands of the operator should also be clean. 

Pontion. — The patient is seated in a chair with the head thrown 
back against the back of the chair, »nd with the chin raised sufficiently 
to make the passage between the mouth and the esophagus as straight 
a line as is possible. The surgeon stands in front of the patient, 
while, if desired, an assistant may steady the head from behind. In the 




Fig. 434. — Shows ihe first step 

case of a child, it will be necessary to confine its a 
ihem held by a nurse or by including them in a sheet i 
the child's body. 

Anesthesia. — In an adult general anesthesia is only necessary in 
exceptional cases, but the pharynx and larynx, if very irritable or scn- 
sitii-e, may be brushed over with a 5 or 10 per cent, solution of cocain. 
Technic. The patient is seated in the proper position with a towel 
about the neck for protection, and is given a basin to catch vomitus or 
saliva. A soft, flexible sound is passed as follows: the bougie, lubri- 



408 THE ESOPHAGUS. 

cated with glycerin and held in the operator's right hand as one would 
a pen, is passed into the patient's open mouth back to the pharynx. 
The patient is then requested to swallow and the instrument 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. 434). 

Sometimes when a rather inflexible bougie is employed or when 
the tongue is thick or the pharynx is swollen, some difficulty may be 




Fig. 435. — Inlroduclion of an esophageal bougie wiih the finger holding the tongue »nd 
e[Hglotiis forward. 

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 
draws the latter forward, and with it the larynx, so that the esophagus 
may be more easily entered (Fig. 435). The bougie is then passed 
on ihe finger as a guide straight back in the median line to the pharynx, 
and, hugging the posterior wall of the pharynx, it is pushed steadily, 
but gently, backward and downward into the esophagus, and thence 
into the stomach, unless some obstruciion be encountered. 



EXAlDNAnON BY SOUNDS AND BOUGIES. 



409 



The patient should be instructed to breathe deeply during the pass 
g-^s of the bougie, even if gagging is produced, and he should be 
i.^«_«tioned not to bite the examiner's finger or the tube. There will 
s.'w.jally be gagging and some attempts to vomit as the tube is inserted, 
l:». ■*, unless very distressing, they may be disregarded. The patient 's 
^ i-Kd, however, should be bent forward over a basin as soon as the 
■.tae is well within the esophagus to receive any vomitus, mucus, or 
■-l-ava (Fig. 436). 

If dyspnea and cough are induced, the instrument has probably 
■"»- "tiered the larynx. To settle this point, the patient should be told to 




Fig. 436. — Shows ihe second step in introducing an esophageal bougie. 



phonate "ee"; if he can do so, one may be sure the bougie is not in the 
larynx. If the passage of the tube becomes impeded at any point, the 
tube should be slightly withdrawn and then again pushed gently on- 
ward, when, unless a stenosis exists, it will advance without difficulty. 
The points of normal conslriclion at which a bougie may be arrested 
without any diseased condition being present should, however, be 
kept in mind. They are: (i) 6 inches (15 cm.) from the upper incisor 
leeth; (2) 10 inches (25 cm.) from the incisors; and {3) 16 inches 
(40 cm.) from the incisors (see Fig. 430). 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 inflammation, 
ulceration, or malignancy. When the bougie meets a real obstruction 



4IO 



THE ESOFHAGQ5. 



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 overcome 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 spasmodic 
stricture will always disappear if the patient is placed imder the influ- 
ence of a general anesthetic. If the obstruction does not yield, the 



'■ 437- 



Fig. 43S. 

n esophageaJ striclu 



Fjo. 4j;. — Method of estimaling the length of a 
boule at the [ace of the stricture. 

Fio. 438. — Method of estimaling the lei^h of an esophageal strictur 
boule is wilhdravm until its base is arrested at the distal end of the si 



bougie is removed and a smaller one is inserted; and, if necessary, 
smaller sizes are successively introduced until one is selected that will 
pass completely through the stenosed area into the stomach. In this 
way the degree of stenosis is ascertained. It is quite imjx>rtant in 
making this examination to insert the bougie into the stomach, as, 
olhenvise, a second stricture below the first may be overlooked. 

To determine ihe length of a stricture, a large olive-tipped sound 
is inserted until it reaches the face of the stricture (Fig. 437), and the 
distance of the stenosis from the upper inrisor teeth is estimated from 
the markings on the shaft of the instrument. The bougie is then 
withdrawn and a size that will Just pass is inserted well through the 



EXAMINATION BY SOUNDS AND BOUGIES. 



411 



stricture. Upon withdrawing the instrument, the base of the bulb 
catches in the lower rim of the constriction (Fig. 438), and the distance 
of this point from the mouth is also estimated. By subtracting the 
first of these measurements from the second, the length of the contrac- 
ture is readily determined. 

It is often possible for a practised hand to determine the consistency 
of an obstruction from the sensation imparted by contact with the tip 
of the instrument. By means of a metal-tipped bougie k boule the 
consistency of hard foreign bodies, such as teeth, corns, bone, etc., may 
be readily recognized, and at times a distinct sound may be distinguished 
when the two come in contact. 



/ 




Fic. 439. Fic, 440. ' Fic, 441. 

Fig. 439- — Shows a sound passing the opening of a diverticulum. (After Gumprecht.) 
Fic. 440.— Shows ihe ease with which a sound wilt enter a diverticulum when the latter 
Is full. (After Gumprecht.) 

Fig. 441. — Shows the ease with which a sound follows the esophagus when the diver- 
ticulum is empty. (After Gumprecht.) 

If the bougie has entered a diverticulum, it will be possible to 
move its end freely in different directions, and, if the diverticulum be 
located high up, the end of the bougie may often be felt in the neck. 
Again, by withdrawing the instrument somewhat so as to disengage 
the tip, and by changing its direction (Fig. 439), it can frequently be 
passed by the diverticulum into the stomach. A bougie will be more 
apt to enter a diverticulum if the sac be full (Fig. 440) and pass to the 
stomach when the sac is empty (Fig. 441). This intermittent obstruc- 
tion to the passage of a bougie is characteristic of a diverticulum, 
and is a point in the differential diagnosis from stricture. 



412 THE ESOPHAGUS. 

The bougie should always be examined after its withdrawal for 
the presence of blood or pus which may be found adhering to its surface 
or tip. With the hollow bougie provided with a lateral opening near 
its tip, fragments of tissue sufficiently large for examination may be 
brought away by the instrument, which when placed under the micro- 
scope may confirm a diagnosis of possible malignancy. 

ESOPHAGOSCOPY. 

Esophagoscopy, a method devised by Mikulicz, consists in direct 
inspection of the interior of the esophagus by the aid of a long endo- 
scopic tube illuminated by electricity. By the use of the esophagoscope 
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 examination. 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 examina- 
tion as a routine. 

In the passage of the esophagoscope the same care should be 
observed as in the passage of any esophageal instruments. The 
contraindications to its use are practically the same as those mentioned 
for the sound or bougie, viz., aortic aneurysm, recent hemorrhage 
from the esophagus, advanced pulmonary or cardiac disease, etc. 

Instruments. — Von Mikulicz's instruments (Fig. 442) are cylin- 
drical tubes about 2/5 to 1/2 inch (ro to 13 mm.) in diameter, bevelled 
at the end and supplied with an obturator to aid in their introduction. 
On the outside, the tubes are marked off in a centimetric scale. They 
are made in different lengths, according to the depth to which it is 
wished to pass the instrument. The illumination is supplied by a 
panelectroscope at the proximal end of the instrument. 

Other tubes, such as Jackson's (Fig. 443) 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 former it is difficult 
to direct the light properly on account of the length of the tube. To 
examine the entire length of the esophagus, for adults Jackson uses 
a tube about 22 inches (53 cm.) long and 2/5 inch (10 mm.) thick, 
and for children, a tube 18 inches (45 cm.) long and 7/25 inch (7 mm.) 
thick. In addition to the esophagoscope, a Sajous applicator, swabs 
on holders, various shaped forceps for removing foreign bodies or 
sections of tissue for examination, etc., are required. 



ESOPHAGOSCOPY. 



413 



Asepsis. — The tubes and accessory instruments may be sterilized 
by boiling and the lights by immersion in alcohol. 

Preparation of Patient. — The patient's stomach should be empty, 




Fig. 442. — Von Mikulicz set of instruments for esophagoscopy. (Gottstein in Keen's 

Surgery.) 

to avoid regurgitation of its contents. Where there is a marked 
dilatation of the esophagus, a preliminary lavage (see page 416) may 
be necessary. The clothing should be loosened from about the patient's 




Fig. 443. — Jackson's esophagoscope. 

neck and chest and any plates or artificial teeth should be removed . 
from the mouth. 

Position of Patient. — Some operators perform esophagoscopy 



414 



THE ESOPHAGUS. 



with the patient sitting up; others, with the patient on a table in a 
right lateral position, with the head supported and controlled by an 
assistant. This latter posture, or that known as Rose's posture, 
viz., the patient recumbent with the head hanging over the end of a 
table, supported by an assistant, who raises, lowers, or turns the head 
at will (Fig. 444), is preferable. 

Anesthesia. — General anesthesia may be required in children. 
For adults, painting the phar3mx, Isrynx, and entrance of the esopha- 




FiG. 444. — The position of the patient and assistant for esophagoscopy. (After Ja( kson.) 



gus with a 10 per cent, solution of cocain by means of a cotton swab 
held in a Sajous applicator some minutes before the introduction of 
the tube will suffice. This may be very eflfectually done through a 
short split-tube spatula, such as is used in direct laryngoscopy (see 
page 364). 

Technic. — 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 with glycerin, the patient's mouth is well opened, 
and, with the index-finger of the left hand, the base of the tongue is 
drawn forward (Fig. 446). The operator then introduces the tube, 
with the obturator inserted in place, backward to the posterior part of 



ESOPHAGOSCOPY. 



the pharjmz and then downward, the assistant at the same time extend- 
ing the patient's head so as to bring the mouth and esophagus nearly 




Fic. 445. — Shows the Diethod of holding the esophogoscope. (After Jackson.) 

in the same straight line. The patient is directed to aid the passage 
of the tube by swallowing. As soon as the esophagus has been well 




hr,. 446.— Fifst step in esophagoscopy, the left tndex-finger guiding the ii 
the esophagus, (After Jackson.) 

enlered, the obturator is removed, the illumination is turned on, and 
the lube is gently pushed on into the canaJ by direct sight, the surgeon 




Fig. 447. — Shows the esophagoscope in place- 
Standing or being seated at the head of the table (Fig. 447). Under 
direct inspection the direction of the esophagus can be distinguished 



41 6 THE ESOPHAGUS. 

and the tube advanced accordingly, care being taken to avoid compres- 
sion 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 esopha- 
geal 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 appli- 
cators or by the aspirating apparatus with which some of the tubes 
are supplied. In this manner the whole interior of the canal down to 
the cardia may be minutely inspected, and diseased areas treated by 
local applications if desired. Following 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 are capable of casting a shadow in the 
X-ray, a diverticulum or dilated area may be mapped out. For this 
purpose capsules of bismuth subnitrate 5 to 30 grains (0.32 to 1.95 gm.) 
or a mixture of bismuth and potato soup are employed. The bismuth 
forms a coating in the gullet and the outline of the tube is thus rep- 
resented in the skiagraph by a dark shadow. 

Therapeutic 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. 448). More elaborate apparatus 
has been devised for esophageal lavage, such as, for example, Boas' 



LAVAGE OF THE ESOPHAGUS. 




Fig. 448. — Apparatus for esophageal lavage. 
1 the dp of the tube; b, glass funnel; c, mark (o indicate the distance from 
the teeth to the stomach. 




Fic. 44g. — Boas' apparatus for esophageal lavage. (After Guroprecht.) 



4l8 THE ESOPHAGUS. 

tube (Fig. 449), 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 Other 
solutions with an antiseptic or astringent action are also sometimes 
employed. 

Temperature. — The solution should be introduced warm, i.e., at 
a temperature of about 100*^ F. 

Frequency. — In some cases the lavage will be required as frequently 
as every day; in other cases once every other day is sufficient. 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 chin elevated. 
The operator 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 receix-ing 
any vomitus that may be expelled during the passage of the tube. 
He then opens his mouth widely, and the operator slowly inserts 
the stomach-tube, lubricated with glycerin, down to the seat of the 
dilatation, being careful at first to keep the tip of the instrument 
close to the posterior wall of the pharynx to prevent its entering 
the larynx. The funnel end is then raised and through it from 2 to 
2 1/2 ounces (60 to 75 c.c.) of warm water are poured into the esopha- 
gus. The funnel end is then lowered and the contents are drained 
off. By alternately pouring in solution and draining it off, the 
esophagus may be thoroughly cleansed and all particles of food 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 dilata- 
tion by the bougies is most frequently employed and, generally speak- 
ing, 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 intervals 



DILATATION OF ESOPHAGEAL STRICTURES BY BOUGIES. 



419 



during the remainder of the patient's life. When the stricture involves 
the greater part of the canal, dilatadon is frequently unsuccessful. 
Dilatation is contraindicated in very recent bums of the esophagus. 
Moderate and carefully performed dilatation, however, is not contra- 
indicated by carcinoma. 

Strictures may be located in any part of the esophagus, but the 
majority are situated near the points of normal constriction of the 



y 




Fig. 450. — The most frequent. seats of stricture of the esophagus. (Eisendrath). 

.4, Aorta, D, Diaphragm, i, Stenosis from carcinoma of lower end of the pharynx 

and beginning of the esophagus; 2, stenosis from pressure of tumors of the neck; 3, stenosis 

due to aneurysm the arch of the aorta; 4, stenosis as the result of caustic or lye bums; 

5, stenosis as result of carcinoma of lower end of the esophagus and cardiac end of stomach. 

canal (Fig. 450). They are usually single, but may be multiple, and 
they also vary in form and shape, being valve-like, annular, semi- 
circular, or tortuous. The portion of the canal immediately above 
a tight stricture dilates from the accumulation of food; especially 
is this the case if the stricture is low in the canal, and as a result in- 
flammation or suppuration may develop. In such cases there is great 



420 THE ESOPHAGUS. 

danger of perforating the walls of the esophagus unless exceei&g 
gentleness in manipulation is observed. 

The danger of passing a bougie through an aneurysmal sac should 
also be kept in mind, and to avoid such an accideni a careful physical 
examination should be made in every case before inserting any esopha- 
geal instrument. By such examination the discovery of other growlb 



Flo, +si.-*Cylindrical esophageal bougie. 

within the neck or mediastinum producing compression is often pos- 
sible. It is next necessary to determine by means of a bougie the 
locadon, the degree, the approximate length, and, if possible, the 
character of ihe stricture before any attempts at dilatation are made. 
Instruments. — Flexible bougies of woven material impregnated 
with elastic gum, which become soft when placed in warm water and 



F:c. Ai'' — Conical eso|jh:tgi'al lx>ugie, 

rigid when placed in cold water, are generally employed. The bouses 
vary in size from 1/12 to 3/5 inch (2 to 14 mm.). In a normai 
esophagus, a bougie 1/2 to 3/5 inch (13 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 



Fig. 453. — Bullmus esoplia^al bougie. 



bougies (Fig. 451) may be employed; for smaller strictures the conical 
or bulbous instruments (Fig. 453) are used. 

In the dilatation of very light strictures catgut strings, flexible 
whalebone, or linen filiforms similar to the urethral filiforms are 
sometimes employed. They are inserted by the aid of the esophago- 
scope or through a special hollow sound. 



DILATATION OF ESOPHAGEAL STRICTURES BY BOUGIES. 42 1 

Other more complicated instruments are sometimes used, such as 
Schreiber's and Billroth's sounds. The former (Fig. 454) consists 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. Bilhoth's sound consists of a cloth sound filled 
with mercury. These instruments, however, possess no advantages 
over the ordinary flexible bougie. 

J> 





mlU 



Fig. 454, — Schreiber's esophageal sound. (Gottstein in Keen's Surgery.) 

Asepsis. — The gum-elastic bougies may be sterilized in formalin 
vapor or by immersion in a saturated boracic acid solution. 

Preparation of Patient. — In cases of marked dilatation of the 
canal above the stenosis full of stagnant food and mucus, preliminary 
esophageal lavage (page 416) is indicated. 

Rapidity of Dilatation. — The stretching should be done gradually. 
Rapid dilatation or divulsion is dangerous and inadvisable. 

Frequency. — ^As a rule, the bougies may be inserted every second 
or third day. If the bougie be employed too frequently, irritation at 
the seat of stricture is produced and the condition is made worse 
instead of improved. After full dilatation has been reached the 
intervals between treatments may be stretched to a week, and then 
gradually to a month. The patient should not be permitted to go 
longer than this, however, without the passage of a bougie, as con- 
traction is extremely liable to develop. At any signs of recurrence of 
the trouble, more frequent treatments are necessary. 

Position of Patient. — The patient should be seated in a chair with 
the head thrown well back and with the chin raised. 

Anesthesia. — Though not absolutely necessary, preliminary cocaini- 
zation of the pharynx and larynx with a 10 per cent, solution of cocain 
renders the operation easier. 

Technic. — A bougie of a size that will enter the stricture is chosen. 
This is determined from the examination of the stricture previously 
made. The bougie is softened in warm water and bent to a gentle 
curve near its tip, and is well lubricated with glycerin. The operator, 
standing in front of the patient, inserts the bougie into the patient's 
mouth to the posterior wall of the pharynx, and, keeping it close to 
this latter structure, it is slowly advanced into the esophagus (see Fig. 



422 THE ESOPHAGUS. 

434). If difficulty is encountered in entering the esophagus, the 
tongue may be drawn forward by the left index-finger, as shown in 

Fig- 435- 

When the stricture is reached care must be taken not to use any 

force in attempting to pass it, as a false passage may be made or the 

instrument may simply be doubled upon itself. By gently withdrawing 

and then advancing the instrument, and by moving its tip in different 

directions, the opening will be entered if the particular instrument is 

of sufficiently small caliber. When the instrument is once within the 

stricture the operator is acquainted with the fact by the tight grasp 




Fig. 455. — ^\^on Hacker's method of introducing thin catgut bougies. (Gottstein in Keen's 

Surgery.) 
a, 6, c, Into the stricture; b\ through a wide hollow bougie (R), 

upon the bougie exerted by the stricture. The bougie should be 
slowly passed entirely through the constriction, and should be allowed 
to remain in place from five to ten minutes before it is withdrawn. At 
the next sitting the same size bougie is again inserted, and, if the 
stricture seems very tight, this same instrument may be passed on two 
or more occasions before a larger one is employed. When there is 
more than one stricture, no attempt should be made to dilate the 
lower ones until dilatation of the upper is secured. 

Very tight strictures may be dilated by means of filiform bougies 
inserted through an esophagoscope or by von Hacker's method of 



INTUBATION OF THE ESOPHAGUS. 423 

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. 455). They are left in place 
fifteen to thirty minutes, and, as the gut swells, the contracture is 
stretched. As soon as sufficient dilatation for the passage of a small 
bougie has been thus produced, bougies of a conical shape may be 
substituted. 

mTUBATION OF THE ESOPHAGUS. 

This consists in the insertion of a tube into a stenosed esophagus 
which is left in place continuously for vaiying periods at a time. It 
is a method of treatment used in cancer of the esophagus when the 
patient is unable to swallow food, and sometimes as a means of dilating 
elastic strictures which are dilatable, but rapidly contract after the 
withdrawal of a bougie. 

Long tubes inserted into the stomach through the mouth or nose 
or short tubes which can be passed through the stenosed area by the 
aid of a guide are employed. The use of the short tubes is preferable 
and is far more agreeable for the patient, as with them it is pos- 
sible for the patient to swallow saliva and to take food in the natural 
way, the ability to taste food being also preserved by the patient. 
They are, however, more difficult to insert than are the long tubes. 
Another disadvantage of the short tube is that if it becomes blocked 
it may have to be removed for cleansing. If the obstruction is 
situated very near the entrance of the esophagus, the use of short 
tubes is usually impracticable, as the expanded end of the tube 
presses on the larynx and produces laryngeal irritation and spasm. In 
such cases long tubes are indicated. Long tubes are also indicated 
in the later stages of carcinoma of the esophagus, with a fistulous 
opening between the esophagus and air-passages, when it is necessary 
to prevent any food from passing through the esophagus in order to 
avoid danger of lung complications. 

Instruments. — When long tubes are indicated, an ordinary hollow 
cylindrical esophageal tube (see Fig. 431) or a rubber stomach-tube 
of appropriate size may be employed. For the purpose of feeding the 
patient, a glass funnel that will fit into the proximal end of the tube 
will also be required. 

Short tubes of gum elastic and hard rubber have been devised by 




Symonds, \on Leyden, and others. Symonds' tubes (Fig. 456) an 
about 6 inches (15 cm.) long, and may be obtained in sizes of varfm% 
caliber. The lower end of the tul>e has a terminal or a lateral opening, 
■while the upper extremity ends in a funnel-shaped expansion, which 
rests upon the superior surface of the stricture or growth and prevenia 
the lube from slipping down the esophagus; to this expanded end silt 
threads are secured as shown in Fig. 456, for the purpose of estracring 




Fir. 456. — Symonds' short lube for intubaiion of ihc esophagu; 



the tube. A special whalebone guide for inserting the tube is also 
required (Fig. 457). 

Asepsis. — Gum-elastic instruments are sterilized by formalin rapor 
or by immersion in a saturated solution of boracic acid. Rubber lubes, 
however, may be boiled. Before reinserting the same tube, it should 
be thoroughly washed with soap and water and restcrilizcd. 

Duration of the Intubation. — For djlatitig a stricture the tube is 
left in place twenty-four to forty-eight hours, and, if it has then become 




Fig. 457- — Symonds' tube on introducer. 

loosened through stretching of the contracture, it is removed and 1 
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. 

In cancer of the esophagus the tube is worn continuously eicept 
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. 



INTUBATION OF THE ESOPHAGUS. 435 

Porition 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 pharynx 
and larynx may be sprayed with a to per cent, solution of cocain. 

Tedinic. — 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 operator 
gently inserts the tube in the manner already described tor the passage 
of an esophageal bougie (page 407). The tube is passed into the stom- 
ach, and the proximal end, which Is brought out of a comer of the 
mouth, is htted with a cork and is secured to the ear by a piece of silk. 
It will be necessary for the patient to remain in a recumbent position 
with the head to one side to allow saliva which collects to escape, as this 
is prevented from passing down the canal. 




Fig. 458. — Shows long esophageal lube passed through (he nose 

Instead of passing the tube through the mouth it may be inserted 
through the nostril (Fig. 458), a method that will be far more agreeable 
to the patient. The free end, corked as above, is then secured in place 
by means of adhesive plaster. 

2. Short Tubes. — A tube of the proper size is selected and placed 
upon the introducer, being prevented from falling o£f 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 inserted 
through the stricture by means of the introducer, following the same 



426 



THE ESOPHAGUS. 



steps as for the passage of a bougie (Fig. 459). 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 comer 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. 




Fig. 45g. — Showing the method of miroducing fjymondii' short tulic. 



Should the tube become blocked, it may be possible to remove ihe 
obstruction by passing a very small bougie down through it; otherwise 
the tube will have to be removed and cleaned. Withdrawal of the 
tube is effecled by making gentle traction upon the threads secured 
to its proximal end. 

Feeding. — While the tube is in place Ihe patient is kept upon a 
fluid diet, such as milk, broth, eggs beaten in milk, etc. W'iih the short 
tubes food may be administered by mouth, but when the long tubes 
are employed the nourishment is introduced through a funnel inserted 
in ihc proximal end of ihc tube. Between feedings the end of the tube 
may be closed by means of a cork. 



CHAPTER XV. 
THE STOMACH. 

Anatomic Considerations. 

The stomach may be described as a hollow, mvened, pear-shaped 
org^n, the greater part of which lies in the epigastric and left hypo- 
cKoaadriac regions, about one-sixth of the oi^an extending beyond the 
riglit of the median line. When empty it lies deep in the abdomen in 
froan-t of the pancreas, being covered by the liver and diaphragm for 
al>oxit two-thirds of its area and by the abdominal wall over the remain- 
irig one-third. The space in which the stomach comes in contact with 




Fic. 460. — The normal poMlion of the stomach. 

the anterior abdominal wall is triangular in shape, bounded on the 
right by the lower border of the liver, on the left by the 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 relation 

with the diaphragm above and the concave surface of the spleen to the 

left. The lower limit or greater curvature extends to the level of a 

427 



428 THE STOMACH* 

line connecting the lowest portions of the ninth or tenth ribs or to 
within 2 inches (5 cm.) of the umbilicus. In contraction or dilatation 
of the organ, however, this normal position of the greater curvature 
may be modified to a marked degree. The cardiac or superior open- 
ing lies about 1/2 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 sternum and seventh costal cartilage. It is situated 
about 4 1/2 inches (11 cm.) posterior to the anterior abdominal wall. 
The pyloric opening is situated in front of, but on a lower plane than, 
the cardiac opening, lying 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 lumbar vertebra or anteriorly on a level with a point 2 
or 3 inches (5 to 7 . 5 cm.) below the stemoxiphoid joint. The long axis 
of the undistended stomach lies in more of a vertical than a horizontal 
plane with the lesser curvature directed 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 down- 
ward; at the same time the pylorus 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 1/2 pints (1200 c.c). When the stomach is empty, 
the longest diameter measures 7 1/4 to 8 inches (18 to 20 cm.) and the 
transverse diameter 2 3/4 to 3 1/4 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 3 1/4 or 4 
inches (8 or 10 cm.). 

Diagnostic Methods. 

In the diagnosis of stomach diseases a history of the previous and 
the present condition of the patient should be carefully taken and a 
general physical examination should be made before the examination of 
the stomach itself is undertaken. In obtaining the patient's history, 
in addition to the usual questions common to all histories, inquiry 
should be directed especially to the following points: the general con- 
dition of the health, the appetite, any loss of weight, the date and 
manner of onset of the symptoms, pain, sensation of pressure or dis- 
tention, nausea, vomiting, vomiting of blood, etc. Of special diag- 
nostic importance is a history of gastric pain, vomiting, or the vomiting 
of blood. 

As to pain, one should ascertain its character, its location, whether 



DIAGNOSTIC METHODS. 429 

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 prob- 
ably due to hjrperchlorhydria, 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 localized. 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 vertebra 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 uniformly relieved by vomiting. 

With a history of nausea and vomiting, the examiner should inquire 
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 important 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 vomiting 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 comparatively long intervals, and the amount 
brought up is correspondingly large. Blood in the vomitus is always 
of diagnostic importance. A profuse hemorrhage 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 
is referred to works on diagnosis where these will be found fully dis- 
cussed. 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 examination should never be neglected, even 
though the patient refers his symptoms to the stomach alone, for 



430 THE STOMACH. 

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 exam- 
ination of the blood, etc. When all possible information has been 
obtained from these sources a special examination of the stomach 
itself should be made for which the following methods are available: 
(i) inspection; (2) palpation; (3) percussion; (4) auscultation; (5) 
inflation; (6) examination of the gastric secretion; (7) tests for determin- 
ing the motor and absorptive power of the stomach; (8) transillumina- 
tion; (9) gastroscopy; and (10) skiagraphy. 

* 

INSPECTION. 

Abdominal inspection in thin individuals may at times give valuable 
information, but in stout persons the method is of very limited value. 
In favorable cases it may be possible by this means to determine the 
size and position of the stomach by tracing the shadow which represents 
the outline of the greater curvature. Inspection is greatly aided by a 
preliminary inflation of the organ (page 437). When thus distended 
the stomach becomes separated from the surrounding organs and its 
contour is more easily made out. At the same time abnormal positions 
or new growths may be better recognized. 

Position of Patient. — The patient is placed upon a firm flat table, 
with his head directed toward the source of light, so that the rays will 
fall from the head toward the feet. The light should be so regulated 
by adjustment of the window shades that it enters on a plane only a 
little above the patient. 

Technic. — The examiner takes his stand near the patient's feet 
and, by mo\dng from side to side, is enabled to make out the stomach 
outlines from the shadows cast by the inequalities of the alxlominal 
wall produced by the stomach beneath (Fig. 461). At times tumors 
of the body of the stomach or of the pylorus may be observ^ed elevating 
the abdominal walls, and, if the growth be movable, a change in its 
position may be noted when the stomach is full and when it is empty. 
If there be obstruction 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 toward the 
pylorus from under the ribs in the left upper quadrant to the right 
lower quadrant. Peristalsis may be excited by lapping the abdomen or 
by the application of cold. A dilated stomach may be determined from 
the great bulging in the epigastrium and from tracing the greater 



INSPECTION. 431 

curvature to a point considerably below the umbilicus, and at times an 
hour-glass contractioii may be recognized (Fig. 462). In gastroptosis 
the epigastrium will be retracted* and the lesser curvature may be seen 




Fic. 462. — Showing the shape of: (i) A dilated stomach, (s) an hour-glass stomach, 
(3) Ihc stomach in gastroptoms. 

represented by a groove extending from the umbilicus to the ribs upon 
the left and above. Depression of the epigastrium will also be seen 
in stenosis of the cardia. 



THE STOMACH. 



PALPATION. 



Palpation is by far the most reliable of the methods of physical 
examination. The stomach should, when possible, be palpated both 
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 carried 
out systematically, and of course it must not be limited to the stomach 
alone, but all the other abdominal organs should be palpated as well. 




Fio. 463, — Method of palpating the stomach. 

Poaitioa of Patient. — The patient lies recumbent with the abdomi- 
nal muscles as relaxed as possible. If it is necessary to obtain greater 
relaxation than is possible by this posture, the knees should be drawn 
up and the head and thorax should be slightly raised upon a pillow. 
Where there is considerable rigidity of the abdominal muscles or in 
fat individuals, relaxation may be secured by placing the patient in a 
warm bath. 

Technic. — The examination should be performed in a warm 
room and the physician's hands should be warmed to avoid the mus- 
cular spasm produced by cold hands. The patient is instructed to 
keep his mouth open and to breathe regularly and deeply to induce 



PALPATION. 433 

ffae fullest amount of relaxation. The examiner sits or stands beside 
the patient and places both hands flat upon the abdomen, with the 
palms down and the fingers slightly flexed, and palpates with the finger- 
tips. Only gende manipulations should be employed, as otherwise 
fiasm of the abdominal muscles will be induced and the aim of the 
xa.imner will be defeated. 

When it is desired to perform deep palpation for the recognition , 
f deep-seated tumors, one hand is superimposed upon the other, the 
pper hand making the pressure and the lower one performing the 
alpation (Fig. 463). Deep palpation is greatly aided by having the 




Fru. 464. — Palpating 



of ihe stomach between the fingets of the two huida. 



patient breathe deeply; it then becomes possible for the palpating hand 
to follow the receding abdominal walls with expiration. 

In palpating tumors, one hand is used to fix the growth and the 
other outlines Its size and determines its consistency, fixity, or mobility, 
and the presence or absence of pulsation, tenderness upon pressure, etc. 
(Fig. 464)- 

The examiner should first determine the size and position of the 
stomach. Inflation (page 437) is a great aid to palpation, as it is 
usually impossible to palpate the outline of an empty organ. Another 
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 «xtenl that it lies along the greater curvature. The ^rtater 
curvature and the pylorus may thus be outlined by palpating the lube 
through the abdominal walls. /\J1 parts of the organ are next carefully 
palpated with the purpose of deterniining the presence orabsenceof new 
growths, painful spots, etc. Tumorsof the pylorus and the greater cur- 
vature are readily palpable. The former are usually situated lo iheriglil 
of (he median line, between the xiphoid and the umbilicus, but ihcy ha^t 
a wide range of modon unless adherent. Tumors of the lesser cuna- 
ture 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. Chang- 
ing the position of the patient to a lateral one is often of senicc in 
rendering a growth more accessible to the examiner. The knce-che*l 
posture is also of value, as deep-seated movable tumors then fall for- 
ward toward the anterior abdominal wall. 



w 




s of pressure lendemess in ulcer of the stomacli. (Mayo Robson ii 
Keen's surgeiy.) 



Eliciting tender spots on palpation is frequently also 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 on 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 com- 
mon points of tenderness for ulcer are between the left costal margin and 



PEHCUSSION. 435 

the mid-line (Fig. 465) ; points of pressure tenderness are also at times 
found I to 2 inches (3.5 to 5 cm.) to the left of the spine, in the neigh- 
borhood of the twelfth dorsal vertebra (Fig. 466). In affections of 
the gall-bladder similar tender points will be frequently found more 
to the light of the spinal column. 




Fic. 46(1, — Points of pressure tenderness found posteriorly in (ilcer of the stomach. (Mayo 
Robsoa in Keen's Surgery.) 



PERCUSSION. 

Only the greater curvature and the portion of the anterior surface 
of the stomach in contact with the anterior abdominal wall are access- 
ible for percussion, consequently the chief use of this method is to 
determine the shape and size of the slomach. Percussion of the 
stomach, even under the most favorable conditions, is unreliable, on 
account of the proximity of other air-containing organs. The chief 
source of error is the resonance of the transverse colon, which may be 
confused with that of the stomach. To avoid this the slomach may 
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 water. In 
either case a contrast between the tympany of the one and the dulness 
of the other will be obtained on percussion. The percussion note over 
the stomach is a high-pitched metallic tympany, but it will vary much, 
depending upon whether the stomach is empty, whether it is full of 
food, or simply contains air. Percussion should be performed when 
the stomach contains some air; under inflation of the organ percussion 
furnishes even more valuable results. 



436 THE STOMACH, 

Position of the Patient.— The patient should He in the recumbent 
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 held firmly against 
the surface, while with the flexed middle finger of the right band a 
number of sharp taps or blows are struck (Fig. 467). The force of the 




Fio. 467. — Percussion of ihe stomach. 



percussion should, as a rule, be very light, but, if it is desired to make 
out a deeply placed growth, firm hea^7 percussion will be required. 
The same is true when the abdominal walls are very thick. Ha\*ing 
outlined the stomach with (he patient recumbent, the percussion should 
be performed with the patient upright to determine if the organ sinks 
down from its normal position. 

AUSCULTATION. 

By listening to sounds produced within the esophagus during the 
swallowing of fluids and to sounds originating within the stomach 
itself, certain information of diagnostic importance may be obtained. 
By the first method it is possible to determine whether there be an 
obstruction of the cardia or not. It is carried out as follows: 



INFLATION OF THE STOMACH. 437 

The operator listens with his stethoscope placed over the esophagus, 
that is, to the left of the ensiform cartilage or to the left of the spinal 
column opposite the ninth or tenth dorsal vertebra while the patient 
is swallowing fluids. Two sounds are thus heard: first, a spurting 
sound that immediately follows the act of swallowing, and a second 
sound, more rattling in character, known as the "deglutition murmur," 
which is heard six or seven seconds (sometimes as much as twelve 
seconds) later; it represents the passing of food through the cardiac 
orifice into the stomach. If this second sound is constantly absent, 
more or less complete occlusion of the cardia is presumable. 

The succussion or splashing sounds that originate in the stomach 
itself are of greater diagnostic importance. In order to obtain these 
sounds the stomach must contain air and be partly filled with fluid. 
The padent lies recumbent and the operator listens with his ear near 
the abdomen while he taps the abdominal, wall in the region of the 
stomach with his finger-tips. Succussion sounds may also be elicited 
by moving the patient quickly from side to side. These sounds should 
be differentiated from other gurgling sounds which are heard when the 
stomach contains only air or is empty. Succussion in itself is of no 
diagnostic importance, for it may be heard in a normal stomach con- 
taining a quantity of fluid. It is pathological, however, if obtained 
when the stomach should normally be empty, that is, in the morning 
before breakfast, three hours after a test breakfast, or seven hours after 
a test dinner. It then indicates a condition of atony or deficient 
motility. When succussion is heard over an abnormally large area, 
or beyond the normal boundaries of the organ, it indicates dilatation 
or gastroptosis. The outlines of the stomach may be mapped out with 
considerable accuracy by tapping first from above downward, and then 
from side to side, the examiner listening the while with a stethoscope 
placed over the stomach and noting where 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 per- 
cussion. 

The inflation may be performed by means of efferv-escent solu- 
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 



438 THE STOMACH. 

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 sufficient gas 
in a capacious stomach or, if too much gas is formed, it may produce 
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 clearly outlined, so that conditions 
of dilatation, gastroptosis, and hour-glass contractions may be dis- 
tinguished and tumors may be rendered more pronoimced. Before 
performing inflation in the case of suspected gastric tumor, the abdo- 
men should be carefully examined and the exact situation of the growth 
noted; by then noting the position of the growth after inflation it 
can be determined whether the growth is connected with the stomach 
and whether it is fixed by adhesions or is movable. Frequently 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 downward and to the right 
under inflation. Tumors of the lesser curvature near the cardia are 
displaced to the right under the liver. At the same time spurious 
tumors due to spasm disappear. 

Apparatus. — For inflation with carbonic acid gas no apparatus is 
required. A stomach-tube should be at hand, however, for the pur- 
pose of relieving the patient of distention from gas if necessary. 

To inflate with air an ordinary stomach-tube 30 inches (75 cm.) 
long, of soft rubber, to the proximal end of which a double cautery 
bulb or a Davidson syringe is attached, will be required (Fig. 468). 

Position of the Patient. — If desired, the tube may be passed 
with the patient sitting up, but the inflation and the examination 
should be carried out with the patient recumbent and with the chest 
and abdomen well exposed to view. 

Technic. — i. By Carbonic Acid Gas. — The patient is given i 
dram (3.9 gm.) of bicarbonate of soda dissolved in 3 ounces (89 c.c.) 
of water, and then a little less than i dram (3.9 gm.) of tartaric acid 



INFLATION OF THE STOMACH. 



439 



dissolved in 3 ounces (89 c.c.) of water. As the two solutions come 
in contact, carbonic acid gas is generated and the stomach is thereby 
distended. In dilatation of the stomach, however, it may be necessary 
to give a second dose to obtain sufficient distention for the purpose of 
mapping out the outlines of the organ. 

2. By Air. — To inflate a stomach successfully with air through a 
tube it is essential that the padent be accustomed to the passage of the 
stomach-tube — the tube should certainly have been passed at least 
once previously. The tube is inserted as follows: The patient is 
instructed to open the mouth and the tube, moistened with water or 
glycerin, is passed along the roof of the mouth to the pharynx. From 




Flc 46S. — Stomach-tube and Davidson syringe for inflating the stomach. 

this point it is advanced partly by swallowing efforts on the part of 
the patient and partly by tlie operator who pushes it on until it has 
passed a sufficient distance to have carried it beyond the cardia. By 
alternately compressing and relaxing the inflation bulb the stomach is 
then gently pumped up with air until it is sufficiently distended for 
the purposes of the examination. In the case of an insufficiency 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 general- 
ized 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 dbagreeable distention. The abdomen may be 
kneaded to facilitate the escape of the air. 



EXTRACTION OF THE STOMACH COHTENTS FOR EXAMIHATIOH. 

The contents of the stomach may be removed for puiposes uf 
diagnosis when it is desired to examine the gastric secretion c-hemically 
and to test the motor functions of the stomach. Such eiamlnarioa 
often gives results of value both diagnostically and prognosticaliy, 
but, while gastric analysis is of great importance, the results obiained 
by such examination must not be relied upon to the exclusion of otiier 
methods of diagnosis, as ihey are by no means final. In all cases the 
history and the results of physical examination should be given due 
consideration. 

To test the digestive power of the stomach it is neccssaiy to 
examine the contents at the height of digestion. In other cases, as 
when hypersecretion or disturbance of the molor power of the stomadi 
is suspected, the contents of the fasting stomach should be examined 
Normally, the stomach should be empty within eight hours after a full 
meai, and if empty it should not secrete hydrochloric acid. If, there- 
fore, the contents of the stomach, removed in the morning before anj 
food has been taken since the evening before, show the presence of 
food or if a considerable quantity of fluid containing free hydrochloric 
acid is obtained, it points in the former case to motor insufficiency and 
in the latter to hypersecretion. 

Test Meals. — To obtain results from which comparisons may be 
drawn the patient should be given on an empty stomach a meal of a 
definite composition and the contents of the stomach should be removed 
after a definite lapse of time. For this purpose either a test bnakfast 
or a mid-day test dinner is employed. 

The Ewald-Boas lest breakfast consists of one or two rolls— be- 
tween I and 2 ounces (35 and 70 gm.), a cup of tea without sugar or 
milk, or 10 to 14 ounces (300 to 400 c.c.) of water. This is given upoa 
an empty stomach in the morning and removed in one hour. 

The Riegel lest dinner consists of a large plate of meat soup- 
about 14 ounces (400 c.c), a large portion of beefsteak or other 
meat, weighing 5 to 7 ounces (150 to 200 cc), mashed potatoes— 
1 1/2 ounces (50 gm,), and a roll — i ounce (35 gm,). The contents 
of the stomach are removed and examined three or four hours later. 

Examinadon of the Stomach Contents. — The object of a gastric 
analysis is twofold: First, to determine the presence or absence of 
constituents which are normally present, and, second, to ascertain 
whether other substances exist which should normally be absent. 
Normally, the gastric contents one hour after a test breakfast conast 



EXTRACTION OF THE STOMACH CONTENTS FOR EXAMINATION. 44I 

of from I to 2 1/3 ounces (30 to 70 c.c.) of acid material which upon 
filtration yields a clear yellow or yellowish-brown fluid. Upon analysis 
this contains a total acidity of 40 to 60 (0.15 to 0.21 per cent.), free 
hydrochloric acid 25 to 50 (o.i to 0.2 per cent.), pepsin, rennin, al- 
bumoses, peptones, maltose, achroodextrin, and erythrodextrin. 

The technic of gastric analysis will be found in works upon clinical 
laboratory methods. Such examination, however, should be made 
along the following lines: 

1. Macroscopical examination, noting the quantity, character, 
odor, reaction, etc. 

2. Microscopical examination, 

3. Chemical Examination. — ^This should include tests to determine 
the presence or absence of free hydrochloric acid and of combined 
hydrochloric add, the degree of total acidity, the presence of lactic 
acid, the presence of volatile acids, the products of digestion, the 
presence of rennin and pepsin, and the character of the carbo- 
hydrates. 

The Significance of Variations in the Composition of the Gastric 
Secretion. — Hyperchlorhydria. — ^Free hydrochloric acid is found in 
excess in the early stages of chronic gastritis, in gastric neuroses, in 
gastric ulcer, and in hypersecretion. It points strongly against cancer 
except in cases where an ulcer is imdergoing malignant change. 

Hypochlorhydria, — ^A diminished secretion of hydrochloric acid 
occurs in the late stages of chronic gastritis, in gastric neuroses, in 
gastric atrophy, in dilatation of the stomach, in the early stages of 
gastric cancer, and sometimes in ulcer when associated with chronic 
gastritis or a cachectic condition. It is also diminished in fevers, 
wasting diseases, pernicious anemia, chlorosis, neurasthenia, etc. 

Ancu:hlorhydria, — Hydrochloric acid is absent when the secreting 
glands have been destroyed, as in atrophic catarrh and in cancer of 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. 

An increase in the total acidity may be the result of excessive out- 
put of hydrochloric acid or it may be caused by organic acids 
(lactic, butyric, and acetic). 

A diminished total acidity denotes a deficiency in the amount 
of hydrochloric acid, the significance of which has been mentioned 
above. 

Lactic acid is the result of bacterial fermentation. It is found in 
appreciable amounts only when hydrochloric acid is absent and in 



442 THE STOMACH. 

general sigm&es insufficiency of the motor power and stagnation of the 
stomach contents, as is found in dilatation, obstnicdoa of the pylorus, 
and cancer. The presence of lactic acid alone is not diagnostic of 
cancer, as small amounts may be found after a meat diet and may also 
be present in other pathological conditions, nor does its absence prove 
the nonexistence of cancer. When, however, it is found in consider- 
able amount and is associated with an absence of hydrochloric acid 
and with deficient motility, it is strongly suggestive of cancer, especially 
if the Oppler-Boas bacillus b also present. 

Pepsin and rennin 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 condition. 

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 




Fib. 469. — Stomach-tube and funnel for expressing the stomach ci 
a. Showing the lateral fenestra:; b, funnel; c, mark lo indicate the distance frum the 
indaor leeth lo the stomach. 

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 contraindicated in the presence of aortic aneurysm, in patients 
liable to cerebral hemorrhage, or in those who have recently suffered 
from gastric or pulmonary hemorrhages, in those who are very weak, 
in those suffering from severe pulmonary or cardiac troubles, etc. 
Apparatus. — When the expression method of removing the stomach 



tXTKACnON OF THE STOMACH CONTENTS FOK EXAIDNATION. 443 

contents is employed the following apparatus will be required: A soft- 
lubber stomach-tube about 30 inches (75 cm.) long and 1/4 of an 
inch (6 mm.) in caliber, with two smooth-edged lateral openings and 
1 blind end, connected by a piece of glass tubing 3 to 4 inches (7.6 
to 10 cm.) long to 2 feet (60 cm.) of rubber tubing, to the end of 
wtich a glass funnel is attached (Fig. 469). 




Fig. 470. — Boas' aspirating bulb. 

When aspiration is employed, the stomach-tube may be connected 
with a bottle aspirator, with a. stomach-pump, or with a rubber-bulb 
form of aspirator, such as Boas employs (Fig. 470). The bottle 
aspirator (Fig. 471) consists of a large glass bottle supplied with a 
lightly fitting rubber stopper through which two glass tubes-pass; one 
of these is coimected with the stomach-tube while to the other a Potain 
s>Tinge is attached, by means of which the air in the bottle is exhaizsted. 




Fic. 471, — Botlte arranged for aspirating the slomacb contenta. 
<i Luge glaaa bottle; b, tubing connected with a Potain aspirator; c, the slomach-tube. 



Position of tiio Patient — The patient is seated upright in a chair or 
in bed. 

Technic. — Any ardfidal teeth or plates should be removed from 
the patient's mouth and he should be protected by a towel or an 
>pn>n fastened about the neck. A small bowl should be given to him 
fi» the piu:pose of receiving any excessive secretion of mucus or saliva 
which may collect in the mouth. The tube is moistened in warm water, 



TliE STOMACH. 





Fig. 47j. — Introdudng the stomach -tube. Second 



RACTION OF THE STOMACH CONTENTS FOB EXAMINATION. 445 




Fig. 474. — Introducing the stomach-tube. Third step. 




Fig. 475. — Aspiration of the slomich contents. First step. 



446 



THE STOMACH. 



or is well lubricated with glycerin and is passed into the patient's 
open mouth back to the pharynx. The patient is then requested to 
swallow, and the instrument is thus advanced into the esophagus, 
partly by the swallowing action and partly by the operator (Fig. 473). 
During this maneuver the patient is instructed to breathe regularly 
and deeply, 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 




Fig. 476. — Aspiration of the stomach contents. Second step. 



the throat (Fig. 474). 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 
in dilatation, for example, it may be more. When the tube has been 
introduced for the properdistance,thecontentsofthcorgan are removed, 
either by expression or by suction furnished from one of the forms of 
aspirating apparatus described above. 




TEST OF TBE MOTOR FUNCTION OF TBE STOMACH. 447 

Expression of the stomach contents is accomplished by pressing 
over the region of the stomach while the patient bends forward and 
strains as if at stool. The proximal end of the tube is in the mean- 
time lowered over a dish or bowl to a point below the level of the 
stomach. 

Aspiration with the Boas aspirator is performed as follows: With 
the clamp closed the operator compresses the bulb (Fig. 475) and 
then releases it, thus filling the bulb with the stomach contents. The 
damp is then opened and the bulb is compressed, causing the contents 
to be forced out into a receptacle (Fig. 476). 

Variation in Tectinic. — Einhorn employs a small bucket for 
withdrawing samples of the stomach contents at various periods of 
digestion. In this way the chemical composition of the gastric juice 
at any time may be ascertained, and also the func- 
tional activity of the stomach may be determined, by 
noting the progress of digestion at any given time after 
the administration of a test meal. 

Einhom's apparatus consists of an olive-shaped 
capsule of silver 11/16 inch (17 mm.) long and 5/16 
inch (8 mm.) wide. It is provided with an opening in ^'g. 477- 
the top, above which is a cross-bar to which a heavy * °™ s s omac 
silk thread is attached (Fig. 477). The small bucket 
is moistened and placed well back on the patient's tongue whence 
it is readily swallowed. It is allowed to remain in the stomach five 
minutes and is then carefully removed by drawing on the thread and 
with it sufficient of the stomach contents for an ordinary examination 
of the acidity, etc. 

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 function 
is deficient, as from obstruction of the pylorus due to cancer, ulcer, etc., 
or from impairment of the gastric musculature, food accumulates in 
the stomach and dilatation finally results. Early recognition 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, 
imong which are the following: 

Leube'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 
^ empty seven hours later and nothing can be removed by lavage, 



448 THE STOMACH. 

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 administering salol to a patient 
after a meal and noting the length of time before salicylic acid appears 
in the urine. Salol is unaffected by the gastric juice, but is split into 
salicylic acid and carbolic acid in the intestine. In performing this 
test the bladder is first emptied; the patient is then given 15 grains 
(i gm.) of salol in two gelatin-coated capsules and is instructed to urinate 
at intervals of half an hour for two hours and to preserve the speci- 
mens separately; these are later tested with neutral ferric chlorid 
solution for the presence of salicylic acid. In the presence of salicylic 
acid the test gives a violet-blue color. In normal cases the salicylic 
acid should be recognized in the urine in from thirty to seventy-five 
minutes. Delay in its appearance indicates deficient motor power. 

lodipin Test. — ^This drug is unaltered by the gastric juice, but in 
the intestine it is split up and iodin is absorbed and eliminated in 
the saliva. Fifteen grains (i gm.) of iodipin are administered in gelatin- 
coated capsules in the morning with breakfast and the saliva is then 
tested with starch-paper and nitric acid for iodin every fifteen minutes. 
In a normal case the iodin is recognized in the sailva within about an 
hour. 

TEST OF THE ABSORPTION POWER OF THE STOMACH. 

The usual method of determining this is by the test known as that 
of Penzoldt and Faber. It is performed as follows: 3 grains (0.2 gm.) 
of chemically pure potassium iodid are given in a gelatin-coated capsule 
on an empty stomach, and the urine or the saliva is then tested with 
starch-paper and fuming nitric acid every few minutes for iodin. Its 
presence is indicated by a blue or a violet reaction. Iodin should 
normally 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 GASTRODIAPHANY. 

A method introduced by Einhom, 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 position of a 



TSAIISILLDICINATION OF THE 5T01IACH. 449 

gnnrth or a thickening of the anterior wall of the stomach may be 
recognized from the lack of transparency. It is of value in the diag- 
nosis o£ dilatation and in the differentiation of this condition from 
gastioptosis. In the former the illuminated area is larger than 
nramal, while in the latter it is small and situated low down. Trans- 
illuminatioa, however, is not used as a routine, since it is complicated 
and requires special apparatus; furthermore, there are simpler methods 
of determining the size and position of the organ. One advantage of 
the method, however, is that the organ is seen in its natural condition, 
whereas under inflation it is apt to be stretched beyond the normal. 
To employ the method successfully it is necessary that the patient be 
iccustomed to the insertion of the stomach-tube, otherwise retching 
and vomiting will interfere with the examination. 




Fig. 478.— Lynch's gastrodiaphatie.' (From a drawing in the posieawon of 
Dr. ]. M. Lj-nch.) 



Apparatus. — Einhom's gastrodiaphane consists of a small Edison 
incandescent lamp attached to the distal endof a soft-rubber stomach- 
tube. The wires which convey the electricity to the lamp pass down 
inside the tube while at the proximal end are two screws for attaching 
the wires leading from the battery. A six to eight dry-cell battery 
fcuTiislres the necessary power. 

Lynch has modified Einhom's gastrodiaphane by employing a 
Wger tube— S3 inches (135 cm.) long— sufficiently long to jjass 
through the pylorus— and by supplj-ing it with an inner auxiliary 
tube through which the stomach may be inflated with air or water 
M the contents of stomach or duodenum may be aspirated (Fig, 478), 

'Made b<r tbe Electro Surgical Instrument Co. 



45© THE STOMACH, 

Position of the Pktient. — The examination is perfonned with Ae 

patient in the erect position. 

Technic. — Transillumination must be performed upon an empiy 
stomach; if necessary, the stomach should be lirst emptied by means 
of the stomach-tube. The patient is then given two glasses of waler 
to drink to prevent overheating the stomach from the lamp. The 
lube is lubricated with glycerin and is carefully guided into the phar- 
ynx and the patient is instructed to swallow, the descent of the lube 
being aided by the operator who pushes it on as soon as it is well within 
the esophagus. When the lamp is within the stomach, the illumiralion 
is turned on and the room is darkened, while the results of the transil- 
lumination are noted. A bright luminous area will be noted on the 
anterior abdominal wall which corresponds in size to the outlines of 
the stomach. In the case of a tumor of the anterior stomach wall, 
even if too small to be felt, a dark patch will appear in the illununated 
area. 

Variation in Technic. — In order to increase the brilliancy of ihe 
transillumination, Kemp advocates the introduction of fluorescent 
media into the stomach preliminary to the passage of the gastrodia- 
phanc. It is claimed for this method that it is possible to perform i 
satisfactory transillumination even when the abdominal walls are very 
thick. 

Two media are employed: Bisulphate of quinin and fluorescein, 
The former, which gives a pale violet fluorescence, is administered in 
the proportion of bisulphate of quinin gr, x (0.65 gm.) to i pint 
(473. II c.c.) of water with the addition of 5 nii (0.30 c.c.) of 
dilute phosphoric or sulphuric acid to increase the acidity and so inten- 
sify the fluorescence. 

Fluorescein, which gives a green fluorescence, is 'administered as 
follows: The patient is given 8 ounces (236 c.c.) of water to drink 
in which is dissolved 15 grains (0.97 gm.) of sodium bicarbonate li> 
render alkaline the acid stomach contents. A second drink is thetx 
given, consisting of 8 ounces of water (236 c.c) in which are mixe^ 
1/2 to 1/4 grain (0.008 to 0.0016 gm.) of fluorescein, i djai** 
(3.75 c.c.) of glycerin, and 15 grains (0.97 gm.) of bicarbonate of soda- — 
After the administration of the fluorescent medium the lamp is inlro-— 
duced and the examination is proceeded with as above. 

GASTROSCOPY. 

Gastroscopy consists in ihe insertion into the stomach of a stif^ 
metal tube, illuminated by eleclricily, through which the interior of 



. GASTROSCOPY. 45 1 

the organ is inspected. This method of examination was inaugurated 
by Mikulicz in 1881, but, on account of its limited value and the 
technical difl&culties in the use of the instrument, it never came into 
general use. Later, in 1896, Rosenheim devised a gastroscope on 
similar principles. Both these instruments were made with prisms 
on the principle of the cystoscope. Chevalier Jackson, in 1906, 
reported results with a gastroscope of his design. Jackson proceeded on 
entirely diflferent principles, employing large tubes with the illumination 
at the distal end, similar to those used in direct tracheo-bronchoscopy 
and esophagoscopy, and he has made it possible to explore the greater 
part of the stomach by direct vision. Furthermore, he has demonstrated 
that lesions may be palpated by means of a probe passed through the 
instrument, applications may be made to diseased areas, foreign bodies 
may be removed, and sections of tumors may be excised for micro- 
scopical examination. Gastroscopy, however, cannot supplant other 
methods of diagnosis. It hecessitates 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. Furthermore, with the present instru- 
ments the method is somewhat limited in scope, as it is rarely possible 
to inspect the whole of the interior of the organ. As a rule, from two- 
thirds to three-fourths of the stomach, including the pylorus, is available, 
for examination, depending upon the range of lateral motion of the 
hiatus esophagei. A stomach which occupies a vertical position pre- 
sents the largest area for exploration while the more horizontally the 
organ is placed the less of it will be available for examination. 

According to Jackson, gastroscopy is without danger other than 
that from the anesthesia. At the same time, the operation requires 
great skill which is best obtained by practising upon the cadaver. 
He considers the operation unadvisable under the following conditions: 
"In the profound cachexia of the last stages of malignancy; 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 cirrhosis of the liver, etc." Diseases 
of the esophagus may, of course, interfere with or render gastroscopy 
out of the question. 

Apparatus. — Jackson's gastroscope (Fig. 479) consists of a cylindri- 
cal tube about 32 inches (80 cm.) long with a lumen 2/5 inch 
(10 mm.) in diameter, and with a thickened distal end. In the wall 
of the instrument are two small accessory tubes; one through which 



452 THE STOMACH. 

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 lube an aspirating apparatus is attached. 
The instrument is also provided with an obturalor having a coniai 
tip lo facilitate its insertion. 

Asepsis. — The tube may be boiled and the light-carrying apparatus 
maybe sterilized by immersion in a i to 20 carbolic acid solution, fol- 
lowed by rinsing in alcohol, or alcohol alone may be employed. 

Preparatioiis. — These should include the ordinary prejarations 
for a general anesthetic; that is, the patient is gi\'en a cathartic ihe 
night before the operation and food is withheld for a period of twelve 
hours before the operation (sec also page 18). It is essential that the 






Fig. 47g, — Jackson's gastroscopc. 

stomach be empty when gastrosci>py is pertiirmt'd, and, ifnccessan', 
lavage of the stomach should be practised three or four hours previous 
to the operation. In dilatation with atony preliminary lavage is a 
necessity. 

Position of the Patient. — The patient is placed in the recumbent 
posture with the shoulders brought 4 to 6 inches (10 to 15 cm.) ova 
the edge of the table and the head supported by an assistant seated 
at the head of the table and to the right, after the manner shown in 
the accompanying illustration (Fig. 480). This .assistant also conlrols 
the mouth gag. Jackson recommends that, as soon as the tube 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 will 
not only inlerfere with the examination, but may make the procedure 
a dangerous one. 

Technic.^ — The mouth gag is inserted and the operator introduces 
the left forefinger inlo the patient's mouth to the base of the tongue of 
behind the epiglottis and draws the tongue forward. The gastroscope> 



GASTROSCOPY. 



453 



well lubricated, is then introduced held in the operator's right hand, 
following the forefinger, already in the patient's mouth, as a guide 
(Fig. 481). At this stage the assistant who controls the patient's 




f \ >r-^^ 



Fig. 480. — ^Poation of patient for gastroscopy. (After Jackson.) 

head should bend the patient's neck well backward so as to bring 
the mouth and esophagus in as straight a line as possible. As soon 
as the instrument has been passed beyond the entrance of the esophagus, 
the obtiurator is withdrawn and the light is turned on. The instru- 




FiG. 481. — Method of inserting the gastroscopc. (After Jackson.) 

ment is passed the rest of the way entirely by sight, care being taken to 
avoid compressing the trachea by the point of the instrument. To 
pass the hiatus at the diaphragm, the instrument is rotated in such a 



way that the long axis of a cross section of ihe tube corresponds lo 
that of the hiatus {this extends from behind and the right to the front 
and the left). To pass the alxlominal esophagus as it bends to the lef!, 
the head and neck of the patient are turned lo the right (Fig, 48J), 
When the tube has entered the stomach, the interior of the organ 
should be systematically explored according to the technic described 
by Jackson,' which the writer takes the liberty of quoting: 

"There are two plans of exploration, both of which should be 
carried out. First, the gastroscope should be passed down carefully 





1 



—Showing the bead and neck of patient drawn lo the right to allow Ihe insini- 
it to pass through the hiatus and abdominal esophagus. (After Jackson.) 



and gently to the greater curvature, inspecting the anterior and pos- 
terior walls. At times these walls do not seem to be fully collapsed 
ahead of the tube, and one will have to be examined first, then the 
other. Then the tube is withdrawn, inclined slightly laterally in ihe 
same plane, then pushed gently downward again in a new series of 
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. 483), 

"After the whole possible range has been covered in this way 
we proceed to the second plan. The lube is passed down until the 
extremity touches the wall of the greater curvature, in the extrewe 
left of the possible field. Then the tube is moved slowly along the 
greater curvature, but not in too close contact therewith, until lh6 

'Jackson. Tiacheo-bronchoscop}-, Eaophagoscopy, and Gastroscopv, page 149- 



GASTSOSCOPY. 455 

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 deft 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 accom- 
plished 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 in its new position, the 
gastroscope is again pushed downward and the newly available sur- 
faces are explored. Should retching supervene whUe the tube is in 




Fro. 483.— -Showing the patient's head and neck turned lo the left to allow the 
10 reach the pyloric end. (After Jackson.) 

the esophagus, no harm will result, but when the tube is in the stomach 
retching is the signal for immediate withdrawal of the gastroscope 
until the distal end of the tube is above the diaphragm. 

"The vertical diameter of the stomach is easily determined by 
measurement. The depth from the teeth to the cardia is taken, then 
the gastroscope is passed on down until the greater curvature is encoun- 
tered, and the distance from the teeth is again taken. The difference 
between this and the first measurement gives the vertical diameter of 
the stomach at this point. Care must be used that the measurements 
are not rendered inaccurate by pushing the greater curvature down- 
ward, which is exceedingly easy to do without knowing 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 



4S6 THE STOMACna. 

is touched. Having taken our measurements, we then place the obtu- 
rator externally parallel to the tube within and indicate to the abdom- 
inal 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 the empty stomach at that 
point. Care must be taken, of course, to resterilize the obturator 
should it touch anything unclean." 

SKIAGRAPHY. 

The X-ray is useful in locating foreign bodies impermeable to the 
rays and to some extent in determining the size and position of the 
organ. By inserting a long soft stomach-tube, which is filled with 
bismuth or shot, in the stomach along the greater curvature and then 
taking an X-ray while the patient is in the erect position, the outline 
of the stomach and position of the pylorus have been mapped out. 
Another method of determining the size of the stomach is to have the 
patient swallow keratin-coated capsules of bismuth subnitrate or to 
give the patient on an empty stomach a pint (473.11 c.c.) of milk or 
gruel into which an ounce (31.10 gm.) of bismuth subnitrate is sus- 
pended by a thorough mixing. Another mixture frequently used, and 
with which there is no danger of nitrite poisoning, is the oxychlorid 
of bismuth 2 ounces (62. 20 gm.) suspended in a bottle of kumiss. 
These may be administered shortly before the skiagraph is taken. 

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 only 
method by which a correct diagnosis can be arrived at. It is an oper- 
ation that only requires a small incision and which, if properly carried 
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 employment 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 explorator)' incision is certainly a justifiable procedure and 
its prompt performance is clearly indicated, since an early recognition 
of the trouble furnishes the only hope of cure. The surgeon must be 



LAVAGE OF THE STOMACH. 457 

convinced, however, that he can accomplish 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 opera- 
tion or upon whom it is evident that the performance of a gastro- 
enterostomy would give scarcely any hope for relief of his symptoms 
must be condemned. 

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 siphoning 
it oflf. It is a most useful therapeutic procedure, and if performed 
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 
atonic stomach when the stomach is unable to empty itself of its con- 
tents after eight or ten hours. In such conditions lavage is especially 
valuable, as it cleanses the mucous membrane in preparation for 
fresh food and thus promotes the appetite; at the same time the stom- 
ach 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 preparation 
for gastric operations. (5) In intestinal obstruction and peritonitis 
with fecal vomiting for the purpose of diminishing the vomiting and 
at the same time removing toxic material from the digestive tract; and 
as a preliminary to operation in such cases where it is important to 
have the stomach empty to avoid the danger of vomited matter entering 
the air-passages. (6) Finally, lavage may be employed 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 those 
given against the use of the stomach-tube for diagnostic purposes, viz., 
in the presence of recent gastric hemorrhage, in acute inflammation of 
the stomach, in aortic aneurysm, in advanced uncompensated valvular 
heart lesions, etc. In cases of marked general arteriosclerosis and in 
general weakness or prostration it should be used with caution. 



4S8 



THE STOMACH. 



^jHimi^ 



Apparatus. — ^The employment of a stomach-pump is not advisable 
on account of the danger of injuring the mucous lining of the stomach; 
instead, an ordinary siphonage apparatus should be employed. This 
consists of a soft-rubber stomach-tube joined by means of 3 to 4 inches 
(7.6 to 10 cm.) of glass tubing to a piece of rubber tubing 2 or 3 feet 
(60 to 90 cm.) long, to the free end of which a glass funnel having a 

capacity of about a pint (473.11 c.c.) is fitted (see 
Fig. 469). The stomach-tube should be about 30 
inches (75 c.c.) long, 1/4 to 1/2 an inch (6 to 12 mm.) 
in diameter, and should be provided preferably with 
a closed tip and with two lateral openings of fairly 
large size so as to give passage to solid particles of food 
(Fig. 484). These openings should be situated as close 
to the tip as possible. The tube should also have a 
mark indicating the distance from the upper incisor 
teeth to the stomach, so that the operator may know 
when he has passed it a sufficient distance. 

For an infant the following apparatus may be em- 
ployed: A soft rubber catheter, 16 American (24 
French) in size, provided with a large lateral eye and 
joined by a glass connection to 2 feet (60 cm.) of 
rubber tubing, to the free end of which an 8-ounce 
(236 C.C.) glass funnel is attached. In addition, a 
mouth gag may be required. 

Asepsis. — The whole apparatus should be sterilized 
by immersion in an antiseptic solution and then rinsed 
in water before using. After use it should be wxll 
cleaned, care being taken to see that particles of food 
are not left adhering to the interior of the tube, 
especially about the lateral windows. 

Solutions Employed. — ^For cleansing purposes boiled 
lukewarm water is generally employed. To rid the 
stomach of mucus, alkaline mineral waters, as Carlsbad or Vichy, or 
Carlsbad salt, i dr. (4 gm.) to i quart (946 c.c.) of water, or sodium 
bicarbonate (i to 5 per cent.), may be employed. 

Temperature. — The solution should be of a temperature of from 
90° to 100^ F. 

Quantity. — The stomach should not be overdistended with solu- 
tion, about a pint (473. 11 c.c.) being introduced at a time. The wash- 
ing-out process is to be continued, however, until the contents of the 
stomach return clear, provided the patient's condition permits it. In 



Fig. 484. — En- 
larged view of the 
tip of a stomach- 
tube with a closed 
end and lateral 
fenestrae. 



LAVAGE OF THE STOMACH. 459 

some cases the process must be repeated ten or twelve times before 
this is attained. 

Time for Lavage. — When employed to remove stagnated food from 
a dilated stomach, lavage may be performed either in the morning 
before the first meal or at night, three or four hours after the last meal. 
The former time is preferable, as the stomach is thus given all possible 
opportunity for assimilation of its contents and no nourishment is 
withdrawn. In some cases, however, when the distress caused by 
the flatulency is such as to interfere with the night's rest, evening 
lavage is indicated. In very severe cases it may be necessary to wash 
out the stomach twice a day, night and morning. 

Position of Patient. — The patient sits in a chair facing the operator, 
with the head slightly bent forward. If the patient's condition is 
such that this is not advisable, the operation may be performed with the 
patient semiupright in bed. A child should be supported in a sitting 
position upon the lap of a nurse with its head held forward by an 
assistant so as to allow saliva and vomitus to escape from the mouth. 

Anesthesia. — In case gagging is excessive the pharynx may 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. — Any 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 vomitus 
or saliva that may escape from the mouth. The tube is then well 
moistened with water or glycerin to facilitate its passage. Oily lubri- 
cants 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 pharynx 
^ is reached, when the patient is instructed to swallow and the instru- 
ment, grasped by the pharyngeal muscles, is carried on into the esopha- 
gus (see Fig. 473). 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 the 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 it may 
be necessary, however, to apply some slight pressure over the epigas- 



46o THE STOUACH. 

trium, after the method employed in expressing a test-meal (see 
page 442.) 

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 (473.11 c.c.) of 
solution (Fig. 485}. The compression is then removed from the 




Fic. 485. — 5hon-ing Ihe method of washing out the stomach. (After Boston.) 



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 
conients 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 la^■age is continued by 
alicmaicly pouring solution into the stomach through the funnel 
and ihen 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 move about during the Ia\'age; 



LAVAGE OF THE STOUACH. 461 

for example, after one or more wasliings in the upright position 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 should be 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 stom- 
ach empty, as portions of mucous membrane may be drawn into the 
fenestrie of the tube and be lacerated or otherwise injured. 




Ac. 4S6. — Showing the passage of a stomach-tube through the ni 
lavage upoD infants. 



Variation in Technic. — In insane individuals or unruly children 
who try to prevent the passage of the lube by refusing to open the 
mouth or by biting the instrument, the tube may be passed through 
a nostril (Fig. 486}. As a rule, this method of introduction is not diffi- 
cult, as the tube hugs the posteripr wall of the pharynx and readily 
enters the esophagus. A smaller-size tube, however, is required, and 
care should be taken to see that it is well-lubricated. 



THE STOMACH. 



THE STOMACH DOUCHE. 



Gastric douching consists in irrigaling the stomach by means oi 
solutions introduced under pressure. The fluid is preferably itilro- 
duced through a iube 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 &ne 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 insufEciencj 
for the purpose of stimulating peristalsis and secretion. It is also 
employed in neuroses affecting the sensory apparatus of the stom 




Fig. 48S — Euihoin'a apparatus 
for giving & stomach douche. 



Apparatus. — A glass funnel with a capacity of i pint (473.11 W' 
a piece of rubber tubing 2 to 3 feet (60 to 90 cm.) long, a glass con- 
necting tube 3 to 4 inches (7 to 10 cm.) long, and a stomach-tube about 
30 inches (75 cm.) long, with a large number of side openings i/^S 
to 1/12 inch (i to 2 mm.) in diameter and a terminal opening 
1/8 to 1/6 inch (3 to 4 mm.) in diameter, should be pTo\ided 
(Fig. 487). The large opening in the end of the tube is necessary ui 



THE STOMACH DOUCHE. 463 

order to drain the solution quickly out of the stomach and at the same 
time remove any solid particles. 

Einhom has devised a douche apparatus which consists of a 
rubber tube 26 inches (65 cm.) long and 3/8 inch (9 mm.) 
in diameter, terminating at the stomach end in a hard- 
rubber cap with numerous side openings and a large end 
opening (Fig. 488). Within the tip of this cap lies a freely movable 
aluminum ball which is prevented by two crossbars from entering 
the main portion of the tube. This ball falls over the terminal opening 
as the solution flows into the stomach and causes the fluid to flow 
out through the small openings. When the current is reversed, the 
ball is driven upward and the solution is carried off through the large 
opening. 

Asepsis. — The apparatus should be thoroughly cleansed after use 
and immersed in an antiseptic solution, then rinsed off before use. 

Solutions. — ^Plain boiled water is usually employed. For the 
removal of mucus, alkaline solutions, as sodium bicarbonate (i to 5 
per cent.), Carlsbad salt i dr. (4 gm.) to i quart (946 c.c.) of water, 
etc., are used. As antiseptics and antifermentatives are the following: 
salicylic acid (0.3 per cent), sodium salicylate (0.5 to i percent.), 
boric add (2 to 3 per cent.), sodium benzoate (i to 3 per cent.), 
resorcin (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 sensation 
and salt solution (0.4 per cent. ) to increase gastric secretion. Chloro- 
form 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. Occasionally, 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 early in 
the morning or three to four hours after the first meal. 

Amount of Pressure. — To be most effective the solution should be 
introduced under considerable pressure. The funnel end is conse- 
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. 



THE STOMACH. 

Anesthesia. — In the presence of excessive irritation or gag^glbt 

pharynx may l>c sprayed with a 5 per cenL solution of cocaJDui 
preiiminary to the passage of the tube. 

Technic. — The patient is given a small bowl to receive any votniltd 
matter or an excessive flow of saliva and his chest and lap are pro- 
tected by an apron. The lube is then moistened with wann waier ot 
glycerin and is inserted into the patient's mouth, being kept in close 
contact with the roof of the mouth until the pharynx is reachal 
From this point on the tube is advanced partly by ihe action of ihf 
pharyngeal muscles as the patient swallows, aided by the operator 
who gently pushes it onward. The tube is inserted only a sulEcicm 
distance to bring the perforated tip within the cardia (Fig. 489), which 



K 




Fig. 489. — Showing the mechanism of the 



douche. (After Gumprecht) 



I 



is determined by a mark placed upon the tube for that purpose. The 
funnel end is then raised and a pint (473. 11 c.c.) of solution is poured 
into the furmel end, 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 b pinched while there is still some 
liquid in it and is mserted some 4 or 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- 
The medicated solution is then introduced in the same manner, b"' 
should be allowed to remain only from a half minute to a minute. " 
is then siphoned off, and the stomach is again douched out with wann 
water. The lube is then removed, care being taken to compress " 



GAVAGE. 



465 



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 when the 
patient struggles against the passage of the tube and tries to bite the 
instrument, and with infants. 

This method of feeding may be employed after intubation and 
tracheotomy, in certain operations about the mouth and throat, in 
cerebral diseases, when the patient is unconscious, and in acute dis- 
eases such as diphtheria, scarlet fever, typhoid fever, etc., when the 




Fig. 490. — Apparatus for nasal gavage. 

patient will not take nourishment. It is especially valuable in phar- 
yngeal paralysis when the patient cannot swallow food or liquids. 
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.) 
30 




Fig. 491. — Gavage. Second step, administering the food. 



GAVAGE. 467 

long, 3 feet (60 cm.) of rubber tubing Joined to the stomach-tube by a 
gtiss connecting tube 3 or 4 inches (7 to 10 cm.) long, and a glass 
funnel with a capacity of about i pint (473 . 1 1 cm.) (see Fig. 469). 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. 490). 

Asepsis. — Strict asepsis should be observed in the care of the 
apparatus. Ordinarily a thorough washing and immersion in an 




^i*^- 49J-— Gavage. Third step, 






antiseptic solution followed by a thorough rinsing off with water is 
suScienL In contagious cases, as diphtheria, for example, the appa- 
isius should be boiled. 

The Food. — ^The material employed for feeding will, of course, vary 
according to the indications in the individual case. When the digestive 
P^wer of the stomach is impaired predigested food should be employed. 



The intervals between the feedings of a child should be soroewlat 
increased when gavage is employed. 

Position of Patient.— The child should be held flat on its back 
across the nurse's knees with the head slightly elevated. Its anus 
and legs may be confined by wrapping it in a sheet from the chin lo 
the knees. 

Technic. — The tube or catheter is moistened in warm water or 
lubricated with glycerin and is passed into the mouth to the base of 
the tongue and then gently down the esophagus to the desired deplh 
(Fig. 491). In an infant at birth the distance from the alveolus to the 
cardia is 6 3/4 inches (18 cm.}; at two years it is 9 inches (23 cm.); 
at ten years it is 11 inches (28 cm.), and in an adult it is aboul 16 
inches (40 cm.). After the tube has been inserted to the proper deplh, 
the funnel is eles'ated and ihe required amount of food introduced 
(Fig. 492). The tube is then rapidly withdrawn, pinching it the while 
so as to prevent any dripping of food into the pharynx and lan'iu 
(Fig. 493). The patient should be kept quietly in the recumbem 
position for some time after the introduction of the food. In casts 
complicated by gastroenterilis, etc., a preliminary lavage of thesfom- 
ach with warm water, just before giving the food, is often advisable. 
It removes mucus and any food remnants of a previous feedhig, 
cleanses the mucous membrane, and at the same time stimulates il 10 
a better absorption of the freshly introduced food. 

MASSAGE OF THE STOMACH. 

Massage systematically and properly performed is a valuable thera- 
peutic procedure in certain diseases of the stomach. It is applied w 
this organ with the same object in view as when used upon other 
muscular organs; that is, to strengthen weak and atonic muscular 
walls with impaired contractile power. Massage also aids in the pro- 
pulsion 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 ihe purpose of strengthening ihe 
relaxed ligamentous supports. Finally, it is supposed to stimulaie 
the normal secretions of the stomach, and is recommended by some 
authorities in cases with impaired gastric secretion and in nen'ous 
dyspepsia. 

Before recommending massage an exact diagnosis is essential 
Massage is contraindicated in acute inflammation of the stomach, in 



liASSAGE OF THE SIOICACH. 469 

recent gastric ulcers, in hemorrhage from the stomach, in great disten- 
tion of the stomach from gas, and in inflammation of the peritoneum. 
The massage should be performed by one thoroughly familiar with the 
technic and preferably by the physician himself. 

Time for Massage. — This will depend upon the purposes of the 
treatment. When employed simply for the purpose of toning up and 
strengthening the stomach wall massage is best performed early in 
the morning when the stomach is empty. In cases of dilatation, how- 
ever, the object is to propel the contents of the stomach into the 
intestines, and the massage is then performed upon a full or partly 
full stomach. The best time for tliis, as a rule, is six to seven hours 
after the principal meal of the day. 

Frequency. — The massage, to be of any value, should be perfOTmed 
every day. 




f f— 

Fio. 494. — Stroking massage applied to the slomach. (After Gant.) 



IF" 



Duration. — During the first treatments the manipulations should 
be of short duration — about two to three minutes at a sitting — and 
later, as the patient becomes more accustomed to the treatment, the 
sitting may be extended to periods of five and ten minutes. 

Podtion of the Patient.— The patient lies upon his back with his 
head slightly raised and the legs flexed so as to relax the abdominal 
muscles. 

Technic. — Stroking movements (efifleurage) and kneading (petris- 
sage) are the manipulations most employed. In performing effleurage 
the operator places his left hand upon the right hypochondriac region 
for the purpose of counterpressure and with his right hand, the 



fingers of which are outstretched, he performs stroting mo^-emtaits 
from the fundus toward the pylorus; i.e,, from left to right (F^,4^), 
KtipaHing of the Stomach may alternate with these stroking moT^ 
merits to ad^'aniage. In these manipulations large folds of the 
abdominal wall, including the stomach, are picked up between the 
thumb and four fingers of the two hands by deep haJidgjasps and are 
kneaded by alternately squeezing and rela x i n g the fingers (Fig. 49;)^ 

I The force used in the various movements of massage will depend upon 

" the sensitiveness of the patient, the thickness of the abdominal walls, 

and the rigidity of the muscles. The manipulations, however, should 
never produce pain or be disagreeable to the patient 

To accelerate the passage of the stomach contents into the intestines, 
the fundus of the stomach and contents are grasped through ihe 
abdoininal walls between the thumb and fingers of the right hand and 
by propulsive movements directed backward an attempt is made to 
throw the contents of the stomach toward the pylorus. 



ELECTROTHERAPY VR DISEASES OF THE STOMACH. 

Electricity has undoubted beneficial effects upon certain diseases 
of the stomach, although the manner in which the electric curren' 
acts is not well understood, and the experimental evidence of its ulu^ 
is both contradictory and in some cases not in accord with the resalts 
obtained clinically. It seems probable, however, that electricity 
increases the motor activity, stimulates the secretion of the gastric 
juice, and increases the absorption power of the stomach. AccordinS 
to clinical experience, at any rate, its use is- followed by favorable 
results in simple atony, dilatation from atony, hypochlorhydriai 



ELECTROTHERAPY IN DISEASES OF THE STOMACH. 



471 



nervous anorexia, nervous vomiting, paresthesia, hyperesthesia, and 
gastralgias. 

Both the faradic and the galvanic currents are employed and they 
may be used percutaneously or intraventricularly. As to the choice 
of current and the method of its application, authorities again disagree. 




i. 4g6. — Large flat sponge elettrode. 



The majority, however, advise the use of the faradic currents when 
the motor functions are diseased and the galvanic in neuroses and in 
cases where the secretory apparatus is at fault. The intraventricular 
method seems more desirable when the necessary apparatus is at 
hand, as the stomach is thus directly treated. External application of 




dfglutibli^ I 



electricity, on the other hand, is simpler to carry out and is a less 
disagreeable method for the patient. 

Apparatus. — For the percutaneous application there will ' be 
required two curved flat electrodes of about 9 square inches' surface 
(500 to 600 sq. cm.) (Fig. 496). For intrastomachic applicalion a 




472 THE STOMACH. 

special gastric electrode, such as Bardet's, Stockton's, or Wegele's, 
inserted within a stomach-tube, may be employed or Einhom's deglu- 
tible electrode may be used. The latter (Fig. 497) consists of a hard- 
rubber shell, shaped like an egg, with numerous small perforations 
piercing its surface, and within this capsule is a button of copper or 
brass. A small rubber tube 1/25 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. 

Duration of Application. — Each treatment should consume about 
ten minutes. 

Frequency. — At first treatments are employed daily; after two or 
three weeks, twice weekly; and, finally, applications are made at 
weekly intervals imtil the treatments are discontinued. 

Strength of Current. — ^For galvanism from 15 to 20 ma. are ordi- 
narily used. With the faradic current it is not possible to measure 
exactly its strength; the current should be strong enough, however, to 
produce strong and visible contractions of the abdominal wall and back 
muscles without causing pain. 

Position of Patient. — The patient should be in the recumbent 
position with the head slightly elevated and legs flexed so as to relax 
the abdominal muscles. 

Technic. — i. Percutaneous Application. — The two electrodes are 
well moistened and the negative pole is placed over the region of the 
pylorus, the positive over the spine in the region of the seventh or 
eighth dorsal vertebra. The negative electrode may be held stationary 
for short periods or may be moved about over the parts with friction 
during the treatment. Either the faradic or the galvanic current may 
be employed. 

2. Intrastomachic Application, — The treatment should be given on 
an empty stomach, preferably one or two hours after a light breakfast. 
If necessary, the stomach should be emptied by means of a stomach- 
tube. When an electrode, such as Wegele 's or Stockton 's, is employed, 
it is introduced in the same manner as a stomach-tube. One or two 
glasses of water are then introduced into the stomach through the tube 
or, if Einhom's electrode is used, before the electrode is swallowed. 
In introducing this latter the patient should be requested to open the 
mouth widely and the electrode is placed well back in the patient's 
mouth and the patient is then instructed to swallow. If there is any 
difficulty in accomplishing this, drinking a glass of water will be of 
material assistance. 

The gastric electrode is connected with the negative pole of the 



ELECTROTHERAPY IN DISEASES OF THE STOMACH. 473 

battery, the positive pole is connected to a plate electrode. This 
electrode is applied for part of the stance over the region of the stomach, 
first held in one place for a few moments at a time. A smaller sponge 
electrode is then substituted and is moved about over the region of the 
stomach from left to right for several minutes, and is then shifted to 
the spine in the region of the seventh or eighth dorsal vertebra where 
it is allowed to remain a minute or more, and finally it is applied once 
more to the epigastrium over which it is gently moved for a minute or 
so. The current is then gradually decreased and the gastdc electrode 
removed. 




Fig. 498. — Sagittal sectioit of the n 



are distinct and a knowledge of their direction is imprartant for the 
proper introduction of the finger or instruments in making an examin*- 
tion. There are also two slight lateral curves, first to the right afd 
then to the left, but of less practical importance. 

For purposes of description the rectum may be divided into th^ 
rectum proper and the anal canal. 

The rectum proper extends from the middle of the third sacial 
vertebra to the upper border of the internal sphincter muscle, or to 
474 



n 



ANATOMY. 475 

about the level of the apex of the prostate gland, and measures 3 to 
4 inches (7.6 to 10 cm.) in length. This portion of the rectum is 
Sacculated in form, exliibiting three pouches or dilatations, of which 
tile lowest and largest, called the ampulla, measures in some cases nearly 
I o inches (25 cm.) in circumference. The constrictions between which 
lie these dilatations are produced by an infolding of the coats of the 
Isowel in the fonnatioti of the so-called rectal valves. In the male, 
the rectum is in relation anteriorly with the recto-vesical pouch, the 
trigone of the bladder, the seminal vesicles, and the prostate gland, 
-vrhile in the female, the vagina and the recto-vaginal pouch with the 
small intestine therein contained He anteriorly. 

The anal canat is about i 1/2 to 2 inches (3.8 to 5 cm.) long. 
It extends downward and backward, tenninating at the surface of the 
body as the anus. This portion of the rectum has no peritoneal 
covering. It is embraced by the internal sphincter muscle and is 
supported by the levatores ani muscles. At the anus the skin is dark 
brown in color and puckered up into radiating folds. The anal canal 
is in relation anterioriy in the mate with the bulb and membranous 
portion of the urethra; and in the female the perineal body separates 
it from the lower end of the vagina. 




Fig. 499. — The rectal valves as seen through the proctoscope. (After Gant.) 

Structure. — The mucous membrane of the rectum is dark and 
muscular and is thrown into a series of folds, the most importantof 
which are known as Houston's valves, or the rectal valves. These are 
three — sometimes two or four — semilunar folds, projecting like trans- 
verse shelves into the cavity of the bowel when it is distended. Accord- 
ing to the usual arrangement the inferior fold projects from the left 
wall of the rectum at a point about 2 inches (5 cm.) above the anal 
orifice; the middle and most constantly present one projects from the 



476 THE RECTUM AND COLON. 

right wall at a point situated 3 inches (7.6 cm.) from the sous; 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 foid 
(Fig, 499). These valves are attached to the walls of the rectum for 
a distance of from 1/3 to 1/2 its circumference 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 making digital examinations and they may act as 
obsta,cles to the passage of a rectal tube. 

In the anal canal the mucous membrane is thrown into a series 
of longitudinal folds, five to twelve in number, called the columns of 
Morgagni. They are about 1/2 inch (i cm.) in length, and are pro- 
longed upward from the radiating folds about the anus. Stretched 
between these columns at their inferior ends are semilunar folds of 
mucous membrane forming pouches that open upward, known as the 
valves of Morgagni (Fig. 500). 




Fig. 500. — The anLtl canal, showing the columns and valves of MorgagnL 



The muscular wall of the rectum is composed of two layers, longi- 
tudinal and circular, and is quite thick. The internal circular layer 
is especially well developed in the anal canal where it forms the 
internal sphincter. 

The Peritoneal Coat. — The rectum has no peritoneal coat posteriorly, 
but the upper portion is covered anteriorly and laterally. The lateral 
portion of peritoneum gradually disappears as the rectum is traced 
downward, and at a point 3 to 3 1/2 inches (7.6 to 8.9 cm.) from the 
anus the anterior portion is reflected from the rectum to the bladder in 



DIAGNOSTIC METHODS. 477 

the male and to the vagina and uterus in the female, forming the 
retrovesical or retrovaginal pouch. 

Diagnostic Methods. 

For the successful treatment of rectal diseases a systematic examina- 
tion should be made in every case. On account of the close relation 
and the anatomic proximity 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 affections 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, stone in the bladder, or 
a displacement of the uterus, for example, to produce a set of symptoms 
which point to the rectum as their seat. All the information possible 
should be first obtained from a careful history of the case and by a 
general physical examination; then a local examination is made to 
determine the cause of the symptoms complained of and the proper line 
of treatment to pursue. 

The methods employed for such an examination are: (i) Inspection, 
(2) palpation, (3) instrumental examination, and (4) inflation of the 
bowel. 

Preparation of the Patient. — Before beginning a systematic 
examination the rectum should be emptied of its contents 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 con- 
dition 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 com- 
plete 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 Sitnsj or left lateral position, is obtained by placing the patient 
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 behind the 
back and the thighs are well flexed upon the body with the right knee 



drawn up nearer ihe body than the left. The buttocks lie near the 
edge of the tabic and are elevated upon a hard pillow {Fig. 501}. 
This position will be found most useful for routine esaminatioos, and 
probably will be found less objectionable lo the paUent than the lithotomy 
or knee-chest positions. 




The tilholomy position is secured by placing the patient flat on ilie 
back and flexing the thighs upon the abdomen and the legs upon 
the thighs. The buttocks, which are elevaled upon a hard flat pQioiv, 
project over the end of the table (Fig 502). In very stout indittduais 




Fic. 502. — ^The lilhotomy pos 



this position will permit of a more satisfactory examination iha" 
will the Sims. 

The knee-chest position is oblained by having the patient kneel upon 
a table with the thighs at right angles to the legs and with Ihe body 
well flexed upon the thighs, ihe chest resting upon a pillow placed upon 



INSPECTION. 



479 



the same level as the knees (Fig. 503). The knee-chest position favors 
displacement of the coils of intestine upward, thus allowing the rectum 
to be distended by the entrance of air upon the insertion of a 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. 




" ni iiiiili i i i Hiiiiiiiiiiiii iiiiiii umi iii n ii w w 



Fig. 503. — The knee-chest position. 

The squatting 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. 



mSPECTION. 

The anus is first inspected. The presence of discharges from the 
rectum, excoriations, eczema, thickening of the epidermis, gears, 
ulcerations, fistulous openings, condylomata, the swelling of an abscess, 
and external hemorrhoids, are carefully looked for. Then, by separat- 
ing 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. 504). 
Slight degrees of prolapse, fissures, ulcers, hemorrhoids, and polypi 
or other growths may be readily demonstrated in this way. 



THE BECTUM AXD COLON. 



PALPATION. 



Palpation of the rectum may be performed by means of the tnger 
or by the whole hand. With the index-finger one may examine ih* 
anus, the anal canal, and the ampulla of the rectum. The firsi 4 inch« 
(10 cm.) of ihe rectum may be thus explored. 

Introduction of the whole hand into the rectum, as adrocated by 
Simon, for ihe 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 g\o\e larger than 7 3/4 should 
never be introduced into the rectum except in a life or death emergency. 




Fig. 504. — Inspection of the anus. (Asbloit.) 



Manual palpation is rarely required, being only necessary for examining 
tumors high up that cannot be inspected by means of a speculum or a 
proctoscope. In addition, it is a serious procedure, as there is danger 
of rupture or undue distention of the bowel in careless hands. 

Anesthesia. — General anesthesia will be required for palpation by 
the whole hand, as complete dilatation of the rectum is essential. 

Technic. — i. By Ike Finger. — No anesthesia will be required. The 
direction of the rectum, which is at first slightly forward from the anuS' 
then back into the hollow of the sacrum, then to the right, and finally 
to the left toward the sigmoid flexure, should be kept clearly in mind. 
The index-finger of the right hand is covered with a rubber finger col- 
If, however, it is desired to preserve the tactile sense of the finger,* 
covering is dispensed with, in which case soap should be forced under 
the nail. The finger is well lubricated with sterile vaselin or with one 



PALPATION. 481 

of the preparations of Iceland moss made for the purpose and is then 
introduced slowly and with a rotary motion, the patient being requested 
to strain genUy to facilitate its passage through the sphincter. Rough- 
ness in inserting the finger or disregard 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. 




Fic. 505.— Palpatiou of the rectum. (Gaot.) 



As the finger passes through the anal canal the condition of the 
sphincter should be noted, the examiner observing whether it is close, 
rigid, and resisting, or loose and patulous. When the internal sphinc- 
ter has been passed, the finger is swept lightly over the mucous mem- 
brane, palpating the rectal wall in all directions. The size and sensi- 
tiveness of the rectum b thus ascertained. The examining finger will 
readily detect the presence of impacted feces, polypi, large hemor- 
rhoids, malignant groWths, ulcerations, fissures, and strictures if a 
systematic examination is made. In the male, enkrgement, indura- 
tion, degrees of sensitiveness, or softness of the prostate should be 
carefully noted, and likewise information regarding the condition of 
the seminal vesicles and bladder should be obtained. A vesical cal- 
culus may frequently be discovered by such examination. In the 
female, the uterus, tubes, ovaries, and broad ligaments are carefully 
examined for displacements or signs of inflammation. Finally, the 
coccyx should not be overlooked, as this bone may be responsible for 
considerable rectal disturbance. 

If pus, blood, or mucus be present in the bowel there will be an 
escape of the material from the anus when the finger is withdrawn or 
3' 




ot one linger of each hind. 

2. By the Whole Hand. — Stretching of the sphincters is commenced 
by introducing into the anus the two forefingers with the palmar sur- 
faces out, and separating them slowly and gently in all directions, are 
being taken to avoid injury to (he mucous membrane if i 
(Fig. 506). As soon as a liltle dilatation has been secured, two and 




Fig. 507. — Method of dilating the 



.0 fingers of each hand- 



then three fingers of each hand may be introduced, carry&ig them w ^ 
point well above the internal sphincter. The fingers are then gradu- 
ally separated until sufficient dilatation is obtained to allow the hand 
to pass (Fig, 507}. The hand is then well lubricated and, with ^^^ 
fingers formed in the shape of a cone, it is gradually introduced pis' 



EXAMINATION BY THE SPECULUM OR PROCTOSCOPE. 483 

the sphincter muscles until it enters the dilated ampulla. From this 
point on only two fingers should be used in palpation, and great care 
and gentleness are necessary to prevent injury, as the canal gradually 
narrows down. 

EXAHnrATION BY THE SFECULXTM 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 alteration 
in color or unevenness of the surface of the mucous membrane are noted. 
Ulcers, polypi, new growths, malignant disease, strictures, the internal 
openings of fistulous tracts, hemorrhoids, and congestions or inflamma- 
tion of the rectal mucosa may be distinguished by the experienced 
examiner. 

Instruments. — The ordinary rectal specula are made in various 
shapes and styles, such as the Sims (Fig. 508) , the bivalve, the duck- 




FiG. 508. — The Sims rectal speculum. (Hirst.) 

bill (Fig. 509), the fenestrkted-blade (Fig. 510), 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 a set of 
tubular specula (Fig. 511) which permit a thorough inspection of the 
whole rectum and the sigmoid flexure. This set of instruments con- 
sists 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.) 



484 THE RECTUM AND COLON. 

and of the upper end i 1/5 inches {3 cm.). The cyUnder of the short 
proctoscope is 5 1/2 inches (14 cm.) long, and 7/8 inch {22 mm.) in 
diameter. The long proctoscope is 8 inches (20 cm.) long and of the 
same diameter as the short proctoscope, and the sigmoidoscope is of 
like diameter and 14 inches (35 cm.) long. Each speculum consists 
of a cylindrical metal tube, at the outer end of which is a funnel-shaped 
rim about 2 inches (5 cm.) in diameter to which a handle is attached. 
A blunt obturator is provided to facilitate the introduction of the 
instrument into the bowel. Illumination is seciu^ from an electric 





Fio. 509. — Duck-bi[1 rectal speculum. Fio. 510. — Fenesttated-blaiie rectal s|>eciili 



light held close to the sacrum, which is reflected by a head mirror into 
the speculum, or else an electric head light or the direct sunlight may 
be employed. 

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 inserting a 
speculum through the anus each time a smaller size is used. The 
sphincteroscope is used first, and into this the next smaller size is passed 
without withdrawing the original instrument, until all have been intro- 
duced in succession. 

The pneumatic proctoscope, such as Tuttle's modification of 
Law's instrument (Fig. 512) is not dependent upon atmospheric 



EXAIONATION BY THE SPECDLUH OK PKOCTOSCOPE. 485 

pressure as a means of dilatation, this being accomplislied by a special 
inflatioa apparatus connected with the instrument. Tuttle 's procto- 



*=— 



3N^ 




Fig. S"- — Kelly's se! of tubular specula. 

:, Swab and holder; 3, ugmcddoscope ; j, long proctoscope; 4, short proctoscope; 

5, sphincteroscope. 




Fig. sii. — TuHle'a pneumatic proctoscope. 

I, Proctoscope with obturator removed; 3, obturator; t, handle; 4, air-tight plug 

with glass window; 5, inflating apparatus. 

scope consists of a long cylinder, to the circumference of which is 
fitted a small metallic tube closed at its distal extremity by a flint-glass 



THE RECTUM AND COLON. 



515) and then upward towaiil the sacral hollow (Fig. 516). As soon 
as ihe tube enters ihe ampulla, the obturator should be withdrawn 
allowing air to enter and expand the bowel. The light is then thron 
into the instrument and the ampulla is inspected. From this point ihe 




Fro. 516. — Proctoscopy. Thitd siep, show-ing ilie 'iirection of the ii 
the ampuilo. 




FlO. 517. — Proctoscopy. Fourth step, showing the 



instrument is advanced past the \-alve5 entirely by sight. Some diffi- 
culty may be experienced in following the dijection of the canal from 
a \alve or fold of mucous membrane occluding the en*d of the instru- 
ment. In such a case the distal end of the instrument should be gendy 



EJCAIONATION BY THE SPECULUM OR PttOCTOSCOPE. 487 

shaped rim prevents its further progress. The obturator is then 
removed, allowing air to pass in and distend the bowel. The light 
is reflected into the instrument in such a way as to thoroughly illumi- 




FlC. 515. — Proctoscopy. Second step, showing the direi 
through the a: 



nate the interior, and, as the instrument is slowly withdrawn, the whole 
of the anal canal is carefully inspected. 

The proctoscope is inserted in precisely the same manner, first 
pushing the instrument in a direction downward and forward (Fig. 



490 THE RECTUM AND COLON. 

2. Wiih TtUUe^s Proctoscope. — ^The proctoscope, wanned and well 
lubricated, is introduced in much the same manner as 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 then to introduce the 
instrument with the end of the auxiliary tube pressed against the 
finger (Fig. 519); 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. Pressure upon the bulb of the 
inflating apparatus distends and straightens out the canal as the instru- 
ment is advanced. Should the lamp become obscured by feces or 
mucus, the plug is removed from the instrument and, without remo\Tng 
the instrument, the glass is wiped off with a cotton wipe held in long 
dressing forceps. At the completion of the examination 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 emplo)rment of the rectal sound or bougie for the diagnosis of 
stricture has been superseded to a large extent by the use of the proc- 
toscope. The bougie, furthermdre, is not a very reliable instrument, 
as strictures that do not exist may be imagined to be present from the 
point of the instrument catching in the folds of mucous membrane or 
in a diverticulum, or from being arrested by fecal matter, the prom- 
ontory 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. 520) 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 proctoscope, 
as they may easily be pushed through the rectal wall into the 
peritoneal cavity, especially if the rectum is weakened by some patho- 
logical condition. The Wales bougie is made of soft rubber in 
different sizes, and in length measures about 12 to 14 inches (30 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 Da\'idson syringe should be 
provided. 



EXAMINATION BY THE BOUGIE X BOULE, 



491 



» 

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 interfering with 




Fig. 520. — ^Wales' bougies. 

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. 

EXAMINATION BY THE BOUGIE A BOTTLE. 

The rectal bougie k boule is made use of in diagnosis to determine 
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 wkich acorn-tips of 
various sizes may be screwed (Fig. 521). The bougie Jt boule is used 



! n TTTTrrrrrrTTTviTii UT1 lip nTTTi I nTTrm n 1 1 nrnrr> i rn m iTTT\; 



TTniimnuii'u w. 



nnllw 



o 





Fig. 521. — Rectal bougie k boule. 



to best advantage in connection with a cylindrical speculum or a 
proctoscope. 

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. 
522). If it is found to be too large to enter the stricture, smaller instru- 



492 



THE RECTUM AND COLON. 



menis 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 base calches 



FlC. ; 



Fic. saj. 



Flo. 511. — Method oi estimating the length oE n reciai stricture, the bougie \ Iwulf " 
the face of Ihc stricture. 

Fig. 5*3. — Methori _of estimating the length of a rectal stricture. The Ixjiipe i bmile 
is withdrawn until its base is arrested at the distal end of the si 



the distal opening of the stricture (Fig. 523). From this examinii- 
tion the exact length and size of the contracture may be readily 
ascertained. 

EXAUmATION BY THE PROBE. 

Probing has but little utility in the diagnosis of rectal diseases 
except as a means of determining the situation and course of a recto- 
vaginal or ischiorectal fistula. 



Fig. 524. — Rectal ptobe. 



Instruments. — A silver probe S or 10 inches (20 to 25 cm.) long 
with a flat handle is employed (Fig. 524), The probe should be flex- 
ible that it may be bent in any direction if desired. When examining 



INFLATION OF THE COLON. 



493 



for a recto-vaginal fistula a Sims speculum will be required in addition 
to expose the fistulous opening in the vagina. 

Technic. — The index-finger of the left hand, well lubricated, is 
first introduced into the rectum. The probe, grasped in the right 
hand, is then passed through the external opening in the supposed 
direction of the fistulous tract. The tract of the sinus is thus slowly ex- 
plored, removing the probe and bending it so as to alter its shape to cor- 
respond 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. 525). 




Fig. $7$. — Showing the method of probing an ischiorectal fistula. (Ashton.) 



INFLATIOn OF THE COLON. 

This procedure is performed both as a diagnostic and as a thera- 
peutic measure (for the latter see page 517). The bowel may be 
inflated either by means of air or fluids. For diagnostic purposes, 
however, air is preferable, as there is thus produced a contrast on 
percussion between the tympany of the air-distended bowel and the 
flatness of a tumor. It has the disadvantage, however, that the amount 
injected cannot be measured as can fluids, and consequently the degree 
of dbtention 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, 



494 i^e: seciuh and colon. 

position, and mobility may be determined. It thus also becomes 
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 will be but slightly 
distended or not at all so, depending upon the degree of occlusion. 
Under inflation, tumors 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 determin- 
ing the probable seat of other abdominal tumors; the distention of the 
bowel causes a change in the position of the tumor, 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 liver is pushed upward and forward; a tumor of the 




Fig. 5j6. — Rectal lube and caulery bulb for inflating the colon. (Eisendrath.) 



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 itimor of ihe spleen will lie in front of the colon and 
the growth will become more readily palpable from being pushed for- 
ward, 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 
reclal tube attached to the reservoir by about 6 feet {i8o cm.) of rubber 
tubing 1/4 to 3/8 inch (6 to 9 mm.) in diameter. 

For the injection of air a special inflation apparatus may be employed, 
but a rectal tube attached to a Davidson syringe, cautery bulb (Fig. 
526), hand bellows, or bicycle pump will answer equally well. The 



INFUTION OF THE COLON. 495 

pumping apparatus may be dispensed with if only oxygen or carbonic 
gas are used. In the case of the former the rectal tube is simply 
attached to the oxygen tank (Fig. 527), while, if the latter gas be em- 
ployed, the tube is attached to a syphon of carbonic, and the latter is 
inverted so that the gas escapes without the water following. 

Media for Inflation. — Of fluids, warm normal salt solution (dr. i 
(3 . 9 gm.) of salt to a pint (473 . 1 1 c.c.) of water) is besL Air, oxygen, 
or carbonic acid gas may be used when gaseous distention is desired. 




Fig. 517. — Inflation of the colun with oxygen. (AEter Gant.) 

Amount Injected. — When inflating with gas there is no way to 
determine accurately the amount of gas injected, and the patient's 
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. 

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 hour 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. 



496 THE RECTUM AND COLON. 

Technic. — If there is any 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 lubricated 
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 between 
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 but- 
tocks 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 infla- 
tion may be then continued. When the colon has been sufficiently dis- 
tended and the purposes of the examination are accomplished, 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 rap- 
idly 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 hold- 
ing the anus open. 

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 relief 
of much the same conditions, yet in practical application they are 
quite distinct. By an enema is understood the introduction into the 
bowel of clysters of fluid to be retained some little time at least. The 
quantity of fluid so injected is usually small in amount, rarely exceeding 
I or 2 pints (473.11 to 946 c.c). Enteroclysis, on the other hand, is 
an irrigation of the lower bowel, the fluid returning almost as rapidly 
as it is introduced. In this procedure, large quantities of fluid are 
made use of — frequently several gallons at an irrigation. The enema 
and the irrigation may both be administered either low or high, accord- 
ing to whether the fluid is introduced a few inches up the rectum or 
high in the colon. 

Enemata. — Enemata may be of several kinds, according to the 
purpose for which they are employed. They may be designed simply 



ENEMATA AND ENTEROCLYSIS. 497 

to secure an action of the bowels in ordinary constipation or to unload 
the bowel of long-standing fecal acciunulations or impactions and 
at the same time relieve the accompanying tympanites. These are 
known as purgative enemata. Such injections owe their action to 
the stimulating effects upon intestinal peristalsis and to the softening 
produced in the hardened fecal matter. In the treatment of consti- 
pation, however, the use of enemata should be restricted as much as 
possible; they should not be advised for long-continued use, as they 
gradually lose their potency, and constantly increasing quantities are 
necessary to produce an effect. For the local effects in colitis, dysen- 
tery, catarrhal and ulcerative conditions of the rectum and colon, 
small enemata of antiseptic, astringent, or sedative solutions to be 
retained some little time are administered after each movement or 
following a cleansing irrigation. While used mainly for purgative 
and cleansing effects, enemata have other valuable uses in tlierapeutics. 
Rectal injections of saline solution are made use of in the treatment of 
shock, hemorrhage, sepsis, etc. (see Saline Infusions, p. 508). Rectal 
enemata are likewise employed as a means of introducing fluids and 
nutriment into the bowel (see Rectal Feeding, p. 514) and for the 
administration of drugs which affect the general system after 
absorption. 

In employing the rectum as an avenue for the administration of 
<irugs, however, certain facts are to be kept in mind. The drug should 
"^- Iways be given in such a state that the active principle is in an aqueous 
Solution or else is capable of being dissolved in the fluids of the rectum, 
-^t should also be remembered that, while the absorption power of the 
^^■*ectum may be great, drugs are taken up but slowly and if a rapid 
ffect is desired, this method should not be employed. As a rule, un- 
ess the drug is very powerful and is capable of being rapidly absorbed, 
"^he dose is twice the amount given by mouth. 

Apparatus. — ^The simpler the apparatus, provided it is eflScient, 
nhe better. A fountain syringe or a glass irrigating jar, capable of 
folding a quart (946 c.c.) of solution, will be required as a reservoir, 
but in an emergency a large funnel will answer. A rubber tubing 
about 1/4 to 3/8 inch (6 to 9 mm.) in diameter and at least 6 feet 
(180 cm.) long is coimected with the outlet of the reservoir, and to the 
free end an appropriate nozzle is attached (Fig. 528). 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 up 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 3/8 to 1/2 inch 
3a 



THE RECTUM AND COLON. 



f 9 to 1 2 mm.) in diameter. A very simple apparatus consists of a lifflg 
colon tube and a funnel (Fig. 529). 

Rectal tubes are made with the openings at the side, or with one 
opening at the end (Fig. 530). The latter are better, as the fluid may 




Fig. 538.— Fountain syringe and nozzle fur FlG, 529. — Colon tube and fu 

giving a low enema. 

be injected directly through the tube for the purpose of dislodgiDg 
any feces or folds of mucous membrane that may obstruct the pas- 
sage of the tube. In addition, a bed-pan or a douche-pan should be 
provided. 



Fig. 530. — Rectal tubes. 



Formulary. — For simple cleansing purposes or to produce a" 
evacuation in mild cases of costiveness an enema consisting of nonon^' 
salt solution (dr. i (3.9 gm.) of salt to i pint (473.11 c.c.) of waf" 
water) or the soap-suds enema, made by adding to i quart (946 c.c; 



ENEMATA AND ENTEROCLYSIS. 499 

of hot water sufficient castile soap scrapings to make suds, may be 
used. The continued use of the latter is not advisable, however, as 
some irritation may be caused by the lye which is apt to result in proc- 
titis or skin eruptions. 

In habitual constipation the injection of from 2 to 6 oimces (59 to 
1 78 cc.) of warm sweet oil into the bowel or the use of the flax-seed 
gyiema will often give good results. The latter is prepared by adding 
X ounce (31. 10 gm.) of flax-seed to i pint (473.11 cc.) of cold water 
^uJid then boiling the mixture for ten minutes. The resulting muci- 
l^igbous mixture is strained and injected while warm. Another 
enema consists of equal parts of milk and molasses. When 
more profound effect is desired there are a number of drugs that 
y be incorporated in the enema. Of these may be mentioned 
live oil, castor oil, glycerin, ox gall, turpentine, magnesium sulphate, 
Ci^rlsbad salt, etc. The following combinations of the above will 
t>« found useful: 

IJ Olive oil or castor oil, oz. ii (59 . 2 cc.) 

Warm soapy water, oz. iv (118.40.0.) 

9 Glycerin, oz. i (30 cc.) 

Olive oil, oz. iii (89 cc.) 

Warm soapy water, oz. iv (118. 4 cc) 

H Oxgall, dr. ii (7.8 gm.) 

Warm water, O i (473.11 cc) 

^ Oxgall, dr. ii ( 7.8 gm.) 

Glycerin, oz. iv (118. 4 cc) 

Warm water, O i (473.11 0.0.) 

I) Magnesium sulphate, oz. i (31.10 gm.) 

Glycerin, oz. ii (59.2 cc) 

Warm water, oz. iii (89 cc) 

Q White of egg (beaten), 

Oil of turpentine, dr. i (3 . 75 cc) 

Olive oil, oz. i (30 cc) 

Warm water, O i (473.11 cc) 

^ Magnesium sulphate, oz. ii (62 . 2 gm.) 

Oil of turpentine, dr. ii (7.50 cc) 

Glycerin, oz. ii (59.2 cc.) 

Warm water, oz. iv (118. 4 c.o.) 

For the relief of tympanites a turpentine enema or an enema con- 
sisting of 3 ounces (89 cc.) of milk of asafetida may be used. For 
^^tability of the rectum the use of a small flaxseed enema or the 



THE RECTUM AND COLON. 

Starch-water enema, to which lo to 20Ti\ (0.6 to 1.25C.C.) of laudaouiD 
are added, will often give great relief. The starch-water enema Is 
prepared by adding to an ounce (31 . 10 gm.) of starch sufficient cold 
water to form a thick paste; enough boiling water is then added lo 
dilute this mixture to the consistency of mucilage. 

Temperature.— The enema should be given warm — at a temper- 
ature of about 100° F. ^unless contraindicatcd. 

Rapidity of Flow. — The solution should always be injected slowly 
to avoid discomfort and spasm from a sudden distention of the bowri. 
The reservoir is consequently elevated about 2 to 3 feet {60 to gocm.l 
above the patient. 

Quantity. — To stimulate peristalsis and produce an evacuation 
of the bowels a bulk of liquid sufficiently large to distend the walk of 
the intestine should be injected. For this purpose between i pint 
(473. II c.c.) and I quart (946 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 inamount,asa 
rule containing only 2 or 3 ounces (59 to 89 c.c.) of Suid. 

Position of the Patient, — The dorsal, the Sims, or the knee-chest 
position may be utilized. In the case of the two former the hjps 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 when placed upon the attendant's lap, lying upon the back. 

Technic. — The tube is first well lubricated with vaselin, and any aii 
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 at 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. Haiing 
traversed the anal canal, the tube enters the rectum proper, and is 
then slowly advanced in an upward and slightly backward direction. 
From this point some difficulty may be met with in passing the tube, 
as it often doubles upon itself from the point's catching in a fold of 
mucous membrane or one of the vah'cs or from being obstructed by 
feces. Withdrawing the tube slightly and advancing it will oflen 
suffice lo free it; in other cases allowing the fluid to flow as the tube is 
advanced displaces or removes any obstruction 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 grea' 
discomfort, provided gentleness and no force be employed. 



ENEMATA AND ENTEEOCLVSIS. 



501 



When the tube ia introduced to the desired height, the reservoir is 
elevated a distance of 2 or 3 feel (60 to 90 cm.), and its contents are 
allowed to enter the bowel slowly (Fig. 531). The patient is apt to 
complain of fulness in the rectum as the fluid enters and distends it, 
but, by temporarily stopping the flow, this feeling soon passes off, and, 
as the rectum becomes tolerant to the pressure, more fluid can be 
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 as long as possible before using the 
bedpan, certainly for five or ten minutes at least 




Fio. sji.— Method ot giving a low enema. (Macfarlane.) 

Enteroclysis. — Like enemata, urigations are used mainly for 
cleansing purposes, to remove putrefying material or toxins from the 
bowels, and to bring medicated fluids into contact with diseased areas 
of mucous 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 entero- 
clysis, the bowels are thoroughly cleansed and absorption of 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 enteroclysis has a wide 
field of usefulness in the treatment of renal insulficiency, uremia, 
toxemia, general septic conditions, etc., producing marked diuresis, 
and not only diluting the toxins in circulation, but favoring their 
elimination. 

Enteroclysis with hot normal salt solution, through the stimulating 
effect on the circulation and the elevation of bodily temperature, 



S03 



THE RECTUM AND COLON. 



produces marked and beneficial results in shock due to whatever cause 
(see Saline Rectal Infusions, page 508). 

In proctitis and in catarrhal, dysenteric, and ulcerative condtuons 
of the large Ixjwel irrigations are employed for cleansing purposes, 
remo\ing foreign substances, mucus, and pus, and thus renderag 
bacteria less active; they also sen'c as a means of bringing medicinal 
agents in contact wi'h 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 hemorrhoids or 
hemorrhage from ulcers situated in the rectum or lower bowel. Such 
irrigations are likewise employed in genitourinary and g>-necolopcal 
practice for the treatment of congestion and inflammalion locaiiil 
in the bladder, prostate, and deep urethra, or the uterus and iis 
appendages. 

Apparatus. — The ^ese^^'oir for the solution may be either a quan- 
glass irrigating jar or a fountain syringe, attached to which is about 
6 feet (180 cm.) of rubber tubing 1/4 lo 3/8 inch (,6 to 9 mm.) 




Fig. 53*, — Apparati 



in diameter. Irrigating tubes come in two styles: a single-flow tut^^ 
in which the fluid enters and escapes through the same tube, and 
double-current tube^ in which the inflow enters and the outflow escap^^ 
through different compartments. 

In irrigating with a single tube, it will prove most satisfactory 
to use a colon tube about 20 inches (50 cm.) long and 3/8 to i/s-* 
inch (9 to 12 mm.) in diameter, with the opening at the end. Wilt^ 
this form of tube fluid may be deposited high in the colon or low ic* 



ENEMATA AND ENTEROCLYSIS. 



503 



the rectum at will. For infants, a catheter, 16 to 18 French, may be 
used. The irrigating tube is connected to the end of the rubber tub- 
iig of the irrigator by a T-shaped glass tube, to the long arm of 
which is attached a short piece of rubber tubing closed by a clip 
(Fig. 532). The solution is passed into the bowel with this clip 
closed, and when it is to be drawn off the inflow of solution is tempo- 
rarily stopped by pinching the tubing between the glass connection and 
tlie irrigator, the clip is opened, and the fluid returns through the same 
t:xibe and escapes through the long arm of the T-tube into a waste pail 




Fig. 533. — Kemp's return-flow irrigator. 

^"'cady for that purpose. The same thing may be very simply accom- 
I>Iished with a long colon tube and a funnel (see Fig. 529). The solution 
^s forced in through the funnel, and, when sufficient has entered the 
■^owel, 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 
^^^gation. A very efficient double-flow apparatus, especially for high 
^^■^gating, may be improvised by passing a moderate-sized single-flow 
^^V>e high into the bowel, alongside of which is inserted a second tube 




Fig. 534. — ^Tuttle's return-flow irrigator. 

larger caliber to carry off the return flow. There are any number of 

^^xellent double-flow irrigators on the market, of which Bodenhamer's, 

hemp's (Fig. 533), or Tuttle's tubes are satisfactory models. These 

itistruments are made of hard rubber so that they may be readily 

sterilized. Tuttle's irrigator (Fig. 534) consists of a cylinder enclosing 

a smaller tube which opens at the end of the irrigator. This 

smaller tube conducts the fluid into the bowel. The outside cylinder 

\ias numerous openings in its sides to carry off the outflow. It ends in 

a discharge tube to which a long piece of rubber is attached to carry off 

the waste. 



i 



504 THE KECIDU AND COLON. 

A bath- thermometer, a douche-pan or a bedpan, a slop-pail, 
and rubber sheeting to protect the bed complete the neassitj 

equipment. 

Solutions for Irrigation.^Tn the great majorily of cases, unless i 
specific action is required from direct contact of remedies with the 
surface of the intestine, normal salt solution (dr. i (3 . 9 gm.) of salt to 
a pint (473 . 1 r c.c.) of warm water) is used. For cleansing purposes 
and to aid in the expulsion of flatus, 5 to 15 rry (0.3 to 0.92 cc.) of 
oleum cinnamomi or oleum menthie piperitie may be added to each 
pint of solution. 

The following solutions will be found useful in catarrhal or 
ulcerative conditions of the lower bowel, according as towhfthcra 
soothing, antiseptic, stimulating, or astringent action is desired; 
aqueous extract of krameria, i to ao; fluid extinct of Hydrastis, i to ;o; 
fluid extract of hamamelis, i to 50; baric acid, i to 20; hydroj!" 
peroxid, 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 
acid, I to 500; quinin, i to looc; argyrol, i to 1000; tannic acid, i to 
500; silver nitrate, i to 2000, etc. In using the more powerful anit 
poisonous drugs, such as carbolic acid and bichlorid of mercury, tor 
instance, any excess of solution remainuig in the bowel at the 
completion 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 simple 
 cleansing purposes and in the treatment of colitis and dysenterj* ihe 
irrigation should enter the bowel at a temperature of 100" to 105° F- 
Hot irrigations (110° to 115° F.) are indicated when the stimulating 
action of heat is desired, or for the diuretic effect and to increase the 
eliminative action of the skin, and for the effect of heat upon inHam- 
mations of neighboring organs. 

Cold enteroclysis (65° to 70° F.) has a beneficial action upon the 
whole intestinal tract, toning up the mucous membrane and stimulating 
the muscular tissue, and so increasing peristalsis. This is indicated m 
the treatment of internal hemorrhoids, inflammatory conditions of the 
rectum, prostate, deep urethra, etc. In hemorrhage from the bowel. 
\-ery cold (50° F.) or \ery hot (i 20° F.) irrigations are used. It should 
not be forgotten, however, that prolonged enteroclysis with verj' hoi or 
very cold fluid will cause a rise or lowering of the bodily tempcralur^ 
amounting to several degrees. 

Rapidity of Flow. — The fluid should enter the bowel with com- 



ENEMATA AND ENTEROCLYSIS. 505 

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 irrigation of from ten minutes to one-half, 
an hour or more at a time gives the best results in shock, septic con- 
ditions, toxemias, inflammations in the organs adjacent to the bowel, 
etc. Several gallons of solution are needed for such an irrigation. 
On an average, from i to i 1/2 pints (473. 11 c.c. to 710 c.c.) of solu- 
tion in high enteroclysis, and from 2 to 8 ounces (59 to 236 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 membrane 
of the bowel, the irrigation is continued until the solution returns clear. 

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 thoroughly, the posi- 
tion 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 entero- 
clysis as were detailed for giving an enema. The tube, well lubricated 
with vaselin or oil, is grasped in the fingers of the right hand not far 
from its extremity, while the left hand separates the patient's buttocks. 
The patient is instructed to strain suflSciently 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 cm.) and then upward and slightly backward toward 
the sacrum. There is very little difficulty in passing a rectal tube or 
an irrigating nozzle the necessary distance for a low irrigation, if the 
normal direction of the bowel is followed, a well-oiled tube almost 
slipping in of its own accord at times. To pass a flexible tube the 
remainder of the way into the sigmoid is not so simple, as it is not 
possible to guide the tube after it gets 3 or 4 inches (7 . 5 or 10 cm.) into 
the bowel, and it has to practically find its own way along. It will be 
found a distinct aid, however, in accomplishing this if the solution is 



5o6 THE KECTOU Ain> COLON. 

allowed to flow gently as soon as the anal canal is passed. This tends 
to make the tube stifier and at the same time it straightens out the 
folds of mucous membrane and carries the valves out of the way, which 
mi^t otherwise form obstructions. When the tube has been inserted 
to the desired distance, the reservoir is raised 3 or 4 feet (90 or 120 cm.), 
and the washing-out process begins. 

In performing enteroclysis with a single tube, i to i 1/2 quarts 
(946 to 1419 c.c.) of solution — depending upon the capacity ajid toler- 
ance 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 




Fic. sjs. — Showing one method of irrigating the bowel with a tingle tube. 



desire on the part of the patient to expel it be resisted a few 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. 535), or, if a funnel constitutes 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. 536). This 
process of lavage b repealed until the fluid returns clear. 



ENEHATA AND ENTEKOCLYSIS. 



507 



The colon may be more thoroughly irrigated, as already mentioned, 
by altering the patient's position as follows: With the patient in the 
Sims position, for instance, and with the hips elevated, the descending 
:o]on is first thoroughly washed out About i 1/2 to 2 pints (710 to 
P46 C.C.) of solution are then retained, and the patient 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 transverse and 




13 of a funnel and 



iscending colon. To allow the solution to gravitate down the ascend- 
ng colon to the caput coU, the patient's shoulders are raised slightly 
ligher than his hips. The process is then exactly reversed: the 
.boulders are first lowered, the patient then rolls to the dorsal position, 
ind finally to the left side again. 

In using the double-flow style of irrigator, the outflow tube is 
;ompressed until a pmt (473 . 1 1 c.c.) or more of solution runs into the 
x>wel (Fig, 537), when it is released, the solution still continuing to 




Fig. 53;. — Shoiving the method of irrigating Uie bowel by meaosofa re(um-flow irrisalw- 



SALINE RECTAL INFUSIONS. 

The value of saline infusions in the treatment of hemorrhage and 
in the pretention and relief of surgical shock has already been con- 
sidered in Chapter V. The rectal infusion, being a somewhat slowft 
and less effective method of introducing salt solution into the circulation 
than either the intravenous or the subcutaneous methods, is usedwiin 
greater success in the milder forms of shock and hemorrhage, and in 
the se\'cre cases as an adjunct to intravenous infusion or hypodertntf 
clysis. It has, however, the distinct advantage of simplicity overlW 
other two methods, requiring no preparation of the patient and but 



SALINE RECTAL INFUSIONS. 509 

the crudest form of apparatus; hence its value as an emergency measure. 
In septic conditions, toxemias, renal insuflSciency, 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 products 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 purging, 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 gradu- 
ated glass irrigating jar or fountain s)rringe, 6 feet (i8o cm.) of rubber 
tubing, about 1/4 to 3/8 inch (6 to 9 mm.) in diameter, and a rectal 
tube, 20 inches (50 cm.) long and 3/8 to 1/2 inch (9 to 12 mm.) in 
diameter. In an emergency, a large funnel will answer as a reservoir, 
^nd a large long soft-rubber catheter will take the place of the rectal 
tube. 

Solution. — Normal salt solution, (dr. i (3.9 gm.) of salt to a pint 

C473.11 C.C.) of water) is used. For a stimulating effect, whisky or 

t>randy, oz. ss. to oz. i (15 to 30 c.c.) may be added. In surgical 

^hock 30 TT^ (1.9 c.c.) of a I to 1000 solution of adrenalin chlorid may 

t>e added to the enema for the purpose of raising blood pressure. 

Temperature. — The solution should enter the bowel at a temper- 
ature of no® to 115° F. As there is but little loss of heat on account 
^f the rapidity of the flow, the solution in the reser\'oir should be at 
^e same temperature at which it is desired to have it enter the bowel, 
^^ not more than one or two degrees higher. 

Rapidity of Flow. — ^The fluid should be introduced slowly and not 
^^th such rapidity as to excite intestinal spasm. With this in view, 
tJ>e reservoir is held not over 3 to 4 feet (90 to 120 cm.) above the 
t>atient. 

Quantity. — Small amounts are more apt to be retained by the bowel. 
^rom 1/2 pint (236 c.c.) to a quart (946 c.c.) may be given at a single 
Uijection. 

Position of the Patient. — ^The infusion may be given with the patient 

preferably 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 solu- 



lion of the proper temperature, and a thermometer is placed in it ftat 
the temperature may be kept uniform. The rectal tube should be 
well lubricated with vaselin or oil. Some of the solution isihen 
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 extremiiy while the left hand 
separates the buttocks. As the patient strains slightly, relaxing the 
sphincter, the lube 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— iniisl 
be kept in the mind of the operator. When the internal sphincter is 
passed, the solution is again allowed to flow gently, in order lo displace 
any feces, folds of mucous membrane, etc., that might act as an obstruc- 
tion, and the tube is pushed on into the bowel for a distance of at least 
8 to 10 inches (20 to 25 cm.). The resen'oir is then raised from j 10 
4 feet (90 to 1 20 cm.) , and the required amount of solution is introduced. 
If it is injected slowly and the tube is passed high up, no difficult)' rfl 
be found in introducing and having retained often as much as aquatt 
(046 c.c.) of solution. At the completion of the operation the tube is 
withdrawn and the patient is instructed to remain quiet in the recum- 
bent position. 

COHTINUOUS PROCTOCLYSIS. 

By this method a continuous stream of saline solution is instilled 
into the rectum at very low pressure. Given slowly, so as not lo 
irritate the rectum, enormous quandties 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 quandty of fluid absorbed reverses the lymph 
currents, so that, instead of absorption taking place from the peritoneal 
surface, the lymphatics pour out fluid and wash out the peritoneum, 
as it were. At the same time, stimulation of the heart and kidnep 
results, and with the latter an increased elimination of toxins and septic 
material. WTiile employed mainly in cases of peritonitis, where ihe 
results have certainly been mar\-eIous, continuous proctoclysis «tI' 
be found an excellent means of infusing salt solution in any sepuc 
condition or general toxemia, shock, uremia, etc. 

Apparatus. — A glass reservoir or a fountain syringe with a capacity 
of at least 2 quarts (1892 c.c.), 3 to 4 feet {90 to 120 cm.) of rubber 
tubing 1/4 to 3/8 of an inch {6 to 9 mm.J in diameter, and a vaginal 



CONTINUOUS PROCTOCLYSIS. 



Sii 



nozzle of hard rubber with numerous openings on the sides, bent at an 
angle of 35 degrees about 2 inches (5 cm.) from the tip (Fig. 538) 
ianns the simplest apparatus. Hot-water bags or hot-water cans, 
which surround the reservoir and prevent the solution from cooling, 
should also be provided. 

Saxon has devised an apparatus especially for proctoclysis (Fig. 
539), consisting of a copper bucket, inside of which is placed a glass 
resen'oir for the salt solution. Between the copper bucket and reser- 




Fto. 538.— A very ample apparatus for continuous proctocIjW. 

Voir is provided a space of 2 1/2 inches (3 . 7 cm.) for hot water. A 
thermometer is placed in the tubing which leads from the reservoir, 
^nd a vent pipe for the escape of flatus is also provided. 

A very simple apparatus is described by Iversen {Jour. Am. Med. 
Assoc., Jime 12, 1909) in which the solution is kept at the required 
temperature by means of an 8-candIe-power electric lamp. The 
mechanism is sufliciently clear from the accompanying illustration 
(Fig. 540). There are a number of more elaborate forms of apparatus 
made, however, in which the heat is furnished by a thermolite warmer 
Off by electricity. 

Sohition. — Normal salt solution, dr. i (3.9 gm.) of salt to a pint 
(473. n cc) of water, should be used. 



5" 



THE RECTUM I 



Temperature. — The solution should be at a lemperaturc of about 
100° lo 105° F. as it enlers the rectum, and it must therefore be at 1 
temperature of from 120° to 130° F. in the resen-oir. The solution 
must be kept at a uniform degree of heat by either constantly replenish- 
ing with hot solution or by surroundmg the resen.'oir with hot-walei 
bags, unless one of the special heating devices is employed. 




Fio. 539. — Saion's apparat 

Fig. 540. — Ivereen's apparali 

eleclric bulb; 6, cock; c, Y-shaped 



proctoclysis. 

cloclysis. il, Eght-candlc-pu»'" 
i, vent tube for the escape li 8^ 



Rapidity of Flow. — ^The salt solution Just trickles into the bowel, 
not much faster than it is absorbed, at about the rate of 60 to So drops 
(3-75 to 5 c.c.) a minute. In this way 1 1/2 pmts (710 c.c) will 
flow into the rectum in about two hours. The reser\'oir should "^ 
elevated only from 4 lo 18 inches (10 to 45 cm.) above the leve! of ihc 
rectum, depending upon the rate of absorption, and the elevation of 
the reservoir must be so regulated that no accumulation of fluid occurs 
in the bowel. 

Quantity. — The instillation is practically continuous, and the 
quantity of fluid introduced is limited only by the absorbing power 01 
the rectum. From 6 to 15 quarts (6 to 15 liters) may be absorbed 10 
twenty-four hours. Murphy has given as much as 30 pints (15 liters) m 



b 




CONTINUOUS PROCTOCLYSIS. 



513 



Iirenty-four hours to a child of eleven. It was all retained. Monroe, 

however, sounds a note of warning against overuse of this method, 

claiming that it is possible for a patient to absorb more fluid than can 

be eliminated, shown by an overfull pulse, by cough, and by r&les from 

edema of the lungs. 

Technic. — The reservoir is filled with solution and sufficient fluid 
|9 allowed to escape to expel any air from, the tubing. The right- 
^i^gled nozzle, well-lubricated, is introduced into the rectum just 
l>«yond the sphincter muscle, so that the angle fits closely to the anus, 
^vid is secured in place by adhesive plaster passing to the thigh (Fig. 
^^i). The reservoir is then raised about 6 inches (15 cm.) — ^Just 




— SiiuTriii)( iiic mcinou oi auminiaienng ( 
Noble.) 
Strap fastening the tubing to the ihigh; 
of 35 degrees. 



proctoclysis. (Kelly ftnd 



b, vaginal nozzle bent a. 



^efficiently high to overcome the intraabdominal pressure and allow 
y»e fluid to trickle into the bowel. Forceps or other means of con- 
striction should not be applied to the tube to regulate the flow, unless 
the apparatus be provided with an accessory vent to carry off the 
flatus, as they interfere with the free expulsion of gas through 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 defeca- 
tion, as the constant reinsertion will prove irritating to the rectum. 




It is rarely necessary to continue the proctoclysis for more than thrte " 
or four days. Exact technic and almost constant attention on the pirt 
of the nurse are necessary to gain success with this method, 

HUTRIENT ENEMATA. 

The nutrient enema is employed in cases when feeding by Iht 
natural way is undesirable or impracticable. Rectal feeding has ils 
time limitations, howe\-er. The capacity of the rectum is small,and I 
absorption is considerably slower than by the natural way, so that onlj 
about a quarter of the amount of nourishment necessary for sustenance 
can be given in this way. As a temporary ei- 
pedient or as an adjunct to natural feeding it is 
most useful, but for permanent feeding it is 
quite impracticable. If it alone is depended 
upon for nourishment, life can rarely be jin>- 
longed for more than four to six weeks, though 
it is true that certain exceptional cases ha« 
been reported where patients have Ii\'ed exclu- 
sively upon rectal feeding for longer periods. 

Indications. — i. In cases where some impedi- 
ment to the passage of food exists, as esophageal 
stricture, new growths encroaching upon ihe 
esophagus, and in pyloric or duodenal stenosis. 
2. In incessant and uncontrollable vomiting, y 
In any condition where it is desirable to give the 
alimentary tract a rest, as in acute inflammaiioD 
or ulceration of the upper part of the alimentan' 
canal, acute gastritis, gastric ulcer, typhoid {ever, 
Fig. S42.-Funncl and ^^^ lesions of the small intestine. 4, As an 
colon tube for adminii- adjunct to natural feeding in any condition when 
tering nutrieni cneraata. the patient cannot receive sufficient nourishmeni 
by mouth. 
Apparatus. — A large glass funnel, 2 to 3 feet (60 to 90 cm.) of 
rubber tubing 1/4 to 3/8 of an inch (6 to 9 mm.) in diameter, and a 
plain rectal tube 20 inches {50 cm.) long, Xo. 35 French in size (Fig. 
542) make a simple and very effective apparatus, and one that can 
be easily cleaned. If desired, a hard-rubber syringe with a capacH)' 
of from 4 to 6 ounces {118 to 178 c.c.) (Fig. 543) or a Davidson s>Tingf 
attached directly to the rectal tube may be used. In children a No- '° 
to 20 French ordinary rubber catheter is substituted for the iKial 
tube. 



} 



NUTRIENT ENEMATA. 



SIS 



Asepds. — ^The tube should be boiled before using, and it must be 
carefully cleaned after each injection. S)ninges, if employed, should 
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 




Fig. 543. — Colon tube and syringe for administering nutrient cnemata. (Ashton.) 



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 absorption. 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 (59.20 c.c), ammonium carbonate gr. xx 
(1.3 gm.), and beef tea q.s. ad oz. viii (236 c.c). A pint (473. 11 c.c.) 
of black coffee alone has also a marked stimulating effect. 

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 (89 c.c), and liquor pancreatis dr. ii (7.5 cc.) 



(s) One raw egg; salt, gr. xv (0.97 gm.); brandy or whisky oz. ss. 
(15 C.C.); and peptonized milk oz, iii (89 c.c). 

{3) One egg; liquor pancrcatis dr. ii (7.5 c.c); and beef juice oz, 
iii (89 ex.), 

(4) One raw egg, and peptonized milk oz. iii (89 c.c.}. 

(5) Salt, gr, XV (0.97 gm.); beef juice oz. i {30 c.c); and peptonized 
milk oz. iii (89 c.c). 

(6) Yolk of one raw egg; brandy or whisky dr. n {22.5 c.c); 
!if[iior pancreatis dr. ii (7.5 c.c); and beef-tea oz. iii (89 c.c). 

Temperature. — Give the injection at a temperature near thai of 
thf body, about 95° F.— never cold or very hot — as peristalsis may In: 
excited and the rectum will probably reject the feeding. 

Quantity. — Only a small amount of food should be injected al one 
time, usually i lo 6 ounces {30 to 178 c.c), depending on the reiaininj 
capacity of (he rectum and whether the patient is a child or an aduli. 
Large quantities are liable to be expelled by the bowel. 

Frequency of Feedings.— This will depend upon the quantity taken 
al one time. A patient who can retain as much as 6 ounces (178 c.c.) 
need only be fed every six hours. Cases where but small amounts ire 
retained will require thrce-to four-hour interval feedings. 

Care of the Rectum. — A cleansing enema, consbting of salt dr. 11 
(7.8 gm.) lo a quart (946 c.c.) of lukewarm water, is given each morn- 
ing at least an hour before the first feeding. This ser\-es 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 
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 vaselin or wilh 
sweet oil to facilitate its passage and to avoid irritating the rectum. 
The tube is slowly and gently introduced, according to the direclions 
already given for the introduction of the enema or enteroclysis tube wtH 
into the bowel for a distance of 10 to 12 inches (25 to 30 cm.), so as 10 
prevent expulsion of the food and furnish an extensi\-e surface (of 
absorption. To pre\-cnt injecting air, the tube and the reservoir or Ih^ 
syringe are filled with the material to be injected before the lube is 
inserted into the rectum. The fluid must be injected verj' slcfl}'- 
When the proper amount is introduced, the tube is carefully removed 
and the patient is instructed lo remain quietly in the recumbent 



I 



INJECTIONS OF FLUID OR AIR INTO THE BOWEL. 517 

position with the hips elevated for at least half an hour, to lessen the 
:hances of the food l^eing expelled. In cases of marked irritability of 
the rectum, 5 to 10 n\. (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 IN 

INTUSSUSCEPTION. 

The slow injection of bland fluids or air into the bowel may be 
mployed for its mechanical effect in overcoming an obstruction due 
intussusception. Success from either method, however, depends 
irgely upon an early diagnosis of the condition, for disinvagination 
►ecomes more difficult in direct proportion to the length of time which 
Las elapsed from the onset of the symptoms. After the first twenty- 
9iMr hours of an attack, attempts at reduction by means of hydrostatic 
►r gaseous pressure are not justifiabley as tight adhesions, which render 
eduction impossible, or strangulation and partial necrosis of the gut 
/ith the added danger of rupture may be present. The greatest 
Ejection to this method of treatment lies in the fact that in many cases 
t is impossible to tell immediately whether the invagination has been 
educed, and the success of the procedure can only be determined by 
.llowing the patient to come out of the anesthetic and carefully observ- 
ng the symptoms. 

Not more than fifteen minutes to a half hour should be consumed 
a attempts at relief by these nonoperative measures. In ail cases 
)reparations for operation should be made beforehand so that, should 
eduction fail, an immediate laparotomy can be performed. Treat- 
aent by injections is, of course, only applicable when the intussuscep- 
ion occurs in the large bowel, on account of the obstruction by the 
leo-cecal valve to the passage of fluid or gas into the small intestine. 

Treatment by Injection of Fluid. — Apparatus. — A fountain 
yringe or a graduated glass irrigating jar as a reservoir and a rectal 
lozzle or a large catheter, attached to the reservoir by 6 feet (180 cm.) 
>f rubber tubing 1/4 to 3/8 inch (6 to 9 mm.) in diameter, should 
)e provided. 

Solutions Employed. — Normal salt solution — salt dr. i (3.9 gm.) 
o a pint (473. II c.c.) of water — thin gruel or milk and water may be 
ised. 

Temperature. — As the relaxing effect of heat is desirable, the solu- 
ion should be at a temperature of about 105° F. as it enters the bowel. 

Quantity.— The capacity of the colon varies from 10 ounces 



(295 c.c.) in a child of five months to a pint {473- n C-c) or more in a 
child a year old. Not more than i 1/2 pints (710 c.c.) of solution 
should be injected into the bowel of a. child under one year. In an 
adult, ihe rectum and colon hold as much as 9 pints (4385 cc) mih- 
out undue distention. 

Rate of Flow. — The fluid should enter the boweJ in a gradual, 
steady, continuous flow. From ten to fifteen minutes are consumwi 
in injecting the given quantity of solution. 

Amount of Pressure. — Slartmg -with the reservoir elevated about 
3 feet (90 cm.), which gives a pressure of less than 2 poimds, the 
height may be slowly increased to 4 or 5 feet (120 to 150 cm.) if nccts- 
sary. A greater pressure than obtained at the latler elevaiion 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 exltal lo 
produce muscular relaxation is necessary. 

Technic. — The nozzle or catheter is well lubricated with oil or 
I'aselin, and any air is expelled from the tube. The nozzle is then 
inserted into the rectum for several inches, and the resen'oir is elevated 
about 3 feet {90 cm.) and the solution is allowed lo flow slowly into the 
bowel. Escape of the fluid along ihc side >>i the lube is pa-venied by 
tightly packing cotton about the anus and pressing the buttocks fiimly 
together. While the solution is flowing, the abdomen may be rff/ 
gently kneaded or the child may be inverted several times. Diminu- 
tion of the pressure necessary to inject the fluid indicates that disin- 
vagination or else a rupture of the bowel has occurred, and the injec- 
tion should be immediately stopped. 

After a thorough trial by injection, if in doubt as to the result, tte 
solution is allowed to escape and the patient is examined. If there 
were present at the outset a distinct tumor, the success of the procedure 
will be denoted by its disappearance. A tumor still present and retain- 
ing its full 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 



DILATATION OF RECTAL STRICTURES BY THE BOUGIE. 519 

OTdinary 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 distention 
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 pre- 
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 BOUGIE. 

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 curative, 
is a most valuable palliative measure. By means of gradual dilatation, 
the lumen of a stricture may be so much increased in size that the 
patient is relieved of his obstructive symptoms 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 tortuous in shape. 
The bowel above the stricture is often markedly dilated and the rectal 



520 THE RECTUM AND COLON. 

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. 544). 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. 




Fig. 544. — Wales* bougies. 

Rapidity of Dilatation. — The stricture is stretched slowly and 
gradually. 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 
hemorrhage 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 produced which 
induce the very condition it is intended to correct. As a rule, the 
stretching should not take place oftener than every other day. In 
some cases, the lapse of two or three days between each treatment is 
necessary, for the bougie ought not to be reintroduced until all signs of 
the discomfort it has produced have entirely passed oflF. Later, when 
full dilatation has been reached, an interval 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 interv'al. 

Position of the Patient. — The patient is to be in the Sims position, 
with the knees 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 guidance of 



DILATATION OF RECTAL STRICTURES BY THE BO0GIE. $21 

eye through a proctoscope introduced to the seat of stricture (Fig. 
;), as recommended by Tuttle, The adv-antages of this method are 
nous. The greatest gentleness must be observed in inserting the 



Fig. J45. — Method of inserting a bougie into a stricture through a proctoscope. 




Fig. 546 



igies, and under no circumstances should the tissues be lacerated. 
E first instrument should be of such a size that ii enters the stricture 
h ease. The next one, a size larger, is left in place for a few moments, 



522 THE RECTUM AND COLON. 

and then a third mstrument is inserted if it can be done without pain 
to the patient The proctoscope is then withdrawn and the bougie 
left in situ ten to fifteen minutes. 

Following the treatment, an irrigation of hot normal salt solution 
is given, and the patient is kept quiet for a quarter to a half-hour. 
At the subsequent sittings, it is well to commence with an instrument 
a size smaller than the largest one used at the previous sitting. An 
increase in the dilatation is attempted at each instrument. 

COLONIC MASSAGE. 

Abdominal massage is indicated for the relief of chronic constipation 
and its accompanying symptoms the result of the 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 con- 
ditions as gastric or intestinal ulcers, intestinal obstruction, appendicitis, 
hemorrhage from the bowel, inflanmiation 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. 

Duration. — Each treatment should consume from five to fifteen 
minutes. The treatments should be persisted in until the regularity 
of the stools is re-established, to effect which may require several weeks 
or months. 

Frequency. — Treatments should be given daily. 

Preparations. — The bladder and, if possible, the rectum should be 
empty. 

Position of the Patient. — The patient lies in the dorsal position with 
the shoulders and knees slightly elevated, so as to secure as much 
relaxation as possible. 

Technic. — The masseur stands upon the patient's left side and 
begins his manipulations by making light circular movements (eflSeur- 
age), starting at the cecum and following the course of the ascending, 
transverse, and descending colon. The small intestine and the rest of 
the abdomen are similarly manipulated. Then deep pressure and 



THE RECTUM AND COLON. 

and then a third instrument is inserted if it can be done without p^ 
to the patient. The proctoscope is then withdrawn and the bouf^ 
left in situ ten to fifteen minutes. 

Following the treatment, an irrigation of hot nonnal salt solution 
is given, and the patient is kept quiet for a quarter to a half-hour. 
At the subsequent sittings, it is well to commence with an instrument 
a size smaller than the largest one used at the previous sitting. Aa 
increase in the dilatation is attempted at each instrument, 

COLONIC UASSAGE. 

Abdominal massage is indicated for the relief of chronic constipation 
and its accompanying symploms the result of the atony of the intestines, 
in which class of cases, if properly carried out, it is a most valuable 
therapeutic measure, lending to strengthen the muscles of ihe 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 f>erislallic action. 
To be of value, however, it should be performed by one trained for 
such work. Massage is contraindicaled during menstruation and in 
pregnancy, and, of course, in the presence of such pathological con- 
ditions as gastric or intestinal ulcers, intestmal 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. 

Duration. — Each treatment should consume from five to fifi«" 
minutes. The treatments should be persisted m until the regularity 
of the stools is re-established, to effect which may require several weeks 
or months. 

Frequency. — Treatments should be given daily. 

Preparations. — The bladder and, if possible, the rectum should ^ 
empty. 

Position of the Patient.— The patient lies in the dorsal position wi'^ 
the shoulders and knees slightly elevated, so as to secure as mucn 
relaxation as possible, 

Tecbnic. — The masseur stands upon the patient's left side a"'' 
begins his manipulations by making light circular movements (efflenf" 
age), starting at the cecum and following the course of the ascendi'iS' 
transverse, and descending colon. The small intestine and theresio' 
the abdomen arc similarly manipulated. Then deep pressure and 



COLONIC UA5SAGE. 




Tte. 548. — Showing !hc method of kneading the colon. (Bandlcr.) 



i 



524 TtlE RECTUM AND COLON. 

kneading movemenis (petrissage) are substitufed. In these movements 
the whole colon is manipuialed in the first instance by perfonniDs 
zigzag movements while making deep pressure with one hand super- 
imposed upon the other (Fig. 547), and, in the second instance, by 
raising up deep handgrasps of the abdominal muscles and the intestines 
and kneading them by alternately compressing and relaxing llie 
fingera (Fig. 548). In performmg these deeper manipulations one 
will be governed as to the amount of force that may be employed b^ 
the sensitiveness of the patient. Care should be taken that the 
manipulations be not too vigorous, lest some injury to the Wscera result 

AUTO -MASSAGE. 

Massage may be very effectually carried out by the patient himself 
by rolling a ball over the abdomen, beginning at the ceeunn and 
following the course of the colon up the right side, then across ibe 
abdomen, and down the left side in the direction of the descending 
colon. A cannon ball or a wooden ball filled with shot weighing 
3 to 5 pounds (1.4 to 2.2 K-l, covered with chamois or flannel 
(Fig. 549), may be used for this purpose. 




Fig. S49. — Camion ball for aulo-massage of Ihe abdomen. 

THE APPLICATIOH OF ELECTRICITY TO THE RECTUM ABD 
COLON. 

Electricity is of value in conjunction with abdominal massage in 
all forms of constipation, but especially so in the atonic variety. Und^'' 
the stimulating action of the electric current, the nerves, muscles, and 
glandular structures connected with the bowel are favorably influenced, 
so that the peristaltic action and the secretion of mucus are mcreased, 
at ihe same time, the contracting power of the voluntary muscles « 
the abdomen is strengthened- 

Bolh the faradic and the galvanic currents are employed, the former 
being generally preferred for atonic constipation and intestinal paresis 



APPLICATION OF ELECTRICITY TO THE RECTUM AND COLON. 525 

and the galvanic for spastic constipation and painful neuroses. They 
may be applied percutaneously or internally. 

Apparatus .^For the percutaneous applications a large flat sponge 
electrode {Hg. 550) and a small sponge electrode (Fig. 551) will be 
required. When it is desired to make internal applications, a special 
irrigating reclal electrode, such as Boas' (Fig. 552) or Kemp's, and a 
flat abdominal sponge electrode will be required. 



IG, 550. — Large flat sponge eleclrodc. 



Strength of Current — As there b 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 contrac- 
tions 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. 

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 recumbent 
position, with the head slightly elevated and the legs flexed, so as to 
relax the abdominal muscles. 

Technic. — i. Penulanemis Applkalion. — 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 applied 




526 THK RECTUM AND COLON. 

to the abdomen for a few minutes at a time, first over the cecum, tha 
along the course of the transverse colon, and finally along the descenii- 
ing colon. This is supplemented by circular motions with the nega- 
tive electrode over the same regions. Finally, the entire abdomen is- 
similarly treated. 





Fig. 551. — Small sponge Fro. 552. — Boas' rectal electrode. {Dandier.) 

electrode. (Bacdler.) 

2. Rectal Applkaiion. — An irrigating electrode attached to thz»e 

negative pole of the ballery is inserted in the rectum and the positi^'e 
electrode is placed over the spine or abdomen. When the current is 
turned on, saline solution is allowed to flow slowly through the rectaJ 
electrode, carrying the current to all portions of the colon. 



CHAPTER XVII. 
THE imETHRA AND PROSTATE. 

Anatomic Considerations. 

The Male Urethra. — The urethra is a closed canal, composed of 

erectile and muscular tissue, and lined by mucous membrane, extending 

from the bladder to the external urinary meatus. Its entire length is 

frcm 6 1/2 to 9 inches (16 to 33 cm.), depending upon the length of 




Fic. 553. — Section ot ptms, bladder, eie. (Teslul.) 
T, Symphysis pubis; i, prevesical space; 3, abdominal nail; 4, bladder; 5, urachui; 
^1 seminal vesicle and vas defeiens; 7, prostate; 8, plexus uf Santoiini; g, sphincter vi 
>o, suspensory ligament of penis; 11, penis in flaccid condilion; X3, penis in state of erei 
>], gUns penis; 14, bulb o( urethra; 15, cul-de-sac of bulb, a. Prostatic uiethra; *, mem- 
branous urethra; c, spongy urethra. 

Ihe penis. For purposes of description it is dirided into the following 
portions, corresponding to the parts through which it passes: (r) The 
spongy portion, or pars cavernosa, {2} the membranous portion, or 
pars membranosa, and (3) the prostatic portion, or pars prostatica 
ff'ig. 553). Clinically and for all practical purposes, however, it may 
527 



528 THE URETHRA AND PROSTATE. 

be divided into the anterior urethra, that portion Ijnng in front of lie 
anterior layer of the triangular ligament; and the posterior urethra. 
the portion lying behind the anterior layer of Ihe triangular ligameni. 

The Spongy Urethra.— It extends the entire length of ihe corpus 
spongiosum opening externally upon the glans penis as a vertical slii, 
the meatus. The spongy urethra measures on the awragc about 6 
inches (15 cm.). The lumen of this portion of the urethra is noi of 
the same size throughout, but presents two fusiform dilatations, one 
at the bulb, the bulbous urethra, and the other within the glans, the 
fossa naWcularis. 

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 Cow-per's glands open side by side. Scattered all 
through the mucous membrane of the urethra are the urethral glands 
or glands of Littr^. Upon the roof, the mucous membrane is studded 
with small cr>'pt5 or diverticula, Ihe lacunae. The orifices of these 
lacunre open toward the meatus forming liille pockets inio which 
instruments may find their way and be arrested in their passage. 
One of these, the lacuna magna, is especially liable to interfere with 
the passage of instruments. It lies in the roof of the fossa navicularis 
about I inch (3.5 cm.) from the meatus. These mucous glands and 
lacuna; are liable to infection and may become the seal of smal] gonor- 
rheal abscesses. 




Fic. 554.— The interior of the urethra. 
I, Meatus; 2, fossa navicularis; 3, urethral glands; 4. orifices of Cowper's glands; 
inper's glands; 6, ejaculatoiy dutls; 7, sinus pocularis; 8, v 



The Membranous Urethra. — It is ihat portion of the urethra tring 
between ihe two layers of the triangular ligament, and extends from 
the apex of the prostate gland to the bulb of Ihe spongy portion. It 
measures about 1/2 inch 1 1 cm.) in length. The membranous 
urethra is the most fixed, as well as the least distensible of all segmenis 
of the urethra. In its course it pierces both layers of the triangular 
ligament and receives prolongaiions from these structures, and is also 



n 



ANATOMY. 529 

surrounded by the compressor urethrae muscle. Spasm of this muscle 
is a frequent hindrance to catheterization and the passage of sounds. 
Embedded in the j&bers of the compressor urethrae 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. 

Proetatic Urethra. — It measures 3/4 to i 1/4 inches (2 to 3 cm.) 

in length and extends from the internal urethral orifice to the posterior 

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 

^^v-elling, the verumontanum or caput gallinaginis. At the front and 

prominent part of the verumontanum is seen the slit-like opening 

the sinus pocularis, a blind pouch or diverticulum, usually 1/4 to 

^x^3 inch (6 to 8 mm.) in length, which runs up in the substance 

^ the prostate beneath the middle lobe. It is regarded as homologous 

5th the uterus in the female. Within the sinus pocularis or upon its 

are the slit-like openings of the ejaculatory ducts. On each 

de of the verumontanum is a depression, the prostatic sinus into 

hich the openings of the prostatic ducts empty. 

The Caliber of the Urethra. — The caliber of the urethra varies 

dy. While the average diameter is 0.3 inch (0.75 cm.) or 

7 French scale, the individual urethra is not of the same uniform 

liber from end to end, there being a number of constricted and 

ilated portions. The wide parts are: (i) The pars prostatica, 

2) the bulbous urethra, and (3) the fossa navicularis. The narrow 

rtions are: (i) The meatus, (2) the penoscrotal junction, (3) the 

embranous urethra, and (4) the internal prostatic opening. Of 

"^ihese the meatus is the narrowest, and in a normal individual an 

^Jistrument that will pass the meatus should pass the other narrow 

^^X)ints. 

Normally, the walls of the urethra are in contact and on cross 
'lection 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 vertical 
slit 

Curves of the Urethra. — The anterior urethra is freely movable 
and may be made to assume any curve. The posterior urethra is 

34 





53© THE URETHRA AND PROSTATE. 

fixed, however, between the suspensory ligament of the penis and the 
internal vesical opening, and its natural curves are important to bear 
in mind in the passage of instruments. In the prostatic portion the 
direction of the urethra is downward; in the membranous, downward 
and forward; and in the spongy portion, forward and slightly upward 
for 2 inches (5 cm.), and then sharply downward. Thus two cur\es 
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. In 
children and in thin indi\dduals, the fixed curve is much sharper, 
while in large, stout men it becomes flattened. A distended bladder or 
an enlarged prostate lengthens it. 

The Female Urethra, — It extends from the neck of the bladder 
to the external urinary meatus, curving downward and a little fon^-ard. 
The female urethra measures i 1/4 to i 1/2 inches (3 to 3.8 cm.) in 
length and 1/4 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 finger. 
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 urelhrae 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 
1/5 to 1/4 inch (5 to 6 mm.) in length, about i inch (2 . 5 cm.) posterior 
to the base of the clitoris. 

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 i 1/2 inches (4 cm.) transversely, i 1/4 inches (3 cm.) 
vertically, and 3/4 inch (1.9 cm.) longitudinally. It weighs 4 to 6 
drams (16 to 23 gm.). The size of the prostate is not constant, how- 
ever, varying greatly in different individuals and depending upon the 



DIAGNOSTIC METHODS. 53I 

age of the patient. In a. childj the gland is only rudimentary, not reach- 
ing 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 h3'pertrophy, the median lobe forms a projection which 




FlO. 555.^ — The prostale gland and seminal vedcles. 

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 forming this union in front 
is spoken of as the anterior commissure and the portioa behind as the 
posterior commissure or isthmus {pars intermedia). 

Diagnostic Methods. 

In the examination of ihe 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 ailments, 
and the patient's description of the present trouble, its onset, 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. 



532 THE UHETHHA AND PROSTATE. 

The examiner should ihen lake up more in detail the smptoms 
complained of by the patient It should lie ascertained whether the 
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 simplj' 
glues the lips of ihe meatus together; whether it occurs only with the 
first urine passed, or in the intervals as well; whether there is any dis- 
charge with defecation; also whether defecation is accompanied by 
pain about ihe 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 presenl al the 
beginning or end of the act ; also whether there is an increased fre- 
quency in urination. The patient should l>e questioned as to the char- 
acter of the stream of urine, its force and caliber; whether there is any 
dribbling; whether the stream is interrupted or suddenly slopped, 
such as would be the case with enlargement of the prostate or in 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 presenl, and their character. More 
exact information upon these latter points, however, will be obtained 
after a complete examination of the urine, 

Hanng questioned the patient along the lines above indicated, 
secretions and discharges, if present, should be collected for eMinina- 
tion (see pages 203. 534), and then the actual examination of the 
urethra and prostate may be taken up. The methods a\-ailable for 
this include: (i) glass tests and injection tests for the purpose of locai- 
ing the seat of the discharge, (3) inspection, (3) palpation, and (4I 
instrumental examination. The use of instruments, however, shoi^ 
not be undertaken if there is an active discharge from the urelkra for 
fear of aggravating the inflammation and producing such complica- 
tions as abscess, stricture, etc. It is far better to postpone such explora- 
tion until the severity of the inflammation and the discharge have 
been reduced by the use of injections or irrigations. 

GLASS TESTS. 

A number of tests have been employed for the purpose of deter- 
mining whether the seal of the pus has its origin in the anterior ot 
posterior urethra. The simplest of these are known as the two-glas^ 
test and the three-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 upon presentii^ 



GLASS TESTS. 533 

liimself for examination he is told to urinate into two glasses or grad- 
uates. He should pass about 2 ounces (59 c.c.) into the first glass 
md the remainder into the second. If the contents of the first glass, 
in which are collected the washings from both the anterior and poste- 
rior urethra, contains pus or shreds revealed by holding the glass before 
El strong light and the contents of the second glass is clear, it may be 
inferred that the anterior urethra is involved, but the posterior urethra, 
if at all, only slightly so. If, on the other hand, the contents of both 
glasses are cloudy or contain shreds, it shows that there is sufficient 
secretion from the posterior urethra to have escaped into the bladder 
md discolored its contents, or that the secretion comes from the bladder 
itself, the ureters, or kidneys. In the former case, the contents of the 
5rst glass is more turbid than that in the second glass; while in the 
latter conditions there is bnt little difference between the two specimens. 

Another method and one that is more certain in differentiating 
>etween an anterior and posterior urethritis, consists in first thoroughly 
rrigating the anterior urethra with a warm boric acid or normal salt 
olution by means of a catheter introduced as far as the bulb, and 
hen having the patient urinate into two glasses. If the contents of both 
glasses are clear, we may be sure the posterior urethra is free. Pus 
)r shreds appearing in the second glass indicate a posterior urethritis, 
)r that they come from the bladder or beyond. 

The Wolbarst Three^Qlass Test. — This is more reliable than the 
wo-glass test, and is also employed for the purpose of determining 
vhether the seminal vesicles are inflamed. The technic is as follows: 
The anterior urethra is washed out with sterile water until the washings 
return clear. These washings are collected in the first glass and 
represent the contents of the anterior urethra. A soft catheter is next 
Introduced into the bladder and a sample of its contents is drawn off 
into a second glass. This represents the bladder urine. If this 
specimen proves to be clear and free from shreds, the catheter is removed 
ajid the patient is instructed to void a little urine into a third glass. 
This glass represents the contents of the posterior urethra. If it should 
be found, however, that the contents 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 
third glass. The prostate and seminal vesicles are next massaged and 
the patient then voids the urine or solution containing pus expressed 
from the prostate and seminal vesicles into a fourth glass. 



THE URETHRA AND PROSTATE. 



IHJECTIOH TEST. 



For the purpose of differentiating between an anterior and a pos- 
terior urethritis, the anterior urethra may be injected with a solutinn 
that will color the shreds in that portion of the canal. A i per cent. 
solulioti of methylene blue is employed. By means of a blunl-poiniwl 
urethral syringe the anterior urethra is filled with the mclhyiene blue 
and the patient is instructed to bold the solution in the urethra for 
about a minute. The solution is then allowed to escape. If upon 
urination the shreds appear blue, they come from the anterior urethra; , 
unstained shreds from the posterior urethra. A microscopical elimi- 
nation may be necessary, however, to determine whether the shreds  
remain unstained. In making this test it is essential that the palienl 
should not have urinated for some time previously. 

INSPECTION. 

In the Male. — In ihe male, inspection of the urethra withoul the 
aid of instruments is limited lo the meatus and the exterior of the canal 
as far as the peno-scrotal junction. Swelling, signs of inflammalion, 
new growths, etc., which present externally may thus be recognJMil. 
While comparatively limited in scope, inspection should never i* 
neglected, but should form part of the routine eitamination. 

Position of Patient. — The patient may siand or be in the ddNil 
position, 

Technic. — The penis is elevated so as to bring its under surface lo 
view and any abnormalities are noted. The 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 obtained upon a slide, and later should be stained ana 
examined for gonococci. 

In the Female.— In the female, the mouth and the vaginal surface 
of the canal in its entire course may be inspected. 

Position of Patient. — The patient should be placed in the dorsal 
position. 

Technic. — The operator, sitting in front, separates the labia and 
notes the condition of the meatus and searches for signs of inflammation, 
the presence of new growths, eversion of the mucous membrane, 
discharges, etc. The presence of the latter may be more readily 
demonstrated by stripping the canal from the bladder forward by means 
of a finger passed into the vagina (Fig. 556). The mouth of the urethra 



PALPATION. 535 

may be exposed by drawing the lips apart by means of the fingers, one 
placed on each side as shown in Fig. 557, In this 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 depressed, 
so that the whole extent of the vaginal surface of the urethra is exposed. 
In this manner tumors, dilatations, cysts, sacculations, etc., will be 
noted. 




Fig. 556. — Method of stripping a discharge Fic. 557. — Method of inspecting the urcthal 
from the urethra. (Ashton.) orifice in the (emale. (Aahton.) 



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 recognized. 

Position of Patient. — The urethra may be palpated with the patient 
standing or in the dorsal position. To palpate the prostate the patient 
should be placed in the knee-chest position, or should bend over with 
the hands resting upon a chair and the thighs separated. 

Technic. — In palpating the urethra the penis should be grasfied 
just behind the glans between the thumb and forefinger of the left hand, 
and, while putting the organ on the stretch, the penile portion of the 
urethra is palpated between the thumb and forefinger of the right hand 
(Fig. 558). It should be noted whether the urethra is elastic, as it 
normally should be, 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 bulging 
the wall of the canal. A cancerous growth will be hard, nodular, and 
adherent. By inserting a sound and then palpating the urethra upon 




Fig. 559- — She 



methud of palpating ihe prostate gland. 



a little urine. The operator standing upon the patient's left ih*'' 
inserts his right forefinjjer. protected by a finger cot and well lubricatwli 
inio Ihe bowel (see Palpation of ihe Rectum, page 480). After passing 
the sphincter, the examining finger comes in contact with the Jotm- 



PALPATION. 537 

branous urethra for a space of 1/2 inch (i cm.)i and then the 
prostate gland is reached. Normally, the latter is not very distinctly 
felt, but in the presence of hypertrophy it readily is, and sometimes 
it is so enlarged that it can be palpated bimanually. Points of tender- 
ness, softening, painful swellings, or a general enlargement 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 examination. 




Fig. 560. — Combined rectal and instrumental 



of the prostate gland. 



This is done by carrying the finger up over each seminal vesicle in 
turn and, while making firm pressure, carrying the finger downward 
over each lobe of the prostate toward its base. The massage will 
force the discharge into the urethra and it may then be collected upon 
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 introduced 
into the bladder, and, by engaging the prostate between it and the 
examining finger (Fig. 560), the extent of hypertrophy as well as the 
amount of induration may be ascertained. 



538 THE URETHRA AND PROSTATE. 

In the Female. — In the female, the entire canal may be explored 
by palpation through the vagina and valuable information 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 the symphysis. 
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 information possible by the means already 
detailed, an instrumental exploration of the urethra, provided the latter 
is not the seat of an acute inflammaiiony for the purpose of determining 
the presence or absence of strictures is the next step. While such 
symptoms as a gleety discharge, dribbling at the end of urination, 
malformation in the shape of the stream, diflSculty in starting 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 careful 
local examination of the urethra that the diagnosis of 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. 

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 tJie slightest force should always be 
avoided. It is only by cultivating a delicate touch that painless 
manipulation of urethral instruments is possible. In making such an 
examination it should be remembered that the passage of an instru- 
ment for the first time may result in a severe chill, and a rise of temper- 
ature. To prevent this, it is well to terminate the examination with an 
instillation of i to 1500 nitrate of silver to lessen the urethral congestion. 
After one exploration the urethra should be given a rest for a few days, 



EXAMINATION BY SOUNDS AND BOUGIES. 



539 



as not infrequently the irritation produced aggravates a chronic 
urethral discharge. 

Instruments. — Blunt steel sounds of the proper curve (Fig. 561) 
are preferable for the diagnosis of strictures of a caliber above 15 





Fig. 561. — Blunt steel sound. 

French. There is considerable risk of injuring the urethra when a 
rigid steel instrument of a size smaller than 15 French is used, and 
it is safer for those not especially skilled in the manipulation of urethral 
instruments to employ woven-silk olivary bougies (Fig. 562) in examin- 




FiG. 562. — ^Flexible urethral bougie. 

ing small strictures. A set 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 whalebone filiform bougies (Fig. 563) are necessary. They 



\ 



Fig. 563. — Filiform bougies. 

are provided with small bulbous points from which they taper for i 
inch (2 . 5 cm.) or so until the full size of the shaft is reached. To 
facilitate the entrance of these instruments into tortuous canals the 
tips may be softened in hot water and then bent into various shapes, 





Fig. 564. — Female sound. (Ashton.) 

as curves, spirals, angles, etc. For diagnostic purposes the filiforms 
should be about 12 inches long (30 cm.). For exploring the female 
urethra a slightly curved steel sound is employed (Fig. 564). 

Asepsis. — Metal instruments are boiled for five minutes in a i per 



S40 



THE URETHRA AND PROSTATE. 



cent, soda solution. The best makes of the silk-elastic instruments 
may also be boiled, but some of the others will not last long if so 
treated, and it is safer to sterilize them in formalin vapor for twenty- 
four hours and then rinse well in sterile water before using. A special 
apparatus (Fig. 565) is required for this, however. It consists of a 
glass cylinder about 16 inches {40 cm.) long with 
a perforated plate near the top for holding the 
catheters and in the base a receptacle for formalin 
tablets. In its absence the instrument may be 
soaked in a i to 30 carbolic add solution followed 
by immersion in a saturated boric acid solution 
and rinsing in sterile water. Whalebone bougies 
may be boiled, though they will not stand pro- 
longed boiling. The examiner's hands should be 
likewise carefully cleaned. 

The glans penis should be first washed with 
soap and water, then with a i to 5000 bichlorid 
solution followed by sterile water. The urethra is 
irrigated with a warm saturated solution of boric 
acid or with a i to gooo solution ol potassium 
permanganate both before and after the examina- 
tion. 

Position of Patient. — The patient should He in 
the dorsal position with his shoulders slightly raised 
and thighs flexed and rotated somewhat outward, 
and near that side of the table upon which (he 
operator stands. The operator takes his place 
just above the patient 's hips and facing the 
patient's side, upon whichever side of the table is 
most convenient for him — generally the left side is 
chosen, 

Xectmic. — In beginning the examination (he largest instrument 
thai will pass the meatus should be introduced. As the meatus is ihe 
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 578). The operator grasps the 
penis behind the corona between the ring and 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 Iceland-moss preparations. 




Fig. 563.— 
alin sterilize 
urethral ins 

for calhelera; c, con- 
tainer for fonnalin. 



EXAMINATION BV SOUNDS AND BOUGIES. 



541 



ii grasped lightly between the fingers of the right hand, and is genlly 
introduced into the meatus. As the point of the instrument is inserted 
ia the meatus ihe handle should lie parallel to the abdominal wall and 




Flo. 566.— Fir 



suiting a urethral sound. 



ir» line with the fold of the groin (Fig. 566). From this position the 
handle is gradually swept to the center line (Fig. 567), and the instru- 
nncnt is further introduced with its point firsi hugging the floor of the 




567. — ^auuil alefi 111 in^eiliug d urethral suund, 



urethra and then gerUly following ihe roof of the canal through the 
rest of its course inio the bladder. The instrument is then pushed 
onward and downward, the penis being drawn over it until the point 




thus pcrmiliing (he point of the instrument to follow the fixed cum? 
of the urethra beneath the pubic arch (Fig. 569). 



£XAU1NATI0N BY SOUNDS AND BOUGIES. 543 

Care must be taken, however, not to raise the handle of the instru- 
ment too soon, that is before the beak has entered well into the bulb- 
ous urethra, as otherwise its point will be made to lodge against the 
upper part of the anterior layer of the triangular ligament instead of 



"■^^W^^^TOjw-. 




ac 570. — Showing false passage of sound from depressing the handle of the 




Fig. 571. — Showing the tip of the sound caught at the anterior layer of the triangular 
ligament. 

altering the membranous portion (Fig. 570). Again, the sound may 
fail to enter the membranous urethra from the point lodging against 
Lhe lower portion of the triangular ligament (Fig. 571). Tiiis may be 
ivoided by depressing the handle and at the same time by lifting up 



544 



THE URETHRA AND PROSTATE. 



on the point of the instmment with Ihe fingers inserted behind the 
scrotum so as to press against the perineum (Fig. 572). 

Hanng passed the beak of the sound into the membranous uretbra 




Fio. sji. — Method t)[ lifting up the tip of ihc sound ubstnicted bj the Ic 
triangular ligament. 




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. 573), provided, of course, that no obstruction has been 
encountered. While this is being done the free hand should mai^ 




EXAMINATION BY SOUNDS AND BOUGIES. 545 

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 ascertained 
whether the beak has entered the bladder or is still in the prostatic 
urethra. Furthermore, by sweeping the beak of the instrument about 
the vesical neck any irregularity or disproportion between the two 
lobes of the prostate will be noticed. 

If an obstruction is met in any portion of the canal, the instrument 
sAould 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 
^Instruction is due either to spasm or to an organic stricture. When 
seat of obstruction is in front of the bulbous urethra, spasm may be 
led out, but an obstruction at the bulbo-membranous junction or in 
€ membranous urethra, on the other hand, is often caused by spasm. 
M> determine this, the instrument is not withdrawn, but should be 
pt firmly and gently pressed against the face of the obstruction for a 
w moments, when, if spasm were the cause, it will in time subside so 
t the instrument can be readily passed into the bladder. Further- 
ore, upon attempting to withdraw the instrument, that characteristic 
of the instrument such as is found in the presence of a tight 
Tganic stricture will be absent. When an obstruction is met deeper 
n 61/2 inches (16.5 cm.) from the meatus, or in the prostatic 
Tethra, stricture may be ruled out; such an obstruction may be due 
an enlarged prostate, a stone, or spasm of the internal sphincter. 
In this way the presence of a stricture is determined and its distance 
^^m the meatus is readily estimated. To ascertain its caliber is the 
^Xi thing. When the examining instrument encounters the stricture 
Q force should be used in attempting to make it pass; instead, that 
^-^rticular instrument is withdrawn, and smaller sizes inserted in 
^ Accession, substituting flexible bougies for steel instruments below a 
"^o. 15 French, until an instrument is found that will readily pass. 
"^f even the smallest-size bougies will not pass, filiforms should be used. 
a general rule, no attempt should be made to pass a filiform on the 
me day that other exploration has been attempted, for after repeated 
Attempts have been made to pass an instrument, the opening in the 
Stricture becomes distorted from pressure of the sounds or bougies, 
^tid for a time is impassable even to a filiform. In using filiforms it 
^Hould be remembered that, owing to their small size, they are liable to 
t>e obstructed from being caught in folds of mucous membrane or in 
^e orifices of the glands and ducts so abundant throughout the urethra, 
35 



546 THE URETHRA AND PBOSTATE:. 

and il is very easy lo make a, false passage wilh one of these instnuncnte 
if undue force is used. If a filiform catches in a pockel or fold of 
mucous membrane, it should be withdrawn slightly, and then genlly 
advanced, or it may be gently rotated as it is advanced. SomeiiniB 
the passage of a filiform will be greatly facilitated by injecting suffi- 
cient sterile oil through the meatus alongside the filiform to thorou^j 
distend the canal, and then, while keeping the lips of the meatus closed, 
ihc instrument is gently advanced. 

\\'hen once an instrument has entered the stricture there can be no 
doubt of this fact from the tightness with which it is grasped bj- the 




Flo. 574. — Showing the method of passing a. filiform bougie through a smalt stricluit b; 
first filling the canal with filiforms. 

Stricture, a sensation, which, once recognized, will not be forgotten- 
Should it not be possible to find the opening with a single filiform, 1I1' 
canal may be filled with them and, by first advancing one and &^ 
another, it will usually be possible to make one engage ia the striclun 
(Fig, 574). Failing by this maneuver, a urethroscope maybeiniro^ 
duccd down to the face o£ the stricture and through it the instrument 
may be passed under direct vision. 

After such exploration the urethra should be irrigated with w»nD 
normal salt solution or wilh a warm saturated solution of boric acid. 

EXAMINATION BY THE BOUGIE A BOULE. 

The bougie ^ boulc or bulbous bougie is employed for the purpose 
of determining the size and length of a stricture. The usefulness of 



EXAMINATION BY THE BOUGIE X BOULE. 547 

this instrument is limited to the anterior urethra, as, if passed into the 
membranous portion, the compressor urethrae muscle is liable to con- 
tract 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 frequently 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 sufficiently 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. 575). The latter are preferable as being less rigid. 
These instruments are made in sizes from 5 to 40. 



o 






Fig. 575. — Urethral bougies k boule. 

Asepsis. — ^The proper sterilization of these instruments has already 
been described in detail (page 539). The hands of the operator are to 
be thoroughly cleaned. The glans penis should be washed off with 
soap and water, and then wiped with a swap wet with a i to 5000 
bichlorid of mercury solution followed by sterile water. The urethra 
should be thoroughly washed out with a i to 5000 potassium per- 
manganate solution, or a saturated solution of boric acid both before 
and after examination. 

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 side and just above his hips. 

Technic. — As large an instrument as will pass the meatus is chosen. 
The operator grasps the penis behind the corona between the middle 
and ring fingers of the left hand, and with the thumb 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. 576). The distance of the obstruction from the meatus is 



548 THE DRETHKA AND PROSTATE. 

measured upon the shaft and the instrument is withdrawn. Success- 
ively smaller sizes are introduced until a. size that will pass the stricture 





*» the size of the stricture is determined. The 
rfHy through the stncture and is then with- 



URETHROMETRY. 549 

drawn until resistance caused by the shoulder of the instrument striking 
the distal face of the stricture is felt (Fig. 577). 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 sub- 
tracting the previous measurement from this gives the length of the 
stricture. In this way the entire anterior urethra to the bulbo-mem- 
branous 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 540). As 
already mentioned, spasmodic contraction of the compressor urethras 
muscle may simulate stricture. After removal of the bougie the ure- 
thra should be irrigated with boric acid solution. 

URETHROMETRY. 

It is a method of measuring the caliber of the anterior urethra by 
means of a special instrument, the urethrometer. This instrument 
lias an advantage over a sound or bougie in that it can be introduced 
through a narrow meatus and strictures of large caliber can be detected 
and measured. At the same time, several strictures may be examined 
by one insertion of the instrument. The method is, however, more 
irritating to the urethral mucous membrane than the use of a sound or 
bougie, and it is only applicable to the anterior urethra. In inexperi- 




«0K^ 



Fig. 578. — Otis* urethrometer. 
a, Instrument open; 6, instrument closed; c, rubber stall to cover the end of instrument. 

enced hands it is often an unreliable method of examination, 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. 578) 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 shape 
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 



THE URETHRA AND PROSTATE. 

extent of expansion. A thin rubljer stall is drawn over the end of 
the instrument when closed, for the purpose of protecting the urelhra. 

Asepsis. — The urethrometer is boiled in a i per cent, solution of 
carbonate of soda. The external genitals are thoroughly cleaned, »nd 
the urethra is irrigated with a mild antiseptic solution. ' The operator's 
hands are sterilized in the usual way. 

Position of Patient. — The patient is placed in the dorsal recumbeni 
posture. 

Tecbnic. — The closed instrument, warmed and lubricated, is 
introduced through the meatus and is passed as far as the bulbo- 
mcmbranous junction. The bulb is then expanded by turning the 
thumbscrew upon the proximal end of the instrument until the patient 
feels a fulness in the perineum. This indicates the normal size of 
that portion of the urethra. The instrument is then slowly withdrawn 
until an obstruction is met. when the instrument is screwed down until 
it is of sufficiently small size to pass and is then again enlarged and 
drawn forward. In this way the entire anterior urethra may be 
measured, and striclures located and calibrated. It should be remem- 
bered when employing this instrument that the urethra is not of 
uniform caliber, but normally is the seat of dilatations and constric- 
tions. Thus, the bulbous urethra is the widest and most distensible 
portion, and the meatus the most contracted. More or less constric- 
tion of the canal is also encountered at the pcno-scrolal junction. 

At the completion of the operation the canal is irrigated with m 
antisepdc soludon. 

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 uriw 
begins to flow. This may vary from 6 1/2 to 9 inches (16 to 22 an). 
but on the average it is 7 1/2 to 8 1/4 inches (19 to 21 cm.). A 
marked increase beyond the normal in the urethral length indicate 
that the proslalic urethra is lengthened and that the prosuie 'S 
therefore enlarged- 
Instruments, — An ordinarj' silk gum-elastic catheter or a catheier 
marki:d off in inches (Fig, 579) may be employed. 

Asepsis. — The catheter is Ixiiled or immersed in a t to 20 carbolic 
acid solution followed by rinsing in sterile water. The external 
genitals are thoroughly cleansed and the urethra is irrigated with a 



URETHROSCOPY. 55 1 

mild 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 without 



Fig. 579. — Catheter marked off in inches. 

obstruction and urine begins to flow when the eye of the catheter is a 
distance of from 7 1/2 to 8 1/4 inches (19 to 21 cm.) from the meatus, 
we may conclude that the prostate is not enlarged. 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 in the routine 
examination of the urethra direct inspection is not always necessary, 
the urethroscope becomes a valuable instrument for the diagnosis of 
conditions in which the 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 thus accurately located and 
their character definitely determined. Furthermore, by means of the 
urethroscope, it is possible to make local applications directly to dis- 
eased areas or to remove calculi, foreign bodies, polypi, etc., (see page 
572). The instrument is also sometimes of value in the treatment 
of strictures, as by its aid it is possible to discover the opening of a very 
tight or eccentrically placed stricture and insert a filiform under 
direct vision. 

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 22 French, preliminary dilatation by means of sounds 



552 



THE URETHRA AND PROSTATE. 



should be carried out. In acute gonorrhea the use of the urethroscope 
is contraindicated. 

Apparatus. — The urethroscope consists of a metal tube supplied 




Fig. 580. — Instruments for urethroscopy. 
I, Chetwood's tubes; 2, tube with light in place; 3, applicator. 

with an obturator to aid in its introduction and an electric light 
for illuminating its interior. The tubes for the use in the anterior 
urethra are straight and are 4 to 5 inches (10 to 12 cm.) long, while 
those for the posterior urethra are 5 to 6 inches (12 to 15 cm.) long; 




Fig. 581. — Swinburne's urethroscope for examining the jxistcrior urethra. 

a 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 (Fig. 581). The caliber of the tubes is from 22 to 
32 French. The illumination is furnished through a two-or 



URETHROSCOPY. 553 

iir-volt lamp from a four-to six-dry-cell battery. In the Chetwood 
stniment, the illumination is supplied by means of a delicate cold lamp 
the distal end of the instrument, while in the Otis lu-ethroscope the 
light is placed at the proximal end of the instrument. In their stead, 
a. head light and Klotz tube (Fig. 582) may be employed. 

In addition to the urethroscope long slender applicators wrapped 
r ith cotton are necessary. 



Fig. 582. — Klotz's urethral tube. 




Asepsis. — The tube and applicators should be boiled; while the 
^ «mp may be immersed in a i to 20 carbolic acid solution and then in 
ilcohol. The operator's hands should, of course, be sterile. The 
[lans penis is washed with soap and water, and is then wiped with a 
^ to 5000 bichlorid of mercury solution. The urethra is to be irrigated 
^^th a warm saturated solution of boric acid or i to 5000 potassium 
^rmanganate solution. 

Position of Patient. — The patient should be upon a flat table in 
the recumbent position for anterior urethroscopy and in the lithotomy 
position for examination of the posterior urethra. 

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 by the urethroscope. 

Technic. — A tube as large as will pass through the meatus should 
be used, as very little information is obtained by inspection through a 
small tube. If the meatus is abnormally small, it should be cut (see 
page 578). The patient voids his urine naturally just before the 
examination is begim. Before proceeding with the examination, the 
patient is instructed to tell the operator if any particular sensitive spot 
is encountered while the instrument is being passed. The penis is 
held vertically upward in the fingers of the left hand, and the tube, 
well warmed and lubricated, and with the obturator in place, is inserted 
through the meatus (Fig. 583), and thence onward until it meets an 
obstruction or reaches the bulbous urethra, proNided the anterior 
portion of the canal only is to be examined. The obturator is then 



554 



THE USETHRA ASD PaOSTATE. 



removed, the light is turned on. and the insmiment is slowly withdrawn, 
the raucous membrane being inspected the while, as it falls over Ihe 
distal end of the lube iFig. 584). If the prostatic urelhrs is to bt 
inspected, the tube is inserted all the way into the bladder. This is 
accomplished by turning the instrument down between the thighs lo 
an almost horizontal position 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 or inlo 
the bladder. Inserting a straight tube into the posterior urcthia 'n 




fiG. 583. — Method of inserting the uiettaraso^K. 



generally painful and it may not be possible without employing locil 
anesthesia; introduction of the cu^^"cd urethroscope is much If'* 
disagreeable for the patient. 

.\s soon as the instrument is inserted to the desired depth, the 
obturator is removed, the light is turned on. and, as the tube is slo'ly 
withdrawn, the different portions of the mucous membrane are inspecie<i 
as they appear in the end of the urethroscope. If a clear riew ofihe 
mucous membrane is interfered with by blood or secretion coUccimg 
in the end of the lube, long applicators covered with cotton should be 
inserted through the instrument and the mucous membrane moppw 
dr?-; care should be taken not to push the tube back in the canal aiKT 



UKETHSOSCOFY. 



555 



the examination has once begun without mserting the obturator, as 
the edges of the tube might cause damage to the parts. 

Before one can become competent m recognizing pathological 
conditions it is necessary that the examiner should be acquainted with 
the normal appearance and color of the urethral mucous membrane. 
Beginning at the posterior urethra in a normal case the central figure 
appears as a cone, the mucous membrane, which is of a dark 
red color, being thrown into longitudinal folds. As the instrument 




Pic. 584. — Showing the method of examining tlie anterior urethra through the urethroscope. 



is withdrawn, the verumontanum comes to view in the form of a 
semilunar curve with the convexity upward (Fig. 585) and the 
mucous membrane appears of a bright red color. By slightly changing 
the position of the instrument, it is possible to obtain a view of the sinus 
pocularis and openings of the ejaculatory ducts (Fig. 586). Upon the 
further withdrawal of the instrument, the ridge of the verumontanum 
become gradually less marked and the mucous membrane takes on a 
paler hue. In the membranous urethra the central figure appears as 
a cone with a central dot, the mucous membrane extending out in 
radiating folds (Fig. 587). In the bulbous urethra the central figure 
changes to a vertical slit with the mucous membrane bulging on each 



1 



55* n 

sidf a=iK. 58S). lo t 

still [mlcr in color. The c 

a vcnical ^lit to a triaitgahropgii; -f^ ^•- 

jundioD it takes, the fonn at a 1 




Pi", 3B\. 

rill, jw,— 



lepciRwsof del 



rilnndliiK to the periphery (fig. 590). la the 
ri'ntrni ri|{tiri- UKuin bccomcfi cone-shaped fFi^ 591I 
mdiittii ll appears as a. vertical slit, the color of the 
thuntfiiiH fntin n pnlc pink to a purplish hup 





i[>l>riirance of ihe membranous uretha. (After Stem.) 
I'lii, vis. I'lip <i|iiH-ar.iinc of the bulbous urethra. (After Stem.) 

In iMiniiiiinn llic urethra through the urethroscope it should be 
■A iiM ritniiiiil wlu'thiT the normal elasticity of the canal is impaired 
iiiil, rhi- is mniniplished by noting the central figure as thelul* 

willulniwu. In ilimnic inflammatory conditions the urclhra 



U2ETHR05C0PY. $57 

becomes more or less rigid and does not immediately collapse over 
the end of the urethroscope as it b withdrawn; instead, the cone-like 
central figure often becomes elongated or else distorted Irom being 
contracted at certain points, if the inflammation is a localized one, 




Flo. 589. Fio. 590. 

FtC. 589. — The appearance of the perineal portion of the spongy urethra. (After Stem.) 
Fig. 590. — The appearance of the urethra at the penoscrotal junction. (After Stem.) 



and, in addition, the whole mucous membrane in such cases not 
infrequently becomes of a. paler hue than normal. Changes in the 
api>earance of the mucous membrane should also be noted. In 
chronic urethritis there will at times be found localized congesttnl 
areas, granular patches which frequently bleed, and superficial ulccra- 




FiG. 591. — The appearance of the pendulous urethra. (.After Strm. 



tions covered with secretion. Inflamed lacuns ap|>ear as rhI (i|n'ninns 
upon the surface of the mucous membrane from which will frt'qiu-ntly 
be seen exuding drops of pus. Retention cysts, iHiiypi. etc., arc 
readily diagnosed by this means. If, during the examination, it is 



558 THE URETHRA AND PROSTATE. 

desired to more closely study the condition of the mucous membrane at 
any particular spot this may be accomplished by 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 irri- 
gated with a warm saturated boric acid or normal salt solution, and, 
if the instrument has been passed into the deep lu-ethra, the bladder 
should also be irrigated. 

URETHROSCOPY IN THE FEMALE. 

The female urethra being shorter and capable of greater distention 
than that of the male lends itself more readily to examination by the 
urethroscope. 

Instruments. — Short male endoscopic tubes or a regular female^ 
urethroscope may be employed. They may be obtained with thfc- 
light at the distal end or, as in the Kelly tubes (Fig. 592), with th& 




Fig. 592. — Kelly's urethral tube-speculum. 

light reflected from a head mirror. The female urethroscope should 
be about 3 inches (7 . 6 cm.) long. The tubes vary in size anywhere 
from 24 to 36 French. 

A Kelly cone-shaped urethral dilator (Fig. 593) should be proWded 
for dilating the meatus. Applicators or alligator-jawed forceps and 
absorbent cotton will also be required. 

Asepsis. — The tubes, applicators, etc., may be boiled for five 
minutes in a i per cent, soda solution. The lamp is sterilized by 



DSETHSOSCOPV IN THE FEICALE. 



SS9 



immersion in a i to 20 carbolic acid solution and then rinsed off in 
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. 

—If the urethra is hyperesthetic, a small pledget of 




Fig. 593. — Kelly's cone-shaped urelhi 



(Ashlo 



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. 

Tecbnic. — The urine is voided naturally before the examination 
begins. If necessary, the meatus is dilated sufficiently to admit a good- 
sized tube by means of a Kelly dilator (Fig. 594). The instrument, 
with the obturator in place and well lubricated, is then inserted into 




Ftg. S04. — Showing the method of dilating the urethra. (Ashton.) 



the mouth of the urethra and is carefully passed into the bladder (Fig. 
595). The obturator is next removed and the lighting apparatus is 
properly adjusted. The instrument is then gradually withdrawn 
while the examiner notes the condition of the mucous membrane as it 
falls over the end of the tube (Fig. 596). 

At the internal urethral orifice there appears through the urethro- 



scope a hrge cpen ^ atHWindcfl by a narrow ring of mucous mem- 
bnac As dK asmaatnt is viihdniirn the central figure becomes 
fast moR onl and Aai iower domi appears as a transverse slit with 
Ac BHic o«» memtnac tbrovB mto folds that radiate to the perif^ry-, 
F1B1II7, St ibc cztnaal onioe Ifae central figure appears as a venial 
tSt, vbSe Ibe anxfNB sKmbmie appears thrown into a number of 





■t>w 



Fkj. 505. — tmniducriaa ol ihe uirthnwrope inlo the female urethra. (Afhlon I 

Fic. yib. — Showing the method of inspecting the female urethra through the urethroscope. 

(.\shion.) 



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 z 
small hand syrinj^c is employed either for simple cleansing purposes in 
preparation for ihe passage of urethral instruments or for the purpose 
of trcaiinj; 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 irritaling discharges and cleansing the 
mucous membrane. They may, however, be prescribed in the acute 



HAND INJECTIONS FOK THE URETHRA. 



561 



Stages in the form of mild antiseptic solutions to be used by the patient 
himself as an adjunct to irrigations carried out by the physiqian. In 
the declining stages of the disease or when the condition becomes 
chronic, astringent injections are of undoubted 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 harmful in not irritating the mucous mem- 
brane. They should not be strong enough to cause more than tem- 
porary 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 membrane 
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 injected into the bladder, 
which, however, rarely happens, as the cut-off muscle interposes a 
barrier. If it should occur, infective material will necessarily be 
carried back into the deep urethra with a good chance of starting up 
a posterior urethritis and epidid)rmitis. For this reason, only a small 
quantity of fluid should be injected at a time and that without force. 
Used with these precautions, injections may be safely employed by the 
patient himself when desired. 




Fig. 597. — Urethral syringe. 



The Syringe. — The best form of instrument for injections is a hand 
syringe with a capacity of about 3 drams (11 c.c). It should be 
preferably of glass so that it can be sterilized by boiling. The nozzle 
should be cone-shaped (Fig. 597) 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 moves easily and without any 
jerks. A basin should also be provided to receive the solution that 
flows back from the urethra. 

Solutions Employed. — Many solutions with soothing, astringent, or 
antiseptic properties are employed, a few of which are given : 
36 



1 Sf" 


THE nSETS&A 


KSD PROSTATE. ^^^| 




Saialhv 
F! eii. hydrastis, 

Aqu* destU,. 


Iftjettiont. 

n|T3-x« (i.a-i.gcc.) 
5i <30 C.C.) 


L 


Morph. sulph , 
Cocaina, 
Muc. hcadx, 
Aqu£e distil., 


gr. %-iii (o.si gm.) 
gr, iv (o.jtigm.) 
Si (JO c.c.) 
(]. s. ad 5ii (60C.C.) 


 , 


.iilrtfi^m/ InjttlioHi. 
Zinci sulphalis, gr. tv-%-iii (0.16-0.51 gm.) 
Aqux distil., Siv {i30 c.c) 


R. 


Zinci sulphocarbolads, 
Aqu^ distil.. 


gr. vi-rii (0.4-0. 78 gm.) 
3iv(i3oc.c.) 


B. 


Plumbi aceucia, 
Aqux disiO., 


gr. iv-xii (0.16-0,78 gm,} 
Sivdioc.c) 


R 


Zinci chloricU, 
Aquae, 


gr, ii-iv(o.»6-o.5igin,) 

Siv (.«. c.c.) 


B 


Zinci stctatis, 
AquarosK, 


gr.i-Tv (0,065-0. Q7gin,) 
5i (30 c.c) 


B. 


Antiseptic Injeetimis. 
Sol. prolargol, 0.25 to i per cent 


B 


Sol, argyrol, 


10% 


- — n. 




1-5000 to 3000 



Temperature. — The solution should be used at about the temper- 
ature of the body. 

Quantity.— Only sufficient quantity of the solution to distend the 
anterior urethra should be injected at a time. At first only about 
3i (3  75 C.C.) should be used at a time; later this may be increased to 
3iii (II c.c). 

Frequency. — The injections should be used 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 remembered, however, 
that in some cases after a time the continued use of injections mV 
prevent a discharge from entirely disappearing, and it is necessai}'"* 
stop ihcm entirely for a week or more before a cure is obtained. 

Position of Patient. — Injections may be given with the patient lying 
recumbent or sitting upon the edge of a chair. 

Preparation. — The glans penis and the lips of the meatus should be 
washed off with soap and water, followed by a i to 5000 solution 01 
bichlorid of mercury. 



HAND INJECTIONS FOK THE USETHRA. 563 

Technic.^ — The patient urinates immediately before the injection 
is ^ven so as to wash out as much of the discharge as is possible and 
also that he may not have to urinate soon afterward, thus allowing 
the solution to remain in contact with the urethra as long a time as 





Fic. 59Q. — Second step in injection of the urethra, holding Ihe solution in the urethra. 

possible. The syringe is then filled with from i to 2 drams {3.75 to 
7 , 50 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 right hand 




the nozzle of the syringe is inserted into the meatus, and the solutionis 
gently injected into the urethra and inamedialely allowed to escape. 
A second syringeful of solution is then injected into the urethra until 
the latter is well distended (Fig. 598). The syringe is then removed 
and the meatus is held together for from three to fi^'e minutes so as to 
keep the solution in contact with the mucous memfjrane {Fig. 599), 
The solution is then allowed to run out into the receptacle protided 
for the purpose. 



IRRIGATIONS OF THB URETHRA. 

Irrigation of the urethra is accomplished by flushing out the canal 
with copious quantities of mild antiseptic solution. It is a method 
employed extensively in the treatment of acute gonorrhea. To be 




Flc. 600. — ValenlLnc irrigator and Chetivood's urelhral irrigaling noulc. 



effective large quantities of fluid must be used and the urethra mu5t 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 treatment, properly 
employed, the intensity of the symptoms is much lessened and the 
duration of the attack shortened. On the other hand, many autho"" 



IRRIGATIONS OF THE URETHRA. 565 

ties oppose this form of treatment on the ground that it increases 
the dangers of prostatic infection and that the virulence of the infect- 
ion is increased. If gentleness is observed and the precaution 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 setting up complications is slight. It is not a 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 an- 
terior and the posterior urethra may be irrigated. 

Apparatus. — An irrigating reservoir that can be raised or lowered 
to any desired height at will, such as Valentine's, a Chetwood two-way 
blunt glass urethral nozzle, a waste-pail, and two pieces of rubber tubing, 
one about 8 feet (240 cm.) long for connecting the inflow with the irri- 
gator and another, a short piece, leading from the outflow tube to the 
waste-pail, are required for anterior irrigations. 




Fig. 601. — Syringe and catheter for irrigating the posterior urethra. 

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. 601) should be provided. 

Solutions. — Mild antiseptic solutions are employed. Those most 
frequently used are : 

Permanganate of potash, 1-6000 to 1-4000 

Bichlorid of mercury, 1-30,000 to 1-10,000 

Silver nitrate, 1-12,000 to 1-8000 

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 (118 to 355 c.c.) of 
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 
sufficient. 



5fi6 THE URETHRA AND PROSTATE. 

Hedght of Reservoir. — The reservoir should not be raised above 4 
feet- {120 cm.). Such an elevation will give all the necessary distention 
of the urethra without forcing the solution beyond the anterior urethra. 
If it produces pain, the pressure should be lessened by lowering ite 
reservoir or partially pinching off the inflow tube. 

Position of Patlent.^For anterior irrigations the patient may stand 
_ or be seated upon the edge of a chair, while for a posterior irrigatioii 
the patient should be lying down. 

Preparation of Patient.— For protecting the clothes the patient 
should wear a rubber apron in which is provided an opening for the 
penis (Fig. 602). The glans penis and lips of the meatus should be 




Fig. 601. — Apron for protecting the patient during ». uiethial irrigation. 



I 



• 



■washed off with soap and water, followed by a i to 5000 biehlorid of 
mercury solution, 

Technlc. — i. Anterior Irrigations. — The patient should empt)!iis 
bladder before each treatment. The operator holds the penis behind 
the glans between the thumb and forefinger of the left hand and, com- 
pressing the rubber inflow tube between the thumb and index-finger of 
the right hand, inserts the glass nozzle into the meatus. He then 
releases the inflow tube, at the same time closing the outflow tube by 
means of his right little finger. As soon as the urethra is filled wi'b 
solution the inflow tube is again pinched, at the same time remo^ng 
the little fmger and thus opening the outflow tube. By thus altemalelf 
opening or shutting the inflow tube, and at the same time shutting or 
opening the outflow, the urethra is alternately distended with soluHO" 
and emptied without the necessity of removing the nozzle. It tatw 




IBXIOATIONS OF THE USETHSA. 567 

t five minutes to thus irrigate the urethra with i quart (i titer) of 
ion. 
Posterior Irrigations. — The anterior urethra is first iizigated as 




j«.— Rm step in irrigating the posterior urethra. Catheter b inserted into the 

bladder uaiil urine be^ns to flow. 

Jescribed. A No. 12 to 18 French catheter, well lubricated with 
if the Iceland-moss preparations, is then inserted into the urethra 
the eye upward until urine just escapes (Fig. 604). After the 



568 TEE DKETHBA AND PROSTATE, 

bladder is emptied, the catheter is then withdrawn i inch (2.5 cm.) 
until its point lies in the prostatic urethra and from 4 to 12 ounces (118 
to 355 c.c.) of the antiseptic solution are gently injected (Fig. 605), 
The posterior urethra is thus washed backward toward the bladder. 




Flc. 605. — Second Ettp m irngaUng the poslenc- 1 urelhra The calheler is wiUidraua 
until its tip lies in the deep urethra an J the sululion is then injected. 

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 urethise. 



INSTILLATIONS. 

Instillations are employed when it is desired to medicate the urethra 
with small quantities of strong solutions. They are indicated in chronic 
gonorrhea, but should not be used in acute cases; they are specially 
useful in chronic posterior urethritis. The object of such injections 
is to induce a hyperemia of the tissues; that is, to substitute an acule 
inflammation in place of the chronic one with the hope that it \nll w 
followed by absorption of the old as well as the new products of inflam- 
mation and by a return to normal. It is a method that may be appliw 
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 postenor 
urethritis when the prostate and seminal vesicles are the seat of an 



INSTILLATIONS, 569 

acute inflammation. Instillations are also valuable in the treatment 
of sexual neurasthenia when inflammatory lesions are present in the 
posterior urethra. 

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. 606), will be found more 
satisfactory. The latter consists of a long curved nozzle of silver, 
provided with a central opening, to the proximal end of which is 
attached a large hypodermic syringe with the piston graduated in 
minims. 



'k 




Fig. 606. — Keyes-Ultzmann instillation syringe. 

Asepsis. — The s)rringe should be sterilized by boiling for five 
minutes in a i per cent, solution of sodium carbonate. The glans 
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 irrigations it is well to start with 
a weak solution, employing it till the urethra becomes tolerant, and 
then to gradually increase the strength. The solutions most frequently 
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. 

Protargol, 0.25 to 10 per cent. 

Ichthyol, 2 to 10 per cent. 

Temperature. — The solution should be given at about the temper- 
ature of the body — say 100° F. 

Quantity. — Ten to twenty minims (0.6 to 1.25 c.c.) 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 Patient. — ^The patient should be lying down upon a 
bed or table. 



57© THE URETHRA AND PROSTATE. 

Technlc. — i- Posterior Inslitlations. — The patient should void his 
urine prc\"ious 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 Iceland-mo« 
preparations, is carefully introduced in the same manner as one would 
pass a sound (page 540) until its point lies behind the compressor 
urethra muscle in the membranous urethra (Fig. 607). This will be 



:oy: 



f\\.:. cu;.— Shvm-ii^ tb« srriDge in poatioa for > d«p uictlinl instilLatioD. 

at a distancv of about 5 i '1 to 6 inches (14 to 15 cm.) from the meatus 
or R>u};hly when the shaft of the instrumeat is at an angle of 45 degrees 
with the horLttui. From 5 10 jo drops (o. 3 to 1 . 25 c.c.) of solution are 
then sJowlv injected. Care must be taken in removing the nozzle of 
the in>irt;nieni to a\vid ha\-ing any solution drip from the point along 
the .mtoriv^r urx-thra. To a\xiid this, the piston of the s>Tinge should 
Ix- withdrawn slvjihUy beforv ihe niizile i? remo\-cd. 

Gtneraliy ihcrx- is considerable burning upon urination following 
a iy>>;i;-rivT ins::lU:k'in and a: times, there may be pain and tenesniui 
and sv>ine d;A."h.iri^' during ;he &rst rwentj^-four hours. As a Tule, 
these synr,>ti.>ms subside w:;hia six to twent^--four hours. If ihe 
ir4Clktn is s^-wrv, howewr. the i\itiec: should remain quietly in h™ 



APPUCATION OF OINTMENTS TO THE URETHRA. 57 1 

and an opium suppository should be introduced into the rectum and 
heat applied to the perineum. 

2. Anterior Instillations. — 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 introduced 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 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 ODrTMENTS TO THE URETHRA. 

Astringent and stimulating ointments are at times employed in the 
treatment of chronic urethritis instead of instillations. They are con- 
sidered by some authorities more efficient than the use of drugs in 
solution, as being more penetrating and more lasting in effect. 




Fig. 608. — Cupped sound. 




Instruments. — Ointments may be applied to the whole urethra, in 
which case an ordinary sound or a cupped sound (Fig. 608) is employed, 
or they may be brought into any particular area by means of Tomasoli's 
or some other form of ointment syringe (Fig. 609). This latter in- 





FiG. 609. — Urethral ointment syringe. 

strument consists of a hollow curved catheter-like nozzle and a 

plunger for forcing the ointment out at the end. 

Formulary. — Unna's ointment for use with sounds consists of: 

^. OL cocae, Siii (89 c.c.) 

Cerae flav., 5ss (i .95 gm.) 

Argent, nitratis, gr. xv (0.97 gm.) 

Bals. peruviani, 3ss (i .9 c.c.) M. 



572 THE URETHRA AND PROSTATE. 

The mixture is melted over a hot-water bath and the sound is then 
dipped into if and the ointment is permitted to solidify by cooling. 
Finger's ointment consists of: 

IJ. Argent, niiratis or cu. sulphatis, gr. sv (o . 97 gm. ) 
01. olii-ie, oiss(5.6c.c.) 

Lanolin, 3iii(89c.c.) M. 

Another consists of: 

R. Pot. iodidi, 5ss(i.95gm.) 

lodi. pur., gr. V (0.32 gm.) 

01. oliiTE, OSS (1.9 e.c. ) 

Lanolin, 3i (30c,c ) M. 

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, and the urethra is cleansed 
by an injection or irrigation. 

Technic. — When a sound is employed, as large a one as will com- 
fortably pass the meatus is coated with the ointment, or if a cupped 
sound is used, the depressions are filled with the ointment, and it a 
passed through the urethra and is left in place about five minules. 
The ointment melts and thus medicates the entire urethral mueoui 
membrane. 

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 URETHROSCOre IN THE TREATMENT OF URETHRAL 
DISEASES. 

By means of the urethroscope or an open wire speculum (Fig. 610) 
lesions in the uretiira may be accurately located and efforts at treal- 
ment can be thus focused on the exact seat of the disease. Endo- 
scopic treatment is thus of great \alue in the presence of locaii«d 
lesions of the urethra which, resisting the ordinary methods of treat- 
ment by irrigations, instillations, etc., are often the cause of a persistent 
gleety discharge. For example, through the urethoscope and by tic 
aid of suitable instruments, strong applications may be made to granu- 
lar patches, erosions, and ulcerations; suppurating glands or follicles 



URETHROSCOPE IN THE TREATMENT OF URETHRAL DISEASES. 573 

may be incised and small growths may be removed from the canal 
under direct vision. 

The technic of using the urethroscope has previously been fully 
described (page 553) so that the application of the instrument to the 
treatment of various urethral conditions will simply be outlined in a 
general way. As has been already emphasized in previous pages, it 
is essential that one should be familiar with the normal appearance of 
the urethra before attempts to employ the instrument for treatment are 




Fig. 610. — Open wire urethral speculum. 




made. Furthermore, the greatest gentleness in manipulation is neces- 
sary to avoid injury to parts already diseased. 

In the treatment of congested and granular patches, erosions, and 
ulcerations local applications of silver nitrate or copper sulphate may 
be made by means of cotton- wrapped probes through the urethroscope 
previously passed to the seat of the disease. In this way strong solu- 
tions of these drugs — 30 to 60 gr. (1.95 to 3.9 gm.) to the ounce 
(30 c.c. ) — which would be extremely irritating if applied to the whole 




Fig. 611. — Urethral probe. 

mucous membrane, may be applied. If the diseased areas are numer- 
ous and extensive the strength of the applications should be somewhat 
weaker — say 5 or 10 gr. (0.32 to 0.65 gm.) to the ounce (30 c.c). 
When using the stronger solutions, care should be taken to make the 
application exactly to the diseased area and not to leave any excess of 
solution to run over the healthy mucous membrane. Such applica- 
tions should not be made too frequently — not oftener than once a 
week — as usually an acute urethritis, often accompanied by a bloody 



574 



THE URETHRA AND PROSTATE. 



discharge, is set up. This, as a rule, subsides in twenty-four to forty- 
eight hours. 




Fig. 6i2. — Urethral knife. 



Areas of indiu'ation may be incised through the urethroscope by 
means of a urethral knife (Fig. 612). Two or 3 drops of a 4 per cent. 





Fig. 613. — Kollman's urethral syringe. 

solution of cocain with adrenalin chlorid should be applied to the dis- 
eased area by means of a cotton-wrapped probe, and the incision may 



^ 



< 



Fig. 614. — Urethral curet. 



then be made without pain. In the same manner abscesses of Littr^'s 
glands or inflamed follicles may be opened. A discharging cr>'pt or 




Fig. 615. — Urethral snare. 



follicle may be injected every few days with a few drops of a peroxid 
of hydrogen solution by means of Kollman's syringe and cannula 



DIRECT APPLICATION OF COLD TO THE URETHRA. 



575 



(T*ig. 613). Polyps and papillomata may be removed by a urethral 
cviret (Fig. 614) or by caustics. If pedunculated, a wire snare (Fig. 
5) or the galvanocautery snare may be employed. In any case the 
of operation should be first cocainized in the manner above 
<1 escribed. 



DIRECT APPLICATION OF COLD TO THE URETHRA BY 

THE PSYCHROPHORE. 

In the treatment of spermatorrhea and sexual neurasthenia where 
urethra is congested or hyperesthetic the direct application of cold 
the deep lu^thra by means of the cold-water sound or psychrophore 
often of value. An ordinary cold sound is also employed in treating 
uch conditions, but is not so eflFective, as the instrument soon becomes 
arm from contact with the urethra. With the psychrophore it is 
pK)ssible to keep a continuous cold application in the urethra as long 
is desired. 




Fig. 616. — Apparatus for applying cold water to the urethra. 

« 

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 portion of the 
instrument to be kept cold. The inflow canal is connected with a 
rubber tube leading from a douche bag or irrigating jar (Fig. 616). 



576 THE URETHRA AND PROSTATE. 

Temperature. — The temperature of the water should be about 
50° to 40° F, to start with. As the urethra grows more tolerant the 
temperature may be lowered. 

Duration of Treatments. — The sound should be left m place for 
from five to ten minutes at a sitting. 

Frequency. — Treatments may be gi\'en 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 540) until the curved portion lb 
in the membranous and prostatic portions of the urethra. The tubing 
from the reser\'oir is then connected with the inflow canal and a curreQt 
of cold water is allowed to pass through the instrument, escaping from 
the outflow canal into a basin provided for the purpose. In this wjv 
the hyperesthetic urethra is exposed to the mechanical effect of the 
sound and the sedative action of cold. 

PROSTATIC SIASSAGE. 

Massage of the prostate gland by means of the finger in the rectum 
is frequently employed, and with good results, in the treatmtci of 
chronic prostatitis in which the inflammation extends deep in the gland 
tissue. The object is to squeeze out of the prostate into the posterior 
urethra as much as possible of the purulent contents of the gland and 
to cause absorption of the products of inflammation from indurated 
areas. It is also used for the purpose of emptying the distended 
seminal vesicles and hastening resolution. It should not be employed 
in acute prostatitis or acute vesiculitis, and care should be taken not 
to perform the massage too vigorously, otherwise the tissues will be 
bruised and the inflammation will be made worse. 

Duration of Treatment — The massage should be carried out for 
two or three minutes at a sitting. 

Frequency. — Unless followed by irritation, treatments may be 
given once every four or iive 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 glo\'c on the right hand or a finger cot on bis 
right index-finger and, after lubricating the index-finger well, intro- 
duces it into the rectum (Fig. 617), canying the finger high up on one 
side over the seminal v-esicle. Firm but gentle pressure is then made 
with the finger over the seminal \'esicle and the finger is slowly drawn 



PROSTATIC MASSAGE. 




'□ of [he patient and method of inlToduciiig the finger into the n 
prostatic massage. 




Fig. 6i8. — Showing the method of massaging the proslatt 



578 THE LTIETHRA AND PROSTATE. 

down over the vesicle toward its duct and also over the corresponding 
lobe of the prostate (Fig. 6i8). This procedure is then repeated upon 
the opposite side, and finally o\-er the central portion of the gland. 
M\ portions of the gland arc thus massaged, but special attention should 
be paid to those portions that are enlarged or diseased. 

After completing the massage the patient urinates, thus emplyirg 
the bladder of pus and debris squeezed out by the massage. 

MEATOTOMY. 

Meatotomy consists in dividing a narrow meatus. It may be 
required as a preliminary to the passage of large instruments 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 prof>erly performed, it is an operation without danger. 

Instruments. — The incision is best made with an Otis meatome 
(Fig. 619) or with an ordinarj' blunt-pointed straight bistoury. 



19. — Ods' meBtome. 

Location of Incision. — The meatus should be cut exactly in the 
median line upon the floor of the urethra. 

Preparations.— The glans penis and meatus should 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 proposed 
incision is infiltrated with a o. i per cent, solution of cocain introduced 
through the frenum or, if desired, by the topical application of a weak 
cocain solution (see page 76). 

Technlc. — 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 distanceot 
I I /a 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 permanently 
maintain it — a meatus that will give passage to a No. 30 F. sound is 
sufiiciently enlarged. If it is found upon inserting an instrument thai 
the constriction has not been entirely cut, any remaining bands should 
be divided. 



) 



TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. 579 

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 without the meatus. Each time the patient urinates 
this plug is removed and a fresh one inserted. Should the bleeding 
be severe, the incision should be grasped between the thumb and fore- 
finger 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 the 
urethra include gradual dilatation, continuous dilatation, and 
cutting 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 that 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 instruments 
of increasing size should be the method of choice when possible, as, 
if properly performed, it is without danger. It is, of course, only 
applicable to strictures which are permeable, but a large proportion of 
such may be successfully treated by this method. It is especially 
suited to those strictures which are fairly recent, soft, and dilatable. 
For old strictures with considerable scar tissue formation, 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 applied to the so-called 
resilient strictures; these, while dilatable, are so elastic that they recon- 
tract 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 complicated by numerous false passages and 



suppurating fistulous tracts, and all strictures near the meatus should 
be cut. For strictures complicated by cystitis, intermittent dilatation 
is likewise undesirable on account of the dangers of pyelonephritis; 
these require cutting of the stricture and free drainage of the hbdder. 

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 suffidenl 
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 [joint in the canal except in the prostatic urethra, 
but the most frequent sites are: (i) in the region of the bulbomem- 
branous junction, (z) within 21/2 inches (6 cm.) of the meatus, and 
(.■5) 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 tbe 
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 ob.siruction and the canal at this fwinl 
becomes more or less dilated and the mucous membrane is thinned 
out. Urine collects in this dilated portion and decomposes, with the 
result that an inflammation is set up accompanied by a gieety discharge. 
This may in time go on to ulceration and extravasation of urine with 
the formation of false passages and fistuke. 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 inflammation and dilatation of the ureters 
and kidney follow, resulting in pyelitis and pyelonephritis. 

Mention is made of these complications because their presence, or 
absence, and severity, if present, are of direct practical importance in 
determining the method of treatment to pursue. It should further be 
borne in mind that the stricture itself is usually congested and the 
mucous membrane is softened and inflamed, so that in performing 
dilalatiofi the greatest care and gentleness are necessary to ai'oio 
lacerating and contusing Ike 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 mildreaC' 
tionary hyperemia, which is accompanied by softening and absorption 



TREATMENT OF STMCTITRES BY INSTRUMENTAL DILATATION. 58 1 

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 simply aggravated. 

Instruments. — ^For strictures above No. 15 French conical steel 





Fio^ 620. — Conical steel sound. 



sounds of a proper curve are employed. These may be of the style 
shown in Fig. 620, or those with a double taper (Fig. 621) may be used. 
The latter instrument has a slight advantage in that, the shaft being 
smaller than the shoulder, dilatation of the deeper parts is effected 





Fig. 621. — Double-taper steel sound. 

without unduly stretching the meatus. For strictures in the pendulous 
urethra in front of the bulb a straight conical sound (Fig. 622) may 
be employed; such an instrument should not be used, however, in the 
deep lu'ethra. 



(^ 




Fig. 622. — Straight steel sound. 

With small steel instruments there is a considerable chance of 
making a false passage and always the danger of inflicting traumatism, 
so that for strictures of a smaller size than No. 15 French, soft instru- 
ments should be employed. Flexible olivary bougies (Fig. 623) are 




Fig. 623. — Flexible urethral bougie. 

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. 



582 THE URETHRA AND PROSTATE, 

For dilating tight strictures whalebone filiform bougies and tun- 
neled sounds (Fig. 624) should be provided. The liUfonns should 
be at least 18 inches (45 cm.) long and of such size that the tiinncltd 
sounds will easily slip over them. Care should be taken not to u« 
rough or split liliforms. In fact, any instrument, no matter what the 
variety, must be perfectly smooth and sound; imperfect instruments 
should be discarded as unsafe. 




Fig. 634. — Gouley tunneled sound and liliform. 

Asepsis. — The strictest asepsis should be obser\"ed in regard lo 
the instruments used. Metal instruments should be boiled for five 
minutes in a i per cent, solution of sodium carbonate. Filiformsand 
the newer gum-elastic instruments will stand moderate boiling. Thty 
may also be sterilized by formaldehyd vapor, after which ihey should 
be well rinsed in sterile water; or they can be immersed first in a i tOM 
carbolic solution and then in a saturated solution of boric acid. 

The gians and meatus should be washed with soap and water 
followed by a i lo 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 1 to 5060 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 practicall)' 
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. I" 
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 sutside 



TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. 583 

before instruments axe 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 short intervals between the treatments, while for those that are 
easily dilated and do not readily reform longer intervals can be 
employed. After the stricture has been stretched to 28 or 30 French, 
the intervals between the treatments may be increased, at first to once 
a week, then 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 
the extent to which a strictiu-e is to be dilated. Various scales have 
been devised for determining the approximate size of the urethra from 
comparison with the circumference of the penis, but they are not 
accurate. As a general rule, dilatation of the stricture to the size of the 
meatus, provided it is of normal caliber, is sufficient. 

Position of Patient. — The patient should be in the dorsal position 
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 side 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 
ordinarily cause no pain. In such cases the urethra is well distended 
with a o . 2 per cent, solution of cocain and adrenalin solution and the 
solution is confined in the urethra for fifteen minutes by holding the 
meatus closed. 

Technic. i. Large Strictures, — Under this heading wUl be con- 
sidered strictures above 15 French in size. A sound of a size that will 
easily pass through the stricture — determined by previous exploration 
— is warmed, well lubricated with lubrichondrin or other Iceland- 
moss preparation, and is very gently introduced in the following manner: 
The operator grasps the penis behind the corona between the ring-and 
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 is grasped lightly between the thumb and first two 
fingers of the right hand and is carefully inserted into the lu-ethra. At 
this stage the handle of the instrument should be parallel to the abdom- 
inal wall and in line with the folds of the groin (Fig. 625). As the sound 



584 ■THE URETHRA AND PROSTATE. 

is pushed onward and downward, the handle of the instrument is grad- 
ually swept to the center line (Fig. 626) and is then slowly raised to a 
perpendicular so that its beak passes beneath the pubic arch (Fig. 637) 




-First step in pasang a sound. 



into the membranous urethra. Unless the stricture be in the deep 
urethra, it is not necessary to insert the sound into the bladder— tic 
instrument should simply be passed through the stricture. To insert 




passing a sound. 



the instrument the full distance, the handle is brought forward and 
downward between the thighs (Fig. 628). When the point of '^^ 
sound reaches the stricture, the utmost gentleness in manipuUW 



TREATMENT OF STRICTDRES BY INSTEUMENTAL DILATATION. 58$ 

should be used in engaging it in the stricture, and no attempt to 
enforce the instrument along should be made, until it is certain that its 





Fic. 62S. — Fourth step in passing a sound. 



point has entered the opening in the stricture. Having passed the 
sound entirely through the stricture, it is removed by a reversal of these 






586 THE URETHB,^ AND PROSTATE. 

Steps and a second one is introduced. If this causes pain orspas[n,it 
is immediately witlidrawn, and no immediate further attempt to 
dilate is made. If, however, the urethra tolerates the second in- 
strument, a third one may be introduced. 

.A.t the next sitting the dilatation is begun by inserting a sound one 
size larger than the first instrument used at the previous treatmeni, 
and the dilatation is increased one or two sizes as before. In this way 
the treatments are continued until the desired degree of dilatation k 
obtained. 

The passage of the sound will cause more or less smarting, but it 
is only transitory. At times a few drops of blood may follow &x 
remoA-al of the instrument. The next act of urination b apt to bf 
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. 



Fig. 6ig. — Method of inserting a flexible bougie through a urethral slricture. 

2. Small Strictures. — For small strictures, that is, below 1 5 French, 
soft bougies are employed. A bougie of a size that will readily enter 
the stricture is selected. The penis is held straight up and upon tie 
.stretch in the fingers of the left hand after the manner described above, 
and the bougie, well lubricated, is carefully passed straight doftH W 
the seat of obstruction (Fig. 629), provided the latter is in the anterior 
urethra. An instrument can thus be readily passed straight as far as 
the bulbomembranous junction, but here it is apt to be obstructed. 
To pass this point and enter the deep urethra, the bougie should be 
introduced bent as much as possible to the shape of a curved sound. 



TREATMENT OF sntKTTKfS BX DSniilKXtU. DOATATIOX. $i~ 

and, when the point reaches the bulb, di^it pnsKiir abouM be made 
with the fingers on the perineum laee Fig. 573 . When the in^xrument 
strikes the face of the obstnmian. gentle attempts are made to cngagt 
its point in the stricture. This accQmph=hrd. the in^tniment b 
pushed OQ entirely throu^ the stricmre. and the dilatation 15 ptx>- 
ceeded with in the same "^nn^f as when oang sounds. Sled inani- 
ments may be substituted for tbe bouses when the tUlatatioD has 
been carried as high as 15 French. 

3. Filiform Sutures. — In tbe be^nning m tbe treatment of a 
filiform stricture it often requires tbe greatest pawaence and skill 
to enter the bladder, as freqnenih' tbe stricture is of =uch small caliber 
or the opening is so situated that it is extremely di&cult to en^ge 
e\-en a fine filiform. Once, iKnrenr. the filiftxin is inserted, the main 
difSculty is surmounted. In introducing filifonns the same method 
is employed as for stiai^t bougjes. The penis, grasped in tbe fingers 




Fio, 6,10. — Method of pa 



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 the opening 
of some lacuna, it should be withdrawn slightly and then slowly 
reinserted. When the face of the stricture — the location of which ha<; 
been previously determined — obstructs the further adx'ance of the 
filiform the instrument should be slowly rotated about, making attempts 
to engage its point in the stricture the while, but n-ithout using any 



588 THE URETHBA AND PROSTATE. | 

force. Sometimes by distending the canal with warm oO it is possible 
to enter the liliforra 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 unsuccessfdi, 
additional filiforras are inserted until the urethra contains sis or sewn 
of them. Then gentle attempts are made to pass each in turn, and 
usually one will finally slip into the opening (Fig. 630), whence it can 
be readily passed into the bladder. If, after a fair trial, it is impossiblt 
to insert an instrument, it is better to give up the attempt for the lime 
being, and try again a few days later. Sometimes upon a second or 
third trial the opening will be readily located. Gentle manipulaiitjn 
combined with perseverence will result in success in the great majoritj' 
of cases, but, if it is impossible to pass the instrument by these means 
a urethroscope may be passed as far as the obstruction and tie 
filiform inserted by direct sight. 




Fig. 631. — Melhod of passing a tunneled sound over a filiform. 

Having finally passed a filiform, the smallest size tunneled sound 
should be inscrii-d over it as a guide (Fig. 631). If there has been 
much manipulation in passing the filiform, the operator's efforts had 
be.st stop at this, or, at the most, a second sound is introduced- At 
the next silting the filiform is again inserted and the dilatation in- 
creased by inserting larger instruments over it as a guide. After Hjmc 
dilatation has been thus obtained, soft bougies may be substituted for 
the (informs and tunneled sounds, and the treatments may be carried 
out as outlined above. 



TREATMENT OF STlUCTURES BY INSTRUMENTAL DILATATION. 589 

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 manipu- 
lation, the passage of a sound produces sufficient shock to cause the 
pMitient 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 occiu", 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 instrumentation. 
It may be the result of absorption of toxic elements which are present 
in the urine, in the urethra, or are introduced from without with the 
instrument, or it may be the result of shock to the kidneys. 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 fol- 
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 
(0.32 to 0.65 gm.) doses, and the administration of genitourinary 
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 strictiu-e, 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 should 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 



1 



590 THE DRETHRA AND PROSTATfi. 

or an attempt at too great a degree of dilatation at one sitting. Bleed- 
ing may occur, however, in some cases where the urethra is markedly 
congested with scarcely any injury to the tissues. The bleeding 
tisually 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 fordng 
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. ttTien i 
false passage is made, there will generally be free hemorrhage at tbe 
time or upon withdrawal of the instrument, and the patient will com- 
plain of severe i>ain 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 
ciir\-ed 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: ih:it is, he r-hould be put in bed 
and given urinary antiseptics and carefully watched. Should extrav- 
asation of urine occur or an abscess develop, prompt and free drainage 
should be established and perineal urethrotomy should be performed' 

CONTINUOUS DILATATION. 

Continuous dilatation consists in inserting a filiform or small bougie 
through a stricture and leaving it in place for twenty-four or forlj- 
eight hours. By the end of this period more or less absorption of the 
stricture has taken place, so that there is some dUatation, and a larger 
instrument may then be inserted. It is a method that may be some- 
times employed for securing dilatation of tight strictures not amenable 
to gradual dilatation, and is worthy of trial in such cases before resort- 
ing 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 instrument 
in the urethra is apt to cause urethritis which may in turn lead to 
cystitis. The method is contraindicated in the presence of cys'i"* 
or if renal complications exist. 



CONTINUOUS DILAXATION. 591 

Instruments. — Filifonn (see Fig. 563) or soft bougies (see Fig. 562) 
may be employed. 

Asepsis. — Rigid asepsis is, of course, imperative. The instruments 
are to be sterilized as already described (page 539). The penis and 
meatus are washed with soap and water, followed by a i to 5000 bi- 
chlorid of mercury solution. The lu^thra should be irrigated with a 
I to 5000 permanganate of potash or satiu^ted boric acid solution, and 
the bladder should be likewise irrigated with boric acid solution, if 
pebble, upon changing the instruments. 

Tecfanlc. — The instrument is passed through the stricture after the 
method already described for intermittent dilatation (page 586), and is 
then securely fastened in place. There are several methods of doing 
this, but the following is the simplest and most efifective: Four pieces 
of adhesive, each about 4 inches (12 cm.) long and 1/4 inch (6 mm.) 
wide are secured to the bougie (which for a space of an inch (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 lies upon 
the dorsum, one on the ventral surface, and one on either lateral sur- 
face of the penb. 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 




Fig. 633. — Shoeing the method of securing a bougie or catheter in the urethra. (After 
Sinclair, Polyclinic Journal, July, 1908.) 

is placed horizontally about the penis just behind the corona cover- 
ing the four small strips (Fig.632). 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 between the 
glans and the small strips, A liberal sterile gauze dressing is then 
wrapped about the peins 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 changed 
when saturated. Within twenty-four or forty-eight hours the bougie 
is removed, and the stricture will be found sufficiently stretched to per- 
mit the easy introduction of a larger instrument. This is left in for 



S9i 



THE URETHRA AND PROSTATE. 



>val gradual dilatation m&jr 



the same length of time, and upon its r 
be begun. 

When there is retention of urine, the filiform is passed as before and 
a tunneled catheter is passed over it as a guide into the bladder (page 
588), and the urine is drawn off. The bladder is then irrigated and the 
catheter removed, but the filiform is secured in place as described 
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 XVIIL 
THE BLADDER. 

Anatomic Considerations. 

The bladder is a musculomembranous reservoir for the reception of 
urine, lying behind the pubes and in front of the rectum in the 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 rec- 
tum and into which open the ureters; (3) a body, or middle portion; 
and (4) a neck, or constricted portion, opening into the urethra. It 
has an average physiological capacity of from 6 to 9 ounces (178 to 
266 c.c), and a normal maximum capacity of 24 ounces (710 c.c), but, 
under certain pathological conditions, it may become enormously 
distended without rupture. Its shape and position depend to a certain 
extent upon whether it is empty or full. When empty, it lies weU behind 
the pubes, and upon median section appears triangular in outline; 
when partially filled, it becomes rounded in outline; and, when com- 
pletely distended, it becomes oval and rises partly from the pelvis into 
the abdominal cavity. 

The peritoneum partially covers the anterior surface and sides of 
the bladder, and entirely covers the superior surface, extending pos- 
teriorly 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 ab- 
dominal 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. 633). 

Beneath the peritoneal coat lies the muscular layer. It consists of 
three coats: external, middle, and internal. The external is composed 
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 fibers are arranged longitudinally and others circularly. 

38 593 




Fio. 633. — Showing the space abo e he pubes ihmugh nh h t is possible locnutllK 
bladder without opening mlo the pentotie 




Flc. 634. — The inlerior of the bladder. 
l.Trigone; a, orifice of ureter; 3, muscular layer; 4, mucous membnuie; 5i '"'* 
ureteric line; 6. prostate gland. 



DUGNOSTIC METHODS. 595 

The mucous coat is composed of stratified pavement epithelium. 
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 
-fcnown as the trigone where it is always smooth. The mucous mem- 
brane of the bladder is comparatively insensitive to touch when in a 
'iormal condition, as it has a scant nerve supply, the most.sensitive por- 
"^ion being over the trigone. The trigone is a smooth triangular space 
the base of the bladder, the apex of which corresponds to the opening 
f the lu-ethra and the base to a line passing between the orifices of the 
ureters (Fig. 634). 
The ureters pierce the bladder wall obliquely and appear upon the 
*"*^\icous membrane as round openings or oval slits directed forward 
^-i^d inward. These orifices are from i to i i /2 inches (2.5 to 3.8 cm.) 
^-I^art and about i inch (2 . 5 cm.) from the beginning of the lu-ethra. 

Diagnostic Methods, 

When examining a case of suspected bladder disease the symptoms 
Complained of should first receive careful attention. In addition to 
"^he usual questions, information bearing upon the act of urination 
should be sought, ascertaining whether there is frequency of lu-ination, 
'Whether there is urgency, whether the act is difficult, whether pain is 
present and, if so, its relation to the passage of lU'ine, whether the force 
Or caliber of the stream is changed, etc., etc. 

Frequency of urination is common in all bladder affections where 
the mucous membrane is inflamed. It is also a symptom 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 
^'hen the bladder is healthy, as in diabetes, in hysteria, in those who 
cirink large quantities of water, in those whose urine contains excessive 
a.mounts of uric acid or oxalates^ etc. 

Urgency of micturition, or the feeling of being compelled to pass 
Vxrine the instant the desire is felt, points strongly to inflammation of 
the bladder or the prostate. Inflammation or irritation of the urethra 
may also cause it. It is, however, sometimes observed as the result 
of certain mental emotions, as fright or apprehension, or mental sug- 
gestions, 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 BLADDER. 

the seat of the pain and the exact relation it bears to the act of urination. 
Pain from prostatitis is generally felt in the perineum or rectum, pam 
in bladder disease is felt over the pubes, in kidney disease in the bins. 
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, prostale. 
or bladder wall. Pain at the end of urination occurs when a vesical 
calculus is present or when there is inflammation involving the neck 
of the bladder or the prostate. In acute prostatitis pain is also pre^ 
ent upon defecation. When pain is present in the intervals belwcen 
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 dorsal position, it is believed by some 
writers to be pathognomonic of vesical calculus. 

Difficulty of urination, as a rule, indicates stricture of the urethra (ir 
an enlarged prostate. Changes in the caliber of the stream generally 
point to stricture. In the [iresence of enlarged prostate, disease of 
the bladder wall, and in some nervous aflections. 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 symptomatology 
in the diagnosis of vesical affections. The symptoms are often decep- 
tive, as they may be common to diseases involving the bladder, kidneys, 
or urethra. E\en when they clearly point to the bladder as their seat 
of origin, they are frequently of but little value in differentiating between 
the various morbid conditions that may affect this organ. An accurate 
diagnosis can only be arrived at by a physical examination along ihe 
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 tbe 
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 
the bladder or kidneys. The proper method of collecting the sp«'' 



EXAMINATiaN OF THE URINE. 597 

men for such examination has been previously described (page 224), 
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 
normal condition of the urine as far as appb'es to vesical and renal 
disease will, however, be briefly considered. 

The quantity of urine passe'd normally by a healthy adult amounts 
to from 35 to 50 ounces (1000-1500 c.c.) in twenty-four hours, but this 
may be greatly modified even in health, depending upon the season 
of 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 output of 
urine may be greatly decreased (oligiu-ia). On the other hand, an 
increased quantity of iirine (polyuria) will be found in hysteria, in 
the presence of interstitial changes in the kidney, from the use of diu- 
retics, 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 respect, in- 
volvement of the kidneys or some constitutional disease may be 
implied. 

The specific gravity ranges normally from 1018 to 1022. The 
specific gravity is closely related to the amount of solids excreted, so 
to be of value the test should be applied to a mixture of the urine 
void