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Full text of "Diagnostic and therapeutic technic; a manual of practical procedures employed in diagnosis and treatment"

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BOOKS 



ALBERT S. MORROW, M. D. 



Diagnostic and Therapeutic Technic 

Octavo ot 830 pages, with 860 line- 
drawings. Cloth, $5.00 net. 
The New {2d) Edition 



Immediate Care of the Injured 

i2mo of 35; pages, with 242 illus- 
trations. Cloth, $2.50 net. 
The Ne^u {2d) Edition 



DIAGNOSTIC 



AND 



THERAPEUTIC TECHNIC 

A Manual of Practical Procedures 
Employed in Diagnosis and Treatment 



BY 

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

CLINICAX PROFESSOR OF SURGERY IN THE NEW YORK POLY- 
CLINIC; ATTENDING SURGEON TO THE WORXHOUSE HOSPITAL, 
AND TO THE CENTRAL AND NEUROLOGICAL HOSPITAL 



WITH 860 ILLUSTRATIONS. MOSTLY ORIGINAL 



SECOND EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1916 






Copyright, lyit, by W. B. Saunders Company. Reprinted January, 
1912, and January, 1913 Revised, entirely reset, re- 
printed, and recopyrighted January, igi.s 
Reprinted July, 1915 



Copyri;;ht, 1915, by W. B. Saunders Compnny 
Reprinted November. IQ15 






CoViNJ ^ 



PSrNTED IN AMEBIC* 

PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



To the memory of my Father 

Prince a. Morrow, m. D., 

This book is dedicated 



PREFACE TO THE SECOND EDITION 

In the short time that has elapsed since the pubKcation of the 
first edition of this work many advances have been made in diagnosis 
and treatment necessitating in the preparation of the present edition 
a very careful revision of the old manuscript and the addition of 
much new material. Many new illustrations have been added and 
some of those appearing in the previous edition have been redrawn. 
These additions have resulted in a somewhat larger volume, though 
the plan of the original work has been followed without change. 
Every effort has been made to bring the present volume up to date 
and to maintain the thoroughly practical character of the original 
work, and it is earnestly hoped that the changes and additions that 
appear in this new edition will add materially to the usefulness of the 
book. 

Finally, the writer wishes to express his appreciation of the very 
kind reception accorded this book by the Profession, without which 
this revision would have been impossible. 

A.S.M. 
New York City. 



vn 



PREFACE 



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

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

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

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



X PREFACE. 

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

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

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

A. S. M. 

New York City. 



CONTENTS 



CHAPTER I 



Page 

The Administration of General Anesthetics i 

Preparations of the patient for general anesthesia 2 

Stages of anesthesia 6 

Ether anesthesia 8 

Chloroform anesthesia 17 

Nitrous oxid anesthesia 23 

Nitrous oxid and oxygen anesthesia 27 

Nitrous oxid and ether sequence 28 

Ethyl chlorid anesthesia 30 

Anesthetic mixtures 33 

Intubation anesthesia 34 

Intratracheal insufflation anesthesia •. . 36 

Anesthesia through a tracheal opening 40 

Intravenous general anesthesia 41 

Rectal anesthesia . 44 

Oil-ether colonic anesthesia 47 

Scopolamin-morphin anesthesia . 48 

Accidents during anesthesia and their treatment 48 

After-effects of anesthetics 55 

After-treatment of cases of general anesthesia 57 

CHAPTER II 

Local Anesthesia 59 

Advantages and disadvantages of local anesthesia 60 

Methods of producing local anesthesia 63 

Drugs employed for local anesthesia 64 

Preparation of patient for local anesthesia 67 

Conduction of an operation under local anesthesia 68 

Local anesthesia by cold 69 

Surface application of anesthetic drugs ' 70 

Infiltration anesthesia 71 

Endo- and perineural infiltration 76 

Practical application of infiltration, endo- and perineural methods of anes- 
thesia to special localities 78 

Operations on inflamed tissues under local anesthesia 92 

Bier's venous anesthesia 93 

Arterial anesthesia 97 

Spinal anesthesia 98 

Sacral anesthesia 105 

CHAPTER III 

Sphygmomanometry 109 

Normal blood-pressure no 

xi 



XI 1 CONTENTS 

Page 

Instruments for estimating blood-pressure iii 

Technic of estimating blood-pressure 114 

Variations of blood-pressure in disease 116 

CHAPTER IV 

Transfusion of Blood 119 

Indications and contraindications 120 

Hemolysis 121 

Selection of the donor 121 

Artery to vein transfusion 121 

Technic by Crile's method 125 

Brewer's method 127 

Hartwell's method 128 

Levin's method 128 

Elsberg's method 129 

Technic by Carrel's suture 129 

Vein to vein transfusion 131 

Injections of Human Blood Serum 132 

CHAPTER V 

Infusions of Physiological Salt Solution 135 

Indications 135 

Preparation of normal salt solution 136 

Artificial sera for infusions 137 

Intravenous infusion 138 

Intraarterial infusion 144 

Hypodermoclysis 148 

Rectal infusion 151 

CHAPTER VI 

Acupuncture 152 

Venesection 153 

vScarification 158 

Subcutaneous Drainage for Edema 160 

Cupping 162 

Leeching 166 

CHAPTER VII 

Hypodermic and Intramuscular Injection of Drugs 170 

ADMINISTRATIO>r OF SaLVARSAN AND NeOSALVARSAN 1 75 

Administration of Diphtheria Antitoxin 183 

Vaccination 188 

CHAPTER VIII 

The Treatment of Neuralgia by Injections 194 

Trifacial neuralgia 194 

Sciatica 200 



CONTENTS XIU 

CHAPTER IX 

Page 

Bier's Hyperemic Treatment 203 

Passive hyperemia 203 

Effects of h3^peremia 204 

Indications 206 

General principles underlying hyperemic treatment 207 

Passive hyperemia by means of constricting bands. 209 

Passive hyperemia by means of suction cups 215 

Active hyperemia 220 

The Diagnosis and Treatment of Fistulous Tracts by IMeans of Bismuth 

Paste 223 

CHAPTER X 

Collection and Preservation of Pathological ^Material 227 

Method of making smear preparations for microscopical examination. . 227 

Method of inoculating culture tubes 235 

Collection of discharges and secretions for bacteriological examination . 238 

Collection of blood for microscopical examination 245 

Collection of blood for bacteriological examination 250 

Collection of sputum 252 

CoUection of urine 252 

Collection of stomach contents. 254 

CoUection of feces 254 

Removal of a fragment of solid tissue for examination 254 

CHAPTER XI 

Exploratory Punctures ^58 

Exploratori' punctures in general 258 

Exploratory puncture of the pleura 259 

Exploratory puncture of the lung 264 

Exploratory puncture of the pericardium 265 

Exploratory puncture of the peritoneal cavit}" 268 

Exploratory puncture of the liver 269 

Exploratory puncture of the spleen 271 

Exploratory puncture of the kidneys 273 

Exploratory puncture of joints 274 

Spinal puncture 277 

Spinal puncture as a means of administering antitoxic sera 283 

CHAPTER XII 

AsPIR.\TIONS 285 

Aspiration of the pleural cavity 285 

Aspiration of the pericardium 293 

Aspiration of the abdomen for ascites 296 

Aspiration of the tunica vaginalis 300 

Aspiration of the bladder 303 

CHAPTER XIII 

The Nose and Accessory* Sinuses 304 

Anatomic considerations. 304 



XIV CONTENTS 

Page 

Diagnostic methods 309 

Rhinoscopy 309 

Inspection of the nasopharynx l)y means of Hays' pharyngoscope . . .317 

Palpation by the probe 319 

Digital palpation of the nasopharynx 322 

Transillumination of the accessory sinuses 323 

Skiagraphy 325 

Therapeutic measures 325 

Nasal douching 325 

The nasal syringe 329 

The nasal spray 330 

Direct application of remedies 332 

Insufflations 334 

Lavage of the accessory sinuses 336 

Passive hyperemia in diseases of the nose and accessory sinuses .... 343 

Tamponing the nose for the control of hemorrhage 343 

CHAPTER XIV 

The Ear 348 

Anatomic considerations 348 

Diagnostic methods 352 

Direct inspection 354 

Otoscopy 355 

Determination of the mobility of the drum membrane 359 

Hearing tests 360 

Inflation of the middle ear for diagnosis 363 

Therapeutic measures 370 

The ear syringe 370 

Instillations 373 

Application of caustics 375 

Inflation of the middle ear for therapeutic purposes 376 

Inflation with medicated vapors 376 

Injection of solutions into the Eustachian tubes 377 

The Eustachian bougie 378 

Massage of the drum membrane 380 

Incision of the drum membrane 381 

CHAPTER XV 

The Larynx and Trachea 385 

Anatomic considerations 385 

Diagnostic methods 389 

Laryngoscopy and tracheoscopy 389 

Direct laryngoscopy 396 

Autoscopy 399 

Direct tracheo-bronchoscopy 400 

Palpation by the probe 407 

Skiagraphy 408 

Therapeutic measures 408 

The laryngeal spray 408 

Direct application of remedies 409 

Insufflations 411 

Steam inhalations 412 



CONTENTS XV 

Page 

Dry inhalations 4^5 

Intubation 4i5 

Tracheotomy 424 

CHAPTER XVI 

The Esophagus 435 

Anatomic considerations 435 

Diagnostic methods 43° 

Auscultation 437 

Percussion 437 

Palpation 437 

Examination by sounds and bougies 437 

Esophagoscopy 445 

Skiagraphy 449 

Therapeutic measures 449 

Lavage of the esophagus • • 449 

Dilatation of esophageal strictures by the bougie 45 1 

Intubation of the esophagus 45^ 

CHAPTER XVII 

The Stomach ■ ■ 46i 

Anatomic considerations 461 

Diagnostic methods .• 462 

Inspection 464 

Palpation ■ ■ • 466 

Percussion 469 

Auscultation . ■ 47^ 

Inflation of the stomach 47 1 

Extraction of stomach contents for examination 474 

Test of motor function 482 

Test of absorption power 483 

Gastrodiaphany 483 

Gastroscopy 485 

Skiagraphy 493 

Exploratory laparotomy 493 

Therapeutic measures 494 

Lavage of the stomach 494 

The stomach douche 499 

Gavage 502 

Duodenal feeding 505 

Massage 5^7 

Electrotherapy 509 

CHAPTER XVIII 

The Colon and Rectum 5^3 

Anatomic considerations 5^3 

Diagnostic methods 5^7 

I. Abdominal Examination 518 

Inspection 5^8 

Palpation 5^9 

Percussion ■ 520 



XVI CONTENTS 

Page 

Auscultation 520 

Inflation of the colon 521 

Skiagraphy 524 

II. Internal Examination 524 

Inspection 526 

Palpation by the finger 527 

Manual palpation 529 

Examination by the speculum or proctoscope 530 

Examination by sounds and bougies 537 

Examination by the bougie a boule 538 

Examination by the probe 539 

Lavage of the bowel 540 

Examination of the feces 541 

Therapeutic measures 541 

Enemata 541 

Enteroclysis 546 

Saline rectal infusion 554 

Continuous proctoclysis 556 

Nutrient enemata 560 

Injection of fluids or air into the bowel in intussusception 563 

Dilatation of rectal strictures by the bougie 565 

Colonic massage 568 

Auto-massage 570 

Application of electricity to the rectum and colon 571 



CHAPTER XIX 

The Urethra and Prostate 574 

Anatomic considerations 574 

Diagnostic methods 578 

Glass tests for locating urethral pus 579 

Injection test for locating urethral pus 581 

Inspection 581 

Palpation 582 

Examination by sounds and bougies 585 

Examination by the bougie a boule 594 

Urethrometry 596 

Estimation of the urethral length 597 

Urethroscopy in the male 598 

Urethroscopj'^ in the female 605 

Therapeutic measures *. . . 607 

Urethral injections 607 

Irrigations of the urethra 611 

Instillations 616 

Application of ointments 618 

Urethroscopic treatment 620 

Direct application of cold to the urethra 622 

Prostatic massage 624 

Meatotomy 626 

Treatment of strictures by gradual dilatation 627 

Treatment of strictures by continuous dilatation 640 



CONTENTS XVll 

CHAPTER XX 

Page 

The Bladder 642 

Anatomic considerations 642 

Diagnostic methods 644 

Urinalysis 646 

Inspection 650 

Percussion 651 

Palpation 651 

Sounding for stone 653 

Test of bladder capacity 657 

Estimation of residual urine 658 

Test for absorption from the bladder 659 

Cystoscopy in the male 659 

Cystoscopy in the female ; 665 

Skiagraphy 671 

Therapeutic measures 671 

Irrigations 671 

Auto-irrigations 675 

Instillations 676 

Cystoscopic treatment 677 

The destruction of vesical growths by the high frequency current . . . 678 

Catheterization in the male 680 

Catheterization in the female 687 

Continuous catheterization 689 

Aspiration of the bladder 692 

CHAPTER XXI 

The Kidneys and Ureters 695 

Anatomic considerations 695 

Diagnostic methods 698 

Inspection 698 

Palpation of the kidney 699 

Palpation of the ureters 701 

Percussion 703 

Urinalysis 704 

Catheterization of the ureters in the male 705 

Catheterization of the ureters in the female 714 

Pyelometry 720 

Segregation of urine • . 721 

Determination of the functional capacity of the kidneys 725 

Skiagraphy 730 

Pyelography 731 

Exploratory incision 731 

Therapeutic measures 732 

Medication of the renal pelvis and ureters 732 

Dilatation of ureteral strictures 733 

CHAPTER XXII 

The Female Generatwe Organs 735 

Anatomic considerations 735 

Diagnostic methods 737 



XVIU CONTENTS 

Page 
I. Examination of the abdomen. 

Inspection , 742 

Palpation 743 

Percussion • 745 

Auscultation 747 

Mensuration 747 

II. Examination of the pelvic organs. 

Inspection 748 

Examination of discharges 749 

Digital palpation 750 

Bimanual palpation 752 

Examination by means of specula 759 

Sounding the uterus 764 

Digital palpation of the uterine cavity 766 

Examination of sections and scrapings from the uterus 768 

Exploratory vaginal incision 768 

Therapeutic measures 771 

Vaginal irrigations 77 1 

Local applications to the vagina and cervix 774 

Application of powders to the vagina 775 

Vaginal tampons 776 

Intrauterine douche 779 

Intrauterine applications 783 

Tamponing the uterus 786 

Bier's hyperemic treatment in gynecology 789 

Pelvic massage 789 

Scarification of the cervix 791 

Pessary therapy 792 

Dilatation of the cervix 803 

Curettage 807 



Index 81 



o 



Diagnostic and Therapeutic 
Technic 



CHAPTER I 
THE ADMINISTRATION OF GENERAL ANESTHETICS 

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

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



2 TH£ ADMINISTRATION OF GENERAL ANESTHETICS 

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

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

Diet. — The diet for twenty-four hours before the operation should 
be of an easily digestible character, and should be taken in small 
amounts to prevent overloading the alimentary canal. If the opera- 
tion is set for earh- in the morning, no food should be given after a 
light supper the previous night; if it is fixed for the afternoon, a very 
light breakfast may be taken, not later than 8 a.m. A feeling of 
faintness or weakness may necessitate the giving of a cup of hot 
broth or beef tea even later than this in some cases, but it should be a 
general rule not to give any food by mouth within three hours of 
the time for anesthesia, since, if the stomach is not empty at the time 
of operation, vomiting is almost sure to occur, adding not only to the 
dajiger of the anesthetic, but to the subsequent distress of the patient. 
In some cases of special gravity on account of shock or marked 
feebleness, a nutrient enema (see page 58), 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 performed when 
a full meal has been taken shortly before. Preliminary washing out 
of the stomach will be required when that organ is the seat of opera- 
tion; it should also be practised if a general anesthetic is to be admin- 
istered when intestinal obstruction with vomiting is present, for, in 
such cases, patients have been known to fairly drown from the con- 
tents of the stomach suddenly pouring out under the relaxation of the 



PREPARATIONS FOR ANESTHESIA AND PRECAUTIONS 3 

anesthetic. To avoid undue excitement and possible collapse, the 
lavage may be performed just as the patient is under complete 
anesthesia. 

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

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

Many surgeons administer morphin hypodermically before anes- 
thesia. In some cases this is of advantage, shortening the stage of 
excitement and necessitating less of the anesthetic to maintain insen- 
sibility, but it should not be a routine practice. In highly excitable, 
vigorous, alcoholic individuals it is of distinct advantage. With its 
use, however, it is necessary to maintain lighter anesthesia than 
without it. The chief objection to morphin is that it depresses 
respiration and, by its action upon the pupils, may mask symptoms of 
overnarcosis; furthermore, it delays the awakening from the anes- 
thesia. In children or the very old it must be used with caution. 
Any condition producing embarrassed or obstructed respiration 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. 

By some operators atropin gr. i/ioo (0.00065 gm.) is given half 
an hour before the anesthetic is started as a routine procedure for 
the purpose of suppressing the secretion in the upper air passages 
and bronchi, thus lessening irritation of the respiratory mucous 
membrane. 

Physical Examination. — A thorough physical examination should 
be made in all cases as a routine preHminary to general anesthesia, for 
exact knowledge as to the state of health is essential to an intelligent 
selection of the anesthetic and its safe administration. Such an 
examination has a good moral effect upon the patient, and, if assur- 
ance can be given that nothing abnormal can be discovered, it does 
much to allay the natural fear and timidity of a nervous individual. 
This examination should include a record of the pulse, temperature. 



4 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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

The urine should always be examined if the case is such that time 
allows, noting the total amount for twenty-four hours, the specific 
gravity, and the amount of urea, and making tests for albumin, sugar, 
etc., as well as a microscopical examination for casts. The quantity 
of urea eliminated within twenty-four hours is especially important. 
A normal adult male will pass 250 to 450 gr. (16 to 29 gm.), and 
females less. If the quantity eliminated falls much below this normal 
minimum, the operator should be put on his guard, and, when the 
total urea falls below 100 gr. (6.5 gm.), no one can safely be given a 
general anesthetic (Fowler). If albumin be present, the dangers of a 
general anesthetic are increased, especially wdth ether. In the pres- 
ence of large quantities of albumin and casts the operation should be 
postponed or local anesthesia substituted. With sugar in the urine, 
the chances of diabetic coma developing should be carefully con- 
sidered. The presence of acetone and diacetic acid is of especial 
dangerous significance. 

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

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



PREPARATIONS FOR ANESTHESIA AXD PRECAUTIONS 5 

The position assumed by the patient upon the operating-table 
should be unconstrained and as comfortable as is consistent with the 
needs of the case. A supine position, ^\'ith the head elevated suffi- 
ciently upon a small pillow to allow freedom in breathing, answers in 
the majority of cases. Ether and nitrous oxid may be given with the 
patient's head and trunk elevated, but great caution should be 
observed in administering chloroform to a patient sitting up or semi- 
upright, on account of the danger of cerebral anemia. In weak 
anemic individuals the upright position should, for the same reasons, 
be avoided with anv anesthetic. 




Fig. I. — The anesthetist's supphes. i, Pus basin; 2, mouth wipes on artery 
clamps; 3, mouth wedge; 4, tongue forceps; 5, mouth gag; 6, hypodermic 
syringe. 

Before administering the anesthetic, anything that interferes with 
or obstructs the respiration in the shghtest degree should be removed. 
Tight collars, bandages about the neck, clothing, belts, straps, braces, 
etc., should invariably be loosened, no matter how short the anes- 
thesia. The mouth should be examined, and false teeth, obturators, 
plates, chewing gum. tobacco, etc., should be removed lest they fall 
back into the larynx and cause choking. No noise or talking should 
be permitted in the anesthetic room. It is always well to have a 
third person present in case help is needed, and in the case of a female 
patient this is very necessary, as erotic dreams may lead to damaging 
accusations against the anesthetist. 

The Anesthetist'' s Supplies. — Besides the apparatus necessary for 
the actual administration of the anesthetic, the anesthetist should 
be provided with the following: a mouth gag, a wedge or screw- 



6 THE ADMINISTRATION OF GENERAL ANESTHETICS 

shaped piece of hard rubber to force the jaws apart, tongue forceps, 
a hypodermic syringe in good working order, with whisky, camphor, 
adrenalin, atropin, and strychnin at hand, a number of small mouth 
wipes with an artery clamp as a holder, and a small pus basin 
(Fig. i). A cylinder of oxygen should be ready for use, and an 
infusion set and tracheotomy tube should be accessible. 

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




Fig. 2. — Arrangement of the operating-table and the anesthetist's supplies. 



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

The Initial Stage. — The inhalation of anesthetics like ether or 
chloroform produces irritation of the mucous membrane of the respir- 
atory tract and a profuse secretion of mucus with some coughing and 
frequent acts of swallowing. To some persons, the odor and taste of 



PREPARATIONS POR ANESTHESIA AND PRECAUTIONS 7 

the anesthetic are exceedingly unpleasant, so that temporary holding 
of the breath is not uncommon. If the vapor is given in too concen- 
trated a form, violent coughing will be induced, accompanied by 
cyanosis, and frequently a sense of suffocation is experienced and the 
patient tries to tear off the mask. If given slowly, the coughing 
passes off and the respirations become rapid and regular. Spots 
appear before the eyes and the patient becomes drowsy. A flushed 
face, rapid and full pulse, with hurried respirations are characteristic 
of this stage. The pupils dilate, but react to light, and the cornea 
responds to touch. In this stage the reflexes are increased, so that 
a painful examination or sudden shock is dangerous. 

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

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

The guide to the depth of anesthesia after the disappearance of 
the conjunctival reflex is the condition of the pupils. With light 
anesthesia, the pupils are moderately contracted and readily react to 
light; under deeper anesthesia, the pupils are contracted and fail to 
react to light; and when a very profound and dangerous stage of 



8 THE ADMINISTRATION OF GENERAL ANESTHETICS 

anesthesia is established, the pupils dilate widely and remain so 
without reaction to light, and the respirations become shallow and 
gasping. In the early stages of anesthesia, and when the patient is 
coming out, the pupils also dilate, but they still react to light and the 
corneal reflex is also present. After complete anesthesia has been 
once reached, it may be readily maintained by adding small amounts 
of the anesthetic from time to time; just enough should be adminis- 
tered to keep the pupils midway between contraction and dilatation, 
with a response to Hght at all times. 

Stage of Recovery. — The recovery from the anesthetic is character- 
ized by the occurrence of these same stages in reverse order. In 
some cases the recovery is more rapid than in others. The breathing 
becomes slower and less audible, and there is frequent sighing. The 
conjunctival reflex reappears, the pupillary reflex becomes active, 
and the patient rolls the eyes about. Frequent swallowing occurs, 
followed by retching. Vomiting of frothy and often bile-stained 
mucus is present in most cases, and may be continued for an hour or 
more. Partial consciousness, wath 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 irritabiHty. complaints of discomfort, and 
pain are to be expected. Some, however, especially children, pass 
nto a deep sleep lasting for several hours. 

ETHER ANESTHESIA 

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

Ether fumes, when inhaled, prove very irritating to the mucous 
membranes of the nose, mouth, and respiratory tract, and produce 
an increased secretion of mucus and sahva, often accompanied by 
coughing. Lesions of the lungs are thus apt to follow its use, and may 
be due to the aspiration of saHva as well as to the direct irritation of 
the ether vapor. Ether is a distinct cardiac stimulant, accelerating 
the heart action and raising blood-pressure; this effect is well shown 



ETHER ANESTHESIA 9 

when ether is administered to a very ill person, the character of the 
pulse often being improved immediately and continuing so until the 
end of the anesthesia. While its primary effect is one of stimulation, 
in toxic doses it acts as a depressant, especially upon the respiratory 
centers. It is estimated that ether is about five times as safe as 
chloroform, and, as it is less rapid in its action, danger signs can be rec- 
ognized and proper treatment instituted with more chances of success 
than with the latter. Upon the kidneys it acts as an irritant, andpro- 
longed 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 (Ham- 
burger and Ewing). According to Graham the phagocytic power of 
the blood is reduced after an ordinary ether anesthesia. 

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

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

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

On account of its irritant action, ether should be avoided in 



lO 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



bronchitis or acute lung troubles, and, for the same reason, in 
advanced Bright's disease. In patients over sLxty years old, ether, 
as a rule, is to be avoided, as they are very likely to be afflicted with 
respiratory troubles, and the circulatory system is usually the seat of 
degenerative changes. For children, a mixture of chloroform and 
ether, or chloroform alone, is the better anesthetic, ether proving 
irritating to the delicate respiratory mucous membrane of a child, 
and often producing such a flow of mucus and saliva that breathing is 
seriously interfered with. 

Ether is not recommended in cerebral operations — at the begin- 
ning, at any rate — on account of the struggling, resultant conges- 
tion, and increased liability to hemorrhage. It should never he 




Fig. 3. — The Esmarch mask. 



administered in operations about the mouth or face requiring the use 
of a cautery near by. 

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

The Allis inhaler (Fig. 6) is a type of the semiopen cone. It 



ETHER ANESTHESIA 



II 



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





Fig. 4. — The Schimmelbusch mask. 



Fig. 5. — Chloroform dropper. 



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

There are many excellent closed inhalers, such as the Clover 
(Fig. 8), the Bennet (Fig. 9), the Gwathmey, the Pedersen, etc. These 




Fig. 6.— The AlHs inhaler. 

consist essentially of a metal face-piece surrounded by an inflatable 
rubber rim, an ether chamber filled with gauze, and a closed rubber 
bag into and out of w^hich the patient breathes. They are also pro- 
vided with suitable openings for the entrance of air.^ With such 

1 Space does not permit a detailed description of these inhalers, nor is it necessary, 
as a description of the mechansim and full instructions are furnished with each 
instrument. 



12 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



inhalers, the temperature of the ether vapor is raised by the expired 
air and the supply of carbon dioxid, the normal stimulant of the 
respiratory and cardio-vascular centers, is maintained through the 
rebreathing, thus adding to the value and safety of the anesthetic. 
To obtain the benefit of the warm vapor without the disad- 





FiG. 7. — Towel cone. 

vantages of the closed inhalers, the vapor method of etherization is 
preferred by some. It is an excellent method of anesthesia to use in 
operations about the mouth, as the vapor can be delivered through a 
small tube passed into the mouth without interfering with the opera- 
tion. There are a number of inhalers for this purpose, of which 




Fig. 8. — The Clover ether inhaler. 

Gwathmey's apparatus is a type. Gwathmey's vapor apparatus 
(Fig. 10), as described by him {Journal of American Medical Associa- 
tion, October 27, 1906), consists of two six-ounce (180 c.c.) bottles, one 
for chloroform and one for ether. Both bottles are placed in a tin 
vessel containing thermolite. This '' thermolite warmer," if placed in 



ETHER ANESTHESIA 



13 



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 accompHshed 
by simply taking the stoppers out, thus exposing the thermolite to the 
atmosphere. The liquid then begins to recrystallize, and on turning 
to a sohd form gives off heat for another hour and a half. In each of 




Fig. 9.— The Bennet ether inhaler. 

the bottles there are three tubes, varying in length from one that 
reaches to the bottom of the bottle to one that penetrates only the 
stopper, and representing three degrees of vapor strength. The small 
switches at the top of each bottle are so arranged that chloroform 
or ether can be given, combined or separately, and in any strength 




Fig. 10. — Gwathmey's vapor apparatus. 

desired. In addition, by simply turning a small lever, without 
removing the mask, the patient receives pure air or a mixture of oxy- 
gen and air. By compressing the hand bulb, air or oxygen is forced 
into the apparatus and the warmed ether or chloroform vapor is 
carried to the patient by the efferent tube. 

Inhalers, whatever the variety, should always be sterilized 



14 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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 carboUc acid after each administration. The parts are 
then dried, and fresh gauze packing is suppHed for the closed inhalers 
and the open ones are covered with new gauze or canton flannel. 

Administration. — Drop Method. — The usual precautions ahead}- 
detailed having been observed, and the eyes of the patient being 
protected by a folded piece of gauze, the mask is placed over the 
mouth wiih. the request that the patient breathe naturally and regu- 




FlG. II. — Showing the administration of ether by the drop method. 

larly. As soon as several breaths have been taken, a few drops of 
ether are poured upon the mask. After a few more breaths, more 
ether is added, gradually increasing the amount each time. If the 
patient struggles or begins to cough and choke, the amount of ether 
should be lessened for the time being. In from five to six minutes the 
stage of excitement and struggb'ng begins, and the ether should then 
be dropped more rapidly. Large amounts should never be poured 
on suddenly, however, as this simply irritates the respiratory 
tract and produces laryngeal spasm, causing the patient to cough, 
choke, or hold his breath. If the dropping is properly performed, 
full anesthesia should be obtained in from ten to fifteen mintues. By 
the drop method an even anesthesia without cyanosis is produced. 



ETHER ANESTHESIA 1 5 

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 
respiration 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 accompanying illustration (Fig. 12). 
This prevents the relaxed epiglottis from being forced back by the 
tongue over the opening in the larynx, since, if the jaw is pushed for- 
v/ard, the tongue goes with it, giving a clear passage. In holding the 



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

jaw forward, care should be taken not to use force or bruise the 
tissues. If this maneuver does not overcome the obstruction from 
the tongue, the latter should be pulled out and held well forward by 
means of a tongue forceps or a silk thread passed through its tip. 
This, however, is seldom necessary if the jaw is properly held and the 
head is turned to one side so as to ailow the mucus and saliva to flow 
out through the corner of the mouth. Should vomiting occur, the 
inhaler must be removed and the patient's head turned to one side so 
that the vomited matter can escape; and, before the mask is reap- 
pHed, the mouth should be well cleared of vomitus. 

The pulse under the effect of ether becomes somewhat rapid, but 
of greater volume and increased tension. At first the pupils are 
widely dilated and then tend to moderately contract. Should they 
suddenly dilate and remain so without responding to hght 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 



1 6 THE ADMINISTRATION OF GENERAL ANESTHETICS 

or cyanosis. Hiccough usually means that the patient is getting 
ready to vomit. Rolling of the eyes and repeated acts of swallowing 
are preliminaries to the patient coming out. Both conditions require 
more ether. 

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

Semiopen Method. — Etherization with a semiopen inhaler differs 
in no material way from the drop method. The anesthesia should be 
started slowly by pouring into the top of the cone small quantities 
of ether at a time. After complete anesthesia is obtained, it may be 
maintained by the use of less ether than with the drop method, as the 
ether 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 
apphed and the patient is instructed to take regular breaths, breath- 
ing back and forth through the bag. As soon as he becomes accus- 
tomed to the apparatus, ether is slowly turned on during an inspira- 
tion 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. As the patient breathes into and out of the rubber bag, it 
should be seen that the latter is kept about two-thirds full of air — it 
should never be allowed to become empty. Usually with a closed 
inhaler anesthesia can be produced in from four to six minutes. On 
account of rebreathing the same air, some duskiness of countenance is 
to be expected, but this may be regulated by admitting more air or by 
administering oxygen. A distinct livid color should not be allowed to 
persist with either a closed or an open inhaler. Such a condition is a 
sign of poor administration of the anesthetic, or else the particular 
anesthetic used is not suited to the case. 

Anesthesia by the closed method, besides being more rapid, 
reduces considerably the amount of ether used. Recovery from the 
effects of the anesthesia is more prompt, and the after-effects, as 
nausea and vomiting, are greatly diminished. Furthermore, the 



CHLOROFORM ANESTHESIA 



17 



ether vapor inhaled from the bag, being warm, is safer, more effective, 
and less apt to produce irritation of the respiratory tract. 

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




Fig. 13. — Showing the administration of ether with a closed inhaler. 

completely under, a medium or low percentage of vapor is used, 
according to the depth of anesthesia desired. The mask used in this 
method is covered with gauze, over which an impermeable material, 
as rubber tissue or oil silk is placed, with a small opening in the center 
about the size of a ten-cent piece, through which additional anesthetic 
may be dropped if it is found to be difficult to induce narcosis with 
the vapor alone. 

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

CHLOROFORM ANESTHESIA 

Chloroform is a clear, colorless, heavy, volatile liquid with a sweet- 
ish taste and characteristic odor. When used for anesthetic purposes. 



15 THE ADMINISTRATION OF GENERAL ANESTHETICS 

it should be absolutely pure and neutral to litmus. Under the influ- 
ence of heat or light, it decomposes into hydrochloric acid, chlorin, 
etc., hence it should always be kept in well-stoppered, dark amber- 
colored bottles and in a cool place. It is more irritating to the skin 
than ether and, if confined, will produce bhsters. For this reason the 
lips, nose, and cheeks with which it may come in contact during 
anesthesia should be well protected with vaselin. 

When inhaled, chloroform vapor has a depressant effect upon all 
the vital functions, but especially upon the circulation, lowering 
blood-pressure to a marked degree through vasomotor depression. 
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 tem- 
porary fatty changes in the kidneys, heart muscle, and liver (more 
marked upon the latter) which may be severe and later lead to fatal 
results if these organs are already diseased. 

Death from chloroform is usually sudden and without premoni- 
tory signs. Vasomotor paralysis causing dilatation of the vessels 
and capillaries and fatal syncope is the primary cause, though the 
inhiditory 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 chloroform occur early in its administration when, during 
the stage of excitement and struggling, more of the drug is inhaled 
than is expected, or it is pushed too rapidly in an attempt to overcome 
the struggHng. With a trained and watchful assistant as an anes- 
thetist, chloroform is robbed of many of its dangers, but in inex- 
perienced hands it is a most dangerous drug, being estimated to be 
about five times more fatal than ether. 

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

Chloroform should always be administered warm. This can be 
accompUshed by using some one of the warm vapor inhalers, or by 
simply placing the bottle containing the drug in warm water (ioo° 
F., 38° C.) every few moments. 



CHLOROFORM ANESTHESIA I9 

Chloroform should not be given with the head very high, or with 
the patient sitting up, on account of the danger of syncope; this 
precaution should also be borne in mind when lifting or moving per- 
sons under the influence of chloroform. As a rule, the recovery from 
chloroform anesthesia is quicker than from ether, though the vomit- 
ing 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 respiratory tract. It is preferred to ether for patients with 
advanced Bright' s disease who are free from myocardial trouble, in 
obstructive conditions of the larynx or trachea, and for those whose 
lungs are involved by such conditions as tuberculosis, asthma, 
bronchitis, etc. 

In heart disease with broken compensation and dyspnea, in 
aneurysm, and in cases of marked degeneration of the blood- 
vessels, chloroform is better than ether on account of the milder 
preliminary stages. In cases of myocarditis and of fatty degeneration 
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 
surgical anesthesia is required in such cases, ether is indicated. 
In eclampsia chloroform should not be used on account of its destruc- 
tive action upon the liver. In fact, in the presence of any liver lesion 
it should be avoided. 

Chloroform should be avoided as an anesthetic in hemorrhage or 
shock, on account of its depressant effect upon the circulation; and 
likewise in anemia, as it decreases hemoglobin. In cerebral surgery, 
chloroform is preferred by many surgeons, and also in operations 
about the face and mouth, as it causes but little cough and flow of 
saliva, and the anesthesia can be maintained with but a small 
amount of 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 con- 
traindicated. 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 
inhaler. Either the open drop method, with a free mixture of air, or 
the warm vapor method should be employed. For the former, a 



20 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



handkerchief, 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 
Schimmelbusch's (see Fig. 4), covered with canton flannel or several 
layers of gauze, is more suitable. In addition, a drop bottle (see 
Fig. 5) from which the flow can be accurately regulated, and a recep- 
tacle for warm water will be required. 




Fig. 14. — Chloroform mask improvised from the corner of a towel. 

Different forms of apparatus for accurately estimating the 
strength of vapor, as Junker's (Fig. 15), Braun's, Gwathmey's (see 
Fig. 10), etc., are often used. These are supplied with a tracheal 
tube and are especially useful in operations about the mouth or throat. 
By squeezing the bulb, air is forced through the warmed chloroform, 
and a vapor containing a definite mixture of chloroform and air is 
administered. By attaching the bulb to a tube connected with an 




Fig. 15. — Junker's chloroform inhaler. 

oxygen cylinder, oxygen may be readily administered instead of air. 

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

Administration. — The patient's lips, nose, mouth, and cheeks 
should be well greased with vaselin or lanolin. The anesthetic is 
started by holding the mask wet with a few drops of warm chloro- 



CHLOROFORil AXESTHESLA. 



21 



form 4 or 5 inches (lo to 12 cm.) from the face (Fig. 16), the patient 
being told to breathe naturally and regularly. As soon as the patient 
grows accustomed to the vapor, the chloroform is dropped steadily at 
a rate of 10 to 30 drops a minute, and the mask is brought nearer the 
face, being careful, ho^Yever, not to touch the skin with portions of 
the mask wet with chloroform (Fig. 17). When given gradually in 
this way, the struggHng is not usually prolonged or violent. The 
anesthetic should never be poured on suddenly in large quantities; 
it must always be administered well diluted with air. In the stage of 
excitement, chloroform must he given with extreme care; if the patient 




Fig. 16. — Showing the method of administering chloroform (first step). 

struggles, the drug should not 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 aheady oversaturated 
mask. Coughing and vomiting mean that the vapor is too strong, 
and it should be promptly diluted as it should also if the patient's 
breathing becomes embarrassed. The jaw must be kept well forward 
if there is the slightest impediment from the tongue to free respiration. 
When the patient is fully anesthetized, only smaU quantities of the 
anesthetic should be administered, just sufficient to keep him under. 
With chloroform anesthesia, we have practically the same stages 



22 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



as with ether. l)ut the)- succeed each other more rapidly, and a dan- 
gerous degree of anesthesia is quickly produced unless proper 
care be taken. The stage of excitement is less marked and shorter 
than with ether, and the patient presents a more tranquil appearance 
in every way. It should be the aim of the anesthetist to keep the 
patient in about the following condition: regular and fairly deep 
respirations, with only a slight snore; pupils moderately contracted 
and sluggishly sensitive to hght; conjunctival reflex just aboHshed; 
full muscular relaxation; and a good color without blueness of the 
lips or cheeks. The latter is an indication for a weaker vapor and 




Fig. 17. — Showing the method of administering chloroform (second step). 

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 close watch should be 
kept over the respirations, the pulse, the condition of the eye reflexes, 
and the general appearance of the patient. It is only by the constant 
and undivided attention of the anesthetist that the safety of the 
patient can be guaranteed. The slightest alteration in the respira- 
tions should be taken as a warning, as this is often the precursor to 
circulatory failure. Very shallow, irregular, or gasping respiration, a 
weak, thready, or intermittent pulse, sudden and continued dilatation 



NITROUS OXID ANESTHESIA 23 

of the pupils In the absence of eye reflexes, and marked duskiness or 
sudden pallor of the skin, are all indications that a dangerous stage 
of narcosis has been reached. 

The administration of anesthetics by the vapor method has 
already been described under ether anesthesia (page 17), and will not 
be repeated here. With chloroform, it is an especially valuable 
method to employ, as the warm vapor may be administered in a defi- 
nite strength, and with air or oxygen as desired. 

NITROUS OXID ANESTHESIA 

Nitrous oxid is a colorless gas, heavier than air, and with no per- 
ceptible odor or taste. It is obtained in a liquid form, highly com- 
pressed in steel cyUnders or containers, from which, when liberated, 
it escapes as a gas. It has marked anesthetic properties, though the 
anesthesia is not so profound as that from ether or chloroform. It 
increases the rate and depth of respiration and accelerates the heart 
action, at the same time raising blood-pressure. If pushed too far, 
the respirations cease, though the heart continues to beat for some 
time. For short operations it is the safest of all the general anes- 
thetics, I in 100,000 being the generally accepted death rate. 

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

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

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

With the admixture of air or oxygen in proper quantities to pre- 
vent asphyxial symptoms, and administered by an expert, it may be 



24 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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

Nitrous oxid is contraindicated in cases of dilated heart or advanced 
valvular disease, and in patients with atheroma of the blood-vessels, 
on account of the danger of cerebral hemorrhage. In 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 suffering 
from goiter, enlarged tonsils, or adenoids. In operations about the 
rectum and perineum, it is sometimes unsatisfactory, as the patient 
may stiffen up or straighten out the limbs, thus interfering with the 
operator. The same may be said of its use in alcoholics, or strong, 
robust, or fat individuals, though, according to Gwathmey, by pre- 
liminary medication with morphin alone, or with morphin and chlo- 
retone, or morphin and hyoscin, any patient can be anesthetized 
satisfactorily. 

Apparatus. — Nitrous oxid may be administered alone or with air 
by means of any of the usual inhalers for that purpose, such as Hew- 
itt's, Gwathmey's, Bennett's (Fig. i8), etc. In general, these consist 
of a metal mask with a pneumatic rubber rim that fits the face 
accurately so as to exclude air, a gas chamber with inspiratory and 
expiratory valves or openings, and, attached to the gas chamber, 
a rubber balloon connected by rubber tubing with the nitrous oxid 
cylinder. With such apparatus, air may be admitted through the 
openings provided for that purpose or the inhaler may be removed 
every two to five inspirations, allowing the patient to get a supply of 
pure air. Oxygen may likewise be administered by passing the 
oxygen tube under the rim of the mask. 



NITROUS OXID ANESTHESIA 



25 



When a definite amount of oxygen is to be given, a special appara- 
tus, as that of Hewitt (Fig. 19), Gwathmey (Fig. 20), Teter, Cunning- 
ham, or Gatch, is essential. With these inhalers any desu"ed com- 
bination of nitrous oxid gas and oxygen may be obtained by regulating 
special s^^'itches, which are provided with indicators showing the 




Fig, 18. — The Bennett nitrous oxid gas inhaler. 




Fig. 19. — The Hewitt nitrous oxid gas and oxygen inhaler. 

exact strength of the vapor which the patient receives. Carbon 
dioxid, which has been proved so valuable as a respiratory stimulant, 
is provided by rebreathing or by connecting the apparatus with a 
tank of CO9. 



26 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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

Administration. — In giving pure nitrous oxid, the apparatus is 
properly connected with the supply cylinder, and the rubber balloon 
is about three-fourths filled with gas. The gas should be turned on 
slowly, as, at times, when suddenly released, it escapes from the cylin- 
der with a loud noise which might tend to frighten a nervous patient. 
The face-piece is then tightly appUed over the mouth and nose, so 
that air cannot be drawn in around the rubber rim. The expiratory 




Fig. 20. — Gwathmey's nitrous oxid gas and oxygen inhaler. 



valve is opened and the patient is told to breathe regularly. After 
two or three breaths of air, during which the patient becomes accus- 
tomed to the apparatus, the gas is allowed to enter the mask by open- 
ing the proper stopcock. The patient thus breathes in pure nitrous 
oxid and expires nitrous oxid and air, so that he constantly receives 
more nitrous oxid into the lungs. After a few breaths, the expiratory 
valve is closed and the patient breathes the gas back and forth. 

The first few inspirations of pure gas are soon followed by a change 
in the color of the face — it becomes dusky, and finally a deep Uvid 
hue. There is at first incoherent speech, but this is soon followed by 



NITROUS OXID ANESTHESIA 



27 



the anesthetic snoring, rapid respiration, and a laryngeal stertor. 
There is usually tremor or twitching of the superficial muscles of the 
eyes, mouth, neck, etc., and at times complete rigidity and violent 
jactitations of the limbs. The anesthetic cannot be continued 
beyond this point without danger of asphyxiation. If the mask is 
removed, there is still a period of surgical anesthesia, lasting about a 
minute. This is soon followed by a reactionary redness or blush 
about the face, and a return to normal breathing. By reapplying the 
mask before the patient comes entirely out, and administering more 
nitrous oxid, the anesthesia may be prolonged nearly an hour, pro- 




FiG. 21. — Showing the method of administering nitrous oxid gas. 

vided sufficient air is admitted to avoid extreme cyanosis, stertor, 
and muscular twitchings, and yet not so much as to keep the patient 
insufficiently anesthetized. This may be accomplished by allowing 
two to five breaths of nitrous oxid to one of air, or the air may be 
administered in combination with the nitrous oxid through the open- 
ing provided on the inhaler for that purpose. A slight duskiness of 
the countenance, moderate snoring, and regular respiration should be 
aimed at. 

Administered with oxygen, a complete absence of symptoms of 
asphyxia is secured. An even anesthesia is best obtained with some 
form of apparatus that accurately regulates the percentage of oxygen. 
The technic is essentially the same as that employed in giving pure 



28 THE ADMINISTRATION OF GENERAL ANESTHETICS 

nitrous oxid. The patient first breathes pure air, then the nitrous oxid 
is turned on, and finally the oxygen. Starting with but a very small 
proportion of oxygen (2 to 3 per cent.) it may be increased to from 5 
to 10 per cent., or more, depending upon the case. Enough oxygen 
should always be given to prevent cyanosis without detracting from 
the anesthetic effects of the nitrous oxid. There is no doubt that it 
requires special training for one to become expert in administering 
this combination. Success depends upon the abihty of the anesthe- 
tist to provide a combination of gas and oxygen that will produce 
narcosis without cyanosis. With the proper amount of oxygen, the 
patient goes under the anesthetic in two to three minutes without 
any of those unpleasant symptoms seen with pure nitrous oxid, the 
color of the skin is normal, the breathing becomes regular and slightly 
snoring, and the pulse may be slightly increased in rate. Recovery is 
rapid and is usually unaccompanied by any unpleasant after-effects. 

NITROUS OXID AND ETHER SEQUENCE 

By this method the patient is thoroughly anesthetized with gas 
and then a change is slowly made to ether. It is a most valuable 
method for avoiding the disagreeable effects of the early stages of 
anesthesia ordinarily encountered when straight ether is admin- 
istered from the start. A combination of gas and ether carries the 
patient into a stage of surgical anesthesia very rapidly — usually in 
about one to three minutes. Much less ether is required both in 
starting and maintaining narcosis than when ether alone is employed, 
and, the patient not being saturated with the drug, the after-effects 
of ether anesthesia are not nearly so frequent or pronounced. It is 
safer than ether given alone by the open or semiopen inhalers, prob- 
ably because the stage of excitement is absent, and, in the second 
place, the carbon dioxid content is maintained and the ether vapor 
is warmed through the constant rebreathing; and, finally, a much 
smaller amount of the anesthetic is required. 

Apparatus. — If desired, the gas may be administered by any of the 
ordinary nitrous oxid gas inhalers, and the ether by the open or semi- 
open method, though a combination gas and ether apparatus, such as 
Clover's, Hewitt's, Bennett's (Fig. 22), Gwathmey's (Fig. 23), or 
Pedersen's, is preferable and more convenient. These inhalers con- 
sist of the usual metal mouth-piece and inflatable rubber rim, inspira- 
tory and expiratory valves, and gas bag. In addition, the inhalers 
have an ether chamber containing gauze upon which the ether is 



NITROUS OXID AND ETHER SEQUENCE 29 

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




Fig. 22. — The Bennett gas and ether apparatus. 

ether vapor. In the Bennett apparatus the gas bag is removed as 
soon as the patient is well under the nitrous oxid, and a second bag is 
substituted; with the Gwathmey inhaler, this is improved upon, and 




Fig. 23. — Gwathmey's gas and ether apparatus. 

but one bag is used for both gas and ether. As with all apparatus 
having mechanism likely to get out of order, the inhalers should 
always be tested before using. The same inhaler should never be 
taken from one person to another without sterilization. 



30 THE ADMINISTRATION OF GENERAL ANESTHETICS 

Administration. — 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 breath- 
ing properly, the expiratory valve is opened and the nitrous oxid is 
turned on. After a few breaths the expiratory valve is closed and the 
patient breathes the gas back and forth, gradually going under its 
influence, which is denoted by duskiness of color, irregular snoring 
respiration, and muscular twitching. 

The addition of ether vapor is now commenced by rotating the 
ether chamber slowly. A small amount of ether is administered at 
first, and this is gradually increased until the patient is getting the full 
strength of ether. During this period, if symptoms of asphyxia 
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 administration of the ether is proceeded with in the usual way 
when using a closed cone. 

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

ETHYL CHLORID ANESTHESIA 

Ethyl chlorid is a colorless, very volatile and inflammable liquid. 
If pure, it has an ethereal odor, and should not be acid to litmus. 
For general anesthetic purposes the purest quality of the drug should 
be used, and only that labelled "for general anesthesia." This can be 
obtained in containers furnished with a spring stopcock, which per- 
mits the drug to be administered in a fine stream in any desired quan- 
tity (Fig. 24), or in hermetically sealed glass tubes containing about 
I 1/4 drams (5 c.c.) of the drug. The latter is best suited for the 
closed inhalers, the whole amount being emptied into the inhaler at 



ETHYL CHLORID ANESTHESIA 



31 



once. Ethyl chlorid Is decomposed by light and air, hence it should 
be kept in a dark place and in tightly stoppered tubes. 

When inhaled, it is very rapidly absorbed and is quickly eHmi- 
nated, anesthesia being produced in from thirty seconds to a minute or 
so, and lasting two to three minutes after the withdrawal of the anes- 
thetic. Recovery is not quite so rapid as with nitrous oxid, and after- 
effects, such as headache, nausea, vomiting, and dizziness, are not at 
all uncommon. It is not nearly so safe as nitrous oxid, nor so pleas- 
ant an anesthetic to take. It has the advantage, however, of not 
producing cyanosis, and the anesthetic effects are more prolonged; 




Fig. 24. — Ethyl chlorid tube. 

fiu-thermore, it may 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 peripheral vessels. 

Suitable Cases. — Ethyl chlorid is employed mainly for brief 
operations or for examinations not requiring full muscular relaxation, 
and as a preliminary to ether to get the patient under rapidly without 
strugghng and excitement. It acts especially well in children on 




Fig. 25. — Showing the Schimnaelbusch mask covered with gauze and oil silk for the 
administration of ethyl chlorid. 



account of its rapidity of action. It should never be immedi- 
ately followed by chloroform, as both are circulatory depressants. 
Its use is contraindicated when there is any respiratory obstruction. 
Apparatus. — Omng to its great volatility, ethyl chlorid is most 
satisfactorily administered by means of a closed inhaler, though the 
semiopen method may be employed, and is preferred by many as 
being safer. For the latter, one may employ an Esmarch or Schim- 



32 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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

There are a number of inhalers, however, devised especially for 
this drug and similar anesthetics. Ware's inhaler (Fig. 26) consists 
of a pliable rubber mouth-piece, to the top of which is fitted a metal 
chimney. At the point the latter joins the mouth-piece, several 
layers of gauze are interposed upon which the anesthetic is sprayed 

through the top of the apparatus. The 
somnoform inhaler consists of a glass face- 
piece with an inflatable rubber rim and 
rubber balloon. The balloon is attached 
to the mouth-piece by a T-shaped cham- 
ber which is provided with a valve and a 
small opening through which the anes- 
thetic may be sprayed. 

Administration. — In administering 
ethyl chlorid by the closed method, the 
inhaler is placed over the patient's face 
during expiration in order to fill the bag, 
and, as soon as the patient is breathing 
regularly, from i to i 1/4 dr. (4 to 5 c.c.) 
of ethyl chlorid are sprayed into the bag, 
or, if a special inhaler is used, into the opening provided for the 
purpose. If the face-piece be tightly applied, so as to prevent the 
entrance of air, signs of anesthesia appear in from thirty seconds to 
one minute. As soon as anesthesia is produced, the patient should 
be allowed to have air. 

Full anesthesia is characterized by rapid and shghtly stertorous 
breathing, dilated pupils, absence of conjunctival reflex, and more 
or less complete relaxation. There is no cyanosis, though the color 
of the skin is heightened from the dilatation of the peripheral vessels. 
The inhaler should now be removed and the operation proceeded with, 
or else ether is substituted. If the patient recover too rapidly, more 
anesthetic may be given, provided a plentiful supply of air is allowed. 
By an interrupted administration of ethyl chlorid — that is, first 
securing deep narcosis and then giving air — a prolonged light anes- 
thesia may be obtained, though at times muscular relaxation is not 




Fig. 26. — Ware's ethyl 
chlorid inhaler. 



ANESTHETIC MIXTURES 33 

complete and the patient is apt to remain partly conscious. Danger 
signs from ethyl chlorid anesthesia are gasping, shallow respirations, 
pupils widely dilated and not reacting to light, and general pallor of 
the skin. 

Administered by the semiopen method, a greater quantity of the 
drug will be necessary, and somewhat more time will be consumed in 
getting the patient under than by 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. or Vienna mixture contains: 

Chloroform, i part 

Ether, 3 parts 

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

Anesthol is composed of: 

Ethyl chlorid, 17 per cent. 

Chloroform, 35.89 per cent. 

Ether, 47 ■ 10 per cent. 

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

3 



34 THE ADMINISTRATION OF GENEIL\L 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 comphcations and 
dangers that may arise during the administration of these mixtures, 
however, are those met with from chloroform rather than from ether, 
and, as a general principle, mixtures should be given with as much 
caution as would be observed in the administration of the most dan- 
gerous drug they contain. 

Suitable Cases. — When nitrous oxid or ether are considered inad- 
visable, a mixture of chloroform and ether is the next choice. Thus 
in children and in persons over sixty, in the fat and plethoric, in cases 
suffering from chronic lung trouble, as emphysema, bronchitis, etc., 
in advanced cardiac disease with lack of compensation, in atheroma, 
in alcoholics, in those with renal disease, and in cerebral operations 
mixtures are most useful. Being agreeable to take, they are often 
used as a means of obtaining primary anesthesia to ether when nitrous 
oxid or ethyl chlorid are unavailable. 

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

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

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

SPECIAL METHODS OF 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 



SPECIAL METHODS OF ANESTHESIA 



35 



as Crile's method, will be found of great service. The advantages are 
that the anesthetist and inhaler are removed from the seat of opera- 
tion so that they in no way interfere with the operator, and the anes- 
thetic may be administered continuously, as it is not necessary to 
delay or stop the operation every little while in order to get the patient 
well under, as is the case when the ordinary interrupted form of anes- 
thesia is employed. As the pharynx is packed with gauze, aspiration 
of mucus or blood from the site of operation is avoided, nor is there 
vomiting or coughing up of blood that may have collected in the back 
of the pharynx. 

Apparatus. — The apparatus consists of two rubber tubes of a size 
that will comfortably pass through the nares, each about 8 inches 




Fig. 27. — Showing the method of inserting the tubes and packing the pharynx for 

intubation anesthesia. 



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

Technic. — After full anesthesia has been obtained in the usual 
way, a mouth gag is inserted, the throat is well cleared of mucus by 
means of small gauze swabs, and the two tubes, well lubricated, are 
carefully passed through the nares and down to the epiglottis with 
their pointed ends directed downward and forward. The tongue is 



36 THE ADMINISTRATION OF GENERAL ANESTHETICS 

then drawn well forward and the whole pharynx is firmly packed with 
a single piece of gauze in such a way that the packing does not ob- 
struct the lateral fenestras or ends of the tubes (Fig. 27). Care 
should be taken at this stage to hsten at the ends of the tubes in order 
to make sure that the patient is breathing properly. If he is not, 
the gauze should be promptly removed and the pharynx repacked. 
As soon as regular breathing is established through the tubes, the 
funnel is connected and the anesthetic is continued by the drop 
method. 

Intratracheal Insufflation Anesthesia. — Intratracheal in- 
sufHation anesthesia, tirst suggested by Meltzer and Auer, con- 
sists essentially in the introduction deep into the trachea of a 
flexible tube with a diameter considerably less than the lumen 
of the trachea and the forcing of a current of air and ether vapor 
through the tube, the space between the tube and trachea per- 
mitting the return of air from the lungs. This method of anes- 
thesia was originally adopted to supply a positive pulmonary pres- 
sure for operations upon the thoracic viscera, the resistance to the 
return of air through the trachea being sufficient to prevent the 
lungs from collapsing when the thorax is opened. For this pur- 
pose it has largely replaced the various differential pressure 
chambers. 

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

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



SPECIAL METHODS OF ANESTHESIA 



37 



duced beyond the bifurcation of the trachea, and that during the 
insertion of the tube the pharynx and trachea are not injured. 

Apparatus. — There are several good intratracheal insufflation 
machines on the market, such as Elsberg's, Janeway's, and Boothby's, 
which are elaborate in their completeness. A very simple and inex- 
pensive apparatus (Fig. 28), which answers all purposes, is described 
by Meltzer (Keen's Surgery, Vol. VI) as follows: 

"By means of a glass-blower's foot-bellows (B) air is driven 
through a system of branching tubes into the intratracheal tube 
In.-T) . The first branching of the tubes is introduced for the purpose 




Fig. 28. — Apparatus for intratracheal insufflation anesthesia (Meltzer in Keen's 

Surgery) . 



of regulating the interruption of the air-stream. From the right 
branch a tube is led off laterally, carrying a stopcock (St. 3), which is to 
be used for the interruptions of the air-current. During the opening 
of the stopcock a part of the air-current continues through the left 
tube, thus preventing too great a reduction of the pressure, which is 
undesirable. By means of a screw-clamp (S.C.) the amount of air 
which is to pass through the left tube can be regulated; a narrowing 
of this tube causes a greater collapse of the lung during the interrup- 
tion. The second branching of the tubes is introduced for the pur- 
pose of regulating the anesthesia. The ether bottle (E) is interpo- 
lated in the left branch; the right branch runs uninterrupted outside 
of the bottle to unite with the part of the left tube which comes from 
the ether bottle. When the stopcock in the right branch (St. 2) is 



38 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



closed, all the air passes through the ether bottle; when, instead, both 
stopcocks in the left branch (St. i and St. 4) are closed, only pure air 
reaches the intratracheal tube, and when all three stopcocks are 
open only one-half of the air is saturated with the anesthetic. By 
partial closing of the stopcocks various degrees of anesthesia can be 
obtained. The third opening in the ether bottle carries a tube with 
a funnel (F) through which the bottle is filled with the anesthetic; 
the tube is otherwise kept tightly closed by means of a screw-clamp 
(S.C.). All three rubber stoppers are firmly and permanently wired 
down to resist various pressures. When the ether bottle is to be 
refilled during insufflation, both stopcocks on the left side are closed, 
while the one on the right side is open." 

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




Fig. 29. — Jackson's direct view laryngoscope. 

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



SPECL\L METHODS OF AXESTHESLA. 39 

(35 cm.) long, with a mark lo 1/2 inches (27 cm.) from the distal end 
and with the opening preferably at the end. A silk woven catheter, 
No. 22 to 24 French, and for children of a correspondingly small size, 
is frequently used. There will be required in addition a mouth-gag 
and a Jackson's direct view laryngoscope (Fig. 29). Elsberg has 
devised a special bit or holder to keep the tube from sHpping up or 
down after it has been properly introduced, but, in its absence, 
adhesive plaster may be employed for this purpose. 

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

Preparations of the Patient. — The patient is prepared as for any 
anesthesia (see page 2) and is given morphin gr. 1/6 (0.0108 gm.) 
and atropin gr. i/ioo fo. 00065 S^^-) by hypodermic half an hour 
before the operation. 

Technic. — The patient is first etherized in the usual way and is 
placed upon the operating-table with his head hanging over the edge 
in which position it is supported by an assistant (see Fig. 474), 
the patient's mouth being held open by a mouth-gag. ^ The 
Jackson laryngoscope is then introduced (for the technic of this see 
page 398), and, with the epiglottis pulled forward by the beak of the 
instrument so that a good view of the larynx is obtained, the tracheal 
catheter, wet in cold water, is inserted. . No force should be employed 
in introducing the catheter, and, as soon as it is well in the larynx, 
the tubular speculum is removed. The catheter is then pushed for- 
ward until it meets a resistance which is generally the right bronchus. 
The catheter is then withdrawn 2 to 2 1/2 inches (5 to 6 cm.) until the 
mark on the catheter is at the patient's teeth. The operator must 
be certain that the catheter is in the patient's trachea and not in the 
esophagus. The catheter is finally fixed in place, and, after the 
apparatus is properly connected, the insufflation of the air and ether 
vapor is commenced. The vapor at first should be blown in under 
sHght pressure, that is, about 10 mm. of mercury and then under 
higher pressure — 15 to 20 mm. of mercury. The air current should be 
interrupted 5 to 6 times a minute by opening the vent for that purpose 
a second or two at a time. The anesthesia is pushed to complete 
muscular relaxation and abohtion of reflexes, and, when the desired 
degree of narcosis is obtained, the dose of ether should be kept uni- 
form, as the degree of anesthesia from a certain dose is practically 
stationary. At all times it should be seen that there is a free passage 
for air, and the tongue should not be allowed to fall back and produce 
any obstruction. A spasm of the glottis may in some cases be the 
cause of obstruction; if so. full anesthesia will relieve the condition. 



40 THE ADMINISTRATION OF GENERAL ANESTHETICS 

The color and respirations of the patient should be carefully watched, 
and, if the latter become shallow and infrequent, the anesthetic 
should be diminished. 

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

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




Fig. 30. — The Trendelenburg apparatus for tracheal anesthesia. 

Anesthesia Through a Tracheal Opening. — In some opera- 
tions 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 a Trendelenburg 
cannula is employed. These instruments consist essentially of a 
metal funnel, covered or filled with gauze upon which the anesthetic 
is dropped, and connected with a special tracheotomy tube by means 
of a piece of tubing. The tracheal tube of the Hahn apparatus is 
surrounded by a flat dried sponge fastened securely in place, which, 
when wet, swells up and acts as a tampon, preventing blood from de- 
scending along the side of the tube. The same result is obtained with 
the Trendelenbm-g instrument (Fig. 30) by surrounding the lower 
portion of the cannula with a delicate air bag, which is gently inflated 



SPECIAL METHODS OF ANESTHESIA 



41 



by compressing an inflating bulb supplied with the apparatus as soon 
as the tracheotomy tube is in place (Fig. 31). 

Technic. — A preliminary tracheotomy is first performed (see 
page 389). The tracheal tube is then introduced into the opening, 
care being taken to see that the tamponade is effective, so as to pre- 
vent blood from entering the trachea. The tube to convey the anes- 
thetic vapor from the funnel is then attached to the tracheal cannula, 
and the anesthetic is administered by dropping chloroform on the 
gauze of the inhaler. 

Intravenous General Anesthesia. — Burkhardt in 1909 de- 
vised a method of producing general narcosis by administering 
ether intravenously in a normal salt solution. Since then the 
method has been given a trial by a number of operators abroad and 




Fig. 31. — Showing the tracheal cannula in place. 



by a few in this country, but further experience will be necessary be- 
fore its true value can be determined. From our present knowledge 
it is not probable that intravenous etherization will ever supplant 
the inhalation method as a routine. In certain operations, as those 
about the face, upper air passages, mouth, tongue, and neck, 
the absence of a mask near the field of operation and the even and 
uninterrupted anesthesia that is produced by this method is of 
undoubted advantage. Furthermore, the stimulating effect of a 
continuous saline infusion makes the method one of special value in 
ill-nourished, debilitated, or cachectic subjects. On the other hand, 
there are the dangers of sepsis, thrombosis, embolism, and pulmonary 
edema if all the details of the technic are not carefully observed. 
When properly administered it is claimed that the anesthesia is 
rapidly obtained, that there is seldom any stage of excitement, that 



42 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



pulmonary irritation and nausea are absent, and that the recovery 
from the anesthesia is prompt and without discomfort. According to 
Kummell intravenous anesthesia is contraindicated in the presence of 
arterio-sclerosis, myocarditis, and general plethora. 

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

Apparatus. — An apparatus, such as described 
by Rood {British Medical Journal, Oct. 21, 
191 1), which will permit a continuous but slow 
flow of solution is required.^ The apparatus 
should consist of (i) a glass reservoir with a ca- 
pacity of 3 pints (1500 c.c.) supported upon a 
stand at a height of 8 feet (240 cm.) from the 
floor, (2) a glass dripping chamber with a capa- 
city of 8 ounces (250 c.c.) and (3) a warming 
chamber surrounded by a jacket containing 
water at a temperature of 100° F. (38° C.) (Fig. 
32). When the apparatus is working the solu- 
tion drips from the pipette leading from the res- 
ervoir into the indicator, the lower half of which 
is filled with solution and the upper half with air. 
A tap below the indicator controls the rate of 
flow, the rate at which the solution drips from 
the pipette being an index of the rate at which 
it will enter the vein. 

Instruments. — The operator will require a 
scalpel, a pair of blunt-pointed scissors, thumb forceps, an aneurysm 
needle, a needle holder, curved needles with a cutting edge, and No. 
2 plain catgut (Fig. 1,2,). 

Solutions. — Ether is used in a 5 per cent, solution in normal salt 

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



Fig. 32 — Appara- 
tus for intravenous 
anesthesia. 



SPECIAL METHODS OF ANESTHESIA 



43 



solution by Burkhardt and in a 7.5 per cent, solution by Rood. Hedo- 
nal and paraldehyde have also been used with success. Fedoroff 
employs a 0.75 per cent, solution of hedonal in normal salt solution. 
The objection to the use of this drug is the length of time the hypnotic 
effect persists when large amounts are administered. Noel and Sout- 
tar {Annals of Surgery, January, 1913) first called attention to the 
anesthetic effects of paraldehyde when given intravenously. Honan 
and Hassler {Medical Record, Feb. 8, 1913) employ paraldehyde 
2 1/2 per cent, and ether 3 per cent, in normal salt solution. 

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




Fig. 33. — ^Instruments for intravenous anesthesia, i, Scalpel; 2, blunt- 
pointed scissors; 3, thumb forceps; 4, aneurysm needle; 5, needle holder; 6, 
curved needles; 7, No. 2 plain catgut. 

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

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

Preparations of Patient. — It is advisable to give the patient hypo- 
dermically an hour before the operation morphin gr. 1/6 (0.0108 gm.), 
atropin gr. i/ioo (0.00065 gm.), and scopolamin gr. i/ioo (0.00065 
gm). All clothing should be removed from the arm chosen for the 
infusion and the arm should be bandaged to a well-padded splint so 
that the infusion cannula cannot be disturbed by movements of the 
patient. 



44 THE ADMINISTRATION OF GENERAL ANESTHETICS 

Asepsis. — The solution must be absolutely sterile. The instru- 
ments are sterilized by boiling. The site for the infusion is shaved 
and thoroughly cleansed twenty-four hours before the operation, 
and is then dressed with sterile gauze. At the time of operation 
the skin is painted with tincture of iodin. 

Technic. — A tourniquet is placed about the arm above the site of 
injection. Under infiltration anesthesia with a 0.2 per cent, solution 
of cocain or a i per cent, novocain solution the median cephalic or the 
median basilic vein is exposed through a small incision. The 
distal porton of the vein is ligated, the proximal portion is in- 
cised, and the cannula inserted with the solution flowing as described 
under intravenous infusion (page 138). The constriction is then 
removed from the arm and the ether solution is allowed to run, at first 
rapidly until anesthesia is induced, and then drop by drop, being 
guided by the depth of anesthesia. 

It usually requires from four to ten minutes to induce full anes- 
thesia, using 3 to 6 ounces (100 to 200 c.c.) of solution. After 
anesthesia is obtained the flow of solution should be at about the 
rate of 40 to 60 drops per minute. Should edema of the eyelids 
appear at any time, the infusion should be temporarily stopped. 
During the anesthesia the anesthetist must take the same pre- 
cautions to maintain unobstructed air passages as with inhalation 
anesthesia. 

At the completion of the operation the cannula is removed, the 
vein ligated with catgut, and the wound sutured. A sterile dressing 
is then applied. 

Rectal Anesthesia. — It consists in producing narcosis by means 
of warm ether vapor slowly forced into the rectum. This method 
was employed in 1847 by Roux. Later, in 1884, it was taken up by 
Molliere and in this country by Dr. Weir and Dr. Bull, but it never 
came into general use. In the early cases coHcky 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 administering the anesthetic, and with the 
improved technic of Cunningham the method has given better results. 

Though it cannot be said to be free from risks, rectal anesthesia has 
a definite place among the methods of anesthetizing at our disposal. 
Its greatest field of usefulness is in cases of extreme pulmonary or 
bronchial involvement and empyema, and in operations about the 
face, mouth, and larynx, where other means of anesthesia areunsuited. 
To the former class of cases it is especially suited on account of the 



SPECIAL METHODS OF ANESTHESIA 



45 



absence of pulmonary or bronchial irritation from the ether. While 
it is true that the greater part of the ether is eHminated from the lungs,, 
the direct irritation of concentrated vapor is overcome, as is shown 
by the absence of the bronchial secretion, cough, etc. The method 
also has the advantage of requiring but Httle ether to induce and main- 
tain anesthesia, and there is practically no stage of excitement or 
postoperative nausea and vomiting. On the other hand, the induc- 
tion of narcosis is slow, and, in some cases where the absorptive power 
of the rectum is hmited, enough of the drug is not taken into the 
system to keep the patient under, so that other means of anesthetizing 
must be utilized. It is not a suitable method to employ in abdominal 
operations on account of the distention produced, nor should it be 
used if the intestines are inflamed or their walls weakened. 




Fig. 34. — Apparatus for rectal anesthesia. 

Apparatus. — The necessary apparatus consists of the following: 
A wash bottle to hold the ether, about 8 inches (20 cm.) high and 4 
inches (10 cm.) in diameter, supplied with a tight stopper in which 
are two perforations. Through one of these openings a glass tube 
leads to the bottom of the bottle, and through the other a glass tube, 
cut off flush with the under surface of the stopper, leads out. A 
double cautery bulb is attached to the aft'erent tube by a piece of 
rubber tubing, while to the efferent tube is connected a piece of rubber 
tubing leading to a plain rectal tube, a glass bulb being interposed be- 
tween the rectal tube and the rubber tubing to catch any condensed 
ether vapor and prevent it from entering the rectum. Both the affer- 
ent and the eft'erent tubes should be of sufficient length to permit the 



46 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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. (32° 
C), but not much above, as the ether will boil at 96° F. (35° C). 
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 satu- 
rated with warm ether vapor. 

Preparation of the Patient. — A thorough cleansing of the bowels is 
absolutely necessary, otherwise absorption cannot take place and the 
first essential of the anesthesia is defeated. A cathartic is given to 
the patient the night before the operation, and on the following 
morning a colonic irrigation, followed by an ordinary soapsuds 
enema an hour before the operation, complete the preparations. 

Technic. — The patient lies upon the table with one thigh elevated 
upon a sand-bag so as to afford room to insert the tube, etc. The 
bottle is filled about two-thirds with ether, leaving one-third of its 
capacity for vapor, and the apparatus is tested to see that it works 
properly. The rectal tube, well lubricated, is inserted 8 to 10 
inches (20 to 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, likewise, be allowed to escape. 

In from three to five minutes the odor of the drug will be distin- 
guished in the patient's breath, and the patient soon begins to feel 
drowsy. The breathing, at first rapid, becomes regular and finally 
slightly stertorous, and the patient then passes into complete surgical 
narcosis, generally without the preliminary stage of excitement. The 
time necessary for this varies from five to fifteen minutes, according 
to the patient and the absorption power of the bowel. The anesthetic 
cannot be pushed, however, for the more the bowel is distended 
beyond a certain point the less is the absorption. As soon as anes- 
thesia is complete 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 



SPECIAL METHODS OF ANESTHESIA 47 

from the apparatus, and, by gentle abdominal massage of the colon, 
the vapor remaining unabsorbed is forced out. This should be fol- 
lowed by a cleansing enema. 

OiI=ether Colonic Anesthesia. — Recently Gwathmey of New 
York has developed a method of rectal anesthesia by means of a 
mixture of olive oil and ether injected into the rectum to which he 
applies the name "oil-ether colonic anesthesia" (N. Y. Medical 
Journal, Dec. 6, 19 13). Up to the present writing this method 
of anesthesia has been used in something over 100 cases and, while 
it may be said to be still in the experimental stage, it promises 
to be a most valuable addition to the field of anesthesia. The 
method is especially useful in operations about the head and neck, 
though it has been used in a great variety of operations. According 
to Gwathmey, it is contraindicated in cohtis, hemorrhoids, fistula in 
ano, or other pathological conditions of the lower bowel, and in most 
cases where ether is contraindicated. Under this form of anesthesia 
there is complete relaxation, the reflexes remain active, and there is 
an absence of nausea. For from one to three hours following the 
anesthesia there is a pain-free period. So far no diarrhea or bloody 
stools or other untoward effects have been observed. 

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

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

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

Preparations of Patient. — The usual preparations as for any anes- 
thetic are carried out, and the colon is irrigated until the fluid returns 
clear. For adults a preliminary hypodermic injection of 1/8 to 
1/4 gr. (0.0081 to 0.0162 gm.) of morphin and i/ioo gr. (0.00065 
gm.) of atropin is given half an hour before operation and at the same 
time 5 gr. (0.3 gm.) of chloretone in 2 drams (8 c.c.) of olive oil and 
2 drams (8 c.c.) of ether is introduced into the rectum. For children 
preliminary medication is generally omitted, as the weaker solutions 
are not irritating to the bowel. 

Technic. — The anesthetic mixture is introduced into the bowel 
while the patient is in bed in the Sims position. The small catheter, 



48 THE ADMINISTILA.TION OF GENERAL ANESTHETICS 

well lubricated, is inserted a few inches into the rectum and the desired 
quantity of solution, depending upon the weight of the patient, is 
slowly poured into the funnel. About five minutes should be con- 
sumed in introducing 8 ounces (250 c.c), the quantity generally 
required for an adult of ordinary size. The tube should be left in 
place until the patient is partially unconscious. In from five to 
twenty minutes the anesthesia is estabhshed. During the anesthesia 
the anesthetist should keep the air passages free and the jaw well for- 
ward and should keep careful watch over the general condition of the 
patient. Should the patient become too deeply under the influence 
of the anesthetic, shown by cyanosis, shallow, embarrassed or ster- 
torous respirations, a rectal tube is introduced and 2 to 3 ounces 
(60 to 90 c.c.) of solution are withdrawn. 

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

Scopolamin-morphin Anesthesia — Hypodermic injections of 
scopolamin and hyoscin (which is claimed to be chemically the same) 
have been used quite extensively in combination with morphin to 
produce anesthesia. From the number of deaths reported from this 
combination when used in large enough quantities to produce 
anesthesia unaided, it would appear to be a very dangerous form of 
anesthesia, and up to the present time it has a higher death percent- 
age than chloroform or ether. In small doses, however, hyoscin 
and morphin may be used with good results as an adjunct to local 
or general anesthesia. In such cases they can be given as follows: 
Hyoscin, gr. i/ioo (0.00065 S^-) ^.nd morphin, gr. 1/6 to 1/4 
(0.0108 to 0.0162 gm.) by h}^odermic, one hour to two hours before 
operation. This combination is more efl&cacious than morphin alone, 
and has the effect of producing a drowsy state and even sleep, which 
may last five to six hours after the operation. It is contraindicated 
in patients with heart disease or when there is a tendency to pulmon- 
ary edema. In the young and the aged hyoscin and morphin should 
be used with great caution. 

ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT 

The accidents and dangers that may arise during the adminis- 
tration of anesthetics are connected with the respiratory or circulatory 



ACCIDENTS DURING ANESTHESIA 49 

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 occurring as the result of the depressing effects of the drug upon 
the circulation. Practically, however, in severe cases failure of the 
respiratory centers and circulatory paralysis, if not coincident, pre- 
cede or follow one another in such rapid sequence that it is often 
impossible to distinguish between the two or to determine which is 
the primary cause, and treatment must be directed toward both 
conditions. 

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

Asphyxiation. — It is characterized by a moderate cyanosis 
or a marked lividity of color and gasping respirations. It may 
be only transient, or it may become progressively worse and 
severe. Such a condition should be promptly treated by re- 
moval of the cause which will be found to be some one of the fol- 
lowing: coughing, struggling, locking of the Jaws, awkward posi- 
tion of the patient, an improper holding of the cone, the so-called 

4 



50 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



" forgetfulness to breathe," falling back of the tongue and epiglottis, 
obstruction to the air passages by blood, mucus, saliva, or foreign 
bodies, partial or complete occlusion of the nose from deformities of 
the bones and nasal growths, or from collapse and falling in of the 
ake nasi during inspiration under deep narcosis. 

Treatment.— Cyanosis due to coughing or struggling may be 
overcome by simply removing the inhaler and permitting the patient 




Fig. 35. — Method of holding the jaw forward. 

to get a breath of fresh air. When the position of the patient is 
responsible, it should be corrected without delay. If the cyanosis 
be due to obstruction or partial occlusion of the nares, the mouth 
should be kept sufficiently open by means of a mouth-gag to permit 
the entrance of the necessary amount of air. "Forgetting to 
breathe" is met by removing the inhaler and, after waiting a moment, 




Fig. 36. — Showing the method of drawing the tongue and epiglottis forward. 

the patient will in the majority of cases take a breath. If this is not 
sufficient, a sharp slap upon the sternum with a wet towel or a momen- 
tary compression of the sternum is frequently all that is necessary. 
Failing by these means, the jaws should be held apart and rhythmic 
traction exerted upon the tongue to excite a reflex inspiration. 

Obstruction caused by the falling back of the tongue and epiglot- 



ACCIDENTS DURING ANESTHESIA 



51 



tis is corrected by properly holding the lower jaw forward (Fig. 35), 
or by traction upon the tongue by means of tongue forceps or a silk 
suture. 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. 3^)- 

When the asphyxial symptoms are due to obstruction by collec- 
tions of fluid in the throat or foreign bodies, the patient's head should 
be turned to one side, the jaws forced open, and the air passages 
cleared. Sohd bodies may be removed by the finger or forceps. If 
this is not possible, tracheotomy (page 424) should be performed 
without hesitation. 

In any case of asphyxia, if the cyanosis is severe and grows pro- 




FiG. 37. — Artificial respiration (inspiration). Note the assistant's hands ready 
to make counterpressure over the lower portion of the chest. 



gressively worse in spite of the above line of treatment, the anesthetic 
and the operation should be discontinued while artificial respiration, 
combined with inhalations of oxygen, is carried out. This is effec- 
tively performed by a combination of the Sylvester and Howard 
methods, or by the use of Meltzer's insufflation apparatus or some 
one of the machines made especially for performing artificial respira- 
tion. Any of the methods of artificial respiration are useless, how- 
ever, as long as there is any obstruction in the air passages, and 
these should always be first cleared out, as previously directed. 

In the absence of special apparatus, artificial respiration is 
carried out as follows: The foot of the operating-table is raised 



52 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



upon a stool and the patient is slid down so that the head hangs 
partly over the edge. The anesthetist, standing at the patient's 
head, takes a firm hold just below the elbows and draws the arms 
upward and outward until they are very nearly perpendicular above 
the head (Fig. 37). This thoroughly expands the chest and pro- 
duces an inspiration. The arms are maintained in this position for 
a second or two, to allow the air to thoroughly expand the lungs. 
Expiration is produced by the reversal of the above maneuver, 
bringing the arms downward with firm 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 




Fig. 38. — Artificial respiration (expiration). The operator brings the patient's 
arms firmly against the chest while the assistant makes counterpressure. 

upward toward the diaphragm (Fig. 38). This counterpressure 
prevents the effects of the expiratory maneuver being lost upon 
the diaphragm and abdominal viscera. After another second or 
so, the assistant suddenly releases the lower portion of the chest and 
at the same time elevation of the arms is again performed. The 
movements producing artificial respiration should be made as nearly 
as possible at the rate of normal respiration, certainly not over twenty 
times a mmute. 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 gradual return 
of the natural color, at first feeble gasps and then stronger attempts at 



ACCIDENTS DURING ANESTHESIA 53 

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

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

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

Treatment. — This is a condition requiring prompt and energetic 
treatment. The anesthetic and the operation should be immediately 
stopped and every effort made to revive the patient. It should be 
seen that there is no impediment to the free entrance of air into the 
respiratory passages, and then the foot of the table should be elevated 
upon a stool, while artificial respiration is performed after the manner 
above described (page 52). 

Cardiac Paralysis. — Syncope may occur during anesthesia from 
chloroform or ether, but is more apt to be produced by the former. 
It is the most serious of all the anesthetic accidents. From the fact 
that a 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 vaso- 
motor paralysis, is the cause. There is no doubt that fright or strug- 
gling during the early stage of anesthesia is sufficient in some cases 
to cause dilatation of the heart and vasomotor paralysis, especially 
if the individual is already affected with degenerative changes in the 
heart, or is suffering from severe anemia or shock. But fatal syncope 



54 THE ADMINISTRATION OF GENERAL ANESTHETICS 

has occurred in many cases after only a few inhalations of chloroform, 
when the patient was in strong physical condition and exhibited no 
fear of the operation whatever. Such cases and those occurring after 
full anesthesia has been established can only be ascribed to the toxic 
action of the drug from sudden overdosage. 

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

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

External cardiac massage maybe 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 may be massaged by grasping it between the thumb and 
forefinger, through the relaxed diaphragm, and alternately compress- 
ing 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 suc- 
cessfully 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, 



THE AFTER-EFFECTS OF ANESTHESIA 55 

however, as adrenalin chlorid, 5 to 2oTri (0.30 to 1.25 c.c.) injected 
into a vein, camphorated oil, 2oTn. (1.25 c.c), whisky, 2oTri (1.25 
c.c), etc., may be tried with better chances of success. ' An intra- 
venous infusion of hot salt solution, combined with 15 to 3oTn. 
(i to 2 c.c) of a I to 1000 solution of adrenalin chlorid injected 
drop by drop by means of a hypodermic directly into the rubber 
tube of the infusion apparatus while the solution is flowing, should 
be given by an assistant while the other means of treatment are being 
carried out. According to Crile's experiments, an intraarterial in- 
fusion of adrenahn in salt solution injected toward the heart (see 
page 145) has more effect in raising blood-pressure and would be a 
more rational form of treatment. When there is no improvement 
within ten or fifteen minutes, the case is usually hopeless. 

THE AFTER-EFFECTS OF ANESTHESIA 

Vomiting. — This is the most frequent postanesthetic complica- 
tion. The best way to avoid it is by careful preparation of the 
patient before anesthesia and a skilful administration of the anes- 
thetic. In some cases, however, it occurs in spite of all that can be 
done, and may be persistent. That from chloroform is 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 efficient, serving to 
dilute the mucus and wash out the stomach contents. Fifteen to 
20 gr. (i to 1.5 gm.) of bicarbonate of soda in a glass of warm water 
is also recommended. Likewise pure olive oil in ounce doses has 
been successfully employed. Cerium oxalate, gr. v (0.3 gm.), bis- 
muth subnitrate, gr. v (0.3 gm.), acetanilid in i gr. (0.065 g^^-) 
doses every one-half hour until 8 gr. (0.5 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 (see page 494) should be carried out and repeated as often 
as necessary. In fact, it is the best means of preventing vomiting 
in any case, and some surgeons employ it as a routine, having it 
performed while the patient is still on the operating-table before 
becoming conscious. 

Respiratory Complications. — These are seen more frequently 
after ether than chloroform, and include edema of the lungs, bron- 



56 THE ADMINISTRATION OF GENERAL ANESTHETICS 

chitis, bronchopneumonia, and lobar pneumonia. They should be 
treated along the lines ordinarily followed in such cases. Lung com- 
plications are especially liable to follow anesthesia where a diseased 
condition is already present, as bronchitis, emphysema, or tuber- 
culosis, or in the aged or feeble. 

To avoid as far as possible such complications, the mouth, nose, 
and teeth should be carefully cleansed before anesthesia, the appa- 
ratus employed for administering the anesthetic should not be carried 
from one patient to another without sterilization, and due care should 
be observed while administering the anesthetic to prevent aspiration 
of fluids or vomitus. As a further precautionary measure, the patient 
should always be carefully protected against chilling, both during the 
anesthesia and while he is being removed to his bed. 

Renal Complications. — Temporary albuminuria and casts are 
not uncommon after both ether and chloroform, and, if a diseased 
condition of the kidneys be present beforehand, it is much aggra- 
vated, though of the two drugs chloroform exerts less of an irritant 
action. Scanty excretion of urine with actual suppression and hema- 
turia are occasionally seen. Such a condition should be treated by 
mild diuretics, cathartics, and saline rectal irrigations. 

Postoperative Anesthetic Paralyses. — These are mostly per- 
ipheral from pressure upon some nerve during the period of uncon- 
sciousness, though paralysis of central origin may take place as the 
result of cerebral emboHsm or hemorrhage, especially in those with 
high arterial tension and degenerative changes in the blood-vessels. 
Peripheral paralysis may affect the arm, leg, or face. Injury to the 
musculospiral nerve from pressure by the edge of the table if the arm 
is allowed to hang down, and injury to the brachial plexus from pres- 
sure 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, aceto- 
nuria, and acid intoxication, most frequently follows chloroform nar- 
cosis and is more common among children. The symptoms do not 
appear until the patient has recovered from the anesthesia develop- 
ing in from 10 to 150 hours (Bevan and Favill). 

The condition is characterized by persistent vomiting, jaundice, 
sweetish breath, rapid pulse. Cheyne-Stokes respiration, in some 



THE AFTER-TREATMENT OF ANESTHESIA 57 

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

Bicarbonate of soda given by mouth in mild cases, and in salt 
solution by rectum, by hypodermoclysis, or intravenously in the 
severer ones, seems the most valuable remedy for this condition. For 
intravenous injection i 1/2 ounces (45 gm.) of bicarbonate of soda 
is dissolved in i quart (liter) of normal salt solution [salt 5 ii (8 gm.) 
to the quart (1000 c.c.) of water], and 1/2 pint (250 c.c.) is admin- 
istered every three or four hours until the entire amount is injected. 
In addition, free ehmination by the skin should be encouraged, and 
the bowels should be kept freely open. 

THE AFTER-TREATMENT OF CASES OF GENERAL 
ANESTHESIA 

Before moving a patient from the operating-table to his bed, it 
should be seen that he is well protected and properly wrapped in warm 
dry blankets. During the process of moving, care should be taken 
not to elevate the head or chest. The recovery room should be well 
ventilated, but the patient should be protected from any draughts. 
The bed should have been previously prepared and well warmed by 
means of hot-water bags, 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 burn the patient. 

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



58 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



by an attendant until consciousness returns, for, if left alone, he may- 
choke from mucus or vomited material collecting in the throat, or 
attempt to sit up, remove his dressings, or in other ways do himself 
harm. Delirious patients should be gently restrained, but not tied 
in bed. Inhalations of oxygen or vinegar, and washing the patient's 
face in cold water, are of aid in arousing to consciousness. 

The patient should not be allowed to sit up for at least six hours. 
Small quantities of hot water or cracked ice are given in the first 
few hours, but no food is allowed within six hours, and not then 




Fig. 39. — The ether bed. 

unless the patient has stopped vomiting. In cases of collapse, or 
for patients who are very weak, nutrient or stimulating enemata 
may be prescribed to sustain the patient until food can be 
taken. The first food taken by mouth should be liquid in character, 
consisting of broth, beef tea, or soup. If this is retained, other 
articles of soft diet should be added, until the ordinary diet is being 
taken. It is important to have the urine examined for several days 
after anesthesia, and after the use of chloroform special reference 
should be paid to detecting the presence of acetone or diacetic acid. 



CHAPTER II 
LOCAL ANESTHESIA 

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

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

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

In the choice between local and general anesthesia for any given 
case, the question to be decided is whether under local anesthesia 
pain sensibility can be entirely aboHshed and, at the same time, 
sufficient muscular relaxation be obtained to insure the proper per- 
formance of the procedures contemplated. If these condidons can 
be satisfactorily obtained, and if the operator possess the necessary 
experience and skill in its use, then local anesthesia should be offered 

59 



6o LOCAL ANESTHESIA 

to the patient, if for no other reason, simply to avoid the well-known 
unpleasant after-effects of general narcosis, and to obtain a less dis- 
turbed 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. — There are 
certain advantages peculiar to local anesthesia that should be care- 
fully considered when selecting the anesthetic in any given case. 
Most important is the absolute safety to the Ufe of the patient when 
this form of anesthesia is employed with proper precautions. With 
the substitution of the weak for the old-time strong cocain solutions, 
and the discovery of the newer less toxic analgesics, together with a 
knowledge of the amount of these drugs that can be safely used, the 
dangers of poisoning may be disregarded. 

Furthermore, under local anesthesia, shock is lessened, and the 
depression observed after the use of general narcosis is absent to a 
marked degree, so that this form of anesthesia becomes the method 
of choice when an anesthetic 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 effectually blocks the passage of all shock-producing impulses 
along that particular nerve. As Crile puts it: "As no impulses of 
any kind can pass either upward or downward, there is no more 
shock in dividing the tissues, even the nerve trunks thus "blocked," 
than in dividing the sleeve of the patient's coat." The value of this 
principle is so well established that the injection of cocain into nerve 
trunks supplying a region of operation is frequently performed 
for the purpose of preventing shock even where general anesthesia is 
employed, as, for example, the preliminary blocking of the sciatic 
nerve in hip amputations. 

Under local anesthesia the postoperative blood changes and the 
kidney, heart, and lung complications are all avoided, while the 
unpleasant after-effects that pertain to general anesthesia are re- 
duced to a mimimum. The avoidance of vomiting is especially im- 
portant for the proper healing of wounds, and the prevention of 
such complications as hernia. A further advantage in operat- 
ing under local methods is that the most favorable conditions 
for primary union are obtained, for, as gentleness in handling tissues 
is essential for the successful employment of this method of anes- 
thesia, the minimum amount of trauma will be inflicted upon the 
tissues. 

Another feature connected with an operation under local anes- 



LOCAL AXESTHESLA. 6 1 

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

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

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

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

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



62 LOCAL ANESTHESIA 

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

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

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

For the majority of abdominal operations local anesthesia is not 
satisfactory. It is not that there is any difficulty in entering the 
abdominal cavity — this can be very readily done under careful in- 
filtration of the various layers of the abdominal wall — but the trouble 
is in meeting the various comphcations that may be present. We 
know that the abdominal organs are insensible to pain, but the 
parietal peritoneum is most sensitive, especially if inflamed. The 
separation of adhesions and procedures that require dragging upon 
the mesentery are likewise painful. Exploratory operations and pro- 
cedures, such as colostomy, gastrostomy, gastrotomy, simple drain- 
age of the gall-bladder and appendiceal abscess, suprapubic cystotomy, 
suture of the intestines following typhoid perforation, appendicostomy , 
and some interval operations for appendicitis, requiring but little 
intraabdominal manipulation, can be readily performed without a 
general anesthetic; but when extensive manipulation is required, 
with the separation of adhesions necessitating more or less pulhng 
upon the mesentery, local anesthesia is contraindicated. Further- 
more, in abdominal surgery complete muscular relaxation is usually 
required to secure the necessary wide retraction, and this cannot 
always be obtained under local anesthesia. 

Local anesthesia is ideal in the operations for inguinal hernia on 
account of the superficial location of the structures involved and the 
definite position and course of the sensory nerve trunks supplying the 
region of operation. Other forms of hernia may be operated upon 
by employing infiltration alone, but not with the entire satisfaction 



LOCAL ANESTHESIA 63 

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

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

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

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

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

The methods of employing anesthetics may be in turn divided 
into two classes: (i) Where the drug is used in such a way that the 



64 LOCAL ANESTHESIA 

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

Drugs Employed for Local Anesthesia. — Cocain. — Of the many 
local anesthetics cocain was the first employed and holds the most 
important place, having successfully stood the test of time. When 
applied to the unbroken skin it is without effect, but in contact with 
mucous membranes it completely deadens sensibility within a few 
moments. Injected into the tissues, cocain produces anesthesia 
within the area of contact; when injected into or about a sensory 
nerve, it is rapidly absorbed and produces complete insensibility in the 
whole distribution of the nerve peripheral to the point of injection. 

Solutions of cocain should always be freshly prepared at the time of 
operation, as it is well known that they are prone to decompose, and 
in a short time such a solution becomes capable of producing sup- 
puration. A medium isotonic with the fluids of the body, as normal 
salt solution, is the best 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 efficient 
method is to place the cocain in a small test-tube plugged with cotton, 
and then to sterilize it by means of dry heat at a temperature of 300° 
F. for fifteen minutes. Several firms^ prepare hermetically sealed 

' Parke, Davis & Co., and Squibbs. 



LOCAL ANESTHESIA 



65 



glass tubes of sterilized salt and cocain according to Bodine's formula, 
each tube containing 2 4/5 gr. (0.18 gm.) of sodium chlorid and i 
gr. (0.065 gm.) of cocain muriate. The contents of one of these tubes 
dissolved in an ounce (30 c.c.) of sterile water gives approximately a 
I to 500 solution of cocain in normal salt solution. Alkalis render 
cocain inert. For this reason soda should not be put in the water in 
which the syringes, needles, and solution glasses are boiled. 

Solutions of cocain used in the following strength will be found 
amply strong for the purpose for which they are recommended. For 
anesthetizing the skin and for perineural injections, a i to 500 (1/5 
of I per cent.) solution; for deeper infiltration, a i to 1000 (i/io of 

1 per cent.) solution; for massive infiltration, a i to 3000 (1/30 of i 
per cent.) solution; and for endoneural injections, 10 to 30111 (0.6 to 

2 c.c.) of a I to 200 (1/2 of I per cent.) solution are employed. 
Schleich has three solutions containing a combination of cocain, 
morphin, and sodium chlorid: 





No. I, strong 


No. 2, medium 


No. 3, weak 


Cocain hydrochlor- 


gr. 3 (0.2 gm.) gr. i 1/2 (c.i gm.) 


gr. 1/6 (o.oi gm.) 


ate. 






Morphin hydro- 


gr. 1/3 (0.02 gm.) gr. 1/3 (0.02 gm.)| gr. 1/12 (0.005 


chlorate. 




gm-) 


Chlorid of sodium 


gr. 3 (0.2 gm.) i gr. 3 (0.2 gm.) 


gr. 3 (c.2 gm.) 


Distilled sterilized 


oz. 3 1/3 (100 c.c.) oz. 3 1/3 (100 c.c.) 


oz. 3 1/3 (100 c.c.) 


water. 









The strong solution is used for the skin, perineural injections, 
etc. An ounce (30 c.c.) may be used without risk. Of the medium 
strength solution, used for ordinary infiltration of the tissues below 
the skin, 2 ounces (60 c.c.) may be used; while as much as 10 
ounces (300 c.c.) of the weaker solution, which is employed for 
massive infiltration of large areas, may be safely injected. Tablets 
according to the Schleich formulae may be obtained from most phar- 
macists, 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- 



66 LOCAL ANESTHESIA 

constrictor and has the same effect in the way of an adjunct to local 
anesthesia as constriction of the part has, increasing as well as pro- 
longing the anesthetic effects to a marked degree. At the same time, 
by preventing capillary oozing, it gives a much drier lield of opera- 
tion. With its use there is some danger of secondary hemorrhage 
if the large blood-vessels are not properly secured, since, owing to its 
styptic action, even arteries of some size may be prevented from 
bleeding at the time and so be overlooked. It is a good rule, there- 
fore, to at least clamp any vessel that bleeds, however slightly, when 
using adrenahn. From 5 to 10 minims (0.3 to 0.6 c.c.) of the i 
to 1000 solution of adrenalin chlorid is added to the cocain and salt 
solution before it is to be used. 

In the early history of its development cocain was used in solu- 
tions as strong as 10 and 15 per cent., with the result that frequently 
a set of dangerous symptoms, and in some cases death, were the 
sequels. This toxic action is due to the absorption of more of the 
drug than the tissues can take care of. The amount of the drug that 
can be 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 mucous membranes from 
which rapid absorption takes place. With the weaker cocain solu- 
tions (0.2 to 0.1 per cent.) it is rarely necessary to exceed this amount, 
even in extensive operations. Of course, when a large proportion of 
the solution escapes, or when the circulation is impeded by constric- 
tion, a larger amount may be used with safety. 

To avoid the untoward effects of cocain, a number of drugs, as 
eucain B, tropacocain, stovain, alypin, novocain, acoin, nirvanin, 
orthoform, anesthesin. quinin and urea hydrochlorid, etc., which are 
less toxic but have about the same action as cocain, have been intro- 
duced as substitutes. Of these, eucain B, novocain, and quinin and 
urea are probably most frequently used. These newer preparations 
are preferred by many operators to cocain, and they have the advan- 
tage that their solutions may be sterilized by boiling. Weak solu- 
tions of cocain, however, used with proper precautions, the writer 
has always found to be perfectly safe as well as efficient. 

B-Eucain. — Eucain was one of the first substitutes for cocain. 
It is claimed to be one-fourth as toxic as cocain; on the other hand the 
anesthetic effect is slower and less pronounced. It has the advan- 
tage over cocain that its solutions may be boiled. Eucain is a vaso- 



LOCAL ANESTHESIA 



67 



dilator and the addition of adrenalin to its solutions has not nearly 
so pronounced an effect as when added to cocain. The drug is 
generally used in 1/2 per cent, solution with adrenalin. 

Novocain. — Novocain, one of the more recent and at the present 
time the most popular substitute for cocain, was introduced in 1905. 
It is estimated to be one-sixth to one-seventh as toxic as cocain. Like 
eucain, its solutions are not affected by boiling. It is precipitated 
from solution by free or carbonated alkalis, so syringes, needles, etc., 
should be boiled in pure water. Used in conjunction with adrenalin 
its anesthetic powers are about equal to cocain when injected into the 
tissues, but as a local anesthetic for mucous surfaces it is far inferior 
to cocain. 

Braun employs four novocain solutions: 





No. I 


No. II 


No. Ill 


No. IV 


Novocain.. . 


3 3/4 gr. (0.2s gm.) 


3 3/4 gr. (0.25 gm.) 


I 1/2 gr. (o.i gm.) 


I 1/2 gr. (o.i gm.) 


Normal salt 










solution. 


3 1/3 oz. (100 c.c.) I 2/3 oz. (50 c.c.) 


2 1/2 dr. (10 c.c.) 


I 1/4 dr. (5 c.c.) 


Adrenalin 










i-iooo or I 

Homorenonf 


5 drops 


5 drops 


5 drops 


ID drops 


4 per cent. J 











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

Quinin and Urea Hydrochlorid. — This combination was intro- 
duced into surgery in 1907. So far as known, it has no toxic effects, 
and the anesthesia produced by it is a protracted one, often lasting 
four or five days. In its early use solutio ns of i per cent, were employed, 
but it was found they produced an exudate of fibrin that sometimes 
interfered with wound healing, so that at the present time the 
drug is employed in 1/2 to 1/4 per cent, solutions. Upon mucous 
membranes, solutions of 10 to 20 per cent, may be used. It, how- 
ever, does not produce a shrinkage of the tissues as cocain does 
and for this reason is inferior to it in nasal work. 

Preparation of the Patient. — The usual preparation of the bowels, 
etc., recommended as preliminary to general anesthesia, is advisable. 
There is no need for the patient to fast, however, and a light meal of 
eggs, coffee, milk, toast, etc., may be allowed, unless the character 
of the operation contraindicates it. If it seems probable that a 
general anesthetic will be required to complete the operation, the 
patient's stomach should, of course, be empty, and the same precau- 
tions should be taken as for general anesthesia (see page 2). Appre- 



68 . LOCAL ANESTHESIA 

hensive anticipation on the part of the patient should be prevented 
as far as possible by reassurances and by a good night's sleep before 
the operation. 

Preliminary medication with morphin is advisable in all cases, 
where the operation is to be at all extensive, unless some distinct 
contraindication to its use exists. It serves a threefold purpose: it 
allays nervousness on the part of the patient and thus removes the 
psychic element; it somewhat deadens sensibility; and it is the 
physiological antidote for cocain poisoning. It may be given hy- 
podermically in the dose of i/6 to 1/4 gr. (0.0108 to 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/ioo gr. (0.00065 gm.) of 
hyoscin may be administered hypodermically two hours before 
operation. 

The Conduction of the Operation. — It may not be out of place at 
this point to say a few words about the proper conduction of an opera- 
tion under local anesthesia. The successful and satisfactory em- 
ployment of this method of 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 an}' given region. These are essential. Much also depends upon 
the temperament of the operator and upon his method of operating. 
For this reason, with some operators, the use of local anesthesia will 
be impossible; with others, it will necessitate a radical change in their 
operative technic. A nervous fidgety operator, in a hurry to get 
through his work, will never find much to encourage him in attempts 
to employ local anesthesia in major surgery. 

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



LOCAL AXESTHESLA. 69 

solution and leave him lying in a chilly pool for the remainder of the 
operation. 

With very nervous individuals, it is \yell to keep the instruments 
covered from view and to avoid all reference to knives, scissors, etc. 
In fact, strict silence should be enjoined upon all. The patient's 
mental attitude can be further influenced to advantage by observing 
a quiet demeanor in the operating-room, by the avoidance of haste, 
and by a most careful handling of the tissues. Clean-cut dissection 
only is allowable in operations under local anesthesia. Rough ma- 
nipulations, or tearing of the tissues, or unnecessary pulling with 
retractors by an awkward assistant causes pain by dragging upon 
structures outside the anesthetized area and is often sufficient to cause 
restlessness and apprehension on the part of the patient, a state of 
mind which, if produced in the early part of an operation, rapidly 
changes to complete demoralization, and renders the chances of com- 
pleting the operation without the aid of a general anesthetic very 
smaU. 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. Xeglect in observing these small and apparently trivial 
details is responsible for many of the failures with local anesthesia, 
and often results in condemnation of the method, though the fault 
lies with the operator. 

THE PRODUCTION OF LOCAL ANESTHESIA BY COLD 

The anesthetic properties of intense cold have long been recog- 
nized and utilized in minor surgery. The tissues may readily be 
frozen sufficiently for anesthetic purposes by the apphcation of sait- 
and ice, or by spraying the part with 
some rapidly evaporating chemical. 
such as ether, rhigoline. or ethyl 

chlorid. The tissues as a result be- ^ 

r , 1 ] ,1 11 1 J Fig. 40. — Ethvl chlorid spray tube, 

come first red and then blanched, 

and a superficial anesthesia is produced, which persists but a few 
minutes. This form of anesthesia has a very small field of useful- 
ness, and is only suitable for small incisions or punctures; even in 
these cases the method is open to the objection that the tissues be- 
come so hard that it is diflicult 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; 




70 LOCAL AXESTHESLV 

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 line point and furnished with a spring 
tip (Fig. 40) or with a screw cap. The method of application is 
extremely simple. The tube is uncovered and held inverted in the 
hand at a distance of 12 to 18 inches (30 to 45 cm.) from the surface of 
the skin. Under the heating influence of the hand the liquid is 
forced out of the container upon the tissue in a fine jet or spray. 
Rapid evaporation occurs, and, in about thirty seconds, the skin 
becomes white and sufficiently frozen to be devoid of sensation. 

THE SURFACE APPLICATION OF ANESTHETIC DRUGS 

Cocain and other drugs with similar anesthetic action may be 
applied to mucous surfaces (i) by instillation, as in the eyes, bladder, 
urethra, etc.; (2) by means of a spray or atomizer, as in the mouth or 
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 pol}-pi or small tumors, and opening 
of infections may thus be performed. 

For operations about the eye. a drop or two of a 2 to 4 per cent, 
solution of cocain is instilled into the eye every ten minutes until 
three or four drops have been given. 

Local anesthesia of the nasal mucous membrane may be pro- 
duced by applying a 4 per cent, solution of cocain upon swabs of 
cotton directly to the part to be anesthetized. Spraying is not 
so desirable, as the solution is Kable to ran 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 efi'ectiveness of the 
cocain and obtain a bloodless field of operation, a spray of a i to 
iCMDo adrenalin solution may be employed after the cocainization. 

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



INFILTRATION ANESTHESIA 7 1 

The anterior urethra may be sufficiently anesthetized by filling it 
with a 0.2 per cent, cocain and adrenalin solution, introduced by 
means of a urethral syringe. The solution should be confined in the 
urethra for at least fifteen minutes, by holding the meatus closed. 
The posterior urethra may be anesthetized by instilling into it a few 
drops of a I per cent, cocain and adrenalin solution or a 2 per cent, 
novocain adrenalin solution by means of an instillation syringe or 
through a soft rubber catheter. 

For the bladder, a o.i per cent, cocain and adrenalin solution is 
sufficient. Five ounces (150 c.c.) of such a solution to which is added 
twenty drops (1.25 c.c.) of adrenalin is slowly introduced warm by 
means of a catheter, the bladder having been previously irrigated. 
The operator should then wait fifteen to twenty minutes for the drug 
to take effect. 

INFILTRATION ANESTHESIA 

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

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

Apparatus. — For the purposes of ordinary infiltration the 6oTn, 
(4 c.c.) or the 10 c.c. (2 1/2 dram) sub-Q syringe is very satisfactory. 
This syringe has a solid glass barrel and glass piston with asbestos 
packing, and can be readily sterilized, and is cheap. Several of these 



72 



LOCAL ANESTHESIA 



syringes should be on hand for the operation, and are to be kept filled 
in readiness, so that the infiltration may be carried on rapidly without 
waiting to recharge the same syringe. The needles should be sharp 
and fine, with a very short bevel, and they should fit the syringe with- 
out any leakage at the joint. It will be convenient to have a short 




Fig. 41. — Apparatus for infiltration. — i, Medicine glasses for cocain solutions; 
2, ampule of sterile cocain and salt crystals; 3, dropper for adrenalin; 4, syringe 
armed with a short needle; 5, long fine needle for deep infiltration. 

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 infiltration of the deeper 
tissues. 

For massive infiltration a large syringe or a special apparatus 




Fig. 42. — The Matas massive infiltrator. 

which will allow a continuous and rapid infiltration of the tissues is 
more satisfactory. The ]Matas infiltrator (Fig. 42) 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 



INFILTRATION ANESTHESIA 



73 



rubber inflating apparatus is attached to the first cock, and to the 
other is a needle connected by a suitable length of hose. The reser- 
voir is filled about three-fourths full and is then charged with air, 
and the bulb and tubing are removed. Infiltration is performed by- 
inverting the apparatus and opening the outflow stopcock. Several 
needles of different lengths, shapes, and sizes are provided with this 
instrument. The author uses an infiltrator made on much the same 
principles as the Matas instrument. 
It consists of a long graduated glass 
cylinder capable of holding lo ounces 
(300 c.c), with an outlet at the bot- 
tom 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. 43). 
The reservoir is almost filled with the 
solution, leaving about one quarter 
for air space, and the instrument is 
charged with sufficient air to cause 
the fluid to flow through the needle 
in a strong stream. 

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

Technic. — In all cases where an 
extensive or prolonged operation is 
contemplated morphin, gr. 1/4 
(0.0162 gm.), should be given hypo- 
dermically half an hour beforehand, 

unless contraindicated. For the skin infiltration, a warm 0.2 per 
cent, solution of cocain and adrenalin or a i per cent, novocain 
adrenalin solution in normal salt solution may be used. The 
syringe is filled with solution and the needle is shown to the pa- 
tient with an explanation of just what is intended to be done. This 
is necessary in order to avoid an often unexpected shock from the 
first prick of the needle. The needle, held almost parallel to the 
surface, is pushed into the skin just beneath the epidermis — not 
beneath the skin — so as to anesthetize the sensitive end organs. If 
the needle lies properly, its point will be almost visible immediatcl}' 




Fig. 43. — The author's apparatus 
for massive infiltration. 



74 



LOCAL ANESTHESIA 



below the skin surface. A few drops of solution are injected and the 
skin becomes blanched and raised into a wheal about the size of a 
ten-cent piece (Fig. 44). The needle is then reinserted into the 
edge of the wheal and more solution injected in the same manner, 




Fig. 44. — Showing the method of infiltrating the skin. The needle is inserted 
in such a way that, with the injection of a few drops of solution, a wheal the size 
of a ten-cent piece is produced. 

until the entire line of the proposed incision is one continuous wheal 
(Fig. 45). In this way, only the first prick of the needle is felt by 
the patient. 

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




Fig. 45. — Showing the reinsertion of the needle into the edge of the wheal. 

infiltrated, using a longer and somewhat larger needle. For this 
purpose cocain and adrenalin in a i to 1000 solution for ordinary 
cases and in a i to 3000 to i to loooo solution for massive infiltration 
of large areas or a 1/4 to 1/8 per cent, novocain adrenalin solution may 



INFILTRATION ANESTHESIA 



75 



be used. The needle is inserted into the line of the skin cocainiza- 
tion, and the solution is injected in all directions from this 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 operation for inguinal hernia 
about the external ring where the main nerve trunks break up into 




Fig. 46. — Showing the directions in which the needle should be inserted in massive 
infiltration of deep structures. 

their terminal filaments. In the case of an operation upon a cir- 
cumscribed growth, the infiltration is carried out in such a way as to 
completely encircle the diseased area and isolate it from nerve com- 
munication with the surrounding parts. In like manner fascia„ 
muscles, down to or including the periosteum, may be infiltrated in 
a mass, after the method of Matas (Fig. 46), or each structure sepa- 




FiG. 47. — Showing the application of a constricting band to the finger in order to 
prolong and intensify the anesthesia. 

lately as it is exposed during the course of the operation. Muscle, 
tendon, bone, and cartilage have no sensation, but their coverings 
are extremely sensitive; hence particular care must be taken to in- 
filtrate fascia, muscle, and tendon sheaths, periosteum, and joint 
capsules, and when operating upon joints to anesthetize the synovial 
membranes by a preliminary instillation of weak cocain solution 



7 6 LOCAL ANESTHESL\ 

into the joint before operation. With proper infiltration the whole 
field is thoroughly edematized and is changed into a tumor-like mass 
that is perfectly anesthetic. 

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

Upon an extremity, more complete and prolonged anesthesia may 
be obtained if. after infiltration, stasis of the circulation is produced 
bv means of elastic constriction applied centrally to the seat of in- 
filtration (Fig. 47). In such a case, where large quantities of solu- 
tion are used and remain in the tissues when the operation is com- 
pleted, it is a wise precaution to loosen the constriction gradually 
and intermittently, so as not to rapidly flood the system with a large 
volume of cocain solution. 

ENDO- AND PERINEURAL INFILTRATION 

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

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



ENDO- AND PERINEURAL INFILTRATION 



77 



Apparatus. — The ordinary 60T11 (4 c.c.) or 10 c.c. (2 1/2 dr.) 
"Sub-Q" syringe, with a fairly long needle will be found most 
satisfactory. 

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

Technic. — In the perineural method of infiltration the analgesic 
solution is injected in such a way as to surround the nerve trunk or 
"envelop the nerve in an anesthetic atmosphere," as Matas expresses 
it. A spot in the skin from which the nerve can be reached with the 
hypodermic needle is infiltrated as already described, and through 
this area the needle is inserted toward the known location of the par- 
ticular nerve to be anesthetized. The syringe is charged with a 0.2 
per cent, solution of cocain and adrenalin or a i per cent, novocain 




Fig. 48. — Method of infiltrating a large nerve trunk. The anesthetic solution 
should be injected into the nerve in all directions so that the entire nerve is ren- 
dered anesthetic below the point of injection. 



adrenahn solution and from 15 to 20 drops are injected into the 
tissues surrounding the nerve. The solution is allowed to become 
diffused, and then, if the nerve be in an extremity, the part is ex- 
sanguinated by elevation and an elastic constriction is apphed cen- 
trally to intensify and prolong the anesthesia. In a few moments the 
entire region supplied by the blocked nerve becomes insensible. It 
may happen that, in regions where constriction is inapplicable, the 
anesthesia may not be sufficiently lasting for a prolonged operation, 
and it will be necessary to repeat the injection more than once to 
maintain the anesthesia. 

By the endoneural method, if the nerves are injected in the field 
of operation, the technic is very simple, the individual nerves being 
infiltrated with a few drops of a 0.5 per cent, solution of cocain or a 2 
per cent, solution of novocain as they are exposed. When the injec- 



78 LOCAL ANESTHESIA 

tion is made at a point distal to the seat of operation the nerve is 
first exposed by dissection under infiltration anesthesia and is then 
thoroughly infiltrated, the fluid being injected into all portions of 
the nerve so that an entire transverse section is thoroughly 
blocked (Fig. 48). Other nerves supplying the region of operation 
are similarly dealt with. The part is then exsanguinated by eleva- 
tion and an elastic constriction is applied centrally to the point of 
injection. In a short time all sensation below the seat of injection 
becomes benumbed, and operations of any magnitude may be 
performed. 

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

The Head. — Operations upon the scalp, such as wound suture, 
the removal of tumors, cysts, etc., and even procedures requiring 
incision of the periosteum and opening into the brain, may be per- 
formed painlessly 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. 49). The 
small occipital and great occipital nerves supply the posterior part 
of the scalp as far forward as the vertex. The great auricular nerve 
suppHes the mastoid region, as does also the small occipital. The 
parietal portion of the scalp receives its supply from the auriculo- 
temporal and a branch of the temporomalar. The supratrochlear 
branch of the frontal nerve suppHes 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. Blocking 
these nerves by cross strips of infiltration at the points where they 
penetrate the muscular fascia and become subcutaneous (Fig. 50), 
or performing a thorough circumscribed infiltration around the area 



EXDO- AND PERINEURAL IXEILTRATION 



79 



of operation, with infiltration of the periosteum, if necessary, renders 
many cases amenable to local measures which are now performed 
under general narcosis. Constriction by means of a rubber tourni- 
quet passed around the forehead above the ears and over the occipital 
protuberance will be found most useful as an aid to anesthesia. 

About the lips, chin, nose, cheeks, tongue, mouth, and lower jaw 
local means of anesthesia are often quite sufficient. Blocking of the 
mental nerve as it emerges from the mental foramen will render 
insensitive the region of the chin and the skin and mucous membrane 




Fig. 49. Fig. 50. 

Fig. 49. — The superficial ner\'es of the scalp and face, i, Supratrochlear nerve; 
2, supraorbital nerve; 3, temporal branch of the temporomalar nerve; 4, auriculo- 
temporal nerve; 5, great auricular nerve; 6, small occipital nerve; 7, great occipi- 
tal nerve; 8, infratrochlear nerve; 9, infraorbital nerve; 10, nasal nerve; 11, 
mental nerve. 

Fig. 50. — Showing the area of anesthesia after blocking the supratrochlear, 
supraorbital, and mental nerves. The dots indicate the points for infiltration. 



of the lower lip of the same side (see Fig. 50). In like manner the 
upper lip may be anesthetized by blocking of the infraorbital 
nerves. The inferior dental nerve is readily reached for blocking as 
it enters the inferior dental foramen at the outer side of the spine of 
Spix. This point lies near the median line of the internal surface of 
the ramus of the jaw about haK an inch (i cm.) above the upper surface 
of the last molar tooth (Fig. 51). The lower jaw may be thus anes- 
thetized and teeth may be painlessly extracted. The Ungual nerve 



8o 



LOCAL ANESTHESIA 



may be perineurally infiltrated at about the same point, as it lies 
close to the inferior dental. The floor of the mouth and the tongue 
are thus rendered insensitive, and quite extensive operations may 
be performed. Infiltration alone, however, is often sufl5cient in the 
smaller operations about the lips and mouth. 

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




Fig. 51. — Showing the method of blocking the inferior dental nerve. 



jaws after cocainization of the second division of the fifth nerve. 
More recently Braun and others have reported extensive operations 
performed by similar methods. The technic of reaching these nerves 
is similar to that employed by Schlosser, Patrick, and others in the 
use of alcoholic injections for trifacial neuralgia (see page 197). 

The Neck. — Operations upon 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 
massive infiltration of the surrounding tissues. As already men- 
tioned, thyroidectomy and tracheotomy may be carried out by 
following the same principles. In superficial operations upon the 



EXDO- AXD PERINEURAL IXFILTRATION 8 1 

anterior and posterior triangles, perineural blocking by a strip of 
infiltration, or direct injection of the superficial branches of the cervi- 
cal plexus as they escape from the posterior border of the sterno- 
mastoid muscle at or about its middle will be of great aid (Fig. 53). 
Operations upon the larynx may be performed under infiltration 
anesthesia combined T\ath blocking of the superior laryngeal nerve 
at the tip of the greater cornu of the hyoid bone. 




Fig. 52. Fig. 53. 

Fig. 52. — The superficial cervical plexus. The dotted lines indicate the course 
of the stemomastoid muscle. 

Fig. 53. — Showing the area of anesthesia after blocking the superficial cervical 
plexus. The dots indicate the points for infiltration. 

The Thorax. — Exploratory punctures, aspiration of the peri- 
cardium and pleura, rib resection for empyema, and the removal of 
benign growths from the breast may all be satisfactorily performed 
under infiltration. In the operation of rib resection the infiltration 
should be carried out layer by layer, including the periosteum. 
Perineural blocking of the intercostal nerves as they pass between the 
intercostal muscles in the upper portion of the intercostal space, or 
endoneural injection of each nerve as it is exposed, will assist in ren- 
dering the operation painless where more than one rib is to be re- 
sected. For a perineural injection the needle is inserted close to 
the lower margin of the rib about one and one-fifth inches (3 cm.) 
from the median line and is pushed in for a distance of i ^/^ to 2 in. 
(4 to 5 cm.) when it strikes the bone. An attempt is next made to 
guide the needle below the lower edge of the rib. The injection is 
6 



82 LOCAL ANESTHESIA 

then commenced and is continued as the needle is carried inward 
and toward the median Hne well into the subcostal angle for a distance 
of 1/4 to 1/2 an inch (6 to 12 mm.). As many of the other inter- 
costal nerves as may be necessary are similarly blocked. After the 
periosteum over the rib is incised and reflected, the rib may be ex- 
sected without pain. The parietal pleura, like the peritoneum, is 
very sensitive and requires infiltration before incision. 

The Upper Extremity. — Almost any operation may be performed 
in this region under a skilful use of local anesthesia. The brachial 
plexus may be anesthetized by exposing it under infiltration anes- 
thesia above the clavicle (Fig. 54) and blocking each branch sepa- 
rately by direct injection with a 0.5 per cent, solution of cocain or a 




Fig. 54. — Exposure of the brachial plexus for infiltration, i, External jugular 
vein; 2, transversalis colli artery; 3, scalenus anticus muscle; 4, fifth cervical 
root; 5, sixth cervical root; 6, seventh cervical root; 7, clavicle. 

2 per cent, solution of novocain, or by a perineural injection after the 
method of Kulenkampff. His technic is as follows: The patient is 
placed in the sitting position and the subclavian artery is located by 
palpation. This is usually at a point where, if the external jugular 
vein were extended, it would strike the clavicle. The needle is 
inserted just outside this point immediately above the clavicle in 
an obhque direction slightly back and downward in a line which, if 
carried back, would strike the spines of the 2d or 3d dorsal vertebra. 
At a distance of about i 1/5 inches (3 cm.) the needle should reach 
the nerve trunks. Paresthesia throughout the arm and motor phe- 
nomena indicate when this has been accomphshed.^ If the needle 
strikes the first rib it has been introduced too far. Kulenkampft" in- 

1 Injury to the phrenic nerve with embarrassed respiration and diminished 
breath sounds has been reported following perineural injection of the brachial plexus, 
so that care should be taken to determine the presence of paresthesia before 
making the injection and not to anesthetize both sides at the same time. 



ENDO- AND PERINEURAL INFILTRATION 



83 



jects 2 1/2 drams (10 c.c.) of a 2 per cent, solution of novocain and 
adrenalin. In 10 to 30 minutes all sensation in the area below the 
point of injection is destroyed, and amputations or other operations 
may be performed at any level below the seat of injection. In shoul- 
der-girdle amputations, however, infiltration of the hnes 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 blocking of the median, ul- 
nar, and musculospiral nerves. This may be accomplished by block- 
ing the brachial plexus as already described, by directly injecting all 
three nerves after exposure under infiltration anesthesia in the upper 





Fig. 



Fig. 56. 



Fig. 55. — -Exposure of the musculospiral and median nerves at the elbow. 
Musculospiral nerve; 2, median nerve. 

Fig. 56. — Exposure of the ulnar nerve just aJ)Ove the internal condyle. 



portion of the arm, or by separately exposing and blocking each nerve 
just above the elbow. In following the latter method, the median 
nerve is exposed by an incision across the elbow to the inner side of 
the biceps muscle, the brachial artery lying jast external to it; the 
ulnar, in the groove between the internal condyle and the olecranon; 
and the musculospiral, between the biceps tendon and the supinator 
longus muscle. Blocking each nerve with a 0.5 per cent, solution of 
cocain or a 2 per cent, solution of novocain produces complete in- 
sensibility of the extremity below the point of injection excepting 
the skin and subcutaneous tissues of the upper central portion of the 
forearm, supplied by the musculocutaneous and internal cutaneous 



84 



LOCAL ANESTHESIA 



nerves. A circular area of subcutaneous infiltration at the elbow, 
however, as advised by ^Matas, abolishes any remaining sensibility 
in this region (Fig. 57). 

Just above the wrist, the median, ulnar, and radial nerves are 
available for perineural injection. The median is reached by intro- 




Fic. 57. — Showing the method of anesthetizing the small superficial nerves by cir- 
cular strips of subcutaneous infiltration. 

ducing the needle to the ulnar side of the tendon of the palmaris 
longus and inserting it obUquely for a distance of 1/2 to 3/4 inch 
(i to 2 cm.) in the direction of the radius. The ulnar nerve may be 
anesthetized perineurally a little above the head of the ulna by insert- 




FiG. 58. — 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, Interosseousnerve; 2, radial nerve; 3, radial artery; 4, median nerve; 
5, ulnar ner\^e; 6, areas of skin infiltration; 7, flexor carpi ulnaris tendon; 8 pal- 
maris longus tendon; 9, flexor carpi radialis tendon. 

ing the needle to a depth of about 4/5 inch (2 cm.) between the ulna 
and the tendon of the flexor carpi ulnaris. The radial nerve and its 
branches are best caught by a cross strip of subcutaneous infiltra- 
tion just above the styloid process of the radius (Fig. 58). Perineural 
injection alone for operations upon the wrist is not satisfactory, as 



ENDO- AND PERINEURAL INFILTRATION 



85 



this region is also supplied 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. 57). 




Fig. 59. — Points for inserting the needle in perineural infiltration of the digital 

nerves. 

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

Anesthesia of the fingers is obtained by infiltrating two points in 
the skin on the dorsal surface near the base of each finger (Fig. 59). 




Fig. 60. — Cross-section of the finger showing the direction of the needle for 
perineural infiltration of the digital nerves. (After Braun.) i, Extensor tendons; 
2, bone; 3, flexor tendons; 4, areas of skin infiltration. 

Through these points the needle is inserted toward each of the four 
digital nerves, and the anesthetic solution injected (Fig. 60). All 
nerve communication is thus blocked and the finger may be incised, 
amputated, etc., without pain. By injecting in the known location 



86 LOCAL ANESTHESIA 

of the digital nerves as they pass between the metacarpal bones, the 
bases of the fingers and even the metacarpals may be anesthetized. 

The Abdomen. — The abdomen may be opened in any region by 
simple infiltration, combined with endoneural injection of nerves as 
they are exposed. The skin, the subcutaneous tissues, the fasciae, 
the muscular layers, and the peritoneum should be separately in- 
filtrated, layer by layer. More perfect anesthesia may be obtained 
by combining with the infiltration a paravertebral injection of the 
nerves supplying the field of operation after the method of Kappis. 
For work about the kidney or upper abdomen the last five thoracic 
and upper two lumbar nerves should be blocked. The technic is 
as follows: The needle is inserted about i 2/5 in. (3.5 cm.) from the 
median hne on a level with the lower border of the rib and is inserted 
for a distance of i 3/5 to 2 in. (4 to 5 cm.) when the bone should be 
reached. The needle is then made to pass beneath the lower border 
of the rib and the injection is begun. The solution is slowly injected 
while the needle is pushed onward for a distance of 1/4 to 1/2 in. 
(6 to 12 m.m.) slightly toward the median line into the subcostal 
angle. The same method is employed for the lumbar nerves, the 
transverse processes of the vertebrae being the guides instead of the 
ribs. The limitations of local anesthesia in abdominal surgery have 
already been considered (page 62) and will not be reiterated here. 

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

For inguinal hernia a combination of infiltration and endoneural 
injection is possible on account of the anatomical arrangement of the 
inguinal region, which is supplied by three fairly large nerve trunks 
having a rather constant course — namely, the iliohypogastric, the 
iHoinguinal, and the genitocrural. The iliohypogastric will be found 
in the upper angle of the hernial incision after reflecting the aponeu- 
rosis of the external oblique, usually running downward and inward 
on a line drawn from about the anterior-superior spine to a point 
an inch (2.5 cm.) above the external ring. The ilioinguinal will 
usually be found in the line of incision just beneath the aponeurosis 
of the external oblique, and on a lower level than the iliohypogastric, 
running downward in the long axis of the hernia (Fig. 61). It may 
even lie as far out as Poupart's ligament. This nerve is often smaller 
than the iliohypogastric, and in some cases it may be absent, in which 
event its place is taken by the genitocrural. The genitocrural will be 



ENDO- AND PERINEURAL INFILTRATION 



87 



found after reflecting the aponeurosis of the external oblique lying 
among the structures of the cord, and frequently it lies behind the 
cord. Infiltration anesthesia is employed until the aponeurosis of 
the external obhque is reflected, when the above nerves are separately 
blocked. In performing the infiltration, special care should be taken 
to inject plenty of solution in the region of the external ring where 
the nerves break up into their terminal filaments. After the nerves 
are properly blocked, the remainder of the operation may be pain- 
lessly performed without the use of additional anesthesia, though it 
is better to infiltrate about the neck of the sac before ligating and 
removing that structure. Omentum may be amputated, adhesions 
within the sac separated, and gut resected if necessary, without pain. 




Fig. 61. — Showing the nerve supply of the inguinal region. (After Gushing.) 
I, Iliohypogastric nerve; 2, ilioinguinal nerve; 3, conjoined tendon; 4, cremaster 
muscle; 5, aponeurosis of the external oblique incised and edges reflected. 



Femoral hernia may be operated on under simple infiltration of 
the skin, subcutaneous tissues, and sac; or, preferably, by a combi- 
nation of infiltration and endoneural injection. If this latter method 
is employed, the incision is placed so as to expose in addition the 
external abdominal ring. The aponeurosis of the external obhque 
is thus exposed and is incised for a short distance, so that the ilio- 
inguinal and genitocrural nerves may be identified and injected. 
Blocking of these nerves, combined with infiltration, renders the 
field of operation more nearly anesthetic than infiltration alone. 

In operations for umbilical and ventral hernias, the infiltration 



88 



LOCAL ANESTHESIA 



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




Fig. 62. — Showing the method of infiltrating about the cord in operations upon 

the testicle. 

The Scrotum. — Any of the operations about the scrotum and 
testicles, such as those for varicocele, hydrocele, castration, etc., 
may be carried out by perineural injection around the cord as it 
escapes from the external ring (Fig. 62), combined with infiltration 
along the site of incision. 



i 




Fig. 63. — Points for injection in infiltration about the anus. 

Penis and Urethra. — Circumcision may be performed by infiltrat- 
ing the skin and mucous membranes along the hues of proposed in- 
cision, being careful to infiltrate the frenum thoroughly. More ex- 



ENDO- AND PERINEURAL INEILTRATION 89 

tensive operations upon the pendulus portion may be performed by 
subcutaneous infiltration of a ring about the base of the penis, care- 
fully injecting the solution around each of the dorsal nerves. Exter- 
nal urethrotomy may be performed under infiltration combined 
with topical anesthesia of the mucous membrane (see page 71). 

Rectum and Anus. — The limitations of local anesthesia in rectal 
operations have been previously pointed out. For the removal of 
external hemorrhoids, skin tabs, etc., injecting a small amount of 
anesthetic solution into the base of the growth is sufficient. When 
it is necessary to stretch the sphincter, anesthesia may be obtained 
in the following manner: Four wheals are made in the skin — in 
front, behind, and at the sides (Fig. 63) — and through these points 
the hypodermic needle, guided by a finger in the rectum, is carried 
up along the bowel and the sphincter is thoroughly infiltrated. 

Lower Extremity.— Blocking of the anterior crural, the external 
cutaneous, and the sciatic nerves, combined with a circular strip of 
subcutaneous infiltration, completely blocks all sensation in the lower 
extremity below the level of the "block," and amputations can thus 
be performed as high as the lower and middle thirds of the thigh. 
Above this point, however, the nerve supply is complicated and it 
will be necessary to massively infiltrate along the line of incision as 
well as to "block" the nerve trunks already mentioned. The exter- 
nal cutaneous nerve may be reached for injection by an incision so 
placed as to expose the nerve as it emerges from under the anterior 
superior spine (Fig. 64), or it may be blocked by a perineural injection, 
the needle being inserted just to the inner side of the anterior superior 
spine. Skin grafting may be readily performed by blocking the nerve 
after the manner just described and taking the grafts from the outer 
side of the thigh. The anterior crural nerve may be exposed by an 
incision placed about 1/2 inch (i cm.) external to the center of 
Poupart's ligament. The nerve will be found just external to the 
femoral artery. The sciatic nerve may be reached for perineural 
injection by inserting the needle at a point where a horizontal line 
through the tip of the great trochanter cuts a vertical line through 
the outer margin of the tuberosity of the ischium. A needle about 3 
inches (8 cm.) long is reqoired. It is introduced directly backward 
until bone is reached and is then withdrawn for a distance of 1/25 
inch (i mm.). After injection of the anesthetic solution about 1/2 
an hour is required for complete anesthesia. The sciatic may also be 
blocked after exposure under infiltration anesthesia at the lower bor- 
der of the gluteus maximus muscle, or at the upper border of the pop- 



90 



LOCAL ANESTHESLA. 



liteal space. In the former case, an incision 3 to 4 inches (7.5 to 
10 cm.) long is made between the tuberosity of the ischium and the 




Fig. 64. — Exposure of the anterior crural and external cutaneous nerves for 
injection. i, Anterior crural nerve; 2, external cutaneous nerve; 3, femoral 
artery; 4, femoral vein. 

great trochanter, with its center over the lower margin of the gluteus 
maximus muscles. By retracting the gluteus maximus upward and 
the ham-string muscles inward, the nerve will be found lying under 




Fig. 65. — Exposure of the sciatic nerve in the upper part of the thigh for injec- 
tion. I, Gluteus maximus muscle; 2, biceps muscle; 3, semitendinosus muscle; 
4, sciatic nerve. 



the outer edge of the biceps muscle (Fig. 65). In the upper portion 
of the popliteal space the nerve may be exposed by a vertical incision 



EXDO- AXD PERINEURAL IXFILTRATIOX 



91 



in the mid-line; it will be foancl lying between the biceps and semi- 
membranosus muscles. It should be injected before it divides, or 
else both the internal and external popliteal nen-es are to be blocked. 




Fig. 66. — Exposure of the internal saphenous nerve for injection, i, Internal 
saphenous nerv^e; 2, internal saphenous vein. 

In operations below the tubercle of the tibia, it is unnecessary to block 
the anterior crural and external cutaneous; blocking the sciatic in 




Fig. 67. — Cross-section of the leg above the ankle-joint, showing the direction 
of the needle for perineural infiltration of the posterior tibial nerve. (After Braun.) 
I, Posterior tibial nerve; 2, external saphenous nerve; 3, area of skin infiltration; 
4, musculocutaneous ner\'e; 5, anterior tibial nerve; 6, tendo achillis; 7, peronei 
muscles; 8, flexor longus haUucis; 9, extensor longus digitorum; 10, extensor 
longus hallucis; li, tibialis anticus; 12, tibialis posticus; 13, flexor longus 
digitorum. 

the popliteal space and the external saphenous as it passes to the 
inner and posterior aspect of the knee-joint is suihcient (Fig. 66). 
Below the knee, the large nerves are not available for injection 



LOCAL ANESTHESLA. 



until the ankle is reached. Behind the ankle the posterior tibial may 
be perineurally injected by inserting the needle on the inner side of 
the tendo achillis directly forward almost to the posterior surface of 
the tibia (Fig. 67). The anterior tibial may be likewise perineurally 
injected by inserting the needle on the dorsum of the? ankle between 
the tendons of the tibialis anticus and the extensor longus hallucis 
and the innermost tendon of the extensor longus digitorum. By a 
circular strip of subcutaneous inliltration. the remainder of the sen- 
sory nerve supply may be blocked and complete anesthesia of the foot 
may be obtained. 

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

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




FiG. 68. — Showing the method of anesthetizing an inflamed area. 

neural blocking of the nerves supplying the region affected gives 
most satisfaction. Where these methods are not applicable infiltra- 
tion anesthesia may be employed if care is taken not to inject the 
solution directly into the inflamed tissues. An attempt should be 
made to surround the diseased area with the anesthetic solution, 
making the injections through healthy skin into the subcutaneous 
tissues (Fig. 68), thus cutting oflf all sensory communication wath the 



BIER S VENOUS ANESTHESIA 



93 



surrounding parts. Infiltration of the inflamed tissues should be 
avoided as any increase in distention of the already swollen structures 
causes intense pain and in some cases seems to lower the resistance to 
such an extent that cellulitis results. 

BIER'S VENOUS ANESTHESIA 

Quite recehtly Bier has developed an innovation in the production 
of local anesthesia in extremities, termed venous anesthesia. It 
consists essentially in rendering the limb bloodless and, after isolating 
the field of operation from the circulation by means of tourniquets 
applied above and below the area to be anesthetized, injecting the 
anesthetic solution into one of the veins between the two tourniquets. 
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 
local anesthesia which are sufficient for the superficial tissues; its 
special field is for major operations, such as amputations, resection of 
joints, and operations upon bones, muscles, tendons, etc. According 
to its originator, diabetic and senile gangrene and arteriosclerosis are 
contraindications to its use. 

While this method of anesthesia has not received the extended 
trial in the hands of different operators that some of the older meth- 
ods of local anesthesia have, it has been thoroughly tested by its 
originator and by him is considered to be far ahead of other methods 
for producing anesthesia of the extremities. Bier reported {Berliner 
klinische Wochenschrift, March 19, 1909) 134 operations under venous 
anesthesia, including amputations, arthrotomies, bone suture, extirpa- 
tion of varicose veins, etc., and of this total in 115 cases the anesthesia 
was perfect, in fourteen satisfactory, and in five unsatisfactory. Of 
the latter, however, three were operations upon children. In iifteen 
cases in which the writer has employed this method the anesthesia was 
all that could be desired. 

Apparatus. — A syringe, such as the Sub-Q or the Janet, with a 
capacity of about 3 ounces (90 c.c), Bier's special cannula, a short 
heavy piece of rubber tubing for connecting the syringe with the can- 
nula, a small medicine glass, a small syringe and fine needle for infil- 



94 



LOCAL ANESTHESIA 



trating the site of operation, a glass graduate for the vein solution, 
and three rubber bandages, each 2 1/2 inches (6 cm.) wide and 6 
feet (180 cm.) long (Fig. 69), will be required. 

Bier's cannulas are 1/16 inch (1.5 mm.) in diameter for children and 
1/14 to 1/12 inch (1.75 to 2 mm.) in diameter for adults. The distal 
end of the cannula is provided with grooves into which the ligatures 




Fig. 69. — Apparatus for venous anesthesia, i, Rubber tourniquets; 2, 
medicine glass; 3, glass graduate; 4, large glass syringe and Bier's cannula; 5, 
ampule of anesthetic; 6, syringe for preliminary infiltration of the skin at the site 
of operation. 

with which it is tied in the vein fits, and at the other end there is 
a stopcock and a bayonet connection (Fig. 70). In the absence of a 
special cannula, an ordinary infusion cannula may be used, an artery 
clamp applied to the rubber tubing acting as a stopcock. 




Fig. 70. — Enlarged view of Bier's cannula for venous anesthesia. 



Instruments. — Instruments necessary for an ordinary infusion are 
required; namely, a scalpel, mouse-toothed thumb forceps, a pair of 
blunt-pointed scissors, an aneurysm needle, needle holder, two 
curved needles with a cutting-edge. No. 2 plain catgut, and a few 
artery clamps (Fig. 71). 

Solution. — Bier employs a 0.5 per cent, solution of novocain in 
normal salt solution. 



bier's venous anesthesia 



95 



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

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

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

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




Fig. 71. — 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; 8, artery clamps. 

the limb up to a point well above the site of injection. Some care 
should be taken in applying this bandage as it is necessary that the 
veins be thoroughly emptied. A tourniquet is then applied at the 
upper limit of the bandage used to exsanguinate the part by wrap- 
ping a soft rubber bandage about the limb in broad bands so as not 
to cause the patient any unnecessary discomfort, and the first band- 
age is removed for a distance of 4 to 10 inches (10 to 25 cm.). At 
this point a second tourniquet is applied and the remaining portion 
of the Esmarch is entirely removed (Fig. 72). When the operation 
is near an extremity only one tourniquet need be employed. It 
should not be placed, however, higher than the middle of the fore- 



96 



LOCAL ANESTHESIA 



arm or leg. Under infiltration anesthesia with a o. 2 per cent, solu- 
tion of cocain or a i per cent, solution of novocain, one of the main 
subcutaneous veins or one of its large tributaries, previously selected, 
is exposed by a small transverse incision in the proximal part of 
the isolated area. The vein is opened by cutting with scissors, its 
proximal end is tied ofif, and the cannula is secured in its distal end. 
Any small veins that may be cut are securely clamped to prevent 
leakage of the solution. The anesthetic is then injected under con- 
siderable pressure toward the periphery,^ i.e., against the valves of 
the veins, until the superficial veins swell and the whole segment 
between the two bandages becomes paler than before. The stopcock 
is then closed and the syringe removed, the cannula being left in 
place for further injection if necessary. 

In this way the anesthetic solution is distributed through the 
tissues between the two tourniquets and is brought in contact with 
the nerve trunks and nerve endings of the whole area. Direct anes- 




FiG. 72. — Bier's venous anesthesia. Showing the application of the bandages and 

the site of injection -|-. 



thesia follows between the bandages in three to five minutes, and 
indirect anesthesia beyond the distal bandage is observed in six to 
twenty minutes. If the proximal bandage causes pain, as is some- 
times the case, a second one may now be placed immediately below it 
on the anesthetized area and the first one may be removed. As 
a rule, some motor paralysis occurs in the anesthetized area, but it 
soon disappears after removal of the bandages. Anesthesia per- 
sists as long as the bandages remain in place and rapidly disap- 
pears after their removal, so it is absolutely necessary that the op- 
eration, including hemostasis and suturing, be completed before the 
bandages are removed. If difiiculty is experienced in recognizing 
cut vessels, sahne may be injected into the cannula and it will spurt 
from the open ends. The danger of poisoning from absorption of 
the drug employed for anesthesia may be disregarded. This appar- 

1 Bier in a later communication {Edinburg Medical Journal, Aug., 19 10) states 
that the injection may also be made centrally, opening the vein close to the distal 
bandage. 



BIER S VENOUS ANESTHESIA 97 

ent danger was formerly guarded against by washing out the veins 
with saHne at the end of the operation. This precaution is now 
regarded as unnecessary, for, according to Bier, the anesthetic 
quickly goes through the vein wall and the greater portion of it 
becomes bound up in the tissues, returning to the circulation very 
gradually. 

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

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

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

It is claimed that the cocain thus introduced is carried by the 
capillaries to the individual nerve endings and the solution is diffused 
through the capillary walls into the surrounding tissues so that little, 
7 



98 LOCAL ANESTHESIA 

if any, solution is returned to the general circulation. The writer 
has had no experience with the arterial method. 

SPINAL ANESTHESIA 

This form of anesthesia is produced by injecting weak solutions of 
drugs having local analgesic properties into the subarachnoid space. 
Cocainization of the spinal cord was first suggested by Corning in 
1885. Bier, in 1899. improved upon the method and made it prac- 
ticable for surgical purposes. 

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

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

Solutions Used. — All the various local anesthetics have been used, 
but at the present time stovain and tropacocain are the drugs most 
frequently employed for spinal anesthesia. 

Cocain is now generally discarded for some of the less dangerous 
substitutes. If employed, it may be used in a 2 per cent, solution in 
normal salt solution, 10 to 4oTrL (0.6 to 2.5 c.c.) of such a solution, 
containing between 1/5 and i gr. (0.01296 and 0.065 gm.) of cocain, 
are injected. The addition of a few drops of a i to 1000 solution of 
adrenahn chlorid to the cocain is said to be of great benefit, prevent- 
ing the rapid difi'usion of the anesthetic, and many of the impleasant 
after-effects. 

Stovain is less toxic than cocain and is very highly recommended 



SPINAL ANESTHESIA .99 

by many authorities. A 5 per cent, solution is used, the dose being 
3/4 to I gr. (0.0486 to 0.065 gm.). 

Novocain is also frequently employed. It is about seven times 
less poisonous than cocain. A 5 per cent, solution in normal salt 
solution is employed. The ordinary dose is from 3/4 to i 1/2 gr. 
(0.0486 to 0.0974 gm.). 

Tropacocain is another substitute for cocain frequently used, and 
the anesthesia is more lasting. It is given in a dose of from 1/2 to 
I gr. (0.0324 to 0.065 gm.) in a 5 per cent, solution. 

At the present time many operators employ solutions with a higher 
or a lower specific gravity than the cerebrospinal fluid, so that when 
the solution is injected it will either fall or rise. To render the solu- 
tion lighter or more diffusible alcohol is added. Babcock (/. A . M. A., 
Oct. II, 19 13) gives the following formulas for light solutions: 



A. Stovain, 
Lactic acid, 
Absolute alcohol, 
Distilled water, 

B. Tropacocain, 
Absolute alcohol, 
Distilled water, 

C. Novocain, 
Absolute alcohol, 
Distilled water. 

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

Barker employs the following solution: 

Stovain, five parts 

Glucose, five parts 

Distilled water, ninety parts (all by weight). 

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

The injection of a solution of Epsom salt has been advocated by 
Meltzer, Haubold, and others. Sixteen minims (i c.c.) of a 25 per 
cent, solution are given for every 25 pounds (10 K.) of body weight. 
Three to four hours after the injection paralysis and analgesia in the 





(Approximately) 


0.08 gm. 


I 1/4 gr- 


0.04 c.c. 


2/3 gr- 


0. 2 c.c. 


3 minims 


1.8 c.c. 


30 minims 


0. 1 gm. 


I 1/2 gr. 


0.2 c.c. 


3 minims 


1.8 c.c. 


30 minims 


0. 16 gm. 


2 1/2 gr. 


0. 2 c.c. 


3 minims 


1.8 c.c. 


30 minims 



lOO 



LOCAL ANESTHESIA 



legs and pelvic regions appear and persist for from eight to fourteen 
hours. It is claimed that ov^erdosage endangers life from respiratory 
paralysis. 

Apparatus. — A special stylet needle and an appropriate syringe 
with a capacity of about i 1/4 drams (5 c.c.) should beprovided. The 
needle should be of platinum or nickel, 1/25 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 the 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 




Fig. 73. — Apparatus for spinal anesthesia, i, Ethyl chlorid; 2, medicine 
glasses, one for receiving the spinal fluid and the other for the anesthetic solution ; 
3, ampule containing the anesthetic; 4, scalpel; 5, syringe and trocar. 



into the canal and part outside the subarachnoid space is quite remote. 
In addition, a scalpel for making the preliminary puncture and ster- 
ilized medicine glasses for holding the solution to be injected should be 
provided (Fig. 73). 

Location of the Puncture. — Any of the spaces between the second 
lumbar and the first sacral vertebra is available for the puncture, but 
the usual site is between the third and fourth, or the fourth and 
fifth lumbar vertebra (Fig. 74). The spaces may be identified by 
counting down from the seventh cervical vertebra. If this is difficult 
on account of 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 



SPINAL ANESTHESIA 



lOI 



(Fig. 75). Puncture in the mid-line is generally practised, as it 
insures the solution being more evenly distributed on both sides of 
the cord and lessens the chance of a one-sided analgesia. A point 




Fig. 74. — Points for injecting the anesthetic solution in spinal anesthesia. 

between the two spines in the mid-line is chosen, and starting from 
this point the needle is passed slightly upward and forward between 
the spinous processes. The average space available for the puncture 




Fig. 75. — Showing the method of locating the fourth spinous process by passing a 
line through the highest points of the iliac crests. 

between the bones in the lumbar portion of the cord is 18/25 to 4/5 
inch (18 to 20 mm.) in the transverse, and 2/5 to 3/5 inch (10 to 
15 mm.) in the vertical diameter. 



I02 



LOCAL ANESTHESIA. 



Asepsis. — The operation should be performed with the greatest 
aseptic care. The needle and syringe should always be boiled in 
plain water, the solution injected must be sterile, and the operator's 
hands and site of ooeration should be prepared with all the care that 
would be observed in any operation. 




Fig. 76. — Sitting position for spinal puncture. 

Preparation of the Patient. — This should be the same as for an 
operation under general anesthesia (see page 2). If the operation 
is to be a prolonged one, morphin gr. 1/4 (0.0162 gm.) should be 
given hypodermically half an hour beforehand. 




Fig. 77. — Lateral position for spinal puncture. 



Position of the Patient. — The body of the patient is curved well 
forward so as to widen the intervertebral spaces as much as possible. 
For this purpose the patient sits up, leaning well forward, with his 
back to the operator (Fig. 76), or else lies upon one side with the 
back in the form of an arch (Fig. 77). 



SPINAL ANESTHESIA 



103 



Technic. — The spot chosen for the puncture is anesthetized with 
ethyl chlorid or by infiltration with a few drops of cocain, and a small 
puncture is made in the skin with a scalpel (Fig. 78), to lessen the 
danger of carrying in infection with the needle. The operator then 
identifies with his finger a point in the mid-line between the two spi- 
nous processes bounding the space for the puncture, and inserts the 
needle armed with its stylet in a slightly upward and forward direc- 
tion until it enters the subarachnoid space (Fig. 79). Lessened resist- 
ance, followed by the escape of the fluid from the needle, determines 
when this is accomplished. The distance necessary to be traversed 
varies from i to i 1/2 inches (2.5 to 4 cm.) in a child, 2 1/2 to 3 inches 





Fig. 78. 
Pig. 78. — Spinal anesthesia. 
Fig. 79. — Spinal anesthesia. 



Fig. 79. 
First step, nicking the skin at the site of puncture. 
Second step, inserting the needle. 



(6 to 7.5 cm.) in an adult. In inserting the needle, if it strikes bone, it 
should be withdrawn slightly and its direction changed. The cere- 
brospinal fluid should gush out with some force on removal of the 
stylet and should be clear. If only a few drops escape or the fluid is 
reddish in color it indicates that the needle is not properly inserted, 
and a new puncture should be made. A quantity of cerebrospinal 
fluid, corresponding to the amount of anesthetic to be injected, should 
be allowed to escape before the analgesic solution is introduced (Fig. 
81). This will vary from 10 to 4oTn, (0.6 to 2.5 c.c), according to 
the strength of the solution to be used. As soon as the desired 
quantity of cerebrospinal fluid has escaped, the flow is stopped by 



I04 



LOCAL ANESTHESIA 



placing a finger over the end of the needle, and the syringe, filled 
with the proper amount of solution, is attached. Some operators 
prefer to dissolve the analgesic agent in the cerebrospinal fluid with- 




FlG. 80. — Showing the direction of the needle in entering the spinal canal. 





Fig. 81. Fig. 82. 

Fig. '8 1. —Spinal anesthesia. Third step, allowing the cerebrospinal fluid to 
escape. 

Fig. 82. — Spinal anesthesia. Fourth step, injecting the anesthetic solution. 

drawn and reinject the solution thus formed. The solution should 
always be slowly introduced (Fig. 82). The needle is then with- 
drawn and the puncture sealed with collodion and cotton, or is 



SPINAL ANESTHESIA 105 

dressed with a piece of gauze held in place by adhesive plaster. If a 
heavy solution is employed and the operator desires a low anesthesia 
only, the patient is kept in the upright position for a few moments 
after the injection to allow the solution to gravitate downward, but, 
if a light solution is used, the patient's head must be immediately 
lowered to prevent its rapid spread upward. 

As the solution comes in contact with the nerve roots it blocks 
their conductivity, and in from ten to fifteen minutes loss of sensation, 
often accompanied by muscular paralysis, takes place. The anesthe- 
sia becomes marked first in the anal and perineal regions, and then in 
the lower extremities, being limited above,as a rule, to a zone not higher 
than the waist line. With a successful injection, any operation about 
the lower extremities, the anus, perineum, or pelvis may be readily 
performed. The anesthesia thus obtained persists for two hours or 
longer. 

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

Sacral Anesthesia. — The idea of anesthetizing the sacral nerves 
by injecting drugs into the extra-dural space through the lower end 
of the sacral canal originated with Cathelin. Later the method was 
employed in obstetrics for the purpose of obtaining painless deliver- 
ies, but it never came into general use. More recently sacral anes- 
thesia has been revived and the technic improved by Lawen and 
others to such an extent that the method is now of recognized value in 
operations upon the genital and anal regions below the level of the 
fifth lumbar nerve. 

Like spinal anesthesia, the sacral method fails in a certain propor- 
tion of cases even in the hands of those skilled in its use, and in some 
cases only partial anesthesia is obtained. Most of the failures are 
met with in very stout individuals. In a successful case the anes- 
thesia usually lasts for from 3/4 to an hour. The anesthesia is 
not accompanied by unpleasant symptoms, such as headache and 
vomiting, that are sometimes observed in spinal anesthesia, though 
a transient pallor, acceleration of the pulse, and a fall in blood- 
pressure may occur. 

Anatomy. — Upon the dorsal surface of the sacrum in the median 
line may be recognized the spinous processes of the three or four upper 
vertebras, the fourth spine sometimes, and the fifth spine always being 
absent through failure of the lamina to coalesce. A triangular gap, 
known as the hiatus sacralis, is thus formed through which a needle 



io6 



LOCAL ANESTHESLV 



may be readily passed into the sacral canal. The lower margins of 
this opening are prolonged downward as two tubercles, the sacral 
cornua (Fig. 83). 



^acraJ canal 




Sacral 
Sacra.1 cornu 
hiatus 



Fig. 83. — The posterior surface of the sacrum, showing the hiatus sacralis. 

The sacral canal contains the lower end of the cauda equina, the 
lilum terminale, and the spinal dura. The latter extends to the level 
of the second sacral vertebra or to within 21/2 inches (6 cm.) of the 
hiatus (Fig. 84). 




fllum termmelt 

Fig. 84. — Showing the interior of the sacral canal. 



Instruments. — The instruments required are the same as for 
spinal anesthesia (page 100), except a larger syringe — one with a 
capacity of about 5 drams (20 c.c.) — will be found preferable. 



SPINAL ANESTHESIA 107 

Solutions Used. — Cocain, novocain, and quinin and urea have all 
been used for sacral anesthesia, but novocain is the drug generally 
employed. It is claimed that the addition of sodium bicarbonate to 
the novocain solution adds to the anesthetic effect. The solution is 
made up as follows: 

Sodium bicarb, puriss., 0.25 gm. (3 3/4 gr.) 

Sodium chlorid, 0.5 gm. (8 gr.) 

Novocain, i gm. (15 gr.) 

This is dissolved in 100 c.c. (3 1/3 ounces) of cold sterile distilled 
water, and is sterilized by boiling. When it has cooled, 5 drops of a 
I to 1000 adrenalin chlorid solution are added. The quantity of 
novocain used at a dose is from 0.4 to 0.6 gm. (6 to 9 gr.). 

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

Site of Puncture. — The puncture is made in the median line 
through the lower end of the sacral canal. The opening is identified 
by palpating the spinous processes of the sacrum downward until it 
is felt that they divide in a fork-like manner, forming the boundaries 
of a triangular area, the hiatus. 

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

Preparation of Patient. — The patient is given by hypodermic half 
an hour before the operation morphin gr. 1/6 (0.0108 gm.) and atro- 
pin gr. i/ioo (0.00065 g^i-)- To this may be added scopolamin 
gr. i/ioo (0.00065 gm.), if the operation is especially difficult or 
prolonged. 

Technic. — The point of proposed puncture is located and the 
skin is infiltrated with a 0.2 per cent, solution of cocain or a i per 
cent, solution of novocain. A small nick is then made in the skin, 
and the needle, with the trocar in place, is inserted at an angle of 
about 45 degrees until it strikes the bone forming the anterior wall of 
the canal (Fig. 85). The trocar is then withdrawn, and the direction 
of the needle is changed to correspond with the direction of the sacral 
canal. It is then pushed into the canal for a distance of about an 
inch (2.5 cm.). If the needle is in the canal its point may be freely 
moved about, and, upon making a test injection with normal salt 
solution, the solution can be injected with ease. If difficulty is met 
in inserting the needle, the sacral opening may be first exposed by 
an incision under infiltration anesthesia as recommended by Lynch. 



io8 



LOCAL ANESTHESIA 



A little blood may flow from the needle, due to injury to some 
small veins, and may be disregarded, but, if the bleeding is profuse, 
or if blood escapes in spurts, the injection should be abandoned; 
the same is true if clear fluid escapes from the needle indicating that 
the dura has been punctured. The anesthetic solution should be 




Fig. 85. — Direction taken by the needle in entering the sacral canal. 

injected very slowly, and, when the desired quantity has been intro- 
duced, the needle is removed and the point of puncture is sealed with 
collodion and cotton. The patient is then brought into position for 
operation, and in from 3 to 5 minutes the anesthesia is complete. 



CHAPTER HI 
SPHYGMOMANOMETRY 

Sphygmomanometry is the instrumental estimation of arterial 
blood-pressure. The determination of blood-pressure has become a 
subject of such practical importance that both physicians and sur- 
geons should be familiar with the technic. In certain cases it is 
often of the greatest value not only in making a diagnosis, but for 
purposes of prognosis and as a guide to the treatment. It is es- 
pecially important in surgical work in determining the fitness of a 
subject for anesthesia (see also page 4) and during an operation 
in revealing impending danger from shock or cardiac weakness. 
For the latter purposes it should be employed as a routine in all 
serious operations likely to be attended by shock or considerable 
hemorrhage. 

In studying blood-pressure two measurements are made, namely, 
the systolic and the diastolic pressure, and from these readings the 
pulse pressure and the mean pressure are determined. The systolic 
pressure is the maximum pressure caused by the systole of the heart; 
diastolic pressure is the minimum pressure in the artery. The pulse 
pressure is the difference between the systolic and the diastolic pres- 
sure; while the mean pressure is the arithmetic mean of the systolic 
and diastolic pressures; for example, if the systolic pressure is esti- 
mated at 145 mm. and the diastolic pressure at 105 mm., the mean 
pressure would be 125 mm. 

The instrument employed for estimating blood-pressure consists 
essentially of a hollow rubber band for compression of an artery, con- 
nected with a manometer and inflating bulb. The amount of pres- 
sure necessary to obliterate the pulse distal to the point of constric- 
tion measured in millimeters of mercury represents the systolic blood- 
pressure. The diastolic pressure is obtained by gradually releasing 
the air from the compression band after the pulse has been obliterated 
and noting the oscillations of the column of mercury in the manom- 
eter, the base line of the greatest oscillation representing the dias- 
tolic pressure. Both systolic and diastolic pressure should be taken 
when it is possible, but of the two the determination of the systolic 

log 



no SPHYGMOMANOMETRY 

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~QO mm. of mercury 

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

For adults, 100-130 mm. of mercury 

In females the pressure is about 10 mm. less than in males. After 
middle life the pressure generally reads higher — often as high as 145 
mm. A systolic pressure between 145 and 90 mm. in an adult may, 
therefore, be considered within the limits of health. If, on repeated 
examinations, the pressure registers above or below these limits, it 
should be viewed with suspicion. A pressure above 200 mm. is 
considered very high and below 70 mm. very low, while below 45 to 
40 mm. the pulse can rarely be recognized. The diastolic pressure 
normally registers 25 to 40 mm. less than the systolic. If the differ- 
ence between the two is less than 20 mm. or more than 50 mm., it 
indicates, in the first instance, an abnormally small pulse, and, in the 
latter case, an abnormally large pulse. 

As blood-pressure is dependent upon the quantity and velocity of 
the blood entering the circulation with the contraction of the left 
ventricle, the elasticity of the arterial walls, the volume of blood in 
the circulation, and on the resistance in the peripheral vessels, it can 
be readily seen that it may be subject to considerable variation in 
health and may be modified by many circumstances. Anything 
which increases one or other of these factors will raise the blood-pres- 
sure and vice versa. Thus a recent meal, fear, anxiety, self-conscious- 
ness, mental application, pain, drugs which act upon the vascular 
system, such as camphor, caffein, strychnin, digitalis, adrenalin, etc., 
increase blood-pressure. Cold causes a rise in blood-pressure through 
its constricting effect upon the peripheral vessels; warmth has the 
opposite effect. Smoking likewise increases it if it has a stimulating 
effect, but causes it to fall if it depresses. Exercise has the same 
effect, that is, it increases pressure unless it is carried to exhaustion, 
when the pressure falls. The posture of the individual also modifies 
the pressure reading, it being 10 to 15 mm. higher with the person 
standing than when lying down. Likewise, the pressure is generally 
higher in the afternoon. The size of the encircling band is also impor- 
tant, the narrow bands giving a higher reading than the broad ones. 
Furthermore, as the estimation of pressure depends on the tactile 



SPHYGOMOMANOMETRY 



III 



sense of the individual palpating the pulse, the pressure readings in the 
same patient will vary somewhat with different observers. There- 
fore, 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 employing the same size armlet. 

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




Fig. 86. — The Riva-Rocci Sphygmomanometer. 

The Riva-Rocci sphygmomanometer (Fig. 86), 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 can- 
vas, and suppHed with hooks and eyes for fastening it in place. A 
Richardson double inflating bulb is connected with the armlet, and 
also with the manometer by means of a glass T-tube and rubber tub- 
ing. A second glass T-tube is inserted in the rubber tubing near the 
manometer, to the long arm of which is attached a short rubber tube 
supplied with a pinchcock, for the purpose of releasing the pressure. 



112 



SPHYGMOMANOMETRY 




Fig. 87. — Stanton's Sphygmomanometer. 




Fig. 88. — Janeway's Sphygmomanometer. 



SPHYGMOMANOMETRY 



113 



Stanton's instrument (Fig. 87) consists of a rubber compression 
armlet 4 1/2 inches (11.5 cm.) wide by 16 inches (40 cm.) long, 
inclosed in a cuff of leather or thick canvas reinforced by tin strips. 
In the center of the cuff is cemented a glass tube 1/4 inch (6 mm.) 
in diameter. The manometer consists of a metal cistern connected 
by a metal tube with a glass mercury tube having a scale registering 
to 300 mm. The metal cistern is provided with a screw cap having a 
T-shaped metal tube, one arm of which is connected with the armlet 
and the other with the inflating apparatus, which consists of a double 
inflating bulb. At the top of the metal cistern is a screw valve for 
the gradual release of pressure, and on the arm connected with the 
inflating apparatus is a stopcock to shut off the inflation. 

Janeway's instrument (Fig. 88) consists of a U-shaped manometer 
with a sliding scale, connected with a cistern, to one side of which is 
attached the armlet and to the other a Politzer bag for the purpose of 




— Rogers' Sphygmomanometer. 



inflation. The armlet is a closed rubber bag measuring 4 3/4 inches 
(12 cm.) in width and 18 inches (45 cm.) in length, inclosed in a 
leather cuff that is fastened to the limb by means of two straps. A 
stopcock containing a needle valve for the release of pressure is inter- 
posed between the cistern and inflating bag. The instrument is 
unassembled for packing in its case as follows: The scale is sHd down 
and the upper part of the manometer is removed and placed in rings 
provided for this purpose on the lid. The open end of the manometer 
is plugged by a small cork "A" and the other end is closed automatic- 
ally when the lid is shut by a block which compresses the rubber 
"B." The inflation bulb is removed, and, as the box shuts, the stop- 
cock slips under a spring "C." 

Rogers' Sphygmomanometer (Fig. 89) registers blood-pressure 
by means of an aneroid scale. The instrument consists of a rubber 
armlet connected by two tubes with a gage and an inflating bulb. 



114 



SPHYGMOMANOMETRY 



The dial registers from o to 260 mm. of mercury. Upon the tube 
leading from the inflating bulb is placed a valve for releasing the air 
from the armlet. The readings obtained by this instrument corre- 
spond very closely to the figures obtained with the mercury instru- 
ments, and the instrument has an advantage over the latter in its 
simplicity and ease of operation. 

Whatever form of instrument is employed, a wide armlet (4 1/2 to 
4 3/4 inches (11.5 to 12 cm.)) should be used. 

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

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

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

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

Janeway^s Instrument. — The armlet is properly secured about the 



SPHYGMOMANOMETRY 



115 



limb as described above and the scale is so adjusted that the level of 
the two columns of mercury is at zero. With the fingers on the radial 
pulse the armlet is gradually inflated by compressing the bulb 
until the pulse disappears. Then, by slowly releasing the bulb until 
the pulse just returns, the systolic pressure is estimated. In cases of 
very high pressure, it may be necessary to employ more than one bulb 
full of air to obliterate the pulse. In such a case, the stopcock is 
closed, and, after the bag is refilled, the cock is opened again and the 
pressure raised as high as desired. The diastolic pressure is obtained 
in the same manner as described under the technic with the Stanton 
sphygmomanometer. 




Fig. 90. — Technic of sphygmomanometry with the Stanton instrument. 

Rogers^ Instrument. — The compression band is applied about the 
arm like a bandage and is secured by slipping the free end under the 
last turn. The aneroid gage is hung from a hook on the outer aspect 
of the armlet and the gage and inflating bulb are properly connected. 
To measure the systolic pressure the cuff is inflated until the radial 
pulse is obliterated, and the pressure in the cuff is raised i to 2 mm. 
higher. Air is then allowed to escape slowly from the armlet until 
the radial pulse beats just reappear. The figure on the dial at which 
the hand points at this moment represents the systolic pressure. The 
diastolic pressure is obtained by allowing air to escape from the arm- 
let very slowly until the dial shows a maximum range of oscillations. 
The valve is then quickly closed and the minimum oscillation is 
taken as the diastolic pressure. 



ii6 



SPHYGMOMANOMETR Y 



The Auscultatory Method of determining systolic and diastolic 
pressure is carried out by the aid of a stethoscope instead of by pal- 
pation. The cuff is applied and the pulse obliterated in the usual 
way. The operator then places a stethoscope over the brachial 
artery below the cuff and listens for the reappearance of the first 
sound (Fig. 91). The height of the column of mercury when this 
occurs represents the systolic pressure. If the armlet be further 
deflated there will still be heard murmurs which rapidly disappear 
when the mercury drops 30 to 45 mm. below the systolic reading. 
The point at w^hich all sounds disappear represents the diastoHc 
pressure. 




Pig. 91. — Sphygmomanometer by the auscultatory method. 

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

Variations of Blood-pressure in Disease.^ — Pain of all kinds 
causes an increase in the peripheral resistance, and a rise in pressure. 
Thus, in conditions attended with severe pain, as in acute biliary or 
renal colic, during labor, in acute 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. 

* For a complete exposition of this phase of the subject the reader is referred to 
Janeway's "Clinical Study of Blood-pressure." 



SPHYGMOMANOMETRY 



117 



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

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

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

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

Cardiovascular Diseases. — In valvular lesions pressure may or 
may not be elevated; in fact, the results of blood-pressure observa- 
tions in this class of cases are too varied to be of value. In primary 
myocarditis the blood-pressure is low, but when secondary to arterial 
or kidney disease it may be high. In arteriosclerosis the pressure is 
generally elevated, especially with hypertrophy of the left ventricle. 
Arteriosclerosis may exist, however, without elevation of pressure, 
and, if cardiac muscle 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 all other symptoms in the beginning 
of peritonitis from typhoid, appendicular, or other forms of perfora- 
tion. 

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

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

In shock and collapse a fall in blood-pressure is uniformly present. 
According to Crile, in shock, the fall in pressure is gradual, while the 
term "collapse" should be limited to those conditions in which there 



IlS SPHYGMOMANOMETRY 

is a sudden fall in blood-pressure due to hemorrhage, injuries of the 
vasomotor centers, or to cardiac failure. 

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

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

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



CHAPTER IV 

TRANSFUSION AND THE INJECTION OF HUMAN 
BLOOD SERUM 

TRANSFUSION 

The term transfusion, as commonly used, is applied to the trans- 
ference of blood from the vessels of a healthy individual (the donor) 
to those of the patient (the recipient), while the term infusion is 
restricted to cases in which other media than blood are so introduced. 

There is good evidence from records of cases that transfusion has 
been practised for many centuries, but it was not until Lower, in 
1665, and Denys, in 1667, published their results that the operation 
was used to any great extent. After this, it was employed for such a 
variety of purposes and so extravagant were the claims of its expo- 
nents that the French government prohibited its use, and it soon fell 
into disrepute. Early in the nineteenth century the operation was 
revived, and it became a recognized means of supplying the body with 
fluids to replace that lost from excessive hemorrhage, notably that 
occurring after childbirth. 

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

As the subject became more thoroughly studied and better 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 circu- 
lation, and that direct transfusion from artery to vein or vein to vein 
only was permissible.^ Furthermore, it was contended by many that 

^ Recently, transfusion by the old method of aspiration and injection has been 
revived. 

119 



I20 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

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

During the past 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 anasto- 
mosis it has become a practical operation, the value of which in cer- 
tain 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 shown that if performed 
early enough it is a specific remedy. Experimentally he has suc- 
cessfully treated every degree of hemorrhage; dogs were even bled to 
the last drop that would flow and were then successfully transfused. 
Transfusion is also indicated in pathologic hemorrhage, where the 
coagulability of the blood is deficient, as in hemophiha, cholemia, 
hemorrhage from the bowels, etc. In these cases the condition of the 
patient has been at least improved by the operation and in most 
cases the hemorrhage has been controlled. Some of the reported 
cases were transfused more than once before permanent improvement 
was noted. 

For shock, according to Crile, transfusion is the best form of 
treatment we now possess. It exerts far greater influence on blood- 
pressure than does saline solution. Both will raise blood-pressure, 
but the latter will not maintain the rise in pressure. Transfusion, 
on the other hand, frequently raises the blood-pressure above normal 
and will sustain it at a high level for a number of hours. 

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

In pellagra marked improvement and some cures have followed 
the transfusion of blood from healthy donors or healed pellagrins, 
but it has not proved as valuable a remedy in this disease as was first 
thought. The beneficial results are probably due to an increased 



TRANSFUSION 121 

resistance on the part of the patient, due to the restoration of the 
blood to a more normal condition. 

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

Tests for hemolysis should be made upon the donor and the recip- 
ient whenever possible. Hemolysis between the donor's corpuscles 
and the patient's serum is not necessarily harmful, but if it is found 
that there is reversed hemolysis, that is, if the donor's serum hemol- 
yses the patient's corpuscles, another donor should be chosen. Theo- 
retically, agglutination of the red corpuscles and precipitation may 
also occur; though, according to Crile, in practice these changes may 
be disregarded. 

Selection of the Donor. — If possible, a young vigorous adult 
should be selected to supply the blood. The subject should prefer- 
ably be from among the relatives of the patient — a close blood rela- 
tion, as a brother or sister, if possible. It is essential that the donor 
chosen be free from arterio-sclerosis, organic heart disease, malaria, 
syphilis, etc., and a thorough physical examination, including a 
Wassermann reaction, should be made to determine his fitness. 

ARTERY TO VEIN TRANSFUSION 

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



122 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

ture. In addition, there is frequently a contraction of the vessels 
at the point of suture, and thrombosis is more Hkely to occur. The 
operator intending to perform transfusion should, however, be famil- 
iar with both methods. 

Instruments. — There will be required a scalpel, an ordinary pair 
of blunt-pointed scissors, a small pair of curved scissors, thumb for- 
ceps, very fine tissue forceps, two small Crile clamps, mosquito hemo- 
stats, and transfusion cannulae. If direct suture is employed, instead 
of the Crile tubes, there will be needed several No. i6 cambric needles 
and fine strands of silk (Fig. 92). The silk should be thoroughly 
impregnated with vaselin and should be threaded into the needles 
before the operation is begun. 




Fig. 92. — Instruments for transfusion, i, Scalpel; 2, thumb forceps; 3, 
blunt-pointed scissors; 4, mosquito hemostats; 5, fine tissue forceps; 6, Crile 
clamps; 7, small pair of curved scissors; 8, Crile cannulas; 9, needles threaded with 
fine strands of silk. 



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 in place (Fig. 94). At least four sizes of these tubes should be 
at hand, and the largest size that can be used without injury to the 
arterial coats by undue stretching should be employed. 

To avoid the necessity of having several sizes of cannulae and to 
furnish an instrument that can be more easily manipulated, Buerger 
has devised a cannula which is supplied with a long handle and is 
made with a slit in the circumference of the tube so that it is possible 
to alter the diameter of the cannula to fit the individual vessels (Fig. 
95). 



TRANSFUSION 



123 



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




Fig. 93. — Enlarged view of Crile's clamps. (After Fowler.) I, Clamp without 
rubbers; 2, rubber tubes to fit on jaws of clamps; 3, clamp applied to artery. 

small square table upon which the arms of the donor and recipient 
rest during the operation. The operator is seated upon a stool in 
front of this table, and his assistant opposite (Fig. 96). 

Asepsis. — The strictest asepsis must be observed during the 
entire operation. The instruments are boiled, and the hands of the 
operator are prepared in the usual way. The forearms of the donor 





Fig. 94. — Enlarged view of Crile's cannula. 
Fig. 95. — Buerger's cannula. 

and the recipient should be sterilized by painting with tincture of 
iodin. 

Anesthesia. — The operation is performed under local anesthesia, 
employing a 0.2 per cent, solution of cocain or a i per cent, solution 
of novocain for the skin and a o.i per cent, cocain solution or a 
0.5 per cent, solution of novocain for deeper infiltration. 

Quantity Transfused. — It is impossible to estimate the exact 
amount of blood transfused and the guides should be the condition of 



124 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 



the donor and the recipient; the amount should also vary according 
to the condition for which the transfusion is performed. Twenty 
to forty-live minutes' flow in a good anastomosis is usually sufficient. 
As soon as the donor shows signs of loss of blood — indicated b}- a 
gradual pallor about the nose and ears, deepening of the lines of 
expression, sighing or irregular respiration, etc. — the transfusion 
must be immediately stopped. If it is carried too far, the donor 
goes into a state of collapse, and a condition is produced in him similar 
to that for the relief of which the operation was performed. Fur- 
thermore, transfusion of excessive am.ounts of blood may cause ser- 



Upe rating 7a hie 
J /Lecipient~ 



0. 



Operating /ahle. 
Z jDonor 



Fig. 96. — Arrangement of the operating-tables for a transfusion. (After 
Crile.) I, Table for recipient; 2, table for donor; 3, table for arms of recipient 
and donor; 4 and 5, stools for operator and assistant; 6, instrument table; 7, 
table for dressings, etc. 

ious damage to the viscera of the recipient, and even death. Acute 
dilatation of the heart, manifested by dyspnea, cyanosis, cough, 
pain over the precordium, and falling blood-pressure, is the most 
frequent sequel to overtransfusion. Should such a complication 
ensue, the transfusion must be immediately stopped, the patient 
should be placed in a reverse Trendelenburg position with the feet 
lowered, and external massage of the heart (page 54) performed to 
assist in emptying it. 

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 com- 
pressing the lumen of the artery by means of the fingers. 



TRAXSFUSIOX 



125 



Teclinic by Crile's Method. — The radial artery of the donor and 
any of the superficial A-eins in front of the elbow of the recipient are 
chosen for making the anastomosis — in a child the pophteai vein 
may be utilized. Both the donor and the recipient are given 1/4 
gr. (0.0162 gm.) of morphin hA-podermically half an hour before the 
operation unless it is contraindicated. 

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




Fig. 97. — Transfusion bj' Crile's method. First step, exposure of the vein and 
artery with Crile's clamps applied. 

the artery, or, in the absence of a special clamp, a piece of tape 
may be placed around the artery and clamped sufficiently tight to 
compress the vessel and shut ofi' the circulation. The distal 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 ofi' as clean as possible. 
The field of operation is now covered vnth a compress well soaked 
with hot saline solution. The vein of the recipient is then exposed 
in the same manner, and about i i/'2 inches (4 cm.) of it is freed from 
the surrounding tissues. The distal end of the vein is ligated, and 
to the proximal end is applied a Crile clamp CFig. 97), or a narrow 
piece of tape 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 in an artery clamp, 
is pushed over the vein. A suture inserted in the edge of the vein, 
as shown in Fig. 98, 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. 99), and is tied in the second 



126 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

groove of the cannula. The forearms of the donor and the recipient 
are then placed so that the hand of the donor is directed toward the 
elbow of the recipient. The cuffed portion of the vein is lubricated 




Fig. 98. Fig. 99. Fig. 100. 

Fig. 98. — Transfusion by Crile's method. (After Crilc.) Second step, draw- 
ing the vein through the cannula. 

Fig. 99. — Transfusion by Crile's method. (After Crile.) Third step, 
method of cuffing back the vein. 

Fig. 100. — 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. 

with sterile vaselin, three mosquito forceps are applied to the edges 
of the artery, and it is gradually drawn down over the cuffed vein 
(Fig. 100) 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 




Figs. 101 and 102. — Transfusion by Crile's method. 

anastomosis completed. 



Fifth step, showing the 



first. The clamp upon the artery is then very gradually opened, 
allowing the blood to flow into the vein of the recipient (Figs. loi 
and 102). At the completion of the operation the vessels are ligated, 



TRANSFUSION 1 27 

the tube is excised, and the skin incision is sutured and dressed 
with sterile gauze. 

In performing the operation there are several precautions to be 
observed. The vessels to be anastomosed must be handled with the 
greatest care. They should never be bruised with artery clamps or 
picked up with toothed forceps. Some difficulty may be experienced 
from retraction of the vessels when they are cut. This may be over- 
come to a great extent by keeping them constantly moistened with 
hot saline solution. In the case of a contracted artery, Crile advises 
that it be dilated by gently inserting a fine pair of closed artery clamps 
covered with vaselin and using it as one would a glove stretcher. 
Care should be taken that the anastomosis be made without undue 
tension, and that the cannula be placed accurately in the long axis 
of the vein and artery, otherwise the flow will be more or less impeded. 




Fig. 103. — Brewer's glass tubes lined with paraffin for transfusion. 

Variations in Technic. — Brewer has simplified Crile's method 
of making an anastomosis by employing long glass tubes lined with 
paraffin (Fig. 103). These tubes are about 2 1/2 inches (6 cm.) long, 
and are made small at the end to be inserted into the artery and large 
at the end over which the vein is drawn. Each end is slightly bul- 
bous, and is provided with a sulcus into which the ligature holding 
the vessel in place falls. 

The tubes are thoroughly sterilized and are then dipped in 
melted paraffin, shaken out, and allowed to cool. The vein and 
artery are exposed and isolated in the usual way and two Crile clamps 
are applied as shown in Fig. 97. The artery is drawn over one end of 
the tube and is secured by a ligature. A longitudinal or a transverse 
cut is made in the wall of the vein (see Fig. 118), and, after loosening 
the arterial clamp sufficiently to permit the tube to fill with blood, 
the distal end of the tube is quickly inserted into the vein in the 
manner shown in Fig. 119, and is secured in place by a ligature. The 
clamps are then removed and the blood is allowed to flow. 



128 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

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

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




Fig. 104. — Levin's transfusion clamp. 

the artery is passed directly into it for a distance of an inch (2.5 cm.). 
One of the guiding sutures is then passed through the rolled up 
adventitia on the artery, to hold the two vessels in contact, and the 
greater or less amount of superfluous circumference of the vein is 
clamped or sutured so as simply to approximate the artery but not 
to constrict it. The obstructing clamps are removed, and the blood 
current is allowed to flow." 

Levin {Annals of Surgery, ]March, 1909) describes a clamp form 
of transfusion cannula. This instrument (Fig. 104) is made in the 
form of an artery clamp with a small cannula attached to the tip 
of each blade. Upon the free edge of each cannula are placed four 
small pin points, and upon the outer surface are four grooves into 
which the pins fit when the two cannulas 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 
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. 



TRANSFUSION 1 29 

Elsberg {Journal of the American Medical Association, March 
13, 1909) describes a very practical cannula that does away with the 
necessity for the Crile clamps. His method of performing the anasto- 
mosis differs from the Crile method in several points. "The cannula 
(Fig. 105) is built on the principle of a monkey wrench, and can be 
enlarged or narrowed to any size desired by means of a screw at its 
end. The smallest lumen obtainable is about equal to that of the 
smallest Crile cannula, and the largest greater than the lumen of any 
radial artery. The instrument is cone-shaped at its tip, a short dis- 
tance from which is a ridge with four small pin points which are 
directed backward. The lumen of the cannula at its base is larger 
than at its tip." 

In using this instrument, after first exposing and separating the 
artery from the surrounding tissues in the usual manner, the cannula 




Fig. 105. — Elsberg's transfusion cannula. 

is widely opened and is placed around the artery before the latter is 
cut. The cannula is then screwed together, thereby shutting off the 
arterial flow. The distal end of the artery is next ligated at about 
1/2 inch (i cm.) from the end of the cannula, and three fine silk trac- 
tion sutures or small tenacula are passed through the artery at equi- 
distant points on its circumference a short distance from the ligature. 
The artery is then cut close to the ligature, and the end is cuffed back 
by drawing upon the traction stitches or tenacula and is caught in the 
teeth upon the clamp. The vein of the recipient is then exposed and 
two ligatures are applied, the distal one being tied (see Fig. 117). 
The vein is opened by means of a small transverse slit in the same 
manner as for an intravenous infusion (see Fig. 118), 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 con- 
trolled by the extent to which the cannula is opened. 

Technic by Carrel's Suture.— Under local anesthesia the radial 
artery of the donor and the median basilic vein of the recipient are 
dissected free for a distance of i 1/2 inches (4 cm.), and any small 
branches are tied off with fine silk close to the main trunk. A small 
Crile clamp is applied to the proximal portion of the artery as near as 



130 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

possible to the upper limit of the incision, and the distal end of the 
vessel is tied off. The artery is then cut close to the distal ligature 
and the adventitia is drawn down over the end of the vessel and 
trimmed off. The field of operation is then covered by a pad mois- 
tened in saline solution, while the attention of the operator is directed 





Fig. 106. Fig. 107. 

Fig. 106. — Transfusion by Carrel's suture. (After Carrel.) First step, show- 
ing the method of inserting the three traction sutures. 

Fig. 107. — Transfusion by Carrel's suture. (After Carrel.) Second step, the 
three traction sutures in place. 

to preparing the vein. The extreme distal end of the vein is tied off 
with a ligature, a Crile clamp is applied to the proximal portion, and 
the vessel is severed close to the distal ligature (see Fig. 97). 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 




Fig. 108. Fig. 109. 

Fig. 108. — Transfusion by Carrel's suture. (After Carrel.) Third step, 
showing the method of suturing the artery and vein. 

Fig. 109.— Transfusion by Carrel's suture.. (After Carrel.) Fourth step, 
the anastomosis completed. 

a small table, so that the vessels may be brought together without 
tension, the hand of the donor pointing toward the elbow of the 
recipient. The ends of the two vessels are then sutured together as 
follows: 



VEIN TO VEIN TRANSFUSION I3I 

The needle, threaded with a fine strand of silk impregnated with 
vaselin, is passed through the wall of the artery from without in and 
through the wall of the vein (Fig. io6), and the two ends of the suture 
are tied and left long, to serve as a traction stitch. Two other sutures 
are similarly placed at such points that the circumference of the 
vessels is divided into three equal parts (Fig. 107). Two of these 
traction sutures are made taut, and the walls of the vessels between 
them are readily sutured. A continuous stitch is employed for this, 
the stitches being placed near the edges of the vessels and close to- 
gether to prevent leakage (Fig. 108). Before performing this sutur- 
ing 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 portions 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 
again shifted to the under stay. The remaining third is united in 
precisely the same manner, thus completing the suturing around the 
entire circumference of the two vessels (Fig. 109). The clamp upon 
the vein is removed first, and then the arterial clamp is slowly un- 
screwed, 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. 

VEIN TO VEIN TRANSFUSION 

In place of the artery to vein method, vein to vein transfusion 
has been advocated by Dorrance and Ginsburg as being simpler and 
easier to perform than artery to vein anastomosis on account of the 
superficial location of the vessels. Another advantage claimed for 
this method is that the flow of blood being slower, the danger of pro- 
ducing acute dilatation of the heart is avoided. Vein to vein 
anastomosis may be performed by the direct suture method of Carrel 
or by means of any of the mechanical devices already described under 
artery to vein transfusion. Fauntleroy has devised paraffin-coated 
curved glass tubes, somewhat similar to those of Brewer, by the use 
of which vein to vein transfusion is very much simplified. 

Technic. — The arm of the donor is constricted immediately below 
the axilla with a tourniquet applied with just sufiicient tension to 
distend the superficial veins but not tight enough to obstruct the 
arterial flow. This causes the superficial veins to dilate and stand 
out prominently. The veins of the recipient are similarly treated. 



132 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

Under infiltration anesthesia the median cephalic or the median 
basilic veins of both the donor and the recipient are exposed through 
a 3-inch (7.5 cm.) incision and an anastomosis between the distal end 
of the donor's vein and the proximal end of the recipient's vein is 
made by some of the methods previously described under artery to 
vein anastomosis. As soon as the anastomosis is completed the 
tourniquet is removed from the recipient's arm while that upon the 
donor's arm is simply loosened, being left with sufficient tension to pro- 
duce a well-marked hyperemia and an increase in the venous pres- 
sure. In this way there is enough pressure created in the vein of the 
donor to cause the blood to flow freely into the vein of the recipient. 
By this method the flow of blood will be less rapid than in an artery 
to vein anastomosis and the transfusion will need to be continued 
over a longer period of time. 

INJECTIONS OF HUMAN BLOOD SERUM 

For manv vears it has been known that blood serum contained 
some agent that hastened the coagulation of blood. In 1882 Hayem 
estabhshed this fact while performing experiments with different 
sera to determine their effect on coagulation. It is only, however, 
since Weil in 1905 published the results of his work along this line 
that the injection of fresh animal and human serum has become gen- 
erally recognized as a method of value for the prevention and control 
of certain forms of hemorrhage, such as is seen in hemophilia, chole- 
mia, and purpuric conditions supposed to be dependent upon defi- 
cient coagulability of the blood. ]More recently Welch of New York 
has shown that the subcutaneous injection of human blood serum 
is almost a specific remedy for the treatment of hemophilia neona- 
torum; from the rapid gain in weight after its use he also considers 
it a most efficient food for premature and malnourished infants. 
Blood serum is, likewise, claimed to be of value in septic conditions 
on account of its bactericidal action. 

Wbile horse serum, rabbit serum, and human serum have all 
been employed in these cases of pathologic hemorrhage, the latter 
should always be used in preference. With animal sera there is 
danger of producing serum sickness and anaphylaxis, especially where 
repeated injections are made, but this is apparently not the case 
with human serum. 

It should be remembered that, while the injection of human serum 
is an efficient method of controlling pathologic hemorrhages, it does 



INJECTIONS OF HUMAN BLOOD SERUM 



133 



not, of course, replace the cellular elements lost through excessive 
bleeding. In such cases, where the cellular elements are greatly 
diminished, transfusion is indicated. 

Apparatus. — The apparatus for collecting the blood, described by 
Welch {American Journal of Medical Sciences, June, 19 10), consists, 
of an Erlenmeyer flask stoppered with a rubber cork through which 
are two perforations. Through one is fitted a U-shaped tube, to the 
outer end of which is attached a short aspirating needle of No. 19 
caliber by means of a rubber tubing. The needle is cotton plugged 
in a small test-tube in which it is sterilized. 
Through the other perforation is inserted a 
fusiform glass tube containing cotton to pre- 
vent contaminating the contents of the flask. 
Upon the end of this tube is placed a small 
suction tube for drawing the blood into the 
flask (Fig. no). 

A 30 to 60 c.c. (i to 2 ounces) glass syringe 
with a glass piston should be provided for in- 
jecting the serum. 

Selection of Donor. — Preferably young 
adults from among the relatives of the patient 
should be selected. The donors, of course, 
must be free from any constitutional or other 
disease, and a thorough physical examination, 
including a Wassermann test, should be made 
to determine their fitness. 

Dosage. — In hemophilia neonatorum Welch 
advises that i ounce (30 c.c.) of serum be given 
twice a day to moderate bleeders and, if the bleeding is excessive, 
that it be given every four hours until the bleeding is under control. 

As a preventive of postoperative hemorrhage in chronic jaundice, 
Willy Meyer advises that i to 2 ounces (30 to 60 c.c.) of serum be 
administered three times a da,y beginning two days before the opera- 
tion and continuing for forty-eight to seventy- two hours afterward. 

Site of Injection. — The serum is injected subcutaneously in the 
loose tissues of the axilla or in the subcutaneous tissues of the abdo- 
men on either side of the umbilicus. In cases of great urgency it may 
be given intravenously. 

Asepsis. — The apparatus for collecting the blood and the syringe 
for injecting the serum should be sterilized, the operator's hands 
should be cleansed as for any operation, and the arm of the donor 




Fig. 1 10. — Welch's 
apparatus for collect- 
ing blood serum. 



134 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

and the site of injection are sterilized by painting with tincture of 
iodin. 

Technic. — To collect the blood, a tourniquet is first placed about 
the arm of the donor with sufficient tension to make the veins stand 
out prominently. One of the veins at the bend of the elbow — prefer- 
ably the median basilic — is then identified and the needle of the 
collecting apparatus is thrust into it, holding the needle almost paral- 
lel with the skin surface. About lo ounces (300 c.c.) of blood is then 
drawn into the flask, which is promptly stoppered with a sterile plug 
of cotton. The flask is then placed in a slanting position until the 
serum has formed. It usually takes four to six hours for all the serum 
to separate. When this has taken place, the serum is transferred 
to a sterile flask and is placed on ice until used. 

The technic of injecting the serum is as follows: The neck of the 
flask is sterilized, and the desired quantity of serum is drawn into 
the syringe. Care should be taken to see that all the air is ex- 
pelled from the syringe. A fold of skin in the region decided upon 
for making the injection is then raised up between the thumb and 
forefinger of the left hand, and, with the right hand the needle is 
quickly thrust into the subcutaneous tissues at the base of this fold 
of skin. The serum is injected slowly, and the resulting swelling 
is very gently massaged until the serum is all absorbed. After 
withdrawal of the needle, the point of puncture is sealed with 
collodion and cotton. Usually within twenty-four of forty-eight 
hours after beginning the injections the bleeding will be controlled. 



CHAPTER V 
INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 

The administration of physiological salt solution was originally 
introduced as a substitute for transfusion of blood in the treatment 
of hemorrhage on account of the numerous risks that attended the 
latter operation as formerly performed, and the difficulty of obtain- 
ing a suitable donor when most needed. The technic of direct blood 
transfusion has, however, been wonderfully perfected, and it can 
now be said to be an operation without danger if employed with 
proper precautions; but, notwithstanding this and the fact that no 
media has been found as efficient as blood in making up the loss 
from a severe hemorrhage, the infusion of salt solution is employed 
in preference to transfusion in the great majority of cases. This 
may be readily understood when we consider that the methods of 
administering salt solution can be carried out on short notice, that 
they require but little preparation, that they are marked by sim- 
plicity in technic, and that they are within the reach of all; on 
the other hand, transfusion becomes a formidable operation in 
comp arison. 

Salt solution may be introduced into the circulation through a 
vein (intravenous infusion), through an artery (intraarterial infu- 
sion), through the subcutaneous tissues (hypodermoclysis), and by 
way of the bowel (rectal infusion). 

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

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

(2) In the prophylaxis and treatment of mild surgical shock, for 
the purpose of restoring heat to the body and raising arterial tension. 
As shown by Crile, however, in severe shock, unless due to hemor- 

135 



136 INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 

rhagc, the rise of blood-pressure is so temporary that the first benefits 
derived from the infusion are not maintained. In such cases, the 
combination with the salt solution of drugs which raise blood-pressure, 
such as adrenalin chlorid, is followed by more marked and beneficial 
results. For a single infusion, 10 to 30 Tn,(o.6 to 2 c.c.) of the i to 
1000 solution of adrenalin chlorid may be added to a pint (500 c.c.) 
of salt solution, or the adrenalin may be administered by thrusting 
a hypodermic needle into the rubber tubing near the cannula and 
injecting the drug as the solution flows into the vein. 

(3) To increase the fluids in the tissues where there is deficient 
absorption of food, as in excessive vomiting, peritonitis, etc., or to 
replace the fluids lost through purging, as in dysentery and cholera. 
The administration of salt solution may also be used to advantage 
before undertaking operations upon poorly nourished individuals. 

(4) For its stimulating effects and the production of a 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 ad- 
vanced 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 0.7 per cent. — roughly, i dram (4 gm.) of chem- 
ically pure sodium chlorid to a pint (500 c.c.) of distilled water. It 
is of the utmost importance that the solution be accurately made, 
and it should not vary much from this strength of seven parts per 
thousand, as solutions not isotonic with the blood produce certain 
untoward changes in the corpuscles. It is the opinion of Mummery 
that symptoms, such as chills and sweating, which are sometimes 
seen after intravenous infusions, are due to the incorrect chemical 
composition of the fluid employed. Carelessness in this respect, 
as well as disregard of the proper temperature of the solution, are 
without doubt also responsible for many of the cases of reported 
sloughing of the tissues after subcutaneous infusion. 

A convenient method of keeping the salt solution ready for use 
is to have a sterilized and very concentrated solution put up in 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION I37 

hermetically sealed tubes, in such a strength that the contents of 
one tube emptied into a quart < looo c.c.j of sterile water gives a 
normal salt solution (Fig. in). In hospital practice it is customary 
to keep the solution in stock bottles ready for use. The solution is 
made up in the proper strength from sterile salt dissolved in sterile 
water, and is then prepared as follows.^ "■ Filter into flasks (sterilized 
by washing with bichlorid solution, then rinsing with sterile water) 
stoppered with nonabsorbent cotton, sterilize for one hour for three 
successive days at a temperature of 220° F., and cover the cotton 
stoppers wdth a small square of rubber tissue held in place by a 
rubber band. Wlien needed, place the flask in a deep basin filled 
with hot water until raised to the proper temperature."' A more 




Fig. III. — A tube of concentrated sterile salt solution. 

convenient method of bringing the solution to the required tempera- 
ture W'hen needed for use is to have at hand very hot and cold salt 
solutions in separate flasks. The solution may be quickly heated 
by placing the flasks, surrounded by water to their necks, in a steril- 
izer or a deep basin, and bringing the water to the boiling-point. 
Some of the cold solution is poured into the reservoir first, and suffi- 
cient of the hot solution is then added to bring the contents of the 
reservoir to the proper temperature. 

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

Hare's formula: (Approximately.) 



Calcium chlorid, 


0.25 gm. 


gr. iv. 


Potassium chlorid, 


0. 10 gm. 


gr. I 12 


Sodium chlorid, 


9 gm. 


dr. 2 1,4 


Distilled water, 


1000 c.c. 


qt. i. 


Ringer's formula: 






Potassium chlorid, 


0.25 gm. 


gr. iv. 


Calcium chlorid, 


0.3 gm. 


gr. 4 1/2 


Sodium chlorid, 


7 gm. 


dr. I 2/3 


Distilled water, 


1000 c.c. 


qt. i. 


1 Fowler. "The Operating-room 


and the Patient." 





138 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



Locke s formula: 

Calcium chlorid, 
Potassium chlorid, 
Sodium bicarbonate, 
Glucose, 
Sodium chlorid. 
Distilled water, 

Szumann's formula: 

Sodium chlorid, 
Sodium carbonate. 
Distilled water 



o 


2 


gm. 


gr. HI. 


o 


42 


gm. 


gr. VI. 


o. 


3 


gm. 


gr. 4 1/2 


I 




gm. 


gr. XV. 


9 




gm. 


dr. 2 1/4 


I coo 




c.c. 


qt. i. 


6 




gm. 


dr. I 12 


I 




gm. 


gr. XV. 


I coo 




c.c. 


qt. i. 



INTRAVENOUS INFUSION 

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




Fig. 112. — Apparatus for giving an intravenous infusion. (Ashton.) 

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



INTRAVENOUS INFUSION 



139 



Apparatus. — There should be provided a thermometer, a gradu- 
ated glass irrigating jar, about 6 feet (180 cm.) of rubber tubing, 
1/4 inch (6 mm.) in diameter, and a blunt-pointed metal infusion 
cannula (Fig. 112). In addition, a constrictor for the arm, a gauze 
compress, and a bandage will be required. 

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

Instruments. — The operator will require a scalpel, a pair of blunt- 
pointed scissors, mouse-toothed thumb forceps, an aneurysm needle, 
a needle holder, two curved needles with a cutting edge, and No. 2 
plain catgut (Fig. 113). 




^ 



i ^^ o ^ 4 

Fig. 113. — Instruments for intravenous infusion, i, 
pointed scissors; 3, thumb forceps; 4, aneurysm needle; 
curved needles; 7, No. 2 plain catgut. 



7 
Scalpel; 2, blunt- 
5, needle holder; 6, 



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

Temperature of Solution. — Most operators advise that the solu- 
tion be administered at a temperature of a few degrees above that 
of normal blood, i.e., at about 105° F. (41° C). 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 



140 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTON 



used at a tempearture of 115° to 118° F. (46° to 48° C.) without 
harmful effects. It should be borne in mind that there will be some 
loss of heat while the solution is flowing from the reservoir. For 
this reason, the fluid in the reservoir should be kept at a temperature 
of from 2° to 3° higher than the temperature at which it is wished 
to give the infusion. 

It is of the greatest importance that the solution be introduced 
into the body at a uniform temperature throughout the entire opera- 
tion. To insure this, a thermometer is kept 
in the solution continuously. By watching 
the thermometer and adding hot solution 
from time to time, as that in the reservoir 
cools, a uniform temperature may be 
maintained. 

Rapidity of Flow. — The speed of the 
flow may be regulated by raising or lower- 
ing the reservoir, or compressing the rub- 
ber tube. The rate of flow should be 
about one pint (500 c.c.) in five to ten 
minutes. It should be remembered that the 
weaker tJie action of the heart the slower must 
the fluid be introduced. Acute dilatation of 
the heart may be produced by disregard of 
this caution. Furthermore, if the solution 
enters the circulation too rapidly, the fluid 
that is driven from the heart to the lungs 
may consist of pure salt solution, and signs 
of imperfect oxygenation of the blood with 
embarrassed respiration and restlessness will 
follow. If such symptoms appear, the in- 
fusion must be discontinued until the dan- 
gerous signs have passed. 

Quantity Given. — It has been shown that only a certain amount of 
the solution will be retained in the circulation; after a time it escapes 
into the tissues and produces edema. Hence there is no object in 
infusing enormous quantities. The average amount administered 
at a time varies from one pint (500 c.c.) to three pints (1500 c.c), 
depending 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 




Fig. 114. — The super- 
ficial veins of the forearm. 
(Ashton.) 



IXTR-WEXOUS INFUSION 



141 



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. 114), preferably the median 
basilic which runs across the bend of the elbow from without inward.^ 
At times a vein exposed in the course of an operation may be con- 
veniently utilized. 

Preparation of the Patient. — All clothing should be removed from 
the area selected for the infusion, and that about the axilla loosened 




Fig. 115. — Showing the application of the bandage to the arm to constrict the 

veins, (Ashton.) 

if the arm is chosen for the infusion. The bend of the elbow is 
shaved, if necessary, and is then painted with tincture of iodin. A 
sterile bandage is tightly wrapped above the elbow to compress the 
veins and make them more prominent (Fig. 115). If the circulation 
is very feeble, even this expedient may fail to make the veins stand 
out conspicuously. 



1 Dawbarn advises that the infusion be performed through the internal saphen- 
ous vein at a point anywhere above the ankle, claiming (i) that it is as large or 
larger than the veins at the bend of the elbow; (2) that there are no important 
structures near by to be injured by a careless operator; (3) that the scar is unob- 
jectionable; and (4) that the assistants performing the operation will usually 
interfere less with the operating surgeon than if the arm is used. 



142 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



Anesthesia. — Anesthesia of the skin is obtained by infiltration at 
the site of incision with a 0.2 per cent, solution of cocain freshly 
prepared or a i per cent, solution of novocain, or by freezing with 
ethyl chlorid or a piece of ice dipped in salt. 

Technic. — With the forearm supinated, a transverse incision is 
made over the median basilic vein (Fig. 116). The vein is dissected 
from its 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 of an aneurysm needle, or, in its absence, by a pair of 
thumb forceps. The distal portion of the vein is tied off as low as 
possible with one ligature, and the second ligature is placed high up 
around the portion of the vein nearest the heart, ready to be tied 
(Fig. 117). A portion of the exposed vein is now grasped in a mouse- 




FiG. 116. — Intravenous saline infusion. (Ashton.) First step, showing the vein 

exposed by a small incision. 



toothed forceps at a short distance from the distal ligature, and, 
while the vein is put upon the stretch, a cut directed obliquely up- 
ward is made with scissors through half the vein, exposing its lumen 
(Fig. 118). The solution is first allowed to flow through the cannula 
to expel any air or fluid that may have become cold by standing, and 
the cannula, with the solution still flowing, is then inserted well into 
the cut vein (Fig. 119) 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 easilv loosened when the cannula is to be withdrawn at the end of 



INTRAVENOUS INFUSION 



143 



the operation (Fig. 120). The bandage is now removed from above 
the elbow, and the saline solution is allowed to enter the circulation, 
the reservoir being raised 2 to 6 feet (60 to 180 cm.) above the patient. 




Fig. 117. — Intravenous saline infusion. Second step, showing the distal end 
of the vein tied and a second ligature being passed under the proximal end of 
the vein 

During the infusion the temperature of the solution must be kept 
uniform, the thermometer in the reservoir being constantly watched, 





Fig. 118. Fig. 119. 

Fig. 118. — Intravenous saline infusion. Third step, showing the method of 
incising the vein. 

Fig. 119. — Intravenous saline infusion. (Ashton.) Fourth step, showing the 
cannula being inserted into the vein. 

and care must be taken to replenish the fluid in the reservoir bejore it 
has all escaped, otherwise air will enter the vein when a fresh supply 
is added. 



144 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



When sufficient solution has been introduced, the ligature about 
the cannula is loosened, and the latter is withdrawn. With this 
same ligature the proximal end of the vein may be then tied off 
(Fig. i2i). The edges of the skin wound are united with several 
catgut sutures, and a sterile gauze dressing, held in place by a few 
turns of a bandage, is applied. 

Variation in Technic. — Some operators perform intravenous 
infusion without making a preliminary incision to expose the vessel. 
The same apparatus is employed as for an ordinary intravenous infu- 




FiG. 1 20. Fig, 121. 

Fig. 120. — Intravenous saline infusion. Fifth step, showing the cannula tied 
in place. 

Fig. 121. — Intravenous saline infusion. (Ashton.) Sixth step, showing the 
infusion cannula removed and the proximal end of the vein ligated. 

sion, except that a hypodermic or a small aspirating needle is substi- 
tuted for the blunt cannula. The needle, with the solution flowing, 
is plunged through the skin directly into the wall of the vein. 

The difficulty in placing the needle accurately in the vein, espe- 
cially if the subject is very fat, 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 
distal end of the vessel, or into the proximal end against the blood 
current. The advantages claimed by its advocates for this method 
of infusion over the venous route is that the fluid, being first driven 



INTRAARTERIAL INFUSION I45 

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 solution enters a vein, and, as a result, there is less disturbance 
produced in the circulation. Infusion against the blood current has, 
in addition, it is claimed, a stimulating effect upon the heart. 

These alleged advantages of arterial infusion, however, seem to 
be overbalanced by the accidents that may follow employment of 
this method, there having been reported a number of cases in which 
sloughing about the area of infusion resulted, in some even necessi- 
tating amputation of the hand, so that for ordinary purposes saline 
solution introduced through a vein should be the method of choice. 

Crile and DoUey {Journal of Experimental Medicine, Dec, 1906), 
however, have shown that the infusion of normal salt solution and 
adrenalin into an artery against the blood current is suspended ani- 
mation from the effects of anesthesia or other causes is the most 
effective way of raising the blood-pressure and stimulating the heart. 
They point out that adrenalin administered by the venous system 
comes in contact with vessels having the least power of influencing 
blood-pressure, and that before a material rise can be effected by the 
action of the adrenalin upon the arteries it is necessary for the solu- 
tion to pass through the right heart, the lungs, and then back to the 
left heart before it reaches the aorta and coronary arteries. This 
often causes an accumulation 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. 

Apparatus. — The same apparatus described on page 139 for intra- 
venous infusion, or an infusion cannula attached to a large glass 
funnel by a piece fo rubber tubing, may be employed. In addition, 
a hypodermic syringe will be required. 

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

Technic. — Crile {Am. Jour, of Med. Sciences, April, 1909) gives 
the following technic for employing arterial infusion in humans for 
purposes of resuscitation. "The patient, in the prone position, is 
subjected at once to rapid rhythmic pressure upon the chest, with 
one hand on each side of the sternum. This pressure produces 



146 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



artificial respiration and a moderate artificial circulation. A can- 
nula is inserted toward the heart into an artery. Normal saline, 
Ringer's or Locke's solution, or, in their absence, sterile water, or, in 
extremity, even tap water is infused by means of a funnel and rubber 
tubing. But as soon as the flow has begun the rubber tubing near 
the cannula is pierced with a hypodermic syringe loaded with i to 
1000 adrenalin chlorid and 15 to 3oTn, (i to 2 c.c.) are at once in- 
jected. Repeat the injection in a minute, if needed. Synchro- 
nously with the injection of the adrenalin, the rhythmic pressure on 
the thorax is brought to a maximum. The resulting artificial cir- 
culation distributes the adrenalin that spreads its stimulating contact 







Fig. 122. — ^Showing the method of infusing salt and adrenalin solution into the 
carotid artery. (After Da Costa.) 

with the arteries, bringing a wave of powerful contraction and pro- 
ducing a rising arterial, hence coronary, pressure. When the coro- 
nary pressure rises to, say, 40 mm. or more, the heart is liable to 
spring into action. The first result of such action is to spread still 
further the blood-pressure-raising adrenalin, causing a further and 
vigorous rise in blood-pressure, possibly even doubling the normal." 
. . . "Just as soon as the heart-beat is established, the cannula 
should be withdrawn, first, because it is no longer needed, and, second 
the rising blood-pressure will drive a current of blood into the tube 
and funnel." 

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



INTRAARTERIAL INFUSION 



147 



hypodermic, or a long line aspirating needle, inserted into the com- 
mon femoral artery. Dawbarn recommends it as an emergency 
method in the absence of cannula and instruments necessary for in- 




PiG. 123. — Apparatus for infusing salt solution into an artery in Dawbarn's 

emergency method. 

travenous infusion, or where the superficial veins are small and very 
difficult to locate. 

Apparatus. — A hypodermic needle, or a long fine aspirating 
needle, and an ordinary Davidson syringe (Fig. 123) are all that are 
required. 




Fig. 124. — Showing the method of infusing salt solution into the femoral artery. 

Technic. — The femoral artery is first carefully defined just 
below Poupart's ligament. The aspirating needle is then forced by 
a slow rotary movement directly into the artery, entering it at right 
angles. As soon as the needle enters the vessel, bright red blood 



148 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



will fill 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 from a basin directly into the arterial circulation 
(Fig. 124). According to Dawbarn, it requires about half an hour to 
inject a pint (500 c.c.) of solution by this method. If a fountain 
syringe is used instead of a Davidson syringe, it must be held at 
least 6 feet (180 cm.) above the patient to secure the necessary 
pressure, otherwise the blood will be forced back up the tube. 

HYPODERMOCLYSIS 

The subcutaneous method of infusion does not permit as rapid 
an introduction of large quantities of solution as the intravenous, 




Fig. 125. — Apparatus for giving hypodermoclysis. (Ashton.) 



on account of the slowness with which the solution is absorbed. It 
is indicated in the same conditions as venous infusions, when urgency 
is not of prime importance. It is also frequently used as an adjunct 
to intravenous infusion. Hypodermoclysis is contraindicated where 
the tissues are edematous from dropsy, or where the circulation is 
so feeble that absorption of the solution is very slow or impossible. 
Apparatus. — There will be required a thermometer, a graduated 
glass, irrigating jar, 6 feet (180 cm.) of rubber tubing, 1/4 inch (6 
mm.) in diameter, and an aspirating needle of fair size (Fig. 125). 
When it is desired to introduce the fluid under both breasts at once, 



HYPODERMOCLYSIS I49 

two needles fastened to the rubber tubing by means of a Y-shaped 
glass connection, as shown in Fig. 126, 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 should be boiled, the seat of 
injection painted with tincture of iodin, and the operator's hands 
carefully cleansed. The thermometer is sterilized by immersion in 
a I to 500 bichlorid solution for ten minutes, followed by rinsing in 
sterile water. 

Temperature of the Solution. — The solution should enter the body 
at about 110° F. (43° C). When using a large aspirating needle the 
fluid in the reservoir should be kept at a constant temperature of 
about 3 degrees higher. If a h^'podermic needle be employed, about 
5 degrees should be allowed for cooling. 

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




Fig. 126. — Showing two needles arranged for hypodermoclysis. 

about a pint (500 c.c.) of fluid may be injected in from twenty to 
thirty minutes, the reservoir being held from 3 to 4 feet (90 to 120 
cm.) above the patient. W^hen a hypodermic needle is employed, 
the needle being so small in caHber, it will be necessary to raise the 
reservoir 5 or 6 feet (150 to 180 cm.) to get sufiicient force. 

Quantity Given. — Injections of small quantities of solution, re- 
peated several times, give better results than a single large injection. 
As a rule, from 8 to 16 ounces (250 to 500 c.c.) of solution are intro- 
duced at a single injection, and repeated in a few hours, if necessary. 
According to Hildebrand, it is not safe to introduce a larger quantity 
of solution in fifteen minutes than i dram (4 c.c.) to each pound 
(453 gm.) of body weight. If this ratio is exceeded, the fluid accu- 
mulates and the tissues become water-logged, as the kidneys do not 
secrete rapidly enough to carry it off. Furthermore, very large 
quantities of solution should not be injected into one area, as it may 



ISO 



INFUSIONS OF PHYSIOLOGICAL SALT SOLUTION 



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 




Fig. 127. — Sites for hypodermoclysis. 

is an abundance of loose connective tissue. The usual sites are: 
(i) under the mammary glands; (2) in the subcutaneous tissue be- 
tween 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. 127). 




Fig. 128. — Giving hypodermoclysis under the left breast. (Ashton.) 

Anesthesia. — The point of skin puncture may be anesthetized by 
the injection of a drop or tw^o of a 0.2 per cent, solution of cocain 
or a I per cent, solution of novocain, or by freezing with ethyl chlorid 
or salt and ice. 



HYPODERMOCLYSIS I51 

Technic. — The reservoir is raised from 3 to 4 feet (90 to 120 cm.) 
above the patient, and some of the fluid is allowed to escape from the 
needle, to expel any air or cold solution. With the solution still 
flowing, the operator, using steady pressure, inserts the needle ob- 
liquely 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. 128). If, as soon as the tissues 
in one area become distended, the needle be partly withdrawn and 
its direction be changed shghtly, a large amount of solution may be 
infiltrated over a wide area without producing too great tension at 
any one spot. The absorption of the solution may be hastened by 
gentle massage over the infiltrated area. During the operation, the 
temperature of the solution is to be kept uniform, and sufficient 
solution must be in the reservoir at all times to prevent air from 
entering the tube. 

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

RECTAL INFUSION. (See page 554.) 



CHAPTER VI 

ACUPUNCTURE, VENESECTION, SCARIFICATION, SUBCU- 
TANEOUS DRAINAGE FOR EDEMA, CUPPING, AND LEECHING 

ACUPUNCTURE 

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

For the relief of tension, and to furnish an exit for the effusion 
beneath 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 substituted for the punctures. In acute epididymitis and similar 
cases acupuncture is also often used with good results. 

Of the second class of cases it is employed with greatest success 
in lumbago and sciatica. Just how acupuncture acts in such cases is 
not clear; relief of pain is not invariably afforded, for in some cases it 
seems to have no effect, but at any rate the method is worthy of 
trial, especially before more severe forms of treatment, as nerve 
stretching, etc., are instituted. 

Instruments. — To relieve tension, the pun,ctures may be made 
with triangular-pointed surgeon's needles or with a very narrow- 




FiG. 129. — Instruments for acupuncture. 

bladed bistoury (Fig. 129). Employed for the relief of the pain of 
muscular rheumatism or neuritis, half a dozen cyhndrical needles 
about 3 or 4 inches (7.5 to 10 cm.) long will be required. Long darn- 
ing needles or sharp hat pins will answer very well. 

Asepsis. — The skin should be sterilized by painting the sites of 
puncture with tincture of iodin; the instruments are to be boiled; 
and the operator's hands are cleansed as for any operation. It is 
especially important to observe all aseptic precautions both during 
and after puncture of dropsical effusions, as the tissues in such cases 
have poor resistance and are a good soil for infection. 

1^2 



ACUPUNCTURE I 53 

Anesthesia. — There is but little pain connected with this opera- 
tion, but if desired the skin at the sites of puncture may be frozen with 
ethyl chlorid. 

Technic. — Puncture for the relief of tension simply consists in 
making a single or, when required, numerous deep stabs with the 
needle or bistoury into the swollen area, avoiding injury to important 
vessels or nerves. This allows the escape of serum which may be 
encouraged by the application of moist heat in the form of dressings 
saturated with some mild antiseptic, as boric acid. 

When treating muscular rheumatism by this method, several 
sharp round needles are thrust through the skin into the painful parts 
of the affected muscle to a depth of i to i 1/2 inches (2.5 to 4 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. 

Applied to a nerve, the same technic is employed. An endeavor 
is made to transfix the affected nerve with from four to six needles 
along the painful part of its course. It may sometimes be difficult 
to strike some of the smaller nerves, but with a large nerve like the 
sciatic there is usually no trouble. The patient's sensations will be a 
guide as to whether the nerve is reached, for, as soon as this occurs, 
a sharp pain will be felt different from that experienced as the needle 
passes through the superficial tissues. The needles when properly 
placed should be left in site about five or ten minutes. 

VENESECTION 

The operation of venesection, or phlebotomy, consists in the open- 
ing of some superficial vein and the abstraction of blood from the 
general circulation for therapeutic purposes. 

The beneficial effects of bleeding have been recognized from the 
time of Hippocrates. Unfortunately, though, bleeding was formerly 
much overdone, and in the early part of the last century it came to be 
the custom to bleed indiscriminately for almost any sickness. In 
consequence of its abuse this valuable operation has lost much of its 
popularity and is now but rarely practised. Popular prejudice, 
furthermore, often prevents its employment, so that even in cases 
where it is of undoubted therapeutic value the practitioner of to-day 
prefers to put his trust in drugs to accomplish the desired effects. 
In spite of this neglect, bleeding is a powerful and beneficial thera- 
peutic measure when employed in the proper class of cases, and, as 



154 



ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 



Hare points out, " the indications for venesection are as clear and well 
defined as are the indications for any remedy." 

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

Upon the general system venesection also has beneficial effects 
causing a lessened activity of the various functions; the cardiac and 




Fig. 130. — Instruments for venesection, i, Glass graduate; 2, ethyl chlorid; 
3, scalpel; 4, stick for patient to grasp; 5, bandages. 

respiratory actions become less active, the temperature is lowered, 
and cell proliferation is diminished. 

In general, then, it may be said that venesection is indicated for 
the relief of congestion in cases of excessive vascular tension evidenced 
by a rapid, strong, full, incompressible pulse, while low arterial ten- 
sion and circulatory depression with a slow, soft, irregular, and com- 
pressible pulse are, as a rule, contraindications. Thus in sthenic 
t)^es of croupous pneumonia with dilated right heart, dyspnea, and 
cyanosis, in pleurisy, peritonitis, pulmonary edema, pulmonary 
hemorrhage, emphysema with marked dyspnea and cyanosis, conges- 
tion of the brain, cardiac valvular disease with engorged right heart, 
bleeding both lowers vascular tension and relieves engorgement. In 
cases where toxins or other deleterious substances are present in the 



VENESECTION 



■:>:) 



blood, as in eclampsia, uremic convulsions, illuminating-gas poison- 
ing, poisoning by hydrogen sulphid, prussic acid, etc., bleeding serves 
the double purpose of reducing arterial tension and removing a defi- 
nite quantity of toxic material. 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. 

Instruments. — There will be required a 
scalpel or bistoury, a sterile gauze pad, 
several bandages, a round object as a stick 
or roller bandage for the patient to grasp, 
and a large glass graduate (Fig. 130). 

Quantity Withdrawn. — On an average 
from 6 ounces (180 c.c.) to 15 ounces (450 
c.c.) may be abstracted from an adult, and 
from I ounce (30 c.c.) to 3 ounces (90 c.c.) 
from a child, depending on the condition 
and the character of the pulse and upon the 
appearance of the patient. This amount 
may be increased, hov/ever. if the venesection 
is to be supplemented by transfusion or 
saline infusion. Under such conditions 20 
ounces (600 c.c.) or more may be removed 
from an adult. 

Site of Operation. — Some one of the 
large veins in front of the elbow-joint is 
usually selected (Fig. 131). but the internal 
jugular or internal saphenous may be 
utilized. 

Position of the Patient. — The patient should be sitting upright or 
in a semirecHning position on a couch, with his head turned away 
from the seat of operation, as the sight of blood may cause faintness. 
The semiupright position is a safeguard against withdrawing too 
much blood, as the patient becomes faint sooner than if he were lying 
down. 

Asepsis. — While this is a small operation, at the same time all 
aseptic precautions should be observed. In former times many 
patients lost their lives from septic thrombosis. Accordingly, the 
instruments and dressings should be sterile, and the hands of the 
operator should be as carefully prepared as for any operation. The 
bend of the patient's elbow is first shaved if necessary and is then 
painted with tincture of iodin. 




Fig. 131. — Superficial 
veins of the forearm. 
(Ashton.) 



156 



ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 



Anesthesia. — The area of incision may be anesthetized by infil- 
trating with a few drops of a 0.2 per cent, solution of cocain or a i 
per cent, novocain solution, or by freezing with ethyl chlorid or salt 
and ice. 

Technic. — A few turns of a roller bandage are placed about the 
patient's arm above the elbow with just sufficient tension to obstruct 
the venous circulation and make the veins stand out prominently 
(Fig. 132). 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 patient's arm is then placed in an extended and 
abducted position. The operator next identifies either the median 




Fig. 132. — 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 trans- 
versely to the long axis of the vein (Fig. 133), which is exposed by 
dissection and a small opening made in its anterior wall (Fig. 134). 
The arm is then turned over, the thumb removed, and the blood is 
permitted to escape into a glass graduate (Fig. 135). 

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, 
otherwise the cut through the skin and that into the vein will not 
coincide when the finger is removed and the skin released, with the 



VENESECTION 



157 



result that the blood will escape under the skin into the subcutaneous 
tissues. If the median basilic vein is utilized, the incision into its 




Fig. 133. Fig. 134. 

Fig. 133. — Venesection. Second step, vein exposed and operator's finger 
compressing the distal portion of the vessel. 

Fig. 134. — Venesection. Third step, showing incision into vein walls. 




Fig. 135. — Venesection. Fourth step, showing the operator's finger removed from 
the vein and the blood being collected in a glass graduate. 



wall must not be made too deeply for fear of wounding the brachial 
artery. 



158 ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 

When a sufficient quantity of blood has been abstracted, a gauze 
pad is held over the wound by the thumb, and the bandage is removed 
from the arm. The incision is then dressed with a sterile gauze 
compress held in place by a bandage. If simple compression is not 
sufficient to stop the breeding, both ends of the vein should be sought 
and ligated with fine catgut. The patient should be instructed to 
carry the arm in a sling for a few days following this operation. 

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

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

Variations in Technic. — Some operators extract the blood by 
means of a medium sized aspirating needle attached to a large 
antitoxin syringe or through a vein trocar to which is attached a piece 
of rubber tubing which leads to a glass graduate. The needle or tro- 
car is plunged through the skin into the vein in the same manner as 
is done in withdrawing blood for bacteriological examination (see 
page 223). 

SCARIFICATION ' 

Scarification consists in making multiple incisions into the tissues 
for the relief of local congestion or tension. By this method of local 
bleeding, engorged blood-vessels are emptied and effusions of serum 
are permitted to escape; thus undue 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 apphcation. Thus in inflamed 
ulcers, threatened gangrene from extreme tension, phlegmonous ery- 
sipelas, etc., prompt relief often follows its use. Scarification may 
also be employed in the place of multiple punctures for the rehef 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 aff"ections and edemas of the pharynx, uvula, tonsils, and glot- 
tis it is often indicated; in involvement of the latter with progressive 



SCARIFICATION 



159 



dyspnea and cyanosis the scarification should be performed without 
any delay. 

Instruments. — An ordinary scalpel or bistoury is all that is neces- 




FiG. 136. — Automatic scarificator. 

sary. A special scarifier (Fig. 136) may be employed, however, if 
desired. This instrument consists of a metal box containing a num- 
ber of sharp blades, which, upon touching a spring, are suddenly 



Fig. 137. — Knife wrapped with adhesive plaster. 

forced out in such a way as to cut the tissues to which the instrument 
is applied to any desired depth. 

For incising the tonsil, glottis, etc., a sharp-pointed curved, 
bistoury wrapped with adhesive plaster to within 1/4 inch (6 mm.) of 




Fig. 138. — Protected laryngeal knife. 

its point (Fig. 137) should be employed in the absence of a protected 
laryngeal knife (Fig. 138). 

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



i6o 



ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 



Anesthesia. — Where extensive incisions are required, as in urinary 
extravasation, for example, nitrous oxid anesthesia will be required. 
In other cases local anesthesia with a 0.2 per cent, solution of cocain 
or a I per cent, novocain solution, or by freezing, if the nutrition of 
the parts is unimpaired, will suffice. Mucous surfaces may be anes- 
thetized with a 4 per cent, solution of cocain sprayed upon or applied 
directly to the parts. 

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. 139) and in other regions paral- 
lel to the lines of cleavage, care being taken not to wound the super- 
ficial nerves or large veins. Warm fomentations applied to the scar- 
ified area assist in maintaining the escape of blood and serum. 




Fig. 139. — Showing the method of scarifying a Hmb. 

Scarification of the larynx is performed with the aid of laryngos- 
copy (page 389). 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 424) must be 
performed without hesitation. 

DRAINAGE IN EDEMA OF THE LOWER EXTREMITIES 

Three operative procedures may be employed for reKeving edema 
of the lower extremities when the tension becomes too great, namely. 



DRAINAGE IN EDEMA OF THE LOWER EXTREMITIES 



l6l 



multiple punctures (page 152), incision (page 158), and drainage by 
the trocar and cannula. Of these, the latter is less troublesome, more 
cleanly, and certainly far more comfortable for the patient. 

From one to four cannulas may be employed at a time, and con- 
siderable fluid may be drained off in this way. When more than one 
cannula is used several quarts may be abstracted in twenty-four 
hours, but the operator should be cautious about withdrawing too 
great a quantity for fear of inducing a condition of cerebral anemia. 
Should such a condition be produced, the drainage should, of course, 
be immediately stopped and stimulants administered. 




Fig. 140. — Southey's trocars and cannula. 



Apparatus. — Southey's tubes (Fig. 140) or those of Curschmann 
may be employed. The former are made in a set consisting of one 
trocar and four cannulae. Each cannula has lateral openings as well 
as a distal opening. The lumen of the cannula is about 1/25 inch 
(i mm.) in diameter. In addition, pieces of rubber tubing about 3 feet 
(90 cm.) long to lead from the tubes to receptacles are required. 

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

Asepsis. — Rigid asepsis should be observed to avoid infection. 
The trocar and cannula are boiled, the operator's hands carefully 
cleansed, and the spot chosen for puncture is first shaved and then 
painted with tincture of iodin. 



l62 



ACUPUNXTURE, VEXESECTIOX, SCARIFICATION, ETC. 



Technic. — One cannula at a time is placed on the trocar and is 
inserted an inch (2.5 cm.) or more into the subcutaneous tissues at 
right angles to the surface. The trocar is then removed and to the 
free end of the cannula is attached a rubber tube idled with some 
antiseptic solution. The distal end of the tube is allowed to drain into 
a basin placed upon the floor by the side of the patient's bed (Fig. 
141). Three or more cannulae are introduced in this manner. The 
cannulse should be secured in place by means of adhesive plaster, and 
sterilized dressings should be placed about them. Elevation of the 




Fig. 141. — Showing the method of draining an edematous limb with Southey's 
cannula. (After Gumprecht.) 

head of the bed from 6 to 24 inches (15 to 60 cm.) allows the fluid to 
gravitate to the extremities and is of considerable help when the 
edema is generalized. Care should be taken that the cannula? are not 
displaced, and for this reason, with restless patients, it is better to 
remove them at night. It is preferable in any case to make new 
punctures than to leave the cannulae in place for several days. After 
removal of the cannulae, the sites of the punctures should be sealed 
with collodion and cotton. 

CUPPING 

Cupping may be either dry or wet according to the method of 
application. Dry cupping produces a local congestion of the super- 
ficial tissues and relieves congestion of the deeper .subjacent organs 



CUPPING 



103 



by deviating the blood from these parts. Wet cupping, in addition, 
actually abstracts blood from the tissues. Cupping finds its chief 
appKcation in the relief of congestion of deeply placed organs as the 
brain, spinal cord, lungs, liver, kidneys, etc. 

Apparatus. — Special cupping glasses supplied with a rubber bulb 
for exhausting the air (Fig. 142) are obtainable and will be found very 




Fig. 142. — Bulb form of cupping glass. 

convenient, but the ordinary cupping glasses in which the vacuum is 
created by igniting a httle alcohol smeared over the interior of the cup 
are just as efficient. In an emergency, 2-ounce (60 c.c.) whisky or 
wineglasses, or thick tumblers with smooth rounded edges will answer 




Fig. 143. — Instruments for wet cupping, i, Cupping glasses; 2, swab in alcohol; 
3, alcohol lamp; 4, scalpel. 



equally well. From 8 to 1 2 cups will be required in dry cupping and 
from 2 to 6 in wet cupping, depending upon the extent of surface to 
which they are to be applied. 

In addition to the cups there should be provided some alcohol, a 
small stick to the end of which a cotton swab is attached, and matches 



164 



ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 



or an alcohol flame. If wet cupping is to be employed, there will 
also be required a sharp scalpel or lancet (Fig. 143). 

Sites of Application. — Cupping glasses are never to be applied 
directly over inflamed tissues on account of the pain that would 
result. Nor should they be placed over bon}' or irregular surfaces on 




Fig. 144. — Cupping. First step, swabbing the interior of the cupping glass with 

alcohol. 

account of the impossibility of excluding air. Where the brain is the 
seat of the trouble, the cups are applied to the back of the neck; in 
pericarditis, to the precordial region; in involvement of the lungs or 
pleura, to the chest between the vertebral column and scapular line; 




Fig. 145. — Cupping. Second step, igniting the alcohol in the cupping glass. 

in renal congestion or acute nephritis, to the lumbar regions; in affec- 
tions of the eye, to the temples; etc. Wet cups, however, are often 
followed by scarring, hence they should not be applied over conspicu- 
ous regions or upon the shoulders or chests of women. 



CUPPING 



165 



Technic. — i. Dry Cupping. — Any hair should be first shaved off 
the part and the surface of the skin dampened with warm water so 
that the cups will adhere. To apply caps supplied with an exhausting 
bulb, simply compress the rubber bulb, then place the cup upon the 
skin, and release the bulb. A partial vacuum is thus produced and 
the skin and underlying tissues engorged with blood are sucked up 
into the cup. 

When ordinary cups are employed, the swab, saturated with 
alcohol, is lightly wiped over the interior of each cup (Fig. 144), 
care being taken not to leave any excess of alcohol that may run down 



Fig. 




Cupping. Third step, the application of the cups. 



over the edges. The alcohol is then ignited (Fig. 145), and the cup is 
quickly and tightly applied to the skin. The contained air is rapidly 
exhausted by the flame, and, as the cup cools, a strong vacuum is 
created, which draws up the underlying tissues (Fig. 146)) and pro- 
duces local congestion. A number of cups — anywhere from eight to 
ten — may be applied in the same manner over any given region. If 
the cups are air-tight, the flame is extinguished before the patient 
feels the heat from the burning alcohol. When the swelling of the 
skin and underlying tissues has taken place to such an extent as to 
replace the exhausted air, the cups become loosened and drop off. 
If, however, it is desired to remove the cups before this has occurred, 
simply tip the cup to one side and press down the skin at the edge of 
the glass and thus allow air to enter. 



l66 ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 

2. Wet Cupping. — By this method a definite amount of blood 
may be removed, each cup being capable of abstracting from i to 3 
drams (4 to 12 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 reappHed. The cups are 
then immediately applied for the second time. Blood will be drawn 
from the scarified area into the cups until 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 sur- 
face, they are applied again, or hot fomentations may be employed to 
encourage the bleeding. When sufficient blood has been withdrawn, 
a sterile gauze dressing is applied over the scarified region. 

LEECHING 

Leeching may be employed for the purpose of abstracting blood 
from contused or congested areas inaccessible to wet cupping. It is 
thus a valuable means of local blood-letting in ecchymoses, or begin- 
ning acute inflammation about the eye, ear, nose, gums, genitals, etc. 

There are two varieties of leech used for this purpose: the small 
American leech which is capable of withdrawing about a dram (4 
c.c.) of blood and the Sweedish leech which will suck from 3 to 4 
drams (4 to 15 c.c). According to the amount of blood it is desired 
to remove, from one to six leeches may be applied at one time. 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 irritat- 
ing, they should not be applied directly to an inflamed area; instead, 
they are to be applied to the periphery. They should never be 
allowed to take hold of the skin directly over a superficial artery, 
vein, or nerve. 

Leeches are generally applied to the temples or the back of the 
neck in congestion or inflammation of the brain, to the mastoid and 
in front of the tragus in acute mastoiditis and acute otitis media, to 
the perineum when the scrotum, penis, or labia are the regions 



LEECHING 167 

alTected, and to the coccyx for the rehef of congested or inflamed 
hemorrhoids. 

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

Technic. — The leech is applied to the part and confined under 
a pill-box or wineglass until it takes hold. A special leech-tube or a 
test-tube may be employed for this purpose, in which case the leech 
is placed in the tube tail or large end first and the tube is then 
inverted so that the leech's head comes in contact with the skin. 
This may be removed as soon as the leech takes hold, but, in employ- 
ing leeches about the orifices of mucous cavities, they should always be 
confined so as to prevent their escape 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 in 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 not 
seem inclined to do so. When once the leech has begun to draw 
blood, it should not be pulled off — it will drop off when filled. If it is 
desirable, however, to remove it. sooner, sprinkling salt over it will 
induce it to let go. 

By applying hot fomentations to the part after the removal of 
the leech bleeding can be encouraged and often an ounce (30 c.c.) or 
more of blood may be withdrawn in this way. After removal of the 
leech the bite should be bathed with sterile water and a small gauze 
dressing applied. 

Sometimes a considerable and troublesome bleeding continues 
from the leech bite, due to the fact that the tissues become infiltrated 
with material excreted from the throat of the leech which prevents 
coagulation of the blood. The bleeding can usually be controlled, 
however, by compression or by applying a piece of cotton saturated 
with some styptic, as a solution of i to 1000 adrenalin chlorid, alum, 
or tannic acid. The use of the actual cautery or passing a harelip 
pin or needle beneath the bite and winding a thread about the two 
ends so as to constrict the part are also advised. Failing in these 
measures, the bite should be excised and the tissues sutured. 

The Artificial Leech. — This apparatus may be employed instead 
of live leeches. It consists of a small cupping apparatus combined 
with a scarifier (Fig. 147). 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 



l68 ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 




Fig. 147. — Artificial leech. 




Fig. 148. — Application of the artificial leech to the mastoid. (After Ballenger.) 
First step, showing the method of scarifj'^ing. 




Fig. 149. — Apphcation of the artificial leech to the mastoid. (After Ballenger.) 
Second step, withdrawing blood. 



LEECHING l6g 

lancet to rapidly rotate, as shown in the accompanying illustration 
(Fig. 148), the blades of the instrument being adjusted so as to cut to 
the desired depth. Then the cupping tube is apphed and blood 
abstracted by withdrawing the piston and creating a vacuum (Fig. 
149) . With this instrument as much as i ounce (30 c.c.) of blood may 
be withdrawn. 



CHAPTER VII 

HYPODERMIC AND INTRAMUSCULAR INJECTIONS, 
THE ADMINISTRATION OF SALVARSAN AND NEO- 
SALVARSAN, THE ADMINISTRATION OF DIPHTHE- 
RIA ANTITOXIN, VACCINATION 

THE HYPODERMIC AND INTRAMUSCULAR INJECTION OF 

DRUGS 

Drugs may be administered by injection into the subcutaneous or 
muscular tissues when a rapid effect is desired, or when, for any 
reason, medication by the mouth is undesirable or is contraindicated. 
The injection of soluble, nonirritating substances is made into the 
subcutaneous tissues, from which the absorption is very rapid; but 
when the solution is insoluble or irritating, so that its presence 
in sensitive tissues would produce pain, it had best be given 
intramuscularly. 

The advantages of hypodermic medication, besides the prompt- 
ness of the effects obtained, consist in aft'ording a method whereby 
it is possible to administer remedies in the presence of nausea and 
vomiting, or inability or unwillingness on the part of the patient to 
swallow; furthermore, the absorption of the drug is not dependent 
upon the functional activity of the gastrointestinal tract. 

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



e 
Fig. 150. — -Ordinary glass and metal hypodermic syringe. 

a leather-covered piston (Fig. 150). Such syringes, however, are 
difficult to keep clean and, if they are frequently boiled, the leather 
packing soon dries out and becomes inefficient unless carefully at- 
tended to. Syringes of solid metal (Fig. 151) or those consisting of 
a glass barrel and soHd glass piston, as the Luer (Fig. 152), or with 
an asbestos-covered piston, as the "Sub-Q," will be found preferable. 

170 



HYPODERMIC AND INTRAMUSCULAR INJECTION OF DRUGS 171 

and may be easily cleaned and repeatedly boiled without harm. A 
syringe with a capacity of 3oTn, (2 c.c.) is amply large for ordinary 
use. 

The needles should be as tine 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 




Fig. 151. — All metal hypodermic syringe. 

large. To prevent the needles rusting and the lumen becoming 
plugged, they should be first well cleaned out with water after using, 
followed by alcohol and ether to remove any remaining fluid from the 
interior that might cause rusting, and, finally, they should be put 
away with a fine wire inserted in the lumen. 

Preparation of the Solution. — The drugs most frequently used for 
hypodermic medication are morphin, atropin, strychnin, hyoscin, 
pilocarpin, cafi'ein, cocain, apomorphin, quinin, mercury, digitalis, 
ergotin, nitroglycerin, adrenalin, alcohol, ether, etc. As the majority 




Fig. 152. — Luer's hypodermic syringe. 

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 
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 icTtl (o-3 to 0.6 c.c.) of boiled water when required for use. Sterile 
solutions of the drugs, however, may be obtained in hermetically 



172 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



sealed glass ampoules, each containing suflScient for one dose. The 
solution must be as nearly neutral as possible; irritating solutions or 
strongly alcoholic preparations should be avoided on account of the 
danger of subsequent sloughing at the seat of injection. When 
whisky or brandy is employed, it is, therefore, well to dilute them 
with an equal amount of water before using. Insoluble preparations, 
as the salicylate of mercury, for example, are best administered in 
some sterile oil as albolene or benzoinol. 

Sites for Injection. — For ordinary injections the least sensitive 
portions of the body provided with plenty of cellular tissue are 




Fig. 153. — Sites for hypodermic injections. 



selected, the spot chosen, of course, being distant from the immediate 
neighborhood 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 
an area in the gluteal region, lying between the gluteal fold below and 
a horizontal line through the upper margin of the great trochanter, 
is usually chosen (Fig. 153). Where numerous injections are given 
care should be taken to alternate between the two sides and to avoid 



HYPODERMIC AND INTRAMUSCULAR INJECTION OF DRUGS 1 73 

repeating the injections in the same spot each time. Meltzer 
{Medical Record, March 25, 191 1) recommends that intramuscular 
injections be made in the lumbar muscles, claiming that absorption 
is more rapid than from the glutei. The spot chosen is at the junc- 
tion of the inner and middle thirds of a line uniting the highest 



Fig. 154. — Showing the method of giving a hypodermic injection. 

points of the iliac crest with the third or fourth lumbar spinous 
process. 

Position of Patient. — For a deep intramuscular injection the 
patient lies upon the opposite side or upon the abdomen. 

Asepsis. — The strictest regard as to cleanliness should always 
be observed. The needle and syringe should be boiled or at least 




Fig. 155. — Deep intramuscular injection. First step, inserting the needle. 

immersed in some antiseptic solution before use, and the skin at 
the site of the injection should be painted with tincture of iodin or 
rubbed clean with a piece of cotton or gauze saturated with alcohol. 
Technic.^ — The required amount of solution is drawn into the 
barrel of the syringe with the needle in place and any air is expelled 
by elevating the needle end and depressing the piston. The skin 



174 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC 



over the site of the proposed injection is then pinched up between 
the thumb and forefinger of the left hand, while with the right hand 
the needle is quickly thrust at an angle of 45 degrees into the sub- 




FiG. 156. — Deep intramuscular injection. Second step, showing the syringe 
removed and inspection of the needle for the flow of blood. 

cutaneous tissues at the base of this fold (Fig. 154). If the needle 
is sharp and it be quickly plunged through the skin, but little, if any, 
pain will be experienced. The solution should be injected slowly to 
avoid too sudden distention of the tissues. When the required 




Fig. 157. — Deep intramuscular injection. Third step, injecting the solution. 

amount has been introduced, the needle is quickly withdrawn, and 
the finger is placed over the site of puncture, and gentle massage is 
practised for a moment or two to diffuse the solution. 



ADMINISTRATION OF SALVARSAN AND NEOSALVARSAN 1 75 

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. 155). As soon as the needle 
is in place, it is advisable to remove the syringe and observe whether 
there is any flow of blood from the needle (Fig. 156); if so, a new 
puncture should be made. Observance of this precaution will 
obviate injecting the solution into the blood current should the needle 
point penetrate some vein. The solution is then injected slowly 
(Fig. 157), and at the completion of the operation the site of punc- 
ture is sealed with collodion or by means of a small piece of adhesive 
plaster. 

THE ADMINISTRATION OF SALVARSAN AND 
NEOSALVARSAN 

SALVARSAN 

Salvarsan, or "606," is a yellowish crystalline powder containing 
about 1/3 of its weight of arsenic. It was introduced by Ehrlich 
in 1 9 10 for the cure of syphilis after years of experimental work 
upon animals with spirillicidal drugs. Although salvarsan has 
proved a most important addition to therapeutics, we have 
been compelled to revise materially our early conceptions of its 
value. It was originally claimed that one large dose would entirely 
destroy the spirochetes of syphilis, but unfortunately this early prom- 
ise has not been realized in the majority of cases. There is no 
doubt that this new remedy is a powerful spirochetal poison and it 
unquestionably causes certain of the manifestations of syphilis to 
disappear very rapidly, but whether the results obtained from its 
use, even in repeated doses, are permanent or only temporary will 
require many years to establish. Owing to numerous relapses that 
have followed single injections, it is now generally agreed that a single 
dose is not curative. At the present time, the majority of authori- 
ties advise that the injection should be repeated one or more times 
and that its use should be followed by the administration of mercury 
for the usual period. 

Salvarsan is indicated in all stages of syphilis. It gives the best 
results, however, the earlier in the disease it is used, being more 
rapidly effective than mercury, especially upon mucous lesions, and 
causing the Wassermann reaction to become more quickly negative. 
So that in the primary and early secondary stages the most brilliant 



176 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

results are obtained, while in the late secondary and tertiary stages 
it becomes more difficult to eradicate the infection. It has little or 
no effect in well marked locomotor ataxia and paresis.^ It is contra- 
indicated in advanced degenerative processes of the central nervous 
system and in long-standing cardiac and vascular degenerations, 
and in nonsyphilitic retinal and optic nerve afTections. Syphilitic 
eye and ear diseases, however, are not contraindications to its use. 
Any known idiosyncrasy against arsenic should lead to great caution 
in its use. 

Salvarsan has also been employed in the treatment of other diseases 
due to spirilla with excellent results. In relapsing fever, filariasis, yaws, 
and in some forms of malaria, it has proved very efficacious, frequently 
one injection sufficing to produce a cure. It has also been tried in 
leukemia, splenic anemia, leprosy, tuberculosis, and pellagra with 
questionable results. In certain of the infectious diseases in which 
it has been used, as scarlet fever, small-pox, anthrax, glanders, it is 
too early to give a positive opinion as to its value. 

Salvarsan was at first given subcutaneously. Then intramus- 
cular injections were substituted, but these proved very painful. 
The drug was not always absorbed, and at times caused great irri- 
tation at the site of injection and, in some cases, sloughs that were 
very slow in separating. At the present time the intravenous 
method of administration is generally adopted. 

Its administration is likely to be followed in from one to six hours 
by a systemic reaction, consisting of a chill, a rise of i to 2 degrees in 
the temperature, gastric irritation, and diarrhoea. These symptoms, 
however, are not always present, and the temperature and chill are 
less likely to occur if freshly distilled water is used in the preparation 
of the solution. In exceptional cases, following an injection, or as 
late as one or two days after, the patient becomes quite sick; he has 

1 Recently, Swift and Ellis of the Rockefeller Institute have developed a new 
line of treatment for syphilis of the central nervous system, employing intra- 
spinous injections of salvarsanized serum. The results in the cases so far 
reported have been most encouraging, and it would seem that in some cases of 
tabes and paresis a cure may be effected and even in well-marked cases the 
disease may be checked by the intraspinous serum treatment. 

The technic is briefly as follows: Salvarsan is given intravenously, usually in a 
maximum dose, and an hour later 10 drams (40 c c.) of blood are withdrawn from 
the patient by venous puncture into a bottle-shaped centrifuge tube. This is 
allowed to coagulate, after which it is centrifuged. The next day 3 drams 
(12 c.c.) of the resulting clear serum are removed by means of a pipette, 
mixed with 5 drams (18 c.c.) of sterile normal salt solution, and heated for half 
an hour at a temperature of 132.8° F. (56° C). This serum is then injected by 
lumbar puncture, after withdrawing a small quantity of the cerebrospinal fluid. 



ADMINISTRATION OP SALVARSAN AND NEOSALVARSAN 



177 



headache, vertigo, severe gastric irritation, high temperature, 
loose stools, and disturbance of circulation. A transient albumi- 
nuria may be present during elimination of the drug. In some cases 
death has resulted with all the symptoms of arsenical poisoning. 
Apparatus. — There will be required (i) a graduated glass cylinder 




10 

Fig. 158. — Apparatus for intravenous injection of salvarsan. i, Graduated 
reservoir, rubber tubing, and vein needle; 2, graduate and glass rod for mixing 
the solution; 3, decanter for distilled water; 4, glass funnel; 5, medicine dropper; 
6, bottle of sodium hydroxid solution; 7, tube of salvarsan; 8, file; 9, catheter for 
constricting arm; 10, artery clamp, 

with a capacity of about 10 ounces (300 cc), (2) 4 feet (120 cm.) of 
rubber tubing with a short piece of glass tube inserted in it to allow 
detection of any air bubbles, (3) a Schreiber infusion needle, 2 1/2 
inches (6 cm.) long and of No. 18 caliber, (4) a glass decanter for dis- 
tilled water, (5) a glass graduate for mixing the solution, (6) a funnel 




Fig, 159. — Enlarged view of vein needle, 

in which is placed filter paper or sterile cotton to filter the solution 
through, (7) a glass stoppered bottle containing a solution of 15 per 
cent, sodium hydroxid, (8) a medicine dropper, (9) a glass stirring 
rod, (10) a catheter and artery clamp for constricting the arm of the 
patient, (11) a tube of salvarsan and a file to open it with (Fig, 158). 



178 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC 

In addition, it is well to have at hand a scalpel and a cocain 
syringe in case it is necessary to expose the vein before inserting the 
needle. 

Asepsis. — The apparatus is sterilized by boiling. The tube con- 
taining the salvarsan and the file are placed in alcohol, and the 
operator's hands are prepared as carefully as for any operation. 

Preparation of the Solution. — It has been found that much of 
the immediate systemic reaction is due to impurities in the water, 
for this reason only freshly distilled sterile water should be employed 
in the preparation of the solution. The ampoule of salvarsan 
is dried off, the glass is nicked with the file, the tube is broken 
open, and its contents are poured into 30 to 40 c.c. (i to i 1/2 
ounces) of hot sterile distilled water previously placed in the 
mixing glass. The solution is then shaken or stirred until all the drug 
is thoroughly dissolved. To the resulting clear acid solution is 
added drop by drop the 15 per cent, sodium hydroxid solution b\- 
means of the dropper, the solution being shaken after each drop is 
added. This causes a precipitate to form, which dissolves as the 
solution becomes alkaline. It requires about 20 drops of the sodium 
hydroxid solution to render a mixture containing 0.5 gm. (7 1/2 
gr.) of salvarsan perfectly clear. Having obtained an absolutely 
clear solution, it is diluted with sterile 0.5 per cent, saline solution, 
made from chemically pure sodium chlorid and sterile, freshly distilled 
water, up to 250 c.c. (8 ounces) if, for example, 0.5 gm. (7 1/2 gr.) 
is the dose, that is, 50 c.c. (i 2/7, ounces) of fluid is used for every 
0.1 gm. (i 1/2 gr.) of salvarsan. The solution is now ready for use 
and is finally filtered through sterile cotton placed in a funnel into 
the intravenous apparatus. 

Temperature of the Solution. — The solution is given at about a 
temperature of 105° F. (41° C). 

Dosage. — An average dose for men is 0,4 to 0.5 gm. (6 to 7 1/2 
gr.), for women 0.3 to 0.4 gm. (4 1/2 to 6 gr.), for children 0.2 to 
0.3 gm. (3 to 4 1/2 gr.), and for infants 0.02 to 0.05 gm. (1/3 to 3/4 
gr.). In this country it is becoming customary to employ smaller 
initial doses, that is, 0.2 and 0.3 gm. (3 and 4 1/2 gr.) doses and, if 
no unpleasant symptoms follow, the second dose may be increased 
0.1 gm. (i 1/2 gr.). 

Repetition of the Dose. — The injection may be repeated in from 
one to four weeks, depending upon the reaction produced and the 
effect on the lesions. In the early cases from three to four injections 



ADMINISTRATION OF SALVARSAN AND NEOSALVARSAX 1 79 

are usually given, and in the late cases from five to six, or more, un- 
til the Wassermann reaction remains negative. 

Site of Injection. — Some one of the prominent veins on the 
anterior aspect of the arm in front of the elbow-joint — preferably 
the median basilic — is chosen for the injection. 

Position of the Patient. — The injection should be given with the 
patient in the recumbent posture. 

Preparations of Patient. — All tight clothing should be removed 
from the arm selected for the infusion. The site of puncture is 
painted with tincture of iodin, and the rubber catheter is secured 
about the arm with sufficient tension to make the veins stand out 
prominently. 

Technic. — With the tourniquet properly apphed about the fore- 
arm, the operator identifies the vein into which he wishes to insert 
the needle and instructs the patient to work his fingers until the 



Fig. 160. — ■Method of inserting needle into the vein. 

vein becomes quite prominent. The needle, held almost flat with 
the skin surface, is then thrust through the skin into the vein toward 
the axilla (Fig. i6o). The successful entrance into the vein is indi- 
cated by a flow of blood from the end of the needle. Care must be 
taken to insert the needle into the vein and not through the opposite 
wall of the vein. If the needle is held almost parallel with the sur- 
face of the arm, this accident is not likely to occur. If there is any 
difficulty in finding the vein, it should be exposed by a small trans- 
verse nick through the skin under infiltration anesthesia and the 
needle inserted by sight. The tourniquet is then removed from the 
patient's arm, and, after seeing that all the air is expelled from 
the tubing of the intravenous apparatus, the latter is connected 



i8o 



HYPODERMIC AND INTRAMUSCULAR IN'JECTIOXS, ETC 



with the needle, and the solution is permitted to flow into the vein. 
The solution is injected very cautiously at first until it is certain 
that it is entering the vein and not the surrounding tissues, or a 
test injection of a small amount of normal salt solution is made. 
Any leakage of the salvarsan solution into the tissues causes 
a severe burning pain and necessitates the immediate stoppage of 
the injection. During the injection the reservoir is raised 24 to 




Fig. 161. — Method of giving salvarsan intravenously. 

30 inches (60 to 75 cm.) above the level of the patient. It takes 
about ten minutes for the entire quantity of solution to flow 
into the vein: at the completion of the operation the needle is 
quickly removed and a sterile pad is placed over the site of puncture 
and is secured by a few turns of a bandage. 

While some operators administer salvarsan intravenously in their 
ofl5ce. the patient being required to go home immediately and remain 



NEOSALVARSAN 



Ibl 



quiet for several hours, there is considerable risk connected with such 
a procedure, and it is safer to give the first injection, at any rate, in 
the patient's home or at a hospital, following which the patient is 
required to remain quiet in bed for twelve hours. 

NEOSALVARSAN 

Lately a new and very soluble form of salvarsan has been intro- 
duced under the name of neosalvarsan, or "914." The general prop- 
erties of neosalvarsan are similar to those of salvarsan and it is 
claimed to be just as efficacious. It, however, possesses certain 
decided advantages over salvarsan in that it is better tolerated and 
is less often followed by a systemic reaction, so that larger doses 
can be employed and the dose may be repeated more frequently. 
Furthermore, the preparation of the solution is very simple, the drug 
being quite soluble in water and not requiring to be neutralized with 
caustic soda, 

Neosalvarsan is given intravenously or by intramuscular injec- 
tion — preferably by the former method. 

Apparatus. — For the intravenous administration of dilute solu- 
tions of neosalvarsan the same apparatus described for the adminis- 
tration of salvarsan (page 177) will be required. 




1 K 3 » 

Fig. 162. — Apparatus for intramuscular and intravenous injections of con- 
centrated solutions of neosalvarsan. i, Decanter of distilled water; 2, medicine 
glass; 3, all glass syringe and needle; 4, tube of neosalvarsan; 5, small file. 

For the intravenous administration of concentrated solutions and 
for intramuscular injections there will be required: (i) a Luer or 
Record syringe with a capacity of 10 to 20 c.c. (2 1/2 to 5 dr.), (2) 
a needle about 2 1/2 inches (6 cm.) long and of No. 18 caliber, (3) a 
glass decanter for distilled water, (4) a medicine glass for mixing the 
solution, (5) a tube of neosalvarsan and a file to open it with, and 



1 82 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

(6) a glass rod for stirring (Fig. 162). In addition, for an intra- 
venous injection a tourniquet will be required . 

Asepsis. — The apparatus and instruments are sterilized by 
boiling, the operator's hands are cleansed as for any operation, and 
the tube of neosalvarsan and the file are immersed in alcohol. 

Preparation of the Solution. — For intravenous injections a dilute 
or a concentrated solution may be used. The former is prepared by 
dissolving each 0.15 gm. (2 1/3 gr.) of salvarsan in 25 c.c. (6 3/4 dr.) 
of freshly distilled sterile water. The water should not be heated, 
but should be at about the temperature of the room, that is, 68° to 
71.6° F. (20° to 22° C). 

The concentrated intravenous solution is prepared by dissolving 
0.45 to 0.6 gm. (6 3/4 to 9 gr.) of neosalvarsan in 10 c.c. (2 3/4 dr.) 
of freshly distilled sterile water, or 0.75 to 0.9 gm. (11 1/2 to 14 gr.) 
of neosalvarsan in 15 c.c. (4 dr.) oi freshly distilled sterile water. 

The solution for an intramuscular injection is prepared by dis- 
solving each 0.15 gm. (2 1/3 gr.) of neosalvarsan in about 3 c.c. 
(48 minims) of freshly distilled sterile water. 

Temperature of the Solution. — The solution should not be injected 
at a higher temperature than 68° to 71.6° F. ( 20° to 22° C). 

Dosage. — The average dose of neosalvarsan for men is 0.6 to 
0.75 gm. (9 to II 1/2 gr.), for women 0.45 to 0.6 gm. (6 3/4 to 9 
gr.), for children 0.15 to 0.3 gm. (2 1/3 to 4 2/3 gr.), and for infants 
0.05 gm. (3/4 gr.). 

Repetition of the Dose. — Injections of neosalvarsan may be 
repeated at intervals of from 3 to 7 days. 

Site of Injection. — Intravenous injections are given in the median 
basilic or some other prominent vein at the bend of the elbow. 

Intramuscular injections are given in the gluteal region (see 
page 172). 

Position of Patient. — For an intravenous injection the patient 
should be recumbent; for an intramuscular injection the patient 
lies upon the abdomen. 

Preparation of the Patient. — If the intravenous method is em- 
ployed, all constricting clothing should be removed from the patient's 
arm. The site of puncture is well painted with tincture of iodin. 

Technic. — (i) Intravenous Administration. The technic differs 
in no material way from that already described for the administra- 
tion of salvarsan (see page 179). When the concentrated solution 
is employed, however, the injection is more conveniently made with 
a syringe instead of a gravity apparatus. 



ADMINISTRATION OF DIPHTHERIA ANTITOXIN 1 83 

(2) Intramuscular Injecti&n. — A spot in the gluteal region dis- 
tant from the course of the sciatic nerve is chosen, and the needle is 
thrust deeply into the muscle. If there is no bleeding, about 60 
drops of 0.5 per cent, novocain solution is injected into the region in 
order to diminish the sensibility. Then, after waiting a few moments, 
the desired quantity of neosalvarsan is injected through the same 
needle. The site of puncture is finally sealed with a piece of adhesive 
plaster. (The technic of intramuscular injections is more fully 
described on page 175.) Following the injection, the patient is kept 
in the recumbent position on his side or abdomen for 15 to 20 
minutes. 



THE ADMINISTRATION OF DIPHTHERIA ANTITOXIN 

Antitoxin is now almost universally used in the treatment of diph- 
theria, and its administration is a procedure with which all physicians 
should be familiar. It has enormously reduced the 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 dis- 
appear. 

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

Dosage. — There is no definite rule for fixing the dose. It is known 
how much antitoxin is required to neutralize a given amount of toxin, 
but in practice there is no method of estimating the latter in any given 
case. Conclusions drawn from experience and clinical studies give 
the only practical guides. The dose should always be large, however, 
for the serum is harmless and it is better to administer too much than 
not enough. The average dose advised by the New York Health 
Department is 5000 units, repeated the following day if the condition 
of the patient has not improved. According to Holt '' for a child over 
two years, an initial dose for a severe attack, including all laryngeal 

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



1 84 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



cases, should not be less than 4000 to 5000 units; and the dose should 
be repeated in six or eight hours provided no improvement is seen. 
Children under two years should receive from 2000 to 3000 units. 
Cases of exceptional severity where the injection is given late should 
receive from 8000 to 10,000 units, to be repeated in from six to eight 
hours if the progress of the disease is unfavorable. Mild cases should 
receive from 2000 to 3000 units as an initial dose, a second being rarely 
required." 

An immunizing dose should be given to those exposed to the con- 
tagion in all cases, 1000 units for a child under two years old, and for 
older children and adults a larger dose (2000 units) may be adminis- 
tered. The immunity thus furnished is not permanent, however, 
lasting only three or four weeks. 

Time of Administration. — Antitoxin should be given as soon as a 
clinical diagnosis is made, not waiting for a bacteriological examina- 
tion. There are no contraindications to its use in the presence of 
urgent symptoms. No matter how late a case is seen, an injection 
should be given, though it may not be possible to undo the harm 
already produced by the diphtheria toxin. Cases treated very early 
give the best results. This is well shown by the following table of 
the cases injected in 1902-4, prepared by the New York Health 
Department: 



Day. 


No. cases. 


Case fatality. 


Percentage. 


I 


623 


10 


1.6 


2 


1689 


53 


31 


3 and 4 


1871 


127 


6.7 


5 and over 


455 


82 


18 



The Syringe. — The simpler the syringe, the better. The syringe 
should have a capacity of about i 1/4 to 2 1/2 drams (5 to 10 c.c). 




Fig. 163. — The record antitoxin syringe. 

Glass syringes with asbestos packing or those with the solid glass 
piston, as the Luer, are most easily sterilized. The record syringe 
(Fig. 163) is also an excellent instrument. A moderately fine needle 
or the smallest through which the serum will flow is preferable to one 



ADMINISTRATION OF DIPHTHERIA ANTITOXIN 



185 



of very large caliber. In charging the syringe it is better to remove 
the piston and pour the antitoxin into the syringe, as it is difficult to 
draw it up through the needle. The piston is then inserted and, with 
the syringe elevated, any air is expelled. Many of the manufac- 
turers at the present time Supply a syringe already sterilized and filled 
with antitoxin (Fig. 164). The advantages of this in the saving of 
time are obvious. 



Fig. 164. — -The New York Board of Health Antitoxin Syringe. The syringe 
comes steriHzed and already loaded with antitoxin and, upon inserting the needle 
into the distal end, is ready for use. 

Site of Injection. — The subcutaneous tissues of the outer aspect 
of the thigh, of the back part of the axilla, or of the upper portion of 
the abdomen are usually chosen for the injection (Fig. 165). 

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 sterilized by 
painting with tincture of iodin. 

Technic. — In order to prevent any undue excitement, the injec- 
tion should be made with the patient in such a position that he cannot 




Fig. 165. — Sites for antitoxin injection. 

see what is going on; in children this Is especially necessary. Care 
must be taken to expel any air from the syringe by elevating its point 
and depressing the piston a little. A fold of the skin from the area 
previously sterilized is then raised up between the thumb and fore- 
finger of the left hand, and, with the right hand, the needle is quickly 
plunged into the subcutaneous tissue (Fig. 166). If done quickly 
with a sharp-pointed needle, preliminary local anesthesia of the skin 
is unnecessary. The serum is then injected very slowly and the swell- 
ing produced is not massaged, being allowed to subside as the serum 



i86 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC- 



is absorbed. After withdrawal of the needle the puncture is sealed 
with collodion and cotton. Following the injection there may be a 
slight reaction consisting of some redness, edema, and pain at the 
site of puncture, but these usually subside in a short time. 

Effects of Antitoxin. — In favorable cases a prompt and marked 
improvement in the local and general symptoms follows the use of 
antitoxin. In a few hours the pseudomembrane begins to lose its 
dirty color and becomes blanched and somewhat swollen. Within 
twelve to twenty-four hours the membrane loosens at the edges and 




Fig. 1 66. — Showing the method of injecting diphtheria antitoxin in the subcuta- 
neous tissue of the axilla. 



rolls up, becoming detached in a mass, or in small pieces. This seems 
to take place more rapidly about the tonsils than elsewhere. The 
usual time for restoration to the normal condition in the throat is 
twenty-four hours to three or four days. Sometimes the membrane, 
after disappearing, forms again; such cases should promptly receive 
more antitoxin. 

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

In laryngeal diphtheria antitoxin prevents the extension of the 
membrane 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. 



ADMINISTRATION OF DIPHTHERIA ANTITOXIN 



187 



The effects upon the constitutional symptoms are Ukewise impres- 
sive. 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. 



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CASE FATALITY 1 

DEATH RATE. | 



Fig. 167. — Chart prepared by the New York Board of Health, showing the reduc- 
tion in the mortaUty from diphtheria since the introduction of antitoxin. 



The reduction in the mortahty rate since the introduction of anti- 
toxin is well shown in the following table (Fig. 167) prepared by the 
New York Department of Health, the small reduction shown in the 
first three years of its use being explained by the fact that sufficiently 
large doses of antitoxin were not used at first and that the serum used 
later was more efficient. 

Complications. — In a certain percentage of cases skin eruptions 
develop after several days. These may be erythematous, scarlati- 
form, morbiliform, or urticarial in character. Urticaria is said to 
follow in about 30 per cent, of the cases and usually comes on from the 
eighth to the fourteenth day. It frequently develops upon the but- 
tocks, abdomen, and chest and may be the cause of great discomfort 



1 88 HYPODERMIC AND INTRAMUSCULAR IN'JECTIONS, ETC. 

and annoyance to the patient. Infection and cellulitis may result 
from the injection 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 symp- 
toms, however, are not due to the antitoxin, but are caused by the 
horse serum, and depend upon the susceptibility of the patient to the 
serum. 

VACCINATION 

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

The immunity rendered by vaccination is not claimed to be invari- 
ably complete. In a great majority of cases, though, a successful 
inoculation grants a person immunity to smallpox for a number of 
years, though the effects may in time wear off and the individual again 
become susceptible. The mortality in such cases, however, is very 
low compared with the mortality in those who have never been vac- 
cinated. According to Osier, in the former it is 6 to 8 per cent, and in 
the unvaccinated 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 admir- 
ably attest its efiEiciency. Localities in which vaccination is systemat- 
ically carried out develop fewer cases and present the lowest death 
rate from smallpox. In Germany, since 1874, compulsory vaccina- 
tion and revaccination have been enforced and since then there have 
been no epidemics of smallpox in that country. On the other hand, 
the results of disregard to the value of vaccination are well illustrated 
by the mortality rate of smallpox in European countries between 
1893 and 1897, inclusive, quoted by Schamberg {New York Medical 
Journal, Jan. 16, 1909) from the Imperial Board of Health reports of 
the German Empire. He says: "We are startled to note in this per- 
iod there died in the Russian Empire, including Asiatic Russia, 275,- 
502 persons from smallpox, Spain lost over 23,000 lives, Hungary over 
12,000, Austria and Italy over 11,000. In Germany the number of 
smallpox deaths during this period was only 287, representing one 
death to every 1,000,000 of population a year." 

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. 



VACCIXATIOX 



189 



The virus is obtained under rigid aseptic precautions by cujetting 
the pustule from a calf and making an emulsion of it with glycerin. 
This is then collected in capillary tubes and is hermetically sealed 
imtil 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 capiUary tubes as there is danger of 
the virus being contaminated by handling. 

Time for Vaccination. — In choosing the time for vaccination the 
age and the general health of the individual should be taken into 
consideration. As a general rule, unless contraindicated, the child 
should be three to sLx months old before vaccination. The operation 
should be avoided if possible in dentition; and children who are 
delicate or suffering from malnutrition, syphihs, or skin eruptions, 
should not be vaccinated until 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- 
vidual is in infancy or in old age. he should always be immediately 
vaccinated. 

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




5 ^ 



Fig. 168. — Xew York Department of Health vaccination outfit, i, Instru- 
ments in case; 2, rubber tube for blowing the virus out of the tube; 3, tube con- 
taining 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 be used for more than one case. Special scarificators 
are made, but they have no advantages over a lancet or a needle. If 
the vaccine points are used, no scarificator is necessary. 

The Xew York Department of Health supplies with each capillary 
tube of vaccine virus, a needle, a flat tooth pick for spreading the virus. 



igo 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



and a piece of small rubber tubing which fits over one end of the cap- 
illary tube and is used to blow the vaccine out of the tube (Fig. i68). 
Site of Vaccination. — The vaccination is performed either upon 
the arm or leg. As a rule, the arm is preferred as a site, especially in 
children who are running about, as being more easily kept at rest and 
less likely to be injured. Mothers often prefer to have their girls 
vaccinated upon the leg to avoid the disfiguring eiifect of the scar. 
If the arm is chosen, the point selected is at about the insertion of the 
deltoid muscle; in the leg a spot on the outer aspect at the junction 
of the middle and upper third is selected. 




Fig. 169. — Vaccination. First step, scarifying the arm. 

Asepsisi — The operation of vaccination should be regarded as an 
important one and, as most of its dangers are due to infection, the 
operator should see that all aseptic precautions are observed. The 
instrument employed for scarifying the skin should be carefully ster- 
ilized and the same instrument should not be used more than once 
without resterilization. The hands of the operator are prepared as 
carefully as for any operation. The patient's skin is washed with 
soap and warm water followed by alcohol and ether and is allowed to 
dry. The use of strong disinfectants is not advised as the chances of a 
successful inoculation may be lessened. 

Technic. — Vaccination by the scarification method is generally 
practised in this country. 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 



VACCINATION 



191 



serum, but no blood (Fig. 169). If more than one inoculation is to be 
made, as is frequently done, the area scarified should be at a distance 




Fig. 170. — Vaccination. Second step, blowing the virus out of the capillary tube 
onto a small piece of wood. 




Fig. 171. — Vaccination. Third step. Rubbing the virus into the scarified area. 

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. 171). The site of vaccination is 



192 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



finally covered with a piece of sterile gauze held in place with two 
small strips of adhesive plaster, or, if desired, a wire shield (Fig. 172) 
may be used, provided it is applied in such a way as not to constrict 
the arm (Fig. 173). After the vesicle has formed, the part should be 
gently washed with sterile water once a day and dressed with fresh 
gauze or covered with a shield to prevent contact with the clothing. 

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





Fig. 172. — Vaccination shield. 



Fig. 173. — Showing the shield in place. 



vesicle is depressed, while the margins are elevated and shghtly indur- 
ated. By the tenth day a bright red areola has developed covering a 
space of from i to 2 inches (2.5 to 5 cm.) around the vesicle and the 
contents of the vesicle become purulent. In a day or two more the 
areola commences to fade and the vesicle dries up forming a dark 
brown crust. Usually about the twenty-first day this crust falls off, 
leaving a bluish pitted scar which later slowly fades to white. 

Constitutional symptoms more or less marked accompany the 
eruption. Remittent fever of from 101° to 104° begins on the fourth 
day and may persist imtil the eighth or ninth day. when it drops 
gradually to normal. In children irritabihty, loss of appetite, and 
restlessness at night may accompany the fever. The axillary or 



VACCINATION 1 93 

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

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

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

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

SyphiHs is no longer feared under modern 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. Tet- 
anus can only follow carelessness as to asepsis and neglect of pre- 
cautions in preparing the lymph. 

Revaccination. — Immunity furnished by vaccination is not per- 
manent, and in all persons revaccination should be performed several 
years after the first vaccination. The New York Health Department 
advises that revaccination be repeated at intervals of not more than 
three years if permanent immunity is to be acquired. . The vaccina- 
tion 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. 



CHAPTER VIII 

TREATMENT OF NEURALGIA BY INJECTIONS 
TIC DOULOUREUX 

For the purpose of relieving the pain of trifacial neuralgia various 
drugs and gases, such as stovain, cocain, chloroform, antipyrin, osmic 
acid, and air, have been injected into the branches of the fifth nerve 
or subcutaneously into the painful areas. Schlosser in 1900 was the 
first to practise direct injection of the different branches of the 
fifth nerve with 80 per cent, alcohol at their exit from the skull through 
the basal foramina. Schlosser's method of injection was, however, 
rather difficult, and it was not until Levy and Baudouin in 1906 
devised a comparatively simple technic that alcoholic injections were 
employed to any great extent. While injection of the superficial 
branches of the fifth nerve with osmic acid and the deep branches with 
alcohol have both given brilliant results, the use of osmic acid neces- 
sitates exposure of the affected nerve or nerves and, for this reason, 
it has been largely discarded in favor of alcohol alone or in combina- 
tion with other drugs. 

Alcohol when injected into a nerve causes a degeneration of its 
fibers. Relief from pain is thus obtained usually for a period of six 
months to two years, but it varies considerably depending upon the 
thoroughness with which the nerve is injected. In some cases one 
injection has given an apparent cure, bat, as a rule, the injection 
has to be repeated several times. 

All three branches of the nerve have been injected,^ but, on 
account of the difficulty of reaching the ophthalmic branch and the 
proximity of the optic nerve, and the third, fourth, and sixth nerves, 
deep injection of this branch has been abandoned by the majority of 
operators . 

Anatomy. — The fifth nerve closely resembles a typical spinal 
nerve, being a mixed nerve with its sensory and motor roots arising 
separately from the brain, and the sensory root possessing a ganglion, 
the Gasserian ganglion. The latter is a crescent-shaped body, com- 
posed of nerve fibers and nerve cells, lying in a depression, Meckel's 
cave, on the apex of the petrous portion of the temporal bone. From 

' More recently injections have been made directly into the Gasserian ganglion. 

194 



TIC DOULOUREUX 



195 



the anterior convex border of the ganglion the sensory portion emerges 
in three trunks: the ophthalmic, the superior maxillary, and the 
inferior maxillary. The superior maxillary division is joined on the 
distal side of the ganglion by the motor root. 

The first division passes from the skull through the sphenoidal fis- 
sure in three branches: the lachrymal, the frontal, and the nasal. It 
is purely a sensor}- nerve supplying the upper eyelid, conjunctiva, 
eyeball, lachrymal gland, forehead, anterior portion of the scalp, 
frontal sinus, and the root and anterior portion of the nose. 

The second division leaves the skull through the foramen rotundum, 
crosses the spheno-maxillary fossa, and, after entering the orbital 




Fig. 174. — Anatomy of the trifacial ner\^e. (After Campbell.) 



cavity through the spheno-maxillary fissure, passes to the face by way 
of the infraorbital groove. It is also a sensory nerve, supplying the 
cheek, anterior portion of the temporal region, the lower eyehd, the 
ridge of the nose, upper lip. upper teeth, mucous membrane of the 
nose, nasopharynx, antrum, posterior ethmoidal cells, soft palate, 
tonsil, and roof of the mouth. 

The third division is a mixed nerveformedby the third trunk of the 
sensory root and the motor root. The two pass from the cranium 
through the foramen ovale and immediately unite to form a single 
branch. The sensory portion of the nerve supplies the skin of the 
side of the head, auricle of the ear, external auditory meatus, lower 
portion of the face, lower lip, lower teeth and gums, mucous mem- 



196 



TREATMENT OF NEURALGIA BY INJECTIONS 



brane of the mouth, tongue, and mastoid cells, and salivary glands. 
The motor portion supplies the muscles of mastication. 

Instruments. — There will be required a special needle 4 3/4 inches 
(12 cm.) long and 1/14 in. (1.75 mm.) in diameter, a glass syringe 
with a capacity of at least 30 minims (2 c.c), a scalpel, a fine needle, 
2 1/2 inches (5 cm.) long which can be fitted to the syringe for the 
purpose of infiltrating the skin at the site of puncture or performing 
peripheral injections of nerve branches, and two medicine glasses, 
one for a cocain solution and the other for the alcohol solution 
(Fig. 175)- 




Fig. 175. — Apparatus for injecting the branches of the fifth nerve, i, Two 
medicine glasses; 2, Luer syringe; 3, Levy and Baudouin needle; 4, small hypo- 
dermic needle; 5, ampoule containing anesthetic; 6, scalpel. 

The needle should have rather a blunt point and should be pro- 
vided with a stylet which extends flush with the point of the needle 
when pushed home. The outside of the needle is graduated in cen- 
timeters up to five. The proximal end of the needle should be made 
to accurately fit the end of the syringe (Fig. 176). 




Fig. 176.— Enlarged view of the Levy and Baudouin needle and stylet. 

Solution Used. — The solution originally used was a mixture of 
cocain, morphin, chloroform, and 80 per cent, alcohol, but the mor- 
phin and chloroform are generally discarded at the present time. The 
addition of chloroform causes considerable inflammation at the 
site of injection and the formation of scar tissue. Patrick {Jour- 



nal of the Americaji Medical Association, 
following: 



Jan. 20, 1912'! uses the 



Cocain muriat., gr. ii (0.13 gm.) 

Alcohol, dr. iiiss (13 c.c.) 

Aq. dest., q.s. ad., oz. ss (15 c.c.) 

The solution should be freshly prepared for each injection. 



TIC DOULOUREUX 



197 



Quantity Used. — For a deep injection 3oTn. (2 c.c.) of solu- 
tion are generally injected into each branch. Eight minims (0.5 
c.c.) is sufficient for a peripheral injection. 

Position of Patient. — The injection is made with the patient sit- 
ting upright in a chair or the recumbent position may be employed 
with the patient's head resting on the side. 

Asepsis. — The instruments are sterilized by boiling, the operator's 
hands cleansed as for any operation, and the site of injection painted 
with tincture of iodin. 

Anesthesia. — General anesthesia is to be avoided if possible, as 
the best guide to a successful injection is the spasm of pain and the 




Fig. 177. — Showing the method of injecting the supraorbital branch of the first 
division of the fifth nerve. 



anesthesia that results over the area of distribution of the nerve. 
Infiltration of the skin with a few drops of 0.2 per cent, cocain solu- 
tion or a I per cent, novocain solution at the point through which 
the needle enters is usually sufficient. 

Technic. — The site of injection and the direction in which the 
needle islnserted will vary according to the branch injected. 

First Division. — Deep injection of this nerve at the sphenoidal fis- 
sure is rarely practised on account of its dangers; instead, the supra- 
orbital nerve is injected at the supraorbital notch or foramen. The 
supraorbital notch is located by palpation or by the sensations of 
the patient when the nerve is compressed between the finger and the 
skull. The skin over the site of the notch is anesthetized, and an 
attempt Is made to insert the fine needle into the foramen, the eye- 
ball being protected by the index finger of the operator's left hand 



198 



TREATMENT OF NEURALGIA BY INJECTIONS 



(Fig. 177). When the needle strikes the nerve a sharp shooting pain 
will be felt by the patient extending up the forehead. If possible, 
the needle should be inserted for a distance of 1/5 to 2/5 of an inch 
(5 to 10 mm.) into the canal. About 10 minims (0.6 c.c.) of the 
alcohol solution is then injected. A successful injection will result in 
immediate anesthesia within the distribution of the nerve. 

The Second Division is injected at the foramen rotundum. The 
posterior border of the orbital process of the malar bone is identified 
and from it is dropped a verticle line to the lower border of the zy- 
goma; 1/5 inch (0.5 cm.) behind the point where this perpendicular 
line crosses the zygoma is the point for entrance of the needle. The 




Fig. 178. — -Needle in place for injecting the second division of the fifth nerve. 

skin at this point is infiltrated with cocain and is nicked with a 
scalpel. The needle is inserted with the stylet withdrawn until it is 
well into the subcutaneous tissues; then the stylet is pushed home in 
order to furnish a blunt point and avoid any injury to the blood- 
vessels. The direction of the needle should be at first horizontally 
inward and then slightly upward, and at a depth of 2 inches (5 cm.) 
the needle should reach the nerve at the foramen rotundum. If, 
after passing through the subcutaneous tissue, the needle strike the 
coronoid process of the lower jaw, it will have to be re-inserted at a 
point shghtly more forward. This will necessitate changing the 
angle of the needle to correspond with the new site of entrance. Care 
must be observed against inserting the needle so far forward that the 
orbit will be entered or so deep that the sixth nerve is reached. With 
the needle introduced the correct distance, the stylet is withdrawn 



TIC DOULOUREUX 



199 



and the alcohol solution is slowly injected and, if the needle is prop- 
erly placed, a sharp pain will be felt by the patient in the area of 
distribution of the nerve. If the nerve is not reached, the needle 
should be withdrawn a little and its direction shghtly changed. At 
the completion of the injection, the needle is removed and the point 
of puncture is sealed with collodion and cotton. The patient should 
be kept in a recumbent position for 10 to 15 minutes. 

If it is found impossible to reach the nerve at its exit from the 
skull, its infraorbital branch may be injected at the infraorbital 
foramen, using a long fine needle for this purpose. About 10 to 15 
minims (0.6 to i c.c.) of the solution are injected. 

The Third Division is injected at the foramen ovale. The descend- 
ing root of the zygoma is identified, and at a point I inch (2.5 cm.) 
in front of it just below the zygoma, the needle enters the skin. The 
skin at this point is anesthetized and is nicked with a scalpel, and the 
needle with the stylet withdrawn is pushed through the subcutaneous 




Fig. 179.-— Needle in place for injecting the third division of the fifth nerve. 



tissues in a direction slightly upward and backward. The stylet is 
then pushed home, and needle is carried in through the deeper tis- 
sues, still slightly upward and backward, until it reaches a depth of 
1 1/2 inches (4 cm.); it should then be at the foramen ovale. When the 
needle strikes the nerve, the patient, as a rule, will be conscious of a 
sharp pain in the tongue or lower jaw. The stylet is then removed, 
the syringe, loaded with the alcohol solution, is fitted to the needle, 
and the injection is made. At the completion of the operation, the 
needle is withdrawn and the skin puncture is sealed with collodion 
and cotton. 



200 



TREATMENT OF NEURALGIA BY INJECTIONS 



Following a deep injection, there is considerable swelling of the 
face, which the patient should be warned beforehand to expect. 
Sometimes a hematoma may result from puncture of some vessel 
during the insertion of the needle. To avoid this, Patrick advises 
that the needle always be inspected for oozing and, if present, 
that the needle and stylet be left in place until it stops. 

SCIATICA 

The injection of alcohol and other drugs which have a destructive 
action upon nerves and which have been effectively employed in 
neuralgia of the fifth nerve should be avoided in sciatica, as the sciatic 
is a mLxed nerve and the use of such drugs has produced grave motor 
changes- in the nerve. The injection of physiological salt solution, 




Fig. i8o. — Apparatus for injecting the sciatic nerve. I, Medicine glass; 2, 
glass graduate; 3, large glass syringe and blunt needle for injecting the nerve; 4, 
ampoule of cocain; 5, small syringe and needle for the preliminary infiltration of 
the site of puncture; 6, scalpel. 

however, has given good results in relieving the pain of sciatica with- 
out causing any harmful results. The injection is made into the 
nerve-sheath with the idea of separating the adhesions that have 
formed around the inflamed nerve, and, if it is used in the proper 
cases, in the great majority of instances it gives rehef. Frequently 
more than one, and in the severe cases, a number of injections are 
required to produce a cure. 

Apparatus. — There will be required a needle 43/4 inches (12 
cm.) long and 1/16 inch (1.5 mm.) in diameter, a glass syringe with 
a capacity of 3 to 4 ounces (90 to 120 c.c), a piece of rubber tubing to 
connect the syringe and needle, a scalpel, a cocain syringe, a small 
medicine glass for the cocain solution, and a glass graduate for the 
salt solution (Fig. 180). 



SCIATICA 



20I 



The needle is of a type similar to that used for trifacial injections 
(see Fig. 176). It should be graduated in centimeters from i to 10, 
and the point should be rather blunt. 

Solution Used. — ^Normal salt solution (salt i dram (4 gm.) to a 
pint (500 c.c.) of boiled water) with or without the addition of a local 
anesthetic is used. 

Temperature of the Solution. — The solution is injected either at 
about the temperature of the body or at 32° F. (0° C). 

Quantity. — Two to 4 ounces (60 to 120 c.c.) of the warm solution 
and 2 1/2 to 5 drams (10 to 20 c.c.) of the cold solution may be 
injected. 

Intervals between Injections. — When it is necessary to repeat 
the injections, they may be given at intervals of 24 to 72 hours. 

Site of Injection. — Several points for reaching the nerve are 
advised. That used by D'Orsay Hoecht and one that gives access to 




Fig. 181. — Showing the method of locating the point for injecting the sciatic 

nerve. (After Hoecht.) 



the nerve high up is as follows: A line is drawn from the sacrococ- 
cygeal joint to the postero-external border of the great trochanter, 
and one finger's breadth external to the junction of the inner one-third 
and outer two-third of this line is the point for inserting the needle 
(Fig. 181). 

The nerve may also be reached by inserting the needle at a point 
where a horizontal line through the tip of the great trochanter cuts a 
verticle line through the outer margin of the tuberosity of the ischium. 

Position of the Patient.^ — The patient lies upon the abdomen with 
the legs extended and with a pillow beneath the groins. 



202 TREATMENT OF NEURALGIA BY INJECTIONS 

Asepsis. — The instruments are boiled, the hands of the operator 
are sterilized as carefully as for any operation, and the field of opera- 
tion is painted with tincture of iodin. 

Anesthesia. — The point on the skin through which the needle is 
inserted is anesthetized by infiltration with a few drops of a 0.2 
per cent, solution of cocain or a i per cent, solution of novocain. 

Technic. — The syringe is filled with the salt solution of the proper 
temperature and is placed ready for use near at hand. A small nick 
is made in the skin at the point chosen for the puncture, and the 
needle, armed with the stylet, is inserted perpendicularly to the body 
through the tissues until it hits the nerve. If the needle strikes bone, 
it is then withdrawn 1/25 inch (i mm.) and should be in close prox- 
imity to the nerve. The moment the nerve is reached the patient 
experiences a sharp lancinating pain low down the back of the leg or 
in the heel, frequently accompanied by a jerking motion of the leg. 
The stylet is then removed, the syringe is attached to the needle, and 
the desired amount of solution is slowly and steadily injected. At 
the end of the injection, the needle is removed, and the site of skin 
puncture is sealed with collodion and cotton. 

Following the injection, the patient should be instructed to keep 
quiet for several days. For the first few days there may be some sore- 
ness, and not infrequently there is a slight rise of temperature for the 
first 24 to 48 hours. 



CHAPTER IX 

BIER'S HYPEREMIC TREATMENT AND THE DIAGNOSIS 

AND TREATMENT OF FISTULOUS TRACTS BY 

MEANS OF BISMUTH PASTE 

HYPEREMIC TREATMENT 

While the value of artificially producing hyperemia with the 
definite purpose of increasing the inflammatory reaction has only 
recently been recognized, it is 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 independently have called attention to the value of hypere- 
mia in similar conditions. To Bier, however, belongs the credit of 
placing treatment by hyperemia upon a logical and scientific basis, 
and of demonstrating its great practical value. 

There are two distinct forms of hyperemia, namely, active and 
passive. The former, obtained by means of dry hot air, produces a 
more active flow of arterial blood through the parts, and is especially 
useful for the absorption of the products of chronic, nontubercular 
inflammations. The passive, venous, or obstructive form of hypere- 
mia, as it is designated, has for its object the increase of the amount 
of venous blood in the part, and may be produced by means of elastic 
compression of the venous circulation, or by suction cups. This 
form gives the best results in pyogenic infections, whether acute or 
chronic. 

PASSIVE HYPEREMIA 

Bier was first led to employ passive hyperemia through study of 
the observations of Farre and Travers who, as far back as 1815, 
called attention to the frequency of phthisis in persons whose lungs 
were rendered anemic because of stenosis of the pulmonary orifice, 
and by the reverse of this, namely, the rarity of pulmonary tubercu- 
losis in individuals suffering from cardiac conditions tending to pro- 
duce congestion or hyperemia of the lungs, as later pointed out by 
Rokitansky. Impressed by these observations, Bier conceived the 
idea of artificially producing a hyperemia for the cure of tubercular 
affections in other parts of the body. Encouraged by the results 

203 



204 BIER S HYPEREMIC TREATMENT 

- obtained in the treatment 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 inflamma- 
tion represents nature's efforts for protection of the body against 
bacterial invasion and in the restoration of a part to a healthy condi- 
tion. Bier's teachings in regard to inflammation take exactly the 
opposite view from what has hitherto been held and taught. For- 
merly it was the aim of treatment to combat in every way possible 
the phenomena accompanying an inflammation. In the presence of 
pain, heat, redness, and swelling, cold applications, elevation of the 
part, rest, and immobilization were advocated for the rehef 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 overcome noxious influences and produce a cure; 
and these are to be encouraged as beneficial 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 natural resistance of the tissues. 

Difficult as it may be to give up our old ideas and accept a 
method of treatment so radically at variance with former teachings, 
the results obtained under hyperemia, properly carried out, are in 
certain cases so remarkable and so far in advance of any other 
methods as to furnish ample evidence of its superior value and to 
prove conclusively the correctness of the theories upon which Bier's 
treatment rests. 

Effects of Hyperemia. — The beneficial effects of hyperemia are 
most striking — the more marked, the earlier the treatment is begun. 

Diminution of Pain. — The prompt relief of pain is one of the most 
remarkable features of the treatment. Accepting the theory that 
» pain from an inflammation is due to irritation of the cells and end 
organs by toxins, as well as to the high specific gravity of the inflam- 
matory exudate, its relief under the influence of hyperemia, which 
both destroys and dilutes toxins and also dilutes the exudates, may 
be readily understood. If pain be not relieved, or at least mitigated, 
or if discomfort results from the treatment, the operator's technic is 



PASSIVE HYPEREMIA 205 

probably at fault. The patient should always be impressed with the 
necessity of reporting any discomfort in the part subjected to the 
hyperemia, and his sensations should be an important guide for the 
operator. 

Through the prompt decrease of pain and sensitiveness, reflex 
contracture of muscles is avoided and earlier motion in a part is pos- 
sible. This is especially important in infections involving tendon 
sheaths and joints, as with early motion much better functional re- 
sults are possible. Even in an extremely sensitive joint, it is remark- 
able 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 through hyperemia cer- 
tain forces are brought to bear which either directly or indirectly 
antagonize bacterial growth and either destroy or dilute the toxins. 
Beginning infection, such as a furuncle or a carbuncle, in which red- 
ness, tenderness, swelling, and slight infiltration are the only signs 
present, can thus often be made to subside without suppuration, 
while, if suppuration has already developed, the infectious process 
may be prevented from extending to the deeper tissues and the cKn- 
ical course be greatly shortened. Accidental soiled wounds, which 
from experience we have every reason to beHeve will become infected, 
under the influence of hyperemia can often be made to heal without 
infection, and not infrequently by primary union, and there is no 
better means than the increased secretion induced by the hyperemia 
for thoroughly flushing out and rapidly cleansing these dirty wounds. 

There is considerable difference of opinion as to the agent under- 
lying this bactericidal action, and several theories have been advanced 
in explanation. Some believe that it is due to an increase in the 
phagocytes; some consider the carbonic acid of the venous blood to be 
the agent; others offer Wright's theory as to increase of the opsonic 
index as the beneficent factor; and still others claim that the in- 
creased transudate induced by the hyperemia mechanically flushes 
out the affected part and thereby dilutes the toxins and removes dead 
bacteria. It is difficult to say which is the exact cause. Bier him- 
self, I believe, inclines to the phagocytosis theory. Personally, the 
writer feels that the mechanical flushing of the part by the increased 
transudate is quite an important factor, especially in the presence of 
open wounds or sinuses. 

Limitation of the Pathological Process. — Under hyperemia, necrosis 
of even badly damaged parts is often prevented by the superabundant 



2o6 bier's hyperemic treatment 

nourishment of the tissues, or, when the infection has advanced to the 
destruction of tissues, the disease process is more promptly localized, 
and a line of demarcation between the healthy and diseased tissues is 
earlier in evidence. Sloughs and sequestra are thus early separated 
and cast off, while in tubercular aft'ections 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 hyper- 
emia thus makes unnecessary many of the operations of resection, etc. 
This is well illustrated in the excellent functional results, with free- 
dom from ankylosis and deformity, obtained in tubercular and other 
joint affections. 

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

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

Passive hyperemia has also been employed with success in medi- 
cine for such conditions as acute rheumatism, gout, and pulmonary 
tuberculosis. 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 rhinology, 



PASSIVE HYPEREMIA 207 

otology, gynecology, obstetrics, and dermatology, passive hyperemia 
has been recommended and appHed with varying degrees of success. 

General Principles Underlying Hyperemic Treatment. — As em- 
phasized by the author of this method of treatment, and others, it is 
not a panacea or cure for all troubles. One should recognize that it 
has its limitations. In some of the milder forms of infection, com- 
plete 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 operative interference should never be delayed when indicated. 
Pus ?nust always be promptly evacuated, and cold abscesses likewise 
are to be opened. This is accomplished by small incisions or punc- 
tures, the old-time extensive incisions, which often result in unsightly 
scars and even deformities, being unnecessary under this form of 
treatment. The hemorrhage incident to such incisions should be 
controlled by packing the wound for two to three hours before the 
hyperemia is induced. In an infection of the tendon sheaths, the 
anatomy of the parts should be carefully kept in mind and the inci- 
sions made accordingly. Small multiple incisions are employed and 
should be so placed as to avoid cutting the transverse palmar liga- 
ments opposite the finger joints. In the case of infection of a large 
joint, the pus is aspirated and the joint cavity is irrigated through a 
large trocar; in other localities, ordinary surgical principles should be 
the guide as to the incision. The curettage 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. Certain cases of very rapidly extending infection, with 
acute onset, however, require early incision in conjunction with the 
hyperemia, even before softening has occurred. If incisions are not 
made, the hyperemia may do harm and the local inflammation be- 
come worse, for the transudate which is induced by the hyperemia, 
added to the exudate already present, has no outlet and may drive 
the bacteria and their toxins into healthy tissue and favor the exten- 
sion of the infection. 

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

In acute infections, the results are often prompt and most strik- 



2o8 bier's hyperemic treatment 

ing. In favorable cases, the temperature declines, pain is relieved, 
extension to deeper tissues is prevented, and the process rapidly sub- 
sides 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 distinguish- 
able, and mobility gradually increases; secretions from sinuses be- 
come serous instead of purulent, the sinus taken on a healthy appear- 
ance and finally closes. In tubercular affections, likewise, slight 
motion of the affected limb is allowed, provided it produces no pain. 
Fixation of the joint, in cases of tuberculosis of the wrist, elbow, or 
shoulder can thus usually be dispensed with — a sling at most is used — 
but in knee or foot tuberculosis a suitable apparatus should be worn, 
or the part so immobilized by a movable splint when the patient is 
moving about that pressure is removed from the diseased articular 
surfaces. In the presence of contractures of the joints, suitable 
extension is applied and used in conjunction with the hyperemic 
treatment. 

Bier gives as contraindications to the use of hyperemia in tuber- 
culosis of joints the following: 

1. Commencing amyloid disease and advanced pulmonary 
involvement. 

2. Large abscesses, filling up the whole joint cavity and demand- 
ing operation. 

3. Faulty position of the joint, such that cure would give a joint 
less useful than could be obtained by resection. In such conditions 
he advises operative interference. 

Successful hyperemic treatment necessitates correct technic, and 
many of the poor results at first obtained by those unfamiliar with 
this method may be ascribed to errors in this direction. It certainly 
requires time and close attention, as well as considerable experience 
on the part of the attendant, to obtain good results; but, if the treat- 
ment be properly carried out with perseverance, one will be amply 
repaid. At first the patient must be carefully watched as, with the 
use of the elastic band, for instance, it may be necessary to remove or 
reapply the constriction several times in the course of a single treat- 
ment in order to maintain the proper degree of hyperemia. Intelli- 



PASSIVE HYPEREMIA 



209 



gent patients may later be instructed in carrying out the treatment 
with either the bandage or the cup, and in time they themselves can 
apply the treatment at home, but they should always remain under 
the supervision of the surgeon. 

Methods of Producing Passive Hyperemia. — As already indicated 
the passive form of hyperemia may be obtained by means of soft 
rubber bandages or by special suction apparatus. The principle in 
each is the same, but the technic requires special description. 

Passive Hyperemia by Means of Constricting Bands. — This 
is the oldest method of producing an obstructive hyperemia. It is 
especially applicable to affections involving the extremities, head, 
and neck. The hip-joint is the only one in either of the extremities 
to which the method cannot be satisfactorily applied. There is no 
doubt that the proper application of the band requires more skill 
than does cupping. Exact technic is necessary, and great caution 




Fig. 182. — Esmarch elastic bandage for obstructive hyperemia. 

must be observed not to exceed the proper grade of hyperemia, and 
in tubercular cases not to lower the vitality of the tissues by too pro- 
longed obstruction. Only a mild hyperemia is necessary to produce 
results; otherwise, distinct harm is done. For this reason, the band- 
age should 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, thin elastic bandage, such as 
Esmarch's or Martin's, about 2 1/2 inches (6 cm.) in breadth, is 
employed (Fig. 182). 

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

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 provided with hooks and 

14 



2IO BIER S HYPEREIKIC TREATMENT 

eyes so that it may be adjusted to any size, as shown by the ac- 
companying illustration (Fig. 183), answers the purpose admirably. 
Site of Application. — The constriction should always be applied 
over healthy tissue and well above the area of inflammation. In 
involvement of the hand, for instance, the bandage is applied above 
the elbow, and above the knee if the foot be the seat of trouble. To 
avoid undue compression continually at the same spot, it is well to 
change the location of the bandage at each application, moving it a 
little either up or down the limb. 




Fig. T83.— Elastic garter for producing obstructive 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 
twenty 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 diminished until it is only of from one to 
two hours. 

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

Technic. — To apply the bandage, its initial extremity is first wet 
sufljciently to make it adhere to the skin and prevent it from slipping. 



PASSR'E HYPEREMIA 



211 



The bandge is wound around the hmb with moderate tension six or 
eight times well above the seat of disease, each layer overlapping the 
preceding by about 1/2 inch (i cm.). The bandage is then made 
secure by adhesive plaster or tapes previously sewed to the terminal 
end (Fig. 184). 

The degree of h}'peremia is of the utmost importance. The 
object is to moderately constrict the veins of a part, without in 
any way interfering with the arterial supply, thereby partly checking 
the reflux of blood and increasing the quantity of venous blood nor- 
mally present. It requires practice and careful attention to detail 
to apply the bandage in such a way that the arteries are not com- 
pressed, while at the same time the right amount of venous obstruc- 
tion is obtained. If the constriction is applied properly, the veins 




Fig. 184. — Showing the method of applying the elastic bandage to the arm. 



in the part distal to the bandage become slightly distended, and the 
part takes on a bluish-red hue and becomes warm to the touch. This 
degree of hyperemia is essential, as the hot hyperemia only has 
therapeutic value. As already emphasized the pulse should never he 
obliterated. It must at all times be distinguished, not even weakened. 
Furthermore, the application of the bandage should never cause pain 
or annoyance, or hj^eresthesia of the part. If too great a degree of 
compression is employed, nutritional disturbances from the increased 
stasis injures the tissues and reduces their natural resistance. In 
such a case, a white edema is produced, or the skin becomes grayish- 
blue in color, or has a mottled red and white appearance, and the part 
remains cold to the touch. Such a condition demands removal of 
the bandage and its proper reapplication. 



212 BIER S HYPEREMIC TREATMENT 

For obtaining the proper degree of hyperemia, it has been sug- 
gested that a sphygmomanometer, such as the Riva-Rocci instru- 
ment, for example, be employed. The cuff is secured about the part 
in the same manner as would be done in taking the blood-pressure 
and the systolic pressure is estimated (seepage 114). The mercury is 
then allowed to drop about 10 mm., which gives the proper tension, 
after which the tube leading to the inflation band is tightly clamped. 

In chronic cases it is sometimes very difl&cult 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 suffices. In 
other cases, the part may be first exsanguinated by means of an 
Esmarch bandage, as would be done preliminary to an amputation, 
and upon removal of the bandage a profuse reactionary flow results, 
after which the constrictor is applied. 

If the constriction is to remain in place for long periods at a time, 
it is advantageous to apply a soft flannel bandage beneath the rubber 
to prevent undue pressure upon the soft parts, which might produce 
an irritation of the skin, or even atrophy of the muscles. This is 
especially necessary when treating aged or thin, flabby individuals. 
While the bandage is in place, all dressings, splints, etc., are 
removed so as not to interefere 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 is 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 consequently 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. 

Head and Neck. — About the neck a special band, already de- 
scribed (page 2 10) , is used. It should be applied about the root of the 
neck, well below the larynx, with only moderate tension. To obtain 
the greatest degree of hyperemia with least constriction, small pieces 



PASSIVE HYPEREMIA 213 

of felt or wadding may be placed under the constricting band on 
either side of the larynx over the great veins (Fig. 185). If properly 
applied, such a bandage can be worn with entire comfort. It causes 
a pronounced edema of the face, particularly about the eyelids. This 
is no contraindication to its use, however. Care should be taken not 
to apply the band too tightly — of course it should never strangulate 
or interfere with eating or swallowing. If throbbing or a feeling of 
marked fullness in the head is complained of, the bandage should be 
removed and reapplied. 

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 




Fig. 185. — Showing the appUcation of the neck band. 

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 tub- 
ing in front of the joint, and passes across the chest, under the opposite 
axiUa, and around the back, where it is secured to the portion of the 
rubber ring behind the joint (Fig. 186). By adjusting the bandage 
and regulating the tightness of the rubber tubing, the proper degree 
of constriction may be obtained. 

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



214 



BIER S HYPEREMIC TREATMENT 



twenty-four hours, with correspondingly longer intermissions, in 
preference to the ten or eleven hour applications. 

Scrotum. — Tubercular and other affections of the testicle may be 
treated by means of constriction about the root of the scrotum. A 




Fig. i86. — Showing the method of obtaining obstructive hyperemia of the 

shoulder. 




Fig. 187. — Showing the method of producing obstructive hyperemia of the testicles. 

(After Meyer-Schmieden.) 

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. 187). 



PASSIVE HYPEREMIA 215 

Hyperemia by Means of Suction Cups. — Innumerable forms 
and styles of suction cups for producing hyperemia in regions not 
accessible to constriction, as well as large chambers for use upon the 
extremities and large joints, have been 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 obtaining the proper degree of hyperemia 
cannot be too strongly emphasized. 

When one of the cups is applied to a surface and a vacuum pro- 
duced, the skin and underlying tissues are sucked into the chamber 
and venous stasis with a consequent increase in the supply of blood 
in the skin and deeper layers result. Besides producing hyperemia, 
the mechanical effect of the cupping glass is also of distinct advantage. 
From an open discharging wound pus and broken-down tissues 
are rapidly and effectually aspirated. Small sequestra of bone are 
often quickly separated and discharged through a sinas 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 conjunction with the rubber bandage. 

Apparatus. — Cups suitable for furuncles, 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, otologist, and other specialists are now manufactured. 
Types of some of these are shown in the following illustrations (Figs. 
188 to 198). If there is considerable discharge, a type of cup shown 
in Fig. 189 will be found most useful. 

In selecting the cup, one should be chosen of sufiiciently large 
diameter to extend well outside the limits of an acute inflammation, 
and with 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 bulbs. With the larger apparatus, stronger 
suction is required and a special exhausting pump is necessary (Fig. 
199). A further convenience for use with the larger apparatus is a 
three-way stopcock inserted between the glass chamber and the 
pump to allow admission of air when the negative pressure is too 
great or is to be discontinued. 

In addition to these cups and chambers, larger and stronger appa- 
ratus for orthopedic use is made for the purpose of bending stiff 
joints by atmospheric pressure, as shown by Fig. 200. Here the arm 
is drawn firmly in the glass case as the air is exhausted until the hand 



2l6 



bier's hyperemic treatment 



meets the obstacle at the lower end of the chamber, when the wrist 
turns in the direction of least resistance. Other joints of the body 




Fig. 198. 

Fig. 188. — Cup for sty. 189. Cup for small abscess. 190. Cup for large 
abscess. 191. Cup for gums. 192. Cup for carbuncle. 193. Cups for ton- 
sils. 194. Breast cup. 195. Cup for cervix. 196. Cup for nose. 19 7- 
Finger suction glass. 198. Hand suction glass. 

may be similarly treated by the use of suitable apparatus. Klapp 
has also devised metal chambers which are provided with an air 
pump and a heavy rubber bag for obtaining motion in a partially 



PASSIVE HYPEREMIA 21 7 

ankylosed joint. Upon exhausting the air in the apparatus, the 
rubber bag descends and exerts an evenly regulated pressure upon 
the part to be treated, as shown in Fig. 201. 




Fig. 199. — Pump for producing a vacuum in the larger cups and suction glasses. 

Asepsis. — In using suction apparatus in the neighborhood of open 
wounds or sinuses, strict asepsis should be observed. To avoid all 
danger of adding to the infection, the cups should be boiled before 




Pig. 200. — Showing the method of obtaining motion in a stiff wrist by the aid of 

passive hyperemia. 

used. They should be again boiled and well cleaned before being 
put away. 




Fig. 201. — Showing the method of obtaining motion in a stiff knee-joint by the 
aid of passive hyperemia. 

Duration of Application. — In the use of cups, brief applications 
often repeated are essential. Accordingly, the cup is applied for five 



2l8 



BIER S HYPEREMIC TREATMENT 



minutes, and is then removed for an interval of two or three 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 
blood with bactericidal properties is brought to the part, the entire 
treatment consuming about three-quarters of an hour. 

Technic.— Pus, if present, is always to be evacuated by means of a 
small incision or puncture, as previously described, before application 
of the suction apparatus. 

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




Fig. 202. — Showing a cup applied to a carbuncle. 



bulb, and the cup is placed over the affected region, care being taken to 
use a cup that is large enough. Upon releasing the bulb, the air in 
the cup is partly exhausted, causing the area covered by the cup to 
be drawn up into it, and, if a proper amount of suction is exerted, 
the cup adheres to the surface and a pronounced hyperemia results 
(Fig. 202). 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 already been strongly emphasized and is reiterated here. It 
must be remembered that the suction should be just sufficient to 
slightly decrease the outflowing blood without interfering with the 
inflow. The object is to produce a reddish-blue color of the part. 
.1 distinct blueness or mottling of the skin, or complaint of pain on the 
part of the patient, indicates too great an amount of suction and requires 
ivithdrawal and reap plication of the cup. Pain should never be 



PASSIVE HYPEREMIA 



219 



produced even in acutely inflamed regions. Sometimes more than 
one application of the cup is necessary before the proper degree of 
hyperemia is obtained. With the suction pump, the degree of 
hyperemia may be more nicely regulated. In this case, the cup with 
the edges well lubricated is simply applied to the affected region, 
and the air is slowly exhausted until the proper degree of hyperemia 
is induced. If the vacuum is produced too rapidly, it is apt to cause 
some pain. Should it be found that too great a degree of suction is 
produced, the stopcock may be opened slightly and air allowed 
to enter the chamber until the desired degree of congestion is attained. 
In the use of the large chambers, such as are employed for the 
treatment of a hand or foot, the member to be subjected to hj^eremia 
is first coated with soap or vaselin so that the rubber sleeve will more 
easily sHp over the skin and at the same time leakage of air may be 
avoided. The patient then thrusts the arm or foot into the appara- 
tus, and the rubber sleeve is bandaged securely about the limb with 
a rubber bandage (Fig. 203). A partial vacuum is then produced. 
This causes the part to be drawn more deeply into the chamber, and 




Fig. 203. — Showing a suction glass applied to the hand. 

some care will be necessary to avoid injuring the limb by suddenly 
drawing it against the closed end of the apparatus. A distinct 
hyperemia of the whole part within the chamber is thus produced, 
which may be increased or lessened at will by increasing or decreas- 
ing 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 be- 
tween applications by gentle bathing of the part with warm sterile 
water or some antiseptic solution. At the end of the treatment the 
whole part should be gently bathed with warm solution, and all 
loose exudate or necrotic tissue removed with forceps or sterile gauze. 
A simple wet dressing is then appUed. 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. 



2 20 BIER S HYPEREMIC TREATMENT 

The suction treatment should be applied daily at first. The 
amount of pus usually rapidly decreases each day, first becoming less 
purulent and more serous, until finally only a little serum is with- 
drawn 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 be- 
comes red and hyperemic through local increase in the supply of 
arterial blood. The effects of hot-water bags, hot compresses, hot 
povdtices, hot sand, etc., are all familiar examples of active hyperemia. 
Hot air in a dry form, however, is the most effective means for in- 
ducing such a hyperemia on account of the high degree of heat that 
can be borne without discomfort. A part may be subjected to the 
influence of dry hot air of a temperature of 212° F. (100° C.) or more 
without danger of producing a burn or other injurious effects. On 
the other hand, moist heat of a temperature of 125° F. (52° C.) is 
capable of doing distinct harm, and is unbearable even for short 
periods. 

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

Indications. — Active hyperemia has a solvent and absorbent 
action upon exudate^, infiltrations, adhesions, etc., and a marked 
analgesic effect, causing a sensitive part to become less so or to be 
entirely reUeved soon after the appHcation is begun. It thus acts 
favorably in chronic rheumatism, chronic arthritis, chronic synovitis, 
and arthritis deformans. It aids greatly in promoting the absorption 
of edemas and of effusions of blood into the soft parts, and in synovial 
sacs — as in traumatic synovitis. Other affections in which active 
hyperemia has given good results are neuralgia, sciatica, neuritis, 
lumbago, gout, varicose veins, varicose ulcers, etc. 

In fractures near a joint with painful involvement of the joint 
itself, it is of great value in reducing the edema and at the same 



ACTIVE HYPEREMIA 



221 



time hastening the repair, thus increasing the chances of obtaining a 
more useful hmb through the abihty to perform early passive motion. 
In a CoUes' fracture, for example, the bones should be properly re- 
duced and within a few days the part should be daily subjected to 
the influence of heat. After ten days the splint may be discarded 
entirely, unless there seems a likelihood that the deformity will recur, 
and the hot-air treatment is daily continued, with the addition of 
both active and passive motion. 




Fig. 204. — Apparatus for applying active hyperemia to the hand and wrist and the 
method of its application. 

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

Apparatus. — Active hyperemia may be induced either by the use 
of hot-air boxes or hot-air douches. There are many makes of hot- 
air boxes on the market. The simplest are made of cotton-wood 
carefully fitted together and covered with cloth to prevent any leakage 
of air. They are provided with a lid and have openings at one or 



222 



BIER S HYPEREMIC TREATMENT 



both ends for receiving a limb. These openings are lined with cuffs 
of felt to avoid any danger of burning the skin, and are provided with 
straps so that the cuffs may be securely fastened to a limb. Open- 
ings for hot air are provided on both sides of the box, the one not in 
use being shut by a slide. Into one of these a chimney is fitted 
through which the hot air is conducted from the heating apparatus. 
The heat is supplied by an alcohol lamp or a gas burner secured to a 
bracket so that the lamp may be raised or lowered at will. The lids 
have one or more openings for ventilation of the apparatus. The air 




-^ ^ 



Fig. 205. — The hot-air douche being applied in sciatica. (The nozzle of the 
apparatus should be shown directed more to the posterior surface of the limb.) 

is thus constantly in motion, which is important in order to permit 
evaporation of the perspiration upon the part and to maintain the 
dryness of the air, A thermometer is also provided with each box 
for indicating the temperature. Such boxes are made to fit various 
parts of the body, as the arm, hand, shoulder, foot, knee, hips, etc. 

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 
of a long metal movable chimney, underneath which is the lamp or 
gas burner (Fig. 205). 

Temperature. — The degree of heat to which the part is subjected 
may vary from 150° F. to 212° F. (60° C. to 100° C.) or even higher. 
The temperature must never be high enough, however, to cause dis- 



BISMUTH PASTE INJECTIONS 223 

comfort, and the patient's feelings should be the guide. It should be 
remembered that the prolonged application of a very high degree of 
heat lowers the sensibility of a part, and great care must be taken not 
to burn the patient; the same caution must be observed when apply- 
ing active hyperemia to tissues with lowered resistance. A moderate 
temperature should be employed at the start, and this should be 
increased gradually as tolerance is attained. The temperature is 
regulated by raising the lamp nearer the box or moving it farther 
away, and also by the size of the flame. 

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

Technic. — The patient assumes a comfortable attitude, either 
seated or lying down, with the apparatus close at hand. The part 
to be baked is then placed in the box and the lid is closed. The lighted 
lamp is placed under the funnel and the temperature is gradually 
raised until a degree of heat is attained that can be comfortably borne 
by the patient. 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 change of temperature, such as would be occasioned by 
immediately removing the part to the outside atmosphere, is to be 
avoided. The part, when removed from the baking apparatus, is 
hot and hyperemic and remains so for some little time. Immediately 
following the treatment, gentle massage and passive motion, if 
indicated, should be practised. 

THE DIAGNOSIS AND TREATMENT OF FISTULOUS TRACTS 
BY MEANS OF BISMUTH PASTE 

The injection of a mixture of bismuth and vaselin for the 
diagnosis and treatment of fistulae, tubercular sinuses, and abscess 
cavities was devised by Beck of Chicago. He originally employed 
the method for the purpose of determining the size, course, and ex- 
tent of fistulous tracts. His first injection of a fistula for diagnostic 
purposes resulted, however, in the prompt closure of the sinus, and 
led him to extend the use of the injections to curative purposes with 
most favorable results. 



224 



BIER S HYPEREMIC TREATMENT 



For diagnostic purposes the fistula or abscess cavity is filled with 
the bismuth mixture and then a radiograph is taken. As the bis- 
muth offers great resistance to the penetration of the X-rays, a clear 
shadow is obtained of the fistula and all its ramifications. This 
gives much more information than the usual methods of probing and 
injecting colored fluids, peroxid, etc. 

As a therapeutic measure the method of application is equally 
simple, the bismuth paste being injected into the fistula or abscess 
cavity and allowed to remain there. Later it is absorbed. It 
is claimed that the bismuth has a bactericidal, chemotactic, and 
astringent action on the tissues. Furthermore, through its me- 
chanical effect, it promotes healing by keeping the walls of the sinus 
separated and forming a framework for the granulating tissue to 
work through. The method is applicable to all fistulae or abscess 
cavities except biliary or pancreatic fistulae and those communicating 
with the cranial cavity or urinary bladder. It is contraindicated 
in acute processes and new sinuses, as absorption occurs very readily 






Fig. 206. — Types of syringe for bismuth paste injections. 

from the fresh lining of the walls. In old sinuses and abscess cavities 
this is not the case, the thick fibrous walls possessing a greatly dimin- 
ished power of absorption. 

Toxic effects have been observed after the use of bismuth paste, 
and, in some instances, death has resulted. The symptoms are those 
of nitrite poisoning: black lines upon the gums, ulcerative stomatitis, 
vomiting, diarrhea, albuminuria, cyanosis, and collapse. To avoid 
this danger not more than 100 gm. (3 ounces) of the mixture should 
be injected the first time, and the patient should be carefully watched 
for the appearance of any toxic symptoms. Should they develop 
the cavity must be promptly evacuated. This may be accomplished 
by injecting into the cavity some warm sterile olive oil and removing 
it within twenty-four to forty-eight hours by aspiration. The 
cavity should never be curetted, as this simply opens up new chan- 
nels for absorption. 



BISMUTH PASTE INJECTIONS 225 

Apparatus.— There will be required a vessel to heat the bismuth 
mixture in, a glass rod to stir the mixture, and a large blunt-pointed 
glass syringe with asbestos packing. For injecting rectal fistula 
Beck has devised a syringe with a nozzel of special shape and curve 

(Fig. 206). 

' Formulary. — Two mixtures are used by Beck: 

No. I. Bismuth subnitrate, 33% 

Vaselin, 67% 

No. II. Bismuth subnitrate, 30% 

White wax, 5% 

Soft paraffin (120° F. melting point), 5% 

Vaselin, 60% 

Formula No. I is used for diagnostic purposes and for early treat- 
ments, while No. II is used for late treatments after the discharge 
from the sinus has ceased. Only arsenic-free bismuth should he used. 
The paste is mixed by melting the vaselin and while still hot stirring 
into it the bismuth. It is claimed that the efiiciency of the paste is 
increased by adding 1/2 to i per cent, formalin. 

To avoid the dangers of nitrite poisoning, various other substances 
have been incorporated in the vaselin, such as the subcarbonate, 
oxychlorid, and subgallate of bismuth, chalk, oxid of iron, etc., 
but in the opinion of Beck they are inferior to bismuth subnitrate for 
therapeutic purposes. 

Asepsis. — The syringe and receptacle for warming the bismuth 
mixture and the stirring rod should be sterilized by dry heat. If the 
syringe needs lubricating the packing may be dipped in sterile olive 
oil. The paste is sterilized by heating over a water bath, care being 
taken not to allow any water to come in contact with the mixture. 

Preparations of the Patient. — No general preparation of the pa- 
tient is necessary; the sinus or cavity to be injected may be dried 
out by means of a strip of gauze if this is feasible, but no irrigation 
should be attempted. The opening of the sinus is carefully wiped off 
with alcohol. 

Technic. — The paste is heated over a water bath and is stirred 
until thin enough to be drawn into the syringe. The syringe is then 
filled with the melted mixture, the point of the syringe is pressed 
closely into the mouth of the sinus, and the mixture is injected under 
sufiicient pressure to distend and penetrate all the ramifications of 
the sinus. Both for purposes of diagnosis and treatment it is 
absolutely essential that the paste be made to enter all portions of 
the tract. When the patient feels a sense of distention from the 
IS 



2 26 bier's hyperemic treatment 

injection, the latter is stopped and a pledget of gauze is quickly placed 
over the opening. An ice-bag is then applied to the part and the 
patient is kept quiet for a few hours. 

As a rule, after the first injection, the secretions change in char- 
acter and become first seropurulent, then serous, and finally cease. 
Should the discharge continue the injection may be repeated at the 
end of a week and after that every three to five days until the sinus 
closes. If any improvement is going to take place it should be 
noticed inside of a month. Tracts that show no disposition to 
close should be carefully examined for the presence of dead bone 
or other foreign body, which, if present, must be removed. A small 
per cent, of the cases show no results at all from the treatment. 



CHAPTER X 

THF COLLECTION AND PRESERVATION OF PATHO- 
LOGICAL MATERIAL 

With the present-day refinements of laboratory methods, the aid 
furnished by an examination of discharges, blood, urine, sputum, 
etc., is of great importance, and often without the information so 
obtained a correct diagnosis is impossible. It is not within the scope 
of this work to enter into the details of laboratory methods — these 
may be found in books devoted to the subject — but it is the writer's 
purpose in this section to give brief instructions as to the methods of 
collecting material and the preparation of specimens for subsequent 
pathological examination. 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 examina- 
tion 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 
cHnical history of the case, together with a statement of from what 
part of the body or from what organ the growth, discharge, or what- 
ever. it may be, was obtained, should accompany the specimen. If 
chemicals have been employed for preserving the specimen, this 
should also be stated on the slip sent to the pathologist. 

METHOD OF MAKING A SMEAR PREPARATION FOR 
MICROSCOPICAL EXAMINATION 

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

The slides should be absolutely clean and free from grease. 
Unless the sKdes are very dirty, the following method of cleansing 
the glass will suffice: First wash off the sHde 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 

227 



228 



COLLECTION OF PATHOLOGICAL MATERIAL 



cleansed, care should be taken that the surface of the slide does not 
come into contact with the skin, as, if it does, a thin tilm of grease 
will be left upon the glass. 

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



FlG. 207. — Roughened wire for making a swab. 

tube and a piece of stiff wire, of a length somewhat longer than that 
of the tube, are obtained. One end of the wire is first roughened with 
a file (Fig. 207) and is then tightly wrapped with a small roll of 
cotton (Fig. 208). The swab is then loosely laid in the test-tube and 
the mouth of the tube is plugged with sterile cotton (Fig. 209), and 





Fig. 208. — Showing the method of wrapping cotton on the end of a wire. 

the 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 and dipped into the pus or the secretion, care being taken 



Fig. 209. — Sterile swab in a glass test-tube. 

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. 210). 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 dry and are then piled up and secured one 



SMEAR PREPARATION POR MICROSCOPICAL EXAMINATION 229 

upon another, but with their surfaces separated by matches or tooth- 
picks, as shown in Fig. 211. 




Fig. 210. — Method of making a smear. 

From the Mouth and Pharynx. — Equipment. — Sterile swabs, 
glass slides, and a tongue depressor will be required (Fig. 212.) 




Fig. 211. — Glass slides separated by match sticks and held together with rubber 
bands ready for shipment to the laboratory. (Ashton.) 

Technic. — It should be seen that no antiseptic mouth washes or 
gargles have been used for at least two hours previous to the time the 
smear is made. The patient is seated in a good light, with his 




Fig. 212. — Instruments for taking a smear from the pharynx, i, Sterile swabs; 
2, glass slides; 3, tongue depressor. 

mouth widely opened, and the tongue controlled by the tongue de- 
pressor held in the operator's left hand, so that a good view of the 



230 



COLLECTION OF PATHOLOGICAL MATERIAL 



diseased area may be obtained. The sterile swab is then removed 
from its container, taken in the right hand, and is passed into the 
mouth, the operator being careful not to allow it to come in contact 
with the lips or tongue. When in contact with the area from which 
the material is to be obtained, the swab should be rotated about so 
as to bring as much as possible of its surface in contact with the 
secretions (Fig. 213). In removing the swab the same care against 
contamination from contact with the tongue, etc., should be observed. 




Fig. 213. — Showing the method of taking a smear from the pharynx. 



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

From the Nose. — Equipment. — Swabs, slides, a nasal speculum, 
a head mirror, and an angular pipette (Fig. 214) will be required. 

Technic. — Ordinarily, for microscopical examination, a smear 
made in the usual way from secretions blown from the nose into a 
clean handkerchief is sufficient. If, however, it is desired to obtain 
a smear from any one locaUty, the secretion should be first removed 
by means of a pipette (page 243), and from this the smear is made. 

From the Eyes. — Equipment. — Slides, a sterile swab, a platinum 
needle, and an alcohol lamp (Fig. 215) will be necessary. 

Technic. — There should be no preliminary cleansing of the eyes. 
The platinum needle is first sterilized by passing it through the 



SMEAR PREPARATION FOR MICROSCOPICAL EXAMINATION 



2^1 



flame, and when it has cooled the hds are separated, the loop is 
brought into contact with the pus and some of it is transferred 
to a slide. A smear is then made by means of the swab. 




Fig. 214. — Instruments for taking a smear from the nose, i, Sterile swab; 2, 
nasal speculum; 3, glass slides; 4, angular pipette; 5, head mirror. 

From the Urethra. — Equipment. — Slides and sterile swabs 
(Fig. 216) should be provided. 

Technic. — In a male, the meatus should be cleansed, and a drop 





Fig. 215. — Instruments for taking a smear from the eyes, i, Sterile swab; 2, 
glass slides; 3, alcohol lamp; 4, platinum needle. 

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 usual way. 



232 



COLLECTION OF PATHOLOGICAL MATERIAL 






Fig. 2i6. — Instruments for taking a smear from the urethra, i, Sterile swab; 

2, slides. 




Fig. 217. — Forcing the discharge out of the urethra b}^ pressure against the canal 
with the tip of the finger in the vagina. (Ashton.) 



SMEAR PREPARATION FOR MICROSCOPICAL EXAMINATION 233 

In the female, the labia are held apart by an assistant, the index 
finger is inserted in the vagina, and the urethra is stripped from 
behind forward (Fig. 217). 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 usual way. 

From the Vagina. — Equipment. — Swabs, slides, and a vaginal 
speculum (Fig. 218) are needed. 

Technic. — The labia are separated and the speculum is introduced 
so as to obtain a good view of the parts. The swab is then introduced 





Pig. 218. — Instruments for taking a smear from the vagina, i Sterile swab; 
2, glass slides; 3, vaginal speculum. 

without touching the vulva and is rubbed in the discharge, mucous 
patch, or whatever it may be. A smear is then made from the 
material thus obtained. 

From the Cervix. — Equipment. — A long swab, a speculum, two 
tenacula, a sponge holder, and glass slides (Fig. 219) should be 
provided. 

Technic. — The speculum is introduced so that the cervix is well 
exposed to view, and, by means of a tenaculum placed in each lip, 
the cervix is drawn as far down as possible. The swab is then passed 
into the cervical canal (Fig. 220), but care is taken that it does not 
enter the uterus for fear of carrying infection to what may be a healthy 
organ from a diseased cervix. The swab is then withdrawn, and 
a smear is made in the usual way. 



234 



COLLECTION OF PATHOLOGICAL MATERIAL 




Fig, 219. — Instruments for taking a smear from the uterus. I, Sterile swab; 
2, tenacula; 3, Simon's speculum; 4, glass slides; 5, sponge holder. 




Fig. 220. — Method of collecting the secretions from the uterus. (Ashton.) 



METHOD OF INOCULATING CULTURE TUBES 235 

METHOD OF INOCULATING CULTURE TUBES 

Equipment. — Culture tubes, sterile swabs, platinum needles, 
thumb forceps, and an alcohol lamp (Fig. 221) 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 




3i Lm 



M 



H 



Fig. 221. — Instruments for making a culture, i, Alcohol lamp; 2, thumb 
forceps; 3, sterile swabs; 4, culture tubes; 5, platinum needle. 

test-tubes, generally plugged with cotton. When they are to be 
kept for any length of time, the tubes should, in addition, be sealed 
with rubber caps or oiled paper to prevent their contents from drying 
out. 

The inoculation of the tubes is performed by means of a swab 
or a platinum needle. The method of making and sterilizing the 



Fig. 222. — Platinum needles. 

former has been described above (page 228). The needle consists 
of a platinum wire, 3 to 4 inches (7.5 to 10 cm.) long, which is in- 
serted into the end of a glass rod 6 to 8 inches (15 to 20 cm.) long, 
which serves as a handle. The free end of the wire may be made 
into the form of a loop or it may be simply left straight (Fig. 222), 



236 



COLLECTION OF PATHOLOGICAL MATERIAL 



according to whether a streak or a stab culture is to be made. Before 
use, the wire should be sterilized by passing it back and forth through 
a flame for a few seconds. 

Technic. — In making a culture the greatest care must be exer- 
cised as to the asepsis and the avoidance of contamination. The 
culture tubes, platinum needles, etc., are arranged upon a towel 
within easy reach, and the alcohol lamp is lighted. The end of the 
culture tube containing the cotton plug is first passed through the 
flame, the cotton being singed so as to destroy any germs that may 
be deposited upon it (Fig. 223). The culture tube is held between 
the thumb and forefinger of the left hand, with the mouth of the 




Fig. 223.-:-Singeing the cotton stopper of a culture tube preparatory to its 

inoculation. 



tube pointing downward, if it contains a solid medium, so as to pre- 
vent the entrance of any dust. A pair of thumb forceps, after being 
passed through the flame, are used to remove the cotton plug which 
is then transferred to the left hand where 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 
sterilized by passing it through the flame, including the portion of 
glass handle that will enter the tube, and, after permitting it to cool, 
the tip of the needle is dipped into the secretion or pus — care being 
taken that it touches nothing else — and is passed to the bottom of 
the culture tube and then gently withdrawn over the culture medium 
so as to spread the material in a thin streak upon its sloping surface 
(Fig. 224). The platinum needle is again passed through the flame 



METHOD OF INOCULATING CULTURE TUBES 



237 



and is then laid aside. The tube is finally closed with the cotton 
plug, fijst singeing the cotton, however, in the flame while held with 
the thumb forceps. 




Fig. 224. — Alethod of making a streak culture. (Levy and Klemperer.) 




Fig. 225. — Showing "a" stab culture, and "b" smear culture. 

When a stab culture is to be made, a straight needle is employed 
instead of a looped one. The technic is precisely the same as for a 
streak culture except that the needle is inserted straight into the 
culture medium and is then withdrawn. 



238 COLLECTION OP PATHOLOGICAL MATERIAL 

A smear culture with a swab is made as follows: The culture tube 
and the tube containing the sterile swab are held side by side between 
the thumb and the index finger of the left hand. The cotton plugs 
are removed with sterile forceps, the ends of the tubes and the ex- 
posed cotton being first singed, as described above. The cotton 
plugs are held between the ring and little finger and the ring and 
middle fingers of the left hand, while, with the right hand, the swab 
is withdrawn from its tube, dipped in the secretion, and is then in- 
serted into the culture tube and is rubbed thoroughly over the surface 
of the culture medium (Fig. 226). The swab is then replaced in its 
container and the cotton plug is singed and reinserted into the mouth 
of the culture tube. 

When a number of cultures are being made, care should be taken 
to immediately number each tube as it is inoculated. 




Fig, 226. — The method of making a smear culture. 

COLLECTING DISCHARGES AND SECRETIONS FOR BACTERI- 
OLOGICAL EXAMINATION 

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 collected in sterile glass pipettes which are 
then hermetically sealed. This insures against leakage as well as 
any chance of contamination during transportation. 

Equipment. — A number of glass pipettes, a rubber suction bulb or 
a suction syringe, an alcohol lamp, scissors, and suitable specula (Fig. 
227) will be required. 



COLLECTING DISCHARGES AND SECRETIONS 



239 



The pipettes may be easily made from thin glass tubing of an ex- 
ternal diameter of about i/ 4 inch (6 mm.). The center of a piece of 
such tubing about 6 inches (15 cm.) long is heated over a flame, the 





Fig. 227. — Apparatus for collecting discharges for bacteriological examination 
I, Alcohol lamp; 2, scissors; 3, suction syringe; 4, pipettes. 

tube continually being turned the while, until the glass is softened 
over about 1/2 inch (i cm.) of space (Fig. 228). The tubing is then 
removed from the flame, and, while the glass is still soft, the two ends 
are drawn apart so that the softened central portion is stretched out 




Fig. 228. — Heating the glass tube at its center over a Bunsen flame. (Ashton.) 

into a capillar}- tube several inches long (Fig. 229). The center of 
this capillary tube is again heated in the flame until it melts, and, by 
drav-ing upon the ends, it parts in the center, leaving two pipettes, 



240 



COLLECTION OF PATHOLOGICAL MATERIAL 



each with one sealed end (Fig. 230). The center of the thick por- 
tions of each of these pipettes is then melted in the same way and is 
drawn out into a capillary tube an inch (2.5 cm.) or more long, so 



Fig. 229.^ — The glass tube is shown drawn out at its center. (Ashton.) 

that we have as a result two pipettes each drawn to a point at one end, 
wide at the other, and between the two ends a bulb separated from 
the wide end by a capillary constriction (Fig. 231). The pipettes are 




Fig. 230. — Fusing apart the center of the drawn-out portion of the tube. (Ashton.) 

sterilized, after inserting a piece of cotton wool in the wide ends, by 
passing the whole tube through the flame until it is hot (Fig. 232), 
but not so hot as to melt the glass or burn the cotton plug. Thus 




Fig. 231. — Making a bulbous pipette by heating the thick portion and drawing it 
out to a thin tube. (Ashton.) 

sterilized, the pipettes may be kept on hand ready for use almost 
indefinitely. 

The suction for drawing up secretions into the pipettes may be 




Fig. 232. — Sterilizing the interior of the bulbous portion (b) and the slender end 
(a) of the pipette; (d) plug of cotton. (Ashton.) 

furnished by the bulb of a medicine dropper, or by attaching a piece 
of rubber tubing to the pipette and applying the lips or a small suc- 
tion syringe to the free end of the rubber tubing. 



COLLECTING DISCHARGES AND SECRETIONS 



241 



Technic. — The pipettes are arranged near at hand upon a towel, 
and the alcohol lamp is lighted. The sealed end of the pipette should 
be cut off with scissors (Fig. 233) and should be then rounded off 




Fig. 233. — Snipping off the fused point of the slender end (a) of the pipette with 

scissors. (Ashton.) 




Fig. 234. — Rounding off the rough edges of the glass in the flame. (Ashton.) 

smooth in the flame, so as to avoid producing any injury to the tissue 
(Fig. 234). 

The pipette is then slowly passed through the flame so as 




Fig. 235. — Sterilizing the outer surface of the slender end (a) of the pipette. 

(Ashton.) 




Fig. 236. — Hermetically sealing the secretions in the bulbous portion of the pipette 
by fusing it in the flame at a and c. (Ashton.) 

to sterilize the entire outer surface of the tube (Fig. 235). When 
the tube has cooled, the rubber nipple or tubing is placed upon the 
large end, and the small end is inserted in the discharge or secretion. 
16 



242 



COLLECTION OF PATHOLOGICAL MATERIAL 



which is then drawn up into the pipette by suction. The suction bulb 
is then removed, and the small end of the pipette is sealed by melting 
it in the flame. The constricted portion is likewise melted in the 
flame, and the portion of the pipette containing the cotton wool is 
removed, and the remaining end of the pipette is sealed (Fig. 236). 
In this way the discharge is hermetically sealed in small glass tubes 
(Fig. 237) and can be sent to any distance for later bacteriological 



Fig. 237. 



-Showing the bulbous portion of the pipette sealed and containing the 
secretion. (Ashton.) 



examination. Each tube as it is prepared should be carefully labeled 
with a distinguishing number. 

From an Abscess Cavity. — Care must be taken that no anti- 
septic irrigating fluid is used before the discharge is secured. A 
specimen should be obtained free from blood, if possible. To 
avoid contamination, the first portion of the pus should be allowed 




Fig. 238. — Instruments for obtaining secretions from the nose for bacteriological 
examination, i, Sterile angular pipette; 2, alcohol lamp; 3, scissors; 4, nasal 
speculum; 5, head mirror. 

to escape; the edges of the incision are then separated while the 
pipette is inserted into the cavity, and a specimen is withdrawn 
from its depths. 

From Serous Cavities. — The method of obtaining fluid 
from serous cavities is described under exploratory punctures (Chap- 
ter XI). 



COLLECTING DISCHARGES AND SECRETIONS 



243 



From the Nose and Accessory Sinuses. — Equipment. — An 

angular pipette will be required, as well as an alcohol lamp, scissors, a 
nasal speculum, suitable illumination, and a head mirror (Fig. 238). 

The angular pipette may be made by taking a straight pipette 
■with a long capillary tube, heating the latter at a distance of about 
3 inches (7.5 cm.) from its extremity and, when soft, bending it to 
an angle of 135 degrees. The end should be well smoothed off in a 
flame before using. 

Technic. — The same general principles as outlined above are 
foUowed. The patient is seated as for an anterior rhinoscopic exami- 
nation (page 312), the nasal speculum is introduced, and the light is 




Fig. 239. — Method of sucking secretion into a pipette from the female urethra 

(Ashton.) 



reflected so that the interior of the nose can be clearly observed. 
The tip of the pipette is then inserted until it comes in contact with 
the discharge, care being taken not to have it touch the mucous mem- 
brane or the vibrissas about the vestibule. The point of the instrument 
is moved about in the secretion while suction is exerted and some of 
the discharge will thus be withdrawn. The pipette is then removed, 
sealed, and properly labeled. 

From the Eyes. — The technic is not different from that already 
described for collecting discharges from other regions, and no special 
forms of pipettes are necessary. Any preliminary cleansing of the 
eyes should, of course, be avoided. 



244 



COLLECTION OF PATHOLOGICAL MATERIAL 



From the Urethra. — Equipment. — Pipettes and the other ap- 
paratus necessary for collecting discharges (see Fig. 227) will be 
required. 

Technic. — The urine should not be voided for several hours prior 
to obtaining the specimen. The urinary meatus is first exposed, 
and, after the end of the pipette has been inserted into the canal, the 
secretion is sucked into the pipette (Fig. 239). When the discharge 
is scanty, sufficient may be obtained by expressing the pus from the 
posterior portion of the urethra by drawing the finger along the 
urethra from behind forward. In the female the same method may 
be employed with the index finger in the vagina (see Fig. 217). 
When a specimen has been obtained, the ends of the pipette are 
sealed and the tube is properly labeled. 





Fig. 240. — Instruments for obtaining secretions from the vagina for bacterio- 
logical examination. I, Alcohol lamp; 2, scissors; 3, suction syringe; 4, sterile 
pipettes ; 5, vaginal speculum. 

From the Vagina. — Equipment. — Pipettes, a suction syringe 
and rubber tubing, scissors, an alcohol lamp, and a vaginal speculum 
(Fig. 240) 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 distal end of the pipette is then carefully introduced into the dis- 
charge, and sufficient secretion for the purposes of the examination is 
withdrawn by means of suction. The pipette is then removed, 
both ends are sealed, and the specimen is properly labeled. 

From the Uterus. — Equipment. — Pipettes, a suction syringe 
and rubber tubing, scissors, an alcohol lamp, vaginal specula, two 
tenacula, and sponge holders (Fig. 241) will be required. 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION 245 

Technic. — The speculum is introduced into the vagina and the 
cervix is well exposed to view. Any vaginal secretions are removed 
by 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 pipette 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. 




Fig. 241. — Instruments for collecting discharges from the uterus for bacterio- 
logical examination. (Ashton.) i, Pipettes; 2, suction syringe; 3, Simon's 
speculum; 4, tenacula; 5, scissors; 6, sponge holder; 7, alcohol lamp. 



COLLECTION 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 promptly — say within half an 
hour. A smear is made when the morphology of the cellular ele- 
ments is to be studied after being properly stained. 

Equipment. — Slides, cover-glasses, an alcohol lamp, thumb for- 
ceps, and a spear-pointed needle or a lancet (Fig. 242) are necessary. 
The cover-glasses and slides should be of the best material. The 
former should be very thin and about 7/8 inch (22 mm.) square. 
Both should be absolutely clean and free from grease; the cleansing 
may be performed after the method described on page 227. 

Location 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, 



246 



COLLECTION OF PATHOLOGICAL MATERIAL 



and it is usually cleaner, so that the chances of infection are less. 
Furthermore, when the puncture is made in the ear, the operation is 
removed from the view of the patient, which is an important con- 
sideration in the case of children and nervous individuals. 




\ 

\ 

3 




Fig. 242. — Instruments for collecting blood for microscopical examination. 
I, Thumb forceps; 2, spear-pointed needle; 3, cover-glasses; 4, glass slides; 5. 
alcohol lamp. 

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




Fig. 243. — Making a fresh blood smear. First step, puncturing the ear. 

Technic. — i. Fresh Specimen. — Care should be taken to avoid 
chilling the specimen and exposing it to the air any longer than is 
necessary; accordingly, everything should be in readiness for the 



COLLECTION OF BLOOD FOE. MICROSCOPICAL EXAMINATION 247 

examination. The slide is warmed over the alcohol lamp or by 
vigorously rubbing it with a piece of linen, and is then laid on a 
sterile towel. The cover-glass is likewise warmed and placed near at 
hand. The lobe of the ear is grasped between the thumb and fore- 
finger of the left hand and with a quick stab the lowest portion of the 




Fig. 244. — Alaking a fresh blood smear. Second step, collecting the drop on a 

cover-glass. 

lobe is punctured (Fig. 243). The blood should be allowed to flow 
■without pressure or rubbing, as these maneuvers produce a hyperemia 
and the constituents of the blood may be changed in character or 
the blood cells may be deformed. The first drop is wiped away 




Pig. 245. — Making a fresh blood smear. Third step, placing the cover-glass 
holding the blood drop on a slide. 

and a second drop is allowed to flow. The cover-glass is then taken 
up in the thumb forceps and is applied by its under surface to the 
apex of the drop (Fig. 244), but is not allowed to touch the skin. 
The cover-glass is then gently lowered upon the w^armed slide (Fig. 
245) and the drop of blood is thus caused to spread out in a thin 



248 



COLLECTION OF PATHOLOGICAL MATERIAL 



circular layer between the slide and the cover-glass. If the drop is 
not too large, the blood will not spread beyond the margins of the 
cover-glass. The cover-glass should not be pressed down upon the 
slide, as this will injure the corpuscles. 

2. Dried Specimen. — A puncture is made in the lobe of the ear 




Fig. 246. — Method of making a drj' blood smear with two slides. 

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 drop thus collected and is drawn along the surface of the 




Fig. 247. — Making a dry blood smear with two cover-glasses. Second step, 
collecting the drop on a cover-glass. 

first slide, spreading out the drop in a broad thin smear (Fig. 246). 
To be of any value the smear must be spread out evenly and thinly. 
A second method is to employ cover-glasses. Two cover-glasses 
are thoroughly cleansed and are placed conveniently at hand. The 
ear is punctured in the way described above (see Fig. 243), and the 



COLLECTION OF BLOOD FOR MLRCOSCOPICAL EXAMINATION 249 

first drop of blood is removed. One cover-glass is then held by its 
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. The under surface of the first cover is then applied to the apex 
of the drop of blood (Fig. 247), and is quickly placed upon the second 




Fig. 248. — Making a dry blood smear with 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. 




Pig. 249. — 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 layer between them. 




Fig, 250. — Making a dry blood smear with two cover-glasses. Fifth step, showing 
the method of drawing the two covers apart. 

glass, with the angles of the two not coinciding (Fig. 248), so that the 
drop spreads out by its own weight in a thin film between the two 
covers (Fig. 249). If too large a drop is taken, the upper cover will 
simply float around upon the lower. The upper cover is finally 



2^0 



COLLECTION Or PATHOLOGICAL MATERIAL 



seized between the thumb and forefinger of the right hand and, still 
holding the lower cover in the left hand, the two covers are shd apart 
in the same plane (Fig. 250). Unless too small a drop has been 
taken, this is readily accomplished. The films thus obtained are then 
allowed to dry, and later they may be fLxed and properly stained. It 
is always well to make 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 FOR BACTERIOLOGICAL 
EXAMINATION 

The best method of securing blood for culture is by a venous punc- 
ture. The ordinary method of obtaining blood through a prick of 
the ear or of the finger is worthless for bacteriological purposes on ac- 
count of the small amount of blood obtained and the chances of con- 
tamination, especially from the skin. If properly performed, a venous 
puncture is harmless and gives the patient but little discomfort. 




%2^ 
Fig. 251. — Apparatus for collecting blood for bacteriological examination. 

Equipment. — A glass syringe with a capacity of 2 1/2 drams 
(about 10 c.c), a moderately large needle with a sharp point, broth 
and agar-agar culture tube, and a bandage (Fig. 251) are necessary. 

Site of Puncture. — The median cephalic or median basilic vein is 
usually chosen (see Fig. 114), but, if these are not available, the inter- 
nal saphenous vein in the leg or any of the smaller veins about the 
wrist may be made use of. 

Asepsis. — The skin at the site of puncture is painted with iodin, 
the hands of the operator are as carefully sterilized as for any 
operation, and the instruments are boiled. 



COLLECTION OF BLOOD FOR BACTERIOLOGICAL EXAMINATION 25 1 

Anesthesia. — In ordinary cases anethesia is unnecessary. If it 
is necessary to expose the vein by an incision, as in the case of an 
individual with much fat or whose tissues are edematous, infiltration 
with a 0.2 per cent, solution of cocain or a i per cent, novocain 
solution is employed. 

Technic. — A bandage is wound about the arm between the seat of 
puncture and the heart with sufficient tension to produce a slight 
venous stasis and cause the veins to stand out prominently, but with 
not enough compression to cut off the arterial flow. By gently forc- 
ing the blood along toward the seat of constriction by means of the 
forefinger or thumb, the vein may be made to stand out more promi- 
nently. In stout persons, however, it may be necessary to expose 
the vein by an incision. 

The needle with the syringe attached is then passed obliquely 




Fig. 252. — Showing the method of making a venous puncture. 

through the skin into the vein (Fig. 252), and the blood is gently 
sucked into the syringe by slowly withdrawing the piston. If too 
great an amount of suction is exerted the wall of the vein will be 
forcibly collapsed and will act as a valve against the further with- 
drawal of blood. About i 1/4 drams (5 c.c.) of blood may be taken 
from a child, and about 2 1/2 drams (10 c.c.) from an adult. The 
needle is then withdrawn, the constriction being first removed from 
the arm to avoid subcutaneous hemorrhage from the punctured 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 inoculation should be 
done immediately and before the blood has time to clot in the 
syringe. 

During the inoculation of the tubes the greatest care should be 



252 



COLLECTION OF PATHOLOGICAL MATERIAL 



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, and the inoculation is made through the sterile end of the 
syringe. In doing this, the same technic described on page 236 should 
be followed. Inoculations are usually made with i6Tn, (i c.c.) of 
blood into definite quantities of media. At the completion of the 
operation the seat of puncture is sealed with collodion. 



THE COLLECTION OF SPUTUM 

Sputum should be collected in absolutely clean wide-mouth 
ounce (30 c.c.) glass bottles, provided with a water-tight cork 
(Fig. 253), so that there can be no leakage during transportation. 
Suitable bottles may be obtained from any laboratory 
or from most drug stores. The specimen should be 
obtained from the sputum coughed up early in the 
morning before any food has been taken, and it should 
be seen that the material is coughed up from the lungs 
and that it is not simply an accumulation from the 
mouth and pharynx. As an added precaution against 
contamination from particles of food, tobacco, vomitus, 
etc., the mouth and pharynx should first be thoroughly 
rinsed out. When there is not sufficient sputum from 
one collection, the whole amount for the day, or for 
twenty-four hours, should be preserved. The specimen 
thus collected should be sent to the laboratory promptly, that it 
may be examined in as fresh a condition as possible. 

In the case of infants and young children it may be next to im- 
possible 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 Internal Medicine, May 15, 19 10) the follow- 
ing 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. 253.— 
vSputum bottle 



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 



THE COLLECTION OE URINE 



253 



in another vessel and then rejected; but if a culture is to be made, the 
urine must be obtained by catheter under rigid asepsis. The catheter 
must be boiled and the hands of the operator must be sterilized as for 
any operation. The meatus and surrounding parts are then washed 
with an antiseptic solution, and the catheter is gently inserted into 
the bladder without touching the adjacent parts (see also page 687). 
The first portion of the urine is to be discarded, and then from i 1/4 
to 2 1/2 drams (about 5 to 10 c.c.) are collected in a sterile test-tube, 
which is immediately plugged. 

When it is desired to obtain a separate specimen from each kidney, 
the ureters may be catheterized (see page 705) or a 
urinary separator maybe employed (see page 721). 

To obtain a twenty-four-hour specimen, as, 
for example, when it is desired to determine the 
total daily amount of urine secreted or to esti- 
mate the total solids, it is necessary to begin and 
end with an empty bladder. The patient is there- 
fore instructed to empty the bladder at a certain 
hour and to discard this specimen. All the urine 
passed for the following twenty-four hours, includ- 
ing that voided at the end of this period, is saved 
in a large clean bottle. For cases of incontinence, 
a retained catheter must be used (see page 689), 
or else a rubber urinal devised for such cases may 
be employed. 

When considerable time must elapse before a 
specimen can be examined, some preservative, 
such as boric acid in the proportion of i grain 
(0.065 gm.) to each ounce (30 c.c), formalin in the 
proportion of i drop to each 4 ounces (120 c.c), or a few drops of 
chloroform to each 4 ounces (120 c.c.) may be added to the speci- 
men. If culutres or inoculations are to be made, any preservative 
should be avoided. 

In the case of infants there are several methods for collecting 
urine. With male infants, for an ordinary examination, the specimen 
may be collected by means of a condom which is secured to the body 
by adhesive plaster, and into which the penis and scrotum are passed ; 
or a bottle may be employed, in the neck of which the penis is placed. 
Chapin has devised a urine collector (Fig. 254) that may be employed 
for both males and females. A method sometimes employed with 
females is to place absorbent cotton over the vulva, and, after the 




Fig. 254.-Chapin.'s 
urine collector. 



254 COLLECTION OF PATHOLOGICAL MATERIAL 

child has saturated the cotton, 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 uncontaminated specimen, catheterizfation must be resorted to, 
employing a small catheter (9 to ii French). 

THE COLLECTION OF GASTRIC CONTENTS 

For a microscopical examination of the stomach contents a test 
meal is not necessary, the vomitus or a portion removed by the 
stomach tube (see page 476) being all that is required. The specimen 
should be received in a clean glass receptacle. 

For a complete chemical examination and to test the condition of 
the stomach, the gastric contents an hour after a test-meal will be 
required (see page 475). 

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 

EXAMINATION 

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 4 
per cent, aqueous solution of formalin (Fig. 255). 

For regions which are not readily accessible, as, for example, the 



REMOVAL OF A FRAGMENT OF TISSUE FOR EXAMINATION 255 







Fig. 255. — Instruments for excising a fragment of solid tissue for examination. 
I, Scalpel; 2, curved sharp-pointed scissors; 3, skin punch; 4, thumb forceps; 5, 
artery clamps; 6, retractors; 7, needle holder; 8, No. 2 catgut; 9, curved cutting- 
edge needles; 10, specimen bottle. 




Fig. 256. — Excision of a piece of tissue from the cervix. (Ashton.) 



2s6 



COLLECTION OF PATHOLOGICAL MATERIAL 



female genitals, volsellum forceps and suitable specula are necessary. 

For collecting material from the interior of the uterus, curettage 
instruments, etc., will be required (see page 808). 

Anesthesia. — As a rule, local anesthesia by infiltration with a 




Fig. 257. — Removal of a fragment of a superficial growth with a skin punch. 

0.2 per cent, solution of cocain or a i per cent, solution of novocain 
in normal salt solution is sufficient. For skin tumors, freezing with 
ethyl chlorid usually suffices. 




^^^^^^^ 



Fig. 258. — Removal of a fragment of a superficial growth with a skin punch- 
Second step, cutting loose the base of the section. 

Asepsis. — The instruments are boiled, the hands of the operator 
are sterilized, and the site of operation is cleaned as for any operation. 

Technic. — The fine of proposed incision is first anesthetized. 
Then, with the tissues well retracted so as to expose the growth, a 



REMOVAL OF A FRAGMENT OF TISSUE FOR EXAMINATION 257 

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. 256). The tissue is then trans- 
ferred to the bottle containing the 4 per cent, formalin solution, and a 
proper label is applied. Any hemorrhage is then controlled, the 
incision is closed, and a sterile dressing is finally applied. 

A fragment of a very superficial tumor or of a skin growth may be 
removed by means of a punch 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. 257), 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. 258). 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 carefully labeled. Care should 
be taken to avoid rough handling of the tissues and to preserve for 
examination all the fragments removed. For the technic of curettage 
see page 809. 



17 



CHAPTER XT 
EXPLORATORY PUNCTURES 

An exploratory puncture consists in the introduction of a hollow 
needle attached to an aspirating syringe into a diseased region, and a 
subsequent aspiration. This comparatively simple operation may 
be performed for the purpose of determining the presence 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, 
inaccessible to other means of diagnosis, this method of exploration 
often gives most valuable information. The liver, the lungs, the 
pleural and pericardial cavities, the spinal canal, and other organs 
and regions difficult of access may thus be tapped and explored with 
comparative safety. 

Whenever fluid is detected a quantity suflScient for examination 
should be withdrawn. Frequently by a gross examination of the 
fluid sufficient information may be obtained as to its character. 
With the naked eye. one can often make a diagnosis between a serous, 
bloody, or purulent fluid, by carefully noting the color, clearness, and 
consistency of the material withdrawn. \'aluable information can 
likewise be obtained from the odor. 

For more definite and exact information, a chemical, microscopi- 
cal, and bacteriological examination will be necessary. In prepara- 
tion for such an examination a few drops of the Hquid should be 
injected into culture tubes, and the remainder placed in a sterilized 
test-tube, previously provided, and kept in readiness for this purpose. 
At times the aspirated fluid may be so thick that only a few flakes or 
floccules 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 
examination may at times be obtained by rotating the needle and 
moving 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. 



EXPLORATORY PUNCTURE OF THE PLEURA 259 

The laboratory examination of the fluid, the technic of which may 
be found fully described in manuals on clinical laboratory methods, 
should be made along the following lines and with reference to the 
special points mentioned. 

1. Physical Characteristics. — The color, odor, clearness, consist- 
ency, reaction, coagulability and specific gravity of the fluid, and 
the character of the sediment should be noted. 

2. Chemical examination should include tests for albumin, serum 
globulin, sugar, bile, urea, blood, pus, etc, 

3. Microscopical examination is made for the purpose of detecting 
the presence of blood-corpuscles, epithelial cells, hematoidin and 
cholesterin crystals, specific tumor cells or fragments, necrotic tissue, 
ameba, hydatid booklets, ray fungi, etc. 

4. Bacteriological Examination. — Smear preparations are made 
and examined for pathogenic bacteria, while organisms susceptible 
of culture are inoculated upon suitable media and later examined 
microscopically. Thus organisms may be identified which are not 
readily detected by direct examination. 

5. Cytodiagnosis. — 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 eft'usion 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. 

Apparatus. — Aspirating needles and a syringe of appropriate size 
should be provided. It Avill be found convenient to have an assort- 
ment of needles of difl'erent lengths and diameters. They should 
measure in length 2 1/2 inches (6.5 cm.), 3 inches (7.5 cm.), 31/2 
inches (9 cm.), and 4 inches (10 cm.); and in diameter 1/50 inch (0.5 
mm.), 1/25 inch (i mm.), 1/18 inch fi.5 mm.), and 1/12 inch (2 
mm,). For ordinary use the needle should be at least 3 inches (7.5 
cm.) long and about 1/25 inch (i mm.) in diameter, so that it will 
readily giv^e passage to fluids of heavy consistency. 

It is preferable to have a syringe with a capacity of from i to 2 
drams (4 to 8 c.c), though an ordinary hypodermic syringe may be 
employed if the large needles are made to fit. The syringe should be 



26o 



EXPLORATORY PUNCTURES 



capable of exerting a strong suction, and the joint between it and the 
needle should be absolutely air-tight. The best form of syringe con- 
sists of a solid glass barrel and a tight-fitting piston provided with an 
asbestos or rubber packing (Fig. 259). Such a syringe is simple in 
mechanism, easy to clean, and can be readily sterilized by boiling. 
If confirmation of the diagnosis of fluid is to be immediately followed 




Fig. 259. — Aspirating syringe and needles. 

by its evacuation, the aspirating apparatus of Potain or Dieulafoy 
(see page 286) may be used for the exploration, thus sparing the 
patient a subsequent operation. 

In addition there should be provided a scalpel and a cocain 
syringe or tube of ethyl chlorid for anesthetizing the point of puncture. 

Before making a puncture the syringe should always be tested 




\^ 



Pig, 260. — Apparatus for making smears and cultures from fluids removed by 
exploratory puncture, i, Glass slides; 2, sterile test-tube; 3, culture tubes. 

by withdrawing the piston with the finger held over the end, to see if 
it will exert proper suction. The syringe should likewise be tested 
with the needle fitted in place. After use, the syringe should be 
taken apart, and both it and the needle should be thoroughly cleansed. 
To guard against rusting, the lumen of the needle should be cleansed 
with alcohol and ether, and a wire of suitable size inserted. 



EXPLOR-\TORY PUNXTURE OF THE PLEURA 



261 



In cases where a complete chemical, microscopical, and bac- 
teriological examination is desired, sterilized test-tabes for collecting 
and transporting the material aspirated, glass slides, and agar-agar 
culture tubes (Fig. 260) should be at hand. 

Location of the Puncture.— No fixed rule can be laid down, the 
point chosen for the puncture depending upon the physical examina- 
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 upper level of 
the effusion. If it is made too high, the point of the needle may 




Fig. 



261. — Showing the points for inserting the needle in exploratory puncture of 
the pleura. (Large dots represent points of election.) 



lacerate the lung; or, if too low, injury to the diaphragm, liver, or 
spleen may result. As a general thing, entrance of the needle in 
the sixth interspace in the anterior axillary line, in the sixth or seventh 
interspace in the midaxillary Une, or the eighth interspace below 
the angle of the scapula will reveal the presence of fluid if such exist 
(Fig. 261). 

Position of the Patient. — If too weak to sit upright, the patient 
may He semirecumbent for a lateral puncture, and for a posterior 
puncture in a lateral prone position, with the body carved forward 
and the arm of the affected side elevated (Fig. 262). In uncom- 
pHcated cases, an upright sitting posture should be assumed, with the 



262 



EXPLORATORY PUNCTURES 



arm of the affected side elevated for the purpose of widening the 
intercostal spaces (Fig. 263). 

Asepsis. — The strictest regard to asepsis must be observed in mak- 




FiG. 262. — Lateral position for exploratory puncture of the pleura. 




Fig. 263. — Exploratory puncture of the pleura with the patient sitting upright. 

ing any exploratory puncture, otherwise there is great risk of in. 
fection and of converting a simple serous exudate into a purulent one. 



EXPLORATORY PUNXTURE OF THE PLEURA 



263 



The site chosen for the puncture should be well painted with tinc- 
ture of iodin. The operator's hands should also be thoroughly 
scrubbed, followed by immersion in an antiseptic solution. The 
needles, svringes, and other instruments employed are sterilized 
by boiling. 

Anesthesia. — ^Local anesthesia by freezing with ethyl chlorid or 
salt and ice. or infiltrating with a 0.2 per cent, solution of cocain 
or a I per cent, solution of novocain, will be all that is required. 
In emplopng cold as an anesthetic, if the patient is poorly nourished 
or the skin is edematous, care should be taken not to freeze the skin 
too thoroughly, on account of the danger of local necrosis. 

Technic. — To avoid injury to the upper intercostal artery the 
needle is inserted near the upper margin of the rib which forms the 





Fig. 264. Fig. 265. 

Fig. 264. — Showing the failure to withdraw flmd from the needle being inserted 
too far. (xAiter Gumprecht.) 

Fig. 265. — Showing the failure to withdraw fluid from the needle entering the 
pleura at too high a level. (After Gumprecht.) 

lower boundary of the space chosen for the puncture. The point of 
puncture is anesthetized and a small nick is made in the skin. 
The thumb and forefinger of the left hand steady the tissues, while 
the needle is slowly and steadily inserted upward and inward, until 
its point enters the pleural sac. From i to i i^ 2 inches (about 2.5 
to 4 cm.) under ordinary conditions, and more in fat subjects or in 
those with very thick pleura, may be estimated as the thickness of 
the thoracic wall through which the needle will have to pass before 
entering the pleural cavity. The lack of resistance and the mobility 
of the needle will acquaint one of its entrance into a ca\"ity. 

If fluid is not immediately obtained, the direction of the needle 
may be changed slightly, or it may be entirely withdrawn and inserted 
in other locations before the attempt is abandoned. Failure to 



264 



EXPLORATORY PUNCTURES 



withdraw fluid may be due to the needle entering the lung CFig. 265) 
or to the fluid being encapsulated in a space not entered by the 
aspirating needle. Again, the point of the needle may become buried 
in adhesions or a thickened pleura (Fig. 266), or its caliber may be- 
come blocked by coagulated material. In addition to determining 
the presence of fluid, any unusual thickness or density of the pleura 
may be appreciated by the operator through the amount of resis- 
tance oft"ered to the entrance of the needle. Upon completion of the 
aspiration, the needle is quickly withdrawn, and the site of the 
puncture is closed with collodion and cotton. 




Fig. 266. — Showing the faikire to' withdraw fluid -from the point of the needle 
becoming imbedded in a thickened pleura. (After Gumprecht.) 



EXPLORATORY PUNCTURE OF THE LUNG 

Previous to undertaking any operative procedure upon a pul- 
monary 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 pleura or of producing 
a cellulitis if aspiration of a pulmonary cavity without immediate 
drainage be performed, hence the exploratory puncture should only 
be performed on the operating-table with the patient ready to be 
anesthetized, and with all preparations to incise and drain the cavity 
completed beforehand, in case pus is obtained. 

Apparatus. — Exploring needles and a glass aspirating syringe, a 
scalpel, ethyl chlorid or a cocain syringe, test tubes, and culture 
tubes will be required (see page 259). 

Location of the Puncture. — This will depend entirely upon the 



EXPLORATORY PUNCTURE OP THE PERICARDIUM 265 

approximate situation of the cavity, as determined by the physical 
signs. 

Asepsis. — The instruments should be boiled, the operator's hands 
sterilized as for any operation, and the site of puncture painted with 
iodin. 

Anesthesia. — Infiltration of the site of puncture with a 0.2 per 
cent, solution of cocain or a i per cent, novocain solution, or freezing 
by means of ethyl chlorid or salt and ice will be sufficient. 

Technic. — A fair-sized aspirating needle, at least 4 inches (10 cm.) 
long, will be required. The point of puncture is anesthetized and 
the skin is nicked with the point of a scalpel. Then, while the patient 
holds the breath to limit movement of the lungs, the needle is in- 
serted in the direction of the supposed cavity, close to the upper 
margin of the rib, in the same manner as already described for ex- 
ploratory puncture of the pleura (page 263). 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 (7.5 to 10 cm.) before the 
cavity is entered. Failing to withdraw pus, the needle should be 
removed and reinserted at another spot. It may even be necessary 
to make a number of punctures before being successful, as the locali- 
zation of a pulmonary cavity is at times a most difficult matter. 
When a needle enters a cavity, some idea of its size may be obtained 
from the range of motion of the needle and from the quantity of 
secretion withdrawn, though, if there has been considerable expec- 
toration 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 
guide for the incision and drainage, and, while the patient is being 
anesthetized, great care should be taken to see that the needle is not 
displaced. 

EXPLORATORY PUNCTURE OF THE PERICARDIUM 

An exploratory puncture may be required as a means of making a 
positive diagnosis of the presence of fluid within the pericardium or 
for the purpose of choosing a route through which such fluid may be 
reached and evacuated. Puncture of the pericardium should not be 
undertaken lightly, and the dangers of injuring the internal mammary 
vessels or pleura, or of puncturing the thin-walled auricles of the 



266 



EXPLORATORY PUNCTURES 



heart, should impress upon the operator the necessity of extreme care 
when performing this operation. 

Apparatus. — A fine exploring needle and a glass aspirating syringe, 
a scalpel, ethyl chlorid or a cocain syringe, test tubes, and culture 
tubes will be required (see page 259). 

Location of the Puncture. — To eliminate as far as possible the 
dangers of the operation, special sites for puncture have been rec- 
ommended, as follows: (i) In the fourth or fifth interspace, either 
close to the left sternal margin or i inch (2.5 cm.) to the left of it. 
Either of these points will avoid the internal mammary artery and 




Fig. 267. — -Points for puncturing the pericardium. The dotted line indicates 
a distended pericardial sac. The course of the internal mammarj'^ vessels is also 
shown. 



veins which run vertically downward 1/2 inch (i cm.) from the ster- 
nal margin. (2) In the fifth intercostal space, close to the right of 
the sternum. It is claimed that from this point it is impossible to 
injure the heart, but this avenue of approach is only suitable when the 
amount of fluid is large. (3) Inserting the needle directly upward 
and backward close to the costal margin in the space between the 
ensiform cartilage and the seventh costal 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 pulsa- 
tion or friction rubs, the method recommended by Curschman, 



EXPLORATORY PU^'CTURE OF THE PERICARDIUM 267 

Romberg, Kussmaul, and others, may be employed. The puncture 
is made in the hfth or sixth left interspace outside the nipple line 
between the apex beat and the outer limit of dullness (Fig. 267). 

The selection of one of these sites over the others will be made 
according to the degree of distention of the pericardium and its 
shape, which is determined by outlining the area of dullness. 

Preparation of the Patient. — If the patient be a male, the chest 
should be shaved, and, in any case, the skin must be steriHzed thor- 
oughly before making the puncture. 

Position of the Patient. — The operation may be performed with 
the patient semirecumbent or in the upright sitting posture. 




Fig. 268.- — Showing the method of inserting the needle in an exploratory puncture 

of the pericardium. 

Technic. — As already emphasized, all the aseptic precautions enu- 
merated under exploratory punctures (page 262) should be carefully 
carried out. The area of dullness is accurately mapped out and the 
point for puncture thereby determined upon. This point is anes- 
thetized and a small nick is made in the skin. The thumb of the left 
hand is placed as a guide upon the lower rib bounding the intercostal 
space selected, and the needle point is inserted just above the margin 
of the rib so as to avoid the upper intercostal artery (Fig. 268). The 
needle should be introduced slowly and with great care almost in the 
sagittal plane and directed slightly toward the median line. En- 
trance into the pericardial sac is suspected when resistance to the 
progress of the needle is no longer encountered, or when the heart is 
felt striking against the needle point. The needle should not be 



268 EXPLORATORY PUNXTURES 

inserted a greater distance than i inch (2.5 cm.), and, if fluid is not 
reached at this depth from one location the other points of entrance 
above mentioned may be employed. Should the fluid obtained be 
purulent in character, prompt incision and drainage is indicated. 

When the purpose of the puncture is accomplished, the needle is 
slowly withdrawn, and the point of puncture is sealed with collodion 
and cotton. 

EXPLORATORY PUNCTURE OF THE PERITONEAL CAVITY 

Aspiration of small quantities of peritoneal fluid and examination 
of the specimen obtained may be required to determine the 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 performed as a diagnostic 
measure, but the dangers of producing serious complications through 
puncture of the intestine or other organs, or from leakage of fluid, 
especiaUy if it be purulent, into the peritoneal cavity stamps it as an 
unsafe method except in those cases where the tumor is in close rela- 
tion 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 valu- 
able information can be thus obtained render this the operation of 
choice. 

Apparatus. — A long exploring needle, a glass aspirating syringe, 
a scalpel, a cocaine syringe, test-tubes, etc., should be provided (see 
page 259). 

Location of the Puncture. — For puncture of the peritoneal cavity, 
a point midway between the umbilicus and the pubes in the median 
line or a point at the junction of the outer and middle thirds of a line 
between the anterior superior spine and the navel should be chosen 
for the insertion of the needle. Both these sites will escape the 
deep epigastric artery (Fig. 269). 

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. For a lateral puncture the 
patient should lie upon his side. 

Preparation of the Patient. — The site for puncture should be 
shaved and properly sterilized. The bladder should always be emptied 
inwiediately before tJie operation. 



EXPLORATORY PUNCTURE OF THE LIVER 



269 



Anesthesia. — Infiltration cocain or novocain anesthesia or freez- 
ing with ethyl chlorid will suffice. 

Technic. — The point chosen for the puncture is anesthetized, and 
a small nick is made in the skin. The needle is inserted directly back- 
ward until the resistance of the abdominal wall is no longer felt and 
the point of the needle moves freely within the abdominal cavity. 
Sufficient fluid is withdrawn for examination, and, after removal of 
the needle, the site of entrance is closed with a thin layer of collodion 
and cotton. 




Fig. 269. — Points for puncture of the peritoneal cavity. 



EXPLORATORY PUNCTURE OF THE LIVER 

Exploration of the liver by means of an aspirating needle may be 
required for the purpose of making a positive diagnosis in cases of 
suspected amebic or pyogenic abscess, or hydatid cyst. 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 small the puncture may be, leakage of 
fluid is liable to occur and cause serious damage. 

Apparatus. — An exploring syringe, needles, a scalpel, test-tubes, 
etc., such as is required for any exploratory puncture (seepage 259), 
should be provided. 



270 



EXPLORATORY PUNCTURES 



Location of the Puncture. — This will depend -upon the symptoms 
and physical signs in each individual case. If at any one point there 
be localized pain, tenderness on palpation, peritoneal crepitation, or 
distinct bulging, such spot should be chosen for the puncture. In 
the absence of signs pointing to localization, the fact that most liver 
abscesses are situated in the upper posterior portion of the right lobe 
should be borne in mind and the puncture made accordingly, the 
needle being inserted in the midaxillary line on the right side through 
the ninth, tenth, or eleventh interspace, or below the angle of the 
scapula through the tenth interspace (Fig. 270). Puncture may also 




Fig. 270. — Points for puncture of the liver. 

be made anteriorly directly into the area of liver dullness below the 
line of the pleura. 

Asepsis. — The operation is performed under all aseptic precau- 
tions (see page 262). 

Anesthesia. — The puncture may be made under local anesthesia, 
but, if it is likely that a number of punctures will be necessary and an 
operation is to be performed, it is better to give a general anesthetic 
at the start. 

Technic— After making a small nick in the skin with a scalpel at 
the site chosen for the puncture, the needle is slowly introduced 
inward and slightly upward to its full extent, and suction is attempted. 



EXPLORATORY PUXCTURE OP THE SPLEEN 271 

If fluid i5 not obtained, the needle is slowly withdrawn, a vacuum 
being maintained in the syringe in the meantime, so as to withdraw 
pus in case the point of the needle has previously passed through a 
ca\-ity into healthy tissue. Near the surface of the liver the direc- 
tion of the needle is altered, and it is inserted again in a different 
plane. In this manner a large area of the HA'er may be explored in 
aU directions from one external puncture, provided care is exercised 
not to injure the pleura and lung above, or the gall-bladder and 
intestines below. The needle should not be inserted to a greater 
depth than 3 3, 4 (9.5 cm.) inches from the surface of the body for 
fear of injuring the inferior vena cava. 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 immedi- 
ately found, a number of punctures should be made before the opera- 
tion is abandoned. Failure to draw pus into the s}Tinge does not 
necessarily signify absence of an abscess, for at times the material 
forming the abscess is so thick that it wiU not pass into the needle, 
and only a drop or two of pus will be discovered on close examination, 
clinging to the needle point. 

Having located an abscess, the needle should be left in situ as a 
guide, for it is not an uncommon experience, when pus is discovered 
by aspiration and the needle removed, to fail to locate the abscess at a 
subsequent operation. 

EXPLORATORY PUNCTURE OF THE SPLEEN 

As a diagnostic measure, puncture of the spleen may be performed 
\\-ithout danger if the organ is hard, as is found in chronic malaria, 
but in infectious diseases with a large, soft, and friable spleen it is 
an unjustifiable procedure. Laceration of the capsule followed by 
hemorrhage, suppuration in the spleen, and peritonitis have been 
known to result. Likewise puncture of the spleen in suspected cases 
of t}'phoid fever is no longer warranted, since we have other methods 
of diagnosis, such as Widal's 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 punc- 
tures of the liver or lungs, preparations for incision and drainage, in 
case such should be necessary, should be completed before the 
puncture is made. 

Apparatus. — Exploring needles, an aspirating syringe, and other 



272 



EXPLORATORY PUNCTURES 



instruments necessary for any exploratory puncture (see page 259) 
should be provided. 

Location of Puncture. — The spleen can be reached by insert- 
ing the needle through the tenth intercostal space in the midaxillary 
line on the left side (Fig. 271), If the organ is markedly enlarged, 
some point below the left costal margin, determined by percussion of 
the spleen, may be chosen. 

Position of the Patient. — The patient may assume either the 
sitting posture with the left arm elevated and the hand on the oppo- 




FlG. 271. — Point for puncturing the spleen. 



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

Asepsis. — The same as for any exploratory puncture (see page 
262). 

Anesthesia. — ^Local infiltration anesthesia or freezing will suffice. 

Technic. — A fine and fairly long aspirating needle should be 
employed. The patient is instructed to hold his breath, to lessen the 
danger of lacerating the organ, and the operator makes a small nick 
in the skin, quickly inserts the needle at the chosen site, and makes 
the aspiration with as httle delay as possible. The needle is then 
withdrawn, and the site of puncture is closed with a thin covering of 
collodion and cotton. 



EXPLORATORY PUNCTURE OF THE KIDNEYS 



273 



EXPLORATORY PUNCTURE OF THE KIDNEYS 

Exploratory aspiration may be employed to detect collections of 
pus or other fluids 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. 

Apparatus. — An aspirating syringe, exploring needles, and other 
apparatus necessary for making an exploratory puncture (see page 
259) should be at hand. 

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 




Fig. 272. — Showing the relations of the kidneys from behind. 

erector spinas muscles, and a httle below the last rib on the left side, 
and, on the right side, between the last rib and the crest of the ilium. 

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

Asepsis. — The usual aseptic precautions are to be observed (see 
page 262). 

Anesthesia. — ^Local infiltration anesthesia or freezing will sufhce. 

Technic. — A long fine needle should be employed. After nicking 
the skin with a scalpel at the site chosen for the puncture, the needle 
18 



274 EXPLORATORY PUNCTURES 

is slowly introduced forward and slightly inward toward the median 
line, frequent tests at aspiration being made as the needle is advanced. 
When fluid is discovered, a sufficient quantity for diagnosis is with- 
drawn, and the site of puncture is sealed with a cotton and collodion 
dressing. 

EXPLORATORY PUNCTURE OF JOINTS • 

This constitutes a most valuable aid in ascertaining the character 
of a joint effusion. Therapeutic puncture of joints for the purpose 
of injecting fluids in the treatment of tuberculous synovitis and 
acute infections involving joints is also becoming a frequent opera- 
tion. Puncture of a joint is not difficult if the joint is distended 
with fluid. Care should be exercised 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 complications result. 

Apparatus. — Exploring needles, a glass aspirating syringe, a 
scalpel, a cocain syringe, etc., should be provided (see page 259). 

Asepsis. — Puncture of a joint, as all exploratory punctures 
should be made under all aseptic precautions. The instruments 
are to be sterilized by boiling, the operator's hands are as carefully 
prepared as for any operation, and the site of puncture is painted 
with tincture of iodin. 

Anesthesia. — Local infiltration is employed. 

Technic. — The skin over the site of puncture is infiltrated with a 
0.2 per cent, solution of cocain or a i per cent, novocain solution and 
the deeper tissues down to the joint capsule are similarly anesthe- 
tized. A small nick is then made in the skin at the point chosen for 
insertion of the needle, and the needle is inserted into the joint in the 
same manner as for any exploration puncture. 

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

The Shoulder=joint. — Entrance to the joint is best eft'ected by 
introducing the needle from the side through the groove between the 
acromion process and the head of the humerus. The direction of the 
needle should be somewhat downward and backward (Fig. 273), if it 
is inserted straight in from the side it is apt to enter the subacromial 
bursa. 

The Elbow=joint. — Puncture of the joint may be made from 
behind or from the outer side. 

To enter the joint from behind, the forearm is flexed to an angle 



EXPLORATORY PUXCTURE OF JOINTS 



7o 



of 135 degrees, and the needle is inserted downward and forward 
behind the olecranon (Fig. 274). 

To pnnctiire the joint from the outer side, the arm is flexed and 
the radial head is identified by the finger as the forearm is rotated. 
The needle is then inserted into the joint between the external con- 
dyle of the humerus and the head of the radius. 

The Wrist-joint. — The joint is best entered from the dorsal sur- 
face, inserting the needle near the radius between the tendons of the 





Fig. 273. — Point for puncturing 
the shoulder- joint 



Fig. 274. — Point for puncturing the 
elbow-joint. 



extensor indicis and the extensor longus pollicis at the level of a line 
joining the styloid process of the radius and that of the ulna. 

The Hip-joint. — The hip may be readily entered by the exploring 
needle from in front, at what is known as Biingner's point, or from 
the side. 

Anterior puncture is performed as follows: A spot is chosen 
midway on a line joining the point at which the femoral artery 
emerges from under Poupart's ligament and the tip of the great tro- 
chanter (Fig. 275), and, wdth the femoral artery identified by the 
forefinger of the left hand to avoid injuring it. the needle is pushed 
directly back into the joint. 

For a lateral puncture the leg should be slightly adducted. The 
needle is then pushed into the joint toward the median fine of the 
body from the side just above the great trochanter (see Fig. 275). 

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



276 



EXPLORATORY PUNCTURES 



point where fluctuation or distention is most in evidence. When the 
swelling is more marked above the patella, the needle may be intro- 
duced from above downward behind the bone (Fig 276), the operator's 




Pig. 275. — Points for puncturing the hip-joint (modified from Pels-Leusden). 

left hand grasping the joint below the patella and forcing the intra- 
articular fluid upward into the suprapatellar recess. 

The Ankle=joint. — To avoid injuring the vessels and nerves 
which lie opposite the middle of the joint, the needle should be intro- 




FiG. 276. — Point for puncturing the knee-joint 



duced from in front midway between the bundle of tendons which 
pass in front of the joint and the corresponding malleolus. On the 
inner side the needle is inserted 1/2 inch (i cm.) above the malleolar 



EXPLORATORY PUNCTURE OF JOINTS 



277 



process in a direction obliquely outward and backward; on the outer 
side the needle enters 3/4 of an inch (2 cm.) above the malleolar 
process in a direction obHquely inward and backward. 



SPINAL OR LUMBAR PUNCTURE 

Lumbar puncture, anx)peration first proposed by Quincke for the 
withdrawal of cerebrospinal fluid from the spinal canal, has both 
diagnostic and therapeutic value. This procedure is of diagnostic 
importance through the information that may be obtained in estimat- 
ing the pressure of the cerebrospinal fluid and determining its char- 




FiG. 277. — Anatomy of the lumbar vertebra. 

acteristics by physical, chemical, microscopical, and bacteriological 
examination. 

Among its therapeutic uses is its employment as a "decom- 
pressive agent," in cases of meningitis, hydrocephalus, intracranial 
tumors, cerebral abscess, uremia, etc., etc. On account of the con- 
tinuity of the spaces in the brain and spinal column, temporary rehef 
of intracranial and intraspinal pressure may be obtained in the above 
cases by the withdrawal of small amounts of fluid from the spinal 
canal. Lumbar puncture should be employed with great caution, 
however, in cases of brain tumor, for sudden death may follow 
removal of a large amount of fluid, the increased intracranial tension 
causing the medulla to be forced against the foramen magnum when 
the intraspinal pressure is reheved. In cerebrospinal meningitis, 
drainage by lumbar puncture is often followed by good results^ as 



278 



EXPLORATORY PUNCTURES 



not only is the pressure upon the cord and cerebral centers lessened, 
but pus is withdrawn, and the toxicity of the spinal fluid is thereb}' 
diminished. 

It is in the administration of antitetanic serum and antiserum 
in cerebrospinal meningitis, and the production of spinal anes- 
thesia, however, that lumbar puncture finds its chief therapeutic 
applications. 




Fi(.. 278. — -Stylet needle for spinal jjuncture. 

•Anatomy. — In the lumbar portion of the vertebral column the spi- 
nous processes do not project downward to such a degree as in 
other portions, and there is a distinct space (about 7/8 inch (22 mm.) 
in 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 spinal canal (Fig. 277.) The 







H 



IX 3 ^ 

Pig. 279, Apparatus tor spinal puncture, i, Scalpel; 2, ethyl chlorid tube; 3, 
small glass graduate; 4, hydrometer; 5 sterile test-tube; 6 culture tubes. 

spinal cord reaches only to the second lumbar vertebra, so if the punc- 
ture be made below that point, and the introduction of the needle be 
carried out under rigid asepsis the operation is practically harmless. 
The Needle. — The puncture is best made with a special stylet 
needle devised for the purpose. It should be of platinum or nickel, at 
least 3 1/2 inches (9 cm.) long and about 1/25 of an inch (i mm.) in 



SPINAL OR LUMBAR PUNCTURE 



279 



diameter, and the point should be short and ground almost squarely 
across (Fig. 278). In the absence of such a needle, the ordinary 
aspirating needle of about the same size may be substituted. In 
addition, a scalpel, a sterilized graduated test-tube, culture tubes, 
and an ordinary hydrometer (Fig. 279) will be required. When it 
is desired to estimate accurately the cerebrospinal pressure, a small 
mercury manometer will also be required. 

Location of the Puncture. — ^The space between the third and 
fourth or that between the fourth and fifth lumbar vertebrae is usually 
chosen (Fig. 280), though, if the puncture is performed for diagnostic 
purposes, it may be made lower — between the fifth lumbar and first 
sacral vertebrae in order to withdraw any sediment that may be 
present. A point just below the tip of the spinous process of the 




Fig. 280. — Points for spinal puncture. 

vertebra forming the upper boundary of the chosen interspace at a 
distance of about 1/2 inch (i cm.) to one side of the median line is 
selected for the 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 
from the seventh cervical vertebra, unless the individual be very 
stout. If, however, any difficulty is experienced in locating this 
vertebra, the landmarks may be quickly determined by passing a 
transverse line between the highest points of the iliac crests with the 
patient standing erect, and it will be found that such a line passes 
through the tip of the spinous process of the fourth lumbar vertebra 
(Fig. 281). 



28o 



EXPLORATORY PUNCTURES 



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. 282), so as to widen the intervertebral spaces as 




Fig. 281. — Showing the method of locating the fourth spinous process by passing a 
line through the highest points of the iliac crests. 

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. 283). 




Fig. 282. — -Sitting posture for spinal puncture. 

Asepsis. — The site for the puncture should be painted with 
iodin, and thorough asepsis must be observed during the entire 



SPINAL OR LUMBAR PUNCTURE 



26l 



operation. The needle should be boiled and the operator's hands 
should be properly sterilized. 

Anesthesia. — With children general anesthesia may be necessary. 
In other cases, local anesthesia with a 0.2 per cent, solution of cocain 




Fig. 283. — Lateral position for spina] puncture. 

or a I per cent, novocain solution, or by freezing, as for any puncture, 
will answer all purposes. 

Technic. — To avoid contaminating the needle by the bacteria 
of the skin as well as to make the insertion of the rather blunt needle 
easier, a puncture should be made with a scalpel through the skin at 





Fig. 284. — Spinal puncture. First step, nick- Fig. 285. — Spinal puncture. See- 
ing the skin at the point of puncture. end step, inserting the needle. 

the chosen spot (Fig. 284). 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 



282 EXPLORATORY PUNCTURES 

(Fig. 285). until it enters the spinal canal. In a child this will usu- 
ally 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 shghtly withdrawn and then rein- 
serted, its direction being changed somewhat. 

As soon as the canal is entered, the stylet is withdrawn, and the 
fluid, as it oozes from the needle drop by drop, is collected in a sterile 
test-tube (Fig. 286). The first few drops are usually blood stained, 
and, if so, they should be discarded. Not more than i 1/4 drams 
(about 5 c.c.) of fluid should be withdrawn from the spinal canal of a 



Fig. 286. — .Spinal puncture. Third step, collecting the cerebrospinal fluid. 

child, nor more than 1/2 ounce (15 c.c.) from an adult, at one time 
for diagnostic purposes. When, however, the puncture is performed 
to relieve intracranial pressure, from i ounce to i 1/2 ounce (30 to 
45 c.c.) of fluid may be removed, according to the tension, and even 
more if no ill effects are observed. Withdrawal of too much fluid 
may cause dizziness, pallor, sweating, and vomiting and later a 
sharp headache. A dry puncture is sometimes encountered and may 
be due to the needle not entering the canal, to its being plugged, or 
from the fluid being too thick to flow through its lumen. 

At the completion of the operation, the site of puncture is sealed 
with collodion and cotton and the patient is kept recumbent in bed 
for 24 hours. 

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 infec- 



SPINAL OR LUMBAR PU^XTURE 283 

tious diseases, it may spurt out. The pressure may be roughly 
estimated by the strength of the flow from the needle, a strong spurt 
of fluid indicating an increased amount of pressure, and very slow- 
coming drops the reverse. It may be more accurately measured by 
attaching to the needle a small mercury manometer by a smaU rubber 
tube, 8 to 16 inches (20 to 40 cm.) long, filled with a i per cent, solu- 
tion of carbolic acid. This, of course, is to be done before any of the 
fluid is permitted to escape. According to Sahli. the normal dural 
pressure in the horizontal position is 60 to 100 mm. of water (5 to 7.3 
mm. of mercury), and 200 to 800 mm. of water (15 to 60 mm. of 
mercury) in certain pathological conditions. 

Normal cerebrospinal fluid is colorless and water-like in clearness, 
of alkaline reaction, has a specific gravity of 1006 to 1008 and exists 
in the spinal canal in but small amounts, varying between 1/2 and 2 
ounces (15 and 60 c.c.) in adults and in infants between 2 1/2 and 5 
drams (10 and 20 c.c). In certain infectious diseases, intracranial 
tumor, 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 (0.7 per cent.), 
a copper-reducing body claimed to be glucose, and traces of urea 
(0.035 to 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 shght increase in the urea. In apo- 
plexy, meningitis, paresis, hydrocephalus, and brain tumor, the quan- 
tity of albumin may be markedly increased. A bloody or blood- 
stained fluid will be found in intrameningeal cranial hemorrhages and 
in injuries of the skull extending through the dura, but in injuries 
outside the dura the fluid will be clear; bloody fluid may also occur in 
meningitis. In jaundice it may be greenish-yellow in color. A 
cloudy, purulent fluid indicates inflammation of the meninges, as does 
a rise in the specific gravity, and the appearance of white blood 
cells on examination. In tubercular meningitis, however, the fluid is 
clear and limpid, and there is present a high lymphocytosis. It is 
only possible to determine the specific form of infection by bacterio- 
logical examination. Identification of the diplococcus intracellularis, 
pneumococcus, streptococcus, or tubercle bacilli \^'ill 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 ad- 
ministering sera in tetanus and cerebrospinal meningitis, a fairly large 
syringe, one with a capacity of at least i ounce (30 c.c), is required in 



284 EXPLORATORY PUNCTURES 

addition to the other instruments necessary for spinal 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 oj the American Medical 
Association, July i, 1905). injects 2 1/2 to 5 drams (10 to 20 c.c.) of 
an ti tetanic serum into the nerves of the cauda equina, as well as 
subcutaneously in the neighborhood of the wound, intravenously, and 
into the nerves of the brachial plexus if the site of infection is upon the 
upper extremity, and into the sciatic and anterior crural nerves if the 
wound is in the lower extremity. In making the spinal injection the 
needle is inserted in the space between the second and third lumbar 
vertebrae, so as to strike the cauda equina, and is manipulated back 
and forth with the object of wounding some of the nerves, which is 
manifested by twitching of the legs; 2 1/2 to 5 drams (10 to 20 c.c.) 
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 c.c.) of serum are injected into the third or fourth lumbar space 
after a like amount of cerebrospinal fluid has been evacuated. Sub- 
sequent injections are given at intervals of twelve to twenty-four 
hours, according to the severity of the case, for three or four days. If 
after a lapse of several days the symptoms return, another series of 
injections is given. In place of a syringe, a glass funnel holding 
about 5 drams (20 c.c.) attached to the needle by rubber tubing may 
be employed for administering the serum, as advised by Koplik. 



CHAPTER XII 
ASPIRATIONS 

ASPIRATION OF THE PLEURAL CAVITY 

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

Indications. — When the presence of fluid has been made out by 
the physical signs and the diagnosis verified by an exploratory punc- 
ture, thoracentesis is indicated in sero-fibrinous effusions under the 
following conditions: 

1. When the fluid is sufficient to produce dyspnea, cyanosis, and 
cardiac weakness. 

2. In very large effusions whether or not pressure symptoms 
are present, especially if bilateral. 

3. When the heart is displaced by the presence of fluid. 

4. When the fluid is not absorbed within a week or ten days in 
spite of medical treatment. 

The advantages of early aspiration are that adhesions may be 
prevented and the course of the disease considerably shortened. 
Long continued pressure upon the lung by an effusion may prevent 
its subsequent 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 
employed. In addition, a scalpel, and collodion and cotton, or a 
pad of sterile gauze and adhesive plaster for the dressing, should 
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 tro- 
car form of needle is employed the point of the cannula may be 
moved about without danger after the stylet is removed, and, should 
the lumen of the cannula become plugged, the obstacle may be re- 

285 



286 



ASPIRATIONS 



moved without the necessity of withdrawing the cannula b\' simple- 
reinserting the stylet. With an aspirating needle, on the other hand, 
the unprotected point of the needle may injure the lung or diaphragm, 
and, furthermore, should the lumen of the needle become blocked, 
it may be necessary to withdraw it entirely in order to clear out the 
obstruction. If an aspirating needle is used, one should be chosen at 
least 3 inches (7.5 cm.) long and from 1/25 inch (i mm.) to 1/12 
inch (2 mm.) in diameter depending upon the consistency of the 
material to be evacuated. 

In a properly made trocar the stylet should fit the point of the 
cannula accurately, and the cannula and stylet should gradually 
taper to a point, as if in one piece. The cannula is provided with a 
stopcock near the proximal end to prevent leakage of air when the 
stylet is withdrawn, while a lateral opening, for connection with the 
aspirator, is placed at a point distal to this stopcock, so that the sty- 
let may be moved back and forth without disturbing the connections 
(Fig. 287). 




Fig. 287. — 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 
sjphonage. The Dieulafoy instrument is most convenient for 
evacuating small collections of fluid and when it is desirable to be exact 
in the quantity removed, while for large effusions the Potain or the 
heat vacuum apparatus is best. 

The Potain instrument (Fig. 288) consists of an exhausting pump. 
a large glass bottle, a rubber stopper through which passes the long 
arm of a Y-shaped metal tube with a stopcock in each limb, and two 
pieces of heavy rubber tubing, one connecting the needle or trocar 
with one arm of the Y. and the other joining the second arm and the 
exhausting pump. The instrument is assembled by inserting the 
stopper 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 



ASPIRATION OF THE PLEURAL CAVITY 



287 



trocar. By means of the second tubing the exhausting syringe is 
connected with stopcock h. The instrument should be carefully 
tested before using to see that all the connections are air-tight. To 
produce a vacuum, stopcock a is closed and stopcock h is opened, 




Fig. 288. — Potain aspirator. 

when, by pumping from thirty to fifty strokes, the air will be suffi- 
ciently exhausted. Stopcock h is then closed, and the needle is 
inserted into the chest. As soon as its point enters the tissues, the 
vacuum is extended to the point by opening stopcock a, so that the 
moment fluid is reached it will be drawn by suction into the bottle= 




Fig. 289. — The Dieulafoy aspirator. 

If the trocar is employed, the stylet is not withdrawn until the tro- 
car enters the chest; as this is done the stopcock on the cannula is 
closed, so as to exclude air. 

The Dieulafoy apparatus (Fig. 289) consists of a glass syringe. 



255 ASPIRATIONS 

with a capacity of 3 to 4 ounces (90 to 120 c.c), provided with two 
outlets, each furnished with a stopcock, and to which are fitted 
heavy rubber tubes. To the extremity of one tube a trocar or 
aspirating needle is attached, and at a distance of about 4 inches 
(10 cm.) from the needle end a piece of glass tubing is inserted as an 
index. The other piece of tubing leads from stopcock & to a basin 
to carry ofif the fluid discharged from the cylinder. To use the in- 
strument both stopcocks are closed, and the piston is fully withdrawn 
and fixed in place by a spring. This produces the vacuum. The 




Fig. 290. — Connell's heat vacuum aspirator. 

aspirating needle is then introduced in the chosen site, and, as soon 
as the needle point is buried in the tissues, the stopcock a is opened, 
allowing the vacuum to extend to the needle. The needle is then 
pushed on in until it enters the chest, the presence of fluid being first 
demonstrated as it passes through the glass index. When the aspi- 
rator is filled, stopcock a is closed and stopcock 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 excellent form of aspirator and one that is frequently 
employed is the vacuum bottle described by Connell {Medical 
Record, July 4, 1903). It consists of a strong glass bottle with a 



ASPIRATION OF THE PLEURAL CAVITY 



289 



capacity of about 5 pints (2.5 liters), having a mouth i inch (2.5 
cm.) wide, fitted with a rubber stopper through which passes a glass 
tube with a heavy piece of rubber tubing attached, ending in an 
aspirating needle. Three drams (12 c.c.) of 95 per cent, alcohol are 
poured into the bottle which is so manipulated that its inner surface 
is entirely coated, when the excess of alcohol is poured off. 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. 290). A vacuum is thus produced which 
is amply sufficient to aspirate a chest. 

Removal of an effusion by syphonage may be readily accom- 
pHshed by means of a very simple apparatus. A piece of heavy 
tubing about 3 feet (90 cm.) long, a clamp to close one end of the 




Fig. 291. — Syphonage aspirator. 



tubing, a funnel, sterile water or sahne solution to fill the tubing, and 
a receptacle to collect the fluid are the necessary requisites. One 
end of the tubing is fastened to a large caliber needle or the side out- 
let of the trocar and the other to the glass funnel (Fig. 291). 

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 with- 
drawal may be facihtated as far as possible by the action of gravity. 
The sixth intercostal space in the anterior axiflary fine, the sixth or 
seventh space in the midaxillary fine, and the eighth space below 
the angle of the scapula are the points of election (Fig. 292). 

Quantity Withdrawn. — It is not essential to empty the chest en- 
tirely at one sitting. The amount of fluid evacuated should be deter- 
19 



290 



ASPIRATIONS 



mined more by the manner in which the patient bears the operation, 
the condition 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 c.c.) may be removed, but it is better to withdraw 
too little than too much, for what remains may be evacuated at a 
subsequent period; and it not infrequently happens that spontaneous 
absorption of the eft'usion follows the removal of even small 
quantities. 

Position of Patient. — The aspiration is preferably performed with 
the patient on a bed so as to avoid the extra exertion of moving after 




Fig. 292. — Sites for aspiration of the pleura. (The large dots represent the points 

of election.) 

the operation. When possible, an upright sitting position should 
be assumed, with the arm of the affected side raised, and the hand 
placed on some support or on the opposite shoulder to increase the 
breadth between the intercostal spaces (Fig. 293). If this is im- 
practicable, the patient may lie near the edge of the bed, upon the 
back for a lateral puncture, or rolled slightly to the opposite side with 
the arm extended over the head for a posterior puncture (see Fig. 262). 
Asepsis. — The skin at the site of operation should be painted with 
tincture of iodin; the operator's hands should also be properly 
cleansed, and the needle or trocar sterilized by boiHng. 



ASPIRATION OF THE PLEURAL CAVITY 



291 



Anesthesia. — Local anesthesia by freezing with ethyl chlorid or 
by infiltration with a few drops of a 0.2 per cent, solution of cocain 
or a I per cent, solution of novocain at the point of puncture will be 
sufficient. 




Fig. 293. — Position of patient for aspiration of the pleura. 

Technic. — 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 
bounding the space, so as to avoid the upper intercostal artery, and 
the skin is nicked with a scalpel. The thumb and forefinger of the 




Fig. 294. — Method of holding the trocar. 

left hand are used to steady the tissues overlying the intercostal 
space, while the needle or trocar is introduced with the right hand, the 
forefinger being placed on the needle to guard against its being in- 
serted too deeply (Fig. 294). As soon as the point of the needle 
enters the tissues, the vacuum already present in the aspirator is 



292 



ASPIRATIONS 



extended to the needle point by opening the proper stopcock, and the 
needle is steadily pushed in until it enters the pleural sac, which will 
usually be at a depth of less than 2 inches (5 cm.). The fluid should 
be withdrawn rather slowly in. order that the structures may have 
time to adjust themselves to the changed conditions in the chest; 
at least twenty minutes to half an hour should be consumed in re- 
moving 2 pints fiooo c.c). 

Should the patient feel faint or sufifer from vertigo or dyspnea 
the operation should be temporarily interrupted and the patient's 




Fig. 295. — Aspiration of the pleura with the Potain apparatus. 



head lowered. Complaints of severe pain, persistent cough, or 
expectoration of blood also demand that the aspiration be 
discontinued. 

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 sj-phonage apparatus the tubing is first filled 
with sterile solution, and the clamp is placed near the end of the tube 
to prevent the solution escaping. The needle is then introduced 
into the chest, while the free end of the tube is placed under water 
in the receptacle provided for the collection of the fluid. On remov- 



ASPIRATION OF THE PERICARDIUM 293 

ing the clamp from the tube the column of water is released and the 
fluid withdrawn by a process of syphonage. 

Complications and Dangers. — Sepsis is not to be feared if the 
ordinary aseptic precautions 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 expectoration has been observed as a sequel to the 
sudden withdrawal of large quantities of fluid. The expectoration 
consists of a yellow^ish. frothy fluid, and it is accompanied by dysp- 
nea, cyanosis, and a weak pulse. This condition usually begins 
during the withdrawal of the fluid, or comes on shortly afterward. 
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 follows. 

Expectoration of blood may result from the rupture of small pul- 
monary vessels, from congestion of the lung, or from injury to the 
lung tissue by the aspirating needle. 

Sudden death is unusual, though it may occur, and at times with- 
out apparent cause. EmboHsm, cerebral anemia, from the sudden 
rush of blood to the expanding lung, hemorrhage into the pleural 
cavities from injury to the lung, and irritation of the terminations of 
the pneumogastric nerve have been suggested as explanations. 

The occurrence of these complications may be reduced to a 
minimum 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 PERICARDIUM 

Paracentesis pericardii, or pericardicentesis, consists in the evacu- 
ation 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 per- 
formed: 

1. If the eft'usion is sufficiently large to endanger Hfe through 
profound disturbance in the cardiac action indicated by severe 
dyspnea, small, rapid, and irregular pulse, and cyanosis, the indicatio 
vitalis, as death may result from syncope if the condition be not 
relieved without delay. 

2. When a large effusion does not show any tendency to absorp- 
tion after a prolonged and fair trial of medical means. 



294 



ASPIRATIONS 



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 Dieu- 
lafoy aspirator to which is attached a fine needle or trocar and can- 
nula may be employed in the same way as used in the pleural 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 




V \ ~ i- 

5>\ ^ — -y^^y^r^ 

I '\ V y --/ 
\ W ~' /' 



Fig. 296. — Points for aspiration of the pericardium. The dotted line indicates 
a distended pericardial sac. The course of the internal mammary vessels is also 
shown. 

by an exploratory puncture (page 265). For the introduction of the 
needle there are four sites recommended: 

1. In the fourth or fifth intercostal space close to the left sternal 
margin, or else i inch (2.5 cm.) to the left of it, thus passing either 
internal or external to the internal mammary artery. 

2. In the fifth interspace close to the right of the sternum. 

3. Close to the costal margin in the angle between the ensiform 
cartilage and seventh costal cartilage on the left, inserting the needle 
upward and backward. 



ASPIRATION OF THE PERICARDIUM 295 

4. In the fifth or sixth left interspace outside the nipple line be- 
tween the apex beat and outer border of dullness (Fig. 296), 

Quantity Withdrawn. — In small effusions the fluid may be re- 
moved at one sitting; but in large effusions, in order to avoid suddenly 
removing the extracardial pressure, it is preferable to withdraw not 
more than 3 to 4 ounces (90 to 120 c.c.) at the first sitting. Thij 
may be followed by absorption of the rest of the fluid, as is often thf. 
case in pleurisy. If there is no improvement at the end of a day 01 
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 painted with tincture of iodin. The operator's hands are 
thoroughly cleansed, and the apparatus to be used in the operation is 
boiled. 

Anesthesia. — ^Local anesthesia by freezing with ethyl chlorid 
or other freezing agents, or by injecting a few drops of a 0.2 per cent, 
solution of cocain or a i per cent, solution of novocain 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 in Fig. 294, 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 produ^ced 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 withdrawn 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 inch (2.5 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 



296 



ASPIRATIONS 



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 opera- 
tion attended by danger. Infection of the pericardium, injury to 
the internal mammary vessels, puncture of the pleura, and lacera- 
tion of the coronary artery and the heart itself by the aspirating needle 
have all been observed. Strict attention to asepsis, extreme care 
in introducing 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 perit- 
oneal 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 individual 
when necessary. 

Indications. — The abdomen may be aspirated in cases of ascites 
when the physical signs show the presence of fluid, and distention 




Fig. 297. — Trocar and cannula for aspirating the peritoneal cavity, i, Trocar 
and cannula assembled; 2, showing trocar removed from the cannula. 

becomes distressing from pressure upward upon the diaphragm. It 
should also be performed when the fluid reaccumulates after a 
previous tapping and gives rise to pressure symptoms. 

Instruments, Etc. — A straight or slightly curved cannula and 
trocar of fair size— about 1/16 to 1/8 inch (1.5 to 3 mm.) in diameter 
— should be used. The trocar is spear-pointed and should lit the 
cannula perfectly so as to prevent the point of the latter catching 
in the tissues during its introduction (Fig. 297) . An excellent form of 



ASPIRATION FOR ASCITES 



297 



cannula, and one frequently used, contains a lateral opening about 
1/8 inch (3 mm.) from its end, for the purpose of avoiding stoppage 
of the escaping fluid, should the intestines or omentum obstruct 
the end opening of the instrument. 

If desired, the aspirating apparatus of Potain or Dieulafoy (page 
286) may be used in place of the simple trocar. 

In addition a scalpel to make a small preliminary incision, a 
sterile abdominal binder, a many-tailed bandage or large towel, and 
collodion and cotton or sterile gauze and adhesive plaster for the 
dressing should be provided. 




Fig. 298. — Sites for aspiration of the peritoneal cavity. 



Site of Puncture. — The selection of a location free from vessels 
and where the abdominal wall is thin is desirable. Usually a 
point in the linea alba midway between the umbilicus and pubes is 
selected, but the puncture may be at a point in the linea semilu- 
naris just outside the rectus muscle at the junction of the outer and 
middle thirds of a line between the umbilicus and the anterior supe- 
rior iliac spine (Fig. 298). A puncture at either of these sites will 
avoid the deep epigastric vessels. Should repeated punctures be 
made, it will be of advantage to change the site a little each time so as 
to avoid entering adhesions which may have been produced by a 
previous puncture. 



298 



ASPIRATIONS 



Quantity Withdrawn. — Whether all the fluid should be removed 
at once will be determined by the condition of the patient and the 
manner in which he bears the operation. As a general thing there is 
no harm in removing all the fluid, provided it is not evacuated too 
rapidly. 

Position of Patient. — The patient should sit upright on the edge 
of the bed, if possible, or, if unable to do this, he may lie propped up 
in a semirecumbent position so as to favor gravitation of the fluid to 




Fig. 299. — Aspiration of the peritoneal cavity. First step, application of the 
* abdominal binder. 



the lowest level of the peritoneal cavity. When the puncture is made 
in the linea semilunaris, the patient should lie upon the side on which 
the puncture is made. 

Preparations. — Tlie bladder and bowels should always be empty 
before operation. The abdominal wall is shaved and the site of punc- 
ture is painted with tincture of iodin. The operator's hands should 
likewise be sterilized, and the trocar is to be boiled. 

Anesthesia. — Local anesthesia with ethyl chlorid, ether, ice and 
salt, or infiltration with a few drops of a 0.2 per cent, solution of 
cocain or a i per cent, solution of novocain may be used. 

Technic. — A broad abdominal binder, or a Scultetus bandage 
with a central slit corresponding to the point where the trocar is to be 
introduced, is first fitted about the patient's abdomen (Fig. 299) and 



ASPIRATION FOR ASCITES 



299 



is to be tightened at intervals during the operation, so that uniform 
pressure may be appKed 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 (Fig. 300), and the trocar is slowly and 
steadily inserted, with the index finger held along the instrument as 
a guide to the depth it is to enter, and to prevent it from being sud- 
denly forced in too far (Fig. 301). As soon as it is judged that the 
peritoneal cavity has been reached, the trocar is withdrawn and the 
fluid is permitted to escape. 




Fig. 300. — Aspiration of the peritoneal cavity. Second step, nicking the skin at 

the point of puncture. 



The fluid should be evacuated slowly, and, if it flows too freely, 
it is well to stop the flow at intervals by placing the finger over the 
end of the trocar, in order to allow the abdominal contents to adapt 
themselves to the changed conditions. If the stream is suddenly 
stopped by the intestines or omentum occluding the end of the instru- 
ment, a slight turn of the cannula or a change in its position may be 
suf&cient to reheve the obstruction; if not, it may be necessary to 
clear the lumen by passing a sterile probe through it. As the fluid 
is withdrawn, and the distention of the abdomen decreases, neces- 
sary support is given to the lax abdominal walls by drawing the 
binder tighter. Syncope may be thus avoided; should it occur, how- 



300 



ASPIRATIONS 



ever, the escape of the fluid must be temporarily stopped by placing 
the finger over the end of the trocar and the patient's head must be 
lowered, care being taken to see that air does not enter the trocar 
while this is being done. 

When fluid ceases to flow, the cannula is quickly removed and, 
if a large opening has been made by the trocar, the skin may be 
drawn together by a subcutaneous stitch and the line of incision 
sealed with collodion and cotton. If there seems to be a good deal 
of oozing of fluid along the track of the trocar, however, a sterile 




Fig. 301. — Aspiration of the peritoneal cavitj'-. Third step, showing the method of 

inserting the trocar. 

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 for 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 
radical cure by injection of carbohc acid. The former is rarely more 
than a palliative measure, as the fluid usually promptly recurs. 



ASPIRATION OF THE TUXICA VAGINALIS 



301 



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 




Fig. 302. — Trocar and syringe for aspirating and injecting a hydrocele. 

of the cord and the testicle. The latter usually lies posterior to 
the tumor, 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. 302). 




Pig. 303. — Aspirating a hydrocele. Showing the method of grasping the scrotum 
and the trocar being inserted. 

Site of Puncture. — The trocar should be introduced at the junc- 
tion of the lower and middle thirds of the anterior surface of the 
scrotum, at a spot where visible blood-vessels are scarce. 

Asepsis. — The usual aseptic precautions should be observed. 
The skin at the site of puncture should be shaved and then painted 



302 



ASPIRATIONS 



with tincture of iodin. The operator's hands should be prepared 
as for any operation, and the instruments boiled. 

Anesthesia. — The spot of intended puncture may be anesthetized 




Fig. 304. — Aspirating a hydrocele. Showing the cannula in place. 

by the injection of a few drops of a 0.2 per cent, solution of cocain 
or a I per cent, solution of novocain, or frozen by ethyl chlorid. 

Technic. — The operator places his left hand behind the scrotum 




Fig. 305. — Method of injecting a hydrocele. 

and grasps the neck of the hydrocele between the thumb and fore- 
finger, thus making the tumor tense by compression. Holding the 
trocar and cannula in the right hand with the index finger placed 



ASPIRATION OF THE TUNICA VAGINALIS 303 

about I inch (2.5 cm.) from its tip so as to prevent the instrument 
being introduced too deeply, the operator thrusts it into the tunica 
vaginaHs in an upward and backward direction (Fig. 303). As soon 
as the trocar enters the sac, indicated by a lack of resistance to its 
further progress, the point of the instrument is turned upward thus 
depressing the free end and the trocar is removed (Fig. 304). All the 
fluid is then allowed 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 (0.3 to 2 c.c.) 
of 95 per cent, (deliquescent) carbolic acid, depending upon the size 
of the hydrocele, are injected through the cannula (Fig. 305). If a 
syringe cannot be attached directly to the cannula, the injection may 
be made by means of a hypodermic syringe and a long needle in- 
serted through the cannula. The skin is then pinched up around the 
cannula, 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 collodion and cotton. 

The patient should remain in bed twenty-four to forty-eight hours 
after the operation with a supporting dressing applied to the scrotum. 
Some swelling follows the injection, but it usually subsides within 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 considered under the section 
devoted to that organ (see page 692). 



CHAPTER XIII 
THE NOSE AND ACCESSORY SINUSES 

Anatomic Considerations 

The Nose. — For purposes of description the nose is divided into 
an external and an internal portion. 

The external nose forms a prominence upon the face resembling a 
triangular pyramid, made up chiefly of bone and cartilage and 
covered with muscles and integument. The bony portion, or bridge, 
is composed 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 cham- 
bers, 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 (i cm.) 
transversely at their widest points. Posteriorly, the nasal fossae 
communicate with the nasopharynx by two corresponding openings, 
the posterior nares. Each fossa also communicates with air spaces 
situated in the frontal, ethmoid, sphenoid, and superior maxillary 
bones. The roof is formed by the nasal bones, the cribriform plate 
of the ethmoid, and the body of the sphenoid. The floor, concave 
from side to side, is formed by the palatal process of the superior 
maxilla and the horizontal process of the palate bones. It separates 
the nose from the mouth. The inner wall, or septum, is formed 
posteriorly by the perpendicular plate of the ethmoid and the vomer, 
and anteriorly by the triangular cartilage. The septum is seldom 
exactly in the median line, but is usually more or less deflected, so 
that it is unusual to find the two fossae of equal size. The outer walls 
of the nose are formed by the superior maxillary, the lachrymal, the 
ethmoid, the palate, and the sphenoid bones. They are very irreg- 
ular, due to the presence of the turbinate bodies which project into 
the fossae and partly divide them into three separate recesses, the 
superior, the middle, and the inferior meatus (Fig. 306). 

304 



ANATOMIC CONSIDERATIONS 



305 



The superior meatus lies between the superior and middle turbi- 
nates. It is narrow and groove-like, and is the smallest of the three. 
The orifices of the posterior ethmoidal cells open upon the upper and 
forepart of its outer wall. 




Fig. 306 — Transverse section of the nasal cavities. (After Zuckerkandl.) 

The middle meatus lies between the middle and inferior turbinates, 
and is more capacious than the superior, extending along the pos- 
terior two-thirds of the outer wall of the nose. Opening into the 
middle meatus on the outer wall is a crescentic slit-like aperture, 




Fig. 307. — Showing the structures in the outer wall of the nasal cavity. 1, 
Opening of the sphenoidal sinus; 2, superior meatus; 3, middle meatus; 4, inferior 
meatus. 



the hiatus 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 



3o6 



THE NOSE AND ACCESSORY SINUSES 



and forward, is a curved groove bounded internally by the uncinate 
process of the ethmoid, known as the infundibulum. From this a 
closed duct leads into the frontal sinus. At the deepest portion of 
the infundibulum near the posterior end, is the opening of the max- 
illary 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. 

From the anatomical relation of these openings, it can be under 
stood how readily infection of the maxillary sinus may follow a sup- 
purative condition of the anterior ethmoidal cells or frontal sinus 




Fig. 308. — Lateral wall of the right nasal cavity showing the orifices of the 
accessory sinuses. (After Schultze and Stewart.) The dotted line indicates the 
outline of the Aiiddle turbinate, which has been removed to show the structures 
beneath. A portion of the inferior turbinate has also been removed, i, Frontal 
sinus; 2, infundibulum; 3, hiatus semilunaris; 4, orifice of the nasal duct; 5, bulla 
ethmoidalis; 6, inferior turbinate; 7, accessory orifice of the maxillary sinus; 8, 
orifice of Eustachian tube; 9, fossa of Rosenmiiller; 10, sphenoidal sinus; 11, 
orifice of the sphenoidal sinus; 12, orifice of the middle and posterior ethmoidal 
cells; 13, orifice of the anterior ethmoidal cells. 



discharges from the latter being very apt to find their way into the 
ostium of the maxillary sinus. 

The inferior meatus, the largest of the three, lies between the 
inferior turbinate bone and the floor of the nasal cavity, extending 
along the entire length of the outer wall of the nose. The nasal duct, 
leading from the orbit, opens into the inferior meatus at the junction 
of the anterior third with the posterior two-thirds. 

The mucous membrane lining the nasal cavity is continuous 
anteriorly with the integument and also with the mucous membrane 
of the pharynx, Eustachian tubes, and accessory sinuses. In the 



ANATOMIC CONSIDERATIONS 



307 



upper portion of the nose the mucous membrane is of the columnar 
variety. In this region it is thin and closely bound to the perios- 
teum and perichondrium beneath, and contains the endings of the 
olfactory nerves. The remainder of the nasal cavity is lined with 
ciliated epithelium. Over the inferior turbinates, the lower portion 
of the middle turbinates, and corresponding parts of the septum the 
mucous membrane is thick and very vascular, containing numerous 
thin-walled venous channels capable of becoming so enormously dis- 
tended with blood that they may even occlude the nares. On the 
floor of the nose the mucous membrane again becomes thinned out. 
The Accessory Sinuses.— Hollowed out of the bones surround- 
ing the nasal foss£e are four cavities filled with air, known as the 
maxillary, frontal, ethmoid, and sphenoid sinuses. These accessory 




Fig. 309. — Cross-section of the maxillary sinuses, showing the close relation of the 
roots of the molar teeth to the floors of the sinuses. (After Zuckerkandl.) 

sinuses are lined with a thin, pale, mucous membrane continuous 
with that of the meatus into which each sinus respectively opens. 
The function of the sinuses is to give resonance to the voice and at 
the same time add to the lightness of the skull. 

The maxillary sinus or antrum of Highmore, lies to the outer side 
of the nasal fossa, occupying the greater portion of the superior max- 
illary bone. It is the largest of all the accessory sinuses. In shape 
it resembles a three-sided pyramid, with the apex at the zygomatic 
process of the maxilla, and the base directed toward the nasal cavity. 
The roof of the antrum is very thin and forms the floor of the orbit. 
The anterior wafl is directed toward the face and corresponds to the 
canine fossa externally. The floor, which is directed toward the 
mouth, is formed by the alveolar margin and outer portion of the hard 



3o8 THE NOSE AND ACCESSORY SINUSES 

palate. The roots of the molar teeth almost protrude through the 
floor into the antrum (Fig. 309), being often separated from the cavity 
by a thin shell of bone, or merely mucous membrane, so that ulcera- 
tion of the teeth may readily lead to infection of the sinus. This 
anatomical arrangement is sometimes taken advantage of in draining 
the antrum, a tooth being extracted and the sinus opened through 
the alveolus. 

Ordinarily, the antrum has a capacity of about 4 drams (15 c.c), 
but its size varies greatly, and in the same individual the two sides 
are frequently disproportionate. The antrum communicates with the 
middle meatus by an ostium opening into the infundibulum, and 
thence through the hiatus semilunaris. This aperture cannot be 
seen until the middle turbinate has been removed. In a small per- 
centage of cases an accessory ostium is found lying posterior to the 
main opening. 

The Frontal Sinus. — The frontal sinuses are two air spaces sepa- 
rated from each other by a septum, lying between the tables of the 
frontal bone above the orbits. Each consists of a vertical portion 
passing upward on the forehead and a horizontal portion extending 
backward over the roof of the orbit. Their size is variable and they 
are often unequal through deflection of the septum to one side. 
Cases have been observed with one sinus entirely absent. The floor 
of the sinus forms by its external portion the roof of the orbit, and by 
its inner portion the roof of some of the anterior ethmoidal cells. 
The latter part of the floor is extremely thin, so that suppuration of 
the frontal sinus is liable to extend to the anterior ethmoidal cells. 
The posterior wall separates the sinus from the frontal lobes of the 
brain by an extremely thin plate of bone. The anterior wall is thick 
and is represented externally by the superciliary ridge. In the 
posterior portion of the floor of the sinus is the rounded or oval 
aperture leading into the infundibulum and thence to the middle 
meatus by means of the hiatus semilunaris. 

The ethmoidal cells lie in the lateral masses of the ethmoid bone. 
These cells vary in size and number. They are divided into two 
sets, anterior and posterior. The anterior open into the middle 
meatus, generally by the infundibulum, while the posterior set 
open into the superior meatus. These cells are separated from the 
cranial cavity and orbit by extremely thin plates of bone. 

The sphenoidal cells are situated in the body of the sphenoid bone 
close to the base of the skull. They are quadrilateral in shape and 
variable in size, and, like the frontal sinuses, they may be asymmetri- 



RHINOSCOPY 309 

cal from deviation of the septum. The anterior wall looks downward 
and forward and forms a part of the roof of the nasal cavity. The 
upper wall is very thin and separates the sinus from the cranial 
cavity. The cells communicate with the nasal cavity through an 
opening situated above and behind the superior turbinate. 

Diagnostic Methods 

Prior to making an internal examination of the nasal cavities, 
careful notes should be taken of the patient's history and symptoms, 
for future reference, and a thorough inspection should be made of the 
external nose. On general inspection one should note the shape of 
the nose, with reference to signs of cretinism, s^^hilis. new growths, 
deviations, or deformities. The shape of the jaws also should be 
observed; likewise the presence or absence of any prominences or 
bulging in the neighborhood of the accessory sinuses; the presence or 
absence of enlarged cervical glands; the presence of excoriations, 
herpes, or crusts about the anterior nares and upper lip, as indica- 
tions of nasal discharge. It should be ascertained whether the patient 
breathes through the mouth, and the patency of the nose should be 
tested by alternately closing each nostril with the finger while the 
patient breathes through the opposite one. The odor of the breath, 
the presence or absence of marked movement of the al^ nasi, or any 
sounds produced during nasal breathing, and the character of the 
voice should also be carefully noted. Having completed this pre- 
liminary examination, that of the interior of the nose may be pro- 
ceeded with. 

For an examination of the nasal caA^ty and accessory sinuses 
five methods are available: namely, (i) inspection or rhinoscopy; 
(2) probing; (3) palpation; (4) transillumination; and (5) skiagraphy. 

RHINOSCOPY 

Inspection of the interior of the nose may be performed by 
anterior and by posterior 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 requires no great skill, but the latter is by no 
means an easy procedure for one not specially trained, and at times 



3IO 



THE NOSE AND ACCESSORY SINUSES 



requires considerable patience on the part of the operator to com- 
plete successfully and satisfactorily. 

Illumination. — To obtain a satisfactory view of the interior of the 
nose, it is necessary to have good illumination. Strong sunlight 
may be utilized for anterior rhinoscopy, but it is not suitable for an 
examination of the posterior nares. A Welsbach burner fitted with a 
mica chimney over which is placed a Mackenzie condenser gives 
excellent illumination (Fig. 310). Electric light from a frosted 
lamp is also much used and has an advantage in that it does not 
give out much heat. 




Fig. 310. — Gas lamp upon an adjustable stand fitted with a Mackenzie condenser. 



Whatever the form of light, it should be so arranged upon a 
suitable bracket that it may be raised, lowered, or turned from side 
to side without inconvenience to the operator. The light should be 
placed upon the patient's right, somewhat behind him, and about 
on a level with the tip of his ear. 

Many operators prefer an illumination furnished by an electrical 
head light (Fig. 311). Such a light, with the current furnished from 
a small pocket storage battery will be found a great convenience 
outside the examining room. 



RHINOSCOPY 



311 



Instruments.— In addition to a suitable light, there will be re- 
quired: a concave head mirror, about 3 1/2 to 4 inches (9 to 10 cm.) 
in diameter, with a large central eye-hole, and secured to a soft 
leather headband by a bah-and-socket joint; a rhinoscopic mirror 




Fig. 311. — Electric head light. 




YiG, 312.— Instruments for rhinoscopy, i, Alcohol lamp; 2, rhinoscopic 
mirror; 3, White's palate retractor; 4, Myles' nasal speculum; 5, head mirror; 
6, nasal appUcator; 7, Fraenkel's tongue depressor. 

1/2 inch (i cm.j m diameter, set at an angle of 100 to no degrees 
with the shaft, which is curved to follow the Hne of the tongue; a 
Myles soUd-blade nasal speculum; a Fraenkel tongue depressor; a 
White palate retractor; and a nasal appKcator with a triangular- 
tipped shaft (Fig. 312). 



312 



THE NOSE AND ACCESSORY SINUSES 



Asepsis. — Instruments, such as tongue depressors, specula, 
applicators, etc., may be sterilized by boiling. The rhinoscopic 
mirrors, however, which are soon destroyed by boiling, may be 
sterilized by immersion in a solution of i to 20 carbolic acid and 
then wiped dry before using. 

Position of the Patient. — The patient is seated upright upon a 
firm, straight-backed chair. The examiner sits, facing the patient, 
upon an adjustable seat, such as a piano stool, which may be readih- 
raised or lowered according to the height of the patient. 

Technic. — i. Anterior Rhinoscopy. — The operator adjusts the 
head mirror in such a way that the central opening is opposite his 
left eye and the light is reflected into the nostrils of the patient. The 
outline of the anterior nares is then brought into view, and the 
relative size of the two fossae may be appreciated. Care should be 
taken to look for fissures, abrasions, or pimples on the inner surface 




Fig. 313. — Myles' speculum in place. 

of the vestibule of the nose, contact with which would make the in- 
troduction of the speculum painful, without preliminary cocainiza- 
tion. The speculum is then introduced with the blades closed, and, 
upon sliding them apart, the necessary amount of dilatation is ob- 
tained (Fig. 313). 

The inspection of the cavity should proceed from before backward, 
the Ught being thrown into all recesses. By slightly elevating the 
tip of the nose, the floor of the nose, the inferior turbinate, and the 
inferior meatus are brought to view. In some cases where the nose 
is very broad or the inferior turbinate small or shrunken, it may even 
be possible to see as far back as the posterior wall of the nasopharynx. 
By bending the patient's head backward and raising the chin, the 



RHINOSCOPY 



313 



middle meatus and the middle turbinate may be seen; only when the 
latter has been removed, or is very much atrophied, however, is it 
possible to obtain a view of the apertures leading to the accessory 
sinuses. Tilting the patient's head still further backward exposes 
to view the upper portion of the middle turbinate and the roof of the 
nose. Occasionally the opening of the sphenoidal sinus may be 
made out, but only in exceptional 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 




Fig. 314. — Showing the method of performing anterior rhinoscopy. 



be caused to shrink and a more satisfactory view of the structures 
within the nose may be obtained. This is especially useful where the 
nasal cavity is narrow or the turbinates are hypertrophied. 

Secretions that 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 in- 
spected and the apparent source of any discharge noted. In general, 
pus in the middle meatus means that the frontal or maxillary sinus 
or anterior ethmoidal cells are involved, as they all drain into this 
recess; while a discharge seen in the space between the middle tur- 
binate and septum signifies infection of either the sphenoidal or pos- 



314 



THE NOSE AND ACCESSORY SINUSES 



terior ethmoidal cells. To ascertain exactly which sinus is involved, 
frequently other aids to diagnosis, as probing, transillumination, or 
skiagraphy, must be employed. 

The attention of the examiner is fmally directed to the bony and 
cartilaginous portions of the nose. Deviations, ulcerations, perfora- 
tions, and spurs of the septum, contracture or hypertrophy of the 
turbinal bodies, the presence of foreign bodies, the presence of new 
growths and their point of attachment, etc., etc., are in a general 
way the conditions to be looked for. 

2. Posterior Rhinoscopy. — The operator adjusts the head mirror 
over his left eye so that the light is thrown upon the patient's mouth. 
The patient is instructed to open the mouth, and a tongue depressor 




Fig. 315. — First step in posterior rhinoscopy, inserting the tongue depressor 



held between the thumb and the index and middle fingers of the left 
hand, is inserted and passed over the dorsum of the tongue 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. 
315). If care be taken not to insert the depressor too far and to avoid 
pushing back on the tongue, gagging will be prevented. A mirror of 
suitable size is then warmed and, with the light reflected upon the 
posterior pharyngeal wall, the mirror is gently introduced into the 



RHINOSCOPY 



3^5 



mouth, lightly held between the thumb and forefinger of the right 
hand with its metal surface directed toward the tongue. The mirror 
should then be carefully carried back into the nasopharynx, avoiding 
the back of the tongue, the palate, and uvula. After the instru- 
ment has entered the nasopharyngeal space, a clear view of the pos- 
terior ends of the turbinates and the other postnasal structures will 
be obtained by depressing the handle of the instrument sHghtly so 
that the upper border of the mirror lies behind the soft palate. At 
the same time, the handle of the mirror should be so held toward 
the left angle of the patient's mouth that illumination is not interfered 
with (Fig. 316). 





Fig. 316. 



Fig. 317. 



Fig. 316. — Showing the rhinoscopic mirror in place. 

Fig. 317. — Posterior rhinoscopic image, i, Roof of pharynx; 2 uvula; 3 
soft palate; 4, opening of Eustachian tube; 5, superior turbinate; 6, middle tur- 
binate; 7, inferior turbinate. 

It should be remembered that it is not possible to obtain a view of 
the whole postnasal space at one time, but, on turning the mirror in 
various directions by rotating its handle, different portions may be 
brought into view and the entire space may thus be examined in 
detail. By first holding the handle of the instrument well up, the 
vault of the pharynx will be brought into view, and the presence or 
absence of adenoids or other tumors may be ascertained. The 
pharyngeal vault is usually smooth and dome-shaped, but it may be 
almost completely filled up and show depressions and elevations 
depending on the size and condition of the pharyngeal tonsil. On 
depressing the handle slowly, the posterior nares may be examined 



3i6 



THE NOSE AND ACCESSORY SINUSES 



in detail from above downward. In the median line is seen the 
septum; on either outer wall from above downward will be seen the 
ridge of the superior turbinate, w4th the superior meatus lying just 
below as a darkened depression. Below this wdll be observed the 
middle turbinate as a pinkish-white fusiform body, and, underlying 
this, the middle meatus. The inferior turbinate appears just below 
this as a grayish- white body. Finally, by turning the mirror to either 
side, the orifices of the Eustachian tubes and the Eustachian cushions 
are brought to view. Care should be taken not to keep the mirror 
in the throat too long or the patient will be tired out; to make a 
complete examination, it is better to reinsert it more than once if 
necessary. 




Fig. 318. — White's palate retractor in place. 

In some cases it may be almost an impossibility to make a satisfac- 
tory posterior rhinoscopic examination. This may be from the forma- 
tion of the parts, as, for example, in the presence of a hard palate 
which extends so far back that there is no room for the mirror, or a 
broad soft palate w^ith a long uvula, or it may be due to the presence of 
a growth in the nasopharynx. The most common obstacle, however, 
is the involuntary elevation of the soft palate on the introduction of 
the mirror, so that the view of the parts above is blocked. Instructing 
the patient to breathe through the nose with the mouth open, or to 
pronounce "en" with strong nasal sound, often suffices to overcome 
this impediment. In other cases it will be necessary to use a palate 



IXSPECTIOX OF THE NASOPHARYNX 



317 



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 wdthin the nose 
(Fig. 318). 



INSPECTION OF THE NASOPHARYNX BY MEANS OF THE 
HAYS PHARYNGOSCOPE 

To overcome the difficulties encountered in examining the naso- 
pharynx with a rhinoscopic mirror, Hays has devised an instrument 
made on the plan of an indirect view cystoscope, which he calls the 
pharyngoscope.^ With this instrument, the use of which requires 
none of the skill necessary for the ordinary posterior rhinoscopic 




Fig. 319. — Hays' phan'^ngoscope. 

examination, it is possible to obtain a clear picture of tne 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. 

Instruments. — All that is required is the pharyngoscope and a six- 
dry-cell battery. The instrument is made in the form of a tongue 
depressor, the horizontal portion of which is flattened in its inner 

-Harold Hays, in the Neiv York Medical Journal, April 19, 1909, and the 
-Laryngoscope, Jnlj, 1909. 



3i< 



THE NOSE AND ACCESSORY SINUSES 



two- thirds, and in its widest part measures less than 5/8 inch (1.6 cm.) 
It contains a central tube into which a movable telescope fits and also 
two wire carriers. At the distal end of the instrument are placed two 
lamps, one on each side of the telescope. On the circumference of the 
eye-piece of the telescope is a small metal guide, to indicate the direc- 
tion in which the lens is turned. The length of the horizontal portion 
including the telescope is about 8 inches (20 cm.). The vertical 
portion or handle of the instrument contains the wires which carry 
the current to the lamps. Near its upper end is placed a switch for 
turning on or ofi" the current (F-'g. 319). 

Asepsis. — The instrument must be thoroughly sterilized before 
use. This is accomplished by means of formalin vapor or by immer- 




FiG. 320. — Showing the method of inserting the Hays' pharyngoscope (after 
Hays, Am. Jour. Surg., Ma\% 1909). 



sion in a I to 20 carbolic acid solution followed by rinsing in alcohol 
or sterile water. It will not stand boiling. 

Anesthesia. — As a rule, anesthesia is not necessary. Should, 
however, gagging be induced by the instrument, the posterior 
pharyngeal wall may be cocainized. 

Technic. — The patient is instructed to open his mouth widely 
and breathe quietly. The instrument is then inserted in the same 
manner as a tongue depressor, until its distal end lies about 1/16 
inch (1.5 mm.) from the pharyngeal wall (Fig. 320). The instru- 
ment is kept steadily in place upon the tongue, and the patient 
is told to close the mouth and breathe through his nose. This 



PALPATION BY THE PROBE 



319 



produces relaxation and consequent widening of the pharynx and 
nasopharynx. The hght is then turned on, and the examiner 
inspects the structures as they are separately 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 tilting the distal end of the instrument slightly 
upward, the posterior nares are viewed. 

To inspect the region of the Eustachian tubes the lens is rotated 
to about 30 degrees to one side, when the orifices of the tubes, Rosen- 
miiller's fossa, etc., will be clearly shown. By rotating the lens so 
that it points downward the epiglottis, larynx, and base of the tongue 
are similarly inspected. 




Fig. 321. — Showing the pharyngoscope in place with the examiner inspecting the 

postnasal space. 



PALPATION BY THE PROBE 



The use of the probe is essential to a complete examination of the 
nose. By its aid the consistency and character of structures normally 
present, as well as the presence of abnormal growths, adhesions, 
foreign bodies, and the patency or obstruction of the openings leading 
to the accessory sinuses, may be determined. 

Instruments. — The instruments comprise those necessary for a 
rhinoscopic examination; a nasal applicator; a nasal probe; and a 
sinus probe (Fig. 322). 

The nasal probe should be of silver, fairly stiff, but at the same 



320 



THE NOSE AND ACCESSORY SINUSES 



time capable of being bent. It should be about 8 inches (20 cm.) 
long, and set into its handle at an angle of 135 degrees. 

The instrument employed for examination of the sinuses must be 
of pure soft silver and tine 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. 

Asepsis. — The speculum, applicator, and probes are sterilized by 
boiling. 

Anesthesia. — The nasal mucous membrane is very sensitive and 
manipulations are apt to produce sneezing, so that the parts should 
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 cocain to take eflfect before proceeding 
with the examination. 




Fig. 322. — Instruments for palpating the interior of the nose. I, Nasal ap- 
plicator; 2, nasal probe; 3, sinus probe; 4, Myles' nasal speculum; 5, head 



Position of Patient. — The positions of the patient and operator are 
the same as for a rhinoscopic examination (see page 312). 

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 ulcerations, etc., are ascertained. All 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 



PALPATION BY THE PROBE 



321 



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. 




Fig. 323. — Showing the steps in the passage of a probe into the frontal sinus. 

To enter the frontal sinus, the distal end of the probe, bent to an 
angel of 135 degrees, is inserted within the middle meatus at the junc- 
tion of the anterior third and posterior two-thirds of the middle tur- 
binate. Its tip is made to hug the outer wall of the middle turbinate, 
and is passed upward and forward through the hiatus and into the 




Pig. 324. — Showing the steps in the passage of a probe into the sphenoidal sinus. 

infundibulum. By depressing the handle of the instrument, its tip 
will traverse the infundibulum and pass through the ostium frontale 
unless some obstruction exists. Gentleness should be employed in 
this maneuver, and no attempt should be made to force the instru- 
ment if any obstruction to its passage exists. 



?s22 



THE NOSE AND ACCESSORY SINUSES 



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 
point enters the cavity of the sinus, which is then carefully explored. 

In either case, when the probing is employed as a preliminary to 
irrigation, and the particular sinus has been successfully entered by 
the probe, if the shape of the irrigator be made to correspond to that 
of the probe it will be of great help in the introduction of the former. 

DIGITAL PALPATION 

Palpation of the posterior nares by means of the finger is employed 
to confirm the diagnosis made by posterior rhinoscopy, or to obtain 




Fig. 325. — Showing the method of palpating the postnasal space with the finger. 



information as to the condition of these parts when the latter is not 
possible. Xo instruments are needed, except in the case of unruly 
children, when a mouth gag may be required. While digital palpa- 
tion is a rather unpleasant procedure for the patient, if performed 
rapidly and skilfully many of the disagreeable features may be 
eliminated. 



TRANSILLUMINATION 323 

Preparations. — The operator's 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. 
The left hand of the operator supports the patient's head, and at the 
same time with the thumb or index finger of the same hand he forces 
the cheek in between the open jaws to prevent the examining finger 
from being bitten (Fig. 325). The index finger of the right hand is 
then gently but quickly introduced into the mouth and is hooked 
around the posterior border of the soft palate into the nasopharynx, 
and the parts are palpated. In this way the presence of adenoids, 
hypertrophies of the posterior ends of the turbinates, or other growths 
are readily recognized. 

TRANSILLUMINATIOlSr 

Transillumination is a valuable aid for determining the conditiori 
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 




Fig, 326. — Coakley's transilluminator. a, Apparatus assembled for trans- 
illumination of the antrum; b, glass hood for use in transillumination of the antrum; 
c, hood for use in transillumination of the frontal sinus. 

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 symmetry of the two sides, due 
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 upon which to base a comparison. The method is of 
greatest service in the diagnosis of empyema of the antrum and of the 
frontal sinus. In the latter it is not so valuable or nearly so reliable 
an aid as in the former, for the size of the two frontal sinuses and the 
thickness in the individual bones are apt to vary. 



324 



THE NOSE AND ACCESSORY SINUSES 



Apparatus. — There are many lamps adapted to the purpose of 
transillumination, Coakley's being an excellent model. This con- 
sists of a handle of nonconducting material containing a lamp and 
glass hood for transillumination of the maxillary sinus, and a second 



\ /■ 



^t) 



Fig. 327. — Transillumination eflFect 
in a normal right frontal sinus. 




Fig. 328. — Transillumination effect 
in a diseased left frontal sinus. 



hood to fit over the lamp in place of the glass one. for use about the 
frontal sinus (Fig. 326). The lamps are of about four or five candle- 
power, the electricity being supplied by a small battery or the street 



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Fig. 329. — Transillumination effect 
in the normal case. (After Harmon 
Smith, in Keen's Surgery.) 



Fig. 330. — Transillumination effect 
in sinusitis of the right antrum. (After 
Harmon Smith, in Keen's Surgery.) 



current. In employing the latter, a current controller, by which the 
amount of current may be regulated, will be necessary. 

Technic. — i. Transillumination of the Frontal Sinus. — The 
patient is seated in a dark room. The black hood is drawn over the 



NASAL DOUCHING 



325 



transilluminator and the instrument is placed beneath the orbital 
portion of the brow at the nasal side. The light is turned on and the 
sinus is clearly illuminated, the operator noting the effect. The oppo- 
site side is treated in the same manner, and the two are compared as 
to the intensity with which the light is transmitted. 

Through a large sinus in a normal condition the light is transmitted 
with greater intensity 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. Transillumination of the Antrum. — The patient is seated in a 
darkened room, any dental plates or obturators that might obstruct 
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 close his lips firmly. Under normal con- 
ditions when the lamp is lighted, the cheeks, up to the infraorbital 
margins, and both pupils are clearly illuminated. If one antrum con- 
tains pus or a solid tumor, the malar region of that side will appear 
darker and an absence of illumination of the pupil will be noted. The 
transmission of light will also be interfered with in the presence of 
thickened walls or lining mucous membrane. 

SKIAGRAPHY 

The X-ray gives important information in regard to the frontal, 
ethmoid, and maxillary sinuses, and, when possible, it should be regu- 
larly employed as one of the aids in diagnosis. To be of any value, 
however, it must be applied by a competent radiographer. It is 
especially valuable in diseases of the frontal sinuses. In a healthy 
condition, the outlines of the sinuses are clear and distinct; while in 
diseased conditions the outlines are not so clearly indicated and the 
whole area of the sinus appears cloudy. In addition the X-ray will 
show the size and shape of the frontal sinus and the position of the 
septum, all of which are important points in making a decision as to 
method of operating, should it be necessary. To determine the size 
of a sinus it is necessary to take two plates, one in profile and the 
other full face. 

Therapeutic Measures 

NASAL DOUCHING 

Nasal douching is employed for the purpose of cleansing the nasal 
cavity prior to operative procedures or for the purpose of removing 



326 



THE NOSE AND ACCESSORY SINUSES 



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 cause an otitis media. For this reason 
only small quantities of solution are employed at a time, and the injec- 
tion should be made without any force. If one side of the nose is 
obstructed, the solution should enter by that nostril and escape from 
the more open one. As a further precaution, any excess of fluid 
remaining after the irrigation should be allowed to flow from the nose 
or be drawn into the mouth and expectorated, but not blown from the 
nose for fear of forcing some into the Eustachian tubes. The patient 
should furthermore be instructed to remain indoors for at least half 
an hour after each irrigation to avoid catching cold. For the patient's 




Fig. 331. — Nasal douche apparatus. 

own use nasal spraying is a safer method to employ, and, if it becomes 
necessary to prescribe a nasal douche, the surgeon should carefully 
instruct the patient in the proper method of its use. 

Apparatus. — An ordinary douche bag with a capacity of about a 
pint (500 c.c), fitted with a nasal nozzle, forms a simple and effective 
douche. There are a number of douches especially made for the 
nose, a convenient type for use with large quantities of solution being 
shown in Fig. 331. It consists of a pint bottle to the bottom of which 
is attached a rubber tube fitted with a nasal nozzle. The small glass 
douche (Fig. 332), known as the "Bermingham douche," is useful 
where the cleansing is to be carried out by the patient. 



NASAL DOUCHING 



327 



Solutions. — For ordinary cleansing purposes the solution should 
be alkaline and as unirritating as possible. 

One of the following formulae may be employed. 



I^. Sodii bicarbonatis, 

Sodii biboratis, 

Acidi carbolici, 

Glycerini, 

Aqu«, q. s. ad. 

i^. Sodii bicarbonatis, 

Acidi salicylici, 

Aquae, q. s. ad. 

I^. Sodii bicarbonatis, 

Sodii biboratis, 

Sodii chloridi, 
Sig. A teaspoonful to a pint of warm water. 



aa. dr. i (4 gm.) 
nrixv (i c.c.) 
oz. i (30 c.c.) 

Oi(5oo c.c.) M. 
dr. i (4 gm.) 
gr. X (0.65 gm.) 
Oi (500 c.c.) M. 



aa. oz. i (30 c.c.) M. 



Some of the proprietary preparations, such as listerin, borolyptol, 
glycothymolin, alkalol, etc., will be found of value where an antiseptic 




Fig. 332. — The Bermingham nasal douche. 

action is also desired. They may be used in the proportion of dr. ss 
to dr. i (2 to 4 c.c.) to the ounce (30 c.c.) of water. When there 
is an offensive discharge, the following may be employed. 



I^. Potassii permanganatis, 
Aquae, 



gr. i-ii (o . 06-0 . 1 gm.) 
ad. oz. i (30 c.c.) M. 



Temperature. — All solutions should be used warm, at a tempera- 
ture of about 100° F. (38° C). 

Quantity. — For ordinary cleansing purposes or for the removal 
of free secretion from the nose, a few ounces of solution are sufi&cient. 
When hard crusts are abundant, however, it sometimes requires a 
pint (500 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, 



328 



THE NOSE AND ACCESSORY SINUSES 



gentle stream — never under high pressure. Accordingly, the reser- 
voir should be raised only 2 or 3 inches (5 to 7.5 cm.) above the level 
of the nose. 

Technic. — The patient sits with his head bent slightly forward 
over a basin or sink, with a towel or napkin placed about his neck for 
protection of the clothes. The douche nozzle, held in the right hand, 
is then inserted into one nostril with sufficient firmness to prevent the 
solution from escaping, while with the left hand the reservoir 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 




Fig. 333. — vShowing the method of using the nasal douche. 



head is bent forward, the fluid does not escape into the pharynx, but 
passes through one nostril back into the nasopharynx and out through 
the other nostril (Fig. t,2>3)- When no obstruction exists in either 
side, half the solution may be injected through one nostril and the 
remainder in the reverse direction through the other. 

With the small glass douche cup the technic is very simple. 
The patient inserts the nozzle of the partially filled instrument into 
one nostril, holding the finger over the side opening. He then throws 
his head well back and removes his finger from the opening, which 



THE NASAL SYRINGE 329 

allows the solution to flow through the nose into the mouth, whence it 
is expectorated. Each nostril in turn may be thus irrigated. 

THE NASAL SYRINGE 

The nasal syringe is employed mainly for cleansing the nose. 
The solution may be injected either from the front, returning through 
the opposite nostril, after the manner of the nasal douche, or the nose 
may be washed out from behind forward. By the latter method the 
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 have been 
mentioned for the use of the douche. 

Instruments. — A syringe with a capacity of i to 2 ounces (30 to 
60 c.c), made of metal or hard rubber, will be required. It should 




Fig. 334. — Xasal sj^ringe with anterior and posterior nasal tips. 

be supplied with a straight nozzle for injection through the anterior 
nares, and with one bent up almost at right angles for cleansing the 
postnasal space (Fig. 334). 

Solutions. — Any of the cleansing solutions mentioned on page 
327 may be employed. They should always be used warm. 

Technic. — In employing the nasal syringe much the same technic 
is followed as with the douche, observing due care against injecting 
the solution with too much force, etc. The nozzle of the syringe is 
inserted into one nostril and the patient is directed to keep his head 
bent well forward over a receptacle and to breathe through the 
mouth. The solution is then slowly injected and returns through the 
opposite nostril. The irrigation should be so regulated that the fluid 
returns as quickly as it enters, thus avoiding any undue accumulation 
in the postnasal space and lessening the dangers of infecting the Eu- 
stachian tubes. 



00' 



THE NOSE AND ACCESSORY SINUSES 



To syringe from the posterior nares, a tongue depressor is intro- 
duced into the mouth to keep the tongue out of the way, while the 
distal end of the postnasal tip is introduced behind the soft palate. 
The patient is then directed to hold his head well forward, the fluid is 
slowly injected and escapes from the anterior nares, flushing out the 




Fig. 335. — Showing the method of syringing the nose from behind, 

postnasal space and nose from behind forward (Fig. 335). On 
account of the sensitive condition of the parts in some cases it may be 
necessary to cocainize the pharynx and soft palate before the syring- 
ing can be properly performed. 

THE NASAL SPRAY 
Sprays or atomizers are utilized either for cleansing purposes or 
for the application of remedies to the nasal mucous membrane when 
it is not necessary to confine the solution to one particular spot. 




Fig. 336. — Whitall Tatum atomizer. • 

Apparatus. — The simplest form of atomizer usually proves most 
satisfactory, and is less liable to get out of order. The Whitall Tatum 



THE NASAL SPRAY 



33^ 



(Fig. 336), the Davidson, or the De Vilbiss (Fig. 337) are all good at- 
•omizers. The latter is especially serviceable, and the spray part, 
being of metal, may be readily sterilized. The instrument should be 
provided 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 
compressed air apparatus (Fig. 338). The latter will be found more 
convenient for ofi&ce work. 

For cleansing purposes, the spray should be rather coarser than 
that employed for medication. Oily preparations may be sprayed 




Fig. 337. — De Vilbiss atomizer. 

with an ordinary atomizer provided with an oil tip, or a special oil 
nebulizer may be employed. 

Solutions. — Any of the cleansing solutions mentioned on page 327 
may be employed in a spray. 




Fig. 338. — Compressed-air atomizing apparatus. 
When a mild antiseptic action is desired, the solutions given on 



page 327 or the following may be used: 

I^. Acidi carbolici 
Glycerini, 
Aquae q, 



gr. V (0.3 gm.) 
dr. i (4 c.c.) 
s. ad. oz. i (30 c.c.) M. 



332 THE NOSE AND ACCESSORY SINUSES 

I^. Resorcini, gr. iii (0.2 c.c.) 

Glycerini, dr. i (4 c.c.) 

Aquae, q. s. ad. oz. i (30 c.c.) M. 

Astringent solutions, for purposes of lessening secretions, include 
such drugs as zinc sulphocarbolate, zinc sulphate, copper sulphate, 
alum, tannic acid, silver nitrate, etc., used in the strength of 5 gr. 
(0.3 gm.) to the ounce (30 c.c.) of water. 

Oily preparations, with albolene or benzoinol as a base, are fre- 
quently used after the application of aqueous solutions for the 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.i 
to 0.3 gm.) or more to the ounce (30 c.c.) for the sedative effect, as 
in the following: 

I^. Eucalyptol, T([x (0.6 c.c.) 

Menthol, gr. v (0.3 gm.) 

Benzoinol, oz. i (30 c.c.) M. 

I^. Thymol, 

Menthol, aa gr. ii (o.i gm.) 

Albolene, oz. i (30 c.c.) M. 

I^. Camphors. 

Menthol, aa gr. v (0.3 gm.) 

Albolene, oz. i (30 c.c.) M. 

When a stimulating action is indicated, the proportion of the 
above drugs may be increased. 

Technic. — The tip of the nose is gently raised and the nozzle of 
the spray is inserted into the vestibule. To avoid injuring the 
mucous membrane of the septum or turbinates, care should be taken 
to keep the long axis of the spray and that of the nose in the same line. 
By alternately compressing and relaxing the rubber bulb, the solution 
is forced into the nose in a spray. The direction of the spray should 
be altered from time to time by raising or lowering the proximal end 
of the atomizer. 

For spraying from the posterior nares, the same technic is 
employed as with the postnasal syringe (see page 330). 

THE DIRECT APPLICATION OF REMEDIES 

This method is employed for the application of strong solutions or 
sohd caustics, or when it is desired to confine the action of the remedy 
to any particular area. 



THE DIRECT APPLICATION OP REMEDIES 



333 




Fig. 339. — Fusing chromic acid on a probe. First step, heating the probe. 

(Gleason.) 




Fig. 340. 




Fig. 341. 



Fig. 342. 



Fig. 340. — Fusing chromic acid on a probe. Second step, dipping the hot 
probe in the crystals. (Gleason.) 

Fig. 341. — Fusing chromic acid on a probe. Third step, heating the crystals 
into a bead. (Gleason.) 

Fig. 342. — Fusing chromic acid on probe. Showing the finished probe. 
(Gleason.) 



334 THE NOSE AND ACCESSORY SINUSES 

Instruments. — For the application of solutions, a nasal applicator, 
the tip of which is wound with a thin layer of cotton, is employed. 
Solid caustics, as chromic acid, silver nitrate, etc., are best applied 
fused upon a probe or applicator. 

Chromic acid may be prepared for application as follows: The 
probe tip is brought to a red heat over an alcohol flame (Fig. 339) 
and is then dipped into crystals of the acid (Fig. 340). 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. 341), and, upon cooling, they recrystallize in the form of a bead 
on the end of the instrument (Fig. 342). If it is desired to employ 
silver nitrate in this way, a few of the crystals should be melted in a 
crucible. The tip of a probe or applicator is then dipped into this 
liquid mass until sufficient of the caustic adheres, and, as soon as it 
solidifies, it is ready for use. In applying chromic acid a second cot- 
ton-wrapped applicator, saturated with a solution of bicarbonate of 
soda — 30 gr. (2 gm.) to the ounce (^o c.c.) — should be at hand to 
neutralize any excess of acid. 

Anesthesia. — The parts should be cocainized by the appHcation 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 neutralized 
with the strong solution of bicarbonate of soda by means of an applica- 
tor 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 usu- 
ally 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. 343 or that shown in 
Fig. 344 may be used. The former is made on the same principle 
as a hand spray, but with larger tubes. It, however, requires the 
use of both hands in its manipulation. The latter instrument con- 



INSUFFLATIONS 



335 



sists of a rubber compression bulb to which is fitted a vulcanized 
rubber tube. Into this latter fits the nasal tip, the proximal end of 
which is made in the form of a scoop for taking up the powder. When 
the instrument is filled, a sudden compression of the bulb forces air 
through the apparatus, blowing the powder out in front of it. This 




Fig. 343. — Powder blower. 

instrument may be manipulated with one hand, and the quantity of 
powder used can be accurately measured. Insuffiators are supplied 
with straight tips for the anterior nares, and with curved tips for 
making applications to the posterior nares. 




Fig. 344. — Scoop powder blower. 

For the patient's use, an insufflator such as Sajous' (Fig. 345) will 
be found convenient. It consists of a small glass receptacle with an 
opening for pouring in the powder, to one end of which a rubber 
mouthpiece is attached, the other end being rounded off to fit into the 
nostril. 




Fig. 345. — Sajous' powder blower. 

Technic. — With a suitable powder blower, the application of 
powders is very simple. The instrument being properly filled, the 
tip is inserted into the nostril or up behind the soft palate, according 



336 THE NOSE AND ACCESSORY SINUSES 

to whether the anterior or the posterior portions of the nose are to 
be medicated, and, with two or three rapid compressions of the bulb, 
the powder is forced out of the instrument and is deposited upon the 
mucous membrane. 

When the insufflation is performed by the mouth, as with the 
Sajous insufflator, the tip is inserted into the nostril, the instrument 
being held with one finger over the opening in the bottom of the 
receptacle to make it air-tight. The mouthpiece 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, for the purpose 
of removing purulent secretions, and for cleansing the mucous 
lining in the treatment of suppuration involving the accessory sinuses. 
It is performed by means of a suitable cannula introduced into the 
sinus through the natural or an artificial opening. Treatment by 
irrigation is most successful in the early cases of empyema; in those 
complicated by granulation tissue or dead bone, it is not so satisfac- 
tory. It should, however, be given a trial in any case before the more 
radical surgical measures are considered. 

Solutions Used. — Normal saline solution (salt oi (4 gm.) to the 
pint (500 c.c.) of boiled water), a saturated solution of boric acid, 
or any of the cleansing solutions mentioned on page 327 may be used. 

Temperature. — All solutions employed in irrigating should be 
warm — at about 100° F. (38° C). 

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 oi its hidden position and the fact that the opening is 
directed somewhat downward and forward from the infundibulum. 
If an accessory opening be present, however, it may be possible to 
irrigate through it, but in most cases an artificial opening will have to 
be made through the inferior turbinate, or through the alveolus after 
removal of the second bicuspid, or the first or second molar tooth. 
The former approach should be chosen when the teeth are sound and 
the origin of infection is apparently from the nose. When a decayed 
tooth is the source of trouble and the tooth is beyond saving, puncture 
through the alveolus is justifiable. 

Instruments. — For irrigating through the inferior meatus, an 
antrum trocar and cannula and small syringe will be required. For 
opening through the alveolus, there should be provided suitable tooth- 



LAVAGE or THE ACCESSORY SINUSES 



337 




Fig. 346. — Instruments for lavage of the maxillary sinus through a puncture in 
the inferior meatus. I, Head mirror; 2, syringe; 3, applicator; 4, Myles' nasal 
speculum; 5, tubing to connect the syringe and cannula; 6, Myles' trocar and 
cannula. 




Fig. 347. — Instruments for lavage of the antrum through the alveolus, i. 
Syringe; 2, cannula; 3, tubing to connect the syringe to the cannula; 4, alveolar 
drill; 5, drainage-tube; 6, tooth-extracting forceps. 



338 



THE NOSE AND ACCESSORY SINUSES 



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 (i to 2 cm.) long 
and provided with a flange to prevent its slipping into the antrum. 

Asepsis. — The instruments are sterilized by boiling, and the 
patient's nose is cleansed by gentle syringing. 

Anesthesia. — For puncture of the antrum through the inferior 
meatus, local anesthesia by the application of a 4 per cent, solution of 
cocain on a pledget of cotton twenty minutes before will be sufficient. 

Nitrous oxid anesthesia should be employed for the extraction 
of a tooth and drilling through the alveolus. 

Technic. — i. Through the Inferior Meatus. — Having obtained a 
good 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. 348. — Showing the method of puncturing the antrum through the inferior 

meatus. 



and about 1/2 inch (i 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. 
348). The relation of the sinus to the orbit should be borne in 
mind when making this puncture and care taken not to enter the lat- 
ter; this may happen if the puncture be made through the middle 
meatus (Fig. 349). As soon as the antrum has been entered, the 
trocar is withdrawn. The syringe is then attached to the cannula by 
a piece of rubber tubing, and the cavity thoroughly irrigated. Any 
secretion is thus forced out through the normal opening of the sinus 
and appears in the middle meatus. During the irrigation, the head 
should be held downward over a receptacle, so that the solution will 
readily escape from the nose. 

The sinus should be irrigated daily until the discharge ceases, 
employing stronger or more stimulating solutions if they seem indi- 
cated. Usually there is no great difficulty in reinserting the cannula 



LAVAGE or THE ACCESSORY SINUSES 



339 



through the opening each day, if it is provided with a blunt obturator. 
The parts should be cocainized, however, before each irrigation. 

2. Through the Alveolus. — The puncture is made through the 



Mddle/li&TlSs, 

/Intfuirt of 
Highuiore 

Jnfer/'crAfea/us 




Fig. 349. — Transverse section through the nose, showing cannula, a. Entering 
antrum through inferior meatus; and h, cannula entering the orbit through the 
middle meatus. (After Coffin.) 



socket of the second bicuspid or the inner root socket of the first or 
second molar tooth (Fig. 350). The affected tooth is first removed, 
and the drill inserted by a boring motion, as follows: For the first 
molar, in an upward and slightly inward direction; for the second 




Fig. 350. — Showing drills entering the antrum through the alveolus. (After 
Schultze 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 
inserted accordingly, the cavity may be missed. As soon as the an- 



340 



THE NOSE AND ACCESSORY SINUSES 



trum has been entered the cavit}- is irrigated by means of a syringe, the 
solution escaping into the nose through the natural opening. To aid 
its escape, the patient's head should be inclined forward. Finally, a 
metal drainage-tube of the proper size is inserted, through which 
subsequent irrigations may be made. 

The irrigations may be performed once or twice a day, and later 
they may be carried out by the patient himself. When the discharge 
ceases, the irrigations are discontinued for a day or two, and, if there 
is no recurrence of the trouble, the tube is then removed and the 
opening allowed to close. 

Lavage of the Frontal Sinus. — The frontal sinus may be irri- 
gated by means of a small cannula introduced through the fronto- 




FiG. 351. — Instruments for lavage of the frontal sinus. i.Myles' nasal speculum; 
2, head mirror; 3, syringe;4, tubing to connect the syringe to cannula ; 5, sinus probe; 
6, nasal applicator; 7, sinus cannula. 



nasal duct. In some cases, where the opening is occluded by the 
middle turbinate or an enlarged bulla ethmoidahs, the middle turbi- 
nate will have to be removed before the attempt is successful. 
Another difficulty presents itself in the close proximity of the anterior 
ethmoidal cells, and the cannula may enter this group instead of the 
frontal sinus. 

Instruments. — A head mirror, a speculum, a nasal applicator, a 
sinus probe, a pure soft-silver sinus cannula that may be easily bent to 



LAVAGE OF THE ACCESSORY SINUSES 



341 



accommodate itself to any curve — such as Hartmann's — and a syr- 
inge that can be attached by means of rubber tubing will be required 
(Fig. 351). 




Fig. 352. — Showing the steps of passing a cannula into the frontal sinus. 

Asepsis. — The instruments are sterilized by boiling, and the 
patient's nose is cleansed by gentle syringing. 

Anesthesia. — A 4 per cent, solution of cocain should be applied 
to the middle meatus for twenty minutes before the operation. 




^ A. <> 6 

Fig- 353- — Instruments for lavage of the sphenoidal sinus, i, Myles' nasal 
speculum; 2, head mirror; 3, syringe; 4, tubing to connect the syringe to cannula; 
5, sinus probe; 6, nasal applicator; 7, sinus cannula. 

Technic. — The cannula, bent at its distal end to an angle of about 
135 degrees, is introduced into the middle meatus at the junction of 
the anterior third with the posterior two-thirds. The tip of the 



342 



THE NOSE AXD ACCESSORY SINUSES 



cannula is passed into the hiatus and then forward and upward into 
the infundibulum. and thence still upward and slightly forward into 
the sinus, through the fronto-nasal duct (Fig. 352). The syringe is 
then attached to the cannula and the sinus is gently irrigated with one 
of the warm cleansing solutions previously mentioned. 

Lavage of the Sphenoidal Sinus. — Instruments. — A head mirror, 
a nasal speculum, a nasal applicator, a sinus probe, a sphenoidal 
curved cannula, and a syringe with rubber-tubing attachment will 
be required (Fig. 353). 

Asepsis. — The instruments are boiled, and the patient's nose is 
cleansed by gentle syringing. 

Anesthesia. — The region is anesthetized with a 4 per cent, solu- 
tion of cocain. 

Technic. — The cannula is passed into the nasal cavity with the 
convexity upward. The point of the instrument is inserted between 




Fig. 354. — Showing the steps of passing a cannula into the sphenoidal sinus. 



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. 354). The depth of the sinus is only about 3/8 inch (1.5 cm.), 
and care should be taken not to force the instrument through its thin 
walls. The syringe is attached to the cannula by rubber tubing, and 
the cavity thoroughly but gently irrigated. During this procedure 
the patient's head should be bent forward and the mouth opened to 
prevent the backward flow of the returning solution. 



PASSIVE HYPEREMIA IN DISEASES OF THE NOSE 343 

PASSIVE HYPEREMIA IN DISEASES OF THE NOSE AND 
ACCESSORY SINUSES 

The beneficial effects of passive hyperemia in the treatment of 
inflammations have aheady been discussed in Chapter IX, to which 
section the reader is referred for a full consideration of the subject 
and the technic of its application. According to Ballenger/ the indi- 
cations 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 tubal catarrh; (5) in chronic purulent inflammation of 
the sinuses. 

The hyperemia may be effected by means of a neck-band (as 
described on page 210) or by a special form of suction apparatus. 
The latter is more efiicacious in the presence of a purulent discharge, 
the vacuum serving to remove secretions as well as to induce a benefi- 
cial hyperemia; but it must be used with great care not to induce a 
harmful degree of hyperemia. The apparatus shown in Fig. 196 or 
one provided 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 close the 
naso-pharynx and nose from the pharynx, and a hyperemia of the 
mucous membrane of naso-pharynx, nose, accessory sinuses, and 
Eustachian tubes is thus induced. 

TAMPONING THE NOSE FOR THE CONTROL OF 
HEMORRHAGE 

Nasal hemorrhage may be the result of trauma, ulcerations, 
new growths, cardiac disease, certain constitutional diseases and infec- 
tions, diseases of the blood, etc. Usually the bleeding ceases spontane- 
ously or under simple treatment which aims at lessening the conges- 
tion of the nasal mucous membrane and favoring the formation of a 
clot, such as the appKcation of cold over the nose and at the base 
of the neck, removing tight collars, etc., from the neck,. or having 
the patient remain quietly in an upright position with the head 
erect, at the same time forbidding any attempts at blowing the nose. 

If these simple measures are insuf&cient, 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 

1 Ballenger: "Diseases of the Nose, Throat, and Ear." 



344 



THE NOSE AND ACCESSORY SINUSES 



be cauterized by touching with the electro-cautery or with silver 
nitrate; or else some styptic solution, as peroxid of hydrogen, a 
watery solution of tannic acid, or a i to looo solution of adrenalin 
chlorid should be appHed to the part upon a pledget of cotton. It 
may be impossible to locate the bleeding point, or the hemorrhage 
may continue in spite of such treatment, so that in the presence of 




Fig. 355. — Instruments for tamponing the anterior nares. i, Nasal applicator; 
2, head mirror; 3, narrow strip of gauze; 4, Myles' nasal speculum. 

a profuse hemorrhage it becomes necessary to pack the nose. In 
the majority of cases tamponade through the anterior nares will 
be sufficient; in others, the bleeding may occur posteriorly and the 
posterior nares as well will have to be packed. 

Instruments, etc. — To pack the nose from the front, a head mir- 




FlG. 356. — Catheter for drawing plug into the posterior nares. 

ror, a nasal speculum, a nasal applicator, and a single narrow strip of 
gauze should be provided (Fig. 355). 

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 
piece of silk thread is tied, the two ends, which should each be about 
28 inches (45 cm.) long, being left free. For the purpose of adjusting 



TAMPONING THE NOSE EOR CONTROL OF HEMORRHAGE 



345 



the tampon in place, a rubber urethral catheter of a size that will 
readily pass through the nose into the mouth (Fig. 356), or an instru- 
ment especially made for this purpose, known as Bellocq's sound 
(Fig. 357), will be necessary. This latter consists of a curved 
metal cannula containing a concealed steel spring, which is protruded 




Fig. 357. — Bellocq's cannula. 

into the pharynx and mouth when the cannula is in place in the nose, 
and to the end of which the tampon is then attached. 

Asepsis. — The instruments are boiled, and the gauze used for the 
tampon should be sterile. 




Fig. 358. — Showing the method of tamponing the anterior nares. 

Technic {Anterior Nares). — In tamponing the anterior nares a 
speculum is inserted in the nose and a good view of the interior 
obtained. A narrow strip of gauze, saturated with peroxid of hydro- 
gen, is then gently carried well back into the nose by means of an 
applicator, and by forcing in more gauze the whole nose is tamponed 



346 



THE NOSE AND ACCESSORY SINUSES 



and the hemorrhage controlled (Fig. 358). 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 




Fig. 359. — Showing the method of drawing a plug into the posterior nares by the 

aid of Bellocq's cannula. 




Fig. 360. — The posterior nasal plug in place. 

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. 

(2) {Posterior Nares). — The tampon, as already described, should 



TAMPONING THE NOSE EOR CONTROL OF HEMORRHAGE 347 

be well lubricated with sterile vaselin and placed near at hand. The 
Bellocq cannula is passed along the floor of the nose on the bleeding 
side until its tip appears back of the soft palate. The steel spring is 
pushed home and is protruded into the mouth. The tampon is then 
tied to the end of the carrier by one of the strings (Fig. 359), the 
spring returned 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. 360). In addition, it is 
well to pack the anterior nares with gauze or a plug of cotton, over 
which is tied the string protruding from the nose. The other end of 
the string, which is left in place for the purpose of removing the pack, 
is brought out through the mouth and loosely fastened to the ear. 
When an ordinary catheter is employed in place of a special sound, 
precisely the same technic is followed. 

The packing should be removed in twenty-four hours, since, if 
left in longer, it is apt to set up an irritation and may lead to infection 
of the Eustachian tube. To remove the pack, the string tied to the 
anterior 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 poste- 
rior plug is then removed by gentle traction upon the string. 



CHAPTER XIV 
THE EAR 

Anatomic Considerations 

The ear is divided into three portions: the external ear, the middle 
ear, and the internal ear. For the purposes of this work, a consid- 
eration of the anatomy of the external ear and the middle ear will 
suffice. 

The external ear comprises the auricle or pinna and the external 
auditory canal. 

The auricle is the irregular shaped mass composed of fibrocartilage, 
covered by perichondrium, connective tissue, and skin, which pro- 
jects from the side of the head. It has the function of collecting 
sounds and reflecting them to the external auditory meatus. The 




Fig. 361. — The left auricle, i, Concha; 2, antihelix; 3, fossa of antihelix; 4, helix; 
5, fossa of the helix; 6, tragus; 7, antitragus; 8, lobule. 

central depressed portion, resembHng a shell in form, is called the con- 
cha. It is bounded by a rim, the antihelix, which runs at first back- 
ward and then upward and forward, finally dividing into two arms. 
The space between these two arms is known as the fossa of the anti- 
helix. 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 antihelix and the helix is designated the fossa 
of the helix. The small backward projection lying in front of the con- 

348 



ANATOMIC CONSIDERATIONS 



349 



cha is called the tragus, and the small tubercle at the lowest portion 
of the antihelix, the antitragus. The lobule of the ear is the lowest 
soft pendulous portion of the auricle. 

The external auditory canal extends from the concha to the drum 
membrane. It serves the purpose of conveying sounds collected by 
the auricle to the drum membrane. The canal measures about 
I 1/2 inches (4 cm.) in length, the floor being slightly longer than the 
roof on account of the oblique position of the drum membrane. Its 
outer third is composed of cartilage, a continuation of that forming 
the auricle, while the inner two-thirds has a bony framework. The 
interior is lined with thin skin, which contains hair follicles and 
cerumenous glands, the latter being most abundant at the junction 



/top/' ct/" 7j//npanum. 



Cerumenous 
Glands 




EusituAiianTulc 

laid open 



Fig. 362. — Front view of the organ of hearing. (Randall.) 



of the cartilaginous and bony portions. The widest portion of the 
canal is near the external orifice, the narrowest portion near the 
center, and, beyond this, as it nears the drum membrane, the canal 
expands again. The direction of the canal traced from without 
inward is at first upward and forward, then backward, and finally 
forward and downward. By traction, however, in an upward, back- 
ward, and outward direction upon the auricle the canal may be 
straightened out and its interior viewed. 

The middle ear, or tympanum, is an irregularly shaped cavity 
situated in the petrous portion of the temporal bone, between the 
external and the internal ear. The interior of the cavity is lined with 
a delicate mucous membrane. Within it lie the chain of ossicles, the 
tympanic muscles, and the chorda tympani nerve. 



35° 



THE EAR 



The tympanic cavity is bounded above by the roof, consisting of a 
thin plate 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 wall composed of the drum membrane and the 
ring of bone into which it is inserted; by an inner wall which is con- 
tiguous to the labyrinth, and presents an oval window closed by the 
stapes and a round window closed by membrane; by an anterior wall 
which separates the tympanic cavity from the carotid canal, and in 
the upper part of which is the tympanic orifice of the Eustachian tube 
and above this the canal for the tensor tympani muscle; and by a 
posterior wall^ in the upper part of which lies the narrow opening 
leading into the mastoid antrum, the aditus ad antrum. The cavity 



Aditus 



Stapes, 




Incus 



Jilalleus 



Eustachian 
tube 



Fig. 363. — Anatomy of the ossicles. (Pyle's "Personal Hygiene.") 



is practically divided by the chain of ossicles into two portions, an 
upper epitympanic space or attic, and a lower cavity or atrium. 

The ossicles are three small bones, the malleus or hammer, the 
incus or anvil, and the stapes or stirrup, joined together by movable 
articulations, and forming an osseous chain between the drum mem- 
brane and the labyrinth. They are held in place by the attachment 
of the malleus to the membrana tympani and of the stapes to the 
oval window, and in addition by various ligaments extending between 
them and the bony walls. Their function is to convey sound waves 
from the drum to the labyrinth. 

The malleus consists of an oval head which extends upward and 
articulates with the incus, a neck, a manubrium or handle which 



ANATOMIC CONSIDERATIONS 35 1 

extends downward and is embedded in the membrana tympani, a 
short process, which extends outward from the neck to the membrana 
tympani and pushes the latter outward before it, and a long process 
which passes anteriorly into the Glaserian fissure. 

The incus is the middle ossicle. It consists of a body which artic- 
ulates with the malleus, a short horizontal process which extends to 
the posterior wall where it is 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 
oval window, to the membrane of which it is attached, two crura or 
legs, and a head which articulates with the orbicular process of the 
incus. 

The membrana tympani, or ear-drum, is a thin elastic membrane 




Fig. 364. — Outer surface of the right membrana tympani. (Gleason.) a, 
Membrana flaccida; h, posterior fold; c, short process; d, incudostapedial articula- 
tion; e, malleus handle;/, umbo; g, cone of light. 

stretched obliquely downward and inward across the inner end of the 
external auditory canal forming the outer wall of the tympanic 
cavity. The drum membrane is made up of three layers, an outer one 
of skin, a middle of fibrous tissue, and an inner formed by the reflec- 
tion of the mucous membrane of the middle ear. It serves the 
purpose of receiving and transmitting sound waves to the chain of 
ossicles. 

It may be described as elliptical in outline, and of a pearly gray 
color, but at the same time translucent. Its outer surface is concave 
and normally smooth. By the aid of a speculum and suitable illumi- 
nation there will be noted a whitish ridge formed by the handle of the 
malleus, running from a tubercle near the upper and anterior per- 
iphery downward and backward toward the center of the membrane. 
This tubercle represents the short process of the malleus. Where the 
handle of the malleus ends near the center of the membrane is a 
depression, the umbo. Under illumination in the anterior and lower 



352 THE EAR 

quadrant of the drum will also be noted a triangular area of light (the 
reflection of light) with its apex at the tip of the handle and its base 
at the periphery of the drum. Extending anteriorly and posteriorly 
from the short process of the malleus are two delicate folds of mem- 
brane which divide the drum into two portions. That portion above 
these folds is known as Shrapnell's membrane, or the membrana 
flaccida, and that below as the membrana tensor. 

The Eustachian tube is a canal about i 1/2 inches (4 cm.) long, 
connecting the pharynx with the tympanic cavity. It has a general 
direction from the tympanum forward, downward, and inward, 
opening upon the lateral wall of the 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 cartilaginous 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 consider- 
ably. Normally the walls are in apposition, but when the palatal 
muscles contract, as, for example, in the act of swallowing or yawn- 
ing, the walls are separated. The function of the Eustachian tube 
is to equalize the atmospheric pressure on the outer and inner sides 
of the drum, and to provide drainage for the tympanic cavity and 
mastoid cells. 

Diagnostic Methods 

A complete examination of the ear should comprise a clinical his- 
tory, an examination of the nasopharynx, and then an investigation 
of the ear itself. 

A history is quite essential, but it need not necessarily be an 
exhaustive one. It should first be ascertained what symptoms or 
symptom the patient complains of, and whether only one ear or both 
are affected. The duration of the trouble is also of importance, as it 
has considerable bearing upon the prognosis in any given case. The 
probable cause of the condition should also be determined as far as 
is possible by careful questioning. Among the many etiological 
factors of ear diseases are severe colds, grippe, some injury, insects, 
acute infectious diseases, syphilis, tuberculosis, etc. The symptoms 
or 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 



ANATOMIC CONSIDERATIONS 353 

former it should be learned whether the deafness developed slowly or 
suddenly, whether one or both ears are involved, and, if the latter be 
the case, which ear is more affected. The duration of the condition 
must also be ascertained. Not infrequently in the presence of 
chronic catarrh of the middle ear, the patient, while not actually deaf, 
will complain of certain disturbances of hearing, as, for example, the 
ability to hear better in the presence of noise, as on a railroad train or 
street car (paracusis Willisii), or hearing sounds as if repeated twice 
(paracusis duplicata), or, again, in the presence of marked unilateral 
deafness the inability to locate the source of sounds (paracusis 
localis) . 

Tinnitus, or subjective noises, are present in middle-ear diseases 
as well as affections of the internal ear, in neurasthenic conditions, 
arteriosclerosis, and may follow the taking of certain drugs, as, for 
example, quinin or the salicylates. They may be described by the 
patient as singing, whisthng, buzzing, loud and roaring or musical 
in character, or they may resemble voices. When present, it should 
be learned whether they are located in the ear or in the head, whether 
unilateral or bilateral, and whether they are modified by mental or 
physical exertion or by the time of day. As a rule they are worse at 
night, and in some cases they may be entirely absent during the day. 

In the presence of pain or earache, its character, the duration, 
and whether constant or intermittent should be noted. Pain may be 
the result of morbid conditions in the ear or it may be reflex, as, for 
example, from a decayed tooth, or from an inflammation of the 
pharynx, tonsils, etc. When it suddenly develops in an ear previously 
healthy it generally 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 destruc- 
tion of bone may be suspected. Pressure tenderness is also of diag- 
nostic importance in determining the origin of the trouble. Thus, 
pain caused by traction upon the auricle or by pressure on the tragus 
points to an inflammation involving the external auditory canal, 
tenderness elicited by pressure in the depression below the lobule of 
the ear to middle-ear inflammation, and pressure tenderness over the 
mastoid to involvement of that bone. 

The presence or absence of a discharge is next determined. With 
a history of a discharging ear, the length of time the discharge has 
lasted, the character of the discharge, whether serous, bloody, or 
purulent, whether scanty or in large amounts and whether continuous 
or intermittent should be noted. It is also important to ascertain if 
23 



354 THE EAR 

the discharge is accompanied by pain, and the relation the pain and 
the discharge bear to one another. 

In addition to the above points, the occupation and habits of the 
patient should be investigated as having an etiological bearing upon 
the case, and in certain cases a general physical examination should be 
made. One should never fail to investigate the condition of the nose 
and throat, especially the nasopharynx, noting the presence or 
absence of congestion, swelling of the mucous membrane, adenoid 
growths, ulcers, etc., and the condition of the pharyngeal ends of the 
Eustachian tubes. The technic of such examination has already been 
described in Chapter XIII. The parts in the vicinity of the ear 
should likewise be inspected as well as palpated for signs of inflamma- 
tion, swellings, new growths, enlarged glands, or signs of tenderness. 
Having completed these preliminaries, the actual examination of the 
ear should be instituted. 

The examination of the ear comprises (i) direct inspection of the 
external ear, (2) inspection of the external auditory canal and tym- 
panic membrane by the aid of specula, (3 ) determination of the 
mobility of the drum membrane, (4) various tests of the power of 
hearing, and (5) determination of the patency of the Eustachian 
tubes. la all cases the examiner should not fail to investigate the 
condition of both ears. 

DIRECT INSPECTION 

A thorough inspection of the auricle and external auditory canal 
should always precede the use of a speculum. In this way the exam- 
iner may be enabled to recognize pathological conditions at the 
entrance of the auditory canal that might otherwise escape attention 
or be hidden from view by the speculum. 

Instruments. — All that is required is suitable illumination. This 
may be furnished by means of an electric head light (see Fig. 311), or 
by means of light reflected upon the part by means of a head mirror. 

Position of Patient. — The patient is seated upon a stool with the 
ear to be examined turned toward the surgeon, who is also seated upon 
a stool of such height that his eyes are on a level with the ear of the 
patient. If reflected light is employed, the source of illumination 
should be a little above the level of the patient's ear and upon the 
examiner's left side. 

Technic. — Under full illumination the auricle is first carefully 
inspected, noting the presence or absence of excoriations from dis- 



OTOSCOPY 



355 



charges, eczema, swellings, deformities, new growths, etc. Then by 
means of traction upon the auricle in an upward and backward direc- 
tion, the external auditory canal is straightened out and a view of a 
considerable portion of its interior becomes possible. The examiner 
should note especially the color of the canal for signs of inflammation, 
the presence or absence of swellings, fissures, foreign bodies, new 
growths, etc. 



OTOSCOPY 

Otoscopy is the inspection of the external auditory canal and 
tympanic membrane by the aid of a speculum and suitable illumina- 
tion. By this means parts of the auditory canal and the drum mem- 
brane invisible to direct inspection may be viewed in detail, and the 
presence or absence of pathological conditions recognized. 

Instruments. — There will be required a strong light, such as is 
obtained from a Welsbach burner covered by a Mackenzie condenser, 




Fig. 365. — Instruments for otoscopy, i, Head mirror; 2, aural specula; 3, ear 
probe; 4, ear curet; 5, angular ear forceps; 6, ear syringe. 

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 (9 cm. 
to 10 cm.) in diameter with a central perforation for the eye, three 
sizes of metal aural specula, a fine ear curet, a probe, a pair of 
PoUtzer angular ear forceps, and an ear syringe (Fig. 365). If 
desired, in place of reflected light, illumination from an electric head 
light may be substituted. 

For purposes of examination Gruber's specula (Fig. 366) are most 
satisfactory, as they are elliptical in shape upon transverse section 
thus corresponding to a transverse section of the external auditory 
canal. Where, however, operative procedures are indicated a spec- 
ulum with a wide proximal end that will permit the manipulation of 



356 



THE EAR 



instruments, such as Boucheron's (Fig. 367) or Toynbee's is prefer- 
able. Electric-lighted specula^ (Fig. 368) are now used to a large 
extent, and simplify the operation considerably. 

Asepsis. — To avoid carrying infection from one patient to another 
the instruments employed in otoscopy should be boiled or immersed 





Fig. 366. — Gruber's speculum. 



Fig. 367. — Boucheron's speculum. 



in a I to 20 carbolic acid solution and then rinsed in sterile water 
and dried before use. 

Position of Patient. — The patient and examiner should be seated, 
the former with the ear turned toward the examiner. The examiner's 
eyes should be on a level with the patient's ear and in a horizontal 




Fig. 368.— Electric-lighted speculum. 

plane with the external auditory canal. If reflected light is employed, 
the source of illumination should be a little above the level of the 
patient's ear and upon the examiner's left. 

^ Manufactured by the Electro-Surgical Instrument Co. of Rochester, N. Y. , 
and the Wappler Co., New York City. 



OTOSCOPY 



357 



Technic. — The examiner directs the light full upon the external 
auditory meatus and, grasping the auricle between the thumb and 
index finger of the left hand (if the right ear is being examined and 
vice versa), makes traction in an upward, backward, and slightly 
outward direction, to straighten out the auditory canal. In infants, 
to accomplish this, it is necessary to pull the auricle outward and a lit- 
tle downward, as the wall of the canal has no bony support at this 
time and lies 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 of the auditory canal, by watching the 




Fig. 369. — Otoscopy with the reflector and ear specuhim. 
course of light. (Gleason.) 



The arrows represent 



parts illuminated at the distal 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. 369). 
Before examining the drum membrane, the external auditory 
canal should be inspected, noting its color, size and shape, and the 
presence or absence of foreign bodies, polypi, discharges, secretions, 
or cerumenous plugs. Signs of inflammation and furuncles should 
also be looked for. Sometimes secretions and collections of wax 
require removal before inspection is possible. This may be accom- 
plished, as a rule, by gently syringing the canal with warm saline 



i58 



THE EAR 



solution or a saturated solution of boric acid (see page 370). Small 
masses of wax and flakes may require removal by means of the curet, 
followed by gentle syringing. The ear is then thoroughly dried by 
means of small mops of sterile cotton held in angular forceps or 
wrapped about the tip of a probe. 

The examiner next inspects the drum membrane. It is placed at 
the distal end of the canal, inclining downward and inward at an angle 
of about 45 degrees. The normal drum appears translucent and of a 
pearly gray color, with its circumference appearing as a white line. 
Extending from above downward and backward in the upper half of 
the drum is seen the handle of the malleus. In the upper and anterior 
portion about 1/25 inch (i mm.) from the superior wall is the short 
process of the malleus, and running forward and backward above the 
short process are two folds of membrane above which lies Shrapnell's 
membrane. Extending from the tip of the malleus toward the per- 
phery, in the lower and anterior quadrant, will be noted the bright 




Fig. 370. — The appearance of the drum membrane as seen through the specukim. 

cone of reflected light. In addition to these landmarks normally to 
be 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 
localized opacities. The presence or absence of granulations or 
perforations should also be determined, the latter being evidenced by 
the greater depth of the drum at the point of perforation. Note also 
if the membrane is retracted or bulging with fluid. If retracted, the 
short process of the malleus appears more plainly, the handle is short- 



DETERMINATION OF MOBILITY OF DRUM MEMBRANE 359 

ened, and the conical folds are deepened. At the same time the cone 
of reflected Hght will appear altered in shape and displaced. If bulg- 
ing is present, its location should be noted. As a rule, bulging occurs 
in the posterior portion of the membrane, or the entire drum may be 
distended. If it occurs in the upper portion only, involvement of 
the attic is present. By changing the position of the speculum 
slightly all portions of the drum may be viewed in detail. By means 
of a cotton-tipped probe, inspection may be supplemented by careful 
palpation, if further information as to the conditions found is desired. 
In all manipulations of the speculum or instruments great gentleness 
should be observed. 

DETERMINATION OF THE MOBILITY OF THE DRUM 
MEMBRANE 

By the aid of a pneumatic otoscope with which the air in the exter- 
nal auditory canal may be alternately condensed or rarefied, it is pos- 
sible to determine the degree of mobility possessed by the membrana 




Fig. 371. — Siegle's pneumatic otoscope. 

tympani, and thus recognize undue rigidity or laxness of the drum or 
the existence of intratympanic adhesions binding the drum or ossicles 
to the walls of the tympanum. 

Apparatus. — Siegle's pneumatic otoscope (Fig. 371) consists of 
an air-tight chamber, the proximal end of which is closed by a plain 
glass window or convex lens placed at an angle of 45 degrees to the 
long axis of the instrument, while to the distal end may be screwed 
different sized specula. Upon the side of the air-tight chamber is 
placed a small perforated knob to which is attached a piece of rubber 
tubing and a hand bulb. The instrument may be obtained with an 
electric light in its interior or illumination may be supplied by an 
electric head light or reflected light from a head mirror. 



360 THE EAR 

Position of Patient. — The patient and the operator occupy the 
same relative positions as employed for an ordinary otoscopic exam- 
ination (see page 356) . 

Asepsis. — The speculum portion of the instrument should be 
sterilized by boiling. 

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 ordinary speculum. A 
small piece of rubber tubing may be slipped over the end of the specu- 
lum, if necessary, to insure its fitting the auditory canal more accu- 
rately. The examiner then observes under good illumination the 
movement of the drum membrane through the window in the oto- 
scope, as he relaxes or compresses the bulb. As the air is rarefied, the 
drum is sucked outward and becomes convex in shape. As the air 
is condensed by compression of the bulb, the drum membrane 
moves inward and becomes more concave. The presence of adhe- 
sions will be evidenced by absence of any mobility at that particu- 
lar point, while other parts of the drum will move freely. Too ener- 
getic use of the instrument must be avoided for fear of rupturing 
a weakened drum. 

HEARING TESTS 

Hearing tests are very important in the diagnosis of ear diseases, 
since they not only furnish information as to the extent the hearing is 
impaired, but also serve to localize the seat of a lesion, that is, whether 
in the conducting apparatus or in the nervous mechanism. While 
there have been a number of hearing tests devised, the following are 
sufficient for all practical purposes: (i) testing the acuteness of hear- 
ing by means of the watch and voice, (2) testing the perception of high 
and low notes, (3) Weber's, and (4) Rinne's test. 

Apparatus. — While it is of advantage to have a complete set of 
tuning-forks, the ordinary tests may be carried out with a low tone 
fork (C-2) having thirty-two vibrations per second, a Galton's whistle 
for high tones, and a C 2 fork having 512 vibrations per second 
for Weber's and Rinne's tests. Galton's whistle gives tones ranging 
from about 7000 vibrations per second to the highest perceptible tone 
limit. The instrument is provided with a scale and screw whereby 
the nimiber of vibrations may be regulated so as to give any tone 
wnthin the Hmits stated above. 

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 



HEARING TESTS 



361 



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 
separately in the following manner: The patient is seated in a chair 



A ^ 



W/ 



n 



WW 



'J 



n 



/ V 



c. 




Pig. 372. — Hartmann's set of tuning-forks vanning from 128 vs. to 2048 vs. 

with his eyes closed, and with his forefinger closing the ear not under 
examination. The examiner first holds the ticking watch close to 
the ear being tested so that the patient can hear it distinctly and then 
slowdy brings it from a distance beyond the range of hearing power 
toward the ear in a line perpendicular to the auricle until the patient 




Fig. 373. — Edelmann's modification of Galton's vv-histle. 

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 



362 THE EAR 

and the numerator the number of inches it is heard by the ear under 
examination. For example, if the watch is heard at forty inches (100 
cm.) by the normal ear and the patient hears it at ten inches (^25 cm.) 
the result is expressed as 10/40. 

2. The Voice Test. — The patient is seated in a large room with the 
eyes closed and the ear not under examination plugged with the fore- 
finger. The examiner then repeats words of one syllable or numerals 
in an ordinary voice and also in a whisper at the end of expiration with 
the residual air from various distances, and measures the distance at 
which the patient can hear and repeat them correctly. The result is 
expressed in a fraction of feet, the denominator of which represents 
the distance in feet at which the normal ear can hear the voice and 
the numerator the actual distance at which it is heard by the ear 
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 16 and 48,000 
vibrations per second. The majority of individuals, however, possess 
a more Kmited 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 differentiating between disturbance of 
hearing due to affections of the conducting and those of the percep- 
tive apparatus. Where the conduction apparatus is at fault high 
tones are heard better than low, while in diseases of the perceptive 
apparatus, the low tones are heard well, but high-tone hearing is lost 
or diminished. It should be remembered, however, that in advancing 
age the upper tone limit is lowered. 

Weber's Test. — It is employed for the purpose of locating the 
seat of unilateral deafness. In this test a C 2 (512 vs.) fork is set 
vibrating and the handle is placed on the incisor teeth or upon the 
cranium in the mid-line. If the sound is heard best in the affected 
ear. it is indicative of some aft'ection 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 normal ear. 

Rinn6's Test.- — This test depends upon the fact that aerial con- 
duction 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 



IXFLATIOX OF THE MIDDLE EAR 363 

"hears any sound, and. if the fork is then brought close to the external 
ear. the sound will again be heard. This is known as a positive Rinne. 
If. however, the sound is not heard again when the fork is thus trans- 
posed, it is known as a negative Rinne. Therefore, in a deaf ear, if 
we obtain a positive Rinne, it is indicative of a lesion in the perceptive 
apparatus, while if, under the same conditions, the test is negative, 
it shows that bony conduction is increased; i.e., there is some obstruc- 
tion or disease of the conduction apparatus. 

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 pat- 
encv of the Eustachian tubes, that is, whether or not an unobstructed 
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- 
ence of a perforation of the membrana tympani; and to determine the 
mobility of the membrana tympani. The therapeutic uses of infla- 
tion will be considered later (see page 376). 

An auscultatory tube is employed in conjunction with inflation 
for the purpose of determining whether air enters the middle ear and 
to distinguish the character of the sound produced which is of diag- 
nostic importance. Thus, in a normal condition of the Eustachian 
tubes and tympanic cavity, air -^^11 be heard to enter the middle ear 
with a soft blowing sound; if the tube be obstructed, the sound will 
have a more or less whistling character, while, if the obstruction is not 
overcome, air will not be heard to enter the middle ear at all and the 
sound wiU 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 flne bubbflng sound will be heard; if it is thick and 
\'iscid, the sound wiU be a coarse bubbling one. In the presence of a 
perforation of the membrana tympani, inflation causes a characteris- 
tic hissing or whistHng sound and often secretion will be forced out 
through the perforation into the external auditory canal. By the aid 
of a speculum, the drum may be inspected and the efl'ect of the infla- 
tion upon it noted and the mobihty determined. 

There are three methods by which the middle ear may be inflated: 
(i) Valsalva's method, (2) PoKtzer's method, and (3) catheteriza- 
tion. Before practising inflation it is a wise precaution to inspect the 
ear-drum to see if it is suf&ciently strong to stand the strain, as cases 



364 THE EAR 

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 all 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 330). 

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 
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, wath the risk of producing a flaccid con- 
dition of the drum unless the patient is cautioned against its overuse. 

Apparatus. — There will be required a head mirror and some 
source of illumination, or an electric head light, aural specula, and an 




Fig. 374.. — Aural stethoscope. 

aural stethoscope. The latter instrument (Fig. 374) 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 exam- 
iner's ear and a black one to fit into the patient's ear. 

Asepsis. — The specula and ear pieces of the aural stethoscope 
should be sterile. 

Technic. — The patient's mouth should be shut and the nostrils 
held closed by the fingers. Then the patient is instructed to give a 
forced expiration and at the same time swallow. The act of swallow- 
ing causes the tubes to relax, and the air, under pressure, is thus 
forced through the tubes into the middle ear. As this occurs the 
patient will have a feehng of distention in both ears, and the exam- 
iner by means of the aural stethoscope will hear the sound of air en- 
tering the middle ear. If the drum membrane is inspected as the 
inflation is performed, it will be noticed that the membrane moves 
outward and becomes somewhat congested. 



INFLATION OF THE MIDDLE EAR 



365 



Politzer's Method. — This is probably the most frequently 
employed 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 PoUtzer air-bag (Fig. 375). The Politzer air-bag con- 
sists of a soft pear-shaped bag of such size and shape that it can be 
readily compressed in the operator's hand, supphed 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 and the specula should be sterilized 
by boiling before use. The ear pieces of the aural stethoscope should 
also be sterile. 

Technic. — The patient is first given a small amount of water — 
about a teaspoonful is sufficient — which he is instructed to hold in his 




Fig. 375. — Instruments for Politzer's method of inflation. i, Head mirror; 2, 
aural specula; 3, aural stethoscope; 4, Politzer inflation bag. 



mouth until told to swallow. The examiner then inserts the nose- 
piece of the PoHtzer bag into one nostril for a distance of about 
1/2 inch (i cm.), and compresses both nostrils about it by means of 
the left thumb and forefinger. The patient is then told to swallow, 
and, as the larynx is seen to rise up at the commencement of the act 
of swallowing, the examiner compresses the air-bag with his right 
hand (Fig. 376). The act of swallowing causes the soft palate to rise 
upward and shut oft' the naso-pharynx, and, at the same time, the 
Eustachian tubes tend to open so that the air is readily forced through 
the tubes into the middle ear. In children crying has the same 
eft'ect as swallowing. 

With the auscultatory tube the character of the sound produced 
is recognized. When it is desired to inflate only one ear, the patient's 
head should be turned to one side, so that the aft'ected ear lies upper- 



366 



THE EAR 



most, while at the same time the opposite ear is closed by the fingers 
pressed against the external auditory meatus. In using Politzer's 
bag care should be taken not to use a great amount of force and 
thereby avoid causing the patient pain. 

Catheterization. — Inflation through an Eustachian catheter is 
only indicated when inflation by the methods previously mentioned is 
impossible. The passage of a catheter into the Eustachian tube is a 
delicate operation requiring skill as well as gentleness of touch for its 
safe and successful performance. If carelessly performed, there is 
danger of injuring the mucous lining of the tube or of making a false 
passage and injecting air into the submucous tissues of the tube, an 




Fig. 376. — Inflation by Politzer's method. 



accident from which deaths from respiratory obstruction have been 
reported. In certain cases it may be impossible to perform catheteri- 
zation, as, for example, in the presence of marked deviations of the 
septum, considerable narrowing of the nasal fossae, tumors, or ade- 
noids, and in nervous or hysterical individuals or in those upon whom 
attempts to pass the catheter excite coughing, retching, or spasm of 
the pharyngeal muscles. 

Apparatus. — There will be required a head mirror and suitable 
illumination or an electric head Hght, aural specula, an aural stetho- 
scope, a Politzer air-bag with an Eustachian catheter tip, and several 
sizes of Eustachian catheters (Fig. 377). The catheter is a metal 
tube 6 1/2 inches (16 cm.) long, curved at its distal end, the extreme 
tip of which is slightly bulbous, and with an expanded proximal end 



IXPLATIOX OF THE MIDDLE EAR 



367 



into which the tip of a PoHtzer bag may be fitted. It should be of 
pure silver so that its curve may be changed to fit the individual case. 
A ring is placed upon the side of the instrument near its proximal 
end to indicate the direction of the beak. Three sizes should be pro- 
vided 1/25, 1/12, 1/8 inch (i, 2, and 3 mm.) in diameter, respectively. 

Asepsis. — The catheter and the specula should be sterilized by 
boiling; the ends of the aural stethoscope should be likewise sterile,, 
and the hands of the operator should be cleansed as for any operative 
procedure. 

Anesthesia. — In sensitive individuals the nose may be anesthe- 
tized by means of a small amount of a 4 per cent, solution of cocain 
apphed by means of a cotton-tipped probe to the inferior meatus. 




=^ 



Fig. 377. — Instruments for inflation through an Eustachian catheter, i, Head 
mirror; 2, aural specula; 3, aural stethoscope; 4, Politzer's inflation bag; 5, Eusta- 
chian catheters. 



Technic. — The operator fijst inspects the nose by the aid of 
illumination for the presence of deviations of the septum or other 
pathological conditions which might interfere with the passage of the 
catheter. The catheter may then be inserted by one of two methods : 

I. Louenherg Method. — The proximal end of the lubricated cathe- 
ter is grasped Hghtly between the thumb and forefinger of the right 
hand, while by means of the thumb of the left hand, the tip of the 
patient's nose is elevated so as to straighten out the canal. The 
beak of the instrument is then introduced within the anterior nares, 
the shaft of the instrument being in an almost vertical position (Fig. 
378). The catheter is then elevated to a horizontal position, and, 
with the tip kept constantly in contact with the floor of the nose, it is 
gently pushed inward until the beak comes in contact mth the pos- 
terior wall of the pharynx (Fig. 379). The beak is then rotated 



368 



THE EAR 



through an angle of 90 degrees toward the median line, until the guide 
ring lies horizontal, and the catheter is drawn forward until its beak 
is found to impinge upon the nasal septum (Fig. 380). The beak is 




Fig. 378. — Catheterizing the Eustachian tube. First step, showing the position 
of the catheter for its introduction. 




Fig. 379. — Catheterizing the Eustachian tube. Second step, catheter being 
passed along the floor of the nose. 

then rotated downward and outward through an angle of a little 
more than 180 degrees until the guide ring points toward the outer 



INFLATION OF THE MIDDLE EAR 



369 



can thus of the eye; at the same time the proximal end of the catheter 
is moved toward the nasal septum, and its tip thus enters the Eu- 
stachian tube (Fig. 381). In all these manipulations care should be 




Fig. 380. — Showing the different positions of the beak of the catheter in its in- 
sertion into the orifice of the Eustachian tube. (After Barnhill and Wales.) 

taken to employ the greatest gentleness. The entrance of the 
catheter into the tube will be recognized by the fact that the tip is 
firmly fixed and cannot be rotated. The catheter is now held 




Fig. 381. — Catheterizing the Eustachian tube. Third step, showing the position 
of the guide when the catheter tip is entering the orifice of the tube. 

in place by the thumb and forefinger of the left hand, the other fin- 
gers resting upon the bridge of the nose, and, with the nozzle of the 
air-bag fitted into the proximal end of the catheter, inflation is per- 
24 



37° 



THE EAR 



formed by compressing the bag in the fingers of the right hand (Fig. 
382). While this is done the examiner notes the sound produced by 
means of the auscultation tube. 

In removing the catheter it is first rotated until its back points 
downward and is then gently withdrawn by a reversal of the move- 
ments employed in its insertion. 

2. Binnajont or Kramer Method. — The instrument is introduced 
in the same manner as described under the Lowenberg 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 degrees 
which causes its tip to rest in Rosenmiiller's fossa. The catheter is 




Fig. 382. — Inflation through an Eustachian catheter. (Gleason.) 



then withdrawn until its tip is felt to slip over the bulging posterior 
lip of the Eustachian mouth when its tip will be at the pharyngeal 
orifice of the tube. The distance it is necessary to withdraw the 
catheter to accomplish this varies usually between 1/4 to 3/8 inch 
(6 to 9 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 is performed as described above. 



Therapeutic Measures 
THE EAR SYRINGE 

Syringing of the ear is employed for the purpose of removing 
foreign bodies or cerumenous masses from the external auditory canal 



THE EAR SYRINGE 



371 



and to keep the ear free from purulent material which collects after 
perforation or incision of the drum membrane. In using an ear 
syringe one must always employ extreme gentleness and solutions of 
the proper temperature, otherwise the procedure is not only rendered 
painful, but is capable of causing harm. Especially is it necessary 




Fig. 383. — Allport's ear syringe. 

to avoid forcible injections in cases where the tympanum is exposed 
through destruction of a considerable portion of the drum membrane. 
The Syringe. — The syringe should be simple in construction and 
of such material that it may be easily sterilized, and should have a 
capacity of i or 2 ounces (30 to 60 c.c). It should be provided with 
a blunt conical nozzle — the ordinary olive-shaped tip is not to be 
commended, as it interferes with a free return flow. A syringe with 




Fig. 384. — Metal ear syringe with a small nozzle. 

a long-pointed nozzle, such as is shown in Fig. 384, will often be found 
more efficacious in removing foreign bodies than the ordinary 
syringe. 

For irrigating the internal ear through a perforation in the attic, 
a smaller syringe, such as Blake's (Fig. 385), with a capacity of 1/2 
dram (2 c.c), provided with specially bent tips, is used. There will 
be required, in addition, suitable illumination, aural specula, and an 
aural applicator. 



372 THE EAR 

Asepsis. — The syringe and nozzle as well as the specula and 
applicator should be sterilized by boiling before being used, and the 
solution used should be sterile. 

Solutions Used. — Normal salt solution (oi (4 gm.) of salt to a 
pint (500 c.c.) of boiled water), a saturated solution of boric 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. (t,8° C). Cold solution should never be 
used, as it is apt to cause, vertigo or fainting. 

Quantity. — For the purpose of removing foreign bodies or wax, 
I or 2 syringefuls of solution are usually sufficient. When syringing 
is employed in cases of otorrhea, much larger quantities are neces- 
sary, as much as 1/4 to i pint (125 to 500 c.c.) being required at a 
time. 

Frequency. — This will depend upon the virulence of the infection 




Fig. 385. — Blake's tympanic .syringe. 

and the amount of discharge. When the latter is very profuse, 
syringing may be indicated three or four times a day or oftener. 

Position of Patient. — The patient is seated with the head held 
erect. 

Technic. — The patient's clothing is protected by means of a towel 
secured about the neck and by having him hold a small glass basin 
below the auricle to receive the returning fluid. The operator then 
grasps the auricle between the left thumb and forefinger and draws it 
upward and backward, so as to straighten out the external auditory 
canal. With the right hand he then introduces the nozzle of the 
syringe into the external canal in such a way that the tip of the 
syringe rests against the superior wall of the canal, so that the solu- 
tion, as it is injected, will pass along the upper wall and wash. out 
purulent matter or foreign material below (Fig. 386). The solution 
is then injected with only a small amount of force in sufficient quanti- 



INSTILLATIONS 373 

ties for the purpose of the operation. Should dizziness or syncope 
supervene, the operation should be immediately stopped. 

At the completion of the syringing all moisture is removed by 
means of a cotton-tipped probe and, in the presence of a discharge, a 
strip of sterile gauze is lightly placed in the external canal. 

In cases where it is necessary to cleanse out the attic through 
a perforation, the drum is exposed by the aid of a speculum and 
good illumination, and Blake's angular cannula is inserted through 




Fig. 386. — Washing impacted cerumen from canal. Showing how to hold auricle 
to straighten the canal and where to direct the stream of water. (Gleason.) 

the perforation under direct vision. The cavity is then carefully 
cleansed by gentle syringing. 

INSTILLATIONS 

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 granula- 
tions 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. 

Instruments. — To instil a solution into the external auditory 
canal, an ordinary glass medicine dropper may be employed. For 



374 



THE EAR 



tympanic instillations a pipette glass dropper with a small curved 
tip, a head mirror and illumination, and an aural speculum will 
be required (Fig. 387). 




Fig. 387. — Instruments for tympanic instillation. i, Head mirror; 2, aural 
specula; 3, glass instillator. 



use. 



Asepsis. — The instruments should always be sterilized before 
Solutions. — Solutions of silver nitrate 5 to 20 per cent., copper 




Fig. 388. — vShowing nozzle of a pipette inserted for a tympanic instillation. 

sulphate 5 per cent., zinc sulphate 5 per cent., alcohol 25 to 95 per 
cent, may be used. 

Temperature. — The solutions should always be warm — at about 
100° F. (38° C). 



APPLICATION OF CAUSTICS 



375 



Position of Patient. — The patient should be seated with the head 
bent sideways so that the affected ear hes uppermost. 

Technic. — The ear is first cleansed and all secretion or fluid re- 
moved by means of a cotton-tipped probe. The operator then 
straightens out- the external auditory canal by grasping the auricle 
between the thumb and forefinger of the left hand and exerting trac- 
tion in an upward and backward direction. With the right hand he 
then instils 5 to 10 drops (0.3 to 0.6 c.c.) of the desired solution into 
the auditory canal. This is retained for from five to ten minutes, or 
for a shorter time if it causes burning or pain, and is then permitted 
to escape by having the patient incline the ear downward. 

In making intratympanic instillations the auditory canal is first 
cleansed and the drum is exposed by means of a speculum. The 
point of the pipette is then carefully inserted through the perforation 
and a few drops of weak solution are injected (Fig. 388). 



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 




Fig. 389. — Instruments for applying caustics to the ear. i, Head 
aural specula; 3, aural probe; 4, applicator. 



mirror; 2, 



frequently employed agents for this purpose are chromic acid or 
silver nitrate. They are applied fused upon the tip of a deHcate ear 
probe. In making such appHcations with strong chemicals great 
care must be taken that the caustic only comes in contact with the 



376 THE EAR 

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. 389). 

The method by which the acid or silver nitrate is fused upon the 
probe has been previously described (see page 334). 

Asepsis. — The instruments should be boiled before use. 

Position of the Patient. — The patient and the operator are seated 
in the same relative positions as for an ordinary otoscopic 
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 carefully applied to the area it is desired to destroy. 

INFLATION OF THE MIDDLE EAR 

The value of inflation in diagnosis has been previously considered 
(see page 363). As a therapeutic measure it is employed in tubal and 
middle-ear disease with occlusion of the tube for the purpose of re- 
storing the normal tension between the drum membrane, ossicles, 
and the internal ear. The circulation is thus improved and hyper- 
emia and infiltration of the tubal and tympanic mucous membrane is 
diminished. At the same time morbid secretions are removed from 
the Eustachian tube and tympanic cavity, and newly formed ad- 
hesions are broken down. 

The methods by which inflation may be performed and the technic 
will be found described on page 364. 

INFLATION WITH MEDICATED VAPORS 

In certain cases of subacute or chronic nonsuppurative otitis 
media, inflation with medicated vapors is often employed to better 
advantage than plain air. The vapor of drugs having either a seda- 
tive or stimulating action may be used. In this way all the benefits 
of inflation plus the sedative or stimulating effect of the vapor upon 
the mucous membrane are obtained. 

Apparatus. — A vaporizer, in which the air current passes over the 
volatile drug it is desired to employ, attached to an Eustachian cath- 



INJECTION OF SOLUTIONS INTO EUSTACHIAN THE TUBES 377 

eter, forms the necessary apparatus. There are a number of con- 
venient vaporizers, such as Hartmann's, Pynchon's, or Dench's 
(Fig. 390). The latter apparatus is especially useful, as plain air 
or medicated vapor may be obtained by simply turning a key on the 
top of the bottle. 

Asepsis. — The catheter should be sterilized by boiling before use. 

Formulary. — Vapors of menthol, camphor, eucalyptol, iodin, 
turpentine, chloroform, and ether alone or in combination are most 
frequently employed. 

Preparation of Patient. — Same as for catheterization (see page 

364). 

Position of Patient. — Same as for catheterization (see page 364). 
Technic. — The Eustachian catheter is passed by one of the 




Pig. 390. — Dench's vaporizer and Eutachian catheter. 

methods described on pages 367 and 370 and with all the precautions 
detailed therein. Inflation with air is then performed in order to 
first force out from the tube any collection of mucus or secretion and 
thus permit 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 advan- 
tage in the treatment of middle-ear catarrh for the purpose of lessen- 
ing 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. 



378 



THE EAR 



Apparatus. — There will be required an Eustachian catheter, a 
small syringe, graduated in drops, and provided with a tip that will 
fit into the proximal end of the catheter (Fig. 391), and a Politzer 
air-bag. 

Asepsis. — The catheter and syringe should be boiled, and the 
solution employed should be a sterile one. 

Solutions Used. — lodid of potassium 5 gr. (0.32 gm.) to the 
ounce (30 c.c), silver nitrate 2 to 5 gr. (0.13 to 0.32 gm.) to the ounce 
(30 c.c), sulphate of zinc i gr. (0.065 S^i-) to the ounce (30 c.c), 
protargol 10 to 50 per cent., bicarbonate of soda 2 to 5 gr. (0.13 to 
0.32 gm.) to the ounce (30 c.c), etc., may be employed. 

Quantity. — About five to ten drops (0.3 to 0.6 c.c) of the 
selected drug are injected at a time. If perforation of the drum 




Fig. 391. — Eustachian catheter and sj^ringe for medication of the Eustachian 

tubes. 

exists more solution may be safely used, but in its absence small 
amounts only are applicable. 

Preparation of the Patient. — Same as for catheterization (see 
page 364). 

Position of Patient. — Same as for catheterization (see page 364). 

Technic. — The catheter is introduced into the tube by one of the 
methods described on pages 367 and 370 and the ear is inflated by the 
Politzer bag to empty it of secretion. The small syringe is then 
charged with the warmed solution, and the desired amount is slowly 
injected through the catheter. The air-bag is then substituted for 
the syringe and the solution is blown into the tube. 



THE EUSTACHIAN BOUGIE 

Eustachian bougies are employed in overcoming tubal obstruc- 
tions which will not yield to inflation and for the purpose of dilating 
tubal strictures. In the latter condition, however, the use of the 
Eustachian bougie is rarely curative if the stricture is composed of 
dense connective tissue. 



THE EUSTACHIAN BOUGIE 379 

The bougie is passed into the tube through a catheter, and it 
should always be inserted with the greatest care and gentleness, as 
it is a very easy matter to injure the mucous membrane with the result 
that, if inflation be immediately performed, air may be forced under 
the mucous membrane through the tear and cause emphysema. It 
is, therefore, advisable to wait a day or two after passing the bougie 
before inflation is attempted. Care must also be observed not to 
pass the bougie a greater distance than the length of the tube; that 
is, not more than i 1/4 inches (3 cm.) beyond the tip of the catheter. 



Fig. 392. — Instruments for dilatation of the Eustachian tubes, i, Eustachian 
catheters; 2, Eustachian bougies; 3, Politzer's inflation bag. 

Instruments. — There will be required an Eustachian catheter, 
Eustachian bougies, and a Politzer air-bag (Fig. 392). The bougies 
are made of silkworm gut or whalebone, with tips conical or bulbous 
in shape, and varying in diameter from 1/64 to 1/25 inch (0.4 mm. 
to I mm.). The catheter used to guide the bougie into the tube 
should be somewhat shorter than ordinary with a longer curved beak. 

Asepsis. — The catheters are sterilized by boiling and the bougies 
by immersion in a saturated solution of boric acid. 




Fig. 393. — Showing the bougie inserted in the catheter ready to be passed into 

the Eustachian tube. 

Frequency, — Bougies should not be inserted more frequently 
than two or three times a week in order to permit the reaction from 
one insertion to subside before another is attempted. 

Preparations of Patient. — Same as for catheterization (see page 

364). 

Position of Patient. — Same as for catheterization (seepage 364). 

Technic. — The bougie is lubricated and is introduced within the 
catheter until the tip is level with the distal end of the catheter (Fig. 
393). The catheter, with the bougie in place, is then introduced 



380 THE EAR 

into the tube in the manner described on page 367. 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 the bougie passes into the Eustachian tube, the patient will com- 
plain 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 
resistance is encountered, the bougie should be pushed forward 
slowly and with great caution, occasionally rotating the bougie; 
forcible manipulations must always he avoided for fear of injuring the 
mucous membrane. Having successfully 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 dip- 
ping a silkworm-gut bougie in some astringent solution, such as 
silver nitrate, before its passage, often has more pronounced and more 
prolonged 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 TYMPANI 

Massage of the ear-drum is performed by alternately rarefying 
and condensing the air in the external auditory meatus. This produces 
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 all cases 
an accurate diagnosis is the first essential, otherwise massage may 
result in harm. It should be avoided in all cases of relaxed drum or 
where portions of the membrane are atrophic. In the latter condition 
the atrophied weakened portion will move under the influence of 
suction while the rest of the drum will be unaffected. 

Apparatus. — The massage is performed with the Siegle type of 
instrument (see Fig. 371), by means of which the drum membrane 
may be observed and the effect of the manage noted. 

Asepsis. — The speculum portion of the instrument should be 
sterile. 



INCISION OF THE MEMBRANA TYMPANI 38 1 

Duration. — The massage may be applied for one to two minutes 
at a sitting. 

Frequency. — Treatments should be given two to three times a 
week, but only so long as improvement in distance hearing takes 
place. 

Technic. — The otoscope is introduced into the ear in the manner 
described on page 360, and the air is alternately rarefied and con- 
densed by relaxation or compression of the bulb. The amount of 
pressure used should be regulated by noting the effect upon the mem- 
brane 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 thereby preventing necrosis 
of the membrana tympani and tympanic contents. It is also indi- 
cated 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, exten- 
sive destructive changes may have occurred and the process may 
rapidly extend to the mastoid antrum or to the cranial cavity. 
Finally, early incision is always indicated 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 
sufficient size to afford free drainage for the products of suppuration, 
varying according to the age of the individual, 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 
paracentesis knife (straight or angular), and an ear syringe (Fig. 

394). 

Asepsis. — The instruments should be sterilized by boiling, and 
the operator's hands cleansed as thoroughly as for any operation. 

Preparations of Patient. — The external auditory canal should be 
thoroughly cleansed by syringing with warm saturated boracic acid 
solution or with a i to 5000 bichlorid of mercury solution. 



382 



THE EAR 



Anesthesia. — The operation is quite painful. In children general 
anesthesia by chloroform is indicated, while in adults nitrous oxid 
gas or some form of local anesthesia may be used. Local anesthesia, 
by means of a solution of cocain applied to the unbroken mem- 
brane, is not satisfactory, as the cocain is not absorbed. Instead, 
the following mixture may be employed: 

T^. Cocain hydrochlorate, gr. vi (0.4 gm.) 

Anilin oil, 
Alcohol, aa 3i (4 c.c.) 

A small amount of this solution is instilled into the external auditory 
canal and is allowed to remain for lifteen minutes. It must be used 




Fig. 394. — Instruments for incising the drum membrane, i, Head mirror; 2, 
aural specula; 3, angular paracentesis knife; 4, Allport's ear syringe. 

with great care if a perforation be present, as it will 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 in the postero-inferior 
quadrant, and the posterior quadrant of the drum is incised in a 
curve upward to the tympanic vault (Fig. 395). In doing this, the 
knife should only be inserted through the drum membrane, so as to 
avoid injuring the inner tympanic wall which lies distant 1/12 
to 1/6 inch (2 to 4 mm.). Of course, if there is any localized bulg- 



INCISION OF THE MEilBRANA TYMPANI 



383 




Fig. 395. — Incision of the membrana tympani in acute otitis media involving the 
lower portion of the tympanic cavitj*. (Dench.j 




Fig. 396. — Incision of the membrana tA^mpani in acute otitis media, involving the 
upper portion of the tympanic cavitj'. (Dench.) 



384 THE EAR 

ing, the incision should be so placed as to relieve it. When the tym- 
panic vault alone is involved, the knife is entered in the posterior 
quadrant opposite the short process of the malleus and the incision 
is carried upward through Shrapnell's membrane. The knife is then 
turned backward, and, as it is wTithdrawn, the tissues of the posterior 
wall of the auditory canal are incised down to the bone for a distance 
of about 1/8 inch (3 mm.) from the drum (Fig. 396). In this way 
tension in the tympanic vault and mastoid is relieved. 

The ear is then carefully cleansed by syringing and, after being 
well dried, is loosely packed with gauze. 

After-treatment. — The ear should be syringed with a warm i to 
5000 bichlorid of merciiry solution as often as secretion collects. At 
first, this will necessitate syringing every two or three hours. As the 
discharge decreases, longer intervals may elapse. 



CHAPTER XV 
THE LARYNX AND TRACHEA 

Anatomic Considerations 

The larynx is that portion of the upper air passages extending 
between the base of the tongue and the trachea. It lies in the median 
line of the neck, opposite the fourth, fifth, and sixth cervical verte- 
brae. Anteriorly, it is practically subcutaneous; posteriorly, it 
forms part of the anterior boundary of the pharynx; while on either 
side of it lie the great vessels of the neck. Above, it is broad and 
triangular in shape, while below it is narrow and cylindrical. 

The framework, consisting of a number of cartilages held together 
by ligaments, 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 respiration and phonation. The most important of these 
cartilages are the thyroid, the epiglottis, the cricoid, and the two 
arytenoids. 

The thyroid cartilage is the largest of all, and consists of two 
broad lateral alas 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; an opening made through this 
space gives easy access to the larynx below the vocal cords. 

The epiglottis is a leaf-shaped piece of elastic cartilage i 1/3 inches 
(3.5 cm.) long, guarding the superior entrance of the larynx. It is 
attached by its stalk to the upper and posterior aspect of the angle 
between the thyroid alae and to the hyoid bone by ligaments. It 
lies directly behind the tongue, and in swallowing it is pushed back- 
ward by the bolus of food, closing more or less completely the laryn- 
geal 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 supe- 
rior border on either side it supports the arytenoid cartilages. 
25 385 



386 



THE LARYNX AND TRACHEA 



The arytenoid cartilages, two in number, are irregularly pyram- 
idal in shape and rest by their bases on the superior border of the 
cricoid cartilage. They rotate upon a vertical axis and also move 
laterally. Through these movements the vocal cords are approxi- 
mated or drawn apart. 

The Interior of the Larynx. — The superior opening is wide and 
semicircular in front where it is bounded by the epiglottis. The 
sides are formed by the arytenoepiglottic folds of mucous membrane 
which run from the sides of the epiglottis to the tops of the arytenoid 
cartilages and gradually approach posteriorly, so that the opening is 




Fig. 397. — Anterior view of the larynx. (After Deaver.) i, Epiglottis; 2, 
lesser cornu of hyoid bone; 3, greater cornu of hyoid bone; 4, thyrohyoid mem- 
brane; 5, thyroid cartilage; 6, cricothyroid membrane; 7, cricoid cartilage; 8, 
trachea. 



narrowed behind. More or less distinct nodular prominences 
formed by the cuneiform and corniculate 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 into two por- 
tions by the vocal cords — above, into the supraglottic region, and, 
below, into the subglottic region. The vocal cords consist of two 
delicate bands of elastic tissue enclosed in thin layers of mucous mem- 
brane having a whitish appearance. They are attached anteriorly 
to the thyroid cartilage and posteriorly to the arytenoids. They 
measure about 3/4 inch (2 cm.) in length in the male, and 1/2 inch 
(i cm.) in the female. Between the two cords is a long narrow 



ANATOMIC CONSIDERATIONS 



387 



chink, the glottis. Above and parallel to the vocal cords are two 
second folds of mucous membrane enclosing ligamentous tissue,. 
attached to the thyroid cartilage in front and to the two arytenoids 
behind, commonly called the false vocal cords. Lying between the 
vocal cords and these two bands are two oblong fossae, the ventricles 
of the larynx. 

The mucous membrane of the larynx is continuous above with 
that lining the pharynx, and below with that of the trachea and bron- 
chi. It is of the columnar ciliated variety, excepting where it covers 
the vocal cords and the space above the vocal cords, in which regions 
it is of the stratified variety. It contains many mucous glands, espe- 
cially numerous upon the epiglottis. 




Fig. 398. — The interior of the larynx, i, Epiglottis; 2, thyroid cartilage; 3, 
ventricle of larynx; 4, cricoid cartilage; 5, false vocal cords; 6, vocal cords; 7, 
first 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 
(10 to 12 cm.) long in males, and from 3 2/3 to 4 1/2 inches (9 to 11 
cm.) long in females. Its transverse diameter measures on an 
average 4/5 of an inch (2 cm.) in males, and less in females. In a 
child of from two to four years, the transverse diameter measures 
1/3 of an inch (8 mm.) ; in a child under eighteen months, it measures 
1/4 of an inch (6 mm.). 

The framework of the trachea is composed of from sixteen to 



388 



THE LARYNX AND TRACHEA 



nineteen rings of hyaline cartilage, incomplete behind, each measur- 
ing 1/12 to 1/5 of an inch (2 to 5 mm.) in breadth. The narrow 
space between these rings is filled with an elastic fibrous membrane 
which splits into two layers to enclose each cartilage, and also 
serves to complete the tube posteriorly. Internally, the trachea is 
lined with a smooth mucous membrane of the ciliated variety, con- 
tinuous above with that of the larynx and below with that of the 
bronchi. It contains an abundance of lymphoid tissue and mucous 
glands. ♦ 



"ThyfoicL 




J7r/'co-/Ayr'. 
Tncmbrane 



Inf. thyr. art. 

iXi'yfif' Comnte>v^ ^^^ ' '^^^ ij-'S^ — " 

Canft/datK 



crr/e/y 



/.eft Jube/avian, 



Fig. 399. — Anatomy of the trachea and its relations. 

The trachea lies in a mass of loose fat which permits free motion 
upward, downward, and horizontally. In its upper part it lies com- 
paratively superficial, but becomes more deeply placed as it ap- 
proaches the thorax. The isthmus of the thyroid gland lies opposite 
the second and third rings; below this the following structures will 
be met from above downward: the inferior thyroid veins, the arteria 
thyroidea ima (if present), the sternohyoid and sternothyroid mus- 
cles, the cervical fascia, an anastomosis of the anterior jugular veins; 
and in the thorax, the remains of the thymus gland, the left innomi- 



LARYNGOSCOPY AND TRACHEOSCOPY 389 

nate vein, the arch of the aorta, and the innominate and the left 
common carotid arteries. Behind hes the esophagus. Laterally, 
the trachea is in relation with the common carotid arteries, the 
lateral lobes of the thyroid, the inferior thyroid arteries, and the re- 
current laryngeal nerves. These relations are important to bear in 
mind in performing tracheotomy. 

Diagnostic Methods 

The diagnostic methods employed in connection with the larynx 
and trachea consist in (i) inspection by means of a laryngeal mirror, 
(2) direct inspection through endoscopic tubes, (3) palpation by the 
probe or finger, and (4) skiagraphy. 

As a preliminary to the actual local examination, attention 
should first be given to the general condition of the patient, and the 
history of other affections that may have a bearing upon the condi- 
tion should be inquired into. This is important, for, while the symp- 
toms of processes involving this portion of the respiratory tract are 
characteristic (consisting of cough, dyspnea, aphonia or dysphonia, 
dysphagia, etc.), and as a rule clearly indicate the seat of the trouble, 
it should be borne in mind that many of these symptoms are second- 
ary to other conditions, such as gout, diphtheria, rheumatism, 
diabetes, nephritis, tuberculosis, syphilis, diseases of the nervous 
system, etc. Thus it becomes of the utmost importance to examine 
other organs as well and not to hmit the investigation to the affected 
region alone. 

Having completed this portion of the examination, external in- 
spection and palpation of the parts should be performed. In this 
way the presence of inflammation, sweUings, new growths, enlarged 
glands, fractures of the cartilages, etc., may be determined, and the 
mobility or fixation of the parts during swallowing and respiration 
may be noted. 

LARYNGOSCOPY AND TRACHEOSCOPY 

By this method the interior of the larynx and trachea are in- 
. spected by means of a laryngoscopic mirror and reflected light. The 
technic is not diihcult, and, if properly carried out, a satisfactory in- 
spection of the tissues may be made as far as the true vocal cords, 
and under favorable conditions the region beyond the glottis as far 
as the subdivision of the trachea may also be explored, and foreign 



390 



THE LARYNX AND TRACHEA 



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 strong light, such as is obtained from 
a Welsbach burner covered by a Mackenzie condenser; a concave head 
mirror, 3 1/2 to 4 inches (9 to 10 cm.) in diameter with a central 
perforation for the eye; laryngeal mirrors of three sizes, 1/2, i, and 
I 1/2 inches (i, 2.5, and 4 cm.) in diameter, that they may be 
adapted to the size of the individual fauces; and an alcohol lamp 
(Fig. 400). The light should be placed upon a suitable bracket, 




Fig. 400. — Instruments for laryngoscopy. I, Laryngeal mirrors; 2, head mirror; 

3, alcohol lamp. 



that it may be raised or lowered to any desired height (see Fig. 310). 

Asepsis. — The laryngeal mirrors should be sterilized by immersion 
in a I to 20 solution of carbolic acid, then rinsed off in sterile water 
and dried before use. 

Position of Patient and Examiner. — 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 



LARYNGOSCOPY AND TRACHEOSCOPY 



391 



mouth, at a distance of about a foot (30 cm.), or the focal length of 
the mirror. 

Anesthesia. — Ordinarily, cocainization of the parts is unneces- 




FiG. 401. — Laryngoscopy. First step, showing the method of grasping the 

tongue. 

sary, but, where the mucous membrane of the pharynx is very sen- 
sitive, brushing a 4 per cent, solution of cocain over the posterior 
pharyngeal wall and soft palate may be required before a satisfactory 
examination is possible. 




Fig. 402. — Laryngoscopy. Second step, heating the mirror. 

Technic. — The operator places himself and patient in the proper 
positions, and adjusts the head mirror over the left eye in such a 
manner that the light will be reflected in a circle upon the mouth of 



392 



THE LARYNX AND TRACHEA 



the patient. The patient is then directed to protrude the tip of the 
tongue, which is surrounded with a piece of clean gauze or small 
napkin and is grasped between the thumb and forefinger of the opera- 
tor's left hand (Fig. 401). Light traction is made outward and sightly 




FiG. 403. — Showing the method of holding the mirror. 

upward rather than downward, so as to avoid forcing the under sur- 
face of the tongue against the lower incisor teeth. The laryngeal 
mirror is then warmed to avoid condensation of moisture upon its 
reflecting surface, by holding it at a httle distance above a flame for a 




I 
Fig. 404. — Laryngoscopy. Third step, showing the mirror being introduced 
and also the relative position of the patient and examiner and the position of the 
light. 

few seconds (Fig. 402), the precaution being taken to test the temperature 
of the mirror before introducing it into the mouth; this is determined 
by bringing the back of the mirror in contact with the back of the 
operator's hand. To introduce the mirror, it should be held lightly 



LARYNGOSCOPY AXD TRACHEOSCOPY 



393 



between the thumb and forefinger of the right hand with its reflect- 
ing surface downward (Fig. 403), and should be made to follow the 
curve of the hard palate until its back touches the uvula and soft 
palate. It is then pushed upward and backward, raising the uvula 
as far out of the way as possible. Care must be taken in performing 
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. Should this accident occur, the mirror 
must be removed and sufficient time must be allowed for the patient 
to recover his breath and the irritabiHty to subside before it is rein- 




FiG. 405.— Lan-ngoscopy. Fourth step, showing the mirror in place. 

(J. U. Anders.) 

troduced. As soon as the instrument is in proper position, the 
handle is moved to one side of the patient's mouth so as to be well 
out of the line of vision. The mirror is then slowly and gently turned 
until a view of the base of the tongue is obtained, and any abnor- 
malities of the organ are noted; it is then rotated in such a manner 
that its face looks downward and the larynx is brought into view 
(Fig. 405). 

It should be remembered that the laryngeal image ^dll be in- 
verted — that is, the structures of the front part of the larynx appear 



394 



THE LARYNX AND TRACHEA 



on the upper part of the mirror, and vice versa; the right and left 
sides of the laryngeal image, of course, correspond to the same sides 
of the patient. In a normal case, the following are noted: at the 
upper part of the picture, the saddle-shaped epiglottis of a yellowish 
color traversed by its pink blood-vessels; extending backward across 





Fig. 406. Fig. 407. 

Fig. 406. — The laryngoscopic image. I, Epiglottis; 2, false vocal cords; 3, 
vocal cords; 4, glossoepiglottic fossa; 5, interarytenoid space; 6, cartilage of San- 
torini and the location of the arytenoid cartilage; 7, cartilage of Wrisberg. 

Fig. 407. — The larynx during gentle respiration. 

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 reddish hue, the ventric- 
ular bands, or false vocal cords; between the vocal cords and the 
ventricular bands may be observed the ventricles of the larynx, 
brought into better view if the head is tilted to the side; where the 





Fig. 408. — The larynx in phonation. 



Fig. 409. — The larynx during deep 
respiration. 



vocal cords terminate at the lower part of the image are to be seen 
the arytenoid cartilages, and between them the interarytenoid space; 
extending from either side of this notch to join the epiglottis are the 
aryepiglottic folds, with the two prominences marking the site of the 
cartilages of Wrisberg and Santorini, the latter lying on top of the 



LARYNGOSCOPY AND TRACHEOSCOPY 395 

arytenoid cartilages; on either side of the image will be noted the 
glossoepiglottic fossee. 

To make a complete examination, the larynx should be inspected 
during quiet respiration, deep respiration, and phonation. During 
respiration the vocal cords are seen to move with each expiration 
toward the median line, and away from the median line with inspira- 
tion (Fig. 407). By requesting the patient to say "ee" or "he," a 
view is obtained of the larynx with the cords almost in apposition and 
the interarytenoid space obhterated (Fig. 408). During deep respi- 
ration the cords are widely separated, and a view is obtained of the 
anterior wall of the region below the vocal cords (Fig. 409). There 
will be seen the broad yellow cricoid cartilage and the yellowish car- 
tilaginous rings of the anterior wall of the trachea with the interven- 
ing red membranous portion. By tilting and carefully adjusting the 
mirror, the bifurcation of the trachea and the openings of the two 
bronchi may be brought into view. To obtain the most favorable 
position for inspection of the trachea, the patient's neck should be 
held straight and the chin extended somewhat forward. The mirror 
will also require a different adjustment, being held more horizontally 
than for laryngoscopy, 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 con- 
gestion or inflammation, bearing in mind that if cocain has been em- 
ployed the parts will appear anemic, and that gagging or retching 
may be responsible for congestion. He should look for the presence 
of exudations, foreign bodies, and any structural changes, such as 
ulcerations, swellings, abscesses, edema, new growths, malforma- 
tions, and dislocations of the arytenoid cartilages, etc. Finally, the 
condition and mobility of the vocal cords during respiration and 
phonation are observed. They should approximate symmetrically in 
the mid-fine during phonation, and separate equaUy with inspiration. 
The whole examination should be made as rapidly as possible, not 
more than half a minute or so being consumed, to avoid tiring the 
patient and inducing an irritable state of the parts. Since often only 
a glimpse of the various structures may be thus obtained, it may be 
necessary to make more than one inspection before the whole ex- 
amination is completed in a satisfactory manner. 

Difficulties in Laryngoscopy. — It is sometimes a difiScult matter 
for a beginner to inspect the parts, owing to faulty technic or to 



396 THE LARYNX AND TRACHEA 

structural peculiarities. A view of the larynx may be missed entirely 
through an improper adjustment of the light, faulty position of the 
patient's head, or holding the mirror at a wrong angle. Clumsy 
and hasty introduction of the mirror, the use of a mirror too hot or 
too cold, or rough traction on the tongue, all militate against success. 
In some cases an excessive irritability of the pharynx precludes a 
successful examination without preliminary cocainization. In other 
cases the presence of enlarged tonsils may prevent a good view of the 
parts. If such a condition is present, a small oval mirror should be 
substituted. A large pendulous epiglottis is not infrequently a cause 
of difficulty. By placing the mirror close to the posterior pharyn- 
geal wall and holding it more nearly vertical than usual, with the 
patient's head thrown back, a better view may often be obtained. 

In young children considerable difficulty may be encountered. 
It is best to wrap the child in a sheet so that the arms are restrained, 
and to have it held upon the lap of an assistant, who also steadies 
the child's head. A tongue depressor with a curved tip should be 
employed to hold the tongue forward, and, if necessary, a mouth-gag 
may be inserted between the teeth. A small laryngeal mirror is 
then introduced, and the examination is mg-de in the usual way. If 
carefully and gently performed, a satisfactory examination may 
often be made even upon unruly children. 

DIRECT LARYNGOSCOPY 

The larynx and portions of the air passages beyond may be exam- 
ined under direct vision either by the aid of illuminated tubes or by 
means of a suitable tongue depressor and illumination from a head 
light, the latter a method designated by Kirstein as autoscopy. The 
parts inspected in this manner appear more nearly normal as to posi- 
tion and color than when a laryngeal mirror is employed. Further- 
more, foreign bodies and new growths may be removed, and applica- 
tions made to diseased areas under direct vision. The method may 
be employed in young children upon whom ordinary laryngoscopy is 
difficult, and it may also be performed upon a patient under general 
anesthesia. It is, however, more uncomfortable for the conscious 
patient than ordinar}' laryngoscopy. 

Instruments. — A tubular spatula, self-illuminated, such as Jack- 
son's (Fig. 410), or with the illumination furnished from an electric 
head light, as Killian's, is generally employed. Kirstein uses a 
tongue depressor of special shape (Fig. 411) and an electric head 



DIRECT LARYNGOSCOPY 



397 



light (Fig. 412). In addition a mouth-gag and a Sajous applicator 
are required (Fig. 413). 




Fig. 410. — Jackson's self-illuminated tube spatula for direct laryngoscopy. 

Asepsis, — The tubes and tongue depressor may be boiled, while 
the light-carrying apparatus in the self-illuminated tube is sterilized 
by immersion in alcohol. 

Position of the Patient. — The patient is seated on a low stool with 
the upper part of the body bent slightly forward and with the head 
raised and thrown back so that a direct view from above downward 




Fig. 411. — Kirstein's tongue depressor. 

is possible. An assistant stands or sits behind, supporting the 
patient's head, and holding the mouth-gag in proper position. The 
operator stands in front. 

A child should be seated upon the lap of a nurse, who encircles 
its 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 



398 



THE LARYNX AND TRACHEA 



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 accomphshed by 
tlie 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 appli- 
cator. This should be performed by the aid of a laryngeal mirror. 




Fig. 412. — Kirstein's head light. 

If operative procedures are required, the application of 20 per cent, 
solution of cocain should follow the preHminary cocainization. In 
young children the examination may be carried out under general 
anesthesia. 

Technic. — The operation should, when possible, be performed 
when the stomach is empty, as, otherwise, retching may result in 
regurgitation of the stomach contents. The parts having been cocain- 




FiG. 413. — Sajous' applicator and mouth-gag. 

ized, and 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 supports the head. With the lamp at the end of the 
instrument properly lighted, if a self-illuminated spatula is employed, 
or with the head lamp lit and adjusted so as to throw the light into 
the mouth, if a nonilluminated tube is used, the tubular speculum is 



DIRECT LARYNGOSCOPY 



399 



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 instrument in an upward and backward direction 
(Fig. 414). 

The operator then inspects the larynx by looking down the tube. 
The arytenoid cartilages, vocal cords, interior of the larynx, and por- 
tions of the trachea may thus be viewed in detail. The points espe- 
cially to be noted in such examination have already been referred to 




piG. 414. — Direct laryngoscopy with Jackson's self-illuminated spatula. (Modi- 
fied from Ballenger,) a. Electric cord supplying lamp of speculum; b, conduit for 
light carrying tube; c, shows the tube holding the epiglottis forward; d, conduit 
for removing secretions, etc., by aspiration during the examination. 



under laryngoscopy. By the aid of these tubes, applications may 
also be made, if desired, to diseased areas, and growths may be re- 
moved by means of delicate instruments of special design. 

Under the method designated by Kirstein as autoscopy, the 
patient is placed in the same position as above, the mouth is illumi- 
nated from the electric head light, and the special tongue depressor 
is gently introduced behind the tongue until its tip rests between the 
epiglottis and the base of the tongue. By elevating the handle of 
the instrument, the base of the tongue is drawn downward and for- 
ward, and the epiglottis is raised, so that a groove is formed along 



400 THE LARYNX AND TRACHEA 

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 larj-nx and trachea are clearly viewed by this 
method, but the anterior parts are not seen so well as with the 
laryngoscopic mirror. 

DIRECT TRACHEO-BRONCHOSCOPY 

In 1897 Killian devised long endoscopic tubes that could be intro- 
duced through the mouth or through a tracheotomy wound, with 
which the trachea and bronchi may be examined by the aid of illu- 
mination from an electric head light. This operation is designated 
respectively as "upper direct tracheo-bronchoscopy," and "lower 
direct tracheo-bronchoscopy." In this country, Chevalier Jackson 
has perfected similar tubes, in which, however, the illumination is 
suppHed by a small electric light at the distal end of the instrument. 

The bronchoscope is employed both for diagnostic and ther- 
apeutic purposes, and is of especial value in locating and removing 




Fig. 415 — Killian''.i bronchoscope. 

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 other- 
wise 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 accomplished specialist; in unskilled hands it becomes a danger- 
ous instrument. 

Tracheo-bronchoscopy through a tracheotomy wound is the 
simpler of the two methods, and, as larger tabes 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-bronchos- 
copy. Upper tracheo-bronchoscopy, however, should be the opera- 
tion of choice when possible. 



DIRECT TRACHEO-BRONCHOSCOPY 



401 



Instruments. — The tubes employed are of rigid, metal highly 
polished internally, somewhat similar to the endoscopic tubes em- 
ployed 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 




Fig. 416 — Jackson's bronchscope. 

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 diame- 
ter by 18 inches (45 cm.) long for adults, and one 1/5 inch (5 
mm.) in diameter by 8 inches (20 cm.) long for children. 




Fig. 417. — Jackson's secretion aspirator. 

In Killian's instruments (Fig. 415) illumination is supplied from 
an electric head light. In the Jackson tubes (Fig. 416) the illu- 
mination is supplied by a small electric light at the distal end of 
the instrument. These latter are somewhat easier to use than 
26 



402 



THE LARYNX AND TRACHEA 



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 purpose of removing secretions that 
may collect and obscure the view (Fig. 417). For inserting these 
instruments, a special split tube (Fig. 418), resembling that used 




Fig. 418. — Jackson's separable speculum for passing the bronchoscope. The 
handle, ab, for use when the patient is in a sitting posture; c, shows the arrangement 
of the lamp at the distal end. 

in direct laryngoscopy, is supplied which is, removed in two halves 
after the bronchoscope has entered the glottis. 

A portable battery with rubber-covered cords, a mouth-gag, a 




Fig. 419. — Accessory instruments for tracheo-bronchoscopy. 

Sajous applicator, variously shaped forceps, applicators for applying 
cocain or drugs to '.he mucous membrane, hooks, etc., for the removal 
of foreign bodies through the instrument, and a tracheotomy set 



DIRECT TRACHEO-BRONCHOSCOPY 



403 



(see page 426) are required. The operator should also be provided 
with a number of extra lamps to replace those that may burn out. 

Asepsis. — Strict asepsis in all details is absolutely necessary. 
The tubes and accessory instruments are boiled, the lighting appara- 
tus is sterilized by immersion in alcohol or in a i to 20 carbohc acid 
solution followed by rinsing in alcohol, and the rubber-covered bat- 
tery cords are wiped off with bichlorid solution. The hands of the 
operator and assistants should be as thoroughly cleansed as for any 
operation. On account of the danger of sepsis from the mouth, the 
patient's teeth should be brushed and the mouth well cleansed with 




Fig. 420. — The position of the patient and the assistant for upper tracheo- 
bronchoscopy. (After Jackson.) 

an antiseptic wash before passing the instruments. A tube employed 
in the upper operation should not be used for lower bronchoscopy 
without resterilization. 

Preparation of the Patient. — If general anesthesia is to be em- 
ployed, the patient should be prepared according to the usual method 
(page 2). In any case, the operation should be performed on an 
empty stomach. For lower tracheo-bronchoscopy, the neck, if 
hairy, should be shaved and painted with tincture of iodin. 

Position of the Patient. — If done under local anesthesia, upper 
tracheo-bronchoscopy may be performed with the patient in the 



404 



THE LARYNX AND TRACHEA 



upright position. The patient sits on a low stool, with the head ex- 
tended backward as far as possible and the tongue projected forward. 
An assistant holds the head from behind and steadies the mouth- 
gag, w^hile the operator stands in front. When a general anesthetic 
is employed, and in all cases of lower bronchoscopy, the patient 
should be in the dorsal position on a table, the front of which is 
slightly elevated, wath 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. 420. 




SUDEOrSPiCULUM R[»o/[D 



Fig. 421. — Showing the various steps in upper bronchoscopy. (After Jackson.) 

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, appHed 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. Even when general anes- 
thesia is used, cocain should be applied by means of cotton applica- 
tors to the larynx and trachea before the introduction of the tube, to 
avoid dangerous reflexes from stimulation of the endings of the su- 
perior laryngeal nerve. 



DIRECT TEACHEO-BRONCHOSCOPY 



405 



Technic. — i. Upper Tracheo-bronchoscopy. — With the patient in 
the proper position, and the parts cocainized, the mouth is widely 
opened and the mouth-gag is inserted and given to the assistant to 
maintain in position. The larynx and vocal cords are exposed by 
introducing a split tube spatula, as for direct laryngoscopy (page 
398). Thebronchoscope, well lubricated with sterile vaseHn, andwith 
the illumination properly turned on, is passed through the split tube 
as far as the epiglottis under the guidance of the operator's eye. 
The operator notes the vocal cords and instructs the patient to breathe 
deeply, and, while the cords are open during inspiration, the instru- 
ment is gently passed through the glottis until it enters the trachea. 
The split tube is then separated and removed. As the bronchoscope 
is advanced, the mucous membrane in front should be anesthetized 
by means of a 20 per cent, solution of cocain applied with cotton 
swabs on a long applicator. The instrument is thus slowly passed 




Fig. 422. — Lower bronchoscopy. (Modified from Ballanger.) 

to the bifurcation of the trachea, and the parts are examined in detail 
as the tube advances. 

To enter the right bronchus, the instrument should be turned 
toward the left angle of the patient's mouth, and toward the 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 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. 



4o6 



THE LARYNX AND TRACHEA 



2. Lower Tracheo-bronchoscopy. — Low tracheotomy is first per- 
formed as described on page 432. After all the bleeding has been 
controlled, a Trousseau dilator is inserted and the tracheal wound is 
held open. The mucous membrane of the trachea is then cocainized 
with a 20 per cent, solution of cocain. A short bronchoscope, with 
the illumination turned on, is then introduced, and the instrument 
is advanced under the guidance of the operator's eye, which is applied 
at the end of the instrument. As soon as the bifurcation of the tra- 
chea is reached, the tube may be directed into either bronchus by 




Fig. 423. — Instruments for probing the larynx. I, Laryngeal probe; 2, laryngeal 
mirror; 3, alcohol lamp; 4, head mirror. 

gentle manipulation. The patient's head is turned 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 should be anesthet- 
ized, as before, in advance of the instrument with cocain applied upon 
long applicators through the instrument, and the examination pro- 
ceeded with as above. 

The after-treatment of the patient consists in inserting a tracheot- 
omy tube which is worn for several days. After the removal of this 



PALPATION BY THE PROBE 407 

tube, the wound should be carefully 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 
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. 423). 

Asepsis. -The probe should be boiled and the laryngeal mirror 
sterilized by immersion in a i to 20 solution of carbolic acid, then 
rinsed off in sterile water and dried before use. 

Position of Patient. — The patient is in the same position as for 
ordinary laryngoscopy. 

Anesthesia. — The larynx should be cocainized by spraying or by 
the application of a lo per cent, solution of cocain. 

Technic. — The tongue is protruded and held by the patient with a 
cloth, and the laryngeal mirror is warmed and inserted in such a 
position that a good view of the larynx is obtained. The probe is 
held in the operator's right hand and is introduced into the patient's 
mouth turned on its side, with the laryngeal portion horizontal and 
the handle in the angle of the mouth until it almost reaches the pos- 
terior pharyngeal wall (see Fig. 424). It is then brought into the 
natural position, with the laryngeal portion vertical and the handle in 
the mid-line, the point of the instrument lying in the pharynx behind 
the epiglottis. By raising the handle of the instrument, the point is 
then brought forward over the arytenoids. By directing the point of 
the probe, guided by the image in the mirror, the diseased areas are 
then explored (see Fig. 425). In performing this manipulation, it 
must be remembered that the image in the mirror is reversed, so that 
movements of the instrument 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. 



4o8 THE LARYNX AND TRACHEA 

SKIAGRAPHY 

Skiagraphy is employed as an adjunct to other diagnostic meas 
ures for locating metal and other foreign bodies which are impene- 
trable to the rays, and also for localizing certain growths of greater 
density than the surrounding tissues. 

Therapeutic Measures 
THE LARYNGEAL SPRAY 

The laryngeal spray is employed for the purpose of cleansing and 
for medication. Cleansing of the larynx is frequently required for 
the removal of purulent secretions the result of syphihticor tubercular 
ulcerations, and to soften and wash away the crusts which are often 
an accompaniment of fetid laryngitis. Whenever possible, spraying 
of the larynx should be done by the surgeon himself, as it can thus 
be performed by the aid of direct vision in a thorough manner. If 
this is not possible, the patient must be very carefully instructed in 
the use of the instrument. 

Medication of the larynx may be required in the treatment of 
acute and chronic inflammations, ulcerations, etc., and according to 
the indications of the individual case, remedies with an antiseptic, 
astringent, 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 stream as to produce irritation and 
possibly add to the local inflammation. The Davidson, the Whitall 
Tatum (see Fig. 336), and the De Vilbiss atomizers (see Fig. 337) are 
simple and very efficient instruments. They should be provided with 
a laryngeal nozzle, which turns downward. The air current may be 
supplied by a rubber compression bulb or by means of a compressed- 
air apparatus (see Fig. 338). 

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 327 for use in the nose may be employed. For 



THE DIRECT APPLICATION OF REMEDIES 409 

topical applications to the larynx, the formulae of antiseptic, astrin- 
gent, sedative, and stimulating solutions given on page 331, 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. (38° C), 

Anesthesia. — When the parts are very sensitive, preliminary 
spraying with a 10 per cent, solution of cocain may be required. 

Technic. — -The patient is directed to open his mouth widely and 
to protrude his tongue, which he may hold forward with the fingers of 
his right hand if desired. The operator then warms and introduces 
a laryngeal mirror, holding it so as to obtain a good view of the parts. 
Then, with his right hand, he introduces the spray nozzle into the 
mouth, and with the aid of the mirror passes it behind the epiglottis 
and depresses the tip so that it points toward the diseased area. 
When the nozzle is in proper position, the mirror is removed and the 
bulb of the spray is sharply compressed, the patient being instructed 
to phonate while this is being done. The spray is then immediately 
removed, as the patient will cough and want to expectorate. When 
performed for cleansing purposes, the spraying should be repeated 
several times until the larynx is well washed out. Each time the 
patient coughs, mucus, purulent secretion, and crusts, which have 
been softened and separated by the spray, will be expelled. 

When the spraying is carried out by the patient, the mouth is 
widely opened and the tongue protruded as before. The spray noz- 
zle, 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 com- 
pressed. In employing oily preparations, the patient should take an 
inspiration at the moment of compressing the bulb, so as to aid in 
drawing the solution into the larynx. Until the patient becomes 
skilled in the introduction of the spray, it is well for him to perform 
the operation standing 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 appHed by means of swabs or brushes. 
SoHd caustics should be fused on a probe. The application should 
be made with the aid of a laryngeal mirror, and great care must be 
taken to avoid bruising the tissues or causing trauma. 



410 



THE LARYNX AND TRACHEA 



Instruments. — For the application of liquids, a camel's-hair 
brush, mounted on a wire which is bent at right angles about 21/2 




Fig. 424 — Method of inserting the laryngeal applicator. 




Fig. 425. — Shows the method of making direct applications to the larynx by the aid 

of the laryngeal mirror. 

to 3 inches (6 to 7 cm.) from the end and inserted into a handle, a 
Sajous appUcator (see Fig. 413), or an ordinary laryngeal applicator 
wrapped with cotton may be employed. In making use of the latter, 



INSUFFLATIONS 4 1 1 

care sliould be taken that the cotton is wrapped tightly about the end 
of the instrument, so that there is no danger of its falHng off and sHp- 
ping 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 334. 

Anesthesia. — The parts should be anesthetized by means of a 10 
per cent, solution of cocain applied by means of a spray or on a cotton 
applicator. 

Technic. — -The laryngeal mirror is warmed and introduced by 
the operator's left hand, so as to obtain a clear view of the parts to be 
medicated. If secretion or mucus be present, the parts should be 
first cleansed by spraying. The applicator is then dipped in the 
solution to be applied, and any excess of fluid is removed to prevent it 
from running into the trachea. This precaution is especially neces- 
sary when using strong solutions or caustics. The instrument, held 
in the operator's right hand, is then introduced into the mouth, with 
the curved surface held first horizontally (Fig. 424), and then, as soon 
as the tip of the instrument reaches the pharynx, turned to a vertical 
position. The applicator is then guided to the desired spot by the 
aid of the laryngeal mirror (Fig. 425). The application should be 
made with great gentleness and care and the instrument quickly 
removed. 

The appHcation 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 (2 gm.) to the ounce (30 c.c). 
A dusting powder may finally be applied to the cauterized area. 

INSUFFLATIONS 

Powders may be applied to the larynx by means of a special 
insufflator. They are of use chiefly in cases of ulceration, where a 
sedative or antiseptic action is desired. A combination of nosophen, 
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. 
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 laryn- 
geal mirror, an alcohol lamp, and suitable illumination are necessary. 
The insufflator shown in Fig. 426 is very convenient, as with it the 
amount of powder may be accurately measured, and the instrument 
may be manipulated with one hand. 



412 



THE LARYNX AND TRACHEA 



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 larynx under the 
guidance 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. . 




Fig. 426. 



-Instruments for applying powders to the larynx, i, Powder blower; 2, 
laryngeal mirror; 3, alcohol lamp; 4, head mirror. 



STEAM INHALATIONS 

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 effect of the steam itself 
is also valuable, for it acts as an anodyne upon inflamed mucous mem- 
branes by supplying moisture and so reHeving the heat and dryness of 
congestion. In the latter stages of an inflammation the steam, fur- 
thermore, dilutes and assists in removing secretions. Steam inhala- 
tions are thus of great value in congestion and edema of the larynx, 



STEAM INHALATIONS 



413 



croup, membranous laryngitis, and bronchitis. They are especially 
serviceable in softening the thick tenacious secretion of chronic 
laryngitis. 




Fig. 427. — Croup kettle. 





Fig. 428. — Steam atomizer. 
Fig. 429. — Steam inhaler improvised from a coffee-pot>. 

The Inhaler. — When it is simply intended to convey the vapor to 
the vicinity of the patient, a croup kettle with a long spout, such as 



414 



THE LARYNX AND TRACHEA 



shown in Fig. 427, is most convenient. For direct inhalation, more 
or less elaborate forms of apparatus are manufactured (Fig. 428), but 
a coffee-pot with a funnel of heavy paper placed in the top makes a 
simple and efficient inhaler (Fig. 429). 

Formulary. — Sedative, stimulating, or antiseptic drugs are the 
ones usually employed for inhalation. These include tincture of 
benzoin compound in the strength of i 5 (4 c.c.) to the pint (500 c.c.) ; 
creosote, 5 to 10 TU (0.3 to 0.6 c.c.) to the pint (500 c.c); ol. 
cubebae, sT([ (0.3 c.c.) to the pint (500 c.c); spirits camphori. sTIft 




Fig. 430. — Crib arranged for steam inhalations. (After Kerley., 

(0.3 c.c.) to the pint (500 c.c); ol. pinus sylvestris, 5 Tn,( 0.3 c.c.) 
to the pint (500 c.c), etc. 

Temperature. — When directly inhaled, the vapor should not be of 
a higher temperature than 150° F. (65° C). If used at too high a 
temperature, irritation of the mucous membrane may be produced 
and there is danger of the steam scalding the face. 

Technic. — Into an inhaler a pint (500 c.c.) of nearly boiling water 
is placed and the proper quantity of the drug is added. The patient 
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., (20° C.) and care should be taken to protect the patient from 
draughts. As the steam relaxes the mucous membrane and renders 



DRY INHALATIONS 415 

the patient susceptible to cold, he should not be allowed out of doors 
for several hours afterward. 

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 to cover the bed of the patient with a sheet arranged in the 
form of a tent and raised sufficiently high to permit a free circulation 
of air, the nozzle of the croup kettle being inserted under one side of 
the tent and the water kept boiling (Fig. 430). 

DRY INHALATIONS 

These are useful in diseases of the upper respiratory tract for those 
who cannot tolerate the steam inhalations. The method has an 
advantage over steam inhalations in that the patient does not have to 
remain in the house afterward. 




Fig. 431. — Inhalation mask. 

The Inhaler. — A special mask made of woven metal, which accu- 
rately fits the mouth and which is provided with a sponge upon which 
the medication is dropped, is employed (Fig. 431). 

Formulary. — Any of the very volatile oils, such as thymol, men- 
thol, eucalyptol, etc., may be employed. 

Technic. — Twenty or thirty drops (1.25 to 2 c.c.) of the oil are 
placed upon the sponge of the mask and the latter is placed over the 
patient's face and is secured by strings fastened back of the head and 
neck. The patient inhales through the mask by means of the mouth, 
and exhales through the nose. The mask may be worn for about half 
an hour two or three times a day. 

INTUBATION OF THE LARYNX 

Intubation of the larynx, an operation devised by O'Dwyer, 
consists in the introduction of a tube into the larynx for the purpose of 
securing free respiration in the presence of obstruction in the larynx 



4i6 



THE LARYNX AND TRACHEA 



or upper portion of the trachea. It is an operation which gives 
prompt rehef without the necessity of cutting and without producing 
any loss of blood or shock. It is less terrifying to the patient 
than the tracheotomy and the after-care is not so troublesome. 
Anesthesia is not required nor is any previous preparation of the 
patient required. Special instruments, however, are necessary, and 
the feeding of the patieiit is often troublesome and, while not a diffi- 
cult operation in itself, it requires special training for its skilful per- 
formance which is best learned by practice upon the cadaver. 




Fig. 432. — O'Dwyer intubation instruments, i, Tube with obturator in place* 
2, tube and obturator separated; 3, gauge; 4, mouth gag; 5, introducer; 6, silk 
thread; 7 extractor. 



Indications. — The operation was originally devised 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- 
sion of the suprasternal and supraclavicular spaces on inspiration, 
and sinking in of the lower portion of the chest. Intubation is also 
employed in laryngeal stenosis from other causes for the purpose of 
producing gradual dilatation of the parts, progressively larger 
tubes being introduced and worn for a few days at a time. 

Instruments. — The instruments required are an O'Dwyer intuba- 
tion set including seven metal or hard-rubber tubes, an introducer, 



INTUBATION OF THE LARYNX 417 

an extractor, a mouth gag, and a gauge indicating the size of the tubes 
according to the age of the patient (Fig. 43 2) . Although these instru- 
ments have been modified and attempts have been made to 
improve upon them, those originally designed by O'Dwyer give the 
best results. 

The intubation tube has an expanded head prolonged backward 
in the form of a flange to prevent it from slipping through the vocal 
cords and a fusiform bulb in the middle to aid in keeping the tube in 
position. In the anterior portion of the head a perforation is pro- 
vided for the attachment of a piece of silk thread. The lower end of 
the tube is rounded off and oval. Each tube is provided with an 
obturator which can be screwed on to the introducer. The free 
extremity of the obturator ends in a protuberance which projects 
beyond the tube and prolongs the latter into a rounded extremity to 
aid in its introduction. 

The introducer, or intubator, consists of a handle in which is set a 
rod, to the extremity of which the obturator may be screwed. A 
sliding joined tube fits over this, which can be pushed forward by a 
small knob set on the handle of the instrument, thereby detaching 
the intubation tube from the obturator when the former is in proper 
position in the larynx. 

The extractor, or extubator, is an instrument supplied with jaws 
which fit into the lumen of the tube, and when opened by pressure 
upon a lever engage the tube with sufficient force to permit its removal 
from the larynx. 

Asepsis. — The instruments should be sterilized before use. 

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 (Fig. 433). Some 
operators, however, 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 mth 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 



4i8 



THE LARYNX AND TRACHEA 



in place by the assistant who supports the child's head. The opera- 
tor, with his eyes, nose, and mouth protected against possible infec- 
tion in diphtheria cases, faces the patient and inserts his left index- 




FlG. 433. — Position of child for intuabation and method of holding. 




Fig. 434. — Intubation. First step, showing the method of drawing the epiglottis 

forward. 

finger into the mouth, hooking up the epiglottis (Fig. 434). In doing 
this care should be taken to keep the finger to the left side and out of 
the way as much as possible. The operator then takes the introducer 
with the tube attached in his right hand, holding it as follows: The 
thumb pressed against the button on the upper side of the handle, the 



INTUBATION OF THE LARYN^X 



419 



index-iinger around the hook on the under surface of the instrument, 
and the loop of silk wound over his little finger, as shown in Fig. 
435. He then slowly introduces the tube into the mouth in the me- 




FiG. 435. — Showing the intubation tube on the introducer and the method of 

holding the latter. 

dian Kne, hugging the center of the tongue and keeping the handle of 
the instrument at first well down on the chest of the patient (Fig. 
436). When the end of the tube reaches the epiglottis (Fig. 437), the 




Fig. 436. — Intubation. Second step, introducing the tube into the patient's 

mouth. 

handle is sharply elevated, so that the tube is brought into a vertical 
position (Fig. 438). If the handle of the instrument is not sufficiently 
elevated, the tube will point toward the entrance of the esophagus 
which it will be apt to enter during the next maneuver (Fig. 439). At 



420 



THE LARYNX AND TRACHEA 



the same time the finger of the operator is moved to the posterior 
portion of the larynx, resting on the arytenoid cartilages to prevent 
the tube from entering the esophagus. The tube is then gently 
pushed through the chink of the glottis and on into the larynx, guided 
by the operator's finger. No force whatever should be used. 





Fig. 437. — Third step in intubation. FiG. 438. — Fourth step in intubation. 

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. 440). The intubator with the obturator 





Fig. 439. — Showing a faulty position Fig. 440. — Fifth step in intubation 

of the tube, due to the handle of the in- withdrawing the introducer while 

troducer not being raised sufficient]}- index-finger holds the tube in place, 
high. 

attached is then removed, and the tube is pushed well into the larynx 
by the finger (Fig. 441). Not more than five to ten seconds should be 
consumed in introducing the tube, for while this is being done breath- 
ing is interfered with; if the tube cannot be promptly inserted, the 
operation should be suspended and a second attempt made after 
allowing the child time to recover its breath. 



INTUBATION OF THE LARYNX 



421 



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 
fifteen minutes, to make sure that there is no obstruction to free 





Fig. 441. — Sixth step in intubation, 
showing the index-finger pushing the 
tube well into the larynx. 



Fig. 442. — Showing the intubation 
tube in place. 



respiration. When certain that the tube is properly placed in the 
larynx, the mouth gag is reinserted, and one strand of silk is cut near 
the angle of the mouth, and the string is withdrawn, the forefinger 
being placed on the tube to maintain it in position (Fig. 443). Some 




Fig. 443. — Final step in intubation, removing the string from the tube. 

operators prefer to leave the string attached for the removal of the 
tube in case of sudden emergency. If this is done, the string should 
be brought out the corner of the mouth, hooked over the ear, and 
secured by adhesive plaster. This method has the disadvantage, 



422 



THE LARYNX AND TRACHEA 



however, of furnishing a chance for the child to remove the tube if it 
gets hold of the string. ? 

Should t he tube be placed in the esophagus by mistake, there will 
be no relief to the dyspnea and the cyanosis, there will be an absence 
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 should be 
removed by pulling on the string, and, after waiting a sufficient time 




Fig. 444. — Method of feeding an intubation patient with the head lowered. 

or the patient to recover from the excitement attending the opera- 
tion, it should be reintroduced. 

In some instances, the tube may become occluded by pushing the 
false membrane ahead of it. If this occurs, the tube should be 
removed at once, and, if the obstructing membrane is not expelled 
from the larynx and cannot be extracted and suffocation seems 
imminent, tracheotomy should be performed. Care should 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 diffi- 
cult, and the patients are only able to take liquid, or, at most, semi- 
solid food. As a rule, by having the patient lie with the head lowered, 



IXTUEATIOX OF THE LARYNX 



423 



fluids will pass along th.e roof of the mouth to the posterior pharyngeal 
wall, and wall enter the esophagus, and, if given slowly, sufficient food 
may be administered in this way (Fig. 444) ; or food may be admin- 
istered by having the patient suck up the food through a tube while 
lying face downward upon the lap of a nurse. In some cases, where 
the patient refuses foods, liquids may be administered by means of the 
stomach-tube passed through the mouth or by means of a soft-rubber 
catheter passed into the stomach through the nose (page 502), though 
by the continued use of the latter method there is danger of producing 
infection of the middle ear. Rectal feeding may be combined with 
the above if indicated. 




When to Remove the Tube. — The tube should always be removed 
as soon as possible, as its prolonged use may produce ulceration of the 
larynx. In cases of diphtheria, where antitoxin has been adminis- 
tered, the tube may be removed in three to seven days, depending to 
some extent upon the age of the patient, being left in for longer inter- 
vals in very young children. If the tube becomes occluded at any 
time, it must be removed -^dthout delay, cleaned, and then reintro- 
duced. When the tube is to be permanently removed, the physician, 
after extracting it, should wait sufficiently long to see that respiration 
does not become impeded and necessitate its reintroduction. 

Technic of Extubation.— The patient is placed and held in the 
same position as for introduction of the tube. The mouth gag is 
inserted, and the operator passes his left index-finger into the mouth 
and over the epiglottis until it rests on the head of the tube. The 
extubator, held in the operator's right hand, is then introduced with 



424 THE LARYNX AND TRACHEA 

its jaws closed, by the same maneuvers employed in introducing the 
intubator, until its tip is felt by the finger on the tube. It is then 
carefully guided into the lumen of the tube. By pressing the lever on 
top of the handle, the jaws of the instrument are separated and obtain 
a secure hold on the tube, so that it may be easily withdrawn (Fig. 
417). To accomplish this, the tube must be lifted at first vertically 
upward. The handle of the instrument is then depressed, and the 
tube is brought out by a reversal of the movements of intubation. 

In an emergency, when the tube becomes obstructed, it may be 
possible to remove it by enucleation, especially if the tube be short. 
This consists in placing the thumb of the right hand on the larynx 
beneath the end of the tube while the patient's head is extended, and 
with a quick motion of the head forward, at the same time exerting 
upward pressure on the larynx, the tube is expelled into the mouth. 

TRACHEOTOMY 

The term tracheotomy is generally used to designate the operation 
of opening into the air-passages at some point between the sternum 
and thyroid cartilage. To be exact, however, the term should be 
limited to operations below the cricoid cartilage, while above that 
point, that is, in the cricothyroid space, the operation is called lar^-n- 
gotomy. Tracheotomy is subdivided into the high operation when 
the opening is made above the isthmus of the thyroid gland, and into 
low tracheotomy when the operation is performed below this point. 

Indications. — Tracheotomy is indicated for the relief of obstruc- 
tive dyspnea, which may be the result of any one of the following 
conditions: The formation of pseudomembrane; the presence of 
foreign bodies; the presence of growths within the larynx or trachea 
or external to these structures; edema of the larynx; spasm of the 
larynx; rapid swelling of the tonsils and pharynx; injuries to 
the larynx and trachea, such as contusions, fractures, burns, cicatri- 
cial stenosis, etc. For the relief of obstruction from diphtheritic 
membranes, however, intubation should, as a rule, be the operation 
of choice, tracheotomy being reserved for those cases where intuba- 
tion 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 administration of tracheal anesthesia in operations upon the 



TRACHEOTOMY 



425 



mouth, pharynx, jaws, or larynx, and as a preliminary to laryngect- 
omy and lower tracheo-bronchoscopy. 

Choice of Operation. — The choice between laryngotomy, high 
tracheotomy, and low tracheotomy depends upon the seat of the 
obstruction and also upon the age of the patient and the necessity for 
haste. Of the three, laryngotomy is the most easily and rapidly 
performed. It thus becomes the operation of choice in a sudden 
emergency where the obstruction is located in the larynx and where 
there is demand for haste in order to avoid imminent suffocation or 
where the proper instruments and assistants are lacking. It is not, 




Pig. 446. — The location of the incisions in laryngotomy and tracheotomy. (After 

Bickham.) 
a. Thyroid cartilage; h, incision for laryngotomy; c and e, branches of superior 
thyroid arteries; d, cricoid cartilage;/, incision for high tracheotomy; g, thyroid 
gland; }i, incision for low tracheotomy; ?, pneumogastric nerve; j, sterno-mastoid 
muscle; k, inferior thyroid veins; /, sterno-thyroid muscle. 

however, a suitable operation to be performed upon those under 
thirteen years of age, on account of the small size of the cricothyroid 
space, nor should it be performed for the relief of conditions requiring 
the wearing of a tube for any length of time, on account of the proxim- 
ity of the vocal cords and their liabiHty to injury by the tube. 

On account of the small number of important vessels encountered, 
and the greater ease with which the trachea is reached, high tracheot- 
omy is preferable to the low operation where the location of the 
trouble permits. It is the operation of choice for children and in 
cases of diphtheria where a tube has to be worn for some time. 



426 



THE LARYNX AND TRACHEA 



Low tracheotomy may be required for the removal of foreign bod- 
ies from the bronchi, for lower tracheo-bronchoscopy, for the relief 
of threatened suffocation from occlusion of the trachea by tumors of 
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 close proximity. 

Instruments. — The instruments that should be provided include: 
a scalpel, a narrow bistoury, scissors, two sharp retractors, two ten- 



f 





Fig. 447.^Instruments for tracheotomy. 
I, Scalpel; 2, curved bistoury; 3, scissors; 4, retractors; 5, tenaculum; 6, artery 
clamps; 7, thumb forceps; 8, needle-holder; 9, Trousseau tracheal dilator; 10, tra- 
cheotomy tube; II, catheter; 12, tracheal forceps; 13, needles; 14, No. 2 catgut. 



acula, artery clamps, two pairs of thumb forceps, tracheal forceps, a 
Trousseau tracheal dilator, a flexible-rubber catheter, tracheotomy 
tubes and tape, a needle-holder, two curved cutting-edge needles, and 
No. 2 catgut for ligatures and sutures (Fig. 447). In an emergency, 
where delay would mean the loss of the patient's life, the operation 
may be performed by the aid of a pocket-knife and two hairpins bent 
in the shape of a hook to hold the trachea open until the proper tube 
can be obtained. 



TRACHEOTOMY 



427 



Tracheotomy tubes of several sizes and with different curves 
should be provided so that one suitable for the individual case may be 
at hand. A silver tube, somewhat flattened from side to side, with- 
out fenestrae, and with a movable inside tube, is preferable (Fig. 448). 





Fig. 448. — Tracheotomy tube. 



Fig. 449. — Tracheotomy tube improvised 
from rubber tubing. 



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 four, a 
No. 3; and for one over four, a No. 4. In an emergency a tube may 




Fig. 450. — Position of patient for laryngotomy and tracheotomy. 

be improvised by bending a piece of rubber tubing into the required 
shape, as shown in Fig. 449. For laryngotomy, a tube shorter than 
the ordinary tracheotomy tube, and flattened from before backward, 
is employed. 

Asepsis. — The instruments are sterilized by boiling or, in an emer- 
gency, by immersion in a i to 20 carbolic acid solution. The hands 



428 THE LARYNX AND TRACHEA 

of the operator and his assistants shouki be prepared with the same 
care as for any operation. 

Position of the Patient. — This should be such as to bring the neck 
into the greatest possible prominence. The patient is therefore 
placed in a strong light on a firm flat table with a cushion under his 
shoulders, thus allowing the head to hang back, but not so far as to 
put the trachea under tension or to flatten it and impede respiration 
(Fig. 450). In an emergency, the patient's head may be simply 
alowed to hang over the edge of the table or a lounge. 

A child should be wrapped in a blanket or sheet, with its arms at 
the sides. The legs should also be secured and an assistant should be 
provided to hold the head in proper position. 

Anesthesia. — In adults, local anesthesia with cocain or novocain 
is sufficient. A 0.2 per cent, solution of cocain is employed for the 
skin, and a o.i per cent, solution for deeper infiltration. When there 
is occasion for great haste in the presence of unconsciousness or dys- 
pnea with marked and increasing cyanosis, an anesthetic may be 
dispensed with, as in such cases the sense of pain is much blunted or 
aboHshed. 

In young children, local anesthesia is not followed by good results, 
as the infiltration alone terrifies the child and produces struggling, 
which adds to the dyspnea. If air enters the lungs at all, chloroform 
given slowly is the best anesthesia, ether being apt to irritate the 
mucous membrane and produce laryngeal spasm, thus adding to the 
dyspnea. 

Preparations. — If hairy, the neck should be shaved. The skin is 
sterilized by painting with tincture of iodin. 

Technic. — i. Laryngotomy. — The thyroid and cricoid cartilages 
are identified, and, with the larynx supported between the thumb and 
forefinger of the operator's left hand, an incision about i 1/2 inches 
(4 cm.) long is made through the skin, exactly in the median line of 
the neck, extending from the lower portion of the thyroid cartilage to 
below the cricoid cartilage. The superficial fascia, platysma, and 
deep fascia are divided, and the sternohyoid and sternothyroid mus- 
cles are separated at the inner borders and held apart by retractors. 
The connective tissue and veins underlying these structures are then 
separated, all veins being clamped or hgated before division. The 
cricothyroid membrane is thus brought into view. The thyroid 
cartilage is 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 



TRACHEOTOMY 



429 



the cricothyroid artery, which runs along the upper border of the 
space below the thyroid cartilage (Fig. 451). If the situation of this 
vessel is such that injury to it or its branches cannot be avoided, it 
should be tied between two ligatures before the membrane is incised. 
In opening the membrane, the incision must be carried deep enough 
to include the mucous membrane lining it, otherwise the laryngotomy 
tube may be pushed in between the two structures and not into the 
larynx at all. The wound is held apart with two small retractors or 
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 




Fig. 451. — Opening the cricothyroid membrane in laryngotomy. 
(After Bickham.) 



cricoid cartilage may be cut. The laryngotomy tube is then care- 
fully introduced and is secured in place by tapes passing around the 
patient's neck, a small square pad, split to its center, being interposed 
between the skin and the flange of the tube. A stitch or two may be 
placed at the upper and lower angles of the wound to bring them to- 
gether, if necessary. Even where the obstruction is immediately 
relieved, it is preferable in any case to insert a tube for a time until the 
tissues become more or less adherent, so as to avoid subcutaneous 
emphysema. 

2. High Tracheotomy. — The thyroid cartilage is grasped between 
the thumb and forefinger of the left hand, so as to steady the trachea, 
and with the right hand a vertical incision i 1/2 to 2 inches (4 to 5 



43° 



THE LARYNX AND TRACHEA 



cm.) long is made exactly in the median line, extending from the cri- 
coid cartilage to a Uttle below the isthmus of the thyroid gland (Fig. 
452). The skin and superficial and deep fascia are incised, and the 
anterior jugular veins which are encountered in the upper part of the 
incision, together with any communicating branches of the superior 
thyroid veins, are caught in forceps and ligated. The sternohyoid 
and sternothyroid muscles are thus exposed, and should be separated 
along their inner borders and retracted to the ?ides. As these luscles 
are pulled apart, the isthmus of the thyroid gland and the deep cervi- 
cal fascia covering the trachea appear. This fascia is then divided 
from the lower border of the cricoid cartilage by a transverse incision 
curved downward at the extremities. The fascia is then stripped 
from the trachea and retracted dow^nward, and with it the isthmus of 
the thyroid gland, thus exposing the rings of the trachea. If the 




Fig. 452. — Exposing the trachea in high tracheotomy. 

thyroid isthmus is very large, two Hgatures may be placed about it, on 
each side of the median line, to control the hemorrhage, and the isth- 
mus with the deep fascia is incised vertically and retracted to each 
side. A tenaculum 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 



TRACHEOTOMY 



431 



sharp narrow bistoury, with its cutting edge up, is inserted through 
the membrane below the second ring of the trachea, and the latter is 




Fig. 453. — Opening the trachea in high tracheotomy. (After Bickham.) 




Fig. 454. — Method of inserting the tracheotomy tube. 

incised in the median line as far up as the cricoid cartilage, care being 
taken to include the mucous membrane of the trachea in this incision 



432 



THE LARYNX AND TRACHEA 



(Fig. 453). The edges of the tracheal opening are separated with 
tracheal forceps, or the wound is held open by the retraction sutures, 
if they were previously inserted, and the tracheotomy tube, with its 
cannula, is carefully passed through the open wound into the trachea 
(Fig. 454). If there is no great urgency, all bleeding should be 
arrested before the trachea is opened, but where haste is important 
this may be omitted until the tube is introduced. 

When the tube has been properly placed, a pad of gauze is inter- 
posed between the skin and the flange of the tube, and the latter is 
securely held in place by tapes passing from each side of the flange 
around the neck (Fig. 455). 

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 
advantage in such cases not to insert the tube at once, but to hold the 




Fig. 455. — Showing the tracheotomy tube in place. (Stoney.) 



tracheal wound open and allow the membrane to be expelled. What 
is not expelled may then be removed, if loose, by forceps. The dan- 
ger of infection from the patient's coughing bits of membrane from 
the tracheal opening into the face of the operator should be guarded 
against by the operator wearing a face mask or by holding a piece of 
wet gauze over the wound. 

3. Low Tracheotomy. — The trachea is steadied with the thumb 
and forefinger of the left hand, and a vertical incision is carried from 
the thyroid cartilage to within 1/2 inch (i cm.) of the sternal notch. 
The skin and superficial and deep fascia are incised, and the inferior 
thyroid veins, or other vessels that may be in the way, are ligated and 



TRACHEOTOMY 433 

divided. The sternohyoid and sternothyroid rmiscles 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 
transversely on each side if necessary to obtain more space. Care 
must be taken in deepening the incision at the lower angle of the 
wound not to injure the innominate vein which may bulge up above 
the sternal notch. The isthmus of the thyroid gland is pulled well up 
out of the way by means of a retractor, and while the trachea is 
steadied, an incision is carried upward through two or more of the 
lowermost rings by means of a narrow bistoury. The edges of the 
tracheal wound are then retracted, and the tube is inserted and 
secured in place as previously described. 

After-care. — The opening of the tube should be covered with a 
piece of gauze moistened with normal salt solution, and the patient 




Fig. 456. — Intracannular alligator forceps. (Fowler.) 

kept in a room at a temperature of about 65° to 70° (18° to 21° C). 
If the operation is performed for inflammatory conditions, the atmos- 
phere should be kept moist by the steam from a croup kettle directed 
so as to play over the tracheal opening (see page 412). 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 facili- 
tated by the use of a guide. Any membrane or mucus that may col- 
lect at the mouth of the tube should be promptly removed. Secre- 
tions blocking the tube may be removed by means of a small catheter 
and a suction syringe. Membrane may be removed from the interior 
of the tube with alHgator forceps (Fig. 456) introduced through the 
cannula. If this is not possible, the tracheotomy tube should be with- 
drawn and the obstruction removed. 

Removal of the Tube. — In cases of diphtheria the tube may be 
permanently removed as soon as there is free respiration through the 
28 



434 THE LARYNX AND TRACHEA 

larynx with the tracheal wound closed. This is usually possible in 
from five days to one week. When tracheotomy is employed for 
the removal of foreign bodies, etc., the tube should be worn for 
twenty-four hours at least. This allows time for the oozing to cease 
and averts the danger of blood entering the trachea and the escape of 
air into the subcutaneous tissues. 

Complications. — Broncho-pneumonia is a common complication 
even when not due to an extension of the diphtheritic process. Infec- 
tion of the wound may follow in diphtheria cases and may spread into 
the loose connective tissue of the neck, producing a cellulitis; or the 
infection may work down and cause septic pneumonia. An improp- 
erly 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 pos- 
terior or lateral walls of the trachea. Hemorrhage from congested 
veins may at times be severe; in the majority of cases, however, the 
bleeding, which may be profuse before the trachea is opened, stops 
spontaneously as soon as respiration is re-established. 



CHAPTER XVI 
THE ESOPHAGUS 

A natomic Considerations 

The esophagus extends from the lower border of the cricoid cartil- 
age to about the level of the ensiform cartilage or, in other words, 
from the level of the disk between the fifth and sLxth cervical verte- 
bras to the tenth dorsal vertebra. Its entire length is about. lo inchs- 
(25 cm.), while the distance from the upper incisor teeth to the cardiac 
end measures about 16 inches (40 cm.) . Antero-posteriorly the esoph- 
agus presents a slight curve with the concavity forward, as it fol- 
lows the direction of the spinal column. Laterally, it has the follow- 
ing curves: from its starting point it turns 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, finally curving in front of, and 
a little to the left of, the aorta to pass through the diaphragm (Fig. 
457). In its course, the esophagus has in front of its upper portion 
the trachea; while below it is crossed by the left bronchus and the 
arch of the aorta. The pericardium and the left vagus nerve also 
lie in front. Posteriorly, it rests upon the spinal column and the tho- 
racic 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 caHber have been described, the 
most marked being as follows: (i) at its commencement, 6 inches 
(15 cm.) from the incisor teeth; (2) at a point 10. inches (25 cm.) 
from the incisor teeth, where it is crossed by the left bronchus; and 
(3) at a point 16 inches (40 cm.) from the incisor teeth, where it 
passes through the diaphragm (Fig. 458). At these points the caKber 
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. 

435 



436 



THE ESOPHAGUS 

Diagnostic Methods 



The methods available for examination of the esophagus include : 
(i) auscultation, (2) percussion, (3) external palpation, (4) instru- 
mental examination, (5) inspection through the esophagoscope, and 
(5) the use of the X-rays. The first three of these methods are of 





Fig. 457. Fig. 458. 

Fig. 457. — The course and relations of the esophagus viewed from behind. 

Fig. 458. — The normal narro wings of the esophagus. (Eisendrath.) i, At 
its junction with the pharynx; 2, opposite the bifurcation of the bronchi; 3, at 
the diaphragm. 

very limited cUnical value, while the use of the esophagoscope is of 
doubtful value except in the hands of an expert, so that in the major- 
ity of cases we have to rely upon the use of bougies and sounds or the 
X-rays. 

As in examination of other regions, a careful history of the case 
should precede any local examination. 



EXAMINATION BY SOUNDS AND BOUGIES 437 

AUSCULTATION 

Auscultation is performed by listening with a stethoscope over the 
course of the esophagus while the patient swallows liquids. The 
usual points for auscultation are upon the left side of the spine oppo- 
site the ninth or tenth dorsal vertebra, or just to the left of the ensi- 
form. 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 stop- 
page of the fluid when it reaches the point of stricture. 

PERCUSSION 

Percussion may reveal the presence of large tumors, dilatations, or 
diverticula. In the latter condition, dulness may be present only 
after eating and be absent when the sac is empty. A tympanitic 
note will be obtained when the diverticulum sac contains gas. 

PALPATION 

External palpation is extremely limited in usefulness, as it is only 
applicable to the cervical portion of the esophagus. By means of 
palpation one may be able to discover hard foreign bodies, tumors, 
enlarged glands, enlargements of the thyroid, as well as any pressure 
tenderness along the esophagus. Diverticula full of food may be thus 
distinguished and mapped out, and not infrequently it is possible to 
empty the diverticulum sac of its contents by pressure. 

By internal palpation with the index-finger, foreign bodies lodged 
in the entrance of the esophagus and strictures, new growths, etc., 
at the same location may be recognized. 

EXAMINATION BY SOUNDS AND BOUGIES 

The sound and bougie are employed for diagnostic as well as thera- 
peutic purposes. By their use valuable information may be obtained 
as to the location of foreign bodies, strictures, diverticula, etc. ; fur- 
thermore, the degree of a stenosis may be accurately determined. 
The passage of esophageal instruments is not difficult. Gentleness 



438 THE ESOPHAGUS 

only should be employed in manipulation, however, since, if due care 
is not exercised in this direction, false passage may be readily made 
through the esophagus into the rnediastinum; especially is such an 



Fig. 459. — Cylindrical esophageal sound. 

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 system — should be made. 
In the presence of aortic aneurysm, recent hemorrhage from the esoph- 
agus or stomach, acute inflammation of the esophagus, and after 




Fig. 460. — Conical esophageal sound. 

recent ulceration, the use of esophageal instruments is contraindi- 
cated. In cases of advanced pulmonary or cardiac disease and cir- 
rhosis of the liver, instruments, if used, should be employed with 
great caution. 

Instruments. — For ordinary examination, graduated esophageal 
bougies and bougies a boule are employed. These instruments vary 



Fig. 461. — Olivary bougies a boule for the esophagus. 

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. 459) or conical (Fig. 460) in 
form. In their stead, however, a thick rubber stomach-tube is often 
utilized. 

The bougie a boule is an essential instrument if the length of a 
stricture is to be estimated. It consists of a flexible whalebone shaft, 



EXAMINATION BY SOUNDS AND BOUGIES 



439 



to the end of which metal or ivory oKve-shaped tips of different sizes 
may be screwed (Fig. 461). The shaft should be marked oil in an 
inch or centimetric scale. 

In cases of very tight stricture filiform bougies of whalebone or 
woven material may be employed to determine whether the stricture 
is at all permeable. They may be introduced into the stricture 
through a hollow bougie which is first passed to the face of the stric- 
ture, 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 sufficiently aseptic by immersion in a saturated solution of 




Fig. 462. — Shows the first step in introducing an esophageal bougie. 

boracic acid, after first thoroughly washing with soap and water. 
The hands of the operator should also be clean. 

Position. — The patient is seated in a chair with the head thrown 
back against the back of the chair, and with the chin raised sufficiently 
to make the passage between the mouth and the esophagus as straight 
a line as is possible. The surgeon stands in front of the patient, 
while, if desired, an assistant may steady the head from behind. In 
the case of a child, it will be necessary to confine its arms, either hav- 
ing 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- 



440 



THE ESOPHAGUS 



sitive, may be brushed over with a 5 or lo per cent, solution of cocain. 
Technic. — The patient is seated in the proper position with a towel 
about the neck for protection, and is given a basin to catch vomitus or 
saliva. A soft, flexible sound is passed as follows: the bougie, 
moistened with water and held in the operator's right hand as one 
would a pen, is passed into the patient's open mouth back to the phar- 
ynx. The patient is then requested to swallow and the instrument is 
thus advanced, partly by the act of swallowing and partly by the 




Fig. 463. — Introduction of an esophageal bougie with the finger holding the 
tongue and epiglottis forward. 

operator, until an obstruction is reached or the sound enters the 
stomaxh (Fig. 462). 

Sometimes when a rather inflexible bougie is employed or when the 
tongue is thick or the pharynx is swollen, some difficulty may be 
encountered in entering the esophageal opening. Under such con- 
ditions the operator passes the index-finger of his left hand into the 
patient's widely opened mouth to a point well back of the tongue and 
draws the latter forward, and with it the larynx, so that the esophagus 
may be more easily entered (Fig. 463). The bougie is then passed 
on the finger as a guide straight back in the median line to the 



EXAMINATION BY SOUNDS AND BOUGIES 



441 



pharynx, and, hugging the posterior wall of the pharynx, it is pushed 
steadily, but gently, backward and downward into the esophagus, and 
thence into the stomach, unless some obstruction be. encountered. 

The patient should be instructed to breathe deeply during the 
passage of the bougie, even if gagging is produced, and he should be 
cautioned not to bite the examiner's finger or the tube. There will 
usually be gagging and some attempts to vomit as the tube is inserted, 
but, unless very distressing, they may be disregarded. The patient's 
head, however, should be bent forward over a basin as soon as the 
tube is well within the esophagus to receive any vomitus, mucus, or 
saliva (Fig. 464). 

If dyspnea and cough are induced, the instrument has probably 
entered the larynx. To settle this point, the patient should be told to 




Fig. 464. — Shows the second step in introducing an esophageal bougie. 

phonate "ee"; if he can do so, one may be sure the bougie is not in 
the larynx. If the passage of the tube becomes impeded at any point, 
the tube should be slightly withdrawn and then again pushed gently 
onward, when, unless a stenosis exists, it will advance without 
difficulty. The points of normal constriction at which a bougie may 
be arrested without any diseased condition being present should, how- 
ever, be kept in mind. They are: (i) 6 inches (15 cm.) from the 
upper incisor teeth; (2) 10 inches (25 cm.) from the incisors; and (3) 
16 inches (40 cm.) from the incisors (see Fig. 458). If a large tube 
can be passed into the stomach, the existence of a stenosis may be 
ruled out, while if the tube passes very easily without any sense of 
resistance, atony or paralysis of the canal is presumable. 



44- 



THE ESOPHAGUS 



Any evidences of pain, however, produced by the bougie in its 
descent should be carefully noted, as pointing to possible inflamma- 
tion, ulceration, or malignancy. When the bougie meets a real 
obstruction the cause should, if possible, be learned; that is, whether 
due to spasm, an organic stricture, a diverticulum, a new growth, or a 
foreign body. No force should be employed in attempting to over- 
come the obstruction, but the bougie should simply be held firmly in 
place for several minutes or be slightly withdrawn when, if a spasm 
were the cause, it can be advanced as relaxation takes place. A spas- 
modic stricture will always disappear if the patient is placed under the 
influence of a general anesthetic. If the obstruction does not yield, 



Fig. 465. Fig. 466. 

Fig. 465. — Method of estimating the length of an esophageal stricture. The 
bougie a boule at the face of the stricture. 

Fig. 466. — Method of estimating the length of an esophageal stricture. The 
bougie a boule is withdrawn until its base is arrested at the distal end of the 
stricture. 



the 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 insert the bougie into the stomach, as, 
otherwise, a second stricture below the first may be overlooked. 

To determine the length of a stricture, a large olive-tipped sound 
is inserted until it reaches the face of the stricture (Fig. 465), and the 



EXAMINATIOX BY SOUNDS AND BOUGIES 



443 



distance of the stenosis from the upper incisor teeth is estimated from 
the markings on the shaft of the instrument. The bougie is then 
withdrawn and a size that will just pass is inserted well through the 
stricture. Upon withdrawing the instrument, the base of the bulb 
catches in the lower rim of the constriction (Fig. 466), and the dis- 
tance of this point from the mouth is also estimated. By subtracting 
the first of these measurements from the second, the length of the con- 
tracture is readily determined. 

It is often possible for a practised hand to determine the consis- 
tency of an obstruction from the sensation imparted by contact with 






Fig. 467. Fig. 468. Fig. 469. 

FiF. 467. — Shows a sound passing the opening of a diverticulum. (After 
Gumprecht.) 

Fig. 468. — Shows the ease with which a sound will enter a diverticulum when 
the latter is full. (After Gumprecht.) 

Fig. 469. — Shows the ease with which a sound follows the esophagus when 
the diverticulum is empty. (After Gumprecht.) 

the tip of the instrument. By means of a metal-tipped bougie a 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 
distinguished when the two come in contact. 

If the bougie has entered a diverticulum, it wiU be possible to 
move its end freely in difi'erent directions, and, if the diverticulum be 
located high up, the end of the bougie may often be felt in the neck. 
Again, by withdrawing the instrument somewhat so as to disengage 
the tip, and by changing its direction (Fig. 467), it can frequently be 
passed by the diverticulum into the stomach. A bougie will be more 



444 



THE ESOPHAGUS 



apt to enter a diverticulum if the sac be full (Fig. 468) and pass to the 
stomach when the sac 'is empty (Fig. 469). This intermittent 
obstruction to the passage of a bougie is characteristic of a diverticu- 
lum, and is a point in the differential diagnosis from stricture. 
Another method of differentiating between a stenosis and a diver- 
ticulum has been devised by Plummer, It is carried out as follows: 
The patient is instructed to swallow with a little water before 
bedtime 3 yards (270 cm.) of button-hole silk and in the morning to 
swallow 3 yards (270 cm.) more at the rate of a foot (30 cm.) an hour. 
By the afternoon of the same day, if there is an opening in the stric- 
ture or diverticulum, the thread will have been carried into the stom- 





FiG. 470. Fig. 471. 

Fig. 470. — Esophageal sound passed over a swallowed thread into a diverti- 
culum. (After Plummer.) 

Fig. 471. — Sound lifted _ out of the diverticulum by tightening the thread. 
(After Plummer.) 

ach and intestines a sufficient distance to withstand moderate trac- 
tion without being withdrawn. A whalebone bougie with an olive 
tip, through which is an opening sufficiently large to acconunodate the 
thread, is then passed down the esophagus on the thread, which is 
held loosely, until an obstruction is encountered. If this obstruction 
be due to stricture, the bougie will not change its level when the 
thread is made taut, but, if the sound is in a diverticulum (Fig. 470), 
the bougie will be elevated to the level of the opening into the esoph- 
agus (Fig. 471). The depth of the diverticulum may be readily 
determined by the distance the bougie is elevated when the thread is 
made taut. 



ESOPHAGOSCOPY 445 

The bougie should always be examined after its withdrawal for 
the presence of blood or pus which may be found adhering to its sur- 
face or tip. With the hollow bougie provided with a lateral opening 
near its tip, fragments of tissue sufficiently large for examination may 
be brought away by the instrument, which when placed under the 
microscope may confirm a diagnosis of possible malignancy. 

ESOPHAGOSCOPY 

Esophagoscopy, a method devised by Mikulicz, consists in direct 
inspection of the interior of the esophagus by the aid of a long endo- 
scopic tube illuminated by electricity. By the use of the esophago- 
scope in the hands of an expert, much valuable information may be 
obtained; foreign bodies may be located and removed; ulcers, new 
growths, strictures, the openings of diverticula, etc., may be directly 
inspected; and fragments of tissue may be removed for examination. 
Still, the discomfort of such an examination for the patient and the 
experience and skill required in the use of the instrument on the part 
of the examiner will not allow it to supplant the ordinary methods of 
examination 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 men- 
tioned for the sound or bougie, viz., aortic aneurysm, recent hem- 
orrhage from the esophagus, advanced pulmonary or cardiac dis- 
ease, etc. 

Instruments. — Von Mikulicz's instruments (Fig. 472) are cylin- 
drical tubes about 2/5 to 1/2 inch (10 to 13 mm.) in diameter, bev- 
elled at the end and supplied with an obturator to aid in their intro- 
duction. 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 sup- 
plied by a panelectroscope at the proximal end of the instrument. 
Among other instruments of this type may be mentioned those of 
Killian and Briinings. 

Other tubes, such as Jackson's (Fig. 473) or Einhorn's, for 
instance, are provided with illumination at the distal end of the 
instrument. These will be found easier to manage, as with the former 
it is difficult to direct the Hght properly on account of the length of 
the tube. To examine the entire length of the esophagus, Jackson 
uses, for adults, a tube about 21 inches (53 cm.) long and 2/5 inch (10 



446 



THE ESOPHAGUS 



mm.) thick, and for children, a tube i8 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 




Fig. 472. — Von Mikulicz set of instruments for esophagoscopy. (Gottstein in 

Keen's Surgery.) 

foreign bodies or sections of tissues for examination, etc., are required. 
Asepsis. — The tubes and accessory instruments may be sterilized 
by boiling and the lights by immersion in alcohol. 




Fig. 473. — Jackson's esophagoscope. 

Preparation of Patient. — The patient's stomach should be empty, 
to avoid regurgitation of its contents. Where there is a marked 
dilatation of the esophagus, a preliminary lavage (see page 449) may 



ESOPHAGOSCOPY 



447 



be necessary. The clothing should be loosened from about the 
patient's neck and chest and any plates or artificial teeth should be 
removed from the mouth. 

Position of Patient. — Some operators perform esophagoscopy 
with the patient sitting up; others, with the patient on a table in a 
right lateral position, with the head supported and controlled by an 
assistant. This latter posture, or that known as Rose's posture, 
viz., the patient recumbent with the head hanging over the end of a 
table, supported by an assistant, who raises, lowers, or turns the head 
at will (Fig. 474), is preferable. 




Fig. 474. — The position of the patient and assistant for esophagoscopy. 
(After Jackson.) 

Anesthesia. — General anesthesia may be required in children. 
For adults, painting the pharynx, larynx, and entrance of the esopha- 
gus with a 10 per cent, solution of cocain by means of a cotton swab 
held in a Sajous appHcator some minutes before the introduction 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 398). 

Technic. — The seat of trouble should have been previously deter- 
mined by means of a bougie, and if the operator possesses tubes of 
different lengths this will enable him to select one of the proper length. 



448 



THE ESOPHAGUS 



The tube is lubricated, the patient's mouth is well opened, and, with 
the index-finger of the left hand, the base of the tongue is drawn 




Fig. 475. — Shows the method of holding the esophagoscope. (After Jackson.) 

forward (Fig. 476). The operator then introduces the tube, with the 
obturator inserted in place, backward to the posterior part of the 




Fig. 476. — First step in esophagoscopy, the left index-finger guiding the in- 
strument into the esophagus. (After Jackson.) 

pharynx and then downward, the assistant at the same time extending 
the patient's head so as to bring the mouth and esophagus nearly 




Fig. 477. — Shows the esophagoscope in place. 

in the same straight line. The patient is directed to aid the passage 
of the tube by swallowing. As soon as the esophagus has been well 



LAVAGE OF THE ESOPHAGUS 449 

entered, the obturator is removed, the illumination is turned on, and 
the tube is gently pushed on into the canal by direct sight, the sur- 
geon standing or being seated at the head of the table (Fig. 477). 
Under direct inspection the direction of the esophagus can be dis- 
tinguished and the tube advanced accordingly, care being taken to 
avoid compression of the trachea by a faulty direction of the end of 
the tube. In the cervical portion, the walls of the esophagus lie in 
apposition, the canal being represented by a slit extending from side 
to side. Below the level of the sternum the canal is open. The 
appearance of the esophageal mucous membrane differs from that of 
the trachea in that it has not the deep red tint of the latter, but 
appears pale red or slightly pink. Any mucus or regurgitated matter 
from the stomach that blocks the end of the tube may be removed by 
means of swabs upon long applicators or by the aspirating apparatus 
with which some of the tubes are supplied. In this manner the whole 
interior of the canal down to the cardia may be minutely inspected, 
and diseased areas treated by local applications if desired. Following 
the operation, if there is pain or difficulty in swallowing, cracked ice 
in small quantities mav be administered. 

SKIAGRAPHY 

The X-rays are useful in locating bones, coins, and other imper- 
vious foreign bodies. By having the patient first swallow bismuth or 
similar metallic substances, which offer resistance to the penetration 
of the X-rays and are capable of casting a shadow, the size, shape, 
and course of the esophagus may be outlined, and the presence of a 
diverticulum, constrictions, or dilatations readily recognized. For 
this purpose a mixture of bismuth subcarbonate, one part, to two of 
mucilage of acacia, milk, or gruel is employed. The bismuth forms 
a coating in the gullet and the outline of the tube is thus represented 
upon the skiagraph by a dark shadow. 

Therapeutic Measures 

LAVAGE OF THE ESOPHAGUS 

Lavage of the esophagus is employed chiefly for the purpose of 
removing collections of mucus and stagnated or decomposing food 
particles which have become arrested in a diverticulum sac or in a 
dilated area above a stenosis. In cancer of the esophagus it is fre- 

29 



45° 



THE ESOPHAGUS 




Fig. 478. — Apparatus for esophageal lavage. 
a, Fenestra in the tip of the tube; b, glass funnel; c, mark to indicate the dis- 
tance from the teeth to the stomach. 




Fig. 479. — Boas' apparatus for esophageal lavage. (After Gumprecht.) 



DILATATION OF ESOPHAGEAL STRICTURES BY BOUGIES 45 1 

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. 478). More elaborate apparatus 
has been devised for esophageal lavage, such as, for example, Boas* 
tube (Fig. 479), which is provided with an inflatable rubber balloon 
for closing the lower end of the esophagus, thus preventing solution 
passing the cardia; but the simple apparatus described above will 
answer in the majority of cases. 

Asepsis. — The tube and funnel should be sterilized by boiling 
before use. 

Solution. — For simple lavage sterile water is sufficient. Solutions 
with an antiseptic or astringent action are also sometimes employed. 

Temperature. — The solution should be introduced warm, i.e., at 
a temperature of about 100° F. (38° C). 

Frequency .^ — In some cases the lavage will be required as fre- 
quently as every day; in other cases once every other day is sufficient. 
It should preferably be performed before the first meal of the day. 

Position of the Patient.— The patient should sit in a chair, or 
else should sit up in bed with the head thrown back and the chin 
elevated. The operator stands in front. 

Technic. — The patient is protected by a sheet or a towel fastened 
about his neck, and is given a basin to hold for the purpose of receiv- 
ing any vomitus that may be expelled during the passage of the 
tube. He then opens his mouth widely, and the operator slowly 
inserts the stomach-tube, moistened with water down to the seat of 
the dilatation, being careful at first to keep the tip of the instrument 
close to the posterior wall of the pharynx to prevent its entering 
the larynx. The funnel end is then raised and through it from 2 to 
2 1/2 ounces (60 to 75 c.c.) of warm water are poured into the 
esophagus. The funnel end is then lowered and the contents are 
drained off. By alternately pouring in solution and draining it off, 
the esophagus may be thoroughly cleansed and all particles of food 
or mucus removed. 

THE DILATATION OF ESOPHAGEAL STRICTURES BY 

BOUGIES 

The treatment of an esophageal stricture comprises dilatation 
by means of bougies, internal esophagotomy, external esophagotomy, 



452 



THE ESOPHAGUS 



and, when the stricture is impassable, gastrostomy. Gradual dila- 
tation by the bougies is most frequently employed and, generally 
speaking, is the best form of treatment, as by this means the majority 
of strictures may be in time dilated. The tendency, however, is for 
the stricture to reform after dilatation unless a bougie be passed at 
intervals during the remainder of the patient's life. When the 
stricture involves the greater part of the canal, dilatation is frequently 




/ 



Fig. 480. — The most frequent seats of stricture of the esophagus. (Eisendrath.) 
A, Aorta, D, Diaphragm, i, Stenosis from carcinoma of lower end of the 
pharynx and beginning of the esophagus; 2, stenosis from pressure of tumors of 
the neck; 3, stenosis due to aneurysm of the arch of the aorta; 4, stenosis as the 
result of caustic or lye burns; 5, stenosis as result of carcinoma of lower end of 
the esophagus and cardiac end of stomach. 



unsuccessful. Dilatation is contraindicated in very recent burns of 
the esophagus. Moderate and carefully performed dilatation, how- 
ever, is not contraindicated by carcinoma. 

Strictures may be located in any part of the esophagus, but the 
majority are situated near the points of normal constriction of the 



DILATATION OF ESOPHAGEAL STRICTURES BY BOUGIES 453 

canal (Fig. 480). They are usually single, but may be multiple, 
and they also vary in form and shape, being valve-like, annular, 
semicircular, or tortuous. The portion of the canal immediately 
above a tight stricture dilates from the accumulation of food; espe- 
cially is this the case if the stricture is low in the canal, and as a 
result inflammation or suppuration may develop. In such cases 



Fig. 481 — Cylindrical esophageal bougie. 

there is great danger of perforating the walls of the esophagus unless 
extreme 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 phys- 
ical examination should be made in every case before inserting any 




Fig. 482. — Conical esophageal bougie. 

esophageal instrument. By such examination the discovery of other 
growths within the neck or mediastinum producing compression is 
often possible. 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 dilata- 
tion are made. 




Fig. 483. — Bulbous esophageal bougie. 

Instruments. — Flexible bougies of woven material impregnated 
with elastic gum, which become soft when placed in warm water and 
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 nor- 
mal esophagus, a bougie 1/2 to 3/5 inch (13 to 14 mm.) in diameter 
will pass the narrow portions without difficulty. 



454 THE ESOPHAGUS 

For strictures of fair size, say the size of a lead pencil, cylindrical 
bougies (Fig. 481) may be employed; for smaller strictures the con- 
ical (Fig. 482) or bulbous instruments (Fig. 483) 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 
esophagoscope or through a special hollow sound. 

Other more complicated instruments are sometimes used, such 
as Schreiber's and Billroth's sounds. The former (Fig. 484) consists 
of a hollow bougie with a rubber bag on the dilating end, which is 
capable of being distended with fluid forced in through the distal 
end of the instrument. Billroth's sound consists of a cloth sound 
filled with mercury. These instruments, however, possess no ad- 
vantages over the ordinary flexible bougie. 



^^~ 




Fig. 484. — Schreiber's esophageal sound. (Gottstein in Keen's Surgery.) 

Asepsis. — The gum-elastic bougies may be sterilized in formalin 
vapor or by immersion in a saturated boracic acid solution. 

Preparation of Patient. — In cases of marked dilatation of the 
canal above the stenosis full of stagnant food and mucus, prelimi- 
nary esophageal lavage (page 449) is indicated. 

Rapidity of Dilatation. — The stretching should be done gradually. 
Rapid dilatation or divulsion is dangerous and inadvisable. 

Frequency. — As a rule, the bougies may be inserted every second 
or third day. If the bougie be employed too frequently, irritation 
at the seat of stricture is produced and the condition is made worse 
instead of improved. After full dilatation has been reached the 
intervals between treatments may be stretched to a week, and then 
gradually to a month. The patient should not be permitted to go 
longer than this, however, without the passage of a bougie, as con- 
traction is extremely liable to develop. At any signs of recurrence 
of the trouble, more frequent treatments are necessary. 

Position of Patient. — The patient should be seated in a chair with 
the head thrown well back and with the chin raised. 

Anesthesia. — Though not absolutely necessary, preliminary co- 
cainization of the pharynx and larynx with a 10 per cent, solution 
of cocain renders the operation easier. 



DILATATION OF ESOPHAGEAL STRICTURES BY BOUGIES 455 

Technic. — A bougie of a size that will enter the stricture is 
chosen. This is determined from the examination of the stricture pre- 
viously made. The bougie is softened in warm water and bent to a 
gentle curve near its tip. The operator, standing in front of the 
patient, inserts the bougie into the patient's mouth to the posterior 
wall of the pharynx, and, keeping it close to this latter structure, it 
is slowly advanced into the esophagus (see Fig. 462). If difficulty 
is encountered in entering the esophagus, the tongue may be drawn 
forward by the left index-finger, as shown in Fig. 463. 




Fig. 485. — Von Hacker's method of introducing thin catgut bougies. (Gott- 
stein in Keen's Surgery.) a, b, c, Into the stricture; b' , through a wide hollow 
bougie {R). 

When the stricture is reached care must be taken not to use any 
force in attempting to pass it, as a false passage may be made or the 
instrument may simply be doubled upon itself. By gently with- 
drawing and then advancing the instrument, and by moving its tip 
in different directions, the opening will be entered if the particular 
instrument is of sufficiently small caliber. When the instrument is 
once within the stricture the operator is acquainted with the fact 
by the tight grasp upon the bougie exerted by the stricture. The 
bougie should be slowly passed entirely through the constriction, and 
should be allowed to remain in place from five to ten minutes before 
it is withdrawn. At the next sitting the same size bougie is again 



456 THE ESOPHAGUS 

inserted, and, if the stricture seems very tight, this same instniment 
may be passed on two or more occasions before a larger one is em- 
ployed. When there is more than one stricture, no attempt should 
be made to dilate the lower ones until dilatation of the upper is 
secured. 

Very tight strictures may be dilated by means of a thread passed 
through the stricture, over which as a guide are passed small 
olivary bougies or conical sounds (see page 444) ; by means of fili- 
form bougies inserted through an esophagoscope, or by von Hacker's 
method of inserting catgut strings. In the latter procedure a hollow 
sound made especially for inserting catgut strands is passed down 
as far as the face of the stricture, and through this the catgut strands 
are insinuated into the opening one after another in a manner simi- 
lar to the method used for tight urethral strictures (Fig. 485). 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 con- 
ical shape may be substituted. 

INTUBATION OF THE ESOPHAGUS 

This consists in the insertion of a tube into a stenosed esophagus 
which is left in place continuously for varying periods at a time. 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 dilat- 
ing elastic strictures which are dilatable, but rapidly contract after 
the withdrawal of a bougie. 

Long tubes inserted into the stomach through the mouth or nose 
or short tubes which can be passed through the stenosed area by the 
aid of a guide are employed. The use of the short tubes is preferable 
and is far more agreeable for the patient, as with them it is pos- 
sible for the patient to swallow saliva and to take food in the natural 
way, the ability to taste food being also preserved by the patient. 
They are, however, more difficult to insert than are the long tubes. 
Another disadvantage of the short tube is that if it becomes blocked 
it may have to be removed for cleansing. If the obstruction is 
situated very near the entrance of the esophagus, the use of short 
tubes is usually impracticable, as the expanded end of the tube 
presses on the larynx and produces laryngeal irritation and spasm. 
In such cases long tubes are indicated. Long tubes are also indi- 
cated in the later stages of carcinoma of the esophagus, with a fistu- 



INTUBATION OF THE ESOPHAGUS 457 

lous 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 compKcations. 

Instruments. — When long tubes are indicated, an ordinary hollow 
cylindrical esophageal tube (see Fig. 459) or a rubber stomach-tube 
of appropriate size may be employed. For the purpose- of feeding 
the patient, a glass funnel that will fit into the proximal end of the 
tube will also be required. 




Fig. 486. — Symonds' short tube for intubation of the esophagus. 

Short tubes of gum elastic and hard rubber have been devised 
by Symonds, von Leyden, and others. Symonds' tubes (Fig. 486) 
are about 6 inches (15 cm.) long, and may be obtained in sizes of 
varying caliber. The lower 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. 486, for 




Fig. 487. — Symonds' tube on introducer. 

the purpose of extracting the tube. A special whalebone guide for 
inserting the tube is also required (Fig. 487). 

Asepsis. — Gum-elastic instruments are sterilized by formalin 
vapor or by immersion in a saturated solution of boracic acid. 
Rubber tubes, however, may be boiled. Before reinserting the same 
tube, it should be thoroughly washed with soap and water and 
resterilized. 



458 



THE ESOPHAGUS 



Duration of the Intubation. — For dilating a stricture the tube is 
left in place twenty-four to forty-eight hours, and, if it has then be- 
come loosened through stretching of the contracture, it is removed 
and a larger one is inserted and allowed to remain in place for the 
same length of time. This process is repeated until full dilatation 
has been obtained. 

In cancer of the esophagus the tube is worn continuously except 
when it is removed once every ten days for cleansing. A long tube, 
however, may be left in place permanently, as it can be kept clean by 
syringing down its interior. 

Position of Patient. — The patient is placed in the same position 
as for the passage of any esophageal instrument, viz., sitting upright, 
the head thrown well back, and the chin elevated. 




Fig. 488. — Shows long esophageal tube passed through the nose. 

Anesthesia. — As an aid in the introduction of the tube the phar. 
ynx and larynx may be sprayed with a 10 per cent, solution of cocain. 

Technic. — i. Long Tubes. — The site of the stenosis is previously 
determined by means of a bougie, and a tube that will comfortably 
pass is selected. The patient widely opens his mouth and the opera- 
tor gently inserts the tube in the manner already described for the 
passage of an esophageal bougie (page 440). The tube is passed into 
the stomach, 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 patient to remain in a recum- 
bent position with the head to one side to allow saliva which collects 
to escape, as this is prevented from passing down the canal. 

Instead of passing the tube through the mouth it may be in- 



INTUBATIOX OF THE ESOPHAGUS 



459 



serted through the nostril (Fig. 488), a method that will be far more 
agreeable to the patient. The free end, corked as above, is then se- 
cured in place by means of adhesive plaster. 

2. Short Tubes. — A tube of the proper size is selected and placed 
upon the introducer, being prevented from falling off by the silk 
threads which are grasped by the operator with the same hand he 
employs in introducing the tube. The patient's tongue is then drawn 
well forward and the tube is passed down the esophagus and is in- 
serted through the stricture by means of the introducer, following the 




Fig. 489. — Showing the method of introducing Symonds' short tube. 



same steps as for the passage of a bougie (Fig. 489). When the tube 
is in proper position the tension on the threads is relaxed and the 
introducer is gently disengaged from the tube and removed. The 
threads are then brought out of a corner of the mouth and are secured 
to the ear or face with adhesive plaster. If any of the patient's 
teeth are missing the threads should be made to emerge from the 
mouth through such a space so as to avoid being cut by the teeth. 

Should the tube become blocked, it may be possible to remove 
the obstruction by passing a very small bougie down through it; 
otherwise the tube will have to be removed and cleaned. With- 
drawal of the tube is effected by making gentle traction upon the 
threads secured to its proximal end. 



4 (jo 



THE ESOPHAGUS 



Feeding. — While the tube is in place the patient is kept upon a 
fluid diet, such as milk, broth, eggs beaten in milk, etc. With the 
short tubes food may be administered by mouth, but when the long 
tubes are employed the nourishment is introduced through a funnel 
inserted in the proximal end of the tube. Between feedings the end 
of the tube may be closed by means of a cork. 



CHAPTER XVH 
THE STOMACH 

A natomic Considerations 

The stomach may be described as a hollow, inverted, pear-shaped 
organ, the greater part of which hes in the epigastric and left hypo- 
chondriac 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 




Fig. 490. — The normal position of the stomach. 

for about two-thirds of its area and by the abdominal wall over the 
remaining one-third. The space in which the stomach comes in 
contact with the anterior abdominal w^all is triangular in shape, 
bounded on the right by the lower border of the liver, on the left 
by the eighth, ninth, and tenth costal cartilages, and below by the 
transverse colon. 

The upper limit of the stomach, the fundus, reaches the level of 
the lower border of the fifth rib in the mammary line, being in rela- 
tion with the diaphragm above and the concave surface of the spleen 

461 



462 THE STOMACH 

to the left. The lower limit or greater curvature extends to the level 
of a line connecting the lowest portions of the ninth or tenth ribs or 
to within 2 inches (5 cm.) of the umbilicus. In contraction or dila- 
tation of the organ, however, this normal position of the greater curva- 
ture may be modified to a marked degree. The cardiac or superior 
opening lies about 1/2 inch (i cm.) to the left of the median line, at 
the level of the eleventh dorsal vertebra, or anteriorly at the level of 
the junction of the sternum and seventh costal cartilage. It is 
situated about 4 1/2 inches (11 cm.) posterior to the anterior abdom- 
inal wall. The pyloric opening is situated in front of. but on a lower 
plane than, the cardiac opening, lying to the right of the median line 
and covered by the right lobe of the liver. It is on a level with the 
upper border of the body of the first lumbar vertebra or anteriorly 
on a level with a point 2 or 3 inches (5 to 7.5 cm.) below the sternoxi- 
phoid joint. The long axis of the undistended stomach lies in more 
of a vertical than a horizontal plane with the lesser curvature directed 
principally to the right and the greater curvature to the left. When 
distended, however, the organ changes its position somewhat; the 
greater curvature is tilted to the front so that the upper surface 
looks upward and the lower dow^nward; at the same time the pylorus 
moves 2 inches (5 cm.) or more to the right. 

The capacity of the stomach is subject to wide variations. The 
average is about 2 1/2 pints (1200 c.c). When the stomach is 
empty, the longest diameter measures 7 1/4 to 8 inches (18 to 20 
cm.) and the transverse diameter 2 3/4 to 3 1/4 inches (7 to 8 cm.). 
When the organ is filled, the longest diameter is increased to 10 or 12 
inches (25 or 30 cm.) and the widest point of the transverse diameter 
to 3 1/4 or 4 inches (8 or 10 cm.). 

Diagnostic Methods 

In the diagnosis of stomach diseases a history of the previous and 
the present condition of the patient should be carefully taken and a 
general physical examination should be made before the examination 
of the stomach itself is undertaken. In obtaining the patient's 
history, in addition to the usual questions common to all histories, 
inquiry should be directed especially to the following points: the 
general condition of the health, the appetite, any loss of weight, the 
date and manner of onset of the symptoms, pain, sensation of pressure 
or distention, nausea, vomiting, vomiting of blood, etc. Of special 
diagnostic importance is a history of gastric pain, vomiting, or the 
vomiting of blood. 



DIAGNOSTIC METHODS 463 

As to pain, one should ascertain its character, its location, whether 
diffuse or circumscribed in area, and especially the time of its onset 
in relation to the taking of food and the length of time it persists 
after meals, A simple feeling of pressure or fulness, however, should 
not be confounded with pain. Patients often confuse the two. It 
is also important to determine whether the pain is present at all 
times or only at certain stated periods and whether any special variety 
of food has an influence. Pain complained of when the stomach is 
empty is probably due to hyperchlorhydria, in which case it is re- 
lieved by eating. On the other hand, the pain of an ulcer or cancer 
comes on after eating, and the seat of pain is usually localized. In 
ulcer it is severe, comes on soon after eating, and is often completely 
relieved by vomiting. Its origin is often located by the patient in the 
back in the region of the lower dorsal vertebra on the left side. In 
cancer the pain is not, as a rule, so severe as that of ulcer nor does 
it come on so soon after eating, and it is not so uniformly relieved 
by vomiting. 

With a history of nausea and vomiting, the examiner should in- 
quire into the relation of these symptoms to the taking of food, the 
frequency of occurrence, the character and the quantity of vomitus^ 
and whether the patient is relieved by vomiting. This all has an im- 
portant bearing upon the case. Nausea, as a rule, but not always, 
precedes vomiting. In certain conditions, especially when of nervous 
origin, nausea may be present when the stomach is empty. The 
time of vomiting is also quite important. In gastric ulcer the vomit- 
ing usually takes place soon after feeding, that is, within an hour or 
so; and, as already pointed out, its occurrence usuaUy reheves the 
pain complained of. In cancer of the stomach, vomiting may not 
appear until late in the disease and, as a rule, the attacks of vomiting 
do not come on at such short intervals after feeding as in the case of 
ulcer. In dilatation, on the other hand, vomiting occurs at com- 
paratively long intervals, and the amount brought up is correspond- 
ingly large. Blood in the vomitus is always of diagnostic importance. 
A profuse 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 farther details the reader 
is referred to works on diagnosis where these will be found fully 
discussed. The writer simply wishes to emphasize the importance 



464 THE STOMACH 

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 
secondary disturbances of the functions of the stomach are present 
in a great variety of diseases. This examination should include the 
mouth, the tongue, the chest, the abdomen, an analysis of the urine, 
an examination of the blood, etc. When all possible information 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) ausculta- 
tion; (5) inflation; (6) examination of the gastric secretion; (7) tests 
for determining the motor and absorptive power of the stomach; (8) 
transillumination; (9) gastroscopy; and (10) skiagraphy. 

INSPECTION 

Abdominal inspection in thin individuals may at times give 
valuable information, but in stout persons the method is of very 
limited value. In favorable cases it may be possible by this means 
to determine the size and position of the stomach by tracing the 
shadow which represents the outline of the greater curvature. In- 
spection is greatly aided by a preliminary inflation of the organ (page 
471). When thus distended the stomach becomes separated from the 
surrounding organs and its contour is more easily made out. At the 
same tinie abnormal positions or new growths may be better 
recognized. 

Position of Patient. — The patient is placed upon a firm flat table, 
with his head directed toward the source of light, so that the rays will 
fall from the head toward the feet. The light should be so regulated 
by adjustment of the window shades that it enters on a plane only a 
little above the patient. 

Technic. — The examiner takes his stand near the patient's feet 
and, by 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. 491). At times tumors 
of the body of the stomach or of the pylorus may be observed elevat- 
ing 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 



INSPECTION 



465 



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 




Fig. 491. — Inspection of the stomach. 




Fig. 492. — Showing the shape of : (i) A dilated stomach, (2) an hour-glass 
stomach, (3) the stomach in gastroptosis. 

abdomen or by the application of cold. A dilated stomach may be 
determined from the great bulging in the epigastrium and from trac- 
ing the greater curvature to a point considerably below the umbili- 

30 



466 THE STOMACH 

cus, and at times an hour-glass contraction may be recognized (Fig. 
492). In gastroptosis the epigastrium will be retracted, and the 
lesser curvature may be seen represented by a groove extending from 
the umbilicus to the ribs upon the left and above. Depression of the 
epigastrium will also be seen in stenosis of the cardia. 

PALPATION 

Palpation is by far the most reliable of the methods of physical 
examination. The stomach should, when possible, be palpated both 




Fig. 493. — Method of palpating the stomach. 

before and after taking food, as tumors of the posterior wall are often 
capable of being felt only when the stomach is empty. The large 
intestine should be emptied by an enema, if necessary, so as to avoid 
mistaking feces for new growths. The examination should be carried 
out systematically, and of course it must not be limited to the stom- 
ach alone, but all the other abdominal organs should be palpated 
as well. 

Position of Patient. — The patient lies recumbent with the abdom- 
inal muscles as relaxed as possible. If it is necessary to obtain greater 
relaxation than is possible by this posture, the knees should be drawn 
up and the head and thorax should be slightly raised upon a pillow. 
Where there is considerable rigidity of the abdominal muscles or in 



PALPATION 



467 



fat individuals, relaxation may be secured by placing the patient in a 
warm bath. 

Technic. — The examination should be performed in a warm 
room and the physician's hands should be warmed to avoid the 
muscular spasm produced by cold hands. The patient is instructed 
to keep his mouth open and to breathe regularly and deeply to induce 
the fullest amount of relaxation. The examiner sits or stands 
beside the patient and places both hands fiat upon the abdomen, with 
the palms down and the fingers slightly flexed, and palpates with the 
finger-tips. Only gentle manipulations should be employed, as 




Fig. 494. — Palpating a tumor of the stomach between the fingers of the two hands. 

otherwise spasm of the abdominal muscles will be induced and the 
aim of the examiner will be defeated. 

When it is desired to perform deep palpation for the recognition 
of deep-seated tumors, one hand is superimposed upon the other, 
the upper hand making the pressure and the lower one performing the 
palpation (Fig. 493). Deep palpation is greatly aided by having the 
patient breathe deeply; it then becomes possible for the palpating 
hand to follow the receding abdominal walls with expiration. 

In palpating tumors, one hand is used to fix the growth and the 
other outlines its size and determines its consistency, fixity, or 
mobility, and the presence or absence of pulsation, tenderness upon 
pressure, etc. (Fig. 494). 



468 



THE STOMACH 



The examiner should lirst determine the size and position of the 
stomach. Inflation (page 471) is a great aid to palpation, as it is 
usually impossible to palpate the outline of an empty organ. An- 
other method of determining the size or the position of the stomach 
is by means of a long soft-rubber stomach-tube passed into the organ 
to such an extent that it lies along the greater curvature. The 
greater curvature and the pylorus may thus be outlined by palpating 
the tube through the abdominal walls. All parts of the organ are 
next carefully palpated with the purpose of determining the presence 
or absence of new growths, painful spots, etc. Tumors of the 




^ite tif tenderness. 
It ulcer o^pylomS 

jSue of tenderness 
aieer oft/u duode/ra/n 



usual sites of 
tenderness in- 
uleer o^J tomach , 



Fig. 495. — Points of pressure tenderness in ulcer of the stomach. (Mayo 
Robson in Keen's Surgery.) 

pylorus and the greater curvature are readily palpable. The former 
are usually situated to the right of the median line, between the 
xiphoid and the umbilicus, but they have a wide range of motion 
unless adherent. Tumors of the lesser curvature lie to the left of 
the median line, thus differentiating them from those of the gall- 
bladder. They are less freely movable than those of the pylorus. 
Tumors of the cardia are seldom palpable. Changing the position 
of the patient to a lateral one is often of service in rendering a growth 
more accessible to the examiner. The knee-chest posture is also of 
value, as deep-seated movable tumors then fall forward toward the 
anterior abdominal wall. 

Eliciting tender spots on palpation is frequently a diagnostic aid. 
In organic diseases, such as ulcer, cancer, gastritis, etc., pain is 



PERCUSSION 



469 



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 
common points of tenderness for ulcer are between the left costal 
margin and the mid-line ^Fig. 495) ; points of pressure tenderness are 
also at times found i to 2 inches (2.5 to 5 cm.) to the left of the spine, 
in the neighborhood of the twelfth dorsal vertebra fFig. 496). In 
affections of the gall-bladder similar tender points will be frequently 
found more to the right of the spinal column. 



jSites of tendertte^f 
in ulcer of — 
ike eSTo/rraeJi 




Fig. 496. — Points of pressure tenderness found posteriorly in ulcer of the 
stomach, (.vlayo Robson in Keen's Surgery.) 



PERCUSSION 

Only the greater curvature and the portion of the anterior surface 
of the stomach in contact with the anterior abdominal wall are access- 
ible for percussion, conseqaently the chief use of this method is to 
determine 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 
soarce of error is the resonance of the transverse colon, which may be 
confused mth 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 wdll be obtained on percussion. The percussion note 



470 



THE STOMACH 



over the stomach is a high-pitched metallic tympany, but it will vary 
much, depending upon whether the stomach is empty, whether it is 
full of food, or simply contains air. Percussion should be performed 
when the stomach contains some air; under inflation of the organ 
percussion furnishes even more valuable results. 

Position of the Patient. — The patient should lie in the recumbent 
posture. 

Technic. — The palmar surface of the middle finger of the left hand 
is laid upon the area it is intended to percuss and is held firmly 




Fig. 497. — Percussion of the stomach. 

against the surface, while with the flexed middle finger of the right 
hand a number of sharp taps or blows are struck (Fig. 497). The 
force of the percussion should, as a rule, be very light, but, if it is 
desired to make out a deeply placed growth, firm heavy percussion 
will be required. The same is true when the abdominal walls are 
very thick. Having outlined the stomach with the patient recum- 
bent, the percussion should be performed with the patient upright 
to determine if the organ sinks down from its normal position. 

AUSCULTATION 

By listening to sounds produced within the esophagus during the 
swallowing of fluids and to sounds originating within the stomach 



IXTLATIOX OF THE STOIIACH 471 

itself, certain information of diagnostic importance may be obtained. 
By the first method it is possible to determine whether there be an 
obstruction of the cardia or not. It is carried out as follows : 

The operator listens with his stethoscope placed over the esopha- 
gus, that is, to the left of the ensiform cartilage or to the left of the 
spinal column opposite the ninth or tenth dorsal vertebra while the 
patient is swallowing fluids. Two sounds are thus heard: first, a 
spurting sound that immediately foUows the act of swaUowing. and 
a second sound, more ratthng in character, known as the '■degluti- 
tion murmur.'" which is heard six or seven seconds (sometimes as 
much as twelve seconds) later; it represents the passing of food 
through the cardiac orifice into the stomach. If this second sound 
is constantly absent, more or less complete occlusion of the cardia 
is presumable. 

The succussion or splashing sounds that originate in the stomach 
itself are of greater diagnostic importance. In order to obtain these 
sounds the stomach must contain air and be partly filled with fluid. 
The patient lies recumbent and the operator Hstens with his ear near 
the abdomen while he taps the abdominal wall in the region of the 
stomach ^dth his finger-tips. Succussion sounds may also be ehcited 
by mo\dng the patient quickly from side to side. These sounds 
should be difl'erentiated from other gurgling sounds which are heard 
when the stomach contains only air or is empty. Succussion in 
itseK is of no diagnostic importance, for it may be heard in a normal 
stomach containing a quantity of fluid. It is pathological, however, 
if obtained when the stomach should normally he empt\\ that is, in the 
morning before breakfast, three hours after a test breakfast, or seven 
hours after a test dinner. It then indicates a condition of atony 
or deficient motility. When succussion is heard over an abnormally 
large area, or beyond the normal boundaries of the organ, it indicates 
dilatation or gastroptosis. The outlines of the stomach may be 
mapped out with considerable accuracy by tapping first from above 
downward, and then from side to side, the examiner listening the 
while with a stethoscope placed over the stomach and noting where 
the splashing sounds stop. 

INFLATION OF THE STOMACH 

The stomach may be inflated for diagnostic purposes to deter- 
mine its size, shape, and position, and to establish the presence or 
absence of tumors. It is of great aid to inspection, palpation, or 
percussion. 



47-2 THE STOMACH 

The inflation may be performed by means of efTervescent solu- 
tions giving off carbonic acid gas or by means of air introduced 
into the stomach through a tube. Inflation by the latter method is 
safer, as it is under the direct control of the operator and may be 
stopped at any moment if desired; furthermore, the distention may 
be immediately relieved if necessary. On the other hand, distention 
by means of carbonic acid gas is of great advantage in nervous individ- 
uals who fear the stomach-tube. It is not always satisfactory, how- 
ever, as the dosage may not be large enough to generate sufficient gas 
in a capacious stomach or, if too much gas is formed, it may produce 
pain and vomiting. With either method some caution must be 
observed and the inflation mast be immediately stopped if pain be 
produced. Inflation is contraindicated in recent hemorrhage of the 
stomach, in suspected gastric ulcer, in advanced cardiac disease, and 
in advanced arterial disease. 

Under distention the stomach is raised from the neighboring 
organs and its limits thus become more clearly outlined, so that condi- 
tions of dilatation, gastroptosis, and hour-glass contractions may be 
distinguished and tamors may be rendered more pronounced. Be- 
fore performing inflation in the case of suspected gastric tumor, the 
abdomen should be carefully examined and the exact situation of the 
growth noted; by then noting the position of the growth after infla- 
tion it may be determined whether the growth is connected with the 
stomach and whether it is fixed by adhesions or is movable. Fre- 
quently under inflation it is possible to determine by sight and by 
palpation the direct continuity between the stomach and the tumor. 
Tumors of the pylorus and of the anterior stomach wall become more 
prominent, while those of the posterior wall become less so when the 
stomach is inflated. Tumors of the pylorus generally move down- 
ward and to the right under inflation. Tumors of the lesser curva- 
ture near the cardia are displaced to the right under the liver. At 
the same time spurious tumors due to spasm disappear. 

Apparatus. — For inflation with carbonic acid gas no apparatus is 
required. A stomach-tube should be at hand, however, for the pur- 
pose of relieving the patient of distention from gas if necessary. 

To inflate with air an ordinary stomach-tube 30 inches (75 cm.) 
long, of soft rubber, to the proximal end of which a double cautery 
bulb or a Davidson syringe is attached, will be required (Fig. 498). 

Asepsis. — The tube should be sterilized by boiling. 

Position of the Patient. — If desired, the tube may be passed with 
the patient sitting up, but the inflation and the examination should 



INFLATION OF THE STOilACH 



473 



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 (4 gm.) of bicarbonate of soda dissolved in 3 ounces (90 c.c.) 
of water, and then a little less than i dram (4 gm.) of tartaric acid 
dissolved in 3 ounces (90 c.c.) of water. As the two solutions come 
in contact, carbonic acid gas is generated and the stomach is thereby 
distended. In dilatation of the stomach, however, it may be neces- 
sary to give a second dose to obtain sufficient distention for the pur- 
pose of mapping out the outlines of the organ. 




Fig. 498. — Stomach-tube and Davidson sj^ringe for inflating the stomach. 



2. By Air. — To inflate a stomach successfully with air through a 
tube it is essential that the patient be accustomed to the passage of 
the stomach-tube- — the tube should certainly have been passed at 
least once previously. The tube is inserted as follows: The patient 
is instructed to open the mouth, and the tube, moistened with water, 
is passed along the roof of the mouth to the pharynx. From this 
point it is advanced partly by swallowing efl'orts on the part of the 
patient and partly by the operator who pushes it on until it has 
passed a sufficient distance to be carried beyond the cardia. By 
alternately compressing and relaxing the inflation bulb the stomach is 
then gently pumped up with air until it is sufficiently distended for 
the purposes of the examination. In the case of an insufficiency of 
the pylorus it may be impossible to distend the stomach, the gas 
being expelled on into the small gut. This will be evidenced by a 



474 THE STOMACH 

generalized swelling of the abdomen, instead of a distention localized 
in the region of the stomach. 

As soon as the examination is completed, the inflation bulb is 
removed from the end of the tube and the air is allowed to escape 
so as to avoid the disagreeable distention. The abdomen may be. 
kneaded to facilitate the escape of the air. 

EXTRACTION OF THE STOMACH CONTENTS 
FOR EXAMINATION 

The contents of the stomach may be removed for purposes of 
diagnosis when it is desired to examine the gastric secretion chemic- 
ally and to test the motor functions of the stomach. Such examina- 
tion often gives results of value both diagnostically and prognosti- 
cally, 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 all 
cases the history and the results of physical examination should be 
given due consideration. 

To test the digestive power of the stomach it is necessary to 
examine the contents at the height of digestion. In other cases, as 
when h}-persecretion 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 hydro- 
chloric acid. If, therefore, the contents of the stomach, removed in 
the morning before any food has been taken since the evening before, 
show the presence of food or if a considerable quantity of fluid con- 
taining free hydrochloric acid is obtained, it points in the former 
case to motor insufiiciency 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 re- 
moved after a definite lapse of time. For this purpose either a test 
breakfast or a mid-day test dinner is employed. 

The Ewald-Boas test breakfast consists of one or two rolls — be- 
tween I and 2 ounces (35 and 70 gm.), a cup of tea without sugar or 
milk, or 10 to 14 ounces (300 to 400 c.c.) of water. This is given 
upon an empty stomach in the morning and removed in one hour. 

The Riegel test dinner consists of a large plate of meat soup — 
about 14 ounces (^400 c.c), a large portion of beefsteak or other meat, 



EXTRACTION OF THE STOMACH CONTENTS 475 

weighing 5 to 7 ounces (150 to 200 c.c), 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 con- 
sist of from I to 2 1/3 ounces (30 to 70 c.c.) of acid material which 
upon filtration yields a clear yellow or yellowish-brown fluid. Upon 
analysis this contains a total acidity of 40 to 60 (0.15 to 0.21 per cent.), 
free hydrochloric acid 25 to 50 (o.i to 0.2 per cent.), pepsin, rennin, 
albumoses, peptones, maltose, achroodextrin, and erythrodextrin. 

The technic of gastric analysis will be found in works upon clinical 
laboratory methods. Such examinations, 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 deter- 
mine the presence or absence of free hydrochloric acid and of com- 
bined 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. 

Eypochlorhydria. — A diminished secretion of hydrochloric acid 
occurs in the late stages of chronic gastritis, in gastric neuroses, in 
gastric atrophy, in dilatation of the stomach, in the early stages of 
gastric cancer, and sometimes in ulcer when associated with chronic 
gastritis or a cachectic condition. It is also diminished in fevers, 
wasting diseases, pernicious anemia, chlorosis, neurasthenia, etc. 

Anachlorhydria. — Hydrochloric acid is absent when the secreting 
glands have been destroyed, as in atrophic catarrh and in cancer of 
the stomach. A diagnosis of cancer, however, cannot be made on 
this alone; the hydrochloric acid must be constantly absent and 
other corroborative facts must be present. 



476 



THE STOMACH 



Hyperacidity, or an increase in the total acidity, may be the result 
of excessive output of hydrochloric acid or it may be caused by 
organic acids (lactic, butyric, and acetic). 

Hypoacidity, or a diminished total acidity, denotes a deticicncy 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 
general signifies insufUciency of the motor power and stagnation of 
the stomach contents, as is found in dilatation, obstruction of the 




Fig. 499. — Stomach-tube and funnel for expressing the stomach contents, a, 
Showing the lateral fencstrae; b, funnel; c, mark to indicate the distance from the 
incisor teeth to the stomach. 

pylorus, and cancer. The presence of lactic acid alone is not diag- 
nostic of cancer, as small amounts may be found after a meat diet 
and may also be present in other pathological conditions, nor does its 
absence prove the nonexistence of cancer. When, however, it is 
found in considerable amount and is associated with an absence of 
hydrochloric acid and with deficient motility, it is strongly sugges- 
tive of cancer, especially if the Boas-Oppler bacillus is also present. 

Pepsin and rennin are only absent when profound organic changes 
have resulted in an almost complete destruction of the gastric 
mucous membrane as the result of chronic inflammation, severe 
atrophy, etc. The presence or absence of these ferments is thus of 
importance in the diagnosis between an organic change and a 
functional condition. 

Extraction of the Stomach Contents. — The stomach contents 
may be removed through a stomach-tube either by the aspiration or 



EXTRACTIOX OP THE STOiLA.CH CONTEXTS 



477 



expression method. The expression method answers in the great 
majority of cases, but it may fail where the contents of the stomach 
are not fluid enough to flow through the tube. The use of the 
stomach-tube is contraindicated in the presence of aortic aneurysm, in 
patients Hable to cerebral hemorrhage, or in those who have recently 
suft'ered from gastric or pulmonary hemorrhages, in those who are 




Fig. 500. — Boas' aspirating bulb. 

very weak, in those sufl'ering from severe pulmonary or cardiac 
troubles, etc. 

Apparatus. — When the expression method of removing the 
stomach contents is employed the following apparatus will be re- 
quired: A soft-rubber stomach-tube about 30 inches (75 cm.) long 
and 1/4 of an inch (6 mm.) in caliber, with two smooth-edged lateral 



Poh 



a ins /Jump 




jJ^macJi n/6e 



Fig. 501. — Bottle arranged for aspirating the stomach contents, c, Large glass 
bottle; h, tubing connected with a Potain aspirator; c, the stonach tube. 

openings and a blind end, connected by a piece of glass tubing 3 to 4 
inches (7.5 to 10 cm.) long to 2 feet (60 cm.) of rubber tubing, to the 
end of which a glass funnel is attached (Fig. 499) . 

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. 500). The bottle- 
aspirator (Fig. 501) consists of a large glass bottle supplied with a 
tightly fitting rubber stopper through which two glass tubes pass; 



478 



THE STOMACH 




Fig. 502. — Introducing the stomach-tube. First step, imparting a curv^e to 
the end of the tube for its more easy passage. 




Fig. 503. — Introducing the stomach-tube. Second step. 



EXTRACTION OF THE STOMACH CONTENTS 



479 




Fig. 504. — Introducing the stomach-tube. Third step. 




Fig. 505. — Aspiration of the stomach contents. First step. 



48o 



THE STOMACH 



one of these is connected with the stomach-tube while to the other a 
Potain syringe is attached, by means of which the air in the bottle 
is exhausted. 

Asepsis. — The stomach -tube should be sterilized before use. 

Position of the Patient. — The patient is seated upright in a chair 
or in bed. 

Technic. — Any artificial teeth or plates should be removed from 
the patient's mouth and he should be protected by a towel or an 




Fig. 506. — Aspiration of the stomach contents. Second step. 

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 collect in the mouth. The tube is moistened in 
warm water, and is passed into the patient's open mouth back to the 
pharynx. The patient is then requested to swallow, and the instru- 
ment is thus advanced into the esophagus, partly by the swallowing 
action and partly by the operator (Fig. 503). During this ma- 
neuver the patient is instructed to breathe regularly and deeply, even 
if a sense of suffocation is produced, and to hold the head slightly 



EXTRACTION OF THE STOMACH CONTENTS 48 1 

forward to alJow the escape of the sahva which collects in the throat 
(Fig. 504). As soon as the tube has passed the entrance of the 
esophagus it may be readily pushed on into the stomach without 
any difficulty. The distance from the incisor teeth to the cardia is 
about 16 inches (40 cm.) and to the lower border of the healthy 
stomach about 22 inches (55 cm.), but in pathological conditions, as 
in dilatation, for example, it may be more. When the tube has been 
introduced for the proper distance, the contents of the organ are 
removed, either by expression or by suction furnished from one of the 
forms of aspirating apparatus described above. 

Expression of the stomach contents is accomplished by pressing 
•over the region of the stomach while the patient bends forward and 
strains as if at stool. The proximal end of the tube is in the mean- 
time lowered over a dish or bowl to a point below the level of the 
stomach. 

Aspiration with the Boas aspirator is performed as follows: With 
the clamp closed the operator compresses the bulb (Fig. 505) and 
then releases it, thus filling the bulb with the stomach contents. 
The clamp is then opened and the bulb is compressed, causing the 
contents to be forced out into a receptacle (Fig. 506). 

Variation in Technic. — Einhorn employs a small bucket for 
withdrawing samples of the stomach contents at various periods of 




Fig. 507. — Einhorn's stomach bucket. 

digestion. In this way the chemical composition of the gastric juice 
at any time may be ascertained, and also the functional activity of 
the stomach may be determined, by noting the progress of diges- 
tion at any given time after the administration of a test meal. 

Einhorn'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 pro- 
vided with an opening in the top, above which is a cross-bar to 
which a heavy silk thread is attached (Fig. 507). 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 



482 THE STOMACH 

minutes and is then carefully removed by drawing on the thread and 
with it sufficient of the stomach contents for an ordinary examination 
of the acidity, etc. 

TEST OF THE MOTOR FUNCTION OF THE STOMACH 

By the motor power of the stomach is meant the ability of that 
organ to propel its contents into the intestine. When this function 
is deficient, as from obstruction of the pylorus due to cancer, ulcer, 
etc., or from impairment of the gastric musculature, food accumu- 
lates in the stomach and dilatation finally results. Early recogni- 
tion of perversion of the motor power is thus of great importance. 
There are a number of tests for determining the motor function of the 
stomach, among which are the following: 

Leu he's Test. — ^This consists in giving the patient a test meal 
composed of a plate of soup, a beefsteak, and a roll. If the stomach 
is empty seven hours later and nothing can be removed by lavage, 
the motor power is normal; on the other hand, if food remains in the 
stomach longer, the motor power is deficient, the degree of impair- 
ment being indicated by the quantity and the character of the food 
remaining. 

Ewald's Test. — This consists in 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 perform- 
ing 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 in- 
structed to urinate at intervals of half an hour for two hours and to 
preserve the specimens separately; these are later tested with neutral 
ferric chlorid solution for the presence of salicylic acid. In the pres- 
ence of salicylic acid the test gives a violet-blue color. In normal 
cases the salicylic acid should be recognized in the urine in from thirty 
to seventy-five minutes. Delay in its appearance indicates deficient 
motor power. 

lodipin Test. — This drug is unaltered by the gastric juice, but in 
the intestine it is split up and iodin is absorbed and eliminated in 
the saliva. Fifteen grains (i gm.) of iodipin are administered in 
gelatin-coated capsules in the morning with breakfast and the saliva 
is then tested with starch-paper and nitric acid for iodin every fifteen 
minutes. In a normal case the iodin is recognized in the saliva 
within about an hour. 



TB_A.XSILLUiIIXATIOX OF THE STOMACH 



483 



TEST OF THE ABSORPTION POWER OF THE STOMACH 

The usual method of determining this is by the test known as 
that of Penzoldt and Faber. It is performed as follows: 3 grains 
(0.2 gm.) of chemically pure potassium iodid are given in a gelatin- 
coated capsule on an empty stomach, and the urine or the saliva is 
then tested with starch-paper and faming nitric acid CA^ery few min- 
utes for iodin. Its presence is indicated by a blue or a violet reaction, 
lodin should normally be detected in the saliva and urine in from sLx 
and a half to fifteen minutes after the ingestion of the iodid of potas- 
sium, while its appearance is considerably delayed if the absorp- 
tion power is interfered with. 

TRANSILLUMINATION OF THE STOMACH, OR G ASTRO - 

DIAPHANY 

A method introduced by Einhorn, which consists of transillumi- 
nating the stomach by means of a small electric light fastened to the 





Cross Sectiorv^ (enUrged) 
Showing inner tube 
extending throughoat 



Fig. 508. — Lynch's gastrodiaphane.^ (From a drawing in the possession of 

Dr. J. M. Lynch.) 



end of a rubber tube. By this method of diagnosis the position and 
size of the stomach may be determined, and the presence and posi- 
tion of a growth or a thickening of the anterior wall of the stomach 
may be recognized from the lack of transparency. It is of value in 
the diagnosis of dilatation and in the difi'erentiation of this condi- 
tion from gastroptosis. In the former the illuminated area is larger 

^ Made bv the Electro-Surgical Instrument Co. 



484 THE STOMACH 

than normal, while in the latter it is small and situated low down. 
Transillumination, however, is not used as a routine, since it is 
complicated and requires special apparatus, furthermore, there are 
simpler methods of determining the size and position of the organ. 
One advantage of the method, however, is that the organ is seen in 
its natural condition, whereas under inflation it is apt to be stretched 
beyond the normal. To employ the method successfully it is neces- 
sary that the patient be accustomed to the insertion of the stom- 
ach tube, otherwise retching and vomiting will interfere with the 
examination. 

Apparatus. — Einhorn's gastrodiaphane consists of a small Edi- 
son incandescent lamp attached to the distal end of a soft-rubber 
stomach-tube. The wires which convey the electricity to the lamp 
pass down inside the tube while at the proximal end are two screws 
for attaching the wires leading from the battery. A six to eight 
dry-cell battery furnishes the necessary power. 

Lynch has modified Einhorn's gastrodiaphane by employing a 
longer tube — 53 inches (135 cm.) long — sufficiently long to pass 
through the pylorus — and by supplying it with an inner auxiliary 
tube through which the stomach may be inflated with air or water 
or the contents of stomach or duodenum may be aspirated (Fig. 508). 

Asepsis. — The instrument should be sterilized before use. 

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 moistened with water and is carefully guided into the phar- 
ynx and the patient is instructed to swallow, the descent of the tube 
being aided by the operator who pushes it on as soon as it is well 
within the esophagus. When the lamp is within the stomach, the 
illumination is turned on and the room is darkened, w^hile the results 
of the transillumination are noted. A bright luminous area will be 
noted on the anterior abdominal wall which corresponds in size to 
the outhnes 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 illuminated 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- 



GASTROSCOPY 485 

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 
(500 c.c.) of water with the addition of 5 tdj (0.30 c.c.) of dilute 
phosphoric or sulphuric acid to increase the acidity and so intensify 
the fluorescence. 

Fluorescein, which gives a green fluorescence, is administered as 
follows: The patient is given 8 ounces (236 c.c.) of water to drink 
in which is dissolved 15 grains (i gm.) of sodium bicarbonate to 
render alkaline the acid stomach contents. A second drink is then 
given, consisting of 8 ounces of water (236 c.c.) in which are mixed 
1/2 to 1/4 grain (0.008 to 0.0016 gm.) of fluorescein, i dram (4 c.c.) 
of glycerin, and 15 grains (i gm.) of bicarbonate of soda. After 
the administration of the fluorescent medium the lamp is introduced 
and the examination is proceeded with as above. 

GASTROSCOPY '■ 

Gastroscopy consists in the insertion into the stomach of a stiff 
metal tube, illuminated by electricity, through which the interior of 
the organ is inspected. This method of examination was inaugu- 
rated by Mikulicz in 1881, but, on account of its limited value and 
the technical difficulties in the use of the older instruments, it never 
came into general use. Later, in 1890, Rosenheim devised a gastro- 
scope on similar principles. Both these instruments were made with 
prisms on the principle of the cystoscope, but had the fatal fault 
that the instrument was inserted blindly and not under the sight of 
the operator. Chevalier Jackson, in 1906, designed a gastroscope on 
entirely different principles, employing large tubes with the illumina- 
tion at the distal end, similar to those used in direct tracheo-bron- 
choscopy and esophagoscopy, and he thus made it possible to ex- 
plore a considerable portion of the stomach by direct vision. As a 
rule, from two-thirds to three-fourths of the stomach, including the 
pylorus, is available for examination with this form of instrument, 
depending upon the range of lateral motion of the hiatus esophagei. 
A stomach which occupies a vertical position presents the largest 
area for exploration while the more horizontally the organ is placed 
the less of it will be available for examination. Furthermore, under 



486 THE STOMACH 

direct view gastroscopy lesions may be palpated by means of a 
probe passed through the instrument, applications may be made to 
diseased areas, foreign bodies may be removed, and sections of 
tumors may be excised for microscopical examination. The latest 
advance in gastroscopy was made in 1910 by Hill in conjunction 
with Herschell, who combined a direct and indirect view esopha- 
gogastroscope and added to the instrument a tap for inflating the 
stomach with air. 

Gastroscopy, however, cannot supplant other methods of diagno- 
sis. It necessitates that the patient submit to a general anesthetic 
and requires such experience and dexterity on the part of the operator 
for its proper performance as to place it outside the domain of any 
but experts. According to Jackson, gastroscopy is without danger 
other than that from the anesthesia. At the same time, the opera- 
tion requires great skill which is best obtained by practising upon the 




(^^^ 



Fig. 509. — Jackson's gastroscope. 

cadaver. He considers the operation unadvisable under the follow- 
ing conditions: "In the profound cachexia of the last stages of malig- 
nancy; in the profound anemia of inanition from known or unknown 
causes; cardiac, pericardiac, or major vascular lesions; general or 
local, acute or chronic conditions associated with either dyspnea or 
dropsical effusions; the late stages of organic diseases, as cirrhosis 
of the liver, etc." Diseases of the esophagus may, of course, interfere 
with or render gastroscopy out of the question. 

Apparatus. — Jackson's gastroscope (Fig. 509) consists of a cylin- 
drical tube about ^2 inches (80 cm.) long with a lumen 2/5 inch 
(10 mm.) in diameter, and with a thickened distal end. In the wall 
of the instrument are two small accessory tubes; one through which 
the illuminating apparatus is inserted and the other for the purpose 
of aspirating fluids that may interfere with the examination. To the 
proximal end of this latter tube an aspirating apparatus is attached. 
The instrument is also provided with an obturator having a conical 
tip to facilitate its insertion. 



GASTROSCOPY 



487 



The Hill-Herschell esophagogastroscope (Fig. 510) for combined, 
direct and indirect gastroscopy consists of a direct view tube with the 
illumination supplied at the proximal end from a Brlinings hand 
lamp and an indirect view periscopic tube with a terminal lamp, 
which can be passed through the direct view tube. The direct view 
tube is supplied with a cap containing a plain glass window and a 
tap through which air can be forced for the purpose of inflation. A 




Fig. 510. — Hill-Herschell esophagogastroscope. a. Direct view esphagoscope 
with Briinings lamp; h, indirect view periscope; c, shows instrument assembled 
for gastroscopy. 

second cap, also with an inflating tap and with a rubber-lined opening 
for the passage of the indirect view tube, is provided. Both caps 
are fastened to the proximal end of the tube by means of a bayonet 
joint. 

Asepsis. — The tube may be boiled and the light-carrying appara- 
tus may be sterilized by immersion in a i to 20 carbolic acid solution, 
followed by rinsing in alcohol, or alcohol alone may be employed. 

Preparations. — These should include the ordinary preparations 
for a general anesthetic; that is, the patient is given a cathartic the 



488 



THE STOMACH 



night before the operation and food is withheld for a period of twelve 
hours before the operation (see also page 2). It is essential that 
the stomach be empty when gastroscopy is performed, and, if neces- 
sary, lavage of the stomach should be practised three or four hours 
previous to the operation. In dilatation with atony preliminary 
lavage is a necessity. 

Position of the Patient. — The patient is placed in the recumbent 
posture with the shoulders brought 4 to 6 inches (10 to 15 cm.) over 




Fig. 511. — Position of patient for gastroscopy. (After Jackson.) 

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. 511). This assistant also con- 
trols 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 pro- 
cedure a dangerous one. 

Technic. — i. Direct View Gastroscopy. — The mouth gag is inserted 
and the operator introduces the left forefinger into the patient's 



GASTROSCOPY 



489 



mouth to the base of the tongue or behind the epiglottis and draws 
the tongue forward. The gastroscope, well lubricated, and held in 
the operator's right hand, is then introduced, following the fore- 
finger, already in the patient's mouth, as a guide (Fig. 512). At 
this stage the assistant who controls the patient's head should bend 




Fig. 512.^ — IMethod of inserting the gastroscope. (After Jackson.) 

the patient's neck well backward so as to bring the mouth and 
esophagus in as straight a line as possible. As soon as the instru- 
ment has been passed beyond the entrance of the esophagus, the 
obturator is withdrawn and the light is turned on. The instrument 




Fig. 513. — Showing the head and neck of patient drawn to the right to allow 
the instrument to pass through the hiatus and abdominal esophagus. (After 
Jackson.) 

is passed the rest of the w^ay entirely by sight, care being taken to 
avoid compressing the trachea by the point of the instrument. To 
pass the hiatus at the diaphragm, the instrument is rotated in such a 
way that the long axis of a cross section of the tube corresponds to 



490 



THE STOMACH 



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 turned to the right (Fig. 
513). When the tube has entered the stomach, the interior of the 
organ should be systematically explored according to the technic 
described by Jackson.^ which the writer takes the hberty of quoting: 
"There are two plans of exploration, both of which should be 
carried out. First, the gastroscope should be passed down carefully 
and gently to the greater curvature, inspecting the anterior and pos- 




FiG. 514. — Showing the patient's head and neck turned to the left to aUow the 
instrument to reach the pyloric end. (After Jackson.) 

terior walls. At times these walls do not seem to be fully collapsed 
ahead of the tube, and one will have to be examined first, then the 
other. Then the tube is withdrawn, inclined slightly laterally in the 
same plane, then pushed gently downward again in a new series of 
folds. This is repeated until the extreme pyloric limit is reached. 
To reach this limit the head and neck of the patient are moved to the 
left, with the tube below the cardia (Fig. 514). 

"After the whole possible range has been covered in this way 
we proceed to the second plan. The tube is passed down until 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 not in too close contact therewith, until the 
extreme right is reached. Withdrawing the tube a centimeter or two, 
the field is slowly swept again in the same plane, but at a higher 

^Jackson. Tracheo-bronchoscopy, Esophagoscopy, and Gastroscopy, page 149. 



GASTROSCOPY 



491 



level, and so on, upward to the cardia. Next the left fingers of one 
skilled in abdominal palpation are called upon to manipulate the 
unexplored portions over the front of the tube. This is sometimes 
better accomplished by turning the patient on his side, first on one 
side, then on the other. During all these manipulations the tube 
must be withdrawn within the esophagus; when the stomach is in 
its new position, the gastroscope is again pushed downward and the 




Fig. 515. — The passage of the outer tube of the Hill-Herschell esophago- 
gastroscope through the esophagus under direct vision. (Mayo Robson in Keen's 
Surgery.) 

newly available surfaces are explored. Should retching supervene 
while the tube is in the esophagus, no harm will result, but when the 
tube is in the stomach retching is the signal for immediate with- 
drawal of the gastroscope until the distal end of the tube is above the 
diaphragm. 

"The vertical diameter of the stomach is easily determined by 
measurement. The depth from the teeth to the cardia is taken, then 
the gastroscope is passed on down until the greater curvature is 
encountered, and the distance from the teeth is again taken. The 
difference between this and the first measurement gives the vertical 



492 



THE STOMACH 



diameter of the stomach at this point. Care must be used that the 
measurements are not rendered inaccurate by pushing the greater 
curvature downward, which is exceedingly easy to do without know- 
ing it if the sense of touch is relied upon to determine when the lower 
wall is reached. If the downward progress of the gastroscope is 
watched through the upper orifice it is easy to see when the wall at 
the greater curvature is touched. Having taken our measurements, 




Fig. 516. — Method of performing indirect view gastroscopy with the Hill-Her- 
schell instrument. (Mayo Robson in Keen's Surgery.) 

we then place the obturator externally parallel to the tube within and 
indicate to the abdominal manipulator the exact position of the lower 
end of the tube, which he can then mark on the skin, giving thus with 
absolute accuracy the exact location of the greater curvature of the 
empty stomach at that point. Care must be taken, of course, to 
resterilize the obturator should it touch anything unclean." 

2, Combined Direct and Indirect View Gastroscopy. — The outer 
direct view tube is passed into the stomach under the sight of the 
operator (Tig. 515) in the manner previously described for the pass- 



EXPLORATORY LAPAROTOMY 493 

age of Jackson's gastroscope (page 488). With the tube in the stom- 
ach the cardiac region may be examined by direct vision under in- 
flation. The optical window and the hand lamp are then removed, a 
handle taking the place of the lamp and the perforated cap the place 
of the glass window. The indirect view tube is now passed through 
the perforated cap and outer tube, being careful to begin the infla- 
tion before it enters the stomach so that the window of the peri- 
scope will not be sofled from contact with the mucous membrane. 
The pylorus is first located (Fig. 516) and from this as a starting point 
the remainder of the stomach is inspected in detail, slowly withdraw- 
ing and turning the gastroscope so that all portions are brought to 
view. The region of the cardia, however, can only be inspected by 
direct view. 

SKIAGRAPHY 

The X-ray is useful in locating foreign bodies impermeable to the 
rays and in determining the size, shape, position, and peristaltic move- 
ments of the organ. By inserting a long soft stomach-tube, which is 
filled with bismuth or shot, in the stomach along the greater curva- 
ture and then taking an X-ray while the patient is in the erect posi- 
tion, the outline of the stomach and position of the pylorus have been 
mapped out. Another method of determining the size and position 
of the stomach is to have the patient swallow keratin-coated capsules 
of bismuth or to give the patient on an empty sto?nach a pint (500 c.c.) 
of milk, kumiss, mucilage of acacia, or gruel into which two ounces 
(60 gm.) of bismuth subcarbonate or the oxychlorid of bismuth is 
suspended by a thorough mixing. These may be administered shortly 
before the skiagraph is taken. Pictures should be taken with the 
patient recumbent and in the erect posture. A normal stomach 
should show an absence of bismuth in from three to six hours after 
the ingestion of the bismuth meal. 

EXPLORATORY LAPAROTOMY 

An exploratory laparotomy is the most valuable of all the methods 
of diagnosis in diseases of the stomach, and in many cases it is the 
only method by which a correct diagnosis can be arrived at. It is 
an operation 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 em- 



494 



THE STOMACH 



ployment in far too radical a manner. It is only justifiable where a 
careful trial of other means has failed to establish a diagnosis. Thus, 
for example, in cases where a cancerous growth is strongly suspected 
but its presence cannot be verified, or where a palpable tumor of the 
stomach is present, and there is a question as to its character and 
whether it can be removed or not, an exploratory incision is certainly 
a justifiable procedure and its prompt performance is clearly indicated, 
since an early recognition of the trouble furnishes the only hope of 
cure. The surgeon must be convinced, however, that he can accom- 
plish something for the relief of the patient before it is attempted, 
and he must be prepared to carry out any operative procedure that 
seems indicated. To perform an exploratory laparotomy simply for 
the purpose of making a correct diagnosis in an individual who is 
manifestly not fit for a severe operation or upon whom it is evident 
that the performance of a gastroenterostomy would give scarcely 
any hope for relief of his symptoms must be condemned. 

Therapeutic Measures 

LAVAGE OF THE STOMACH 

Lavage consists in washing out the stomach by introducing water 
or other fluids through a stomach-tube or catheter and then siphon- 
ing it off. It is a most useful therapeutic procedure, and if per- 
formed with proper precautions is without danger. 

Indications. — Gastric lavage may be required for the following 
purposes: (i) To remove poison and drugs from the stomach. (2) 
To remove mucus, undigested and fermenting food from a dilated or 
atonic stomach when the stomach is unable to empty itself of its 
contents after eight or ten hours. In such conditions lavage is espe- 
cially valuable, as it cleanses the mucous membrane in preparation 
for fresh food and thus promotes the appetite; at the same time the 
stomach is toned and strengthened. (3) To withdraw the irritating 
material from the stomach in acute gastric indigestion, especially 
in infants. (4) For the purpose of cleansing the stomach in prepara- 
tion for gastric operations. (5) In intestinal obstruction and per- 
itonitis with fecal vomiting for the purpose of diminishing the vomit- 
ing and at the same time removing toxic material from the digestive 
tract; and as a preliminary to operation in such cases where it is im- 
portant to have the stomach empty to avoid the danger of vomited 
matter entering the air-passages. (6) Finally, lavage may be em- 
ployed when it is desired to bring medicated solutions in contact 



LAVAGE OF THE STOMACH 



495 



with the gastric mucous membrane, though a more efficacious method 
is by means of the stomach douche. 

The contraindications to lavage are practically the same as those 
given against the use of the stomach-tube for diagnostic purposes, 
viz., in the presence of recent gastric hemorrhage, in acute inflamma- 
tion of the stomach, in aortic aneurysm, in advanced 
uncompensated valvular heart lesions, etc. In 
cases of marked general arteriosclerosis and in 
general weakness or prostration it should be used 
with caution. 

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 ordi- 
nary siphonage apparatus should be employed. This 
consists of a soft-rubber stomach-tube joined by 
means of 3 to 4 inches (7.5 to 10 cm.) of glass tub- 
ing 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 capactiy of about a pint (500 c.c.) is 
fitted (see Fig. 499). The stomach-tube should 
be about 30 inches (75 c.c.) long, 1/4 to 1/2 an 
inch (6 to 12 mm.) in diameter, and should 
be provided preferably with a closed tip and 
with two lateral openings of fairly large size so as 
to give passage to solid particles of food (Fig. 
517). These openings should be situated as close to 
the tip as possible. The tube should also have a 
mark indicating the distance from the upper incisor 
teeth to the stomach, so that the operator may 
know when he has passed it a sufficient distance. 

For an infant the following apparatus may be 
employed: 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(25o c.c.) glass funnel is attached. In addition, 
a mouth gag may be required. 

Asepsis. — The whole apparatus should be sterilized by boiling or 
by immersion in an antiseptic solution and then rinsed in water before 
using. After use it should be thoroughly cleansed, care being taken 
to see that particles of food are not left adhering to the interior of the 
tube, especially about the lateral windows. 



Fig. 517.— 

Enlarged view 
of the tip of a 
s t o m a c h-tube 
with a closed 
end and lateral 
fenestrse. 



496 THE STOMACH 

Solutions Employed. — For cleansing purposes boiled lukewarm 
water is generally employed. To rid the stomach of mucus, alkaline 
mineral waters, as Carlsbad or Vichy, or Carlsbad salt, i dr. (4 gm.) 
to I quart (1000 c.c.) of water, or sodium bicarbonate (i to 5 per cent.), 
may be employed. 

Temperature. — The solution should be of a temperature of from 
90° to 100° F. (32° to 38° C). 

Quantity. — The stomach should not be overdistended with solu- 
tion, about a pint (500 c.c.) being introduced at a time. The wash- 
ing-out process is to be continued, however, until the contents of the 
stomach return clear, provided the patient's condition permits it. In 
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 morn- 
ing before the first meal or at night, three or four hours after the last 
meal. The former time is preferable, as the stomach is thus given all 
possible opportunity for assimilation of its contents and no nourish- 
ment is withdrawn. In some cases, however, when the distress 
caused by the flatulency is such as to interfere with the night's rest, 
evening lavage is indicated. In very severe cases it may be necessary 
to wash out the stomach twice a day, night and morning. 

Position of Patient. — The patient sits in a chair facing the 
operator, with the head slightly bent forward. If the patient's 
condition is such that this is not advisable, the operation may be 
performed with the patient semiupright in bed. A child should be 
supported in a sitting position upon the lap of a nurse with its head 
held forward by an assistant so as to allow saliva and vomitus to 
escape from the mouth. 

Anesthesia. — In case gagging is excessive the pharynx may be 
sprayed or painted with a 5 per cent, solution of cocain. This is 
rarely necessary, however, after the first passage of the tube. 

Technic. — Any plates or artificial teeth should be removed from 
the patient's mouth and an apron or large towel should be fastened 
about the neck and allowed to hang over the chest and lap for protec- 
tion. The patient should be given a small bowl to catch any vomitus 
or saliva that may escape from the mouth. The tube is then well 
moistened with water to facilitate its passage. Oily lubricants 
should be avoided on account of the disagreeable taste. As a rule, 
with a soft tube it is unnecessary to hold the base of the tongue 
forward or to guide the tube in place by the lingers. The tube is 



LAVAGE OF THE STOMACH 



497 



simply passed along the roof of the patient's mouth until the pharynx 
is reached, when the patient is instructed to swallow and the instru- 
ment, grasped by the pharyngeal muscles, is carried on into the 
esophagus (see Fig. 503). 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. 




Fig. 518. — Showing the method of washing out the stomach. (After Boston.) 

As soon as the tube enters the esophagus it is rapidly pushed on 
into the stomach. Frequently when the tube enters the stomach the 
contents immediately escape into the funnel; if not, the funnel 
should be lowered and the contents drained off. To accomplish this 
it may be necessary, however, to apply some slight pressure over the 
epigastrium, after the method employed in expressing a test-meal (see 
page 481). 

Having removed the contents of the stomach, or being sure that 
it is empty, the tube is pinched close to the patient's mouth, and the 
32 



498 



THE STOMACH 



funnel is elevated slightly and filled with about a pint (500 c.c.) of 
solution (Fig. 518). The compression is then removed from the 
tube and almost the entire contents of the funnel is allowed to slowly 
run into the stomach, enough solution being kept in the funnel, how- 
ever, to start the siphonage. The funnel is then lowered and the 
contents of the stomach are siphoned back into the funnel and dis- 
carded, care being taken to see that approximately the same quantity 
returns as was introduced The process of lavage is continued by 
alternately pouring solution into the stomach through the funnel 




Fig. 519.— Showing the passage of a stomach-tube through the nose in performing 
gastric lavage upon infants. 

and then removing the solution by siphonage. In order to reach all 
portions of the stomach and more thoroughly cleanse the mucous 
membrane, it is well to have the patient move about during the lav- 
age; for example, after one or more washings in the upright position 
have the patient lie down and then roll first to one side and then to 
the other. 

At the completion of the lavage the tube should be removed as 
follows: A small quantity of fluid is allowed to remain in the funnel 
and, as the tube is slowly withdrawn, this is permitted to flow back 
into the stomach until the end of the tube is in the esophagus. The 



THE STOMACH DOUCHE 499 

tube is then tightly pinched to prevent the solution from escaping as 
the tube is withdrawn over the larynx and through the mouth. The 
important point is that the tube should not be removed from the 
stomach empty, as portions of mucous membrane may be drawn into 
the fenestrae of the tube and be lacerated or otherwise injured. 

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 biting the instrument, the tube may be passed through 
a nostril (Fig. 519). As a rule, this method of introduction is not 
difficult, 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. 

THE STOMACH DOUCHE 

Gastric douching consists in irrigating the stomach by means of 
solutions introduced under pressure. The fluid is preferably intro- 
duced through a tube provided with many small lateral openings, so 
that all portions of the mucous lining of the stomach are irrigated by 
the solution which flows out in fine streams with considerable force. 
Either plain water or medicated solutions are employed in the douche. 

The stomach douche is useful in slight degrees of motor insuffi- 
ciency for the purpose of stimulating peristalsis and secretion. It is 
also employed in neuroses affecting the sensory apparatus of the 
stomach. 

Apparatus. — A glass funnel with a capacity of i pint (500 c.c), 
a piece of rubber tubing 2 to 3 feet (60 to 90 cm.) long, a glass con- 
necting tube 3 to 4 inches (8 to 10 cm.) 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. 
520), Tne large opening in the end of the tube is necessary in 
order to drain the solution quickly out of the stomach and at the 
same time remove any solid particles. 

Einhorn 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. 521). Within the tip of 
this cap lies a freely movable aluminum baU 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 



500 



THE STOMACH 



the current is reversed, the ball is driven upward and the solution is 
carried off through the large opening. 

Asepsis.' — The apparatus should be boiled or immersed in an anti- 
septic solution and then rinsed off before use, and should be thor- 
oughly cleansed after use. 

Solutions, — Plain boiled water is usually employed. For the 
removal of mucus, alkaline solutions, as sodium bicarbonate (i to 5 
per cent.), Carlsbad salt i dr. (4 gm.) to i quart (1000 c.c.) of water, 
etc., are used. As antiseptics and antifermentatives are the follow- 



• 




Fig. 520. — An enlarged view of a 
stomach-douche tube. 



Fig. 521. — Einhorn's apparatus for 
giving a stomach douche. 



ing: salicylic acid (0.3 per cent.), sodium salicylate (0.5 to i per 
cent.), boric 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 to 0.5 per 
cent.), etc. A solution of silver nitrate in the strength of o.i to 0.2 
per cent, is sometimes employed as an astringent to diminish sensa- 
tion and salt solution (0.4 per cent.) to increase gastric secretion. 
Chloroform water has been recommended as an anodyne in gastralgia. 
Temperature. — As a general rule, the solution should be employed 
warm — at a temperature of 90° to 100° F. (32° to t,S° C). Occasion- 



THE STOMACH DOUCHE 



.501 



ally, however, the alternate use of a warm and a cold douche is found 
beneficial. 

Time for Douching. — The douche should be employed only when 
the stomach is empty. The most effective time for its use is early in 
the morning or three to four hours after the first meal. 

Amount of Pressure. — To be most effective the solution should be 
introduced under considerable pressure. The funnel end is conse- 
quently raised 3 feet (90 cm.) or more, as the solution is flowing. 

Position of the Patient. — The douching may be performed with the 
patient sitting upright in a chair or in bed, but in order to bring 
the solution into contact with all portions of the organ this position 
may be altered from time to time with advantage; that is, changing 
from the upright to the recumbent and first upon one side and then 
upon the other. 




Fig. 522. — Showing the mechanism of the stomach douche. (After Gumprecht.) 

Anesthesia. — In the presence of excessive irritation or gagging the 
pharynx may be sprayed with a 5 per cent, solution of cocain as a 
preliminary to the passage of the tube. 

Technic.^ — The patient is given a small bowl to receive any vom- 
ited matter or an excessive flow of saliva and his chest and lap are 
protected by an apron. The tube is then moistened with warm water 
and is inserted into the patient's mouth, being kept in close contact 
with the roof of the mouth until the pharynx is reached. From 
this point on the tube is advanced partly by the action of the pharyn- 
geal 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. 522), which is deter- 
mined by a mark placed upon the tube for that purpose. The funnel 
end is then raised and a pint (500 c.c.) of solution is poured into the 
funnel, the tube being pinched until the funnel is filled; the solu- 



502 



THE STOMACH 



tion is then allowed to flow into the stomach, the funnel end being 
elevated high enough to obtain the necessary pressure. 

To remove the solution, the tube is pinched while there is still some 
liquid in it and is inserted some 4 or 6 inches (10 to 15 cm.) further 
into the stomach, so that its end will lie in the fluid contents. The 
funnel end is then lowered, the compression of the tube released, and 
the fluid withdrawn by siphonage. 

The stomach should first be thoroughly washed out in the above 
manner with lukewarm water, using several pints for the purpose. 
The medicated solution is then introduced in the same manner, but 
should be allowed to remain only from a half minute to a minute. It 
is then siphoned off, and the stomach is again douched out with warm 
water. The tube is then removed, care being taken to compress it 
between the thumb and forefinger to prevent the fluid dripping from 
it into the larynx as it is withdrawn. 

GAVAGE 

Gavage consists in introducing food into the stomach by means of 
the stomach-tube. The tube may be passed through the mouth or 
through the nose. The latter method may be necessary in the 
case of infants and when the patient struggles against the passage 
of the tube and tries to bite the instrument. 

This method of feeding may be employed after intubation and 
tracheotomy, in certain operations about the mouth and throat, in 
cerebral diseases, when the patient is unconscious, and in acute dis- 
eases such as diphtheria, scarlet fever, typhoid fever, etc., when the 
patient will not take nourishment. It is especially valuable in phar- 
yngeal paralysis when the patient cannot swallow food or liquids. 
It is a method frequently employed in feeding premature infants, or 
children suffering from malnutrition, to whom otherwise it would be a 
difl&cult matter to give sufficient food. 

Apparatus.^ — The same sort of apparatus as is employed for gastric 
lavage will be required, viz., a soft stomach-tube 30 inches (75 cm.) 
long, 2 feet (60 cm.) of rubber tubing joined to the stomach-tube by a 
glass connecting tube 3 or 4 inches (7 to 10 cm.) long, and a glass 
funnel with a capacity of about i pint (500 c.c.) (see Fig. 499). If 
it is intended to employ the apparatus for nasal feeding, a tube of 
smaUer caliber than that ordinarily used will be required. For 
young children a No. 10 American (16 French) catheter should take 
the place of the stomach-tube (Fig. 523). 



GAVAGE 



503 



Asepsis. — Strict asepsis should be observed in the care of the 
apparatus. Before use, it should be boiled or immersed in an anti- 
septic solution followed by a thorough rinsing off with water, and after 
use it should be thoroughly cleansed. In contagious cases, as diph- 
theria, for example, the apparatus should always be boiled. 

The Food. — The material employed for feeding will, of course, 
vary according to the indications in the individual case. When the 
digestive power of the stomach is impaired predigested food should 




Fig. 523. — Apparatus for nasal gavage. 

be employed. The intervals between the feedings of a child should 
be somewhat increased when gavage is employed. 

Position of Patient. — The child should be held flat on its back 
across the nurse's knees with the head slightly elevated. Its arms 
and legs may be confined by wrapping it in a sheet from the chin to 
the knees. 

Technic. — The tube or catheter is moistened in warm water and 
is passed into the mouth to the base of the tongue and then gently 
down the esophagus to the desired depth (Fig. 524). 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 



504 



THE STOMACH 




Fig. 524. — Gavage. First step, introduction of the tube. 




Fig. 525. — Gavage. Second step, administering the food. 



DUODEXAL FEEDING 



505 



the required amount of food introduced (Fig. 525). The tube is then 
rapidly withdrawn, pinching it the while, so as to prevent an}' dripping 
of food into the pharynx and larynx (Fig. 526). The patient should 
be kept quietly in the recumbent position for some time after the intro- 
duction of the food. In cases complicated by gastroenteritis, etc., 
a preliminary lavage of the stomach with warm water, just before 
gi^-ing the food, is often ad\'isable. It removes mucus and any food 




Fig. 526. — Gavage. Third step, showing the tube being compressed as it is re- 
moved to prevent leakage. 

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. 



DUODENAL FEEDING 

Duodenal feeding consists in the administration of food through a 
small tube introduced into the duodenum through the stomach. This 
method of feeding is sometimes employed in conditions where it is 
desired to keep the stomach empty and at rest, as in gastric and duo- 



:o6 



THE STOMACH 



denal ulcer and gastric dilatation not due to organic obstruction. It 
has also been employed in cases where difficulty is found in adminis- 
tering the proper amount of nourishment, as in nervous vomiting, 
the vomiting of pregnancy, and in infants who do not retain the food 
given by gavage. 

Apparatus. — A number of duodenal tubes have been devised that 
can be used for feeding purposes. That of Einhorn consists of a 
No. 8 French tube to the distal end of which is attached an elongated 
perforated brass capsule weighing 48 grs. (3 gm.). The exterior of 
the tube has markings at 40 cm. (16 ins.), 56 cm. (22 ins.), 70 cm. 
(28 ins.), and 80 cm. (32 ins.) from the distal end to indicate the po- 
sition of the capsule after it has been swallowed. A three-way stop- 
cock and a glass syringe complete the outfit (Fig. 527). 




Fig. 527. — Einhorn's duodenal pump, a, Metal capsule, lower half provided 
with numerous holes, the upper half communicating with tube b; i, li, in, marks 
of I = 40, II = 56, III = 70 cm. from capsule ; c, rubber band with silk attached to end of 
tubing which can be placed over the ear of the patient; d, three-way stop-cock; 
e, collapsible connecting tube;/, aspirating syringe. (Kemp.) 

Palefski has modified Einhorn's tube by emplo}dng a heavier (105 
grs. (6.5 gm.)) and shorter perforated gold plated lead ball, which it is 
claimed will pass into the duodenum more rapidly. 

For infants Hess has discarded the lead ball and employs a Xo. 
14 to 15 French soft Nelaton catheter with a large eye. The exterior 
of the catheter has markings at 20 cm. (8 ins.), 25 cm.( 10 ins.), and 
30 cm. (12 ins.) from the eye. 

Preparation of the Food.^ — ]Milk and eggs are the foods used. 
Where the patient cannot tolerate milk, barley water is substituted. 
Einhorn gives the following mLxture: milk 7 to 8 ozs. (200 to 250 c.c), 
one egg, and a tablespoonful of lactose. If the latter produces diar- 
rhea, it is omitted. The egg is beaten in the milk and the mixture is 
strained before it is administered. 

Temperature of the Food.^ — The food should be given at a temper- 
ature of 100 F. (38 C). 



MASSAGE OF THE STOMACH 507 

Frequency of Feedings. — Eight feedings are given a day at 2-hour 
intervals. 

Technic. — The operator places the bulb in the patient's open 
mouth and instructs him to swallow it. When the 40 cm. (16 ins.) 
mark is at the patient's teeth, the lead ball should be at the cardia, 
and at this stage of the operation the patient is given a glass of water 
to drink and is instructed to lie down on his right side to favor by 
gravity the passage of the ball toward the pylorus. When the 56 
cm. (22 ins.) mark is at the teeth the bulb should be at the pylorus, 
and in the duodenum when the 70 cm. (28 ins.) mark is at the teeth. 
From time to time test aspirations are made to recognize more cer- 
tainly the position of the tube, that is, whether it is in the stomach 
or duodenum. If in the stomach, secretion will be obtained and will 
be of an acid reaction while from the duodenum but little secretion 
can be withdrawn and it will be neutral or alkaline in reaction. 
In a normal case it requires from 2 to 3 hours for the ball to pass 
through the pylorus and a considerable longer time in the presence 
of pyloric spasm, gastroptosis, or gastrectasis. 

With the bulb in the duodenum, the food, properly heated and 
strained, is drawn into the syringe and is then slowly injected. After 
each feeding a small quantity of fluid is forced through the tube and 
then some air, in order to cleanse the tube and bulb and prevent them 
from becoming clogged. The tube is left in place during the course 
of the treatment, being fastened to the patient's ear, and, if it does 
not produce an annoying irritation of the pharynx, it may be left in 
place from 10 to 12 days. During the time the tube is worn, the 
patient's teeth and mouth should be frequently cleansed with a 
mouth wash. 

MASSAGE OF THE STOMACH 

Massage systematically and properly performed is a valuable 
therapeutic procedure in certain diseases of the stomach. It is 
applied to this organ with the same object in view as when used upon 
other muscular organs; that is, to strengthen weak and atonic mus- 
cular walls with impaired contractile power. Massage also aids in the 
propulsion of the stomach contents into the intestine. It is thus 
employed with success, chiefly in cases of simple atony and of atonic 
dilatation, and to a lesser degree in dilatation due to pyloric stenosis. 
Massage is advised by some in gastroptosis for the purpose of strength- 
ening the relaxed ligamentous supports. Finally, it is supposed to 
stimulate the normal secretions of the stomach, and is recommended 



;o8 



THE STOMACH 



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 
recent gastric ulcers, in hemorrhage from the stomach, in great disten- 
tion of the stomach from gas, and in inflammation of the peritoneum. 
The massage should be performed by one thoroughly familiar with 
the technic 

Time for Massage. — This will depend upon the purposes of the 
treatment. When employed simply for the purpose of toning up and 
strengthening the stomach wall, massage is best performed early in 
the morning when the stomach is empty. In cases of dilatation, 




r^ 



Fig. 528. — Stroking massage applied to the stomach. (After Ganl.; 

however, the object is to propel the contents of the stomach into the 
intestines, and the massage is then performed upon a full or parti}' 
full stomach. The best time for this, as a rule, is six to seven hours 
after the principal meal of the day. 

Frequency. — The massage, to be of any value, should be per- 
formed every day. 

Duration. — During the first treatments the manipulations should 
be of short duration — about two to three minutes at a sitting — and 
later, as the patient becomes more accustomed to the treatment, the 
sitting may be extended to periods of live to ten minutes. 

Position of the Patient. — The patient lies upon his back with his 
head slightly raised and the legs flexed so as to relax the abdominal 
muscles. 



ELECTROTHERAPY IN DISEASES OF THE STOMACH 



509 



Technic. — Stroking movements (effleurage) and kneading (petris- 
sage) are the manipulations most employed. In performing effleur- 
age the operator places his left hand upon the right hypochondriac 
region for the purpose of counterpressare and with his right hand, the 
lingers of which are outstretched, he performs stroking movements 
from the fundus toward the pylorus; i.e., from left to right (Fig. 528). 

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 fingers of the two hands by deep handgrasps and are 
kneaded by alternately squeezing and relaxing the fingers (Fig. 529). 
The force used in the various movements of massage will depend upon 




Fig. 529. — Kneading massage applied to the stomach. 

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 intes- 
tines, the fundus of the stomach and contents are grasped through 
the abdominal walls between the thumb and fingers of the right hand 
and by propulsive movements directed backward an attempt is made 
to throw the contents of the stomach toward the pylorus. 



ELECTROTHERAPY IN DISEASES OF THE STOMACH 

Electricity has undoubted beneficial effects upon certain diseases 
of the stomach, although the manner in which the electric current 
acts is not well understood, and the experimental evidence of its value 
is both contradictory and in some cases not in accord with the results 
obtained clinically. It seems probable, however, that electricity 



lO 



THE STOMACH 



increases the motor activity, stimulates the secretion of the gastric 
juice, and increases the absorption power of the stomach. According 
to cHnical experience, at any rate, its use is followed by favorable 
results in simple atony, dilatation from atony, hypochlorhydria, 




Fig. 530. — Large Hal sponge electrode. 

nervous anorexia, nervous vomiting, paresthesia, hyperesthesia, and 
gastralgias. 

Both the faradic and the galvanic currents are employed and they 
may be used percutaneously or intraventricularly. As to the choice 




Fu.. 531. — Einhorn's deglutible electrode. 

of current and the method of its application, authorities again disagree. 
The majority, however, advise the use of the faradic currents when 
the motor functions are diseased and the galvanic in neuroses and in 
cases where the secretory apparatus is at fault. The intraventricular 
method seems more desirable when the necessary apparatus is at 
hand, as the stomach is thus directly tre9,ted. External application 



ELECTROTHERAPY IN DISEASES OF THE STOilACH 511 

of electricity, on the other hand, is simpler to carry out and is a less 
disagreeable method for the patient. 

Apparatus. — For the percutaneous application there will be 
required two curved flat electrodes of about 9 square inches' surface 
(500 to 600 sq. cm.) (Fig. 530). For intrastomacbic application a 
special gastric electrode, such as Bardet's, Stockton's, or Wegele's, 
inserted within a stomach-tube, may be employed or Einhorn's deglu- 
tible electrode may be used. The latter (Fig. 531) consists of a hard- 
rubber shell, shaped like an egg, with numerous small perforations 
piercing its surface, and within this capsule is a button of copper or 
brass. A small rubber tube 1/25 inch (i mm.) in diameter carries 
fine wires leading from the button to the instrument. A curved plate 
electrode is connected mth 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, apphcations are made at 
weekly intervals until the treatments are discontinued. 

Strength of Current. — For galvanism from 15 to 20 ma. are ordi- 
narily used. With the faradic current it is not possible to measure 
exactly its strength; the current should be strong enough, however, to 
produce strong and visible contractions of the abdominal wall and 
back muscles without causing pain. 

Position of Patient. — The patient should be in the recumbent 
position with the head slightly elevated and legs flexed so as to relax 
the abdominal muscles. 

Technic. — i. Percutaneous Application. — The two electrodes are 
well moistened and the negative pole is placed over the region of the 
pylorus, the positive over the spine in the region of the seventh or 
eighth dorsal vertebra. The negative electrode may be held station- 
ary 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. Intra stomachic Application. — The treatment should be given on 
an empty stomach, preferably one or two hours after a light breakfast. 
If necessary, the stomach should be emptied by means of a stomach- 
tube. When an electrode, such as Wegele's or Stockton's, is em- 
ployed, 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 Einhorn's electrode is used, before the electrode is 
swallowed. In introducing this latter the patient should be requested 



512 THE STOMACH 

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 accompU?hing this, drinking a glass of water 
will be of material assistance. 

The gastric electrode is connected with the negative pole of the 
battery, the positive pole is connected to a plate electrode. This 
electrode is applied for part of the seance over the region of the stom- 
ach, 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 XVIII 
THE COLON AND RECTUM 

Anatomic Considerations 

The Colon. — The colon is that portion of the alimentaty canal 
lying between the small intestine and the rectum. It is 5 to 6 ft. 
(150 to 180 cm.) long and in its widest portion, the cecum, measures 
3 1/8 inches (8 cm.) in diameter. The average capacity of the colon 
in infants is i pint (500 c.c), at 2 years 2 1/2 pints (1.25 liters), and in 
adults 9 pints (4.5 liters.) 




Fig. 532. — -The course and position of the colon. 

It is divided into the cecum, ascending colon, transverse colon, 
descending colon, and sigmoid colon. 

The cecum, lying in the right iliac fossa below the ileocecal valve, 
is 3 1/8 inches (8 cm.) broad and 2 1/2 inches (6 cm.) long. It is 
usually completely covered by peritoneum. From its inner and pos- 
terior portion is given off the vermiform appendix, a small blind tube 
with an average length of 3 1/4 inches (8 cm.). The ileum opens into 

513 

33 



514 THE COLON AND RECTUM 

the cecum at a point just above the origin of the appendix. Regurgi- 
tation of fluids and gases into the small intestine is prevented by the 
ileocecal valve, a slit-like opening at right angles to the long axis of 
the bowel. 

The ascending colon is 8 inches (20 cm.) long. It extends vertically 
up the right side of the abdomen from the cecum to the inferior sur- 
face of the liver to the right of the gall-bladder, where it turns to the 
left as the hepatic flexure. It passes in front of the posterior abdom- 
inal muscles and the lower pole of the kidney, and is bound to the 
former by connective tissue. Anteriorly and laterally it is covered 
by peritoneum. 

The transverse colon is about 20 inches (51 cm.) in length. It ex- 
tends from the hepatic flexure across the abdomen below the liver and 
greater curvature of the stomach, with a slight downward curve at 
its center, to the spleen, where it turns downward as the splenic 
flexure. The transverse colon is the most movable portion of the 
large gut, being connected with the posterior abdominal wall by a 
long mesentery. 

The descending colon is 8 1/2 inches (21 cm.) long. It extends down 
the left side of the abdomen from the splenic flexure to the sigmoid, 
lying in front of the left kidney and posterior abdominal muscles. 
Anteriorly and laterally it is covered by peritoneum. 

The sigmoid colon is the narrowest portion of the large gut. It is 
about 17 1/2 inches (44 cm.) long and extends from the left iliac crest 
in an S-shaped curve to the third sacral vertebra. In the first portion 
of its course it passes downward almost to Poupart's ligament, then 
turns from the left to the right to enter the pelvic cavity near the 
mid-line, and passing to the right side, it turns upward as far as the 
lower margin of the right iliac fossa. From this point it makes a 
sudden turn and passes downward, backward, and inward to become 
continuous with the rectum. The sigmoid is very movable, having 
a complete peritoneal covering and mesosigmoid. At the junction 
with the rectum the gut exhibits a marked narrowing from an increase 
of the muscular fibers, known as the sphincter of O'Beirne. 

The Rectum. — The rectum commences at the sigmoid flexure, 
opposite the third sacral vertebra, and descends in the middle line of 
the sacrum and coccyx. As it descends it forms a curve with the 
concavity forward until it reaches a point about i inch (2.5 cm.) 
below the tip of the coccyx where it turns, forming a sharp angle, and 
is then continued downward and backward through the thickness of 
the pelvic floor as the anal canal (Fig. 533). The antero-posterior 



ANATOillC CONSIDERATIONS 



515 



curves of the rectum are distinct and a knowledge of their direction 
is important for the proper introduction of the finger or instruments 
in making an examination. There are also two slight lateral curves, 
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 sacral 
vertebra to the upper border of the internal sphincter muscle, or to 
about the level of the apex of the prostate gland, and measures 3 to 
4 inches (7.5 to 10 cm.") in length. This portion of the rectum is 




Fig. 533. — Sagittal section of the rectum. 

sacculated in form, exhibiting three pouches or dilatations, of which 
the lowest and largest, called the ampulla, measures in some cases 
nearly 10 inches (25 cm.) in circumference. The constrictions be- 
tween which lie these dilatations are produced by an infolding 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 seminal vesicles, and the pros- 
tate gland, while in the female, the vagina and the recto-vaginal 
pouch with the small intestine therein contained He anteriorly. 

The anal canal is about i 1/2 to 2 inches (4 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 peritoneal 
covering. It is embraced by the internal sphincter muscle and is 
supported by the levatores ani muscles. At the anus the skin is dark 



5l6 THE COLON AND RECTUM 

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. 

The rectum is lined with a dark and vascular mucous membrane, 
which 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 Hke transverse 
shelves into the cavity of the bowel when it is distended. According 
to the usual arrangement the inferior fold projects from the left wall 
of the rectum at a point about 2 inches (5 cm.) above the anal orifice; 
the middle and most constantly present one projects from the right 
wall at a point situated 3 inches (7.5 cm.) from the anus; while the 




Fig. 534. — The rectal valve as seen thiuugh the proctoscope. (After Gant.) 

superior fold projects from the left wall near the third sacral vertebra, 
or at a point about i inch (2.5 cm.) above the middle fold (Fig. 534). 
These valves are attached to the walls of the rectum for a distance 
of from 1/3 to 1/2 its circumference and protrude into its cavity 
to varying degrees. Their function seems to be to assist the sphinc- 
ters and to serve to support the fecal mass. They may be the cause 
of difficulty in making digital examinations and they may act as ob- 
stacles 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. 535). 



DIAGNOSTIC METHODS 



517 



Diagnostic Methods 

Assuming that the usual lines of inquiry common to all histories 
have been followed and it having been ascertained whether there is a 
past record of syphilis, gonorrhea, dysentery, typhoid fever, appen- 
dicitis, peritonitis, pelvic inflammation, gall-stones, etc., which might 
result in adhesions, ulceration, stricture, or tumor, inquiry is then 
directed to special symptoms. 

In the presence of pain, its location, whether in the abdomen, 
rectum, pelvis, or neck of the bladder; its character, whether sudden 
in onset, acute and cutting, or a dull ache; and the time of day it is 
felt, that is, before or after stools or with every stool, will often fur- 




FiG. 535. — The anal canal, showing the columns and valves of Morgagni. 

nish a clue as to the cause. Pain in the upper part of the abdomen 
is suggestive of gastric, duodenal, or gall-bladder affections. Pain in 
the right iliac fossa may be due to appendicitis or to involvement of 
the cecum. Pain situated in the central portion of the abdomen is 
frequently caused by colic from gas, feces, or mechanical obstruction, 
though not infrequently early in appendicitis the pain is in this local- 
ity. Colic is characterized by short, sharp pains coming on suddenly 
and often shifting in location; furthermore, the passage of gas or feces 
usually gives relief. Constant or prolonged pain is more apt to 
signify some organic lesion. Frequently in place of pain patients 
will complain of more or less discomfort or tenesmus in the anus or 
rectum. It is a frequent symptom in dysentery and in many other 
affections of the rectum. 



5l8 THE COLON AND RECTUM 

If abdominal distention is complained of, it should be ascertained 
whether it is general or localized and whether there is any passage 
of gas from the bowels, and, if so, whether it relieves the condition, 
A total absence of flatus with obstinate constipation suggests ob- 
struction. 

Finally, the habitual state of the bowels should be determined, 
that is, whether they are normal, constipated, or loose, or whether 
constipation and diarrhea are alternately present. The examiner 
should also inquire as to the color, odor, and character of the move- 
ments, whether soft or hard, large or small, and whether they contain 
mucus, pus, or blood. The amount and contour will vary much in 
health as well as in disease, depending upon the form of food taken, 
the quantity of water imbibed, etc. 

When all possible information has been obtained from a history 
and general physical examination, a local examination is made to 
determine more accurately the cause of the symptoms complained of 
and the proper line of treatment to pursue. Especially is it import- 
ant to make a systematic examination in the presence of rectal 
symptoms. On account of the close relation and anatomic prox- 
imity of other pelvic organs, as the uterus, tubes, and ovaries in the 
female and the bladder, urethra, prostate, and seminal vesicles in the 
male, it is necessary to be able to differentiate between many affec- 
tions the symptoms of which may reflexly simulate an abnormal 
condition of the rectum. It is not uncommon for a stricture of the 
urethra, an enlarged prostate, a stone in the bladder, or a displace- 
ment of the uterus, for example, to produce a set of symptoms which 
point to the rectum as their seat. 

The methods available for examination of the colon and rectum 
include abdominal inspection, palpation, and percussion, ausculta- 
tion, inflation of the colon, skiagraphy, rectal inspection and palpa- 
tion, proctoscopy, examination by sounds and bougies, examination 
by the probe, lavage of the bowel, and examination of the feces. 

/. Abdominal Examination 

INSPECTION 

In a thin individual it is often possible to make a diagnosis of 
ptosis, tumors, or constrictions of the colon from the appearance and 
shape of the abdomen. Abdominal inspection is of but very limited 
use in stout individuals. 



PALPATION 519 

Position. — The patient lies with the body symmetrically placed 
upon a firm flat table with the hght falUng obliquely from the head 
toward the foot (see Fig. 491). It is of advantage when examining for 
ptosis to have the patient also assume the erect position. 

Technic. — The patient's abdomen being fully exposed, inspection 
is performed from the side and from the foot of the table (see Fig. 491). 
The examiner notes first the general appearance of the abdomen, 
whether distended or flat and whether the abdominal walls are well 
developed and capable of supporting the contents. In enteroptosis 
the upper part of the abdomen is concave and more or less of a "pot- 
belly" is evident with a sulcus between the two recti above the um- 
bilicus. This characteristic appearance is accentuated with the 
patient in the erect position — the abdomen appears more pendulous 
and the abdominal contents may project like a hernia through the 
space between the two recti. The examiner then makes more careful 
inspection for the presence of hernia, visible swelling, or tumor. A 
tumor may produce sufficient bulging of the part affected to be recog- 
nized by inspection. Likewise, if the individual is thin, in the pres- 
ence of stenosis of the bowel it may be possible to recognize disten- 
tion of the portion of the bowel proximal to the seat of obstruction 
and the strong peristaltic waves. Inflation of the bowel (see page 
521) is of considerable value in making more prominent a tumor or 
the seat of an obstruction. 

PALPATION 

The cecum and parts of the ascending, transverse, descending, and 
sigmoid colon are accessible for palpation, depending upon the stout- 
ness of the individual. It is thus possible to recognize local tender- 
ness, thickening of the gut, and a tumor, and, in the presence of the 
latter, its size, mobility, and consistency. 

Preparations of the Patient. — When feasible, the patient's bowels 
should be emptied by a cathartic given the night before. 

Position. — The examination is performed with the patient in the 
dorsal position upon a flat table with the knees flexed and a small 
pillow beneath the head and shoulders to secure relaxation of the 
abdominal muscles. Shifting the patient from side to side will often 
furnish more complete information in the presence of a tumor or other 
mass. 

Technic. — The examiner stations himself by the side of the pa- 
tient and places his right hand, well warmed, flat upon the patient's 



520 THE COLON AND RECTUM 

abdomen, at first performing gentle circular palpation over all parts. 
Gradually deeper palpation may be employed, but sudden poking of 
any region should be carefully avoided. In performing deep palpa- 
tion reinforcing one hand with the other is of great aid. Tender 
spots, rigidity of the muscles, and the presence of masses should be 
looked for. Tenderness suggests inflammation or ulceration of the 
bowel. In eliciting tenderness it is well to watch the patient's face, 
as this is often a better guide than questions as to his sensations. 
Rigidity of one or both recti is of diagnostic importance signifying 
some local peritoneal irritation in the first instance and general peri- 
tonitis if both recti are involved. A rigid right rectus is not uncom- 
mon, however, in right-sided pneumonia and pleurisy. The sensa- 
tion a mass gives to the palpating hand is frequently a guide to its 
character. Thus, a cancerous growth is generally hard to the touch, 
cannot be indented, and is frequently uneven; a benign growth is 
generally smooth; a fecal impaction is movable, has a doughy feel, 
and can be indented with the fingers. In intussusception the mass is 
smooth and has the characteristic sausage shape. Often more valu- 
able information as to the source and mobility of a mass may be 
elicited by changing the position of the patient from time to time and 
by inflation of the bowel (see page 521). 

PERCUSSION 

The chief use of percussion is to confirm the results obtained by 
palpation. The percussion note over the empty colon is tympanitic 
and of a higher pitch and less volume than over the stomach, and 
over the small intestine the note is of a still higher pitch and less 
volume. When the bowel contains fluid or fecal matter or in the 
presence of a solid tumor the percussion note is flat. Percussion is 
thus of value in differentiating between the empty intestine and a 
solid tumor, and, in the presence of the latter, in determining its size 
and shape. By first inflating the bowel with air or fluid it is possible 
to trace its course and thus recognize the presence and degree of 
ptosis. This method is also of value in locating the seat of a stricture 
of the bowel by the contrast between the percussion note obtained 
over the inflated portion and that over the empty bowel. 

AUSCULTATION 

Auscultation is of but little diagnostic importance in diseases of 
the large bowel. Various splashing, gurgling, and whistling sounds are 



INFLATION OF THE COLON 52 1 

to be heard normally in the intestines and are due to the movements 
of gas and fluids. In chronic obstruction of the large bowel gurgling 
sounds are also to be heard in the region of the obstruction, and, if 
they are always heard in the same location, they are of considerable 
diagnostic importance. An entire absence of intestinal sounds would 
suggest intestinal paresis. By injecting into the bowel small quanti- 
ties of fluid (about a pint (500 c.c.)) it is possible to map out the course 
of the bowel by the splashing sounds heard on auscultation. This 
procedure may be employed to advantage in cases of suspected 
ptosis. 

INFLATION OF THE COLON 

This procedure is performed both as a diagnostic and as a thera- 
peutic measure (for the latter see page 563). The bowel may be 
inflated either by means of air or fluids. For diagnostic purposes, 
however, air is preferable, as there is thus produced a contrast on 
percussion between the tympany of the air-distended bowel and the 
flatness of a tumor. It has the disadvantage, however, that the 
amount injected cannot be measured as can fluids, and consequently 
the degree of distention is not so well regulated. 

The colon may be distended as far as the cecum, provided there 
be no obstruction and the inflation be slowly and carefully performed. 
When thus distended, the bowel is raised from the surrounding parts 
and is caused to stand out against the abdominal wall so that it may 
be readily mapped out by palpation and by percussion, and its size, 
shape, position, and mobility may be determined. It thus be- 
comes possible to locate the seat of a stricture or an obstruction by 
noting the limits of the distended area — the part below the seat of 
stenosis becomes prominent, while the portion of the bowel above will 
be but slightly distended or not at all so, depending upon the degree 
of occlusion. Under inflation, tumors of the large bowel are made 
more prominent and it is frequently possible to recognize that a 
growth is located in or is in connection with the colon by tracing the 
distended bowel directly into the tumor mass. Finally, inflation is 
also of great aid in determining the probable seat of other abdominal 
tumors; the distention of the bowel causes a change in the position 
of the tumor, displacing it in the direction of the normal position 
of the organ from which it takes origin, so that tympany is obtained 
where there was originally dulness; for example, a tumor of the 
stomach is pushed upward; a tumor of the gall-bladder and liver is 
pushed upward and forward; a tumor of the pancreas becomes less 



;22 



THE COLON AND RECTUM 



noticeable; a tumor of the kidney is pushed upward toward the 
normal position of the kidney and hes behind the distended colon; 
a tumor of the spleen will lie in front of the colon and the growth 
will become more readily palpable from being pushed forward, etc., 
etc. 




"^ r j]Tnini'iiir'""'i'ii'""i""i"""''i"'"""'"iMiii7ii™^™™ 
Fig. 536. — Rectal tube and cautery bulb for inflating the colon. 

Apparatus. — The injection of fluids is effected by means of a foun- 
tain syringe or a graduated glass irrigating jar as a reservoir, and 
a rectal tube attached to the reservoir by about 6 feet (180 cm.) of 
rubber tubing 1/4 to '^IZ inch (6 to 9 mm.) in diameter. 




Fig. 537. — Inflation of the colon with oxygen. (After Gant.) 

For the injection of air a special inflation apparatus may be em- 
ployed, but a rectal tube attached to a Davidson syringe, cautery 
bulb (Fig. 536), hand bellows, or bicycle pump will answer equally 
well. The pumping apparatus may be dispensed \A\h if oxygen 
or carbonic gas is used. In the case of the former the rectal tube 



INFLATION or THE COLON 523 

is simply attached to the oxygen tank (Fig. 537), while, if the latter 
gas be employed, the tube is attached to a syphon of carbonic, and 
the latter is inverted so that the gas escapes without the water 
following. 

Media for Inflation. — Of fluids, warm normal salt solution (dr. i 
(4 gm.) of salt to a pint (500 c.c.) of water) is best. Air, oxygen, or 
carbonic acid gas may be used when gaseous distention is desired. 

Amount Injected. — When inflating with gas there is no way to 
determine accurately the amount of gas injected, and the patient's 
sensations and the degree of distention of the bowel must be the 
guide. Never inject sufiicient to cause pain, and care must be taken 
not to endanger the gut. 

As much as 3 quarts (3 liters) of fluid may be injected with 
safety. 

Rapidity. — Fluid or gas should be injected slowly and steadily; 
rapid distention of the bowel is to be avoided. From fifteen minutes 
to half an hour should be consumed in performing the operation. If 
the reservoir be not elevated above 3 feet (90 cm.), the fluid will not 
enter the bowel too rapidly. 

Position of Patient. — The tube may be inserted with the patient 
upon his side, but as soon as the inflation is begun the dorsal position 
should be assumed. 

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 lubri- 
cated with vaselin and is inserted 4 or 5 inches (10 to 12 cm.) within 
the rectum. If fluid is employed, the reservoir is then elevated be- 
tween 2 and 3 feet (60 to 90 cm.) and the solution is allowed to distend 
the bowel slowly, cotton being tightly packed about the anus and the 
buttocks being held in close apposition to prevent leakage. As the 
rectum becomes distended there will be some spasm and an almost 
irresistible desire on the part of the patient to expel the fluid, but if the 
flow be temporarily stopped, or the reservoir lowered, and time be 
given for the fluid to pass upward, this feeling soon passes off and the 
inflation may be then continued. When the colon has been sufficiently 
distended 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 
rapidly or in excess, and at the completion of the examination to draw 
off as much of it as possible, so as to avoid unpleasant distention. Its 



524 THE COLON AND RECTUM 

escape may be aided by inserting two fingers into the rectum and 
holding the anus open. 

SKIAGRAPHY 

The X-rays are of value in recognizing the presence of foreign 
bodies in the intestinal tract, and for determining the position of the 
colon and the seat of strictures, dilatations, angulations, or adhesions 
that may be causing obstruction. For recognizing the latter condi- 
tions a preliminary rectal injection of a bismuth mixture or the inges- 
tion of a bismuth meal is essential. When the bismuth is given by 
mouth, its passage may be traced through the intestinal tract by 
means of repeated X-rays, and valuable information as to the motil- 
ity of the intestinal contents may be secured. 

In preparation for an X-ray examination of the large intestine, 
the patient is given a purge for two nights before and an enema on 
the day of the examination to thoroughly empty the colon. Two 
oimces (60 gms.) of bismuth subcarbonate are mLxed with a little 
starch in 2 quarts (2 liters) of warm water and are injected into the 
bowel with the patient in the Sims position with the hips elevated, or 
while in the knee-chest position, and a radiograph is immediately 
taken; or, the patient may be given by mouth an ounce (30 gms.) of 
bismuth subcarbonate or oxychlorid in 12 ounces (360 gms.) of milk or 
koumiss, and the radiograph be taken at the end of 24 hours when all 
the bismuth should be in the large bowel. A second picture should 
be taken at the end of 48 hours in order to judge of the motility of 
the bowel. Exposures should be made with the patient in the recum- 
bent and in the upright posture. 

//. Internal Examination 

Preparation of the Patient. — In order to make a satisfactory 
examination of the rectum the latter should be emptied of its con- 
tents by means of a cathartic given the night before or by an enema 
administered just before the examination is begun. In some cases, 
however, more useful information as to the usual condition of the 
rectum may be obtained by making a preliminary examination of the 
patient in just the condition he presents himself. The presence of 
blood, pus, or mucus will thus be revealed, of which there would often 
be no trace after a cleansing enema. If necessary, an enema may 
then be given and a more complete examination may be made later. 
The bladder should likewise be evacuated, and tight clothing, such as 



POSITIONS FOR INTERNAL EXAMINATION 



525 



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 pa- 
tient upon the left side with the left side of the face, the left shoulder, 
and the left breast resting upon a flat pillow. The left arm lies be- 
hind the back and the thighs are well flexed upon the body with the 
right knee drawn up nearer the body than the left. The buttocks lie 
near the edge of the table and are elevated upon a hard pillow (Fig. 
538). This position will be found most useful for routine examina- 




FiG. 538. — The Sims position. 



tions, and probably will be found less objectionable to the patient 
than the lithotomy or knee-chest positions. 

The lithotomy position is secured by placing the patient flat on the 
back and flexing the thighs upon the abdomen and the legs upon the 
thighs. The buttocks, which are elevated upon a hard flat pillow, 
project over the end of the table (Fig. 539) . In very stout individuals 
this position will permit of a more satisfactory examination than will 
the Sims. 

The knee-chest position is obtained by having the patient kneel 
upon a table with the thighs at right angles to the legs with the body 
well flexed upon the thighs, the chest resting upon a pillow placed 
upon the same level as the knees (Fig. 540). The knee-chest position 
favors displacement of the coils of intestine upward, thus allowing the 
rectum to be distended by the entrance of air upon the insertion of a 
speculum or proctoscope. The mucous membrane of the rectum, 
which in the dorsal position lies in folds, becomes expanded, and thus 
a more thorough inspection of all portions of the canal is possible. 



526 



THE COLON AND RECTUM 



The squatting posture is only suitable for digital examination. 
The patient assumes an attitude similar to that taken while at stool. 
Portions of the rectum may be thus palpated which in the Sims or the 
dorsal position would be out of reach of the examiner's finger. By a 




Fig. 539. — The lithotomy position. 




'l7llll|||||||I U»l|l|l||l l l llll | l|ll l | l l|l|| ) l|l ) || ;| li ;) |||| )))| | ) || ||| | || | ||)||)|,|)| |i||| | ; |||[ | || |jy 

Fig. 540. — The knee-chest position. 

slight straining effort 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. 



PALPATION 



527 



and external hemorrhoids, are carefully looked for. Then, by separ- 
ating 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. 541). 
Shght degrees of prolapse, fissures, ulcers, hemorrhoids, and polypi 
or other growths may be readily demonstrated in this way. 



PALPATION 

Palpation of the rectum may be performed by means of the finger 
or by the whole hand. With the index-finger one may examine the 
anus, the anal canal, and the ampulla of the rectum. The first 4 
inches (10 cm.) of the rectum may be thus explored. 




Fig. 541. — Inspection of the anus. (Ashton.) 

Introduction of the whole hand into the rectum, as advocated by 
Simon, for the purpose of palpation of portions of the canal out of 
reach of the finger, may be practised if the hand is moderately small. 
Tuttle states that a hand requiring a kid glove larger than 73/4 should 
never be introduced into the rectum except in a life or death emer- 
gency. Manual palpation is rarely required, being only necessary for 
examining tumors high up that cannot be inspected by means of a 
speculum or a proctoscope. In addition, it is a serious procedure, as 
there is danger of rupture or undue distention of the bowel in careless 
hands. 

Anesthesia. — General anesthesia will be required for palpation by 
the whole hand, as complete dilatation of the rectum is essential. 



528 



THE COLON AND RECTUM 



Technic. — i . By the Finger. — No anesthesia will be required. The 
direction of the rectum, which is at first slightly forward from the 
anus, then back into the hollow of the sacrum, then to the right, and 
finally to the left toward the sigmoid flexure, should be kept clearly in 
mind. The index-finger of the right hand is covered with a rubber 
finger cot. If, however, it is desired to preserve the tactile sense of 
the finger, a covering is dispensed with, in which case soap should be 
forced under the nail. The finger is well lubricated with sterile vase- 
lin or with one of the preparations of Irish moss made for the pur- 
pose and is then introduced slowly and with a rotary motion, the 




Fig. 542. — Palpation of the rectum. (Gant.) 



patient being requested to strain gently to f acihtateits passage through 
the sphincter. Roughness in inserting the finger or disregard of the 
natural direction of the canal will be liable to cause spasm of the 
sphincter and give the patient such pain that a thorough examination 
will be impossible. 

As the finger passes through the anal canal the condition of the 
sphincter should be noted, the examiner observing whether it is closed, 
rigid, and resisting, or loose and patulous. When the internal sphinc- 
ter has been passed, the finger is swept lightly over the mucous mem- 
brane, palpating the rectal wall in all directions. The size and sensi- 
tiveness of the rectum is thus ascertained. The examining finger will 
readily detect the presence of impacted feces, polypi, large hemor- 
rhoids, malignant growths, ulcerations, fissures, and strictures if a 
systematic examination is made. In the male, enlargement, indura- 
tion, degrees of sensitiveness, or softness of the prostate should be 



PALPATION 



529 



carefully noted, and likewise information regarding the condition of 
the seminal vesicles and bladder should be obtained. A vesical cal- 
culus may frequently be discovered by such examination. In the 
female, the uterus, tubes, ovaries, and broad ligaments are carefully 
examined for displacements or signs of inflammation. Finally, the 




Fig. 543. — Method of dilating the anus by means of one finger of each hand. 

coccyx should not be overlooked, as this bone may be responsible for 
considerable rectal disturbance. 

If pus, blood, or mucus be present in the bowel there will be an 
escape of the material from the anus when the finger is withdrawn or 
the finger will come away coated. In all cases it is important to note 




Fig. 544. — Method of dilating the anus by means of two fingers of each hand. 

the odor of the examining finger upon its withdrawal. The foul odor 
of cancer is characteristic and will not be mistaken for anything 
else once it is recognized. 

2. By the Whole Hand. — Stretching of the sphincters is commenced 
by introducing into the anus the two forefingers with the palmar sur- 

34 



530 



THE COLON AND RECTUM 



faces out, and separating them slowly and gently in all directions, care 
being taken to avoid injury to the mucous membrane if possible 
(Fig. 543). As soon as a little dilatation has been secured, two and 
then three fingers of each hand may be introduced, carrying them to a 
point well above the internal sphincter. The lingers are then gradu- 
ally separated imtil sufl&cient dilatation is obtained to allow the hand 
to pass (Fig. 544). The hand is then well lubricated and. with the 
fingers formed in the shape of a cone, it is gradually introduced past 
the sphincter muscles until it enters the dilated ampulla. From 
this point on only two fingers should be used in palpation, and great 
care and gentleness are necessary to prevent injury, as the canal 
gradually narrows down. 

EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 

By the aid of suitable specula and reflected Ught, the whole inner 
surface of the rectum up to the sigmoid flexure may be inspected. 
The openings of glands and the condition of the valves and any altera- 
tion in color or unevenness of the surface of the mucous membrane 




Fig. 545. — The Sims rectal speculum. (Hirst.) 



are noted. Ulcers, polypi, new growths, malignant disease, stric- 
tures, the internal openings of fistulous tracts, hemorrhoids, and 
congestion or inflammation of the rectal mucosa may be distin- 
guished by the experienced examiner. 

Instruments. — The ordinary rectal specula are made in various 
shapes and styles, such as the Sims (Fig. 545), the bivalve, the duck- 
bill (Fig. 546), the fenestrated-blade (Fig. 547), the conical, etc. 
These are all useful instruments for inspection of the lower 4 or 5 



EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 



531 



inches (10 to 12 cm.) of the bowel, but their usefulness is limited to 
that region. 

For examination of points higher up Kelly has devised a set of 
tubular specula (Fig. 548) which permit a thorough inspection of the 
whole rectum and the sigmoid flexure. This set of instruments con- 
sists of: (i) a sphincteroscope, (2) a long and (3) a short proctoscope, 
and (4) a sigmoidoscope. The sphincteroscope is short and slightly 
conical; the diameter of the lower end of the tube is i inch (2.5 cm.) 
and of the upper end i 1/5 inches (3 cm.). The cylinder of the short 





Fig. 546. — Duck-bill rectal speculum. 



Fig. 547. — Fenestrated-blade rectal 
speculum. 



proctoscope is 5 1/2 inches (14 cm.) long, and 7/8 inch (22 mm.) in 
diameter. The long proctoscope is 8 inches (20 cm.) long and of the 
same diameter as the short proctoscope, and the sigmoidoscope is of 
like diameter and 14 inches (35 cm.) long. Each speculum consists 
of a cylindrical metal tube, at the outer end of which is a funnel-shaped 
rim about 2 inches (5 cm.) in diameter to which a handle is attached. 
A blunt obturator is provided to facilitate the introduction of the 
instrument into the bowel. Illumination is secured from an electric 
light held close to the sacrum, which is reflected by a head mirror into 
the speculum, or else an electric head light or the direct sunlight may 
be employed. 



532 



THE COLON AND RECTUM 



Murphy has modified Kelly's instrument in such a way that the 
specula telescope, the proctoscope fitting into the sphincteroscope, 
etc. This does away with the necessity of withdrawing and inserting 
a speculum through the anus each time a smaller size is used. The 
sphincteroscope is used first, and into this the next smaller size is 
passed without withdrawing the original instrument, until all have 
been introduced in succession. 




Fig. 548. — Kelly's set of tubular specula, i, Swab and holder; 2, sigmoido- 
scope; 3, long proctoscope; 4, short proctoscope; 5, sphincteroscope. 



The pneumatic proctoscope, such as Tuttle's modification of 
Law's instrument (Fig. 549) is not dependent upon atmospheric 
pressure as a means of dilatation, this being accomplished by a special 
inflation apparatus connected with the instrument. Tuttle's procto- 
scope consists of a long cylinder, to the circumference of which is 
fitted a small metallic tube closed at its distal extremity bv a flint-glass 
bulb. An electric light fitted upon a long metallic stem is carried 
through the small accessory cylinder to the end of the speculum. An 
obturator fits into the distal end of the large cylinder to facilitate the 
introduction of the instrument. In addition, there is an air-tight- 
fitting plug containing either a plain glass window or a lens focused to 
the length of the instrument to be inserted in the proctoscope when 
the obturator is removed. This plug is in connection with an in- 
flating apparatus. An adjustable handle is supplied with the instru- 
ment. These specula vary in length from 4 to 14 inches (10 to 35 
cm.). Tuttle recommends a 4- and a lo-inch (10 and 25 cm.) tube 
for ordinary use. The light is furnished by a four or a six dry-cell 



EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 



53S 



battery. In using the specula and proctoscope long dressing forceps 
and cotton balls with which to swab out the bowel will be required. 
Asepsis. — The specula may be' sterilized by boiling or by im- 
mersion in a I to 20 carbolic acid solution. In case the latter is 




Fig. 549. — Tuttle's pneumatic proctoscope, i, Proctoscope with obturator 
removed; 2, obturator; 3, handle; 4, air-tight plug with glass window; 5, inflating 
apparatus. 

employed, the instrument should be rinsed off with alcohol or sterile 
water before use. 

Position of the Patient. — In employing the ordinary proctoscope, 
the patient should be placed in the knee-chest position, so that the 




FiG. 550. — Method of holding the proctoscope. 



rectum will balloon up upon the entrance of air through the instru- 
ment. When using the pneumatic proctoscope, which does not 
depend upon atmospheric pressure for inflation, the Sims position 
may be employed instead of the knee-chest, if desired. 



534 



THE COLON AND RECTUM 



Anesthesia. — An anesthetic is not required, as a rule, unless the 
patient is extremely hyperesthetic. 

Technic. — i. With the Kelly Instrument. — The instrument should 
always be warmed and lubricated with sterile vaselin before its 




Fig. 551. — Proctoscopy. First step, method of inserting the instrument. 




Fig. 552. — Proctoscopy. Second step, showing the direction of the instrument 
in passing through the anus. 

introduction. In using the sphincteroscope the handle of the instru- 
ment is grasped in the right hand with the right thumb pressing 
against the obturator, as shown in Fig. 550. The buttocks are then 
drawn apart and, with the end of the obturator held against the anal 



EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 535 

orifice, tlie patient strains slightly and the speculum is slowly pushed 
into the bowel in a direction downward and forward until the funnel- 
shaped rim prevents its further progress. The obturator is then re- 
moved, allowing air to pass in and distend the bowel. The light 




Fig. 553. — Proctoscopy. Third step, showing the direction of the instrument in 

entering the ampulla. 




Fig. 554. — Proctoscopy. Fourth step, showing the instrument inserted to its 

full extent. 

is reflected into the instrument in such a way as to thoroughly illumi- 
nate the interior, and, as the instrument is slowly withdrawn, the 
whole of the anal canal is carefully inspected. 

The proctoscope is inserted in precisely the same manner, first 



536 



THE COLON AND RECTUM 



pushing the instrument in a direction downward and forward (Fig. 
552) and then upward toward the sacral hollow (Fig. 553). As soon 
as the tube enters the ampulla, the obturator should be withdrawn 
allowing air to enter and expand the bowel. The light is then thrown 
into the instrument and the ampulla is inspected. From this point 
the instrument is advanced past the valves entirely by sight. Some 
diQiculty may be experienced in following the direction of the canal 
from a valve or fold of mucous membrane occluding the end of the 
instrument. In such a case the distal end of the instrument should be 




Fig. 555. — Showing the method of performing proctoscopy by the aid of a head 
mirror and an electric Hght. 



gently moved from side to side until the opening of the canal is found. 
In this manner the whole interior of the rectum may be inspected. 
As the instrument is withdrawn, the condition and character of the 
mucous membrane as it falls over the end of the instrument is noted 

(Fig. 555)- 

In introducing the sigmoidoscope it is to be remembered that the 
upper portion of the canal gradually turns to the left, hence the point 
of the instrument is turned in that direction as it slowly ascends the 
bowel. 

2. With Tuttle's Proctoscope. — The proctoscope, warmed and well 
lubricated, is introduced in much the same manner as is Kelly's 
instrument. To avoid causing the patient any discomfort from the 
presence of the auxiliary tube, however, it is well to insert the index- 
finger of the left hand into the bowel first and then to introduce the 
instrument with the end of the auxiliary tube pressed against the 



EXAMINATION BY SOUNDS AND BOUGIES 



537 



finger (Fig. 556) ; as the tube enters the bowel the finger is withdrawn. 
When the internal sphincter has been passed, the obturator is with- 
drawn and the plug containing the glass lens is substituted. This 
makes the instrument air-tight. Pressure upon the bulb of the in- 
flating 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 re- 




FiG. 556. — Showing the method of inserting Tuttle's instrument with the finger in 
the rectum and the auxiliary tube pressing against it. 

moving the instrument, the glass is wiped off with a cotton wipe held 
in long dressing forceps. At the completion of the examination the 
cap at the end of the tube is withdrawn and the air is allowed to 
escape from the bowel before the instrument is removed. 

EXAMINATION BY SOUNDS AND BOUGIES 

The employment 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 



538 



THE COLON AND RECTUM 



employed is a soft-rubber one, the Wales bougie (Fig. 557) 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 peri- 
toneal 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. 




!_JL 



O C^ 



Fig. 557. — Wales' bougies. 

Technic. — The bougie, well lubricated, is gently inserted into the 
bowel until its further progress is impeded by some obstruction. 
The Davidson syringe is then attached and a stream of warm water or 
oil is forced through the instrument for the purpose of dislodging any 
fecal matter or folds of mucous membrane that may be interfering 
with its passage. In this way the whole length of the bowel may be 
explored without danger, and the instrument may be passed into the 
sigmoid provided no stricture exists. 

EXAMINATION BY THE BOUGIE A BOULE 

The rectal bougie a boule is made use of in diagnosis to determine 
the size and length of a stricture. 




Fig. 558. — Rectal bougie a boule. 

Instruments. — The bougie a boule consists of a flexible wire or 
rubber shaft with a handle to the extremity of which acorn-tips of 
various sizes may be screwed (Fig. 558). The bougie a boule is used 



EXAMINATION BY THE PROBE 



539 



to best advantage in connection with a cylindrical speculum or a 
proctoscope. 

Technic. — A speculum is introduced into the anus and is carried 
up to the seat of the stricture so that a clear view of its opening may 
be secured. The examiner begins by selecting a large bougie and 
passing it through the speculum to the opening in the stricture (Fig. 
559). If it is found to be too large to enter the stricture, smaller 
instruments are selected until one is found that will just pass through 
the contracture. This is inserted entirely through the stricture, using 



Fig. 559. Fig. 560. 

Fig. 559. — Method of estimating the length of a rectal stricture, the bougie a 
boule at the face of the stricture. 

Fig. 560. — Method of estimating the length of a rectal stricture. The bougie 
k boule is withdrawn until its base is arrested at the distal end of the stricture. 



gentleness only in manipulation, and as it is withdrawn its base 
catches the distal opening of the stricture (Fig. 560). From this ex- 
amination the exact length and size of the contracture may be readily 
ascertained. 

EXAMINATION BY THE PROBE 

Probing has but little utihty in the diagnosis of rectal diseases 
except as a means of determining the situation and course of a recto- 
vaginal or ischiorectal fistula. 

Instruments. — A silver probe 8 or 10 inches (20 to 25 cm.) long 



540 



THE COLON AND RECTUM 



with a flat handle is employed (Fig. 561). The probe should be flex- 
ible that it may be bent in any direction if desired. When examining 
for a recto-vaginal fistula a Sims speculum will be required in addition 
to expose the fistulous opening in the vagina. 



Fig. 561. — Rectal probe. 

Technic. — The index-finger of the left hand, well lubricated, is 
first introduced into the rectum. The probe, grasped in the right 
hand, is then passed through the external opening in the supposed 
direction of the fistulous tract. The tract of the sinus is thus slowly 
explored, removing the probe and bending it so as to alter its shape to 
correspond with the direction of the sinus if necessary. The internal 
finger at once recognizes the tip of the probe as it enters the rectum 
(Fig. 562). 




Fig. 562. — Showing the method of probing an ischiorectal fistula. (Ashton.) 

LAVAGE OF THE BOWEL 

As a diagnostic measure, irrigation of the bowel is sometimes 
employed for the purpose of securing samples of the contents for 
examination. The presence of blood, pus, amebae, tumor fragments, 
etc., in the material thus obtained, will often lead to the recognition 
of ulcerative or suppurative processes or malignant conditions which 
from their location high up in the bowel might otherwise escape 
notice. 



EXAMINATION OF THE FECES 54 1 

Apparatus. — There will be required a rectal tube connected with 
a glass funnel by about 3 feet (90 cm.) of rubber tubing. 

Position of the Patient. — Irrigation may be performed with the 
patient in the dorsal position or lying upon the left side with the 
knees drawn up. 

Technic. — The tube, properly lubricated, is inserted into the rec- 
tum a short distance, and about a pint (500 c.c.) of warm boiled 
water is slowly allowed to run into the bowel through the funnel, 
which is elevated i to 2 feet (30 to 90 cm.) above the level of the 
patient. As soon as any discomfort is felt by the patient, the funnel 
is lowered and the contents of the bowel are syphoned off and pre- 
served for examination. 

EXAMINATION OF THE FECES 

Examination of the stools is of distinct diagnostic value in many 
of the diseases'of the digestive tract. Besides furnishing information 
as to the functional activity of the various organs associated with the 
process of digestion and absorption of food, it is a valuable aid in 
the recognition of those diseases of the rectum and large intestine 
which are due to infection by parasites and bacteria. Without 
attempting to enter into the technic of such examination, the details 
of which will be found fully described in manuals on clinical labora- 
tory methods, the lines along which the investigation should be 
conducted may be briefly referred to. There are four methods of 
examination available: macroscopical, microscopical, chemical, and 
bacteriological. 

Macroscopical examination. — The amount, color, odor, consistency, 
and form of the stool and the presence or absence of mucus, blood, or 
pus should be carefully noted. 

Microscopical examination is made for the purpose of detecting 
intestinal parasites or their ova, fat globules, undigested meat fibers, 
blood, pus, or tumor fragments. 

Bacteriological examination will identify pathogenic bacteria if 
present. 

Chemical examination should include tests for mucin, albumin, 
carbohydrates, fat, blood, bile pigments, etc. 

Therapeutic Measures 
ENEMATA AND ENTEROCLYSIS 

Hydrotherapy of the lower bowel may be carried out by means of 
enemata or by enteroclysis. These two measures are often unneces- 



542 THE COLON AND RECTUM 

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 ex- 
ceeding I or 2 pints (500 to 1000 ex.). Enteroclysis, on the other 
hand, is an irrigation of the lower bowel, the fluid returning almost 
as rapidly as it is introduced. In this procedure, large quantities 
of fluid are made use of — frequently several gallons at an irrigation. 
The enema and the irrigation may both be administered either low 
or high, according 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 to secure an action of the bowels in ordinary constipation 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 eft'ects 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 efi'ect. For the local effects in colitis, dysen- 
tery, catarrhal and ulcerative conditions of the rectum and colon, 
small enemata of antiseptic, astringent, or sedative solutions to be 
retained some little time are administered after each movement or 
following a cleansing irrigation. While used mainly for purgative 
and cleansing effects, enemata have other valuable uses in thera- 
peutics. Rectal injections of saline solution are made use of in the 
treatment of shock, hemorrhage, sepsis, etc. (see Saline Infusions, 
p. 554). Rectal enemata are likewise employed as a means of intro- 
ducing fluids and nutriment into the bowel (see Rectal Feeding, 
p. 560) and for the administration of drugs which affect 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 always 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 



ENEMATA AND ENTEROCLYSIS 



543 



if a rapid effect is desired, this method should not be employed. As a 
rule, unless 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 apparatus, provided it is efficient, 
the better. A fountain syringe or a glass irrigating jar, capable of 
holding a quart (looo c.c.) of solution, will be required as a reservoir, 
but in an emergency a large funnel will answer. A rubber tubing 
about 1/4 to 3/8 inch (6 to 9 mm.) in diameter and at least 6 feet 
(180 cm.) long is connected with the outlet of the reservoir, and to the 





Fig. 563. — Fountain syringe and nozzle 
for giving a low enema. 



Fig. 564. — Colon tube and funnel. 



free end an approximate nozzle is attached (Fig. 563). For low 
enemata the ordinary hard-rubber rectal nozzle provided with every 
douche-bag will answer, but if the injection is to be given high up in 
the bowel a flexible-rubber rectal tube about 20 inches (50 cm.) long 
will be more convenient. The tube should be smooth and from t,/^ 
to 1/2 inch (9 to 12 mm.) in diameter. A very simple apparatus 
consists of a long colon tube and a funnel (Fig. 564). 

Rectal tubes are made with the openings at the side, or with one 
opening at the end (Fig. 565) . The latter are better, as the fluid may 
be injected directly through the tube for the purpose of dislodging 
any feces or folds of mucous membrane that may obstruct the pas- 



544 THE COLON AND RECTUM 

sage of the tube. In addition, a bed-pan or a douche-pan should be 
provided. 

Formulary.— For simple cleansing purposes or to produce an 
evacuation in mild cases of costiveness an enema consisting of normal 
salt solution (dr. i (4 gm.) of salt to i pint (500 c.c.) of warm water) 
or the soap-suds enema, made b}^ adding to i quart (1000 c.c.) of 



II"""""""""""'"" ''''"•^iiiiiiiiti^TuiTmr"'""''^ — — - — ■ ■ -- ' - -> 

Fig. 565. — Rectal tubes. 

hot water sufficient castile soap scrapings to make suds, may be used. 
The continued use of the latter is not advisable, however, as some 
irritation may be caused by the lye which is apt to result in proctitis 
or skin eruptions. 

In habitual constipation the injection of from 2 to 6 ounces (60 to 
180 c.c.) 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 ounce (30 gm.) of flax-seed to i pint (500 c.c.) 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 effect 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 gall, turpentine, magnesium sulphate, 
Carlsbad salt, etc. The following combinations of the above will 
be found useful: 

I^ Olive oil or castor oil, oz. ii (60 c.c.) 

Warm soapy water, oz. iv (120 c.c.) 

I^ Glycerin, oz. i (30 c.c.) 

Olive oil. oz. iii (90 c.c.) 

Warm soapy water, oz. iv (120 c.c.) 

I^ Ox gall, dr. ii (8 gm.) 

Warm water, O i (500 c.c.) 

I^ Ox gall, dr. ii (8 gm). 

Glycerin, oz. iv (120 c.c.) 

Warm water, O i (500 c.c.) 



ENEMATA AND ENTEROCLYSIS 545 

I^ Magnesium sulphate, oz. i (30 gm.) 

Glycerin, oz. ii (60 c.c.) 

Warm water, oz. iii (90 c.c.) 

I^ White of egg (beaten), 

Oil of turpentine, dr. i (4 c.c.) 

Olive oil, oz. i (30 c.c.) 

Warm water, O i (500 c.c.) 

I^ Magnesium sulphate, oz. ii (60 gm.) 

Oil of turpentine, dr. ii (8 c.c.) 

Glycerin, oz. ii (60 c.c.) 

Warm water, oz. iv (120 c.c.) 



For the relief of t^onpanites a turpentine enema or an enema con- 
sisting of 3 ounces (90 c.c.) of milk of asafetida may be used. For 
irritability of the rectum the use of a small flaxseed enema or the 
starch-water enema, to which 10 to 2oTn, (0.6 to 1.25 c.c.) of laudanum 
are added, will often give great rehef. The starch-water enema is 
prepared by adding to an ounce (30 gm.) of starch suflicient cold 
water to form a thick paste; enough boiling water is then added to 
dilute this mixture to the consistency of mucilage. 

Temperature.^ — The enema should be given warm — at a tempera- 
ture of about 100° F. (38° C.) — unless contraindicated. 

Rapidity of Flow. — The solution should always be injected slowly 
to avoid discomfort and spasm from a sudden distention of the bowel. 
The reservoir is consequently elevated 2 to 3 feet (60 to 90 cm.) 
above the patient. 

Quantity. — To stimulate peristalsis and produce an evacuation 
of the bowels a bulk of liquid sufiiciently large to distend the walls of 
the intestine should be injected. For this purpose between i pint 
(500 c.c.) and i quart (1000 c.c.) of fluid is made use of at one injec- 
tion. Enemata to be permanently retained for absorption, such as 
those containing drugs or nutriment, should be small in amount, as a 
rule containing only 2 or 3 ounces (60 to 90 c.c.) of fluid. 

Position of the Patient. — The dorsal, the Sims, or the knee-chest 
position may be utilized. 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 
controlled 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 
35 



546 



THE COLON AND RECTUM 



inserted into the anus, guided by the right hand in which it is held at a 
distance of about 2 inches (5 cm.) from its extremity, the operator 
using a slight boring motion, and bearing in mind that the direction 
of the anal canal with the patient recumbent is upward and slightly 
forward. Having traversed the anal canal, the tube enters the rec- 
tum proper, and is then slowly advanced in an upward and sHghtly 
backward direction. From this point some difi&culty 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 being obstructed by feces. Withdrawing the tube slightly 
and advancing it will often suffice to free it; in other cases allowing the 
fluid to flow as the tube is advanced displaces or removes any ob- 
struction and at the same time causes the tube to straighten out. In 
this manner the tube may be passed into the colon, if desired, without 
causing the patient any great discomfort, provided gentleness and no 
force be employed. 

When the tube is introduced to the desired height, the reservoir is 
elevated a distance of 2 or 3 feet (60 to 90 cm.), and its contents are 
allowed to enter the bowel slowly (Fig. 566). The patient is apt to 




Fig. 566. — Method of giving a low enema. (Macfarlane.) 



complain of fulness in the rectum as the fluid enters and distends it, 
but, by temporarily stopping the flow, this feeling soon passes off, and, 
as the rectum becomes tolerant to the pressure, more fluid can be 
injected. When the desired amount has been introduced, the flow is 
shut off by pinching the tube, which is then withdrawn. The patient 
is directed to hold the enema as long as possible before using the 
bed-pan, certainly for five or ten minutes at least. 

Enteroclysis. — ^Like enemata, irrigations are used mainly for 
cleansing purposes, to remove putrefying material or toxins from the 



ENEMATA AND ENTEROCLYSIS 547 

bowels, and to bring medicated fluids into contact with diseased areas 
of mucous membrane. Large irrigations are not advised, however, in 
the treatment of habitual constipation; the use of small enemata is 
just as efficacious, and there is less danger of producing atony of the 
bowel than where it is continually overloaded and distended with, 
large quantities of fluid. In the treatment of intestinal toxemia by 
enteroclysis, the bowels are thoroughly cleansed and absorption of the 
toxins from the decomposing contents is prevented. At the same 
time, more or less fluid is absorbed; the activity of the skin, kidneys, 
and liver is consequently stimulated and general absorption and 
autointoxication are greatly lessened. For the same reasons entero-" 
clysis has a wide field of usefulness in the treatment of renal insuffi- 
ciency, 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 stimu- 
lating effect on the circulation and the elevation of bodily tempera- 
ture, produces marked and beneficial results in shock due to whatever 
cause (see Saline Rectal Infusions, page 554). 

In proctitis and in catarrhal, dysenteric, and ulcerative conditions 
of the large bowel irrigations are employed for cleansing purposes, 
removing foreign substances, mucus, and pus, and thus rendering 
bacteria less active; they also serve as a means of bringing medicinal 
agents in contact with the diseased surfaces. For the local effect upon 
diseases of the rectum or adjacent organs irrigations are used either 
hot or cold; for example, in the treatment of internal 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 inflammation located 
in the bladder, prostate, and deep urethra, or the uterus and its 
appendages. 

Apparatus. — The reservoir for the solution may be either a quart- 
glass irrigating jar or a fountain syringe, attached to which is about 
6 feet (180 cm.) of rubber tubing 1/4 to 3/8 inch (6 to 9 mm.) 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 



548 



THE COLON AND RECTUM 



this form of tube fluid may be deposited high in the colon or low in 
the rectum at will. For infants, a catheter, i6 to i8 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. 567). The solution is passed into the bowel with this clip 




Pig. 567. — Apparatus for enteroclysis. 

closed, and when it is to be drawn off the inflow of solution is tempo- 
rarily stopped by pinching the tubing between the glass connection 
and the irrigator, the clip is opened, and the fluid returns through the 
same tube and escapes through the long arm of the T-tube into a 
waste-pail ready for that purpose. The same thing may be very 
simply accomplished with a long colon tube and a funnel (see Fig. 




Fig. 568. — Kemp's return-flow irrigator. 



564). The solution is forced in through the funnel, and, when 
sufficient has entered the bowel, the funnel is depressed and the fluid 
allowed to escape. 

With a double-flow tube irrigations may be carried out far more 
conveniently, especially when several gallons of fluid are used at each 
irrigation. A very efficient double-flow apparatus, especially for 



ENEMATA AND ENTEROCLYSIS 549 

high irrigating, may be improvised by passing a moderate-sized 
single-flow tube high into the bowel, alongside of which is inserted a 
second tube of larger caliber to carry off the return flow. There are 
any number of excellent double-flow irrigators on the market, of which 
Bodenhamer's, Kemp's (Fig. 568), 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. 569) consists of a 
cylinder enclosing a smaller tube which opens at the end of the irri- 
gator. 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. 

A bath-thermometer, a douche-pan or a bed-pan, a slop-pail, and 
rubber sheeting to protect the bed complete the necessary equipment. 

Solutions for Irrigation. — In the great majority of cases, unless a 
specific action is required from direct contact of remedies with the 




^^^^^^^^^^^^ 



Fig. 569. — ^Tuttle's return-flow irrigator. 

surface of the intestine, normal salt solution (dr. i (4. gm.) of salt to 
a pint (500 c.c.) of warm water) is used. For cleansing purposes 
and to aid in the expulsion of flatus, 5 to 15 lU (0.3 to i c.c.) of 
oleum cinnamomi or oleum menthas 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 to whether a 
soothing, antiseptic, stimulating, or astringent action is desired: 
aqueous extract of krameria, i to 20; fluid extract of hydrastis, i to 
50; fluid extract of hamamelis, i to 50; boric acid, i to 20; hydrogen 
peroxid, i to 10; thymol, i to 50; carbolic acid, i to 500; bichlorid 
of m.ercury, i to 10,000; permanganate of potash, i to 500; saHcylic 
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. 



55 O THE COLON AND RECTUM 

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 ioo° to 105° F. 
(38 to 41° C.)- Hot irrigations (110° to 115° F. (43° to 46° C.)) are 
indicated when the stimulating action of heat is desired, or for the 
diuretic effect and to increase the eliminative action of the skin, and 
for the effect of heat upon inflammations of neighboring organs. 

Cold enteroclysis (65° to 70° F. (18° to 21° C.)) has a beneficial 
action upon the whole intestinal tract, toning up the mucous mem- 
brane and stimulating the muscular tissue, and so increasing peri- 
stalsis. This is indicated in the treatment of internal hemorrhoids, 
inflammatory conditions of the rectum, prostate, deep urethra, etc. 
Li hemorrhage from the bowel, very cold (50° F. fio° C.)) or very 
hot (120° F. (49° C.)) irrigations are used. It should not be for- 
gotten, however, that prolonged enteroclysis with very hot or very 
cold fluid will cause a rise or lowering of the bodily temperature 
amounting to several degrees. 

Rapidity of Flow. — The fluid should enter the bowel with com- 
parative slowness, to avoid exciting peristalsis and to allow the fluid 
to be well distributed over the intestinal wall. Elevation of the 
reservoir 2 to 3 feet f6o to 90 cm.) for a low irrigation and 3 to 4 feet 
(90 to 120 cm.) for the high will give the proper flow. 

Quantity. — A continuous irrigation of from ten minutes to one- 
half an hour or more at a time gives the best results in septic 
conditions, toxemias, inflammations in the organs adjacent to the 
bowel, etc. Several gallons of solution are needed for such an irri- 
gation. On an average, from i to i 1/2 pints (5CXD c.c. to 750 c.c.) of 
solution in high enteroclysis, and from 2 to 8 ounces (60 to 240 c.c.) 
in the low irrigation are kept in the bowel continuously. For 
cleansing purposes, and in the treatment of diseases involving the 
mucous membrane of the bowel, the irrigation is continued until the 
solution returns clear. 

Position of the Patient. — Enteroclysis may be performed with the 
patient (ij in the dorsal position, with hips elevated; {2) in the Sims, 
or left lateral prone position; and (3) in the knee-chest posture. 

\\Tien it is desired to irrigate the whole colon thoroughly, the 
position of the patient may be altered to advantage from time to 
time in order to allow the force of gravity to act upon the fluid and 
permit it to reach all portions of the colon. Elevation of the patient's 
hips causes the fluid to gravitate toward the transverse colon, and 



ENEMATA AND ENTEROCLYSIS 



551 



thence along this portion of the bowel to the ascending colon if the 
patient is shifted from the left side to the right. 

Technic. — The apparatus is properly connected and the reservoir 
is filled with the solution, first allowing a little to escape from the 
nozzle to expel any air and to see that everything works properly. 
Practically the same steps are followed in inserting the tube for 
enteroclysis 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 




Fig. 570. — Showing one method of irrigating the bowels with a single tube. 

patient's buttocks. The patient is instructed to strain sufficiently to 
relax the sphincter, and the tube is inserted at first upward and 
forward for a distance of 2 to 3 inches (5 to 7.5 cm.) and then upward 
and sHghtly 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 



552 



THE COLON AND RECTUM 



it gets 3 or 4 inches (7.5 or 10 cm.) into the bowel, and it has to prac- 
tically find its own way along. It will be found a distinct aid, how- 
ever, in accomplishing this if the solution is allowed to flow gently as 
soon as the anal canal is passed. This tends to make the tube 
stiffer and at the same time it straightens out the folds of mucous 
membrane and carries the valves out of the way, which might other- 




FlG. 571. — Showing the method of irrigating the bowels by means of a funnel 

and colon tube. 



wise form obstructions. When the tube has been inserted to the 
desired distance, the reservoir is raised 3 or 4 feet (90 or 120 cm.), 
and the washing-out process begins. 

In performing enteroclysis with a single tube, i or i 1/2 quarts 
(i to 1.5 liters) of solution — depending upon the capacity and toler- 
ance of the individual — are allowed to flow into the bowel before the 
fluid is permitted to return. If the fluid enters the bowel slowly and 
the desire on the part of the patient to expel it be resisted a few 
moments until it passes well into the colon, no great difiiculty will be 
encountered. To withdraw the fluid, the outlet placed in the tube 



EXEilATA AXD EXTEROCLYSIS 



OOO 



leading from the reservoir is opened (Fig. 570), or, if a funnel con- 
stitutes the reservoir, this is simply lowered below the level of the 
patient, and the solution escapes through the same tube by which 
it entered (Fig. 571). This process of lavage is repeated until the 
fluid returns clear. 

The colon may be more thoroughly irrigated, as already men- 
tioned, by altering the patient's position as follows : With the patient 




Fig. 572. — Showing the method of irrigating the bowel by means of a return-flow 

irrigator. 

in the Sims position, for instance, and with the hips elevated, the 
descending colon is first thoroughly washed out. About i 1/2 to 2 
pints (750 to 1000 c.c.) of solution are then retained, and the patient 
is gradually rolled to the dorsal position and then to the right side. 
This permits the fluid to pass from the descending colon to the trans- 
verse and ascending colon. To allow the solution to gravitate down 
the ascending colon to the caput coli, the patient's shoulders are 
raised slightly higher than his hips. The process is then exactly 
reversed : the shoulders are first lowered, the patient then rolls to the 
dorsal position, and finally to the left side again. 



554 



THE COLON AND RECTUM 



In using the double-flow style of irrigator, the outflow tube is 
compressed until a pint (500 c.c.) or more of solution runs into the 
bowel (Fig. 572), when it is released, the solution still continuing to 
flow in. In this way a current is soon established, and the descending 
colon and rectum are thoroughly washed out. During the irrigation 
the reservoir should not be allowed to become empty, the supply being 
replenished as often as necessary. In withdrawing an irrigator or a 
tube with openings upon the side, care should be taken to rotate the 
instrument slightly to prevent the mucous membrane from being 
caught in the fenestrae. 

SALINE RECTAL INFUSIONS 

The value of saline infusions in the treatment of hemorrhage and 
in the prevention and relief of surgical shock has already been con- 
sidered in Chapter V. The rectal infusion, being a somewhat slower 
and less effective method of introducing salt solution into the circu- 
lation than either the intravenous or the subcutaneous methods, is 
used with greater success in the milder forms of shock and hemor- 
rhage, and in the severe cases as an adjunct to intravenous infusion 
or hypodermoclysis. It has, however, the distinct advantage of 
simplicity over the other two methods, requiring no preparation of 
the patient and but the crudest form of apparatus; hence its value 
as an emergency measure. In septic conditions, toxemias, renal 
insufficiency, uremia, etc., the fluid thus introduced into the bowel 
is rapidly absorbed, and the skin, kidneys, and liver are stimulated 
to increased activity, with the rapid elimination of poisonous 
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 purg- 
ing, as in dysentery or cholera. It is, furthermore, a most valuable 
means of relieving the thirst so frequently complained of after 
abdominal operations. 

Apparatus. — The equipment will not differ from that used in 
giving an ordinary enema. There will be required a thermometer, 
a graduated glass irrigating jar or fountain syringe, 6 feet (180 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. 



SALIXE RECTAL INFUSION 555 

Solution. — Normal salt solution, (dr. i (4. gm.) of salt to a pint 
(500 c.c.) of water) is used. For a stimulating effect, whisky or 
brandy, oz. ss. to oz. i (15 to 30 c.c.) may be added. In surgical 
shock 30 TTL (2 c.c.) of a I to 1000 solution of adrenalin chlorid may 
be added to the enema for the purpose of raising blood-pressure. 

Temperature.— The solution should enter the bowel at a tem- 
perature of 110° to 115° F. (43° to 46° C). As there is but httle 
loss of heat on account of the rapidity of the flow, the solution in the 
reservoir should be at the same temperature at which it is desired 
to have it enter the bowel, or not more than one or two degrees 
higher. 

Rapidity of Flow. — The fluid should be introduced slowly and not 
with such rapidity as to excite intestinal spasm. With this in view, 
the reservoir is held not over 3 to 4 feet (90 to 120 cm.) above the 
patient. 

Quantity. — Small amounts are more apt to be retained by the 
bowel. From 1/2 pint (250 c.c.) to a quart (1000 c.c.) may be given 
at a single injection. 

Position of the Patient. — The infusion may be given 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 
solution of the proper temperature, and a thermometer is placed 
in it that the temperature may be kept uniform. The rectal tube 
should be well lubricated with vaselin or oil. Some of the solution 
is then allowed to escape from the tube to expel any air or cold 
fluid. The flow is then shut ofl' and the tube is grasped in the fingers 
of the right hand about 2 inches (5 cm.) from its extremity while 
the left hand separates the buttocks. As the patient strains slightly, 
relaxing the sphincter, the tube is gently inserted into the rectum. 
In doing this the normal direction of the bowel with the patient in 
the dorsal posture — first upward and forward, and then upward 
and backward — must be kept in the mind of the operator. When 
the internal sphincter is passed, the solution is again aUowed to 
flow gently, in order to displace any feces, folds of mucous membrane, 
etc., that might act as an obstruction, and the tube is pushed on into 
the bowel for a distance of at least 8 to 10 inches (20 to 25 cm.). 
The reservoir is then raised from 3 to 4 feet (90 to 120 cm.), and the 
required amount of solution is introduced. If it is injected slowly 



556 



THE COLON AND RECTUM 



and the tube is passed high up, no difficulty will be found in intro- 
ducing and having retained often as much as a quart (looo c.c.) of 
solution. At the completion of the operation the tube is withdrawn 
and the patient is instructed to remain quiet in the recumbent 
position. 

CONTINUOUS PROCTOCLYSIS 

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 




Fig. 573. — A very simple apparatus for continuous proctoclysis. 

of septic peritonitis in conjunction 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 time, stimulation of the heart 
and kidneys results, and with the latter an increased elimination of 
toxins and septic material. While employed mainly in cases of 
peritonitis, where the results have certainly been marvelous, con- 
tinuous proctoclysis will be found an excellent means of infusing 



CONTINUOUS PROCTOCLYSIS 



557 



salt solution in any septic condition or general toxemia, shock, 
uremia, etc. 

Apparatus. — A glass reservoir or a fountain syringe with a 
capacity of at least 2 quarts (2 liters), 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 
vaginal 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. 573) forms the simplest apparatus. A soft-rubber catheter 
may be used in place of the hard nozzle, if 
desired. Hot-water bags or hot-water cans, which 
surround the reservoir and prevent the solution 
from cooling, should also be provided. An indi- 
cator, placed in the outflow tube to show the rate 
of flow, is a great convenience. A simple one is 
described by Dewitt {Surgery, Gynecology and 
Obstetrics, February, 191 1). The plunger is 
removed from a 6-inch (15 cm.) metal- topped 
glass syringe and the metal top is perforated wilh 
from 2 to 4 holes for the escape of gas, and through 
the opening for the plunger is inserted a glass 
medicine dropper. The upper end of the dropper is 
connected with the reservoir by a short piece of 
rubber tubing carrying a screw clamp (Fig. 574), 
while the tip of the syringe is attached to the rectal 
tubing. By means of this simple device the rate of 
flow may be observed and an outlet is provided for 
flatus. 

Saxon has devised an apparatus especially for 
proctoclysis (Fig. 5 75), consisting of a copper bucket, 
inside of which is placed a glass reservoir for the Fig. 574. — Mod- 
salt solution. Between the copper bucket and ification of De- 
reservoir is provided a space of 2 1/2 inches (6 T"'^ appliance 

, A 1 ^°^ regulating the 

cm.) for hot water. A thermometer is placed in Aq^ of solution 
the tubing which leads from the reservoir, and a vent in proctoclysis. 
pipe for the escape of flatus is also provided. (Crandon and 

. . 1 . 1 .1 , 1 Ehrenfried.) 

A very simple apparatus is described by 
Iversen {Jour. 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 is sufficiently 
clear from the accompanying illustration (Fig. 576). There are 
a number of more elaborate forms of apparatus made, however, 



558 



THE COLON AND RECTUM 



in which the heat is furnished by a thermolite warmer or by- 
electricity. 

Solution. — Normal salt solution (dr. i (4 gm.) of salt to a pint 
(500 c.c.) of water), or plain boiled tap water may be used. The 
latter has been employed to a great extent in the last few years, 
as it has been found that the large bowel tolerates warm water as 
well as it does saline solutions; furthermore, thirst is more quickly 
and effectively relieved. 





Fig. 575. Fig. 576. 

Fig. 575. — Saxon's apparatus for continuous proctoclysis. 

Fig. 576. — Iversen's apparatus for continuous proctoclysis, a. Eight-candle- 
power electric bulb; b, cock; c, Y-shaped glass connection- d, vent tube for the 
escape of gas. 



Temperature. — The solution should be at a temperature of about 
100° to 105° F. (38° to 41° C.) as it enters the rectum, and it must 
therefore be at a temperature of from 120° to 130° F. (49° to 54° C.) 
in the reservoir. The solution must be kept at a uniform degree 
of heat by either constantly replenishing with hot solution or by 
surrounding the reservoir with hot-water bags, unless one of the 
special heating devices is employed. 

Rapidity of Flow. — The salt solution just trickles into the bowel, 
not much faster than it is absorbed, at about the rate of 60 to 180 
drops a minute. In this way i to 3 pints (500 to 1500 c.c.) will 



CONTINUOUS PROCTOCLYSIS 



559 



flow into the rectum in about an hour. The reservoir should be 
elevated only from 4 to i8 inches (10 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 is practically continuous, and the 
quantity of fluid introduced 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 given as much as 30 pints 




Fig. 577. — Showing the method of administering continuous proctoclysis. 
(Kelly and Noble.) a. Adhesive strap fastening the tubing to the thigh; b, vaginal 
nozzle bent at an angle of 35 degrees. 

(15 liters) in twenty-four hours to a child of eleven. It was all re- 
tained. Monroe, however, sounds a note of warning against over- 
use of this method, claiming that it is possible for a patient to absorb 
more fluid than can be eliminated, shown by an overfull pulse, by 
cough, and by rales from edema of the lungs. 

Technic. — The reservoir is filled with solution and suflicient 
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. 577). The reservoir is then raised about 6 inches (15 
cm.) — just sufiiciently high to overcome the intraabdominal pressure 
and allow the fluid to trickle into the bowel. Forceps or other means 



:6o 



THE COLON AND RECTUM 



of constriction should not he applied to the tube to regulate the flow, 
unless the apparatus be provided with an accessory vent to carry 
off the flatus, as they interfere with the free expulsion of gas through 
the tube or the return of fluid to the reservoir should the patient 
strain or vomit. The injection may be stopped every few hours 
if the pulse becomes too full or the rectum irritable; in such cases 
the tube is not disturbed. Murphy advises that the tube should 
not be removed except for defecation, as the constant reinsertion 
will prove irritating to the rectum. It is rarely necessary to con- 
tinue the proctoclysis for more than three or four days. Exact 
technic and almost constant attention on the part of the nurse are 
necessary to gain success with this method. 



NUTRIENT ENEMATA 

The nutrient enema is employed in cases when feeding by the 
natural way is undesirable or impracticable. Rectal feeding has its 
time limitations, however. The capacity of 
the rectum is small and absorption is con- 
siderably slower than by the natural way, so 
that only about a quarter of the amount of 
nourishment necessary for sustenance can be 
given in this way. As a temporary expedient 
or as an adjunct to natural feeding it is most 
useful, but for permanent feeding it is quite 
impracticable. If it alone is depended upon 
for nourishment, life can rarely be prolonged 
for more than four to six weeks, though it 
is true that certain exceptional cases have 
been reported where patients have lived 
exclusively upon rectal feeding for longer 
periods. 

Indications. — i. In cases where some im- 
pediment to the passage of food exists, as 
esophageal stricture, new growths encroach- 
FiG. 578.— Funnel ^^S upon the esophagus, and in pyloric or 
and colon tube for duodenal stenosis. 2. In incessant and 
administering nutrient uncontrollable vomiting. 3. In any condition 
enema a. where it is desirable to give the alimentary 

tract a rest, as in acute inflammation or ulceration of the upper 
part of the alimentary canal, acute gastritis, gastric ulcer, typhoid 
fever, and lesions of the small intestine. 4. As an adjunct to 




CONTINUOUS PROCTOCLYSIS 



561 



natural feeding in any condition when the patient cannot receive 
sufficient nourishment by mouth. 

Apparatus. — A large glass funnel, 2 to 3 feet (60 to 90 cm.) of 
rubber tubing 1/4 to 2>/^ of an inch (6 to 9 mm.) in diamicter, and a 
plain rectal tube 20 inches (50 cm.) long, No. 35 French in size (Fig. 
578) make a simple and very effective apparatus, and one that can 
be easily cleaned. If desired, a hard-rubber syringe with a capacity 
of from 4 to 6 ounces (120 to 180 c.c.) (Fig. 579) or a Davidson 
syringe attached directly to the rectal tube may be used. In children 
a No. 18 to 20 French ordinary rubber catheter is substituted for 
the rectal tube. 




Fig. 579. — Colon tube and syringe for administering nutrient enemata. (Ashton.) 



Asepsis. — The tube should be boiled before using, and it must be 
carefully cleaned after each injection. Syringes, if employed, should 
likewise be very thoroughly cleansed with soap and water every time 
they are used. 

Material Employed for Feeding. — Whatever the form of nourish- 
ment used, it must be free from all irritating properties and should 
be small in bulk, or it will be immediately expelled. As the lower 
bowel secretes no digestive ferments, the substances injected must be 
of such a nature that they are readily absorbed, otherwise the enema 
acts as a 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 
36 



562 THE COLON AND RECTUM 

egg albumen will be found to be most readily taken up by the bowel. 
The addition of a small quantity of salt to each egg aids in its absorp- 
tion. Alcohol in the form of red wine, brandy, or whisky may be 
incorporated in the enema when a stimulating effect is desired. A 
good stimulating enema consists of brandy oz. ii (60 c.c), ammonium 
carbonate gr. xx (1.3 gm.), and beef tea q.s. ad oz. viii (240 c.c.)- A 
pint (500 c.c.) of black coffee alone has also a marked stimulating 
effect. 

The following formulae (Ashton) will be found very useful. In 
continued rectal feeding it is well to use them in rotation. 

(i) Beef juice oz. iii (90 c.c), and liquor pancreatis dr. ii (8 c.c). 

(2) One raw egg; salt, gr. xv (i gm.); brandy or whisky oz. ss. 
(15 c.c); and peptonized milk oz. iii (90 c.c). 

(3) One egg; liquor pancreatis dr. ii (8 c.c); and beef juice oz. 
iii (90 c.c). 

(4) One raw egg, and peptonized milk oz. iii (90 c.c). 

(5) Salt, gr. XV (i gm.); beef juice oz. i (30 c.c); and peptonized 
milk oz. iii (90 c.c). 

(6) Yolk of one raw egg; brandy or whisky dr. vi (24 c.c); 
liquor pancreatis dr. ii (8 c.c); and beef-tea oz. iii (90 c.c). 

Temperature. — Give the injection at a temperature near that of 
the body, about 95° F. (35° C). — never cold or very hot — as peris- 
talsis may be excited and the rectum will probably reject the feeding. 

Quantity. — Only a small amount of food should be injected at one 
time, usually i to 6 ounces (30 to 180 c.c), depending on the retain- 
ing capacity of the rectum and whether the patient is a child or an 
adult. Large quantities are liable to be expelled by the bowel. 

Frequency of Feedings.— This will depend upon the quantity taken 
at one time, A patient who can retain as much as 6 ounces (180 cc) 
need only be fed every six hours. Cases where but small amounts are 
retained will require three- to four-hour interval feedings. 

Care of the Rectum. — A cleansing enema, consisting of salt dr. 
ii (8 gm.) to a quart (1000 c.c.) of lukewarm water, is given each 
morning at least an hour before the first feeding. This serves to 
wash out of the bowel any particles of waste matter or mucus; it 
furthermore cleanses the mucous membrane and prepares it for more 
thorough absorption by stimulating the circulation. 

Position of the Patient. — In giving any retained enema the patient 
should preferably be in the Sims position with the hips elevated or in 
the knee-chest position. If it is inexpedient to move the patient, the 
dorsal position with hips elevated and knees drawn up will sufl&ce. 



I^7ECTI0X5 OF rLUID OR AIR INTO THE BOWEL 563 

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 direc- 
tions already given for the introduction of the enema or enteroclysis 
tube (see page 545;, well into the bowel for a distance of 10 to 12 
inches (25 to 30 cm.), so as to prevent expulsion of the food and fur- 
nish an extensive surface for absorption. To avoid injecting air, 
the tube and the reservoir 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 intro- 
duced, the tube is carefully removed and the patient is instructed to 
remain quietly in the recumbent position ^^dth the hips elevated for 
at least half an hour, to lessen the chances of the food being expelled. 
In cases of marked irritability of the rectum, 5 to 10 lU. ^0.3 to 0.6 
c.c.) of the tincture of opium may be added to the enema. 

INJECTIONS OF FLUID OR AIR INTO THE BOWEL IN 
INTUSSUSCEPTION 

The slow injection of bland fluids or air into the bowel may be 
employed for its mechanical effect in overcoming an obstruction due 
to intussusception. Success from either method, however, depends 
largely upon an early diagnosis of the condition, for disinvagination 
becomes more difiicult in direct proportion to the length of time which 
has elapsed from the onset of the S}-mptoms. After the first t-wenty- 
four hours of an attack, attempts at reduction by means of hydrostatic 
or gaseous pressure are not justifiable, as tight adhesions, which render 
reduction impossible, or strangulation and partial necrosis of the gut 
■v^dth the added danger of rupture may be present. The greatest 
objection to this method of treatment lies in the fact that in many 
cases it is impossible to tell immediately whether the invagination has 
been reduced, and the success of the procedure can only be determined 
by allowing the patient to come out of the anesthetic and carefully 
observing the symptoms. 

Not more than fifteen minutes to a half hour should be consumed 
in attempts at rehef by these nonoperative measures. In all cases 
preparations for operation should be made beforehand so that, should 
reduction fail, an immediate laparotomy can be performed. Treat- 
ment by injections is, of course, only appHcable when the intussus- 
ception occurs in the large bowel, on account of the obstruction by the 
ileo-cecal valve to the passage 01 fluid or gas into the small intestine. 



564 THE COLON AND RECTUM 

Treatment by Injection of Fluid. — Apparatus. — A fountain 
syringe or a graduated glass irrigating jar as a reservoir and a rectal 
nozzle or a large catheter, attached to the reservoir by 6 feet (180 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 (4 gm.) 
to a pint (500 c.c.) of water — thin gruel or milk and water may 
be used. 

Temperature. — As the relaxing effect of heat is desirable, the 
solution should be at a temperature of about 105° F. (41° C.) as it 
enters the bowel. 

Quantity. — The capacity of the colon varies from 10 ounces 
(300 c.c.) in a child of five months to a pint (500 c.c.) or more in a 
child a year old. Not more than i 1/2 pints (750 c.c.) of solution 
should be injected into the bowel of a child under one year. In an 
adult, the rectum and colon hold as much as 9 pints (4.5 liters) with- 
out undue distention. 

Rate of Flow. — The fluid should enter the bowel in a gradual, 
steady, continuous flow. From ten to fifteen minutes are consumed 
in injecting the given quantity of solution. 

Amount of Pressure. — Starting with the reservoir elevated about 
3 feet (90 cm.), which gives a pressure of less than 2 pounds, the 
height may be slowly increased to 4 or 5 feet (120 or 150 cm.) if neces- 
sary. A greater pressure than obtained at the latter elevation is not 
advisable for fear of rupturing the bowel. This danger should be 
constantly borne in mind. 

Position of the Patient. — The patient should be in the dorsal posi- 
tion, with the hips elevated. 

Anesthesia. — Anesthesia with ether to the full surgical extent to 
produce muscular relaxation is necessary. 

Technic. — The nozzle or catheter is well lubricated with oil or 
vaselin, and any air is expelled from the tube. The nozzle is then 
inserted into the rectum for several inches, and the reservoir is ele- 
vated about 3 feet (90 cm.) and the solution is allowed to flow slowly 
into the bowel. Escape of the fluid along the side of the tube is 
prevented by tightly packing cotton about the anus and pressing the 
Ijuttocks firmly together. While the solution is flowing, the abdomen 
may be very gently kneaded or the child may be inverted several times. 
Diminution of the pressure necessary to inject the fluid indicates that 
disinvagination or else a rupture of the bowel has occurred, and the 
injection should be immediately stopped. 



DILATATIOX OF RECTAL STRICTURES BY THE BOUGIE ::6 



:)^:) 



After a thorough, trial by injection, if in doubt as to the result, the 
solution is allowed to escape and the patient is examined. If there 
were present at the outset a distinct tumor, the success of the proce- 
dure will be denoted by its disappearance. A tumor still present and 
retaining its full size will, of course, signify a failure, and an immediate 
laparotomy should be performed while the patient is still under the 
anesthetic. 

Treatment by Inflation with Air. — In employing air to distend 
the bowel the pressure cannot be so well regulated as with fluid, and, 
furthermore, the weight of the colunn of water, which in some cases 
seems to be an important factor, is lacking. 

Apparatus. — A rectal tube or a catheter of appropriate size and an 
ordinary bellows or a Davidson syringe will be required. In order to 
permit the escape of air the moment it is desired, a T-tube of glass 
may be inserted between the rectal tube and the inflation apparatus. 
One limb of the T-tube is inserted into the rectal tube, the other into 
the tube leading from the inflator, while to the third limb a short 
piece of rubber tubing is attached which can be opened or shut by a 
clip. 

Gases Used. — Ordinary air, oxygen, or carbonic acid gas may be 
employed. 

Pressure. — The air should be injected very slowly. The best 
guide as to the amount to be introduced and the pressure is the dis- 
tention produced along the colon and in the abdomen. 

Anesthesia.— A general anesthetic should be employed to insure 
extreme relaxation. 

Technic. — The tube or catheter is introduced well into the rectum 
and the inflating apparatus is connected. The air is very gently and 
slowly pumped in, while an assistant compresses the buttocks to 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 rumbhng sounds or a gush of liquid fecal matter. 

DILATATION OF RECTAL STRICTURES BY THE BOUGIE 

The surgical treatment of rectal strictures consists of : ( i j Gradual 
dilatation; (2) proctotomy; (3) excision; (4) entero-anastomosis; 
and (5) colostomy. Treatment by dilatation, though not often cura- 
tive, is a most valuable palliative measure. By means of gradual 
dilatation, the lumen of a stricture may be so much increased in size 
that the patient is relieved of his obstructive symptoms and may be 



566 THE COLOX AND RECTUM 

kept comfortable for years, provided the dilatation be maintained by 
the occasional passage of a bougie. 

Exact information as to the site, caliber, length, and thickness of 
the constriction should be previously obtained by means ot a digital 
examination, if within 4 inches (10 cm.) of the anus, or if seated 
higher up, by the use of the proctoscope and bougie, as already 
described, before any attempt at dilatation is made. The majority of 
strictures are situated within 3 inches (7.5 cm.) of the anus, though 
they may De located at any point higher up, or within the anus itself. 
The stricture may consist of a ring-like constriction, or a narrowing of 
the canal for a distance of i inch (2.5 cm.) or more, or it may be tor- 
tuous in shape. The bowel above the stricture is often markedly 
dilated and the rectal walls may be so thinned that rupture of the gut 
readily occurs upon the use of slight force. At the seat of stricture the 
mucous membrane is often ulcerated or replaced by dense scar tissue. 

Instruments. — The instrument employed for dilatation should be 
a soft-rubber bougie with a conical tip, such as the Wales instrument 
(Fig. 580). 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. 




r^^ ^^ L_8_] LJQ. 

Fig. 580. — Wales' bougies. 

Rapidity of Dilatation. — The stricture should be stretched gradu- 
ally. Dilatation ought not to be performed rapidly or by divulsion. 
Such methods are extremely dangerous, as, apart from the shock, on 
account of the laceration of the tissues there is great risk of hemor- 
rhage and septic infection. 

Frequency. — This depends upon the amount of tenderness and 
irritation as the result of the manipulations. If the bougies are 
passed at too frequent intervals, irritation and inflammation are