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2zJt Jf^r-

DIAGNOSTIC

AND

THERAPEUTIC TECHNIC

A Manual of Practical Procedures
Employed in Diagnosis and Treatment

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

ADJUNCT PROFESSOR OP SURGBRY IN THB NBW YORK POLT-
CLINIC; ATTBNDING SURGBON TO THB WORKHOUSB HOSPITAL,
AND TO THB NBW YORK CITY HOlf B POR THB AOBP AND INPIRII

WITH 815 ILLUSTRATIONS, MOSTLY ORIGINAI

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1911

PRtNTEO IN AMERICA

PRESS OF

W. B. 6AUN0ER8 COMPANY

PHILADELPHIA

To my Father

Prince a. Morrò w, M. D.

this hook
is aflFectionately dedicateci

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 tide "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 inteme 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 tum 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, òmit or else describe in a most
condensed manner these so-called minor procedures. If the reader
desires fuU^r and more detailed information it not infrequently happens
that it is necessary for him to consult a number of works before he
obtains ali the desired information. To supply such a want is the
object of this book.

The pian 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
ha ve 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 thisreason,
and that each section might be complete in itself without referring the
reader to other portions of the text, some unavoidable repetition occurs.

Ali 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 ali the illustrations are
line drawings made by Mr. John V. Alteneder, head of the W. B.

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 ha ve 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 ha ve 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 fumished many of the instruments from which drawings
ha ve been made.

A.S. M.

New York City,
Fébfuaryt 19 ii.

CONTENTS

CHAPTER I.

PAGE

The ADinNiSTRATiON 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 ojdd and ether sequence 44

Ethyl chlorìd anesthesia 46

Anesthetic mixtures 49

Intubation anesthe^a 50

Anesthesia through a tracheal opening 52

Rectal anesthesia 53

Scopolamin-morphin anesthesia 55

Acddents durìng anesthesia and their treatment 56

After-effects of anesthetics 62

After-treatment of cases of general anesthesia 64

CHAPTER II.

LocAL Anesthesia 66

Advantages and disadvantages of locai anesthesia 67

Methods of produdng locai anesthesia 70

Preparations of the patient for locai anesthesia 70

Dnigs employed for locai anesthesia 71

Preparation of the anesthetic solution . 72

Conduction of an operation under locai anesthesia 73

Locai 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

Artcrial anesthesia 98

Spinai anesthesia 99

CHAPTER in.

Sphychomanometry 106

Normal blood pressure 106

IO CONTENTS.

PAGE

Instruments for estlmating blood pressure 107

Technic of estimating blood pressure no

Variatlons of blood pressure in dìsease in

CHAPTER IV.

Transfusion of Blood 114

Indications and contraindications 115

Hemolysis 116

Methods of i>erforniing transfusion 116

Selection of the donor 118

Technic by Crile's method 119

Brewer*s method 122

Hartweirs method 122

Lévinas method 123

Elsberg's method 123

Technic by CarrePs suture 124

CHAPTER V.

Infusions of Physiological Salt Solution 127

Indications » 127

Preparation of normal salt solution 128

Artifidal sera for infusions 129

Intravenous infusion 130

Intraarterial infusion 137

Hypodermoclysis 140

Rectal infusion 143

CHAPTER VI.

Hypodermic and Intramuscular Injection of Drugs 144

Administration of Diphtheria Antitoxin 149

Vaccination 153

acupuncture 159

Venesection 161

Scarification 166

SUBCUTANEOUS DRAINAGE FOR EdEMA l68

CUPPING 170

Leeching 174

CHAPTER VII.

BiER*s Hyperemic Treatment 177

Passive hyi>eremia 177

Effects of hyperemia 178

Indications 180

General prindples underlying hyf)eremic treatment 181

Passive hyperemia by means of constricting bands 183

Passive hyperemia by means of suction cups 188

Active hyperemia 194

CONTENTS. II
CHAPTER Vni.

PAGB

CoLLEcnoN AND Pkeservauon of Pathological Material 199

Method of making smear preparations for microscopica! examinatìon 199

Method of inoculating culture tubes 207

CoUection of discharges and secredons for bacteriological examination .... 210

Collection of blood for microscopical examination 217

CoUection 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 IX.

Exploratory Punctures 230

Exploratory punctures in general 230

Exploratory puncture of the pleura 233

Exploratory puncture of the limg 237

Exploratory pimcture of the perìcardium 238

Exploratory puncture of the perìtoneal cavity 240

Exploratory puncture of the liver .* . 241

Exploratory pimcture of the spleen 242

Exploratory puncture of the kidneys 243

Elxploratory puncture of joints 244

Spinai puncture 246

Spinai puncture as a means of administering antitoxic sera 253

CHAPTER X.

Aspirations 254

Aspiration of the pleural cavity 254

Aspiration of the pericardium 263

Aspiration of the abdomen for asdtes 265

Aspiration of the tunica vaginalis 270

Aspiration of the bladder ; 272

CHAPTER XI.

NOSE AND ACCESSORY SlNUSES 273

Anatomie considerations 273

Diagnostic methods 278

Rhinoscopy 278

Insi)ectionof the nasopharynx by means of Hays' pharyngoscope 286

Palpation by the probe 288

Digital palpation of the nasopharynx 291

Transillumination of the accessory sinuses 292

Skiagraphy 294

Therapcutic measures 294

12 CONTENTS.

PAOB

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

Anatomie 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

Indsion of the drum membrane 349

CHAPTER XIII.

The Laeynx apjd Trachea 353

Anatomie 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 ?8o

Dry inhalations 383

Intubation 383

Tracheotomy 392

CONTENTS. 13

CHAPTER XIV.

PAGB

The Esophagus 403

Anatomie consideratìons 403

Dìagnostic methods 404

Auscuttatìon 405

Percussion 405

Palpation 405

Examination by sounds and bougies 405

Esophagoscopy 412

Skiagraphy 416

Therapeutic measures ■ . . 416

Lavage of the esophagus 416

Dìlatation of esophageal strìctures by the bougie 418

Intubation of the esophagus 423

CHAPTER XV.

The Stoicach 427

Anatomie eonsiderations 427

Dìagnostic methods 428

Inspectìon 430

Palpation 432

Percusàon 435

Auscultation 436

Inflation of the stomach 437

Extraction of stomach eontents for ezamination 440

Test of motor function 447

Test of absorption power 448

Gastrodiaphany 448

Gastroscopy 450

Skiagraphy 456

Exploratoiy laparotomy , 456

Therapeutic measures 457

Lavage of the stomach 457

The stomach douche 462

Gavage 465

Massage 468

Electiotherapy 470

CHAPTER XVI.

Rectum and Colon 474

Anatomie eonsiderations 474

Dìagnostic methods 477

Inspectìon 479

Palpation by the finger 480

Manual palpation 482

Examination by the speculum or proctoscof>e 483

EjQunination by sounds and bougies 490

£lxamination by the bougie à houle 49^

Examination by the probe 492

Inflation of the colon 493

14 CONTENTS.

PAOB

Therapeutic measures 496

Enemata 496

Enterocl)rsis 501

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

Colonie massage 522

Auto-massage 524

Application of electricity to the rectum and colon 524

CHAPTER XVn.

The Urethra and Prostate 527

Anatomie considerations 527

Diagnostic methods 531

Glass tests for locating urethral pus 532

Injection test for locating urethral pus 534

Inspection 534

Palpation 535

Ezamination by sounds and bougies 538

Ezamination by the bougie à houle 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

Im'gations 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 graduai dilatation 579

Treatment of strictures by continuous dilatation 590

CHAPTER XVm.

The Bladder 593

Anatomie considerations 593

Diagnostic methods 595

Urinalysis 59^

Inspection 601

Percussion 601

Palpation 602

Sounding for stone 604

Test of bladder capacity 607

Estimation of residuai urine 609

Test for absorption f rom the bladder 609

CONTENTS. 15

PAOB

Cystoscopy in the male 610

C3rstoscopy in the female 615

Skiagraphy 620

Therapeutic measures 620

Irrìgations 620

Auto-irrìgations 624

Instillations 626

Cystoscxjpic treatment , 627

Catheterìzation in the male 628

Catheteiization in the female 635

G^ntinuous catheterìzation 636

Aspiration of the bladder 639

CHAPTER XDC.

The Kidneys and Useters 642

Anatomie considerations 642

Diagnostic methods 645

Inspection 645

Palpation of the kidney 646

Palpation of the uretere 648

Percusàon 650

Urinalysis 651

Catheterìzation of the uretere in the male 652

Catheterìzation of the uretere in the female 661

S^regation of urìne 667

Determination of the functional capadty of the kidneys 671

Skiagraphy 674

Ezploratory incison 675

Therapeutic measures 675

Medìcation of the renai i>elvis and uretere 675

Dìlatation of ureteral strìctures 677

CHAPTER XX.

Female Generative Organs 679

Anatomie considerations 679

DÌ2ignostic methods 681

I. Examination of the abdomen.

Inspection ' 686

Palpation 687

Percussion 689

Auscultation 691

Mensuration 691

II. Examination of the pelvic organs.

Inspection 692

Examination of dischatges '- 693

Digital palpation 694

Binuuiual palpation 696

Examination by means of specula 7^3

Sounding the uterus 7^

Digital palpation of the uterine cavity 7^°

l6 CONTENTS.

PAOB

Examination of secdons and scrapiogs from the utenis 712

Expioratory vaginal incision 712

Therapeutic measures 715

Vaginal irrìgations 715

Locai applicadons 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 gynecology 732

Pelvic massage 733

Scarification of the cervix 734

Pessaiy 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 conditìon of insensibility to pain
and an anesthetic is any agent which produces such a conditìon.
Anesthetìcs are divided into general and locai. General anesthetics are
inhaled as gaseous vapors and enter the circulatìon through the alveoli
of the liings, whence they are carried to ali the tìssues and organs of the
body, including the centrai nervous system, producing loss of conscious-
ness, abolitìon 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 combinatìon
with one another.

The choice of the anesthetìc agent and the decision as to the method
of its administratìon are questìons of vital importance. Under any
general anesthetìc the patìent is brought practìcally to the border-line
between life and death, and, in many cases, the life of the patìent de-
pends, in the first place, upon the selectìon of the anesthetìc, and, in the
second place, upon the way in which it is administered. While the
safety of the patìent should always be the first consideratìon and the
main guide in the choice of the anesthetìc, it is unfortunately impossible
to lay down any hard and fast rules. Each case must be studied sepa-
rately, and the anesthetìc chosen that is best suited to that partìcular
case. According to statìstìcs, the mortality following the administra-
tìon of the different anesthetìcs 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

Statìstìcs, however, are not of absolute value as a guide. The
production of narcosis with the same anesthetic under ali conditìons.
2 17

l8 THE ADMINISTRATION OF GENERAL ANESTHETICS.

even though the particular agent chosen were absolutely safe, would
certainly be unjustìfiable. An anesthetic that couid be used with
safety under some conditions would be a menace to life under others.
The conditìon of the patient, the nature of the opera tion, the anesthetist,
and the operator himself are ali factors that enter mto consideration.
Furthermore, in estimating the relative safety of the dififerent anes-
thetics, one must consider not only the immediate dangers that may
arise, but also the more remote toxic effects that frequently do not
appear until some time later. No general rules will be laid down at
this time as to the selection of the anesthetic, but in considering each
agent an attempt will be made to indicate the cases for which it is best
suited.

Preparatìons 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
usuai 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 moming. Often, how-
ever, the nature of the operation or lack of time does not permit of the
administration of cathartics. In such cases, a purgative enema alone is
relied upon.

DieL — 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 moming, no food should be given after a
light supper the previous night; if it is fixed for the aftemoon, a very
light breakfast may be taken, not later than 8 a. m. A feelmg 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
ne ver 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. I9

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 shordy 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 obstructìon with vomiting is present, for, in
such cases, patients ha ve been known to'fairly drown from the contents
of the stomach suddenly pouring out under the relaxatìon of the anes-
thetic. To avoid undue 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, — ^Prepara tion of the nose,
mouth, and teeth lessens the dangers of aspiratìon pneumonia and
septic bronchitis. As a mie, cleansing the nose and mouth with an
antiseptic solution and thoroughly brushing the teeth is suffident, but,
in some instances, the neglect of the teeth results in a very foul and septic
conditìon, 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 f ortify the
patient and put him in the best possible conditìon for the operation.
With some patients simply a rub-down with alcohol at bedtìme
suffices to induce sleep; in others, espedally if nervous, the administra-
tion of trìonal 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 ovemarcosis; 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 Eocamination. — A thorough physical examination should
be made in ali cases as a routine preliminary to general anesthesia, for
ezact 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 adminìstration. Such an exami-
nation has a good moral effect upon the patient, and, if assurance can
be given that nothing abnormal can be discovered, it does much to
allay the naturai fear and timidity of a nervous mdividual. This
examiìiation should be made, when possible, before the day of opera tion,
so that, if the condition of the patient demands it, the operation may be
postponed without subjecting the patient to unnecessary preparations.
In the presence of acute bronchitis or coryza, a postponement of the
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 ICQ 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 operatìon should be postponed
or locai 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 tìme per-
mits, the blood pressure should be taken in ali cases (see Chapter III).
If it is found to be abnormally high, nitrites should be administered for
several days, and, where there is not tìme for this, nitroglycerin should
be given by hypodermic before the anesthetic is begun. In the pres-
ence of hypotension, cardiac stìmulants for several days previous to the
operatìon are indicated.

Care ofthe Patient. — ^The comfort of the patìent while on the operat-
ing table should be seen to by the anesthetìst. Care should be taken
to maintain the bodily heat and prevent chilling by a proper amount
of covering. The habit of washing patìents with quarts of solution and
leaving them lying in a pool of chilly water is to be condemned. It is
preferable to arrange the patìent upon the table before the anesthetìc
is begun. Anesthetìzing a patìent in one room and then moving him

PREPARATION OF THE PATIENT POR ANESTHESIA. 21

to the operating-room is not to be advised if it can be avoìded. The
lifting around of the patient allows him to partly come out, and often
starts up vomiting.

The position assumed by the patient upon the operating-table shouid
be unconstrained and as comfortable as is consistent with the needs
of the case. A supine position, with the head elevated sufficiently upon
asmall pillow to allow freedom in breathing, answers in the majority of
cases. Ether and nìtrous oxid are sometimes gìven with the patient's
head and trunk elevated, but under no circumstances shouid chloro-
form be given with the patient sitting up or semiupright, on account
of the danger of cerebral anemia. In weak anemie individuai the
uprìght position shouid, for the same reasons, be avoided with any
anesthetic

Fic. I. — The aneslhelist's suppKes.
1, Pus basin: a, mouth wipeson artery clamps; 3, mouth wedge;4, longue forceps; 5
momh gag; 6, hypodermic syringe.

Before administering the anesthetic, anythìng tbat interferes with
or obstructs the respiration in the slightest degree shouid be removed.
Tight coUars, bandages about the neck, clothing, beits, straps, braces,
etc, shouid Invariably be loosened, no matter how short the anesthesia.
The mouth shouid be exatnined, and false teeth, obturators, plates,
chewing gum, tobacco, etc, shouid be removed lest they fall back into
the larynx and cause choking. It is always well to have a third
person present in case hetp is needed, and in the case of a female
patient this is very necessary, as erolic dreams may lead to damaging
accusadons against the anesthetist.

22 THE ADUINISTKATION OF GENERAL ANESTHETICS.

The Aneslhelisl's Supplies. — Besides the apparatus neclssary for
the actual administration of the anesthetic, the anesthetist shouid be
provided with the foUowing: 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 ciamp as a holder, and a small pus basin
(Fig, i). A cylinder of o^gen shouid be ready for use, and an in-
fusion set and tracheotomy tube shouid be accessible, if required.

Fio. 3. — Anangcment of the operaling-table and the anesthetist'a supplies.

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

St^es of Anesthesia. — Anesthesia from most of the general anes-
thetic agents passes through four stages, as follows: (i) The initìal, or
stage of irritadon; (2) the stage of eicitement; (3) the stage of surgical
anesthesia; and (4) the stage of coming out. With some anestheiics
the early stages may be more or less modifìed, or entirely absent, and
the rapidity with which the patient passes through the differcnt stages
depends upon the drug employed and the technic of its administration.

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

STAGES OF ANESTHESIA. 23

secretìon of mucus with some coughing and frequent acts of
swallowing. To some persons, the odor and taste of the anesthetic
are exceedingly impleasant, 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 ofif 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 painf ul examination or sudden shock is dangerous.

The Stage of ExcilemenL — ^FoUowing 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 tìghtly 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. While the patient usually hears those around him talking, he
fails to imderstand what is said. Consciousness and sensation are
gradually diminished. The pupils are stili dilated. The pulse is
rapid and full, with very marked pulsations in the large vessels of the
neck.

Slage ofSurgical 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 stili
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 unconsdousness 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 ADMINISTRATION 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 stili react to light and thecomeal reflex isalso
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 light
at ali 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 sighipg. 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 buming, sweetìsh 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 ha ve 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 ANESTHESIA. 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 eflFect is well shown when
ether is administered to a very ili person, the character of the pulse of ten
being improved immediately and continuing so until the end of the
anesthesia. While its primary eflFect 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
elìminated from the lungs, and it is necessary to give it in a more or
less concentrated form, thus diflEering 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 suìted 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
conditìons ether is also less dangerous. In unskilled hands, however,
there can be no doubt that ether is always the safer.

For the stimulating eflFects 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 ali means the best agent
to use. In anemia ether is preferable to chloroform, as it has a
less marked eflFect 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

30 THE ADUINISTSATION OF GENEKAL ANESTHETICS.

when tbere is high arterìal tension and degenerative changes in the
blood-vessels, it is contraindicated on account of the danger from over-
stimulation. In myocardial disease it is unsafe, but not so dangerous
as is chloroform.

On account of its initant action, ether shouid 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 mie, 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 fiow of mucus and saliva that breathing is seriously
interfered with.

FlG. 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 shouid 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 semìopen, 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 ordinaiy

ETHER ANESTHESIA.

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

— The Schimmelbusth mask. Fio. 5. — Chloroform 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 frante provided with slits through which is threaded a cotton or
fiannel bandage, A very simple semiopen inhaler may be made by
rolhng severa! thicknesses of heavy brown paper ìnto a cuff and cover-
ing it with a towel. The top of the cone, which is held partly closed

Fio. 6. — The Allis inhaler.

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), theBennett (Fig. 9), theGwathmey, thePedersen.etc. 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 ADMINISTRATION OF GENERAL ANESTHETICS.

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

Fio. 7.— Toivel cone.

To obtaìn the benefit of the warm vapor wìthout the disadvantages
of the closed inhalers, the vapor method of etherìzation 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

Fic. 8.— The dover 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. io), as de-
scribed by him {Journal of American Medicai Associalion, October 27,

' space does not permit a detailed description of these inhalers, nor is it necessary,
as a description of th^ mechanism and full instructions are fumished v,ilh each ir

ETHER ANESTHESIA. 29

1906), consists of two six-ounce (178 ce.) bottles, one for chiorofonn
and one for ether. Both bottles are placed in a tìn vessel containìng
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

Fio. 9, — The Bennett ether inhaler,

stoppers out, thus exposing the thermolite to the atmosphere. The
lìquìd then begins to recrystallize, and on tuming to a solid form gives
off heat for another hour and a half. In each of the bottles there are
three tubes, varying in length from one that reaches to the bottom of
the botile to one that penetrates only the stoppar, and representing

Fjc. io. — Gwathmey's vapor apparatus.

three degrees of vapor strength. The small switches at the top of each
botile are so airanged that chioroform or ether, combined or separately,
can be given, and in any strength desired. In addidon, by simply
tuming a small lever, without removing ihe mask, the patienl 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
chloroform vapor is carried to the patient by the efferent tube.

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

Administration. — Drop Method. — ^The usuai precautions already
detailed having been observed, and the eyes ol the patient being pro-

Fio. II. — Showtng the administration of ether by the drop 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 bave been
taken, a few drops of ether are poured on the mask. After a few more
breaths, more ether is added, gradually ìncreasing the amount each tìme.
If the patient struggles or begins to cough and choke, the amount of
ether should be lessened for the lime being. In from five to six min-
utes the stage of excitemeni 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 ìrritates the respiratory
tract and produces laiyngeal spasm, causing the patient to coi^.

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 saliva that collects in the throat. Irregular rapid respira-
tion approaching a gasping type is unsafe. The breathing should
not be allowed to become gurgling or obstructed. To prevent this,
the jaw should be held well forward by placing the fingers back
of the angle, as shown in the accompan)ring 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 lar3mx, 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
fongue, the latter should be puUed 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 tumed to one side so as to allow the mucus and saliva to flow out
through the corner of the mouth. Should vomiting occur, the inhaler
must be removed and the patient's head tumed 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 efiFect of ether becomes somewhat rapid, but of
greater volimie 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 overnarcosis. Other danger signs are
a weak, thready, or irregular pulse, and marked pallor or cyanosis.
Hiccough usually means that the patient is getting ready to vomit
Rolling of the eyes and repeated acts of swallowing are preliminaries
to the patient coming out. Both conditìons 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 ce.) should sufiìce 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 tumed 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
account of rebreathing the same air, some duskiness of countenanceis to
be expected, but this may be regulated by admitting more air or by
administering oxygen. A distìnct liv-id color should not be allowed to
persist with either a closed or an open inhaler. Such a condition is a
sign of poor administrarion of the anesthetic, or else the partìcular
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

ETHEE ANESTHESIA. 33

the anesthesia is more prompt, and the after efiects, as nausea and
vomitìng, are greatly diminished. Furthennore, the ether vapor
inhaied from the bag, being warm, is safer, more eSecti\-e, and less
apt to produce irritatìoQ of the respiratory tract.

Vapor Metfujd. — It is preferable to start the anesthesia by some
of the quick methods, as nitrous oxid gas foUowed by ether, or by
cthyl chlorìd 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 the adminisiration of ether «ith a closed inhaler.

completely under, a medium or low percentage of vapior 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 impermeablc malerial,
as rubber tissue or oii silk is placed, with a smali opening in the center
about the size of a ten-cent piece, through which addìtional anesthetic
may be dropped if it is found to be difficult to induce narcosis with the
\-apor alone.

The vapor method gives a light anesthesia, just abolishing the
reflexes. The breathing more nearly approaches the norma), without
the snoring rapid respiration usuai 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 cleax, colorless, heavy, volatile liquid with a sweet-
ish taste and characteristìc odor. When used for anesthetic purposes,
it should be absolutely pure and neutral to litmus. Under the in-
fluence of beat 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 irrita ting 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
ane§thesia should be well protected with vaselin.

When inhaled, chloroform vapor has a depressant efiFect upon ali
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 fatai 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 fatai 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
fatai 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 saf er than chloroform and air.
The use of this combination is less often accompanied by circulatory
depression, while cyanosis and postoperatire vomitìng are less frequenta

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 pladng the bottle containing the drug in warm water (ioo° 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 syncope; this pre-
caution should also be bome in mind when lifting or moving persons
imder 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
young children and in those over sixty years of age who are free from
myocardial disease, for the reason that it causes less irritation of 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 conditìons 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 preKminary 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 mouth, 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 ADinNISTRATION OF GENZHAL ANESTHETICS.

ìnhaler. Either the open drop method, with a free mixture of air, or
the warm vapor method should be used. Por the former, a handker-
chief, the corner 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 Schìmmel-
busch's (see Fig. 4), covered with canton flannel or several layers of
gauzej is more suitable. In addidon, a drop botile {see Fig. 5) from

Fio. 14. — Chlorofonn mask improvised from the corner of a towel.

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

Different forms of apparatus for accurately estimating the strength
of vapor, as Junker's (Fig. i5),Braun's, Gwathmey's (see Fig, io), etc,
are often used. These are supplied with a tracheal tube and are
cspecially useful in operations about the mouth or throat. By squeez-
ing the bulb, air is forced through the warmed chlorofonn, and a

Fic. 15.— Junker's chioroform inhaler.

vapor containing a definite misture of chioroform and air is adminis-
tered. By atlaching the bulb to a tube connecled with an oxygen
cylinder, oxygen may be readily administered instead of air.

The same care as to the cleanliness of the chioroform mask should
be observed as wouid be with ether inhalers. After each anesthesia
the metal framework should be botied and then recovered.

CHLOKOFORU ANESTHESIA. 37

AdministratìoQ. — The usuai precautions already considered shouM
be observed, and the patient's lips, nose, mouth, and cheeks should be
well greased with vaselin or lanolìn. The anesthetic is started by
holding the mask wet with a few drops of warm chlorofonn 4 or 5
inches {io to 12 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 chlorofonn is dropped steadily at a rate of
IO to 30 drops (o.óoto 1.90 ce.) a minute, and the mask ìs brought

Pie. 16. — Sboning the method of administerìng chtoioform (lirst step).

nearer the face, being careful, however, not to touch the skin with por-
tionsof the mask wet with chlorofonn (Tig. 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 Ihe stage of
excitemenl, chloroform musi be given wilk extreme care; if the patient
stniggles, 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 ADMINISTRATION OF GENERAL ANESTHETICS.

breathing becomes embarrassed. The jaw must be kept well forward
if there is the slightest impedimeat from the tongue to free respiration.
When the patìent is fully anesthetized, only small quantitìes of the
anesthetic shouid be admìnistered, just suffident to keep hitn 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 quìckly produced unless proper care be
taken. The stage of exdtement is less marked and shorter than with

Fio. 17. — Showing the meihod of administering chloroform (sccond step).

ether, and the patìent presents a more tranquil appearance in every
way. It shouid 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 relaxa-
tion; and a good color without blueness of the lips or cheeks. The
latter is an indication for a weaker vapor and more air or oxygen.
With the ordinary chloroform mask, oxygen may be administered by
simply inserting the tube leading from the oxygen cylinder under the
edge of the mask.

During the entire anesthesia, careful and ciose watch shouid 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 ANESTHESIA. . 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 ali 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
bere. With chloroform, it is an espedally 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-
ceptibie odor or taste. It is obtained in a liquid form, highly com-
pressed, in steei cylinders or containers, from which, when liberated, it
escapes ^ 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 contìnues to beat for some time.
It is the safest of ali the general anesthetics, i in 100,000 being the gen-
erally accepted death rate. No deaths bave 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 usuai 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 foUowed by
nausea and vomiting. The lung, kidney, and heart complicatìons of
ether and chloroform are likewise absent.

Suitable Cases. — \Vhen used pure, nitrous oxid ìs 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 locai anesthesia is contraindicated, it becomes the anesthetic
of choice for abscess, felon, empyema, benign tumors, strangulated
hemia, 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
stifiFen 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
individuai, 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 usuai 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,

NITRODS OXm ANESTHESIA. 4I

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

Fio. 18.— The Bennett

F[G. 19. — The Hewitl nitrous oxid gas 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 gìven, a special appara-
tus, as that of Hewitt (Fig, 19) or Gwathmey (Fig. 20), is essential.

42 THE ADMINISTRATION OF GENERAL ANESTHETICS.

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

Ab with ali inhalers, the metal parts shouid be boiied and the nibbers
sterìlized in a solution of i to 20 carbolic acid after use. Beforeusing,
the apparatus shouid always be tested to see that ìt works properly.

FiG. ao. — Gwathmey'B nìuous caìd gas and cnygen inbaler.

Administration. — In giving pure nitrous oxid, the apparatus is
properly connected with the supply cylinder, and the rubber balioon
is about three-fourths filled with gas. In turning the gas on it shpuid
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
opening the proper stopcodt. The patient thus breathes in pure

NITBODS OXID ANESTHESIA. 43

nitrous oxid and expires nitrous oxid and air, so that he constantly
receives more nitrous oiid 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 hnally a deep livid hue.
There ìs at first incoheient speech, but this is soon foliowed by the
anesthetic snoring, rapìd 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 stili a

FiG. II. — Showiog the melhod of adminlsterìng nìtrous oiìd gas.

period o£ 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 administerìng more nitrous oxid, the anesthesia
may be prolonged nearly an hour, provided sufficient air is admittcd
to avoid extreme cyanosis, stertor, and muscular twitchings, and yct
not so much as to keep the patient insuflBcien% anesthetized. This
may be accomplished by allowing two to five breaths of nitrous oxid
Io 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 "n^E 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 tumed 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
IO 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 unpleasant
after-eflfects.

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 eflfects 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-efifects 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 usuai metal mouth-piece and inflatable rubber rim, inspira-
tory and expiratory valves, and gas bag. In addition, the inhalers
bave an ether chamber containing gauze upon which the ether is poured.

NITROnS OXID AND ETHER SEQUENCE. 45

They are arranged so that gas is £rst adminbtered in the usuai way,
and then by slowly revolving a dnim the ether chamber is gradually
opened, the quanti^ of gas at the same lime being correspondingly
diminished, unti! finally the patient receives full strength ether vapor.

Fio. 31. — The Bennelt gas and elher apparalus.

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

FlG, 3j. — Gwathmey's gas and elher apparalus.

both gas and elher. As with ali apparatus ha\ing mechanism likely
to get out of order, the inhalers shouid always be tested before using.
The same inhaler shouid never bc taken from one person to another
with out steri! ization.

46 THE ADMINISTRATION OF GENERAL ANESTHETICS.

Administratìon. — ^The apparatus is properly connected and the
gauze in the ether chamber is well saturated 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 tumed
on. After a few breaths the expiratory valve is closed and the patient
breathes the gas back and forth, gradually going under its influence,
which is denoted by duskiness of color, irregular snoring respiration,
and muscular twitching.

The addition of ether vapor is nowcommenced 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 usuai way when using a
closed cone.

In giving a combination of gas and ether, care must be taken to
tum the ether on rather slowly at first. If the patient commences to
cough and hold his breath, the ether should be tumed 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 controlied by a caref ul 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 labelied "for general anesthesia." This can be
obtained in containers f urnished 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 ce.) of the drug. The latter is best suited for the closed
inhalers, the whole amount being emptied into the inhaler at once.

ETHVL CHLORID ANESTHESIA. 47

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

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

Fio. 34. — Ethyl chlorid tube.

thetic to tate. 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 dilatation of the perìpheral vessels.
Suìtable 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-

Fic. »S- — Sbowing the Schimmelbusch mask covered with gauze and oil dlk far the ad'

mìnistralion of ethyl chlorid.

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

Apparatus. — Owing to its great voladlity, ethyi chlorid is most
satisfactorily given by means of a closed inhaier, 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

40 THE ADMtNISTRATION OF GENERAL ANESTHETICS.

mask, over the gauze of whìch is placed some impervious materìalt
as oil silk or rubber tissue, with only a small opening through which ihe
drug is sprayed (Fig. 25) ; or an Allis inhaler may be used, ieaving only
a. small opening in the top. Any of the ordinary closed inhalers can be
utilized for administerìng ethyl chlorid by slmply 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 wilh
an inflatable rubber rìm and rubber bal-
loon. The balloon is attached to ihe
mouth-piece by a T-shaped chamber which
is provided with a valve and a small open-
ing through which the anesthedc may be
sprayed.

Administratìon. — In administerìng ethyl
chlorid by the closed method, the inhaler
is placed over the patient's face durìng expiration in order to fili 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, ìf a special inhaler is used, into the opening provided for the
purpose. If the face-piece be tightiy applied, so as to prevent the en-
trance of air, signs of anesthcsia appear in from thirty seconds to one
minute. As soon as aneslhesia is produced, the patient should be
aliowed to have air.

Full anesthesia is characterized by rapìd and slightly stertorous
breathing, dilated pupìls, absence of conjunctival reflexes, and more
or less complete relaxation, There is no cyanosis, though the color
of the skin is heighiened 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 recovcr toorapidly, more
anesthetic should be given, provided a plentiful supply of air is al-
iowed. By an interrupted administration of ethyl chlorid — that is,
first securing deep narcosis and then giving air— a Hght anesthesia may
be maintained for some time, though at times muscular relaxation is

ANESTHETIC MDCTURES. 49

not obtained and the patient is apt to remain partly conscious.
Danger signs from ethyl chlorid anesthesia are gasping, shallow res-
piratìons, pupils widely dilated and not reacting to light, and general
pallor of the skìn.

Administered by the semiopen method, a greater quantity of the
drug will be necessary, and somewhat more time wìll 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.

ANESTHETIC 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 . io 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 administratlon 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
sufiFering from chronic lung trouble, as emphysema, bronchitis, etc,
in advanced cardiac disease with lack of compensation, in atheroma,
in alcoholics, in those with renai disease, and in cerebral operations
mixtures are most useful. Being^afipeeabl^o take, they are often used
as a means of obtaining orf^Oy^ancsfe^ìàN^ ether when nitrous
oxid or ethyl chlorid are^Stvailabtef*' — tN

Apparatus. — Mixturefc coi|Jpi^|ifnggcJi^^ always be

given by the open methoB, and for this purpose s^e such mask as the
Esmarch or Schimmelbus^ previdusly'de^cribpd (see page 36), should
be used. ^4^6 H A?:>^

Administration. — ^The same general rules and princìples that
govem 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 begim 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 fuUer 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

mXUBATION ANESTHESIA. 5I

Crile's metbod, will be found of great service. The advantages are
that the anesthetist and inhaler are removed from the seat of operation
so that they in no way interfere with the opwrator, and the anesthetic
can be admìnistered contìnuously, as it is not necessary to delay or stop
the operation every little while in order to get the patient well under,
as is the case when the ordinaiy interrupted form of anesthesia is
employed. As the pbaiynz is packed with ganze, aspiration of mucus
or blood from the site of operation is avoìded, nor ìs there coughing or
\-omiting up of blood that raay ha ve collected in the back of the pharynx.
Apparatua.^ — ^The apparatus consists of two rubber tubes of a size
that will comfortably pass through the nares, each about 8 ìncfaes

Fio. 37. — Sbowing the method of inserting the tubes and packing the phaiynx for intuba-
tion anesthesia.

(20 cm.) long, preferably cut at their distai ends at an acute angle, and
fumished with side openings. The upper ends of the tubes are
connected to the two arros of a Y-shaped glass tube, to the long arm
of whìch is attached by means of a third piece of rubber tubing a funnel
lightly packed with gauze.

Technic. — After full anesthesia has been obtained in the usuai way,
a mouth gag is inserted, the throat is well cleared of mucus by means of
small gauze swabs, and the two tubes, well lubricated, are carefully
passcd through the nares and down lo the epiglottis with their pointed
ends directed downward and forward. The tongue is then drawn well
forward and the whole pharynx is firmly packed with a single piece of

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 shouid he 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 shouid be
promptly removed and the phaiynx repacked. As soon as regular
breathing is cstablished 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,

Fio. 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 fiat
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 tl^en attached to the tracheal cannula, and the

RECTAL ANESTHESIA. 53

anesthetic is admuiistered by dropping chloroform on the gauze of the
ìnhaler.

Rectal Anesthesla. — It consists in producing narcosis by means of
wann elher vapor slowly forced into the rectum. This methodwas
employed in 1847 ^y Roux. Later, in 18S4, it was taken up by
Moilière and in this country by Dr. Weir and Dr, Bull, but it never
carne into general use. In the early cases colicky pains, diarrhea,
bloody stools, and painful distention of the intestine were frequently
observed. These symptoms, no doubt, were in many instances due
to faulty methods of administerìng the anesthetic, and with the im-
proved technic of Cunningham the method has given better results.

FlG. 19, — Sbowing the tracheal cannula in place.

Though it cannot be said to be free from risks, rectal anesthesia has
a definite place among the methods of anesthetizing at our disposai.
Its greatest &eld of usefulness is in cases of extreme pulmonary or bron-
chial involvement and empyema, and in operations about the face,
mouth, and laiynx, 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 irritatlon from the ether. While
il is true that the greater part of the ether is eliminated from the lungs,
the direct irritation of concentrated vapor is overcome, as is sbown
by the absence of the bronchial secretìon, 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 band, 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
palient under, so that other means of anesthetizing must be utilized.

THE ADMINISTRATION 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 foUowing:
A wash bottle to hold the ether, about 8 inches (20 cm.) high and 4
inches (io cm.) in diameter, supplied with a tight stopper in which are
two perforations. Through one of these openings a glass tube leads
to the bottoni of the bottle, and through the other a glass tube, cut off
flush with the under surface of the stopper, leads out. A doublé
cautery bulb is attached to the aflFerent tube by a piece of rubber tubing,
while to the eflferent tube is connected a piece of rubber tubing leading
to a plain rectal tube, a glass bulb being interposed between the rectal

Fio. 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 aflFerent and the eflferent
tubes should be of suflScient 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 the 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 the
opera tion a colonie irriga tion, followed by an ordinaiy soapsuds enema
an hour before the operation, complete the preparations.

Technic. — The patient lies upon the table wìth 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 io
ijiches (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
lime necessary for this varies from five to fif teen minutes, according to
the patient and the absorption power of the bowel. 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.

Scopolamin-itiorphin Anesthesia* — Hypodermic injections of
scopolamin and hyoscin (which is claimed to be chemically the same)
bave 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 ADMINISTRATION OF GENERAL ANESTHETICS.

form or ether. In small doses, however, hyoscin and morphin may
be used with good results as an adjunct to locai or general anesthesia.
In such cases they can be given as follows: Hyoscin, gr. i/ioo
(0.00065 g°^-) ^^^ morphin, gr. 1/6 to 1/4 (0.0108 to 0.0162 gm.)
by hypodermic, one hour to two hours before opera tion. This com-
bination is more eflScacious than morphin alone, and has the eflFect 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 TREATMENT.

The accidents and dangers that may arise during the administra-
tion of anesthetics are connected with the respiratory or circulatory
Systems and include asphyxiation, 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 f oUow 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 ali 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, tum 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 giye due attention to the pulse, the condition

ACCIDENTS DURINO 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 adminìstratìon 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 meamng 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 amount 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
" f orgetf ulness to breathe," falling back of the tongue and epiglottis,
obstniction to the afa* 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 coUapse and falling in of the alae 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 obstniction or partial occlusion of the nares, the mouth should be
kept sufficiendy 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 suflScient, a sharp
slap upon the stemum with a wet towel or a momentary compression
of the stemum is frequently ali 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 ADUINISTRATION OF GENERAL ANESTHETICS,

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 thb is net possible, tracheotomy {page 392) should be performed
without hesitation.

FiG 31. — Melhod cJ holding Ibe 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 dìscontinued whìie artificìal respiration, combined
with inhalations of oxygen, is carried out. This ìs most effectively
performed by a combination of the Sylvester and Howard methods,
Any of the methods of artificial 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.

FlG. j2.^Showing the melhod of drawing the tongue and cpiglottis farward.

Artificial- respiration is carried out asfollows: Thefootoftheoperat-
ÌQg'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 DURINO ANESTHESIA AND THEIB TREATMENT, 59

above the head (Fig. $5). This thoroughly expands the chest and
produces an inspiration. The arms are maintained in this position
for a second or two, to allow the air to thoroughly expand the lungs.
Ejpiration is produced by the reversai of the above maneuver, bring-

FiG, 3j, — Aitificial resi»iatìon (inspiration). Note the aasisiant's hands ready to make
oninterpiessure over the lowet portion o£ the chest.

Ro. 34. — Artifidal respiration (expiratlon) . Theopcrator brings the patiem's arms firmly
agaùut the chest while the assistant makes counterpressure.

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

6o THE ADMINISTRATION OF GENERAL ANESTHETICS.

of the expiratory maneuver being lost upon the diaphragm and abdomi-
nal viscera. After another second or so, the assistant suddenljr
releases the lower portion of the chest and at the same time
elevation of the arms is again performed. The movements producing
artificial respiration should be made as near as possible to the rate of
normal respiration, certainly not over twenty times a minute. As an
adjunct to the above, forcible dilatation of the sphincter ani may be
performed for the purpose of exciting reflex inspiration.

A favorable response to treatment is denoted by a graduai return
of the naturai color, at first feeble gasps and then stronger attempts at
respiration, and a return of the pulse at the wrist. If, after five or ten
minutes, there is no response to the treatment, the prognosis is exceed-
ingly bad, but the artificial respiration should be persisted in for at least
half an hour. Deaths from asphyxia alone during anesthesia can be
prevented in nearly ali cases by foUowing the suggestions and the treat-
ment above described.

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

When the condition occurs in the later stages, after deep narcosìs,
it is the result of too much anesthetic, producing paralysis of the
medullary centers, and is a more dangerous condition. The pupils
suddenly dilate and fail to respond to light, and the conjunctival reflex
is lost; the respira tions become progressi vely weaker and more super-
ficial, and finally 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 relaxation.

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

described (page 58).

Cardiac Paralysis. — Syncope may occur during anesthesia from

ACCIDENTS DUBING ANESTHESIA AND THEIR TREATMENT. 6l

chloroform or ether, but is more apt to be produced from the former.
It is the most serious of ali 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 individuai is
already affected with degenerative changes in the heart, or is suffering
from severe anemia or shock. But fatai 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
capillarìes and veins, especially in the abdomen, so that the patient
has practically bled into his own vessels, and nearly ali the blood is
withdrawn from the cerebral centers.

Treatment. — The treatment of such a condition should consist in
artifidal 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. Artificìal 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.

Extemal 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

02 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 successfuUy
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 2oitl (o. 30 to i . 25 ce.) injectedinto a
vein, camphorated oil, 20111^ (1.25 ce), whisky, 2on]^ (1.25 ce), etc,
may be tried with better chances of success. An intra venous infusion
of hot salt solution, combined with 15 to 3orr|^ (0.92 to 1.9 ce) of a
I to loco 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 f orm of treatment When
there is no improvement within ten or fif teen minutes, the case is usually
hopeless.

THE AIUER-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 ali that can be done, and may be
persistent. That from chloroform is usually more severe and more
difficult to treat.

For the ordinary vomiting, inhalations of vinegar, ice in small
quantities by mouth, or very hot water in small doses (teaspoonfuls)
are the common remedies. The latter is most eflScient, serving to
dilute the mucus and wash out the stomach contents. Fif teen to 20 gr.
(0.97 to 1.3 gm.) of bicarbonate of soda in a glass of warm water
is also reconmiended. 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 8gr. (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 gm.) may 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 stili on the operating-table before becoming conscious.

Respiratory Compi ìcations. — ^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 f urther precautionary measure, the patient
should always be carefully protected against chilling, both during the
anesthesia and while he is being removed to his bed.

Renai Complications. — ^Temporaiy 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 periodofunconscious-
ness, though paralysis of centrai 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 aff ect 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 bang 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

04 THE ADMINISTRATION OF GENERAL ANESTHETICS.

acid intoxicatìon, most frequently follows chloroform narcosis and
especially among children. The symptoms do not appear until the
patient has recovered from the anesthesia, developing m from io to 150
hours (Bevan and Fa vili).

The condition is characterized by persistent vomiting, jaundice,
sweetish breath, rapid pulse, Cheyne-Stokes resptration, 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 fatai cases occurs within
three to five day^. 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 insuflSciency 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 injectìon i 1/2 ounces (47 gm.) of bicarbonate of soda is
dissolved in i quart (liter) of normal salt solution [salt Sii (7.8 gm.)
to the quart (946 ce.) of water], and 1/2 pint (236 ce.) 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 GEIflBRAL ANESTHESIA.

Before moving a patient from the opérating-table to his bed, it
should be seen that he is well protected and properly wrapped in
blankets. During the process of moving, 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 fiat upon the back, with the
head level or a little lower than the body, and with the face turned

PHE AFTER-TREATMENT OF CASES OF GENERAL ANESTHESIA. 65

to one side. If vomiting occurs, the patient shouid be tumed
slightiy to one side and the vomitus received in a basin, after which
the mouth shouid be wiped out. Frequent rinsing of the mouth
with warm water can be practised if the patient is conscious, and wiil
be found to be very grateful. The patient shouid be watched by an
attendant until consciousness retums, 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.

lirìous patients shouid be gently restrained, but net 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 shouid not be allowed to sit up for at least six hours.
Small quantities of warm water or cracked ice are gìven 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 shouid be liquid in character, con-
sisting of broth, beef tea, or soup. If this is retained, other articles
of soft diet shouid be added, until the ordinary diet is being taken.
It b important to have the urine examined for several days after
anesthesia, and after the use of chloroform special reference shouid
be paid to detecting the presence of acetone or dìacetìc acid.

CHAPTER II.

LOCAL ANESTHESIA.

By locai anesthesia is understood the abolition of pain sensation in
a chosen region, without the production of unconsciousness. Analgesia
is a more correct terni to apply to this variety of anesthesia, but usage
has so perpetuated the term "locai anesthesia'' that it will be employed
in these pages. The introduction of cocain by Koller, in 1884, first
made possible locai anesthesia as it is employed at the present time,
compression of thè 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 locai anesthesia by the discovery that
infiltration with cocain, or similar anesthetic agents, into or around a
nerve trunk in any part of its course eflFectually 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 locai anesthesia until it can now be
employed with entire success in a large number of major operations,
as well as the usuai 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 locai anesthesia intelligently used.

In the choice between locai and general anesthesia in any given
case, the question to be decided is whether under locai anesthesia pain
sensibility can be entirely abolished and, at the same time, sufiScient
muscular relaxation be obtained to insure the proper performance of
the necessary procedures contemplated. If these conditions cati be
satisfactorily obtained, and if the operator possess the necessary ex-
perience and skill in its use, then locai anesthesia should be oflFered to
the patient, if for no other reason, simply to avoid the well-known un-
pleasant after-eflFects 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.

ADVANTAGES AND DISADVANTAGES OF LOCAL ANESTHESIA. 67

Advantages and Disadvantages of Locai Anesthesia. — There are,
however, certain advantages in locai anesthesia that should not be lost
sight of. Most important is the absolute safety to the life of the
patìent 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 saf ely used, the dangers of cocain poisoning may be disregarded.

Again, under locai anesthesia, shock is lessened, and the depression
observ'ed after the use of general narcosis is absent to a marked degree,
so that locai 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 eflFectually blocks the
passage of ali 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 tìssues, even the
nerve tnmks 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 amputa tions.

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

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

In certain operations — hernia, for example — there is a distinct
advantage in having the patient conscious, that he may demonstrate
the protrusion by coughing. On the other hand, in some cases
consdousness 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 loca!
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 locai 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 unfamiliarity with the proper
technic, probably accounts for the fact that the wide scope of locai
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 magni tude and extent may be performed, provided the
region is capable of being anesthetized by infiltration or nerve blocking.

For the remo vai of practically ali benign growthsandisolatedglands,
locai anesthesia is quite sufiScient. Thyroidectomy 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 esten-
sive dissection necessary for the removal of malignant growths or long
chains of matted glands, however, locai 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 prindple 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 locai
methods. The latter operation lends itself especially to locai anesthesia

SUTTABLE CASES FOR LOCAL ANESTHESIA. 69

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

For the majority of abdominal operations locai anesthesia is not
satìsfactory. 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
j>erformed without a general anesthetic; but when extensive manip-
ulation is required, with the separation of adhesions necessitating more
or less dragging upon the mesentery, locai anesthesia is contraindicated.
Furthermore, in abdominal surgery complete muscular relaxation is
of ten required to secure the necessary wide retraction, and this cannot
be obtained with locai anesthesia.

Locai anesthesia is ideal in the operations for inguinal hemia 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 hemia can be operated upon
by employing infiltration alone, but not with the entire satisfaction
obtained in the inguinal variety. For strangulated hemia of any
variety, locai 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 baste, 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 ali amenable to
locai anesthesia. Operations about the rectum bave been performed
quite extensively by some operators under locai 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 locai anesthesia.

By a skilful use of locai 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 locai
anesthesia, and then nitrous oxid gas or a small quantity of ether may
be administered to tide the patient over the more painful procedures,
thus avoiding a prolonged general narcosis.

Those cases in which locai 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 individuai, locai anesthesia is generally contraindicated,
or at best it is very unsatisfactory on account of the difficulty of obtain-
ing the necessary quietude.

Methods of Producing Locai Anesthesia. — ^At the present time two
methods of producing locai 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 analgesie agents that we
largely have to rely.

The methods of emplo)ring chemical anesthetics may be in tum
divided into two classes: (i) Where thedrug is used in such a way
that the endings of the sensory nerves are paralyzed (terminal an-
esthesia); and (2) where the drug is brought in contact wilh 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 topìcal application of analgesie 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 tnmk (endo-
neural infiltration), about a nerve trunk (perineural infiltration),
or into the subarachnoid space (spinai anesthesia). Another method
of producing locai anesthesia, termed venous anesthesia, has lately
been introduced by Bier, whereby the analgesie 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 usuai preparation of the bowels,
etc, reeommended as preliminary to a general anesthesia, is advisable.
There is no need for the patient to fast, however, and a light meal of
eggs, coffee, milk, toast, etc, may be allowed, unless the character of the

DRUGS EMPLOYED FOR LOCAL ANESTHESIA, 71

op>eratìon 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 shouid
be taken as for general anesthesia (see page i8). Apprehensive antici-
patìon 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 ali cases
where the operation is to be at ali 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
sensibili ty; and it is the physiological antidote for cocain poisoning.
It may be given hjrpodermically 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
patient 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 hjrpodermically two hours before
operation.

Drugs Employed for Locai Anesthesia. — Locai anesthetics are drugs
which, even in weak solution, when brought into contact with sensory
nerves temporarily paralyze them. Of the many locai anesthetics
cocain was the first employed and holds the most important place,
having successfuUy 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
ihan 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
operation ->. Of course, when a large proportion of the solution escapes,
or when the drculation 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 io and 15 per cent., with the result that frequently a set
of dangerous symptoms, and in some cases death, were the sequels.
To avoid these untoward effects, a number of dnigs, as eucain B,.
tropacocain, stovain, alypin, novocain, acoin, nirvanin, orthoform,
anesthesin, etc, which are less toxic but ha ve 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 opera tors to cocain, and they
have the advantage that their solutions can be sterilized by boiling.
Weak solutions of cocain, however, used with proper precautions, t3ie
writer has always found to be efficient 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 fif teen
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 S^-)
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 infiltra tion, 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, io to 3on\ (0.6 to i .90 ce.) 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.

No. I, strong.

No. 2, medium.

No. 3, weak.

Cocain hydrochlor-

gr. 3 (0.195 gm.)

gr. 11/2(0.097 gm.)

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-)

Distilled sterilized

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

water.

The strong solution is used for the skin, perineural injections,
eie. An ounce (30 ce.) may be used without risk. Of the medium
strength solution, used for ordinaiy 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 formulae may be obtained from most pharmacists,
with full directions for the preparation of a solution of any given
strength. Schleich's solutions find favor with many operators, but
personally the writer prefers to administer the morphin separately
in a definite dose by hypodermic half an hour before operation.

The addition of adrenalin chlorid to the cocain solution, as
advocated by Braun, is of distinct advantage. Adrenalin is a vaso-
constrictor and has the same eflfect in the way of an adjunct to locai
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 overlobked. It is a good rule, therefore, to at least clamp any
vessel 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 lo say a few words about the proper conduction of an operation
under locai anesthesia. The successful and satisfactory employment
of locai 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 nerve 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 opera tors, the use of locai anesthesia will be impossible;
with others, it will necessitate a radicai 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
locai anesthesia in major surgery.

It is important, in the first place, to make the patient ascomfortable
as possible upon the operating-table. Operations under locai anesthe-
sia consume considerale 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 bome 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 for the remainder of the
operation.

With very nervous individuai, it is well to keep the instruments
covered from view and to avoid ali reference to knives, scissors, etc.
In fact, strict silence should be enjoined upon ali. 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 locai anesthesia. Rough manipula-
tions, or tearing of the tissues, or unnecessary pulling with retractors
by an awkward assistant, is often suflBcient 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 locai anesthesia, and often results in
condenmation of the method, though the fault lies with the operator.

THE SURFACE APPLICATION OF ANESTHETIC DRUGS. 75

THE PRODUCTION OF LOCAL AWESTHESIA BY COLD.

The anesthetic properties of intense cold bave long been recog-
nized and utilized in minor surgery. The tissues may readily be frozen
sufficiently 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
with one end drawn out to a fine point
and fumished with a spring tip (Fig.
36) or with a screw cap. The method
of application is extremely simple.

-_- - . , , , , , . Fio. 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 suflBciently 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 instilla tion, 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 op)erations 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.

Locai 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 run 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 eflfectiveness 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 io 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 fiUing 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
suflBcient. Fi ve ounces (150 ce.) of such a solution to which is added
twenty drops (1.25 ce.) 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 eflfect.

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

INFILTRATION ANESTHESIA. 77

upon the nerve endings, partly to the pressure of the fiuìd, and also lo
the interference with the blood supply. The anesthesia may be in-
creased and indefinitely prolonged if the circulation be kept stationaiy
by some form of constriction applied to the part, centrally to the seat

Fio. j7. — Apparaius for ìnfiltration.
I, Medicine glasses for cocain solutions; a, ampule of sterile cocaln and salt ciystals;
3, dmpper for adienaUn; 4, syringe armed with a short needle; 5, long <iiie acedlefordeep
iD&ltration.

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

FlG. j8.— The Matas massive infìitrator.

Apparatus. — For the purposes of ordinary infiltration the 6on\^
{3.75 C.C,) or the io ce. (2 3/4 dram) sub-Q syringe is the best.
This syringe has a solid giass barrel and glass piston with asbestos
packing, and can be readily sterilized, and is cheap. Severa! of these
syiinges should be on band for the operadon, and are to be kept fllled

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 ha ve 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 s)n-inge 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 air, 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, shapes, and sizes are provided
with this instnmient. The author
uses an infiltrator made on much the
same principles as the Matas instru-
ment. It consists of a long graduated
glass cylinder capable of holding io
ounces (300 ce), with an outlet at
the bottom and a rubber stopper fastened in the top by a clamp. A
small glass tube connected with an inflating bulb passes through this
stopper (Fig. 39). The reservoir is almost filled with the solution,
leaving about one quarter for air space, and the instrument is
charged with suflBcient air to cause the fluid to flow through the
needle in a strong stream.

Technic. — In ali cases where an extensive or at ali prolonged
operation is contemplated, unless contraindicated, morphin, gr.
1/4 (0.0162 gm.), should be given hjrpodermically half anhourbefore

Fio. 39. — ^The author's apparatus for
massive infiltration.

INFILTRATION ANZSTHESIA. 79

operadon. For the skin infìltration, 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

RG- 40- — Showiog the methtxl of ìnfiltratìng the skin. The needle is inaerted in such a

way that, wiih the injectioa of a few dmpg of solution, a wheal the size of a ten-

cenl piece is produced.

an often imexpected shock from the first prick of the needle. The
needle, held almost paralUl to the surface, is pushed info the skin just
beneath the epidennis — not beneath the skin — so às 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

Fio. 41, — Showing the rònsertion of the needle imo the edge of the wheal.

are injected and the skin becomes blanched and raised info 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, untìl the entìre line of the proposed incision is one

So LOCAL ANESTHESU.

continuous wheal (Fig. 41), In thìs 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 ìn-
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 i to loooo solu-
tion for massive infìitration of large areas is used. The needle is in-
serted into the line of the skin cocainization, and the solution is injected
in ali 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

Fic. 4«. — Showing Ihe directions in which the needle shouid be inseited in masdve ìnfiU

operation for inguinal hemia about the extemal ring where the main
nerve trunks break up into their terminal filaments. In the case of an
operation upon a circumscribed growth, the infiltration is 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 periosleum, may be
infilirated 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 carlilage ha ve no sensation, but
their coverings are eitremely sensitive; hence particular care must be
taken to infiltrate fascia, muscle, and tendon sheaihs, periosteum, and
joint capsules, and when operating upon joints to cocainize the syn-
ovial membranes by a preliminary instillalion of weak cocain solution
into the joint before operation. With proper infiltration the whole
field b thoroughly edematized 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 shouid nevertheless be injected

ENDO- AND PERINEURAL INFILTRATION. 8l

after the method to be described whenever they are encountered
durìng 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, wherelarge quantities of solution are

Fic. 43- — Sbowing the applìcaiion of a constrìcling band to the finger in order to ptolong
and intenùfy the anesthe^.

used and remain in the tissues when the operatìon is completed, it is a
wise precaution to loosen the constriction gradually and intermittently,
so as noi to rapidly flood the system with a large volume of cocain
solution.

EKDO- Am) PERUTEURAL INFILTRATION.

The discovery that injections of cocain and similar analgesics into
the tissues surrounding a nerve (perineural ìnfiltration) or directly
into it {endoneural ìnfiltration) will effectually block the particular
nen-e and produce anesthesia in the entire area of its distribution has
made possible many operations of magnitude, such as those for hemia,
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 cxposing
the nerve before ùijection; 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 intensiiìed and indefinitely
prolonged by arresting the circulation in the inj'ected and anesthetized
ner\e trunks by means of elastic constriction, as already spoken of
under ìnfiltration, and to a tesser degree by the addìtion of adrenalin to
the analgesie solution.

82 LOCAL ANESTHESIA.

The perineural method of infiltration is more suited to regions sup-
plied by the smaller superfìcìal nerves and to the smaller extremitìes, as
the fingers and toes. Fot anesthetizing the larger nerve trunks wi th thick
sheaths, direct injection of the nerves as they are ezposed in the held of
operation, or at some point along the course of the nerve centrai to the
seat of oi>eration, wìli give more certain resulta. When a region is
supplied by severa! nerves, each wìU bave to he separately isolated and
blocked.

Apparatus. — The ordinary Óon^ (3.75 ce.) or io ce. (2 3/4 dr.)
" Sub-Q" syringe, with a fairiy long needle will be found most sat-

Technic. — In the perineural method of infiltration the analgesie
solution is injected in such a way as to surround the nerve tnink or
" envelop the nerve in an anesthetic atmosphere," as Matas expresses it,
A spot in the skin Irom which the ner\'e can be reached with the hypo-

FiG. 44. — Melhod of Ìn6llniting a large nerve trunk. The anesthetic solution shoul<I
be injected imo the nerve in ali djrectbns so that the entire nerve is rendered anesthetic
below the point of ÌDJection.

dermic needle is iniìitrated 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 ce) are injected
into the tissues surroundìng the nerve. The solution is allowed to be-
come diffused, and then, if the nerve be in an extremity, the part is tx-
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 sufEciently 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
m the field of operation, the technic is very simple, the individuai
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
distai 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 ali 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 à short time ali sensation below the seat of injection becomes be-
numbedy and operations of any magnitude may be performed.

Practical Application of Infiltration, Endo- and Perineural
IVlethods of Anesthesia to Special Localities. — The methods of
locally anesthetizing a part just described ali bave 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 successfuUy 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 f umish 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 does 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 nerve 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.

«4 LOCAI, ANESTHESIA.

Blocking these nerves by cross strips of infiltration at the points where
they penetrate the rouscular fascia and become subcutaneous (Fig. 46),
or performing a thorough circumscribed infìitration around the area
o£ operatJon, with infiltration of the periosteum, if necessary, renders
many cases amenable to locai measures which are now performed
under general narcosi». Constrictìon by means of a nibber tourniquet
passed around the forehead above the ears and over the occipital
protuberance will be found niost useful as an aid to anesthesia.

Fic. 45. FiG. 46.

Fic. 45. — The superficial nervea of the scalp and face, i, Supratrochlear nerve; a,
supraorbiul nerve; 3, (emporal branch of the temporomaJar nerve i 4, aurìculotemporal
nerve; 5, great auricular nerve; 6, amali otcipLtal nerve; 7, great occipital nerve;
8, infratrochlear nerve; 9, infraorbital nerve; io, nasal nerve; 11, mental nerve.

Fig. 46. — Sho«ìng the area of aneslhesia after blocking ihe supmliochlear, supia-
orbital, and mental nerves. The dois indicale the points for infiltration.

About the lips, chin, nose, cheeks, tongue, mouth, and lower jaw
locai means of anesthesia are ofien quite sufBcient. 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
nerves. The inferior dentai nerve is readily reached for blocking as
it enters the inferior dentai foramen at the outer side of the spine of
Spix. This point lies near the median line of the internai surface of
the ramus of the jaw about half an inch (i cm.) above the upper surface

ENDO- AND PERINEURAL INKLIRATION. 85

of the last molar tooth. The lower jaw may be thus anesthetized and
teeth may be painlessiy extracted. The linguai nerve may be perineurally
infìllrated at about the same point, as it iies dose to the inferior dentai.
The floor of the mouth and the tongue are thus rendered insensitive,
and quite estensive 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. 47. Fio. 48.

Fic. 47. — The superfidal cervical pleius. The dolted lines indicate the couiae o£
the stemotnastoid mtiscle.

FiG. 48. — Showing Ihe area of anesthesia after blocking the superficial cervical
pleius. The dols indicate the poìnla for infiltratìng.

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

86 LOCAL ANESTHESIA.

The Thorax. — Exploratory punctures, aspiration of the pericardium
and pleura, rib resection for empyema, and the removal of benign
growths from the breast may ali be satisfactorily carried out under
iniìltration. In the operatìon of rib resection the infìltiation should be
carried out layer by layer, including the periosteum. Perineiiral
blockìng of the mtercostal 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-
tìon 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 parielal pleiu'a, like the peritoneum, is very sensi-
tive and requires infiltration before incision,

The Upper Eztremity. — Almost any operation may be performed
in this region under a skilfut use of locai anesthesia. Exposìng the
brachial plexus under infiltration anesthesia above the clavicle (Fig.
49) and blockìng each branch separately by direct injection with a
o. 5 per cent, solution of cocain destro}'s ali sensation in the area below

Fio. 4g. — Exposure of (he brachial plexus for ìnfillTalìon.

I, Exteraal iugular vein; 2, transveisalis colli artery; 3, scalenus aniicus muscle; 4, fifih

cervical root; s, sixCh 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, infìltration of the Unes 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 forearm require blockìng of the median, ulnar,
and musculospiral nerves. This may be done by direcily injecting
alt three nerves after exposure imder infiltration anesthesia in the upper
portion of the arm or by separately erposing and blockìng each nerve
just above the elbow. In following the latter method, the median nerve

ENDO- AND PERINEURAL INFILTRATION.

is exposed by an incision across the elbow to the inner side of the biceps
muscle, the brachial artery lying just extemal to it; the ulnar, in the
groove between the internai condyle and the olecranon; and the mus-

o ■■ >^

^■^

Fio. 50. FiG. 51.

FiG. 50. — ^Exposuie of the musculospiral and median nerves at the elbow.
culospiral nerve; 3, median nerve.

Fio. 51. — ^Elxposure of the ulnar nerve just above the internai condyle.

I, Mus-

culospiral, between the biceps tendon and the supinator longus muscle.
Blocking each nerve with a 0.5 per cent, solution of cocain produces
complete insensibility of the extremity below the point of injection
exceptìng the skin and subcutaneous tissues of the upper centrai

Fio. 5 2. — Showing the method of anesthetizing the small superficial nerves by circular strìps

of subcutaneous infiltration.

portion of the forearm, supplied by the musculocutaneous and internai
cutaneous nerves. A circular area of subcutaneous infiltra tion, at the
elbow, however, as advised by Matas, abolishes any remaining sensi-
bility in this jregion (Fìg. 52).

LOCAL ANESTHESIA.

Just above the wrist, the median, ulnar, and radiai nerves are
available for perineural mjection. 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 distante 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 radiai nerve and its branches are best
caught by a cross strip of subcutaneous infiltration just above the

Fio. 53. — Cross-section of the forearm above the wrist showing the direction of the needle
for perineural infiltration of the ulnar and median nerves. (After Braun.)

I, Interosseus nerve; 2, radiai nerve; 3, radiai artery; 4, median nerve; 5, ulnar ner\'e;
6, areas of skin infiltration; 7, flexor carpi ulnaris tendon; 8, palmaris 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 nerves higher up. A
circular strip of subcutaneous infiltration above the wrist, however,
will render the anesthesia complete (see Fig. 52). In thin indi\dduals,
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 surf ace near the base of each finger (Fig. 54) . Through
these points the needle is inserted toward each of the four digitai nerves,
and the anesthetic solution injected (Fig. 55). Ali nerve communica-
tion is thus blocked and the finger may be incised, amputated, etc,
without pain. By injecting in the known location of the digitai 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 abdomen may be opened in any region by
simple infiltration, combined with endoneural injection of nerves as
they are exposed. The skin, the subcutaneous tissues, the fasciae, the

Fio. 54. — Foints tor inserling (he necdle in perineural infiltralion of the digitai nerves.

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

Fio. 55.— Cross-section of the finger showing the direction of the necdle for perineural

infiltration of the digitai nerves. (After Braun.)
I, Exiepsot tendoni; 3, bone; 3, fleiorlendons; 4, areaa of skin infiltration.

Hemìa. — While operatìons for heniia of any varìety may be
carried out under locai anesthesia, the inguinal will be found especially
suited to this method of anesthesia, the umbllical and femoral varieties

90 LOCAL ANESTHESIA.

Por inguinal hemìa a combìnation of infiltration and endoneural
injectioQ is possible on account of the anatomical arrangement of the
inguinal region, which is supplied by three fairly large nerve trunks
liaving a rather Constant course— namely, the iliohypogastric, the
ilioinguinal, and the genitocruial. The iliohypogastric will be
found in the upper angle of the hemial incision after reflecting the
aponeurosis of the esternai oblique, usually running downward and
inward on a line drawn from about the anterior-superior spine to a

FiG. 56. — Showing the nerve supply o[ the inguinal region. (After Cushing.)
I, lliohypogaslric nerve; 2, ilirànguinai nerve; 3, conjoined lendon; 4,
muscle; s, aponeuroas o( [he extemal oblique incìsed and edges reflected.

point an inch (2 . 5 cm.) above the extemaL ring. The ilioinguinal
wìU usually be found in the line of incision just beneath the aponeurosis
of the extemal oblique, and on a lower level than the iliohypogastric,
running downward in the long axis of the hernia (Fig, 56). Il may
even lie as far out as Poupart's ligament. This nerve is often smallcr
than the iliohypogastric, and in some cases ìt may be absent, in which
event its place is taken by the genitocrural. The genilocrural wilI be
found after reflecting the aponeurosis of the esternai oblique lying
among the structures of the cord, and frequently it lies behind the cord.
Infiltration aneslhesia is employed until the aponeurosis of the extemal
oblique is reflected, when the above nerves are separately blocked.
In performing the infiltration, espectal care should be taken to inject
plenty of solution in the region of the extemal ring where the nerves
break up into their terminal filamenls. After the nerves are properly

ENDO- AND PERINEUKAL INFILTRATION.

blocked, the remainder of the operation may be painiessly perfonned
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 amputaied, adhesions within the sac separated,
and gut resected if necessary, without pain.

Femoral hemia may be operated on under simple ìnfìltration of
the skìn, subcutaneous tissues, and sac; or, preferably, by a combi-
nation of infìitration and endoneural injection. If this lattar method
is employed, the incision is placed so as to expose in addition the ester-
nai abdominal ring. The aponeurosis of the extemal oblique is thus
exposed and is incìsed for a short dislance, so that the ilioinguinal
and genitocrural nerves may be identified and injected. Blocking of
these nerves, combined with infìitration, renders the field of operation
more nearly anesthetic than infìitration alone.

Fio. 57. — Showing Ihe method ofìnfiltraling about the cord in operationsupon the lesticle.

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

The Scrotum. — Any of the operations about the scrotum and
testìcles, such as those for varicocele, hydrocele, castration, etc,
may be carried out by perineural injection around the cord as it
escapes from the extemal ring (Fig. 57), combined with infìitration
along the site of incision.

Penis and ITrethra. — 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 extensìve
operations upon the pendulus portion may be performed by subcu-
taneous ìnfiltration of a ring about the base of the penis, carefully
injecting the solution around each of the dorsal nerves. External
urethrotomy may be performed under Ìnfiltration combined with
topical anesthesia of the mucous membrane (see page 76).

Rectum and Anus. — The limitations of locai anesthesia in rectal
operations have been pre\dously 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 sufficient. When it is
necessary to stretch the sphincter, anesthesia may be obtained in the
following manner: Four wheals are made in the skin — in front, behind,

\i/

FiG. 58. — Points for injection in Ìnfiltration 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 Ìnfiltration anesthesia and
blocking of the anterior crural, the external cutaneous, and the sciatic
nerves, combined with a circular strip of subcutaneous Ìnfiltration,
completely blocks ali 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 {CentraìblaU f. ChirurgUy 1909) a method of skin-grafting under
locai anesthesia by taking the grafts from the outer side of the thigh after obtaining anes-
thesia in this region by perineurally infiltrating the external cutaneous nerve at the inner
side of the anterior superior spine.

ENDO- AND PERINEURAL INFILTRATION.

for injection by an ìncision so placed as to expose the nerve as it
emerges from under the anterior superior spine (Fig. 59). The anterior
cniral nerve may be exposed by an incision placed about 1/2 inch (i

Fig. 59. — ^Exposure of the anterior crural and extemal cutaneous nerves for injection.
I, Anterior crural nerve; 2, extemal cutaneous nerve; 3, femoral artery; 4, femoral vein.

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

Fig. 60. — ^Exposure of the sdatic nerve in the upper part of the thigh for injection.
I, Gluteus maximus muscle; 2, biceps muscle; 3, semitendinosus muscle; 4, sdatic nerve.

der of the popliteal space. In the former case, an incision 3 to 4 inches
(7.6 to IO 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 marimus 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 internai saphenous nerve for injection.
I, Internai saphenous nerve; a, interna] sapbenous veìn.

popliteal space the nerve may be exposed by a vertical indsion 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

Fio. 63. — Cross- section of the legabove theankle-joint, showing the direction of the needlc
for peiineural infiUration of the poslerior tibial nerve. (After Braun.)
I, Posterior tibial nerve; 2. cxtemal saphenous nerve; 3, area of skin iniìitration; 4,
musculocutaneous nerve; 5, antcrior tibial nerve; 6, tendo achillis; 7, perone! muscles; 8,
flexor longus hallucis; g, extensor longus digìtonim; io, exlensor longus halluds; li,
tibialis anticus; 11, tibìalis postìcus; Ij, flexor longus digitonim.

internai and esternai popliteal nerves are to be blacked. In operations
below the tubercle of the tibia, ìt is unnecessary to block the anterior
crural and extemal cutaneous;- blocking of the sciatic in the popliteal

bier's venous anesthesia. 95

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

Below the knee, the large nerves are not available for injection until
the ankle is reached. Behind the ankle the posterìor tibial may be
perineiirally injected by inserting the needle on the inner side of the
tendo achillis directly forward ahnost 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 halluds 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 locai 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 toumiquets
applied above and below the area to be anesthetized, injecting the
anesthetic solution into one of the veins between the two toumiquets.
What 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
locai anesthesia which are suflBcient 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.

While this method of anesthesia is too new to have received a
thorough trial in the hands of dififerent óperators, it has been thoroughly

LOCAL ANESTHESIA.

tested by its origihator and by him ìs considered to be far ahead of the
other methods for producìng locai anesthesia. Bier reports (Berliner
klinische Wochenschrift, March 19, 1909) 134 operations under
venous anesthesia, includmg amputatìons,,arthrotomies, bone suture.

FiG. 63. — Cannula and syringe for ìnjecting 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 ali that could be desired.

FiG. 64. — Instruments for venous anesthesia.
I, Scalpel; 2, blunt-pointed scissors; 3, thumb forceps; 4, aneurysm needle; 5, needle

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

Apparatus. — An infusion cannula, a syringe, such as the Sub-Q
or the Janet, with a capacity of about 3 ounces (89 ce.) and
supplied with a short heavy piece of rubber tubing for connection with
the cannula (Fig. 63), a hemostat to clamp the rubber tubing, and

BIER S VENOUS ANESTHESIA. 97

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

Instnuneiits. — Instruments necessaiy for an ordinar/ infusion are
required^ namely, a scalpel, mouse-toothed thumb forceps, a pair of
blunt-pointed scissors, an aneurysra needie, needle holder, two curved
needles with a cutting-edge, and No. 2 plain catgut (Fìg. 64).

Solution. — Bier employs a o. 5 per cent, solution of novocain in
normal salt solution.

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

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

Preparations. — The site of injection is carefully cleansed with soap
and water, followed by a 1 to 2000 solution of bichlorid of mercury
and then stqile water. The instruments are boiled, and the operator's
hands cleansed as for any operation.

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

Fic. 65. — Bier's vcnous ancsthe^a. Shoning the application of the bandages and the
site of in]eciion+.

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 toumiquets are then applied,
one at a point above the operadve field and the olher below, by
wrapping 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 the main subcutaneous veins or
one of its large tributaries is exposed in the proximal part of the
isolated area (Fig. 65). The vein isopened by cutting with scissors,
and the cannula is secured in its dblal end. The syringe, filled with

98 LOCAL ANESTHESIA.

the solution, ìs then attached to the cannula and the desired quantìty
of the anesthetic is injected under considerable pressure toward the
periphery/ i.e., 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 toumiquets'and is brought in contact with the
nerve trunks and nerve endings of the whole area, producing com-
plete anesthesia of ali the tissues.

Direct anesthesia follows between the bandages in three to five
minutes, and indirect anesthesia beyond the distai 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 sutvuing the wound, to gradually
loosen the distai tourniquet, but not the centrai one, so as to permit
the veins to fili 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. — ^FoUowing Bier's lead, others have in-
jected locai anesthetics into the arterial system instead of into a vein.
Thus Goyanes {CentràlblaU fùr Chirurgie, 1909, Voi. 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.

RansohoflF {AnncUs of Surgery, Aprii, 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 animais which would seem to show that it is a safe and eflScient
procedure in suitable cases. He recommends. this method as being
especially applicable to operations upon the upper extremity where
the brachial, ulnar, or radiai artery may be exposed without diflSculty
and in operations upon the foot or ankle after exposure of the anterior
tibial artery.

RansohoflF'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 Medicai Joumaly Aug., 1910) states that he
has lately made the injection centrally, opening the vein dose to the distai bandage.

SPINAL ANESTHESIA. 99

above the point of proposed injectìon 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
arterìal circulation. From 4 to 8 ce. (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
capillarìes to the individuai nerve endings and the solution is diffused
through the capillary walls into the surrounding tissues so that little,
if any, solution is retumed 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 spinai 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 spinai 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 coUapse are by no means rare. Spinai 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 locai anesthesia are impracticable.

Injections have been made in ali 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. — AH the various locai anesthetics have been used.
Cocain may be used in a 2 per cent, solution in normal salt solution, io
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 chiorid Io the
cocain is said to be of great benefit, preventing the effusion of the
aneslhetic to the brain, and many of the unpleasant after-effecis,

Eucain B is safer than the cocain, 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 g™-)-

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 i/a gr.
(0.0486 to 0.0974) gm.).

Tropacocain is another substitute for cocain, frequently used, and the
anesthesia is more lasting. At the present lime, it is the anesthetic most
frequently employed for spinai anesthesia. It is given in a dose of from
1/2 to I gr. (0.0324 to 0.065 S""^) infl'S per cent, solution.

FlG. 66. — Apparalus fr
I, Elhyl chiorid; 2, medicine gtasse!^, one for receiving the spinai fluid and the other
for the anesthellc solution; 3, ampule conlaining sterile cocain and salt ciyslals; 4, scalpel;
5, syringe and Irocar. '

The injection of a solution of Epsom salt has lately been advocated
by Meltzer, Haubold, and others. Sixteen minims (i ce.) 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
iegs and pelvic regions appear and persisi for from eight lo fourteen
hours. It is claimed ihat overdosage endangers life from respiratory
paralysis.

Apparatus. — A special stylet needle and an appropriate syringe with
capacity of about 1 1/3 drams (5 ce.) 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 sacrai vertebrae is available for the puncture, but
ihe usuai site is between the third and fourth, or the fourth and fifth lum-
bar vertebrae (Fig. 67). The spaces may be identified by countingdown
from the seventh cervical vertebra. If this is diflScult on account of

'^— .>

Fig. 67. — Points for injecting the anesthetic solution in spinai anesfiiesia.

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
cither side of the spinai 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 (io to 15 mm.) in the vertical diameter.

I02

LOCAL ANESTHESU.

Preparation. — The operatìon shoiUd 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 ali 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 spinai puncture.

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

SPINAL ANESTHESIA.

103

Technic. — ^The spot chosen far 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 canying in
infection with the needle. The operator places his finger as a guide

Fig. 70. — Lateral position for spinai 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.

Fio. 71. — ^Spinai anesthesia.
Fig. 72. — Spinai anesthesia.

FiG. 72.

First stcp, 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-

104

LOCAL ANESTHESIA.

spinai fluid, corresponding to the amount of anesthetic to be injected,
shouid be allowed to escape before the analgesie solution is introduced
(Fig, 74). This will vary from io to 4on\ (o. 6 to 2 . 50 c.c,)i according

Fic. 73- — Showing the direction ci the ueedle in entering Ihe s[nnal a

Fio. 74. FiG. 75-

Fig. 74. — Spinai anesthesia. Third step, allowing ihe cerebrospinal fluid to escape.
Fio. 75.— Spinai anesthesia. Founh siep. ìnjecling the anesthetic solution.

to the strength of the solution to be used. Some operatore prefer to
dissolve the analgesie agent in the cerebrospinal fluid withdrawn and
reinject the solution thus fonned. The solution «houid always be

SPINAL ANESTHESIA. 10$

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 cerebrospìnal 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 paralysis, takes place. The anesthesia becomes marked
first in the anal and perineal regions, and then in the lower extremities,
being limited above, as a mie, 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 IH.
SPHYGMOMANOMETRY.

Sphygmomanometry is the instrumentai estimation of arterial '
blood pressure. The determination of blood pressure has become a
subject of such practical importance that both physicians and surgeons
should be familiar with the technic. In certain cases it is of ten 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 ali 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 distai to the point of
constriction measured in millimeters of mercury represents the blood
pressure. This is far more accurate than the usuai method of palpa ting
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, 90-1 io mm. of mercury

For adults, 100-130 mm. of mercury

In -females the pressure is about io mm. less than in males. After
middle life the pressure generally reads higher — of ten as high as 145 mm.
A systolic pressure between 145 and 90 nmi. 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 nmi. very low, while below. 45 to 40 mm. the pulse can

106

SPHYGMOMANOMETRY. I07

rarely be recognized. The diastolic pressure normally registers 25 lo
40 mm. less than the systolic. If the diflference between the two is
less than 20 mm. or more than 50 mm., it indica tes, 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
mcreases 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 individuai also modifies the pressure
reading, it being io to 15 mm. higher with the person standing than
when lying down. Likewise, the pressure is generally higher in the
aftemoon. 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-
\idual palpatìng the pulse, the pressure readings in the same patient
will vary somewhat with diflferent 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-
mg 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 Bamard, 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 (11 . 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 doublé 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

I08 SPHYGMOUANOHETKY.

the long arm of which is attached a short rubber tube supplied with a
pinchcock, for the purpose of releasing the pressure,

Stanton'sinstrument (Fig, 77) consistsof a rubber compressionarm-
let 4 1/2 inches (11.5 cm.) wide by ló inches (40 cm.) long, inclosed
in a cuff of leather or thìck 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 consista of a metal cistem connected by
a metal tube with a glass raercury tube having a scale registering to
300 mm. The metal cistem is provided with a screw cap ha\Tng a

Fic. 76. — The Riva Rocd SphygmomanDmeier,

T-shaped metal tube, one arm of which ìs connected with the armiet
and the other with the inflating apparatus, which consists of a doublé
inffating bulb. At the top of the metal cistem is a screw valve for the
graduai release of pressure, and on the arra connected with the inflat-
ìng 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 cistem, to one side of which is
allached the armiet and to the other a Politzer bag for the purpose of
inflation. The armiet is a ctosed rubber bag measuring 4 3/4 inches
(12 cm.) in width and 18 inches (45 cm.) in length, inclosed in a leather

SPHYGUOMANOUETRY. lOQ

cuff that is fastened to the limb by means of two straps. A stopcock
containing a needle valve for the release of pressure is interposed be-
Iween the cistem and inflating bag. The instrument is unassembled
for packing in its case as follows: The scale is slid down and the upper
part of the manometer ìs removed and placed in rìngs provided for
thìs 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

Fio. 77.— Slanlon's Spbygmomanomeier,

lid is shut by a block which compresses the rubber " B. " The inflatìon
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 pracdcal purpose
deiermination of the systolic pressure is sufficient. Whatever form of
instrument is £mployed, a wide anniet (4 1/2 to 4 3/4 inchcs (11.5 to
12 cm.)) shouid bc used.

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

no SPHYGMOMANOMETRY.

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

Technic {Riva Rocci Instrumenl). — The armlet is fastened about
the arni midway between the shoulder and elbow by passing the open
end of the cuff beneath the band on the closed end and hooking it in
place. The manometer is placed upon a table near by, and care b taken
to see that the upper portion ot the mercury tube is fitted securely in the
top of the lower one and that the mercury ìs at the zero point. The in-
flating bulb is then propcrly connected with the armlet and manometer,

FiG. 78. — Janeway's Sphygmomanometer.

and the pinchcock ìs closed. The examiner, with the fìngers of one band
palpating the patìent's pulse, gradually inflates the armlet by squeezìng
the bulb with the other band untìi the pressure obliterates the pulse,
when the height of the mercury is noted. The mercury is then allowed
to drop slowly untìI the pulse just reappears which represents the
systolic pressure, For the sake of greater accuracy, this maneuver
is repeated by squeezìng and relaxing the reservoir bulb.

Stanton's Inslrument. — The armlet is buckied in place and b con-
nected with the manometer,- the scale of which b adjust,ed so that the
mercury registers zero. With the valve "B" closed and cock "A"
open, and with the fìngers of the operatoron the patìent's pulse, the arm-
let ìs slowly ìnflated until the pressure causes the pulse to disappear.

SFHVGU01£AN0M£TRV. Ili

The inflation cock "A" is then closed and valve "B" is gradually
opened unlil the pulsa just reappears. The heìght of the mercury
when this occurs represents the systoHc pressure. The pressure is
further slowly reduced a few mìllimeters at a time, and, as the mercuiy
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 b nonnally
25 to 40 mm. below the systolìc pressure.

Fio. 79. — Technk rf sphygmomanomtìry with Ihe Stanton

Janeways Inslrumenl. — The armlet is properly secured about the
limb as described above and the scale is so adjusted that the level of
the two colimins of mercury is at zero, With the fingers on the
radiai pube the armlet is gradually inflated by compressing the bulb
until the pulse disappears. Then, by slowly releasing the bulb unlil
the pulse just retums, the systolic pressure is estimated. In cases of
viTy 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 ihe
pressure raìsed as high as desired. The diastolic pressure is obtained
in the same manner as described under the technic with the Stantcn
sphygmomanometer.

Variatioiu of Blood Pressure in Disease. '—Pain of ali kinds causes

'Fot a complete e%posiìion of th{s phase of the aubjea the reader is referred to
luieiray's "Clinical Sludy of Blood Presaure."

112 SPHYGMOMANOMETRY.

an increase in the peripheral resistance, and a rise in pressure. Thus,
in conditìons attended with severe pain, as in acute biliary or renai
colie, 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.

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

In infeciious diseases low pressure is the rule. In typhoid fever a
rapid drop is indicative of hemorrhage; if perfora tion occurs, there is a
sudden rise in pressure.

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

Renai 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 uremie symptoms, the blood pressure
rises, but falls as improvement in the condition sets in.

CardiovasctUar 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 ventriclc.
Arteriosclerosis may exist, however, without elevation of pressure, and,
if cardiac muscle insufficiency 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 ali 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 subdurai 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.

SPHYGMOVANOMETRY. 1 13

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

In shock and coUapse a fall in blood pressure is uniformly present.
According to Crile, in shock, the fall in pressure is graduai, while the
term "coUapse" 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 mie 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
foUowed 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 locai anesthesia alterations in blood pressure are less marked
than when the same procedures are carried out imder general
anesthesia.

CHAPTER IV.
TRANSFUSION.

The terni transfusion is applied to the transference of blood from
the vessels of a healthy individuai (the donor) to those of the patient
(the recipient), while the temi infusion is restricted to ali 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 wasnot until Lower, in 1665,
and Denys, in 1667, published their results that the opera tion was
used to any great extent. After this, it was employed for such a
varìety 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
cannulae 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
fatai.

As the subject became more thoroughly studied and better under-
stood, it was recognized that the blood of dissimilar species, through its
faculty for breaking up the red blood-corpuscles, was 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 thè 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. 11$

sis as formerly practised and the fact that transfusion required the use
of material and instruments often difficult to procure in an emergency,
materially lìmited the usefulness of the opera tion, and it became less
and less used. Finally, with the introductions of infusions of nonnal
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 country, 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.

Indications and Contraindications. — ^The principal indication for
transfusion is severe hemorrhage. Crile has show» 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 successfuUy transfused.
Transfusion is also indicated in pathologic hemorrhage, where the
coagulability of the blood is defìcient, as in hemophilia, cholemia, and
hemorrhage from the bowels, e te. In these cases the condition of the
patìent has been at least improved by the operation and in most cases
the hemorrhage has been controlied. 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 net maintain the rise in pressure. Transfusion, on the other hand,
frequently raises the blood pressure above norma! and will sustain it
at a high level for a niunber 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 stili undetermined, and we are not as yet fuUy informed as to what
diseases contraindicate its use. There have been cases reported of
fatai hemolysis after transfusion in pemicious 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 obser\ed
against the indiscriminate emplo)rment of transfusion.

1 16 TRANSFUSION.

Tests for hemolysis should be made upon the donor and the recip-
ient whenever possible. Hemolysis betwecn the donor's corpuscles and
the patient's serum b not necessarily harmful, but if it is found that
there is reversed hemolysis, that is, if the donor's senim hemolyses the
palient'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 precipitation may also occur; though, according to Crìle, in practice
these changes may be disregarded.

Hethods of Peiforming Transfusion. — An anastomosis between the
artery of the donor and the vein o£ the recipient may be effected by means
of the special tubes of Crile, or some of the modiiìcations of these tubes,

FiG. Sa — Instrumenls for transfusion.

I, Scatpel; 3, thumb forceps; 3, blunt-poinied scissors; 4,
fine tissue forceps; 6, Crile clamps; 7, small pair of curved scissi
needies threaded with fine strands of silk.

mosquito bemoslats; 5,
)rs; S, Crìle cannula; 9,

or by means of the direct suture method of Cartel. Crile's method is
without doubt the more rapidly and easily performed of the two. It
consists cssentially of slipping the tube over the vein, tuming 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 intimae 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 contraciion 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 tìssue forceps, two small Crile clamps, mosquito hemostats,
and transfusion cannula. If direct suture is employed, instead of the

7
Z

Fio. 81. — ^Enlarged view of Crile's clamps. (After Fowler.)
I, Clamp without nibbers; 2, nibber tubes to fit on jaws of clamps; 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 impregna ted
with vaselin and should be threaded into the needles before the opera-
tion is begim.

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

)

Fig. 82.

Fig. 83.

Fig. 82. — Eniarged view of Crile*s cannula.
Fig. 8^. — 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 in jury to the arterial
coats by undue stretching should be employed.

To avoid the necessity of haring several sizes of cannule and to
fumish 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 ìt is possible to alter
the diameter of the cannula to fit the individuai vessels (Fig. 83).

Asepsis. — ^The strictest asepsis must be observed during the entire
operatìon. The instruments are boiled, and the hands of the operator
are prepared in the usuai way. The forearms of the donor and the
recipient shouid 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 young vigorous adult shouid
be selected to supply the blood. The subject shouid preferably be
from among the relatives of the patient — a dose blood relation, as a
brother or sister, ìf 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, shouid be made to
determine his fitness.

OperaTìnff laile
1 iltcipient'

Operatine Tahle
Z J?onor

Fio. 84. — ^Arrangement of the operating-tables for a transfu»on. (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 assbtant; 6, instrument table; 7, table for dressings, etc .

Position of the Donor and Recipient. — ^The donor shouid He 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 tumed in the
opposite direction. Both tables shouid 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 bis assistant opposite.

Anesthesia. — ^The operation is performed under locai anesthesia,
emplo)ring a 0.2 per cent, solution of cocain for the skinand 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 — ^indicated by a graduai pallor
about the nose and ears, deepening of the lines of expression, sighing or
irregular respiration,etc. — the transfusion must be immedia telystopped.
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 immediately 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 radiai 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 h)rpodermically 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 radiai 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 dose 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 c^mp, a piece of tape
may be placed around the artery and clamped sufiSciendy tight to

I20

TRANSFUSION.

compress the vessel and shut ofiF the circulation. The distai end of
the artery is then ligated and the vessel is cut. The adventitia is pulled
over the end of the vessel and is snipped ofiF as clean as possible.
The field of operation is now covered with a compress well soaked with

1 '|'.V.;M\Ui

FiG. 85. — ^Transfusion by Crile's method. First step, exposure of the vein and artery with

Crile's clamps applied.

hot saline solution. The vein of the redpient chosen is then exposed in
the same manner, and about i 1/2 inches (4 cm.) of it is freed from the
surrounding tissues. The distai end of the vein is ligated, and to the
proximal end is applied a Crile clamp (Fig. 85), or a narrow piece of tape

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 drawing the artery over the vein.

fastened as described above. The vessel is divided and the adventitia
is snipped off after pulling it out over the end of the vessel. A Crile
cannula of appropriate size, held m an artery clamp, is pushed over
the vein. A suture inserted m the edge of the vein, as shown in Fig. 86,

TRANS FUSION.

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 cuff (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 band of the donor is directed toward the elbow of the recipient.
The cuffed 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 compie tion of the opera tion the vessels
are ligated, the tube is excised, and the skin incision is sutured and
dressed with sterile ganze.

In perfonning the operation there are several precautions to be
observed. The vessels to be anastomosed must be handled with the

Fig. 89. — ^Transfusion by Crìle's method. Fifthstep, showingtheanastomosiscompleted.

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
salme 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 giove 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 sìmplified Crile's method
of making an anastomosis by employing long glass tubes lined with
paraffin (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 iarge
at the end over which the vein is drawn. Each end is sUghtly bnlbous,
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 paraflGui, shaken out, and allowed to cool. The vein and
artery are exposed and isolated in the usuai 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

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 suflSciently to perniit the tube to fili with blood, the distai
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 Medicai Associationy 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 foUows: " The artery and vein are dissected out, temporarily clamped
and divided in the usuai manner, with the usuai 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 intestina!
needle and zero silk are sufficiently fine — at intervals of 120 degi'ees

TRANSFUSION. I23

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 dis lance of an inch (2 . 5 cm.). One of the guiding sutures is then
passed through the rolied 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 ofSurgery, March, 1909) describes a clamp forni 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 biade.
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 cannula 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 wall 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 Medicai Associaiion, March
13, 1909) describes a very practicai cannula that does away with the
necessity for the Crile clamps. His method of performìng 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 obtaìnable is about equal to that of the smallest
Crile cannula, and the largest greater than the lumen of any radiai
artery. The instrument is cone-shaped at its tip, a short distante 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 usuai 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 distai 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 dose 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 applìed, the distai 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 controlied by the extent to
which the cannula is opened.

Technic by CarrePs Suture. — Under locai anesthesia the radiai
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 dose 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 distai end of the
vessel is tied off. The artery is then cut dose to the distai 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 distai end of the vein is tied off with a
ligature, a Crile clamp is applied to the proximal portion, and the
vessel is severed dose to the distai 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 band
of the donor pointing toward the elbow of the recipient. The ends of
the two vessels are then sutured together as follows:

TRANSFUSION.

125

The needle, threaded with a fine strand of silk impregnated with
\'aselin, 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 tìed and left long, to serve as a traction stitch. Two other sutures

Fio. 93.

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

Fig. 94. — ^Transfuàon 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 cìrcumference 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. 96.

Fio. 95. — ^Transfusion by Carrel's suture. (After Carrel.) Third step, showing the
mclbod of suturìng the artery and vein.

Fig. 96, — Transfusion by CarrePs suture. (After Carrel.) Fourth step, the anas-
tomosis completed.

placed near the edges of the vessels and dose together to prevent leakage
(Fig. 9s). Before perfonning 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-

1 26 TRANSFUSION.

•

tions of the intima in the suture, As soon as one-third of the vessels
is united, the next two traction stitches are made taut and another third
is sutured, the clamp being also shif ted to the under stay. The remain-
ing third is united in precisely the same manner, thus compieting 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.

INPUSIONS OF PHYSIOLOGICAL SALT SOLUTION.

The administration of physiological salt solution was originallyintro-
duced as a substitute for transf usion of blood in the treatment o£ hemor-
rhage on account of the numerous risks that attended the lattei opera-
tion as formerly performed, and the difficulty of obtaining a suitàble
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 eflFectiveness, as no media have been found 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 litde prepara-
tion, that they are marked by simplicity in technic, and that they are
within the reach of ali; on the other hand, transfusion becomes a
formìdable 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 (ree tal 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 foUowing conditions:

(i) In collapse foUowing 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 fatai 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 beneficiai results.
For a single infusion, io to ^atri (o. 6 to i . 9 ce.) of the i to 1000 solution
of adrenalin chlorid may be added to a pint (473. 11 ce.) of salt solu-
tion, or the adrenalm may be admmistered by thrusting a hypodermic
needle into the rubber tubing near the cannula and injectìng the drug
as the salt solution flows into the vein.

(3) To increase the fìuids in the tissues where there is deficient
absorption of food, as in excessi ve 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 individuai.

(4) For its stimulating efiFects 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 parts sodium
chlorid to one-thousand parts of water. A variation in the strength
of the solution between 0.6 per cent, and 0.9 per cent, is permissible,
however, and in practice the solution is generally made up in the strength
of o. 7 per cent. — ^roughly, i dram (3.9 gm.) of chemically pure sodium
chlorid to a pint (473.11 ce) 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 without doubt also responsible for
many of the cases of reported sloughing of the tissues after subcutaneous
infusion.

A convenient method of keeping the salt solution ready for use is
to ha ve a sterilized and very concentrated solution put upin henne tically
sealed tubes, in such a strength that the contents of one tube emptied

INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION. 129

into a quart (946 ce.) o£ sterile water gives a normal salt solution (Fig.
97). In hospital practice it is customary to keep the solution in stock
bottles jeady for use. The solution is made up in the proper strength
from sterile salt dissolved in sterile water, and is then prepared as
foUows.* **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
m a deep basin filled with hot water unti! raised to the proper tempera-
ture." A more convenient method of bringing the solution to.the

^ ^TkKTLlZED
SALT SOLUTION

Fig. 97. — ^A tube of concentrateci 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 suflScient of the hot solution is then added to bring the con-
tents of the reservoir to the proper temperature.

Other Solutions Employed. — Some operators prefer to employ
artificial sera prepared according to certain formulae, the object being
to obtam a solution as nearly identical to the blood serum as possible.
Some of those most frequently used are as follows:

Hare*s formula:

(Approximately.)

Caldum chlorid.

0.25 gm.

gr. iv.

Potassium chlorìd,

.10 gm.

gr. I 1/2

Sodium chlorid,

9 gm-

dr. 2 1/4

Distilled water,

1000 C.C.

qt. i.

Rmger^s formule:

Potassium chlorìd,

0.2 gm.

gr. iii.

Sodium bicarbonate,

0 . 2 gm.

gr. iii.

Sodium chlorid,

9 gna-

dr. 2 1/4

Dbtilled water,

1000 C.C.

qt L

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

130 INFUSIONS OF PHVSIOLOGICAL SALI SOLUTION.

Locke' s formula:

Caicìum chlorìd, o.a gm. gr, iii.

Potassium chlorìd, o.i gm. gr. i i/a

Sodium bicarbonati, o.i gm, gr. i 1/3

Glucose, I gm. gr. xv

Sodium chlorìd, 9 gm. dr. 3 1/4

Distilled water, 1000 ce. qt. i.

Szumann's formula :

Sodium chlorìd, 6 gm. dr. i 1/3

Sodium carbonate, i gm. gr. x\.

Distilled water, 1000 ce, qt. i

Hayem 's formula:

Sodium chlorìd, 5 gm. dr. i 1/4

Sodium sulphate, i gm. gr. xv.

Dbtìlled water, 1000 ce qt. i.

INTRAVENOUS INFUSION.
The introduction of salt solution directly into a vein assures "us of

its immediate entrance into the circulation and the certain^ of its

— Apparatus for givìng a

infusìon. (Ashlon.)

absorption. The intravenous method i.s thus indìcated in any of the
conditions previously mentioned where there is necessity for great haste
and a prompt response to the treatment. The advantages of thìs
method of infusion are poìnted out by Matas as being almost unrestricted
in possibilities in regard to quantity, comparatìvely much less painful

INTRAVENOUS INFUSION.

131

Ihan the subcutaneous method, and requirtng the simplest and most
readily ìmprovised apparatus. In addition, if properly given, there is
absolute freedom from danger.

Appaiatus. — There should be provided a thermometer, a graduated
^8ss imgating jar, about 6 feet (180 cm.) of rubber tubing, 1/4 inch
(6 mm.) in diameter, and a blunt-pointed metal infusion cannula
(Fìg. 98). In addition, a constrictor for the arm, a gauze compress,
and a bandage will be required.

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

Fia. 99. — Instnimenls (or intravenous infuwin.

I, Scalpel; z, blunt-pcnoled sdssois; 3, thumb forceps; 4, aneuiysm needle; 5, ne«d1e
holder; 6, curved needies; 7, No. i plain catgut.

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

AtepBÌs. — 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
»s carefully scrubbed as for any operation.

Tonperature of Solution. — Most operators advise that 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
iiS*' F. wìthout harmful effects. It should be bome in mind that there
will be some loss of heat while the solution is flowing from the reservoir.
Por 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 importante ihat 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 ce.) in Ave to ten
minutes. It should be remembered that the weaker the action of the
heart the slower must the fluid he 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 foUow. If such symptoms ap-
pear, the infusion must be discontinued until the dangerous signs
have passed.

Quantity Givcn. — It has been shown that only a certain amoimt 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. 11 ce.) to three pints (1419 ce), depend-
ing on the case, but larger quantities may be required in cases of severe
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

INTRAVENOnS INFUSION. 133

which nins across the bend of the elbow from without inward.^ At
times a vein exposed in the couise of an operatìon may be conveniently
utilized.

Preparatton of the Patient — Ali clothing should be removed from
the area selected for the infusion, and that about the axilla loosened
if the arra is chosen for the infusion. The bend of the elbow is shaved,
if necessaiy, and is scrubbed with wann water and soap, then washed

Fio. 100.— The superfidal vàn» of the foreann. (Ashlon.)

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

Anesthesia. — Anesthesia of the skin is obtained by infiltration at
the site of indsion with a 0.2 per cent, solution of cocain freshiy pre-
pared, or by treezing with ethyl chlorid or a piece of ice dipped in sait.

' Dawbam advises that the infusion l>e performed through the internai saphenous
»rin at apoint anywhere above the ankle, clajming (i) that it is as large or larger than the
™n5 at Ihe bend of the elbow; (3) that there are no iroponant slructures near by to be
injured by a careiess operatori (3) that the star is unobjectionable; and (4) that the assis-
Unls peiforming the operation wili usuaily interfere less with the operating surgeon than if
Uie ann i» uaed.

134

INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION.

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

FiG. loi. — !

Showing the application of the bandage to the arni to constrìct the veins-

(Ashton.)

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

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

INTRAVENOUS INFUSION.

135

of an aneurysm needle, or, in its absence, by a pair of thiimb forceps.
The distai portìon of the vein is tied off as low as possible with one
ligatiire, and the second ligature is placed high up around the portion
of the vein nearest the heart, ready to be tied (Fig. 103). A portion of

Fio, 103. — Intravenous saline infusion. Second step, showing the distai end of the
vdn tied and a second ligature being passed under the proximal end of the vein.

Fig. 104. Fig. 105.

Fio. 104. — Intravenous saline infusion. Third step, showing the method of incising
the vein.

FiG. 105. — Intravenous saline infusion. (Ashton.) Fourth step, showing the cannula
being inserted into the vein.

the exposed vein is now grasped in a mouse-toothed forceps at a short
distance from the distai ligature, and, while the vein is put upon the
stretch, a cut directed obliquely upward is made with scissors through
half the vein, exposing its lumen (Fig. 104). The solution is firstallowed

136

INFUSIONS OF PHYSIOLOGICAL SALT 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 stili
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 handage is
now removed from above the elbaWy 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 fluid
in the reservoir before it has ali escaped, otherwise air will enter the vein
when a fresh supply is added.

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

Fio. 106. Fig. 107.

Fig. 106. — Intravenous saline infu^on. Fifth step, showing the cannula tìed in place.
Fig. 107. — Intravenous saline infusion. (Ashton). Sixth step, showing the infusion
cannula removed and the proximal end of the vein ligated.

ligature the proximal end of the vein may be then tied oflf (Fig. 107).
The edges of the skin wound are united with several catgut sutures, and
a sterile ganze dressing, held in place by a few tums of a bandage, is
applied.

Variation in Technìc. — Some operators perform intravenous
infusion without makìng 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 veìn.

The difficulty in placing the needle accurately in the vein, espedally
if the subject is very fat, places a limitation upon the field of usefulness
of this method.

INTRAARTERIAL INFUSION.

Saline solution may be injected into the artery instead of intra-
venously, if desired. The solution may be injected either into the
distai 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 circulàtion. 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 necessita t-
ing amputation of the hand, so that for ordinary purposes saline
solution introduced through a vein should be the method of
choice.

Crile and Dolley {Journal of Experimental Medicine, Dee., 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
ihe right heart, the lungs, and then back to the left heart before it
reaches the aorta and coronary arteries, This often causes an accu-
mulatìon 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 INFOSIONS OF PHYSIOLOGICAL SALI SOLUTION.

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

Site of Infusion. — The carotìd artery or one of its large branches ìs
chosen for Ihe injection as being the most direct route to the coronaiy
arteries.

Teclioìc. — Crile (Am. Jour, of Med. Sciences, Aprii, 1909) gìves
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, wìth one

Fio. loS.^Showing the method of infusing salt and adrenalin solution into the caiotid
artery. {After Da Costa.)

hand on each side of the stemum. This pressure produces artificial
respiration and a moderate artifìcial 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 tunnel and rubber tubing. Bui as
soon as the flow has begun the rubber tubing near the cannula is pierced
wilh a hypodermic syringe loaded with i to 1000 adrenalin chlorìd and
15 to 30 nj (o. 92 to 1 . 90 ce) 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
stili 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 Intraarterìal Infusion.—
This consists in injecting saline solution into the circulation through a

Fio. 109. — ^Apparatus for infusing salt solution into an artery in Dawbam'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 veiy difficult to
locate.

Apporatus* — ^A hypodermic needle, or a long fine aspirating needle,
and an ordinary Davidson syringe (Fig. 109) are ali that are required.

Technic. — The femoral artery is first carefuUy 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 fili its
lumen. The rubber tubing of the syringe, which has been previously
filled 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 IKFUSIONS OF PHYSIOLOGICAL SALT SOLUTION.

from a basin directly into the arterial circulation (Fig. no). Accord-
ing to Dawbam, it requires aboùt half an hour to inject a pint of solu-
tion by this method, If a fountaìn syringe is used ìnstead 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
back up the tube.

Fig. ho. — Showing the method of infusing salt solution into ììk femora] artery.

HYPODERHOCLYSIS.

The subcutaneous method of ìnfusion does not pennit as rapid an
introduction of large quantities of solution as the intravenous, on ac-
count of the slowness with which the solution is absorbed. It is indì-
cated in the same conditions as venous infusions, when urgency is
not of prime imjMrtance. It is also frequently used as an adjunct
to intravenous infusion. Hypodermoclysis is contraindicated where
the tissues are edematous from dropsy, or where the cb:culation is so
feeble that absorption of the solution is very slow or impossible.

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

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

HYPODERMOCLYSIS. 141

deansed. The thcrmomeler is sterilized by immersion in a i to 500
bichlorìd solution for ten minutcs, followed by rinsing in sterile water
Temperature of the Solution. — The solution should enter the body
at about 1 10° F. When usìng a large aspirating needle the fluid in the
resen'oir should be kept at a Constant temperature of about 3 degrees

Fio. III. — Apparatus fot giving hypodermoclyas. (Ashlon.)

higher. If a hypodermic needle be employed, about 5 degrees should
be allowed for coolìng.

Kapìdity of Flow. — As the fluid is taken up with but comparative
slownesslrom the subcutaneous tissues.the injection isgìvenlessrapidly
than by the intravenous method. With a fair-sized needle about a

■Showing Iwo needies arrangcd tor hypodermoclyàs.

1^' (4/3. II C.C.) of fluid may be injected in from twenty to thirty
"ùnutes, the reservoir being held from 3 to 4 feet (90 to 120 cm.) above
ibepitìeat. When a hypodermic needle is employed, the needle being

so small in caliber, it will be necessary to raise the reservoir 5 or 6 feet

(150 to 180 cm.) to gel suificieni 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 te i6 ounces (236 to 473.11 ce.) of solution are
introduced at a single injection, and repeated in a few honrs, if neces-
sary. According to Hildebrand, it is not safe to introduce a largar
quantity of solution in fifteen minutes than i dram (3.75 ce.) 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 usuai sites are: (i) under

Fio. 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 mày 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 stili
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

HYPODERMOCLYSIS. I43

chaoged slightly, a large amount of solution may be infiltrated over a
Wide area without producing toc great tension at any one spot.
The absorption of the solution may be hastened by gentle massage
over the infìltrated area. During the operatìon, the temperature of.

Fio. 114. — Giving hypodermoclj^s under the lelt breast. (Ashton.)

the solution is to be kept uniform, and sufficient solution- must be in
the reservoir at ali times to prevent air from entering the tube.

When the desired quantity of solution has been introduced, the
needle ìs withdrawn and the finger is placed over the puncture to pre-
^■ent the escape of fluid. The puncture is then sealed with sterile cotton
and collodion.

BECTAL mFUSION. (See page 508.)

CHAPTER VI.

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

LEECHING.

THE HYPODERMIC AND INTRAMUSCULAR INJECTION OF

DRUGS.

Drugs may be administered by injection into the subculaneous or
muscular tissues when a rapid eflfect 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 presente 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 hjrpodermic syringe
consists of a glass barrel protected by a metal case and fumished with

FiG. 115. — Ordinary glass and metal hypodermic syringe.

a leather-covered piston (Fig. 115). Such syringes, however, are
difficult to keep clean and, if they are frequently boUed, the leather
packing soon dries out and becomes insuflScient 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 30Tr[ (i . 9 c.c.) is amply large for ordinaiy use.

144

INJECTION OF DRUGS.

145

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, foUowed by

FiG. 116. — Ali metal hyjxxiermic 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,
pilocarpiii, 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 ion\ (0.30 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
ampulte, each containing sufficient for one dose. The solution must
be as nearly neutral as possible; irritating solutions or strongly alcoholic

146

HYPODERBflC 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 salìcylate 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.

Fio. 118. — Sites for hypodennic 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 syrmge should be boiled or at least
immersed in some antiseptic solution before use, and the skin at the
site of the mjection should be washed with soap and water or rubbed
clean with a piece of cotton or gauze saturated with alcohol.

INJECTION OF DRUGS. 147

Technic. — ^The required amount of solution is drawn into the barrel
of the ^ringe with the needle ìn place and any air is expelled by elevating
iheneedle end and depressing the piston. The skin over the site of the
praposed injectioQ is then pinched up between the thumb and fore-
tinger of the left band, while with the right hand the needle is quickly
tbnist at an angle of 45 degrees into the subcutaneous tissues at the

base of this fold (Fig. 119). If the needle is sharp and it be quìckly
plunged through the skin, but little, if Einy, pain wUl be experienced.
The solution should be injected slowly lo avoid toc sudden distention of
the tissues. When the required amount has been introduced, the needle
is quickly withdrawn, and the fìnger is placed over the site of puncture,
and genile massage is practised for a moment or two to diffuse the
solutkm.

Fic. tio. — Deep intnunuscular injectbn. Fiist step, itiseiting 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 INTRAMUSCULAR INJECTIONS, ETC.

is in place, it ìs advisable to' remove the syrùige and observe whether
there isanyflowof bloodfrom theneedle (Fig. i2i);if so,anewpuncture

FiG, izi, — Deep inDunuscular injection. Second step, showing the syrìnge removed and
inspeclioQ of the needle lor the flow o! blood.

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

Fig. 131. — Deep iatramuscuIaT injection. Thìrd step, ìtijecting the solution.

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

THE ADMINISTRATION OF DIPHTHERIA ANTITOXIN. I49

THE ADMmiSTRATION OF DIPHTHERIA ANTITOXIN.

Antitoxin is now almost imiversally used in the treatment of diph-
theria, and its administration is a procedure with which ali physicians
should be familiar. It has enormously reduced the mortality 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 Senim. — As the serum is liable to be contaminated it should
always be obtained from an imquestionable 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 amounts 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 mie for fixing the dose. It is known
how much antitoxin is required to neutralize a given amoimt 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 ali 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 imder 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 imfavorable. 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 ali 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 immimity thus fumished 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 loo fatai doses of diphtheria.

I50

HYPODERMIC AND INTRA MUSCULAR 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 urgent
symptoms. No matter how late a case is seen, an injection should be
given, though it may not be possible to undo the harm already produced
by the diphtheria toxin. Cases treated very early give the best results.
This is well shown by the foUowing table of the cases injected in 1902-4,
prepared by the New York Health Department:

Day.

■

No. cases.

Case fatality.

Percentage.

623

1.6

1689

3 and 4

187 1

127

6.7

5 and over

455

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

Fio. 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 smali-
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

Fig. 1 24. — ^The New York Board of Health Antitoxin Syringe. The syring* comcs
sterilized and already loaded with antitoxin and, upon inserting the needle into the distai
end, is ready for use.

pour the antitoxin into the s)ninge, 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 fiUed with antitoxin (Fig.
124). The advantages of this in the saving of time are obvious.

THE ADMINISTRATION OF DIPHTHERIA ANTITOXIN. iqi

Site of Injectìon. — ^The subcutaneqps 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
mjection (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 carefuUy
prepared by first washingwith a little soap and warm water, followed
by a I to 2000 solution of bighlorid of mercury, and then wiping the
surface with alcohol and ether.

Fio. 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 sjoinge 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 band, and, with the right band, the needle is quickly plunged
into the subcutaneous tissue (Fig. 126). If done quickly with a sharp-
pointed needle, preliminary locai anesthesia of the skin is imnecessary.
The serum is then ìnjected very slowly and the swelling produced is
net massaged, being allowed to subside as the serum is absorbed.
After withdrawal of the needle the puncture is sealed with coUodion and
cotton. Following the injection there may be a slight reaction consist-
ing of some redness, edema, and pain at the site of pimcture, but these
usually subside in a short time.

E£fects of Antitoxin. — In favorable cases a prompt and marked im-
provement in the locai 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 swoUen. Within twelve to twenty-
four hours the membrane loosens at the edges and roUs up, becoming
detached in a mass, or in small pieces. This seems to take place more
rapidly about the tonsils than elsewhere. The usuai time for restora-

152 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC.

tion to the normal condition ii> the throat is twenty-f our 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
bringmg away small or large pieces of detached membrane. The
nasal discharge and swelling soon diminish, and at the same thne the
mouth breathìng ceases.

Fio. X36.-*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 s)rmptoms are likewise impress-
ive. In favorable cases the general condition of the patient improves
noticeably within 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 mortali ty rate since the introduction of anti-

VACCINATION.

153

toxin is well shown in the foUowing 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 senim used
later was more eflScient.

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

YEAR

^ 69 90 91 92 93 9^ 95 96 97 98 99 00 01 02 03 0^ 05 06 07 08

ifl

60
56
5t

»^

r— ^

IS-

/^^*

1 1

— ^

-to'

2B
It

16
12

•

-•^■^

^>i

'•—

-•■-

— 1

— CASe FATAUTV 1

OCATH RATE. 1

Fio* 127. — Chart prepared by the New York Board of Health, showing the reduction in the
mortality f rom diphtherìa since the introduction of antitoxin.

about 30 per cent, of the cases and usually comes on from the 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 observed.

Painful conditions 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 borse
serum, and depend upon the susceptibility of the patient to the serum.

VACCmATION.

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 in vari-

[

154 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. *

ably complete. In a great majority of cases, though, a successful inocu-
lation grants a person immunity to smallpox for a number of years,
though the effects may in time wear off and the individuai 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 Osler, 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 under-
stood, but the results of vaccination are unquestionable and admirably
attest its efficiency. Localitìes 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 band, 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 MedicalJournaly Jan. 16,
1909) from the Imperiai 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 Kves, Hungary over 12,000, Austria and
Italy over 11,000. 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 convincing.
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 glycerm.
This is then coUected in capillary tubes and is hermetically sealed untU
used. The lymph should not be distributed until it has been tested for
tetanus and other pathogenic 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 ivory or celluloid points, but they are not
preferable to the capillary tubes as there is danger of the virus being
contaminated by handling.

VACCINATION. ISS

Time for Vaccination. — In choosing the time for vaccination the
age and the general health of the individuai shouid be taken into
consideration. As a general rule, uniess contraindicated, the child
shouid be three to six months old before vaccination. The operation
shouid be avoided if possible in dentition; and, in children who are
delicate or suffering from malnutrition, s)rphilis, or skin eruptions,
il shouid 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 shouid always be immediately
\'accinated.

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

2 e

FiG. 1 28. — New York Department of Health vaccination outfit.

I. Instruments in case; 2, nibber tube for blowing the virus out of the tube; 3, tube
containing virus; 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 bé used for more than one case. Special scarificators are
made, but they ha ve 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 fiat 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 mie, 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 HYPODERMIC AND INTRA1IUSC0LAR INJECTIONS, ETC.

deltoid muscle; in the leg a spot on ihe outer aspect at the junction of
the middle and upper third is selected.

Asepsis. — The operatìon 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 ali aseptic precautions are obser\-ed. The instru-
ment employed for scarifying the skin should be carefully sterilized
and the same instniment 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 diy. The
use of strong disinfectants is not advised as the chances of a successful
inoculation may be lessened.

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

Fio. 129. — Vaccination. Firsl alep, starifying Ihe arni.

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
senim, but no blood (Fig. 129): If more than one inoculation is to be
made, as is fre^juently 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 scarified 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.

Second slep, blowing the virus out of Ihe capillary tube onto a
small piece of wood.

Fio, iji.^Vacdnation, Third step. Rubbing the vinis into the scarified ai

158 HYPODERMIC AND INTRAICUSCTTUS INJZCTIONS, ETC.

strips of adhesive plaster, or, if desired, a wire shield (Fig. 132) may be
used, provided it is applied in such a way as not to constrict the ann
(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 cx)vered with a shield to prevent contact with the clothing.

Course of Vaccination. — Outside of a little irritation and redness
at the site of inoculation there are no immediate developments aad the
wound heals. On the third day a papule appears surrounded by an
area of slight redness. Thìs is foUowed in twenty-four hours by the
formation of a small vesicle which by the seventh or eìghth day reaches
its full development. Itìs usually round, 1/4 to 1/2 inch (6 to 12 mm.)

Fio, 131. — Vacdnation shield. Fio. 133. — Showing the shield in place.

in diameter, and full of limpìd fluid. The center of the vesicle is
depressed, while the margins are elevated and slightiy 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, leavìng a bluish
pitted scar which later slowly fades to white.

Constitutional symptoms more or less marked accompany the
eruption. Remittent fever of from 101° to 104° begins on the fourlh
day and may persisi until the eighth or ninth day, when il drops grad-
ually to normal. In chiidren irritability, loss of appetite, and rest-
lessness at night may accompany the fever. The axillary or inguinal

ACUPUNCTURE. I59

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

Certam irregular types of vaccmation 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 bave 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 anemie and unhealthy subjects, if
mfection occurs, cellulitis and deep ulcers may form, followed by
estensive 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 fumished by vaccination is not per-
manent, and in ali 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 immimity 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 interval, 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 edema tous 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 fumish 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 bave no eflfect, 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 neuritis, half a dozen cylindrical needles
about 3 or 4 inches (7 . 6 to io cm.) long will be required. Long dam-
ing needles or sharp hat pins will answer very well.

Fio. 134. — Instruments for acupuncture.

Asepsis. — ^The skìn 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
ali aseptic precautions both during and after puncture of dropsìcal
eflfusions, as the tissues in such cases ha ve 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 swoUen 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 borie acid.

When treating muscular rheumatism by this method, several sharp
round needles are thrust through the skin into the painful parts of the
aflfected 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 removing them, care must be
taken not to break them off 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 transfìx the afifected nerve with from four to six needies

along the painful part of its course. It may sometimes be diflScult

to strike some of the smaller nerves, but with a large nerve like the

sciatìc 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

])asses through the superficial tissues. The needies when properly

placed shouid be lef t 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 beneficiai effects of bleeding have been recognized from the
lime of Hippocrates. Unfortxmately, though, bleeding was formerly
much ©verdone, and in the early part of the last century it carne 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 bis
trust m drugs to accomplish the desired effects. In spi te of this neglect,
however, bleeding is a powerful and beneficiai therapeutic measure
when employed in the proper class of cases, and as Hare points cut
**the indica tions for venesection are as clear and well defined as are
the indications for any remedy."

Indications. — These may be better appreciated by an understanding
oi what venesection accomplishes. In the first place, through the
^Jaechanical effect upon the circulation of removal of a quantity o^
blood, the tension in the blood-vessels is diminished, and the vascular
tone becomes more evenly balanced, so that an engorged area, where
tìie vessels are relaxed and dilated, is relieved. At the same thne the
^Peed o{ the circulating blood in the capillaries is accelerated, and
^^is is f urther prevented, and the absorption of exudates hastened.
_ l>n the general system venesection also has t>eneficial effects caus-
^^fessened activity of the various functions; the cardiac and respira-
^^ actions become quieter, the temperature is lowered, and celi
>fiieration is less active.

^general, then, it may be said that venesection is indicated for tne

l62 HYFODERmC AND INTRA HCSCOLAK INJECTIONS, ETC.

relief of congestion ìn cases of excessive vascular tension evidenced hy
a rapid, strong, full, incompressible pulse, while low arterìal tensioa
and circulatory depression wìth a slow, soft, iiregular, and compressible
pulse are, as a mie, contraindica.rions. Thus in sthenic types of croupous
pneumonia with dilated right heart, dyspnea, and cyanosis, in pleurisy,
peritonitis, pulmonary edema, pulmonary hemorrhage, emphysema
wìth marked dyspnea and cyanosis, congestion of the braìn, cardiac
valvular disease with engorged right heart, bleeding both lowers vascu-
lar tension and relìeves engoi^ement. In cases where toxins or other
deleterìous substances are present in the blood, as in eclampsia, uremie
convulsions, ìlluminating-gas poisoning, poisoning by hydrogen sulphid,
prussic acid, etc, bleeding serves the doublé purpose of reducing arterial
tension and removing a definite quanlity of toxic material. 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.

Ftc. 135. — Instruments for v
I, Class graduate; 3, etbyl chlorid; 3, scalpel; 4, stick for patienl to grasp; 5, bandages.

Instruments. — There 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 lai^e glass graduate (Fig. 135).

Quantità Withdrawn. — On an average from 6 ounces (180 ce.)
to 12 ounces (360 ce.) may be abstracted from an adult, and from
I ounce {30 C.C.) to 3 ounces (go ce.) from a child, depending on the
conditìon and the character of the pulse and upon the api>earance 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 conditìons 20 ounces (600 ce) or more raay be removed from an
adult.

Site o( Operation. — Some one of the lai^e veìns in front of the elbow-
joint is usually selected (Fig. 136), but the internai jugular or internai
saphenous may be utilìzed.

Podtioa of the Patìent. — The patient shouid be sitting upright or
in a semìreclining position on a couch, with bis head tumed away
from the seat of operation, as the sight of blood may cause faintness.

Fig. 136, — Supeifidal vdns of the forearm. (Ashton.)

The semiuprìght position is a safeguard against withdrawing toc
much blood, as the patient becotnes faint sooner than if he were lying
dowD.

Asepsis.— While this is a small operation, al the same time ali
aseptic precaudons shouid be observed. In fonner times many
patients lost their Uves from septic thrombosis. Accordingly, the in-
stniments and dressings shouid be sterile, and the hands of the operator
shouid be as carefully prepared as for any operation. The bend of the
patient's elbow ìs first washed with warm water and soap, then rinsed
"ith a I to 2000 solution of bichlorid of mercury, and finally with sterile
water.

104

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 tums of a roller bandage are placed about the
patient's arm above the elbow with just sufficient tension to obstnict
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

Fio. 137. — ^Venesection. 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 xmder the skin into the subcutaneous tissues. K
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

FiG, 138. tic. 139.

fio. ij8.— Veneatction. Second step, vaa exposed and operatot's finger compresàng
"" distai portion of the vessel.
fio. IJ9.— Venesectìon, Thitd step, showing inciwon into vein walU.

Fio. I4a — VcDcsectioD. Fourth step, ahowing the operator's finger lemovcd front the
vein and the blooil bdng collccted in a glass gtiufualc.

l66 HYPODERMIC AND INTRAMUSCUIAR INJECTIONS, ETC.

When a suflScient 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 mcision 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
opera tion.

Complicatìons. — ^The most serious complication is a puncture of
the brachial artery by the incision into the vein producing an arterio-
venous aneuiysm. 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 locai congestion or tension. By this method of locai
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 indica ted; 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 ali 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 incìsing the tonsil, glottìs, 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) shouid be employed in the absence
of a protected laryngeal knife (Fig. 143).

Asepsis. — ^The operation must be performed with ali the usuai
aseptic precautions.

Fig. 142. — Knife wrapped with adhesive plaster.

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

Fio. 143. — Protected laryngeal 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.

i68

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 larynx 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 EXTREHITIES.

There are three operative procedures that may be employed for
relicving 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.

DRAINAGf: IN EDEMA OF THE LOWER EXTREUITIES. 169

but the operator should be cautious abotit withdrawing too great a
quantity for fear of inducìng a condition of cerebraì anemia. Should
suck a condition be produced, Ihe drainage should, ot course, be
immediately stopped and stimulanis administered.

Apparatus. — Southey's tubes (Fig. 145) or those of Curschmann
may be employed. The former come in a set consìsting of one trocar
and four cannule. Each cannula has a lateral as well as a distai
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 cannula.

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

AsepBis. — Rigid asepsk should be observed to avoid infection. The
trocar and cannula are boiled, the operator's hands carefully cleansed,
and 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.

lechnic. — One cannula at a rime is placed on the trocar and is
ìnserted 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 antbeptic solution.
The distai end of the tube is allowed to drain into a basin placed upon

170 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC.

the floor by the side of the patìent's bed (Fig. 146). The cannula
should be secured in place by means of adhesive plaster, and sterilized
dressings should be placed about ìt. Care should be taken that the
cannulie are net displaced, and for this reason, with restless patients,

Fio. 146. — Showing Ihe method of draining an edematoua limb with Southey's cannula,
(After Gumprecht.)

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

cuppmo.

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

Apparatus. — Special cupping glasses supplied with a rubber bulb
(Fig. 147} for exhausting the air are obtainable 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

CUPPING.

171

are just ss efficient In an emergency, a-ounce (59 ce.) whisky or
wineglasses, or thick tumblers with smooth rounded edges will answer
equally well. Frora 8 to 12 cups will be required in dry cupping and
from 2 to 6 in wet cupping, dependìng upon the extent of surface to
which they are to be applied. In addition there should be provided

Fio. 147. — Bulb fonn o£ cupping gloss.

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

Stes of Application.^!^uppÌng glasses are never to be applied
directly over inflamed tissues on account of the pain that wouid lesult.

8. — Instruments for wet cupping.
I, Cupping glasses; 3, swab in alcohol; 3, alcohol lamp; 4, scalpel.

N'or should they be placed over bony or irregular surfaces on account
of the impossibiiity of excluding air. Where the brain is the seat of
the trouble, the cups are applied to the back of the neck; in pericarditis,
lo ihe precordial region; in involvement of the lungs or pleura, to the
chest between the vertebral column and scapular line; in renai con-

172 HYPODERMIC AND INTRA MUSCtTLAR INJECTIONS, ETC.

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

Fio. i4g. — Cuppìng. First step, swabbing the interior of the cupping glaas with alcohol.

Technic. — i. Dry Cupping. — Any hair shouid 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,
sìmply compress the rubber bulb, then place the cup upon the skin,

Fio. 150. — Cupping. Second slep, igniling ihe alcohol in the cupping glass.

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

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

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

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

CUPPING. 173

taken not to leave any excess of alcohol that may run down over the
edges. The alcohol is then ignited (Fig. 150), and the cup is quickly
and tighdy applied to the skin. The contained air is rapidly ex-
hausled by the flame, and, as the cup cools, a strong vacuum is created,
which draws up the underlying tìssues (Fig. 151) and produces locai
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 buming alcohol. When the swelling of the skin and under-
lymg dssues has taken place to such an extent as lo replace the ex-

Fic. 151. — Cupping, Third slep, the application of the cups.

hausted air, the cups become loosened and drop off. If, however,
it is desired to remove the cups before this has occurred, simply tip the
cup to one side and press down the skin at the edge of the glass and
thits allow air to enter.

2. WelCupping. — 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.) apart 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 lime. Blood will be drawn

174 HYPODERMIC AND mTERMUSCULAR INJECTIONS, ETC.

from the scarified area into the cups xintil the vacuum is exhausted and
the cups fall oflf. 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 suflScient 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. Il is
thus a valuable means of locai blood-Ietting in ecchymoses, or begin-
ning acute infiamma tion about the eye, ear, nose, gums, genitals, etc.

There are two varie ties 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 coming 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 infiamed 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 infiammation 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 infiamed 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 pili-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 n«t seem inclined to
do so. When once the leech has begun to draw blood, it should not
be pulled off — ^it will let go of itself when fiUed. 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 ce.) 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

Fio. 152. — ^Artifidal leech.

material excreted from the throat of the leech which prevents coagula-
tion of the blood. The bleeding can usually be controlied, 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 causes the

176

HYFODERUIC AND INTRA MUSCULAR INJECTIONS, ETC.

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

Fio. 153.— Applicai ion of the attifidal leech to the masloid. (After Ballcogcr.) First
step. showing the method of scaiifying.

Fig. 154. — Application of Ihe artilidal leech to the masloid. (After Ballenger.) Second
stcp, withdrawing blood.

desired depth. Then the cupping tube ìs applied and blood abstracted
by withdrawing the piston and creating a vacuum (Fig. 154). With
thìs instrument as much as i ounce (30 ce.) of blood may be drawii.

CHAPTER Vn.
BIER'S HYPEREMIC TREATMENT.

While the value of axtificially producing hyperemia with the definite
purpose of mcreasing 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 locai hyperemia, we now know ha ve 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 Pare 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 hyperemia upon a logicai and scientific basis, and of demonstrating
its great practical value.

As b 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-
tubercular inflammations. The passive, venous, or obstructive form
of hyperemia, 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
observations of Farre and Travers who, as far back as 1815, called
attention to the frequency of phthisis in persons whose lungs were ren-
dered anemie because of stenosis of the pulmonary orifice, and by
the reverse of this, namely, the rarity of pulmonary tuberculosis in
individuals suffering from cardiac conditions tending to produce con-
ia 177

178 bier's hyperemic treatment.

gestion or hyperemia of the lungs, as later pointed out by Rokitansky.
Impresseci by these observations, Bier conceived the idea of artificially
producìng 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 hyperemia
to the treatment of acute inflammatory surgical conditions, with most
remarkable results. In this he was materially aided by his associate,
Klapp, who broadened the scope of the method by devising variously
shaped glass cups and vacuum apparatus for producing a hyperemia
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 inflammation
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 liitherto 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, elevatìon 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 beneficiai instead of combated. An attempt was
accordingly made to artificially reproduce the most evident of these
phenomena, namely, congestion or hyperemia, and thereby increase
the naturai 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 fumish ampie evidence of its superior value and to
prove conclusively the correctness of the theories upon which Bier's
treatment rests.

Effects of Hyperemia. — The beneficiai 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 gravity of the inflammatory

PASSIVE HYPEREMIA. 179

exudate, its relief xinder the influence of hyperemia, which both
destroys and dilutes toxins and also dilutes the exudates, may be
readily nnderstood. 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
reportìng any discomfort in the part subjected to the hyperemia, and
bis 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 fatai to bac-
terial life. Nòtzel succeeded in fifty-one cases out of sixty-seven in
counteracting the effects of fatai doses of anthrax and streptococci
injected into the extremities of rabbits, by first inducing congestion
m these parts, the same doses la ter, 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
mfection, 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-
quente 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 considerale difference of opinion as to the agent underly-
ing this bactericidal action, and several theories have been advanced
m 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 beneficént factor; and stili 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.

i8o bier's hyperemic treatment.

It is difl5cult to say which is the exact cause. Bier himself, I believe,
inclines to the phagocytosis theory. Personally, the writer feels that
the mechanìcal 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 oflF, 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 opera tions of resection, etc. This
is well illustrated in the excellent functional results, with freedom
from ankylosis and deformity, obtained in tubercular and other
joìnt affections.

Indications. — ^Passive hyperemia has been recommended for ali
kinds of acute infiamma tory 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
beneficiai may be summarized as follows: Acute infections and in-
fiammations, 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 prò-
longed hyperemia in tubercular lesions which were complicated by open
sinuses. In diabetes, likewise, the results ha ve 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 off some of the air
entering the alveoli and thus induces a suction hyperemia.

In a host of other affections falling within the domain of rhinólogy,
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 Underljring Hyperemic Treatment. — ^As em-
phasized by the author of this method of treatment, and others, it is
not a panacea or cure for ali troubles. One should recognize that it
has its limitations. In some of the milder forms of infection, complete
cure may often be effected by hyperemia alone; in other cases, of the
more severe infections, it forms only a part of the treatment, and opera-
live interference should never be delayed when indicated. Pus must
always be prompUy evacuated when preseniy 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 controlied by packing the wound for two to three hours before the
h)rperemia is induced. In an infection of the tendon sheaths, the
anatomy of the parts should be caref ully 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 irriga ted 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 infecliony with acute onset, how-
^ver, require early incision in canjunction with the hyperemia^ even
before softening has occurred. If incisions are not made, the hyper-
emia may do harm and the locai 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 mto healthy tissue and favor the extension of the infection.

i82 bier's hyperemic treatment.

In inflammations involving joints or tendon sheaths, mild actìve
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 of ten 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 mobili ty gradually increases; secretions from sinuses become serous
instead of purulent, the sinus taken on a healthy appearance and finally
closes. In tubercular aflfections, likewise, slight motion of the afifected
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 — o, sling at most is used — but in knee or foot
tuberculosis a suitable apparatus should be wom, 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 conjunctìon 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
opera tion.

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 dose attention, as well as considerable experience on the
part of the attendant, to obtain good results; but, if the treatment be

PASSIVE HYPEREMIA. 183

properly carried out with perseverance, one will be amply repaid. At
firet ihe patient must be carefu!!y watched as, with the use of the elastic
band, for instance, ìt 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 palients may
later be instnicted in carrying out the treatment with either the bandage
or the cup, and in lime they themselves can apply the treatment at
home, but they sbould always remain under the supervision of the
surgeon.

Hethods of Producìng Passive Hyperemia. — As already ìndicaled,
the passive form of hyperemia may be obtained by means of soft rubber
bandages or by special suction apparatus. The prìnciple 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
espedally applicable to affectìons involving the extremities, head, and
neck. The hip-joint is the only one in eìther 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 cautìon must be

Fio. 155, — Esmarch elastic bandage for obstructìve hypereinia.

obser\'ed noi to exceed the proprer grade of hyperemia, and in tuber-
cular cases not to lower the vitaiity of the tissues by too prolonged ob-
siniction. Only a mild hyperemia ìs necessary to produce results;
otherwise, distinct harm is done. For this reason, the bandage shouid
be applied by the surgeon himself until an intelligent and competent
person of the household can be instructed in its proper application. .

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

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

184 BIER'S HYPEREinC TREATMENT.

To produce hyperemia 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 pro\'ided with hooks and eyes
so that it may be adjusted to any size, as shown by the accompanyìng
illustration (Fig. 156), answers the purpose admirably.

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

Fio. 156. — Ekstic garter fur produdng obslructive hyperemia of the neck. (After Meyer-
Schmieden.)

Duration of Application — In the treatment of acute processes, the
best results are obtained from prolonged stasis, namely, from twenly to
twenty-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 tìme.
In bis early work on tubercular affections, Bier first employed short
periods of hyperemia, and then prolonged and almost continuous
hyperemia, but he experienced many failures and bad results with the
latter. He found that prolonged stasis in thts class of cases was apt
to devitalize the parts and lead to the rapid formation of cold abscess, as
well as to the development of septic abscess, lymphangitis, adenitis,
erysipeias, etc, so that he retumed 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 HYPEREMIA. 18$

«itended 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
sufEciently to make it adhere to the skin and prevent it from slipping.
The bandage is wound around the limb wìth moderate tension six or
eight times well above the seat of disease, each tayer overlapping the
precedmg by about 1/2 ìnch (i cm.). The bandage is then made
secure by adhesive plaster or tapes previously sewed to the terminai
end (Fig. 157).

PlG. 157, — Showing the method of applyìog the elastìc bandage to the arm.

The degree of hyperemia is of the utmost importance. The
object b simply to moderately constrict the veins of a part, without in
any way interfering with the arterial supply, thereby partly checlting
the reflux of blood and increasing the quantity of venous biood normally
present. It requires practice and carefui attention to detail to apply the
bandage in such a way that the arteries are noi compressed, while at
the same time the proper venous obstruction ìs obtained, If the con-
striction is applied properly, the veins in the part distai 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, Qu pulse shoulà never he oblileraled. It must at ali times be
dislinguished, 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 ìs employed, nutri-
tkma] disturbances from the increased stasis injures the tissues and

i86 bier's hyperemic treatment.

reduces their naturai resistance. In such a case, a white edema is
produced, or the skìn 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 hyperemia, it has been suggested
that a sphygmomanometer, such as the Riva Rocci instrument, for
example, be employed. The cuff is secured about the part in the
same manner as would be done in taking the blood pressure and the
systolic pressure is estimated. The mercury is then allowed to drop
about IO mm., which gives the proper tension, after which the tube lead-
ing to the inflation band is tightly clamped.

In chronic cases it is sometimes very difficult to obtain the proper
amount of hyperemia, and several procedures have been advised to
increase the congestion. Placing the part in a bath of very hot water
for ten minutes before the constriction is applied often suflSces. In other
cases, the part may be first exsanguinated by means of an Esmarch
bandage, as would be done preliminary to an amputation, and upon
removal of the bandage a profuse reactionary flow results, after which
the constrictor is applied.

If the constriction is to remain in place for long periods at a time,
it is advantageous to apply a soft flannel bandage beneath the rubber
to prevent undue pressure upon the soft parts, which might produce
an irritation of the skin, or even atrophy of the muscles. This is
especially necessary when treating aged or thin, flabby indivìduals.
While the bandage is in place, ali 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 HYPEREIOA. 187

Head and Neck. — About the neck a special band, as aiready
descrìbed, is used. It shouid be applied about the root of the neck,
we!l below the larynx, with only moderate tension. To obtain the
greatest degree of hyperemia with least constriction, small pieces of
feh or wadding may be placed under the constricting band on either
side of the larynx over the great veins (Fig, 158). If properly applied,
such a bandage can be wom with entire comfort. It causes a pro-
nounced edema of the face, particularly about the eyelids. This is no
coDtraìndìcation to its use, however. Care shouid be taken not to
apply the band too tightiy — of course ìt shouid never strangulate or

Fic, 158. — Showing the application o£ the neck band.

interfere with eating or swallowing. If throbbing or a feeling of marked
fulloess in the head is complaìned of, the bandage shouid be removed
and reapplied.

Shoulder. — 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 tìghtness 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 attentìon is necessary to avoid pressure necrosis.
For this reason, it is better to apply the constrictìon for short periods —
say three or four hours — at a time, repeated several tìmes in the twenty-
four hours, with correspondingly longer intennissions, in preference
to the ten or eleven hour applications.

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

Scrotum. — Tubercular and other aflfections of the testicle may be
treated by placing constrictìon 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 suctìon cups for producing hyperemia in regions not accessible
to constrictìon, as well as large chambers for use upon the extremitìes
and large joints, ha ve been devised. The hyperemia produced by these
devices 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 HYFEREMIA. 189

obtainìng the proper "degree of hyperemia cannot be too strongly
emphasized.

Wheo one of the cups is applìed to a surface and a vacuum pioduced,
the skin and underlying tissues are sucked into the chamber and venous
slasis wilh 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 qulckly

Fic.' 160. — Showìng Ihe metliod of producing obstnictive hyperemia of the testlcles
(After Meyer-Schmieden.)

separated and discharged through a sìnus under the influence of the
hyperemia combined with suction. In the presence of tubercular
sinuses, daily applications of the suction cups may be employed in con-
junction with the nibber bandage.

Apparatus. — Cups suitable for funtncles, styes, carbuncles, breast
abscess, etc, chambers in which are placed the fingers, hands, feet,
and large joints, as well as apparatus to be used by the gynecologist,
orthopedist, olologist, and other specialists are now manufactured.
Types of some of these are shown in the following illustrations (Figs.
161 lo 171), If there is considerable discharge, a type of cup shown
inFig. 162 will be found most useful.

In selecting the cup, one shouid be chosen of sufficìently large di-
ameter to extend well outside the lìmits of an acute ìnflammation, and
having edges that are thick and smooth, in order to avoid undue
pressure upon the skin. In the smaller glasses the suction is obtained
by means of small rubber buibs. With the larger apparatus, stronger

BIEE'S HVPEREIOC TEEATMENT.

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

Fig. 161. — Cup for sty. 162. Cup for small abscess. 163. Cup for large abscess.
164. Cup for gums. 165. Cup tor carbuncle. 166. Cups fot tonsils. 167. Breast cup.
j68. Cup for cervU. 169. Cup for nose. 170. Fìnger suction glass. 171. Hand

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

PASSIVE MVPEKEMIA. I9I

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 Fìg. 1 73, Here the arm is
drawn firmly in the glass case as the air is exhausted until the band
meets the obslacle 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 abo

Fic. 173. — Pump for produdng a vacuum in the laiger cups and suction glasses.

de\-ised metal chambers which are provided wilh an air pump and a
heai-y rubber bag for obtaining motion in a partially ankylosed joint.
Upon exhausting the air in "the apparatus, the rubber bag descends and
eierts an evenly regulated pressure upon the part to be treated, as shown
in F^ 174.

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

Pio. 173. — Showiog the mcthod of obtaining motion ìn a atiS wrist by the aid of passive

dangerof 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, brìef applications
oflen repeated are essential. Accordingly, the cup is applied for fìve
BÙBuies, and is then removed for an inter\*al of two or ihree minutes,
to allow the congestion, edema, and swelling to subside. The cup is
then again applied for five minutes, and an entirely fresh supply of

192 bier's hypeeemic treatment.

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

Technìc — Pus, if presenl, is always to he evacualed by means of a

Fio. 174. — Showiug the method of oblaining moiion in a stiS knee-jtdnt by tlie ^ of

passive hyperemia.

smail incision or pancture, as previously described, before application
of the suction apparatus.

To apply the cup, the edges of the glass are fiist moistened with
vaselin, to avoid leakage of air. Gentle pressure is then made on the

Fio. 175.— Showing a cup appUed 10 a carbuncle.

bulb, and the cup is placed over the affected region, care being laken lo
kave a cup that is large enougk. Uj)on releasing the bulb, the air in
the cup is partly exhausted, causing the area covered by the cup 10
be drawn up Ìnto it, and, if a proper amount of suction is exeried,

PASSIVE HYPEKEUIA. I93

the cup adheres to the surface and a pronounced hyperemia resuits
(^'g- ^75)- If the application 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 aiready been strongly emphasized and is reiterated here. It
shouid be remembered that the suction is to be only strong enough to
slightly decrease the outflowing blood without interfering with the
infiow, so that the maximum amount of fighting forces is present at
ali times during the application. The cbj'ect is to produce a reddish-
blue color of the part. A disiinct blueness or motUing of the skin, or
complaint of pain on the pari of the fatieni, indicates tao greal an
amount of suction and requires •witkdrawal and reapplication of the
cup. Pain shouid never be produced even In acutely inflamed regions.
Sometimes more than one application of the cup is necessary bef ore 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. Shouid it be found that too great a degree of suc-
tion is produced, the stopcock may be opened slightly and air allowed
lo enter the chamber until the desired degree of congestion is attained.

FlC. 176. — Sbowìng a suction glass applied lo the band.

In the use of the large chambers, such as are employed for the treat-
ment of a. band 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, whìchever it may
be, into the apparatus, and the rubber sleeve is bandaged securely
about the 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 withiù 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 gendy bathed with warm solution, and ali loose exudate
or necrotic tissue removed with forceps or sterile ganze. 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 fapidly 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 every 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 locai increase in the supply of arterial
blood. The eflfects of hot-water bags, hot compresses, hot poultices,
hot sand, etc, are ali familiar examples of active hyperemia. Hot air
in a dry form, however, is the most eflfective means for inducing such
a hyperemia on account of the high degree of heat that can be bome
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 bum 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 airas a therapeutic agent is by no means new,
and has been employed with varying degrees of success for ages, but
the methods of application were crude and often unsatisfactory. Im-
provements in the modem baking apparatus ha ve placed this method
upon a firm basis, and properly applied in certain cases active
hyperemia becomes a therapeutic agent of distinct value.

ACnVE HYPEREMIA. I95

Indications. — Active hyperemia has a solvent and absorbent action
upon exudates, infìltrations, adhesions, etc, and a marked analgesìe
eflPect, 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 s)movitis. Other aflfections 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
lime hastening the repair, thus increasing the chances of obtaining a
more nseful limb through the ability to perform eariy passive motion.
In a CoUes' fracture, for example, the bones should be properiy 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 def ormity will recur, and
the hot-air treatment is daily continued, with the addition of both
actìve and passive motion. In the case of a fracture of the malleolus,
mach the same line of treatment may be pursued. A plaster splint is
applied and wom for ten days. This is then cut down and daily
applications of hot air instituted. In the intervals, the splint is reap-
plied and wom, 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-
nai 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 ha ve openings at one or both ends for
receiving a limb. These openings are lined with cuflFs of felt to avoid
any danger of biiming the skin, and are provided with straps so that
the cuflFs 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

igó BIES'S HYPEREMIC TREATMENT.

a slide. Into one of these a chimney is fìtted through which the hot
air is conducted from the heating apparatus. The heal is supplied by
an alcohol lamp or a gas bumer secured to a bracket so that the lamp
may be raìsed or lowered at will. The lids bave 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 maintaìn the diyness of the air. A thermometer
is also provìded with each box for indicating the temperature. Such
boxes are made fo fit various parts of the body, as the arm, band,
shoulder, foot, knee, hips, etc.

Fic. 177. — Apparatus for applying activc hypetemia tothe band and wrist and Ihe melhod
of its application.

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

Temperature. — ^The degree of beat 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 shouid be the guide. It shouid be
remembered that the prolonged application of a very high degree of
beat lowers the sensibility of a part, and great care must be taken not

ACTIVE HYPEREMIA.

197

to bum the patìent; the same cautìon must be observed when applying
active h)rperemia to tissues with lowered resistance. A moderate
temperatiu^ shouid 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 da)rs. In exceptionally
stubbom cases it may be applied for the same length of time twice
daily.

Fio. 178. — ^The hot-air douche bdng applied in sciatica. (The nozze! of the apparatus
shouid be shown directed more to the posterìor surface of the limb.)

Technic. — ^The patient assumes a comfortable attitude, either seated
or lying down, with the apparatus dose 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 tunnel and the temperature is gradually raised until
a degree of heat is attained that can be comfortably bome 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
is allowed to slowly fall before the member is removed. A sudden

198 bier's hyperemic treatment.

change of temperature, such as would b^ occasioned by immediately
removing the part to the outside atmosphere, is to be avoided. The
part, when removed from the bakmg 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 Vin.

THE COLLECnON AND PRESERVATION OF PATHOLOGICAL

MATERIAL.

With the present-day refinements of laboratory methods, the aid
fumished by an examination of discharges, blood, urine, sputum, etc,
is of great hnportance, and often wìthout information so obtained a
correct diagnosis is hnpossible. It is not within the scope of this work
lo 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
sectìon to give brief instructions as to the methods of coUecting material
and the preparation of spedmens 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 collection 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 bave been employed for preserving the specimen, this
should also be stated on the slip sent to the pathologist

METHOD OF MAEIN6 A SMEAR PREPARATIOIT FOR MICRO-

SCOPICAL EXAMINATION.

Eqtiipment. — 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. When once cleansed,
care should be taken that the surface of the slide does not come into

199

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 applicato! about one extremity
of which some cottoti is wound. They may be obtained sterilized and
ready for use, or may be easily extemporized as follows: A test-tube

Fio. 179. — Roughcned wirc for making a swab.

and a piece of stiflf 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. i8o.-^howing 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

Fio. 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

SUEAK PSZFARATION FOS UICROSCOPICAL EXAUINATION.

diy and are then pìled up and secured one upon another, but with
tbeir suriaces separated hj matches or toothpicks, as shown in Fig. 183.

Fio. iSa. — Melhod of making a

From the Mouth and Pharynx. — Eqnipment. — SteriI» swabs,
glass slides, and a tongue depressor will be required (Fig. 184).

Fic. iSj. — Gbus slides separated by match sticks and held together with nibber b&nds
ready for shipment to the laboralory. (Ashton.)

Techoic. — It shouid be seen that no antìseptic mouth washes or
gargks bave been used for at least two hours previous to the time the

Fig. 184.— Instninients for taking a smear from the phaiyni.
I, Sterile swabs; 3, glass sUdes; 3, tongue depressor.

soear b made. The patient is seated in a good lìght, with bis mouth
*idely opened, and the tongue controlied by the tongue depressor held

202 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL.

in the operator's left band, 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 of«rator
being careful not to allow ìt 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 shouid be rotated about so as to brìng as much of ìls
surface in contact with the secretions as possible (Fig. 185). In
removing the swab the same care a^nst contamination from contact
with the tongue, etc, shouid be observed. A thin smear is then

Fio. 185. — Showing the method of taking a, smear Itom the pbaiyiu.

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 minor, and an angular pipette (Fig. 186) will be required.

Technic. — Ordinarily, for microscopical examination, a smear made
in the usuai way from secretìons 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 shouid 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.

SMEAK FSEFAKATION FOK MICSOSCOPICAL EXAMINATION.

203

Technic. — There shouid be no prelimìnary cleansing of the eyes.
Tbe platinum needle is fìrst sterìlized by passing ìt through the flame,
aod when it has cooled the lids are separated, the loop is brought into

Fio. 186. — InstrumenU for taking a smear from the nosb
I, Sinile sTab; i, nasal speculum; 3, glaaa alìdes; 4, angular pipette; 5. head tt

Fic. 18;. — Instniraents for taking a smear (rom the eyes.
I, Sierile swab; 3, gtass sUde«; 3, alcohol latnp; 4, platinum needle,

contact riih the pus and some of it is transferred to a slide. A smear
is Iheo made by means of the swab.

From the Urethra.— Equìpment— Slides and sterile swabs (Fig.
18S) shouid be pTOvided.

204 COLLECTION AND PRESERVATION OF PATHOLOGICAL MATERIAL.

Fio. 189. — Forcing Ibe diacharge out of the urelhm by pressure sgainsl the canal \vilh the
tip of ihe finger in the vagina. <Ashton.)

SMEAR PREPABATION FOK UICKOSCOFICAL EXAMINATION.

205

Technìc. — In a male, the meatus should be cleansed, and a drop of
pus is expressed by stripping the urethra with the finger from behind
forward. The swab is then dipped in the pus and a thin smear is
made upon a slide in the usuai way.

In the iemale, the labia are held apart by an assistant, the index
finger is inserted in the vagina, and the urethra is strìpped from
behind forward (Fig. 189). The swab is then brought into contact
with the drop of pus that is thus expressed, and a smear is made from
it in the usuai way.

From the Vagina. — Equipment — Swabs, slides, and a vaginal
speculum (Fig. 190) are needed.

Fig. 190. — Instnimenta for taking a smear from the va^na.
I. Stenle swabi 3, glass slides; 3, vaginal speculum.

Technìc. — The labia are separated and the speculum is introduced
so as Io obtain a good view of the parts. The swab is then introduced
without touching the vulva and is rubbed in the discharge, mucous
paich, or whatever it may be. A smear is then made from the material
thus obtained.

From the Cervìx. — Equipment. — A long swab, a speculum, two
tenacula, a spenge holder, and glass slides (Fig. 191) should be
proiided.

Tecbnic. — The speculum is introduced so that the cervix is well
etposed to view, and, by means of a tenaculum placed in each lip, the
cervix ìs drawn as far down as possible. The swab is then passed into

2o6 COLLECnON AND FS£SERVATION OF FATHOLOGICAL UATESIAL.

the cervìcal canal (Fig. 192), but care is taken that it does not enter ihe
utenis for fear of carrying infection to what niay be a healthy organ

Fig. 191. — Inslnimenta for t&ldng a si
., Sleiile swab; 3, tenacuta; 3, Simon's speculum;

ar from the utenis.

, glass slides; 5, sponge bdder.

Fio. 191.— Method of collecting ihe

from ihe utenis. (Ashteci.)

from a diseased cervLc. The swab is then withdrawn, and a smear is
made in the usuai way.

METHOD OF INOCULATING CULTURE TUBES. 207

HETHOD OF nfOCULATUTG CULTUItE TUBES.

Eqnipment. — Culture tubes, sterile swabs, platinum needles, thumb
forceps, and an alcohol lamp (Fig. 193) will be required.

A variety of media are employed for the growth of bacteria, such as
broth, agar-agar, gelatin, and blood serum, according to the kind of
bacteria to be cultivated. The culture media are sold in sterile test-

Fia. 193. — Instruments for making a culture.
I, AkoboE tamp; 3, thumb forceps; 3, sterile swabs; 4, culture tubes; 5, platinum needle.

tubes, generally plugged with cotton. When they are to be kept for
any length of time, the tubes should, in addition, be sealed wìth 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
platinum needle. The method of making and sterìlizing the former

Fio. 194. — Platinum needles.

has been descrtbed 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 rad 6 to 8 inches (15 to 20 cm.) long, which serves as a handle.
The {ree end of the wìre may be made into the form of a loop or it may
be simpljr left straight (Fig. 194), according to whether a streak or a

208 COLLECnON AITO PRESERVATION OF PATHOLOGICAL MATERIAL.

stab culture is to be made. Before use, the wire should be sterìlized
by passing it back and forth through a flame for a few seconda.

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
(F'g- 195)' The culture tube ìs held between the thumb and forefinger
of the left hand, with the mouth of the tube pointing downwaid, if it

Fio. 195. — Singeing the cotion stoppar ol a culture tube preparatoty to Ìls inoculation.

contains a solid medium, so as to prevent the entrance of anydust.
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 platinum 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
dp 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 cuUure medium so astospread
the material in a thin streak upon its sloping surface (Fig. 196). The
platinum needle is again passed through the flame and is then Uid
aside. The tube is finally closed with the cotton plug, first singeing
the cotton, however, in the flame while held with the thumb forceps.

METHOD OF INOCULATING COLTDBE TUBES. 2O9

When a stab culture ìs 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 the culture
medium and is then withdrawn.

Fio. 196.— Method ai maklng a sireak culture, (Levy and Klempeier.)

Fig. 197. — Sbowing "a " slab culture, and "b" smear culture.

A smear culture with a swab k made as follows: The culture tube
and the tube containing the sterile swab are held side by side between
tlie thumb and the index finger of the left band. The cotton plugs

2IO COLLECTION AND PRESERVATION OF PATHOLOGICAL ItATERIAL.

are removed with sterile forceps, the ends of the tubes and the exposed
cotlon being first singed, as described above. The cotton piugs are
held between the ring and little finger and the ring and middle fingers
of the left band, while, with the right band, 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 beìng made, care should be taken to
immediately number each tube as it is inoculated.

Fio. 198. — The method of making a smear culture.

COLLECTniG DISCHARGES AITD SECRETIONS FOR BACTERI-
OLOGICAL EXAHinATIOn.

When in the absence of culture tubes or for other reasons it is
necessary to send fluid material to a laboratory for bacteriological
examination, it is best collecfed in sterile glass pipets which are
then hermetically sealed. This insures against leakage as weli as
any chance of contamination during transportation.

Equipment. — A number of glass pipets, a rubbersuctionbulbora
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 ester-
nai 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 tumed the whìie, until the glass is softened o^'er

COLLECTING DISCHARGES AND SECEETIONS. 211

about 1/2 inch (i cm.) of space (Fìg. 200). The tubing is then removed
from the fiame and while the giass is stili soft the two ends are drawn
apart so tbat the softened centrai portion is stretched out into a capìl-

Fic. 199, — Apparatus for collecting discharges for bacteriological enamination,
I, Alcohol tamp; a, sdssors; 3, suclion syrìnge; 4, pipets.

laiy tube several inches long (Fig. 201). The center of this capillaiy
tube is again heated in the flame until it melts, and, by drawìng upon
the ends, it parts in the center, leaving two pipets, each with one sealed

Fio. mo. — Heatiog the glass tube at

a Bunsen flame. (Ashion.)

rad (Fig, 20z). The center of the thìck portions of each of these
pipets is then melted in the same way and is drawn out into a capiliary
tube 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

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 meit the glass or

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
band ready for use almost indefiniteiy.

Fig. 203. — Making a bulbous pipet 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
f urnished 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; (rf) 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 band upon a towel,
and the alcohol lamp is lighted. The sealed end of the pipet should

COLLECTING DISCHARGES AND SECRETIONS.

213

be cut oflF with scissors (Fig. 205) and should be then rounded oflF
in the flame, so as to avoid producing any injury to the tissue (Fig. 206).

Fig. 205. — Snipping off the fused point of the slender end (a) of the pipet with scissors.

(Ashton.)

The pipet is then slowly passed through the flame so as to sterilize
the entire outer surface of the tube (Fig. 207). When the tube has

a f*

Fig. 206. — Rounding off the rough edges of the glass in the flame. (Ashton.)

cooied, the rubber nipple or tubing ìs placed upon the large end,
and the small end is ìnserted in the discharge or secretion, which is

Fio. 207. — Sterìiiàng the outer suiface of the slender end (a) of the pipet. (Ashton.)

then drawn up into the pipet by suction. The suction bulb is then
removed, and the small end of the pipet is sealed by melting it in

\(r'<^ O'

Fig. 208. — ^Hennetically sealing the secretions in the bulbous portion of the pipet by fuàng

it in the flame at a and e. (Ashton.)

the flame. The constricted portion is likewise melted in the flame,
and 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 ìs sealed (Fig. 208). In this
way the discharge is hermetically sealed in small glass tubes (Fig. 209)
and can be sent to any distante for later bacteriologicai 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 Cavìty, — Care must be taken that no antiseptic
irrigating fluid is used before the discharge is obtained. A specimen
should be obtained free from blood, i£ possible. To obtain this and lo
avoid contamination as well, the first portion of the pus should be
allowed to escape; the edges of the incision are then separa ted while
the pipet is inserted into the cavity, and a specimen is withdrawnfrom
its depths.

Fig. aio. — Instruments for obtaining secretions from the nose for bacterìological

examination.
I, Sterile angular pipet; 2, alcohol lamp; 3, scissors; 4, nasal speculum; 5, head minor.

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).

COLLECTING DISCHARGES AND SECRETIONS, 215

The angular pipette may be made by taking a straight pipet
vith a long capìllary tube, beating the latter at a distance of about
3 inches {7 . 6 cm.) from its extremity and, wben soft, bending it to
an angle of 135°, The end should be well smoothed off in a flame
before using.

Techoic. — The same general principles as outlined above are
followed. The patìent is seated as for an anterior rhinoscopic exami-
nation (page 2S1), the nasal speculum is introduced, and the light is
refiected so that the interior of the nose can be clearly observed. The
tip of the pipet is then ìnserted uniil it comes in contact with the
discharge, care being taken not to have ìt touch the mucous membrane
or the vibrissse about the vestibule. The point of the instrument
is moved about in the secretion whìie suction is exerted, and some of the
discharge will thus be withdrawn. The pipet is then removed, sealed,
and properly labeled.

— Method of sucking secretion imo a pipet frotn the female urcthra.
(Ashton.)

FrMii the Eyes. — The technic is not different from that already
(iescribed for collecting discharges from other regions, and no special
forms of pipets are necessary. Any preliminary cleansing of the eyes
should, of couise, be avoided.

From the Urethra. — Equipment. — Pipets and the other appara-
lus necessary for collecting discharges (see Fig. 199) will be required.

2l6 COLLECTION AND PKESEEVATION OF PATHOLOCICAL MATERIAL.

Technic. — The urine shouid 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 suclced into the pipet (Fìg. 211). When the discharge is
scanty, sufficient may be obtained by expressing the pus from the
posterìor portion of the urethra by drawing the fìnger along the urelhra
from behind forward. In the female the same method may be em-
ployed with the index finger in the vagina {see Fig. 189). WTien
a specimen has been obtained, the ends of the pipet are sealed and
the tube is properly labeled.

, Alcohol lamp;

for obtaining secretiona from the v^ina for bactcrìologìcal

sjringe ; 4, sterile pipets ; S, vaginal speculum.

From the Vagina. — Eqaipment. — Pipets, 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 view. The
distai end of the pipet is then carefully introduced into the discharge,
and sufficient secretion for the purposes of the eiamination is withdrawn
by means of suction. The pipet is then removed, both ends are
sealed, 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 ìs introduced into the vagina and the
cen'ix is well exposed to view. Any vaginal secretions are removed by

COU.ECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION. 21 7

means of sponges on holders, tenacula are inserted in the anterior and
posterior lips of the cervix, and the latter is drawn well down. The
pipet is then inserted into the cervical canal, care being taken not to
push it into the uterus, and the secretion is sucked into it. It is then
withdrawn, and both ends are sealed.

ab OD OD

Fio. 213. — Instruments for collecting discharges from the uterus for bacterìological

examination. (Ashton.)
ijPipcts; 2, suction sjrringe; 3, Simonis speculum; 4, tenacula; 5, sdssors; 6, sponge holder;

7, alcohol lamp.

COLLECnON OF BLOOD FOR MICROSCOPICAL EXAMINATION.

Blood may be examined microscopically either from a fresh
specimen or from a dried smear. The former procedure is suitable
only when the blood can be examined promptiy — say within half an
hour. A smear is made when the morphology of the cellular elements
b to be studied after being properly stained.

Equipment. — Slides, cover-glasses, an alcohol lamp, thumb forceps,
and a spear-poìnted needle or a lancet (Fig. 214) are necessary. The
cover-glasses and slides shouid be of the best material. The former
shouid be very thin and about 7/8 inch (22 mm.) square. Both
shouid be absolutely clean and free from grease; the cleansing may be
performed after the method described on page 199.

Locatìon of Puncture. — The blood may be withdrawn from a
prick in the lobe of the ear or in the tip of the finger. The former
region is preferable, however, as it is not so sensitive as the finger, and
it is usually deaner, so that the chances of infection are less. Further-
more, when the puncture is made in the ear, the operation is removed

2l8 COLLECTION AND PEESERVATION OF PATHOLOGICAL MATERIAL.

from the view of the patient, which is an important consideration ìa
the case of cbildren and nervous individuals.

Asepsis. — The site of puncture shouid be cleaned by first rubbing

FlG. al4. — Instruments for collecting blood for microscopical examinatioil.
I, Thumb forcepsi i, speai^ptunted needle; 3, cover-glasses; 4, glass sljdes; 5, alcohd

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 flame,

Tecbnìc. — i. Fresh Specimen. — Care shouid be taken to avoid

chilling the specimen and ezposing it to the air any longer than is

Fio. 315. — Making a fresh blood

First Biep, puncluring the ei

necessary; accordingly, everything shouid be in readiness for the
examinatìon. The slide is warmed over the alcohol lamp or by vigor-
ously rubbing it with a piece of hnen, and is then laid on a sterile toweL

COLLECnON OF BLOOD FOR MICKOSCOPICAL EXAMINATION. 319

The cover-glass is likewise warmed and placed near af band. The
lobc of the ear is grasped between the thumb and forefinger of the
left band and with a quick stab the lowest portion of the lobe is punc-
tured (Fig. 215), The blood shouid be allowed to flow without pres-
««■( or Tubbmg, as these produce a hyperemìa and the constituents

Fic. 116. — Making a fresh blood smear. Second step, collecting the drop on a cover-glass.

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
lo flow. The cover-glass is then taken up in the thumb forceps and is
apptied by its under surface to the apei of the drop (Fig. 216), but
is noi allowed to touch the skin. The cover-glass ìs then gently

rtc, 31J, — Making a fresh blood smear, Third step, placing the cover^lass holding the
blood drop on a slide.

/offered upon the warmed slide (Fig. 217) and the drop of blood is thus
caused to spread out in a thin circular layer between the slide and the
cover-glass. If the drop is not toc lai^e, the blood will not spread
beyond the margins of the cover-glass. The cover-glass shouid not be
pRsscd down upon the slide, as this will injure the corpuscles.

220 COLLECTION AND PRESEEVATION OF PATHOLOGICAL MATERIAL.

2. Dried Specimen. — A puncture is ma,de 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

Fio. ai8. — Method of making a diy blood smear wìth 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. 218). To be
of any vaiue the smear must be sprcad 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

Fio. 319. — Making a dry blood si

^^-g1asses. Second step, collecting Ihe

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 iis
sides between the thumb and forefinger of the right hand, while the
second one is grasped by its sharp angles in the fingers of the left hand.

COLLECnON OF BLOOD FOR MICROSCOPICAL EXAMINATION. 221

The under surface of this first cover ìs then applied to the apex of the
drop of blood (Fig. 219), and is quickly placed upon the second glass,

Fio. 220. — Making a dry blcx>d smear wìth two cover-glasses. Third step, the
method of holding the two cover-glasses preparatory to placing the one holding the drop
upon the second one.

with the angles of the two not coinciding (Fig. 220), so that the drop
spreads out by its own weight in a thin film between the two covers

Fig. 221. — Making a dry blood smear with two cover-glasses. Fourth step, showing
the two covers with their surfaces in contact and the drop of blood spread out in a thin
laycr bclwcen them.

(Fìg. 221). If too large a drop ìs taken the upper cover will simply
float around upon the lower. The upper cover is finally seized between

Fic. 222.--Making a dry blood smear with two cover-glasses. Fifth step, showing the

method of drawing the two covers apart.

the thumb and forefinger of the right hand and, stili holding the lower
cover in the lef t hand, the two covers are slid apart in the same piane

222 COLLECnON AND PBESERVATION OF PATHOLOGICAl UATERIAL.

(Fig. 222). Unless too small a drop has been taken, this ìs readily
accomplished. The films thus obtained are then allowed to diy, and
later they may be fixed and properly stained. It is always well to
mate three or four of these smears, as some of the films may be poorly
spread, or may be broken in handling.

THE COLLECTION OF BLOOD POR BACTERIOLOGICAL
EXAHINATION.

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 bacterìological 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,

Equìpment. — A glass syringe with a capadty of 2 3/4 drams
(about 10 ce), a moderately large needle with a sharp point, broth
and agar-agar culture tube, and a bandage (Fig. 223) are necessary.

Fio. 333. — Apparalus for collecting blood for bacteriologìcal

Site of Puncture. — The median cephalic or median basilic vein is
usually chosen (see Fig. 100), but, if these are not available, the internai
saphenous vein in the leg or any of the smalier 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 i 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 ìt
is necessary to expose the vein by an indsion, as in the case of an

COLLECTION OF BLOOD FOE BACTEHJOLOGICAL EXAIONATION. 223

individuai with much fat or whose tissues are edematous, infLltration
with a o. 2 per cent, solution of cocain is employed.

Tecbnìc. — A bandage is wound about the arni between the seat of
puncture and the heart with sufficient tension to produce a slìght venous
stasis and cause the veins to stand out prominentiy, but with not enough
compression to cut o£E the arterial flow. By gently forcing the blood
along toward the seat of constriction by means of the forefinger or
thumb, the vein may be made to stand out more prominentiy. In
stout persons, however, it may be necessary to expose the vein by an
incision.

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

Fio, 3a4. — Sbowìng the melhod of making a venous puncture.

witbdrawing the piston, If too great an amount of suction is exerted
the Wall of the vein will be forcibly collapsed and will act as a valve
against the further withdrawal of blood. About i 1/2 drams (5 ce.)
of blood may be taken from a child, and about 2 3/4 drams (io ce.)
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
dot 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 syringe.
In doing this, the same technic described on page 2Ó7 shouid be
followed. Inoculations are usually made with lón]^ (i ce.) of blood
into definite quantities of media. At the completion of the operation
the seat of puncture is sealed with coUodion.

THE COLLECTION OF SPUTDM.

Sputum shouid 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. Siiitable bottles may be
obtained from any laboratory or from most drug stores. The
specimen shouid be obtained from the sputum coughed up early

in the moming before any food has been taken, and it
shouid 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 shouid first be
thoroughly rinsed out. When there is not suffident
sputum from one collection, the whole amount for the
day, or for twenty-four hours, shouid be preserved. The
specimen thus collected shouid be sent to the laboratory
promptly, that it may be examined in as fresh a condi-
tion as possible.

With infants and yòung children it may be next to ìmpossible to
obtain sputum in the ordinary way. A method sometimes employed
is to pass a stomach tube into the esophagus and then examine the
mucus found adhering to the tube upon its withdrawal. Holt advises
{Archives of Internai 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.

Fig. 225.
Sputum botile.

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

any operation. The meatus and surrounding parts are then washed
with an antiseptic solution, and the catheter ìs gently inserted into the
bladder without touching the adjacent parts (see also page 628). The
first portion o£ the urine is to be discarded, and then from i 1/2 to
2 3/4 drams (about 5 to 10 ce.) are collected in a sterile test-tube,
which is immediately plugged.

\Vhen ìt is desired to obtain a separate specimen from each kidney,
the uretere may be catheterized (see page 652) or a urinaiy separator
may be employed {see page 667).

To obtain a twenty-four-hour specimen, as, for example, when
il is desired to determine the total daily amount of urine secreted or to
estimate the total solids, it is necessaiy 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 foUowing twenty-four hours,
induding that voided at the end of this period, is
saved in a large clean botile. For cases of in-
continence, a retained catheter must be used (see
p3gc 637), or else a rubber urinai devised for such
cases may be employed,

When considerable lime must elapse before a
specimen can be examined, some preservative, such
as borie acid in the proportion of 5 grains {0,324
gm.) to I ounce (30 ce), or formalin in the propor-
tion of I drop to each 4 ounces (120 ce.) may be
added to the specimen. If cultures or inoculations
are to be made, any preservative shouid be avoìded.

In the case of infants there are severa! methods
for coUecting urine. With male infants, for an
ordinary examination, the specimen may be collected
by means of a condom which is secured to the '"' ,^=^~^''^P'" *

unne collector.

body by adhesive plaster, and into which the penis
and scrolum are passed; or a botile may be employed, in the neck of
which the penis is placed. Chapin has devised a urine collector (Fig.
226) ihat may be employed for both males and females. A method
sometimes employed with females is to place absorbenl cotton over
the vulva, and, after the child has saturated the cotlon, to express the
urine into a bottle; or the child may simply be placed upon a rubber
sheet from which the urine is collected as often as it is voided. If it
is necessary to obtain an uncontaminaled specimen, catheterization
must 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 o£ the stomach contents a test
meal is not necessary, the vomitus or a portion removed by the stomach
tube (see page 442) being ali 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.

Instruments. — 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 io
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 coUecting material from the interior of the uterus, curettage
instruments, etc, will be required (see page 751).

Anesthesia. — As a mie, locai anesthesia by infiltration with a
0.2 per cent, solution of cocain in normal sfeilt solution is sufficient
For skin tumors, freezing with ethyl chlorid usually suffices.

REMOVAL OF A FRAGMENT OF SOLID TISSOE. 227

Fic. 317. — Instniments tor eicisiQg a fiagraent of solid tisaue
Il Scalpel; 1, curved sharp-pointed sdsson; 3, skin punch; 4, Ihumb forceps; 5, arteiy
cEamps; 6, retractois; 7, needle holder; 8, No. a catgut; 9, cuivcd cutting-edge needles;
n botile.

Flc. 318. — Eici^n irf a piece of tissue from the cervìz. (Asbton).

328 COLLECTION AND PRESERVATION OF PATHOLOGICAL UATEKIAL.

Asepsis. — The instruments are boiled, the hands of the operator

are sterilized, and the site of operation is cieaned as for any operation.

Technìc. — The line of proposed mcìsion is first cocainized. Thea

FiG. iig. — Rerooval of a fragment o( a superficial growlh nith a skin punch.

with the tissues well retracied so as to expose the growth, a wedge-
shaped piece of tissue is removed by means of a scalpel from the portion
of the growth where the pathological changes are most marked or the
tumor is nodular (Fig, 228). The tissue is then transferred to the

Fio. 330. — Removal of a fragment of a superficial growlh with a skin punch. Second stcp,
cutting loose ihe base of the aeclion.

bottle containing the 10 per cent, formalin solution, and a proper label
is applied. Any hemorrhage is then controlied, the incision is closed,
and a sterile dressing is finally applied.

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 pxmch 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.

When 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
preserving fluid. The bottle is then carefuUy labeled. Care should
be taken to avoid rough handling of the tissues and to preserve for

«Kuaamation ali the fragments removed. For the technic of curettage

s^ page 751.

CHAPTER IX.
EXPLORATORY PUNCTURES.

An exploratoiy puncture consists in the introductìon of a hollow
needle attached to an aspirating s)rringe into a diseased region, and a
subsequent aspiration. This comparatively simple operation may be
performed for the purpose of determining the presente or absence of
fluid in any particular area, or to obtain a specimen of fluid for the
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. In
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 spinai canal, and other organs and regions
diflScult of access may thus be tapped and explored with comparative
safety.

Apparatus. — ^Aspirating needles and a s)rringe of appropriate size
should be provided. It will be found convenient to ha ve 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
(S.Qcm.), and 4 inches (iocm.);andindiameter 1/50 inch (0.5 mm.)j
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.) long
and about 1/25 inch (i mm.) in diameter, so that it will readily giva
passage to fluids of heavy consistency.

It is preferable to ha ve a s)rringe with a capacity of from i to 2
drams (3 . 75 to 7 . 5 ce), through an ordinary hypodermic syxinge may
be employed if the large needles are made to fit. The syringe should
be capable of exerting a strong suction, and the joint between it and the
needle should be absolutely air-tight. The best form of syxinge con-
sists of a solid glass barrel and a tight-fitting piston provided with an
asbestos or rubber packing (Fig. 231). Such a syringe is simple in
mechanism, easy to clean, and can be readily sterilized by boiling. If
confirmation of the diagnosis of fluid is to be immedia tely followed by its
evacuation, the aspirating apparatus of Potain or Dieulafoy (see

230

EXPLORATORY PUNCTORES.

231

page 256) may be used for the exploradon, thus sparìng the patient a
subsequent operation.

Before making a puncture the syringe shouid always be tested by
withdrawing the piston with the finger held over the end, to see if it
■will exert proper suction. The syringe shouid likewise be tested with

FlG. 331. — Aspirating syringe and neettles.

the needle fitted in place. After use, the syringe shouid be taken
apart, and both it and the needle shouid be thoroughly cleansed. To
guard against rusting, the lumen of the needle shouid be cleansed
with alcohol and ether, and a wire of suitable size inserted.

In cases where a complete chemicaJ, microscopical, and bac-
teriological examination is desired, sterìlized test-tubes for cotlectìng

Frc. iji.—Apparatus for making

s and culturea frotn fluida removed by exploratoiy
1, Class slides; 3, sterile test-tube^ 3, culture tubes.

and iransporting the material aspirated, glass slides,and agar-agar
culiure tubes (Fig. 232) shouid be at band.

Asepsìs. — The strictest regard to asepsis must be observed in mak-
ing any exploratoiy puncture, otherwise there is great risk of ìnfeclion
and of converting a simple serous exudate into a purulent one. The
site chosen for the puncture shouid be carefully scrubbed with green

232 EXPLORATORY PUNCTURES.

soap and warm water, and then cleansed with alcohol followed by a
I to 2000 solution of bichlorid of mercury. The operator's hands
should also be thoroughly scrubbed, followed by immersion in an
antiseptic solution. The needle and s)rringe should be boiled.

Anesthesia. — Locai anesthesia by freezing with ethyl chlorid or
salt and ice, or infiltrating with a o. 2 per cent, solution of cocain, will
be ali 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 tó freeze the skin too thoroughly, on account of the danger of
locai 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 needlfe 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 is
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 stili unsuccessful, the
needle should be withdrawn entirely, and a new puncture made at some
contiguous point.

After the aspira tion is compie ted, 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-
qqently 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 carefuUy noting the color, cleamess, 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
tìmes 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 movdng it
back and forth sufficiently 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 technìc of which may
be found fuUy described in manuals on clinical laboratory methods,
should be made along the foUowing lines and with reference to the
special points mentioned.

1. Physical Characteristics. — ^The color, odor, cleamess, 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 albiunin, 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 hooklets, 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 mie can be laid down, the
point chosen for the puncture depending upon the physical examina-

234 EXPLORATORY PDNCTDRES.

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
efEusion. If it is made at too high a level, the point of the needle may
lacerate the lung; or, if too low, inj'ury to the diaphragm, liver, or spleen
may result. As a general thing, however, entrance of the needle in
the sixth interspace in the anterior axillaiy line, in the sixth or seventh

FiG. 933. — Showing the poinis for inserting the needle in exploratory puncture of the
pleura. (I^rge dols represenl points of election.)

interspace in the midaxillary line, or the eighth interspace below the
angle of the scapola will reveal the presente of fluid if such exist

Positìon of the Patìent. — 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 forthfi 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 band steady the tìssues, while the needle is

EXPLORATORY PUNCTURE OF THE PLEURA. 235

slowiy and steadìly inserted upward and inward, until its point enters
the pleural sac. From i to i 1/2 inches (about 2.5 to 4 cm.) under

Fio, 334. — Lateial poation for explomtory puncture of the pleu

Fio. 335. — Eiploratoiy puncture of the pleura wiih the patient aiiting upright.

ordinary conditìons, and more in fat subjects or in those with very
thick pleura, may be esdmated as the thickness of the thoracìc wall

236

EXPLORATORY PUNCTURES.

through which the needle will have to pass before enterìng the pleural
cavity. The lack of resistance and the mobìlity of the needle will
acquaint one of its entrance into a cavity.

If fluid is not immediately obtained, the direction of the needle

FiG. 236. FiG. 237.

FiG. 236. — Showing the failure to withdraw fluid from the needle bdng inserted too
far. (After Gumprecht.)

Fio. 237. — Showing the failure to withdraw fluid from the needle enterìng 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 enterìng the lung (Fig. 237) or to
the fluid being encapsulated in a space not entered by the aspirating

Fio. 238. — ^Showing the failure to withdraw fluid from the point of the needle becx>ming

imbedded in a thickened pleura. (After Gumprecht.)

needle. Again, the point of the needle may become burìed 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
lo the entrance of the needle. Upon completion of the aspiration, the
needle is quickly withdrawn, and the site of the puncture is closed with
coUodion and cotton.

EXPLORATORY PUNCTURE OF THE LUNG.

Prevdous to undertaking any operative procedure upon a pulmonary
cavity, 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 pleiu^a 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 ali 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 (io cm.)
long, will be required. While the patient holds the breath to lìmit
movement of the lungs, the needle is inserted in the direction of the
supposed cavity, dose 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 io 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 cavity is at
times a most difficult matter. When a needle ènters a cavity some
idea of its size may be obtained from the range of motion of the needle
and from the quantìty of secredon 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 EXPLORATORY PUNCTORES.

guide for the incision and drainage, and, while the patient is being
anesthetized, great care shouid be taken to see that the needle is not
displaced.

EXPLORATORY PUHCTmtE OF THE PERICARDIDU.

An exploratory puncture raay be required as a means of making a
positive diagnosis ollhe presence of fluid within the pericardium or
for the purpose of choosing a route through which such fluid niay be
reached and evacuated. Puncture of the pericardium shouid not be
undertaken lightly, and the dangers of injuring the internai manunaiy
vessels or pleura, or of puncturing the thin-walled auricles of the heart,
shouid impress upon the operator the necessity of estreme care when
performing this operation.

Location of the Pimcture. — To eliminate as far as possible the
dangers of the operation, special sites for puncture bave been recom-

FiG. 139. — Poinls for puncluring the pericardium. The dolted line indicates a distended

pericardial sac.

mended, as follows: (i) In the fourth or fifth interspace, either
dose to the left stemal margin or i inch (2 . 5 cm.) to the left of it,
Either of these points will avoid the internai mammary artery and
veins which run vertically downward 1/2 inch (1 cm.) from the stemal
margin. (2) In the fourth intercostal space, dose to the right of the
stemum. It is claimed that from this poìnt it is impossible to injuie

EXPLOtATORY PUNCTITRE OF THE PEBICARDIUM. 239

the heart, but this avenue of approach is only suitable when the
amount of fluid is large. (3) Inserting the needle dìrectly upward
and backward dose to the costai margìn m the space between the
ensiform cartilage and the seventh costai cartilage on the left side.
(4) When it is possible to outline accurately the shape of the peri-
cardium and locate the position of the apex beat by means of pulsation
or frìction rubs, the method recommended by Curschman, Romberg,
Kussmaul, and others, may he employed. The puncture is made in
the fifth or sixth lett interspace outsìde the nipple line between the
apex beat and the outer limit of duUness (Fig. 239).

Fio. *4o. — Showing the method ed inserting the needle in an explotatory puncture of the
peiicardium.

The selection of one of these sìtes over the others will be made
according to the degree of distention of the pericardinni and its shape,
which is detennined by outlining the area of duUness.

Preparation 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 uprìght sitting posture.

Technic. — As already emphasized, ali the aseptic precautions enu-
raerated under exploratory punctures (page 231) should be carefully
carried out. The area of dullness is accurately marked cut and the
point for puncture thereby determined upon. The thumb of the left
band is piaced as a guide upon the lower rib bounding the intercostal
space selected, and the needle point is inserted just above the margm
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 piane and directed slightly toward the median line. Entrante
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 entrante 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 coUodion
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 type 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 perfonned 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 dose 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 immediate 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 ca\dty,
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 io 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. Sufficient 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.

EXPLORATORY PONCTURE OF THE LIVZR. 841

EXPLORATORY PUITCTUSE OF THE LIVER.

Eiphjration of the liver by raeans of an aspirating needle may be
required for the purpose of makìng a positive diagnosis in cases of
suspected amebic or pyogenic abscess, or hydatid cyst. Exploratory
puncture should not be performed, however, unless the preparations
for an immediate operation, if such be necessary, are completed
beforehand, for no matter how smali the puncture may be, leakage of
Euid is liable to occur and cause senous damage.

Locatìoa of the Puncture. — This wlll depend upon the symptoms
and physical signs in each individuai case. If at any one poìnt there

FiG. 141. — Points for puncture oE Ihe liver.

be localized pain, tendemess on palpatìon, perìtoneal 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 home in mind and the puncture made accordingly, the
needle beìng inserted in the midaxillary line on the right side through
the ninth, tenth, or eleventh interspace, or below the angle of the
scapula through the tenth interspace (Fig. 241). Puncture may also
be nude anteriorly directly into the area of liver dullness below the
line of the pleura.

242 EXPLORATORY PUNCTURES.

Anesthesia. — ^The puncture may be made under locai anesthesia,
but if it is likely that a number of punctures will be necessary and an
operatìon is to be performed, it is batter to give a general anes the tic
at the start.

Technic. — ^The needle is slowly introduced inward and slightly
upward to its full extent, and suction is attempted. If fluid is net
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 cavity into healthy tissue.
Near the surface of the liver the direction of the needle is altered, and
it is inserted again in a different piane. In this manner a large area
of the liver may be explored in ali directions from one extemal 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 syringe does not neces-
sarily signify absence of an abscess, for at times the material fonning
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 dose 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 foUowed by
hemorrhage, suppuration in the spleen, and peritonitis have been
known 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 and drainage, in case

EXPLORATORV PUNCTURE OF THE KIDNEYS. 243

5uch shouid be necessary, shouid be completed before the puncture
is made.

Location of Puncture. — The spleen can be reached by inserting
the needle through the tenth intercosta.1 space on the left side (Fig. 242).
If the organ is markedly enlai^ed, some point below the left costai
margin, detemuned by percussion of the spleen, niay be chosen.

Position of the Patient. — The patient may assume either the sitting
posture wìth the left ann elevated and the band on the opposite

Fio. 343. — Poinl for punclurìng the spleen.

shoulder, or the recumbent position, depending upon which gives
the most ready access to the region of operation.

Techntc. — A fine and fairly long aspirating needie shouid be
employed. The patient is instructed to hold his breath, to lessen the
danger of lacerating the organ, and the operator quickly inserts the
needle at the chosen site and makes the aspiration with as little delay
as possible. The needle is then withdrawn, and the site of puncture
is closed with a thin covering of collodìon and cotton.

EZPLORATORY PimCTOKE OF THE KIDNEYS.

Eiploratory aspiration may be employed to detect collections of
pus or other fluìds in the region of the kidney. An exploratory incision,
however, and subsequent aspiration after exposure of the mass is a
far more satisfactory method of diagnosis.

244 EXPLOEATORY PUNCTUHES.

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 spinse muscles, and a little below the last rìb on the left side,
and, on the righi side, between the last rib and the crest of the ìlìum.

Position of Patient. — The patient may sit up, with the back bent
forward, or he may He partly upon the unaffected side and partly upon
the abdomen, with the body bent forward in a curve.

FiG. 343. — Showing the relalions of the kidneya from behind.

Tecbnic. — A long fine needle should be employed. The needle is
sìowly introduced forward and slightly inward toward the median line,
frequent tests at aspiratìon being made as the needle is advanced.
When fluid is discovered, a sufficient quantity for diagnosi» is with-
drawn, and the site of puncture is sealed with a cotton and coUodioa
dressing.

EXPLORATORY PUHCTURE OF JOIHTS.

This constitutes a most valuable aid in ascertaining the character
of a joint effusion. The puncture, as in ali exploratory punctures,
should be made under strici aseptic precautions. Care should be
exercbed not to insert the needle at a point where blood-vessels or
important nerves would be encountered and to avoid producing any
injury to the cartilage of the joint, lest serious coniplica,tÌons resulL

EXPLORATORY PUNCTURE OF JOINTS.

245

The sites for puncture of those joints to which the method is most
often applied are as follows:

The Knee-joint. — The needle may be inserted into either side of
the jomt — but preferably in the outer side — beneath the patella at a

Fio. 344. — ^Points for puncturing the knee-joinu

point where fluctuation or distention is most in evidente. When the
swelling is more marked above the patella, the needle may be introduced
from above downward behind the bone (Fig. 244).

Fio. 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-

246 EXPLORATORY PUNCTURES.

ceps muscle downward and inward, beneath the olecranon process
(Fig. 246).

The Ankle-joint. — To avoid injurìng the vessels and nerves
which lie opposite the middle of the joint, the needle shouid be ìntro-
duced from in front between the anterior margm of the extemal
malleolus and the adjoìning surface of the tibia {Fig. 247).

Fig. 347. — Point fur puncluiìng the ankle>joinL

SPINAL OR LUHBAR PUffCTITRE.

Lumbar puncture, an operation first proposed by Quincke for the
withdrawal of cerebrospinal fluid from the spinai canal, has both diag-
nostic and therapeutic value. This procedure is of dìagnostic impor-
tance through the ìnformation that may be obtained in estimating ihe
pressure of the cerebrospinal fluid and determìning ite chajacteristics
by physical, chemical, tnicroscopical, and bacterìological examination.

Among its therap>eutic 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 ihe
spaces in the brain and spinai 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 spinai canal. In
cerebrospinal meningitis, drainage by lumbar jSuncture is often fol-
lowed by good resuits, as net only is the pressure upon the cord and

SPINAL OR LUUBAS FUNCTUItE. 247

cerebral centers lessened, but pus is withdrawn, and the toxidty of the
spinai fluid is thereby dimiiiished.

It is in the administration of antitetanic senim and antìserum in
cerebrospinal meningitis, and the production of spinai anesthesia,
however, that lumbar puncture finds its chief therapeutìc appiications.

Aiutomy. — In the lumbar portion of the vertebral column the

FlG. 348. — 'Anaiomy o( the lumbar vertebra.

spìnous processes do net project downward to such a degree as in
other portions, and there is a distìnct space (about 7/8 inch (22 mm.)
in the transverse and 3/5 inch (15 mm.) in the vertical diameter)
between the vertebral arches filled with ligaments through which a
needle may be readily passed into the spinai canal (Fig. 248). The
spinai cord reaches only to the second lumbar vertebra, so ìf the puDc-

Fio. 34g. — Siylet needle for spinai punciure.

ture be made below that point, and the introduction of the needle be
carried out under rigid asepsis the opwratìon is practically harmless.

The Iteedle. — The puncture is best madc with a special stylet needle
devised for the purpose. It should be at least 3 1/2 inches (9 cm.)
long and about 1/25 of an inch (i mm.) in diameter, and the point
shotild be short and groimd almost squarely across (Fig. 249). In the

248 EXPLORATORY PUNCTURES.

absence of such a needle, the ordinary aspirating needle of about the
same size may be substituted. In addition, a scalpel, a sterilized grad-
uated test-tube, culture tubes, and an onlinary hydrometer (Fig. 250)

Fio, 150. — Apparatus for spinai puncture.
, S4:alpe]; i, ethyl chlorid tube; 3, small glass graduatei 4, hydro
tube; 6, culture lubes.

■; 5, Elerìle trat-

will be required. When it k desired to estimate accurately the cere-

brospinal pressure, a small mercury manometer will also be required.

Location of the Puncture. — The space between the third and

Foints for spinai puncture.

fourth or that between the fourlh and fifth lumbar vertebrae is usually
chosen (Fig. 251), though, if the pimcture is performed for diagnostic

SPINAL OR LUMBAR PUNCTURE.

249

purposes, it may be made lower — between the fifth lumbar and first
sacrai vertebrae in order to withdraw any sediment that may be present.

FiG. 252. — Showing 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 fomiing
the upper boundary of the chosen interspace at a distance of about
1/2 inch (i cm.) to one side of the median Une is selected for the

FiG. 253. — Sittìng posture for spinai puncture.

insertion of the needle. In children, however, the spinous processes
being 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 mdividual be very stout
If, however, any difficulty is experienced m locatìng 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. — Latenti position for spinai 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.
Jn other cases, locai anesthesia with a o. 2 per cent, solution of cocain,
or by freezing, as for any puncture, will answer ali 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), until ìt enters the
spinai 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 coUected in a

FiG. 255. — ^Spinai puncture. First step, nìck- Fio. 256. — Spinai puncture. Second
ing the skin at the point of puncture. ^ep, 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 ce.) of fluid should be withdrawn from the spinai

Fig. 257. — Spinai puncture. Third step, collectìng the cerebrospinal fluid.

canal of a child, nor more than 1/2 ounce (15 ce.) 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 ce.) of fluid may be removed, according to the tension,
and even more if no ili efifects are observed. A dry puncture is some-
times encountered and may be due to the needle not entering the canal,
to ìts 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 pressxire, 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 dxxral 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 cleamess,
of alkaline reaction, has a specific gravity of 1003 to 1004, and exists
in but small amounts, varying between 1/2 and 2 ounces (i 5 and 60 ce.)
in adults and in infants between 3 and 6 drams (io and 20 ce). 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-redudng body claimed to be sugar, and traces
of urea (0.035 ^o 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 skuU 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

logicai examination. Identification of the diplococcus intracellularis,
pneumococcus, streptococcus, or tubercle bacilli will definitely settle
the 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 capaci ty of at least i ounce (30 ce), is required in
addition to the other instruments necessary for spinai puncture. The
puncture is made in the manner described above, and a quantity of
cerebrospinal fluid equal to the amount of serum to be injected is
allowed to escape from the canal; the serum is then warmed and is
slowly injected through the same needle employed for the puncture.

In cases of tetanus, Rogers (Journal of the American Medicai
Associationj July i, 1905), injects 2 3/4 to 5 1/2 drams (io to 20 ce.)
of antitetanic serum into the nerves of the cauda equina, as well as
subcutaneously in the neighborhood of the wound, intra venously, 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 spinai injection the
needle is inserted in the space between the second and third imnbar
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 (io to
20 ce) of serum are then injected into and around these injured
nerves.

For cases of cerebrospinal meningitis, i to i 1/2 ounces (30 to
45 ce) 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 s)rringe, a glass funnel holding about 5 1/2
drams (20 ce) attached to the needle by rubber tubing maybe employed
for administering the serum, as advised by Koplik.

CHAPTER X.
ASPIRATIONS.

ASPIRATION OF THE PLEURAL CAVITY.

Paracentesis thoracis, also spoken of as thoracentesis and pleure-
centesis, consists in the evacuation of fluid from the pleural cavities by
means of a hoUow needle or txocar to which an aspirator is attached.

Indications. — When the presente 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 suflBcient to produce dyspnea, cyanosis, and
cardìac weakness.

2. In very larga 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 medicai 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, shouid
be supplied.

The Aspirating Needle. — Whether an ordinary aspirating needle
or trocar and cannula be employed does not make any material
difference, though the latter has some advantages. Where the trocar
form of needle is employed the point of the cannula may be moved
about without danger after the stylet is removed, and, shouid 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 CAVITY. 255

the stylet. With an aspiratìng needle, on the other hand, the unpro-
tected point of the needle may injure the lung or dlaphragm, and,
f urthermore, should the lumen of the needle become blocked, it may be
necessary to withdraw it entirely in order to clear out the obstructìon.
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 properiy 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 latenti opening, for connection with the aspirator,
is placed at a point distai to this stopcock, so that the stylet may be
moved back and forth without disturbing the connections (Fig. 258).

Fio. 258. — ^Aspirating trocar.

Aspirators. — The Potain, the Dieulafoy, or the heat vacuum
apparatus is most commonly employed, though the aspiration may
be satisfactorily made in a large proportion of cases by simple syphon-
age. The Dieulafoy instnmient is most convenient for evacuating
small coUections 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 whìch 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 ali 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 air will be sufficiently exhausted.

Fio. 259. — Potain aspirator.

Stopcock b is then closed, and the needle is inserted into the chest
As soon as its point enters the Ussues, the vacuum is extended to the
point by opening stopcock a, so that the moment fluid is reached it
will be drawn by suctìon into the bottle. If the trocar is employed,

Fio. 260. — The Dieulafoy aspirator.

the stylet is not withdrawn until the trocar enters the chest; as thisis
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 1 18 ce.) , provided with two outlets,

ASPIRATION 01 THE PLEURAL CAVITY. 257

each fumished with a stopcock, and to which are fitted heavy rubber
tubes. To the extremity of one tube a trocar or aspìrating needle
is attached, and at a distance of about 4 inches (io cm.) from the needle
end a piece of glass tubing is inserted as an index. The other piece
of 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
closed, and the piston is fully withdrawn and fixed in place by a spring.
This produces the vacuum. The aspìrating needle is then introduced
in 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
Deedle. The needle is then pushed on in until it enters the chest, the

FiG. 261. — Connelt's beat vacuum aapirator.

presence of fluid being first demonstrated as it passes tlìrough the glass
index. When the aspirator is filled, stopcock a is closed and stop-
cock b opened, and the fluid is discharged from b by driving the
piston back in place. This process of aspiration may be repeated as
often as necessary without removing the needle or disconnecting the
aspirator.

A very excellcnt form of aspirator and one that is frequently
employed is the vacuum bottle described by Connell {Medicai
Record, 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 (i i ce.) of 95 per cent alcohol are poured inlo
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 sufficientto
aspirate a chest.

Removal of an eflfusion by syphonage 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 dose one end of the tubing, a fun-

FiG. 262. — Syphonage aspirator.

nel, sterile water or saline solution to fili 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 padent bears the opera tion, the

ASPDtATION OF THE PLEURAL CAVTTY. 259

condidon of the pulse, and signs of impending collapse rather than by
the quantity of fluid present. In very large effusions as much as 3
pints (1500 ce.) raay be removed, but it is better to withdraw too little
than too much, for what remaìns may be evacuated at a subsequent
perìod; and it not infrequently bappens that spontaneous absorption
of the effusion follows the removal o£ even small quantities.

fio. 36j. — Siles for BS[nradon of the pleura. (The la^e dots represent the prànts ol
election.)

Positìon of Patient. — The aspir^tion ìs preferably performed with
the patient on a bed so as to avoid the extra exertion of moving after
the operation. When possible, an uprìght sitting position should be
assumed, wìth the ann of the affected side raised, and the band 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 iie near the edge of the bed, upon the back for a lateral
puncture, or roHed slightly to the opposite side with the arm extended
over the head for a jKJSterior puncture (see Fig. 234).

AsepnB. — The skin at the site of operation should be thoroughly
cleansed with soap and water, followed by alcohol, and then a i to 2000
solution of bichlorìd of mercury. The operator's hands should also
be properly cleansed, and the needle or trocar sterjlized by boiling.

Anesthesia. — Locai anesthesia by freezing with ethyl chiorìd or

26o ASPIKATIONS.

by infihration wìth a few drops of a o. 2 per cent, solution of cocain
at the point of puncture wi!I be sufficient.

Technìc. — A vacuum is first produced in the aspirator and the
needle or trocar attached. A point is then selected in the chosen
interspace at a little distance from the upper margin of the lower rib

Fio. 164. — Poution of patient for aspiratìon of ihe pleura.

bounding the space, so as to avoid the upper intercostal arteiy, and the
skin is nicked with a scalpiel. The thumb and forefinger of the left
hand are used to steady the tissues overlying the intercostal space,
while the needie or trocar is introduced with the right hand, the
forefinger being placed on the needle to guard against its being inserted

Fio. «65. — Mcthod of holding the Irocar.

too deeply (Fig, 265). As soon as the poìnt of the needle enters the
tissues, the vacuum aiready present in the aspirator is extended to the
needle f)OÌnt by opening the proper stopcock, and the needle is steadily
pushed in until it enters the pleural sac, which will usually be at a

ASPIRATION OF THE PLEURAL CAVITY, 201

depth of less than 2 inches (5 cm.). The fluid shouid be withdrawn
rather slowly in order that the structures may have lime to adjust
themseives to the changed condìtions in the chest; at least twenty
minutes to half an hour shouid be consumed in removing 2 pints
( 1000 C.C.).

Shouid the patient feel faint or suffer from vertigo or dyspnea
the operation shouid be temporarily interrupted and the patient's
head lowered. Complaints of severe pain, persistent cough, or

FlG. 166. — Aspìration of Ihe pleura with the Polain 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 tubìng is first filled
with sterile solution, and the clamp is placed near the end of the tube
to prevent the solution escaping. The needle is then introduced imo
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 ihc
clamp from the tube the column of water is released and the fluid
withdrawn by a process of syphonage {Fig. 267}.

202

ASPIRATIONS.

Complications and Dangers. — Sepsis is not to be feared if the ordì-
nary aseptic precautìons are observed.

Pneumothorax may follow injury to the lung by the aspirating
needle or trocar, or be due to the rupture of adhesions or a cavity when
expansion occurs, or to the entrance of air along the trocar.

Albuminous expectaration has been observed as a sequel to the
sudden withdrawal of large quantities of fluid. The expectoration
consists of a yellowish, frothy fluid, and it is accompanied by dyspnea,
cyanosis, and a weak pulse. This condition usually begins during the

FiG. 267. — Aspiration of the pleura by syphonage.

withdrawal of the fluid, or comes on shortly af terward. It is explained
on the supposition that the rapid withdrawal of fluid suddenly removes
the pressure from the lung, which as a result becomes congested, and
transudation into the air cells foUows.

Expectoration of blood may result from the rupture of small pul-
monary vessels, from congestion of the lung, or from in jury 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 ha ve 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
amounts 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 suflBdently 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, (he 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 medicai 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

204 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 dose to the left stemal
margin, or else i inch (2 . 5 cm.) to the left of it, thus passing either
internai or extemal to the internai mammary artery.

2. In the fourth interspace dose to the right of the stemum.

3. Close to the costai margin in the angle between the ensiform
cartilage and seventh costai 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 ce.) 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.

Asepsis. — 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. — Locai 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 previously 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
costoxyphoid 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
internai manmiary vessels, puncture of the pleura, and laceration of the
coronary artery and the heart itself by the aspirating needle have ali
been observed. Strict attention to asepsis, extreme care in intro-
ducing the aspirating needle or trocar, and observance 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
cavity 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 individuai
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 prenous
tapping and gives rise to pressure symptoms.

Instruments, Etc. — A straight or slightly cur\'ed cannula and trocar

266

ASPIRATIONS.

of fair size — about i/8 to 1/4 inch (3 to 6 mm.) in diameter — shouid
be used. The trocar is spear-pointed and shouid 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, shouid the intestines or omentum obstruct the end opening of
the instrument.

If desired, the aspirating apparatus of Potain or Dieulàfoy (page
255) may be used in place of the simple trocar.

Fio. 269. — ^Trocar and cannula for aspirating the peritoneal cavity.
I, Trocar and cannula assembled; 2, showing trocar removed from the canuula.

In addition a scalpel to make a small preliminary indsion, a
sterile abdominal binder, a many-tailed bandage or large towel, and
collodion and cotton or sterile gauze and adhesive plaster for the
dressing shouid be provided.

Site of Puncture. — The selectìon 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). Shouid 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 bave been produced by a
previous puncture.

Quantity Withdrawn. — Whether ali the fluid shouid be removed
at once will be determined by the condition of the patient and the
manner in which he bears the opera tion. As a general thing there is
no harm in removing ali the fluid, provided it is not evacuated too
rapidly.

Position of Patient — ^The patient shouid sit upright on the edge

ASPmATlON FOR ASCITES.

367

Fio. aja — Sites for aspiration of the perìtoneal cavìtj.

Pie. 971.— AainnWion of the peritoneal cavity. First step, application al the abdomiiul

268 ASPIRATIONS.

of the bed, if possible, or, if unable Io do this, he may lie propped up
in a semirecumbenl 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 semilunatìs, the patient should lie upon the side.

Preparatìoiu. — The bladder and bowels should always he empty
be/ore operalùm. The abdominal wall is shaved and then scrubbed
with soap and water, followed by alcohol and a final rìnsing with a
I to 2000 solution of bichlorid of mercuiy. The operator's hands
should likewise be sterilìzed, and the trocar is to be boiled.

FiG. 273. — Asp[iation of Ihe peritoneal cavily. Second step, nìcking the skin at the poìnt
of puncture.

Anesthesia. — Locai anesthesia with ethyl chlorid, elher, 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 bìnder, or a Scultetus bandage
with a centrai slil corresponding to the point where the trocar is to
be introduced, is first fitted about the patìent's abdomen (Fig. 271)
and is to be tightened at intervais 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 prevented. With a
scalpel the skin is incised for a distance of 1/4 inch (6 mm.) at the
spot chosen for the puncture (Fìg. 272), and the trocar is slowly and
steadily inserted, with the index finger held along the instrument as

ASPIRATION FOR ASCITES. 269

a guide to the depth it is to enter, and lo prevent it frora beìng suddenly
forced in too far (Fig. 273). As soon as it is judged that the peritoneal
cavity has been reached, the trocar is withdrawn and the fluid is per-
mitted to escape.

The fluid shouid be evacuated slowiy, and, i£ it flows too freely,
it is well to stop the flow at ìntervais 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

Fio. 173. — Aspìration o( the peritoneal cavity. Third step, showing the melhod o£
inserting ihe trocar.

the instrument, a slight tum 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 abdoraen decreases,
necessary support is given to the lax abdominal walls by drawing the
binder tighter. Syncope may be thus avoided; shouid 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 enler the trocar while thìs is
being done.

When fluid ceases to flow, the cannula is quickly removed and, if a
Urge opening has been made by the trocar, the skin may be drawn

270 ASPIRATIONS.

together by a subcutaneous stitch and the line of incision seaied
with coUodion and cotton. If there seems to be a good deal of oozing
of fluid along the track of the trocar, however, a sterile gauze dressing,
held in place with rubber adhesive plaster and changed as often as
necessary, will be found more satisfactory. After the aspiration the
patient should be kept in bed for at least twenty-four hours.

ASPIRATION OF THE TUNICA VAGINALIS.

This operation is employed in the cure of hydrocele. It consists
in introducing an aspirating needle or trocar and cannula into the
tunica vaginalis and removing the contained fluid. It may be per-
formed simply to withdraw the hydrocitic fluid or as part of the
radicai cure by injection of carbolic acid. The former is rarely more
than a palliative measure, as the fluid usually promptly recurs.

The treatment by a combination of aspiration and the injection
of 95 per cent, carbolic acid is, however, successful in more than 80
per cent, of cases (Bevan). It is especially applicable to hydroceles
with thin sacs; in the old, chronic cases with thick sacs it is not often
successful.

The operation is practically without danger, if performed with
proper technic and care is taken to prevent injury to the structures of
the cord and the testicle. The latter usually lies posterior to the tumor,

FiG. 274. — ^Trocar and syrìnge for aspirating and injecting a hydrocele.

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 syringe,
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 usuai 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.

ASPIRATION OF THE TUNICA VAGINALIS. 27 1

The operator's hands shouid be prepared as for any operation, and the
Instruments boiled.

Anesthesia. — The spot of intended puncture may be cocainized

Fio, 375. — Aspiratìng a hydrocele. Showing the method of graspìng Ihe scrotum and the
trocar being inseited.

by the injection of a few drops of a o.z per cent, solution of cocain
or frozen by ethyl chlorid.

Technic. — The operator places liìs left band behind the scrotum
and grasps the neck of the hydrocele between the thumb and forefinger,

FlG. 176. — Aspiratìng a hydrocele. Showing the cannula in place.

thus inaking the tumor tense by compression. Holding the trocar
and cannula in the right band with the index hnger placed alxiut i
inch (3.5 cm.) from ìts tip so as to prevent the ìnstrument being
introduced too deeply, the operator thrusts it into the tunica vaginalis

272 ASPniATIONS.

in an upward and backward direction (Fig. 275). As soon as the
trocar enters the sac, indicaled by a lack of resistance to its further
progress, the point of the instrument is tumed upward thus depressing
the free end and the trocar is removed (Fig, 276). Ali the fluid is then
ailowed to escape, and, to make 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 (o. 30 to i , 90 ce.)
of 95 per cent, (dellquescent) carbolic acid, depending upon the size of
the hydrocele, are injected through the cannula (Fig, 277). If a

Fic. 177. — Method of mjccUng a hydrocele.

syringe cannot be attached directly to the cannula, the injection may
be made by means of a hypKxlermic 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 is manipulated so as
to smear the acid over the whole interior. The puncture is then finally
sealed with coUodion and cotton.

The patient should remain in bed twenty-four to forty-eight hours
after the operation with a supportìng dressing applied to the scrotum.
Some swelling follows the injection, but it usually subsides in a week
or ten days. During this time the patient should wear a well-fitting
suspensory,

ASPIRATION OF THE BLADDER.

Aspiration of the bladder will be consldered under the sectìon
devoted to ihat organ (see page 639).

CHAPTER XI.

THE NOSE AND ACCESSORY SINUSES.

Anatomie Considerations.

The Nose. — ^For purposes of description the nose is divided into an
extemal and an internai portion.

The esternai 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 piate 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 piate 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
mto three separate recesses, the superior, the middle, and the inferior
meatus (Fig. 278).

18 273

274 THE NOSE AND ACCESSORY SINUSES.

The superior meat-us lies between the superior and middle turbina tes.
It is narrow and groove-like, and is the smallest of the three. The
orìfìces of the posterìor ethmoldal cells open upon the upper and
forepart of its outer wall.

FtG. 37S. — Transveise sectktn of the uasal cavities. (After Zuckerkandl.)

The middle meatus lies between the middle and ìnferìor turbinates,
and is more capacious than the superior, extending along the posterìor
two-thirds of the outer wall of the nose. Opening into the middle
meatus on the outer wall is a crescentic slit-like aperture, the hiatus

FlG. 3jg. — Showing the stnictures in the outer wall of the nasal csvìty.

1, Opening of the sphenoidal sinus; i, superior meatus; 3, middle meatus; 4, inferìor

meatus.

semilunaris. Just above it, and at times partly occluding this opening,
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 for-

ANATOMY. 275

ward, is a curved groove bounded intemally by the uncinate process
of the ethmoid, known as the infundibulum. From this a closed duct
leads into the frontal sinus. At the deepest portìon of the infundibulum
near the posterior end, ìs the opening of the maxillary sinus, and
behind this 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.

FtC. lio. — Laleral wall of the rìght nasal cavity ahowing the oiiGce of the accessory
^nuses. (After Schultze and Stewart.) The dotted line indicale^ the oullineof the middle
turtnnate, whicb has been removed to show Ihe stnictures benealh. A portion of the
inferìor turtnnate bus also been removed.

I, Frontal anus; 3, infundibulum; 3, hiatus seinilunaHs; 4, orìSce of the nasal duct;
S, bulla ethmtHdalis; 6, inferior turbinate; 7, accessory orifìcE of the majdllaiy sinus; 8,
orìGce of Eustachian tube; q, fossa of RosenmUUer; io, sphenoìdal sinus; 11, orìfice of the
sphenddal sinus; 13, orì&ce of the middle and poslerìor ethmoidal cells; 13, orìfice of the
SDterior eihmcHdal cells.

From the anatomica) relation of these openings, it can he understood
how readily mfection 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 mealus, 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 ouler 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 two-thirds.

The mucous membrane lining the nasal cavity is continuous
anterioriy with the integument and also with the mucous membrane
of the pharynx, Eustachìan tubes, and accessory sinuses. In the
upper portion of the nose the mucous membrane is of the columnar

276 THE NOSE AND ACCESSORY SINUSES.

variety. In this region if is thin and closely bound to the periosteum
and perichondrium beneath, and contains the endings of the olfaclory
nerves. The remainder of the nasal ca\'ily is lined with ciliated epi-
thelium. Over the inferior turbinates, the lower portion of the middle
turbinates, and corresponding parts of theseptum the mucous membrane
is thick and very vascular, containing numerous thin-walled venous
channels capable of becoming so enormously distended with blood
that they may even occlude the nares. On the floor of the nose the
mucous membrane again becomes thinned out.

The Accessory Srnuses. — HoUowed out of the bones surrounding
the nasal fossae are four cavities filled wìth air, known as the maxillary,
frontal, ethmoid, and sphenoid sinuses, These accessory sinuses

Fio. a8r. — Cross-seclion of the maiillary sinuses. shovring the dose relation of the mota
of the molar teeth lo the floors of the sinuses. (After Zuckerkatidl.)

are lined with a thin, pale, mucous membrane continuous with that of
the meatus into which each sinus respectively opens. The functìon
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 ouler side
of the nasal fossa, occupying the greater portion of the superior max-
illary bone. It is the lai^est of ali the accessory sinuses. In shape
it resembies a three-sided pyramid, with the apex at the zygomatic
process of the maxilla, and the base directed toward the nasal cavity.
The roof of the antrum is very thin and forms the floor of the orbit.
The anterior wall is directed toward the face and corresponds to the
canine fossa extemally. The floor, which is directed toward the
mouth, is formed by the alveolar margin 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 separateci from the cavity
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-
tomica! arrangement is sometimes talcen 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 ce),
but its size varies greatly, and in the same individuai the two sides are
frequently disproportionate. The antrum commimicates 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 extemal 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 suppura tion 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 piate of bone. The anterior wall is thick and is
represented extemally by the superciliary ridge. In the posterior
portion of the floor of the sinus is the rounded or ovai aperture leading
into the infundibulum and thence to the middle meatus by means of
the hiatus semilunaris.

The ethmoidal cells He 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
dose 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 internai examination of the nasal cavities, care-
ful notes should be taken of the patient's history and syinptoms, for
future reference, and a thorough inspection should be made of the
extemal nose. On general inspection one should note the shape of
the nose, with reference to signs of cretinism, syphilis, new growths,
deviations, or defonnities. The shape of the jaws also should be ob-
served; Ukewise the presence or absence of any prominences or bulging
in the neighborhood of the accessory sinuses; the presence or absence of
enlarged cervical glands; the presence of excoriations, herpes, or crusts
about the anterior nares and upper lip, as indications of nasal discharge.
It should be ascertained whether the patient breathes through themouth,
and the patency of the uose should be tested by altemately 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 alae nasi, or any sounds produced during
nasal breathing, and the character of the voice should also be caref ully
noted. Having completed this preliminary examination, that of the
interior of the nose should be proceeded with.

For a thorough examination of the nasal cavity and accessory
sinuses five methods are available: namely, (i) inspection or rhinos-
copy; (2) probing; (3) palpation; (4) transillumination; and (5)
skiagraphy.

RHmOSCOPY.

Inspection of the interior of the nose may be performed by anterior
and by posterior rhinoscopy. 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 pharynx by the aid of reflected light and a
rhinoscopic or small laryngeal mirror. The former is simple and re-
quires no great skill, but the latter is by no means an easy procedure
for one unskilled, and at times requires considerable patience on the
part of the operator to complete successfully and satìsfactorily.

niumination. — ^To obtain a good view of the interior of the nose, it
is necessary to have the best illumination possible. Strong sunlight

RHINOSCOPY.

279

may be utilized for anterior rhìnoscopy, but it is not suitable for an
examination of the posterior nares. Gas or electricity are the two
f orms of artìficial light most used. With the former, a Welsbach bumer
fitted with a mica chimney over which is placed a Mackenzie condenser
gives excellent illumina tion (Fig, 282). Electric light from a frosted
lamp is also much used and has an advantage in that it does not give
out much heat.

Whatever the form of light, it should be so arranged upon a suitable
bracket that it may be raised, lowered, or tmned from side to side

Fio. 282. — Gas lamp upon an adjustable stand fitted with a Mackenzie condenser.

wìthout 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 fumished by an electrical
head light (Fig. 283). Such a light, with the current fumished from
a small pocket Storage battery will be found a great convenience out-
side the examining room.

Instruments. — In addi tion to a suitable light, there will be required:
a concave head mirror, about 3 1/2 to 4 inches (8.9 to io cm.) in di-
ameter, with a large centrai eye-hole, and secured to a soft leather head-

28o

THE NOSE AND ACCESSORY SINUSES.

band by a ball-and-socket joint; a rhinoscopic mirror 1/2 inch (i cm.)
in diameter, set at an angle of 100 to no degrees with the shaft, whìch
is curved to foUow the line of the tongue; a Myles solid-blade nasal
speculum; a Fraenkel tongue depressor; a White palate retractor;
and a nasal applicator with a triangular-tipped shaft (Fig. 284).

Fio. 283. — Electric head light.

Fig. 284. — Instruments for rhinoscopy.

I, Alcohol lamp; 2, rhinoscopic mirror; 3, White's palate retractor; 4, Myles* nasal

speculum; 5, head mirror; 6, nasal applicator; 7, Fraenkel's tongue depressor.

Asepsis. — Instruments, such as tongue deprcssore, specula, appli-
cators, etc, may be sterilized by boiling. The rhinoscopic mirrors,
however, which are soon destroyed by boiling, may be sterilized by

RHINOSCOPY. 281

immersion in a solution of i to 20 carbolic acid and then wiped dry
before using.

Position of the Patient. — The patìent 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. Anlerior Rkinoscopy. — The operator adjusts the
head mirror in such a way that the centrai opening is opposite his left
cye 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 fossa? may be appreciated. Care shouid be taken to
look for fissures, abrasions, or pimples on the inner surface of the

Fio. 385. — 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
s[)eculum is then introduced with the blades closed, and, upon sliding
them apart, the necessary amount of dilatation is obiained (Fig. 285).
The inspection of the cavity shouid proceed from before backward,
the light being thrown into ali recesses. By slightiy 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 reraoved, or is very much atrophied, however, is it
ble to obtain a view of the apertures leading to the accessory

202 THE NOSE AND ACCESSOEY SINUSES.

sinuses. Tilting the patient's head stili further backward exposes
to view the upper portion of the middle turbinate and the roof of the
uose. Occasionally the opening of the sphenoidal sinus may be made
out, but only in excepdonal cases is it possible to see the superior
turbinate.

By the direct application of cocain or adrenalin to the mucous
membrane with cotton pledgets or by spraying, the membrane may be
made to shrink and a more satisfactory view of the structures within
the nose may be obtalned, This is especially usefui where the nasal
cavity is narrow or the turbìnates are hypertrophìed.

Fio. i86. — Showing the melhod ot performing anterior rhinoscopy.

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 ali 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 diagnosi», as probing, transilluminadon, or skiagraphy, must
be employed.

RHINOSCOpy. 283

The attention of the examiner ìs finally directed to the bony and
cartilaginous portjons of the nose. Deviations, ulcerations, perfora-
tions, and spurs oE the septum, contracture or hypertrophy of the
turbinai 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 fon

2. Poslerior Rkinoscopy. — The operator adjusts the head mirror
over his left eye so that the light ìs thrown upon the patient's mouth
The patient is instructed to open the mouth, and a tongue depresso!

FiG. 387. — Fiist step in posterìor rhinoscopy, insertili^ the tongue depressor,

held between the thurab and the index and middle fingers of the left
hand, is inserted and passed over the dorsum of the tongue until 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 suitabie
size is then warmed and, with the light reflected upon the posterior
pharyngeal wall, the mirror is gently introduced into the moulh, lightly
held between the thumb and forefinger of the right hand with its
metal surface directed toward the tongue. The mirror shouM then
be carefully carried back into the nasophaiynx, 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 slightiy 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 itlumìnalìon is not interfered with (Fìg. 288).
It should be remembcred that it is not possìble to obtain a view of
the whole postnasal space at one time, but, on tuming the mirror in

Fio. aSS. Fic. 3S9.

Fio, a88. — ShoBÌng the rhinoscopìc mirror in place.

FiG. 389. — Posterìor rhinoscopic image. i, Root of pharynx; x, uvula; 3, soft palate;
4, opening of Euslachiaa tube; 5, supeiìor turbinate; 6, middle turbinale; 7, inferìor
turbinate.

various directions by rotating its handle, different portions may be
brought into view and the entire space may thus be examìned in
detail. By first holding the handle of the instrument well up, the
vault of the pharynx will be brought into view, and the presente or
absence of adenoids or other tumors may be asccrtained. The
pharyngeal vault is usually smooth and dome-shaped, but it may be
almost compietely 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 wiil be seen the
ridge of the superior turbinate, with the superior meatus lying just
bclow as a darkened depression. Below this will be observed the
middle turbinate as a pinkish-white fusiform body, and, underlying

RHINOSCOPY. 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 Eustachìan cushions
are brought to view. Care should be taken net to keep the minor
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 impossibility to make a sadsfac-
tory posterior rhinoscopic examination. This may be from the forma-
tlon of the parts, as, for example, in the presence of a hard palate
which eitends so far back that there is no room for the mirror, or a

Fio, 290. — While's palale retractor in place.

broad soft palate wìth 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 elevaUon of the soft palate on the introduction of
the mirror, so that the view of the parts above is blocked. Instructing
the patient to breathe through the nose wilh the mouth open, or to
pronounce "en" witha 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 soft palate
and the stem of the instrument so adjusted as to draw the 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 NASOPHARYIVX BY IfEANS OF THE HAYS

PHARYNGOSCOPE.

To overcome the dìflSculties encountered in examining the naso-
pharynx with a rhmoscopic mirror, Hays has devised an instrument
made on the pian of an mdirect 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
rhìnoscopic examination, it ìs 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.

Fio. 291. — ^Hays' pharyngoscope.

Instruments. — AH 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 centrai tube into which a movable telescope fits and also
two wire carriers. At the distai 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 tumed. The length of the horizontal portion
including the telescope is about 8 inches (20 cm.). The vertical portion

*HaroId Hays, in the New York MedicalJoumal, Aprii 19, 1909, and the Laryngo*
scope, July, 1909.

DJSPECTION OF THE NASOPHAEYNX. 287

or handle of the instrument contains the wires which cany the cuirent
to the lamps. Near iis upper end is placed a switch for tuming on or
o£E the cuixent (Fig. 291).

AsepBìs. — The instrument must be thoroughly sterilized before use,
This is accomplished by means of formalin vapor or by immersion in a.
1 to 20 carbolic acid solution followed by rinsing in sterile water. It
will not stand boìling,

Anesthesia. — As a rule, anesthesia is not necessary. Should, how-
ever, gagging be induced by the instrument, the posterior phaiyngeal
wali may be cocainized,

Technìc, — The patient is instructed to open his mouth widely
and breathe quieUy. The instrument is then ìnserted in the same

Fio. 391. — Showìng the method irf ìnserting the Hays' pharyngoscope (after Hajrs, Am,
Jour. Swg., May, 1909).

manner as a tongue depressor, until its distai end lies about
1/16 inch (1.5 nim.) from the pharyngeal wall (Fig, 292). The
instrument is kept steadily in place upon the tongue, and the
patient is told to dose the mouth and breathe through his nose.
This produces relaxation and consequent widening of the pharynx
and nasopharynz. The light is then tumed on, and the examiner
ìnspects the stnictures as they are separalely brought to view 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 tìlting the distai end of the instrument slightly upward,
the posterior nares are viewed.

288 THE NOSE AND ACCESSORY SINUSES.

To inspect the region of ihe Eustachian tubes the lens is rotated
to about 30 degrees to one side, when the orifices of the tubes, Rosen-
mìiller's fossa, etc, will be clearly shown, By rotating the lens so
that it points downward the epiglottìs, larynx, and base of the tongue
are similarly inspected.

FiG. 29,5. — ShowJng Ihe pharyngoscope in place with Ihe eiaminer inspecting the post-
nasal space.

PALPATION BY THE PROBE

The use of the probe is essentìal 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,

Instruments. — The instruments comprise those necessary for a
rhinoscopic examination; a nasal applìcator; a nasal probe; and a
sinus probe (Fig. 294).

The nasal probe shouid be of silver, fairly stiff, but at the same
time capable of being bent. It shouid be about 8 inches (20 cm.)
long, and set into its handle at an angle of 135°.

The instrument employed for examinatlon 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 veiy sensitive and
manipulations are apt to produce sneezing, so thai the parts shouid

PALPATION BY THE PROBE.

289

be cocainized before the probe is employed. This may be done by
applying a 4 per cent, solution on a small pledget of cotton, allowing
sufficient time to elapse for the cocam to take effect before proceedmg
with the examination.

Positìon of Patient. — ^The positions of the patient and operator are
the same as for a rhinoscopic examination.

Technic. — By means of a speculum and reflected light the interior of
the nasal cavity is brought into view and is then systematically explored
by the probe. Any growths are touched to determine their consistency,
and 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, Nasal applicator; 2, nasal probe; 3, sinus probe; 4, Myles' nasal speculum;

5, head mirror.

ations, etc, are ascertained. Ali recesses should be thoroughly
examined, and especially the walls of the sinuses should be gently
palpated 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
cavity cleansed by syringing.

To enter the frontal sinus, the distai 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

290 THE NOS£ AND ACCESSORY SINDSES.

passcd upward and forward through the hiatus and into the infundib-
ulum. By depressing the handle of the instrument, ìts tip will
traverse the infundibulum and pass through the ostium frontale unless
some obstruction exists. Gentleness shouid be employed in thìs
maneuver, and no attempi shouid be made to force the instrument if
any obstruction to its passage exists.

FiG. 195. — Showing (he steps in the passage af a probe into the frontal unus.

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 tip 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, 296.— Showing the steps in the pasaage of a probe into Che sphenoidal anus,

point enters the cavity ot the sinus, which is then carefully explored.
In eithcr 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 introduction of the former.

DIGITAL PALPATION. 29I

DIGITAL PALPATION.

Palpatjon of the posterior nares by means of the finger is employed
to confimi 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 digitai palpatìon
is a rather unpleasant procedure for the patient, if performed rapidly
and stilfully many of the disagreeable factors may be obviated.

Preparatton. — The hands should always be well scrubbed before
making such an examination.

Technic. — 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.

Fic. 397. — Showing tbe melhod of palpating Ihe postnasal space with the fìnger.

The left hand of the operator supporls the patient's head, and at the
same lime with the thumb or index finger of the 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 i&
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 posterior 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 means, 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 variation 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 upoft 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 ìt 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 individuai 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 assemblee! for transillumination of the antrum; &, glass hood for use
in transillumination of the antrum; e, hood for use in transillumination of the frontal
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. TransUluminalion of the Frontal 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 orbitai portion
of the brow at the nasal side. The light is tumed on and the sinus is
clearly illuminated, the operator noting the effect. The opposite side

TRANSILLUUINATION. 393

is treated in the same manner, and the two are compared as to the
inteosity with which the light is transmitted.

Through a large sinus in a normal condition the light is trans-

Fio. 399. — Tranùl lumina tion efEect
in & nonna! light fiontal sinus.

mitted with greater ìntenàty than through a small cavity, or through
one with thickening of the bony walls or the lining membrane, or one
complicated by the presence of pus or a tumor.

2. Transilluminalion of the Antrum, — The patient is seated in a
darlcened room, any dentai plates or obturators that might obstruct

Fio. 301. — Tranàllumination effect in Fio. 30», — Trans! I lumi nalion effect in
Ihe normal case. (After Hannon Smith, sinusitis of the right antrum. (After Mar-
ia Keen's Surgery.) mon Smith, in Keen's Surgery.)

the light having been previously removed. The electric lamp, covered
with the glass hood, is then introduced into the mouth, and the patient
is instructed to dose his lips firmly. Under normal conditions when the

294 THE 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 illummation of the pupil will be noted. The transmission of light
will also be ìnterfered with in the presence of thickened walls or
lining mucous membrane.

SKIAGRAPHY.

The X-ray gives unportant 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, ali 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 puipose of cleansing the nasal
cavity prior to operative procedures or for the purpose of removing
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
xemaining 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 pàtient'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 carefuUy
instruct the patient m the proper method of its use.

Apparatus. — ^An ordinary douche bag with a capacity of about a
pmt (473. n ce), fitted with a nasal nozzle, forms a simple and effect-

Fio. 303. — ^Nasal douche apparatus.

ìve douche. There are a number of douches especially made for the
nose, a convenient tjrpe for use with large quantities of solution being
shown 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 unirrìtating as possible.

296 THE NOSE AND ACCESSORY SINUSES.

One o£ the following formulae may be employed.

I^. Sodii bicarbonatis,

Sodii biboratìs, àà. dr. i (3 . 75 ce.)

Acidi carbolicì, ni.xv (0.92 ce)

Glycerini, oz. i (30 ce.)

Aquae, , q. s. ad. Oi (473. n e.e.) M.

I^. Sodii biearbonatis, dr. i (3 . 75 e.e.)

Acidi salicyliei, gr. x (0.65 gm.)

Aquae, q. s. ad. Oi (473.11 ce.) M. '

I^. Sodii bicarbonatis,
Sodii biboratis,

Sodii chloridi, àà. oz. i (30 ce.) M.

Sig. A teaspoonful to a pint of warm water.

Some of the proprietary preparations, such as listerin, borolyptol^
glycothymolin, alkalol, etc, will be found of value where an antiseptic
action is also desired. They may be used in the proportion of dr. ss
to dr. i (1.9 to 3.75 C.C.) to the ounce (30 ce.) of water. When there
is an offensive discharge, the following may be employed.

I^. Potassii permanganatis, gr. i-ii (0.06-0.13 gm.)

Aquae, ad. oz. i (30 ce.) M.

Temperature. — Ali solutions should be used warm, at a tempera-
ture of about 100® F.

Qtiantity. — ^For ordinary cleansing piuposes or for the removal
of free secretion froin the nose, a few ounces of solution are sufiicient.
When hard crusts are abundant, however, it sometimes requires a
pint (473.11 C.C.) of solution, or more, to loosen them and effect their
removal.

Rapidity 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 ce.) above the level of the
nose.

Technic. — ^The patient stands with his head bent slightly for-
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 band, is then inserted mto 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 SYJLINGE. «97

passes tbrough one Dostril back into the nasopharynx and out through
the other nostril (Fig. 305). When no obstmction eiists in either
side, half the solutton may be injected through one nostril and the
remainder in the reverse dh^ction through the other.

With the small glass douche cup the tecimic is very simple.
The patient inserts the nozzle of the partially filled instrument into

Fic. 305. — Showing the method of uùng the nasal douche. (The reservrar shouid be a
little bwer than sbowo berb)

one nostril, holding the finger over the side opening. He then throws
his head well back and removes his iìnger from the opening, which
allows the solution to flow through the nose into the mouth, whence it
is expectorated. Each nostril in tum may be thus irrigated.

THE NASAL STRINGE.

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

298 THE NOSE AND ACCESSOSY SINOSES.

postnasal space may be more effectually 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 bave been
mentioned for the use o£ the douche.

Instnimeats. — ^A syringe with a capacity of i te 2 ounces {30 to

=«>

Fio. 306. — Nasa! syringe with anterìor and posterior nasal tips.

59 C.C.), made o£ metal or hard rubber, will be required. It should
be supplied with a straight nozzie for injection through the anterior
nares, and with one bent up almost at right angles for cleansing the

postnasal space (Fig. 306).

FiG. 307. — Showing ihe method of syringing ihc nose from behind.

Solution. — Any of the cleansìng soIutions mentioned on page 296
may be employed. They should always be used warm.

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 toc much force, etc. The nozzie of the

THE NASAL SPRAY. 399

syrìnge is inserted into one nostrìl and the patient is directed to keep
his head bent well forward over a receptacle and to breathe through
the mouth. The solution is then slowly injected and retums through
the opposite nostri). The irrigatìon shouid be so regulated that the '
fluid retums as quickly as it enters, thus avoiding any undue accumu-
latìon in the postnasal space and lessening the dangers of infectìng
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 distai
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 anterìor nares, flushing out the post-
nasal space and nose from behind forward (Fig. 307). On account
of the sensitive condltion of the parts in some cases it may be necessary
to cocainize the'pharynx and soft palate before the syringing canbe
properly performed.

THE NASAL SPRAY.

Sprays or atomizers are uUlized 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 get out of order. The Whitall Tatum

Fig. 308.— Whilall Tatmn

(Fig. 308), the Davidson, or the De Vilbiss (Fig. 309) are ali 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

300 THE NOSE AND ACCESSOBY SDJUSES.

compresseli air apparatus (Tig. 310). The latter will be found more
convenient for office work.

Fot cleansing puiposes, the spray shouid be rather coarser than
that employed for medication. OUy preparations may be sprayed

Fio. 309.— De Vllbias

with an ordinaiy atomizer provided wìth an oil tip, or a special oil
nebulizer may be employed.

Solutions. — ^Any of the cleansing solutions raentioned on page 296
may be employed in a spray.

Fio. 310. — Compressed-air atonuzing apparatua.

When a mild antìseptic action is desiied, the solutions given on
page 296 or the following may be used;

H. Addi carbolici,

Glycerini,

Aqux, q. s. ad.

R. Resorcini,

Glycerini,

Aquie, q. s. ad. oz.

v(o.32 gm.)
i (3-7S ce.)
1(30 ce.) M.
iii(o..9C-c.)
" (3 '75 C.C.)
1(30 ce.) M.

THE DIRECT APPLICATION OF REMEDIES. 30I

Astringent solutions, for purposes of lessening secretions, include
such drugs as zinc sulphocarbolate, zinc sulphate, copper sulphate,
alum, tannic acid, sii ver nitrate, etc, used in the strength of 5 gr.
(0.32 gm.) to the ounce (30 ex.) 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 oimce (30 ce.) for the sedative eflEect, as
in the foUowing:

I^. Eucalyptol, n^^x (0.60 ce.)

Menthol, gr. v (0.32 gm.)

Benzoinol, oz. i (30 ce.) M,

I^. Thymol,

Menthol, àà gr. ii (0.13 gm.)
Albolene, oz. i (30 ce.) M.

Q. Camphorae.

Menthol, àà gr. v (o . 32 gm.)
Albolene, oz. i (30 ce.) 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
altemately 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.

302

THE NOSE AND ACCESSORY SINUSES.

Fio. 311. — ^Fusing chromic acid on a probe. First step, heating the probe. (Gleason.)

FiG. 312.

FiG. 313.

Fio. 314.

Fio. 312. — Fusing chromic acid on a probe. Second step, dipping the hot probe in
the crystals. (Gleason.)

Fio. 313. — Fusing chromic acid on a probe. Third step, heating the crystals into a
bead. (Gleason.)

Fio. 314. — Fusing chromic acid on probe. Showing the finished probe. (Gleason.)

INSUFFLATIONS. 303

Solid caustics, as chromic acid, sii ver nitrate, etc, are best applied
f used upon a probe or applicator.

Chromic acid may be prepared for application as foUows: The
probe tip is brought to a red heat over an alcohol flame (Fig. 311)
and is then dìpped into crystals of the acid (Fig. 312). Upon with-
drawing the probe a few crystals will be found adhering to its point.
This 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
on 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 applying chromic acid a second cotton-wrapped
applicator, saturated with a solution of bicarbonate of soda — 30 gr.
(i .95 gm.) to the ounce (30 ce.) — 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
other 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
in Fig. 316 may be used. The former is made on the same principle
as a hand spray, but with larger tubes. It, however, requires the
ixse of both hands in its manipulation. The latter instrument con-
sists of a rubber compression bulb to which is fìtted a vulcanized

304

THE NOSE AND ACCESSORY SINUSES.

rubber tube, Into this lattei fits the nasal tip, the proriraal end of
which Ì5 made in the forra of a scoop for taking up the powder. When
the ìnstniment is fìUed, a sudden compression of the biilb forces air
through the apparatus, blowing the powder out in front of it. This

Fio, 315. — Powder blower.

instruraent tnay be manipulated wìth one band, and the qnantity of
powder used can be accurately measured. Insufflators are supplied
with straight tìps for the anterior nares, and with curved tips for
making applications to the posterior nares.

FiG. 316. — Scoop powder blower.

For the patient's use, an insufflator such as Sajous' (Fig. 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

Fig. 317. — Sajous' powder blower.

mouthpiece is attached, the other end being rounded off to fit into the
nostril.

Technlc. — 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 medìcated, 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 insuflBator, the tip is inserted into the nostril, the instniment
being held with one fìnger 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 invohìng the accessory sinuses.
It is performed by means of a suitable cannula introduced into the
sinus through the naturai or an artificial opening. Treatment by
irrigation is most successful in the early 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 radicai
surgical measures are considered.

Solutions Used. — Normal saline solution (salt 3i (3.9 gna.) to the
pint (473.11 ce.) of boiled water), a saturated solution of borie acid,
or any of the cleansing solutions mentioned on page 296 may be used.

Temperature. — Ali solutions employed in irrigating should be warm
— at 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 inf undibulum. If
an accessory opening be present, however, it may be possible to irrigate
through it, but in most cases an artificial opening will ha ve 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 saving, puncture through
the alveolus is justifiable.

Instruments. — ^For irrigating through the inferior meatus, an antnmi

3o6

: NOSE AND ACCESSORV SINUSES.

Fio. 318. — I nstni menta f or lavage of Ihe maiillarysìnuslhroughapuncturein theinferior

I, Head mirrar; 2, strìnge; 3, applicalor; 4, Myles' nasal speculum; 5, lubing lo connect
the syrìnge and cannula; 6, Myles* trocar and cannula.

Fio. 319.— Inslnjments for lavage of Ihe antrum through the alveolus.

I, Syringe; a, cannula; 3, tubing to connect the syringe to the cannula; 4, alveolar drill;

S, drainage-tube; 6, tooth-eutracting forceps.

LAVAGIT 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 interior
meatus, locai 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 obtaìned a
good view 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 puncturìng 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 home 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 teadily escape
from tbe 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 difficulty in reinserting the cannula through

308 THE NOSE AND ACCESSORY SINDSES.

the opening each day, if it is provided with a blunt obturator. The
paxts should be cocainized, however, before each irrìgatìon.

2, Tkrough the Alveolus. — The puncture is made through the

Fio. 33t. — Transveree seclion through the nose, showing cannula,

a, Enleiing antnim Ihrough inferìor meatus; and b, cannula enterìng Ihe orbit thraugh

Ihe middle meatus. (After Coffin.)

socket of the second bicuspid or the ìnner root socket o£ the first or
second molar tooth (Fig. 332). The affected tooth is first removed,
and the drill inserted by a boring motion, as foUows: For the first
molai, in an upward and slightly inward direction; for the second

Fio. 312. — Showing drills entering the antnim Ihrough the alveolus. {Afier Schuitie
and Stewart).

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 SIND5ES.

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 uose through the naturai opening. To aid its
escape, the patìent's head should be inclined forward, Finally, a
metal drainage-tube of the proper size is inserted, through which
Bubsequent irrigations raay 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 dìscontinued for a day or two, and, if there is
no recurrence of the trouble, the tube is then removed and the opening
allowed to dose.

Lavage of the Frontal Sinus. — The frontal sinus may be irrigated
by means of a small cannula ìntroduced through the fronto-nasal duct.

Fio. 313, — tnstrumenls for lavage o( the frontal sinus.

r, MyW nasal speculum; 2, head miiror; 3, syringe; 4, tubing to conncct the sjtinge lo

cannula ; 5, ^U3 probe; 6, naaat 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 bave to
be removed before the attempt is successful. Another difficulty pre-
sents itself in the dose proximity of the anterior ethmoidal cells, and
the cannula may enter this group instead of the frontal sinus.

Instnimeats. — A head mirror, a speculum, a nasal applicator, a
sinus probe, a pure soft-silver sinus cannula that may be easily bent to

3 IO

; NOSE AND ACCESSOEY SINOSES.

accommodate itself to any curve — such as Hartmann's — and a syringe
that can be attached by means of rubber tubing will be required
(Fig- 323).

FiG. 334. — Showing the sleps of pasàng a cannula into the frontal ùnus.

Anestbesla. — A 4 per cent, solution of cocain should be applied
to the middle meatus for twenty minutes before operation.

Teclinic. — The cannula, bent at its distai end to an angle of about

)

FiG. 335. — Instruments for lavage of the sphenmdal sinus.

I, Myles' nasal speculum; 3, head mìrror; 3, syringe; 4, tubing to connect the syringe (o

cannula; 5, sìnus probe; 6, nasal applicator; 7, ùnus cannula.

135 degrees, is introduced into the middle meatus at the junctìon of the
anterior third with the posterior two-tWrds. The tip of the cannula
is passed into the hiatus and then forward and upward into the infun-

PASSIVE HYPEBEBCIA. 3XI

dibulum, and thence stili upward and slightly forward into the sinus,
thiough the fronto-nasal duct (Fig. 324). The syringe is then attached
to the cannula and the sinus ìs gently irrigated with one of the warm
cleansing solutions previo usiy mentioned.

Lavage of the Sphenoidal Sinus. — Instruments. — ^A head miiror,
a nasal speculum, a nasal applicator, a ^us probe, a sphenoidal
curved cannula, and a syringe with rubber-tubing attachment will
be requìred (Fig. 325).

Anestheda. — ^The ragion is anesthetized with a 4 per cent solution
of cocain.

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).

Fio. 326. — Showìng the steps of pasàng a aumula into tbe sphenoidal àaus.

The depth of the smus is only about 3/8 inch (1.5 cm.), and care
should be taken not to force the instrument through its thin walls.
The syrmge ìs attached to the cannula by rubber tubing, and the
cavity thoroughly but gently irrigated, During this procedure the
patient's head should be bent forward and the mouth opened to pre-
vent the backward fiow of the retuming solution.

PASSIVE HYPEREHU IH DISEASES OF THE ROSE AIID .
ACCESSORY sunrsEs.

The beneficiai effects of passive hyperemia in the treatment of
inflammations bave already been discussed in Chapter VII, to which

312 THE NOSE AND ACCESSORY SINUSES.

section the reader is referred for a full consideration o£ the subject
and the technic o£ its application. According to Ballenger/ the
indications for passive hyperemia in rhinology are: (i) in the first five
days of acute rhinitis; (2) in the first five days of acute sinusitis; (3)
in the first five days of acute inflammation of the pharyngeal tonsils;
(4) in acute tubai catarrh; (5) in chronic purulent inflammation of the
sinuses.

The hyperemia m^y 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 eflScacious in the presence of a purulent discharge, the
vacuum serving to remove secretions as well as to induce a beneficiai
hyperemia; but it must be used with great care not to induce a harmful
degree of hyperemia. The apparatus shown in Fig. 169 or one pro-
vided with glass tips which fit into the nostrils may be used. With
the apparatus applied to the nose, the air is slowly rarefied while the
patient swallows. This causes the soft palate to rise up in apposition
with the posterior wall of the pharynx and to dose the naso-pharynx
and nose from the pharynx, and a hyperemia of the mucous membrane
of naso-4)harynx, nose, accessory sinuses, and Eustachian tubes is thus
induced.

TAMPONINO THE NOSE FOR THE CONTROL OF HEM0RRHA6E.

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 under simple treatment which aims
at lessening the congestion of the nasal mucous membrane and favoring
the formation of a dot, such as the application of cold over the nose
and at the base of the neck, removing tight collars, etc, from the neck,
ha\óng 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 insufiìcient, 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 sii ver nitrate; or
else some styptic solution, as peroxid of hydrogen, a watery solution of
tarinic 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

*Ballenger: "Diseases of the Nose, Throat, and Ear."

TAMPONINO THE NOSE FOR THE CONTROL OF HEMORRHAGE. 3^3

o£ such treatment, so that in the presente 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 bave to be
packed.

FiG. 327. — Instruments for tamponing the anterior nares.
I, Nasal applicator; 2, 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 drawing 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 TBE NOSE AND ACCESSOfiY SINUSES.

sound (Fig. 329), will be necessary. This latter consista of a curved
metal cannula containing a concealed steel sprìng, which is protruded
into the pharynx and mouth when the cannula is in place io the nose,
and to the end of which the tampon is then attached.

a — =1(9

Fig. 339. — Bellocq's cannula.

Technic (Anlerior Nares). — In tamponìng 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 f)erond of hydrogeo, is then
gently carrìed well back into the nose by means of an appHcator, and
by forcing in more gauze the whole nose is tamponed and the hemor-

FiG. 330. — Showìng the method of tomponing the anterior nares.

rhage controlied (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.

TAMPONINO THE NOSE FOE THE CONTROL OF HEMOKRHAGE. 315

(2) {Posterior Nares). — The tampon, as already described, sbould
be well lubricated with vaselin and placed near at band. The Bellocq
canaula is passed along the floor of the nose on the bleedmg side until

Fio, 331.— Showing the metbod of drawing a plug into the posterior uorcs bjr the aid ol
Bellocq's cannula.

FiG. 333. — The posterior nasal plug in place.

its tip appeais back of the soft palate. The steel sprìng is pushed
home and is protruded into the mouth. The tampjon b then tied to
the end of the carrier by one of the strings (Fig. 3^1), the spring

3l6 THE NOSE AND ACCESSORY SINUSES.

retumed within the cannula, and the latter removed from the nose
and with it the end of the tampon spring. By pulling upon the string,
assisted by a finger placed in the naso-pharynx, the tampon is drawn
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 pnrpose 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 foUowed.

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 remove 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 adrenalin chlorid
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.

Anatomie Considerations.

The ear is divided into three portìons, the extemal ear, the middle
ear, and the internai ear. For the purposes of this work, a con-
sideration of the anatomy of the extemal ear and the middle ear will
suffice.

The extemal ear comprises the auricle or pinna and the extemal
audìtory canal.

Tke auricle ìs the irregular shaped mass composed of fibrocartilage,
covered by perichondrium, connective tissue, and skin, which projects
frora the side of the head. It has the function of coUecting sounds
and reflecting them to the extemal auditory meatus. The centrai

Fio. 333. — The left auricle.

I, Concha; 2, atitihelix; 3, (ossa of anlihelix; 4, helU: 5, fossa of the helix; 6, tragus;

7, antitragus; 8, lobule.

depressed portion, resemblìng a shell in form, is called the concha.
It is bounded by a rim, the antihelix, which runs at first backward
and then upward and forward, finally dividìng into two anns. The
space 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
helix, at first in a forward and upward direction and then around the
circumference of the auricle toward the lowest portion. The space
between the antiheliz and the helix is designated the fossa of the helix.
317

3l8 THE EAE.

The small backward projectìon lying in front of the concha is called the
tragus, and the small tubercle at the lowest portion o£ the antihelix,
the antitragus. The lobule of the ear is the lowest soft pendulous
portion of the aurìcle.

The exlernaì audUory canal extends from the concha to the drum
membrane. It serves the purpose of conveying sounds collected by
the aurìcle to the drum membrane. The canal measures about
I I /2 ìnches (4 cm.) in length, the floor being slightiy longer than the
roof on account of the oblique position of the drum membrane. Its
outer third is composed of cartilage, a contìnuation of that forming
the auricle, while the inner two-thirds has a bony framework. The
interior is lined with thin skin, which contaJns hair follicles and

FiG. 334. — Front view of the organ of hearing. (Randall.)

cerumenous glands, the latter being most abundant at the junction
of the cartilaginous and bony portions. The widest portion of the
canal is near the external orifìce, 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 tempora] bone, between the
external and the internai ear. The interior of the cavity is lined with a

ANATOMY ■ 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 piate of bone, the tegmen tympani et antri, which separates it
from the dura; below by the floor which corresponds to the jugular
fossa; by an outer walI composed of the dnim 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 ovai 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
leadìng into the mastoid antrum, the adilus ad anlrum. The cavity
is practically dìvided by the chain of ossicles into two portìons, an
upper epitympanic space or attic, and a lower cavity or atrium.

Fio- 335' — Analomy of the osàdes. (Pyle's "Personal Hygiene.")

The ossicles are three small bones, the malleus or hammer, the
incus or anvil, and the stapes or stirrup, joined together by movable
artìculations, and formlng 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
ovai 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.

320 THE EAK.

The malleus consists of an ovai 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 lattei outward before it, and a long process
which passes anteriorly into the Glaserian fissure.

The incus is the middle ossicle. It consists of a body which artic-
ulates with the malleus, a short horizontal pnxess which extends to
the posterior wall where it is attached 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
ovai 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-dnim, is a thin elastic membrane
stretched obliquely downward and inward across the ìnner end of the
extemal auditory canal forming the outer wall of the tympanic ca\nty.
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 ser\'es the purpose of
receiving and transmitting sound waves to the chain of ossicles.

FiG. 3j6. — Ouler surface ot the righi membrana lympani. (Gleason.)

a, Membrana flaccida; b, posicrior (old; e, short process; d, incudostapedial artlcula-

tion; e, malleus handle; /, umbo; g, coae of Ught.

It may be described as elliptical in outline, and of a pearly gray
color, but at the same time translucent. Its outer surface is conca^■e
and normally smooth. By the aid of a speculum and suitable illumina-
tion there wiil be noted a whitish ridge formed by the handle of the
malleus, nmning 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 trìangular 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 foids 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 pluuynx with the tympanic cavity. It has a general
direction from the tympanum forward, downward, and inward,
openiug upon the lateral wall of the pharynx 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 cartOaginous and membranous, and is lined
with ciliated epithelium which waves in a direction toward the pharynx.
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 t3rmpanic 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
aflfected. 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 symptom 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 leamed 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 afifected. The duration of the condition must also

322 THE EAR.

be ascertained. Not infrequently in the presence of chronic catanrh
. 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 raihoad train or Street car
(paracusis Willisii), or hearing sounds as if repeated twice (paracusis
duplicata), or, again, in the presence of marked nnilateral deafness
the inability to locate the source of sounds (paracusis localis).

Tinnitus, or subjective noises, are present in middle-ear diseases as
well as afifections of the internai 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 leamed whether they are located in the ear or in the head, whether
imilateral or bilateral, and whether they are modified by mental or
physical exertion or by the time of day. As a mie 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 phar)nix, 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 coUection of fluid in the middle ear or destruction of bone may
be suspected. Pressure tendemess is also òf 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 extemal auditory canal, tendemess elicited by pressure
in the depression below the lobule of the ear to middle-ear inflammation,
and pressure tendemess 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 hearing 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 abeady 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, eniarged glands, or signs of tendemess. 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
extemal ear, (2) inspection of the extemal 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 ali cases
the examiner should not fail to investigate the condition of both ears.

DIRECT INSPECTION.

A thorough inspection of the auricle and extemal 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 fumished 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.

Positlon of Patlent. — The patient is seated upon a stool with the
ear to be examined tumed 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 carefuUy
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 extemal 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.

324

THE EAR.

OTOSCOPY.

Otoscopy is the inspectìon of the extemal auditory canal and
tympanic membrane by the aid of a speculum and suitable illumination.
By this means parts of the auditory canal and the drum membrane
ìnvisible to direct inspection may be viewed in detail, and the presence
or absence of pathological conditions recognized.

Instruments. — ^There will be required a strong light, such as ìs
obtained from a Welsbach bumer covered by a Mackenzie condenser,
mounted upon an adjustable bracket so that it may be raised to
any desired height, a concave head mirror 3 1/2 to 4 inches (8.9 cm.

FiG. 337. — Instruments for otoscopy.
I, Head mirror; 2, aural specula; 3, ear probe; 4, ear curet; 5, angular ear forceps;

6, ear syringe.

to IO cm.) in diameter with a centrai 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 desired,
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 extemal 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 is 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 inmiersed

* Manufactured by the Electro-Surgical Instrument Co. of Rochester. N. Y., and
the Wappler Co., New York City.

OTOSCOPY. 325

ÌD a I to so carboUc acid solution and then rinsed in stenle water be-
fore use.

Poritioa of Patl«nt. — The patient and examiner should be seated,
the former with the ear tumed toward the examiner. The examiner's
eyes should be on a level with the patient 's ear and in a horizontal

FiG. J38. — Gniber's apeculum. Fio. 339. — Boucheron's speculum.

piane with the esternai auditory canal. If reflected tight ìs employed,
the souTce of iUumination should be a little above the level^ of the
patient's ear and upon the examiner's left.

Technlc. — The examiner directs the light full upon the esternai
auditory meatus and, grasping the auricle between the thumb and index

Fio. 340. — Electric- lighted speculum.

fìnger of the left band (if the right ear is being examined and vke
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 pulì the auricle outward and a little down-
ward, as tìie wall of the canal has no bony support at thìs 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 introduced 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 o£ the auditory canal, by watching the parts illummated at
the distai end of the speculum until the drum membrane is brought to
view. With the speculum properly 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).

Fic. J41. — Otoscopy with the reflector and ear speculum. The anows tepresent course
of light. (Gleason.)

Before examining the drum membrane, the extemal 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 infiamma tion and furuncles should also be looked for,
Sometimes secretions and collections of wax require removal before
inspection is possible. This may be accomplished, as a rule, by gently
syringing the canal with warm saline solution or a saturated solution of
borie acid (see page 339). Small masses of wax and fiakes may require
removal by means of the curet, foUowed 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 aP
the distai end of the canal, inclining downward and inward at an angle
of about 45 degrees. The norma! drum appears translucent and of a

OTOscopy. 327

pearly gray color, with its circumference appearing as a white line.
Extendmg from above downward and backward in the upper half of
the drum is seen the handle of the malleus. In the upper and anlerìor
portion about i js^ 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. Extending 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 nonnally to be

Fio. 342. — The appearance of the dram membrane as seen through the speculum.

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 deterrained, the latter being evidenced by the greater
deptb 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 reSected tight will appear altered in shape and displaced. If
bidging is present, its location should be noted. As a mie, 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 pwsition of the speculum
slightly ali portions of the drum may be viewed in detail. By means

328 TEE EAB.

of a cotton-tipped probe, inspection may be supplemented by careful
palpation, if further information as to the conditions found is desired.
In ali manipulations of the speculum or instniments great gentleness
should be observed,

DETERHUTATION OF THE HOBILITY OF THE DRUU HEHBRARE.

By the aid of a pneumatìc otoscope with which the air in the extemal
auditory canal may be altemately condensed or rarefied, it is possible
to determine the degree of mobility possessed by the membrana
tympani, and thus recognize undue rigidity or laxness of the drum or
the existence of intratympanìc adhesìons binding the drum or ossicles
to the walls of the tympanum.

Apparatus. — Siegle's pneumatìc otoscope (Fig. 343) consists of
an air-tight chamber, the proximal end of which is closed by a pkin
glass wìudow or convex lens placed at an angle of 45 degrees to the

Fig. 343. — Siegle's pneumatic oloscope.

long axis of the instrument, while to the distai end may be screwed
different sized specula. Upon the side of the air-tight chamber is
placed a small perforated knob to which b 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 lìght or reflected light from a head mirror.

Position of Patìent. — The patient and the operator occupy the same
relative posilions as employed for an ordlnary otoscopie 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 snugly into the
auditory canal in the same manner as an ordìnary speculum. A
small piece of rubber tubing may be slipped over the end of the specu-

HEAKING TESTS.

329

luna, ìf necessary, to insure its fitting the auditory canal more accurately.
The eiaminer then observes under good illuminatìon the movement
of the drum membrane through the window in the otoscope, as he
relaxes or compresses the bulb. As the ah- 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 presente of adhesions will
be evidenced by absence of any mobiiity at that particular point, wtiile
other parts of the drum will move freely. Too enei^tic use of the
instrument must be avoided for fear of rupturìng a weakened drum.

HEARnVG TESIS.

Hearing tests are very important in the diagnosis of ear diseases,
since they not only fumish information as to the extent the hearing is
impaired, but also serve to locaHze the seat of a lesion, that is, whether
in the conducting apparatus or in the nervous mechanlsm. While

\Y/

FiG. 344. — Hartmann'g set of tuning-forks vai7Ìng f ro

there bave been a number of hearing tests devìsed, the following are
suffident for ali practìcal 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) Rinné's test.

330 THE EAIt.

Apparatus* — ^While it is of advantage to bave a complete set of
tuning-forks, the ordiriary tests may be carried cut with a low tone
fork (C-2) having thirty-two vibrations per second, a Galton's whistle
for high tones, and a C 2 fork havmg 512 vibrations per second
for Weber's and Rinné's tests. Galton's whistle (Fig. 345) gives
tones ranging from about 7000 vibrations per second to the highest
perceptible tone limit. The instniment is provided with a scale and
screw whereby the number of vibrations may be regulated so as to
give any tone within the limits stated above.

Fig. 345. — Galton*s whistle.

Tests of the Acuteness of Hearing. — i. The Watch 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 the particular watch is heard by a
normal ear must be determined by experience. Each ear is tested
separa tely in the foUowing manner: The patient is seated in a chair
with his eyes closed, and with his forefinger closing the ear not under
examination. The examiner first holds the ticking watch dose to
the ear being tested so that the patient can bear it distinctly and then
slowly brings it from a distance beyond the range of hearing power
toward the ear in a line perpendiculaf 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 residuai air from various distances, and measures the distance at

HEARING TESTS. 33 1

which the patient can bear and repeat them correctly. The result Ì3
expressed in a fraction of feet, the denominator of which represents
the distante in feet at which the norma! ear can hear the voice and
the numerato! the actual distance at which it is heard by the ear
under 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 diflFerentiating between disturbance of
hearing due to aflFections 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 aflFected ear, it is indicative
of some aflFection 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
sound, and, if the fork is then brought dose to the external ear, the
sound will again be heard. This is known as a positive Rinné. If,
however, the sound is not heard again when the fork is thus transposed,
it is known as a negative Rinné. Therefore, in a deaf ear, if we obtain
a positive Rinné, 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.

332 THE EAR.

INFLATION OF THE MIDDLE EAR.

Inflation 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 unobstnicted
communication exists between the middle ear and the pharynx; 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-
ente of perforation of the membrana tympani; and to determine the
mobility of the membrana tympani. The therapeutic uses of inflation
will be considered later (see page 345).

An auscultatory tube is employed in conjunction with inflation for
the purpose of determining whether air enters the middle ear and to
distinguish the character of the sound produced which is of diagnostic
importance. Thus, in a normal condition of the Eustachian tubes
and tympanic cavity, air will be heard to enter the middle ear with a
soft blowing sound; if the tube be obstructed, the sound will ha ve a
more or less whistling character, while, if the obstruction is not
overcome, air will not be heard to enter the middle ear at ali and the
sound will be distant. When the middle ear contains an exudate, the
sound will vary according to the character of the fluid; if it is thin and
watery, a fine bubbling sound will be heard; if it is thick and viscid,
the sound will be a coarse bubbling one. In the presence of a perfora-
tion of the membrana tympani, inflation causes a characteristic hissing
or whistling sound and often secretion will be forced out through the
perforation into the extemal auditory canal. By the aid of a speculum,
the drum may be inspected and the effect of the inflation upon it noted
and the mobility determined.

There are three methods by which th^ 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 suffìciently strong to stpjid the strain, 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 ali 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 Method. — 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-
dìtion of the dnim 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
aural 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 fingere. 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, imder 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.

Polìtzer'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 opera tor'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.

Technic. — The patient is first given a small amount of water —
about a teaspoonful is sufficient — which he is instnicted to hold in his
mouth until told to swallow. The examiner then inserta the nose-

Fio. 347. — Instruments for Politzer'B method of inflation.
I, Head minor; ì, aura! speculai h aural stethoscope; 4, Politzer inflation 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 rìse up at the commencement of the act

Fio. 348. ^Inflation by Politzer's method,

of swallowing, the examiner compresses the air-bag with hìs right
band {Fig. 348). The act of swallowing causes the soft palate torise
upward and shut off the naso-pharynx, and, at the same time, the
Eustachian tubes tend to open so that the air is readtly 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 tumed 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 extemal 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 ina-
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

Fio. 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 deviatlons of the septum,
considerable narrowing of the nasal fossae, tumors, or adenoids, and in
nervous or hysterical individuai 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. 349). The catbeter is a metal
tube 61/2 inches (16 cm.) long, curved at its distai end, the extreme
tip of wfaìch is slightly bulbous, and wìth an expanded prozìmal end
into which the tip of a Politzer bag may be fitted. It should be of
pure Silver so that its curve may be changed to fit the individuai case.
A ring is placed upon the side of the instrument near ita proximal
end to indicate the direction of the beak. Three sizes should be pro-
vided I /25, I /12, I /8 inch (i, 2, and 3 mm.) in diameter, respectively,

Asepsls. — ^The catheter should be sterilized by boiling and the
hands of the operator should be deansed as for any operative
procedile.

Anestbesla. — In sensitive ìndìviduals the nose may be anesthetized
by means of a small amount of a 4 per cent, solution of cocain applied
by means of a cotton-tipped probe to the inferior meatus.

Technlc. — The' operator first ìnspects 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:

1. Lówenberg Method. — The proximal end of the lubricated catheter
is grasped lightly between the thumb and forefinger of the right band,
while by means of the thumb of the left band, the tip of the patient's
nose is elevated so as to straighten out the canal. The beak of the

INFLATION OF THE MIDDLE EAR. 337

instrument is then introduced within the anterìor 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
iept coTistanUy in contact with ihejloor qf the nose, it is gently pushed

Fig. 353. — Showing the diffeient postions of the beak of the catheter ii

the orìfice of the Eustachian tube. (After Bamhill and Wales.)

inwaid 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 ZAR.

the nasal septum (Fig. 352). The beak is then rotated downward and
outward through an angle ol 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 Ihus enters the Eustachian tube (Fig. 353). In ail these manipu-
latìons care should be taken to employ the greatest gentleness. The
entrante of the catheter into the tube will be recognized by the fact
that the tip is firmly fijced and cannot be rotated. The catheter is

Fio. 353. — Cathelerìdng (he Eustachian tub«. Third step, showing the poaidon of the
guide when (he catheter tip is enterìng the oKfice of the tube.

now held in place by the thumb and forefinger of the left band, the
other fingers resting upon the bridge of the nose, and, with the nozzle
of the air-bag htted into the proximal end of the catheter, infladon is
performed by compressing the bag in the fingere 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 pomts
downward and is then gently withdrawn by a reversai of the move-
ments employed in its ìnsertion.

2. Binnafoni or Kramer Melhod. — The instrument is introduced in
the same manner as described under the Lfiwenberg method until the
beak is in contact with the posterior pharyngeal wall. The beak is
then rotated outward through more than an angle of 90 d^rees which
causes its tip to rest in RosenmùUer's fossa. The catheter is then with-

THE EAS SYKINGE. 339

drawn until its tip is felt to slip over the bulgingposteriorlipof theEusta-
chian mouth when its tip will be at the pharyngeai orifice of the tube.
The distance it b necessaiy to withdraw the catheter to accomplish
this varies usually between 1/4 to 3/8 inch (6 to 9 mm.). 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 !s performed as described above.

FiG. 354. — InSatkin throiigh an Eustachian calbeter. <Gleason.)

Therapeulic Measures.
THE EAK STRINGE.

Syringing of the ear is employed fot the purpose of removing
foreign bodies or cerumenous masses from the esternai auditory canal
and to keep the ear fiee from purulent material which collects after
perforation or incision of the dram 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 ^rringe.— The syringe should be sìmple in construction and of
such material that it may be easily sterilìzed, and should ha ve a capacity
of I or 2 ounces (30 to 59 ce), It should be provided with a blunt
conica] nozzle— the ordinary olìve-shaped tip is not to be commended, as
it interferes with a free return flow. A syringe with a long-pointed

340

THE EAR.

nozzle, such as is shown in Fìg. 356 will often be found more effica-
cious in removing foreign bodies than the ordinary syringe.

For imgating the internai ear through a perforation in the attic, a

Fio. 355. — Allport's ear syringe.

smaller s)ninge, such as Blake's (Fig. 357), with a capacity of i /2 dram
(1.9 ce), provided with specially bent tips, is used. There will be

Fio. 356. — Metal ear syringe with a small nozzle.

required, in addition, suitable illumination, aural specula, and an aural
applicato!.

Fig. 357. — Blake*s tympanic syringe.

Asepsis. — ^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 EAR SYSINGE. 34I

pint (473.11 C.C.) of boiled water), a saturated solution of borie acid,
a solution of bichlorid 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. Gold solution should never be used, as it is
apt to cause vertigo or fainting,

Quantlty. — ^For the purpose of removing foreign bodies or wax, i
or 2 syringefuls of solution are usually sufficient. When syringing is
employed in cases of otorrhea, much larger quantities are necessary,
as much as 1/4101 pint (118 to 473 ce.) being required at a time.

Frequency. — Thìs will depend upon the virulenee of the ìnfection
and the amount of discharge. When the latter is very profuse,
syringing may be indicated three or four tìmes a day or oftener.

Fic. 358.— Washiog impacted cerumen from canal. Showìng how to hold aurìcle to
straighien ibe canal and where to direct the stream of water. (Gleason.)

Posltlon of Fatlent. — The patient is seated with the head held erect,
Technic. — The patient's clothing is protected by means of a towel
secuied about the neck and by having him hold a small glass basili
below the auricle to reeeive 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 extemal auditory
canal. With the righi band he then introduces the nozzle of the
syringe into the extemal 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, wìll pass along the upper wall and wash out purulent matter or

342

THE EAR.

foreign material below (Fig. 358). The solution is then injected with
only a small amount of force in suflBcient quantities for the purpose of
the operation. Should dizziness or syncope supervene, the operation
should be ìmmediately stopped.

At the completion of the syringing ali 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 extemal canal.

In cases where it is necessary to cleanse out the attic through a per-
foration, the dnim is exposed by the aid of a speculum and good illumi-
nation, and Blake's angular cannula is insetted through the perforation
under direct vision. The cavity is then carefuUy cleansed by gentle
syringing.

mSTILLATIONS.

In some cases of otorrhea where the discharge has become scanty,
the long continued use of douches often seems to keep up an irritation
and a persistence of the discharge. In these cases the instillation of
astringent solutions for the purpose of promoting healthy granulations

Fio. 359. — Instruments for tympanìc instillation.
I, Head mirror; 2, aural specula; 3, glass instillator.

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

loBtrumeats. — To instil a solution into the eztemal auditory canali
an ordinaiy glass medicine dropper tnay be employed. For tympanic
instillations a pipet glass dropper with a small curved tip, a head
mirror and illumination, and an aural speculum will be required
(Fig- 359).

Asepsis. — The instniments shouid always be sterìlized before use.

Sohitìons. — 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 shouid always be warm — at about
ioo°F.

Positìon of Patient — The patient shouid be seated with the head
bent sideways so that the affected ear lies uppermost,

Technic. — The ear is first cleansed and ali secretion or fluid re-
moved by means of a cotton-tipped probe. The operator then

Fio. 360. — Showìng nozzle of a pipet inserted for a tympanic instillation.

straightens out the extemal 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 ìn-
stils 5 to IO drops (0.30 to 0.60 ce.) of the desired solution into the audi-
tory canal. Thìs is retained for from five to ten minutes, or for a
shorter time if it causes buming or pain, and is then permitted to
escape by having the patient incline the ear downward.

In making ìntratympanic 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 are injected (Fig. 360).

344

THE BAR.

APPLICATION OF CAUSTICS.

The application of chemical caustics to the ear may be required
for the purpose of destroying granulations or small polypi. The most
frequently employed agents for this purpose are chromic acid or silver
nitrate. They are applied fused upon the tip of a delicate ear probe.
In making such applications with 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 illumination.

Instruments. — There will be required a head mirror and a source
of strong light, aural specula, a delicate aural probe, and an aural
applicator (Fig. 361).

Fio. 361. — Instruments for applying caustics to the ear.
I, Head mirror; 2, aural specula; 3, 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 otoscopie examination.

Technic. — 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 carefuUy applied to the area it is desired to destroy.

INFLATION WITH MEDICATED VAPORS. 345

HrFLATION OF THE MIDDLE EAR.

The value of ìnflation in diagnosis has been previously considered
(see page 332). As a therapeutic measure it is employed in tubai and
middle-ear disease with occlusion of the tube for the purpose of re-
storing the norma) tension between the drum membrane, o&sicles, and
the internai ear. The circuktion is thus ìmproved and hyperemia and
infiltration of the tubai and tympanic mucous membrane is diminìshed.
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 ìnflation 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,
inUation with medicated vapors is often employed to better advantage
than plain air. The vapor of drugs having either a sedative or stlmu-

Fio, 363. — Dench's vaporizer and Eustachian catheier.

lating action may be used. In this way ali 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 drag it ìs 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 ìs especially usef ul, as plain air or medicated vapor
may be obtained by simply tuming a kcy on the top of the bottle.

Asepsls.— The catheter should be sterilized by boiling before use.

Formulaiy. — Vapors of menthol, camphor, eucalyptol, iodin,
turpentine, chloroform, and ether alone or in combination are most
frequenti/ employed.

346 THE EAR.

Preparatioii of Patient, — Same as for catheterizatìon (see page 332).

Position of Patient. — Same as for catheterization (see page 332).

Technic. — The Eustachian catheter is passed by one of the methods
described on pages 336 and 338 and with ali the precautìons detailed
therein. Inflation with ah* is then performed in order to first force out
from the tube any collection of mucus or secretion and thus pennit the
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 EUSTACHIAN

TUBES.

Direct medication of the Eustachian tubes may be used to advantage
in the treatment of middle-ear catarrh for the purpose of lessening the
swelling of the mucous membrane, and to diminish secretions, thereby
rendering the tubes more permeable. Weak astringent solutions are
generally employed for this purpose, injected through an Eustachian
catheter.

Apparattis. — ^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.

Fio. 363. — Eustachian catheter and syringe for medication of the Eustachian tubes.

Asepsls. — 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
(30 C.C.), Silver nitrate 2 to 5 gr. (0.13 to o. 32 gm.) to the ounce (30C.C.),
sulphate of zinc i gr. (0.065 gm.) to the ounce (30 ce), protargol
IO to 50 per cent., bicarbonate of soda 2 to 5 gr. (0.13 to 0.32 gm.) to
the ounce (30 ce), etc, may be employed.

Quantity. — About five to ten drops (o. 30 to o. 60 ce) 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 ìnto 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 secretìon. 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 tubai obstructions
which will not yield to inflation and for the purpose of dilating tubai
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 gentìeness, as it
is a very easy matter to ìnjure the mucous membrane with the result
that, if inflation be immediately performed, air may be forced under
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, PoUtzer's inflation bag.

before inflation ìs 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 var3dng 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 ìnserted 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 catheterìzation (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 distai 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

Fio. 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
manipidaiions musi always be avoided for fear of injuring the mucous
membrane. Having successf ully overcome the obstruction, the bougie
is left in situ for five 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 effect than the plain bougie in overcoming a stenosis due to
congestion or inflammation of the mucous membrane. The medicated
bougie is introduced in the same manner as an ordinary bougie, and
should be allowed to remain in place about fifteen to twenty minutes
to obtain a prolonged action of the astringent.

MASSAGE OF THE MEMBRANA TYMPAM.

Massage of the ear-drum is performed by altemately rarefying and
condensing the air in the extemal auditory meatus. This produces

INCISION OF THE MEMBRANA TYMPANI. 349

an increased mobility in the membrana 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 ali cases an accu-
rate diagnosis is the first essential, otherwise massage may result in
harm. It should be avoided in ali 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 unafifected.

Apparattis. — ^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 timesa 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 altemately 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.

INCISION 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 déstructive changes
may ha ve 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 £AR.

cient sìze to aflford free drainage for the products of suppuratìon^
varying according to the age of the individuai, from 1/4 to 3/8 inch
(6 to 9 mm.) in length.

Instruments. — 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.

Fig. 366. — Instruments for inddng the drum membrane,
z, Head mirror; 2, aural specula; 3, angular paracentesis knife; 4, Allport*s ear syringe.

Preparations of Patient — The extemal auditory canal should be
thoroughly cleansed by syringing with warm saturated boracìc acid
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 oxid gas
or some form of locai anesthesia may be used. Locai 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:

I^. Cocain hydrochlorate
Anilin oil,
Alcohol,

gr. vi (0.4 gm.)
àà 3 i (3.75 ce.)

INCISION OF THE MEUBSANA TYMPANI. 351

A small amount of this solution is instilled into the external audìtory
canal and is allowed te remain for fìfteen minutes. It must be used
with great care if a perforation be present, as it wUI thus enter the
tympanic 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 m 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

FlG. 367. — Inci^on of Ihe membrana tympani in acute olitis media involving the lowar
portioB of Ihe lympanic cavity. (Deach.)

should only be inserted (hrough the drum membrane, so as to avoìd
injuring the inner tympanic wall which lies dìstant only 1/12 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 (he incision is carried upward through
Scrapnell's membrane. The knife is then tumed backward, and, as it
is withdrawn, the tissues of the posterior wall of the auditoiy canal are
incised down to the bone for a distance of about r/8 inch (3 mm.)
from the drum (Fig, 368). In this way tension in the tympanic vault
and mastoid is relieved.

352 THE EA2.

The ear is then carefully cleansed by syrìngìng and after being well
dried, is loosely packed with gauze.

After-treatment. — The ear shouid be syringed with a warm i to
5000 bichlorid of mercury solution as often as secretìon collects. At
first, this will necessitate syringing every two or three hours. As the
dìscharge decreases, longer intervals may elapse.

FiQ. 368. — Ind^on of the membrana (ympani in acute otitU media, involving the upper
portion of Ihe lympanic cavìiy (Dench).

CHAPTER XIII.
THE LARYNX AND TRACHEA.

Anatomie Considerations.

The Larynx is that portìon o£ 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, fif th, and sixth cervical vertebrae.
Anteriorly, it is practically subcutaneous; posteriorly, it forms part of
the anterior boundaiy of the pharynx; while on eìther side of it lie the
great vessels of the neck. Above, it is broad and triangular in shape,
while below it 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 ali, and consists of two
broad latenti 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 en trance of the lar3mx. It is
attached by its stalk to the upper and pósterior 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 p)rramidal
in shape and rest by their bases on the superior border of the cricoid

23 353

354 "^^^ LAKYMX AND TRACHEA,

cartilage. They rotate upon a vertical axìs and also move laterally.
Through these movements the vocal cords are approximated or drawa
apart.

The Interior of the Laiyitz. — The superior opening is wide and
semidrcular in front where ìt is bounded by the epiglotlis. The sìdes
are formed by the arytenoepiglottic folds of mucous membrane which
run from the sides of the epìgloltis to the tops of the arytenoid cartilages
and gradually approach posterìorly, so that the opening is narrowed

Fio. 369. — Anicrìor vìew of the laiyni. (After Deaver.)
I, Epiglottis; 1, tesser comu of hytùd bone; 3, greater coniu of hyoid bone; 4, tbyro-
h)n^d merabranei 5, thyroid cartilage; 6, cricothyroid membrane; 7, crìcoid caitilage;
8, trachea.

behind. More or less distinct nodular prominences formed by the
cuneiform and comiculate cartilages are recognized on these folds.
The cavity of the larynx extends from the superior aperture to the
lower border of the cricoid cartilage. It is divided ìnto two portions by
the vocal cords — above, into the supraglottic region, and, below, into
the subglotdc region. The vocal cords consbt of two delicate bands
of elastic tissue enclosed in thin layers of mucous membrane having a
whilish appearance. They are attached anteriorly to the thyroid
cardiage 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 chìnk, the
glottis. Above and parallel to the vocal cords are two second
folds of mucous membrane enclosing ligamentous tìssue, attached
to the thyroid cartilage in front and to the two arytenoids behind,

ANATOMY. 355

commooly called the false vocal cords. Lying between the vocal
cords and these two bands are two oblong fosss, the ventrìcles of the
laryDz.

The mucous membrane of the laiynx ìs continuous above with
that linÌDg the phaiynx, and below with that of the trachea and bron-
chi. It is of the columnax ciliated variety, excepting where ìt covers
the vocal cords and the space above the vocal cords, in which regions
it is of the stratified variety. It contains many mucous glands, espe-
cially numerous upon the epiglotds.

FiG. 370.— The inlerior of Ihe larjmi.

I, Epiglottli; 3, (hynùd carlilage; 3, veotrìcle of laryni; 4, crìc<nd cartilage; 5, false

vocal corda; 6, vocal cords; 7, ùm 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
(roto 12 cm.) long in males, and from 3 2/3 to4 1/2 inches (gto 11 cm.)
long in females. Its transverse diameter measures on an average 4/5 of
an inch (2 cm.) in maies, 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, ìt measures 1/4 of an inch (6 mm.).

The framework of the trachea is composed of from sixteen to nine-
teen rings of hyalìne cartilage, incomplete behind, each measurìng
1/12 to 1/5 of an inch (2 to 5 mm.) in breadth. The narrow space
between these rings is fiUed with an elastìc fibrous membrane which

356 THE LARYNX AND TRACHEA.

splits iiito two layers to enclose each cardlage, and also serves to com-
plete the tube posteriorly, Internally, the trachea ìs lined with a
smooth mucous membrane of the ciliated variety, continuous above
with that of the larym and below with that of the bronchi. It contains
an abundance of lymphoid tissue and mucous glands.

The trachea lies in a mass of loose fat whìch permits free motion
upward, downward, and horizontally. In its upper part it lies com-
paratively superficial, bui becomes more deeply placed as it approaches

FiG. 37T. — Anatomy of the trachea aad ìts relalioos.

the thoraz. The ìsthmus of the thyroid gland lies opposite the second
and third rings; below this the following structures will be met from
above downward; the interior thyroid veins, the arteria thyroidea ima
{if present), the stemohyoid and stemothyroid muscles, the cervical
fascia, an anastomosis of the anterìor 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 laiyngeal nerves. These
relations are important to bear in mind in performing tracheotomy.

Diagnostic Methods.

The diagnostic methods employed in connection with the laiynx
and trachea consist in (i) inspection by means of a laiyngeal mirror,
(2) direct inspection through endoscopie tubes, (3) palpation by the
probe or finger, and (4) skiagraphy.

As a preliminary to the actual locai examination, attention should
first be given to the general condition of the patient, and the history
of other affections that may ha ve a hearing 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
bome in mind that many of these symptoms are secondary to other
conditions, such as gout, diphtheria, rheumatism, diabetes, nephritis,
tuberculosis, s)rphilis, 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, extemal 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 mobili ty
or fixation of the parts during swallowing and respiration may be noted.

LARYNGOSCOPY AHD TRACHEOSCOPY.

Bythis 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 bumer covered by a Mackenzie condenser. It should be
placed upon a suitable bracket, that it may be raised or lowered to any

358

THE LARYNX AND TRACHEA.

desired height (see Fig. 282). A concave head mirror, 3 1/2 to 4
inches (9 to io cm.) in diameter with a centrai perforation for the eye;
laryngeal mirrors of three sizes, 1/2, i, and i 1/2 inches (i . 2, 2 . 5, and
3.7 cm.) in diameter, that they may be adapted to the size of the
individuai fauces; and an alcohol lamp (Fig. 372) complete the
necessary equipment.

Asepsis. — The laryngeal mirrors should be sterilized by immersion
in a I to 20 solution of carbolic acid, then rinsed oflf in sterile water and
dried before use.

Fig. 372. — ^Instruments for laiyngoscopy.
I, Laryngeal mirrors; 2, head mirror; 3, alcohol lamp.

Position of Patient and Ezaminer. — To obtain the best results, the
examination should be performed in a partially darkened room. The
patient sits in a straight-backed chair with the head raised and 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
is possible.

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 wìll be reflected in a drcle upon the mouth of the patient.

Fio. 373. — Laiyngoscopy. Firet ilep, showing the method of grasping the tongue.

The patient is then dìrected to protrude the tip of the tongue, which is
surrounded witb a piece of clean ganze or small napkin and is grasped
between the thumb and forefinger of operator's left band (Fig. 373).
Light traction is made outward and slightly upward lather than

Fio. 374. — Laryngoscopy. Second step,

downward, so as to avoìd 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 TRACHEA.

holding it a little distance over a dame for a few seconds (Fig. 374),
care Òeing iaken to test ihe temperature of ihe mìrror before introducing
it into tke ntoutk; this is determined by bringing the back of the mirror
in contact with the back of the operator's band. To introduce the

Fio. 375. — Sbowing the melhod of holding the

mirror, it shouid be held lightly between the thumb and forefinger of
the right band with its reflecting surface downward (Fig. 375), and
shouid 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

Fio. 376. — Laryi^oscopy. Third step, showìng the mirror being ìntroduced and also
the relative position of the patient and examiner EUid the position of the tight.

must be taken in perfonning this maneuver 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. Shouid this
accident occur, the mirror must be removed and suf&cient time must be

LARKNGOSCOPY AND TRACHEOSCOPY. 361

allowed to elapse for the patìent to recover hìs breath and the irritability
to subside before it ìs reìntroduced. As soon as the ìnstniment is in
proper position, the handle ìs moved to one side of the patìent's mouth
80 as to be well out of the line of vision. The mirror is then slowly
and gently tumed until a view of the base of the tongue is obtained,
and any abnormalìties of the organ are noted; it is then rotated in
such a manner that ìts face looks downward and the laiynx Ìs brought
to view (Fig. 377).

Fio. 377.— Lwyngosccfty. Fourthstep,showìng the minor in place. (J. M. Andere.)

It shouid be remembered that the laryngeal image witl be ìn-
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 lei t sides
of the laryngeal image, o£ course, correspond to the same sides of the
patient. In a normal case, the foUowing are noted: at the upper part
of the pitture, the saddle-shaped epiglottis of a yellowish color traveised
by its pink blood-vessels; extending backward across the mirror back
of the epiglottis are a pair of pearly-white bands, the vocal cords;
parallel to the vocal cords, but lying anteriorly and outside, are a
second pair of bands with a reddlsh bue, the ventricular bands, or
false vocal cords; between the vocal cords and the ventricular bands

362 THE LARYNX AND TRACHEA.

may be observed the ventricles of the larynx, brought into better view if
the head is tilted to the side; where the vocal corda terminate at the
lower part of the image are to be seeti the arytenoid cartilages, and
between them the interarytenoid space; extending from either side of
this notch to join theepiglotds are the aryepiglottic folds, with the two
prominences marking the site of the cartilages of Wrisberg and San-

Fio. 378. Fio. 379.

Fio. 378. — The laryngoscopic image. 1, Efùglotds; 3, false vocaJ corda; 3, vocal
corda; 4, glossoepiglottic fossa; 5, interarylenoid space; 6, cartilage of Santoilnl
and the locatiOD ot the uytenoid cartilage; 7, cartilage of Wrisbeig.

Fio. 379.— The Urynx during gentle respiration.

tonni, the latter lyìng on top of the arytenoid cartilages; on either side
of the image will be noted the glossoepiglottic foss».

To make a complete examination, the larynx should be inspected
during quiet respiration, deep respiration, and phonadon. Durìng
respiration the vocal cords are seen to move with each ezpiration to-
ward the median line, and away from the median line with inspiratìon

Fio. 380.— The laryni in phonation. Fio. 381.— The larynx during deep respiration.

(F'g- 379)- By requesting the patient to say "ee" or "he," a view is
obtained of the larynx with the cords almost in appositìon and the
interarytenoid space obliterated (Fig. 380). During deep respiration
the cords are widely separated, and a view is obtained of the anterior
Wall of the region below the vocal cords (Fig. 381). There will be

LARYNGOSCOPY ANP 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 ìnto 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
diflferent 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, hearing in mmd that if cocain has been employed
the parts will appear anemie, 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 disio-
cations of the arytenoid cartilages, etc. Finally, the condition and
mobili^ of the vocal cords during respiration and phonation are
observed. They should approximate sjrmmetrically 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 ìnspection before the whole examination is completed in a
satisfactory manner.

Difficultìes 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, ali 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 ovai mirror should be substituted. A large pendulous epiglottis

364 THE LARYNX AND TRACHEA.

is not infrequently a cause of diflSculty. By placing the mirror dose
to the posterior pharyngeal wall and holding it more nearly vertical
than usuai, with the patient's head thrown back, a better view may of ten
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 f orward, 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 usuai way. If carefully and gently
performed, a satisfactory examination may often be made even upon
unruly children.

DIRECT LARYHGOSCOPY.

The lar3aix 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 imder direct vision. The method may
be employed in young children in whom ordinary laryngoscopy is diflS-
cult, and it may also be performed upon a patient under general anes-
thesia. It is, however, more imcomfortable for the conscious patient
than ordinary laryngoscopy.

DIEECT LABYNGOSCOPy. 365

Instniments. — A tubular spatula, self-ÌUumìnated, such asjackson's
(Fìg. 382), or with the illumination fumished from an electtic head light,
as Kitlian's, is generally employed. Kirstein uses a tongue depressor
of spedai shape (Fig. 383) and an electric head light (Fig. 384). In
addition a mouth-gag and a Sajous applica tor are required (Fig. 385).

Fio. jSj. — Kirstein's tongue depresaot.

Asepsis. — The tubes and tongue depressor may be boiled, while
the light-carrying apparatus in the self-ÌUumìnating tube is sterìlized
by immersion in alcohol.

PositiOD 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

Fig. 384.— KJrstdn's head light.

raised and thrown back so that a direct view from above downward is
possible. An assistant stands or sìts 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 applica tor.
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 foUow the preliminary cocainization. In young
children the examination may be carried out under general anesthesia*

Fio, 385. — Sajous* applicator and moutfa-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 Ut 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 laiynx by looking down the tube.
The arytenoid cartilages, vocal cords, interior of the lar3mx, and por-
tions of the trachea may thus be viewed in detail. The points espe-
cially to be noted in such examination ha ve already been referred to
under laryngoscopy. By the aid of these tubes, applications may

DIRECT TRACHEO-BRONCHOSCOPY.

367

also be inade, 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
behind the tongue until ìts 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.)
(i, Electric cord supplpng lamp of speculums h, conduit for light carrying tube; e,
shows the tip of the tube holding the epiglottis forward; d, conduit for removingsecretions,
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 endoscopie 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-

368 THE LARYNX AND TRACHEA.

tìon from an electric head light. This operation is designateci respect-
ively as ** upper direct tracheo-bronctioscopy, " and "lower direct
tracheo-bronchoscopy." In this country, Chevalier Jackson has
perfeeted similar tubes, in which, however, the illumination is sup-
plied by a small electric light at the end of the instrument.

The bronchoscope is employed both for diagnostic and ther-
apeutic purposes, and is of especial value in locating and removing
foreign bodies and growths from the air passages, or in making direct
applications to ulcers and other lesions in the trachea and bronchi.
Marvelous results have been obtained by those expert in the use of
these instruments, and foreign bodies have been frequently removed
from the bronchi of patients upon whom thoracotomy would otherwise
have been required. The use of the bronchoscope, however, requires
such skill and practice as to be only of service in the hands of an ac-
complished specialist. In unskUled hands il becomes a dangerous
instrument.

Tracheo-bronchoscopy through a tracheotomy wound is the simpler
of the two methods, and, as larger tubes may be employed than in the
upper operation, it is often of value for the removal of foreign bodies
too large to be extracted by upper tracheo-bronchoscopy. Upper
tracheo-bronchoscopy, however, should be the operation of choice
when possible.

ISL

■ in ■■£ ,1» fF-Kgr ,l.r ^^jp

Fio. 387. — Killian's bronchoscope.

Instruments. — The tubes employed are of rigid metal highly
polished intemally, somewhat similar to the endoscopie tubes employed
in the urethra. They vary in size according to the age of the patient
and the part of the air passages to be explored. Only the smallest
sized tubes should be used for the bronchi. Jackson employes for
lower tracheo-bronchoscopy a tube 1/3 inch (8 mm.) in diameter
by 8 inches (20 cm.) long for adults, and one 1/5 inch (5 mm.) in
diameter by 5 1/2 inches (14 cm.) long for children; and for upper
tracheo-bronchoscopy a tube 7/25 inch (7 mm.) in diameter by 18

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 instnunents (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 Killian '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 laiyngoscopy, 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 applica tor, variously shaped forceps, applica tors 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

370 THE LARYNX AND TRACHEA.

(see page 394) are required. The operator shouid also be provided
with a number of extra lamps to replace those that may bum out,
Asepsis. — Strict asepsis in ali details is absolutely necessary. The

FiG. 390. — Jackson's separable speculum tor pas^ng the bronchoscope. The handle,

ab, [or use when the patient is in a ^tting posture; e shows the arrangement of the lamp

at the disiai end.

tubes and accessory Instruments are boiied, the lighting apparatus is
sterilìzed by immersion in alcohol or in a i to 20 carbolic acid solution
foUowed by rinsing in alcohol, and the rubber-covered battery cords
are wiped off with bichlorid solution. The tiands of the operator

FiG. jgi.— Accessory

for trachco-bronchoscopy.

and assistants shouid be as thoroughly cleansed as for any operation.
On account of the danger of scpsis from the mouth, the patient 's
teeth shouid be brushed and the mouth well cleansed with an antiseptic
wash before passing the instruments. A tube employed in the upper

DIRECT TRACHEO-BRONCHOSCOPV. 371

operation shouid not be used for lower bronchoscopy without
resterilization,

PreparatioD of the Patìeot. — If general anesthesia ìs to be employed,
the patient should be prepared according to the usuai 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,
foUowed by a 1 to 2000 bìchlorid of mercury solution.

Fio. 39».^The position of the patìenl and Ihe assistant toc upper tracheo-bronchoscopy.
(Ader Jackson.)

Position of the Patient — If done under locai 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 jms&ible and the tongue projecied forward. An
assistant holds the head from behind and steadies the mouth-gag,
while the operator stands in front. When a general anesthelic is
employed, and in ali cases of lower bronchoscopy, the patient should
be in the dorsal posìlion on a table, the front of which is slightiy eie-
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.

372

THE LARYNX AND TRACHEA.

Anesthesia. — In children, general anesthesia is necessary. In
adults, preliminary cocainization of the pharynx and larynx with a 4
per cent, solution of cocain, followed by a 20 per cent, solution of
cocain, applied to the larynx and trachea is in most cases sufficient,
unless the patient is very excitable, although general anesthesia
renders the operation easier in any case. Whichever is used, cocain
should be applied by means of cotton applicators to the larynx and
trachea before the introduction of the tube, to avoid dangerous reflexes
from stimulation of the endings of the superior laryngeal nerve.

Technic. — i. Upper Tracheo-bronchoscopy, — With the patient in the
proper position, and the parts cocainìzed, the mouth is widely opened

J£/WtABl£ SncUKMttll/pìOStTmf

MONCmxoM^mstp TMmatJiMMBii smuum.

9UD£ W ZPiCuwM Rimilo ScfMMste ynvtuM/tcnotyefiiuiftmieMiiKmMt/ifiMMtmot/.

FiG. 393. — Showing the varìous steps in upper bronchoscopy. (After Jackson.)

and the mouth-gag is inserted and given to the assistant to maintain in
position. The larynx and vocal cords are exposed by mtroducing a
split tube spatula, as for direct laryngoscopy .(page 366). The bron-
choscope, well lubrica ted with sterile vaselin, and with the illumi-
nation properly tumed on, is then passed through the split tube as far as
the epiglottis under the guidance of the opera tor's eye. The operator
notes the vocal cords and instructs the patient to breathe deeply, andj
while the cords are open during inspiration, the instrument is gently

DIRECT TRACHEO-BRONCHOSCOPY.

373

passed through the glottìs until it enters the trachea. The split tube
is then separateci and removed. As the bronchoscope is advanced,
the mucous membrane in front should be anesthetized by means of a
20 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 rìght bronchus, the instrument should be tumed
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

^y-i •

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 ali the bleeding has been
controlied, a Troussea\i 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 illumina tion tumed 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 LARYNX AND TRACHEA.

manipulation. The patient's head is tumed sideways, and, if the right
bronchus is to be entered, the tube is inserted on the left side of the
head; if the left bronchus is to be examined, the tube is inserted at
the right side of the head. The bronchi shouid be cocainized, as before,
in advance of the instrument with cocain applied upon long applicators
through the instrument, and the examination proceeded with as above.
The after-treatment of the patient consists in inserting a tracheot-
omy tube which is wom for several days. After the removal of this
tube, the wound shouid be carefuUy protected 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 consistency
and extent of new growths, the depth and size of ulcerations, the

Fio. 395. — Instruments for probing the larynx.
I, Laryngeal probe; 2, laiyngeal mirror; 3, alcohol lamp; 4, head mirror.

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 shouid 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 oflf in sterile water and dried before use.

Position of Patìent. — The patient is in the same position as for ordi-
nary laryngoscopy.

Anestbesia. — ^The larynx should be cocainized by spraying or by
the application of a io per cent, solution of cocain.

Technic. — The tongue is protruded and held by the patient with a
cloth, and theiaryngeal 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 tumed 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
naturai 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 lar}aigeal spray is employed for the purpose of cleansing and
for medication. Cleansing of the larynx is frequently required for

370 THE LARYNX AND TRACHEA.

the removal of purulent secretions the result of syphilitic or tubercular
ulcerations, and to soften and wash away the crusts which are often
an accompaniment of fetid laryngitis. Whenever possible, spraying
of the larjoix should be done by the surgeon himself, as it can thus
be performed by the aid of direct vision in a thorough manner. K this
is not possible, the patient must be very carefully instructed in the use
of the instrument.

Medication of the larynx may be required in the treatment of acute
and chronic infiamma tions, ulcerations, etc, and according to the
indications of the individuai case, remedies with an antiseptic, astrin-
gent, sedative, stimulating, or caustic action are employed. These
may be used in the form of watery or oily solutions. The great
sensitiveness of the laryngeal mucous membrane should be kept in
mind in making any topical application, and the use of very irritating
drugs should be avoided.

Instruments. — It is important to select a spray that will not expel
the solution in such a powerful 6tream as to produce irritation and
possibly add to the locai inflammation. The Davidson, the Whitall
Tatum (see Fig. 308), and the De Vilbiss atomizers (see Fig. 309) are
simple and very efficient instruments. They should be provided with
a laryngeal nozzle, which tums downward. The air current may be
supplied by a rubber compression bulb or by means of a compressed-
air appara tus (see Fig. 301).

A head mirror, a laryngeal mirror, and proper illumination 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 formulae 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.

Anestbesia. — When the parts are very sensitive, preliminary spray-
ing with a IO per cent, solution of cocain may be required.

Technic. — The patient is directed to open bis 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 into the
mouth, and with the aid of the mirror passes it behind the epiglottis and

THE DIRECT APPUCATION OF REMEDIES. 377

depresses the tìp 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 shouid be repeated
several times until the larynx is well washed out. Each time the patient
coughs, mucus, purulent secretion, and crusts, which ha ve been sof tened
and separated by the spray, will be expelled.

When the spra)àng 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-
ploying oily preparations, the patient shouid 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 shouid be fused on a probe. The application shouid
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
shouid be taken that the cotton is wrapped tightly about the end of the
instrument, so that there is no danger of its falling oflf 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.

Anestbesia. — The parts shouid be anesthetized by means of a
IO per cent, solution of cocain applied by means of a spray or on a
cotton applicator.

378 THE LARVNX AND TRACHEA.

Technic. — The laryngeal mirror ìs wanned and introduced hy
the operator's left hand, so as to obtain a. clear view of the parts to be
medicated. li secretion or mucus be present, the parts should be first

FlG. 396. — Method of inserting kryngeal applicator.

Fio. 397. — Sbows the metbod of making direct applications to the larynz by the aid of the

Uryngeal mirror.

cleansed by spraying. The applicator is then djpped in the solution
to be applied, and any excess o/fiuid is removed to prevent it from
runnìng into the trachea. This precautìon is especially necessaiy when

INSUFFLATIONS.

379

using strong solutions or caustics. The instrument, held in the opera-
tor's right hand, is then mtroduced into the mouth, with the curved
surface held first horizontally (Fig. 396), and then, as soon as the tip
of the instrument reaches the pharynx, tumed 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
excess of acid being immediately neutralized by the application of a
solution of bicarbonate of soda, gr. xxx (1.95 gm.) to the ounce
(30 ce). A dusting powder may finally be applied to the cauterized

area.

INSUFFLATIONS.

Powders may be applied to the larjoix by means of a special in-
sufflato!. They are of use chiefly in cases of ulceration, where a seda-
tive or antiseptic action is desired. A combination of nosophen,

Z I

Fio. 398. — Instruments for applying powders to the larynx.
I. Powder blower; 2, laryngeal mirror; 3, alcohol lamp; 4, head mirror.

aristol, europhen, iodoform, etc, with finely powdered starch, stearate
of zinc, or powdered acacia as a base, are usually employed in the pro-
portion of one part of the active principle to two parts of the base.

380 THE LARYNX AND TRACHEA.

Small amounts of morphin or cocain may also be combined with 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 insuflSator shown in Fig. 398 is very convenient, as with it the
amount of powder may be accurately measured, and the instrument
may be manipulated with one hand.

Technic. — ^The laryngeal 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 laiynx 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.

STEAM nmALATIONS.

By means of steam inhalations the active principle of certain drugs
that are readily volatilized by heat may be brought into contact with
the mucous membrane of the respiratory tract and carried beyond the
larynx to the trachea and bronchi. The efiFect of the steam itself is
also valuable, for it acts as an anodyne upon inflamed mucous mem-
branes by supplying moisture and so relieving the heat and drjoiess 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 kettle with a long spout, such as
shown in Fig. 399, is most convenient. For direct inhalation, more
or less elaborate forms of apparatus are manufactured (Fig. 400), but
a coflfee-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 ones
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 ce);
creosote, 5 to io rq^ (0.30 to 0.60 ce.) to the pint (473.11 ce);

STEAM INHALATIONS.

381

FiG. 399.— Croup kettle.

FiG, 401. — Sleara inhaler impTO-
vtaed from a coffee- poi.

38a THE LABYNX AND TRACHEA.

ol. cubebe, 5 tr^ (0.30 ce.) to the pint (473.11 ce); spirìts cam-
phori, 5 ni (0.30 C.C.) to the pint (473-11 c.c); ol. pinus sylvestris,
5 'n, (0-30 C-C.) to the pint {473.11 ce), etc

Temperature. — When directly inhaied, the vapor should not be of a
higher temperature than 150° F. If used at too high a temperature,
ìrritation of the mucous membrane may be produced and there is
danger of the steam scalding the face.

Technic. — Into an inhaler a pint {473.11 ce.) of nearly boìling
water is placed and the proper quantity of the drug is added. The

Fio. 403.— Crib arraoged for sleam inhalatioos. (After Kerley.)

patìent then places his nose over the cone and inhales the escaping
vapor, taking about six to eight breaths a minute. The inhalation
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.,
and care should be taken to protect the patient from draughts. As
the steam relaxes the mucous membrane and renders the paiient
susceptible to cold, he should not be allowed out of doors for several
hours aftenvard.

In using the croup kettle, the steam may be delivered into the room
or directly over the patient. When the latter method is used, it is
well lo cover the bed of the j)atient with a sheet arranged in the form
of a tent and raised sufficiently high to permit a free circulation of air.

DRY INHALATIONS. 383

the Dozzle of the croup kettle being inserted under one side of the tent
and the water kept boiling (Fig. 402).

DRY raHALATIORS.

These are useful m diseases of the upper respiratory tract for those
who cannot tolerate the steara ìnhalations. The method has an
advantage over steam ìnhalations in that the patìent does not have to
lemain in the house afterward.

The Inbaler. — A special mask made of woven metal, which accu-
rateiy fits the mouth and which is provided with a sponge upon which
the medication is dropped, is employed (Fig. 403).

FlG. 403. — Inhalation mask.

Fonnulaiy. — Any of the very volatile oils, such as thymoi, menthol,
eucalyptol, etc, may be employed.

Technic. — Twenty or thirty drops (1.20 to 1.80 ce.) of the oil are
pkced 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
neck. The patient inhales through the mask by means of the mouth,
and exhales through the nose. The mask may be wom for about half
an hour two or three times a day,

IMTOBATIon or THE LARYMX.

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 pordon of the trachea. It is an operation which
gives prompt relief without the necessily of cutting and without pro-
ducing any loss of blood or shock. It is less terrifying to the patient

384 THE LARYNX 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. Special instruments, however, are necessary, and
the feeding of the patient is often troublesome and, while not a di£5-
cult operation in itself, ìt requires special training for its skilful per-
formance which is best leamed by practice upon the cadaver.

Indicatìons. — The operation was originally de\ised for the relief
of obstruction to respiration in cases of laryngeal diphtheria and
has now almost entirely supplanted tracheotomy in such cases. The
immediate indications are dyspnea accompanied by cyanosis, depres-

FlG. 404. — O'Dwyer [nlubation inslnimenls,

r, Tube wUh obturalor in place; 3, tube and obluralor separateti; 3, gaugc; 4, moulh

gag; 5, inCroducer; ó, ^1k thread; 7, exlraclor.

sion of the suprasternal and supraclavìcular spaces on inspb-ation,
and sinking in of the lower portion of the chest. Intubation is also
employed in laryngeal stenosis frora other causes for the purpose of
producing graduai dilatation of the parts, progressively increasing
sizes of tubes being introduced and wom for a few days at a time.

Instruments. — The instruments required are an O'Dwyer intuba-
tion set including seven metal or hard-nibber 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 ihese instru-

INTUBATION OF THE LARYNX. 38$

ments ha ve been modified and attempts have been made to improve
upon them, those originally designed by O'Dwyer give the best results.

The intubatìon 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 ovai. 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 engagé the tube with sufl&cient 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

THE LABYNX AND TRACHEA.

way as much as possible. The operator then takes the ìntroducer
with the tube attached in hìs right hand, holding it as follows: The
thumb pressed against the button on the upper side of the handle, the
jndei-finger around the hook on the und^ surface of the instrument,

Fio. 405. — Poaition of chìld for intubalion and method of hokUng.

Fio. 406. — Intubalion. Firei slep, showing the method of drawing Ihe epigloltis 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).

INTUBAnON OF THE LASYNX. 387

When the eod of the tube reaches the epiglottis (Fig, 409), the handle
is sharply elevated, so that the tube is brought into a vertical posìtion
(Fig. 410). If the haadle of the instrument is not suffideatly elevated,

the tube will point toward the entrance of the esophagus which it wìll
beapt to enter during thenezt maneuvers (Fig. 411). At the same time
the finger of the operator is moved to the posterior portion of the
laryiuE, resting on the arytenoid cartilages to prevent the tube from

Fio. 408. — Inlubalion. Second step, inlroducing Ihe tube inlo the paliem's tnouth.

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 shouid be used.

THE LARYNX AND TRACHEA.

As soon as the tube is in proper position, the operator's forefinger
is placed on its head holding it in place while the button on the handle
of the instrument is pushed forward, thus disengaging the obturator
from the tube (Fig. 412), The intubator with the obturator attached

Fio. 409.— Third step in inlubation. Fio. 410-— Fourth step in inlubation.

is then removed, and the tube is pushed well info the larynx by the
finger (Fig. 413). Not more than five to ten seconda shouid 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 operation

Fio, 411. — Showìng afaulty position of Fio. 411. — Fifth slep in inlubation,

the tube, due to the handle of the intro- withdiavring the introducer while Ihe
ducer not brìng raised suffidently high. ind«x-&nger holds the tube ìd place.

should be suspended and a second attempi made after allowing the
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 quickly
relieved. After the tube is in position, it is well to wait for ten or

INTUBATION 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 laiynx, the
mouth gag is reinserted, and one strand of silk is cut near the angle of
the mouth, and the string is wilhdiawn, the forefinger being placed on

Fio. 413. — Sixth step in intubatìon, Fio. 414. — Showiog the inlubation

showing the indez-finger pushing the tube tube in place.

well into the [aiynz.

the tube to maintain it in position (Fig. 415). Some operators prefer
to leave the string attached lor the removal of the tube in case of
sudden emergency. If this is done, the string should be brought cut
the corner of the mouth, hooked over the ear, and secured by adhesive

Fio, 415. — Final step in inlubation, removing the string from the tube.

plaster. This method has the disadvantage, however, of fumishing 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 mbtake, 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 shorten as the
tube passes down the esophagus. In such a case, the tube shouid be
removed by pulling on the string, and, after waiting a sufl&cient time
for the patient to recover from the excitement attending the operation,
it shouid be reintroduced.

In some mstances, the tube may become occluded by pushing the
false membrane ahead of it. If this occurs, the tube shouid be removed
at once, and, if the obstructing membrane is not expelled from the
larynx and cannot be extracted and sufiFocation seems imminent,

FiG. 416. — Method of feeding an intubatìon patient with the head lowered.

tracheotomy shouid be performed. Care shouid be taken not to
select too 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 the patients are only able to take liquìd or, at most, semisolid food.
As a mie, 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, suffident food may
be administered in this way (Fig. 416) ; or food may be administered

INTUBATION OF THE LAEYNX. 39I

by having the patient suck up the food through a tube whìle 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
calheter 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 wìth
the above if indicated.

When to Remove the Tube. — The tube shouid always be removed as
soon as possible, as ìts 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 padent, being left in for longer intervals in

Fio. 417. — Eiiubation.

very young children. If the tube becomes occluded at any tirae, it
must be removed without delay, cleaned, and then reintroduced.
When the tube is to be perraanently removed, the physicìan, after
extracting it, shouid wait sufficiendy long to see that respiradon does
not become impeded and necessitate its reintroductìon.

Technic of Extubatìon. — The padent is placed and held in the
same posidon as for introduction of the tube. The mouth gag is
ìnserted, and the operator passes his left index-fìnger into the mouth
and over the epiglottis until it rests on the head of the tube. The
extubator, held in the ojierator's right hand, is then introduced with
its Jaws dosed, by the same maneuvers employed in introducmg the
intubator, untìi 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 separateci 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 reversai 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 iorward, 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 stemum and thyroid
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 pomt.

Indications. — Opening into the air-passages is indicated for the
relief of obstructive dyspnea, which may be the result of any one of
the foUowing conditions: The forma tion of pseudomembrane; the
presence of foreign bodies; the presence of growths within the larynx
or trachea or extemal 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 mie, 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 ànd lower
tracheo-bronchoscopy.

Choice of Operation. — The choice between laryngototoy, high

TRACHEOTOMY. 393

tracheotomy, and low tracheotomy depends upon the seat of the
obstruction and also upon the age of the patient and the necessity for
baste. Of the thiee, 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 instrumenls and assbtants are lacking. It is not,
however, a suitable operation to be performed upon those under
thirteen years of age, on account of the small size of the cricoth)'roid
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 prozimity
of the vocal cords and their liabili^ to injury by the tube.

Fio. 418. — Thelocalionof IheincLsionsinlaiyngotomjrandtracheolomy. (After Bickham.)
a, Thyroid cartilage; 6, ìncision for laryngQtomy; e and *, branches of superior thjroid
arterìes; d, cricoid cartilage;/, inci^on for bigh tracheotomy; g, thyroid giand; h, incìsion
for low tracheotomy; i, pneumogastrìc nerve; j, stemo-mastoid muscle; A, infeiior thyroid
veins; /, sUmo-thyroid muscle.

On account of the small number of important vessels encountered,
and the greater case 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

394

THE LARYNX AND TRACHEA.

the thyroid, etc. It requires more skill in its performance than does
the high operation, as in the lower portion of the neck the trachea is
more deeply placed and important structures at the root of the neck
are in dose proximity.

Inetnunents. — The instruments that should be provided include:
a scalpel, a narrow bistoury, sdssors, two sharp retractors, two ten-
acula, artery clamps, two paìr of thumb forceps, tracheal forceps, a
Trousseau tracheal dilator, a flexible-nibber catheter, tracheotomy

FiG. 4i9.^In5lruments for tracheolomy.
I, Scalpel; a, curved bisiouiyij, scis5ors;4, retractors; 5, tcnaculum; 6, artery clamps;
7, thumb forceps; 8, needle-holder; g, Truusseau tracheal dilator; io, tracheotomy tube;
II, catheter; 11, trachea! forceps; 13, needles; 14, No. i catgut.

tubes and tape, a needle-holder, two curved cutting-edge needies, 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 hairpìns bent
in the shape of a hook to hold the trachea open until the proper tube
can be obtained.

Tracheotomy tubes of several sizes and with different curves should
be provided so that one suitable for the individuai case may be at band.
A Silver tube, somewhat flattened from side to side, without fenestrìe,

T8ACHE0T0MY. , 395

and witb 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 from two to tour, a No. 3; and
for one over four, a No. 4. In an emergency a tube may be improvised

Fig. 410. — Tracheolomy Fio. 431. — Tracheotomy tube improvised

tube (enlarged). from nibber 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. 4ia. — Position o£ patient tor laryngotomy and tracheotomy.

placed in a strong lìght on a firm fiat table with a cushion under his
shoulders, thus allowing the head to bang 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 bang 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, locai anesthesia with cocain is suflScient.
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
baste 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, locai 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 ali, chlorofonn
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 band, 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 stemohyoid and stemothyroid muscles
are separated at their inner borders and held apart by retractors.
The connective tissue and veins underlying these structures are then
separated, ali veins being clamped or ligated before division. The
cricothyroid membrane is thus brought into view. 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 ghould 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 tube may

TEACHEOTOMY. 397

be pushed in between the two structures and not into the larynx at
ali. The wound is held apart with two small retractors or a tracheal
dilator, and the foreign body which may be causing the obstruction
is removed by means of tracheal forceps. If there is not sufficient
room to remove the foreign body through this incision, the cricoid
cartilage may be cut. The laryngotomy tube is then carefully intro-
duced and is secured in place by tapes passìng around the patient's neck,
a small square pad, split to its center, being interpgsed between the
skin and the flange of the tube. A stitch or two may be placed at the

Fio. 433. — Opening the ciicolhyroid metnbnine in laryngotomy. (After Bickham.)

upper and lower angles of the wound to brìng 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 tìme 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 foreflnger of the left band, 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 ezactly in the median line, extending from the cricoid
cartilage to a little below the isthmus of the thyroid gland (Fig. 4^4).
The skin and superfìcial and deep fascia are incised, and the anterior
jugular veins which are encountered in the upper part of the incision,
together with any communicatJng branches of the superior thyroid
veins, are caught in forceps and ligated. The stemohyoid and sterno-
tbyroid muscles are thus exposed, and should be separated along their

398 THE LARYNX AND TRACHEA.

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 thea divided from the
lower border of the cricoid cartìlage by a transverse incision curved
downward at the extremities. The fascia is 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 th)Toid isthmus
is very large, two ligatures may be placed about it, on each side of
the median line, to control the hemorrhage, and the isthmus with the
deep fascia is indsed vertically aad retracted to each side. A tenacu-

FiG. 434. — Exposing the trachea ia high tracheototay.

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 curved needle, threaded with fairly
strong silk, is passed on each side through the membrane below the
ring to be cut, emerging through the membrane above. A sbarp
narrow bistoury, with ìts cutting edge up, is inserted through the mem-
brane below the second ring of the trachea, and the latter is incised in
the median line as far up as the cricoid cartilage, care being taken lo
include the mucous membrane of the trachea in this incision (Fig, 425).
The edges of the tracbcal opening are separatcd with trachea) forceps,
or the wound is held open by the retraction sutmes, if they were pre-
vìously inserted, and the tracheotomy tube, with its cannula, is

TRACHEOTOMY.

Fio. 425. — Opening the trachea in high tracheotomj. (After Bickliam.)

FiG. 42Ó. — Melhod of mserting the Iracheotomy tube.

400 THE LARYNX AND TRACHEA.

carefuHy passed through the open wound into the trachea (Fig. 426).
If there is no great urgency, ali 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
amount 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-
cheal 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 ìncision is carried from
the thyroid cartilage to within 1/2 inch (i cm.) of the stemal notch.
The skin and superficial and deep fascia, are indsed, and the inferior
thyroid veins, or other vessels that may be in the way, are ligated and
divided. The stemohyoid and stemothyroid 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
stemal 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 bistomy. The edges of the tracheal
wound are then retracted, and the tube is inserted and secured in place
as previously described.

DifScultìes 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 naturai breathing soon recommences; if it should
not, simple pressure on the stemum 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 coUect 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
a6

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
laiynx with the tracheal wound closed. Thìs 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 wom 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.)

Complicatìons. — Broncho-pneumonia is a common complication
even when not due to an extension of the diphtheritic process. Infec-
tion of the wound may foUow 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 latenti 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 ESOPEÀGUS.

Anatomie Considerations.

The esophagus extends from the lower border of the cricoid cartilage
to about the level of the ensiform cartilage or, m 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 io 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 spinai column." Laterally, it has the foUowing curves:
from its starting point it tums slightly to the left, projecting as much as
1/2 inch (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, fijially 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 spinai column and the thoracic duct; about 3
inches (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 ha ve been described,
the most marked being as follows: (i) at its commencement, 6
inches (15 cm.) from the incisor teeth; (2) at a point io 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 ESOPHAGDS.

Diagnosttc Melhods.

The raethods available for examination of the esophagus include;

(i) auscultation, (2) percussion, (3) extemal palpation, (4) instrumentai

examination, (5) inspection through the esophagoscope, and (5) the

use of the X-rays. The first ihree of Ihese methods are of very limited

Fic. 4»g. — The course and relations of the esophagus vicwed from behind.
FiG. 430. — The normal narrowings of Ihe esophagus. (Eisendrath.) j, At ils junc-
tion wilh Ihe phatynx; 3, opposite the bifurcation o[ the bronchi; 3, at the djaphragm.

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
ha ve to rely upon the use of bougies and sounds or the X-rays,

As in examination of other regions, a careful hìstory of the case
should precede.any locai 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 usuai
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 pòint 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.

Extemal 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
tendemess 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 internai palpation with the index-finger, foreign bodies lodged
in the en trance 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 difficult. 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 are already weakened by disease.
Before any attempt is made to pass instruments, a thorough phys-
ical examination — including the vascular S3rstem — 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 pulmonaiy 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 à houle 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. — Oli vary bougies à houle for the esophagus.

The bougie à houle 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 ivory olive-shaped tips of different sizes
may be screwed (Fig. 433). The shaft should be marked oflf in an
inch or centimetric scale.

In cases of very tight stricture filiform bougies of whalebone or

EXAMINATION BY SODNDS AND BOUGIES. 407

woven material may be employed to delermine whether ihe stricture
is at ali permeable. 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,

Asepsis. — Rubber bougies and tubes may be sterilized by boiling.
The gum-elastic instruments, unless of the very best material, are
ruined by boiling or by the use of strong antiseptics. They may be
rendered sufficientty aseptìc by immersion in a saturated solution of
boracic acid, after first thoroughly washing with soap and water. The
hands of the operator should also be clean.

Positìon. — The patient is seated in a chair with the head thrown
back against the back of the chair, and with ihe chin raised suflBciently
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. 4J4. — Shoirs the fiist step in introducing an esophageal bou(pe.

case of a child, it will be necessary to confine its arms, either baving
them held by a nurse or by including them in a sheet wrapped about
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 sen-
sitive, may be brushed over wilh a 5 or io 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 ^■omitus 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 band as one wou!d
a pen, is passed into the patient's open tnouth 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

Fio. 435. — Introduciion of an esophageal bougie wiih the finger holding Ihe longue and
epigloltis forward.

encountered in entering the esophageal opening. Under such con-
ditions the operator passes the index-finger of his left band into the
patient's widely opcned mouth to a point well back of the tongue and
draws the lalter forward, and with it the iaiynx, so that the esophagus
may be more easily entered (Fig. 435). The bougie is then passed
on the finger as a guide straight back in the median line to the pharynx,
and, hugging the posterior wall of the pharynx, it is pushed sleadily,
but gently, backward and downward into the esophagus, and thence
into the stomach, uniess some obstruction be encountered.

EXAUINATION BY SOUNDS AND BOUGIES, 409

The patient shouid be instructed to breathe deeply during the pass-
age of the bougie, even if gagging is produced, and he shouid be
cauiioned not to bite the examìner's finger or the tube. There will
usually be gagging and some attempts to vomit as the tube is inserted,
but, uniess very distressing, thcy may be dìsregarded. The patient 's
head, however, shouid be bent forward over a basin as soon as the
tube is well within the esophagus to receive any vomitus, mucus, or
saliva (Fig. 436).

If dyspnea and cough are ìnduced, the instrument has probably
entered the larynx, To settle this point, the patient shouid be told to

Fio. 436. — Shows tbe seeond atep in inirodudng an esophagea! boupe.

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 shouid be slightiy withdrawn and then again pushed gently on-
ward, when, uniess a stenosis exists, it will advance without difficulty.
The points of normal constriction al which a bougie may be arrested
without any diseased condilion being present shouid, however, be
kept in mind. They are: (i) 6 inches (15 cm.) from the upper incìsor
leeth; (2) io inches (25 cm.) from the incisors; and (3) 16 inches
(40 cm.) from the incisors (see Fig, 430). If a large tube can bc
passed into the stomach, the existence of a stenosis may be ruled out,
while if the tube [>asses very easìly wilhout any sense of resislancc,
atony or paralysis of the canal is presumable.

Any evidences of pain, however, produced by the bougie in its
descent shouid be carefully notcd, as poinling Io possiblc ìnflammatlon,
ulceration, or malignancy. When the bougie meels a rcal obstruction

4IO THE ESOPHAGUS.

the cause shouid, if possible, be learoed; Chat is, whether due to
spasm, an organic stricture, a diverticulum, a new growth, or a foreign
body. No force shouid be employed in attempting to overcome the
obstruction, but the bougie shouid 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 relaxatìon takes place. A spasmodic
stricture will always disappear if the patient is placed under the influ-
ence of a general anesthetic. If the obstruction does not yield, the

FiG. 437. Fio. 438.

Fic. 437. — Method of eslimating the length of an eaophagcal stricture. The bougie à
boQle ai the tace of the sf-

boQle ai the tace of the sirìclure.

Fro. 438. — Method of estìmating the lenglh of an esophageal atriciurc. The bougie ì,
boule is withdrawn until its base is arrested at the distai end crf the stricture.

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 important in
making this examination to irisert the bougie into the stomach, as,
olherwise, a second stricture below the first may be overlooked.

To determine the length of a stricture, a large olive-tipped sound
is inserted until il reaches the face of the stricture (Fìg. 437), and the
distance of the stenosis from the upper inrisor teeth is estimated froni
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

EXAHINATION 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 subtracling the
first of these measurements from the second, the length of the conlrac-
ture ìs readily determined.

It is often possible for a practised band 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 à boule the
consistency of hard foreign bodies, such as teeth, coins, bone, etc, may
be readily recognized, and at times a distinct sound may be distingufehed
when the two come in contact.

Fio. 439. FiG. 440. Fic. 441.

Fio. 439- — Shows a sound passing the opening of a diverticulum. (After Gumprecht.)
Fig. 440. — Shows the ease wjth which a sound will enter a diverticulum when the lalter
U full. (After Gumprecht.)

Fig. 441. — Shows the ease wiih which a sound foUows Ihe 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 oflen 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 slomach. 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 striclure.

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 latenti opening near
its tip, fragments of tissue suflSciently 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-
scopie tube illuminated by electricity. By the use of the esophagoscope
in the hands of an expert, much valuable informa tion 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. Stili, 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 (io to 13 nmi.) 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 distai 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 (io 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 sterìlized
by boiling and the lights by immersion in alcohol.

Preparatìon of Patient. — The paticnt's stomach shouid be empty,

«•-^

Fic. 441. — Vpn Mikulìcz

1 for esophagoscopy. (GottMdi
Surgery.)

lo avoid regurgitatìon of its contents. Where there is a marked
djlatation of the esophagus, a prelimiaary lavage (see page 416) may
be necessary. The clothing shouid be loosened from about the patient's

-tìa

Fio. 443. — Jackson'a esophagoscope.

neck and chest and any plates or artificial teeih shouid be removed
from the mouth.

Position of Patient. — Some operators periorm esophagoscopy

414 THE ESOPHAGUS.

wìth the patient sitting up; others, with the patìent on a. table in a
Tight lateral position, with the head supporled and controlied by an
assistane 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 tums the head
at will (Fig. 444), is preferable.

Anestbesia. — General anesthesia may be requìred in children.
For adults, painting the pharynx, larynx, and entrance of the esopha-

Fic. 444. — The poùlion of Itie palienl and assistant for esophagoscopy. (After Jackson.)

gus with a IO per cent, solution of cocain by means of a cotton swab
held in a Sajous applicator some minutes before the ìnlroduction of
the tube wIll suffice. This may be very effectually done through a
short split-tube spatula, such as is used in direct laryngoscopy (see
page 364).

Technic. — The seat of trouble should bave been previously deter-
mined by means of a bougie, and if the operator possesses tubes of
different lengths this will enable him lo 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 band, 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 posterìor part of

ESOPHAGOSCOPY.

the pharynx and then downward, the assìstant at the same time extend-
ing the patient's head so as to bring the mouth and esophagus nearly

FiG. 445. — Shows the method of holding the esophagoscope. (Aftrt Jackson.)

in the 5aine straight line. The patient is directed to aid the passage
o£ the tube by swallowing. As soon as the esophagus has been well

Fio. 446. — First stcp in esophagoscopy, the left index-fìnger guiding (he insiniment into
the esophagus. (After Jackson.)

entered, the obturator is removed, the illuminatìon is turned on, and
the tube is gently pushed on into the canal by direct sìght, the surgeon

FiG. 447. — Shona the esophagoscope in place.

Standing or beìng seated at the head of the table (Fig. 447). Under
direct ìnspectìon 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
cer\dcal 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 diflfers from that of the trachea in that it has
not the deep red tint of the lattei, 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
locai 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-
\ious 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.

Therapeuiic Measures.

LAVAGE OF THE ESOPHAGUS.

Lavage of the esophagus is employed chiefly for the purpose of
removing coUections 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 ESOPHAGDS.

FlG. 44S. — Apparatus for esophageai lavage.

n the lip of the tube; b, gUus funnel; e, mark to indicale the dislancc from
Ihe teeth (o the stomach.

FiG. 44Q. — BoBs' apparalus for esophageal Javage. (After Gumprecht)

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, /.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
3hould preferably be performed before the first meal of the day.

Position of the Patìent. — The patient should sit in a chair, or else
should sit up in bed with the head thrown back and the chin elevated.
The oj)erator 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 receiving
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
dose 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 ce.) of warm water are poured into the esopha-
gus. The funnel end is then lowered and the contents are drained
off. By altemately pouring in solution and draining it off, the
esophagus may be thoroughly cleansed and ali 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, internai esophagotomy, extemal esophagolomy,
and, when the stricture is impassable, gastrostomy. Graduai 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 ìntervals

DIIATATION OF ESOPHAGEAI. STRICTURES BY BOUGIES.

419

durìng the remainder of the patient's life. AVhen the stricture involves
the greater pari of the canal, dilatatìon is frequently unsuccessful.
Dilatadon is contraindicated in very recent bums of the esophagus.
Moderate and carefuUy 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 poìnts of normal constriction of the

FlG. 450. — The most frequent s

A, Aorta, D, Diaphragm. i

and beginning of the esophagus; 3, s

due to aneucysm the arch of the

S, sienoùs as result of <

ais of striaure ot the esophagus. (Eisendrath).
Stcnoàs from carcinoma of lower end of the pharynx
enoas from pressure of tumorsof Iheneck; 3, atenusis
Lorta; 4, slenosis as the result of caustic or lye hums;

of lower end of [he esophagus and cardiac end ot st

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 abovc
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 cascs ihere is great

420

THE ESOPHAGUS.

danger of perforating the walls of the esophagus unless exceeding
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 accident a careful physical
examination should be made in every case before inserting any esopha-
geal instrument. By such examination the discovery of other growths

FiG. 451. — 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
location, the degree, the approximate length, and, if possible, the
character of the 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

FiG. 452. — Conical esophageal bougie.

rigid when placed in cold water, are generally employed. The bougies
vary in size from 1/12 to 3/5 inch (2 to 14 mm.). In a normal
esophagus, a bougie 1/2 to 3/5 inch (13 to 14 mm.) in diameter will
pass the narrow portions without difficulty.

For strie tures of fair size, say the size of a lead pencil, cylindrical

FiG. 453. — Bulbous esophageal bougie.

bougies (Fig. 451) may be employed; for smaller strictures the conical
or bulbous instruments (Fig. 453) are used.

In the dilatation of very tight 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 distai end
of the instrument. Billroth's sound consists of a cloth sound filled
with mercury. These instruments, however, possess no advantages
over the ordinary flexible bougie.

D
Jft.

Fig. 454. — Schreiber's esophageai 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.

Preparatìon of Patient. — In cases of marked dilatation of the
canal above the stenosis full of stagnant food and mucus, preliminary
esophageai lavage (page 416) is indica ted.

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 io 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 dose to
this latter structure, it is slowly advanced into the esophagus (see Fig.

422 THE ESOPHAGUS.

434). If diflBculty is encountered in entering the esophagus, the
tongue may be drawn forward by the left index-Bnger, as shown in
Fig- 435-

When the stricture ìs reached care must be taken not to use any
force in atlempting to pass it, as a false passage may be made or the
inslrument may simply be doubled upon itself. By gently withdrawing
and then advancing the instrument, and by moving ìts tip in different
directions, the opening wìll be entered if the particular instrument is
of sufficiently small caliber. When the instrument is once witliin the
stricture the operator is acquainted with the fact by the tight grasp

Fio. 455. — VonHackcr'smelhodof inlroduringthin catgut bougies. (Gottstein in Keen's

Surgery.)

a, b, e, Imo the alricture; b', [hrough a wide hollow bougie {R).

upon the bougie exerted by the stricture. The bougie should be
slowly passed entirely through the constriciion, and should be allowed
to remain in place from five Io ten minutes before it is withdrawn. At
the ncxt sitting the same size bougie is again inserted, and, ìf the
stricture seems very right, this same instrument may be passed on two
or more occasions before a larger one is employed. When there Ìs
more ihan one stricture, no attempt should be made to dllate the
lower ones until dilatation of the upper is secured.

Very tight strictures may be dilated by means of filiform bougics
inseried through an esophagoscope or by von Hacker's method of

INTUBATION OF THE ESOPHAGUS. 4^3

inserting catgut strings. In the lattei 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 strie tures (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.

INTXJBATION OF THE ESOPHAGUS.

This consists in the insertion of a tube into a stenosed esophagus
which is left in place continuously for varying periods at a time. 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 naturai
way, the ability to taste food being also preservxd 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 purj)ose 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

434 ^TH^ ESOPHAGUS.

Symonds, von Leyden, and others. Symonds' tubes (Fig. 456) are
about 6 inches (15 cm.) long, and may be obtained in sizes of varying
caliber. The iower end of the tube 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 prevents
the tube from slipping down the esophagus; to this expanded end silk
threads are secured as shown in Fig. 456, for the purpose of extracting

Fig. 456. — Symonds' short tjbe foi inlubation of [he esophagus.

the tube. A special whalebone guide for inserting the tube is also
required (Fig. 4S7)-

Asepsis. — Gum-elastìc ìnstruments are sterìlized by formalin vapor
or by immersion in a saturaled solution of boracìc acid. Rubber tubes,
however, may be boìled. Before reinserting the same tube, it should
be thoroughly washed with soap and water and resterilized.

Duratìon of the Intubatìon.— For dilatìng a stricture the tube is
ieft in place twenty-four to forty-eìght hours, and, if it has then become

loosened through stretching of the contraciure, it is removed and a
larger one is inserted and aIJowed to remain in place for the same
length of tìme. This process is repeated until full dilatation has been
obtained.

In cancer of the esophagus the tube is wom continuously except
when it is removed once every ten days for cleansing. A long tube,
however, may be Icft in place permanently, as it can be kept clean by
syringing down its interior.

INTDBATION OF THE ESOPHAGDS. 425

Positìon of Patieat. — The padent is placed in the same posidon as
for die passage of any esophageal instrument, viz., sìtdng 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 io per cent, solution of cocain.

Techtiìc. — 1. 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 padent widely opens his mouth and the operator
gently inserts the tube in the manner already described for the passage
of an esophageal bougie (page 407). The tube is passed into the stora-
ach, and the proximal end, which is brought out of a corner of the
mouth, is fitted with a cork and is secured to the ear by a piece of silk,
It will be necessary for the padent to remain in a recumbent posilion
with the head to one side to allow saliva which coUects to escape, as this
is prevented from passing down the canal.

FlG. 45S. — Shows long esophageal tube passed thiough the nose

Instead of passing the tube through the mouth it may be inseried
through the nostrii (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 fàlling off by the silk
threads which are grasped by the operator with the same hand he
employs in introducing the tube. The patient's tongue is then drawn
well forward and the tube is passed down the esophagus and is inserted
through the striclure by means of the introducer, foUowing the same

420 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 dìsengaged from the tube and removed. The threads are
then brought out of a corner of the mouth and are secured to the ear
or face with adhesive plaster. If any of the patient 's teeth are missing
the threads shouid be made to emerge from the mouth through such
a space so as to avoid being cut by the teeth.

Fic. 459- — Showing the method of jntroducìng Symonrls' short tube.

Should the tube become blocked, it may be possible to remove the
obstruction by passing a \ery small bougie down through it; otherwise
the tube will have to be removed and cleaned. Withdrawal of the
tube is effected by making gentle traction upon the threads secured
lo its proximal end.

Feeding. — While the tube is in place the patient is kept upon a
fluid diet, such as milk, brolh, eggs beaten in milk, etc. With the short
tubes food may be adminislered by mouth, but when the long lubes
are employed the nourishment is introduced through a funnel inserted
in the proximal end of ihe tube. Between feedings the end of the tube
may be closed by means of a cork.

CHAPTER XV.
THE STOUACH.

Anatomie Consideraltons.

The stotnach may be described as a hollow, inverted, pear-shaped
organ, ihe greater part of which lies in the epigastric and left hypo-
chondrìac regions, about one-sixth of the organ extending beyond the
right of the median line. When empty it lies deep in the abdomen in
front of the pancreas, being covered by the liver and diaphragm for
about two-thirds of its area and by the abdominal wall over the remain-
ìng one-third. The space in which the slomach comes in contact with

FiG. 460.— The nonnal position 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 costai cartilages, and below by the transverse colon.

The upper limit of the stomach, the fundus, reaches the ie\'el 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 STOMAOL

line connecting the lowest portìons of the ninth or tenth ribs or to
withìn 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
leve! of the eleventh dorsal vertebra, or anteriorly at the level of the
junction of the stemum and seventh costai 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 piane 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 (s to 7 . 5 cm.) below the stemoxiphoid joint. The long axis
of the undistended stomach lies in more of a vertical than a horizontal
piane 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 ce). 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 fiUed, the longest diameter is increased to io or 12 inches (25 or 30
cm.) and the widest point of the transverse diameter to 3 1/4 or 4
inches (8 or io 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 usuai questìons common to ali 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-
tentìon, 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 fuhiess, however, should not
be confounded with pain. Patìents often confuse the two. It is also
important to determine whether the pain is present at ali times or only
at certain stated periods and whether any spedai variety of food has
an influence. Pain complained of when the stomach is empty is prob-
ably due to hypeijphlorhydria, in which case it is relieved by eatìng.
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 eatìng, 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
mie, so severe as that of ulcer nor does it come on so soon after eating,
and it is not so imiformly 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 ali has an important hearing
upon the case. Nausea, as a rule, but not alwa)rs, 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 imtil 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 ali 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 gastricsecretion; (7) tests fordetermin-
ing the motor and absorptive power of the stomach; (8) transillumina-
tion; (9) gastroscopy; and (io) skiagraphy.

INSPECTION.

Abdominal inspection in thin individuai may at times give valuable
information, byt 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 posi tion 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 ìs placed upon a firm fiat 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 piane only a
little above the patient.

Technic— The examiner takes his stand near the patìent's feet
and, by moving from side to side, is enabled to make out the stomach
outlines from the shadows cast by the inequalities of the abdominal
Wall produced by the stomach beneath (Fig. 461). At times tumors
of the body of the stomach or of the pylorus may be observed 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 tapping 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.

curvature to a point considerably below the umbilkus, and at times an
hour-glass contractioa may be recognized {Fig. 462). In gastroptosis
the epigastrium will be retracted, and the lesser curvature may be seen

Fio. 461. — Inspection of the stomach.

Fic. 46j. — Showing the shape ot: (i) A dilated siomach, (i) an hour-glasa stomarh,
(j) ihe stomach in gaslroplosis.

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 slenosis of the cardia.

THE STOUACH.

PALPATION.

Palpation is by far the most reliabie of the methods o£ physical
examination. The stomach shouid, when fK>ssible, be palpated both
before and after takìng food, as tumors of the posterior wail are often
capable of being felt only when the stomach is empty. The large
intestine shouid be emptied by an enema, if necessary, so as to avoid
mistaking feces for new growths. The examination shouid be carried
cut systematically, and of course it must not be lìmited to the stomach
alone, but ali the other abdominal organs shouid be palpated as well.

FiG. 463. — Method of palpating the slomach.

Positioa of Fatient. — The patient lies recumbent with the abdomi-
nal muscles as relaxed as possìble. If ìt is necessary to obtain greater
relaxation than is possible by this posture, the knees shouid be drawn
up and the head and thorax shouid be slightly raised upon a pillow.
Where there is considerable rigidity of the abdominal muscles or in
fat individuais, relaxation may be secured by pladng the patient in a
warm bath.

Technic. — The examination shouid be performed in a warm
room and the physician's hands shouid 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

the fuUest amount of relaxation. The examiner sits or stands beside
Ihe patient and places both hands fiat upon the abdomen, with the
palms dowa and the fingere slightiy flexed, and palpates with the finger-
tips. Only gentle manipuladons shouid he employed, as otherwise
spasm of the abdominal muscles will be induced and the aira of the
examiner will be defeated.

When it is desired to perform deep palpation for the recognition
of deep-seated tumors, one hand is superìmposed upon the other, the
upper hand making the pressure and the lower one performing the
palpation (Fig. 463). Deep palpation is greatly aided by having the

Fiu. 464. — Patpating a tumor of the stomach between the fingerà of the two hands.

patient breathe deeply; it ihen becomes possible for the palpating hand
to follow the receding abdominal walls with expiration.

In palpating tumors, one hand is used to flx the growth and the
other oullines its size and determines its consistency, fixity, or mobility,
and the presence or absence of pulsatìon, tendemess upon pressure, etc,
(Fig. 464).

The examiner shouid firet 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

434

THE STOMACH.

such an extent that it lies along the greater curvature. The greater
curvature and the pylorus may thus be outlined by palpating the tube
through the abdominal walls. Ali parts of the organ are next carefully
palpated with the purpose of determining the presence or absenceof new
growths, painf ul spots, etc. Tumors of the pylorus and the greater cur-
vature are readily palpable. The former are usually situated to the right
of the median line, between the xìphoìd and the umbilicus, but they ha ve
a wide range of motìon unless adherent. Tumors of the lesser curva-
ture lie to the left of the median line, thus diflFerentiating 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 service in
rendering a growth more accessible to the examiner. The knee-chest
posture is also of value, as deep-seated movable tumors then fall for-
ward toward the anterior abdominal wall.

im.

tetitUrfuss iit.

FiG. 465. — Points of pressure tendemess in ulcer of the stomach. (Mayo Robson in

Keen's sui^ery.)

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 tendemess for ulcer are between the left costai margin and »

FEKCUSSION. 435

the mid-Iine (Tig, 465) ; poìnts of pressure tendemess are also at times
found I to 2 inches {2.5 to 5 cm.) to the left óf the spine, in the neigh-
borhood of the twelfth dorsal vertebra (Fig. 466). In affections of
the gall-bladder similar tender poìnts will be frequenti^ found more
to the right of the spinai column.

) ^

in aie,

Fio. 466. — Points of pressure tendemess tound postcriorly in ulcer of tlie stomach. (Mayo
Robson in Kéen's Surgety.)

PERCUSSION.

Only the greater cun'ature and the portion of the anterior surface
of the stomach in contact with the anterior abdomìnal wall are access-
ible for percussion, consequently the chief use of this method is lo
detennine the shape and size of the stomach. 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 stomach 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 o\er
the stomach is a high-pitched metallic tympany, but ìt will vary much,
depending upon whether the stomach is empty, whether it is full of
food, or simply contains air. Percussion shouid be perfonned when
the stomach contains some air; under inflation of the organ percussion
fumishes even more valuable results.

43^ THE STOUACH.

Positìon of the Patìent. — The patìent should lìe in the recumbent
posture.

Technic. — The paimar 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 Ihe right hand a
number of sharp taps or blows are stnick (Fìg. 467). The force of the

Fio. 467.^Ptrcu9Mon of ihe stomach.

percussion should, as a rule, be very light, but, if it is desired to make
out a deeply placed growth, finn heavy percussion will be required.
The same is true when the abdominal walls are very thick. Having
outlined the stomach wìth the patìent recumbent, the percussion should
be perfonned with the patient uprìght to determine if the organ sinks
down from its nornial position.

AUSCULTATION.

By listening to sounds produced within the esophagus during the
swallowing of fluìds and Io sounds originating within the stomach
iiseif, certain information of diagnostic importante 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 lìstens with his stethoscope placed over the esophagus,
that is, to the left of the ensiform cartilage or to the left of the spinai
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) la ter; 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 patient 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 normaUy be empty, that is, in the moming
before breakfast, three hours after a test breakfast, or seven hours after
a test dinner. It then indicates a condition of atony or defident
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 effervescent solu-
tions giving oflf 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 disten tion may
be immediately relieved if necessary. On the other hand, distention
by means of carbonic acid gas is of great advantage in nervous individ-
uai 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 advaiiced cardiac disease, and in advanced
arteria], 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 pronounced. Before
performing inflation in the case of suspected gastric tumor, the abdo-
men shouid be carefully examined and the exact situation of the growth
noted; by then noting the posi tion 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 shouid 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 doublé cautery
bulb or a Davidson syringe is attached, will be required (Fig. 468).

Positìon of the Patient. — If desired, the tube may be passed
with the patient sitting up, but the inflation and the examination
shouid 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 ce.)
of water, and then a little less than i dram (3.9 gm.) of tartaric acid

INFLATION OF THE STOUACH. 439

dissolved in 3 ounces (89 ce.) of water, As the two solutions come
in conlact, 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 distendon for the purpose of
mapping out the oullines of the organ.

2, By Air. — To inflaie a stomach successfully with air through a
tube it is essential that the paiient be accustomed to the passage of the
stomach-tube — the tube shoutd certainly bave 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 (he mouth to the pharynx. From

Fio, 468. — Stomach-lube and Davidson syringe for Inflaling the stomach.

this point it is advanced partly by swallowing efforts on the part of
the patient and partly by the operator who pushes it on unti! it has
passed a sufficient distance to bave carried it beyond the cardia. By
altemately compressing and relaxing the inflation bulb the stomach is
then gently pumped up with air until it is sufficienlly distended for
the purposes of the examinatìon. In the case of an insufficiency of
the pylorus it may be impossible to distend the stomach, the gas being
ezpelled 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 examinadon is completed, the inBadon bulb is
removed from the end of ihe tube and the air is allowed to escape
so as to avoid the disagreeable distention. The abdomen may be
kneaded to facilitate the escape of the air.

440 THE STOMACH.

EXTRACTION OF THE STOMACH CONTENTS POR EXAMINATIO».

The contents of the stomach may be removed for purposes of
diagnosis when it is desired to examine the gastric secretion chemically
and to test the motor functions of the stomach. Such examìnatìon
often gives results of value both diagnostically and prognostically,
but, while gastric analysis is of great importance, the results obtained
by such examination must not be relied upon to the exclusion of other
methods of diagnosis, as they are by no means final. In ali cases the
history and the results of physical examination should be given due
considera tion.

To test the digestive power of the stomach it is necessary to
examine the contents at the height of digestion. In other cases, as
when hypersecretion or disturbance of the motor power of the stomach
is suspected, the contents of the fasting stomach should be examined.
Normally, the stomach should be empty within eight hours after a full
meal, and if empty it should not secrete hydrochloric acid. If, there-
fore, the contents of the stomach, removed in the moming before any
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 breakfast
or a mìd-day test dinner is employed.

The Ewald-Boas test breakfast consists of one or two roUs — be-
tween i and 2 ounces (35 and 70 gm.), a cup of tea without sugar or
milk, or io to 14 ounces (300 to 400 ce.) of water. This is given upon
an empty stomach in the moming and removed in one hour.

The Riegei test dinner consists of a large piate of meat soup —
about 14 ounces (400 ce), a large portion of beefsteak or other
meat, weighing 5 to 7 ounces (150 to 200 ce), mashed potatoes —
I 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.

Examination 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 consist

EXTRACTION OF THE STOMACH CONTENTS FOR EXAMINATION. 44I

of from I to 2 1/3 ounces (30 to 70 ce.) of acid material which upon
filtratìon yields a clear yellowor yellowish-brown fluid. Upon analysis
this contains a total acidi ty 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, achroòdextrin, 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 acid, 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 undergoing 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 assodated with chronic
gastritis or a cachectic condition. It is also diminished in fevers,
wasting diseases, pemicious anemia, chlorosis, neurasthenia, etc.

Anachlorhydria, — Hydrochloric acid is absent when the secreting
glands ha ve 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, but)n4c, 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 STOUACH.

general signifìes insufliciency of the motor power and stagnation of the
stomach contents, as is found in dilatalìon, obstnictìon of the pylorus,
and cancer. The presence of lactic acid alone is net diagnostic of
cancer, as small atnounts 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 wilh deficient motility, it is strongly suggestive of cancer, espedally
if the Oppler-Boas bacillus is also present.

Pepsin and rennin are only absent when profound organic changes
have resulted in an almost complete destruction of the gasine 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

Fio. 469, — Stomach'lube and tunnel for expressing the alomach contents.

a, Showing the lateral feneslra:', b, funnel; e, mark to indicate the distaiice from the
incisor teeth to 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
Uable to cerebral hemorrhage, or in those who have recently suffered
from gastric or pulmonary hemorrhages, in those who are very weak,
in those sufferìng from severe piilmonary or cardiac troubles, etc.
Apparatila. — When the expression method of removing the stomach

EXTRACTION OF THE STOMACH CONTENTS FOB EXAMINATION.

443

contents is employed the following apparatus will be required: A soft-
nibber stomach-tube about 30 inches (75 cm.) long and 1/4 of an
inch (6 mm.) in caliber, with two smooth-edged lateral o[)enings and
a blind end, connected by a piece of glass tubing 3 to 4 inches (7 . 6
to IO cm.) long to 2 feet (60 cm.) of rubber tubing, to the end of
which a glass tunnel is attached (Fig. 4Ó9).

FlG. 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) consista of a large glass bottle supplied with a
tightly fìtting rubber stopper through which two glass tubes-pass; one
of these is comiected with the slomach-tube while to the other a Potain
syringe is attached, by means of which the air in the bottle is exhausted.

^"^/tm^

Fio. 471. — Botile arranged iax aspirating Ihe slomach e
a, Laige glasa bottlei b, tubing connected with a Potain aspirator; e, the slomach-lubc.

Position of the Patient.— The patient is seated upright in a chair or
in bed.

Technic. — Any artificial teeth or plates should be removed from
the patient's mouth and he should be protected by a towel or an
apron fastened about the neck. A small bowl should be given to him
for the purpose of receiving any excessive secretion of mucus or saliva
which may coUect in the moulh. The tube is moistened in warm water.

THE STOMACH.

PlG. 473. — Introducing the stomach-tubc. Second step.

EXTRACTION OF THE STOUACH CONTENTS FOR EXAMINATION. 445

Fio. 474. — Inlrodurìng the stomach-tube. Third step.

Flc. 475. — Aspii&tion of the stonuch contenta. 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 ìnstrument is thus advanced ìnto the esophagus,
partly by the swallowing action and partly by the opera tor (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 slightiy forward to allow the escape of the saliva which coliects in

Fig. 476. — Aspiration of the stomach contents. Second step.

the throat (Fig. 474). As soon as the tube has passed the en trance of
the esophagus it may be readily pushed on into the stomach without
any diflScuIty. 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 pathologicai conditions, as
in dilatation, for example, it may be more. When the tube has been
introduced for the proper distance, the contents of the organare remo ved,
either by expression or by suction fumished from one of the forms of
aspirating apparatus described above.

TEST OF THE MOTOR FUNCTION OF THE 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 aspira tor is performed as follows: With
the clamp closed the operator compresses the bulb (Fig. 475) and
then releases it, thus filiing the bulb with the stomach contents. The
clamp is then opened and the bulb is compressed, causing the contents
to be forced out into a receptacle (Fig. 476).

Variation in Technic. — Einhom 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 ^'^^^'^^'j^'^^
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 carefuUy removed by drawing on the thread and
with it suflScient of the stomach contents for an ordinary examination
of the acidity, etc.

TEST OF THE MOTOR FUWCTION 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 numbèr of tests for determining the motor fimction of the stomach,
among which are the foUowing:

Leube's Test. — ^This consists in giving the patient a test meal
composed of a piate of soup, a beefsteak, and a roU. If the stomach
is 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 instine ted 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 moming 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 usuai method of determining this is by the test known as that
of Penzoldt and Faber. It is performed as foUows: 3 grains (0.2 gm.)
of chemically pure potassium iodid are given in a gelatin-coated capsule
on an empty stomachy 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 GASTRODI APHANY.

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

TRANSILLUMINATION OF THE STOMACH. 449

growth or a thickening of the anterìor wall of the stomach may be
recognized from the lack of Iransparency. It ìs of value in the diag-
nosìs of dilatation and in the differentiation of this condition from
gastroptosis. In the former the illumìnated area is larger than
normal, while in the latter it is small and situated low down. Trans-
illumination, 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 naturai condition,
whereas under inSation it is apt to be stretched beyond the normal.
To employ the method successfully it is necessary that the patient be
accustomed to the insertioti of the stomach-tube, otherwise retching
and vomiting will interfere with the examination,

Fio. 478. — Lynch's gulrodiaphane.* (From a drawing in the possession o(
Dr. J. M. Lynch.)

Apparatus. — Einhom's gastrodiaphane consists of a small Edison
ìncandescent lampaltached to the distai end of a soft-rubber stomach-
tube. The wires which convey the electricity to the lamp pass down
inside the tube while at the prorimai end are two screws for attaching
the wires leading from the batteiy. A six to eight dry-cell batteiy
f umishes the necessary power.

Lynch has modified Einhom's gastrodiaphane by employing a
longer tube — 53 inches (135 cm.) long — sufBciently long to pass
through the pylorus — and by supplying it with an inner auxiliary
tube through which the stomach may be infiated with air or water
or the contents of stomach or duodenum may be aspirated (Fig.478).

• Made by the Electro Sutgical Instrument Co.

450 THE STOMACH.

Position of the Patient — The examination is performed with the
patient in the erect position.

Technic. — ^Transillumination must be performed upon an empty
stomach; if necessary, the stomach should be first emptied by means
of the stomach-tube. The patient is then given two glasses of water
to drink to prevent overheating the stomach from the lamp. The
tube is lubricated with glycerin and is carefully guided into the phar-
ynx and the patient is instructed to swallow, the descent of the tube
being aided by the operator who pushes it on as soon as it is well within
the esophagus, When the lamp is within the stomach, the illumination
is tumed 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 sizeto the outiines 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 illumina ted
area.

Variation in Technic, — ^In order to increase the brilliancy of the
transillumination, Kemp advocates the introduction of fluorescent
media into the stomach preliminary to the passage of the gastrodia-
phane. It is claimed for this method that it is possible to perform a
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 iiR (0.30 ce.) 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 ce.) of water to drink
in which is dissolved 15 grains (0.97 gm.) of sodium bicarbonate to
render alkaline the acid stomach contents. A second drink is then
given, consisting of 8 ounces of water (236 ce.) in which are mixed
1/2 to 1/4 grain (0.008 to 0.0016 gm.) of fluorescein, i dram
(3 . 75 ce) of glycerin, and 15 grains (o. 97 gm.) of bicarbonate of soda.
After the administration of the fluorescent medium the lamp is intro-
duced and the examination is proceeded with as above.

GASTROSCOPY.

Gastroscopy consists in the insertion into the stomach of a stifiF
metal tube, illuminated by electricity, through which the interior of

GASTROSCOPY. 45 1

the organ is inspected. This method of examinatìon was inaugurated
by Mikulicz in 1881, but, on account of its limited value and the
technical difficulties in the use of the instniment, it never carne 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 different principles, employing large tubes with the illumination
at the distai 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 tumore may be excised for micro-
scopical examination. Gastroscopy, however, cannot supplant other
methods of diagnosis. It necessitates that the patient submit to a
general anesthetic and requires such experience and dexterity on the
part of the operator for its proper performance as to place it outside
the domain of any but experts. 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 considera the operation imadvisable under the following conditions:
"In the profound cachexia of the last stages of malignancy; in the
profound anemia of inani tion from known or unknown causes; cardiac,
pericardiac, or major vascular lesions; general or locai, acute or chronic
conditions associa ted with either dyspnea or dropsical effusions; the
late stages of organic diseases, as cirrhosis of the liver, etc." Diseases
of the esophagus may, of couree, 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
(io mm.) in diameter, and with a thickened distai 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 iriay interfere with the examination. To the
proximal end of this latter tube an aspirating apparatus is attached.
The instrument is also provided with an obturator having a conical
tip to facilitate its insertion.

Asepsis. — The tube may be boiled and the light-carrying apparatus
may be sterilized by immersion in a i to 20 carbolic acid solution, fol-
lo wed by rinsing in alcohol, or alcohol alone may be employed.

Preparations. — These should include the ordinary preparations
for a general anesthetic; that is, the patient is given a cathartic the
night before the operation and food is withheld for a period of twelve
hours before the operation (see also page 18). It is essential that the

Fio. 479. — Jackson's gastroscope.

stomach be empty when gastroscopy is performed, and, if necessary,
lavage of the stomach should be practised three or four hours preWous
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 (io to 15 cm.) over
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 controls
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 interfere with the examination, but may make the procedure
a dangerous one.

Technic. — ^The mouth gag is inserted and the operator introduces
the left forefinger into the patient's mouth to the base of the tongue or
behind the epiglottis and draws the tongue forward. The gastroscope,

GASTROSCOPY. 453

well lubricateci, is then introduced held in the operator's right hand,
following the forefinger, ahready in the patient's mouth, as a guide
(Fìg. 4S1). At tM3 stage the assistant who control^ the patìcnt's

Fic. 480. — Positìon of patient for gaatioscopy. (After Jackson.)

head should bend the patient's neck well backward so as to bring
the mouth and esophagus in as straìght a line as possible. As soon
as the instrument has been passed beyond theentranceof theesophagus,
the obtuiator is withdrawn and the light is tumed on. The instru-

FlG. 4S1. — Method of insertìng the gastioscope. (After Jackson.)

ment is passed the rest of the way entìrely by sighl, 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

454 THE STOUACH.

way that the long axis of a cross section of the tube coiresponds to
that of the hiatus (this extends from behind and the right to the front
and the left). To pass the abdominal esophagus as it bends to the left,
the head and neck of the patient are tumed to the right (Fìg. 482),
When the tube has entered the stonmch, the interior of the organ
shouid be systematically explored accordjng to the technic described
by Jackson,* which the writer takes the liberty of quotìng:

"There are two plans of exploration, both o£ which shouid be
carried out. First, the gastroscope shouid be passed down carefully

Fio. 482. — Showing the head and neck of palìeiit drawn to the tight to allow the instru-
meni to pass Ihrougb the hiatus and abdominat esophagus. (After Jackson.)

and gently to the greater curvature, inspectìng the anterior and pos-
terior walls. At times these walls do not seem to be fully coUapsed
ahead of the tube, and one will have to be exainined first, then the
olher. Then the tube is withdrawn, inclined slìghtly laterally in the
same piane, then pushed gently downward again in a tiew serìes 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 pian. The tube ìs passed down unlil the
extremity touches the wall of the greater curvature, in the extreme
left of the possible field. Then the tube is moved slowly along the
greater curvature, but noi in toc dose contact therewith, until the

'Jackson. Tracheo-bronchoscopy, Esophagoscopy, and (laslroscopy, page 149.

GASTROSCOPY.

455

extreme right is reached. Withdrawing the tube a centimeter or two,
the field is slowly swept again in the same piane, 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 tuming the patient on his side, first on one side, then on the
other. During ali 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 while the tube is in

FiG. 483. — Showing the patient*s head and neck turaed to the left to allow the ìnstrument

to 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
imtil the distai 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

456 THE STOMACH.

is touched. Having taken our measurements, we then place the obtu-
rator extemally 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."

SKIA6RAPHY.

The X-ray ìs 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. ii ce.) 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 ali 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
radicai 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 timior of the stomach is present, and
there is a question as to its character and whether it can be removed
or not, an exploratory incision is certainly a justifiable procedure and
its prompt performance is clearly indicated, since an early recognition
of the trouble fumishes the orfly 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
cut any operative procedure that seems indicated. To perform an
exploratory laparotomy simply for the purpose of making a correct
diagnosìs m an individuai 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 Measurés.

LAVAGE OF THE STOMACH.

Lavage consists in washing out the stomach by introducing water
or other fluids through a stomàch-tube or catheter and then siphoning
it off. It is a most useful therapeutic procedure, and if performed
with proper precautions is without dang^r.

Indicatìons. — Gastric lavage may be required for the followmg
purposes: (i) To remove poison and drugs from the stomach. (2)
To remove mucus, undigested and fermenting food from a dilated or
atonie 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
ha ve 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 contraìndications 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 aortìc 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.

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 IO 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 ce.) is fìtted (see
Fig. 469). The stomach-tube should be about 30
inches (75 ce.) 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 latenti openings of fairly
large size so as to give passage to solid particles of food
(Fig. 484). These openings should be situa ted as dose
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 ìnfant 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 ce) 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 well
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 minerai waters, as Carlsbad or Vichy, or
Carlsbad salt, i dr. (4 gm.) to i quart (946 ce) 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 . 1 1 ce) 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

Fio. 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 moming
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 ali 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 moming.

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
mie, 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 instmcted to swallow and the instru-
ment, grasped by tKe 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 immedia tely 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-

460 THE STOMACH.

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 dose to the patient's mouth, and the
futuiel is elevated slightiy and filled with about a pint {473.11 ce.) of
solution (Fig. 485). The compression is then removed from the

Fic 485.^Showing 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 beìng kept in the funnel, how-
ever, to start the siphonage. The funnel is then lowered and the
contents of the stomach are siphoned back into the funnel and dìs-
carded, care being taken to see that approximately the same quantity
retums as was introduced. The process of lavage is contìnued by
altemately pouring solution into the stomach through the funnel
and Ihen removing the solution by siphonage. In order to reach ali
portions of the stomach and more thoroughly cleanse the mucous
membrane, it is well to ha ve the patient move about during the lavage;

LAVACE OF THE STOMACH. 461

for ezample, after one or more washings in the upright position ha ve the
patient lie down and then roll first to one side and then to the other.
At the compietion 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 permilted 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
fenestne of the tube and be lacerated or otherwise injured.

Fio. 4S6. — Showing [he passale of a stomach-lube Ihrough Ihc nose in perforaiing gasine
lavage upon infanls,

Variation in Technic. — In insane individuals or unruly children
who try to prevent the passage of the tube by refusing to open the
mouth or by bidng the instrument, the tube may be passed through
a nostri! (Fig. 486). As a mie, this method of introductìon is not diffi-
cult, as the tube hugs the posterior 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.

402

THE STOMACH.

THE STOMACH DOUCHE.

Gastric douching consists in irrigatìng the stomach by means of
Solutions introduced under pressure. The fluid is preferably intro-
duced through a tube provided with many small lateral openings, so
that ali portions of the mucous lining of the stomach are irrigated by
the solution which flows out in fine streams with considerable force.
Either plain water or medicated solutions are employed in the douche.

The stomach douche is useful in slight degrees of motor insuffidenc)'
for the purpose of stimulating peristalsis and secretion. It is also
employed in neuroses affecting the sensory apparatus of the stomach.

gjiirmugì

LWtl

Fio. 487. — An enlaiged view of
a stomach- douche tube.

Fio. 488. — Einhorn's apparatus
for giving a stomach douche.

Apparatus. — ^A glass funnel with a capaci ty of i pint (473. 11 ce),
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 io c.m.) long, and a stomach-tube about
30 inches (75 cm.) long, with a large number of side openings 1/25
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 provided
(Fig. 487). The large opening in the end of the tube is necessary in

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 ce.) of water,
etc, are used. As antiseptics and antifermentatives are the foUowing:
salicylic acid (0.3 per cent.), sodium salicylate (0.5 to i per cent.),
borie acid (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 toc. 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 anod)me 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 beneficiai.

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 moming 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 tìie Patient. — The douching may be performed with
the patient sitting upright in a chair òr in bed, but in order to bring
the solution into contact with ali 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.

464 THE STOUACH.

AnesthesU. — In the presence of excessive ìmtation or gagging the
pharynx may be sprayed with a 5 per cent, solution of cocain as a
preiiminary to the passage of the tube.

Techoic. — The patient is given a small bowl to receive any vomited
matter or an excessive flow of saliva and his chest and lap are pro-
tected by an apron. The tube is then moistened with warm water or
glycerin and is inserted into the patient 's mouth, being kept in dose
contact with the roof of the mouth until the pharynx is reached.
From this point on the tube is advanced partly by the action of the
pharyngeai muscles as the patient swallows, aided by the operator
who gently pushes it onward. The tube is inserted only a sufficient
distance to bring the perforated tip within the cardia (Fig. 489), which

FiG. 489. — Showitig the mcchanism of the stomach douche. (After Gumprecht.)

is determined by a mark placed upon the tube for that purpose. The
tunnel end is then raised and a pint {473 . 1 1 ce.) of solution is poured
into the tunnel end, the tube being pinched until the tunnel is fìlled;
the solution is then allowed to dow into the stomach, the tunnel end
being elevated high enough to obtain the necessaiy pressure.

To remove the solution the tube is pinched while there is stili some
liquid in it and is inserted some 4 or 6 inches (io to 15 cm.) further
into the stomach, so that its end will He in the fluid contents. The ■
tunnel 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, but
should be allowed to remain only from a halt minute to a minute. It
is then siphoned off, and the stomach is again douched out with warm
water. The tube is then removed, care being taken to compress it

GAVAGE.

465

between the thumb and forefinger to prevent the fluid drippmg 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 melhod may be necessary when the
patient struggles against the passage of the tube and tries to bite the
ìnstrument, 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 wouid
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

466

THE STOUACH,

Fio. 491.— Gavage. Rrsl step, inlroduction of the tube.

Fio. 491. — Cìavage. Second step, admìnìstenng the food.

GAVAOE. 467

long, 2 feet (60 cm.) of nibber tubìng joined to the stomach-tube by a
glass coiuiecting tube 3 or 4 inche& (7 to io 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 feedìng, a tube of
smaller caliber than that ordinarily used will be required. For
young children a No. io American (16 French) catheter should take
the place of the stomach-tube (Fig. 490).

Afiepsis. — Strici asepsis should be observed in the care of the
apparatus. Ordinarily a thorough washing and immersion in an

Fig. 493. — Gavage. Third step, showing the tube bóng compicsscd os it is temoved
to prevent leakage.

antiseptic solution followed by a thorough linsing off with water is
sufficient. In contagious cases, as diphtheria, for example, the appa-
ratus should be boiled-

The Food. — The material employed for feeding will, of course, vary
according to the indicatìons in the individuai case. When the digestive
power of the stomach is impaired predigested food should be employed.

468 THE STOMACH.

The intervals between the feedings of a child should be somewhat
ìncreased when gavage is employed.

Position of Patient. — The child should be held fiat on its back
across the nurse 's knees with the head slightly elevated. Its arms
and legs may be confined by wrappmg it in a sheet from the chin to
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 depth
(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 about 16
inches (40 cm.). After the tube has been inserted to the proper depth,
the funnel is elevated and the 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 larynx
(Fig. 493). The patient should be kept quietly in the recumbent
position for some time after the introduction of the food. In cases
complicated by gastroenteritis, etc, a preliminary lavage of the stom-
ach with warm water, just before giving the food, is often advisable.
It removes mucus and any food remnants of a previous feeding,
cleanses the mucous membrane, and at the same time stimulates it to
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 to
this organ with the same object in view as when used upon other
muscular organs; that is, to strengthen weak and atonie 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 atonie dilatation,
and to a lesser degree in dilatation due to pyloric stenosis. Massage
is advised by some in gastroptosis for the purpose of strengthening the
relaxed ligamentous supports. Finally, it is supposed to stimulate
the normal secretions of the stomach, and is recommended by some
authorities in cases with impaired gastric secretion and in nervous
dyspepsia.

Before recommending massage an exact diagnosis is essential.
Massage is contraindicated in acute inflammation of the stomach, in

UASSAGE OF THE STOUACH. 4Ó9

recent gastric ulcers, in hemorrhage from the stomach, in great disten-
tion of the stomach from gas, and in inflammation of the perìtoneum.
The massage should be performed by one thoroughly familiar with the
technic and preferably by the physician himself.

Time for Hassage. — 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 moming when the stomach is empty. In cases of dilatation, how-
ever, the obj'ect is to propel the contents of the stomach into the
intestines, and the massage is then perfonned npon a full or partly
full stomach. The best lime for this, as a mie, is sii to seven hours
after the principal meal of the day.

Frequency. — The massage, to be of any value, should be performed
every day.

Fic. 494. — SCroking massage applied to the stomach. {Miev Gant.)

Duratioii. — 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 thè treatment, the
sitting may be extended to periods of five and ten minutes.

Position of the Patient.— The patient lies upon his back with his
head slightiy raised and the legs flexed so as to relax the abdommal
muscles.

Technic. — Strokìng movements (efBeurage) and kneading (pétris-
sage) are the manipulations raost employed. In performing effleurage
the operator places his left band upon the right hypochondriac region
for the puipose of counterpressure and with his right hand, the

470 : THE STOUACH.

fìngers of which are outstretched, he performs stroking movements
from the fundus toward the pylonis; i.e., from left to right (Fig. 494).
Kneading of the stomach may alternate with these stroking move-
ments to advantage. In these manipulations large folds of the
abdominal wall, including the stomach, are picked up between the
thumb and four flngers of the two hands by deep handgrasps and are
kneaded by altemately squeezing and relaiing the fingers (Fig. 49S)_

FiG. 495. — Kneading massage applied lo the stomach.

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 the
abdominal walls between the thumb and fingers of the right band and
by propulsive movements directed backward an attempi is made io
throw the contents of the stomach toward the pylonis.

ELECTKOTHERAPY IN DISEASES OF THE STOHACH.

Electricity has undoubted beneficiai effects upon certain diseases
of (he stomach, although the manner in which the electric current
acts is not well understood, and the experimental evidence of its value
is bolh contradictoiy and in some cases not in accord with the resulls
obtaincd 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. According
lo clinica! experience, at any rate, its use is foiiowed by favorable
resulls in simple atony, dilatation from atony, hypochlorhydria,

ELECTROTHERAPV IN DISEASES OF THE STOBCACH. 471

nervous anoreiia, nervous vomiting, paresthesìa, 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.

Fio. 4ij6. — Largc flat sponge electrode.

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
band, as the stomach ìs thus du-ectly treated. Extemal application of

Fio. 497. — Knhom'a deglutible electrode.

alectrìcity, on the other hand, is simpler to cany cut 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. Tl^e latter (Fig. 497) consists of a hard-
rubber shell, shaped like an egg, with numerous small perfora tions
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 piate
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, applica tions are made at
weekly intervals imtil the treatments are discontinued.

Strength of Current — ^For galvanism frotn 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.

Technìc. — 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 gìven 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 piate electrode. This
electrode is applied for part of the séance over the regionof 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 gastric electrode
removed.

CHAPTER XVI.
THE RECTUH AIH) COLON.

Anatomie Considerations.

The rectum cotnmences at the sigmoid flexure, opposite the thìrd
sacrai vertebra, and descends in the middle line of the sacrum and
coccyx. As it descends it forms a curve with the concaWty forward
until it reaches a point about i inch (2.5 cm.) below the tip of (he
coccyx where it turris, forming a sharp angle, and is then contuiued
downward and backward through the thicki^ess of the pelvic floor as
the anal canal (Fig. 498). The antero-posterior curves of the rectum

Fio. 498.— Sagittal seciion of the recium.

are distinct and a knowledge of their direction is importanl for the
pro[>er introductJon of the finger or instnimenls in making an examina-
tion. There are also two slight lateral cur\'es, first to the right and
then to the left, but of less practical importance.

For purposes of description the rectum may be divided into the
rectum proper and the anal canal.

The rectum proper extends from the middle of the third sacrai
vertebra to the upper border of the internai sphincter muscle, or to
474

ANATOMY. 475

about the leve! of the apex of the prostate gland, and measures 3 to
4 inches (7.Ó to io cm.) in length. This p)ortìoQ of the rectum is
sacculated in form, exhìbiting three pouches or dìlatations, of wbìch
ihe lowest and largest, called the ampuUa, measures in some-cases nearly
IO inches (25 cm.) in circumference. The constrictions between which
lie these dilatations are produced by an infoldìng of the coats of the
bowel in the formation 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 seminai vesicles, and the prostate gland,
while in the female, the vagina and the recto-vaginal pouch with' the
small intestine thereìn contained lie anteriorly.

The anal canal b about i i /2 to 2 inches (3.8 to 5 cm.) long.
It extends downward and backward, terminating at the surface of the
body as the anus. This portion of the rectum has no perìtoneal
covering. It is embraced by the internai 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 anteriorly in the male 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.

Fic. 499. — The rectal valves aa seen ihrough the proctoscope. {After Gant.)

Stnictate.—Tke mucous membrane of the rectum is dark and
vascular and is thrown into a series of folds, the most important of
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 usuai arrangement the inferior fold projects from the left
wail 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

470 THE RECTUM AND COLON.

right Wall at a point situated 3 inches (7.6 cm.) from the anus; while
the superior fold projects from the left wall near the third sacrai
vertebra, or at a point about i mch (2.5 cm.) above the middle fold
(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 ils
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 digitai examinations and they may act as
obstacles 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 anal canal, ahoning the columns and valves of Morgagni.

The muscular wall of the rectum is composed of two layers, longi-
tudinal and circular, and ìs quite thick. The internai circular layer
is especially well developed in the anal canal where ìt forms the
internai sphincter.

The Periloneal 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 ìs traced
downward, and at a point 3 to 3 1/2 inches (7.6 to 8.g 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 f emale, forming the
retrovesical or retrovaginal pouch.

Diagnostic Methods.

For the successf ul treatment of rectal diseases a systematìc examina-
tion should be made in every case. On account of the dose relation
and the anatomie proximity of other pelvic organs, as the uterus, tubes,
and ovaries in the female and the bladder, urethra, prostate, and
seminai vesicles in the male, it is necessary to be able to differentiate
between many aflfections 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. Ali the information possible
should be first obtained from a careful history of the case and by a
general physical examination; then a locai 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) instrumentai 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 begim. In some cases, however, more useful
information as to the usuai 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 of ten 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 Sims, 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 fiat pillow. The left arm lies behind the
back and the thighs are well flexed upon the body with the right knee

478 THE RECTUM AND COLON.

drawn up nearer the body than the left. The buttocks He near the
edge of the table and are elevated upon a hard pillow (Fig. 501).
This position will be found most useful for routine examinations, and
probablywillbefoundlessobjectionableto the patient than the lithotomy
or knee-chest positions.

Fio. 501. — The Sima position.

The lithotomy position is secured by placing the patient fiat on the
back and flexing the thighs upon the abdomen and the legs upon
the thighs. The buttocks, which are elevated upon a hard fiat pilIow,
project over the end of the table (Fig 502). In very stout individuais

Fig. soj. — ^The lithotomy poMlion.

this position will permit of a more satìsfactory examination than
will the Sims.

The kme-ckest position is obtained by having the patient kneel upon
a table with the thighs at right angles to the legs and with the 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 favore
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 ali portions of the canal is possible.

'llllll||llll|ll|JII|l|)lllllllll|IIM||H|||||l|M|U|ll)||||J|||i||||||||)|f|R||||

Fio. 503. — ^The knee-chest position.

The squatting posture is only suitable for digitai 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 eflfort protrusions or moderate degrees of prolapse will
be revealed.

INSPECTION.

The anus is first inspected. The presence of discharges from the
rectum, excoriations, eczema, thickening of the epidermis, scars,
ulcerations, fistulous openings, condylomata, the swelling of an abscess,
and extemal 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.

480 THE RECTUM AND COLON.

PALPATION.

Palpation of the rectum may be performed by means of the finger
or by the whole hand. With the ìndex-finger one may examine the
aniis, the anal canal, and the ampulla of the rectum. The first 4 inches
(io cm.) of the rectum may be thus explored,

Introduction of the whole hand into the rectum, as advocated by
Simon, for the purpose of palpation of portions of the canal out of
reach of the finger, may be practìsed if the hand is moderately small.
Tuttle States that a hand requiring a kid giove larger than 7 3/4 should
ne\er be introduced into the rectum except in a life or death eraergency.

Fio. 504.— Inspection of the anus, (Ashton.)

Manual palpation is rarely required, being only necessary for examining
tumore high up that cannot be inspected by means of a speculum or a
proctoscope. In addition, it ìs 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.

Technìc. — i. By the Finger. — No anesthesia will be required. The
direction of the rectum, which is at firet 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, a
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 o£ Iceland moss made for the purpose and is then
introduced slowly and with a rotary motion, the patient being requested
to strain gently to facilitate its passage through the sphincter. Rough-
ness in inserting the finger or disregard of the naturai 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.

Fio. 505.— Palpation of the rectum. (Gant.)

As the finger passes through the anal canal the condition of the
sphincter should be noted, the examiner observìng whether it is dose,
rigid, and resisting, or loose and patulous. When the internai sphinc-
ter has been passed, the finger is swept lightly over the mucous mem-
brane, palpating the rectal wall in ali directions. The size and sensi-
tiveness of the rectum is thus ascertained. The examining finger will
readily detect the presence of impacted feces, polypi, lar^e hemor-
rhoids, malignant growths, ulcerations, fissures, and strictures if a
systematic examination is made. In the male, enlargement, indura-
tion, degrees of sensitiveness, or softness of the prostate should be
carefully noted, and likewise information regarding the condition of
the seminai vesicles and bladder should be obtained. A vesical cal-
culus may frequently be discovered by such examination. In the
femalc, the utenis, 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
considerabte 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

THE BECTUM AND COLON.

the finger will come away coated. In ali cases it is important to note
the odor of the examìning finger upon its withdrawal. The fouì odor
of cancer ìs characteristic and will not he mistaken for anything else
once it is recognized.

FiG. 506. — Method of dilating the anus by means o[ onc finger oE each hand.

2. By the Whole Hand. — Stretching of the sphìncters is commenced
by introducìng into the anus the two forefingers with the palmar sur-
faces out, and separating them slowly and gently in ali directìons, care
being taken to avoìd injury to the mucous membrane if possible
(Fig. 506). As soon as a little dilatatìon has been secured, two and

Fio. 507. — Method of dilatine Ehc onus hy means oE iwo fingers of each hand,

then three fingers of each hand may be introduced, canying ihem to a
point well above the internai sphincter. The fingers are then gradu-
ally separated until sufBcient dilatatìon is obtained to allow the hand
to pass (Fig. 507). The hand is then well lubricated and, with the
fingers formed in the shape of a cone, it is gradually introduced past

EXAMINATION BY THE SPECULUU OR PROCTOSCOPE. 483

the sphincter muscles until it enters the dìlaled ampulla. From this
point on only two fingere should be used in palpation, and great care
and gentleness are necessary to prevenl injury, as the canal gradualiy
narrows down.

EXAMINATION BY tHE SPECULUH OR PROCTOSCOPE.

By the aid of suitable specula and reflected light, the whole ìnner
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 unevennessof the surface ofthemucousmembrane are noted.
Ulcers, poiypi, new growths, malignant disease, strictures, the internai
openings of fìstulous tracts,hemorrhoids, and congestions or inflamma-
tion of the rectal mucosa may be dìstinguished by the experienced
examiner.

Instouments. — The ordinary rectal specula are made in various
shapes and styles, such as the Sims (Fig. 508), the bivalve, the duck-

Fio. 508.— The Sìras leclal speculum. (HirsC.)

bill (Fig. 509), the fenestrated-blade (Fig. 510), the conical, etc. These
are ali useful instruments for inspection of the lower 4 or 5 ìnches
(io to 12 cm.) of the bowel, but theìr usefulness ìs limited to that
region.

For ezamination of points higher up Kelly has devìsed 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 sigmoìdoscope. The sphincteroscope is short and slighily
conical; the diameter of the lower end of the tube is i inch (2.5 cm.)

484 THE SECTUM AND COLON.

and of the upper end i 1/5 inches (3 cm.)- The cylinder of the short
proctoscope is 5 1/2 inches (14 cm.) long, and 7/8 inch (22 min.) in
diameter. The long proctoscope is 8 inches (20 cm.) long and of the
same diameter as the short proctoscope, and the sigmoidoscope b 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-shapcd
rim about 2 inches (5 cm.) in diameter te which a handle is attached.
A blunt obturator is provided lo facilitate the ìntroduction of the
instrument info the bowel. Illuminalion is secured from an electric

Fio. 509, — Duck-bill reclal speculum.

light held dose to the sacrum, which is reflected by a head mirror inio
the speculum, or else an electric head Hght or the direct suniight may
be employed.

Murphy has modified Kelly 's instrument in such a way that the
specula telescope, the proctoscope fitting into the sphincteroscof)e, etc.
This does away with the necessity of withdrawing and inserting a
speculum through the anus each tìme a smaller sìze is used. The
sphincteroscope is used first, and into this the next smaller size is passed
without withdrawing the originai instrument, until ali ha ve been intro-
duced in succession.

The pneumatic proctoscope, such as Tuttle's modification of
Law's instrument (Fig. 512) is not dependent upon atmospheric

EXAUmATION BY THE SFECULUH OR PROCTOSCOPE. 485

pressure as a means of dilatation, thìs being accomplished by a special
inflation apparatus connected with the instrument. Tuttle's procto-

FlG. SII. — Kelly's set of tubular specula.

:, Swab and holder; 3, sagnuàdoscope; 3, long proctoscope; 4, short proctoscope;

5, sphinctcTQScope.

F[G. 513. — Tuttle's pneumatic proctoscope.

1, Proctoscope nith obturator removed; a, obturator; 3, handle; 4, air-Ught plug

with glass window ; 5, inflatìng apparatus.

scope consiste of a long cylinder, to the circumierence of which is
fitted a small melallic tube closed at its distai extremity by a flint-glass

486 THE SECTUU AND COLON.

bulb. An eleciric light fitted upon a. long metallìc stem ìs carried
through ihe small accessory cyiinder to the end of the speculum. An
obturator fits into the distai end o£ the lai^e cyiinder to facilitate the
introduction of the instrument. In addition, there is an air-tight-
fitting plug containing either a plain gìass window or a lens focusedto
the length of the instrument to be inserted in the proctoscope when the
obturator is removed. This plug is in connection with an inflating
apparatus. An adjustable handle is supplied with the instrument.
These specula vary in length from 4 to 14 inches (io to 35 cm.).
Tuttle recotnmendsa4-anda lo-inch {10 and 25 cm.) tube for ordinary
use. The light is fumished by a four or a six dry-cell battery. In
using the specula and proctoscopes long dressing forceps and cotton
baHs with which lo swab out the bowel will be required.

Asepsìs. — The specula may be sterilized by boiling or by immersion
in a I to 20 carbolic acid solution. In case the latter is employed, the
mstrument should be rinsed off with alcohol or sterile water before use.

PositioB of the Patìent. — In employing the ordinary proctoscope,
the patient should be placed in the knee-chest position, so that the
rectum will balloon up upon the entrance of air through the mstrument.
When using the pneumatic proctoscope, whìch does not depend upon
atmospheric pressure for inffation, the Sims position may be employed
instead of the knee-chest, if desired.

Anesthesia. — An anesthelic is not required, as a rule, unless the
patient is extremely hyperesthetic.

fio, 513. — Metbod of holding ihe proctoscope.
Technìc. — i. WÌlk the Kelly Instrument. — The instrument
should always be warmed and lubricated with sterile v-aselin before
its introduction. In using the sphincteroscope the handle of the
instrument is grasped in the right band wilh the right thumb pressing
against the obturator, as shown in Fig. 513. The butlocks are then
drawn apart and, with the end of the obturator held against the anal
orifice, the patient strains slìghtly and the speculum is slowly pushed
into the bowel in a direction downward and forward until the funnel-

EXAUINATION BY THE SPECtTLUM OE PROCTOSCOPE. 487

shaped rìm prevents its further progress. The obturator is then
reraoved, atlowing air to pass in and distend the bowel. The light
is reflected into the instrument in such a way as to thoroughly illumi-

FiG. 514. — Proctoscopy. Fiist stcp, metbod oE inserting ti

FiG. S'S- — Ptocloscopy. Second atep, showing the direction of the instrument in pasùog
through the anus.

nate the interior, and, as the instrument is slowly withdrawn, the whole
of the anal canal is carefully inspected.

The proctoscope is ìnserted in preciseiy the same manner, first
pushing the instrument in a direction downward and forward (Fig.

THE RECTUM AND COLON.

515) and then upward toward the sacrai hollow (Fig. 516). As soon
as the tube enters the ampulla, the oblurator shouid he withdrawn
allowing air te enter and expand the bowel. The light 15 then thrown
into the mstniment and the ampulla is inspected. From thìs point the

Fio. 516. — Proctoscopf. Tblrd step, shonlng the direction of the instniment in entedng
the unpuUa.

Fio. 517. — Procloscopy. Fourlh slep, ^ouing the instrument inserted to ils full extent

instniment is advanced past the valves entirely by sigkl. Some dìflS-
culty may be experienced in following the direction of the canal from
a valve or fold of mucous membrane occluding the end of the instru-
ment. In such a case the distai end of the instrument shouid be gendy

EXAMINATION BY THE SPECOLUM OR PEOCTOSCOPE. 489

moved iroiu side to side until the opening of the canal ìs found. In
this manner the whole interior of the rectum may be inspected. As
the ìnstniment is withdrawn, the condilion and character of the mucous
membrane as it falls over the end of the instrument is noted (Fig. 518).

Fig. 51S. — Shnwing the melbod of performing proctoscopy by the aid of a head minor
and aD decine Ught.

Fio. 519- — Showing the melhod o( inserting Tutllc's insinimenl wiih the finger in the
recium and the auxiliaiy tube pressing against it.

In introducing the sigmoidoscope it is to be remembered that the
upper portion of the canal gradually turas to the left, hence the point
of the instrument is tumed in that direction as it slowly ascenda the
bowel.

490 THE RECTUM AND COLON.

2. With TuHle^s Procioscope. — Thè proctoscope, warmed and well
lubricated, is introduced in much the same manner as is Kelly's
instniment. To avoid causing the patient any discomfort from the
presence of the auxiliary tube, Tiowever, 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 internai 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 upc«i 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 removing
the instrument, the glass is wiped oflF 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)anent 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, furthermore, 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 Davidson syringe should be
provided.

EXAMINATION BY THE BOUGIE X HOULE.

491

Technic. — The bougie, well lubricateci, is gently insertaci into the
bowel until its further progress is impecieci by some obstruction. The
Davicison syringe is then attacheci anci a stream o£ warm water or oil
is forceci through the instrument for the purpose of ciislcxiging any
fecal matter or folcis of mucous membrane that may be interfering with

Fio. 520. — ^Wales* bougies.

its passage. In this way the whole length of the bowel may be explored
without clanger, and the instrument may be passeci into the sigmoid
provided no stricture exists.

EXAMINATION BY THE BOUGIE À BOTILE.

The rectal bougie à houle is made use of in diagnosis to determine
the size and length of a stricture.

Instruments. — ^The bougie à houle consists of a flexible wire or
rubber shaft with a handle to the extremity of which acom-tips of
various sizes may be screwed (Fig. 521). The bougie à houle isused

Fio. 521. — Rectal bougie à houle.

to best advantage in connection with a cylindrical speculum or a
proctoscope.

Technic. — A speculum is intrcxiuced 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-

THE RECTDM AND COLON.

ments 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 catches

Fic. sia. Fio. 533.

Fio. 5JJ.— Melhod of estiraating the length o£ a ractal stricture, the bougie à boule at
the face of the stricture,

FlC. 533. — Method of estìmating the length of a rectal stricture. The bougie à boule
is withdrawn until Its base ù arrested at the distai end of the si

the distai opening of the stricture (Fig. 523). From this examina-
tion the exact length and size of the contracture may be readily
ascerlained.

EZAHUrATION B7 THE PROBE.

Probing has but little utility in the diagnosis of rectal diseases
except as a means of determining the situatìon and course of a recto-
vaginal or ischiorectal fistula.

Fio. 534. — Rectal piotjc.

Instruments. — A silver probe 8 or io ìnches (20 to 25 cm.) long
with a fiat handle is employed (Fig. 524). The probe shouid be flex-
ible that tt may be bent in any direction if desired. When examinìng

INFIATION OF THE COLON. 493

foT a recto- vaginal fistula a Sìms speculum will be requìred in addìiion
to expose the fistulous openìng in the vagina.

Technic. — The ìndex-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 extemal 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 internai finger
at once recognìzes the tip of the probe as it enters the rectum (Tig. 525).

Fio. 535- — Showing the method of probir.;; an ischiorecta] 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 contras! on
pcrcussìon between the tympany of the air-distended bowel and the
fiatness of a tumor. It has the disadvantage, however, that the amount
injected cannot be measured as can fluids, and consequently the degree
of distention is noi so well regulated.

The colon may be distended as far as the cecum, provided there
be no obstruction and the ìnflatìon be slowly and carefuUy performed.
When thus distended, the bowel is raiscd from the surrounding parts
and is caused to stand cut against the abdominal waìl so that it may be
readily mapped out by palpation and by percussion, and its sìze, shape,

494 THE RECTUM 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 net at ali 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 aìd 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 norrnal position of the organ from which it takes origìn,
so that tympany is obtained where there was origìnally dulness; (or
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. 536. — Reclal tube and cautcìy 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 tumor of the spleen will lie in front of the colon and
the growth will become more readily palpable from being pushed for-
ward, etc, etc.

Apparahis.— The injection of fluids is effected by means of a foim-
tain syringe or a graduated glass irrigating jar as a reservoir, and a
rectal tube attached to the reservoir by about 6 feet (180 cm.) of rubber
tubing 1/4 to 3/8 inch (6 to 9 mm.) in diameter.

For the injection of air a special inflation appara tus may be empioyed,
but a rectal tube attached to a Davidson syringe, cautery bulb (Fig.
526), band bellows, or bicycle pump will answer equally well. The

INFLATION 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 te the oxygen tank (Fig. 527), while, if the lattei gas be em-
ployed, the tube ìs 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, ì
(3 . 9 gm.) of salt to a pint (473 . 1 1 ce.) of water) is best. Air, oxygen,
or carbonic acid gas may be used when gaseous distention is desired.

Fio. 537. — InBatioQ of the colon with oxygen. (After Gant.)

Amount Injected. — When inflating with gas there is no way to
determine accurately the amount of gas injected, and the patiènt'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 quaris (3 liters) of fluid may be injected with safety.

Rapidity. — Fluid or gas shouid be injected slowly and steadily;
rapid distention of the bowel is to be avoided. From fifteen minutes
to half an hour sbould be consumed in perforraing the operation. If
the reservoir be not elevated above 3 feet {90 cm.), the fluid will not
enter the bowel toc rapidly.

Position of Patient. — The tube may be mserted with the patient
upon his side, but as soon as the inflation is begun the dorsal position
shouid 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 (io 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 dose 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 suflSciently 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 retuming 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 constìpation or to unload
the bowel of long-standing fecal accumulations 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 eflfects 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 eflfect. For the locai 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
foUowing a cleansing irrigation. While used mainly for purgative
and cleansing effects, enemata ha ve other valuable uses in tfierapeutics.
Rectal injections of saline solution are made use of i^ the treatment of
shock, hemorrhage, sepsis, etc. (see Saline Infusions, p. 508). Rectal
enemata are likewise employed as a means of ptroducing fluids and
nutriment into the bowel (see Rectal Feeding( p. 514) and for the
administration of drugs which aflfect the general system after
absorption.

In employing the rectum as an avenue for the administration of
drugs, however, certain facts are to be kept in mind. The drug should
alwa)rs 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.
It should also be remembered that, while the absorption power of the
rectum may be great, drugs are taken up but slowly and if a rapid
effect is desired, this method should not be employed. As a mie, un-
less the drug is very powerful and is capable of being rapidly absorbed,
the dose is twice the amount given by mouth.

Apparatus. — ^The simpler the appara tus, provided it is eflScient,
the better. A fountain s)nringe or a glass irrigating jar, capable of
holding a quart (946 ce.) 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 connected 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 fiDm 3/8 to 1/2 inch
33

498 THE SECTDM AND COLON.

{9 to 12 mm.) in diameter. A very simple apparatus consists of a long
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

Fio. 518. — Fountain syringe and noxzle for FiG. 539.^ — Colon tube and funneL

giving a tow enema.

be injected directly through the tube fot the purpose of dislodging
any feces or foids 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 an
evacuation in mild cases of costiveness an enema consisting of nonnal
salt solution (dr. 1 {3.9 gm.) of salt to i pint {473.11 ce.) of warm
water) or the soap-suds enema, made by adding to i quart {946 ce.)

ENEMATA AND ENTEROCLYSIS. 499

of hot water suflScient 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 eniptions.

In habitual constipation the injection of from 2 to 6 oimces (59 to
178 ce.) of warm sweet oil into the bowel or the use of the flax-seed
enema will often give good results. The latter is prepared by adding
I oimce (3i.iogm.)of flax-seed to i pint (473.11 ce.) of cold water
and then boiling the mixture for ten minutes. The resulting muci-
laginous mixture is strained and injected while warm. Another
good enema consists of equal parts of milk and molasses. When
a more profound efifect is desired there are a number of drugs that
may be incorporated in the enema. Of these may be mentioned
olive oil, castor oil, glycerin, ox gali, turpentine, magnesium sulphate,
Carlsbad salt, etc The foUowing combinations of the above will
be f ound usef ul :

IJ Olive oil or castor oil, oz. ii (59 . 2 ce.)

Warm soapy water, oz. iv (118. 4 ce.)

I> Glycerin, oz. i (30 ce.)

Olive oil, oz. iii (89 ce)

Warm soapy water, oz. iv (118. 4 ce)

I> Oxgall, dr.ii (7.8 gm.)

Warm water, O i (473.11 ce)

I^ Oxgall, dr.ii (7.8 gm.)

Glycerin, oz. iv (118. 4 ce)

Warm water, O i (473.11 ce)

I^ Magnesium sulphate, oz. i (31.10 gm.)

Glycerin, oz. ii (59.2 ce)

Warm water, oz. iii (89 ce)

IJ White of egg (beaten),

Oil of turpentine, dr. i (3 . 75 ce)

Olive oil, oz. i (30 ce)

Warm water, Oi (473.11 ce)

I^ Magn'esium sulphate, oz. ii (62 . 2 gm.)

Oli of turpentine, dr. ii (7 . 50 ce)

Glycerin, oz. ii (59.2 ce)

Warm water, oz. iv (118. 4 ce)

For the relief of tympanites a turpentine enema or an enema con-
sisting of 3 ounces (89 ce.) of milk of asafetida may be used. For
irritability of the rectum the use of a small flaxseed enema or the

500 THE RECTUM AND COLON.

starch- water enema, to which io to 20 n^ (o. 6 to 1.25 ce.) of laudanum
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 forni a thick paste; enough boiling water is then added to
dilute this mixture to the consistency of mucilage.

Temperature. — ^The enema should be given warm — slì a temper-
ature of about 100° F. — unless contraindicated.

Rapidity of Flow. — The solution should always be injected slowly
to avoid discomfort and spasm from a sudden distention of the bowel.
The reservoir is consequently elevated about 2 to 3 feet (60 to 90 cm.)
above the patient.

Quantity. — To stimulate peristalsìs and produce an evacuation
of the bowels a bulk of liquid suflSciently large to distend the walls of
the intestine should be injected. For this purpose between i pint
(473. II C.C.) and i quart (946 ce.) of fluid is made use of at one injec-
tion. Enemata to be permanently retained for absorption, such as
those containing drugs or nutriment, should be small in amount, as a
rule containing only 2 or 3 ounces (59 to 89 ce) of fluid.

Position of the Patient — The dorsal, the Sims, or the knee-chest
position may be utilized. In the case of the two former the hips should
be elevated upon a hard pillow; especially is this necessary if the
enema is to be injected high into the bowel. Infants can be best
controlied when placed upon the attendant's lap, lying upon the back.

Technic. — ^The tube is first well lubricated with vaselin, and any air
is expelled. The left hand then separates the buttocks, and, while the
patient strains slightly to relax the sphincter, the tube is inserted into
the anus, guided by the right hand in which it is held at a distance of
about 2 inches (5 cm.) from its extremity, the operator using a slight
boring motion, and hearing in mind that the direction of the anal canal
with the patient recumbent is upward and slightly forward. Having
traversed the anal canal, the tube enters the 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 valves or from beihg obstructed by
feces. Withdrawing the tube slightly and advancing it will often
sufl&ce to 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 great
discomfort, provided gentleness and no force be employed.

ENEMATA AND ENTEROCLYSIS. 501

When the tube is introduced to the desired height, the reservoir is
elevated a distance of 2 or 3 feet (60 to 90 cm.), and its contents are
allowed to «iter the bowel slowly (Fig. 531). The patient is apt to
complain of fulness in the rectum as the fluid entere and distenda 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.

f^°- S3I-— Method of giving a bw enema. (Madarlane.)

Enteroclysis. — Like enemata, irrigations ara 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 continuaily 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 pre\ented. At the same time, more
or less fluid is absorbed; the activity of (he skin, kidneys, and livcr is
consequently stimulated an(J general absorption and autoÌn(oxÌcation
are greatly lesscned. For the same reasons enteroclysis has a wide
field of usefulness in the treatment of renai insufficìency, 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.

S02

THE RECTUM AND COLON.

produces marked and beneficiai results in shock due to whatever cause
(see Saline Rectal Infusions, page 508).

In proctitis and in catarrhal, dysenteric, and ulcerative conditions
of the large bowel irrigations are employed for cleansing purposes,
removing foreign substances, mucus, and pus, and thus rendering
bacteria less active; they also serve as a means of bringing medicina!
agents in contact wi*h the diseased surfaces. For the locai effect upon
diseases of the rectum or adjacent -organs irrigations are used either
hot or cold; for example, in the treatment of internai hemorrhoids or
hemorrhage from ulcers situated in the rectum or lower bowel. Such
irrigations are likewise employed in genitourinary and gynecological
practice for the treatment of congestion and inflanmiation located
in the bladder, prostate, and deep urethra, or the uterus and its
appendages.

Apparatusr. — ^The reservoir for the solution may be either a quart-
glass irrigating jar or a fountain syringe, attached to which is about
6 feet (180 cm.) of rubber tubing 1/4 to 3/8 inch (6 to 9 mm.)

FiG. 532. — ^Apparatus for enteroclysis.

in diameter. Irrigating tubes come in two styles: a single-flow tube,
in which the fluid enters and escapes through the same tube, and a
double-current tube, in which the inflow enters and the outflow escapes
through different compartments.

In irrigating with a single tube, it will prove most satisfactory
to use a colon tube about 20 inches (50 cm.) long and 3/8 to 1/2
inch (9 to 12 mm.) in diameter, with the opening at the end. With
this form of tube fluid may be deposited high in the colon or low in

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-
ing 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 oflF the inflow of solution is tempo-
rarily stopped by pinching the tubing between tKe glass connection and
the irrigator, the clip is opened, and the fluid retums through the same
tube and escapes through the long arm of the T-tube into a waste pail

Fio. 533. — Kemp's retura-flow inigator.

ready for that purpose. The same thing may be very simply accom-
plished with a long colon tube and a funnel (see Fig. 529). The solution
is forced in through the funnel, and, when suflScient has entered the
bowel, the funnel is depressed and the fluid allowed to escape.

With a double-flow tube irrigations may be carried out far more
conveniently, especially when several gallons of fluid are used at each
irrigation. A very eflScient double-flow apparatus, especially for high
irrigating, may be improvised by passing a moderate-sized single-flow
tube high into the bowel, alongside of which is mserted a second tube

Fio. 534. — ^Tuttle's retura-flow irrigator.

of larger caliber to carry off the return flow. There are any number of
excellent double-flow irrigators on the market, of which Bodenhamer's,
Kemp's (Fig. 533), or Tuttle's tubes are satisfactory models. These
Instruments 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
has 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.

504 THE RECTUM AND COLON.

A bath-thermometer, a douche-pan or a bedpan, a slop-pail,
and rubber sheetìng to protect the bed complete the necessary
equipment.

Solutions for Imgation. — In the great majority of cases, unless a
specific action is required from direct contact of remedies with the
surface of the intestine, normal salt solution (dr. i (3 . 9 gm.) of salt to
a pint (473. II C.C.) of warm water) is used. For cleansing purposes
and to aid in the expulsion of flatus, 5 to 15 ìt^ (0.3 to 0.92 ce.) of
oleum cinnamomi or oleum menthae piperitae 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 to whether a
soothing, antiseptic, stimulating, or astringent action is desired:
aqueous extrac t of krameria, i to 20; fluid extract of hydrastis, i to 50;
fluid extract of hamamelis, i to 50; borie acid, i to 20; hydrogen
peroxid, i to io; thymol, i to 50; carbolic acid, i to 500; bichlorid
of mercury, i to 10,000; permanganato of potash, i to 500; salicylic
acid, I to 500; quinin, i to 1000; argyrol, i to 1000; tannic acid, i to
500; Silver nitrate, i to 2000, etc. In using the more powerful and
poisonous drugs, such as carbolic acid and bichlorid of mercury, for
instance, any excess of solution remaining 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 dysentery the
irrigation should enter the bowel at a temperature of 100® to 105° F.
Hot irriga tions (no® to 115® F.) are indica ted 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 inflam-
mations of neighboring organs.

Gold enteroclysis (65° to 70® F.) has a beneficiai action upon the
whole intestinal tract, toning up the mucous membrane and stimulating
the muscular tissue, and so increasing peristalsis. This is indicated in
the treatment of internai hemorrhoids, inflammatory conditions of the
rectum, prostate, deep urethra, etc. In hemorrhage from the bowel,
very cold (50° F.) or very hot (120® F.) irrigations are used. It should
not be forgotten, however, that prolonged enteroclysis with very hot or
very cold fluid will cause a rise or lowering of the bodily temperature
amounting to several degrees.

Rapidity of Flow. — The fluid should enter the bowel with com-

ENEMATA AND ENTEROCXYSIS. 505

paratìve 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 imgation and 3 to 4 feet (90 to 120
cm.) for the high will give the proper flow.

Qiiantity. — A continuous imgation of from ten minutes to one-half
an hour or more at a time gives the best results in shock, septiccon-
ditions, toxemias, inflammations in the organs adjacent to thebowel,
etc. Several gallons of solution are needed for such an imgation.
On an average, from i to i 1/2 pints (473. 11 ce. to 710 ce.) of solu-
tion in high enteroclysis, and from 2 to 8 ounees (59 to 236 ce) in the
low irrigation are kept in the bowel continuously. For eleansing pur-
poses, and in the treatment of diseases involving the mucous membrane
of the bowel, the irrigation is eontinued until the solution retums elear.

Positìon of the Patient. — Enteroelysis 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-ehest 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 ali 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 foUowed 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 io 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

506 TH£ RECTUM AND COLON.

allowed to flow gently as soon as the anal canal is passed. This tends
to make the tube stiffer and at the sanie time ìt straightens out the
foids of mucous membrane and carries the valves out of the way, which
might otherwise form obstructions. When the tube has been inserted
to the desired distance, the reservoir is raised 3 or 4 feet (90 or rao cm.),
and the washing-out process begins.

In performmg enteroclysis with a single tube, i to i 1/2 quarts-
(946 to 1419 C.C.) of solution — depending upon the capacity and toler-
ance of the individuai — are allowed to flow into the bowel before the
fluid is permitted to return. If the fluid enters the bowel slowly and the

f'*'' S3S- — Showing one method of inìgating the bowel with e. angle tube,

desire on the part of the patient to expel it be resisted a few moments
imtil it passes well into the colon, no great difficulty will be encountered.
To withdraw the fluid, the outlet placed in the tube leadìng 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 is repeated until the fluid retums clear.

ENEUATA AND ENTEROCLYSIS. SO7

The colon may be more thoroughly irrìgated, as already mentìoned,
by altering the patient's position as follows: With the patìent in the
Sims position, for instance, and with the hips elevated, the descending
colon is first ihoroughly washed out. About i 1/2 to 2 pints (710 to
946 ce.) of solution are then retained, and the patient is gradually
rolled to the dorsal position and then to the rìght side. This pennits
the fluid to pass from the descending colon to the transverse and

IS of a tunnel and

ascending colon, To allow the solution to gravitate down the ascend-
ing colon to the caput coli, the patient's shoulders are raised slightiy
higher than his hips. The process is then exactly reversed: the
shoulders are first lowered, the patient then roUs to the dorsal position,
and finally to the left side again.

In using the double-flow style of irrigator, the outflow tube is
compressed until a pint {473.11 ce.) or more of solution nms into the
bowel (Fig. 537), when it ìs released, the solution stili continuìng to

508 THE RECTUM AND COLON.

flow in. In this way a current is soon established, and the descending
colon and rectum are thoroughly washed out. During the iirigation
the reservoir should not be aliowed to become empty, the supply being
replenished as often as necessary. In withdrawing an irrigator or a
tube with openings upon the side, care should be taken to rotate the
ìnstniment slightly to prevent the mucous membrane from being
caught in the fenestrae.

FiG. 53;. — Showing the meihod of irrigaling the bowei by meansof a retum-flow irrigator.

SALINE RECTAL HIFUSIOnS.

The value of saline infusions in the treatment of hemorrhage and
in the preventìon and relief of surgìcal shock has already been con-
sidered in Chaptcr V. The rectal infusion, being a somewhat slower
and less effective method of introducìng sali solution into the circulation
than either the intravenous or the subcutaneous methods, is used with
greater success in the mìlder forms of shock and hemoirhage, and in
the severe cases as an adjunct lo intravenous infusion or hypodermo-
clysis. It has, however, the dìstinct advantage of sìmplicity over the
other two methods, requiring no preparation of the patient and but

SALINE RECTAL INFUSIONS. $09

the crudest form of apparatus; hence its value as an emergency measure.
In septic conditions, toxemias, renai insuflSciency, uremia, etc, the
fluid thus introduced into the bowel is rapidly absorbed, and the skin,
kidneys, and li ver 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 d)rsentery 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 syringe, 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,
and 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
(473.11 C.C.) of water) is used. For a stimulating effect, whisky or
brandy, oz. ss. to oz. i (15 to 30 ce.) may be added. In surgical
shock 30TrL (1.9 ce.) of a i to 1000 solution of adrenalin chlorid may
be added to the enema for the purpose of raising blood pressure.

Temperature. — ^The solution should enter the bowel at a temper-
ature of iio*^ to ii5*^F. As there is but little loss of heat on account
of the rapidity of the flow, the solution in the reservoir should be at
the same temperature at which it is desired to ha ve it enter the bowel,
or not more than one or two degrees higher.

Rapidity of Flow. — The fluid should be introduced slowly and not
with such rapidity as to excite intestinal spasm. With this in view,
the reservoir is held not over 3 to 4 feet (90 to 120 cm.) above the
patient.

Quantity. — Small amounts are more apt to be retained by the bowel.
From 1/2 pint (236 ce) to a quart (946 ce) may be given at a single
injection.

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-

5 IO IHE RECTUM AND COLON.

tìon of the proper temperature, and a thennometer is placed in it that
the temperature may be kept uniform. , The rectal tube should be
well lubricated with vaselin or oil. Some of the solution is then
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 righi
hand about 2 inches (5 cm.) from its extremity while the left hand
separates the buttocks. As the patient strains slighdy, relaxing the
sphincter, the tube is gendy inserted into the rectum. In doing this
the normal direction of the bowel with the patient in the dorsal posture
—first upward and forward, and then upward and backward — must
be kept in the mind of the operator. When the internai sphincter is
passed, the solution is again allowed to flow gently, in order to displace
any feces, folds of mucous membrane, etc, that might act as an obstruc-
tion, and the tube is pushed on into. the bowel for a distance of at least
8 to IO inches (20 to 25 cm.). The reservoir is then raised from 3 to
4 feet (90 to 120 cm.), and the required amount of solution is introduced.
If it is injected slowly and the tube is passed high up, no difficulty will
be found in introducing and having retained of ten as much as a quart
(946 ce) of solution. At the completipn of the operation the tube is
withdrawn and the patient is instructed to remain quiet in the recum-
bent position.

CONTIHUOUS PROCTOCLYSIS.

By this method a continuous stream of saline solution is instilled
into the rectum at very low pressure. Given slowly, so as not to
irritate the rectum, enormous quantities of salt solution may be thus
absorbed. It was originally employed by Murphy in the treatment of
septic peritonitis in conjimction with free abdominal drainage, on
the theory that the large quantity 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 tìme, stimulation of the heart and kidne)rs
results, and with the latter an increased elimination of toxins and septic
material. While employed mainly in cases of peritonitis, where the
results have certainly been marvelous, continuous proctoclysis wili
be found an excellent means of infusing salt solution in any septic
condition or general toxemia, shock, uremia, etc.

Apparatus. — A glass reservoir or a fountain s)ninge with a capacity
of at least 2 quarts (1892 ce), 3 to 4 feet (90 to 120 cm.) of rubber
tubing 1/4 to 3/8 of an inch (6 to 9 mm.) in diameter, and a vagina!

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)
forms 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 ìs placed a glass
reservoir for the salt solution. Between the copper bucket and reser-

"Fio, 538. — ^A veiy àmpie apparatus for continuous proctodj^às.

voir is provided a space of 2 1/2 inches (3 . 7 cm.) for hot water. A
thennometer is placed in the tubing which leads from the reservoir,
and a vent pipe for the escape of flatus is also provided.

A very simple apparatus is described by Iversen (Jauf. Am. Med.
Assoc., June 12, 1909) in which the solution is kept at the required
temperature by means of an 8-candle-power electric lamp. The
mechanism ìs sufficiently clear from the accompan)dng 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
or by electricity.

Solution. — Normal salt solution, dr. i (3.9 gm.) of salt te a pint
(473. II ce.) of water, should be used.

512 THE EECTUM AND COLON.

Temperature. — The solution shouid be at a temperature of about
ioo° to 105° F. as it enters the rectum, and it must therefore be at a
temperature of from 120° to 130° F. m the reservoir. The solution
must be kept at a uniform degree of beat by either constanti/ replenìsh-
ing with hot solution or by surrounding the reservoir with hot-water
bags, uniess one of the special heating devices is employed.

Fio. 539.

Fio. 539. — Saxon's appamtus

Fio. 540. — Iveisen's apparalug tot continuous proctoclysis. a, Elght-candle- power

electiìc bulb; b, tock; e, Y-shaped glass connection; d, veni tube for the escape of gas.

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 80 drops
{3-75 to 5 C-C.) a minute. In this way i i/a pints (710 ce.) will
flow into the rectum in about two hours. The reservoir shouid be
elevated only from 4 to 18 inches (io to 45 cm.) above the level of the
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 ìs practically continuous, and the
quantity of fluid ìntroduced is limited only by the absorbing power of
the rectum. From 6 to 15 quarts (6 to 15 liters) may be absorbed in
twenty-four hours. Murphy has givenasmuchas3opÌnts (15 liters) in

CONTmuOCS PROCTOCLYSIS. 513

twenty-four hours to a child of eleven. It was ali retained. Monroe,
however, sounds a note of waming against overuse of this method,
claiming that it is possible for a patient to absorb more fluid than can
be eliminated, shown by an overfuU pulse, by cough, and by ràles from
edema of the lungs,

Technìc. — The reservoir is filled with solution and suffident fluid
is allowed to escape to expel any air from the tubing. The right-
angled nozzle, well-lubricated, is introduced into the rectum just
beyond the sphincter muscle, so that the angle fits closely to the anus,
and is secured in place by adhesive plaster passing to the thigh (Fig.
541). The reservoir is then raised about 6 inches (15 cm.) — ^just

Fio, 541. — Showing the melhod of administering conlinuous prxtoclysia. (Kelly and

Noble.)

a, Adhesive slrap fastening the tubing to the thigh; 6, vagìnal nozzle bent al an angle

of 35 degrees.

sufl5ciently high to overcome the ìntraabdominal pressure and allow
the fluid to trickle into the bowel. Farceps or olher means of con-
slrktion shoald noi be applied to the labe lo regalate the fiow, 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 shouid the patient strain or vomit.
The injection may be stopped every few hours if the pulse bccomes too
full or the rectum ìrritable; in such cases the tube is not disturbed.
Murphy advises that the tube shouid not be removed except for defeca-
tion, as the Constant reinsertion will prove irritating to the rectum.

514 THE RECTUM AND COLON.

It is rarely necessaiy to contìnue the proctoclysis for more Ihan three
or four days. Exact technic and almost Constant attention on the part
of the nurse are necessary to gain success with this method.

NUTRIENT EHEMATA.

The nutrient enema is employed in cases when feeding by the

naturai way is undesirable or impracticable. Rectal feeding has its

tìme limitatìons, however. The capacity of the rectum is small and

absorption is considerably slower than by the naturai way, so that only

about a quarter of the amount of nourìshment necessary for sustenance

can be given in this way. As a temporaiy ex-

pedient or as an adjunct to naturai feeding it is

most useful, but for permanent feeding it is

quite impracticable. If it alone is depended

upon for nourìshment, life can rarely be pro-

longed for more than four to six weeks, though

it is tnie that certain exceptional cases have

been reported where patients have lived exclu-

sively upon rectal feeding for longer perìods.

Indications. — i. In cases where some impedi-

ment to the passage of food exists, as esophageal

stricture, new growths encroaching upon the

esophagus, and in pyloric or duodenal stenosis.

3. In incessant and uncontrollable vomiting. 5.

In any condition where it is desirable to give the

alimentary tract a rest, as in acute inflammation

or ulceration of the upper part of the alimentaiy

canal, acute gastrìtis, gastric ulcer, typhoid fever,

Fio. S4a.— Funnei and '"^'^ lesions of the small intestine. 4. As an

colon lube for adminis- adjunct to naturai feeding in any condition when

tering nutrient enemaia. the paticnt cannot receive sufficient nourishment

by mouth.

Apporatus. — A large glass tunnel, 2 to 3 feet (60 to 90 cm.) of

nibber tubing 1/4 to ;ì/8 of an inch (6 to 9 mm.) in diameter, and a

piaìn rectal tube 20 inches (50 cm.) long, No. 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 capacity

of from 4 to óounces (118 to 178C.C.) (Fig, 543) ora Davidson syringe

atiached directly to the rectal tube may be used. In children a No. 18

to 20 French ordinary rubber catheter ìs substituted for the rectal

tube.

NUTRIENT ENEMATA.

S15

Asepsis. — The tube should be boiled before using, and it must be
carefuUy cleaned after each injection. Syringes, if employed, should
likewise be very thoroughly cleansed with soap and water every time
they are xised.

Material Employed for Feeding. — ^Whatever the form of nourish-
ment used, it must be free from ali 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 admìnisterìng 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 efifect is desired. A good stimulating enema
consists of brandy oz. ii (59.20 ce), ammonium carbonate gr. xx
(1.3 gm.), and beef tea q.s. ad oz. vili (236 ce). A pint (473. 11 ce)
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 ce), and liquor pancreatis dr. ii (7.5 ce)

5l6 THE RECTUM AND COLON.

(2) One raw egg; salt, gr. xv (0.97 gm.); brandy or whisky oz. ss.
(15 C.C.); and peptonized milk oz. iii (89 ce).

(3) One egg; liquor pancreatìs dr. ii (7.5 ce); and beef juice oz.
iii (89 ce).

(4) One raw egg, and peptonized milk oz. iii (89 ce).

(5) Salt, gr. XV (0.97 gm.); beef juice oz. i (30 ce); and peptonized
milk oz. iii (89 ce).

(6) Yolk of one raw egg; brandy or whisky dr. vi (22.5 ce);
liquor pancreatìs dr. ii (7.5 ce); and beef-tea oz. iii (89 ce).

Temperature. — Give the injection at a temperature near that of
the body, about 95® F. — never cold or very hot — as peristalsis may be
excited and the rectum will probably reject the feeding.

Quantity. — Only a small amount of food should be injected at one
time, usually i to 6 oimces (30 to 178 ce), depending on the retaining
capacity of the rectum and whether the patient is a child or an adult.
Large quantities are liable to be expelled by the bowel.

Frequency of Feedings. — This will depend upon the quantity taken
at one time. A patient who can retain as much as 6 oimces (178 ce)
need only be fed every six hours. Cases where but small amounts are
retained will require three-to four-hour interval feedings.

Care of the Rectum. — ^A cleansing enema, consisting of salt dr. ii
(7.8 gm.) to a quart (946 ce) of lukewarm water, is given each mom-
ing at least an hour before the first feeding. This serves to wash out
of the bowel any particles of waste matter or mucus; it furthermore
cleanses the mucous membrane and prepares it for more thorough
absorption by stimulating the circulation.

Position of the Patient. — In giving any retained enema the patient
should preferably be in the Sims position with the hips elevated or in
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 with
sweet oil to facilitate its passage and to avoid irritating the rectum.
The tube is slowly and gently introduced, according to the directions
already given for the introduction of the enema or enteroclysis tube well
into the bowel for a distance of io to 12 inches (25 to 30 cm.), so as to
prevent expulsion of the food and fumish an extensive surface for
absorption. To prevent injecting air, the tube and the reservoir or the
syringe are filled with the material to be injected before the tube is
inserted into the rectum. The fluid must be injected very slowly.
When the proper amount is introduced, the tube is carefully removed
and the patient is instructed to remain quietly in the recumbent

INJECTIONS OF FLUID OR AIR INTO THE BOWEL. 517

position with the hips elevated for at least half an hour, to lessen the
chances of the food being expelled. In cases of marked imtability of
the rectum, 5 to io tT[. (0.3 to 0.6 ce.) of the tincture of opium may
be added to the enema.

mjECTIONS OF FLUID OR AIR INTO THE BOWEL IN

INTUSSUSCEPTION.

The slow injection of bland fluids or air into the bowel may be
employed for its mechanical efifect in overcoming an obstruction due
to ìntussusception. Success from either method, however, depends
largely upon an early diagnosis of the condition, for disinvagination
becomes more difficult in direct proportion to the length of time which
has elapsed from the onset of the S)miptoms. After the first tweniy-
four hours of an attack, attempts at reduction by means of hydrostatic
or gaseous pressure are not justifiabley as tight adhesions, which render
reduction impossible, or strangulation and partial necrosis of the gut
with the added danger of rupture may be present. The greatest
objection to this method of treatment lies in the fact that in many cases
it is impossible to teli immediately whether the invagination has been
reduced, and the success of the procedure can only be determined by
allowing the patient to come out of the anesthetic and carefuUy observ-
ing the symptoms.

Not more than fifteen minutes to a half hour should be consumed
in attempts at relief by these nonoperative measures. In ali cases
preparations for operation should be made beforehand so that, should
reduction fail, an immediate laparotomy can be performed. Treat-
ment by injections is, of course, only applicable when the ìntussuscep-
tion occurs in the large bowel, on account of the obstruction by the
ileo-cecal valve to the passage of fluid or gas into the small intestine.

Treatment by Injection of Fluid. — Apparatus. — A foimtain
syringe or a graduated glass irrigating jar as a reservoir and a rectal
nozzle or a large ca the ter, attached to the reservoir by 6 feet (i8o cm.)
of rubber tubing 1/4 to 3/8 inch (6 to 9 mm.) in diameter, should
be provided.

Solutions Employed. — Normal salt solution — salt dr. i (3.9 gm.)
to a pint (473. II ce.) of water — thin gruel or milk and water may be
used.

Temperature. — As the relaxing effect of heat is desirable, the solu-
tion should be at a temperature of about 105*^ F. as it enters the bowel.

Quantity. — The capacity of the colon varies from io oimces

Sl8 THE RECTUM AND COLON.

(295 C.C.) in a child of five months to a pint (473 .11 ce.) or more in a
child a year old. Not more than i 1/2 pints (710 ce.) of solution
should be injected into the bowel of a child under one year. In an
adult, the rectum and colon hold as much as 9 pints (4285 ce) with-
out undue distention.

Rate of Flow. — The fluid should enter the bowel in a graduai,
steady, continuous flow. From ten to fifteen minutes are consumed
in injecting the given quantity of solution.

Amount of Pressure. — Starting with the reservoir elevated about
3 feet (90 cm.), which gives a pressure of less than 2 pounds, the
height may be slowly increased to 4 or 5 feet (120 to 150 cm.) if neces-
sary. A greater pressure than obtained at the latter elevation is not
advisable for fear of rupturing the bowel. This danger should be
constantly bome in mind.

Posìtion of the Patient. — ^The patient should be in the dorsal posi-
tion, with the hips elevated.

Anesthesia. — Anesthesia with ether to the full surgical extent to
produce muscular relaxation is necessary.

Technic. — The nozzle or catheter is well lubricated with oil or
vaselin, and any air is expelled from the tube. The nozzle is then
inserted into the rectum for several inches, and the reservoir is elevated
about 3 feet (90 cm.) and the solution is allowed to flow slowly into the
bowel. Escape of the fluid along the side of the tube is prevented by
tightly packing cotton about the anus and pressing the buttocks firmly
together. While the solution is flowing, the abdomen may be very
genily 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, the
solution is allowed to escape and the patient is examined. If there
were present at the outset a distinct tumor, the success of the procedure
will be denoted by its disappearance. A tumor stili present and retain-
ing its full size will, of course, signify a failure, and an inmiediate
laparotomy should be performed while the patient is stili imder 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

ordinary bellows or a Davidson syringe will be required. In order to
permit the escape of air the moment it is desired, a T-tube of glass may
be inserted between the rectal tube and the mflation 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 soimds or a gush of liquid fecal matter.

DILATATION OF RECTAL STRICTURES BY THE BOUGIE.

The surgical treatment of rectal strictures consists of : (i) Graduai
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 graduai 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
occasionai 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 digitai
examination, if within 4 inches (io cm.) of the anus, or if seated
higher up, by the use of the proctoscope and bougie, asalreadydescribed,
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 tendemess 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 mie, 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 ali signs of
the discomfort it has produced have entirely passed off. 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 interval.

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 welHubricated and, guided by the right
index-finger, is made to enter the orifice of the constriction; or, better
stili, it is inserted accurately into the stricture under the guidance of

DILATATION OF RECTAL STRICTURES BY THE BOUGIE. 521

the eye through a proctoscope introduced to the seat of stricture (Fig.
S4S), as recommended by Tuttle. The advaatages of this method are
obvìous. The greatest gentleness must be observed in inserting the

Fic. 545. — Metbod of inserting a. hiougie into a stricture througb a proctoscope.

Fio. 546. — Showing a tMUgie passed through 1

bougies, and under no circumstances should the tissues be lacerated.
The first instniment should be of such a size that il enters the stricture
with ease. The next one, a size larger, is left in place for a few moments,

522 THE RECTUM AND COLON.

and then a thìrd instrument 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 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. 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, inflammation of the peritoneum, etc.

Time for Massage. — The best time for massage is early in the
moming 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.

Diuration. — ^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 (effleur-
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

COLONIC BIASSAGE.

Fio. 547- — Deep pressure colonie massage. (Bandler.)

V W II

Fio. 548. — Showing th« method of kneading the colon. (Bandler.)

524 THE RECTUM AND COLON.

kneading movements (pétrìssage) are substìtuted. In these movements
the whoie colon is manipulated in the first instance by performing
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 altemateiy compressing and relaxing the
fingers (Fig. 548). In performing these deeper manipulations one
will he govemed as to the amount of force that may be employed by
the sensitiveness of the patient. Care shouid be taken that the
manipulations be not toc vigorous, lest some injury to the viscera result.

AUTO-MJ^SAGE.

Massage may be very effectually carried out by the patient himself
by rolling a ball over the abdomen, beginning at the cecum and
foUowùig the course of the colon up the right side, then across the
abdomen, and down the left side in the direction of the descending
colon. A catmon ball or a wooden ball fìlled with shot weighJng
3 to 5 pounds (1.4 to 2.2 K.), covered with chamois or flannel
(Fig. 549), may be used for this purpose.

Fio. 54g. — Cannon ball for auto-massage of the abdomen,

THE APPLICATION OF ELECTRICITY TO THE RECTUM AITO
COLON.

Electricity is of value in conjunction with abdominal massage in
ali forms of constipation, but especially so in the atonie variety. Under
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 increased,
at the same time, the contracting power of the voluntary muscles of
the abdomen is strengthened.

Both the faradic and the galvanic currents are employed, the former
being generaliy preferred for atonìe constipation and intestìnal paresis

APPUCATION OF ELECTRICITY TO THE RECTUM AND COLON. 525

and the galvanic for spastic constipatìon and paiuful neuroses. Thej
may be applied percntaneously or internally,

Apparatus. — For the percutaneous applications a large fiat sponge
electrode (Fig. 550) and a small sponge electrode (Fig, 551) will be
required. When it ìs desired to make internai applications, a special
irrigating rectal electrode, such as Boas' (Fig. 552) or Kemp's, and a
fiat abdominal sponge electrode will be required.

Fio. 550. — Largc fiat sponge electrode.

Strengtb of Curreat — As there is no means of estimating the
strength of the faracUc current, the sensadons of the patient should be
the guide, the current being strong enough to cause muscular contrac-
tions but no pain. For galvanism, from io to 15 ma. of current
are ordinarily required.

Duiation 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.

Urne of Application. — Treatments aie given with best results at
night, just before the patient retires.

Position of Patient.— The patient should be in the recumbent
posìtion, with the head slightly elevated and the legs flexed, so as to
relax the abdominal muscles.

Technic. — i. Percutaneous Application. — The positive pole is at-
tached to a large fiat electrode, and the latter, well moistened, is
placed over the spinai column. The negative electrode is then applied

526 THE RECTUM AND COLON.

to the abdomen for a few minutes at a time, first over the cecum, then
along the course of the transverse colon, and finally along the descend-
ing colon, Thb is supplemented by circular motions with the nega-
tive electrode over the same regions. Finally, the entire abdomen is
similarly treated.

' Fio. 551, — Small sponge Fio. 559. — Boas' rectal elecliode. (Bandlei.)

electrode. (Bandler.)

2. Reclal Application. — An irrigatmg electrode attached to the
negative pole of the battery is inserted in the rectum and the positive
electrode is placed over the spine or abdomen. When the current is
tumed on, saline solution is allowed to fiow slowly through the rectal
electrode, canying the current to ali portions of the colon.

CHAPTER XVII.
THE URETHRA AHD PROSTATE.

Anatomie ConsideratioTis.

The Male Urethra.^The urethra is a closed canal, composed of

erectile and muscular tissue, and lined by mucous membrane, extending

from the biadder to the extemal urinary meatus. Its entire iength is

from 6 1/2 to 9 inches (16 to 23 cm.), dependjng upon the Iength of

Fio. SS3-— Section of penis, biadder, eie. (Teslut.)
I, Sj-mphyàs pubis; », preveàcal space; 3, abdominal n-all; 4, biadder; ;, uiachus;
6, seminai vesicle and vas deferens; 7, prostate; S, plexus of Santoriai; 9, sphincter veàca:;
IO, suspensory ligament of peitis; 11, penis in flaccid condilion; 19, penis in state oferection;
13, gtang penis; 14, bulb of urethra; 15, cut-de-sac of bulb. a, Fioslatic urethra; b, mem-
branous urethra; e, spongy urethra.

the penis. For piirposes of description it is divided into the following
portions, coiresponding to the parts through which it passes: (i) The
spongy portioa, or pars cavernosa, (2) the membranous portion, or
pars membranosa, and (3) the prostatic portion, or pars prostatica
ff'g- 553)- CHnically and for ali practical purposes, however, it may

528 THE DKETHRA AND PROSTATE.

be divided into the anterior urethra, that poriion lying in front of the
anterior layer of the triangular ligament; and the posterior urethra,
the portion iying behind the anterior layer of the triangular ligament

The Spongy Urethra. — It extends the entire length of the corpus
spongiosum opening extemally upon the glans penis as a vertìcal slit,
the meatus. The spongy urethra measures on the average about 6
inches (15 cm.). The lumen of thb portion of the urethra is not of
the same size throughout, but presents two fusiform dUatations, one
at the bulb, the bulbous urethra, and the other within the glans, the
fossa navicularis.

The mucous membrane is pale pink in color and has opening upon
its surface a number of glands and crypts. In the floor of the bulbous
portion the ducts of Cowper's glands open side by side. Scattered ali
through the mucous membrane of the urethra are the urethral glands
or glands of Littré. Upwn the roof, the mucous membrane is studded
with snull crypts or diverticula, the lacuna. The orifices of these
lacunse open toward the meatus forming little pockets ìnto 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 instniments. It lies in the roof of the fossa navicularis
about I inch (2.5 cm.) from the meatus. These mucous glands and
lacuna are liable to infection and may become the seat of small gonor-
rheal abscesses.

FiG. 5S4.^The interior of the urethra.
1, Meatus; 3, fossa navicularis; 3, urethral glands; 4, orifices of Cowper's glands;
5, Cowper's glands; 6, ejaculatoiy ducts; 7, ^nus pocutaris; S, venimontanuin.

The Membranous Urethra. — It is that portion of the urethra Iying
between the two layers of the triangular ligament, and extends from
the apex of the prostate giand to the bulb of the spwngy portion. It
measures about 1/2 inch (i cm.) in length. The membranous
urethra is the most fìxed, as well as the least distensible of alt segments
of the urethra. In its course it pierces both layers of the triangular
ligament and receives prolongations from these structures, and is also

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 fibers of the compressor urethrae and on either side
of the membranous urethra He the glands of Cowper, the ducts from
which open in the anterior portion of the bulbous urethra.

The mucous membrane lining this portion of the canal is darker
in color and much more sensitive than that in the spongy portion.

Prostatic Urethra. — It measures 3/4 to i 1/4 inches (2 to 3 cm.)
in length and extends from the internai 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
swelling, the verumontanum or caput gallinaginis. At the front and
most prominent part of the verumontanum is seen the slit-like opening
of the sinus pocularis, a blind pouch or diverticulum, usually 1/4 to
1/3 inch (6 to 8 mm.) in length, which runs up in the substance
of the prostate beneath the middle lobe. It is regarded as homologous
with the uterus in the female. Within the sinus pocularis or upon its
margins are the slit-like openings of the ejaculatoTy ducts. On each
side of the verumontanum is a depression, the prostatic sinus into
which the openings of the prostatic ducts empty.

The Caliber of the Urethra. — The caliber of the urethra varies
greatly. While the average diameter is 0.3 inch (0.75 cm.) or
27 French scale, the individuai urethra is not of the same uniform
caliber from end to end, there being a number of constricted and
dilated portìons. The wide parts are: (i) The pars prostatica,
(2) the bulbous urethra, and (3) the fossa navicularis. The narrow
portions are: (i) The meatus, (2) the penoscrotal junction, (3) the
membranous urethra, and (4) the internai prostatic opening. Of
these the meatus is the narrowest, and in a normal individuai an
instrument that will pass the meatus should pass the other narrow
points.

Normally, the walls of the urethra are in contact and on cross
section the canal appears as a mere slit. In the prostatic portion,
from the projection of the verumontanum, it has the appearance of a
half moon, in the membranous portion it is star-shaped; in the cav-
emous 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

530 THE URETHRA AND PROSTATE.

fixed, however, between the suspensory Hgament of the penis and the
mtemal vesical opening, and its naturai 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 slightiy upward
for 2 inches (5 cm.), and then sharply downward. Thus two cun'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 individuals, 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 extemal urinary meatus, curving downward and a little forward.
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 urethrae muscle surrounds it, between the
layers of the triangular Hgament.

Close to the posterior margin of the extemal urethral orifice on
either side of the mid-line are the tubes of Skene. As in the male, the
extemal 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
Hgament 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 patieDt. In a child, the gland b only rudimentary, not reach-
ìng the full size until about the twenty-fifth year. Durìng the later
years of life, ìt often becomes hypertrophied, not infrequently enlargìng
to over twice its originai size.

The prostate consìsts of two lateral lobes which bulge posteriorly
and a so-called middle lobe. The latter ìs that portion of the gland
which lies between the two ejaculatory ducts directly posterior to the
beginning of the urethra. If eniarged, as occurs when the gland is the
seat of senile hypertrophy, the median lobe forms a projection which

FiG. S5S.-r-The pn>sta(e gland and seminai veàcles.

inay cause urinary obstruction and interfere with the passage of
instruments. The two lateral lobes meet and become continuous in
ìront and behind the urethra. The tissue forming ihis union in front
is spoken of as the anterior commissure and the portion behind as the
posterior commissure or isthmus (pars intermedia).

DiagnosHc Methods.

In the examination of the urethra some definite system shouM be
foUowed. The first step consìsts in taking a careful history of the case.
This should embrace the family history, a history of past ailmenis,
and the patient's description of the present trouble, its onset, duratìon,
eie. While in some cases of urethral disease exhaustive questionìng
of the patient ìs superfiuous, it will be found that an exact history will
often be of the greatest aid in arriving at a correct diagnosis.

532 THE URETHRA AND PROSTATE.

The examiner should then take up more in detail the symptoms
complained of by the patient. It should be ascertained whether the
patient has or has had a urethral discharge, and, if so, its character;
whether it is suflScient to stain or stiffen the linen, or whether it simply
glues the lips of the meatus together; whether it occurs only with the
first urine passed, or in the intervals as well; whether there is any dis-
charge with defeca tion; also whether defecation is accompanied by
pain about the prostate or rectum. It is important to inquire into the
act of urination, ascertaining whether the passage of urine causes any
pain, and, if so, its character, and whether the pain is present at the
beginning or end of the act; also whether there is an increased fre-
quency in urination. The patient should be 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 stopped,
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 present, and their character. More
exact information upon these latter points, however, will be obtained
after a complete examination of the urine.

Having questioned the patient along the lines above indica ted,
secretions and discharges, if present, should be coUected for examina-
tion (see pages 203, 534), and then the actual examination of the
urethra and prostate may be taken up. The methods available for
this include: (i) glass tests and injection tests for the purpose of locat-
ing the seat of the discharge, (2) inspection, (3) palpation, and (4)
instrumentai examination. The use of instrumentSy however^ should
noi be undertaken if there is an active discharge from the urelhra 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 seat of the pus has its origin in the anterior or
posterior urethra. The simplest of these are known as the two-glass
test and the three-glass test.

The Two-Qlass Test. — It is performed as follows: the patient is
instructed to hold his urine for three or four hours, and upon presenting

CLASS TESTS. 533

himself for examination he is told to urinate into two glasses or grad-
uates. He should pass about 2 oiinces (59 ce.) into the first glass
and the remainder into the second. If the contents of the first glass,
in which are collected the washings from both the anterior and poste-
rior urethra, contains pus or shreds revealed by holding the glass before
a strong light and the contents of the second glass is clear, it may be
inferred that the anterior urethra is involved, but the posterior urethra,
if at ali, only slightly so. If, on the other hand, the contents of both
glasses are cloudy or contain shreds, it shows that there is suflScient
secretion from the posterior urethra to ha ve escaped into the bladder
and discolored its contents, or that the secretion comes from the bladder
itself, the ureters, or kidneys. In the former case, the contents of the
first glass is more turbid than that in the second glass; while in the
latter conditions there is but little difference between the two specimens.

Another method and one that is more certain in differentiating
between an anterior and posterior urethritis, consists in first thoroughly
irrigating the anterior urethra with a warm borie acid or normal salt
solution by means of a catheter introduced as far as the bulb, and
then having the patient urinate into two glasses. If the contents of both
glasses are clear, we may be sure the posterior urethra is free. Pus
or shreds appearing in the second glass. indica te a posterior urethritis,
or that they come from the bladder or beyond.

The Wolbarst Three-Qlass Test. — This is more reliable than the
two-glass test, and is also employed for the purpose of determining
whether the seminai vesicles are infiamed. 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
and 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 ce.) 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 seminai vesicles are next massaged and
the patient then voids the urine or solution containing pus expressed
from the prostate and seminai vesicles into a fourth glass.

534 THE URETHRA AND PROSTATE.

mjECTION TEST,

For the purpose of diflferentìating between an anterior and a pos-
terior urethritis, the anterior urethra may be injected with a solution
that will color the shreds in that portion of the canal. A i per cent
solution of methylene blue is employed. By means of a blunt-pointed
urethral syringe the anterior urethra is fiUed with the methylene blue
and the patient is instructed to hold 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 exami-
nation may be necessary, however, to determine whether the shreds
remain unstained. In making this test it is essential that the patient
should not ha ve urinated for some time previously.

INSPECTION.

In the Male. — In the male, inspection of the urethra without the
aid of instruments is limited to the meatus and the exterior of the canal
as far as the peno-scrotal junction. Swelling, signs of inflammation,
new growths, etc, which present extemally may thus be recognized.
While comparatively limited in scope, inspection should never be
neglected, but should form part of the routine examination.

Position of Patient. — The patient may stand or be in the dorsal
position.

Technic. — The penis is elevated so as to bring its under surface to
\ ieV 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 extemally,
the presence of any discharge may be demonstrated. If present, some
should be obtained upon a slide, and later should be stained and
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 orìfices
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 urethia is exposed.
In this manner tumors, dilatations, cysts, sacculations, etc, will be
noted.

Fio. 556. — Metbodof stiippingadischaige Fio. 557. — Melhpd of inspecting Ihe urethal
from tbe untlira. (Aahton.) orìfice in the temale. (Aahton.)

PALPATION.

In tbe Male. — Like inspection, palpation of the uretfara ìs of
limited value, especially in the male. By it, however, changes in the
consistency, sensitiveness, and form of the canal may be recognized.

Posìtion of Patient. — The urethra may be palpated with the patìent
standing or in the dorsal position. To palpate the prostate the patient
shouid be placed in the knee-chest position, or shouid bend over with
the hands resting upon a chair and the thighs separated.

Technìc. — In palpating the urethra the penis shouid be grasped
just behind the glans between the thumb and forefinger of the left hand,
and, whìle pultìng the organ on the stretch, the penile portion of the
urethra is palpated between the thumb and forefinger of the rìght hand
(I^ig- 558). It shouid be noted whether the urethra is elastic, as it
normally shouid be, or whether it is hard, indurated, or nodular. An
inftamed 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 wìll be hard, nodular, and
adherent. By inserting a sound and then palpating the urethra upon

536 THE URETHRA AND PROSTATE.

it more valuable information may be obtained, as changes in. the
consistency of the canal will be accentuated.

To palpate the membranous uretbra and prostate a rectal ezamina-
tion will be necessary. For this the bladder shouid preferably contain

Fio. 55S. — Eitemal palpatìon of the urelhra.

Fio. 559. — Showing the method of palpating ibe prostate gland.

a little urine. The operator standing upon the patìent's left Ihen
inserts bis right forefinger, protected by a fìnger cot and well lubricated,
imo the bowel (see Palpatìon of the Rectum, page 480). After passing
the sphincter, the examining finger comes in contact with the mem-

PALPATION, 537

branous urethra for a. space of 1/2 inch (i cm.), and then the
prostate gland is reached. Normally, the latter is not very distinctly
felt, but in the presence of hypertrophy ìt readily is, and sometimes
it b so eniarged that ìt can be palpated bimanually. Points of tender-
ness, softening, painful swellings, or a general eniargement shouid be
looked for and any difference between the two lobes shouid be noted.
The condition of the seminai vesicles shouid likewise be investigated.
They lie above each lobe of the prostate eutending upward and outward,
but are not palpable, unless eniarged or thickened by disease.

If desired, the seminai vesicles and prostate may at this lime be
massaged for the purpose of obtainìng their secretions for examination.

FiG. 560. — Combincd reclal and instrumentai examination of the prostate gland.

This is done by carrying the finger up over each seminai vesicle in
tura 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 explorìng the
prostate. A bladder sound or other metallìc 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
amoiint of induration may be ascertained.

538 THE UREIfHRA AND PROSTATE.

In the Female. — In the female, the entire canal may be explored
by palpation through the vagma and valuable information is thus often
obtained.

Positìon of Patient. — The patient is placed in the dorsal position.

Technic. — ^The examiner, sitting in front, separates the labia with
the fingere of his left hand, while he palpates with his right index-
finger. The meatus is firet 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 couree 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
inferìor 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 SOUimS AND BOUGIES.

Having obtained ali the information possible by the means already
detailed, an instrumentai exploration of the urethra, provided the lalter
is not the seat of an actUe inflammaiiofiy 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
locai 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
à 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 the slighiest 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 firet time may result in a severe chili, 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 sii ver 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 ìs 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

Fio. 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,

Fio. 564. — Female sound. (Ashton.)

as curves, spirals, angles, etc. For diagnostic purposes the filifomis
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

540 THE URETHRA AND PROSTATE.

cent, soda solution. The best makes ol the silk-elastic ìnstnimetits

may also be boiied, but some of the others will not last long if so

treated, and it is safer to sterilize them in fonnalin 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 piate 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 20 carbolic acid solution followed

by immersion in a saturated borie acid solution

and rinsing in sterile water. Whalebone bougies

may be boiied, though they will not stand pro-

longed boiling. The examiner's hands shouid be

likewise carefully cleaned.

The glans penis shouid 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 borie
acid or with a i to 5000 solution of potassium
permanganate both before and after the examina-
tioD.

Poeitìon of Patìent. — The patient shouid lie in
the dorsal position with his shoulders slightiy raised
and thighs flexed and rotated somewhat outward,
and near that side of the table upon wiiich the

Fio. 565. — Form- , rr.t • • • i

alin steKiizer for operator stands. The operator takes his piace
urethrai instruments. just above the patìent 's hips and facing the

a. Top; b, rack patient 's side, upon whichever side of the table is
tL-nerfóTfoii^^n"' ™«^* convenient for him— generally the left side is
chosen.
Technic. — In beginning the examination the largest instrument
(hai will pass the meatus shouid be introduced. As the meatus is the
narrowest portion of the urethra, any instrument that can be intro-
duced through it will pass along the entire canal, unless some con-
tractìon is present. Shouid the meatus be abnormally small, it may
be eniarged 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 lìps of the meatus. The sound,
warmed and well lubricated with one of the Iceland-moss preparations,

EXAMINATION BY SOUNDS AND BOUGIES. 54I

is grasped lightly between the fingers of ihe righi hand, and is genlly
introduced inlo the meatus. As the point of the instrument is inserted
in the meatus the iiandle should lie parallel to the abdominal wall and

FlG. 566.— First step in inscrting a urethial sound.

in 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-
ment is further introduced with its point first hugging the floor of the

Tic. 567. — Second step in inseiting d urethral aounil.

urethra and then genlly following the roof of the canal ihrough the
resi of its course inlo the bladder. The instrument is then pushed
onward and downward, the penis being drawn over it until the point

THE DRETHRA AND PROSTATE.

of the sound ìs deep in the bulbous urethra (Fig. 568). The handle
is next gradually raised to a perpendiculax and is then depressed,

Fig. 568. — Third step in iosertìng a urethral sound.

FiG. 569. — Fourth step in tnserting a urethral sound.

thus permitting the poìnt of the instrument to follow the fixed cun'e
of the urethra beneath the pubic arch (Fig. 569).

EXAMINATION BY SOUNDS AND BOtJCIES. 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 [>oÌnt will be made to lodge against the
upper part of the anterìor layer of the trìangular ligament mstead of

Fro. 570. — Showing false passage of sound fmni depresdng the handle of the

Fio. 571. — Showìog the tip of the sound eaughl at the anterior layer of the trìangular
ligament.

entering the membranous portion (fig- 57o)- Again, the sound may
fail to enter the membranous urethra from the point lodging against
the lower portion of the trìangular ligament (Fig. 571). This may be
avoided by depressing the handle and at the same time by lifting up

544 "rHE URETHRA AND PROSTATE.

on the point of the instrument with ihe fingere inserted behìnd the
scrolum so as to press against the perineum (Fig. 572).

Having passed the beak of the sound ìnto the membranous urethia.

FtG. 57}. — Method of lifting up the lipof the sound obstnicled by [he lowetportìonof the
thangulai ligameat.

l'iG, S73.^Fìnal slep in inserting a uicthra[ sound.

it is then made to tra\'erse the remainder of the canal and to enter the
bladder by sweeping the handle forward and downward betweea the
thighs (Fig. 573), provided, of course, that no obstruction has been
encountered. While this is being done the free band shouid make

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 stili 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
should be slightly withdrawn, and the penis put on the stretch, so as
to straighten out any folds of mucous membrane in which the point
of the instrument may have caught. If it then fails to pass, the
obstruction is due either to spasm or to an organic stricture. When
the seat of obstruction is in front of the bulbous urethra, spasm may be
ruled out, but an obstruction at the bulbo-membranous junction or in
the membranous urethra, on the other hand, is often caused by spasm.
To determine this, the instrument is not withdrawn, but should be
kept firmly and gently pressed against the face of the obstruction for a
few moments, when, if spasm were the cause, it will in time subside so
that the instrument can be readily passed into the bladder. Further-
more, upon attempting to withdraw the instrument, that characteristic
grasping of the instrument such as is found in the presence of a tight
organic stricture will be absent. When an obstruction is met deeper
than 61/2 inches (16.5 cmi) from the meatus, or in the prostatic
urethra, stricture may be ruled out; such an obstruction may be due '
to an enlarged prostate, a stone, or spasm of the internai sphincter.

In this way the presence of a stricture is determined and its distance
from the meatus is readily estimated. To ascertain its caliber is the
next thing. When the examining instrument encounters the stricture
no force should be used in attempting to make it pass; instead, that
particular instrument is withdrawn, and smaller sizes inserted in
succession, substituting flexible bougies for steel Instruments below a
No. 15 French, until an instrument is found that will readily pass.
If even the smallest-size bougies will not pass, filiforms should be used.
As a general rule, no attempi should be mode to pass a JUiform on the
same 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,
and for a time is impassable even to a filiform. In using filiforms it
should be remembered that, owing to their small size, they are liable to
be obstructed from being caught in folds of mucous membrane or in
the orifices of the glands and ducts so abundant throughout the urethra,
35

54^ THE DBETHRA AND PROSTATE.

and it is very easy to make a false passage with one of these instruments
if undue force is used. If a filiform catches in a pocket or fold of
mucous membrane, it shouid be withdrawn slightly, and then gently
advanced, or it niay be gently rotated as it is advanced. Sometimes
the passage of a filiform will be greatly facilitated by injecting suffi-
cient sterile oil through the meatus alongside the fìliform to thoroughly
distend the canal.and then,while keeping the lips of the meatus closed,
the instrument b gently advanced.

When once an instrument has entered the stricture there can be no
doubt of this fact from the tightness with which it is grasped by the

FiG. 574. — Showing the method of passing a Glìfonn bougie through a sr
fiist filling Ihe canal with GlUoima.

stricture, a sensation, which, once recognized, will net be forgotten.
Shouid it net be p)ossibIe to find the opening with a single filiform, the
canal may be filled with them and, by first advancìng one and then
another, it will usually be possible to make one engagé in the stricture
(Fig. 574). Failìng by this maneuver, a m-ethroscope may be ìntro-
duced down to the face of the stricture and through it the instrument
may be passed under direct vision,

After such exploration the urethra shouid be ìrrigated with warm
normal saH solution or with a warm saturated solution of borie acid.

EXAMINATION BY THE BOUGIE X HOULE.

The bougie à houle 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 HOULE. 547

this ìnstniment is limited to the anterior urethra, as, if passed into the
membraAOus portion, the compressor urethrae muscle is liable to con-
tract about the bulb of the instrument and give a sensation of stricture.
Furthennore, when the canal is the seat of more than one stricture, it
is frequently ìmpossible with the bougie à houle to detect the deeper
ones, as those in the anterior portion of the canal may be so tight that
the passage of an instrument suflSdently large to detect the deeper ones
is out of the question.

Instruments. — ^The bulbous bougie consists of a flexible shaf t, upon
the end of which is mounted an acom-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.

Fig. 575. — Urethral bougies à houle.

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. Thìe urethra
should be thoroughly washed out with a i to 5000 potassium per-
manganate solution, or a saturated solution of borie acid both before
and after examination.

Position of Patient. — The patient lies upon a finn 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 URETHRA AND PROSTATE.

measured upon the shaft and the instrument is withdrawn. Success-
ively stnaller sizes are introduced until a sìze that will pass the stricture

Fio. 577. — Method ot estimaling the length of a urethral striclure. The base of the
bougie à boule withdiawn uotil in contaci wìth the distai end of the stricture.

is reached. From this ihe size of ihe stricture is determined. The
instrument is passed entirely through the stricture, and is then wilh-

URETHROMETRY. 549

drawn untìl resistance caused by the shoulder of the mstrument striking
the distai face of the stricture is felt (Fig. 577), The shaft is then
grasped at the meatus as a guide, and the instnunent 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 urethrae
muscle may simulate stricture. After removal of the bougie the ure-
thra should be irrigated with borie 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
has an advantage over a sound or bougie in that it can be introduced
through a narrow meatus and strictures of large caliber can be 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-

FiG. 578. — Otis' urethrometer,
o, Instrument op)en; 6, instrument closed; e, rubber stali to cover the end of mstrument.

enced hands it is often an unreliable method of examination, as
strictures that do not exist may be imagined to be present, which tum
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 tuming a thumb-screw at the
proximal end of the instrument. A dial and indicator show the

550 THE URETHRA AND PROSTATE.

extent of expansion. A thin nibber stali is drawn over the end of
the instrument when closed, for the purpose of protecting the urethra.

Asepsis. — The urethrometer is boiled in a i per cent, solution of
carbonate of soda. The extemal genitais are thoroughly cleaned, and
the urethra is irrigated with a mild antiseptic solution. The operator's
hands are sterilized in the usuai way.

Position of Patient. — ^The patient is placed in the dorsal recumbent
posture.

Technic. — ^The closed instrument, warmeA and lubricated, is
introduced through the meatus and is passed as far as the bulbo-
membranous junction. The bulb is then expanded by tuming 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 strictures located and calibrated. It should be remem-
bered when employing this instrument that the urethra is not of
imiform 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 peno-scrotal junction.

At the completion of the operation the canal is irrigated with an
antiseptic solution.

ESTIMATION OF THE LENGTH OF THE URETHRA.

This procedure is of value in determining whether the prostate is
enlarged. For practical purposes the length of the urethra is the
distance it is necessary to pass a catheter from the meatus before urine
begins to flow. This may vary from 6 1/2 to 9 inches (16 to 22 cm.),
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 indicates
that the prostatic urethra is lengthened and that the prostate is
therefore enlarged.

Instruments. — An ordinary silk gum-elastic catheter or a catheter
marked off in inches (Fig. 579) may be employed.

Asepsis. — ^The catheter is boiled or immersed in a i to 20 carbolic
acid solution foUowed by rinsing in sterile water. The extemal
genitais are thoroughly cleansed and the urethra is irrigated with a

URETHROSCOPY. 551

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 tirine begins to flow. It is then withdrawn until the
flow just stops ànd 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

Fio. 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 eniarged. 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.

XJRETHROSCOPY.

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 locai applications directly to dis-
eased areas or to remove calculi, foreign bodies, polypi, e te, (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 essentiai and the operator must ha ve 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 (io 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 posterior urethra.

a Straight tube may be used in the posterior urethra or the tube may
be obtained with the distai 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

four-volt lamp from a four-tò six-dry-cell battery. In the Chetwood
instrument, the illumination is Supplied by means of a delicate cold lamp
at the distai end of the instrument, while in the Otis urethroscope 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
with cotton are necessary.

Fio. 582. — Klotz's urethral tube.

Asepsis. — The tube and applicators should be boiled, while the
lamp may be immersed in a i to 20 carbolic acid solution and then in
alcohol. The operator's hands should, of course, be sterile. The
glans penis is washed with soap and water, and is then wiped with a
I to 5000 bichlorid of mercury solution. The urethra is to be irrigated
with a warm saturated solution of borie acid or i to 5000 potassium
permanganate solution.

Position of Patient. — The patient should be upon a fiat 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.

Technìc. — 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 begun. Before proceeding with the examination, the
patient is instructed to teli 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, provided the anterior
portion of the canal only is to be examined. The obturator is then

554

THE URETHRA AND PROSTATE.

removed, the light is tumed on, and the instrument is slowly withdrawn,
the mucous membrane being inspected the while, as it falls over the
distai end of the tube (Fig. 584). If the prostatic urethra is to be
inspected, the tube is inserted ali the way into the bladder. This is
accomplished by tuming the instrument down between the thighs to
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 on into
the bladder. Inserting a straight tube into the posterior urethra is

Fio. 583. — Method of inserting the urethroscope.

generally painful and it may not be possible without employing locai
anesthesia; ìntroduction of the curved urethroscope is much less
disagreeable for the patient.

As soon as the instrument is inserted to the desired depth, the
obturator is removed, the light is tumed on, and, as the tube is slowly
withdrawn, the diflFerent portions of the mucous membrane are inspected
as they appear in the end of the urethroscope. If a clear view of the
mucous membrane is interfered with by blood or secretion collecting
in the end of the tube, long applicators covered with cotton should be
inserted through the instrument and the mucous membrane mopp)ed
dry; care should be taken not to push the tube back in the canal after

CRETHROSCOPY. 555

the exatnìnation has once begun without ìnserting the obturator, as
the edges of the tube might cause damage to the parts.

Before one can become competent in recognizing pathological
conditions it is necessary that the examiner should be acquainted with
the normal appearance and color ol the urethral mucous membrane.
Beginning at the posterior urethra in a normal case the centrai figure
appears as a cone, the mucous membrane, whicb is of a dark
red color, being thrown into longitudinal folds. As the mstrumetit

FiD. 5S4. — ShawingthemethodofeiaiiuniDgtlieanterìorurethralhrough theurethrascope.

is withdrawn, the verumontanum comes to view in the form o£ a
semilunar curve with the convexity upward (Fig. 585) and the
mucous membrane appears of a brighi 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 centrai figure appears as
a cone with a centrai dot, the mucous membrane extending out in
radiating folds (Fig. 587). In the bulbous urethra the centrai figure
changes to a vertical slit with the mucous membrane bulging on each

550 THE URETHRA AND PROSTATE.

side (Fig. 588). In this portion of the canal the mucous membrane is
stili paler in color. The centrai figure then gradually changes from
a vertical slìt to a triangular opening {Fig. 589), and at the penoscrota!
junctioQ it takes the form of a transverse slit with radiating toids

Fio. 585. Fio. 586.

Fic, 585. — The appearance of the upper portion of the prostatic urethra. (After Stem.)
Fig. 586. — The appeorance of the middle portion of the prostatic urethia. (After Stem.)

extending to the periphery (Fig. 590). In the pendulous urethra the
centrai figure again becomes cone-shaped (Fig. 591) and, finally, at the
meatus it appears as a vertical slit, the color of the mucous membrane
changing tiY)m a pale pink to a purplish bue.

Fio. 587. FiG. 388.

Fio. 587. — The appearance of the membranous uretha. (After Stem.)
FiG. 588. — The appearance of the bulbous urethra. (Afier Slem.)

In examining the urethra through the urethroscope it should be
first ascertained whether the normal elasticity of the canal is impabed
or not. This is accomplished by noting the centrai figure as the tube
is withdrawn. In chronìc inflammatory conditions the urethra

URETHROSCOPY. 557

becomes more or less rigid and does not immedìately collapse over
the end of the urethroscope as it is withdrawn; instead, the cone-like
centrai figure often becomes elongated or else distorted from being
contracted at certain points, if the inflammation is a localized one,

FiG. 589. Fio. 590.

Fio. 5S9. — The appearance of the perìneal portion of thespongyurethia. (After Stem.)
FiG. 590. — The appearance of the uiethra at the penoscrotal junction. (After Stem.)

and, in addìtion, the whole mucous membrane in such cases not
infrequently becomes of a paler hue than normal. Changes in the
appearance of the mucous membrane should also he noted. In
chronic urethrìtis there will at times he found localized congested
areas, granular patches which frequently bleed, and superficial ulcera-

Fio, sgi. — TTie appearance of the pendulous urethra. (After Stem.;

tions covered with secretion. Infiamed lacunse appear as red openings
bpon the surface of the mucous membrane from which will frequently
be seen exuding drops of pus. Retention cysts, polypi, etc, are
readily diagnosed by this means. If, during the examination, it is

558 THE UBETHHA AND PROSTATE.

desired to more closely study the condition of the mucous membrane at
aay particular spot thls may be accomplished by pushing that part
into the field by digitai compression upon the urethra below the end of
the urethroscope.

After removal of the tube the anterior urethra should be irri-
gated with a wann saturated borie acid or normal salt solution, and,
if the instrument has been passed into the deep urethra, the bladder
should also be inigated.

nRETHROSCOPY UT THE FEHALE.

The female urethra being shorter and capable of greater distention
than that of the male lends itself more readily to examination by the
urethroscope,

Instniments. — Short male endoscopie tubes or a regular female
urethroscope may be employed. They may be obtained with the
iight at the distai end or, as in the Kelly tubes (Fìg. 592), with the

Fio. 593. — Kelly's urethral tube-speculum.

Iight 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 provided
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

URETOROSCOPY m THE FEUALE. 559

immersion in a i to 20 carbolic acid solution and then rinsed off in
alcohol. The vulva and the extemal 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.
Pontion of Patient. — The dorsal posture is employed,
Anesthesia. — If the urethra is hyperesthetic, a small pledget of

Fio. 593. — Kelly's cone-shaped urelhial dilator. (Asbtt

cotton saturated with a 2 per cent, solution of cocain is placed in the
mouth of the urethra for a short lime before the operation.

Technìc. — The urine is voided naturally before the examination
begins. If necessary, the meatus is dilated sufficìently to adrait a good-
sized tube by means of a Kelly dilator (Fig. 594). The instrument,
with the obturator in place and well lubrìcated, is then inserted into

Fig. 594. — Showing the melhod ot dilating the urethra. (Ashton.)

the mouth of the urethra and is carefuUy passed into the bladder (Fig.
595). The obturator is next removed and the lightìng apparatus is
properly adjusted. The instrument is then gradually withdrawn
while the examiner notes the condjtion of the mucous membrane as it
falls over the end of the tube (Fig. 596).

At the internai urethral orifice there appears through the urethro-

560 THE URETHRA AND PROSTATE.

scope a large opening surrounded by a narrow ring of mucous mem-
brane. As the in5trument is withdrawn the centrai figure becomes
first more ovai and then lower down appears as a transverse slit with
the mucous membrane thrown into folds that radiate to the periphery.
Finally, at the extemal orifice the centrai figure appears as a vertical
slit, while the mucous membrane appears thrown into a number of

Fio- S95- Fio. 596.

Fio. 595. — Introduaion of the urethroscope into ihe female urathra. (Ashton.)
FiG. 596. — Showing the method of inspeeting thefemale urethra through theurethroBcope.
(Ashton.)

radiating folds. A posterior fold is especialty marked in the upper
portion of the canal; it is a continuation of the trigone.

The points to be noted in the ezamìnation have been sufficienti/
dealt with under the technic of male urethroscopy and will not be
repeated bere.

Therapeutic Measares.

HARD INJECTIONS FOR THE URETHRA.

The injection of soIutions into the anterior urethra by means of a
small band syringe is eraployed either for simple cleansing purposes in
preparation for the passage of urethral instniments or for the purpose
of treating anterior urethritis. The efficiency of injections in lìtnìting
acute gonorrhea is a question and it is doublful if they have much
effect outside of removing the irrìtaling discharges and cleansing the
mucous membrane. They may, however, be prescribed in the acute

HAND INJECTIONS FOR THE URETHRA.

561

stages in the form of mild antiseptic solutions to be used by the patient
himself as an adjunct to hrigations carried out by the physician. In
the declming 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 ali the folds and depressions of the mucous membrane,
it is important that the fluid, should not be mjected into the bladder,
which, however, rarely happens, as the cut-oflF 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 epididymitis. 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 ce). 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 employied, a few of which are gi ven :
36

$62 THE URETHRA AND PROSTATE.

Sedative InjecHons.

I^. FI. ext. hydrastis, n^xx-xxx (1.2-1.9 ce.)

Aquae desti!., 5i (30 ce.)

I^. Morph. sulph., gr. vili (0.52 gm.)

Coeainse, gr. iv (0.26 gm.)

Mue. aeaei£, Si (30 e.e.)

Aquas distìl., q. s. ad Sii (60 e.e.)

Astringent InjecHons,

I^. Zina sulphatis, gr. iv-viii (0.26-0.52 gm.)

Aqiue distil., Siv (120 e.e.)

IJ. Zind sulphoearbolatis, gr. vi-xii (o . 4-0 . 78 gm.)

Aquas distil., Siv (120 e.e.)

I^. Plumbi aeetatis, gr. iv-xii (0.26-0.78 gm.)

Aquas distil., Siv (120 e.e.)

IJ Zind ehlorìdi, gr. ii-iv (o . 26-0 . 52 gm.)

Aquae, . Siv (120 ce.)

I^ . Zinei aeetatis, gr. i-xv (o . 065-0 . 9 7 gm. )

Aqua rosae, Si (30 e.e.)

AntHeptic Injections.
IJ. Sol. protargol, 0.25 to i per eent

I^. Sol. argyrol, 10%

I^. Sol. potass. permanganat., 1-5000 to 3000

IJ. Sol. biehlorìd of mercury, 1-30,000

Temperature. — The solution should be used at about the temper-
ature of the body.

Quantity. — Only sufl5cient quantity of the solution to distend the
anterior urethra should be injected at a time. At first only about
5i (3.75 C.C.) should be used at a time; later this may be increased to
5iiì (11 C.C.).

Frequency. — ^The injections should be used three to sìx 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 may
prevent a discharge from entirely disappearing, and it is necessary to
stop them 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 oflF with soap and water, foUowed by a i to 5000 solution of
bichlorid of mercury.

HAND INJECTIONS FOR THE UKETHRA. 563

Technic. — The patient urinates immediately before the injection
is given so as to wash out as much of the discharge as is possibk and
also that he may not bave to urinate soon afterward, thus allowing
the solution to remaìn in contact with the urethra as long a time as

FlG. 599. — Second step In injection of the urethra, holding Ihe solution in the urethra.

The syringe is then filled with from i to 2 drams (3 . 75 to
7 . 50 C.C.) o£ solution, and any air is expelled by dcprcssing the piston
while the tip is elevated. The penis is held back of the corona between
the thumb and forefingcr of the left hand, while with the righi band .

504

THE URETHRA AND PROSTATE.

the nozzle of the syringe is inserted into the meatus, and the solution is
gently injected into the urethra and immediately 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 five minutes so as to
keep the solution in contact with the mucous membrane (Fig. 599).
The solution is then allowed to run out into the receptacle provided
for the purpose.

IRRIGATIONS OF THE 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

Fig. 600. — ^Valentine irrigator and Chetwood's urethral irrigating nozzle.

eflfective large quantities of fluid must be used and the urethra must be
so distended that the solution comes in contact with ali 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 authori-

IRRIGATIONS OF THE URETHRA. 565

ties oppose this form o£ treatment on the ground that it increases
the dangers of prostatic mfection 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 rubbertubing,
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.

Fio. 601. — Syiinge and catheter for irrìgating 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

Bichlorìd 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 ce.) 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
suflScient.

566 THE URETHEA AND PROSTATE.

Helght of Reservolr. — The reservoir should not be raised above 4
feet {120 cm.). Such an elevatìon will give ali the necessary distentìon
of the urethra without forcing the solution beyond the anterior urethra,
If it produces pain, the pressure should be lessened by lowerìng the
reservoir or partially pinching oEf the inflow tube.

Posltton of Pattent. — For anterior ìrrigations the patient may stand
or be seated upon the edge of a chair, whUe for a posterior irrigation
the patient should be lying down.

Preparattoa of Pattent. — For protecting the clothes the patient
should wear a rubber apron in which is provided an opening for the
penis (Fig. Ó02). The glans penis and lips of the meatus should be

Fic. 603. — Aproa for protecting the patient during a uiethral inigation.

washed ofi wilh soap and water, followed by a i to 5000 bichlorid of
mercury solution.

Technlc. — I. Anterior ìrrigations, — The patient should empty hìs
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 ìnto 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 lu^thra is filled with
solution the inflow tube is again pinched, at the same time removing
the little finger and thus opening the outflow tube, By thus alternately
opening or shutting the inflow tube, and at the same time shutting or
opening the outflow, the urethra is alternately distended with solution
and emptied without the necessity of removing the nozzle. It takes

ntRIGATIONS OF THE UBETHRA. 567

about five minutes to thus irrigate the urethra with i quart (i Uter) of
solutioD.

2. Posterior Irrigalions. — The anterior urethra is first irrigated as

Fio, 60J. — Meihod ot giving an anterior urethr»! irrìgation.

Fic. 604. — First step in irrigating the posterior urethra. Catheler is insertcd into the
bladder until urine begini to flow.

just describeA A No. 12 to i8 French catheter, well lubrìcated with
one of the Iceland-moss preparations, ìs then inserled into the urethra
with the eye upward until urine just escapes (Fig. 604). After the

S68 THE UBETHRA AND PROSTATE.

bladder is emptied, the catheter is then withdrawn i inch (2,5 cm.)
until its poÌDt lies in the prostatic urethra and from 4 to 12 otmces (i 18
to 355 C.C.) of the antiseptic solution are gently injected (Tìg. 605),
The posterior urethra is thus washed backward toward the biadder.

Fio. 605. — Second slep ìd irrigating the posieiior urethra. The catheter is uithdrawn
untìl ils tip lies in the deep urethra and the solution is then injected.

The catheter is then removed and the patient is instructed to void
the contents of his bladder, thus gi^ing a final washing from behÌDd
forward to both posterior and anterior urethrae.

raSTILLATIONS.

Instillations are employed when it is desired to medicate the urethra
with small quantities of strong solutions. They are indicaied in chronic
gonorrhea, but should not be used in acute cases; they are specìally
useful in chronic posterior urethritis. The object of such injections
is to induce a hyperemìa of the tissues; that is, to substitute an acute
inflammation in place of the chronic one with the hope that it will be
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 applied
to the anterior or posterior urethra. Instillations should not be
employed in cases where injections or irrigatìons of weak solutions are
followed by irritation, and they should likewise be avoided in posterior
urethritis when the prostate and seminai vesicles are the seat of an

mSTILLATIONS. $69

acute inflammation. Instillations are also valuable in the treatment
of sexual neurasthenia when inflammatory lesions are present in the
posterior nrethra.

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 centrai opening, to the proximal end of which is
attached a large hypodermic syringe with the piston graduated in
minims.

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 Empioyed. — 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 per cent.

Thallin sulphate, 3 to io per cent.

Copper sulphate, i to 4 per cent.

Protargol, 0.25 to io per cent.

Ichthyol, 2 to IO 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 ce.) 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 imtil ali irritation from the first has subsided.

Position of Patient. — ^The patient should be lying down upon a
bed or table.

570

THE URETHRA AND PROSTATE.

Technic. — i. Posterior Instillations. — The patient should void his
urine previous to the instillation, and the anterior urethra is first
cleansed by an injection of weak antiseptic solution. The syxinge,
fiUed with the desired amount of solution, and with the nozzle well
lubricated with some nonoily lubricant, as one of the Iceland-moss
preparations, is carefully introduced in the same manner as one would
pass a sound (page 540) until its point lies behind the compressor
urethrae muscle in the membranous urethra (Fig. 607). This will be

FiG. 607. — Showing the syringe in position for a deep urethral instillation.

at a distance of about 5 i /2 to 6 inches (14 to 15 cm.) from the meatus
or roughly when the shaft of the instrument is at an angle of 45 degrees
with the horizon. From 5 to 20 drops (0.3 to i . 25 ce.) of solution are
then slowly injected. Care must be taken in removing the nozzle of
the instrument to avoid having any solution drip from the point along
the anterior urethra. To avoid this, the piston of the syringe should
be withdrawn slightly before the nozzle is removed.

Generally there is considerable buming upon urination foUowing
a posterior instillation and at times there may be pain and tenesmus
and some discharge during the first twenty-four hours. As a rule,
these symptoms subside within six to twenty-four hours. If the
reaction is severe, however, the j)atient should remain quietly in bed

APPLICATION OF OINTBiENTS TO THE URETHRA. 571

and an opium suppository should be introduced into the rectum and
beat applied to the perineum.

2. Anterior InstUlations. — 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 (i . 25 ce.) 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 wom 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-fiUing
elastic band placed behind the corona.

APPLICATION OF OINTMENTS TO THE URETHRA.

Astringent and stimulating ointments are at times employed in the
treatment of chronic urethritis instead of instillations. They are 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 soimd (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 hoUow curved catheter-like nozzle and a

plimger for forcing the ointment out at the end.

Formulary. — Unna's ointment for use with sounds consists of:

I^. 01. cocae, 3iii (89 ce.)

Cene flav., 5ss (i .95 gm.)

Argent. nitratis, gr. xv (0.97 gm.)

Bals. peruviani, 3ss (i .9 ce.) M.

572 THE URETHRA AND PROSTATE.

The mixture is melted over a hot-water bath and the sound is then
dipped into it and the ointment is pennitted to solidify by cooling.
Finger 's ointment consists of:

^. Argent. nitratis or cu. sulphatis, gr. xv (0.97 gm.)
01. olivae, 5iss (5.6 ce.)

Lanolin, 5iii (89 ce.) M.

Another consists of :

^. Pot. iodidi, 3ss (1.95 gm.)

Iodi, pur., gr. v (0.32 gm.)

01. olivae, 3ss (i .9 e.c)

Lanolin, Si (30 e.e ) M.

Preparations. — The patient's bladder shouid be empty. The
glans penis and meatus are washed with soap and water, foUowed by
a I to 5000 bichlorid of mercury solution, and the urethra is cleansed
by an injection or imgation.

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 fiUed with the ointment, and it is
passed through the urethra and is left in place about five minutes.
The ointment melts and thus medicates the entire urethral mucous
membrane.

In employing a special ointment carrier the instrument is partly
filled with the ointment and, after being well lubricated, it is passed as
far as the diseased area. The piston is then inserted and is pushed
through the instrument forcing the ointment out the end into the
urethra.

THE URETHROSCOPE IN THE TREATMENT OF URETHRAL

DISEASES.

By means of the urethroscope or an open wire speculum (Fig. 610)
lesions in the urethra may be accurately located and efforts at treat-
ment can be thus focused on the exact seat of the disease. Endo-
scopie treatment is thus of great value in the presence of localized
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 the
aid of suitable instruments, strong applications may be made to granu-
lar patches, erosions, and ulcerations; suppurating glands or foUicles

URETHROSCOPE IN THE TREATBiENT OF URETHRAL DISEASES. 573

may be inciseci and small growths may be removed from the canal
under direct vision.

The technic of using the urethroscope has previously been fuHy
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 speculimi.

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 locai 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

Fio. 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 io gr. (0.32 to 0.65 gm.) to the ounce (30 ce).
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.

Fio. 6i2. — Urethral knlfe.

Areas of induration may be incised through the urethroscope by
means of a urethral knife (Fig. 612). Two or 3 drops of a 4 per cent.

Fio. 613. — Kollman*s urethral syrìnge.

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

Fio. 614. — Urethral duret.

then be made without pain. In the same manner abscesses of Littré 's
glands or inflamed foUicles may be opened. A discharging crypt or

Fio. 615. — Urethral snare.

foUicle may be injected every few days with a few drops of a peroxid
of hydrogen solution by means of KoUman's syringe and cannula

DIRECT APPLICATION OF COLD TO THE URETHRA.

575

(Fig. 613). Polyps and papillomata may be removed by a urethral
curet (Fig. 614) or by caustics. If pedimculated, a wire snare (Fig.
615) or the galvanocautery snare may be employed. In any case the
area of operation should be first cocainized in the manner above
described.

THE DIRECT APPLICATION OF COLD TO THE URETHRA BY

THE PSYCHROPHORE.

In the treatment of spermatorrhea and sexual neurasthenia where
the urethra is congested or hyperesthetic the direct application of cold
to the deep urethra by means of the cold- water sound or psychrophore
is often of value. An ordinary cold somid is also employed in treating
such conditìons, but is not so efifective, as the instrument soon becomes
warm from contact with the urethra. With the psychrophore it is
possible to keep a continuous cold application in the urethra as long
as is desired.

Fio. 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 in place for
from five to ten minutes at a sitting.

Frequency. — Treatments may be given daily or on alternate days.

Tedinic. — An instrument as large as the normal caliber of the
urethra should be used. It is well lubricated and gently inserted m
the same manner as a sound (page 540) until the curved portion lies
in the membranous and prostatic portions of the urethra. The tubing
from the reservoir is then connected with the inflow canal and a current*
of cold water is allowed to pass through the instrument, escaping from
the outflow canal into a basin provided for the purpose. In this way
the hyperesthetic urethra is exposed to the mechanical effect of the
sound and the sedative action of cold.

PROSTATIC HASSAGE.

Massage of the prostate gland by means of the fìnger in the rectum
is frequently employed, and with good results, in the treatment 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
seminai 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 foUowed by irritation, treatments may be
given once every four or five days.

Position of Patient. — The operation may be performed with the
patient bending forward over a chair or in the knee-chest position.

Technic. — If possible, the patient's bladder should be full. The
operator wears a rubber giove on the right hand or a fìnger cot on his
right index-finger and, after lubricating the index-finger well, intro-
duces it into the rectum (Fig. 617), carrying the 'finger high up on one
side over the seminai vesicle. Finn but gentle pressure is then made
with the finger over the seminai vesicle and the fìnger is slowly drawn

FSOSTATIC UASSAGE,

FtG. 617.— Poàtioa of the patient and method of introdudng the finger iato the re
prostatk massage.

Fio. 618. — Sbowing the method of masuging the piostatc

578 THE URETHRA AND PROSTATE.

down over the vesìcle tòward its duct and also over the corresponding
lobe of the prostate (Fig. 618). This procedure is then repeated upon
the opposite side, and finally over the centrai portion of the gland.
Ali portions of the gland are thus massaged, but special attention should
be paid to those portions that are enlarged or diseased.

After completing the massage the patient urinates, thus emptying
the bladder of pus and débris 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 properly performed, it is an operation wìthout danger.

Instruments. — The incision is best made with an Otis meatome
(Fig. 619) or with an ordinary blunt-pointed straight bistoury.

Fio. 619. — Otis' meatome.

Location of Indsion. — ^The meatus should be cut exactly in the
median line upon the ftoor of the urethra.

Preparations. — The glans penis and meatus should be washed
with soap and water foUowed by a i to 5000 solution of bichlorid of
merciuy. The anterior urethra should be irrigated with a saturated
borie 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).

Technic. — The operator retracts the foreskin and, stead)dng the
penis between the thumb and forefìnger of his left hand, inserts the
knife, with the cutting-edge down, into the urethra for a distance of
1 iJ2 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
sufficiently enlarged. If it is found upon inserting an instrument that
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 controlied by inserting a plug of ganze for an inch
(2 . 5 cm.) or so without the meatus. Each time the patient nrinates
this plug is removed and a fresh one ìnserted. 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 instrumentai 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
mrethra include graduai dilatation, continuous dilatation, and
cutting the stricture either from within — internai urethrotomy — or
from without — extemal urethrotomy. Two other methods, namely,
divulsion and electrolysis, which are sometimes described in téxt-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 ne ver 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
radicai 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 foUowed by pain and spasm resulting in
retention of urine, those in which the passage of instruments is foUowed
by chills and fever, those complicated by numerous false passages and,

580 THE URETHRA AND PROSTATE.

suppurating fistulous tracts, and ali strictures near the meatus should
be cut. For strictures complicated by cystitis, intermittent dilatatici!
is likewise undesirable on account of the dangers of pyelonephritis;
these require cutting of the stricture and free drainage of the bladder.

Before making any attempt to treat strictures, the number of
strictures, their exact location, their size, and their extent should be
determined by instrumentai exploration of the urethra, and sufficient
time for the tissues to react — at least seventy-two hours — should elapse
after such an examination before the dilatation is begun. Strictures
may occur at any point in the canal except in the prostatic urethra,
but the most frequent sites are: (i) in the region of the bulbomem-
branous junction, (2) within 21/2 inches (6 cm.) of the meatus, and
(3) near the penoscrotal junction. They may be single or multiple,
and in shape annular or tortuous. The opening is seldom situated
in the center of the stricture, but generally lies to one side of the
median line of the urethra.

AH strictures ha ve a tendency to contract and in time cause more
or less impediment to the urinary flow with serious results to the whole
urinary tract. The urethra immediately behind the stricture is the
first to feel the effects of this obstruction and the canal at this point
becomes more or less dilated and the mucous membrane is thinned
out. Urine collects in this dilated portion and decomposes, with the
result that an inflanmiation is set up accompanied by a gleety discharge.
This may in time go on to ulceration and extravasation of urine with
the formation of false passages and fistulae. The eflfect of the urinary
obstruction is also felt upon the bladder. It first hypertrophies and
may later become thinned and dilated, and it is not unconunonly 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
bome in mind that the stricture itself is usually congested and the
mucous membrane is softened and inflamed, so that in perfortning
dilatation the greatest care and genileness are necessary to avoid
lacerating and coniusing the already irritated tissues. Roughness or
carelessness in introducing the instrument can do only harm. The
beneficiai effects of dilatation depend not only u]>on the mechanical
distention to which the urethra is subjected, but also upon the simple
presence of the instrument which stimulates the tissues to a mild reac-
tionary hyperemia, which is accompanied by softening and absorptioa

TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. 581

of the scax tissue. If more than this is done, that is, if the tissues axe
so irritateci that an inflammation is induced, the value of the treatment
is lost and the originai 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 doublé 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 eflfected

Fig. 621. — Double-taper steel sound.

without imduly stretching the meatus. For strictures in the pendulous
lu-ethra 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 urethra.

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 dilatmg tight strictiu-es whalebone filiform bougies and tun-
neled sounds (Fig. 624) should be provided. The filiforms should
be at least 18 inches (45 cm.) long and of such size that the tunneled
sounds will easily slip over them. Care should be taken not to use
rough or split filiforms. In fact, any instniment, no matter what the
variety, must be perfectly smooth and sound; imperfect Instruments
should be discarded as unsafe.

Fig. 624. — Gouley tunneled sound and filiform.

Asepsis. — The strictest asepsis should be observed in regard to
the instruments used. Metal Instruments should be boiled for five
mlnutes in a i per cent, solution of sodium carbonate. Filiforms and
the newer gum-elastic instruments will stand moderate boiling. They
may also be sterillzed by formaldehyd vapor, after which they should
be well rinsed in sterile water; or they can be immersed first in a i to 20
carbolic solution and then in a saturated solution of borie acid.

The glans and meatus should be washed with soap and water
foUowed by a I to 5000 bichlorid of mercury solution. The urethra Is
irrigated both before and after each treatment with a saturated solu-
tion of borie acid or a i to 5000 permanganate of potash solution, and,
if the bladder Is infected, It should likewise be irrigated, provided the
strlcture is sufiìciently large to admit a catheter.

The same regard to cleanliness should also apply to the operator's
hands.

Rapldity of Dilatation. — ^This can only be determlned by a study
of the individuai case. It Is Important, however, not to do too much
dilating at a time. It phould not be carrled to a point where dlscom-
fort or pain Is caused. If the stretching Is too rapid, It practlcally
amounts to divulsion with Its attendant risks of Inflammatlon and
sepsis. Furthermore, tearing of the strlctiu-e results in new formatlon
of tlssue which in tum contracts. In the case of tight strictures the
Introductlon of a second instrument after the first Is sufliclent. In
other cases the dilatation may be carrled further, using three or four
instruments in ali.

Frequency of Treatment. — ^After the passage of an Instrument a
reactionary hyperemia sets In and this should be given time to subside

TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. 583

before instruments axe reintroduced. A lapse of three to seven days
shoiild, therefore, occur between treatments — on an average an Inter-
vai 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 ha ve
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 óf the stricture to the size of the
meatus, provided it is of normal caliber, is sufificient.

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. — Locai anesthesia is only necessary where the patient
is nervous and the urethra hyperesthetic, or upon the first passage of a
soimd after urethrotomy, as properly introduced instruments should
ordinarily cause no pain. In such cases the urethra is well distended
with a 0.2 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 will be con-
sidered strictures above 15 French in size. A sound óf 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 foUowing 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 caref ully inserted into the urethra. 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 DRETHKA AND PROSTATE.

is pusbed onward and downward, the handte of the ìnstrument ìs grad-
uaJly swept to the center line (Fig. 626) and is then slowly raised to a
perpendicular so that ìts beak passes beaeath the pubic arch (Fig. 627)

Fio. 03$. — First step in passing a sound.

into the membranous urethra. Unless the stricture be in the deep
urethra, it is not necessary to insert the sound into the biadder — the
ìnstrument should simply be passed through the stricture. To insert

Fic. 626. — Second step in passing a sound.

the Ìnstrument the full distance, the handle is brought forward and

downward between the thighs {Fig. 628). When the point of the
sound reaches the stricture, the utmost gentleness in manipulation

TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. 585

should be used in engaging it in the stricture, and no attempi to
enforce the instniment along should be made, until it is certain that its

Fio. 637.— Thiid «ep in pasaog a sound.

FlG. 638, — Fourth step in pas^ng a sound.

point has entered the opening in the stricture. Having passed the
sound entirely through the stricture, it is removed by a reversai of these

5 86 THE URETHRA AND PROSTATE.

steps and a second one is introduced. If this causes pain or spasm, it
is immediately withdrawn, and no immediate further attempt to
dilate is made. If, however, the urethra tolerates the second in-
strument, a third one may be introduced.

At the next sitting the dilatation is begun by inserting a sound one
size larger than the first instrument used at the previous treatment,
and the dilatation is increased one or two sizes as before. In this way
the treatments are continued imtil the desired degree of dilatation is
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 foUow the
removal of the instrument. The next act of urination is apt to be
painful, and not infrequently the gleety discharge is increased for
twenty-four or forty-eight hours. The patient should be wamed of
these symptoms beforehand.

Fio. 629. — Method of insertìng a flexibie bougie through a urethral stricture.

2. Small Strictures. — ^For small strictures, thatis, below isFrench,
soft bougies are employed. A bougie of a size that will readily enter
the strictiu-e is selected. The penis is held straight up and upon the
stretch in the fingers of the left hand after the manner described above,
and the bougie, well lubricated, is carefully passed straight down to
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 lu-ethra, the bougie should be
introduced bent as much as possible to the shape of a curved sound.

TREATMENT OF STHICTUSES BY INSTRUMENTAL DILATATION. 587

and, when the point reaches the bulb, slight pressure should be made
with the fingers on the perineum (see Fig. 572). When the instrument
strikes the face of the obstruction, gentle attempts are made to engagé
its point in the stricture, This accomplìshed, the instrument is
pushed on entìreiy through the stricture, and the dUatation is pro-
ceeded with in the same manner as when using sounds. Steel instru-
ments may be substituted for the bougies when the dilatation has
been carried as high as 15 French.

3. FUiform Strictures. — In the beginning of the treatment of a
fìliform stricture it often requires the greatest perseverence and skìll
to enter the bladder, as, frequently the stricture is of such small caliber
or the opening is so situated that it is extremely difficult to engagé
even a fine fìliform. Once, however, the filiform is inserted, the main
difficulty is surmounted. In introducing filiforms the same method
is employed as for straight bougies. The penis, gr&sped in the fìngers

by first filling the canal

of the operator's left band, is put upon the stretch and the filiform, well
lubricated, is inserted along the fioor of the canal. If the point of the
instrument is obstructed by a fold of mucous membrane or the opening
of some lacuna, ìt should be withdrawn slightiy and then slowly
reinserted. When the face of the stricture — the location of which has
been previously determined — obstructs the further advance of the
filiform the instrument should be slowly rotated about, making attempts
to engagé its point in the stricture the while, but without using any

$88 THE URETHRA AND PROSTATE.

force. Sometimes by distending the canal with warm oil it ìs possible
to enter the filiform in the opening of the strictiu-e. Failing with one
filiform, a second may be inserted beside the first one and the same
manipnlatìon is carried out as with the first. If stili unsuccessful,
additional filiforms are inserted until the urethra contains six or seven
of them. Then gentle attempts are made to pass each in tum, and
usually one will finally slip into the opening (Fig. 630), whence ìt can
be readily passed into the bladder. If, after a fair- trial, it is impossible
to insert an instrument, it is better to give up the attempt for the time
being, and try again a few days later. Sometimes upon a second or
third trial the opening will be readily located. Gentle manipulation
combined with perseverence will result in success in the great majority
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 the
filiform inserted by direct sight.

FiG. 631. — Method of pasàng a tunneied sound over a filiform.

Having finally passed a filiform, the smallest size tunneied sound
should be inserted over it as a guide (Fig. 631). If there has been
much manipulation in passing the filiform, the operator's efforts had
best stop at this, or, at the most, a second sound is introduced. At
the next sitting the filiform is again inserted and the dilatation in-
creased by inserting larger Instruments over it as a guide. After some
dilatation has been thus obtained, soft bougies may be substituted for
the filiforms and tunneied sounds, and the treatments may be carried
out as outlined above.

TREATMENT OF STRICTURES BY INSTRUMENTAL DILATATION. ^Sg

Acddents and Complicatlons Attending Dilatation. — There axe
several troublesome as well as serious complications that may follow
the passage of urethral instniments.

Shock. — In some cases, in spite of the utmost gentleness in manipu-
lation, the passage of a sound produces sufficient shock to cause the
patient to faint or collapse. It is more likely to occur in patients upon
whom an instrument is passed for the first time, especially if they are
of a distinctly nervous type and look upon the operation with fear and
apprehension.

Much may be done in preventing such a complication when the
nervous element is in evidence by avoiding pain through the use
of locai anesthesia. Should fainting occur, the patient's head is to be
immediately lowered and stimulants administered if necessary,

Urethral Chili and Fever. — ^A form of urinary septicemia spoken of
as urethral chili 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 chili 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 lu-ethral 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 stricture, prostatitis, or cystitis may follow as a result of injury
to the urethra or vesical neck from rough or careless introduction of
instruments or from failure to pay due regard to cleanliness. The
inflammation may extend, in addition, from the urethra down the
ejaculatory ducts and set up an epididymitis. In the presence of such
complications, attempts at dilatation should cease imtil 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 mie, indicates a false passage

590 • THE URETHRA AND PROSTATE.

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
usually stops of its own accord. If excessive, the patient should be
kept quietly in bed and cold applications should be applied to the
perineum.

False Passage. — Another accident that may result from the use of
urethral instruments is the formation of a false passage by forcing
the instrument through the urethral wall into the surrounding tissues,
It is more liable to happen when using rigid instruments of small size
and probably occurs more frequently than is recognized. When a
false passage is made, there will generally be free hemorrhage at the
time or upon withdrawal of the instrument, and the patient will com-
plain of severe pain and may show signs of shock. At the same time,
the operator, while conscious that the instrument has passed the
obstruction, will recognize that the point is not in the urethra from the
direction of the handle. In such a case, if an examination is made by
the rectum, the point of the instrument will be «f ound in the perineum
near the rectal wall. Furthermore, the instrument, if it be a rigid
curved one, cannot be rotated about its own axis as would be the case
were its point in the bladder.

Following such an accident, if the patient can urinate, the treat-
ment should be expectant in the main; that is, he should be put to bed
and given urinary antiseptics and carefully watched. Should extra v-
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 ìnserting a filif orm or small bougie
through a strictiu-e and leaving it in place for twenty-four or forty-
eight hours. By the end of this period more or less absorption of the
stricture has taken place, so that there is some dilatation, and a larger
instrument may then be inserted. It is a method that may be some-
times employed for securing dilatation of tight strictures not amenable
to graduai dilatation, and is worthy of trial in such cases before resort-
ing to a radicai 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 tum lead to
cystitis. The method is contraindicated in the presence of cystitis
or if renai complications exist.

CONTINUOUS DILATATION. S9I

Instruments. — Filiform (see Fig. 563) or soft bougies (see Fig. 562)
may be employed.

Asepsls. — Rigid asepsis is, of course, imperative. The instrumetits
are to be sterilized as alieady described (page 539). The penis and
meatus are washed with soap and water, foliowéd by a i to 5000 bi-
chlorìd of mercury solution. The urethra shouid be irrigated with a
I to 5000 permanganate of potash or saturated borie acid solution, and
the bladder shouid be likewise irrigated with borie acid solution, if
possible, upon changing the instntments.

Tedmlc. — The ìnstrument is passed through the stricture after the
method already described for intermittent dilatatioa (page 586), and is
then securely fastened in place. There are several methods of doing
ihis, but the following is the simplest and most effective: Four pieces
of adhesive, each about 4 inches (12 cm.) long and 1 14 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
ali 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 penis. When a foreskin is present, it is drawn down over
the glans and each strip is carried over it and caused to adhere to '
the penis. An additiooal strip of adhesive i inch (3,5 cm.) wide

FiG. 6jj. — Showing the method o£ securìng a boupe or catheter in the urethra. (After
Sinclair, Palyclinic Journal, July, 1908.)

is placed borizontally about the penis just behind the corona cover-
ing the four small strips (Fig.632). This strip shouid not entirely
encircle the penis, thus avoiding any danger of constricting it Where
there is no foreskin, a piece of gauze shouid be interposed between the
glans and the small strips. A liberal sterile gauze dressing is then
wrapped about the peins and the protruding ìnstrument, and the
whole is supported by means of a T-bandage. The urine escapes
along the side of the bougie into the gauze, which shouid be changed
when saturated. Within twenty-four or forty-eight hours the bougie
is removed, and the stricture will be found sufEcientiy stretched to per-
mit the easy introduction of a larger Ìnstrument. This is left in for

59^ T^HE URETHRA AND PROSTATE.

the same length of time, and ui>on its removal graduai dilatation may
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 ìs drawn off. The bladder is then irrigated and the
catheter removed, but the filiform is secured in place as described
above. Usually xxrìnt will begin to pass along the bougie in a short
while, but if not it may be withdrawn as of ten as necessary by means
of a tunneled catheter.

CHAPTER XVIIL
THE BLADDER.

Anatomie Consideraiions.

The bladder is a musculomembranous reservoir for the reception o£
urine, l3Óng 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 ce), 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 well 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 ovai 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 seminai 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: extemal, middle, and internai. The extemal 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 internai vesical
sphincter. The internai layer is thinner than either of the others.
Some of its fibers are arranged longitudinally and others circularly.

38 593

THE BLADDES.

FiG. 633. — Showing the space above Ihe pubea throu^ whìch it is posàble 1
bladder withoul opening imo the peritoneum.

FiG. 634. — The interior of the bladder.
i.Trigone; a, orì&ce of ureter; 3, muscular layer; 4, mucou
urelerìc line; 6, prosiate gland.

DIAGNOSTIC 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
known as the trigone where it is always smooth. The mucous mem-
brane of the bladder is comparatively insensitive to touch when in a
normal condition, as it has a scant nerve supply, the most sensitive por-
tion being over the trigone. The trigone is a smooth triangular space
at the base of the bladder, the apex of which corresponds to the opening
of the urethra and the base to a line passing between the orifices of the
two ureters (Fig. 634).

The ureters pìerce the bladder wall obliquely and appear upon the
mucous membrane as round openings or ovai slits directed forward
and inwaxd. These orifices are from i to i i /2 inches (2.5 to 3.8 cm.)
apart and about i inch (2 . 5 cm.) from the beginning of the urethra.

Diagnostic Methods.

When examining a case of suspected bladder disease the symptoms
complained of should first receive careful attention. In addition to
the usuai questions, information hearing upon the act of urination
should be sought, ascertaining whether there is frequency of urination,
whether there is urgency, whether the act is difficult, whether pain is
present and, if so, its relation to the passage of urine, whether the force
or caliber of the stream is changed, etc, etc.

Frequency of urination is common in ali bladder affections where
the mucous membrane isinflamed. 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, whìle in the case of an enlarged prostate it is more
pronoimced at night. Frequent micturition may, however, occur
when the bladder is healthy, as in diabetes, in hysteria, in those who
drink large quantities of water, in those whose urine contains excessive
amounts of urie acid or oxalates, etc.

Urgency of micturition, or the feeling of being compelled to pass
urine the instant the desire is felt, points strongly to mflammation 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

590 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, pain
in bladder disease is felt over the pubes, in kidney disease in the loins.
A vesical calculus, however, will frequently cause pain in the head of
the penis. Pain at the beginning of urination, as a rule, points to some
obstruction to the outflow of urine or to inflanimation of the urethra,
or it may be the result of very irritating urine. If it occurs during
micturition, it may be caused by inflammation of the urethra, prostate,
or bladder wall. Pain at the end of urination occurs when a vesical
calculus is present or when there is inflammation involving the neck
of the bladder or the prostate. In acute prostatitis pain is also pres-
ent upon defecation. When pain is present in the intervals between
the acts of urination, it may be caused by a vesical calculus, tumors,
or prostatic abscess. When such pain is increased upon exertion and
entirely relieved by rest in the 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 or
an enlarged prostate. Changes in the caliber of the stream generally
point to stricture.- In the presence of enlarged prostate, disease of
the bladder wall, and in some nervous affections, the force of the
stream may be greatly diminished, so much so as to amoimt 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 invohang the bladder, kidneys,
or urethra. Even 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 the
lines detailed below.

The methods available for examination of the bladder include
urinalysis, inspection, percussion, palpation, soundìng, cystoscopy,
tests of the capacity, the sufficiency, and the absorption power of the
bladder, and the X-rays.

EXAMINATION OF THE URINE.

A complete chemical, microscopical, and bacteriological examina-
tion of the urine should be made in ali cases of suspyected disease of
the bladder or kidneys. The proper method of collecting the speci-

EXAMINATION 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 applies to vesical and renai
disease will, however, be briefly considered.

The quantity of urine passed normally by a healthy adult amounts
to from 35 to 50 ounces (1000-1500 ce.) 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 (oliguria). On the other hand, an
increased quantity of urine (polyuria) will be found in hysteria, in
the presence of interstitial changes in the kidney, from the use of diu-
retics, in diabetes, in renai 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
voided during twenty-four hours.

In diseases of the bladder the specific gravity is unafifected, but in
renai disease it may be markedly changed. A low specific gravity
and an increased output of urine, when the bladder is diseased, points
strongly to pyelitis or pyelonephritis.

The odor of urine is faintly aromatic, the more marked the greater
the proportion of solids. The taking of such drugs as copaiba, cubebs,
turpentine, and sandalwood modify this characteristic odor. In
diabetic coma the odor of the urine resembles that of chloroform from
the presence of acetone and diacetic acid. Urine that has imdergone
ammoniacal decomposition, as is frequently the case in chronic cystitis,
has the characteristic and offensive odor of stale urine. Urine coming
from a bladder which communicates with the rectum by a rectovesìcal
fistula has an odor of skatol. In the presence of ulcerations within
the bladder, especially ulcerating tumors, the urine will be foul-smelling
and may even ha ve a distinct odor of putrefaction.

598 THE BLADDER.

The color of the urine is a light or dark amber depending upon the
concentration. The presence of blood gives the urine a bright red or
reddish black hue, depending upon whether the hemorrhage is recent
or old. Bile gives a dark yellow or brownish color with a greenish
tinge. In chyluria the urine appears milky. Fevers render the urine
darker than normal. Various drugs may also modify the color, thus
Senna, rhubarb, and santonin may color the urine a golden-yellow or
deep red hue, methylene blue gives a greenish-blue color, and poison-
ing from carbolic acid, chlorate of potash, or creosote makes the urine
smoky or black.

Trans par ency, — Normal urine should be clear and transparent
when voided. In bladder diseases the urine is, as a rule, turbid. Tur-
bidity may be caused by urates, phosphates, -blood, pus, epithelium,
chyle, or bacteria. The turbidity caused by urates disappears upon
heating the urine, that due to phosphates clears up upon the addition
of one or twp drops of acetic acid.

In bacteriuria, as is seen after the passage of unclean Instruments,
the turbidity is slight and remains unchanged upon standing, upon the
application of heat, or in the presence of acetic acid. The condition is
readily recognized by the aid of the microscope.

The turbidity produced by pus is increased upon heating the urine,
and does not disappear upon the addition of an acid. Furthermore,
upon allowing such a specimen to stand a few hours, it will be found that
the pus settles to the bottom leaving the rest of the fluid clear. A
simple test for the presence of pus is to add a little solution of potassium
hydrate to the suspected specimen) in the presence of pus a gelatinous
precipitate is formed.

The reaction of urine is normally slightly acid. The acidity is in-
creased in fevers, gout, lithemia, rheumatism, chronic Brights disease,
etc, and upon a diet composed chiefly of proteids. A vegetable diet
and laxge quantities of fluids render the urine neutral or alkaline.

In diseases of the bladder the urine may be acid or alkaline, thus
in acute cystitis the urine is usually acid. In chronic cystitis it may
be either acid or alkaline, always the latter in the presence of ammoni-
acal fermentation, but when due to the gonococcus, tubercle bacillus,
or colon bacillus it is acid. In uncomplicated cases of pyelitis and
pyelonephritis the urine also has an acid reaction.

Albuminuria. — ^Albumin in the urine is not to be considered an
invariable sign of kidney disease. It will be foimd in any case ^th
blood or pus in the urine, and it is sometimes a difficult matter io
decide whether the albumin be due to an existing cystitis or is of renai

EXAMINATION OF THE URINE. 599

origin. Sometìmes the two wUl exist together. If the bladder alone
is affected, the albumin will be in proportion to the amount of blood or
pus present, and, as a rule, will be small in amount, rarely over o.i
per cent. In pyelitis the proportion is much higher.

Hematuria, — Blood in the urine may ha ve its source in any part of
the genitourinary tract, as the urethra, prostate, bladder, ureters, or
kidneys. While it is not always possible to determine the source of
the hemorrhage from an examination of the urine, there are certam
characteristic differences in hemorrhages from these different regions.

Urethral hemorrhage may arise from acute urethritis or inflamed
strictures, or may follow traumatism to the canal, the passage of instru-
ments, etc. In urethral hemorrhage, if the source is from in front of
the compressor urethrae muscle, the blood appears independently
of urination, and may escape from the meatus freely, in drops, or
in the form of long clots. If from the posterior urethra, the blood finds
its way backward into the bladder and, when of considerable quantity,
uniformly discolors the urine. If, however, the posterior hemorrhage
is slight, the first and last portions of the urine passed may be blood-
tinged while the intermediary portion will be clear.

Vesical hemorrhage may follow the sudden and complete emptying
of the bladder in retention, or it may be due to trauma, the passage of
instruments, varicosities, stone, inflammation, ulcer, tuberculosis,
tumors, etc. The urine in a recent vesical hemorrhage may be com-
paxatively clear at first, or only slightly discolored, becoming more so
as the bladder is emptied, until it finally has a bright red color or con-
sists of almost pure blood. It may contain large clots which ha ve no
definite shape, and, if long retained, they appear black and tarry. The
reaction of the urine is generally alkaline.

Renai hematuria may be due to inflammation, congestion, trauma,
stone, tubetculosis, tumors, the use of strong diuretics, etc, etc. The
blood will be thoroughly mixed with the urine, imparting to the latter
a smoky tint or deep red-brown color. It will be found that the cor-
puscles are greatly changed and without coloring matter, often appear-
ing as mere shadows, but in cases of ruptured kidney or in severe renai
hemorrhage from other cause, they may remain unaltered and the
urine will be much lighter in color. The urine during renai hemorrhage
and just after is generally acid in reaction unless the bleeding has been
severe or pus is present. Laxge clots are seldom formed unless the
blood coagulates after reaching the bladder, but there may be foimd
casts of the kidney tubules or cylindrical-shaped clots from the ureters.

A more positive diagnosis between hematuria of renai origin and

6oO THE BLADDER.

that of the bladder may be made by introducing a catheter and thor-
oughly washing out the bladder with a warm normal salt solution,
being careful to wash out ali the clots. If the blood is of renai origin,
the last washings will consist of clear fluid and will remain clear until
more blood flows from the ureters. If , on the other band, the bleeding
arises from the bladder, it will be found impossible to completely free
the fluid from blood.

By means of a cystoscopic examinatìon (page 6 io) the bladder may
be excluded as the source of the blood if it is found free from disease,
or it may be possible to see blood escaping from one or other ureter.
(See also the absorption test, page 609.)

Pyuria. — ^Pus in the urine is a common accompaniment of bladder
diseases and also those affecting the urethra and kidneys. Pyuria is
a symptom of suppuration or catarrh in the genitourinary tract; thus
it will be found in pyonephritis, pyelitis, tuberculosis, cystitis, urethritis,
etc. It is characterized by cloudy urine in which a thick yellow sedi-
ment settles upon standing.

A differential diagnosis between urethral pus and bladder pus may
be made by having the patient void his urine in two glasses (page 532.)
If the urethra is the source, the first glass of urine will be found cloudy
and the contents of the second glass clear or nearly so. When the
bladder is affected the contents of both glasses will be equally cloudy.

In deciding between vesical and renai pyuria, it should be bome in
mind that in the former condition the amount of albumin will be slight
and there will be no renai casts, but bladder epithelium will be found;
while in urine containing pus from the kidney albumin will be foimd
in a greater proportion than can be accounted for by the amount of
pus, and casts may be present. The use of the catheter or cystoscope
will, however, furnish more exact evidence as to the source of the
pyiuria.

To apply the first test, the bladder is thoroughly washed with
a warm normal salt or borie acid solution through a catheter until
the fluid retums clear. The catheter is then clamped and allowed to
remain in place ten or fifteen minutes, and what urine has entered the
bladder in the meantime is drawn off. If this last specimen is again
turbid we may conclude that the pus comes from the kidneys.

On cystoscopic examination, if the bladder be foimd free from
disease, this evidence points to the kidney as the source of pus. The
diagnosis may be made absolute if pus is seen exuding from the
ureters or a sample of urine obtained by ureteral catheterization con-
tains pus.

msPEcnoN.

mSPECTION.

Inspectìon of the bladder without the aid of instruments is extremely
hmited in value, By inspection of the abdomen, it is possible to recog-
nize a distention of the bladder, and, in the female, by means of a
vaginal inspectioD, some mforma.tion as to the condition of the floor of
the bladder raay be gamed.

Posltton of Pattent. — For ordmary abdominal inspection the patient
hes fiat on the back with the body uncovered from the umbilicus to the
knees, and with the legs extended in the same piane as the body.

For inspection through the vagina the patient should be in the
dorsal posture.

FiG. 6j5. — Vaginal iaspecdon of the bladder. (Asbtoti.)

Technlc. — i, Abdominal Inspection. — The examiner takes bis
position upon one side of the patient and carefuUy notes any change in
the size or shape of the hypogastrìum. A distended bladder appears
as an ovoid tumor with the narrow end down, situated above the sym-
physis generaUy in the median line.

2. Vaginal Inspection. — The examiner sits facing the vulva, and,
by retracting the perineum with the index-finger of the !eft band intro-
duced within the vagina (Fig. 635), the anterior vaginal wall is exposed
for inspection. In this way a displacement of the bladder, protrusion
from distention, or a vesicovaginal fistula may be recognized.

PERCUSSION.

Percussion of the bladder is chiefly of use in determining the pres-
ence or absence of distention. The percussion note over the hypo-

6o2 THE BIADDER.

gastrium is normally tympanitic, When the bladder becomes dis-
tended with fluid, there wUl be a fiuctuating tumor above the symphysìs
which gives a flat percussion note and tympany at the sìdes. If, how-
ever, coOs of intestine fili the space between the bladder and the abdom-
inal walI, as Is sometimes the case where the intestines become adherent
as the resuh of pelvic peritonttis, percussion will fumish but imperfect
information, as a tjanpanitic note may be obtained and yet the bladder
be distended, Any doubt as to the presence of distention should be
ìmmediately settled by passing a catheter into the bladder.

PALPATION.

■ In the case of thin individuai with relaxed abdominal walls pal-
pation will often give valuable information, but in fat or very muscular
patients it is of limited use. The palpation may be perfonned abdom-
inally or bimanually. The latter method yields the most valuable
information. Distention, foreign bodies, calculi, tumors, and tender

Fio. 636. — Abdominal palfiation of a distended bladder.

areas may be thus recognized, and an idea as to the thickness and sen-
sibility of the bladder walls may be obtained. It is an especially useful
method to employ in examining the bladders of children.

Digital palpation of the bladder by means of a fìnger introduced
through a perineal or suprapubic wound or through the urethra in the
female are methods now rarely employed for diagnosis alone, as we
ha ve other equally efficient and more simple means of examination.

Positlon of Patient. — For abdominal palpation the patient should
be in the dorsal fwsture with the thighs flexed and the body uncovered

PALPATION. 603

from the umbilicus down, This or the knee-chest posture may be
employed for bimanual examinatioti.

Anesthesla. — In stout indiviiiuals or those wìth rigid abdominal
walls, it may be ìmpossible to make a satisfactoiy bimanual examina-
tìon without the aid of general anesthesia.

Technlc. i. Abdominal Palpation. — The examiner stands uf)On
the left side of the patient, and, placing bis right band fiat upon the
abdomen just above the pubes, gently palpates the hypogastric region
by means of his finger tips. In thin individuais, if distcntion is present,
a fluctuating tumor will be recognized. By requesting the patient to
breathe deeply with the mouth open and at the same lime pressing the
ubar border of the band deeply toward the pelvis, it is often possible

Fio. 637, — Bimanual palpation o£ the bladder.

to outline theswellingof a distended bladder more distinctly (Fig. 636).
Such manipulation will frequently cause the patient to evince a desire
to urinate.

2. Bimanual Palpation. — The bladder should be first emptied.
The index-finger of the right band or the index and middle fingers, if
possible, are introduced into the rectum in the male or the vagina in the
female, after first being well lubricated. The tour fingers of the left
hand are then placed above the symphysis, and, while they make counter
pressure toward the base of the bladder, the entire viscus is palpated
bimanually (Fig, 637).

6o4 THE BLADDER.

SOUITDING.

Palpation of the interior of the bladder by means of a suitable
sound is a method of exploration employed in cases of suspected stona,
foreign bodies, or tumors. The sound is also of value in testing the
sensitiveness of the bladder walls and in estimating the amount of
intra vesical enlargement of the prostate (page 537) and in the diag-
nosis of cystocele in the female.

While sounding is a fairly reliable method in searching for a stone,
there are certain difEculties and sources of error that should be bome
in mind. A stone may be encrusted with blood and mucus and so be
missed entirely, or it may be encysted with only such a small portion
exposed that it may be difEcuIt to reach it, or it may lie behind an
enlarged middle lobe of the prostate. Very small stones may likewise
be missed or they may be so light that the slight shock imparted by
contact of the instrument is unnoticed. A tumor or a contracted
thick bladder wall encrusted with lime salts or phosphates may give
a sensation that is conf used with the click of a stone.

Instruments. — ^For soimding the male bladder a Thompson metal-
lìc searcher (Fig. 638) is employed. This instrument has a fairly

FiG. 638. — Thompson stone searcher.

large beak, flattened from side to side, which joins the shaft at the
angle of 120 degrees. The shaft should be slender— 12 to 15 French
scale — so it can be readily moved back and forth or rotated from
side to side within the urethra. The handle of the instrument is
supplied with a guide which indicates the direction of the beak.

Asepsis. — The sound is boiled for fi ve minutes in a i per cent
sodium carbonate solution. The extemal genitals are cleansed with
soap and water foUowed by a i to 5000 bichlorid of mercuiy solution.
The hands of the operator should be sterilized in the usuai way. The
urethra should be irrigated with a saturated solution of borie acid or
a I to 5000 permanganate of potassium solution. The bladder is
emptied and irrigated with borie acid solution.

Position of Patient. — The patient should be in a recumbent position
with the hips raised several inches higher than the head and the thighs
extended fiat.

SOUNDING. 605

Preparatioiis of the Patient — The rectum should be empty. About
4 oiinces (120 C.C.) in an adult and 2 oiinces (60 ce.) in a child of
a saturated borie acid solution or a normal salt solution should be
introduced into the bladder, so as to permit easy movement of the
searcher and to prevent the stone from being concealed in the folds of
mucous membrane.

Anesthesia. — ^As a mie, no anesthesia is necessary. In sensitive
cases the instillation of a few drops of a 2 per cent, solution of cocain
into the posterior urethra will suffice, or the bladder may be filled
with 5 ounces (150 ce.) of a warm o. i per cent, solution of cocain to
which is added 20 drops (i . 25 ce) of adrenalin chlorid. This is to
be retained fifteen to twenty minutes. If the bladder is extremely
irritable and the patient nervous, a general anesthetic may be adminis-
tered. In children anesthesia is always necessary.

Tcchnic. — The instrument is well lubricated with lubrichondrin
or one of the other Iceland-moss preparations and is introduced in the
same manner as a sound (page 540). When the beak of the instrument
reaches the triangidar ligament, the fingers of the left hand are applied
to the perineum and assist in guidmg the point into the opening. The
handle of the soimd is then brought down between the thighs and the
instrument is at the same time gently pushed into the bladder. As the
instrument traverses the fixed curve of the urethra, pressure should be
made over the region of the pubes to relax the suspènsory ligament of
the penis (see Fig. 569). To be sure the point is within the bladder,
the instnunent should be introduced a distance of about 8 inches
(20 cm.).

A systematic examination of the entire bladder is then performed.
The instrument, being held lightly between the thumb and the fore-
finger of the right hand, is first inserted to the full length, and is then
slowly withdrawn, rotating the beak from side to side, so that the point
of the sound is brought into contact with every portion of the bladder
Wall. In this way any thickness or rigidity of the bladder wall, as is
found in hypertrophy, chronic inflammatory conditions, and in the
presence of finn growths, may be recognized. In the same manner
sensitiveness of the organ may be tested. Normally, the bladder has
but little sensation to touch except in the region of the trigone. In
cases of posterior urethritis this region may be markedly hyperesthetic
Locai areas of increased sensitiveness point to ulceration or new growths,
while in cases of cystitis the entire bladder will be sensitive.

In examining for suspected stone the search should be carried out
in the same systematic manner, carrying the instrument to the fundus

6o6 THE BLADDER.

first and then tapping each lateral wall in succession as the instrumebt
is wìthdrawn to the vesical neck. The upper wall of the bladder is then
palpated by depressing the handle of the instrument weli down between

'1>

Fio. 639. — Palpatìon of a stone lodged above the vesical opening.

the thighs, and as an aid the bladder wall may be depressed toward the
instrument by means of the free hand placed above the pubes. In
this way a stone located above the vesical opening may be located

(Fig. 639). The beak of the sound is then rotated and tumed down-
ward. In doing this, if the point catches in the mucous membrane,
the handle should be depressed so as to lift the beat clear of the floor.

TEST OF TBE BLADDER CAPACITY. 607

THe posterior prostatic region is then explored. Shouid the prostate
be enlarged, the handle of the instrument shouid be raised somewhat,
and, with a finger in the rectum, it will be possible to bring a stone, if
one is present, within reach of the instrument (Fig. 640).

When the sound strikes a stone, the examiner will recognize the
fact by a distinct click that may be heard as well as felt. Some idea
as to the consistency of the stone may be gained from the sharpness
of the ring; a high-pitched metallic click generally indicates a hard
stone (oxalate), while a dull low-pitched sound would indicate a soft
stone (urate). It is also possible to determine whether a stone is
rough or smooth from the sensation imparted as the beak of the instru-
ment is drawn over its surface. If possible it shouid be ascertained
whether a stone is movable or fixed by attempting to dislodge it vy^ith
the beak of the instrument or by changing the position of the patient,
that is, after the stone is located, the sound is withdrawn and the patient
is put in the knee-chest posture; on resuming the dorsal position, the
instrument is again inserted and any change in the position of the stone
is noted.

To determine the size of the stone, the beak of the instrument is
carried over the posterior surface and the position of the meatus is
marked on the shaft. The instrument is then slowly withdrawn,
tapping the stone the while, imtil the anterior border is reached and
the relation of the meatus to the shaft is again noted. Subtracting the
latter measurement from the first one gives approximately the length
of the stone in its antero-posterior diameter. The transverse diameter
may be likewise estimated by tapping the stone from side to side.

At the completion of the operation the instrument is removed by
a reversai of the steps taken in its insertion, and the bladder is irrigated
with a warm saturated solution of borie acid, followed by a deep ure-
thral instiUation of i to 1500 silver nitrate solution.

TEST OF THE BLADDER CAPACITY.

By distending the bladder with fluid itscapacity is readily estimated,
and from this it may be determined whether the bladder is normal,
atonie, or contracted. If large quantities of solution can be injected
without inducing contractions, it may be inferred that atony or paralysis
exists; but if, on the other band, the bladder is in an inflamed condition
or is contracted, it will often not be possible to inject mòre than an
ounce (30 C.C.) or so without the patient's complaining of distention.

This test is also useful in the diagnosis of a ruptured bladder.
By injecting a definite amount of solution into the bladder and noting

6o8 THE BLADDER.

the quantity that retums, the presence or absence of rupture may be
readily recognized. In performing this test, however, it is necessary
to inject 6 to 8 ounces (178 to 236 ce) of fluid, as small amounts may
give misleadÌQg results.

Apparatus. — An ordìnary soft-nibber catheter for the male or a
glass catheter for the female and a large syrìnge, such as a Janet or
Record (Fig. 641), are required

FlG. 641. — Catheter and syringe for estimatila the bladder capadtf.

Aspetis. — The apparatus ìs sterilized by boilìng and the eiaminer's
hands are to be thoroughly cleansed. The esternai genitals are washed
with soap and water, followed by a i to 5000 solution of bichlorid of
mercury, and the urethra is irrigated with a saturated solution of borie
acid or a I to 5000 solution of potassium permanganate.

Frc. 643. — Method of distendiug the bladder with fluid when estimating ils capaci^,

Posltion of Patlent. — ^The patient should be in the dorsal position
upon a flat table.

Technìc. — The catheter, well lubricated with lubrichondrin, is in-
troduced into the bladder and ali the urine is drawn off. The syringe
is then fìlled with a warm (100° F.) saturated solution of borie acid
or normal salt solution, and the solution is slowly injected into the
bladder (Fìg, 642). As soon as the patient eomplains of distention, the

ESTIMATION OF RESIDUAL URINE. 609

injection is stopped and the quantity of fluid that has entered the
bladder is estimated. The syringe is then disconnected from the
catheter and the fluid is allowed to escape from the bladder through
the catheter.

ESTIMATION OF RESIDUAL URINE.

Normally, with micturition the bladder empties itself almost
completely, but, if the evacuation o£ urine is interfered with by obstruc-
tion from a stricture or an enlarged prostate or from the condition of
the bladder itself, as, for example, in atony, cystocele, etc, the evacua-
tion will be incomplete and more or less residuai urine will remain.
The amount of residuai urine often has a hearing upon the prognosis
as well as the treatment to be pursued in a given case, and its estimation
is thus of some importance.

Apparatus. — ^All that is required is a Mercier catheter with a coudé
curve and a glass graduate.

Asepsis. — The catheter is sterilized by immersion in a i to 20
carbolic acid solution followed by rinsing in sterile water. The exter-
nal genitals are cleansed in the usuai way and the urethra is irrigated
with a mild antiseptic solution. The hands of the operator should
likewise be sterile.

Technic. — The patient is instructed to empty his bladder as com-
pletely as possible while in the upright position. He is then placed
in the dorsal position. The catheter, well lubricated, is introduced
into the bladder, and any urine that remains is drawn off into the
graduate and is measured. This may amount to from i dram (3.75 ce.
to several oimces. If there is more than 2 ounces (59 ce.) of resid-
uai urine, it is certain that some interference with the voluntary evacua-
tion of the bladder exists. Observation of the flow of urine from the
catheter may also fumish valuable Information. If the urine is
expelled in a strong gush, it indicates that the muscular structure of the
bladder is competent, while, if it simply escapes by gravity, an atonie
condition is probably present.

THE ABSORPTION TEST,

A test sometimes employed to determine whether blood in the
urine has its source in the bladder consists in injecting a solution of
ìodid of potassium into the bladder and later testing the saliva for
iodin. Ordinarily there will be no absorption from the healthy
bladder, but, if raw or ulcerated surfaces are present, absorption of the
39

6lO THE BLADDE&.

iodid of potassium is quite rapid and iodin will be eliminated in the
saliva.

Aparatus. — There will be required an ordinaiy soft-rubber irrigating
catheter, a Janet syringe, and a test-tube.

Asepsis. — ^The usuai aseptic precautions employed when introducing
an instrument into the bladder should be observed.

Technic. — The patient first empties his bladder. The soft catheter
is then introduced and the bladder is well irrigated with normal salt
solution. From 2 to 3 ounces (59 to 89 ce.) of a i per cent, solution of
potassium iodid are then injected into the bladder and the catheter is
removed. At the end of ten or fifteen minutes some of the patient's
saliva is coUected in a test-tube and is tested for iodin. This is readily
done by adding a few drops of a dilute solution of cooked starch and
stirring with a glass rod dipped in fuming nitric acid. If iodin is
present in the saliva, the mixture will turn blue.

CYSTOSCOPY.

Cystoscopy is the inspection of the interior of the bladder by the
aid of an instrument especially devised for the purpose, the cystoscope.
It is a method of examination that may be of the greatest value when
employed by an expert, but it is of limited use in the hands of the
inexperienced, for it is absolutely essential that the examiner be familiar
with the appearance of the normal bladder before he can recognize
and correctly interpret pathological conditions, and this can only be
learned by practical experience.

By a cystoscopic examination properly carried out it is possible to
obtain an accurate picture of the interior of the bladder and to study
the appearance of the ureteral orifices as well as the condition of the
urine that escapes from them; that is, whether it contains pus or blood*
Cystoscopy thus becomes of service not only for diagnosis of obscure
vesical affections that may escape recognition by other means, but also
in the diagnosis between a possible vesical and kidney lesion.

The method has, however, certain limitations. It cannot be em-
ployed with success in the presence of marked hypertrophy of the pros-
tate, when the bladder is greatly contracted, or when there is an active
vesical hemorrhage going on which obscures the view. It is contra-
indicated in the presence of acute urethritis, acute prostatitis, epididy-
mitis, or acute cystitis. The urethra must, as a rule, be of a caliber o£
22 to 24 French, and, if the meatus is narro w, it must be first cut, or,
if strictures are present, they must be suflSciently dilated before the
mstrument can be introduced.

CYSTOSCOPY. 6ll

Instruments. — Cystoscopes are of two tyipes, the direct view, in
which the light is on the convex side of the beak and the eye looks
down a straight tube through a window in the distai end, and the in-
direct view, in which the light is placed on the concave side and the
image is reflected at right angles to the eye-piece, thus giving an inverted
picture. Some of the newer indirect view instruments, however, give
an upright picture.

For the simple examination of the bladder the use of an indirect- '
view cystoscope gives the best results, as with such an instrument the
roof, floor, and walls of the bladder — excepting a part of the posterior
Wall — may be readily inspected. The examination may be satisf actorily
performed either by means of a special explorìng cystoscope, such as the
Nitze, Otis, Schapira, etc., or by means of one of the ureter-catheter-
izing cystoscopes to be described later on (see page 652). The ex-
ploring cystoscope has an advantage over the catheterizing instruments,
however, in that its shaft being small the examination is less painful.

FiG. 643. — ^Nitze's cystoscopes.

The Nitze instrument (Fig. 643) is the oldest type of the indirect
or right-angled view cystoscope. It consists essentially of a metal tube
9 inches (23 cm.) long and from 15 to 24French scale in size, having
at the distai end a short beak fitted with a small electric lamp and on
the concave side of the instrument at the point where the beak joins
the shaft a lens, beneath which is placed a prism. From the prism
the image is reflected at right angles through a series of lenses to the
eye-piece. A small knob soldered on the circumference of the eye-
piece indicates the position of the cystoscopic window. The instrti-
ment is fitted with two-way stopcocks for irrigation should the lens
become cloudy. Space does not permit a description of the many
modifications of the Nitze instrument, each of which has advantages
of its own.

The illumination for cystoscopes may be fumished from a six- or

6l2 THE BLADDER.

eight-cell battery or from the Street current provided a controller is
employed.

Additional instruments required are a Janet syringe, holding from
3 to 8 ounces (89 to 148 ce), or an irrigating jar and a catheter.

Asepsis. — ^Formalin vapor may be employed or the instrument may
be immersed m a i to 20 carbolic acid solution or m a i to 5000 oxy-
cyanid of mercury solution for ten minutes foUowed by rinsing in
sterile water. The extemal genitals should be cleaned with soap and
water foUowed by a i to 5000 bichlorid solution. The examiner's
hands are to be likewise sterilized.

Position of the Patient — The examination is performed with the
patient in the lithotomy position and with his buttocks dose to the
edge of the table. The best form of table to use is one provided with
uprights which are surmounted with doublé inclined rests about 15
inches (37 cm.) above the level of the table for the support of the
patient's thighs and knees. The table should also be provided with
a wheel within reach of the operator, by turning which it may be raised
or lowered at will.

Anestìiesia. — Locai anesthesia is generally necessary, though in
exceptional cases cystoscopy may be performed without anesthesia.
The instillation into the deep urethra of a few drops of a 2 per cent,
solution of cocain may be sufficient. The interior of the bladder may
be rendered insensitive by first emptying it and then filling it with
5 ounces (150 ce.) of a warm o.i per cent, solution of cocain to which
is added 20 drops (1.25 ce) of adrenalin and having the whole amount
retained for fifteen to twenty minutes. Guyon's method of obtaining
locai anesthesia consists in injecting into the rectum three-quarters o£
an hour beforehand a mixture containing:

Antipyrin, gr. xiv (0.9 gm.)

Laudanum, ìi\x(o.6c.c.)

Water, 3iii (89 ce.)

In some adult cases, where the urethra, bladder, or prostate are
extremely sensitive, and in children general anesthesia may be required.

Preparations. — ^The bladder should first be emptied and should
then be thoroughly irrigated with a saturated solution of borie acid
by means of a catheter and Janet syringe until the fluid returns clear,
as a satisfactory examination can be made only in a clean bladder.
Four to 6 ounces (118 to 178 ce) of a saturated solution of borie acid
or normal salt solution are then injected into the bladder and allowed
to remain so as to smooth out the foids of mucous membrane and
fumish space for the cystoscope to be moved about.

CYSTOSCOPV. 613

If there is sufficient bleeding from the bladdcr to interiere with
the examìnation, a solution of i to 3000 adienalin chiorìd may be in-
jected through the catheter and allowed to remain for about ten or
fìfteen mìnutes, when it is drawo off and the bladder is distended.

Everything that will be required during the examìnation should be
placed near at iiand, and the cystoscope lìght should be tested under
water before the instrument is introduced.

Tedmic. — The instrument after being thoroughly tested, is lubri-
cated with glycerinor lubrichondrin and bgentlypassed into the bladder
in the same manner one would pass a sound. Great care should be
taken not to use any force in introducing the instrument, If there is
any difficulty In making the beak eoter the opening in the trìangular

FiG. 644. — Podtion of the cystoscope for inspection of the roof of the bladder.

ligament, pressure applìed on the perineum by the fingers of the free
hand will assist in its passage into the membranous urethra. As soon
as the instrument has entered the bladder, it can be freely moved about.
The operator then takes his seat with his eyes on a level with the
ocular end of the instrument, the light is turned on, and the interior of
the bladder is systematically ìnspected, care being taken not to touch
the mucous membrane with the light. It should be remembered that
in using a prism form of indirect \'iew cystoscope the image will be
reversed, as in the laryngoscope. The instrument being introduced
with its beak turned up, the roof of the bladder will first come in view
(Fig, 644). In order to see as much of this portion of the bladder as

6l4 TEE BLADDEB.

possible, the instrument should be rotated first in one direction and
then in the other and then pushed farther in, repeating these movements
until the entbe roof has been inspected, By depressing or elevating
the shaft a more complete view of the anterlor or posterior wall is
obtained. The beak. of the instrument is then rotated so that it faces
toward the floor of the bladder (Flg. 645), and the instrument is with-
drawn until the prostate appears as a clear dark red crescent. If
hypertrophied, it will appear deformed in the picture, and the degree
of its eniargement and its location may be recognized. The instrument
is next pushed slowly backward in the median line as far as the fundus.

FiG. 645, — Po^iioD of the cystoscope forinspectionof the Soorof the bladder.

the .examiner carefully examining the floor of the bladdder as the
instrument is advanced. By slightly rotating the instrument first to
one side and then to the other a large extent of the floor may be viewed.

The mucous membrane normally has a salmon or grayish-pink tint
and is smooth and glossy with the superficial vessels standing out herc
and there. When acutely inflamed, it becomes a dark red color and
has a velvety appearance and there is a general hyperemìa so that the
small blood-vessels disappear. In chronic inflammatìon the mucous
membrane may take on a grayish tint and the folds appear much
thickened. This region should be carefully examined for small stone,
tubercuiar ulcers, and new growths,

Having inspected the floor, the instrument is tumed 45 degrees to one
side and is gradually withdrawn from the fundus. In this way the open-
ing of the ureter on that side wìli come to view as an oblique slit or as
a small dimple {Fig, 646) in a prominent papilla, and, if it is watched, it
will be seen to emit a gush of urine every ten to fifteen seconds. If not

CYSTOSCOPY IN THE FEMALE. 615

immediately found, the interureteric line, which runs transversely
acToss the centrai field between the two ureters, should be identìfied
and, by tracing this to one side or the other, the ureteral orifice may be
located. The appearance of the ureteral orifice should be carefuUy
inspected for signs of ulceration, erosions, or infiammation which might
indicate a diseased kidney on that side, and likewise the character of
the urine which escapes should be noted, i.e., whether clear, purulenta
or bloody.

The lateral wall is carefully inspected as far as the vesical neck.
The instrument is then rotated 90 degrees to obtain a view of the
opposite side and it, including the ureter of that side, are examined

Fic. 646. — Appearance of the ureteral orificea.

while the instrument is slowly passed to the fundus again. FoUowing
some such scheme, the entire bladder may be inspected except a portion
of the posterior wall which is invisible with an indirect view instru-
ment. During the examination it is well to shut off the light at inter-
vals so as to allow the instrument to cool.

At the end of the examination the light is tumed off and the instru-
ment is carefully withdrawn, taking care to see that the beak is again
tumed up before this is done. The patient's bladder is then emptied
and iiTÌgated with borie acid solution.

CYSTOSCOPY IN THE FEMALE.

The examination of the female bladder may be performed by using
an ordinary male cystoscope or a somewhat shorter female instrument.
Such examination, which is less diffìcult than in the male on account
of the short length of the urethra, requhes no separate description,
as the technic differs in no essential way from the method used in
the male. A far simpler method of vesical inspection, however, is by
means of Kelly's open straight tubes and atmospheric distention of
the bladder.

Instruments. — For cystoscopy according to Kelly's method there
will be required: Kelly's specula, or some of their modifications,

6x6

THE BLADDER.

an electric head light or head mirror, a Kelly dilator to stretch the
esternai urcthral orifice, a urine evacuator to draw off residuai urine,
alligator forceps for holding cotton swabs, and a ureteral probe

Fio. 647. — Instnimeots fot cystoscopy in the femaJe.
1, Eleetric-lighted open-tube cystoscope; a, uiethnil diUtor; 3, urine
alligator-jawed forceps; 5, ureteral searcher.

for probing the mucous membrane or locating the ureteral orifices
(Fig. 647).

The specula consist of cylindrical tubes 31/5 inches (8 cm.) long,
of equal length throughout, and in sizes of from 1/5 inch (5 mm.)

Fio. 648. — Kelly's open-tube cystoscope.

in diameter up to 4/5 ìnch (20 mm.). Those below No. 12 are
generally employed for diagnostic purposes. The tubes are of German
Silver or nickel-plated, each having a conical expansion at the ocular

CVSTOSCOPY m THE FEMALE. 617

end to which is fastened a strong handle (Fig. 648). Each tube is
supplied with an obturator having a conical end-piece. The ìllumina-
tion is fumished by reflected light or from an electric head light, the
latter being preferable. These specula, however, may be obtained
fumished with an electric light at the distai end' (Fig. 649), an instru-
ment which simplìfies the operation for one not accustomed to the use
of a head light.

The urethral dilator ìs a cone-shaped metallic instrument which
gradually increases in size from the point until at the base it measures

F^G. ófg. — Eniarged view of an electiic-lighted open-tube «TStoscope.

16/25 ^^^^ (^6 min.) in diameter. The instrument ìs graduated
so that the examiner can determine the required amount of dilatatìon.

The urine evacuator is necessary for the purpose of removing the
urine that collects in the floor of the bladder and interferes with the
examination. It consists of a suctìon bulb attached by means of a
long delicate rubber tube to a small perfbrated glass bulb. In the
Luy's open tube cystoscope an aspirating tube is incorporated in the
instrument

Asepsls. — Ali the Instruments should be boiled for five minutes in
a I per cent, soda solution. The operator's hands should be care-
fuUy sterilìzed and the esternai genitals and mouth of urethra should
be cleansed with soap and water, followed by a i to 5000 solution of
bichlorid of mercury.

'They are made by ihc Elcrlro-surgical Instrument Company of Rochester, New York.

6l8 THE BLADDER.

Posltlon of Pattent — Two positions are employed, the dorsal and
the knee-chest. In the dorsal position the patìent lies witfa the head
and thorax resting on the table and the hips elevated 8 to 12 inches
{20 to 30 cm.) upon cushions so as to raise the pelvis and jiermit the
bladder to distend with air when the cystoscope is introduced. While
the dorsal posture is the least wearing on the patient, it is not suited
for stout persons. In such cases, the knee-chest posture, with the knees
separated io or 13 inches (25 or 30 cm.), is more suitable.

Preparatlons of Patient. — Before the patient is placed upon the
table the rectum and bladder should be emptied.

Anestbesia. — Locai anesthesia is gcnerally sufficient except in very
nervous women. A pledget of cotton saturated with a 2 per cent.
solution of cocaine introduced upon an appljcator within the meatus
and allowed to remain for live minutes will anesthetize the urethra
sufBciently to allow of its being dilated.

Fio. 650. — Method of dilaiing Ihe ureUini. (Ashton.)

Technlc. — As a rule, it is first necessary to dilate the urethral
orifice; the rest of the canal, being veiy dilatable, is easily stretched by
the cystoscope in its passage. The dilator is lubricated with one of
the Iceland-moss preparations and is introduced ìnto the urethra with
a slight boring motion until the required amount of dilatation is reached
(Fig, 650). Dilatation to about No. 12 on the dilator is generally
sufficient. Aspeculum of a size from 7 to io, dependìng upon the
age of the patient, is then selected. It should be grasped in the opera-
tor's right band, the cylinder lying between the index and middle
fingers, with the thumb against the obturator, as shown in Fig. 651.

CYSTOSCOPY IN THE FEMALE. 619

With the fingers of the left hand the labia are separated and the specu-
lum, wetl lubricated, is introduced through the urethral orifice, whence
it is gradually pushed into the bladder foUowing the urethral curve
under the pubic arch. Upon removal of the obturator, air rushes in

Ftc. 651. — Meihod of holding the open-tube cystoscope during ita introduction inlo the
bladder.

distending the bladder. If the bladder fails to distend, it will probably
be due to a faulty position of the patient. If, when the patient is in
the knee-chest position, the bladder does not balloon up, two fingers
may be introduced into the vagina so as to distend ìt with air. The

Fio. 653. — InspecUon of ihe temale bladder thcough an open-tube cystoscope.

illumination is then tumed on, or, in the absence of a self-illuminated
speculum, the light from the electric head light or head mirror is
thrown into the bladder through the speculum, and the bladder is
systematically examined (Fig. 652).

020 THE BIADDEK.

fiy altemately moving the speciilum from side to side and depress-
mg or elevating the handle ali portions of the bladder may be in-
spected. If the patient is in the doisal posture, urine soon collects
in a pool on the base of the bladder, and this must be removed as often
as required by means of the evacuator (Fig. 653). By means of the

W ri -^

Fig. 653. — Method of removing residuai urine during a cystoscopic examinatioii.

cotton mops held in the alligator, forceps mucus, blood, or pus that
may obscure a clear view of the mucous membrane may be wiped
away.

SEIAGRAPHY.

The X-rays are sometimes used in locating a vesical stone which,
from being buried in a pocket or being situated behind the prostate,
may escape detection by other means. The success of the skiagraph
depends to a large extent upon the composition of the calculus. Oxa-
late and phosphate stones cast a dense shadow, but those composcd
of urates and urie acid cast very faint shadows, and so may be missed
entirely. The bony walls of the pelvis may likewise interfere and give
a negative result.

Therapeulic Measures.
IRRIGATIONS.

Irrigations of the bladder may be employed eìther for simple
cleansing purposes, as is required in preparation for an instrumentai

ntSIGATIONS. 631

examination or operative procedure, or to produce a locai effect upon
the mucous membrane. Imgations are thus of the greatcst value in
the treatment of various inflaramatory affections of the bladder. In
acute cystitis, however, on account of the distention produced, they
often increase the pain and may aggravate the tròuble. They should
be employed, however, in acute cases if the bladder does net completely
empty itself and there is decomposition of urine. Irrìgations are also
contraindìcatcd where the bladder cannot hold more than i ounce
(30 ce.) of fluid without exciting a desire to urinate; in such cases,
instillations should be substituted.

There are two methods of performing vesical irrigation; (i) by
ìnjecting the fluid in sufficient quantity to distend the bladder and
having it retained a short lime before allowing it to escapef and (2)
by using a double-flow catheter which allows the fluid to escape as fast
as it flows in. In the majority of cases the former ìs the preferable
method to eraploy, as a certain amount of distention of the bladder is
necessary in order to wash out pus, bacterìa, and débrìs from the folds
of mucous membrane.

FiG. 634. — Apparatus tor bladder imgation».

Apparatus. — A large glass tunnel, 4 feet {120 cm.) of rubber tubing,
a soft-rubber catheter, a large glass graduate, a thermomcter, and a
waste pail are required (Fig, 654).

A double-flow soft catheter (Fig. 655) may be employed in place of
the ordinary catheter if desired. When this is used a graduated glass
irrìgating jar should take the place of the funnel.

Aaepds. — The apparatus is boiled and the thennometer sterilized
by immersion for io minutes in a i to 500 bichlorid of mercury solu-

622 THE BLADDER.

tion foUowed by a thorough rinsing in sterile water. The operator's
hands should be thoroughly scrubbed.

Solutions Used. — Normal salt solution (3i (3.9 gm.) of salt to the
pint (473.11 C.C.) of water), a saturated solution of borie acid, silver
nitrate i to 15,000 to i to 5,000, potassium permanganate i to 8000 to
I to 4000, bichlorid of mercury i to 100,000 to i to 5,000, hydrogen
peroxid 20 to 40 per cent., carbolic acid, etc, are among the numerous
agents employed.

It is always well to begin the treatment with the weaker solutions
and gradually increase the strength as indicated. After an irrigation
with a poisonous drug, the bladder should be douched with normal
salt solution to prevent any being left for absorption.

Fio. 655. — Retum-flow soft-rubber catheter.

Temperature. — The irrigating fluid should be at a temperature of
100° to 105° F.

Quantity. — The irrigations should be continued until the fluid
retums clear. As a mie about i pint (473.11 ce.) of solution will be
sufEcient.

Frequency. — When there is profuse suppuration and rapid decom-
position of urine, the irrigations are employed twice a day. In a mild
case daily irrigations or on alternate days will suffice. A lapse of one
or two days, however, should intervene when very strong solutions are
employed.

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

Preparation of Patient — ^The bladder should be empty. The
external genitals are washed with soap and water foUowed by a i to 5000
bichlorid of niercury solution, and the urethra is irrigated with a borie
acid or i to 5000 potassium permanganate solution.

Technic. i . Single Catheter Methods. — The catheter, well lubrieated,
is gently passed into the bladder, and any residuai luìne is allowed to
escape. The funnel is fiUed with from 3 to 6 ounces (89 to 178 e.c.)
of the solution, and the tubing leading from the funnel is attached to
the catheter, first taking care to see that air or any cold solution is
expelled from the tube. The funnel is then raised 2 or 3 feet (60 to

m&IGATIONS. 623

90 cm.) above the patient and the solution is permitted to slowly flow
in and distend the bladder. As soon as the patient complains of the
distention, the flow is shut off. After allowing the solution to remain
in the bladder a few momeots, the tunnel is lowered below the level of
the bladder and the fluid is allowed to escape into the waste pail (Fig.
656). The tunnel is then refilled and the process repeated until the
fluid retums clear.

Fio. 656. — Showing (he method of irrigating the bladder by the ^ngle-catbetcT metlnd.

In making the irrigation care must be observed not to overdistend
the bladder. Just how much can be injected at a time depends upon
the individuai case, but it should not be sufficient to cause any pain.
Entrance of air into the bladder should also be guardcd against

2. Double-floTv Catkeler Metkod. — The technic varies a little from
that just described. The catheter is inserted in the bladder and the
irrigating tubing is attached to the inflow tube of the catheter. The
reservoir, filled with the entire amount of fluid to be used during the

624 THE BIADDER.

irrigatioQ, ìs then raised 2 to 3 feet (60 to 90 cm.) above the bladder and
the solution is allowed to flow. As fast as it enters the bladder, it is
carricd off again through the outflow tube (Fig. 657) ; but, by occasion-
ally compressing the outflow tube, the bladder may be more or less
completely filled before the fluid is perraitted to escape.

Fic. 657. — Iirigation of the bladder wilh a double-flow catheter.

AUT0-IRRI6ATIONS.

While it is not advisable to allow a patient to irrigate his own bladder
in the presence of a severe cystitìs, auto-irrigation may be safely per-
formed for the purpose of keeping the bladder clean by those who are'
compeiled to lead a catheter life. The patient should, however, be
carefuUy instructed how to sterìlize the catheter, his hands, etc, and
in the proper method of performing the irrigation, and he should be
fully wamed of the dangers of neglecting to foUow the strìctest rules of
cleanliness.

AUTO-IRRIGATIONS.

625

Apparatus. — ^A douche bag with a capacity of i quart (i liter), 4
feet (120 cm.) of rubber tubing, a T-shaped glass tube, a soft-rubber
catheter, and a waste pail comprise the necessary outfit. The T-shaped
glass connection ìs placed between the catheter and the tubing of the
reservoir and to its long arm is attached another piece of tubing that
leads to the waste pail. A shut-oflf clip is placed on the tube leading
from the irrigator and another upon the waste tube (Fig. 658).

FiG. 658. — ^Apparatus for auto-irrigation of the bladder.

Solution Used. — It is better not to entrust the patient with strong
antiseptic solutions; instead a saturated (4 per cent.) solution of borie
acid shouid be used. It is prepared by dissolving about 5 teaspoon-
fuls (19 gm.) of borie acid crystals in i pint (473 .11 ce.) of hot water.

Position of Patient. — The irrigation is most conveniently given with
the patient sitting in a chair and with the waste pail on the floor between
the legs.

Technic. — ^The reservoir is filled with i pint (473.11 ce.) of warm

(105° F.) borie acid solution and is hung on a hook about 3 feet

(90 cm.) above the level of the bladder. The patient then introduces

his catheter into the bladder and draws oflf the urine. The solution

is allowed to flow from the tubing to expel any air or cold fluid, and the

tubing ìs then connected with the catheter. The solution is allowed

to flow into the bladder until there is a feeling of distention, when the

flow is shut off and the outflow pipe is opened allowing the fluid to

escape into the waste pail. The process is repeated imtil the reservoir

is emptied.
40

020 THE BLADDER.

mSTILLATIONS.

Instillations diflfer from irrigations in that a smallar quantity o£
solution is used and the fluid is allowed to remain in the bladder.
Stronger solutions can thus be employed and it is possible to obtain a
more lasting effect upon the mucous membrane than from an irrigation.
Instillations are very useful in ali cases of cystitis, but especially those
in which the inflammation is particularly severe about the trigone and
vesical neck.

The immediate effect of the instillation is to induce a moderate
congestion accompanied by an increased desire to urinate and some
pain, but this soon passes off and is followed by reaction and a graduai
relief of the symptoms.

Syringe. — ^A Keyes-Ultzmann syringe will be required (Fig. 659).
When, however, it is desired to inject more than 1/2 dram (1.9 ce.)

Fig. 659. — Keyes-Ultzmann instillation syringe.

of solution, a soft-rubber catheter and glass syringe of the desired capac-
ity should be substituted for the above.

Solutions Used. — Silver nitrate beginning with a i to 1500 solution
increased to 5 per cent., protargol i to 20 per cent., bichlorid of mercury
I to 10,000 to I to 5,000, a IO per cent, emulsion of iodoform and
glycerin, etc, are often employed.

Quantity. — As a rule about 15 to 30 ir^ (0.9 to 1.9 ce.) are in-
jected, but when it is desired to medicate a large surface, as much as
I dram (3 . 75 ce) or more may be used.

Frequency. — Instillations may be employed e very other day to e very
third or fourth day according to the reaction they provoke.

Position of Patient. — The dorsal position is used.

Preparatlons of Patient. — ^The bladder should be empty, and if
there is residuai urine it should be drawn off by a catheter. The
extemal genitals are cleansed and the urethra is irrigated with a borie
acid solution.

Technic. — The syringe is first fiUed with the desired amount of
solution. The nozzle, after being well lubricated with lubrichondrin^

CYSTOSCOPIC TREATMENT.

627

is then introduced in the same manner employed in passing any curved
urethral instrument (see page 540) until its point lies in the prostatic
urethra. This will be when the shaft of the instrument has been
depressed between the legs to an angle of a little less than 45 degrees
with the horizon. The required amount of medication is then slowly
injected into the prostatic urethra, whence it flows over the vesical neck
and trìgone. In removing the syringe the piston should be first with-
drawn a little so as to prevent any solution leaking from it along the
urethra.

When using the catheter method of instillation, the same technic as
for a posterior irrigation (page 567) is foUowed.

CYSTOSCOPIC TREATMENT.

In the hands of an expert the cystoscope becomes an instrument of
great value in treating vesical lesions. While cystoscopic treatment is
more diflScult in the male than in the female, such procedures as
removing small calculi and foreign bodies, snaring small growths,
the curettage of ulcers, the direct application of strong solutions of

Fio. 660. — ^Bransford Lewis operating cystoscope. (Lewis in Keen's Surgery.)

sUver nitrate to diseased areas by means of a cotton-tipped probe, etc,
may be satisfactorily performed, even in the male, by a physician of
skill and experience.

Instruments. — For male cases, a direct-view-air-distention cysto-
scope provided with a perforated window and bulb-aspirator (Fig. 660)
is necessary. In the female, Kelly *s tubes (page 616) or some of their
modifications are employed.

628 THE BLADDER.

Technfc. — ^The method of exposing and treating diseased areas is
performed in the same manner in which the bladder is inspected
(pages 613, 618) and requires no further description here. In making
applications of strong solutions, however, care shonld be taken to
bring the solution only in contact with the diseased area and not to
saturate the applicator with an excess of solution.

CATHETERIZATION OF THE BLADDER.

Catheterization of the bladder is indicated in ali cases of complete
retention of urine and in some cases of partial retention, as, for example,
in prostatic hypertrophy when the residuai urine amounts to more
than 2 ounces (59 ce). Retention may be the result of obstruction
from stricture, spasm of the compressor urethrae muscle, hjrpertrophy
or congestion of the prostate, clots of blood, calculi, foreign bodies or
tumors in the bladder or urethra, perineal abscess, traumatism, etc,
etc, and as the result of defective expulsion power of the bladder
through impairment of the nervous mechanism, as in hysteria, certain
diseases of the brain and spinai cord, shock, fevers, after the use of
certain drugs, foUowing rectal operations, etc, etc The probable
cause of the retention should, if possible, be ascertained before at-
tempts to pass a catheter are made.

Fio. 661. — Soft-nibber catheter.

Retention may come on suddenly or gradually. In the presence of
acute retention there is great desire, but inability, to urinate, accom-
panied by a severe and aching pain in the abdomen and perineum.
Unless the condition is relieved, the symptoms rapidly grow worse and
the patient lapses into a comatose state. When the retention is graduai
in onset, these severe symptoms are sometimes absent even in cases of

CATHETERIZATION OF TBSi BLADDER. 629

enormous distention, and it may be only the dribbling of the overflow
from the overdistended bladder that the patient complains of, the
so-called "false incontinence." Physical examination will, however,
reveal an elastic fluctuatmg tumor occupying the hypogastrium,

FiG. 662. — Silver catheter.

which is dull on percussion and becomes more promìnent with the
patient standing erect.

Instruments. — ^An assortment of the various forms of catheters
should be on hand. For the ordinary cases of retention, uncomplicated
by stricture or an enlarged prostate, a soft-rubber Nélaton (Fig. 66i)
or a blunt sii ver catheter with a short curve (Fig. 662) may beemployed.

Fio. 663. — Gum-elastic olivary catheter.

In the presence of strictures a gum elastic olivary catheter (Fig. 663)
and a set of Gouley's tunneled catheters and filiforms (Fig. 664) will
be required. In place of the latter a whip catheter (Fig. 665) may be
employed. This consists of a flexible gum elastic catheter tapering
off for several inches into a filiform.

Fig. 664. — Gouley's tunneled catheter and fìliforms.

The best form of catheter to use when the prostate is enlarged is a
Mercier coudé catheter (Fig. 666). The slight angle at the end of this
instrument permits it to override an obstruction. Guyon's mandarin
coudé catheter (Fig. 667) and a long-curved silver prostatic catheter
(Fig. 668) should also be provided. The caliber of the Instruments
for this class of cases should be fairly small, say from 15 to 18 French.

630

THE BLADDEK.

Fio. 665.— Whip catlieter.

%::

1^3

^^^

FiG. 666. — Catheters with a coud£ and bicoudé curve.

^==^

FiG. 667. — Guyon's mandarin coudf catheter.

CATHETERIZATION OF THE BLADDER. 63 1

Asepsis. — The greatest care shouid be taken to avoid infection of
the bladder. Metal and rubber catheters, as well as the better make
gum elastic mstniments are boiied for five minutes. Instruments
that will not stand boiling are sterilized by formalin vapor (page 540)
or by immersion in ai to 20 carbolic acid solution followed by rinsing
in sterile water. The operator's hands are to be sterilized as carefully
as for any operation.

Fio. 668. — Silver prostatic catheter.

Quantity of Urine '^thdrawn. — Except when the distention is
slight and of short duration, the bladder shouid never be emptied com-
pletely at the first catheterization. As the result of long standing
vesical distention there occurs a dilatation of the ureters and renai
pelvis with changes in the kidney structure, and a sudden evacuation of
the urine is apt to be followed by suppression of urine; or hemorrhage
from the vesical mucous membrane or kidneys may result from the
sudden relief of pressure upon the distended veins. Therefore, not
more than 8 oimces (236 ce.) of urine shouid be withdrawn at the first
catheterization, gradually increasing the amount at subsequent cathe-
terizations, until at the end of three or four days the bladder is com-
pletely emptied each time.

Frequency. — As a rule, in complete retention the bladder requires
emptying every four to eight hours. When the catheter is empiqyed
for withdrawing the residuai urine of prostatic hypertrophy the fre-
quency wilI depend upon the amount of residuai urine. Thus, if this
amoimts to from 2 to 4 ounces (59 to 118 ce), one daily catheteriza-
tion before the patient retires in the evening will suffice; if it amounts
to from 4 to 6 oimces (118 to 178 ce), the catheter shouid be used twice
a day, i.e., m the evening and moming; larger quantities of residuai
urine demand that the bladder be emptied three or four times a day.

Position of. Patient. — Catheterization shouid always be performed
with the patient recumbent, as shock or other unexpected symptoms
may appear at any time during the operation. The patient is there-
fore placed in the dorsal position with his shoulders slìghtly raised and
thighs somewhat flexed and rotated slightiy outward.

632 THE BIADDEK.

Preparatlon of Patìent. — The glans penis and meatus should be
washed with soap and water, followed by a i to 5000 bichlorid of
mercury solution and then sterile water. The urethra is irrigated
with a warm saturated solution of borie acid or a i to 5000 solution
of potassium permanganate.

FlG. 669. — Showìng the method of pa:>^g a soft-nibber catheter.

FlG. 670. — Showing soft-rubbtr calheler passed into the bladder.

Technlc. — i. In Cases U ncomplicated by Stricture or Enlarged Pros-
tale.^AfuU-sized soft-rubber catheter is tried first, It is well lubricated
and, while the penis is held upright, is slowly fed into the urethra
a little at a time (Fig. 669). If the catheter becomes obstructed, the

CATHETERIZATION OF THE BLADDEE. 633

penis should be put upon the stretch to obliterate any wrìnkles in the
mucous membraDe, and the instrument is again advanced as before
or by rotating it while the attempt is made to make it pass. In this
way a soft instrument can usually be made to enter the bladder when
the retention is simply due to detective espulsive power. In with-
drawing a catheter the instrument shquld be compressed between the
thumb and forefinger, or the tip of the finger should be placed over
the opening at the proximal end so as to prevent the urine which
remains in the catheter from dripping out and wettìng the patient's
clothes.

In cases of spasmodic stricture, failing in attempts to pass a soft
instrument, a full-sized metal catheter should be resorted to. Such a
catheter is passed precisely as one would a sound (see page 540).
When the poìnt of the instrument has been introduced as far as the

Fio. 671. — Shoning an ordinaty catheter obstructed by an eniarged middle lobe crf ihe
prostate gland.

obstruction, it should be held pressing steadily against the face of the
stricture for a few minutes until the spasm passes off, when it may be
easily slipped into the bladder.

2. In the Presence of Slrkture.—Jn dealing with a retention due to
stricture a small soft-rubber catheter should be given first trial, If
unsuccessful, attempts may be made to pass an olivaiy pointed catheter.
If this fails, a filiform should be introduced through the stricture (see
page 545) and a Gouley tunneled catheter passed over this as a guide,

634 1^£ BLADDEK.

or, in its stead, a whip catheter may be employed. Shouid the strie-
ture be o£ such small caliber that ìt is only possible to inserì a filifonn,
the latter shouid be left in place to act as a capillary drain, taJdng care,
however, to fasten it in such a way that it cannot slip cut (page 638),
Ih this way the bladder will empty itself in a few hours and, by the
end of twenty-four hours, suffigient dilatatioD will usually have taken
place to allow the passage of a tunneled catheter. Failing to pass even
a filiform the bladder shouid be aspirated (page 639).

3. In thePresence ofProslalic Hyperlropky. — A soft flexible catheter
shouid be tried and then a coudé catheter. The latter will often suc-
ceed where a soft catheter fails because the bend of the tip of this
ìnstrument keeps the point in contact with the upper wall of the ure-
thra and thus permits it to more easily override a median prostatic
enlargement (Fig. 672). Sometimes, if an ordìnary coudé catheter

Fio. 67 2. — Showing a coudé catheter passtng the obstniction.

will not pass, an elbowed catheter with a stylet can be made to do so.
With this Ìnstrument ìt is possible to elevate the point more sharply,
when obstructed, by withdrawing the mandarin a little, so that the
point of the Ìnstrument passes upward over the obstruction into the
bladder.

After repeated and unsuccessful efforts with the above ìnstrument
a metal prostatic catheter shouid be tried before resorting to aspira-
tion. Great gentleness shodd be employed in its introduction to avoid
makìng a false passage. Sometimes assìstance in finding its point
may be derived from placing a finger in the rectum.

CATHETERIZATION IN THE FEMALE. 635

CATHETERIZATION IH THE FElfALE.

Catheterization of the female bladder is a simple procedure. It
should always be done, however, by direct sight; the old method of
passing a catheter by touch carries with it the great risk of infection.

Instruments. — A glass female catheter, 5 inches (13 era.) long and

Fio. 673. — Glasa female catheter. (Ashtoa.)

1/5 of an inch (5 mm.) in diameter with a gentle curve in opposite
directions at both ends (Fig, 673), is the best instrument to employ.

Asepsls. — The catheter is boiled for five minutes and the operator's
hands are carefully scrubbed in soap and water, followed by immersion
in an antiseptic solution.

Fig. 674. ^Method of pasùng a catheter in Ihe female. (Ashton.)

Positloii of Patient. — The patient should be in the dorsal position
with the thighs flexed and the legs well separated.

Preparations of Patiant. — The externai genitals and meatus are
cleansed with soap and water followed by a i to 5000 bichlorid of
mercury solution.

636 1BE BLADDEB.

Technlc. — The operator separates the labia with the thumb and
forefinger of the left hand so as to expose the meatus. The catheter,
held near the proximal end in the fingers of the rìght hand, is then
introduced through the urethra into the biadder (Fig. 674). When the
bladder has been emptied, the forefinger ìs first placed over the proxi-
mal end of the catheter to prevent the escape of the urine it contains
(Fig. 675) and the instrument is then withdrawn.

Fio. 675. — Showing Ihe method of preventing urine drìpping front the catheter as it is

withdrawn. (Ashion.)

CONTINUODS CATHETERIZATION.

A catheter may be introduced into the bladder and left In place in
cases where drainage of the bladder for a brief period is desired. It
may be employed in chronic cystitis accompanied by the presence of
large amountsof pus, frequent urination, and tenesmus, in vesical hemor-
rhage, and in cases of obstniction from an enlarged prostate where
the Constant introduction of a catheter causes spasm or hemorrhage,
or where catheterization is diflicult. The bladder is thus put at resi
and at the same time is kept constantly emptied, the beneficiai efiects
of which are shown by a rapid decrease of the inflammation and
congestion, decline of the fever, and relief of the pain and tenesmus.
Continuous catheterization is also indicated in wounds of the urethra
or after certain operations upon the urethra when it is desirable to
prevent the contact of infected urine with raw surfaces.

At first, when the catheter is inserted, there may be a feeling of
weight in the perineum, but this soon passes off. In some instances a

CONTINUOUS CATHETERIZATION. 637

mechanìcal urethritis is set up which may persist until the instrument is
removed and, if neglected, urethral abscess or extension of the mfec-
tion backward into the bladder may result.

Instruments. — A simple soft-rubber catheter of about i8 French
with the eye near the end or the retention catheters of Pezzer or Malecot
may be employed. The Pezzer catheter (Fig. 676) has a flange to

Fio. 676. — ^The Pezzer retention catheter.

rest against the vesical neck, while the Malecot instrument (Fig. 677)
has wings on either side. When introduced over a stylet, these pro-
jections are made to disappear, but reappear when the stylet is removed.
Asepsis.— The catheter should be thoroughly sterilized by boiling
or by formalin vapor and, if the latter method is employed, care must
be taken to remove ali trace of the formalin by thoroughly rinsing the

Fio. 677. — ^The Malecot retention catheter.

catheter in sterile water. The operator's hands should likewise be
perfectly sterile.

Duration. — This will depend upon the toleration of the urethra.
In some cases, continuous drainage may be kept up for over two weeks
without the catheter causing much irritation; in others, the presence of
an instrument in the bladder produces so much irritation and vesical
spasm that it cannot be used at ali.

Preparation of Patient. — ^The glans penis and meatus are washed
with soap and water followed by a i to 5000 solution of bichlorid of
merciuy, and the urethra is thoroughly irrigated with a mild antiseptic
solution.

Technic. — i. By the Ordinary Catheter, — If a simple rubber
catheter is employed, it is well lubricated and is then introduced in
the usuai way until its eye lies just within the bladder. It is quite
important that the point of the catheter be not introduced too far, for,
if so, it will not only fail to drain the bladder properly, but will irritate
the vesical floor. To insure that the instrument is properly placed,
it should first be introduced into the bladder until the urine flows freely
and then slowly withdrawn until the flow just stops, when it is pushed

638 THE BIADDES.

into the bladder again, this lime for a distance of i /4 inch (6 mm.).
It ìs then secured in place as follows:

The portion of the catheter protruding from the meatus is thor-
oughly dried and ali grease is removed. Then four pieces of adhesive
plaster, each about 4 inches (12 cm.) long and i /4 inch (6 mm.) wide,
are secured to the catheter at the point it emerges from the meatus in
such a way that one strip lies upon the dorsum, one on the ventral sur-
face, and one on either side of the penis, Each strip is carried back
over the foreskin and is made to adhere to the body of the penis, An
additional strip of adhesive i inch {2 . 5 cm.) wide is placed horizontally
about the penis back of the corona, covering the four small strips (Fig.

Fio. 678. — Sbowing the niethod o£ seciiring a catheter in ihe bladder. (After Sinclair,
Fotyclinic Journal, July, 190S.)

678). Care shouid be taken, however, not to have this strip entirely
encircle the penis. The penis is then wrapped in sterile gauze and is
supported over one groin by a T-bandage. If upon inspection it is
found that the urine escapes freely, the free end of the catheter is
finally connected with a drainage-tube which conducts the urine to a
receptacle at the side of the bed. The receptacle shouid be half-luU
of some antiseptic solution.

If the retained catheter is employed in a case of long standing
retention where it is dangerous to empty the bladder at once, an inter-
mittent form of drainage may be employed by discarding the drainage-
tube and simply inserting a plug in the end of the catheter, which is
removed at definite intervals and an increasing quantity of the urine
drawn off each time until it is considered safe to empty the bladder
completely, when the above method is used.

2. By Ihe Self-relaining Catheter. — In inserting a special self-retain-
ing catheter, a stylet curved f o the shape of a sound Ìs introduced within
the instrument so as to obliterate the projecting coUar or wings. When
the catheter is in place, the stylet is withdrawn, thus allowing the bladder
end of the catheter to expand again so that the catheter is retained in
place unless some force is used in withdrawing it. In spile of this,
however, it Ìs safer to fix the catheter in place by the method above

ASPIRATION OF THE BLADDER. 639

described, after first withdrawing it until the resistance shows that the
termmal enlargement is at the vesical neck.

After-care. — The catheter rapidly becomes encrusted with lime
salts, blood, or pus and should, therefore, be changed every two or
three days to permit of its being cleansed. At this time the urethra and
bladder should be thoroughly irrigated with a mild antiseptic solution
and the catheter thoroughly sterilized before it is reinserted. In the
presence of pus or blood the bladder may be irrigated through the
catheter as frequently as seems indicated.

If urethritis develops, the urethra should be irrigated once or twice
daily with a saturated solution of borie acid. This may be accom-
plished by withdrawing the catheter until its extremity lies in front of
the bulbous urethra and then flushing out the urethra from behind
through the instrument by means of an irrigating apparatus. The
catheter is then pushed back to its originai position. Constant watch
should be kept lest ulceration of the urethral wall develop at the peno-
scrotal junction from pressure of the catheter. To avoid this, the penis
should be supported in such a position that the sharp angle formed at
the peno-scrotal jimction when the organ hangs vertically is obliterated.

ASPIRATION OF THE BLADDER.

Suprapubic aspiration of the bladder is indicated as a temporary
expedient when there is complete retention of urine and catheterization
is impossible from the presence of a tight stricture, prostatic enlarge-
ment, or from any other cause. The operation is easily performed and,
if properly done, is a safe procedure. At times after a single aspiration
the congestion is so much lessened that within a few hours it becomes
possible to pass a catheter, or the patient voids spontaneously, but, if
necessary, the bladder may be emptied several times a day for a week
or more by this method without danger.

Where a permanent drainage for some time is desired, suprapubic
pimcture by means of a trocar and cannula may be performed. Punc-
tiure through the perineum or rectum, on the other hand, should be
avoided as unsafe.

Instruments. — ^For temporary relief an aspirating needle and
syringe should be employed. The needle should be fairly fine and
about 3 inches (7.6 cm.) long. The Potain aspirator (Fig. 679) is the
best to use. This instrument has already been described (page 255).

When a trocar and cannula are used, a curved instrument with the
convexity of the curve upmost should be obtained. A scalpel to nick
the skin is also required.

640

THE BLADDER.

Asepsis. — The instruments are boUed for five minutes in a i per
cent, sodium carbonate solution and the operator's hands are sterilized
in the usuai way as for any operation.

Site of Puncture. — The puncture is made in the median line about
I /2 inch (i cm.) above the pubes. The extraperitoneal space above
the pubic bone is increased when the bladder is distended and a needle
or trocar may be inserted here without danger of entering the perito-
neum. When a number of punctures are made, the site may be changed
a little each time.

Fio. 679. — ^Potain aspirator.

Positlon of Patlent. — The operation may be performed with the
patient recumbent or partly sitting up.

Preparatlons of Patient. — ^The pubes should be shaved and then
washed with green soap and warm water, followed by a i to 2000 bi-
chlorid of mercury solution.

Anesthesia. — Sufficient anesthesia is obtained by freezing the
surface tissues with ethyl chlorid or salt and ice to render the operation
painless.

Technic. — i. By the Aspirator. — ^The suprapubic region is first
carefuUy percussed to maké sure that there are no coils of intestine
lying in front of the bladder. The aspirator is assembled, tested, and
the air in the bottle exhausted. A small nick is then made in the skin
at the spot chosen for the puncture and the needle, held in the rigbt
hand with the index-finger placed on its shaft as a guide, is introduced
through the tissues, directed downward and backward, until a lessened

ASPIRATION OF THE BLADDER. 64I

resistance signifies that the bladder has been entered. This will
usually he when the needle has entered from i i /2 to 2 i /2 inches (4 to
6 cm.), depending upon the thickness of the abdominal wall. The
asph-ator is then attached and the vacuum is extended to the needle-
point by opening the inflow cock. If no urine is withdrawn, the needle
is introduced stili further imtil fluid is reached. The contents of the
bladder are then partly or completely emptied, depending upon
the duration of the retention and the amount of the distention (see
page 631).

In removing the needle, care should be taken to keep up the suction
until the needle is completely withdrawn, otherwise some urine may
escape from the tip of the needle as it traverses the prevesical space
and cause an infection. The site of the pimcture is finally covered
with a piece of sterile gauze held in place by adhesive plaster.

2. By the Trocar and Canntda. — A small nick is made in the skin
as before at the chosen site and through this the trocar and cannula
with the convexity up is inserted into the bladder, care being taken to
guard against the instrument entering too deeply by placing the index-
finger on the shaft of the instrument as a guide. The trocar is then
removed and the cannula is secured in place for permanent drainage
by means of tapes. A rubber drainage-tube leading to a receptacle
half filled with an antiseptic solution is fastened to the cannula.

The bladder may be irrigated through the cannula once or twice
daily if it contains much pus. The cannula should be removed and
sterilized every few days. To do this a small catheter is passed through
the lumen of the cannula into the bladder where it is maintained while
the catheter is being cleansed. The cannula is then easily reintro-
duced over the catheter as a guide.

The permanent cannula should be removed as soon as it is possible
to pass a catheter through the urethra without difficulty. The sinus
remaining is allowed to dose by granulation.

CHAPTER XIX.
THE KIDHEYS AND URETERS.

Anatomie Consideralions.
The Kidneys. — The kidneys are two bean-shaped organs, each
measuring on an average from 4 to 43/4 inches (io to 12 cm.) in
length and 2 1/2 inches (6.3 cm.) in breadth. They He deeply
situated in the abdominal cavity on each side of the vertebral column,
behind the p^erìtoneum embedded in a loose layer of areolar tissue,
the perìrenal fat, restìng upon the diaphragm, the quadratus lumborum,
andpsoas rauscles. Surrounding the perìrenal fat is a layer of fascia.

FiG. 680. — The poàtion ot (he kidneys and coucse of the ureters from bebind.

complete except along the inner border of the kìdney and at its lower
pole, which is firmly attached to the spine and diaphragm, and serves
to anchor the kidney in place.

The position of the kidneys from behind corresponds to the space

between the upper border of the twelfth dorsal vertebra and the first

and second, or third, lumbar vertebne. The right kidney generally

lies about 1/3 to i (2 inch (0.7 to 1.3 cm.) lower than the !eft on

642

ANATOMY.

643

account of the position o£ the liver above it, the upper extremity of
the right kidney usually reaching to the level of the lower. border of the
eleventh rib and that of the left tó the upper border of the eleventh rib.
The inferior poles of the kidney s reach to within i i /2 inches (4 cm.)
on the right and to within 2 inches (5 cm.) on the left of the crest
of the ilium. During deep inspiration or when the patient stands
erect the kidney will descend to a somewhat lower level. The long
axis of the kidney is directed obliquely downward and outward, so
that the superior poles lie from 1/2 to i inch (i to 2.5 cm.) nearer the
median line than the lower poles.

Anteriorly, the position of the kidney may be mapped out by passing
a horizontal line through the umbilicus and a vertical line from the

Fio. 681. — ^The kidneys and uretere from the front.

middle of Poupart's ligament to the costai border perpendicular to the
horìzontal line — the former passes just below the lower poles of the
kidneys, while the latter cuts the long axis of the kidney at the junc-
tion of its middle and outer thirds. If the kidney lies to the outer
side of the vertical line or below the horizontal umbilical line, it is
indicative of enlargement or a displacement.

Relations of Kidneys. — Behind, the kidneys are in relation with the
diaphragm, quadratus lumborum, psoas muscles, and with the last
dorsal, iliohypogastric, and ilioinguinal nerves. The dose relations

044 I^E KIDNEYS AND URETERS.

of these nerves account for the referred pains sometimes encountered
in diseases of the kidneys.

In front of the right kidney are the under surface of the right lobe
of the liver, the second portion of the duodenum, the ascending colon,
and the hepatic flexure. The left kidney is in relation in front with
the spleen, the fundus of the stomach, the tail of the pancreas, the
splenic vessels, and the descending colon.

Ureters. — ^The ureters are two in number, one for each kidney.
They are about 12 inches (30 cm.) in length and ha ve a caliber equal
to that of a goose quill. The ureter begins at the neck of the renai
pelvis opposite the lower pole of the kidney and passes down on the
psoas muscle behind the peritoneum to the brim of the pelvis. A line
drawn on the abdominal wall vertically upward from the junction of
the middle and inner thirds of Poupart's ligament roughly represents
the course of the ureter from the kidney to the pelvic brim.

The ureter in the male, after crossing the pelvic brim and the com-
mon iliac vessels, passes downward and backward in front of the
sacroiliac joint and enters the parietal attachment of the posterior false
ligament of the bladder. It then passes forward and inward to the
base of the bladder which it enters just above the seminai vesicle, first
passing imder the vas deferens.

The ureter in the female, after crossing the pelvic brim and iliac
vessels, passes downward and backward along the lateral wall of the
pelvis as in the male. It then enters the base of the broad ligament
and passes down parallel with the cervix and upper portion of the
vagina, at a distance of about i /2 inch (i cm.) external to the cervix
and posteriorly to the uterine artery. After crossing the upper third
of the vagina the ureter enters the bladder opposite the middle of the
vagina. The pelvic portion of the ureter in the female is thus readily
palpated through the vagina or rectum.

The ureters enter the bladder i i /2 to 2 inches (4 to 5 cm.) apart
and, after passing obliquely forward and inward for a distance of 3 14
of an inch (2 cm.) through the bladder wall, they appear on the mucous
membrane about i i /4 inches (3 cm.) apart and the same distance
posterior to the internai urethral orifice. Through this oblique in-
sertion of the ureters into the bladder regurgitation of urine when the
bladder is distended is efifectually guarded against.

The ureters are composed of three coats, an outer fibrous, a middle
or muscular, and an internai or mucous. Normally the walls are
collapsed and He in contact. The lumen of the ureter presents three
constrictions and two intermediate dilated portions. The constric-

INSPECTION. 645

tions are : First, about 21/2 inches (6 cm.) from the hilum of the kidney ;
second, at the point where the ureter crosses the pel vie brim; and, third,
at its entrance into the bladder.

Diagnostic Meihods.

In suspected disease of the kidney or ureter a careful history of the
past ailments and present symptoms shouid first be obtained. Ere-
quently pain will be the only symptom complained of. In such case
its exact location shouid be determined; that is, whether limited to the
loin or radiating along the course of the ureter, and whether unilateral
or bilateral. Severe attacks of pain radiating from the loin down
toward the bladder, testicle, and thigh are strongly suspicious of cal-
culus. The character of the pain shouid also be ascertained; whether
it is dull or aching, or paroxysmal and lancinating, and whether con-
tinuous or periodic. Periodic attacks of sharp pain accompanied by
a considerable diminution in the amount of urine secreted, followed
by relief of the pain and an abimdant flow of urine are characteristic
symptoms of hydronephrosis due to a movable kidney. The patient
shouid also be questioned as to the character of his urine, ùe., whether
bloody, etc, supplemented by inquiry as to special points along the
lines mentioned in the sections upon the urethra and bladder. This
is followed by a thorough physical examination.

Having obtained ali the information possible by these means, the
actual examination of the organ under consideration may be taken up.

The methods available for examination of the kidneys and ureters
include inspection, palpation, percussion, urinalysis, cystoscopic
examination, ureteral catheterization, segregation of urine, determina-
tìon of the f unctional capacity of the kidneys, skiagraphy, and explora-
tory incision.

mSPECTION.

On account of the deep situation of the kidney in the abdomen,
inspection gives no information if the kidney is normal. When, how-
ever, the kidney is greatly enlarged it may produce a visible swelling
in the loin or protrude anteriorly and cause a bulging of the lower ribs
upon the side affected.

Inspection shouid be performed from in front with the patient
lying fiat on the back, and also from behind and laterally with the
patient standing and bending forward, so as to make any bulging more
prominent through relaxation of the abdominal muscles.

646 THE KIDNEYS AND URETERS.

PALPATION OF THE KIDITEYS.

Palpatìon is by far the most valuable of the methods of physical
diagnosis f or determining the presence of enlargement or displacements
of the kidney. While the normal kidney can seldom be felt, unless the
individuai is very thin and the abdominal walI is lax, and then it is
only possible to palpate the lower pole of the kidney, an increase in the
size of the organ or undue mobility is readily recognized. By palpa-
tion it is also possible to determine the sensitiveness of the kidney and
in the presence of a tumor, its characteristics — namely, its size, shape,
and whether soft, hard, or fluctuating.

Palpation is sometimes performed with one hand, so placed that
the fiiigers press in the loin while the thumb lies on the abdomen
beneath the costai arch, but a more satisfactory method is the bimanual.

Position of Patient. — The patient should lie fiat on the back with
the head and shoulders elevated upon a small pillow and the lower
extremities flexed so as to thoroughly relax the abdominal walls.
Sometimes in cases of movable kidney additional Information may be
elicited by palpating with the patient standing, his body bent forward
from the hips, and with his hands resting on the arm of a chair for
support; or else the patient may assume the lateral position, lying on
the sound side, and with the thighs slightly flexed (see Fig. 683).

Preparations of Patient. — Care should be taken to have the colon
empty at the time of the examination; if necessary a cathartic should
be administered the night before for this purpose. AH clothing that
is likely to interfere with the examination should be removed.

Anesthesia. — If palpation is difficult through rigidity of the abdom-
inal muscles or from increased sensitiveness, a general anesthetic may
be required in order to make a satisfactory examination.

Technic. — ^The examiner should stand upon the side he wishes to
examine. When palpating the right kidney the fingers of the left
hand are placed under the loin just below the last rib and the right
hand is placed fiat on the abdomen below the costai arch (Fig. 682) ;
to palpate the left kidney the position of the hands is reversed. The
patient is instructed to breathe deeply but quietly, and any manipula-
tions should be gentle in character to avoid inciting muscular contrac-
tion. The kidney descends during inspiration and, if at this time
forward pressure is made with the hand under the loin and the hand
upon the abdomen is pressed backward under the ribs, the kidney, if
enlarged, will be felt. If the kidney is displaced, it may be caught
between the two hands as it descends during deep respiration and may

PALPATION OF THE KIDNEYS. 647

be prevented front returning to its former position. In the presence
of a tumor, the size, shape, and consistence of the growth shouid be
determined and its sensìtiveness ascertained. Palpation of the normal
kìdney causes a peculiar sensation which has been likened to pressure

FiG. 6Sj. — Palpation of (he kidney with the patienl in the dotsal position.

on the testicle; actual pain will be elicited, however, in the presence of
some tumors, kidney calculus, or pus fonnation.

Tumors of the colon, gall-bladder, pylorus, spleen, ora pedunculated
ovarìan or uterine growth may be mistaken for a renai tumor or a

Fio. 683, — Palpation of the kidney with the patient on the ade

movable kidney. The symptoms complained of and the relation of the
colon to the tumor, however, wilI usually settle the diagnosis. The
colon lies in front or to the inner side of the kìdney and, if necessary,
it shouid be tnflated to more accurately map it cut.

648 THE KIDNEYS AND URETERS.

At times the so-called " ballottement of the kidney " may be obtained
if the kidney is freely movable. To elicit this sign sudden sharp
pressure is applied to the loin by the posterior hand, when, if movable
or enlarged, the kidney will be driven forward with a slight impact
against the hand on the abdomen in front.

PALPATION OF THE URETERS.

The ureters may be palpated through the abdominal wall, through
the vagina^ or through the rectum. Abdominal palpation is only of
value if the patient is thin and the abdominal walls lax, and then it is
only possible to palpate the ureter if thickened or if it contains a
calculus. In some cases, however, if inflamed and painful, the ureter
may be traced from the kidney pelvis to the pelvic brim from the
pain elicited on palpation. Through the vagina it is possible to palpate
the ureter from the base of the broad ligament to its entrante into
the bladder. Calculi, thickening, or inflammation of this portion of
the ureter is thus readily recognized. In the male by rectal examina-
tion the ureter may be palpated in its course from the pelvis to the
bladder.

Positions of Patient. — ^For abdominal palpation the patient should
lie fiat on the back with the head and shoulders slightly elevated and
the thighs flexed.

Vaginal or rectal palpation is performed in the dorsal position
with the thighs flexed.

Preparations of Patient. — ^The bladder and bowels should be empty
at the time of examination.

Technic. — i. Abdominal Palpation. — The examiner stands on the
side to be palpated and first locates the promontory of the sacrum by
deep palpation with the examining hand. The ureter crosses the
pelvic brim at a point about i 1/4 inches (3 cm.) to the side of the
promontory and a little below it. A thickened ureter may be palpated
at this point if the patient has thin, relaxed abdominal muscles.
Beginning at this point, the ureter may be traced upward along its
course by making deep pressure along the outer border of the rectus
muscle (Fig. 684). If the ureter is inflamed, palpation will elicit pain.
On the right side such pain must be differentiated from that of chole-
cystitis or appendicitis.

2. Vaginal Palpation. — The right hand is employed to palpate
the right ureter and the left hand for palpation of the left ureter. The
index- finger is inserted in the vagina and is carried to the vaginal fomix

PALPATION OF THE URETEES. 649

corresponding to the ureter to be palpateci. From this poìnt it is
pushed upward and outward toward the pelvic walI, and a careful
search is made for the ureter which will be recognized as a fiat cord
passing forward and inward from the pelvic wall around the cervix to

FiG. 684. — Abdominal palpalo o( the u

Fio. 685.— Vaginal palpalìon of ihe ureter. (Aahlon.)

the bladder (Fig. 685). Sometimes, by means of a bimanual examina-
tion, with one band placed on the abdominal walI and exerting down-
ward pressure the ureter may be more satisfactorily examined.

6so THE KIDNEYS AND XJEETEBS.

3. Reclal Palpatùm. — ^The right band palpates the right ureter and
vke versa. The index-finger well lubricated is inserted into the
rectum and is carried upward a little higher than the level of the base
of the seminai vesicle. The finger is then tumed toward the lateral
Wall of the pelvis and the ureter is sought by moving the finger back-
ward and forward. It will be recognized as a fiat cord-like strutture

tic. 686.— Palpation of the ureter per recium.

passing at first downward along the side of the pelvis and then forward.
It may be traced as far as the bladder and will be recognized passing
forward and inward from the pelvic wall to the base of the bladder,
where it will be felt a little above the seminai vesicle.

PERCTTSSION.

Percussion of the kidney is of slight value unless the organ is greatly
enlarged. At best it is difEcult on account of the thick layer of muscles
in the dorsal and lumber regions and the depth of the kidney from the
anterior abdominal wall. In fat individuals the difficultiesare ìncreased
in proportioii. Percussion is important, however, for the puqxise of
showing the position of the colon in relation to a tumor occupying the
region of the kidney and in differentiating growths of the kidney from
the spleen and liver.

Posltton of Pstlent — To percuss from behind the patient should
lie face downward with a finn cushion or several pillows under the
abdomen to make the lumbar region more prominent (Fig. 687).

URINALYSIS. 651

For anterior percussion the patient lies in the dorsal posture with
the legs eztended.

Preparattons of Pattent. — The colon must be emptied so as not to
obscure the results.

Technlc. — It is necessary to employ very strong percussion to out-
line the oi^an, but in fat indivìduals even this may yield unsatìsfactory
results. In a nonnal case the kidney dulness will be found to extend
about 2 inches (5 cm.) below the làst rib, merging above into that of

Fio. 687.— Position o( the patient for percussion of the Iddneys front behind

the liver or spleen. In a large renai growth percussion will give dul-
ness extending outward and downward beyond the nonnal limits, with
colon resonance in front or internai to the tumor.

Tumors of the spleen or liver may give much the same area of dul-
ness, but the colon resonance will be behind. Indation of the colon
(page 493) may be necessary before its position can be accurately
determined.

URINALYSIS.

The examination of the urine is of the greatest importance. It
should comprìse a complete physical, chemical, microscopical, and
bacterìological analysis. Abnormality may be due to general diseases,
renai diseases, or to lesions in the lower genitourinary tract, so that it
is not sufBcient to simply recognize a departure from the nonnal, but
the seat of the trouble, i.e., whether in the bladder, ureter, or kidney,
-must be determined and, if the ureters or kidneys are affected, which
side is involved as well. For this purpose the cystoscopw and ureteral
catheter are of the greatest aid. Other methods for determining the
source of abnormal urinary constituents have already been described
(see page 596).

CYSTOSCOPY. (See page 610.)

652 THE KIDNEYS AND URETERS.

CATHETERIZmG THE URETERS.

The use of the ureteral catheter is of the greatest diagnostic aid in
diseases of the kidney or ureter, as it is possible by this means to collect
urine separately from each kidney for analysis uncontaminated by
contact with the bladder or urethra, and to expiore the entire length
of the ureter from the bladder to the kidney pelvis. This method of
examination is thus of value in determining whether both kidneys are
present, in estimating the functional capacity of either kidney, and in
the presence of blood or pus in the urine in determining whether its
source is the kidney or the ureter and from which side it comes. It is
also of the greatest aid in recognizing stricture or calculus of the ureter,
hydroureter, hydronephrosis, etc.

Ureteral catheterization has certain drawbacks that should be
mentioned. Under the most favorable conditions it requires con-
siderable skill to catheterize the ureters, and in some cases, compli-
cated by the presence of tight urethral strictures, enlargement of the
prostate, tumors, or thickening of the bladder mucous membrane it
may be impossible. Then there is always present the danger of carry-
ing infection from the bladder into a healthy ureter or kidney. With
proper aseptic precautions in performing the operation, however, this
may be obviated.

Instruments. — Catheterizing cystoscopes, like the exploring cysto-
scopes, are of two types, the direct view and the indirect view.

Fio. 688. — ^Bransford Lewis cystoscope.

The direct view cystoscope, of which the Brenner, Brown, Bransford
Lewis, Elsner, etc, instruments are types, are arranged with the light
either on the convex side of the beak, or with a window both on the
convexity and concavity so that the light is shed in both directions,
and are provided with a straight observation telescope having a window
at the distai end. The catheter chambers are placed on the under
surface of the telescope so that the catheters protrude at the lower
part of the field of vision in a straight line. An obturator takes the
place of the telescope when the instrument is being inserted into the
bladder.

CATHETERIZING THE URETERS. 653

The indirect catheterizing cystoscope, such as the Nitze, Casper,
Albarran, Bierhoff, Buerger, etc, ha ve the light upon the concave side
of the beak, while the image is reflected at right angles, by means of a
prism, to the eye-piece at the proximal end. The catheter chambers
are enclosed within the sheath of the instrument lying above the tele-
scope. A small movable tongue or finger, which can be raised or
lowered by means of a screw at the ocular end of the instrument, is
provided for the purpose of changing the angle of the catheters as they
emerge from the instrument. Irrigating cocks are provided with both
styles of cystoscope.

Instruments may also be obtained with which it is possible to
employ either the direct or indirect methods of observation andcatheter-
ization, as McCarthy's composite cystoscope, which has both indirect

Fio. 689. — The Bierhoff cystoscope.

a, Showing the instrument with the telescope in position for catheterìzation; b, showing
the telescope rotated within the sheath to facilitate removal of the instrument.

and direct view telescopes and an indirect doublé catheterizing attach-
ment, and the universal cystoscopes of Tilden Brown and Bransford
Lewis, which combine in one instrument direct and indirect observa-
tion and doublé catheterization by either the direct or indirect method.

While the choice of the make of instrument must rest with the
individuai operator, there is no doubt that in the majority of cases it
is easier to catheterize with the direct view instrument, exceptions
being the presence of intra vesicular hypertrophy of the prostate and
a trabeculated bladder, in which class of cases the indirect view in-
strument is essential; on the other hand, it is far easier to locate
the ureteral orifices by indirect view.

The catheters, which are of silk elastic material about 24 inches
(60 cm.) long and 5 to 7 French in size, should be of dififerent colors to
differentiate them. The distai end is either blunt or olive pointed.
Before using, it should be seen that the catheters are smooth and the
eyes perfect; the patency of the catheters should also be tested by

654 THE KIDNEYS AND URETERS.

injecting water through them. They are best kept at full length in
glass tubes plugged with cotton at either end.

For the purpose o£ diagnosing calculi the end of the catheter may
be dipped in melted wax (2 parts of dentai wax and i part of olive oil)
and allowed to harden in the air (Fig. 690). On coming in contact
with a stone scratch marks will be produced on the wax tip. The
wax catheters can only be used, however, with the direct view instru-'
ment and to avoid scratching the wax they should be threaded through
the instrument from the vesical end backward.

Fio. 690. — Wax-tipped u reterai catheter.

In addition to the ureteral catheters an irrigating jar or a Janet
syringe holding 3 to 8 ounces (89 to 148 ce.) of solution and a soft-
rubber catheter should be provided for irrigating the bladder.

Illumination for the cystoscope may be obtained from a six- or
eight-cell battery or from the Street current provided a controller is
employed.

Asepsls. — ^The cystoscope should be well cleaned with tincture of
green soap and water and is then placed in a i to 20 carbolic acid
solution or 95 per cent, alcohol, or it may be sterilized by formalin.
Before using, it should be rinsed off in a saturated solution of borie acid.
The catheters are sterilized by boiling for one or two minutes in plain
water, care being taken to wrap them separately in gauze to prevent
their sticking together and to place them at full length in the sterilizer.
The examiner's hands are carefully sterilized in the usuai way.

Posltion of Patient. — ^The patient may be in the lithotomy position
with the buttocks dose to the edge of the table, or as preferred by some
operators in a semirecumbent posture. The table should be provided
with uprights which are surmounted with doublé inclined rests for the
thighs and knees.

Anesthesia. — Locai anesthesia is usually sufl&cient. It is obtained
by the instillation into the deep urethra of a small quantity of a 2 per
cent, solution of cocain or by filling the empty bladder with 5 oimces
(150 C.C.) of a warm o.i per cent, solution of cocain to which is added
20 drops (1.25 C.C.) of adrenalin. This must be retained foratleast
fifteen to twenty minutes. Guyon's method may also be employed
(see page 612). In some few cases it may be necessary to employ

CATHETEKIZmG THE USETEKS. 655

general anesthesia; for chìldren general anesthesia should always be
used.

Preparattons of Patient. — The extemal genitals should be cleansed
wiih soap and water followed by a i to 5000 bichlorid of mercury
solution. The bladder is then emptied and thoroughly irrigated with
a.saturated solution of borie acid by raeans of a catheter and a large
syringe until the fluid retums clear. Four to 6 ounces (118 to 178 ce.)
of a saturated borie acid or normal salt solution are then injected into
the bladder and allowed to remain for the purpose of distention.

If hemorrhage from the bladder is suflìcient to interfere with the
operation, a i to 3000 adrenalin chlorid or i to 15000 silver nitrate
solution should be injected through the catheter and allowed to remain
in the bladder for ten to fifteen minutes before it is distended.

Tectanic. — i. Direct Catheterization.—The cystoscope and catheters
having been thoroughly tested, the instrument, well lubricated with

glycerin or lubrichondrin and with the obturator in place, is in-
troduced into the bladder. The obturator is then removed and the
catheterìzing telescope is inserted in its place, after which the light
is tumed on and the ureteral orifices are sought for, They are located
at the upper angles of the trigone about 3/4 inch (2 cm.) from the
median line and linch (2.5 cm.) from the internai openingof the urethra.
By first locating the apex of the prostate and then pushìng the instru-
ment in about i inch (2.5 cm.) the interureteric line which passes
between the two ureters, forming the base of the trìgone, will come to

656 THE KIDNEYS AND URETERS.

view and if this is traced to one side or the other the orifice of the ureter
will be recognized in the lateral angle o£ the trigone. It may appear
either as a slit or as a dimple on the apex of a papilla, and, ìf carefully
watched, urine will be seen coming from it in intermittent spurts, It
may be extremely difficult to locate the ureter, but a careful search
will usually reveal it. In ali manipulations of the cystoscope it is of
the utmost importance to employ extreme gentleness otherwise bleed-
ing will supervene and interfere with the examination.

With the direct view cystoscope the instrument is not rotated
about an axis, but the beat is kept constantly pointìng upward while
the vesical end is tumed from one side to the other or up and down
as the case may be (Fig. 691). The mouth of the ureter having been
located, the heei of the cystoscope is brought dose to it (Fig. 692) and

Fio. t>i)2. — Caiheterìiation by the direct melhod, sbowing the heel of ihc qratoscope
brought dose to the mouth of the ureler.

an attempt is made to engagé the catheter in its lumen. The catheter
is then slowly and gently threaded up the ureter to the desired distance
(Fig. 693). If the purpose of the cathetcrization is simply to with-
draw urine from the ureter, the catheter is introduced 3 to 4 inches
(7.6 to IO cm.); in exploring the ureter for stone or stricture, or to
determine whethcr pus has its origin in the ureter or kidney pelvis, the
catheter should be passed as far as the renai pelvis — 13 to 15 inches
(32 to 37 cm.). The other ureter is located and catheterized in the
same manner.

CATHETERIZDJG THE URETERS. 657

The light is then extinguished and the catheterizing attachment is
first carefully removed and then the sheath, keepìng the catheters in
posìtion in the ureter by threadìng them through the ìnstniment as
it is withdrawn. Unless the catheters are of different colors, they
should be labeled "left" or "right" in order to distinguish them.
The first urine that flows is discarded and the ends of the catheters
are then wiped off and inserted into sterile bottles plugged with cotton.
A catheter may become plugged with mucus, blood clots, or pus. If
so about 15 ni. (i ce.) norma! saU solution may be injected through
it by means of a syringe.

Fio. 693. — Catheterization by the direct method, showing the calheler entering the ureter.

From 2 to 4 ounces of urine are, as a rule, sufiicient for examina-
tion. While the urine is being collected, the patient's legs should be
released from the crutches holding them and he should be allowed to
assume as comfortable a posìtion as possible. At the completion of
the operatìon the catheters are carefully removed and the bladder is
irrigated with a saturated solution of borie acid.

2. Indirect Catheterization. — The instrument, well lubricated, is
introduced into the bladder and is then rotated completely around so
that its beak looks posteriorly. The prostate is thus located and by
rotating the instrument through an angle of 30 to 45 degrees the lateral
ridge of the trigone may be traced running backward at an angle from
the prostate. At the point of the junction of this ridge with the intcr-
ureteric line will be found the ureteral orifice. It should be remem-

Ó58 THE KIDNEYS AND URETEKS.

bered that with this form of instniment the image will appear inverted,
that is, the prostate will appear at the upper portion of the fieM instead
of at the lower. Having located the ureteral orifice the instrument

Fio. 694. — C&thelerìzation by the indirect method, showing the cystoscope in postìoo.

Fio. 695. — Catheteiization by the indirect melhod, the calheter being pushed into the

instrument until ita tip passes sljghtiy beyond the ureteral orìficc.

is brought dose to it (Fig. 694) and the catheter is pushed gently for-
ward until its tip passes slightiy beyond it (Fig. 695). The" small
director is then elevated slightìy (Fig. 696) and the catheter is again

CATHETERIZDJG THE UEETERS. 659

pushed forward. If it mìsses the orifice, the ìnstrument is wìthdrawn
a little and a second attempi made to introduce it. By pushing the

Fic. 696. — Catheteiìzalion by the indirett method, showing the tip of the catheter being
deflected toward the ureteral oiiGce by elevating the director.

Fio. 6g7.— Catheterìzation by the indirect method, showing the calhewr inserted in the

catheter forward a little or withdrawìng it and changing ìts angle of
deflection slightly, it is finally introduced into the ureter (Fig. 697).

66o THE KIDNEYS AND URETERS.

The other ureter is then locateti and the catheter ìs introduced in the
same way. The catheterizing telescope is then carefully removed,
first turning the deflector down and extinguishing the lamp. It is
sometimes a dìfficult malter to remove the sheath of the cystoscope
and stili leave the catheters in place when using this forni of ìnstni-
ment. The foUowing manipulations, however, described by Buerger
{Annals of Surgery, February, 1909), simpUfy this portion of the
opera tion :

" After having introduced the catheters a little higher than we wouid
if the instrument were to remain in the bladder, and after removal of
the telescope, the following movements should be carried out: first.

Fio. 698. Fic. 699.

Fio. 69S. — Removdl of Ihe sheath. Fìnt step, showing the tclescope removed tjid the

catheters lyijig loosely in the sheath. (After Buerger, AnnaJs a} Surgery, Feb., 1909.)

FlG. 699. ^Removal of the sheath. Second step, showing Ihe ocular end depres^ed and

carried lo the left until clear of the catheters. (After Buei^er, Anitais oj

Surgery, Fcb., iQog.)

the ocular is depressed and carried a little to the left, thus separating
the beak from the line of the catheters (Fig. 699); second, the whole
instrument is rotated to the right on its longitudinal axis through an
are of 190 degrees, retaining the relative position just described, thus
making the beak, point upward (Fig. 700) ; third (stili in the same piane,
with the ocular a little to the left), the ocular is raised and brought
back to the median line in order to bring the convexity of the beak
against the trigone of the bladder (Fig. 701); and fourth, the sheath

URETEHAL CATHETERIZATION IN THE FEMALE. 66l

is removed, its inferior aspect being made to hug the posterior wall
of the urethra."

Removal of the Bierhoff instrument is comparatively simple, as
it is arranged so that the telescope may be rotated within the sheath
until the beak poìnts upward without disturbing the catheters (see
Fig. 689).

Fio. 700. FiG, 701,

Fio. 700. — Remova] o£ the sheath. Third step, showing the beak being lumcd upward.

(After Buetger, Annali oj Surgery, Feb.iigog.)

FiG. 701. — Removal of the shealh. Final step, the beak in position for removal of the

shealh. (After Buerger, Annali of Sargery, Feb., J^og.)

URETERAL CATHETERIZATION XK THE FEHALE.

Ureteral calheterization in the female has the same field of useful-
ness as when applied to the male (see above). In addition, catheters
are often inserted ìnto the ureters as a guide to their position so as to
avoid injuring them in difEcuIt pelvic operations. Cathcterization may
be performed, as in the male, by means of one of the catheterizing cysto-
scopes, the method of performing which requires no further explana-
tion than that given above, or by means of open tubes under air dis-
tention after the method of Kelly. This latter method requires
separate description.

Instruments. — The ordinaiy Kelly speculum with illumination
fumished by reflected Hght or some of the modìfìcations of Kelly's
tubes with the light at the distai end may be employed. The latter
are preferable.

662

THE KIDNEYS AND URETERS.

In addition there will be required a cone-shaped urethral dilator,
alligator-jaw-shaped forceps, a residuai urine evacuator, Kelly 's ure-
teral searcher, silk flexible catheters, a metallic catheter, and hard-
rubber flexible sounds (Fig. 702).

Fio. 702. — Instruments for catheterìzing the uretere in the female.
I, Open-tube cystoscope; 2, Kelly urethral dilator; 3, residuai urine evacuator; 4,
alligator-jawed forceps; 5, ureteral searcher; 6, metal ureteral catheter; 7, flexible uretere!
cathetere with stylets; 8, ureteral bougies.

The cystoscope, alligator-jaw forceps, urethral dilator, and searcher
ha ve been previously described (page 616).

The flexible silk catheters are made in two lengths: 12 inches (30 cm.)
long for ordinary ureteral catheterization and 20 Inches (50 cm.) long
for catheterization of the kidney pelvis. The tips are blunt or olivary
and ha ve an ovai eye about 3/4 inch (2 cm.) from the distai end.
They may be obtained in sizes running from 1/16 to 1/8 inch (13/4

Fig. 703. — Ashton's forceps for guiding the catheter into the ureter. (Ashton.)

to 3 mm.) in diameter. A wire stylet is introduced within the catheter
to fumish it with the necessary stiffness for passage into the ureter, or
forceps, such as Ashton *s (Fig. 703), may be employed for this pur-
pose. As an aid in recognizing a calculus the ends of the catheters
may be wax-tipped (see Fig. 690).

URETERAL CATHETERIZATION IN THE FEMALE. 663

Metal catheters are 12 inches (30 cm.) long and 1/12 inch (2 mm.)
in diameter and are supplied with three eyes situated back of the
point which is conical in shape and slightly curved. They are employed
when a stricture low down in the ureter interferes with the passage of a
flexible catheter.

Solid, flexible, hard-nibber bougies are employed in exploring the
ureters or dilating strictures. They are 20 inches (50 cm.) long and
1/12 inch (2 mm.) in diameter. When warmed they become flexible
and in this state may be passed the entire length of the ureter without
danger. For the purpose of locating stpne they may be wax-tipped
(Fig. 704).

Fio. 704. — ^Wax-tapped bougìe. (^shton.)

Asepsis. — Great care should be taken to observe ali aseptic details.
The operator's hands should be thoroughly cleansed, and precautions
should be taken not to allow the sterile catheters to touch the table or
patient 's body during their introduction. Metal Instruments and hard-
rubber bougies are sterilized by boiling for Ave minutes in a i per
cent, soda solution. Silk catheters are boiled for not over two minutes
in plain water and are then placed in cold sterile water to make them
stiff. Care should be taken when boiling the catheters to place them
in the sterilizer at full length and to wrap them separately in gauze so
as to keep their surfaces from becoming glued together.

After use the catheters should be thoroughly cleaned inside and
outside with warm water and tincture of green soap and then put away
at full length in a glass receptacle.

Position of the Patient* — ^As for cystoscopy two positions are
employed, namely, the dorsal elevated and the knee-chest. In the
former the patient lies with the head and thorax resting on the table
and the hips elevated 8 to 12 inches (20 to 30 cm.) upon a cushion so
as to raise the pelvis sufficiently to allow the bladder to distend with air
when the cystoscope is in place. If the bladder does not inflate with
the patient in the dorsal position, the knee-chest posture is employed.
The latter position is usually necessary in stout people.

Preparations of Patient. — It should be seen that the rectum and
bladder are empty before beginning the examination. The external
genitals are then washed with soap and water followed by a i to 5000
solution of bichlorid of mercury, and the bladder is irrigated with a

604 THE iODNEYS AND URETERS.

warm saturateci solution of borie acid until the fluid retums clear.
The solution is then ali drained off before the cystoscope is inserted.

Anesthesia. — Locai anesthesia, obtained by inserting into the
meatus a small pledget of cotton saturated with a 2 per cent, solution
o£ cocain and allowing it to remain for five minutes, is generally
sufficient. In extremely nervous patients general anesthesia may be
required.

Tcchnic. — The urethra is first dilated and the cystoscope is intro-
duced in the manner already described (page 618). The obturator is
then removed, when, if the patient is in the proper position, air rushes
in and distends the bladder. The light is then adjusted and a search is
made for the ureteral orifices. In doing this it is well to first withdraw
the instrument until the mucous membrane of the internai urethral ori-
fice begins to dose over the end of the instrument, and then to advance
it 1/2 to 3/4 inch (i to 2 cm.) tumed either to the right or leftabout
30 degrees from the center line along the dark lateral ridge of the trigone.
The distai end of the instrument is then brought dose to the base of
the bladder by raising the handle of the cystoscope if the patient is in
the dorsal position, or depressing the handle if the knee-chest position
is used. By moving the instrument carefully about, the mouth of the
ureter will be located somewhere near the end of the cystoscope. It
may appear as a small slit or as a distinct hole or as a dark point in the
bladder mucous membrane. If it is not readily found, the speculum
should be directed toward its normal location and a careful search
made for it with an ureteral searcher in the folds of mucous
membrane.

Having located the orifice, the end of the cystoscope is brought dose
to it and the catheter is introduced. Metal catheters or sounds are not
difficult to introduce. They should be well lubricated and, while the
cystoscope is maintaìned in position with the left hand, they are
guided by means of the right hand into the ureteral orifice.

Flexible catheters may be introduced in two ways, either by the
use of a stylet to give them stiffness or by the aid of a specially made
forceps, such as Ashton's (see Fig. 703). By the former method the
catheter, well lubricated, with the stylet in place, is gently inserted in
the same manner as a metal catheter into the mouth of the ureter
(Fig. 705). The stylet is then withdrawn and the catheter is pushed
on until it has entered the desired distance. For ordinary purposes
of catheterization this will be 3 or 4 inches (7.6 to io cm.). In intro-
ducing these flexible catheters care must be observed that the portion
outside the cystoscope does not become contaminated by touching the

URETERAL CATHETERIZATION IN THE FEUALE. 66$

patient or the table, and for thìs purpose it is well to keep this part of
the catheter wrapped in sterile gauze.

If it is desired to catheterize both ureters, the mouth of the other one
is then located and the catheter introduced in the same manner. The
cystoscope is then withdrawn and the catheters are labeied right and
left to distinguish them. After wiping the ends of the catheters, they
are placed in two small sterile bottles plugged with sterile cotton, and

of the uieier in the temale by mcans of a flcxibJe ca.the(er
anned with a stylet.

about 2 to 4 drams (7.5 to 15 ce.) of urme are coUected from each
kidney (Fig. 706).

Variation in Technic. — The following method, devised by
Kelly, for coUecting urine from one kjdney without using a catheter
is sometimes employed when it is undesirable to introduce a catheter into
the ureter for fear of canying an infection from the bladder or from
other causes. Brieily, it consists in placing the patient in the knee-
chest posture, introducing into the bladder a speculum with the end
cut on the slant, and exposing to view the ureteral orifice from which it
is desired to obtain a specimen of urine. The orifice of the ureter is
then wiped clean and the speculum is held dose agaìn^t the bladder

THE KIDNEYS AND URETERS.

Wall SO that the urine escapes into the speculum whence it ìs collected
by means of a small glass graduate (Fig, 707). In this way often in

FlG. 706. — M«thod of collectìng separate urine from each kìndey. (Ashtoo.)

Fio. 707.— Kelly's method of collectìng urine troia a kidney wilhout using a c&theter.

(After Kelly,)

a short time sufficient urine may be collected for purposes of ex-
amination.

SEGREGATION OF UKIME. 667

SEGREGATION OF URINE.
Special instruments, known as segregators, which separate the
bladdfir into two halves through the formation of an artificial dam,
may be employed to collect the urine separately from the kidneys
when a catheter caiinot be passed into the ureter or ureteral catheter-
izatlon ìs contraindicated. They are easier to empioy than the ure-
teral catheter and with theìr use there is no danger of carrying infec-
tion into the ureters, but, on the other hand, they are not so accurate,
as an incomplete watershed may be formed allowing the urine from
the two sides to mìngle, and the introduction of the instruments may
incite vesical bleeding and give misleading, results. Again, if the
bladder is diseased, the urine obtained is, of course, contaminated and
it is not possible to determine whether the source of blood or pus is
the bladder, ureter, or kidney. If the bladder Ìs very irritable or bleeds
easily, as is the case in the presence of acute cystitis, vesical caiculus,
tumors, and prostatic hypertrophy, a segregator should not be used.
In heaithy bladders, however, segregation properly performed is fairly
reliable.

Frc, 708.— The Harris segregator. (Ashion.)

InrtrumentB.— There are several types of urine separators among
which may be mentioned the instruments of Harris and Luys.

The Harris segregator (Fig. 708) consists of two catheters having
a common sheath except at the distai and proximal ends. The intra-
vesical ends when in contact form a cylinder with a doublé curve and
are supplied with numerous small eyes which lead to the interior of
the catheter. The extravesical portions end in curved metal tubes to
which are connected by means of pieces of rubber tubing two aspirating

668

THE KIDNEYS AND URETERS.

bottles. A long lever, connected to the shaft of the instniment by means
of a fulcrum and spring, which is inserted into the rectum or vagina
for the purpose of raising up the bladder wall in the mid-line in the
form of a dam, is also provided.

Luys' instrument (Fig. 709) consists of two catheter tubes separated
by a metal parti tion, the vesical end of which has a Béniqué forni of
curve. On the concave side of the intravesical portion is a small chain
covered with thin india-rubber membrane, so arranged that after the
instrument is within the bladder by tuming a screw at the proximal
end of the instrument the rubber membrane is made to partition the

Fio. 709. — ^The Luys segregator.

bladder into two halves. Near the proximal end are two discharge
tubes which empty into small bottles. In males this instrument causes
less discomfort than does the Harris segregator.

Asepsis. — The instruments and the bottles for collecting the urine
should be sterilized by boiling for five minutes, and the operator*s
hands are cleansed as for any operation.

Position of Patient. — In using the Harris instrument the patient
lies fiat on the back with the feet, hips, and head on a level and with
the thighs flexed.

The same position is employed in inserting the Luys instrument,
but, when the instrument is in the bladder, the patient is elevated to a
semi-sitting position.

Preparations of Patient. — The rectum should be empty. The ex-
temal genitals are cleansed with soap and water foUowed by a i to 5000
solution of bichlorid of mercury. The urethra is irrigated with a
I to 5000 solution of potassium permanganate. The bladder is emp-
tied by means of a catheter and is then irrigated with a saturated solu-
tion of borie acid or sterile water. About 5 ounces (150 ce.) of solu-
tion is lef t in place when using the Harris instrument to permit manip-
ulation of the instrument, less distention being necessary with the
Luys instrument.

SEGREGATION OF URINE. 669

Anesthesla. — Locai anesthesia may be required il the urethra or
bladder are hyperesthetic.

Technic. — i. Harris' Melkod. — The instrument, closed so the

FlG. 710.— Segregation of urine by raeansof the Harris segregalor. First slep, inslrumcnt
in po^lion in the bladder. (Aijllon.)

catheters forni a continuous tube, is well lubricated and is introduced
into the bladder until its beak lies just withm the vesical nect (Fig, 710).
The proximal ends are then rotated outward so that the vesical ends
are made lo lie on either side of the ureteral orifices and are fixed in

ot the Harris segregator. Second step, vesical
separaled. (Ashion.)

this position by the small spring at the proximal end of the instrument
(Fig. 711). The long lever, well lubricated, is then introduced into
the rectum of the male or the vagina of the female and is secured by a

670 THE KIDNEYS AND URETERS.

clamp to the sheath of the catheters. By means of a spirai sprìng the
rectal or vagìnal end is forced upward causing a longitudinal rìdge of
bladder wall to be formed in the mid-line between the two ureteral
orifices with the end of each catheter lying at the bottom of the corre-
sponding compartment of the bladder. The fluid left in the bladder
is then allowed to escape from each catheter until it has ali been drained
off. The aspirating apparatus is then attached and the urine is genlly
sucked out of the viscus from time to time by means of the suction bulb
and is collected in two sterile bottles (Fig. 712). The instrument must

Fio. 711. — Scgi^ation of urine by meani of the Harris s^rcgator. Hiiid step, tbc
instnimeiil in ptace. (Ashton.)

be left in place about half an hour to coUect suf&cient urine for exam-
ìnation. Care must be taken to avoid too vigorous aspiration or
hemorrhage will be incited.

At the completion of the operation the lever is detached, the
catheters are folded back in place, and the instrument is carefully
removed, following which the bladder is irrigated with a saturateti
solution of borie acid.

2. Luys' Method. — The rubber dam is first carefully examined to
sce if it is intact. The instrument, well lubricated, is then introduced
in the same manner one would insert a sound, depressing the handle
well between the thighs as soon as the tip enters the prostatic urethra
so as to carry the curved portion into the bladder. As soon as the
iastrument is well within the bladder, the patient is raised to a. semi-

DETERMINATION OF THE FUNCTIONAL CAPACITY OF THE KIDNEVS. 67I

sitting posture and the diaphragm is raised, carefully keeping the
instrument exactly in the median line. The handle of the instrument
is then elevated untii resistance shows that the intravesical portion is
in contact with the base of the bladder. This should be confirmed by
vagina! or rectal palpation. After ali solution has been drained from
the bladder, the urine as it trickles into the bladder is carried off by a
catheter on each side and is collected in the small tubes at the proximal
ends of the instrument (Fig. 713).

Fic. 713 — Showing Ihe melhod of us'ng the Luys segiegator.

At the completion of the operation the diaphragm is lowered and
the instrument is withdrawn. This is followed by a vesical irrigation
of borie acid.

DETERMINATION OF THE FUNCTIONAL CAPACITY OF THE
KIDNEYS.

By the functional capacity is understood the ability of a given organ
to perform its excretory functions. In surgical work it isalwaysimpor-
tant to determine whether the kidneys are doing normal excretory work,
but, unless a severe operation is to be undertaken, a careful urinalysis.
including the total daily amount of urbe, the daily excretion of urea,
etc, is sufficient. When the removal of one kidney is conteraplated,
however, in addition to determining whether the two kidneys are
fuctionating properly, the functional capacity of each kidney should
be determined as far as possible. A variety of procedures with this
in view ha ve been devised. These include (i) estimation of the amount
of urea excreted, (2) inducing artifìcial glycosuria by phlorìdzin, (3)
the methylene-blue and indigo-carmin tests, (4) cryoscopy of the
blood and urine, and {5) the experimental polyuria test.

672 THE KIDNEYS AND URETERS.

While these tests are very valuable, none of thefm are infallible, for,
though they demonstrate which kidney is functionating best, they do
not absolutely prove that a particular kidney is healthy and capable
of doing suflScient excretory work after removal of its mate.

The Urea Test. — The average daily amount of urea excreted in
health amounts to from 250 to 450 grains (16 to 29 gm.). In the
presente of one diseased kidney, if it is found on repeated examinations
that the average total daiiy amount is not reduced to below 250 grains
(16 gm.), it is evident that the sound kidney is compensating for the
other*s inefficiency. CoUection of the separate urine from each kidney
by ureteral catheterization and estimation of the amount of urea in
each specimen will, however, show exactly the proportion of work
each kidney performs.

The Phloridzin Test. — This test depends upon the property of
the healthy kidneys to form sugar from phloridzin. The bladder is
first emptied and then 16 n^^. (i ce.) of a i to 200 solution of phloridzin
are injected into the buttock. If the kidneys are healthy, glycosuria
should appear within fifteen minutes to half an hour after the admin-
istration of the phloridzin and should persist for about two to four
hours. Delay in its appearance or the excretion of only small amounts
of sugar points to renai insufficiency, while an entire absence of sugar
indicates that the kidneys are seriously affected. If the functional
activity of each kidney is to be determined, a catheter is placed in
each ureter and the relative proportion of sugar in each specimen of
urine thus obtained is estimated.

Methylene-blue and Indiso-carmin Tests. — Another method
of testing the functional activity of the kidneys is to inject drugs,
such as methylene blue or indigo-carmin, which color the urine after
entering the circulation. For this purpose 16 tì]^. (i ce.) of a 5 per
cent, solution of methylene blue is given hypodermically or 65 ti]^.
(4 C.C.) of a 4 per cent, solution of indigo-carmin is injected intra-
muscularly. If the kidneys are normal, upon cystoscopic examination
within half an hour after administration of the methylene blue and
within ten to twelve minutes after the administration of the indigo-
carmin, stained urine will be seen escaping from the ureteral orifices.

It is claimed for these tests that if the coloring of the urine is
delayed or its intensity lessened it tends to show that there is some
impairment of the renai function.

Cryoscopy. — Cryoscopy is the determination of the freezing-point
of a liquid compared to that of distilled water. The underlying prin-
ciple of this test is that fluids containing a small amount of solid

DETERMINATION OF THE FUNCTIONAL CAPACITY OF THE KIDNEYS. 673

material give a high freezing-point while liquids with greater concen-
tration freeze at a lower temperature. Applied to the blood and
urine, cryoscopy is valuable in determining the renai activity of the
kidneys and in some cases may be of prognostic value when renai
impairment exists. For example, if the kidneys are doing an insuffi-
cient amount of excretory work, there will be an accumulation of solid
material in the blood which will, therefore, freeze at a lower temperature
than normal, and at the same time the urine in such a case, through
impairment of the power of the kidneys to eliminate properly, will
give a higher freezing-point than normal.

The freezing-point of normal blood is 0.56^ C. below that of dis-
tilled water. In weakened anemie individuai, however, it may rise
to — 0.55° C. or even as high as —0.53° C. or — 0.52° C. If cryoscopy
of the blood gives a freezing-point below — o. 56° C, it is regarded as
indicating some impairment of the renai function with retention of waste
products in the blood. According to Kummell, who has had a very
large experience with this method and places great reliance in it, if
the freezing-point of blood falls to — o . 60° C. it indicates such a degree
of renai impairment that nephrectomy is contraindicated.

Cryoscopy of the urine is of less value than when the test is applied
to the blood. He^-lthy urine freezes at — 0.9° C. to — 2° C, and
if the freezing-point is higher than — 0.9° C. it is considered to be
indicative of insufficient renai activity. Cryoscopy of urine coUected
separately from each kidney by ureteral catheterization will give more
information than when the test is applied to the bulk of urine,

To carry out this test 3 drams (io ce.) of blood and urine are
required. For comparative examination the two should be collected
at the same time, the former by venous puncture (page 222) and the
latter by ureteral catheterization.

For the technic of cryoscopy, which requires a considerable
amount of skill to properly carry out, the reader is referred to some of
the manuals on clinical laboratory methods.

Experimental Polyuria Test. — Stili another method of estimating
the functional activity of the kidneys is that known as the experimental
polyuria test, devised by Albarran, which consists essentially in obtain-
ing the urine from each kidney when the patient is dry and comparing
the two specimens and then having the patient drink a large quantity
of water and noting the effect upon the activity of the two kidneys.

The test is based upon the foUowing laws: First, a diseased kidney
has a more uniform function than a healthy one, and the more exten-
sively its parenchyma is destroyed the less will its function vary from
43

674 THE KIDNEYS AND URETERS.

tìme to time; second, when one kidney alone is diseased or is more
diseased than the other, if the urinary f unction is disturbed, its f unction
is less modified than the othet. In other words, if an ìncreased excre-
tory demand is placed upon the kidneys through the ingestion of large
quantities of water and the urine is coUected separately, the less diseased
orgdn should show a greater increase in activity, manifested by the
excretion of a larger total amount of fluid and solids, though the per-
cottage of solids will be diminished, while the diseased kidney will
show a relatively small or no increase in activity. The test thus
becomes of value in determining which kidney is functionating best
and the power of each to accommodate itself to increased demands
for excretory work.

The technic is as foUows: The patient should not ha ve eaten any-
thing for four hours or taken any liquids for three hours. A single
catheter is placed in one ureter and the urine from the other side is
collected by means of a small catheter passed into the bladder. The
urine which flows for the first ten or fifteen minutes is discarded in
order to permit the reflex pol)niria which follows the introduction of
the ureteral catheter to subside, and the urine that then flows is col-
lected for half an hour. This is saved for comparison with specimens
taken after the administration of the fluid. At the end of half an hour
the patient is given two to three glasses of Evian water and the urine is
collected separately and examined at half *hour intervals for one and
a half hours. Not only is the total quantity of urine noted, but the
specimens are tested as to the freezing-point, quantity of urea and
sodium chiorid, and, if phioridzin has been given, the amount of sugar
is estimated,

SKIAGRAPHY.

The X-rays are of the greatest aid in the diagnosis of ureteral and
renai calculi. A good picture will give positive information as to the
positionof a calculus, that is, whether it is located in the ureter or kidney
and will demonstrate their number and size, as well as the position of
the kidneys. In order to interpret the results of the X-ray correctly
the piate should show the following anatomie landmarks. The
twelfth rib, the transverse processes of the vertebrae, the crests of the
ìlia, and the psoas muscle. If these points are shown, the position of
a calculus may be determined with accuracy. The shadows cast by
tumors, fecal concretions, calcified retroperitoneal glands, buried
sutures which have become calcified, phleboliths, the thickened tip

MEDICATION OF THE RENAL PELVIS AND URETERS. 675

of an appendix, etc, are sometimes wrongly interpreted as calculi.
Such errors may be avoided if a metallic sound or a catheter in which
a lead wire stylet has been placed is inserted into the ureter and renai
pelvis, and an X-ray is then taken. The shadow of a calculus will be
shown to be in dose relation to that produced by the wire in the ureter.
Thus, while a positive picture can usually be taken as proof of the pres-
ente of a calculus, this cann'ot always be said of the negative evidence
fumished by an X-ray. It must be remembered that great thickness
of the abdominal wall may interfere with the success of a picture and
that the chemical composition of the stone is also an important element,
for while oxalate and phosphate stones give a deep shadow, those
composed of urie acid fumish but faint shadows and may escape
recognition. In ali cases to obtain a successful picture it is absolutely
essential that the stomach be empty and the bowels be thoroughly
cleared by a purge.

EXPLORATORY INCISION.

In cases of contemplated nephrectomy where other means of
diagnosis fail to give satisfactory results, an exploratory operation will
determine the exact condition of the second kidney. The kidney
requiring removal is first exposed and thoroughly explored. If its
removal seems indicated, it is replaced for the time being and the kidney
supposed to be healthy is then cut down upon by a lumbar incision, the
capsule is incised, and the organ is palpated and if necessary inspected.
If it is found to be healthy, the wound is closed and the other kidney
may then be removed. Should, however, such exploration reveal
serious disease of the second kidney, nephrectomy is contraindicated.

Therapeutic Measures.

MEDICATION OF THE RENAL PELVIS AND URETERS.

Lavage of the kidney pelvis and ureter has been employed with
considerable success by Kelly and others in treating chronic infection
of the kidney pelvis and ureter. The procedure is not difficult for one
skilled in the passage of the ureteral catheter, and properly performed
seems to be without danger. It is not a suitable method of treatment,
however, in acute infections, and in chronic cases, even, other measures
should be first given a trial.

Instruments. — In addition to the apparatus necessary for ureteral
catheterization (see pages 652, 661) there will be required a glass

676 THE KIDNEYS AND UKETERS.

syringe with a capacity o£ i or 2 ounces {30 to 60 ce.) supplied with a
biunt nozzle sufficiently small to iit into the end of the catheter.

Asepsls. — The same precautions against infection should be
observed as detaiied under ureteral catheterization (pages 654, 663),

Solutions Used. — A saturated solution of borie acid, silver nitrate
in the strength of i to 8000 inereased in strength up to i to sooo,
protargol i to 500 to 2 per cent., bichlorid of mercury i to 150,000 to i
to 16,000 may be employed. Too strong solutions wìll resuU in colie.

For the purpose of aidìng the passage of an impacted calculus
injections of sterile olive oil have been employed.

Temperature. — ^The solution should be at a temperature of 100° F.

Quantity. — One to 2 drams (about 5 to io ce.) of solution are
generally injected at a time. If large amounts are employed, over-
distention of the renai pelvis will result with consequent colie.

Fio. 714. — Medication ot the renai pelvis,

Frequency. — The treatments may be applied once or twice a week.

PodUon ofPatlent. — Sameas for ureteral catheterization (pages
654, 663).

Anesthesla. — {See pages 654, 664.)

Preparatlons of Patlent. — The same as for ureteral catheterization
(pages 655, 663).

Technlc. — The catheter is inserted into the renai pelvis as previously
described (pages 655, 664), Any pus collection is then allowed to drain
off, and the tip of the syringe, charged with the solution, is introduced

THE DILATATION OF URETERAL STRICTDRES. 677

into the end of the catheter and i or 2 drams (5 to io ce.) of solution
are injected. Care must be taken to see that the syringe contains no
air and the injection must be given slowly to avoid a sudden distention
of the kidney peivis. The syringe is then disconnected, the patient is
raìsed to a semi-upright posìtion, and the solution is ali allowed to
cscape; if a small catheter is employed, the solution may, however,
escape beside it into the bladder. This washing-out process may be
repeated until the solution returns clear. The syringe is agaìn con-
nected with the catheter whìch is slowIy withdrawn, the solution being
injected the while so as to medicate the entire ureter. At the com-
pletion of the operation the bladder is irrigated,

To aid the passage óf a ureteral calculus by the injection of olive
oil, the following technic is employed: a ureteral catheter is passed
beyond the stone if possible, and, if not, up to it, and a few drops of
sterile olive oil are injected. This acts as a lubricant and the stone
is often readily passed as a result.

THE DILATATIOIT OF URETERAL STRICTURES.

The graduai dilatation of ureteral strictures may be performed by
suitable bougies, introduced with the aid of the cystoscope. While it
is doubtful if a permanent cure can be obtained in many cases by this

Fio. 715, — Showing the melhodof dilatingaureleralstrLciure. (After Kelly and Noble.)

method, as such strictures, like those of the urethra, rectum, ctc, tend
to recontract in the majority of cascs, the patient is greatly benefited
for the time being through relief of the distention of the ureter and
kidney peivis causcd by the obstruction. The majority of strictures are
located near the ureteral orifices, and these are most readily dilated,

678 THE KIDNEYS AND URETE2S.

though the method may be applied wìth success to strictures in any
part of the canal.

Instruments. — Dilatation may be affected by means of flexible
whalebone bougies, flexible catheters or, if the stricture is near the
vesical end, by metal catheters. These instruments as well as the
cystoscopes have been already described (pages 652, 661).

Asepsis. — (See pages 654, 663.)

Frequency of Dilatation. — Treatments are employed every two or
three days.

Position of Patient. — Same as for ureteral catheterization (pages
654, 663).

Preparations. — (See pages 655, 663.)

Anesthesia. — (See pages 654, 664.)

Technic. — The ureteral orifice ìs located as already described and
the dilator is introduced into the ureter in the same manner as the
ureteral catheter (pages 655, 664). Choosing an instrument that the
stricture will readily admit, it is passed completely through the stric-
ture and is left in place for a few moments and then a larger size is
inserted. At the next treatment the stricture is dilated one or two
sizes more until finally it is stretched sufEciently to admit a No. 5 or 6
catheter with ease. Following each treatment lavage of the kidney
pelvis and ureter may be practised as described above.

CHAPTER XX.
THE FEMALE GENERATIVE 0R6ANS.

Anatomie Considerations.

The Vagina. — The vagina is a musculo-membranous canal
extending from the uterus to the vulva, lying between the bladder and
urethra in front and the rectum behind. With the woman in an erect
posture it is directed downward and forward at an angle of 60 degrees
with the horizon. The anterior wall, which is shorter than the poste-
rior Wall, due to the position of the cervix, measures 2 to 2 i /2 inches
(5 to 6 cm.) in length, while the posterior wall measures 3 to 3 1/2
inches (7.6 to 9 cm.). Normally the walls are in contact, but when
distended the vagina becomes conical in shape and larger above than
below. That portion surrounding the cervix uteri is spoken of as the
roof or fomix. It is divided for description into four parts: the anterior
fomix, in which is normally felt the body of the uterus; the posterior
fomix, the deepest portion, which is in dose relation with the cul-de-
sac of Douglas; and the two lateral fomices.

Relations. — Anteriorly, in its lower portion the vagina is in relation
with the urethra and in its upper half with the neck and fundus of the
bladder. Posteriorly, it is in relation with the perineal body in its
lower quarter, in its upper quarter with the cul-de-sac of Douglas,
and between the two with the rectum.

Structure. — It consists of a mucous, muscular, and connective-
tissue coat. The mucous membrane, which is of the squamous
variety, exhibits on the anterior and posterior walls numerous ridges,
or rugae, which extend out transversely from a centrai column. They
are more distinct on the anterior wall.

The muscular coat is arranged in two layers, an inner longitudinal
and an outer circular.

The connective-tissue coat is a thin fibrous structure containing a
few smooth muscle fibers. In its meshes this layer gives support to a
plexus of veins.

The Uterus and Appendages. — The uterus, or womb, is a hoUow
pear-shaped organ lying in the pelvis between the bladder and the
rectum. It measures about 3 inches (7.6 cm.) in length, 2 inches
(5 cm.) in breadth, and i inch (2 . 5 cm.) in thickness.

679

68o THE FEUALE GENERATIVE OBGANS.

Extemally ìt is flattened from before backward, and at the poìnt
where the perìtoneum is reflected from the uterus lo the bladder there
appears a constriction, the isthmus, which corresponds with the posilion
of the internai os and divides the uterus into two portions. The
poTtion lying below the isthmus is the cervix, that part between the
isthmus and aline joiningtheentranceof the tubesisknown as the body,
while the portion abo\e the piane of the entrance of the tubes ìs known
3s the fundus. The cervix in tum is also dii-ided into three portions:
an infravaginal portion, below the attachment of the anterior vaginal
Wall; a supra vaginal portion, above the attachment of the posterior
vagina! wail; and an intermediate portion, lying between the two.

The interior of the uterus measures about 21/2 inches {6 cm.) in
lenglh and is divided into two portions by the internai os. That
portion of the canal above this point is triangolar in shape with the

Fio. 716. — The nornial poalion of the uterus. (Ashlon.)

base upward and with the walls normally in contact. In the cervical
portion the canal is fusiform in shape. The uterus opens into the
vagina through the external os, a transverse aperture having an anterior
and a posterior lip, while above it connects with the peritoneal cavity
through the Fallopian tubes.

Positìon of Uterus. — Normally the uterus lies in a slightiy ante-
flexed position with the fundus pointing toward the umbilicus (Fig.
716). Its position, however, is modified from time to time by the
neighboring organs. Thus a distended bladder will push it toward
the sacrum, while a full rectum pushes it forward.

Stnicture. — The uterus is made up of a mucous, muscular, and a

DIAGNOSTIC METHODS. 68l

peritoneal coat. The mucous membrane of the body of the uterus is
smooth and pale in color, with the mouths of numerous tubular glands
opening upon its surface. The lining epithelium is of the ciliated
variety having a motion from within outward.

In the cervix it is firmer in structure and is thrown into numerous
folds, the arbor vitae. These are arranged in the form of a median
ridge on the anterior and posterior walls, from which branch secondary
ridges in an upward and outward direction. Between these ridges are
located the openings of tubular and racemose glands. In the upper
portion of the cervix the mucous membrane is the same as that found
in the body of the uterus and below it is similar to that in the vagina.

Extending out from either superior angle of the uterus are the two
Fallopian tubes. They measure 3 to 5 inches (7.6 to 12.7 cm.) in
length and lie in the free borders of the broad ligaments between the
ovaries behind and the round ligaments in front. They are lined
with ciliated epithelium having a direction toward the uterus. Their
external apertures, the fimbriated extremities, open into the peritoneal
cavity near the ovary. Intemally each tube opens into the uterine
cavity at its superior angles.

The ovaries, two in number, lie on either side of the uterus, about
on a level with the pelvic brim, near the abdominal extremities of the
tubes. Each ovary measures i 1/2 inches (3.8 cm.) in length, 3 I4
inch (1.9 cm.) in breadth, and 1/3 to 1/2 inch (0.8 to 1.2 cm.) in
thickness.

Diagnostic Methods,

In making a gynecological examination the investigation should
comprise an inquiry into the patient 's general condition as well as an
examination of the pelvic organs. A clear and concise history of the
subjective symptoms should be the first step in every case. It is prefer-
able to allow the patient to first detail her own symptoms and to sup-
pleme^;it this by inquiry as to essential points. In doing this it is well
to foUow a routine system in order to avoid omitting some important
point that may have direct hearing upon the case, and also that the
examiner may have a complete record for future reference.

In addition to the usuai questions commonly asked in obtaining a
history, special information should be sought in regard to the following
points: First the menstrual history should be inquired into, ascertain-
ing the age at which menstruation began, the precautions taken during
menstruation, the interval between the periods, the regularity of the
periods, the duration of Che flow, and its character, whether painful,

682 THE FEMALE GENERATIVE ORGANS.

whether accompanied by the passage of clots, and whether scanty or
profuse. The latter is especially important, as excessive menstruai
bleeding points to the presence of some pathological condition.

With a history of painful menstruation the time the pain begins
and ceases in relation to menstruation should be ascertained. It
should also be found out whether there has been any bleeding between
the periods. If the menopause has occurred, its date and the presence
or absence of any bleeding since are to be noted. If the patient is
married, certain data relating to child-bearing should be sought, com-
prising the number of children, the dates of their births, a history of
the labors, whether easy, diflScult, or instrumentai, and whether they
were foUowed by a long and protracted convalescence.

With a history of abortions or miscarriages the period of pregnanqr
at which they occurred and their probable cause should be ascertained.
At times it is also important to know something of the maritai relations,
that is, the frequency of coitus, whether the act is painful and whether
measures to prevent conception ha ve been employed, and, if so, the
methods used.

The patient is next questioned as to the presence or absence of a
vaginal discharge. If present, its character should be inquired into,
whether foul, blood-tinged, or having the characteristics of an ordinary
leukorrhea. The quantity of discharge is also to be noted, and whether
it is always present or only occurs midway between the monthly periods.

Pain is another frequent and important complaint upon which full
information should be sought. The character and situation of the
pain should always be determined. The pain complained of may be
in the form of a headache, a bearing-down feeling, backache, or its
situation may be referred to some part of the pelvis, the coccyx, or the
inguinal region. Inguinal pain generally points to some disease of
the uterine appendages or ligaments; on the other hand, backache is
found as an accompaniment of a number of conditions, such as chronic
constipation, uterine displacements, pel vie and uterine tumors^ etc,
while pain in the coccyx is often a symptom of neurasthenia. It
should also be ascertained if the pain is modified by menstruation, and
if so, whether it is worse before the flow begins, during the flow, or
afterward, also whether it is aflFected by exercise, any sudden jolt or
jar, or by coitus.

Finally, since many gynecological patients have in addition to their
pelvic troubles other disorders, the general symptoms and the functions
of other organs should be similarly inquired into. Thus the patient
should be questioned as to her appetite, loss of weight, nausea and

PREPARATION OF PATIENT FOR EXAMINATION. 683

vomiting, and if the latter is present, its character and relation to the
takmg of food, the condition of the bowels, and whether she sleeps
well or suffers from nervousness, hysteria, palpitation of the heart, hot
flashes, etc, etc.

Having obtained the above data, a thorough physical exammation .
is then made. It should comprise a caref ul observation of the patient 's
general condition, color, and nutrition, and an examination of the
heart, lungs, nervous system, urine, and blood. After this is completed
the patient is prepared for a general examination of the abdomen and
pelvic organs.

The methods available for such examination include abdominal
inspection, palpation, percussion, auscultation, and mensuration, in-
ternai examination by inspection and palpation, the use of specula
and the uterine sound, digitai exploration of the uterus, test excision,
test curettage, and exploratory incision.

Preparation of Patient. — Certain preparation of the patient is
essential for a thorough examination, otherwise the results will be
imsatisfactory. If an anesthetic is to be given, the preparations for
such, previously detailed (page i8), should be carried out. In any
case, the bowels should be thoroughly evacuated by means of a mild
purgative taken the day before, foUowed by an enema on the moming
of the examination. The bladder is emptied spontaneously just
before the patient presents herself for examination.

A suitable examining-table should be provided, and the simpler
it is the better. It should be about 2 i /2 to 3 feet (60 to 90 cm.) high,
strong in construction, provided with adjustable foot-rests, and capable
of being lengthened so that the patient may be placed upon it in the
horizontal position. A small step, to aid the patient in mounting it,
is also necessary. A second small table should be placed near at hand,
upon which are placed solutions, instruments, etc, that may be required
during the examination.

When it is necessary to make a vaginal examination in the patient's
home, an ordinary kitchen table or the bed may be utilized. In the latter
case the patient is placed lengthwise across the bed, with an ironing-
board covered by several thicknesses of a sheet placed on the mattress
under the patient's hips, and with the patient's feet supported on two
chairs (Fig. 717).

With the patient in the desired position upon the table it should
be seen that the corsets and any constricting bands are removed from
about the waist and that the patient is so covered by sheets that only
the region to be examined is exposed. For an abdominal examination

684 "^^^ FEMALE GENERATIVE ORGAMS.

two sheets are employed, one draped over the pelvic region and lower
part of the abdomen and the other over the upper abdomen. For a
vagina) examination the sheet is thrown over the lower extremities
and is then separated so as to expose the vulva. If the examiner is
provided with a nurse, these details may be left to her. While a nurse
is not absolutely necessary, it is always preferable to bave some woman
present at the examination, not only for the greafer comfort of the
patient, but for the protection of the physician against malicìous
charges at the hands of unscrupulous females.

FiG. 717, — Po^tJon ot the patienl for an eiamìnalìon upon a bed. (Ashton.)

Gynecologlcal Postures-^In examining the femaie pelvic organs
a number of postures are available. These include the dorsal, the
Sims, the knee-chest, the erect, and the squatting positions.

Thf: dorsal position, which is the best for digitai or bimanual
examinations, ìs obtained by placing the patient, facing the light, fiat
on the back, with the hips near the edge of the table and with the
feet supported upon the foot-rests (Fig. 718).

The Sims position is obtained by placing the patient upon her left
side, with the left side of the face, the left shoulder, and left breast
resting upon a fiat pillow. The left arm lies behind the back, the
thighs are well flexed upon the body, and the right knee is drawn up .
neaier the body than the left (see Fig. 501). In this position an excel-

GYNECOLOGICAL POSTURES.

68s

lent view may be obtained of the vaginal fomices, the anterior vaginal
walI, and the cervix, but it is not satisfactory for a digitai examination,
as the pelvic organs are more difficult to reach than with the patient
in the dorsal posture.

Fio. 718. — ^The patient in the dorsal position. (Ashton

FiG. 719. — Examination with the patient standing erect. (Ashton.)

The knee-chest position is obtained by having the patient kneel upon
a table, with the thighs at right angles to the legs, the chest resting
upon a pillow placed upon the same level as the knees (see Fig. 503).

686 THE FEMALE GENERATIVE ORGANS.

In this posture the intestines gravitate toward the diaphragm, and the
vagina becomes distended so that the numerous folds of mucous.
membrane are spread out smootHy.

The Erect Posture. — The patient, with her clothes elevated and a
sheet fastened about her hips, stands with one foot on the floor and the
other resting upon a stool 6 to 8 inches (15 to 20 cm.) high. The
examiner kneels in front of the patient and, passing his hand beneath
the sheet, makes a digitai examination of the vaginal outlet and the
uterus (Fig. 719). In this position a prolapse of the uterus or a relaxa-
tion of the vaginal outlet is more readily recognized than in the dorsal
posture.

The squatting posture is sometimes useful in ascertaining the degree
of a uterine prolapse and the relaxation of the vaginal walls. The
patient takes the same position as when at stool and, by a slight
straining effort, any tendency to prolapse is readily made visible to the
examiner.

Asepsis. — In ali gynecological examinations every precaution must
be taken to avoid infecting a patient as well as to prevent infection of
the examiner by the patient. Ali instruments that are used are boiìed
for five minutes in a i per cent, soda solution, and no instrument should
be used on more than one patient without resterilization. The exam-
iner's hands are sterilized by a thorough scrubbing with tincture of green
soap and water, followed by inmiersion in an antiseptic solution. The
examiner should also see that his finger-nails are cut short to avoid
hurting the patient

If the patient is suspected of having syphilis or gonorrhea, or in
the presence of a septic discharge, the examiner should protect himself
by wearing rubber gloves previously sterilized by boiling. In the
majority of cases it is sufficient to wipe off the vulva with a swab soaked
in a I to 2000 bichlorid solution, but where a profuse or foul discharge
is present a vaginal douche should be given. When it is desired to
obtain a specimen of a discharge for examination, antiseptic solutions
or douches should be omitted until this has been done.

/. Examination of the Abdomen,

INSPECTION.

From the appearance of the skin, the shape of the abdomen, and
the effect of respiration upon a tumor valuable information may be
obtained.

ABDOMINAL PALPATION. 687

Positlon of Patlent. — The patient should He with the body sym-
metrically placed upon a finn fiat table in the horizontal position.

Technic. — With the patient's abdomen entirely exposed and the
light faliing obliquely upon the abdomen, the examinw inspects it
first from the side and then from the foot of the table (see Fig. 461).
The color of the skin of the abdomen, the presence or absence of stria,
eruptions, scars, edema, and dilated veins, the condition of the abdomi-
nal walls, whether rigid or lax, and the shape and symmetry of the
abdomen should ali be noted.

In enlargement of the abdomen due to obesity, the lower portion
of the abdominal wall usually hangs down over the patient's thighs.
In ascites the abdomen is more or less flattened, and the sides
bulge outward. In the presence of pregnancy or an ovarian cyst the
enlargement is smooth and regular, in the former case the abdo-
men being symmetrically enlarged, while an ovarian cyst, especially
if small, may distend one side only. Fibroid tumors may present as
irregular and nodular gro^^lhs. If a tumor is discovered, the pres-
ence or absence of mobility with respiration and whether the ab-
dominal walls move over the growth should be noted. Evidence of a
weakened condition of the recti muscles or the presence of a hernia
should also be sought by having the patient strain and cough.

PALPATION.

Palpation of the abdomen is the most satisfactory of the methods of
abdominal examination and should form a part of every routine
g3mecological examination. By it the presence of tumors, rigidity,
fluctuation, or locai tenderness that might escape notice by trusting
simply to a vaginal examination may be recognized, and, in the pres-
ence of an enlargement, its situation, origin, shape, mobility, and con-
sistency may be determined.

Positlon of Patient. — The patient lies in the dorsal position, with
the shoulders slightly elevated and the thighs somewhat flexed to
secure thorough relaxation.

Technic. — The examiner first thoroughly warms his hands. Then,
taking his place upon one side of the patient, he systematically palpates
ali portions of the abdomen. In doing this the palpating hand — usually
the right — is placed upon the abdomen, palm downward, and firm but
gentle pressure is made — sharp pressure with the finger tips should
be avoided as it incites the muscles to contract. Locai or general
rigidity of the abdominal wall, sensitive areas, and the presence of a
tumor are thus ascertained.

688 THE FEUALE GENERATIVE OKGANS.

To dìEFerentiate obesity from intraabdominal growths both hands
are employed and make deep pressure from the sides toward the mid-
line, at the same time Hftmg upward on the abdotninal walls (Fig. 720).

FiG. 730. — Showing the method of estunating the ihìckaess of the abdoniìnal walls.

The situation, origin, size, or mobility of a tumor is determined by
making deep pressure with both hands in ali dhrections about the
mass (Fig. 721). An eniarged uterus is mapped out in the same
manner. In examining the lateral regions of the abdomen bimanual

FlC. 711. — Bimanual palpati'

palpation is often of scrvice, one hand being placed under the flank
and making forward pressure while the other hand palpates the
antere- lateral surface of the abdomen.

ABDOMINAL PERCUSSION.

689

Fluid coUections are recognized by a thrill or wave produced by
placing one band with the palm fiat on one side of the abdomen and
tapping the abdomen from the opposite side with the fingers of the
other hand. To avoid confusing a wave produced by tapping a fat
abdomen with that of fluid the examiner should ha ve an assistant
place the ulnar edge of his hand firmly on the summit of the abdomen
while the tapping is performed (Fig. 722). In the case of fat the wave
is then absent.

Fig. 722. — Method of differcntiating between a wave produced when tapping a fat abdomen

and one containing fluid. (Ashton.)

PERCUSSION.

Abdominal percussion is valuable when employed as an adjunct
to inspection and palpation in differentiating between tympany,
acites, cystic and solid tumors, and in determining the size and shape
of a tumor, and its origin. To avoid errors, the large intestine should
be emptied by an enema before the examination.

Position of Patient. — ^Percussion is performed, first, with the patient
lying on the back and, then, tumed upon the side.

Technic. — The examiner places the palmar surface of the middle
finger of the left hand firmly upon the area to be percussed and, using
the tip of the middle finger of the right hand, bent at a right angle, as
a plexor, strikes quick, sharp blows (see Fig. 467). The normal
resonance of the abdomen is tympanitic except in the regions of the
liver and spleen where it is dull. Fecal masses, cystic and solid tumors,
and fluid coUections give dulness on percussion. When distended
44

690 THE FEUALE GENERATIVE ORGANS.

intestùles overlie a growth, however, the note will be tympanitìc, and
ìt will be necessary to employ deep and strong percussion to bring out
the dulness. By carefully percussing around the margins of a tumor

-rYMPAMv

Fio. 71J. — Shovnng the area, of dulness and t^mpany in asdtes when Ihe patient is
recumbenL (Ashlon.)

and noting where tympanitic resonance is absent, it is often possible
to determine the origln of the growth.

In the presence of ascites with the patient in the dorsal position,
duhiess will be elicited in the flanks, while the center of the abdomen

Fio. 714. — Showing the area of dulness and tympany in ascites when the patient lìes
on her side. (Aahton.)

will be tympanitic, as the intestines float to the highest point (Fig,
723). With a change in the patient's position the fluid grantates to
the lowest point and the location of the dulness and tympany is like-
wise changed (Fig. 724). On theother hand, the area of dulness due
to tumors is not afiected by changes in the patient's position.

MENSURATION. 69I

AtrSCULTATION.

Auscultation is of limited use except in the differential diagnosìs
between pregnancy and other tumors. In the former case the fetal
heart sounds and the funic soufflé settle the diagnosìs. Much impor-
tante cannot be attached to the uterine faruit, however, in theabsence
of other signs pointing to pregnancy, as it is also heard in large fibroid
tumors. In some cases of peritonitis it may be possible to bear a
friction note,

HENSURATION.

Measuration of the abdomen is useful in determining whether the
abdomen is symmetrically eniarged or not, in noting any increase of
ascites, and in recording the rapidity of eniargement in a tumor.

Podtlon of Patient.^ — The measurements are taken with the patient
in the horizontal recumbent position.

Ftc 735. — Showing the measurements taken in recording the growth of an abdominal

Technic— An ordinary tape measure is employed and the following
measurements are taken: (i) the circumference of the abdomen at the
level of the umbilicus, (2) the distance from the ensiform cartilage to
the pubes, {3) the distance from the umbilicus to each anterior superior
spine, {4} the distance between the two anterior superior spines, and
{5) the distance from the anterior superior spines to the pubes (Fig,
725). To have any vaine for purposes of comparison, these measure-
ments shouid be taken from the same points each time and with the
patient in exactly the same position.

692 ■ THE FEHALE GENERATIVE ORGANS.

//, Examinalion 0/ the Pelvic Organs.

mSPECTION.

A careful inspection of the extemal genitais and the vaginal orìfice
should always be made as a routine before a digitai examination, other-
wise lesions involving the vulva and neighboring parts may entirely
escape notice, Inflammations, new growths, the presence of abnormal
secretions, prolapse of the anterior or posterior vaginal walls, lacera-
tions of the perineum, and many other pathological conditions are
readily recognized by inspection.

FiG. 716. — Inspection of the vaginal outlet. (Bandler.)

PoslUon of the Patient.^ — Inspection is performed with the patient
in the dorsal posture with the feet toward the light.

Technlc. — The examiner sits or stands facing the vulva and begins
his inspection without dìsturbing the relation of the parts. He should
first note the general appearance of the vulva, whether the labia are
closed or in apposition, and whether the vulva is the scat of inflamma-

EXAMINATION OF DISCHAKGES. 693

tion, ulcerations, warts, swelling, edema, varicosites, eruptions, or exco-
riations, the latter a frequent accompaniment of a discharge. If a
dìscharge ìs present, its color, quantity, and other characteristics
should be noted.

The labia are next sej)arated with the fingere of the left hand, and
the entrance to the vagina is inspected (Fig. 726), notìcing the color
of the mucous membrane, the presence or absence of the hymen, the
condition of the openings of the ducts of Bartholin and the orifice of
the urethra, and the presence or absence of laceratìons, cystocele, or
rectocele. By instructing the patient to bear down or strain slightiy,

Fig. 7:7. — Method of exposing ihe anterìor and postcrìor vag^nal walls fur inspectìon
(Ashion.)

a prolapse of the anlerior or posterior vagìnal walls is made more
evident. The hood of the clitoris should also be retracled and an
cxamination made for adhesions or concretions that may be the cause
of nervous symploms. By retracting the perineum with two fingerà
inserted in the vagina, as shown in Fig. 727, the lower portion of the
anterior and posterior vaginal walls may be brought to view,

EXAHmATtON OF DISCHARGES.

If an abnormal discharge is present, specimens should be obtained
at this time for later microscopical or bacteriological examination.
The importance of such an examination cannot be too strongly empha-
sized. The technic for collecting and preparing the specimens has
been previously delaiied at length in Chapter Vili.

694 THE FEMALE GENERATIVE OBGANS.

DIGITAL PALPATION.

Paipation by means of the finger is employed to obtain more
complete information as to abnormal conditioas of the vulva or vaginal
outlet discovered on ìnspection, and to determine the condition of the
vagina, vaginal fomices, and the cervir. For a satisfactory examina-
tion of the other peivic organs, bimanual paipation is neces^ry.

Asepsls. — Ali the aseptic precautions previously detaiied (page 686)
should be observed.

FiG. 72S. — The diagnosls of a cyslocele by the aid of a bladder sound. (Ashton.)

PosiUon of Patient. — The dorsal position is ordinarily employed,
but the erect posture will be found useful in estimating the degree of a
uterine prolapse.

Preparations. — {See page 683.)

Teclmlc. — The examiner first palpates between the thumb and
forefinger of the right hand any abnormal conditions, such as swellings,
new growths, etc, about the vulva and the vaginal outlet, and also the
glands of Bartholin for signs of inflammation or thickening.

The labia are then separated between the thumb and index-fìnger
of the right hand, and the index-finger of the left hand, well lubricated,
is introduced into the vagina. The condition of the vagina is then
investigated, noting the presence or absence of congenita) malforma-
tions, its sensitiveness, its temperature, and whether the vaginal walls
ha\e their normal roughness or are smooth and unduly relaxed. By
tuming the examining finger, palmar surface up, the anterior vaginal

DIGITAL PALPATION. 695

Wall may be palpated and the presence or absence of an urethrocele or
a cystocele may be ascertained. By introducing a sound into the

FlG. 719. — MethiHJ of eslimaling ihe thkkiiess of Ihe perineum, (Ashtoo.)

Fio. 730. — Digital [alpaiion o( the cervix. {Aahton.)

bladder and palpating its point with the finger in the vagina (Fig. 728)
a cystocele, if present. may be more readily recognized. The posterior
vagina! watl is likewise examined by rotating the examining finger.

696 THE FEMALE GENERATIVE ORGANS.

palmar surface back, and, by placing the thumb of the same hand near
the rectum the perineum may be grasped between the two fingers and
its firmness and thickness estimated (Fig. 729). The vaginal fornices
on ali sides of the cervix are next palpated, noting their depth, any
rigidity, mduration, or tenderness.

If the uterus is m a normal position, it will be possible to feel its
body through the anterior fomix, while, if retroverted, the latter will
be felt in the posterior fornix. The condition of the uterus is more
satisfactorily made out, however, by bimanual palpation.

Finally, the cervix is palpated (Fig. 730), noting especially its size,
whether closed or oped, whether hard or soft, its mobility, and its
position, that is, whether pointing backward toward the^sacrum, as in
retroflexion of the uterus, or pointing forward toward the symphysis,
as is found when the uterus is retroverted or anteflexed. The presence
or absenceof lacerations, erosions, cysts, etc, should also be determined.

BIMANUAL PALPATION.

Bimanual palpation by means of the fingers of one hand in the
vagina or rectum and the fingers of the other hand making counter-
pressure above the symphysis is the most valuable method for investi-
gating the condition of the pelvic organs. By it one may map out the
size and shape of the uterus and determine its consistency, position,
mobility, and the presence or absence of new growths. The tubes,
ovaries, broad ligaments, etc, may likewise be palpated and their
condition ascertained.

Vagino-abdominal palpation is the most satisfactory and the more
generally employed method. It should be supplemented by recto-
abdominal palpation, however, in any doubtful cases. The latter
method is especially useful in exploring the posterior surface of the
uterus and the appendages in cases of posterior displacement of the
uterus, as these structures may then be more readily reached from the
rectum than from the vagina. Recto-abdominal palpation is also
indicated in children, in the unmarried, and in cases where the \'agina
is unduly sensitive or obstructed by tumors or an imperforate hymen.

To perform a successful bimanual examination it is necessary that
the abdominal walls be thin, relaxed, and free from tenderness upon
pressure, and that the vagina be sufficiently large to admit the fingers
of the examining hand. In the case of individuai with very muscular,
fat, or rigid abdominal walls or a small vagina the examination is
usually unsatisf actory without an anesthetic. In any case, the examina-

BIMANUAL PALPATION. 697

tion must be performed with the utmost gentleness. Rough manipula-
tions accomplish nothing and are capable of* causing great harm,
especially in cases where the pelvis contains a tube filled with pus,
a thin walled cyst, an ectopie pregnancy, etc.

Asepsis. — ^For the necessary precautions agamst infection see
page 686.

Position of Patlent. — Bimanual palpation is most satisfactorily
performed with the patient in the dorsal position.

Preparatlons. — (See page 683.)

Anesthesia. — General anesthesia is not often required in individuai
with thin and relaxed abdominal walls, but in muscular, fat, or nervous
individuai or where^the parts are tender and sensitive an anesthetic
may be necessary to secure relaxation. A general anesthesia shouid
also be employed if any doubt remains as to the conditions found
after an ordinary. bimanual examination, and in ali cases where it is
necessary to make a vaginal examination upon virgins.

Technic. — i. Vagino-abdominal. — The examiner stands facing the
patient a little to one side or the other depending upon which hand he
palpates with. The labia are then separated between the thumb and
forefinger of one hand and the index-finger of the other hand, or the
index and middle fingers if the parts are sufficiently relaxed to admit
them, are well lubricated and are inserted into the vagina, while the
fingers of the free hand are placed on the abdomen above the pubes.
The external hand is used to steady or depress the organs while the
internai hand does the palpating. As a rule the left hand is employed
to palpate with, being the smaller of the two and possessing greater
tactile sensibility, but the examiner shouid be equally proficient with
either hand. The last two fingers of the internai hand shouid be
folded back upon the palm, as shown in Fig. 731, so as to invaginate
the pelvic floor and thereby permit the greatest possible penetration.
The palmar surfaces of the fingers of the internai hand are brought in
contact with the cervix and its condition and position are first deter-
mined. With the internai fingers in contact with the cervix and
exerting upward pressure the external hand locates the fundus of the
uterus and makes gentle pressure from above. The length, sensitive-
ness, consistency, and position of the uterus are thus determined, and
likewise the mobility by making a series of gentle pushes from above
and below (Fig. 732).

By placing the internai fingers in front of the cervix and the fingers
of the external hand behind the fundus the thickness of the uterus
may be estima ted (Fig. 733). If the fundus is pressed well forward by

698 THE FEMALE GENERATIVE OKGANS.

the extemal hand, the anterior and lateral surfaces may be palpated
and any irregularity óf the surfaces which might be caused by fibroids
or other growths is noted. By canying the fingers of the internai hand
posterior to the cervix and pressing the fundus backward the posterior
surface ìs in like manner explored. When the fundus is not found in
its normal position, it shouid be sought for anteriorly near the sym-
physis, or posteriorly. To palpate for anterior displacements, the
internai finger is carried up in front of the cervix into the anterior
fornix while the external hand exerts pressure downward behind the
symphysis, If anteSexed. the fundus will be readily felt between the

Fio. 7ji. — Melhod of inaerting the ezamining fingers in Hmanual palpation, Small
figure shows the method of holding the fìngerà.

fingers of the external and internai hands (Fig, 734), while in posterior
displacements the opposed fingers may be brought together as shown
in Fig. 735. In such case the fundus shouid then be sought posteriorly
by carrying the internai finger up into the posterior cul-de-sac while
external pressure is made by the external hand from above {Fig. 736).

A posterior fiexion will be readily differentiated from a version by
the bend or angle on the posterior aspect of the uterus (Fig. 737). In
the presence of a posterior displacement it shouid be determined
whether the uterus is mobile or fixed through adhesions by passing
the internai fingers high up posteriorly and by the aid of the external
hand attempting to lift the uterus up.

After thoroughly examining the uterus the conditioa of the broad
and uterosacral ligaments shouid be ascertained. By carrying the

BIUANUAL PALFATION. 699

fingers up beside the cervix mio the lateral fornices and makingcounter-
pressure from above the condition of the broad ligaments may be

FiG. 731. — Method ot delerminìng the lenglh Fio, 733. — Method of eslìmating the

and mobilily ot the uterus. (Ashton.) thickness of the uterus. (Ashion.)

determined, and any pain on pressure, thickening, or induration noted.
Palpation of the uterosacral ligaments through the posterior foraix
may be performed in like manner.

FiG. 734. — Diagnosisof un anteflexìon of the utems by liimanual [>alpaiion. (Ashton.)

The tubcs and ovaries shouid also be examined with reference to
their size, shape, consistency, sensitiveness, position, and mobility.

700 THE FEMALE GENERATIVE ORGANS.

It ìs of advantage to use the right hand in palpating the rìght side and
the left hand for the left side. The examining hngers are inserted well

F'<5- 73S — WagnoMs of a posterior Fio. 736. — Shows the meihodof paU

displacemtnl of the uterus by bimiuiual pating the body of the ulenis in a

palpation. (Ashlon.) posteiìor displacement. (Ashton.)

up in the lateral fomix beside the cervìx in an upward and backward
direction, while the externai hand makes deep pressure downward
through the abdominai walI on the corresponding side. By altering

^1^' 737' — Diognosis of a, posterìor fìexìon of the uterus by bimanual palpation.

(Aditon.)

the position of the iìngers of the two hands from lime to time the ovary
and tube are finally grasped between the opposed fingers (Fig. 738).

BMANUAL PALPATION. 701

Except where the abdominal walls are extremely thin and the vagina
ìs relaxed, the normal tube cannot be felt, but, when enlarged, it may
be readily recognized at a club-shaped mass graduai!/ narrowing down

Fio. 738. — Examinatìon of the ulerine appeodages by bimanual palpalion, (Ashton.)

FlC. 739. — Rectt>«bdoimoal palpalion of the utenis. (Aahton.)

as it approaches the uterus. The normal ovaries, however, are gener-
ally palpable as small, ovai masses, somewhat tender upon pressure,
on each side of the uterus. When, as the resultof chronic inflammation,

702 THE FEUALE GENERATIVE ORGANS.

extensive adhesive formation has taken place the tubes and ovaries
are often inatted together into irregular masses, and it may not be possi-
ble to map them out separately. Having examined one side of the
pelvis, the same procedure is repeated upon the other side.

a. Recto-abdominal. — The exatniner stands facing the patient and
inserts the well-lubricated index-finger of the left hand high into the
rectum. At the same time the extemal hand placed on the abdomen
above the symphysis makes counter-pressure, while the uterus and

Fio. 740. — Reclo-alxlomìnal palpation of the uterus with the latler dia
vaginal oullet by means of a (enaculum. (Ashton.)

appendages are carefuily palpated (Fig. 739). Care must be taken,
however, not to exert too much force with the fingers in the rectum for
fear of lacerating or otherwise injuring the bowel.

By drawing the uterus well down by means of a pair of bullet
forceps caught in the cervix, and ihen performing recto-abdominal
palpation, a much more complete etamination is possìble {Fig. 740).
This method, however, should never be attempted when the uterus is
lìxed by adhesions or the appendages are Ìnl]amed. As a rule, general
anesthesia is necessary. Care should always be taken to replace the
uterus in its normal position at the completion of such an examination.

EXAMINATION BY SPECULA.

EXAMinATION BT SPECULA.

By means of suitable specula the mucous membrane of the entire
vagina and cervix may be directly ìnspected. The use of specula

Fio. 741,— Goodeli's vaginal speculum. (Ashton.)

furnishes little infonnatlon outside of the color and conditìon of the
mucous membrane and the origin of a discharge, which is not as readily

Fio. 743. — Trivalve vagina! speculum.

obtainable by digitai palpation. In gynecological treatment and
operative procedures, however, specula are indìspensable.

Fic. 74J. — Sima' vagiiial speculum. (Ashlon.)

8. — Numerous specula have been devised, such as the
bivalve (Fig. 741), the trivalve (Fig. 742), the cylbidrical, the Sims

704 THE FEliALE GENERATIVE ORGANS.

(Fig. 743), Simon 's, the self-retaining weighted speculum, etc, «te.
Fot diagtiostic purposes the bivalve and the Sims specula are
probably most commonly employed, To prevent the anterior vaginal

Fio. 744. — Vagina! depressor. {Ashton.)

Wall from obscuring the view when using the Sims speculum a vaginal
depressor ìs also required (Fig. 744). A sponge holder (Fig. 745)
and cotton wipes should be provided for removing secretions.

Fig. 745. — Sponde holder and snab.

Asepds. — The speculum should be sterilized by boiling for five
minutes in a i per cent, soda solution before use.

Fig. 746. — Method of inserting the bivalve speculum. (Ashton.)

Posltlon of Patient. — When the bivalve or trivalve speculum is
employed the patient should be in the dorsai position. In using the

EXAMINAnON BY SPECULA. 7O5

permeai retractors, such as the Sims, the left lateral or the knee-
chest position may be employed.

Preparatloiis of Patient. — (See page 683.)

Fio. 747. — Melhod ot cxpoàDg the loleral waJls of the vagina by means of the bivalve
speculum. (Ashlon.)

Frc. 748. — Melhod o( exponng the anterior anri posterior vaginal walls by means of a
bivalve speiuium. (Ashion.)

Technic— I. Wilh the Bivalve Spectdum.— The examiner stands or
sits facing the vulva, Then, with the [abia well separated between
the index and middle fìngers of the left hand, the speculum, wetl lubrì-

7o6 THE FEMALE GENERATIVE ORGANS.

cated, is inserted into the vagina with its blades parallel to the ^tìJvb.
opening (Fig. 746). The speculum ìs introduced about 2 inches
(5 cm.) and is then rotated so that the blades Uè parallel with the
anterìor and posterior vaginal walls. By widely separating the blades
(F'g- 747) a view of the cervix and the lateral walls of the vagina is
obtained. For inspectìon of the anterior and posterior vaginal walls
the blades of the speculum are turned so that they lie parallel with the
outlet of the vulva and they are then opened (Fig. 748). The con-
dition of the entire vaginal nmcous membrane may he thus ascertaìned,
and inflammatory conditions, a fistulous opening, new growths, etc,
will be readily recognized if present. If a discharge is present, its
origin should be determined.

Fio. 749. — Shows the method of inserting Sims' speculutu.

■ The cervix is then inspected, noting its size and shape and whelher
it is lacerated or is the seat of inflammation, erosions, cysts, or new
growths, and whether a discharge issues from the external os. If
secretìons obstruct the view, they should be carefully wiped away by
means of cotton wipes held by a spenge holder. In some cases, where
the vagina is very long and narrow, a clear view of the cervix can only
be obtained by drawing it down into the vagina by means of a tenacu-
lum or bullet forceps.

2. Wilk the Sims Speculum.— The shaft of the speculum is grasped
in the operator's right hand while with the left band the upper buttock

EXAMINAnON BY SPECOLA.

Fio. 7SO. — ShOmng the Kms speculum in place. {Ashtoo.)

F10.751. — Method of inspecting the cervu by the aid of Ihe Sìms speculum and a vaglnal
depreuoT. (Ashton.) ,

7o8 THE FEMALE GENERATIVE ORGANS.

is raised so that the vulva is well separateci. The biade of the specu-
lum, which has been previously lubricated, is then inserted into the
vagma parallel with the cleft of the vulva (Fig. 749). The biade is
then rotated so that it lies parallel with the anterior and posterior
vaginal walls and is further introduced until its distai end lies back of
the cervix. By making traction backward and outward the perineum
is retracted so that an excellent view of the anterior vaginal wall and
cervix is obtained (Fig. 750). Should the anterior vaginal wall obstruct
the view, it may be drawn out of the way by means of the vaginal
retractor as shown in Fig. 751.

SOUIfDING THE UTERUS.

The uterine sound, which was formerly employed to a great extent
in gynecological diagnosis, is now seldom used, as little information is
gained by its use, outside of determining the length, size, and consist-
ency of the uterine cavity, that is not as readily obtainable by other and
less dangerous means. The sound should always be regarded as an in-
trument capable of great harm and the operation of sounding as any-
thing but simple. The unskilled use of the uterine sound has often led
to the introduction of septic material into the uterus carried from the
vagina or cervix, as well as to the infliction of serious injury upon the
uterine mucous membrane and even perforation of that organ. To
avoid these risks the position of the uterus should be ascertained before
an attempt is made to introduce the sound, and, during the attempt,
only gentle manipulations of the instrument should be made; it should
never be used as a means of righting a displaced uterus. The sound
should never be introduced by touch alone, but always with the cervix
clearly exposed by means of a speculum, and in every case the date of
the last menstruation should be ascertained beforehand so as not to
interrupt a possible pregnancy. Its use is contraindicated if the uterus
is infected or is the seat of a malignant disease, or if the uterine appen-
dages are involved in a suppurative disease.

Instruments. — The operator will require a vaginal sf)eculum, a
pair of bullet forceps, cotton wipes, a sponge holder, and a uterine
sound (Fig. 752).

The sound is made of flexible metal, about 12 inches (30 cm.) long
and from 1/12 to 1/8 inch (2 to 3 mm.) thick, with a bulbous
tip. The shaft is marked off in inches, and 21/2 inches (6 cm.) from
the distai end is a small protuberance to indicate the normal depth of
the uterus.

SOUNDING THE UTERUS.

709

Asepsls. — The introduction of a sound or any instrument into the
uterus should be regarded as a surgical operation and should be carried
out with every aseptic detail. Ali the instruments should be boiied
for fi ve minutes in a i per cent, soda solution. The extemal genitals
should be thoroughly cleansed with soap and water followed by a
I to 2000 bichlorid solution and the vagina should be douched with
some antiseptic. The operator's hands are cleansed as thoroughly as
for any operation.

Positlon of Patient. — The patient should be in the lithotomy
position.

Fio. 752. — Instruments for sounding the uterus.
I, Garrigues' weighted speculum; 2, dressing forceps; 3, tenaculum; 4, uterine sound.

Technic. — The operator sits facing the vulva and, after separating
the labia, introduces the speculum. The anterior lip of the cervix is
then seized by means of bullet forceps and, after being pulled down
into view, is thoroughly wiped off with a cotton swab soaked in a
I to 2000 bichlorid solution. The sound with its distai 3 inches (7 . 6
cm.) bent in a slight forward curve is grasped lightly between the
thumb and forefinger of the right hand and is introduced into the
extemal os, being careful not to touch any portion of the vagina. By
gently depressing its handle the sound should readily glide up the
canal to the fundus. If the point is arrested by catching in a fold of
mucous membrane or at the internai os, gentle manipulation will
usually result in its passage— /orce should never be employed.

7 IO THE FEUALE GENERATIVE ORGANS.

Sometimes, when the cervix is bent forward, the sound may be
more readily passed if it is started with the concavity o( its curve
tumed backward and, as soon as it becomes arrested, rotating it for-
ward, When the tip of the instrument reaches the fundus, the opera-
tor's righi index-finger shouid be slid along the shaft of the instrument
until it Comes in contact with the cervix for the purpose of indlcating
the deptfa of the canal when the instrument is removed (Fig. 753).

DIGITAL PALPATION OF THE UTERINE CAVITY.

Digital exploration of the interior of the uterus is occasionally
required in the diagnosis of intrauterine growths or retained products
of conception which are not revealed by other methods of examination.
With the finger in the cavity of the uterus it is possible to determine
whether the uterus is empty or not, the length and direction
of the canai, and the thickness, consistency, and other characterìstics
of the endometrium,

Digital exploration necessitates a thorough preliminary dìlatation
of the cervjx, except in puerperal cases, and shouid, therefore, be con-
sidered in the same Hght as a surgical operatlon. It shouid not be
attempted until the possibiiity of pregnancy has been excluded by
determining the date of the last menstruation and by a careful eiami-

DIGITAL PALPATION OF THE UTERINE CAVITY. JH

nation. In the presence of pelvic inSammation or ezudates it is
contraindìcated.

Instruments. — Instniments for dilating the cervùt are required.
These include a vagina! speculum, a pair of dilators, spenge holders,
and two bullet forceps. (See Fig. 806.)

Asepsis. — Strict aseptic precautions shouid be observed. The
extemal genitais are washed with soap and water, followed by a
I to 2000 bichlorid of mercury solution. The vagina is scrubbed with
soap and water by means of a sponge on a holder and is then douchcd
with an antiseptic solution. The instruments are boìled for five
minutes in a i per cent soda solution and the operator's hands are
prepared with the same care as for any operation.

Fig- 754-— Digiul exptoration o£ the ulerine cavily. (Ashton.)

Positlon of Patient. — The lithotomy position is employed.

Anesthesla. — General anesthesia is required except in postpartum
cases.

Technlc— The cervix is first dilated sufficiently to admit the oper-
ator's finger (see page 746). The index-finger of the right band or,
where possible, as in postpartum cases, the index and middle fingers
are then passed into the uterus, while, with the left band on the
abdomen, the operator presses down upon the fundus uteri, so as to
bring the uterus within reach of the internai fingers (Fig. 754). The
interior of the uterus is then systematically explored by the internai
fingers.

712 THE FEMALE GENERATIVE OKGANS.

THE EXAHmATION OF SECTIONS AND SCRAPIKGS FROM THE

UTEHUS.
To determine the nature of a suspicìous growth a portion shouid
be excised for examination. The method of doing this has already
been described (page 226). Where the interior of the uterus is the
seat of suspected disease, scrapings from the endometrium shouid be
collected by a thorough curettage for examination (see page 751).

EXPLORATORT INCISION.

Direct palpation of the pelvic structures is sometimes required in
the diagnosis of obscure pelvic conditìons. It may be accompHshed
by means of an abdominal incÌ5Ìon or through a small openìng made
in the cul-de-sac of Douglas. The latter method is preferable, as it
is not a dangerous operation, and the recovery of the patient is more
rapid than when an abdominal sectìon is performed. The operator

FiG. 755. — Instruments for ah exploraloty va^nal section.

I, Garriguca' weighied speculum; 3, spenge holder; 3, tenaculum; 4, thuinb forceps;

5, sharp-poinled scissors; 6, anery clamps; 7, needle holder;

8, needles; 9, No. 3 catgut.

shouid be prepared, however, to perform any operative procedures,
such as draining a pus sac, removing suppurating tubes, or opening the
abdomen, if the fitidings indicate it,

Instruments. — There will be required a weighted vaginal speculum,
sponge holders, buliet forceps, toothed thumb forceps, sharp-pointed
curved scissors, artery clamps, curved cutting-edged needies, a needle
holder, and No. 2 catgut (Fig, 755).

EXPLORATOBY INCISION. 713

Asepds. — The instruments are boiled for five minutes in a i per
cent, soda solution. The extemal genìtals are scnibbed with soap
and water followed by a i to 2000 bìchlorid solution, and the vagina is
cleansed by first washing with soap and water and then by means of an
antiseptic douche. The operator's hands are sterilized in the usuai
way.

Positlon of Patlent. — The patient shouid be in the lithotomy
position.

FiG. 756- — First atep in perfomiìng a posteriot vaginal sectìon, openìng Ìnlo the poeteriur
cul-de-sac.

PreparaUon of Patlent. — The patient shouid bave been prepared
for general anesthesia and the bowels and bladder shouid be empty
at the time of operation.

Anesthesia. — General anesthesia is employed.

Technlc. — The vagina! speculum is placed in the vagina and the
posterior lip of the cervix is seized in bullet forceps which are given
to an assistant to hold. The operator then picks up the posterior
vaginal wall by means of thumb forceps at a poinl in the mid-line, Just
back of where it is reflected from the cervix, and with a pair of scissors
makes a transverse incision about i inch (2.5 cm.) long through the
vaginal wail (Fig. 756). The vaginal wall posterior to the incision is
then separated by blunt dissection from the underlying peritoneum

THE FEUALE GENERATIVE ORGANS.

FlG. 757. — Shows the posterìor cul-de-sac opened.

n iato tlie posterìor

VAGIMAL IRRIGATIONS. 715

for a short space (Fig. 757). The peritoneum thus exposed is then
picked up and a transverseopening, sufficientlylarge toadmit the iìngers,
is made in it. Through this opening the pelvic stmctures may be
thoroughly palpatedby the finger (Fig. 758), andif desired the append-
ages may be brought down to view and mspected.

At the completion of the operation the opening in the peritoneum
and that in the vagìnal wall are closed by a few catgut sutures.

Therapeutic Measures.

VAGINAL IRRIGATIONS.

Vaginal irrigation, or douching, may be employed for simple
cleansing purposes, as in leukorrhea or in preparation for operati\-e
procedures, for the purpose of bringing soothing, astringent, or anti-
septic Solutions in contact with diseased vaginal or cervical mucous
membrane, and as a means of applying heat to the pelvic organs to
relieve congestion or inflammation, to hasten ìnvolution after labor,

F'iG, 75g. — Apparatus foi vaginal douching.

to control uterine hemorrhage, etc. In pregnancy and durìng menstru-
ation they shouid be used with caution.

Apparatus. — There will be required a large glass irrigating jar or
douche bag, a bath thermometer, 6 feet (180 cm.) of rubber tubing,
1/4 inch (6.3 mm.) in diameter, leading from the reservoir to the

7l6 THE FEMALE GENERATIVE ORGANS.

douche nozzle, a glass vaginal douche nozzle, and a douche pan with a
spout to which is attached a piece of rubber tubing sufficiently long
to convey the waste fluid to a slop paìl (Fig. 759).

The douche nozzle should preferably be of glass wilhotU any curve
and having perforations on the sides but with none al the end (Fig. 760).
With such an instrument there is little danger of the solution entering
the uterus in cases of a patulous cervix.

Fig. 760. — Enlaiged view of a glass vaginal douche nozzle.

Asepsis. — The greatest care should be taken against infection
especially in puerperal cases. The apparatus should, thjerefore, be
boiled for five minutes in plain water and the thermometer should be
sterilized by immersion in a i to 500 bichlorid of mercury solution, after
which it is rinsed in sterile water. The attendant's hands should be
cleansed in the usuai way and the extemal genitals should be washed
with soap and water followed by a i to 2000 bichlorid solution. When
the patient administers the douches herself, the dangers of infection
and the proper means of avoiding it should be carefully explained to her.

Solutions Used. — Among the many solutions used for vaginal
injection are the following: Plain sterile water; normal salt solution —
salt 3i (39 gni-) to the pint (473.11 ce.) of boiled water; — borie acid,
2 per cent.; thymol i to 1000; lysol i per cent.; creolin i per cent.;
tannic acid 5i (39 gm.) to the quart (liter); alum acetate 3i (3-9
gm.) to the quart (liter) ; permanganate of potash i to 2000; bichlorid
of mercury i to 5000; carbolicacid i per cent., etc. Theuseof poison-
ous drugs, such as the latter two, should be followed by a douche of
sterile water or saline to avoid any danger of absorption.

Temperature. — Ordinarily the irrigation is given at a temperature
of 100° to 105^ F. When the stimulating and vascular constricting
effect of heat is desired, however, the temperature should be from
115^ to 120® F.

Quantlty. — At least i gallon (4 liters) of solution should be used at
a time. If it is desired to obtain a prolonged effect from the heat,
several gallons may be used over a period of fifteen to thirty minutes.

Height of Elevation. — This is important, since, if the reservoir is
elevated too high, the pressure will be so great that solution may be

VAGINAL lERICATIONS. ^l^

forced ìnto the utenis. An elevation of 2 to 3 feet (60 to 90 cm.) is
amply suf&cient.

Frequeacy. — This will depend upon the purposes of the douche
from once a day to three or more tiraes daily.

Posltion of Patleat. — The patient lies in bed on a douche pan in
the dorsal position, with the knees fiexed, or else recumbent in a bath
tub. The douche should noi be iaken wilh ike patient silling on the
toilel.

FiG. 761. — Showiog the correct (a) and the incorrect (b) method of giving ava^iul

douche. (Ashton.)

Technlc. — The labia are wìdely separated with the fingers of the
left hand and with the rìght hand the nozzle is introduced into the
vagina, first, however, allowing the solution to flow in order to expel
any air or cold fluid. The desired amount of solution is then pennitted
to enter the vagina which balloons up under the influence of the disten-
tion and thus allows the solution to come in contact with its entire
surface (Fig. 761).

In cases of a relaxed vagina, it is necessary to compress the vaginal
outlet somewhat about the douche tube in order to obtain this disten-
tion. This procedure should, however, be used with caution in puerperal
cases, for, if the intra vaginal pressure be too great, some of the solution
will necessarily be forced into the uterus, During the irrigation care
must be taken to protect the patient from cold by suilable covering.

7l8 THE FEMALE GENERATIVE ORGANS.

LOCAL APPLICATIONS TO THE VAGINA AND CERVIX.

Locai applications are employed in treating inflammadons of the
vagina and the vaginal portion of the cervix. They may be made by
means of cotton-tipped applicators or by tampons (see page 719).
The former method shouid be employed when it is desired to medicate
localized areas of inflammation or ulceratìon or to employ strong
Solutions.

Instruments. — ^There will be reqnired a bivalve vaginal speculum
and a metal applicator or a pair of dressing forceps (Fig. 762).

FiG. 762.— Instruments for making locai applications to the vagina.

I, Bivalve speculum; 3, applicator.

Asepsis. — The instruments are boiled in a i per cent, soda solution
for five minutes and the extemal genitals are cleansed with soap and
water followed by a i to 2000 bichlorid of mercury solution. The
operator's hands shouid likewise be clean.

Solutions Used. — Tincture of iodin, silver nitrate gr. xx to xxx
(1.3 to 1.95 gm.) to the ounce (30 ce), argyrol 50 per cent., copper
sulphate gr. v to xx (0.32 to i .3 gm.) to the ounce (30 ce), zinc sul-
phate gr. V to XX (0.32 to 1.3 gm.) to the ounce (30 ce), etc, are
among the solutions generally employed.

Frequency. — Applications may be made every three or four days.

Positlon of Patient. — ^The patient shouid be upon a firm table in
the dorsal position.

Technic. — The diseased area ìs exposed by means of a speculum
and, after removing any mucus or secretion, the surface it is desired
to medicate is wiped dry. An applicator or dressing forceps wrapped
with cotton is then dipped in the solution and the saturated swab is
thoroughly rubbed over the diseased area. Following this a light
vaginal tampon is inserted and allowed to remain in place twelve to
twenty-four hours.

VAGINAL TAMPONS.

719

APPLICATION OF POWDERS TO THE VAGIHA.

Powders are sometimes employed with success in place of liquids
in the treatment of chronic vaginìtis, especially if uicerated surfaces
are present.

Instruments. — A vagina! speculum, dressing forceps, and a powder
blower are required (Fig. 763).

Fig. 76.1.— InMramenls fot the application of powd«ra to the vagina.
I, Bivalve speculum; 3, dressing forceps; 3, powder blowei.

Foimnlary. — Soothing or astringent powders, such as borie acid,
zinc oxid, bismuth subnitrate, calomel, tairnic acid, glycerole of tannin,
acetanilid, alone or in combination, are frequently employed.

Positton of Patlent. — The patient shouid be in the dorsal posture.

Technlc. — The vagina is first well cleansed with a douche. A
speculimi is then inserted and, by means of a cotton swab held in adress-
ing forceps, the mucous membrane is thoroughly dried. The entìre
inflamed surface is then coated with the desired powder applied by
means of the powder blower. A light tampon is fìnally inserted and
is left in place for twenty-four hours,

VAGINAL TAMPONS.

Vaginal tampuns are used for a variety of purposes, namely, to
bring medication in contact with the vagina or the cervix in the treat-

720

THE FEMALE GENERATIVE ORGANS.

ment of inflammations involving these structures, to protect and keep
separateci inflamed or ulcerateci vaginal walls, to apply glycerin for its
ciepleting effect upon the uterus anci pelvic organs, to support a pro-
lapseci ovary, for the purpose of stretching acihesions or supporting
the uterus by ciistention of the vagina anci fomices, and alone or in
combination with the uterine pack to control hemorrhage from the
uterus.

FiG. 764. — Showing the method of making a cotton vaginal tampon. (Kelly and Noble.)

Tampons should not be left in place more than twenty-four hours,
as they tend to become foul and offensive, and strings should always
be attached to that they may be removed by the patient. The patient
should, of course, be informed of the exact number of tampons inserted.

Instniments. — Bivalve and Sims' specula and ciressing forceps are
required.

VAGINAL TAUPONS. 721

The Tampon. — Tampons are made of absorbent cotton, lambs*
wool, or gauze. For canying medication absorbent cotton is prefer-
able, while for purposes of support lambs' wool or gauze, having more
body, are best.

The cotton tampon is made by cutting a fiat layer of absorbent
cotton into an oblong shape, placing a hea^7 silk string about 14 inches
{35 cm.) long, across ìts center as shown in Fig. 764, and roUing the
cotton about the string. On tying the string the two ends of the
cotton roti are brought together and, at the same time, the string is
buried in and securely fastened to the cotton,

Lambs' wool tampons may be made in the same manner or a silt
string may be simply lied to the center of a wad of the wool.

A gauze tampon shouid consist of a single piece of gauze 3 feet
(90 cm.) or more long, depending on the capacity of the vagina and
the firmness with which ìt is to be packed, and folded to a width of
about 2 inches (5 cm.).

Fic. 765. — Vagina! lampon» in poàtion.

The Uedlcated Tampon. — The tampon is made as above described
and is then saturated with the desired medication. For this purpose
the following drugs are employed: Ichthyol and glycerin 25 per cent.,
boroglycerid, glycerite of tannic acid 20 per cent., argyrol 10 to 25
per cent., protargol 2 per cent., etc. When indicated the tampon
may be covered with some of the powders mentioned on page 719 ìn
place of these solutions.

Asepeis. — The instruments shouid be boiled and the tampons
thoroughly sterilized. The esternai genìtais are washed with soap

y22 THE FEUALE GENERATIVE ORCANS.

and water followed by a i to 2000 bichlorìd of mercury solution. The
operator's hands are cleansed in the usuai way.

PoBition of Patient. — For insertìng the medica ted tampon the
patient may be in the dorsal posture, but when it is desired to thor-
oughly pack the vaginal vault for the purposes of support and to con-
trol hemorrhage the Sims or the knee-chest posture is preferable,

Preparatlons oi Patient. — The bladder and bowels shouid be
empty. Any clots or secr^tions are wiped from the vagina and the
entire vagina is then swabbed out with a i to 2000 bichlorìd of mercury
solution.

Technlc. — For applying a medicated tampon a bivalve spcculum
is inserted and the tampon, soaked in the medicament, is carried in

FiG. 766. — Shows the metbod of packing the vagina with the patient in the Sims position.

dressing forceps to thedesired spot. A wool tampon is then inserted
to retain the first one in position and, while the tampons are held
securely in place by means of the dressing forceps, the speculum is
removed, care being taken that the strìngs attached to the tampons are
left hanging from the vagina {Fig. 765).

The tampon is to be removed by the patient within twenty-four
hours, at which time a cleansing douche shouid be taken.

To thoroughly pack the vagina, as is necessary for example, for
the control of hemorrhage, the patient being in the Sims or the knee-
chest posture, a Sims speculum is inserted and the posterior vaginal

THE INTRAUTERINE DOUCHE. 723

Wall is put upon the stretch. Then, by means of a pair* o£ dressing
forceps, the entire vagina is thoroughly tamponed with a strip of jgauze,
beginning with the posterior vaginal fomix, then fiUing the lateral .and
anterior fomices, and, as the rest of the vagina is packed, gradually
withdrawing the speculum (Fig. 766). A T-bandage is then applied
to retain the pack in place. Such a pack properly inserted will con-
trol any ordinary hemorrhage from a nonpuerperal uterus, but in
severe hemorrhages and in postpartum cases the uterus also should
be tamponed (page 729).

Removal of the packing in twelve or twenty-four hours should be
foUowed by a cleansing douche.

THE INTRAUTERINE DOUCHE.

Uterine douches are employed in the treatment of septic conditions
affecting the uterus, to control hemorrhage, and for cleansing the uterus
after curettage and other intrauterine operations. They are more
dangerous than vaginal douches, and certain precautions in their use
are necessary. They should always be given by the physician himself
and in their use the same care and attention to cleanliness should be
observed as in any operative procedure. It is absolutely essential that
a free and unimpeded return of the solution be provided by havìng the
cervix well dilated or by employing a return-flow irrigating nozzle,
otherwise there is danger of overdistention of the uterus with resulting
shock or of the fluid being forced into the uterus through the tubes.
Furthermore, the use of poisonous drugs, such as carbolic acid or
bichlorid of mercury^ should always be foUowed by an intrauterine
irrigation of sterile water or of normal salt solution.

Apparatus. — There will be required a glass irrigating jar or a
large douche bag, a thermometer, 6 feet (180 cm.) of rubber tubing,
I /4 inch (6 . 3 mm.) in diameter, connecting the reservoir and the douche
nozzle, a douche pan with a spout to which is attached a piece of
rubber tubing suffìciently long to convey the returning fluid to a waste
pail (see Fig. 759).

There are several forms of intrauterine douche nozzles. When the
cervix is widely dilated, as in postpartum cases, a curved glass nozzle
with the openings upon the sides, such as the Chamberlain tube (Fig.
767), is sufficient.

In other cases it is necessary to employ some form of return-flow
nozzle. The Fritsch-Bozeman nozzle (Fig. 768) is the safest of these.
It consists of an outer tube fenestrated near the tip, with a second open-

724

THE FEMALE GENERATIVE ORGANS.

mg upon the under surface o£ the instrument near its lower end for the
return flow. Inside this outer tube is a smaller inflow tube. This
instrument requires some dilatation of the cervix, however, before it
can be introduced and where this is lacking a smaller instrument, such

Fio. 767. — Glass intrauterìne douche nozzle.

as Talley's intrauterine catheter (Fig. 769), may be employed. This
latter consists of a curved metal catheter with two heavy wires on its
under surface, which may be expanded or closed by tuming a small
thumb-screw. The catheter is introduced into the uterus with the
wires lying dose to the catheter and, when in the uterus, the wires are

Fio. 768. — Fritsch-Bozeman retum-flow uterine douche nozzle. (Bandler.)

expanded, thereby dilating the cervix sufficiently to permit a return of
the injected solution.

Instruments. — In addition to the above apparatus a vaginal
speculum, a sponge holder, and a pair of bullet forceps are required
(Fig. 770).

^ ....«'■^

Fio. 769. — Retum-flow dilating catheter. (Ashton.)

Asepsis. — The apparatus and instruments should be sterilized by
boiling and the thermometer by immersion in a i to 500 bichlorid of
mercury solution followed by rinsing in sterile water. The extemal
genitals are first washed with soap and water and then with a i to 2000

THE INTRAUTERINE DOUCHE.

725

bichlorid of mercury solution. The vagina is cleansed by means of
a I to 5000 bichlorid of mercury douche, foUowed by sterile water.
The operator's hands are sterilized in the usuai way.

Solutions Used. — Plain sterile water, normal salt solution — salt
5i (3.9 gm.) to the pint (473. 11 ce.) of water, i to loooo to i to 5000
bichlorid of mercury, 50 per cent, alcohol, 0.5 per cent, solution of
lysol, 0.5 per cent, solution of creolin, sii ver nitrate i to 1000, etc,
etc, are among the solutions employed.

Temperature. — Ordinarily the temperature of the solution is about
105® F. Where the stimulating and constricting effect of beat is
desired the temperature of the solution should be 115^ to 120® F.

Quantlty. — About i quart (i liter) of solution is used at a time.

FiG. 770. — Instruments for intrauterine douching.
I, Garrigues* weighted speculum; 2, sponge holder; 3, tenaculum.

Rapidity of Flow. — The fluid should not be allowed to enter the
uterus more rapidly than it can escape, otherwise there is danger of its
being forced into the tubes. Therefore, the reservoir should not be
elevated more than 2 feet (60 cm.).

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

Technic. — If the cervix is well dilated so that the entrance of the
douche nozzle is not interfered with, the latter may be inserted by
touch alone, as follows: One or two fingers of the left band are passed
into the vagina and the extemal os is thus located. The douche
nozzle, with the solution flowing so as to avoid injecting any air, is then
inserted into the uterus by the right band, being guided through the

•J26 THE FEUALE GENERATIVE OKGANS.

cervix by the fingers of the left hand (Fig..77i), The nozzle is then
gently passed to the fundus of the uterus and the cavity ìs thoroughJy
iirigated. The return flow must be carefully watched to see that it

Fic. 771.— Inserting the douche nozzle when Ihe cervix is well dilated,

is not obstructed. It is well to place the left hand extemally over the
fundus uteri in puerperal cases to prevent any possible overdistention
of the uterus and opening up of the sinuses (Fig. 772).

Fic. 7;z. — Method of giving an intraulerìne douche in a postpaitur

To introduce the douche nozzle by sight, the posterior vaginal wall
is retracted by means of a speculum, and, if the cervix is not readily
accessible, it is drawn down into the vagina by means of bullet forceps

INTRAUTERINE APPUCATIONS. 727

caught in its anterìor lip. The cervùt is then wiped off by means of a
swab OH a spenge holder wet with a i to 20C» bìchlorid of mercury solu-
tion, and a return-flow nozzle is inserted by direct sight, taking care to
bave the solution first flowing (Fig. 773), In inserting the nozzle
extreme gentleness shouid be used to avoid injuring the tissues or
possibly perforating the utenis. The lattar accident has happened
frequently enough to warrant this caution.

FiG. 773. — Showa the melhod a( giving an intraulerìne douchc wilh a retum-flow nozzle.

INTRAUTERINE APPLICATIONS.

The application of drugs with an astringent or caustic action to the
mucous membrane of the uterus is employed in the treatment of endo-
metritis in conjunction with curettage or alone. The best resuits are
obtained, howcver, when intrauterine applications are used after a
preliminary curettage.

The indiscriminate employment of intrauterine applications
shouid be condemned, as they often do more harm than good. They
shouid only be employed in cases where thorough asepsis can be
obtained, and then only with the cervix sufRciently dìlated to allow
thorough subsequent drainage. The procedure, therefore, is one that
rises to the dignity of an operation and shouid never be attempted
as a part of the office treatment.

The position and size of the uterus and the condition of the other
pel vie organs must be determined bybimanual ezamination beforehand.

728

THE FEMALE GENERATIVE ORGANS.

In the presence of adnexal involvement or other complications intra-
uterine applications are contraindicated.

Instruments. — There should be provided a vagina! speculum,
spenge holders, bullet forceps, and two uterine applicators (Fig. 774).

Asepsis. — The instruments are boiied for five minutes in a i per
cent, soda solution. The extemal genitals are washed with soap and
water foUowed by a i to 2000 bichlorid solution. The vagina is douched
with a I to 5000 bichlorid of mercury solution followed by sterile water
The operator's hands are likewise sterilized.

Fig. 774. — Instruments for inaking intrauterine applications.
ly Garrigues' weighted speculum; 2, sponge holder; 3, tenaculum; 4, applicator.

Solutions Used. — Sulphate of zinc 5 to io per cent., chlorid of zinc
5 to IO per cent., Silver nitrate 5 to io per cent.,perchlorid of iron 5 per
cent., ichthyol 5 to io per cent., tincture of iodin 50 per cent., Churchill 's
solution of iodin^ pure carbolic acid, etc, etc, may be employed.

Position of Patient. — The patient is placed in the dorsal position.

Technic. — The vaginal speculum is inserted and the cervix is
drawn down into view by means of bullet forceps which seize the ante-
rior lip. Any secretion or coUection of mucus is then wiped away
from the extemal os by means of a swab soaked in a i to 2000 bichlorid
solution, and the cervix is dilated if necessary (see page 746). A
small pledget of dry cotton is then securely wound round an applicator,
taking care that the tip of the instrument is well covered. The swab
thus fashioned is to be of such size that it will readily pass the cendx.
The applicator is curved to the shape of the canal and is passed into

TAMPONING THE UTERUS. 729

the uterus for the purpose of removing any secretions and thus allow
the solution to come in contact with ali portions of the mucous mem-
brane. A second applicator, sìmilarly wrapped with cotton, is dipped
in the solution. Any excess of fluid is squeezed from the cotton and

Fio. 775. — Shows the melhod of making an inlrauterìne application.

the application is then made to the interior of the uterus, carrying the
cotton-tlpped applicator well up to the fundus and moving the instru-
ment about in the ca\ity (Fig. 775), A vaginal tampon is finaily
inserted, which is removed in twenty-four hours. The patient shouid
remain quiet for a day or two, and if a strong caustic has been employed
she shouid be wamed that at first there will be an increased discharge.

TAMPOiraTG THE UTERUS.

Tamponage of the uterus may be required to control severe uterine
hemorrhage, to secure dilatation of the cervix for the expulsion of the
uterine conlents or In preparation for intrauterine manipulations, and
to aid in the separation of retained products of conception. The
technic of tamponìng the uterus for the control of hemorrhage is
something with which every physician shouid be familiar. as occasions
often arise when the operation is demanded without delay as a life-
saving measure; at the same time it shouid be regarded as a surgical
procedure and one that shouid always be performed under thorough
aseptic precautions. The position and size of the uterus shouid be
ascertained by bimanual examination beforehand, otherwise the uterus
may be inj'ured in attempting to inserì the packing.

730

THE FEMALE GENERATIVE ORGANS.

Instruments. — A Simon or a Garrigues speculum, sponge holders,
two bullet forceps, a pair of dressing forceps, and a cannula and packer
are required (Fig. 776). In the majority of cases a pair of curved
dressing forceps may be employed for inserting the packing, but, where
the cervix is not well dilated, a special packer, such as is shown in

Fig. 776. — Instruments for tamponing the utenis.
I, Garrigues' speculum; 2, sponge holder; 3, tenaculum; 4, uterine drcsàng forceps; 5,

uterine packer.

Fig. 777, by means of which the packing is pumped into the uterus
through the cannula, is more convenient.

Packing Material. — ^The most satisfactory material to pack with
is sterilized ganze. This should be folded into strips 2 inches (5 cm.)
Wide for use when the cervix is well dilated and into strips i /2 inch
(i . 2 cm.) Wide for an incompletely dilated cervix. Care should be

Fig. 777. — Showing the cannula and plonger of the uterine packer separated.

taken to see that the strips are so folded that no frayed edges are
exposed. The ganze is best kept in long strips packed in sterile glass
tubes.

Asepsis.— The instruments are boiled for five minutes in a i per
cent, soda solution. The patient's extemal genitals are washed with
soap and water, followed by a i to 2000 bichlorid solution and the

TAMPONINO THE UTEBUS. 73I

vagina is first cleansed with soap and water and then douched with a
I to 5000 solution of bichlorìd of mercury.

Posltloo of Patient. — The patient shouid be in the lithotomy
position.

Preparatlons of Patient. — The patient's bladder and bowels should
be empty.

Technlc. — Any clots are first wiped cut of the vagina. The cervix
is exposed by means of the speculum and the anterior and posterìor

Fia. 77S. — Method of tamponing the utenis with a, long strip of gauM inserted by means
of d ressi ng forceps.

lips are seized in bullet forceps which are given to an assistant to hold.
A strip of gauze is then seized in dressing forceps in such a way that the
gauze falls over the end of the forceps so as to avoid inflicting any
injury upon the tissues and is carried to the fundus. Successive sec-
tions of the gauze are inserted ìn the same manner until the cavity
is filled (Fig, 778). Whenever possible, a single strip oj gauze should
be employed. While inserting the gauze the operator's free band
should be kept upon the abdomen in order to control the uterus, and
care should be taken that the gauze does not come in contact with any-
thing that is not sterile. The end or ends of the gauze, if more than
one strip is used, should be left projecting into the vagina, so that it
may be easily found, when the gauze is to be removed, which should be
within twenty-four hours of its insertion.

In cases of severe hemorrhage the vagina also should be packed

73» THE FEMALE GENERATIVE ORGANS.

(see page 719), taking care, however, to tie the vagina) strip to that
within the uterus or else to bring the ends of both vaginal and uterine
strips to the vaginal outlet. Upon removal of the gauze a vaginal
douche should be given.

In tamponing the uterus by means of the sp>ecìal packer shovm in
I'''g- 777i the cervix is exposed as before and is drawn down by means
of bullet forceps. The cannula is then inserted into the uterus and a
narrow strip of gauze is caught on the sharpened end of the piston and
is carried into the uterus by a pumping motion of the piston (Flg. 779).

FlG. 779. — Method of using the uleiine packer.

BIER'S HYPEREMIC TREATUENT IN GYNEC0L06Y.

Passive hyperemia by means of special forms of suction cups
cpplied to the cervix uteri .has been employed with good resuits in
cases of puerperal and other forms of infections of the cervix and
uterus, in ulcerations of the cervix, in chronic metritis, and in amenor-
rhea. The use of cups is contraindicated, however, if the adnexa are
inflamed.

In dysmenorrhea there have been numerous favorable reports from
the application of large suction cups to the breast once or twice a day
for periods of fifteen to thirty minutes, beginnlng a few days before the
date of expected menstruation and continuing the treatments till the
end. Pelvic exudates have also been treated with success by means o£
hot-air boxes in which the pelvis and hips rest.

PELVIC UASSAGE. 733

The apparatus for obtaining actìve and passive hyperemia, as well
as the metbod of its use, have been previously descrìbed in Chapter VII.

PELVIC HASSAGE.

Felvic massage after the method of Brandt has been employed for
the purpose of hastening the absorption of pelvic exudates through
stimulation of the circulation and lymph currents, to stretch or separate
old adhesions, to stimulate contractions ìn the uterus, and to strengthen
and tone up weakened or thickened pelvic ligaments. In certain
selected cases this method of treatment has value, Pelvic massage

Fio. 780. — Showing Ihe position of the luads in commeucing pelvic massage.

must never he employed, however, in ihe presente of acute injUimma-
tion or with pus collections in the lubes or pelvis, so that the diagnosis
must be carefuUy made in every case before it can be safely attempted,
and then it shouid only be performed by the physician himself. In
individuais with erotic tendencies it shouid be avoided,

Duration of Treatments. — The massage is performed for about ten
minutes at a sitting.

Frequency. — Treatments are given daily.

Position of Patlont. — The patient shouid be in the dorsal posture.

Preparatlons. — The bladder and bowels shouid be emptied before-
hand and the clothing shouid be loosened from the abdomen.

734

THE FEMALE GENERATIVE ORGANS.

Technic. — Under ali aseptic precautions two fìtigers of the ieft band
are introduced into the vagina and are canìed up to the part to be
massaged. Then, by tneans of the tight band placed on the abdonien,
at first genite circular movements and then deep pressure manipula-
tions are made over the diseased part which at the same time is raised
and fixed within reach of the extemal hand by the internai fingers.
The manipulations shouid be begiui each time over the periphery of
the diseased part and shouid always be made with the greatest care and
with the absence of any approach to roughness.

When employed for the purpose of gradually stretching adhesions
or contracted ligaments, gentle intermittent traction is applied to the
uterus through the internai and extemat hands in a direction opposite
to the point of the fìxation (Fig, 780), By thus gradually stretching
the adhesions and through the stimulating eEFect of the manipulations
the fibrous tissue is gradually absorbed and the muscular and elastic
tissues become regenerated. Such manipulations are especially useful
when used in conjunction with hot douches and tampons in gradually
replacing a utenis bound down with adhesions.

Fio. 781.
[, Bivalve speculum; 3

-InstnimenU for scarìficadon of the c<
sponge bolder; 3, tenaculum; 4

SCARIFICATION OF THE CERVIX.

The withdrawal of blood from the cer\'ix ìs a valuable therapeutic
measure in cases of chronic congestion of the uterus and pelvic organs.
It is also employed with good resuits for the relief of the pain and colie
of dclayed menstrualion due to pelvic congestion.

PE5SASY THERAPY. 735

Instrumeiits. — A vaginal speculum, spenge holders, bullet forceps,
and a narrow-bladed bistoury are required (Fig, 781).

Asepsis. — AH aseptic precautions should be observed. The
ìnstruments are to be boiied for five minutes in a i per cent, soda solu-
tion. The esternai genitats are cleansed with soap and water, followed
by a I to 2000 bìchlorid solution, and
the vagina is douched.

Posltlon of Patient. — The patient
should be in the dorsal posture.

Tochnlc. — The cervix is exposed
by the speculum and, after being
mopped off by means of a wipe

Pio. 783. — Melhod of scarìfying the Pio. 783. — Scarilication of the cervix, show-

cervix by puncturcs. (Ashton.) ing the method of making the supeificial ind-

sìana. (Ashton.)

moistened in a i to 2000 bìchlorid solution, is seized by the builet
forceps and is drawn well down toward the vaginal outlet. Numerous
punctures are then made by means of the point of the bistoury to the
depth of I /4 to I J2 inch (6. 3 to 12 . 7 mm.) around the circumference
of the cervix (Fig. 782), or, instead of punctures, cross cuts may be
employed (Fig. 783). In this way from 1/2 ounce (15 ce.) to 2
ounces (60 ce.) of blood may be withdrawn. A tampon of ichthyol
and glycerin or tannin and giycerin is then inserted into the upper
portion of the vagina, to be removed within twelve hours.

PESSARY THERAPY.

Pessaries are employed for the purpose of maintaìnìng a retrodis-
placed or prolapsed uterus in place and to supporl a cystocele. In the
case of a prolapse of the uterus or a cystocele a pessary is only of
value as a palliative measure where operative relief is refused or is
undesirable on account of the age or condition of the patient. In a
certain proportion of retrodìsplacements, however, a properly fitted

736 THE FEMALE GENERATIVE ORGANS.

pessary will in time produce a cure, the most favorable cases being
those in which the displacement is only of short duration as, for
example, after confinement. The only cases of displacement in which
pessary therapy is suitable are those where the pelvic floor has suflRcient
tonicity to give support to the pessary and where the displacement is
not complicated by pelvic lesions. Their use is contraindicated in the
presence of considerable enlargement or a prolapse of the ovary,
hydrosalpinx, pyosalpinx, or new growths, and where the uterus is
bound down by adhesions. Some cases of adhesions, however, under
appropriate treatment by medicated tampons, hot douching, etc,
may be so stretched or even be made to disappear that later a pessary
may be satisfactorily employed.

Pessaries are not designed as a means of replacing a uterus, but
simply to hold the organ suspended in proper position after it has been
replaced. This it does by distending the vaginal walls, and not
through any force exerted by the instrument upon the uterus itself.
Every pessary should be fitted to the individuai case, and it is here
that the experience of the physician counts for much. When properly
fitted, the pessary shotUd never cause any pain or even make the
patient conscùms of its presence, and it may be wom for years, with
certain precautions as to cleanliness, to be mentioned later, without
harm. On the other hand, an ili fitting pessary or one employed in
a case not suitable for such treatment is distinctly harmful. It should,
therefore, always be impressed upon the patient that if the least pain
or an undue amount of leucorrhea results from the insertion of the
pessary, she should report to the physician immediately, or else remove
the pessary herself.

Pessaries. — ^Pessaries are made of hard rubber in a great variety
of shapes. For retrodisplacements the most commonly employed is
th^ Hodge-Smith (Fig. 784). If, however, the pel\ic floor is relaxed,
a Hodge pessary (Fig. 785) is preferable, as its wide lower bar renders
it less liable to slip out. These act as levers in the vagina in such a
way that the force is exerted upon the posterior cul-de-sac and the
uterosacral ligaments, so that the cervix is pulled backward and the
uterus is thus tipped forward.

Ring pessaries (Fig. 786) are also employed in retrodisplacements
where there is not sufficient support for the ordinary pessary.
They act by so distending the vagina in ali directions that the
uterus is supported by the lower vaginal structures. The ring
should be smooth and fairly thick, at least i /4 inch (6 mm.), so as to
avoid any danger of its eroding through the vaginal walls. The

PESSARY THERAPy.

737

ring pessary ìs also employed for retaining a prolapsed uterus in
place; but in many cases of prolapse, the perìneum ìs so relaxed that
the pessary immediately slips out, and some sort of pessary held in

FiG. 787. — Gehrung's pessaiy.

Fio. 788,— Skene's pessary. (Shown bere
upside down.}

Fio, yHf). — Cup or ring (a) pessary wilh cxiernal support. (Ashton.)
place by an abdominal support, such as is shown in Fig. 789, will be
nccessary.

For supporting a cystoccle Gehrung's anteversion pessary (Fig. 787)
or Skene's pessary (Fig. 788) is often used with s

738 TEE FEMALE GENERATIVE OEGANS.

As previously stated the pessary shouid be fitted to each individuai
case. The shape of the pessary may be readily changed by first
coating the instniroent wìth oil or vaselìn and then softeoìng it by the
heat of an alcohol lamp. When it has been moulded to the desired
shape it is hardened again by immersion in cold water. The tendency
is to employ too large a pessary, which is dangerous, as it may exert un-
due pressure upon the vaginal Wall and produce excorìations, orin time
even ulcerate fhrough. On the other hand, if the pessary is too small,
it will not remain in place. The safest pian is to measure the vagina
in each case and shape the pessary accordingly. The depth of the
vagina is determined by canying two fìngers as high as possible into
the posterior cul-de-sac and measuring the distance from the inferior
border of the symphysis, while the width is estimated by noting the
distance to which the two fingers in the vagina may be separated.
About 1/2 inch (i era.) shouid be deducted from the former measure-
ment for the correct length of the pessary.

Asepsis. — A pessary shouid never be taken from one patient and
inserted in another without thorough sterìlìzation. The ring pessary
may be sterilized by boiling, but the others, if so treated, tose their

Fio. 790. — First step in replacing a retrovertcd utenis. (Ashton.)

shape; prolonged immersion in some antiseptic solution, such as r to
500 bichlorid of mercury, shouid be employed instead,

Po^tlon of Patient. — For inserting the pessary the patient is ordi-
narily placed in the dorsal posture, though in some cases the knee-chest
position may be used to better advantage.

Preparatloiis of Patient. — The bladder and bowels shouid be
empty, and the clothing well loosened,

Technic. — i. Replacement of the Retroverled Ulerus. — There are
two methods of replacement; (i) By bimanual manipulation, and

PESSARY THERAPY. 739

(2) with the patient in the knee-chest posture. The fonner method
is usually effective if the abdominal walls are not thick and rigid and
the vagina is sufficiently roomy. It is periormed as follows: Two

Fio. 791. — Second stcp in repladng a reltoverted ulems. (Ashton.)

fingers of the left hand are introduced into the vagina and are carried
up into the posterior cul-de-sac where they exert pressure in an upward
and forward direction upon the body of the utenis (Fig. 790). As

Fio. 791. — Third step in repladng a retroveited uterus. (Ashion.)

the uterus is thus elevated, the rìght hand is placed upon the abdomen,
and an attempi is made to hook the fingers behind the fundus (Fig.
791). The fundus ìs then puUed forward by the fingers of the extemal

74° THE FEMALE GENERATIVE ORGANS.

band while the internai fingers are shifted to the anterior fomix, where
they malte backward pressure upon the cervix and the lower segment
of the uterus (Fig. 792). Sometimes, howcver, it is not possible to

Fig. 753- — Second melhod of repladng a retro\-erted uterus. First atcp. (Kelly
and Noble.)

raise the fundus past the promontory by this melhod. In such a case
the anterior lip of the cervix shouid be grasped in bullet forceps, and
the wbole uterus -is then puUed down toward the vaginal outlet (Fig.

FtG. 794. — Second method of replacìng a relroverted uterus. Second step. (Kelly and

Noble.)

793). At the same time the index-finger of the left band covered with
a giove is inserted into the rectum and the fundus ìs elevated past tbe
promontory (Fig. 794), The cervix is then pushed backward (Fig,

PESSARV THERAPY.

Fio. 795.— Second raethod of repladng a letroverted uterus. Thlrd slep. (Kelly and

Noble,)

Fio. 7q6. — Replacemetil of a poslcrior uterine displacement in Ihe knee-chest poùlìon.
Showing the cervii drawn forward and the fundus swinging clear of the promonlury.
Illusiration a ahows the fundus pushed anteriorly by direct pressure. (Ashton.)

742 THE FEUALE GENERATIVE 0RGAM5.

795), the bullet forceps are removed, and reposition is completed
bimanually as described above.

If these manipulations fail, the patient shouid be placed in the
knee-chesl posture and the posterior vaginal walI retracted by means
of a Sims or Simon sfyeculum. This frequeatly results in the utenis
falling forward through the effect of gravity. If it does not, the cer\-ìx
shouid be grasped with bullet forceps and pulled downward, whiie the
fundus is pushed forward by means of a pair of dressing forceps armed
with a pledget of cotton carried up into the posterior cul-de-sac (Fig,
796). The patient is then slowly and carefully tumed to the dorsal
position, and a bimanual examination is made to determine if the
the uterus ìs stili in position before a pessary is inserted.

Fio. 797. — First step in intioduÒDg a retroversion pessary.

In ali manipulations toward replacement of a uterus, the utmost
genikness shouid he employed. If the patient is very sensitive or the
abdominal walls rigid, it is preferable to give a general anesthetic
rather than employ force.

2. Introduction of Pessaries. — To inserì the ordinary retroversion
pessary, the left index-finger is carried mto the vagina and the vaginal
wall is retracted, while with the right hand, the pessary is ìntroduced
at first obliquely (Fig. 797), and then turned so that it lies
transversely in the vagina (Fig. 798). The index-finger of the left
hand is then shifted so that it lies under the anlerior bar with its tip

PE5SASY THEKAFY. 743

resting upon the posterior bar (Fìg. 799). The posterior bar is then
pressed downward and backward until it lies behind the cervix (Fig.
800). After the pessary has been introduced, the patient is examined
while in the erect position to see i£ it fits properly. A properly fìtting

Fio. 79S. — Showing the peaury in the vagin» with the posterior bar ii
cervix. (AihtoD.)

Fio. Tqf). — Second step in introducìng a retroveràon pessaiy, depressing the posterior
bar and inserling il behind the cervix. (Ashton.)
Fio. 800. — Showing the rettovetuon pessaiy in place. (Aahton.)

pessary shouid hold the utenis in place and at the same time shouid
not be so tight that the examining finger cannot be passed between the
vagina! walls and the pessary on ali sides.

744 1^^ FEICALE GENERATIVE ORGANS.

The ring pessary is ìntroduced in much the same way, that is, the
left indei-finger retracts theposteriorvaginal wall while with thefingers
of the right hand the jressary is ìntroduced obliquely into the \'agina
(Fig. 8oi), It is ihen tumed transversely and is manipulated by the

FiG. 8oi. — Fitai atep in iniiodudng a ring pessaty.

Fio. 8oi. — Shous the ring pessai^' in place.

internai fingers until it lies in proper position with its opening sur-
rounding the cervix (Fig. 802).

Skene's cystocele pessary is Ìntroduced into the vagina in the same
manner as the rctroverslon pessary, with the posterior bar lying behind

PESSARY THERAPY. 745

the cervix, and the broad anterior bar supporting the bladder (Fig.
803).

Gehrung's cystocele pessary is more difficult to introduce.
The following method is eraployed: The pessary is placed upon a

Fio. 803. — Shoning Skene's pessaiy in plac

Fig. 804. — First step in introducing Gehrung's pessary.

table in such a way that it rests upon its inferior arch, with the
two curves, right and left, facing toward the operator, who then
grasps the curve L between the thumb and forefinger of the right hand,
and inserts curve R into the right side of the vagina (Fig. 804) and then

74^ '^HE FEUALE GENERATIVE ORGAMS.

curve L into the left side. The pessary is then manipulated into such
position, that the superior arch lies up in front of the uterus, the inferior
arch under the pubic arch, and the two curves R and L on the posterior
vagina! wall (Fìg. 805).

After-care.^Within three or four days after introduction of the
pessary, the vagina is inspected te determine whether there is any
erosion from undue pressure of the pessary. The patient is then
examined once every month or six weeks, at which time the pessaiy is
removed and well cleansed before re-insertion and the vagina is exam-
ined for signs of ulceration, which, if present, necessitate the removal

Fio. S05. — GehruQg's pessary in poùtion.

of the pessary and the substìtution of medicated tampons until healing
has been effected. Once a week and after each menstntal period the
patient shouid take a warm borie acid or soapsuds douche for cleansing
purposes, while, if there is irritation from the presence of the pessary,
a daily douche shouid be administered. In cases where the displace-
ment is accompanied by considerable uterine congestion and enlarge-
ment, a hot vaginal douche shouid be given night and moming (see
page 715). In ali cases the physicìan shouid impress upon the patient
the necessity of reporting if at any time the pessary causes any pain or
discomfort.

DILATATION OF THE CERVIX.

Dilatation of the cervix, while a small operation, is one of consider-
able importance, as it forms a part of many gynecological procedures.
Thus it may be required as a preliminary to exptoration of the interior
of the uterus, intrauterine irrigations and applications, curettage, and
to secure sufficient dilatation for the extraction of retained secundìnes

DILATATION OF THE CEEVK.

747

following an incomplete aboition. Dilatation of the cervìx is also
employed for the egre of dysmenorrhea and sterility dependent upon
cervical stenosis. The operation should always be performed under
ali aseptic precautions and after the position of the uterus and the con-
ditioti of the appendages have been first determined by bimanual
examìnation. Pelvic peritonitis, pelvic abscess, pyosalpinx, etc, are
contraindicatìons to dilatation, unless the procedure is to be immedi-
ately foUowed by operative treatment of these conditions.

There are two methods of performing dilatation: (i) Graduai'
dilatation by means of spenge, laminaria, or tupelo tents, and (2)
rapid dilatation. The former method, besides being painful, is no
longer looked upon with favor on account of the dangers of infection
and will not be described.

Fio. 806. — Instrumenis for dìlaiìng the cervut.

t, Garrigues' speculum; a, spenge holder; 3, tenaculum; 4, ulerine sound; 5, Goodell

dilatots; 6, Friucb-Bozeman return flow iirigftlor.

Instruments. — A ^If-retaining speculum, a spenge holder, two
bullet forceps, a uterine sound, two pairs of Goodell's dilators (a
small and a large size), and a Frìtsch-Bozeman return flow ìrrigator
are required (Fig. 806). Some operators prefer to employ graduated
sound dilators, such as Hanks' or Hegar's (Fig. 807), in place of the
giove stretcher form of dilator, as produdng less laceratìon of the
cervical tissue.

Asepsls.— The instnunents are boiied ìn a i per cent, soda solution
for fìve minutes and the operator's hasds are thorougMy cleansed.

748 THE FEMALE GENERATIVE ORGANS.

PoslUon of Patient.— The patient should be in the lithotomy
posture.

Anesfhesia. — While the operation may be performed under locai
anesthesia by infiltrating the cervical tissue with a 0,2 per cent.

Hegar*: gmduated dilatori. (Bandler.)

solution of cocain aad inserting a pledget of cottoti saturated with a
4 per cent, solution of cocain into the cer\'ical canal, general anesthesia
will be found preferable in the majority of cases.

FlG. 80S.— Firsi step ii

dilatalion of the cervix. Th<
by a tenaculum.

Exposed and drawn down

Preparatioiis of Patient.— The bladder and bowels are to be empty.
The hair is shaved or closely cut from the labia and the external
genitais are washed with soap and water followed by a i to 2000

DILATATION Ot THE CERVIX. 749

bichiorid solution. The vagina is then washed with soap and water
by the aid of a swab on a sponge holder and this is followed by a
douche of i to 5000 bichiorid.

Technic. — The speculum is introduced into the vagina and the
anterior cervical lip is seized by bullet forceps and is drawn toward
the vagina! orifice (Fig. 808). The cervix is then swabbed with a
I to 2000 bichiorid solution. A sound ìs next introduced for the pur-
pose of determining the direction of the uterine canai, and this is

important in order to avoìd perforating or otherwise injuring the uterus
with the dilators in case of a retrodisplacement or a sharp anteilexion.
The small size Goodell dìlator is then insertcd into the cervix, carefully
manipulating it past any obstruction from the internai os, but above
ali avoiding the use 0/ any force. With the instrument through the
internai os the dilators are gradually expanded, iirst in one direction
and then, after rotation of the instrument, in another, until a moderate
amount of dilatation has been obtained, when the large size dilator
may be substituted. The dilatation is thus continued, the operator

being guided as to the force he may exert by the amount of resistance
offered by the cervix, until the cervix has been sufficiently stretched
for the purposes of the operation.

At the completion of the operation the uterus is irrìgated tbrough
a Fritsch-Bozeman double-flow tube. Following the operation the

Fio. Sto. — Showing the method of dilating the cervix by meana of the graduated dilators

patient shouid remain in bed three to four days during which tìme
a daily vaginal douche of warm 4 per cent, boracic acid solution or
sterile water is given.

Dilatation by means of the Hegar style of dilator is comparatively
simple. The cervix is exposed and drawn down as above, and then,
beginning with the small ones, successive larger sizes of the dilators

Fio. 811. — Intrauterine stem pessaiy. (Bandler.)

are inserted into the cervix, lubricating each sound with sterile vaselin
before its introduction. In using the smaller sìzed sound great care
must be observed against making a false passage in case any obstruc-
tion is offered by the internai os.

When dilatation is perfonned for sterilìty due to stenosis, some

CURETTAGE. 75 1

operators foUow the operation by introducing into the cervix a. hard-
rubber stem, such as is shown in Fig. 8ii, for the purpose of maintain-
mg the dilatation. The stem is from 22 to 25 French in size and is
provided with a groove upon its lateral walI for the escape of discharges.
It has this objection, however, that it is liable to irritate the cervical
lining.

CURETTAGE.

Curettage, or the scraping of the inner lining of the uterine cavity,
may be performed for the purpose of removing diseased mucosa in
chronic endometritis, for the purpose of obtaining tissue for subsequent
microscopie examination in suspected cancer of the uterus, and as
a preliminary to repair of the cervix and operations upon the uterine
appendages. In puerperal cases the operation is indicated for the
removal of pieces of decidua or placenta retained after labor or follow-
ing incomplete abortions.

The operation is contraindicated in cancer of the uterus except to
obtain tissue for examination and as a preliminary to a radicai operation
and likewise in pelvic peritonitis, pyosalpinx, pelvic cellulitis, ectopie
pregnancy, etc, unless as a preliminary to a laparotomy. Curettage
is dangerous in the presence of submucous fibroids, as sloughing of the
growths may result through injury from the curet. In streptococcus
infections of the utei:us, the operation, if performed at ali, should be
done with caution, as new channels for infection are opened up by the
curet and extension of the process to the deeper tissues is liable to
foUow.

A curettage should always be j>érformed under the strictest asepsis
and with care and gentleness, as a false passage may easily be made
through the wall of the uterus with the curet or dilator; especially is
this liable to happen in septic conditions and in puerperal cases where
the uterine wall is soft. The position of the uterus and the condition
of the adnexa should be ascertained beforehand by means of a bimanual
examination.

Instruments. — ^A Simon or a Garrigues self-retaining speculum,
sponge holders, two bullet forceps, a uterine so\md, a pair of large and
small Goodell dilators, Sims' curets, a Martin curet, a large blunt
curet, placental forceps, uterine dressing forceps, and a Fritsch-
Bozeman retum-flow irrigator will be required (Fig. 812).

Asepsis. — AH the instruments are boiled for five minutes in a i per
cent, soda solution, and the operator's hands are sterilized as for any
operation.

75^ THE FEUALE GENERATIVE ORGANS.

Positìon of Patìent.— The patient shouid be in the lithotomy
posture.

Anestbesla. — General anesthesia is necessary.

Preparatioiis of PaHent.— The bladder and bowels are to be empty.
The hair is shaved or cut from the labia and the exiemal genitais are
washed with soap and water followed by a i to 2000 bichiorid solution.
The vagina is first thoroughly scrubbed with soap and water by means
of a swab on a spenge holder and is then thoroughly douched with a
I to 5000 bichiorid of mercury solution.

Fic. 813. — Instnimenls for cureltage.
I, Carrìgues' weighled apeculum; a, aponge holder; 3, tenacula; 4, uterine sound;5,
Hoodell dilatots; 6, Frìlsch-Bozeman aozr.\e; 7, Sims' curets; 8, Martin's curet; q,
blunt curet; io, placenta! forceps; 11, uterine dressing forceps.

Technic. — i. Nonpuerperal Cases. — The cervix is exposed by
means of the speculum and the anterior or both the anterior and
posterior lips are caught by means of builet forceps and are drawn
well down toward the vulva. The cer\'ix is then wiped with a swab
soaked in a i to 2000 bichiorid solution and, after first determinine
the direction of the canal, the cer^TX is dilated in the manner described
on page 746. The entire uterus is then thoroughly scraped with a
sharp curet of the largest size that will pass through the cervix.
This shouid be done in a systematic manner — for exaniple, beginning
with the anterior wall, the curet is carried to the fundus and is then
withdrawn along the front wall and out of the uterus in one sweep.
Any adherent tìssue is wiped off the curet and the inslrument is

CURETTAGE. 753

reinserted and withdrawn over another section of the aaterìor wall.
The process is repeated until the entire anterior walI has been scraped,
and then the two side walls and the posterior wall are sìmilarly dealt

FiG. 813. — Dilatation and curatile of the utenis. Illustration a shows the endo-
metrìum txjng removcd wilh Sìms' curei; illuslralion b shows the mucous membrane on
the fuadus being removcd with Martin'a cuiet. (AshtOQ.)

Fio. 814. — Shows the uterine canty being swabbed out wilh pure carbolic acid. (Ashton.)

with. A Martin curet is then substituted for the Sims instrument
and the fundus is well scraped. The cavity is then irrigated with
sterile water or norma! salt solution by means of the retum-flow
48

754 "^^^ FEMALE GENERATIVE ORGANS.

catheter in order to remove any débrìs or loose shreds of tìssue, and a
light packing is inserted for a few moments to dry the cavity. The
packing is then removed and the uterine cavity is swabbed with pure
carbolìc acid introduced by means of a cotton swab on dressing forceps
(Fig. 814). In doing this care must be taken not to touch the vagina
with the carbolìc acid and to remove any excess of acid from the
swab before inserting it in the cervix. The vagina is then cleansed,
the bullet forceps are removed from the cervix, and a light vaginal
tampon is placéd in contact with the cervix. The vulva is finally
covered with a gauze pad.

Fio. 815.— Digital curettage of the uterus. (Ashton.)

2. Puerperal Cases. — Unless the cervix is already dilated, it should
be stretched sufficìently to admit one or, if possible, two fingers. The
operator then inserts the index and middle fingers or, if this is not possi-
ble, the index-finger of the right band into the uterus and, while counter-
pressure is made over the fundus with the left band, he thoroughly
explores the cavity and separates any retained material by means of
the internai fingers (Fig. 815). Large pieces of tissue thus loosened
may be then removed by means of placenta! forceps. The cavity of
the uterus is then irrigated with norma] salt solution or with sterile
water and is lightly scraped with a large dull curet. In doing this
great care and gentleness are necessary to avoid perforatìng the ut^us.

CURETTAGE. 755

Sharp curets shotdd never be employed in paeperal cases. After a
final exploration with the finger the cavity is again irrigateci and the
operation is concluded by cleansing the vagina and covering the vulva
with a sterile gauze pad secured in place by a T-bandage. Only in
cases where the operation is accompanied by severe bleeding or where
it is desired to introduce contraction in a flabby organ is it necessary to
pack the uterus (see page 629). If this is done, the packing should be
removed in twenty-four hours.

After-care. — The vagina should be douched daily with a i to 5000
warm bichlorid solution followed by sterile water or normal salt
solution. In cases of curettage for simple endometritis the patient
may be allowed out of bed within a week, in other cases the duration
of the stay in bed will depend upon the condition of the patient.

INDEX

Abdomen, aspiration of, 265
auscultation of, 691
inspection of, 686
mensuration of, 691
palpation of, 687
percussiòn of, 689
Absorption power of the stomach, Penzoldt
and Faber's test of, 448
test of the bladder, 609
Accessory sinuses, anatomy of, 276
lavage of, 305
probing, 289
transillumination of, 292
skiagraphy of , 294
Accidents durìng anesthesia and their

treatment, 56
A. C. E. general anesthetic mixture, 49
Acid intoxication, 63
Acoin, 72

Active hyperemia, 194
Acupuncture, 159
in muscular rheumatism, 160
in neuritis, 161
Administration of antisenim in cerebro*
spinai meningitis, 253
of antitetanic senim, 253
of chloroform by the drop method, 37

by the vapor method, 39
of dìphtheria antitoxin, 149
of ether by the closed method, 32
by the drop method, 30
by the semiopen method, 32
by the vapor method, 33
of ethyl chlorid, 48
of general anesthetics, 17
of nitrous oxid gas, 42
and ether, 46
and oxygen, 44
Adrcnalin chlorid as an aid to locai
anesthesia, 73
and saline solution in shock, 128
Advantages and disadvantages of locai
anesthesia, 67

After-effects of general anesthetics, 62

treatment of cases of general anesthe-
sia, 64
Air-bag, Politzer's, 333

hot, IQ4

inflation of the colon with, 493, 517
of the stomach with, 439
Albarran's cystoscope, 653

experimental polyuria test, 673
Albuminous expectoratìon after aspiration

of the chest, 262
Allis' ether inhaler, 27
Allport's ear syringe, 340
Alypin, 70

Anal canal, anatomy of, 475
inspection of, 479
palpation of, 480
Anastomosis, blood-vessel, 119, 124
Anatomy of the accessory sinuses, 276

of the anal canal, 475

of the bladder, 593

of the ear, 317

of the esophagus, 403

of the ethmoid sinus, 277

of the Eustachian tubcs, 321

of the f emale urethra, 530

of the frontal sinus, 277

of the kidneys, 642

of the larynx, 353

of the male urethra, 527

of the maxillary sinus, 276

of the nose, 273

of the prostate, 530

of the rectum, 474

of the sphenoid sinus, 277

of the stomach, 427

of the trachea, 355

of the ureters, 644

of the uterus and appendages, 679

of the vagina, 679
Anesthesia, arterial, 98

chloroform 34

ether, 24

757

7S8

INDEX.

Anesthesia, ethyl chlorìd, 46
general, 17

accidents durìng, 56
A. C. E. misture for, 49
acid intoxication from, 63
after-effects of, 62
after-treatment following, 64
asphyxìatìon from, 57
Billroth's mixture for, 49
cardiac paralysis during, 60
C. E. mixture for, 49
delayed poisoning from, 63
mixtures for, 49
mortality from, 17
postoperative palàes following, 63
preparations of patient for, 18
renai compHcations of, 63
respiratory complications of, 63

paralysis durìng, 60
Schleich mixture for, 49
stages of, 22
vomiting from, 6a
infìltration, 76
intubation, 50
locai, 66
adrenalin chlorìd as an aid to, 73
advantages and disadvantages of, 67
by endo- and perìneural infiltration, 81
by freezing, 75
by infiltration, 76

by surface application of anesthetics, 7 5
conduction of an opecation under, 73
ethyl chlorìd in, 75
drugs used for, 71
in abdominal operations, 89
in hernia operations, 89
in operations on the bladder, 76

on the eyes, 75

on the face, 84

on the head, 83

on the larynx, 85

on the lips, 84

on the lower extremity, 99
jaw, 84

on the mouth, 85

on the neck, 85

on the nose, 76

on the penis, 91

on the rectum, 92

on the scalp, 83

on the scrotum, 91

on the thorax, 86

on the tongue, 85

Anesthesia, locai. In operations on the
upper extremity, 86
on the urethra, 76, 91
methods of producing, 70
preparations of patient for, 70
Schleich mixtures for, 72
suitable cases for, 68
limibar, 99
nitrous oxid, 39
and ether, 44
and oxygen, 44
rectal, 53
regional, 71

scopolamin-morphin, 55
spinai, 99
subarachnoid, 99
terminal, 71
tracheal, 52
venous, 95
Anesthesin, 72 ^

Anesthetic mixtures, 49
Anesthetics, general, administratìon of, 17

locai, 71
Anesthetist's supplies, 22
Anesthol, 49

Ankle-joint, exploratory puncture of, 246
Anterìor crural nerve, cocainization of, 92
rhinoscopy, 281

tibial nerve, cocainization of, 95
Antiserum, administration of, in cerebro-

spinal meningitis, 253
Antitetanic serum, administration of, 253
Antitoxin, diphtherìa, administration of, 149

syringes, 150
Anus, dilatation of, 482
inspection of, 479

locai anesthesia in operations on, 92
palpation of, 480
Application of caustics to the bladder, 627
to the ear, 344
to the larynx, 377
to the nose, 301
to the vagina, 7 18
Arterìal anesthesia, 98

infusion of salt solution, 137
Crile'smethod, 138
Dawbam's method, 139
Artifidal leech, 175
respiration, 58
sera for infu^on, 1 29

Hare's formula for, 129
Hayem 's formula for, 130
Locke *s formula for, 130

INDEX.

759

Artificial sera, Ringer's fonnula for, 129

Szumann's fonnula for, 130
Ascìtes, aspiration of abdomen for, 265
Asphyxiation durìng general anesthesia, 57
Aspirating bulb, Boas*, 443

syringe, 231

trocat, 255, 266
Aspiration of abdomen in asdtes, 265

of bladder, 639

of peiicardium, 263

of perìtoneal cavity, 265

of pleura, 254

of stomach contents, 447

of tunica vagìnalis, 270
Aspirator, bottle, for stomach contents,

443
Connell's beat vacuum, 257

Dieulafoy, 256

Potain, 255

syphonage, 258

Atomizer, Davidson, 299

DeVilbiss, 299

Whitall Tatum, 299

Aural stethoscope, 333

Speculum, Boucheron*s, 324

electric lighted, 324

Gruber's, 324

Toynbee 's, 324

Auriculotemporal nerve, cocsdnization of,

Auscultation of abdomen, 691

of esophagus, 405

of stomach, 436
Auto-irrigation of bladder, 626

-massage, 524
Automatic scarifìcator, 167
Autoscopy, 367

Bacteiìological examination, coUection of
blood for, 222
coUection of discharges and secretions
for, 210
from an abscess cavity, 214
from the eyes, 215
from the nose and accessory sinu-

ses, 214
from urethra, 215
from uterus, 316
from vagina, 216
Bandage, elastic, for passive hyperemia,

183
Bellocq's cannula, 314

Bennett's gas and ether inhaler, 45

Bermingham nasal douche, 295
Bicoudé catheter, 630
BierhoflTs cystoscope, 653
Bier's active hyperemia, 194
passive hyperemia, 177

in diseases of nose and accessory

sinuses, 311
in gynecology, 732
venous anesthesia, 95
Billroth's esophageal sound, 421
general anesthetic mixture, 49
Bimanual palpation of bladder, 603

of pelvic oigans, 696
Binnafont inethod of catheterìzing the

Eustachian tubes, 338
Bivalve rectal speculum, 703

vaginal speculum, 483
Bladder, anatomy of, 593
application of caustics to, 627
aspiration of, 639
auto-irrigation of, 624
bimanual palpation of, 603
capacity of, 593
catheterization of, 628, 635
cohtinuous catheterization of, 636-
cystoscopic examination of, 610, 615
inspection of, 601
instillations for, 626
irrigation of, 620
palpation of, 602
percussion of, 601
sound, Thompson's, 604
sounding, 604
Blake's ear syringe, 340
Bleeding, 161
Blocking nerves, 83

Blood, coUection of, for bacterìological
examination, 220
for microscopical examination, 217
cryoscopy of, 672
freezing-point of, 673
pressure, determination of, 106
diastolic, 107
normal, 106
systoUc, 106

variations of, in disease, iii
in health, 107
àgnificance of, in urine, 599

in vomitus, 429
smears, method of making, 218
transfusion of, 114
Blood- vessel anastomosis, 119, 124
Boas' aspirating bulb, 443

760

INDEX.

Boas' rectal electrode, 525

tube for esophageal lavage, 416
Boas-Ewald test breakfast, 440
Bodenhamer's doublé current rectal irriga-

tor, 503
Bodìne's fonnula for cocain and salt

solution, 72
Bottle aspirator for extracting stomach

contents, 443
Boucheron*s ear speculum, 324
Bougìes, esophageal, 406, 420

Eustachian, 347

filiform, 539, 582

rectal, 490, 520

urethral, 539, 581

Wales', 490, 520
Bougìes à boule, esophageal, 406
rectal, 491
urethral, 547
Boxes, hot-air, 195
Brachial plexus, cocainization of, 86
Braun's vapor inhaler, 36
Brenner*s cystoscope, 652
Brewer's methodof transfusion, 122

transfusion tubes, 122
Bronchoscope, Jackson's, 368

Killian's 368
Bronchoscopy, lower, 373

upper, 372
Brown's cystoscope, 652, 653
Buerger's cystoscope, 653

transfusion cannula, 117

Calculi, renai, X-ray in detection of, 674

ureteral, X-ray in detection of, 674

vesical, X-ray in detection of, 620
Caliber of urethra, 529
Cannula, Bellocq's, 314

Buerger's transfusion, 117

Crile's transfusion, 117

Elsberg's transfusion, 123

Hahn's tracheal, 52

Trendelenburg's tracheal, 52
Cannon ball for abdominal massage, 524
Capacity of bladder, 593
test of, 607

of stomach, 428
Cardiac massage, 61

paralysis during anesthesia, 60
Carotid artery, infusion of adrenalin and

salt solution into, 138
Carrel's method of transfusion, 124
Casper's cystoscope, 653

Catheterìzation, continuous, of bladder, 639
of Eustachian tubes, 335

Kramer or Binnafont method, 338
Ldwenberg method, 335
of f emale bladder, 635
of male bladder, 628

in presence of hypertrophy of the

prostate, 634
in presence of strictures, 633
of ureters, 652, 661
direct view method, 655
indirect view method, 657
Catheter, bicoudé, 630
coudé, 529
Eustachian, 336
f emale, 635

Gouley's tunneled, 629
Guyon's mandarìn coudé, 629
Malecot retention, 637
Nélaton, 629
Pezzer, 637
prostatic, 629
retained, 637
Silver, 629
ureteral, 653, 662
wax-tipped, 654, 662
whip, 630
Caustics, application of, to bladder, 627
toear, 344
to larynx, 377
to nose, 301
to urethra, 573
C. E. general anesthetic mixture, 49
Cerebrospinal fluid, normal, 252
pathological changes in, 252
meningitis, administration of antiserum

in» 253
pressure, 252
Cervical plexus, cocainization of, 85
Cervix, dilatation of, 746

scarifìcation of, 734
Chamberlain 's intrauterine douche nozzle,

723
Chapin's urine coUector, 225

Chetwood's urethral irrìgating nozzle, 565

urethroscope, 552

Chloroform, administration of, by drop

method, 37

by vapor method, 39

anesthesia, 34

suitable cases for, 35

delayed poisoning from, 63

efifects of, on blood, 35

INDEX.

761

Chloroform inhalers, 35

mortality rate of, 17

physiological action of , 34
Chromic acid, method of fusing on a

probe, 303
Clamp, Crile's, 117

Lévinas transfusion, 123
Cleansing enemata, 498.
Closed method of admìnistcrìng ether, 32
Clover's ether inhaler, 27
Coakley's transilluminator, 292
Cocain, 71

Bodine's formula for, 72

Schleich formula for, 72

Solutions, preparations of, 72
sterìlization of , 7 2

surface application of, 75
Cocainization of the anterior crural nerve

93
tibial nerve, 95

of the auriculotemporal nerve, 83

of the brachial plexus, 86

of the cervical plexus, 85

of the digitai nerves, 89

of the extemal cutaneous nerve, 93

of the f rontal nerve, 83

of the genitocrural nerve, 90

of the great aurìcular nerve, 83

occipìtal nerve, 83

sciatic nerve, 93
of the iliohypogastrìc nerve, 90
of the ilioinguinal nerve, 90
of the inferior dentai nerve, 84
of the infraorbital nerve, 84
of the intercostal nerve, 86
of the linguai nerve, 85
of the median nerve at the wrist, 88

in the arm, 87
of the mcntal nerve, 84
of the musculospiral nerve, 87
of the posterior tibial nerve, 95
of the radiai nerve, 88
of the small occipital nerve, 8^
of the spinai cord, 99
of the superior laryngeal nerve, 85
of the supraorbital nerve, 83
of the temporomalar nerve, 83
of the ulnar nerve al the wrist, 88
in the arm, 87
Collection and preservation of pathological

material, 199
of blood for bacterìological examination,
222

Collection of blood for microscopical ex-
amination, 217
of discharges and secretions for bacterìo-
logical examination, 211
from an abscess cavity, 214
from the eyes, 215
from the nose and accessory sinuses,

214
from the urethra, 215
from the uterus, 216
from the vagina, 216
of feces, 226
of sputum, 224
of stomach contents, 226, 442
of urine, 225
Colon, inflation of, 493, 517
irrìgation of, 501
massage of, 522
tube, 498
Composition of the gastric juice, 440
Connell 's aspirator, 257
Constipation, electro therapy in, 524
Continuous catheterization of bladder, 636
dilatation of esophageal strictures, 423
of urethral strictures, 590
Coudé catheter, 629
Crile's clamps, 117
method of intraarterial infusion, 138

of transfusion, 119
transfusion cannula, 117
Croup kettle, 380
Cryoscopy of blood, 672

of urine, 672
Cup and ring pessary, 737
Cupped sound, 571
Cupping, 170
dry, 172
wet, 173
Cups for abstracting blood, 171

for passive hyperemia, 189
Curetment, test, 229, 712
Curettage, 751
Curves of urethra, 529
Cystoscope, Albarran's, 653
BierhofiTs, 653
Brenner's, 652
Brown's 652, 653
Buerger's, 653
Casper's, 653
direct view, 652
EIsner's, 652
indirect view, 653
Kelly 's f emale, 615, 661

762

INDEX.

Cystoscope, Lewis', 627, 652, 653

Luys' open tube, 617

McCarthy's, 653

Nitze's, 611, 653

Otis*, 611

Schapira's, 611
Cystoscopic treatment, 627
Cystoscopy in the f emale, 615

in the male, 610

Davidson atomizer, 299

Dawbam*s method of intraarterial infu-

sion, 139
Deglutible stomach bucket, Einhom's, 447

electrode, Einhom's, 472
Deglutition sounds, 405, 437
Delayed chloroform poisoning, 63
Dench*s vaporizer, 345
DeVilbiss atomizer, 299
Diastolic blood pressure, 107
determination of, 11 1
Dieulafoy aspirator, 256
Digital nerves, cocainization of, 88
palpation of anal canal, 480
of nasopharynx, 291
of pelvìc organs, 694
of rectum, 480
of uterine cavity, 7 io
Dilatation, continuous, of esophageal
strìctures, 423
of urethral strìctures, 590
of anus, 480
of cervix, 746

of esophageal strìctures, 418
of Eustachian tubes, 347
of female urethra, 559
of rectal strictures, 519
of rectum, 480
of ureteral strìctures, 677
of urethral strìctures, 579
Diphtherìa antitoxin, administration of,
149
after-effects of, 151
Direct applications to the ear, 344
to the larynx, 377
to the nose, 301
to the vagina, 718
laryngoscopy, 364
tracheo-bronchoscopy, 367
lower, 373

upper. 372
view cystoscopes, 652

view method of catheterìzing uretere, 655

Doublé current catheter, 621

rectal irrìgator, Bodenhamer's, 503

Kemp's, 503

Tuttle's, 503
uterine irrigator, Fritsch-Bozeman's,

723
Talley's, 724

Douche, hot-air, 196

intrauterine, 723

nasal, 294

stomach, 462

vaginal, 715
Drainage in edema of the lower extremities,

168
Drop method of administerìng chloroform,

37
ether, 30

of infusing salt solution into rectum, 510
Drum membrane, anatomy of, 319

determination of mobility of, 328

indsion of, 349

inspection of, 324

massage of , 348
Dry cupping, 17 2
inhalations, 383
Duck-bill rectal speculum, 483

Ear, anatomy of, 317
application of caustics to, 344
inspection of, 324
instillations for, 342
speculum, Boucheron's, 324
electric lighted, 324
Gniber's, 324
Toynbee's, 324
syringe, AUport's, 340

Blake's, 340
syringing the, 339
Exiema, acupuncture for, 159
of glottis, scarification in, 168
of lower extremities, drainage in, 168
Einhom's esophagoscope, 412
gastrodiaphane, 449
stomach bucket, 447
douche, 463
electrode, 472
Elastic bands for passive hyperemia, 183
Elbow-joint, exploratory puncture of, 245
Electrotherapy in constipation, 524

in diseases of the stomach, 470
Elsner's cystoscope, 652
Elsberg's method of transfusion, 124
transfusion cannula, 123

INDEX.

763

Endo and perìneural infiltradon, 81
Enematai cleansing, 498

medicated, 497

nutrìent, 514

puigative, 499

saline, 508
Enterocljrsis, 501

with doublé tube, 507

with single tube, 506
Epistaxis, tamponing the nose for, 312
Epsom salt for spinai anesthesia, 100
Erect posture for gynecological examina-

tions, 686
Esmaich bandage for passive hyperemia,

183

inhaler, 26
Esophageal bougies, 406

bougies à boule, 406

lavage, 416

sounds, Billroth's, 421
Schreiber's, 421

strìctures, dilatation of, 418

tube, Symonds, 424
Esophagoscope, Einhorn's, 4x2

Jackson's, 412

Mikulicz's, 412
Esophagoscopy, 412
Esophagus, anatomy of , 403

auscultation of, 405

dilatation of strìctures of, 418

intubation of, 423

lavage of, 416

normal constrìctions of, 403

palpation of , 405

percussion of, 405

skiagraphy of, 416
Estimation of the urethral length, 550
Ether, administration of , by closed method,

by drop method, 30
by semiopen method, 32
by vapor method, ^^
anesthesia, 24

suitable cases for, 25
blood changes from, 25
inhalers, 26
mortality from, 17
physiological action of , 24
Ethmoid sinuses, anatomy of, 277
Ethyl chlorìd, administration of, 48
anesthe^a, 46

suitable cases for, 47
as a locai anesthetic, 75

Ethyl chlorìd inhalers, 47

mortality from, 17
Eucain B, 72

in spinai anesthesia, 100
Eustachian bougies, 347
catheters, 336
tubes, anatomy of, 321
catheterization of, 335
dilatation of strìctures of, 347
inflation of, by catheter, 335
by Politzer*s method, $^^
by Valsalva*s method, 332
with medicated vapors, 345
medication of, 346
Ewald-Boas' test breakfast, 440
Ewald's salol test, 448
Expectoration, albuminous, 262
Ezperimental polyuria test, Albarran's, 673
Exploratory indsion for inspecting the
kidney, 675
for palpating the pel vie organs, 712
laparotomy, 456
punctures, 230
of ankle-joint, 246
of elbow-joint, 245
of kidneys, 243.
of knee-joint, 245
of liver, 241
of lungs, 237
of perìcardium, 238
of perìtoneal cavity, 240
of pleura, 233
of shoulder-joint, 245
of spinai canal, 246
of spleen, 242
Expression of stomach contents, 447
Extemal cutaneous nerve, cocainization

of, 92
Extraction of stomach contents by aspira-

tion, 447
Extubation, 391
Extubator, O'Dwyer's, 385

False passages from urethral instrumenta-

tion, 590
Feces, coUection of, for examination, 226
Female catheter, 635

generative organs, anatomy of, 679
methods of examining, 681
therapeutic measures, 715

urethra, anatomy of, 530
Feeding by gavage, 465

by rectum, 514

764

INDEX.

Feeding, intubation cases, 390
Filiform bougies, esophageal, 420

urethral, 539, 582
Fingers, locai anesthesia in operations on,

88
Fluid, cerebrospinal, normal, 252

pathological varìationa in, 252
Fluorescein in gastrodiaphany, 450
Formalin sterìlizer, 540
Freezing, locai anesthesia by, 75
point of blood, 673
of urine, 673
Fritsch-Bozeman douche nozzle, 723
Frontal nerve, cocainizatìon of. 83
sinus, anatomy of, 277
lavage of, 309
probing, 289
skiagraphy of , 294
transillumination of, 292
Functional capacity of the kidneys, deter-
mination of, 671
by cryoscopy, 67 2
ezperìmental polyuria test for, 673
indigo-carmin test for, 67 2
methylene-blue test for, 672
phlorìdzin test for, 672
urea test for 67 2
Fusing chromic add on a probe, 303
Silver nitrate on a probe, 303

Galton 's whistle, 330
Gastrìc juice, composition of, 440
Gastrodiaphany, 448
Gastrodiaphane, Einhom's, 449

Lynch *s, 449
Gastroscope, Jackson *s, 451
Mikulicz's, 451
Rosenheim's, 451
Gastroscopy, 450
Gavàge, 465
Gehrung's pessary, 737
General anesthesia, 17

accidents during, 56

A. C. E. mixture for, 49

acid intoxication from, 63

after-effects of, 62

after-treatment following, 64

asphyxiation from, 57

Billroth 's mixture for, 49

cardiac paralysis durìng, 60

C. E. mixture for, 49

delayed poisoning from, 63

mixtures for, 49

General anesthesia, mortality from, 17
postoperative palsies following, 63
preparation of patient for, 18
renai complications of, 63
respiratory complications of, 63

paralysis durìng, 60
Schleich mixture for, 49
stages of, 22
vomiting from, 62
anesthetics, administration of, 17
Genitocrural nerve, cocainization of. 90
Glass catheter, f emale, 635
test, two, 532
three, 533
Glasses, cupping, for abstracting blood,
171
for passive hyperemia, 189
Goodell speculum, 703
uterine dilators, 747
Gouley tunneled catheter, 629

sound, 582
Great auricular nerve, cocainization of, 83
occipital nerve, cocainization of, 83
sciatic nerve, cocainization of, 93
Gruber's ear specula, 324
Gwathmey 's gas and ether inhaler, 44
nitrous oxid gas and oxygen inhaler, 42
vapor apparatus, 28
Gynecological examination, 681

postures, 684
Gynecology, Bier*s hypercmic treatment

in, 732
Guyon's mandarin coudé catheter, 629

Hahn's tracheal cannula, 52
Hanks' uterine dilators, 747
Hare's formula for arrifìcial scrum for

infusions, 129
Harris' segregator, 667
Hartmann 's tuning forks, 330

vaporizer, 345
Hartwell's method of transfusion, 122
Hayem's formula for artifìcial serum for

infusions, 130
Hays' pharyngoscope, 286
Head, locai anesthesia in operations on, S$

passive hyperemia of, 187

lamp, electric, 280
Kirstein's, 365
Hearing tests, 329
Heart massage, 61

Heat vacuum aspirator, Connell *s, 257
Hegar's uterine dilators, 747

INDEX.

765

Hemolysis and transfusion, 1 16
Hemorrhage, tamponing nose for, 312
Hernia, locai anesthesia in operations

l'or, 89
Hewitt 's gas and ether inhaler, 44
nitrous oxid gas inhaler» 40

and oxygen inhaler, 41
High tracheotomy, 397
Hodge pessary, 736
Hodge-Smith pessary, 736
Hot air, active hyperemia by, 194
boxes, 195
douche, 196
Hyoscin-morphin anesthesia, 55
Hyperemia, active, 194
passive, 177
by cups, 188
by elastic bands, 183
in diseases of the nose and sinuses, 311
in gynecology, 732
Hypodermìc injection of drugs, 144

syringes, 144
Hypodermoclysis, 140
Hydrocele, aspiration and injection of, 270

Iliohypogastric nerve, cocainization of, 90
Ilioinguinal nerve, cocainization of, 90
Illumination for rhinoscopy, 278
Imago, laryngeal, 361

rhinoscopic, 284
Improvised tracheotomy tube, 395
Incision, exploralory, for inspecting the
kidneys, 675
for palpating the pelvic organs, 712
in diseases of the stomach, 456

of dnim membrane, 349
Indigo-carmin test of the functional

capacity of kidneys, 672
Inferior dentai nerve, cocainization of, 84
Infìltration anesthesia, 76

endo- and perineural, 81
Infiltrator, Matas*, 78

Morrow's, 78
Inflation of colon for diagnostic purposes,

493
in intussusception, 517

of middle ear, 332, 345

by Politzer's method, $$$

by Valsalva's method, 332

through a catheter, 335
of stomaA, 437

with air, 439

with carbonic acid gas, 438

Infraorbital nerve, cocainization of, 84
Inf usions of physiological salt solution, 1 27
intraarterial, 137
intravenous, 130
rectal, 508

by drop method, 510
subcutaneous, 140
Inhalations, dry, 383

steam, 380
Inhaler, Allis' ether, 27, 48
Clover^s ether, 27
Bennett's ether, 27

gas, 40

gas and ether, 44
Braun's vapor, 36
Esmarch chloroform, 26, 36, 48
Gwathmey's gas and ether, 44

gas and oxygen, 42

vapor, 28
Hewitt's gas and ether, 44

nitrous oxid gas, 40

nitrous oxid gas and oxygen, 41
Junker's vapor, 36
Pedersen's gas and ether, 44
Schimmelbusch chloroform, 26, 36, 48
Skinner's chloroform, 36
towel, 28, 36
Ware^s ethyl chlorid, 48
Injection of air and fluids into the bowels

in intussusception, 517
test for urethral pus, 534
Injections, hypodermic, 144
intramuscular, 144
urethral, 560
Inspection of abdomen, 686
of anus, 479
of bladder, 601

through a cystoscope, 610, 615
of drum membrane, 324
of ear, 323

of esophagus through esophagoscope, 412
of kidneys, 645

of larynx by the laryngoscope, 357
of nasopharynx by Hay's pharyngo-
scope, 286

by rhinoscopic minor, 283
of nose, 278
of rectum, 479

through proctoscope, 483
of stomach, 430

by means of a gastroscope, 450
of trachea, 357
of urethra in f emale, 534

766

INDEX.

Inspectìon of urethra in the female by the
urethroscope, 558
in male, 534

by the urethroscope, 551

of vagina, 692
Instillation syrìnge, Keyes-Ultzmann, 569,

626
Insti liations for bladder, 626

for ear, 342

for urethra, 568
Insufflations for the larynx, 379

for the nose, 303

for the vagina, 719
Insufflator, laryngeal, 380

nasal, 303
Intercostal nerves, cocainization of, 86
Intraarterìal infusion of salt solutions, 137
Crile's method, 138
Dawbam's method, 139
Intramuscular injection of drugs, 144
Intrauterine applications, 727

douche, 723

tampons, 729
Intravenous infusion of salt solutions, 130
Intubation anesthesia, 50

of esophagus, 503

of larynx, 383

tubes, O'Dwyer's, 385
Intubator, O'Dwyer's, 385
Intussusception, injection of air and fluids

in, 517
lodipin test of motor power of stomach, 448
Irrigations, bladder, 620

colonie, 501

ear, 339

intrauterine, 723

nasal, 294

rectal, 501

urethral, 564

vaginal, 715
Irrigator, bladder, 621

doublé flow rectal, 503
urethral, 565
uterine, 723
Ivers^n's apparatus for proctoclysis, 511

Jackson 's bronchoscope, 368

esophagoscope, 412

gastroscope, 451

laryngoscope, 365
Janeway's sphygmomanometer, 108
Jaw, method of holding forward dudng

anesthesia, 31

Joints, ezploratory puncture of, 244
Junker 's chloroform inhaler, 36

Kelly *s female cystoscope, 616, 661

method of coUecting urine from ureter
without a ureteral catheter, 665

proctoscope, 484

sigmoidoscope, 484

sphmcteroscope, 483

ureteral catheter, 663
searcher, 616, 662

urethral dilator, 558, 617, 662

urethroscope, 558

urine evacuator, 617, 662
Kemp's doublé flow rectal irrigator, 503

rectal electrode, 525
Kettle, croup, 380
Keyes-Ultzmann instillation syringe, 569,

626
BCidneys, anatomy of, 642

exploratory puncture of, 243

inspection of, 645

palpation of, 646

percussion of, 650

position of, 642

relations of, 643
Killian's bronchoscope, 368

laryngoscope, 365
Kirstein's head light, 365

tongue depressor, 365
Klotz urethroscope, 553
Knee-chest posture for gynecological exam-
inations, 685
for rectal examinations, 478
Knee-joint, exploratory puncture of, 245
Kramer's method of catheterizing Eusta-

chian tubes, 338
Kuhn 's mask, 181

Laparotomy, exploratory, 456
Laryngeal image, 361

insufflator, 380

mirror, 358

probe, 374
Laryngoscope, Jackson*s, 365

Killian's, 365
Laryngoscopy, 357

direct, 364
Laryngotomy, 396
Larynx, anatomy of, 353

anesthesia of, 85

application of caustics to 377

direct applications for, 377

INDEX.

767

Larynx, dry inhalations for, 383

inspection of, 357

insufflations for, 380

intubation of, 383

palpation of, by the probe, 374

skiagraphy of, 375

steam inhalations for, 380
Lavage of esophagus, 416

of frontal sinus, 309

of maxillary sinus, 305

of sphenoidal sinus, 311

of stomach, 457
Leech, artifidal, 175
Leeching, 174

Length of urethra, estimation of, 550
Leube's test of raotor power of stomach,

447
Lévinas transfusion clamp, 123
Lewis' operating cystoscope, 627

universal cystoscope, 653
Linguai nerve, cocainization of, 85
Lithotomy position in recta! examinations,

478
Li ver, exploratory puncture of, 241
Locai anesthesia, 66

advantages and disadvantages of, 67
adrenalin chlorìd as an aid to, 73
by endo- and perìneural infiltration, 81
byfreezing, 75
by infìltration, 76

by surface application of drugs, 75
conduction of operation under, 73
ethyl chlorìd in, 75
drugs uscd for, 7 1
in hemia operations, 89
in operations on abdomen, 89
on bladder, 76
on eyes, 75
on face, 84
on head, 83
on laiynx, 85
on lips, 84
on lower extremity, 99

jaw, 84
on mouth, 85
on neck, 85
on nose, 76
on penis, 91
on rectum, 92
on scalp, 83
on scrotum, 91
on thorax, 86
on tongue, 85

Locai anesthesia in operations on upper
extremity, 86
on urethra, 76, 91
methods of produdng, 70
preparation of patient for, 70
Schleich mixtures for, 72
suitable cases for, 68
anesthetics, 71
application of cocain to mucous mem-

branes, 75
applications to bladder, 627
to ear, 344
to larynx, 377
to nose, 30X
to urethra, 573
to uterus, 727
to vagina, 718
Locke's formula for artifìcial serum for

infusions, 130
Low tracheotomy, 400
Lòwenberg method of catheterizing the

Eustachian tubes, 335
Lower extremity, locai anesthesia in opera-
tions upon, 92
Lower tracheo-bronchoscopy, 373
Lumbago, acupuncture in, 160
Lumbar anesthesia, 99
puncture, 246
as a means of administerìng antitoxic
sera, 253
Lungs, exploratory puncture of, 237
Luys* open tube cystoscope, 617

segregator, 668
Lynch's gastrodiaphane, 449

Malecot catheter, 637

Manual palpation of rectum, 482

Martìn's elastic bandage for passive

hyperemia, 183
Massage, auto, 524

cannon ball for, 524
'colonie, 522
of drum membrane, 348
of heart, 6i
of prostate, 576
of stomach, 468
Matas' massive infiltrator, 78
Maxillary sinus, anatomy of, 276
lavage of, 305
skiagraphy of , 294
transillumination of, 293
McCarthy*s cystoscope, 653
Meatome, Otis', 578

768

INDEX.

Meatotomy, 578
Medicateti enemata, 497
Eustachian bougìe, 348
tampons, 721
Medication, hypodermic, 144
of Eustachian tubcs, 346
of ureters and renai peUis, 675
Median nerve, cocainizationof, atwrist, 83

in arm, 87
Membrane, dram, anatomy of, 319
determination of mobility of, 328
incision of, 349
inspection of, 324
massage of, 348
Mensuration of abdomen, 691
Mental nerve, cocainization of, 84
Method of making a dry blood smear, 220

fresh blood smear, 219
Method of making a smear culture, 2(X)

preparation for microscopical ex-
amination, 199
from eyes, 202

from mouth and pharynx, 201
from nose, 202
from urethra, 203
from uterus, 205
from vagina, 205
a stab culture, 209
a streak culture, 208
of holding jaw forward during anesthesia

of inoculating culture tubes, 207
Mikulicz's esophagoscope, 412

gastroscope, 451
Middle ear, anatomy of, 318
inflationof, 332, 345

\vith medicated vapors, 345
Mirror, head, 279
laryngeal, 358
rhinoscopic, 280
Mixture, A. C. E., 49
anesthol, 49
Billroth's, 49
C. E., 49

Schleich general anesthetic, 49
locai anesthetic, 7 2
Mixtures, anesthetic, 49
Mobility of dram membrane, determina-
tion of, 328
Morphin as a preliminary to general
anesthesia, 19
to locai anesthesia, 71
Morphin-hyoscin anesthesia, 55

Morrow's infìltrator, 78

Mortality from general anesthetics, 17

Motor functions of the stomach, tests

for, 447
Murphy's proctoclysis, 510

rectal specula, 484
Muscular rheumatism, acupuncture in, 160
Muscubspiral nerve, cocainization of, 87

Nares, anterìor, 273
poste rio r, 273
digitai palpation of, 291
inspection of, 283
Nasal douche, Bermingham's, 295
douching, 294
spraying, 299
syringing, 297
Nasopharynx, inspection of, 283

by means of Hays' pharyngoscope, 286
digitai palpation of, 29 r
Ncck band for passive hyperemia, 184
Nélaton catheter, 629
Nerve blocking, 83
Neuritis, acupuncture in, 161
Nirvanin, 72

Nitrous oxid, administration of, 42
and ether, administration of, 46
anesthesia, 44
inhalers, 44
and oxygen, administration of, 44

inhalers, 41
anesthesia, 39

suitable cases for, 40
inhalers, 40
mortality from, 17
physical properties of, 39
Nitze cystoscope, 611, 653
Normal cerebrospinal fluid, 252
salt solution, preparation of, 128
sterilization of, 129
Nose, anatomy of, 273
application of caustics to, 301
douching, 294
inspection of, 278
insufflations for, 303
passive hyperemia in disease of, 311
probing, 288
spraying, 299
syringing, 297
tamponing, 312
Novocain, 72

in spinai anesthesia, 100
Nutrient enemata, 514

INDEX.

769

Obstnictive hyperemìa by the cup, 188
by the elastic ban4, 183

O'Dwyer's intubation instniments, 384

Ointments, application of, to urethra, 571

Orthoform, 72

Ossicles of ear, 3 19

Otis meatomei 578
urethrometer, 549

Otoscope, Siegle's, 328

Otoscopy, 324

Oxygen and chloroform anesthesia, 39
and ether anesthesia, 25
and nitrous oxid anesthesia, 44

Paiate retractor, Wliite's, 285
Palpation of abdomen, 687
of anus, 480
of biadder, 602
of esophagus, 405
of female urethra, 538
of kidneys, 646
of larynx by the probe, 374
of male urethra, 535
of nose by the probe, 288
of prostate, 536
of rectum, 480
of seminai vesicles, 537
of stomach, 432
of uterus, 696
of vagina, 694
of vulva, 694
Paracentesis abdominis, 265
membranae tympani, 349
perìcardii, 263
thorads, 254
tunioe vaginalis, 270
Passive hyperemia, 177
by bands, 183
by cups, 188
in diseases of nose and accessory

sinuses, 311
in gynecology, 732
of head and neck, 187
of shoulder, 187
of testicles, 188
Pathological changes in cerebrospinal fluid,
252
materìal,collectionand preservationof, 199
Pedersen's gas and ether inhaler, 44
Pel vie massage, 733
organs, anatomy of, 679
bimanual palpation of, 696
digitai palpation of, 694

Penzoldt and Faber's test of absorpUon

power of stomach, 448
Percussion of abdomen, 689

of biadder, 601

of esophagus, 405

of kidneys, 650

of stomach, 435
Percutaneous application of electridty to
colon, 525
to stomach, 472
Pericardicentesis, 238
Pericardium, aspiration of, 263

exploratory puncture of, 238
Peritoneal cavity, aspiration of, 265

exploratory puncture of, 240
Pessary, cup and ring, 737

Gehrung's, 737

Hodge's, 736

Hodge-Smith's, 736

ring, 736

Skene's, 737

stem, 750

therapy, 735
Pezzer retained catheter, 637
Pharyngoscope, Hays*, 286
Pharynz, inspection of, 283
Phlebotomy, 161
Phloridzin test for functional capadty of

kidneys, 672
Physiological action of chloroform, 34
of ether, 24
of ethyl chlorid, 46
of nitrous oxid, 39

salt solution, infusions of, 127
Pleura, aspiration of, 254

exploratory puncture of, 233
Pleurocentesis, 254
Pneumatic otoscope, 328

proctoscope, Tuttle's, 484
Poisoning, delayed chloroform, 63
Politzer's air bag, SS3

method of inflating middle ear, 333
Position of kidneys, 642

of stomach, 427

of uterus, 680
Positions for gynecological examination, 684

for rectal examination, 477
Posterior nares, 273
inspection of, 283
palpation of, 291

rhinoscopic image, 284

rhinoscopy, 283

tibial nerve, corainization of, 95

770

INDEX.

Postnasal syringe, 298
Postoperative anesthetic palsies, 63
Potain aspirator, 255
Powder blower, laryngeal, 380
nasal, 303
Sajous, 304
Preparatìon of cocain solutìons, 72
of normal salt solution, 128
of patient for general anesthesia, 18
for gynecological examination, 683
for locai anesthesia, 70
for rectal examination, 477
Pressure, cerebrospinal, 252
Probing the accessory sinuses, 289
the larynx, 374
the nose, 288
Proctoclysis, continuous, 510
Proctoscope, Kelly 's, 483
Murphy's, 484
Tuttle's, 484
Proctoscopy, 486
Prostate, anatomy of, 530
massage of, 576
palpation of, 536
Prostatic catheter, 629
Pulmonary tuberculosis, Kuhn's mask

for, 181
Puncture, exploratory, 230
of joints, 244
of kidneys, 243
of liver, 241
of lungs, 237
of perìcardium, 238
of perìtoneal cavity, 240
of pleura, 233
of spinai canal, 246
of spleen, 242
lumbar, 246
spinai, 246
venous, 222
Purgative enemata, 499
Psychrophore, 575
Pynchon's vaporizer, 345

Radiai nerve, cocainization of, 88
Ransohoff 's method of arterìal anesthesìa,98
Rectal anesthesia, 53

bougie, Wales*, 491, 520

bougie à houle, 491

feeding, 514

infusions of salt solutìons, 508

irrigations, 501

irrìgdtor, Bodenhamer's, 503

Rectal irrìgator, Remp's, 503

Tuttle's, 503 '

palpation of pelvic oigans, 702

of ureter, 650
speculum, bivalve. 483
duck bill, 483
fenestrated biade, 483
Kelly 's, 483
Murphy*s, 484
Sims*, 483
Tuttle's, 484
Strictures, dilatation of, 519
Rectum, anatomy of, 474
digitai palpation of, 480
examination of, by the bougie, 490

by the bougie à houle, 491
inspection of, 479

locai anesthesia in o'perations on, 92
manual palpation of, 482
probing of, 492
structure of, 475
Regional anesthesia, 70
Relations of kidneys, 643

of vagina, 679
Removal of f ragments of tissue for exam-
ination, 226
Renai calculi, X-ray in detection of, 674
complications followìng general anes-
thesia, 63
Replacement of a retroverted uterus, 738
Residuai urine, 609
Respiration, artificìal, 58
Respiratory complications foUowing general
anesthesia, 63

paralysis during general anesthesia, 60
Retention catheter, Malecot's, 637

Pezzer's, 637
Retroverted uterus, replacement of, 738
Revaccination, 159
Rhinoscopic image, 284

mirror, 280
Rhinoscopy, anterìor, 281

posterior, 283
Riegei 's test dinner, 440
Ring pessary, 736

Ringer's formula for artifidal sera, 129
Riva Rocci sphygmomanometer, 107
Rosenheim's gastroséope, 451

Saline enemata, 508
solution, administration of adrenalin
chlorid in, 128
intraarterial infuaon of, 137

INDEX.

771

Saline solution, intravenous infusioh of , 130
preparation of, 128
rectal infusion of, 508
sterìlization of, 129
subcutaneous infusion of, 140
Salol test for motor power of stomach, 448
Sajous' insufflator, 304
Saxon's appaiatus for proctoclysis, 511
Scarìficatìon, 166

of cervix, 734

of glottis, 168

of larynz, 168
Scarìficator, automatic, 166
Schimmelbusch inhaler, 26, 36, 48
Schleich's cocain solutions for locai anes-
thesia, 72

general anesthetic mixture, 49
Sdatic nerve, cocainization of, 93
Sciatica, acupuncture in, 161
Scopolamin-morphin anesthesia, 55
Scrotum, locai anesthesia in operations

upon, 91
Searcher, stone, 604
Segregation of urine, 667
Segregator, Harris', 667

Luys', 668
Seminai vesicles, massage of, 537, 576

palpation of, 537
Semiopen method of administerìng ether, 32
Shock, adrenalin in, 128
Shoulder, passive hyperemia of, 187
Shoulder-joint, exploratory puncture of,

245
Siegle's otoscope, 328

Sigmoidoscope, Kelly 's, 484

Murphy's, 484

Tuttle's, 484

Silver nitrate, method of fusing on a

probe, 303

prostatic catheter, 629

Sims* position, 477, 684

rectal speculum, 483

vaginal speculum, 703

Sinus, ethmoid, anatomy of, 277

frontal, anatomy of, 277

lavage of, 309

probing, 289

skiagraphy of, 294

transìllumìnation of, 292

maxillary, anatomy of. 276

lavage of, 305

skiagraphy of, 294

transillumination of, 293

Sinus, sphenoidal, anatomy of, 277
lavage of, 311
probing, 290
Sinuses, accessory, 276
Skene*s pessary, 737
Skiagraphy of accessory sinuses, 294

of esophagus, 416

of larynx, 375

of renai calculi, 674.

of stomach, 456

of ureteral calculi, 674

of vesical calculi, 620
Skinner's mask, 36
Small occipital nerve, cocainization of,

Smear, blood, method of making, 218
culture, method of making, 209
preparation for microscopical examina-
tion, method of making, 199
from eyes, 202

from mouth and pharynx, 201
from nose, 202
from urethra, 203
from uterus, 205
from vagina, 205
Sounding the bladder, 604

the uterus, 708
Sounds, Billroth's, 421
bladder, 604
cupped, 571
esophageal, 406, 420
Schreiber's, 421
ureteral, 663

wax-tipped, 663
urethral, 539, 581
uterine, 708
Southey's trocars and cannula, 169
Specula, bladder, Kelly's, 615, 661
ear, Boucheron's 324
electric lighted, 324
Gruber's, 324
Siegle's, 328
Toynbee's, 324
nasal, Myles*, 280
rectal, Kell/s, 483
Murphy's, 484
Sims', 483
Tuttle's, 484
vaginal, Goodell's, 703
Sims', 703
Sphenoidal sinus, anatomy of, 277
lavage of, 311
probing, 290

772

INDEX.

Sphincteroscope, Kelly's, 483

Muqshy'Sy 484
Sphygmomanometer, Janeway's, 108
Riva Rocd, 107
Stanton'Sy 108
Sphygmomanometry, 106
Spinai anesthesia, 99
canal, puncture of, 246
cord, cocainization of, 99
Splashing sounds in stomach, 437
Spleen, ezploratory puncture of, 242
Sprays, laryngeal, 376

nasal, 299
Sputum, method of collecting, 224
Squatting posture in g3mecological exami-
nations, 686
in rectal examinations, 479
Stab cultures, method of making, 209
Stages of anesthesia, 22
Stanton's sphygmomanometer, 108
Steam inhalations, 380
Stem pessary, 750
Sterilization of cocain solutions, 72
of saline solutions, 129
of urethral instruments, 539
Sterilizer, formalin, 540
Stethoscope, aural, 333
Stomach, absorption power of, Penzoldt
and Faber's test of, 448
anatomy of, 427
auscultation of, 436
bucket, Einhom's, 447
capadty, 428

contents, collection of, 226, 440
composition of , 440
extraction of, by aspìration, 447
by ezpression, 447
douche, Einhom's, 463
douching, 462
electrode, Bardet's, 472
Einhom's, 472
Stockton's, 472
Wegele*s, 472
electrotherapy in diseases of, 470
inflation of, by air, 439

by carbonio add gas, 438
lavage of, 457
massage of , 468

motor power of, Ewald*s test of, 448
iodipin test of, 448
Leube's test of, 447
palpation of, 432
percussion of, 435

Stomach, position of, 427

skiagraphy of, 456

succussion sounds in, 437

transillumination of, 448

tube, 443, 458
Stovain, 72

in spinai anesthesia, 100
Streak culture, method of making, 208
Strìctures of esophagus, dilatation of, 418

of rectum, dilatation of, 519

of ureter, dilatation of, 677

of urethra, dilatation of, 579
Subarachnoid anesthesia, 99
Subcutaneous drainage in edema, 168

saline infusion, 140
Succussion sounds in stomach, 437
Suction cups for passive hyperemia, 189
Suitable cases for chloroform anesthesia,

35
for ether anesthesia, 25

for ethyl chlorid anesthesia, 47

for general anesthetic mixturcs, 50

for locai anesthesia, 68

for nitrous ozid, anesthesia, 40

Superior laryngeal nerve, cocainization of,

85
Supplies, anesthetist's, 22

Supraorbital nerve, cocainization of, 83

Surface application of locai anesthetics, 75

Symond's esophageal tube, 424

Syphonage aspirator, 258

Syringes, antitoxin, 150

aspirating, 231

ear, 340

hypodermic, 144

nasal, 298

urethral, 561, 569, 574
Systolic blood pressure, 106
Szumann's formula for artificial sera for

infusion, 130

Talley's intrauterine douche nozzle, 724
Tampon, medicated, 721

uterine, 729

vaginal, 719
Tamponing nose for control of hemorrhage,

312
Temporomalar nerve, cocainization of, 83
Terminal anesthesia, 71
Test, Albarran's experimental polyuria, 673

breakfast, Ewald-Boas*, 440

curetment, 229, 712

dinner, Riegei 's, 440

INDEX.

773

Test, Ewald*s, of motor power of stomach,

448
excisions, 228, 712

for absorpdon from bladder, 609

for perception of musical notes, 331

indigo-carmin, for functional capacity

of kidneys, 672
injection, for urethral pus, 534
iodipin, of motor function of stomach,

448
Leube's, of motor function of stomach,

447
meals, 440

methylene-blue, for functional capacity
of kidneys, 672

of absorption power of stomach, 448

of acuteness of hearing, 330

of bladder capacity, 607

of functional capacity of kidneys, 671

of motor power of stomach, 447

of residuai urine, 609

phlorìdzin, of functional capacity of
kidneys, 672

Rinnè's, for deafness, 331

salol, of motor power of stomach, 448

three glass, for urethral pus, 533

two glass, for urethral pus, 532

urea, for functional capacity of kid-
neys, 672

voice, of hearing, 330

watch, of hearing, 330

Weber *s, for deafness, 331
Testicles, passive hyperemia of, by elastic

band, 188
Tetanus antitoxin, administration of, 253
Tornasoli *s urethral ointment applicator,

571
Tongue depressor, Kirstein's, 365
Towel cone, 28, 36
Toynbee 's aural specula, 324
Trachea, anatomy of, 35^

inspection of, 357
Tracheal anesthesia, 52

cannula, Hahn's, 52
Trendelenburg's, 52
Tracheo-bronchoscopy, lower, 373

upper, 372
Tracheoscopy, 357

Tracheotomy, high, 397

low, 400

tubes, 394
Transfusion cannula, Brewer's, 122
Crile's, 117

Transfusion cannula, Elsberg's, 123
Levin's, 123
Buerger's, 117
of blood, Brewer*s method, 122
Carrel's method, 124
Crile's method, 119
Elsberg's, method, 124
Hartweirs method, 122
Transillumination of frontal sinus, 292
of maxillary sinus, 293
of stomach, 448
Transilluminator, Coakley's, 292
Trendelenburg tracheal cannula, 52
Trivalve vagina! speculum, 703
Trocar and cannula for aspirating, 255, 256

Southey*s, 169
Tropacocain, 72

in spinai anestheàa, 100
Tube, colon, 498

for esophageal lavage, Boas% 416
rectal, 498
stomach, 443, 458
Tubes, intubation, 385

tracheotomy, 394
Tunica vaginalis, aspiration of, 270
Tuning forks, Hartmann 's, 330
Tuttle *s protoscope, 484
rectal irrigator, 503

Ulnar nerve, cocainization of, at wrist, 88

in arm, 87
Upper extremity, locai anesthesia in opera-

tions on, 86
Upper tracheo-bronchoscopy, 352
Urea test of functional capacity of kidneys,

672
Ureteral calculi, detection of, by X-ray, 674

catheter, flexible, 662
metal, 663
wax-tipped, 654, 662

catheterization in the female, 66x
in the male. 652

sound, 663
waz-tipped, 663

stricture, dilatation of, 677
Ureters, anatomy of , 644

catheterization of, 652, 661

course of, 644

lavage of, 675

medication of, 675

palpation of, 648
Urethra, anatomy of, 527

application of caustics to, 573

774

INDEX.

Urethra, application of ointments to, 571

caliber of, 529

collectìng dìscharges from, for bacterio-
iogical examination, 215
for mìcroscopical examìnadon, 203

curves of, 529

estimation of length of, 550

false passages of, from instrumenta-
tion, 590

inspection of, 534

locai anesthesia in operation upon, 76, 91

palpation of, 535

sounding of, 538

strìctures of, dilatation of, 579
Urethral bougies, 539, 581
à houle, 547

curet, 574

dilator, Kelly*s, 558, 617

fever, 589

filiforms, 539, 582

injections, 560

instillations, 568
Urethral irrigatìng nozzle, Chetwood's,

565

irrìgations, 564

knife, 574

snare, 575

sounds, hlunt, 539
conical, 581
cupped, 571
douhle taper, 581

strictures, dilatation of, 579

syringes, 561, 569, 574
Urethrometer, Otis', 549
Urethrometry, 549
Urethroscope, Chetwood's, 552

Kelly's, 558

Klou's, 553

Swinhume's, 552
Urethroscopic treatment, 572
Urethroscopy in the female, 558

in the male, 551
Urìnalysis in bladder diseases, 596

in cases for general anesthesia, 20

in kidney diseases, 596, 651
Urine, albumin in, signifìcance of, 598

blood in, signifìcance of, 599

coUection of, for examination, 224
from infants, 225
in presence of incontinence, 225

collector, Chapin's, 22^

color of, 598

cryoscopy of, 672

Urino, eàtimating the quantity of, for
twenty-four hours, 225
the residuai, 609
evacuator, Kelly's, 617, 662
freezing-point of, 673
odor of, 597

pus in, signifìcance of , 600
quantity of, passed in twenty-four

hours, 597
reaction of, 598
specifìc gravity of, 597
transparency of, 598
Uterine dilators, GoodelPs, 747
Hanks', 747
Hegar's, 747
douche, 723

nozzle, Chamberlain's, 723
Frìtsch-Bozeman's, 723
Talley's, 724
sound, 708
tampon, 730
Uterus, anatomy of, 679
applications to, 727

collecting dischaiges from, for bacterì-
ological examination, 216
for microscopical examination, 205
curettage of, 751
digitai exploradon of, 7x0
dilatation of, 746
inspection of, 704
palpation of, 696
position of, 680
sounding of, 708
tamponing, 729

Vaccination, 153
Vagina, anatomy of, 679

application of caustics to, 718

of powders to, 719
collection of discharges from, for bac-
terìological examination, 2 16
for microscopical examination, 205.
inspection of, 692, 703
palpation of, 694
relations of, 679
Vaginal douche, 715
nozzle, 716
inspection of bladder, 601
irrìgations, 715
palpation of ureters, 648
speculum, bivalve, 703
Goodell's, 703
Sims', 703

INDEX.

775

Vaginal speculum, trivalve, 703
tarapon, 719
medicateci, 721
Valentìne's irrigator, 565
Valsalva'smethodof infladng middle ear,332
Vapor method of administerìng chloroform,

39
ether, 33

Vaporizer, Dench's, 34.5

Hartmann 's, 345

Pynchon's, 345
Venesection, 161
Venous anesthesia, 95

puncture, 222
Vomiting after anesthesia, 62
Vomitus, blood in, 429
Von Hacker 's method of dìlating esophageal
strìctures, 422

Leyden's esophageal tubes, 424

Mikulicz's esophagoscope, 412
gastroscope, 451

Wales* bougies, 490, 520
Ware's ethyl chlorìd inhaler, 48
Watch test for hearing, 330
Wax-tipped ureteral cathcter, 654, 662

sound, 663
Weber *s test for deafness, 331
Wet cupping, 173
Whip catheter, 629
Whistle, Galton 's, 330
Whitall Tatum atomizer, 299
White's palate retractor, 285

X-ray examination of accessory sinuses, 294
of esophagus, 416
of larynx, 375
of stomach, 456
in detection of renai calculi, 674
of ureteral calculi, 674
of vesical calculi, 620

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Trained Nurse and Hotpiial Review

" There is not a chapter in the book that does net contain valuable suggestions."

Aikens* Hospital Mana^^ement in November

Hospital Management. By Charlotte A. Aikens, fonnerly Direc-
rector of Sibley Memorial Hospital, Washington, D. C. i2mo of 450
pages, illustrated.

Miss Aikens* long experience as hospital director has well fitted her to
write on this subject. Her book is a concise, careful, and thoughtful disciis-
sion of the subject, presented in a way that must strike home at once.

8 SAUNDERS' BOOKS ON

Hoxie's Medicine for Nurses

Practice off Medicine ffor Nurses. A Text-Book for Nurses and Students
of Domestic Science, and a Hand-Book for Ali Those Who Care for the Sick.
By George Howard Hoxie, M. D., Professor of Internai Medicine. Uni-
versity of Kansas. With a Chapter on Technic of Nursing by Pearl L.
Laptad, Principal of the Training School for Nurses, University of Kansas.
i2mo of 284 pages, illustrated. Cloth, I1.50 net.

This work is truly a practice of medicine for the nurse, enabling her to recognize any
signs and changes tbat may occur between visita of the physician, and. if necessary. to
combat them until the physician's arrivai. This information the author presents in a way
most acceptable, particularly emphasizing the nurse's part.

Trained Nurse and Hospital Review

" This hook has our unqualifìed approvaL'

••

McCombs* Diseases of Children for Nurses

Diseases off Ctiildren ffor Nurses. By Robert S. McCombs, M. D..
Instructor of Nurses at the Children* s Hospital of Philadelphia. i2mo of
430 pages, illustrated. Cloth, |2.oo net.

Dr. McCombs' experìence in lecturing to nurses has enabledhim to emphasize/tu//A^ie
points that nurses most need to know. The nursing side has been wrìtten by head nurses,
especially praiseworthy being the work of Miss Jennie Manly.

National Hospital Record

" We bave needed a good work on children's diseases adapted for nurses' use, and this
volume admirably fills the want."

Wilson's Obstetric Nursinf^

A Refference Hand-Boolc off Obstetric Nursins:* By W. Reynolds
Wilson, M, D., Visiting Physician to the Philadelphia Lying-in Charity.
32mo of 258 pages, illustrated. Flexible leather, I1.25 net

Dr. Wilson's work discusses the subject of obstetrics entirely from the nurse's point of
view. presenting in detaìl everything connected with pregnancy and labor and their man-
agement. The text is copio usly illustrated.

American Journal of Obstetrics

" Every page emphasizes the nurse's relation to the case.'*

Prùhwald and Westcott on Children

Diseases of Ctiildren. A Practical Reference Book for Students and
Practitioners. By Professor Dr. Ferdinand Frìjhwald, of Vienna.
Edited, with additions, by Thompson S. Westcott, M. D., Associate in
Diseases of Children, University of Pennsylvania. Octavo volume of 533
pages, containing 176 illustrations. Cloth, $4.50 net.

E. H. Bartley, M. D., Long Islnnd College Hospital, New York.

" It is a new idea, which ought to become popular because of the alphabetic arrange-
ment. Its title expresses just what it is— a ready reference hand-book."

NURSING.

Macfarlane's Gynecolo^ for Nurses lUuttnted

A Reference Hand-Book of Gynecology for Nurses. By Cath-
ARiNE Macfarlane, M. D., Gynccologist to the Woman's Hospital of
Philadelphia. 32mo of 150 pages, with 70 illustiations. Flexible
leather, $1.25 net.

A. M. Seabrook, M. D.» Woman s Medicai College of Philadelphia,

" It is a most admirable little hook, covering in a concise but attractive way the subject from
the noxse's ttandpoint."

Galbraith's Personal Hy^ene and Physical Trainini^

for Women IUcmIj in November

Personal Hygiene and Physical Training for Women. By
Anna M. Galbraith, M. D., Fellow New York Academy of Medicine.
i2mo of 350 pages, with originai illustrations.

Dr. Galbraith' s hook is just what has long been needed — a simple mancai
of hygiene and physical training along scientific lines.

De Lee's Obstetrics for Nurses ^^ ^^^ ^^2^00

Obstetrics for Nurses. By Joseph B. De Lee, M. D., Professor of
Obstetrics in the Northwestern University Medicai School. i2mo vol-
ume of 512 pages, fully illustrated. Cloth, $2.50 net.

J. Clifton Ed^ar, M. D..

Professar o/Oòstetrics and Clinical Midwifny, Cornell Medicai School, N, K.

'* It is far-and-away the best that has come to my notice, and I shall talee great pleasnre in recom«
mendingit to my nurses and studenu as well."

Davis' Obstetric Nursing New (W) Editìon

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M.,
M. D., Professor of Obstetrics, Jefferson Medicai College and Philadel-
phia Polyclinic. i2mo of 436 pages, illustrated. Buckram, $1.75 net.

The Lancet, London

" Not only nurses, but even newly qualified medicai men, would team a great deal bv a perusal of
this book. It is wrìtten in a clear and pleasant style, and is a work we can recommend.

Beck's Hand-Book for Nurses New (2d) Edition

A Reference Hand-Book for Nurses. By Amanda K. Beck, of
Chicago, 111. 32mo of 200 pages. Flexible leather, $1.25 net.

This little book contains information upon every questìon that comes to a
nurse in her daily work, and embraces ali the information that she requires
to carry out any directions given by the physician.

Botton Medicai and Sur^kal Journal

** Must be regarded as an extremely useful book, not only for nurses, but for physicians."

,o SAUNDERS' BOOKS ON

Res(ister*s Pever Nursini^

A Text-Book on Practical Fever Nursing. By Edward C.
Register, M. D., Professor of the Practice of Medicine in the North
Carolina Medicai College. i2mo of 352 pages. Cloth, $2.50 net.

The work completely covers the field of practical fever nursing. The illustiations show
the nurse how to perform those measures that come withm ber province.

Treined Nune and Hospital Review

" Nurses will fìnd this hook of great value in this practical bianch of their work."

Hecker, Tnimpp, and Abt on Children

Atlas and Epitome of Diseases of Children. By Dr. R. Hecker
and Dr. J. Trumpp, of Munich. Edited, with additions, by Isaac A.
Abt, M.D., Assistant Professor of Diseases of Children, Rush Medicai
College, Chicago. With 48 colored plates, 144 text-cuts, and 453 pages
of text. Cloth, $5.00 net.

The many excellent lithographic plates represent cases seen in the authors' clinics, and
bave been selected with great care, keeping constantly in mind the practical needs of the
general practitioner. These beautiful pictures are so true to nature that their study is
equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added ali new
methods of treatment.

Johni Hopkins Hospital Bulletin

" The entire field has been covered. With the excellent plates, it will be found of real
value to both students and practitìoners."

Lewis' Anatomy and Physiolo^ The New (ad) cdition

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D.,
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the
Lewis Hospital, Bay City, Michigan. i2mo of 375 pages, with 150
illustrations. Cloth, I1.75 net.

A demand for such a work as this, treating tht subjects fram the nurses* point of view^
has long existed. Dr. Lewis has based the pian and scop>e of this work on the methods
employed by him in teaching these branches, making the text unusually simple and clear.

The Nurses Journal of the Pacific Coast

" It is not in any sense- rudimentary, but comprehensive in its treatment of the subjects
in hand. The application of the knowledge of anatomy in the care of the patient is
emphasized."

Priedenwald and Ruhràh's Dietetics New (ad) cditioo

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor
of Diseases of the Stomach, and John Ruhrah, M. D., Professor of
Diseases of Children, College of Physicians and Surgeons, Baltimore.
i2mo volume of 395 pages. Cloth, $1.50 net.

This work has been prepared to meet the needs of the nurse, both in the training
school and after graduation. It aims to give the essentials of dietetics. considering briefly
the physiology of digestion and the various classes of foods and the part they play in
nutritìon.

American Jotimal of Nursing

" It is exactly the hook for which nurses and others bave long and vainly sought. A
simple manual of dietetics. which does not tum into a cook-book at the end of the first
or second chapter.

NURSING AND CHILDREN 1 1

Paul's Pever Nursini^

Nursing in the Acute Infectious Fevers. By George P. Paul,
M.D., Assistant Visiting Physician to the Samari tan Hospital, Troy, N. Y.
i2mo of 200 pages. ^Cloth, $1.00 net.

Dr. Paul has taken great pains in the presentation of the care and management of each
fever. The book treats of fevers in general, tben each fever is discusseci individually, and
the latter part of the book deals with practical procedures and valuable information.

The London Lancet

" The book is an excellent one and wiU be of value to those for whom ìt is intended.
It is well arranged, the text is clear and full, and the illustrations are good."

PauPs Materia Medica for Nurses

Materia Medica for Nurses. By George P. Paul, M.D., Assistant
Visiting Physician to the Samaritan Hospital, Troy. iimo of 240 pages.
Cloth, $1.50 net.

Dr. Paul arranges the physiologìc actions of the drugs according to the action of the
drug and not the organ acted upon. An important section is that on pretoxic signs,
giving the wamings of the full action or the beginning toxic effects of the drug, which,
if heeded, may prevent many cases of drug poisoning.

Tha Medicai Record, New York

"This volume will be of real help to nurses; the material is well selected and well
arranged, and the book is as readable as it is useful."

Pyle*s Personal Hy^ene the New (4th) Ediaon

A Manual of Personal Hygiene : Proper Living upon a Physiologic
Basis. By Eminent Specialists. Edited by Walter L. Pyle, A. M.,
M.D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo
volume of 472 pages, fully illustrated. Cloth, $1.50 net.

To thb new edition there have been added, and fully illustrated, chapters on Domestic
Hygiene and Home Gymnastics. besides an appendix containing methods of Hydro-
therapy, Mechanotherapy, and First Aid Measures. There is also a Glossary of the
medicai terms used.

Boston Medicai and Surgical Journal

" The work has been excellently done, there is no undue repetition, and the writers
have succeeded unusually well in presenting facts of practical signifìcance based on sound
knowledge."

Galbraith's Pour Epochs of Woman*s Life second Edition

The Four Epochs of Woman's Life. By Anna M. Galbraith,
M.D. With an Introductory Note by John H. Musser, M.D., Univer-
sity of Pennsylvania. i2mo of 247 pages. Cloth, J1.50 net.

Binnin^ham Medicai Review

" We do not as a rule care for medicai books writtcn for the instruction of the public;
but we must admit that the advice in Dr. Galbraìth's work is in the main wise and whole-
some."

Starr on Children secondcdhkm

American Text-Book of Diseases of Children. Edited by Louis
Starr, M.D., assisted by Thompson S. Westcott, M.D. Octavo, 1244
pages, illustrated. Cloth, J7.00 net; Half Morocco, $8.50 net.

12 SAUNDERS' BOOKS ON

Brower and Bannister

on Insanity

A Practical Manual of Insanity. For the Student and General
Practitioner. By Daniel R. Brower, A. M., M.D., LL.D., Professor
of Nervous and Mental Diseases in Rush Medicai College, in affiliation
with the University of Chicago ; and Henry M. Bannister, A. M.,
M. D., formerly Senior Assistant Physician, Illinois Eastern Hospital
for the Insane. Handsome octavo of 426 pages, with a number of
fuU-page inserts. Cloth, |[3.oo net.

FOR STUDCNT AND PRACTITIONER

This work, intended for the student and general practitioner, is an intelligible,
up-to-date exposìtion of the leading £aicts of psychiatry, and will be found of in-
valuable service, especially to the busy practitioner unable to yìeld the time for a
more exhaustive study. The work has been rendered more practical by omitting
elaborate case records and pathologic details, as well as discussions of speculative
and controversial questions.

American Medidne

" Commends itself for lucid expression in clear-cut English, so essential to the student in
any department of medicine. . . . Treatment is one of the best features of the book. and for
this aspect is especially commended to general practitioners."

Bergey's Hygiene

The Principles of Hygiene: A Practical Manual for Students,
Physicians, and Health Officers. By D. H. Bergey, A. M., M. D.,
Assistant Professor of Bacteriology in the University of Pennsylvania.
Octavo volume of 555 pages, illustrated. Cloth, IÌ3.00 net

THE NEW (3d) EDITION

This book is intended to meet the needs of students of medicine in the
acquirement of a knowledge of those principles upon which modem hygienic
practises are based, and to aid physicians and health officers in familiarizing
themselves with the advances made in hygiene and sanitation in recent years.
This new third edition has been very carefully revised, and much new matter
added, so as to include the most recent advancements.

Buffalo Medicai Journal

*' It will be found of value to the practitioner of medicine and the practical sanitarian ; and
students of architecture, who need to consider problems of heating, lighting, ventilation, water
supply, and sewage disposai, may consult it with profit."

CHILDREN AND HYGIENE, 13

Griffith's Care of the Baby

The Cure of the Baby. By J. P. Crozer Griffith. M. D.. Clinical
Professor of Diseases of Children, University of Penn. ; Physician to the
Children's Hospital, Phila. i2mo, 455 pp. Illustrateci. Cloth, $1.50 net

TUE NEW (4ili) CDITION

The author has endeavored to fumish a reliable guide for mothers. He has
made bis statements plain and easily understood, in the hope that the volume
may be of service not only to mothers and nurses, but also to students and practi-
doners whose opportunities for observing children bave been limited.

New York Medicai Journal

" We are confìdent if this little work could fìnd its way into the hands of every trained
nurse and of every mother, ìnfant mortality would he lessened by at least fifty per cent."

Crothers' Morphinism

Morphinism and Narcomania from Opium,' Cocain, Ether, Chloral,
Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment,
and Medicolegal Relations. By T. D. Crothers, M. D., Superintendent
of Walnut Lodge Hospital, Hartford, Conn. Handsome i2mo of 351
pages. Cloth, ^2.00 net.

Tlie Lancet» London

"An excellent account of the varìous causes, symptoms, and stages of morphinism, the
discussion being throughout illuminated by an abundance of facts of clinical, psychological, and
social interest."

Ruhràh's Diseases of Children

A Mantial of Diseases of Children. By John Ruhràh, M. D.,
Professor of Diseases of Children, College of Physidans and Surgeons,
Baltimore. i2mo of 425 pages, fully illustrated. Flexible leather,
^2.00 net.

TOC NEW (2d) CDinON

In rcvising this work for the second edition Dr. Ruhràh has carefìilly in-
corporated ali the latest knowledge on the subject. Ali the important facts are
givcn concisely and explicitly, the therapeutics of infancy and childhood being
outlined very carefuUy and clearly. There are also directions for dosage and
prescrìbing, and many useful prescriptions are included.

American Journal of tiie Medicai Sdencei

"Treatment has been satisfactorily covered, being quite in accord with the best teaching,
yet withal broadly general and free from stock prescriptions."

14 SAUNDERS' BOOKS ON

Peterson ano Haines'
Legai Medicine £rToxicolo|(y

A Text-Book of Legai Medicine and Toxicolosy. Edited by
Frederick Peterson, M. D., Professor of Psychiatry in the College
of Physicians and Surgeons, New York; and Walter S. Haines,
M. D., Professor of Chemistry, Pharmacy, and Toxicology, Rush
Medicai College, in affiliadon with the University of Chicago. Two
imperiai octavo volumes of about 750 pages each, fully illustrated.
Per volume: Cloth, ;Js.oo net; Sheep or Half Morocco, ^.50 net.
Sold by Subscription,

IN TWO VOLUMCS

The object of the present work is to give to the medicai and legai prdfessions
a comprehensive survey of forensic medicine and toxicology in moderate compass.
This, it is believed, has not been done in any other recent work in Elnglish. Under
' * Expert Evidence * * not only is advice given to medicai experts, but suggestìons
are also made to attorneys as to the best methods of obtaining the desired infoi -
madon from the witness. An interestmg and important chapter is that on ' ' The
Destructìon and Attempted Destruction of the Human Body by Fire and Chemi-
cals.** A chapter not usually found in works on legai medicine is that on " The
Medicolegal Relations of the X-Rays. " This section will be found of unusual im-
portance. The responsibility of pharmacists in the compounding of prescriptions,
in the selling of.poisons, in substituting drugs other than those prescribed, etc,
fiimishes a chapter of the greatest interest to every one concemed with questions
of medicai jurisprudence. Also mcluded in the work is the enumerati on of the
laws of the varìous states relating to the commitment and retention of the insane.

OPINIONS OF THE MEDICAL PRESS

Medicai News» New York

" It not only fills a need from the standpoint of timeliness. but it also sets a standard of
what a text-book on Legai Medicine and Toxicology should be."

Coltsmbia Law

" For practitioners in criminal law and for those in medicine who are called upon to give
court testimony in ali its varìous forms . . . it is extremely valuable."

Ponntylvaiiia Medicai Journal

" If the excellence of this volume is equaled by the second. &e work will easily take rank
as the standard text-book on Lec^ Medicine and Toxicology."

LEGAL MEDICINE. 15

Draper's Lre^al Medicine

A Text-Book of Legai Medicine. 6y Frank Winthrop Draper, A. M.,
M. D., Late Professor of Legai Medicine in Harvard University, Boston.
Octavo of 573 pages, illustrated. Cloth, $4.00 net ; Half Morocco, $5.50 net

Non. OHn Biyail, LL. B.» Baltimore Medicai College.

" A carefiil reading of Draper's Legai Medicine convìnces me of the excellent character
of the work. It is comprehensive, thorough, and must, of a necessity, prove a splendid
acquisition to the librarìes of those wbo are interested in medicai jurisprudence."

Chapman's Medicai Jurisprudence Tiurd Editioii

Medicai Jurisprudence, Insanlty, and Toxicology. 6y Henry C.
Chapman, M. D., late Professor of Institutes of Medicine and Medicai Juris-
prudence in Jefferson Medicai College, Philadelphia. i2mo of 329 pages,
illustrated. Cloth, $1.75 net.

Golebiewski and Bailey's Accident Diseases .

Atlas and Epitome of Diseases Caused by Acddents. By Dr. Ed.

Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, M. D.,
Consulting Neurologist to St. Luke*s Hospital, New York. With 71 colored
illustrations on 40 plates, 143 text illustrations, and 549 pages of text. Cloth,
$4.00 net. In Saunders' Hand- Atlas SerUs,

Hoftnann and Peterson's Le|(al Medicine HandXu^

Atlas of Legai Medicine. By Dr. K von Hofmann, of Vienna.
Edited by Frederick Peterson, M. D., Professor of Psychiatry in the
College of Physicians and Surgeons, New York. With 120 colored figures
on 56 plates and 193 half-tone illustrations. Cloth, I3.50 net.

Jakob and Fisher^s Nervous System

and itS Diseases in Saunden* Hand^tlaset

Atlas and Epitome of the Nervous System and Its Diseases. By

Professor Dr. Chr. Jakob, of Erlangen. Front the Second Revised
German Edition, Edited, with additions, by Edward D. Fisher, M. D.,
Professor of Diseases of the Nervous System, University and Belle vue
Hospital Medicai College, New York. With 83 plates and copious text
Cloth, $3. 50 net

Abbott's Transmissible Diseases second Editton

The Hygiene of Transmissible Diseases : Their Causes, Modes of Dis-
semination, and Methods of Prevention. By A. C. Abbott, M. D., Pro-
fessor of Hygiene and Bacteriology, University of Pennsylvania. Octavo of
351 pages, illustrated. Cloth, $2.50 net

l6 SAUNDERS' BOOKS ON CHILDREN.

American Pocket Dictionary shàSm

American Pocket Medical Dictionary. Edited by W. A. New-
man DoRLAND, M. D., Assistant Obstetrician to the Hospital of the
University of Pennsylvania. Containing the pronunciation and defini-
tion of the prìncipal words used in medicine and kindred sciences^ with
64 extensive tables. With 598 pages. Flexible leather, with gold
edges, |i.oo net; with patent thumb index, I1.25 net.

" I can recommend it to our students without reserve." — ^J. H. HOLLAND. M. D., Dtam
oftht Jefferson Medicai College^ Philadelphia.

Morrow's Immediate Care of Iniured

Immediate Care of the Injured. By Albert S. Morrow, M. D.,
Attending Surgeon to the New York City Hospital for the Aged and
Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, I2.50 net

Dr. Monrow's hook on emergency procedures is written in a definite and decisive style,
the reader being told just what to do in every emergency. It is a practical hook for every
day use. and the large number of excellent illustrations can not but make the treatment to
be pursued in any case clear and intelligible. Pbysicians and nurses will find it indispensible.

Poweirs Diseases of Children ThM cdidon. Reviied

Essentials of the Diseases of Children. By William M. Powell,
M. D. Revised by Alfred Hand, Jr., A. B., M. D., Dispensary
Physician and Pathologist to the Children's Hospital, Philadelphia.
i2mo volume of 259 pages. Cloth, |i.oo net. In Saunders*
QuesHon-Compend Serie s,

Shaw on Nervous Diseases and Insanity rourth Eanoo

Essentials of Nervous Diseases and Insanity: Their Symptoms
and Treatment. A Manual for Students and Practitioners. By the late
John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and
Nervous System, Long Island College Hospital, New York. i2mo of
204 pages, illustrated. Cloth, |i. 00 net. In Saunders^ Questiona Com-
petid Series.

" Clearly and intelligently written ; we have noted few inaccuracies and severa! sug-
gestive points. Some affections unmentioned in many of the large text-books are noted.^
— Boston Medicai and Surgical Journal.

Starr's Diets for Infants and Children

Diets for Infants and Children in Health and in Disease. By
Louis Starr, M. D., Consulting Pediatrist to the Matemity Hospital,
Philadelphia. 230 blanks (pocket-book size). Bound in flexible leather,
I1.25 net.

Grafstrom's Mechano-Therapy second Revised Ediikm

A Text-book of Mechano-therapy (Massage and Medicai Gymnas-
tics). By Axel V. Grafstrom, B. Se, M. D., Attending Physician to
the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200
pages, illustrated. Cloth, $1.25 net.

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