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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, performing 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. 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
^ — ^\ z-"-^-.
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-. ^^\ X
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-< ^ \
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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.
"^ rj]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|||||||IU»l|l|l||lllllll|l|lll|ll|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
produced which induce the very condition it is intended to correct.
As a rule, the stretching should not take place oftener than every
DILATATION OF RECTAL STRICTURES BY THE BOUGIE
567
other day. In some cases, the lapse of two or three days between
each treatment is necessary, for the bougie ought not to be reintro-
duced until all signs of the discomfort it has produced have entirely
Fig. 581. — Method of inserting a bougie into a stricture through a proctoscope.
Fig. 582. — Showing a bougie passed through a stricture.
passed off. Later, when full dilatation has been reached, an interval
up to a month may elapse between each treatment, if it is found that
there is no tendency for the contraction to recur in the interval.
568 THE COLON AXD RECTUil
Position of the Patient. — The patient is to be in the Sims position,
with the knees well drawn up, or in the knee-chest position if a procto-
scope is to be used.
Technic. — The bougie is well lubricated and, guided by the right
index-linger, is made to enter the orifice of the constriction; or, better
still, it is inserted accurately into the stricture under the guidance of
the eye through a proctoscope introduced to the seat of stricture (Fig.
581), as recommended by Tuttle. The advantages of this method are
ob\'ious. The greatest gentleness must be observed in inserting the
bougies, and under no circumstances should the tissues be lacerated.
The first instrument should be of such a size that it enters the stric-
ture with ease. The next one. a size larger, is left in place for a few
moments, and then a third instrument is inserted if it can be done
without pain to the patient. The proctoscope is then withdrawn and
the bougie is left iu situ ten to fifteen minutes.
Following the treatment, an irrigation of hot normal salt solu-
tion is given, and the patient is kept quiet for a quarter to a half-hour.
At the subsequent sittings, it is well to commence with an instrument
a size smaller than the largest one used at the previous sitting. An
increase in the dilatation is attempted at each instrument.
COLONIC MASSAGE
Abdominal massage is indicated for the relief of chronic consti-
pation and its accompanying symptoms the result of the atony of the
intestines, in which class of cases, if properly carried out, it is a most
valuable therapeutic measure, tending to strengthen the muscles of
the abdomen and bowel and the tone of the nervous system, as well
as to stimulate the secretory function of the colon and to increase the
peristaltic action. To be of value, however, it should be performed
by one trained for such work. Massage is contraindicated during
menstruation and in pregnancy, and. of course, in the presence of such
pathological conditions as gastric or intestinal ulcers, intestinal
obstruction, appendicitis, hemorrhage from the bowel, inflammation
of the peritoneum, etc.
Time for Massage. — The best time for massage is early in the
morning before breakfast. In cases where this is not possible, care
should be observed that it is not given until at least one hour has
elapsed since the last meal.
Duration. — Each treatment should consume from five to fifteen
minutes. The treatments should be persisted in until the regularity
COLONIC MASSAGE
;6q
Fig. 583. — Deep pressure colonic massage. (Bandler.)
Fig. 584. — Showing the method of kneading the colon. (Bandler.)
570 THE COLON AND RECTUM
of the stools is re-established, to effect which may require several
weeks or months.
Frequency. — Treatments should be given daily.
Preparations. — The bladder and, if possible, the rectum should be
empty.
Position of the Patient. — The patient lies in the dorsal position
with the shoulders and knees slightly elevated, so as to secure as
much relaxation as possible.
Technic. — The masseur stands upon the patient's left side and
begins his manipulations by making light circular movements (effleur-
age), starting at the cecum and following the course of the ascending,
transverse, and descending colon. The small intestine and the rest
of the abdomen are similarly manipulated. Then deep pressure and
kneading movements (petrissage) are substituted. In these move-
ments the whole colon is manipulated in the first instance by perform-
ing zigzag movements while making deep pressure with one hand
superimposed upon the other (Fig. 583), and, in the second instance,
by raising up deep handgrasps of the abdominal muscles and the
intestines and kneading them by alternately compressing and relax-
ing the fingers (Fig. 584). In performing these deeper manipulations
one will be governed as to the amount of force that may be employed
by the sensitiveness of the patient. Care should be taken that the
manipulations be not too vigorous, lest some injury to the viscera
result.
AUTO-MASSAGE
Massage may be very effectually carried out by the patient him-
self by rolling a ball over the abdomen, beginning at the cecum and
Fig. 585. — Cannon ball for auto-massage of the abdomen.
following the course of the colon up the right side, then across the
abdomen, and down the left side in the direction of the descending
colon. A cannon ball or a wooden ball filled with shot weighing 3 to
5 pounds (1.4 to 2.2 K.), covered with chamois or flannel (Fig. 585),
may be used for this purpose.
APPLICATION OF ELECTRICITY TO RECTUM AND COLON
571
THE APPLICATION OF ELECTRICITY TO THE RECTUM AND
COLON
Electricity is of value in conjunction with the abdominal massage
in all forms of constipation, but especially so in the atonic variety.
Under the stimulating action of the electric current, the nerves,
muscles, and glandular structures connected with the bowel are favor-
ably influenced, so that the peristaltic action and the secretion of
mucus are increased, at the same time, the contracting power of the
voluntary muscles of the abdomen is strengthened.
Both the faradic and the galvanic currents are employed, the
former being generally preferred for atonic constipation and intestinal
paresis and the galvanic for spastic constipation and painful neuroses.
They may be applied percutaneously or internally.
Apparatus. — For the percutaneous applications a large flat sponge
electrode (Fig. 586) and a small sponge electrode (Fig. 587) will be
Fig. 586. — Large flat sponge electrode.
required. When it is desired to make internal applications, a special
irrigating rectal electrode, such as Boas' (Fig. 588) or Kemp's, and a
flat abdominal sponge will be required.
Strength of Current. — As there is no means of estimating the
strength of the faradic current, the sensations of the patient should be
the guide, the current being strong enough to cause muscular contrac-
tions but no pain. For galvanism, from 10 to 15 ma. of current are
ordinarily required.
0/
THE COLON AND RECTUM
Duration of Application. — Each treatment should consume from
ten to fifteen minutes.
Frequency. — At first applications are made daily, then every other
day, and, as the conditions improve, once or twice a week.
Time of Application. — Treatments are given with best results at
night, just before the patient retires.
Fig. 587. — Small sponge
electrode. (Bandler.)
Fig. 588. — Boas' rectal electrode. (Bandler.)
Position of Patient. — The patient should be in the recumbent
position, with the head sUghtly elevated and the legs flexed, so as to
relax the abdominal muscles.
Technic. — i. Percutaneous Application. — The positive pole is at-
tached to a large flat electrode, and the latter, well moistened, is
placed over the spinal column. The negative electrode is then
appHed to the abdomen for a few minutes at a time, first over the
cecum, then along the course of the transverse colon, and finally
along the descending colon. This is supplemented by circular
motions with the negative electrode over the same regions. Finally,
the entire abdomen is similarlv treated.
APPLICATION OF ELECTRICITY TO RECTUM AND COLON 573
2. Rectal Application. — An irrigating electrode attached to the
negative pole of the battery is inserted in the rectum and the positive
electrode is placed over the spine or abdomen. When the current is
turned on, saline solution is allowed to flow slowly through the rectal
electrode, carrying the current to all portions of the colon.
CIL\PTER XIX
THE URETHRA AND PROSTATE
Anatomic Considerations
The Male Urethra. — The urethra is a dosed canal, composed of
erectile and muscular tissue, and lined by mucous membrane, extend-
ing from the bladder to the external urinary meatus. Its entire
ength is from 6 1/2 to 9 inches (16 to 23 cm.), depending upon the
Fig. 589. — Section of penis, bladder, etc. (Testut.) i, Symphysis pubis;
2, prevesical space; 3, abdominal wall; 4, bladder; 5, urachus; 6, seminal vesicle
and vas deferens; 7, prostate; 8, plexus of Santorini; 9, sphincter vesicae; 10,
suspensory ligament of penis; li, penis in flaccid condition; 12, penis in state of
erection; 13, glans penis; 14, bulb of urethra; 15, cul-de-sac of bulb, a, Prostatic
urethra; b, membranous urethra; c, spong}' urethra.
length of the penis. For purposes of description it is divided into
the following portions, corresponding to the parts through which it
passes: (i) The spongy portion, or pars cavernosa, (2) the membran-
ous portion, or pars membranosa. and (3) the prostatic portion, or pars
prostatica (Fig. 589). Clinically and for all practical purposes,
574
ANATOMIC CONSIDERATIONS
575
however, it may be divided into the anterior urethra, that portion
lying in front of the anterior layer of the triangular ligament; and the
posterior urethra, the portion lying behind the anterior layer of the
triangular ligament.
The Spongy Urethra. — It extends the entire length of the corpus
spongiosum opening externally upon the glans penis as a vertical slit,
the meatus. The spongy urethra measures on the average about 6
inches (15 cm.). The lumen of this portion of the urethra is not of
the same size throughout, but presents two fusiform dilatations, one
at the bulb, the bulbous urethra, and the other within the glans, the
fossa navicularis.
The mucous membrane is pale pink in color and has opening upon
its surface a number of glands and crypts. In the floor of the bulbous
portion the ducts of Cowper's glands open side by side. Scattered all
through the mucous membrane of the urethra are the urethral glands
or glands of Littre. Upon the roof, the mucous membrane is studded
with small crypts or diverticula, the lacunae. The orifices of these
lacunae open toward the meatus forming little pockets into which
instruments may find their way and be arrested in their passage.
One of these, the lacuna magna, is especially liable to interfere with
the passage of instruments. It Kes in the roof of the fossa navicularis
about I inch (2.5 cm.) from the meatus. These mucous glands and
lacunas are liable to infection and may become the seat of small gonor-
rheal abscesses.
Fig. 590. ^The interior of the urethra, i, Meatus; 2, fossa navicularis; 3,
urethral glands; 4, orifices of Cowper's glands; 5, Cowper's glands; 6, ejaculatory
ducts; 7, sinus pocularis; 8, verumontanum.
The Membranous Urethra. — It is that portion of the urethra
lying between the two layers of the triangular ligament, and extends
from the apex of the prostate gland to the bulb of the spongy portion.
It measures about 1/2 inch (i cm.) in length. The membranous ure-
thra is the most fixed, as well as the least distensible of all segments of
the urethra. In its course it pierces both layers of the triangular Hga-
ment and receives prolongations from these structures, and is also
^76 THE URETHRA AND PROSTATE
surrounded by the compressor urethrse muscle. Spasm of this muscle
is a frequent hindrance to catheterization and the passage of sounds.
Embedded in the libers of the compressor urethrse and on either side
of the membranous urethra He the glands of Cowper, the ducts from
which open in the anterior portion of the bulbous urethra.
The mucous membrane lining this portion of the canal is darker
in color and much more sensitive than that in the spongy portion.
Prostatic Urethra. — It measures 3/4 to i 1/4 inches (2 to 3 cm.)
in length and extends from the internal urethral orifice to the posterior
layer of the triangular ligament, traversing the prostate gland from
base to apex. In the presence of hypertrophy of the prostate, the
caliber of this portion of the canal may become obstructed or
deformed.
The floor of the prostatic urethra is encroached upon by a fusiform
swelling, the verumontanum or caput galHnaginis. At the front and
most prominent part of the verumontanum is seen the slit-like open-
ing of the sinus pocularis, a blind pouch or diverticulum, usually 1/4 to
1/3 inch (6 to 8 mm.) in length, which runs up in the substance of the
prostate beneath the middle lobe. It is regarded as homologous with
the uterus in the female. Within the sinus pocularis or upon its
margins are the slit-like openings of the ejaculatory ducts. On each
side of the verumontanum is a depression, the prostatic sinus into
which the openings of the prostatic ducts empty.
The Caliber of the Urethra. — The caliber of the urethra varies
greatly. While the average diameter is 0.3 inch (7.5 mm.) or 27
French scale, the individual urethra is not of the same uniform cali-
ber from end to end, there being a number of constricted and dilated
portions. The wide parts are: (i) The pars prostatica, (2) the bulb-
ous urethra, and (3) the fossa navicularis. The narrow portions
are: (i) The meatus, (2) the penoscrotal junction, (3) the membran-
ous urethra, and (4) the internal prostatic opening. Of these the
meatus is the narrowest, and in a normal individual an instrument
that will pass the meatus should pass the other narrow points.
Normally, the walls of the urethra are in contact and on cross
section the canal appears as a mere slit. In the prostatic portion,
from the projection of the verumontanum, it has the appearance of a
half moon, in the membranous portion it is star-shaped; in the cav-
ernous portion, it appears as a transverse sHt; in the glans, as a verti-
cal slit.
Curves of the Urethra. — The anterior urethra is freely movable
and may be made to assume any curve. The posterior urethra is
ANATOMIC CONSIDERATIONS 577
fixed, however, between the suspensory hgament of the penis and the
internal vesical opening, and its natural curves are important to bear
in mind in the passage of instruments. In the prostatic portion the
direction of the urethra is downward; in the membranous, downward
and forward; and in the spongy portion, forward and slightly upward
for 2 inches (5 cm.), and then sharply downward. Thus two curves
are formed: (i) concave forward, and (2) concave downward. The
latter may be straightened or obliterated by lifting up the penis, but
the first is fixed and can only be straightened by using some force. In
children and in thin individuals, the fixed curve is much sharper,
while in large, stout men it becomes flattened. A distended bladder
or an enlarged prostate lengthens it.
The Female Urethra. — It extends from the neck of the bladder
to the external urinary meatus, curving downward and a little forward.
The female urethra measures i 1/4 to i 1/2 inches (3 to 4 cm.) in
length and 1/4 inch (6 mm.) in diameter, but, as it is not surrounded
by resisting structures, it is possible to so dilate it as to admit the
finger. It lies in front of, and is very closely associated with, the
anterior wall of the vagina through which it may be readily palpated.
Its walls, composed of muscular, erectile, and mucous tissue, are
normally in contact, presenting a stellate appearance on cross section.
The mucous membrane is pale in color and is thrown into a series of
longitudinal folds, one of which, on the upper half of the posterior
wall, is quite marked and corresponds to the verumontanum in the
male. The compressor urethrse muscle surrounds it, between the
layers of the triangular ligament.
Close to the posterior margin of the external urethral orifice on
either side of the mid-line are the tubes of Skene. As in the male, the
external meatus is the narrowest portion. It appears as a vertical
slit 1/5 to 1/4 inch (5 to 6 mm.) in length, about i inch (2.5 cm.)
posterior to the base of the clitoris.
The Prostate Gland. — The prostate is a sexual organ composed
of glandular, muscular, and fibrous tissue, lying in front of the neck of
the bladder. It is pierced above by the urethra and below by the
ejaculatory ducts. In shape it resembles an irregular truncated cone,
the apex of which rests against the posterior layer of the triangular
ligament while the base is directed toward the bladder. In size it
measures about i 1/2 inches (4 cm.) transversely, i 1/4 inches (3 cm.)
vertically, and 3/4 inch (2 cm.) longitudinally. It weighs 4 to 6
drams (16 to 24 gm.). The size of the prostate is not constant, how-
ever, varying greatly in different individuals and depending upon the
37
;78
THE URETHRA AND PROSTATE
age of the patient. In a child, the gland is only rudimentary, not
reaching the full size until about the twenty-fifth year. During the
later years of life, it often becomes hypertrophied, not infrequently
enlarging to over twice its original size.
The prostate consists of two lateral lobes which bulge posteriorly
and a so-called middle lobe. The latter is that portion of the gland
which lies between the two ejaculatory ducts directly posterior to the
beginning of the urethra. If enlarged, as occurs when the gland is the
seat of senile hypertrophy, the median lobe forms a projection which
Fig. 591. — The prostate gland and seminal vesicles.
may cause urinary obstruction and interfere with the passage of
instruments. The two lateral lobes meet and become continuous in
front and behind the urethra. The tissue forming this union in front
is spoken of as the anterior commissure and the portion behind as the
posterior commissure or isthmus (pars intermedia).
Diagnostic Methods
In the examination of the urethra some definite system should be
followed. The first step consists in taking a careful history of the
case. This should embrace the family history, a history of past ail-
ments, and the patient's description of the present trouble, its onset,
duration, etc. While in some cases of urethral disease exhaustive
questioning of the patient is superfluous, it will be found that an exact
GLASS TESTS 579
history will often be of the greatest aid in arriving at a correct
diagnosis.
The examiner should then take up more in detail the symptoms
complained of by the patient. It should be ascertained whether the
patient has or has had a urethral discharge, and, if so, its character;
whether it is sufficient to stain or stiilen the linen, or whether it simply
glues the hps of the meatus together; w^hether it occurs only with the
first urine passed, or in the intervals as w^ell; whether there is any dis-
charge with defecation; also whether defecation is accompanied by
pain about the prostate or rectum. It is important to inquire into the
act of urination, ascertaining whether the passage of urine causes any
pain, and, if so, its character, and whether the pain is present at the
beginning or end of the act; also whether there is an increased fre-
quency in urination. The patient should be questioned as to the
character of the stream of urine, its force and cahber; whether there is
any dribbling; whether the stream is interrupted or suddenly stopped,
such as would be the case with enlargement of the prostate or in the
presence of a vesical calculus. The character of the urine passed
should also be inquired into; whether the presence of blood has been
noted, and whether shreds are present, and their character. More
exact information upon these latter points, however, will be obtained
after a complete examination of the urine.
Having questioned the patient along the lines above indicated,
secretions and discharges, if present, should be collected for examina-
tion (see pages 231, 581), and then the actual examination of the
urethra and prostate may be taken up. The methods available for
this include: (i) glass tests and injection tests for the purpose of locat-
ing the seat of the discharge, (2) inspection, (3) palpation, and (4)
instrumental examination. The use of instruments, however, should
not he undertaken if there is an active discharge from the urethra for
fear of aggravating the inflammation and producing such complica-
tions as abscess, stricture, etc. It is far better to postpone such ex-
ploration until the severity of the inflammation and the discharge
have been reduced by the use of injections or irrigations.
GLASS TESTS
A number of tests have been employed for the purpose of deter-
mining whether the seat of the pus has its origin in the anterior or
posterior urethra. The simplest of these are known as the two-glass
test and the three-glass test.
580 THE URETHRA AND PROSTATE
The Two=glass Test. — It is performed as follows: The patient is
instructed to hold his urine for three or four hours, and upon present-
ing himself for examination he is told to urinate into two glasses or
graduates. He should pass about 2 ounces (60 c.c.) into the first glass
and the remainder into the second. If the contents of the first glass,
in which are collected the washings from both the anterior and poste-
rior urethra, contains pus or shreds revealed by holding the glass be-
fore a strong light and the contents of the second glass is clear, it may
be inferred that the anterior urethra is involved, but the posterior
urethra, if at all, only slightly so. If, on the other hand, the contents
of both glasses are cloudy or contain shreds, it shows that there is suffi-
cient secretion from the posterior urethra to have escaped into the
bladder and discolored its contents, or that the secretion comes from
the bladder itself, the ureters, or kidneys. In the former case, the
contents of the first glass is more turbid than that in the second glass;
while in the latter conditions there is but little difference between the
two specimens.
Another method and one that is more certain in differentiating
between an anterior and posterior urethritis, consists in first thor-
oughly irrigating the anterior urethra with a warm boric acid or
normal salt solution by means of a catheter introduced as far as the
bulb, and then having the patient urinate into two glasses. If the
contents of both glasses are clear, we may be sure the posterior ure-
thra is free. Pus or shreds appearing in the second glass indicate a
posterior urethritis, or that they come from the bladder or beyond.
The Wolbarst Three=glass Test. — This is more rehable than
the two-glass test, and is also employed for the purpose of determining
whether the seminal vesicles are inflamed. The technic is as follows:
The anterior urethra is washed out with sterile water until the wash-
ings return clear. These washings are collected in the first glass and
represent the contents of the anterior urethra. A soft catheter is next
introduced into the bladder and a sample of its contents is drawn oft'
into a second glass. This represents the bladder urine. If this
specimen proves to be clear and free from shreds, the catheter is re-
moved and the patient is instructed to void a little urine into a third
glass. This glass represents the contents of the posterior urethra. If
it should be found, however, that the contents of the second glass is
not clear, that is, if the bladder urine is cloudy, the catheter is left in
place and the bladder is emptied and is then washed out with sterile
water, allowing from 4 to 6 ounces (120 to 180 c.c.) of clear solution to
remain. The catheter is then removed and the test is carried out as
INSPECTION 551
before for the third glass. The prostate and seminal vesicles are next
massaged and the patient then voids the urine or solution containing
pus expressed from the prostate and seminal vesicles into a fourth
glass.
INJECTION TEST
For the purpose of differentiating between an anterior and a pos-
terior urethritis, the anterior urethra may be injected with a solution
that "will color the shreds in that portion of the canal. A i per cent,
solution of methylene blue is employed. By means of a blunt-pointed
urethral syringe the anterior urethra is filled with the methylene blue
and the patient is instructed to hold the solution in the urethra for
about a minute. The solution is then allowed to escape. If upon
urination the shreds appear blue, they come from the anterior urethra;
unstained shreds from the posterior urethra. A microscopical exami-
nation may be necessary, however, to determine whether the shreds
remain unstained. In making this test it is essential that the patient
should not have urinated for some time previously.
INSPECTION
In the Male. — In the male, inspection of the urethra without
the aid of instruments is limited to the meatus and the exterior of the
canal as far as the peno-scrotal junction. Swelling, signs of inflam-
mation, new growths, etc., which present externally may thus be
recognized. While comparatively limited in scope, inspection should
never be neglected, but should form part of the routine examination.
Position of Patient. — The patient may stand or lie flat upon a
table.
Technic. — The penis is elevated so as to bring its under surface to
view and any abnormalities are noted. The presence or absence of a
discharge should also be determined. By stripping the urethra from
the scrotum forward by means of the index-finger applied ejJternally,
the presence of any discharge may be demonstrated. If present, some
should be deposited upon a slide, and later should be stained and
examined for gonococci.
In the Female. — In the female, the mouth and the vaginal sur-
face of the canal in its entire course may be inspected.
Position of Patient. — The patient should be placed in the dorsal
position.
Technic. — The operator, sitting in front, separates the labia and
582
THE URETHRA AND PROSTATE
notes the condition of the meatus and searches for signs of inflamma-
tion, the presence of new growths, eversion of the mucous membrane,
discharges, etc. The presence of the latter may be more readily dem-
onstrated by stripping the canal from the bladder forward by means
of a finger passed into the vagina (Fig. 592). The mouth of the ure-
thra may be exposed by drawing the lips apart by means of the
fingers, one placed on each side as shown in Fig. 593. In this manner
the orifices of Skene's glands may be exposed. Finally, the index-
finger or a speculum is passed into the vagina and its posterior wall is
depressed, so that the whole extent of the vaginal surface of the ure-
thra is exposed. In this manner tumors, dilatations, cysts, saccula-
tions, etc., will be noted.
Fig. 592. — Method of stripping a dis-
charge from the urethra. (Ashton.)
Fig. 593. — Method of inspecting the
urethral orifice in the female.
(Ashton.)
PALPATION
In the Male. — ^Like inspection, palpation of the urethra is of
limited value, especially in the male. By it, however, changes in the
consistency, sensitiveness, and form of the canal may be recognized.
Position of Patient. — The urethra may be palpated with the
patient standing or in the dorsal position. To palpate the prostate
the patient should be placed in the knee-chest position, or should bend
over with the hands resting upon a chair and the thighs separated.
Technic. — In palpating the urethra the penis should be grasped
just behind the glans between the thumb and forefinger of the left
hand, and, while putting the organ on the stretch, the penile portion
PALPATION
583
of the urethra is palpated between the thumb and forefinger of the
right hand (Fig. 594). It should be noted whether the urethra is
elastic, as it normally is, or whether it is hard, indurated, or nodular.
An inflamed urethra will be painful to the touch and will feel tense and
Fig. 594. — External palpation of the urethra.
Fig. 595. — Showing the method of palpating the prostate gland.
swollen. A urethral abscess appears as a painful swelling bulging
the wall of the canal. A cancerous growth will be hard, nodular, and
adherent. By inserting a sound and then palpating the urethra upon
it more valuable information may be obtained, as changes in the
consistency of the canal will be accentuated.
584
THE URETHRA AND PROSTATE
To palpate the membranous urethra and prostate a rectal exami-
nation will be necessary. For this the bladder should preferably
contain a little urine. The operator, standing upon the patient's left,
inserts his right forefinger, protected by a finger cot and well lubricated,
into the bowel (see Palpation of the Rectum, page 527). After pass-
ing the sphincter, the examining finger comes in contact with the mem-
branous urethra for a space of 1/2 inch (i cm.), and then the pros-
tate gland is reached. Normally, the latter is not very distinctly
felt, but in the presence of hypertrophy it readily is, and sometimes
it is so enlarged that it may be palpated bimanually. Points of ten-
derness, softening, painful swellings, or a general enlargement should
be looked for and any difference between the two lobes should be
noted. The condition of the seminal vesicles should likewise be
investigated. They lie above each lobe of the prostate extending
upward and outward, but are not palpable, unless enlarged or
thickened bv disease.
Fig. 596. — Combined rectal and instrumental examination of the prostate gland.
If desired, the seminal vesicles and prostate may at this time be
massaged for the purpose of obtaining their secretions for examina-
tion. This is done by carrying the finger up over each seminal vesicle
in turn and, while making firm pressure, carrying the finger downward
over the lobe of the prostate toward its base. The massage will
force the discharge into the urethra and it may then be collected
upon a clean slide by stripping the urethra from behind forward.
EXAMINATION BY SOUNDS AND BOUGIES 585
At times a combined examination with the finger in the rectum
and an instrument in the urethra will be of assistance in exploring the
prostate. A bladder sound or other metallic instrument is introduced
into the bladder, and, by engaging the prostate between it and the
examining finger (Fig. 596), the extent of hypertrophy as well as the
amount of induration may be ascertained.
In the Female. — In the female, the entire canal may be ex-
plored by palpation through the vagina and valuable information
is thus often obtained.
Position of Patient. — The patient is placed in the dorsal position.
Technic. — The examiner, sitting in front, separates the labia with
the fingers of his left hand, while he palpates with his right index-
finger. The meatus is first examined by pressing with the examining
finger placed just outside the vaginal outlet up against the symphysis.
Then by means of the index-finger in the vagina the whole length of
the urethra may be explored by tracing the course of the canal back as
far as the bladder. By rolling the urethra with the index-finger from
side to side and exerting pressure upward upon the canal with the
inferior and posterior surfaces of the symphysis as points of counter-
pressure, changes as to sensitiveness, consistency, or form of the canal
may be readily recognized.
EXAMINATION BY SOUNDS AND BOUGIES
Having obtained all the information possible by the means already
detailed, an instrumental exploration of the urethra, provided the latter
is not the seat of an acute inflammation, for the purpose of determining
the presence or absence of strictures is the next step. While such
symptoms as a gleety discharge, dribbling at the end of urination,
malformation in the shape of the stream, difficulty in starting the
stream, retention of urine, etc., may point strongly to the presence
of a stricture, they are by no means infallible, and it is only by a care-
ful local examination of the urethra that the diagnosis of stricture can
be absolutely made. For the purpose of simply locating a stricture
and determining its size, sounds and bougies are employed, while for
determining the length of the contracture the bulbous bougie or
bougie a boule is necessary.
In inserting an instrument into the urethra, the utmost gentleness
is required. The instrument should be passed slowly so that, if an
obstruction is suddenly encountered, there will be no danger of pro-
ducing injury to the canal; even the slightest force should always he
S86
THE URETHRA AND PROSTATE
avoided. It is only by cultivating a delicate touch and keeping in
mind the anatomical variations in the urethra that painless manipu-
lation of urethral instruments is possible. In making such an exam-
ination it should be remembered that the passage of an instrument
Fig. 597. — Blunt steel sound.
for the first time may result in a severe chill, and a rise of tempera-
ture. To prevent this, it is well to terminate the examination with an
instillation of i to 1500 nitrate of silver to lessen the urethral conges-
tion. After one exploration the urethra should be given a rest for a
Fig. 598. — Flexible urethral bougie.
few days, as not infrequently the irritation produced aggravates a
chronic urethral discharge.
Instruments. — Blunt steel sounds of the proper curve (Fig. 597)
are preferable for the exploration of strictures of large caliber. There
\.
Fig. 599. — Filiform bougies.
is considerable risk of injuring the urethra when a rigid steel instru-
ment of a size smaller than 15 French is used, and it is safer for those
not especially skilled in the manipulation of urethral instruments
to employ woven-silk olivary bougies (Fig. 598) in examining small
Fig. 600. — Female sound. (Ashton.)
strictures. A set of these instruments from the smallest size made
up to No. 20 French should, therefore, be at hand. The best are
made in France. For finding the channel through very tight stric-
tures whalebone filiform bougies (Fig. 599) are necessary. They are
EXAMINATION BY SOUNDS AND BOUGIES
587
provided with small bulbous points from which they taper for an inch
(2.5 cm.) or so until the full size of the shaft is reached. To facilitate
the entrance of these instruments into tortuous canals the tips may
be softened in hot water and then bent into various shapes, as curves,
spirals, angles, etc. For diagnostic purposes the filiforms should be
about 12 inches long (30 cm.). For exploring the
female urethra a slightly curved steel sound is
employed (Fig. 600).
Asepsis. — Metal instruments are boiled for
five minutes in a i per cent, soda solution. The
best makes of the silk-elastic instruments may
also be boiled, but some of the others will not
last long if so treated, and it is safer to sterilize
them in formalin vapor for twenty-four hours and
then rinse well in sterile water before using. A
special apparatus (Fig. 601) is required for this,
however. It consists of a glass cylinder about 16
inches (40 cm.) long with a perforated plate near
the top for holding the catheters and in the base a
receptacle for formalin tablets. In its absence
the instrument may be soaked in a i to 20 car-
bolic acid solution' followed by immersion in a
saturated boric acid solution and rinsing in sterile
water. Whalebone bougies may be boiled, though
they will not stand prolonged boiling. The ex-
aminer's hands should be as carefully cleansed as
. . Fig. 601. — Form-
for any operation.^ ^ ^li„ sterilizer for
The glans penis should be first washed with urethral instruments.
soap and water, then with a i to 5000 bichlorid ^' '^°P' *' ^^'^^
for 03 l^iif topi's ' c ooTT""
solution followed by sterile water. The urethra ^^.^^^ ^^^ formalin.
is irrigated with a warm saturated solution of
boric acid or with a i to 5000 solution of potassium permanganate
both before and after the examination.
Position of Patient. — The patient should lie in the dorsal position
with his shoulders slightly raised and thighs flexed and rotated some-
what outward, and near that side of the table upon which the opera-
tor stands. The operator takes his place just above the patient's hips,
facing the patient's body, upon whichever side of the table is most
convenient for him — generally the left side is chosen.
Technic. — In beginning the examination the largest instrument
that will pass the meatus should be introduced. As the meatus is the
588
THE URETHRA AND PROSTATE
narrowest portion of the urethra, any instrument that can be intro-
duced through it will pass along the entire canal, unless some con-
traction is present. Should the meatus be abnormally small, it may
Fig. 602. — First step in inserting a urethral sound.
be enlarged by an incision (see page 626). The operator grasps the
penis behind the corona between the ring and middle fingers of the
left hand and with the thumb and index-fingers of the same hand he
retracts the foreskin and separates the lips of the meatus. The sound,
warmed and well lubricated with one of the Irish-moss preparations.
Fig. 603. — Second step in inserting a urethral sound.
is grasped lightly between the fingers of the right hand, and is gently
introduced into the meatus. As the point of the instrument is in-
serted in the meatus the handle should lie parallel to the abdominal
EXAMINATION BY SOUNDS AND BOUGIES
589
wall and in line with the fold of the groin (Fig. 602), From this posi-
tion the handle is gradually swept to the center line (Fig. 603), and the
Fig. 604. — Third step in inserting a urethral sound.
Fig. 605. — Fourth step in inserting a urethral sound.
instrument is further introduced with its point first hugging the floor
of the urethra and then gently following the roof of the canal through
590
THE URETHRA AND PROSTATE
the rest of its course into the bladder. The instrument is then
pushed onward and downward, the penis being drawn over it until the
point of the sound is deep in the bulbous urethra (Fig. 604). The
handle is next gradually raised to a perpendicular and is then de-
Fig. 606. — Showing false passage of sound from depressing the handle of the
instrument too soon.
Fig. 607. — Showing the tip of the sound caught in the bulb at the anterior layer
of the triangular ligament.
pressed, thus permitting the point of the instrument to follow the
fixed curve of the urethra beneath the pubic arch (Fig. 605).
Care must be taken, however, not to raise the handle of the instru-
ment too soon, that is before the beak has entered well into the bulb-
EXAMINATION BY SOUNDS AND BOUGIES
591
ous urethra, as otherwise its point will be made to lodge against the
upper part of the anterior layer of the triangular ligament instead of
entering the membranous portion (Fig. 606) . Again, the sound may
Fig. 608. — Method of lifting up the tip of the sound obstructed by the lower
portion of the triangular ligament.
Fig. 609. — Final step in inserting a urethral sound.
fail to enter the membranous urethra from the point lodging in the
bulbous urethra against the lower portion of the triangular ligament
(Fig. 607). This may be avoided by depressing the handle and at the
same time by lifting up on the point of the instrument with the fin-
592 THE URETHRA AND PROSTATE
gers inserted behind the scrotum so as to press against the perineum
(Fig. 608).
' Having passed the beak of the sound into the membranous
urethra it is then made to traverse the remainder of the canal and to
enter the bladder by sweeping the handle forward and downward
between the thighs (Fig. 609), provided, of course, that no obstruc-
tion has been encountered. While this is being done the free hand
should make pressure over the pubes in order to relax the suspensory-
ligament of the penis.
By rotating the sound about its own axis it can readily be ascer-
tained whether the beak has entered the bladder or is still in the
prostatic urethra. Furthermore, by sweeping the beak of the instru-
ment about the vesical neck any irregularity or disproportion between
the two lobes of the prostate will be noticed.
If an obstruction is met in any portion of the canal, the instrument
should be slightly withdrawn, and the penis put on the stretch, so as
to straighten out any folds of mucous membrane in which the point
of the instrument may have caught. If it then fails to pass, the
obstruction is due either to spasm or to an organic stricture. When
the seat of obstruction is in front of the bulbous urethra, spasm may
be ruled out, but an obstruction at the bulbo-membranous junction or
in the membranous urethra, on the other hand, is often caused by
spasm. To determine this, the instrument is not withdrawn, but
should be kept firmly and gentl}' pressed against the face of the ob-
struction for a few moments, when, if spasm were the cause, it will in
time subside so that the instrument can be readily passed into the
bladder. Furthermore, upon attempting to withdraw the instru-
ment, that characteristic grasping of the instrument such as is found
in the presence of a tight organic stricture will be absent. When an
obstruction is met deeper than 6 1/2 inches (16.5 cm.) from the mea-
tus, or in the prostatic urethra, stricture may be ruled out; such an
obstruction may be due to an enlarged prostate, a stone, or spasm of
the internal sphincter.
In this way the presence of a stricture is determined and its dis-
tance from the meatus is readily estimated. To ascertain its caliber
is the next thing. When the examining instrument encounters the
stricture no force should be used in attempting to make it pass;
instead, that particular instrument is withdrawn, and smaller sizes
inserted in succession, substituting flexible bougies for steel instru-
ments below a No. 15 French, until an instrument is found that will
readily pass. If even the smallest-size bougies will not pass, filiforms
EXAMINATION BY SOUNDS AND BOUGIES
593;
should be used. As a general rule, no attempt should he made to pass
a filiform on the same day that other exploration has been attempted, for
after repeated attempts have been made to pass an instrument, the
opening in the stricture becomes distorted from pressure of the sounds
or bougies, and for a time is impassable even to a filiform. In using
filiforms it should be remembered that, owing to their small size, they
are liable to be obstructed from being caught in folds of mucous mem-
brane or in the orifices of the glands and ducts so abundant through-
out the urethra, and it is very easy to make a false passage with one of
these instruments if undue force is used. If a filiform catches in a
pocket or fold of mucous membrane, it should be withdrawn slightly,
and then gently advanced, or it may be gently rotated as it is ad-
vanced. Sometimes the passage of a filiform will be greatly facili-
tated by injecting sufficient sterile oil through the meatus alongside
the filiform to thoroughly distend the canal, and then, while keeping
the lips of the meatus closed, the instrument is gently advanced.
Fig. 6 10. — Showing the method of passing a fiHform bougie through a small
stricture by first filling the canal with filiforms.
When once an instrument has entered the stricture there can be no
doubt of this fact from the tightness with which it is grasped by the
stricture, a sensation, which, once recognized, will not be forgotten.
Should the operator be unable to find the opening with a single fili-
form, the canal may be filled with them and, by first advancing one
and then another, it will usually be possible to make one engage in the
stricture (Fig. 6io). Failing by this maneuver, a urethroscope may
38
594 THE URETHRA AND PROSTATE
be introduced down to the face of the stricture and through it the
instrument may be passed under direct vision.
After such exploration the urethra should be irrigated with warm
normal salt solution or with a warm saturated solution of boric acid.
EXAMINATION BY THE BOUGIE A BOULE
The bougie a boule or bulbous bougie is employed for the purpose
of determining the size and length of a stricture. The usefulness of
this instrument is limited to the anterior urethra, as, if passed into the
membranous portion, the compressor urethrae muscle is liable to con-
tract about the bulb of the instrument and give a sensation of stric-
ture. Furthermore, when the canal is the seat of more than one
stricture, it is frequently impossible with the bougie a boule to detect
the deeper ones, as those in the anterior portion of the canal may be
so tight that the passage of an instrument sufficiently large to detect
the deeper ones is out of the question.
Instruments. — The bulbous bougie consists of a flexible shaft,
upon the end of which is mounted an acorn-shaped tip. The head of
the instrument should be short and should join the shaft at rather an
abrupt angle. They are made of metal or of woven material with a
rubber head (Fig. 6ii). The latter are preferable as being less rigid.
These instruments are made in sizes from 5 to 40.
O
O
Fig. 611. — Urethral bougies a boule.
Asepsis. — The proper sterilization of these instruments has already
been described in detail (page 587) . The hands of the operator are to
be thoroughly cleaned. The glans penis should be washed off with
soap and water, and then wiped with a swab wet with a i to 5000
bichlorid of mercury solution followed by sterile water. The urethra
should be irrigated with a i to 5000 potassium permanganate solu-
tion, or a saturated solution of boric acid both before and after
examination.
Position of Patient. — The patient lies upon a firm table in the
dorsal position. The operator stands upon the side most convenient
for him, facing the patient's body and just above his hips.
EXAMINATION BY THE BOUGIE A BOULE
595
Technic— As large an instrument as will pass the meatus is chosen.
The operator grasps the penis behind the corona between the middle
Fig. 6 12. — Method of estimating the length of a urethral stricture. The bougie 4
boule arrested at the face of the stricture.
Fig. 613. — ^Method of estimating the length of a urethral stricture. The
base of the bougie a boule withdrawn until in contact with the distal end of the
stricture.
and ring fingers of the left hand, and with the thumb and forefinger of
the same hand retracts the foreskin and opens the meatus. The
396 THE URETHRA AND PROSTATE
bougie, well lubricated and held lightly between the thumb and first
two fingers of the right hand, is introduced until an obstruction is
met (Fig. 612). The distance of the obstruction from the meatus is .
measured upon the shaft and the instrument is withdrawn. Success-
ively smaller sizes are introduced until a size that will pass the stric-
ture is reached. From this the size of the stricture is determined.
The instrument is passed entirely through the stricture, and is then
withdrawn until resistance caused by the shoulder of the instrument
striking the distal face of the stricture is felt (Fig. 613). The shaft is
then grasped at the meatus as a guide, and the instrument is removed.
The distance from the meatus to the shoulder is then measured, and
subtracting the previous measurement from this gives the length of
the stricture. In this way the entire anterior urethra to the bulbo-
membranous junction may be explored and strictures, if present,
calibrated.
In exploring the deep urethra the shaft of the instrument, if of
wire, should be bent to correspond to the normal curve of the canal.
It is then introduced in the same manner as a sound (see page 587).
As already mentioned, spasmodic contraction of the compressor
urethrae muscle may simulate stricture. After removal of the bou-
gie the urethra should be irrigated with boric acid solution.
URETHROMETRY
It is a method of measuring the caliber of the anterior urethra by
means of a special instrument, the urethrometer. This instrument
has an advantage over a sound or bougie in that it can be introduced
through a narrow meatus and strictures of large caliber can be de-
tected and measured. At the same time, several strictures may be
examined by one insertion of the instrument. The method is, how-
ever, more irritating to the urethral mucous membrane than the use
of a sound or bougie, and it is only applicable to the anterior urethra.
In inexperienced hands it is often an unreliable method of examina-
tion, as strictures that do not exist may be imagined to be present,
which turn out to be the normal constrictions of the canal.
Instruments. — The urethrometer of Otis (Fig. 614) consists of a
small straight cannula marked oft' in inches and half-inches, ending in
a series of short metallic arms hinged upon themselves, and upon the
shaft of the instrument, which may be enlarged into a bulb-like shape
of any size — from 16 to 45 French — by turning a thumb-screw at the
proximal end of the instrument. A dial and indicator show the
ESTIMATION OF THE LENGTH OF THE URETHRA 597
extent of expansion. A thin rubber stall is drawn over the end of
the instrument when closed, for the purpose of protecting the urethra.
Asepsis. — The urethrometer is boiled in a i per cent, solution of
carbonate of soda. The external genitals are thoroughly cleansed,
and the urethra is irrigated with a mild antiseptic solution. The
operator's hands are sterilized in the usual way.
Position of Patient. — The patient is placed in the dorsal recum-
bent posture.
Fig. 614. — Otis' urethrometer. a, Instrument open; h, instrument closed; c,
rubber stall to cover the end of instrument.
Technic. — The closed instrument, warmed and lubricated, is
introduced through the meatus and is passed as far as the bulbo-
membranous junction. The bulb is then expanded by turning the
thumbscrew upon the proximal end of the instrument until the pa-
tient feels a fulness in the perineum. This indicates the normal size
of that portion of the urethra. The instrument is then slowly with-
drawn until an obstruction is met, when the instrument is screwed
down until it is of sufhciently small size to pass and is then again en-
larged and drawn forward. In this way the entire anterior urethra
may be measured, and strictures located and calibrated. It should
be remembered when employing this instrument that the urethra is
not of uniform caliber, but normally is the seat of dilatations and
constrictions. Thus, the bulbous urethra is the widest and most
distensible portion, and the meatus the most contracted. More or
less constriction of the canal is also encountered at the peno-scrotal
junction.
At the completion of the operation the canal is irrigated with an
antiseptic solution.
ESTIMATION OF THE LENGTH OF THE URETHRA
This procedure is of value in determining whether the prostate is
enlarged. For practical purposes the length of the urethra is the
distance it is necessary to pass a catheter from the meatus before
urine begins to flow. This may vary from 6 1/2 to 9 inches (16 to 22
598 THE URETHRA AND PROSTATE
cm.), but on the average it is 7 1/2 to 8 1/4 inches (19 to 21 cm.). A
marked increase beyond the normal in the urethral length indicates
that the prostatic urethra is lengthened and that the prostate is
therefore enlarged.
Instruments. — An ordinary silk gum-elastic catheter or a catheter
marked off in inches (Fig. 615) may be employed.
Asepsis. — The catheter is boiled or immersed in a i to 20 carbolic
acid solution followed by rinsing in sterile water. The external
Fig. 615. — Catheter marked off in inches.
genitals are thoroughly cleansed and the urethra is irrigated with a
mild antiseptic solution. The operator's hands are also thoroughly
cleansed.
Position of Patient. — The dorsal position is employed.
Technic. — The catheter, well lubricated, is introduced into the
bladder until urine begins to flow. It is then withdrawn until the
flow just stops and the point where the catheter protrudes from the
meatus is noted. The distance from this mark to the eye of the
catheter represents the length of the urethra. If the catheter passes
without obstruction and urine begins to flow when the eye of the
catheter is a distance of from 7 1/2 to 8 1/4 inches (19 to 21 cm.) from
the meatus, we may conclude that the prostate is not enlarged. On
the other hand, a marked increase in the distance the catheter has to
travel indicates an increase in the length of the prostatic urethra.
URETHROSCOPY
It consists in direct inspection of the interior of the urethra through
a metal tube by the aid of suitable illumination. While in the routine
examination of the urethra direct inspection is not always necessary,
the urethroscope becomes a valuable instrument for the diagnosis of
conditions in which the pathological changes are slight and of such a
character as not to be detected by means of the sound or bougie.
Lesions of the mucous membrane may be thus accurately located and
their character definitely determined. Furthermore, by means of the
urethroscope, it is possible to make local applications directly to dis-
eased areas or to remove calculi, foreign bodies, pol}-pi, etc. (see page
620). The instrument is also sometimes of value in the treatment
of strictures, as by its aid it is possible to discover the opening of a
URETHROSCOPY
599
very tight or eccentrically placed stricture and insert a filiform under
direct vision.
To successfully employ the urethroscope care and gentleness in
manipulation are absolutely essential and the operator must have had
considerable experience in its use and must be familiar with the
normal appearance of the different portions of the urethra in order to
properly interpret the findings. If strictures exist or the caHber of
the canal is below 22 French, preliminary dilatation by means of
sounds should be carried out. In acute gonorrhea the use of the
urethroscope is contraindicated.
Fig. 616. — Instruments for urethroscopy, i, Chetwood's tubes; 2, tube with light
in place; 3, applicator.
Apparatus. — The urethroscope consists of a metal tube supplied
with an obturator to aid in its introduction and an electric light for
illuminating its interior. The tubes for use in the anterior ure-
thra are straight and are 4 to 5 inches (10 to 12 cm.) long, while those
for the posterior urethra are 5 to 6 inches (12 to 15 cm.) long; a
straight tube may be used in the posterior urethra or the tube may
be obtained with the distal end slightly curved to facilitate its intro-
duction, as the Swinburne urethroscope (Fig. 617) or the Goldschmidt
instrument. The caliber of the tubes is from 22 to 32 French. The
illumination is furnished through a two- or four-volt lamp from a
four- to six-dry-cell battery. In the Chetwood instrument, the
6oo
THE URETHRA AXD PROSTATE
illumination is supplied by means of a delicate cold lamp at the
distal end of the instrument, while in the Otis urethroscope the
light is placed at the proximal end of the instrument. In their
stead, a head light and Klotz tube (Fig. 6i8) may be employed.
In addition to the urethroscope long slender applicators wrapped
with cotton are necessary.
Fig. 617. — Swinburne's urethroscope for e.xamining the posterior urethra
Asepsis. — The tube and applicators should be boiled for five
minutes in a i per cent, soda solution, while the lamp may be im-
mersed in a I to 20 carbolic acid solution and then in alcohol. The
operator's hands should, of course, be sterile. The glans penis is
washed with soap and water, and is then wiped with a i to 5000
bichlorid of mercury solution. The urethra is to be irrigated with
a warm saturated solution of boric acid or i to 5000 potassium
permanganate solution.
Position of Patient. — The patient should be upon a flat table in
the recumbent position for anterior urethroscopy and in the
lithotomy position for examination of the posterior urethra.
Fig. 618. — Klotz's urethral tube.
Anesthesia. — Cocain is not to be used if it can be avoided, as it
alters the appearance of the mucous membrane somewhat and by
deadening sensibility it conceals valuable information as to the con-
dition of the canal. Hyperesthesia of the urethra, if present, may be
lessened to a considerable degree by the passage of a full-sized sound
once or twice before the intended examination by the urethroscope.
Technic. — A tube as large as will pass through the meatus should
be used, as very little information is obtained by inspection through
URETHROSCOPY
6oi
a small tube. If the meatus is abnormally small, it should be cut
(see page 626). The patient voids his urine naturally just before
the examination is begun. Before proceeding with the examination,
the patient is instructed to tell the operator if any particular sensi-
tive spot is encountered while the instrument is being passed. The
penis is held vertically upward in the fingers of the left hand, and
the tube, well warmed and lubricated, and with the obturator in
place, is inserted through the meatus (Fig. 619), and thence onward
until it meets an obstruction or reaches the bulbous urethra, pro-
vided the anterior portion of the canal only is to be examined.
Fig. 619. — Method of inserting the urethroscope.
If the prostatic urethra is to be inspected, the tube is inserted all
the way into the bladder. This is accomplished by turning the
instrument down between the thighs to an almost horizontal posi-
tion as soon as its point reaches the bulbous urethra and, at the
same time, making gentle upward pressure upon the point of the
instrument by means of the fingers on the perineum. In this way
the point of the instrument is made to pass through the opening
in the triangular ligament. The tube is then gently pushed on into
the bladder. Inserting a straight tube into the posterior urethra is
generally painful and it may not be possible without employing
local anesthesia; introduction of the curved urethroscope is much
less disagreeable for the patient.
As soon as the instrument is inserted to the desired depth, the
obturator is removed, the light is turned on, and, as the tube is
6o2
THE URETHRA AND PROSTATE
slowly withdrawn, the diflferent portions of the mucous membrane
are inspected as they appear in the end of the urethroscope (Fig.
620). If a clear view of the mucous membrane is interfered with
by blood or secretion collecting in the end of the tube, long appli-
cators covered with cotton should be inserted through the instru-
ment and the mucous membrane mopped dry; care should be taken
not to push the tube back in the canal after the examination has
once begun without inserting the obturator, as the edges of the tube
might cause damage to the parts.
Fig. 620. — Showing the method of examining the anterior urethra through the
urethroscope.
Before one can become competent in recognizing pathological
conditions it is necessary that the exam.iner should be acquainted
with the normal appearance and color of the urethral mucous mem-
brane. Beginning at the posterior urethra in a normal case the
central figure appears as a cone, the mucous membrane, which is
of a dark red color, being thrown into longitudinal folds. As the
instrument is withdrawn, the verumontanum comes to view in the
form of a semilunar curve with the convexity upward (Fig. 621)
and the mucous membrane appears of a bright red color. By slightly
URETHROSCOPY
603
changing the position of the instrument, it is possible to obtain a
view of the sinus pocularis and openings of the ejaculatory ducts
(Fig. 622). Upon the further withdrawal of the instrument, the
ridge of the verumontanum becomes gradually less marked and the
Fig. 621. — The appearance of the
upper portion of the prostatic urethra.
(After Stern.)
Fig. 622. — The appearance of. the
middle portion of the prostatic urethra.
(After Stern.)
mucous membrane takes on a paler hue. In the membranous
urethra the central figure appears as a cone with a central dot,
the mucous membrane extending out in radiating folds (Fig. 623).
In the bulbous urethra the central figure changes to a vertical slit
with the mucous membrane bulging on each side (Fig. 624). In
Fig. 623. — The appearance of the Fig. 624. — The appearance of the
membranous urethra. (After Stern.) bulbous urethra. (After Stern.)
this portion of the canal the mucous membrane is still paler in color.
The central figure then gradually changes from a vertical slit to a
triangular opening (Fig. 625), and at the penoscrotal junction it
takes the form of a transverse slit with radiating folds extending to
6o4
THE URETHRA AND PROSTATE
the periphery (Fig. 626), In the pendulous urethra the central
figure again becomes cone-shaped (Fig. 627) and, finally, at the
meatus it appears as a vertical slit, the color of the mucous membrane
changing from a pale pink to a purplish hue.
Fig. 625. — The appearance of the FiG. 626. — The appearance of the
perineal portion of the spongy urethra. urethra at the penoscrotal junction.
(After Stern.) (After Stern.)
In examining the urethra through the urethroscope it should be
first ascertained whether the normal elasticity of the canal is im-
paired or not. This is accomplished by noting the central figure as
the tube is withdrawn. In chronic inflammatory conditions the
urethra becomes more or less rigid and does not immediately collapse
Fig. 627. — The appearance of the pendulous urethra. (After Stern.)
over the end of the urethroscope as it is withdrawn; instead, the cone-
like central figure often becomes elongated or else distorted from
being contracted at certain points, if the inflammation is a localized
one, and, in addition, the whole mucous membrane in such cases
URETHROSCOPY IN THE FEMALE
60;
not infrequently becomes of a paler hue than normal. Changes in
the appearance of the mucous membrane should also be noted. In
chronic urethritis there will at times be found localized congested
areas, granular patches which frequently bleed, and superficial
ulcerations covered with secretion. Inflamed lacuna appear as red
openings upon the surface of the mucous membrane from which will
frequently be seen exuding drops of pus. Retention cysts, polypi,
etc., are readily diagnosed by this means. If, during the examina-
tion, it is desired to more closely study the condition of the mucous
membrane at any particular spot this may be accomplished by
pushing that part into the field by digital compression upon the
urethra below the end of the urethroscope.
After removal of the tube the anterior urethra should be irri-
gated with a warm saturated boric acid or normal salt solution, and,
if the instrument has been passed into the deep urethra, the bladder
should also be irrigated.
URETHROSCOPY IN THE FEMALE
The female urethra being shorter and capable of greater dis-
tention than that of the male lends itself more readily to examination
by the urethroscope.
Fig. 628. — Kelly's urethral tube-speculum.
Instruments. — Short male endoscopic tubes or a regular female
urethroscope may be employed. They may be obtained with the
light at the distal end or, as in the Kelly tubes (Fig. 628), with the
light reflected from a head mirror. The female urethroscope should
6o6
THE URETHRA AND PROSTATE
be about 3 inches (7.5 cm.) long. The tubes vary in size anywhere
from 24 to 36 French.
A Kelly cone-shaped urethral dilator (Fig. 629) should be pro-
vided for dilating the meatus. AppHcators or alligator-jawed forceps
and absorbent cotton will also be required.
Fig. 629. — Kelly's cone-shaped urethral dilator. (Ashton.)
Asepsis. — The tubes, applicators, etc., may be boiled for five
minutes in a i per cent, soda solution. The lamp is sterilized by
immersion in a i to 20 carbolic acid solution and then rinsed off in
alcohol. The vulva and the external urethral orifice are sterilized
by washing with tincture of green soap and water, next with a i to
5000 bichlorid of mercury solution, and finally with sterile water.
Position of Patient. — The dorsal posture is employed.
Fig. 630. — Showing the method of dilating the urethra. (Ashton.)
Anesthesia. — If the urethra is hyperesthetic, a small pledget of
cotton saturated with a 2 per cent, solution of cocain is placed in
the mouth of the urethra for a short time before the operation.
Technic. — The urine is voided naturally before the examination
begins. If necessary, the meatus is dilated sufficiently to admit a
good-sized tube by means of a Kelly dilator (Fig. 630). The in-
HAND IXJECTIOXS FOR THE L^RETHBA
607
strument, with the obturator in place and well lubricated, is then
inserted into the mouth of the urethra and is carefully passed into
the bladder (Fig. 631). The obturator is next removed and the
lighting apparatus is properly adjusted. The instrument is then
gradually withdrawn while the examiner notes the condition of the
mucous membrane as it falls over the end of the tube (Fig. 632).
At the internal urethral orifice there appears through the urethro-
scope a large opening surrounded by a narrow ring of mucous mem-
brane. As the instrument is withdrawn the central figure becomes
first more oval and then lower do"\^TL appears as a transverse slit with
the mucous membrane thro-mi into folds that radiate to the peri-
phery. Finally, at the external orifice the central figure appears
as a vertical sht, while the mucous membrane appears throwm into
a number of radiating folds. A posterior fold is especially marked
Fig. 631. — Introduction of the urethroscope
into the female urethra. (Ashton.)
Fig. 632. — Showing the method
of inspecting the female urethra
through the urethroscope. (Ashton.)
in the upper portion of the canal; it is a continuation of the trigone.
The points to be noted in the examination have been sufficiently
dealt with under the technic of male urethroscopy and will not be
repeated here.
Therapeutic Measures
HAND INJECTIONS FOR THE URETHRA.
The injection of solutions into the anterior urethra by means of a
small hand syringe is employed either for simple cleansing purposes
6o8 THE URETHRA AND PROSTATE
in preparation lor the passage of urethral instruments or for the
purpose of treating anterior urethritis. The efficiency of injections
in limiting acute gonorrhea is a question and it is doubtful if they
have much efifect outside of removing the irritating discharges and
cleansing the mucous membrane. They may, however, be pre-
scribed in the acute stages in the form of mild antiseptic solutions
to be used by the patient himself as an adjunct to irrigations carried
out by the physician. In the declining stages of the disease or when
the condition becomes chronic, astringent injections are of un-
doubted value in reducing the congestion and thus drying up the
thin discharge that remains.
When injections are employed, certain precautions should be
observed. In the first place, mild solutions are preferable to very
strong ones, as being less irritating to the mucous membrane.
They should not be strong enough to cause more than temporary
pain or stinging, otherwise they are likely to do more harm than
good. In the second place, the greatest gentleness in making the
injection is necessary to avoid injuring the urethral mucous mem-
brane. Furthermore, whUe it is desirable that the solution should
be brought into contact with all the folds and depressions of the
mucous membrane, it is important that the fluid should not be in-
jected into the bladder, which, however, rarely happens, as the
cut-oli" muscle interposes a barrier. If it should occur, infective
material will necessarily be carried back into the deep urethra with
a good chance of starting up a posterior urethritis and epididymitis.
For this reason, only a small quantity of fluid should be injected at
a time and that without force. Used with these precautions, in-
jections may be safely employed by the patient himself when
desired.
Fig. 633. — Urethral syringe.
The Syringe. — The best form of instrument for injections is a
hand syringe with a capacity of about 2 1/2 drams (10 c.c). It
should be preferably of glass so that it can be sterilized by boiling.
The nozzle should be cone-shaped (Fig. 633) that it may fit into the
meatus, and it should be seen that it is perfectly smooth. Before
using, the syringe should be tested to see that the piston moves
HAND INJECTIONS FOR THE URETHRA 609
easily and without any jerks. A basin should also be provided
to receive the solution that flows back from the urethra.
Solutions Employed. — Many solutions with soothing, astringent,
or antiseptic properties are employed, a few of which are given :
Sedative Injections
I^. Fl. ext. hydrastis, TTlxx-xxx (i . 2-2 c.c.)
Aquae destil., §i (30 c.c.)
I^. Morph. sulph., gr. viii (0.5 gm.)
Cocainae, gr. iv (0.26 gm.)
Mug. acaciae, 5i (30 c.c.)
Aquae destil., q. s. ad 5ii (60 c.c.)
Astringent Injectiotis
I^. Zinci sulphatis, gr. iv-viii (0.26-0.5 gni-)
Aquae destil., §iv (12c c.c.)
I^. Zinci sulphocarbolatis, gr. vi-xii (0.4-0.8 gm.)
Aquae destil., 5iv (120 c.c.)
I^, Plumbi acetatis, gr. iv-xii (o. 26-0.8 gm.)
Aquae destil., 5iv (120 c.c.)
R. Zinci acetatis, gr. i-xv (0.065-1 gm.)
Aquae rosae, 5i (30 c.c.)
Antiseptic Injections
I^. Sol. protargol, 0.25 to i per cent.
I^. Sol. argyrol, 5 to 10%
I^. Sol. potass, permanganat., ' 1-5000 to 3000
I^. Sol. bichlorid of mercury, 1-30,000
Temperature. — The solution should be used at about the tem-
perature of the body.
Quantity. — Only sufl&cient quantity of the solution to distend
the anterior urethra should be injected at a time. At first about
5i (4 c.c.) should be used; later this may be increased to oiii (12 c.c).
Frequency. — The injections may be employed three to six times
daily, depending upon the severity of the case. As the symptoms
improve they may be given less frequently. It should be remem-
bered, however, that in some cases after a time the continued use
of injections may prevent a discharge from entirely disappearing,
and it is necessary to stop them entirely for a week or more before
a cure is obtained.
Position of Patient. — Injections may be given with the patient
lying recumbent or sitting upon the edge of a chair.
Preparation. — The glans penis and the lips of the meatus should
be washed off with a i to 5000 solution of bichlorid of mercury.
Technic. — The patient urinates immediately before the injection
39
6io
THE URETHRA AND PROSTATE
is given so as to wash out as much of the discharge as is possible and
also that he may not have to urinate soon afterward, thus allowing
the solution to remain in contact with the urethra as long a time as
Fig. 634. — Method of giving a urethral injection.
Fig. 635. — Second step in injection of the urethra, holding the solution in the
urethra.
possible. The syringe is then tilled with from i to 2 drams (4 to
8 c.c.) of solution, and any air is expelled by depressing the piston
while the tip is elevated. The penis is held back of the corona be-
IRRIGATIONS OF THE URETHRA
6ll
tween the thumb and forefinger of the left hand, while with the right
hand the nozzle of the syringe is inserted into the meatus, far enough to
completely occlude the meatus and prevent leakage, and the solution
is gently injected into the urethra and immediately allowed to escape.
A second syringeful of solution is then injected into the urethra until
the latter is well distended (Fig. 634). The syringe is then removed
and the meatus is held together for from three to five minutes so as
to keep the solution in contact with the mucous membrane (Fig.
635). The solution is then allowed to run out into the receptacle
provided for the purpose.
IRRIGATIONS OF THE URETHRA
Irrigation of the urethra is accomplished by flushing out the
canal with copious quantities of mild antiseptic solutions. It is a
method employed extensively in the treatment of acute gonorrhea.
Fig. 636. — Valentine irrigator and Chetwood's urethral irrigating nozzle.
To be effective large quantities of fluid must be used, and the urethra
must be so distended that the solution comes in contact with all
recesses and folds in the mucous membrane.
It is claimed that under the irrigation method of treatment,
6l2 THE URETHRA AND PROSTATE
properly employed, the intensity of the symptoms is much lessened
and the duration of the attack shortened. On the other hand,
many authorities oppose this form of treatment on the ground that
it increases the dangers of prostatic infection and that the virulence
of the infection is increased. If gentleness is observed and the pre-
caution is taken not to give the anterior injection under too great
Fic. 637. — Chetwood's alternating cut-off.
pressure, that is, not to force the solution into the bladder, as is so
frequently done, the danger of complications is slight. It is not a
method of treatment, however, that can be paced in the hands of
the patient, but it should always be carried out by the physician.
Both the anterior and the posterior urethra may be irrigated.
Apparatus. — An irrigating reservoir that can be raised or lowered
to any desired height at will, such as Valentine's, a Chetwood two-
way blunt glass urethral nozzle, a waste-pail, and two pieces of rubber
Fig. 638. — Syringe and catheter for irtrigating the posterior urethra.
tubing, one about 8 feet (240 cm.) long for connecting the inflow
with the irrigator and another, a short piece, leading from the out-
flow tube to the waste-pail, are required for anterior irrigations.
While not absolutely necessary, an alternating irrigating clamp
(Fig. 637) is a convenience.
For irrigating the posterior urethra a No. 12 to 18 French soft-
rubber catheter with a smooth beveled eye, and a large glass syringe
(Fig. 638) should be provided.
IRRIGATIONS OF THE URETHRA
613
Solutions. — ]Mild antiseptic solutions are employed. Those most
frequently used are:
Permanganate of potash,
Bichlorid of mercurv',
Silver nitrate,
1-6000 to I— 1000
1-30,000 to I-IO,OOC
1-15,000 to 1-2000
Temperature. — The solutions should be used at about the body
temperature.
Quantity. — About a quart (i literj of solution should be used in
an anterior irrigation.
For posterior irrigations from 4 to 12 ounces ^120 to 360 c.c.) of
solution are employed.
Frequency. — Early in the disease, when the discharge is free, two
daily irrigations give the best results. Later, one irrigation a day is
sufficient.
Height of Reservoir. — The reservoir should not be raised above
4 feet (120 cm.). Such an elevation wiU give all the necessary dis-
tention of the urethra without forcing the solution beyond the an-
terior urethra. If it produces pain, the pressure should be lessened
by lowering the reservoir or partially pinching off the inflow tube.
Fig. 639. — -Apron for protecting the patient during a urethral irrigation.
Position of Patient. — For anterior irrigations the patient may
stand or be seated upon the edge of a chair, while for a posterior
irrigation the patient should be lying down.
Preparation of Patient. — For protecting the clothes the patient
may wear a rubber apron in which is provided an opening for the
penis (Fig. 639). The glans penis and lips of the meatus should be
washed off with a i to 5000 bichlorid of mercury solution.
6i4
THE URETHRA AND PROSTATE
Technic. — i. Anterior Irrigations. — The patient should empty
his bladder before each treatment. The operator holds the penis
behind the glans between the thumb and forefinger of the left hand
and, compressing the rubber inflow tube between the thumb and in-
dex-finger of the right hand, inserts the glass nozzle into the meatus.
He then releases the inflow tube, at the same time closing the out-
flow tube by means of his right little finger. As soon as the urethra
is filled with solution the inflow tube is again pinched, at the same
time removing the little finger and thus opening the outflow tube.
Fig. 640. — Method of giving an anterior urethral irrigation.
By thus alternately opening or shutting the inflow tube, and at the
same time shutting or opening the outflow, the urethra is alternately
distended with solution and emptied without the necessity of remov-
ing the nozzle. This alternate filling and emptying of the urethra
is much easier to perform with the scissor-like clamp of Chetwood
than with the fingers. It takes about five minutes to thus irrigate
the urethra with i quart (i Hter) of solution.
2. Posterior Irrigations. — The anterior urethra is first irrigated
as just described. A No. 12 to 18 French catheter, well lubricated
with one of the Irish-moss preparations, is then inserted into the
urethra with the eye upward until urine just escapes (Fig. 641).
After the bladder is emptied, the catheter is then withdrawn i
inch (2.5 cm.) until its point lies in the prostatic urethra and from
4 to 12 ounces (120 to 360 c.c.) of the antiseptic solution are gently
IRRIGATIONS OF THE URETHRA
615
injected (Fig. 642). The posterior urethra is thus washed backward
toward the bladder. The catheter is then removed and the patient
Fig. 641. — First step in irrigating the posterior urethra. Catheter is inserted into
the bladder until urine begins to flow.
Fig. 642. — Second step in irrigating the posterior urethra. The catheter is with-
drawn until its tip lies in the deep urethra and the solution is then injected.
is instructed to void the contents of his bladder, thus giving a final
washing from behind forward to both posterior and anterior urethras.
6i6
THE URETHRA AND PROSTATE
INSTILLATIONS
Instillations are employed when it is desired to medicate the
urethra with small quantities of strong solutions. They are in-
dicated in chronic gonorrhea, but should not be used in acute cases;
they are specially useful in chronic posterior urethritis. The ob-
ject of such injections is to induce a hyperemia of the tissues; that is,
to substitute an acute inflammation in place of the chronic one with
the hope that it will be followed by absorption of the old as well as
the new products of inflammation and by a return to normal. It
is a method that may be applied to the anterior or posterior urethra.
Instillations should not be employed in cases where injections or
irrigations of weak solutions are followed by irritation, and they
should likewise be avoided in posterior urethritis when the prostate
and seminal vesicles are the seat of an acute inflammation. In-
stillations are also valuable in the treatment of sexual neurasthenia
when inflammatory lesions are present in the posterior urethra.
The Syringe. — While the instillation may be given by means of a
flexible catheter and small syringe, a special instrument, such as
Keyes' modification of the Ultzmann syringe (Fig. 643), will be
Fig. 643. — Keyes-Ultzmann instillation syringe.
found more satisfactory. The latter consists of a long curved
nozzle of German silver, provided with a central opening, to the
proximal end of which is attached a large hypodermic syringe with
the piston graduated in minims.
Asepsis. — The syringe should be sterilized by boiling for five
minutes in a i per cent, solution of sodium carbonate. The glans
penis and meatus are then washed with warm water and soap,
followed by a i to 5000 bichlorid of mercury solution.
Solutions Employed. — In using irrigations it is well to start with
a weak solution, employing it till the urethra becomes tolerant, and
then to gradually increase the strength. The solutions most fre-
quently made use of are:
INSTILLATIONS
617
Silver nitrate,
Thallin sulphate,
Copper sulphate,
Argyrol,
Protargol,
Ichthyol,
0.5 to 2 per cent.
3 to 10 per cent,
1 to 4 per cent.
10 to 20 per cent.
0.25 to 10 per cent.
2 to 10 per cent.
Temperature. — The solution should be given at about the tem-
perature of the body — say 100° F. (38° C).
Quantity. — Ten to twenty minims (0.6 to 1.25 c.c.) solution are
injected at a time.
Frequency. — Instillations may be given at from forty-eight- to
seventy- two-hour intervals. As a general rule, a second injection is
not to be given until all irritation from the first has subsided.
Fig. 644. — Showing the syringe in position for a deep urethral instillation.
Position of Patient. — The patient should be lying down upon a
bed or table.
Technic. — i. Posterior Instillations. — -The patient should void
his urine previous to the instillation, and the anterior urethra is
first cleansed by an injection of weak antiseptic solution. The
syringe, filled with the desired amount of solution, and with the
nozzle well lubricated with some nonoily lubricant, as one of the
6l8 THE URETHRA AND PROSTATE
Irish-moss preparations, is carefully introduced in the same manner
as one would pass a sound (page 587) until its point lies behind the
compressor urethrae muscle in the membranous urethra (Fig. 644).
This will be at a distance of about 5 1/2 to 6 inches (14 to 15 cm.)
from the meatus or roughly when the shaft of the instrument is at
an angle of 45 degrees with the horizon. From 5 to 20 drops (0.3
to 1.25 c.c.) of solution are then slowly injected. Care must be
taken in withdrawing the nozzle of the instrument to avoid having
any solution drip from the point along the anterior urethra. To
avoid this, the piston of the syringe should be withdrawn slightly
before the nozzle is removed.
Generally there is considerable burning upon urination following
a posterior instillation and at times there may be pain and tenesmus
and some discharge during the first twenty-four hours. As a rule,
these symptoms subside within six to twenty-four hours. If the
reaction is severe, however, the patient should remain quietly in bed
and an opium suppository should be introduced into the rectum and
heat applied to the perineum.
2. Anterior Instillations. — In giving an anterior instillation the
same preparations are followed as for a posterior instillation. The
nozzle of the instrument, well lubricated, is then carefully intro-
duced as far as the bulb of the urethra "and about 20 drops (1.25
c.c.) of solution are injected. The solution follows the instrument
as it is withdrawn, medicating the whole anterior urethra. A piece
of cotton should be placed over the glans and worn for a few hours
to prevent any excess of solution escaping from the meatus and
soiling the patient's clothing. The cotton may be readily secured
in place by means of a loose-fitting elastic band placed behind the
corona.
APPLICATION OF OINTMENTS TO THE URETHRA
Astringent and stimulating ointments are at times employed in
the treatment of chronic urethritis instead of instillations. They
are considered by some authorities more efficient than the use of
drugs in solution, as being more penetrating and more lasting in
effect.
Instruments. — Ointments may be applied to the whole urethra,
in which case an ordinary sound or a cupped sound (Fig. 645) is
employed, or they may be brought into any particular area by means
of Tomasoli's or some other form of ointment syringe (Fig. 646).
APPLICATION OF OINTMENTS TO THE URETHRA
619
This latter instrument consists of a hollow curved catheter-like nozzle
and a plunger for forcing the ointment out at the end.
Formulary. — Unna's ointment for use with sounds consists of:
^.
01. coc£e,
Ceree flav.,
Argent, nitratis,
Bals. peruviani,
giii (90 c.c.j
3ss (2 gm.)
gr. XV (i gm.)
3ss (2 c.c.) M.
Fig. 645. — Cupped sound.
The mixture is melted over a hot-water bath and the sound is then
dipped into it and the ointment is permitted to solidify by cooling.
Finger's Ointment consists of:
I^. Argent, nitratis or cu. sulphatis,
01. olivffi,
Lanolin,
Another consists of:
I^. Pot. iodidi.,
lodi. pur.,
01. olivce,
Lanolin,
gr. XV (i gm.)
3iss (5.6 c.c.)
Biii (90 c.c.) M.
3ss (2 gm.)
gr. V (0.3 gm.)
5ss (2 c.c.)
51(30 c.c.) M.
Fig. 646. — Urethral ointment syringe.
Preparations. — The patient's bladder should be empty. The
glans penis and meatus are washed with soap and water, followed by
a I to 5000 bichlorid of mercury solution.
Technic. — When a sound is employed, as large a one as will
comfortably pass the meatus is coated with the ointment, or if a
cupped sound is used, the depressions are filled with the ointment,
and it is passed through the urethra and is left in place about five
minutes. The ointment melts and thus medicates the entire urethral
mucous membrane.
620 THE URETHRA AND PROSTATE
In employing a special ointment carrier the instrument is partly
filled with the ointment and, after being well lubricated, it is passed
as far as the diseased area. The piston is then inserted and is
pushed through the instrument forcing the ointment out the end
into the urethra.
THE URETHROSCOPE IN THE TREATMENT OF URETHRAL
DISEASES
By means of the urethroscope or an open wire speculum (Fig.
647) lesions in the urethra may be accurately located and efforts at
treatment can be thus focused on the exact seat of the disease.
Endoscopic treatment is thus of great value in the presence of
localized lesions of the urethra which, resisting the ordinary methods
of treatment by irrigations, instillations, etc.. are often the cause of
Fig. 647. — Open wire urethral speculum.
a persistent gleety discharge. For example, through the urethro-
scope and by the aid of suitable instruments, strong applications
may be made to granular patches, erosions, and ulcerations; sup-
purating glands or follicles may be incised and small growths may be
removed from the canal under direct vision.
The technic of using the urethroscope has previously been fully
described (page 600) so that the application of the instrument to
the treatment of various urethral conditions will simply be outlined
in a general way. As has been already emphasized in previous
pages, it is essential that one should" be familiar with the normal ap-
pearance of the urethra before attempts to employ the instrument
for treatment are made. Furthermore, the greatest gentleness in
manipulation is necessary to avoid injury to parts already diseased.
In the treatment of congested and granular patches, erosions,
and ulcerations, local applications of silver nitrate or copper sulphate
may be made by means of cotton-wrapped probes through the
urethroscope previously passed to the seat of the disease (Fig. 649).
In this way strong solutions of these drugs — 30 to 60 gr. (2 to 4
TRETHROSCOPE IX THE TREATMENT OE URETHRAL DISEASES 62 1
gm.) to the ounce (30 c.c.) — which would be extremely irritating if
applied to the whole mucous membrane, may be applied. If the
diseased areas are numerous and extensive the strength of the appli-
FiG. 648. — Urethral probe.
cations should be somewhat weaker — say 5 to 10 gr. (0.3 to 0.6 gm.)
to the ounce (30 c.c). When using the stronger solutions, care
Fig. 649. — ^Method of making applications to the urethra through the
urethroscope.
should be taken to make the application exactly to the diseased area
and not to leave any excess of solution to run over the healthy mucous
Fig. 650. — -Urethral knife.
membrane. Such applications should not be made too frequently —
not oftener than once a week — as usually an acute urethritis, often
622
THE URETHRA AND PROSTATE
accompanied by a bloody discharge, is set up. This, as a rule,
subsides in twenty-four to forty-eight hours.
Areas of induration may be incised through the urethroscope by
means of a urethral knife (Fig. 650). Two or 3 drops of a 4 per cent,
solution of cocain with adrenahn chlorid should be applied to the
diseased area by means of a cotton-wrapped probe, and the incision
may then be made without pain. In the same manner abscesses
Fig. 651. — Kollmann's urethral syringe.
of Littre's glands or inflamed follicles may be opened. A discharg-
ing cr^-pt or follicle may be injected every few days with a few drops
of a peroxid of hydrogen solution by means of Kollmann's syringe and
^
Fig. 652. — Urethral curet.
cannula (Fig. 651). Pol}'ps and papillomata may be removed by a
urethral curet (Fig. 652) or by caustics. If pedunculated, a wire
snare (Fig. 653) or the galvanocautery snare may be employed. In
Fig. 653. — Urethral snare.
any case the area of operation should be first cocainized in the manner
above described.
THE DIRECT APPLICATION OF COLD TO THE URETHRA BY
THE PSYCHROPHORE
In the treatment of spermatorrhea and sexual neurasthenia where
the urethra is congested or h}peresthetic the direct application of
DIRECT APPLICATION OF COLD TO THE URETHRA 623
cold to the deep urethra by means of the cold-water sound or psy-
chrophore is often of value. An ordinary cold sound is also employed
in treating such conditions, but is not so effective, as the instrument
soon becomes warm from contact with the urethra. With the psy-
chrophore it is possible to keep a continuous cold application in the
urethra as long as is desired.
Apparatus. — The psychrophore is a double-current closed sound
within the outer sheath of which are two canals, one for the inflow
of cold water and the other for the outflow, which communicate
near the terminal end of the instrument, thus permitting that portion
Fig. 654. — Apparatus for applying cold water to the urethra.
of the instrument to be kept cold. The inflow canal is connected
with a rubber tube leading from a douche bag or irrigating jar
(Fig. 654).
Temperature. — The temperature of the water should be about
50° to 40° F. (10° to 5° C.) to start with. As the urethra grows more
tolerant the temperature may be lowered.
Duration of Treatments. — The sound should be left in place for
from five to ten minutes at a sitting.
Frequency. — Treatments may be given daily or on alternate
days.
Technic. — An instrument as large as the normal caliber of the
urethra should be used. It is well lubricated and gently inserted in
the same manner as a sound (page 587) until the curved portion lies
624 THE URETHRA AND PROSTATE
in the membranous and prostatic portions of the urethra. The tub-
ing from the reservoir is then connected with the inflow canal and
a current of cold water is allowed to pass through the instrument,
escaping from the outflow canal into a basin provided for the purpose.
In this way the hyperesthetic urethra is exposed to the mechanical
effect of the sound and the sedative action of cold.
PROSTATIC MASSAGE
Massage of the prostate gland by means of the finger in the
rectum is frequently employed, and with good results, in the treat-
ment of chronic prostatitis in which the inflammation extends deep
in the gland tissue. The object is to squeeze out of the prostate
into the posterior urethra as much as possible of the purulent con-
tents of the gland and to cause absorption of the products of inflam-
mation from indurated areas. It is also used for the purpose of
emptying the distended seminal vesicles and hastening resolution.
It should not be employed in acute prostatitis or acute vesiculitis,
and care should be taken not to perform the massage too vigorously,
otherwise the tissues will be bruised and the inflammation will be
made worse.
Duration of Treatment. — The massage should be carried out for
two or three minutes at a sitting.
Frequency. — Unless followed by irritation, treatments may be
given once every four or five days.
Position of Patient. — The operation may be performed with the
patient bending forward over a chair or in the knee-chest position.
Technic. — If possible, the patient's bladder should be full. The
operator wears a rubber glove on the right hand or a finger cot on his
right index-finger and, after lubricating the index-finger well, intro-
duces it into the rectum (Fig. 655), carrying the finger high up on one
side over the seminal vesicle. Firm but gentle pressure is then
made wilh the finger over the seminal vesicle and the finger is
slowly drawn down over the vesicle toward its duct and also over
the corresponding lobe of the prostate (Fig. 656). This procedure
is then repeated upon the opposite side, and finally over the central
portion of the gland. All portions of the gland are thus massaged,
but special attention should be paid to those portions that are
enlarged or diseased.
After completing the massage the patient urinates, thus emptying
the bladder of pus and debris squeezed out b}' the massage.
PROSTATIC MASSAGE
625
Fig. 655. — Position of the patient and method of introducing the finger into the
rectum in prostatic massage.
Fig. 656. — Showing the method of massaging the prostate.
40
626 THE URETHRA AND PROSTATE
MEATOTOMY
Meatotomy consists in dividing a narrow meatus. It may be
required as a preliminary to the passage of large instruments into
the urethra or bladder and in the presence of urethral inflammation,
when the size of the meatus is such that free drainage is interfered
with. If properly performed, it is an operation without danger.
Instruments. — The incision is best made with an Otis meatome
(Fig. 657) or with an ordinary blunt-pointed straight bistoury.
Location of Incision. — The meatus should be cut exactly in the
median line upon the floor of the urethra.
Fig. 657. — Otis' meatome
Preparations. — The glans penis and meatus should be washed
with soap and water followed by a i to 5000 solution of bichlorid of
mercury. The anterior urethra should be irrigated with a saturated
boric acid solution.
Anesthesia. — To render the operation painless the line of pro-
posed incision is infiltrated with a o.i per cent, solution of cocain
introduced through the frenum or, if desired, by the topical applica-
tion of a weak cocain solution (see page 71).
Technic. — The operator retracts the foreskin and, steadying the
penis between the thumb and forefinger of his left hand, inserts the
knife, with the cutting-edge down, into the urethra for a distance of
I 1/2 inches (4 cm.). The meatus is then incised exactly in the mid-
line by drawing the knife out. To allow for subsequent contraction
it is well to incise the canal to a size larger than is desired to per-
manently maintain it — a meatus that will give passage to a No. 30
F. sound is sufficiently enlarged. If it is found upon inserting an
instrument that the constriction has not been entirely cut, any
remaining bands should be divided.
At first there may be some hemorrhage from the incision, but
this can usually be controlled by inserting a plug of gauze for an
inch (2.5 cm.) or so within the meatus. Each time the patient
urinates this plug is removed and a fresh one inserted. Should the
bleeding be severe, the incision should be grasped between the
thumb and forefinger placed on either side of the frenum and should
be comp-ressed until the hemorrhage stops.
THE TREATMENT OF STRICTURES 627
The After-treatment.— This consists in passing a full-sized
straight sound through the meatus, at first daily and then every
second day for a week or ten days, otherwise the narrowing is apt
to reform. When meatotomy is performed as a preliminary to
instrumental examination, the exploration may be performed at
the same sitting.
THE TREATMENT OF STRICTURES BY INSTRUMENTAL
DILATATION
The methods of treatment applicable to organic stricture of the
urethra include gradual dilatation, continuous dilatation, and cut-
ting the stricture either from within — internal urethrotomy — or
from without — external urethrotomy. Two other methods, namely,
di\ailsion and electrolysis, which are sometimes described in text-
books, are now practically obsolete. Divulsion is so dangerous that
it has been abandoned, while electrolysis is an operation that is of
doubtful benefit and has never found much favor.
Intermittent dilatation of strictures by the passage of instru-
ments of increasing size should be the method of choice when pos-
sible, as, if properly performed, it is without danger. It is, of course,
only applicable to strictures which are permeable, but a large pro-
portion of such may be successfully treated by this method. It is
especially suited to those strictures which are fairly recent, soft, and
dilatable. For old strictures with considerable scar tissue format-
tion, which are rigid and unyielding, attempts at dilatation are
apt to fail, so, if after a fair trial of the. method in these cases it
does not give results, more radical means of treatment should be
substituted. Again, intermittent dilatation is not apt to be suc-
cessful when applied to the so-called resilient strictures; these, while
dilatable, are so elastic that they recontract between treatments,
and little, if any, advance is made beyond a certain point. Stric-
tures which are irritable, that is, those in which attempts at dilata-
tion are followed by pain and spasm resulting in retention of urine,
those in which the passage of instruments is followed by chills and
fever, those complicated by numerous false passages and suppurating
fistulous tracts, and all strictures near the meatus should be cut.
For strictures complicated by cystitis, intermittent dilatation is
Kkewise undesirable on account of the dangers of pyelonephritis;
these require cutting of the stricture and free drainage of the bladder.
Before making any attempt to treat strictures, the number of
628 THE URETHRA AND PROSTATE
Strictures, their exact location, their size, and their extent should be
determined by instrumental exploration of the urethra, and sufficient
time for the tissues to react — at least seventy-two hours— should
elapse after such an examination before the dilatation is begun.
Strictures may occur at any point in the canal except in the prostatic
urethra, but the most frequent sites are: (i) in the region of the
bulbomembranous junction, (2) within 2 1/2 inches (6 cm.) of the
meatus, and (3) near the penoscrotal junction. They may be single
or multiple, and in shape annular or tortuous. The opening is
seldom situated in the center of the stricture, but generally lies to one
side of the median line of the urethra.
All strictures have a tendency to contract and in time cause
more or less impediment to the urinary flow with serious results to the
whole urinary tract. The urethra immediately behind the stricture
is the first to feel the effects of this obstruction and the canal at this
point becomes more or less dilated and the mucous membrane is
thinned out. Urine collects in this dilated portion and decomposes,
with the result that an inflammation is set up accompanied by a
gleety discharge. This may in time go on to ulceration and extra-
vasation of urine with the formation of false passages and fistulas.
The effect of the urinary obstruction is also felt upon the bladder.
It first hj-pertrophies and may later become thinned and dilated,
and it is not uncommonly the seat of cystitis. In time inflammation
and dilatation of the ureters and kidney follow, resulting in
pyelitis and pyelonephritis.
Mention is made of these compHcations because their presence,
or absence, and severity, af present, are of direct practical impor-
tance in determining the method of treatment to pursue. It should
further be borne in mind that the stricture itself is usually congested
and the mucous membrane is softened and inflamed, so that in
performing dilatation the greatest care and gentleness are necessary to
avoid lacerating and contusing the already irritated tissues. Rough-
ness or carelessness in introducing the instrument can do only
harm. The beneficial effects of dilatation depend not only upon
the mechanical distention to which the urethra is subjected, but also
upon the simple presence of the instrument which stimulates the
tissues to a mild reactionary hyperemia, which is accompanied by
softening and absorption of the scar tissue. If more than this is
done, that is, if the tissues are so irritated than an inflammation is
induced, the value of the treatment is lost and the original trouble
is simply aggravated.
THE TREATMENT OF STRICTURES
629
Instruments. — For strictures above No. 15 French conical steel
sounds of proper curve are employed. These may be of the style
shown in Fig. 658, or those with a double taper (Fig. 659) may be
used. The latter instrument has a slight advantage in that, the
shaft being smaller than the shoulder, dilatation of the deeper parts
is effected without unduly stretching the meatus. For strictures
Fig. 658. — Conical steel sound.
in the pendulous urethra in front of the bulb a straight conical sound
(Fig. 660) may be employed; such an instrument should not be used,
however, in the deep urethra.
Kollmann dilators are used in preferance to sounds by some
operators. They are made on the principle of the Otis urethrometer
with four blades regulated by a wheel at the proximal end of the
Fig. 659. — Double-taper steel sound.
instrument. A dial and indicator show the extent to which the
blades are separated. Two styles of dilators are generally em-
ployed— a straight one for the anterior urethra (Fig. 661) and a
curved instrument (Fig. 662) for the posterior urethra. Some are
supplied with attachments for irrigating the urethra. A rubber
sheath is provided with these instruments to be drawn over the
Fig. 660. — Straight steel sound.
blades (Fig. 663) and so avoid injuring the urethral mucous mem-
brane when the instrument is being closed. This is not used, how-
ever, with the irrigating dilators. When closed the instruments
measure 20 French and may be expanded to 45 French. On account
of their small size, they may be used for dilating strictures in the
presence of a narrow meatus without first cutting the latter.
630
THE URETHRA AND PROSTATE
With small steel instruments there is a considerable chance of
making a false passage and always the danger of inflicting traumatism,
Fig. 661. — KoUmann's straight dilator.
Fig. 662. — KoUmann's curved dilator
for the posterior urethra with irrigat-
ing attachment.
Fig. 663. — Rubber sheath in position.
so that for strictures of a smaller size than No. 15 French, soft instru-
ments should be employed. Flexible olivary bougies (Fig. 664) are
the best in this class of cases, as they find their way through the
THE TREATMENT OF STRICTURES 63 1
Stricture with greater ease and there is less danger of making a false
passage. They are made of woven material covered with rubber
and the best are of French make.
Fig. 664. — Flexible urethral bougie.
For dilating tight strictures whalebone filiform bougies and tun-
neled sounds (Fig. 665) should be provided. The filiforms should
be at least 18 inches (45 cm.) long and of such size that the tunneled
sounds will slip easily over them. Care should be taken not to use
rough or split filiforms. In fact, any instrument, no matter what the
variety, must be perfectly smooth and sound; imperfect instruments
should be discarded as unsafe.
Fig. 665. — Gouley tunneled sound and filiform.
Asepsis. — The strictest asepsis should be observed in regard to
the instruments used. Metal instruments should be boiled for five
minutes in a i per cent, solution of sodium carbonate. Filiforms and
the newer gum-elastic instruments will stand moderate boiling.
They may also be sterilized by formaldehyd vapor, after which they
should be well rinsed in sterile water; or they can be immersed first in
a I to 20 carbolic solution and then in a saturated solution of boric
acid.
The glans and meatus should be washed with soap and water
followed by a I to 5000 bichlorid of mercury solution. The urethra is
irrigated both before and after each treatment with a saturated solu-
tion of boric acid or a i to 5000 permanganate of potash solution, and,
if the bladder is infected, it should likewise be irrigated, provided the
stricture is sufficiently large to admit a catheter.
The same regard to cleanliness should also apply to the operator's
hands.
Rapidity of Dilatation. — This can only be determined by a study
of the individual case. It is important, however, not to do too much
dilating at a time. It should not be carried to a point where discom-
632 THE URETHRA AND PROSTATE
fort or pain is caused. If the stretching is too rapid, it practically
amounts to divulsion with its attendant risks of inflammation and
sepsis. Furthermore, tearing of the stricture results in new formation
of tissue which in turn contracts. In the case of tight strictures the
introduction of a second instrument after the first is sufficient. In
other cases the dilatation may be carried further, using three or four
instruments in all.
Frequency of Treatment. — After the passage of an instrument a
reactionary hyperemia sets in and this should be given time to subside
before instruments are reintroduced. A lapse of three to seven days
should, therefore, occur between treatments — on an average an inter-
val of about five days. One will be guided, however, partly by the
amount of contraction that takes place between treatments and also
by the toleration of the urethra. Instruments should never be passed
so frequently as to produce irritation. Very contractile strictures
require short intervals between the treatments, while for those that
are easily dilated and do not readily reform longer intervals may be
allowed. After the stricture has been stretched to 28 or 30 French,
the intervals between the treatments may be increased, at first to once
a week, then once or twice a month, and finally to several times a
year.
Extent of Dilatation. — There is no fixed rule to be followed as to
the extent to which a stricture is to be dilated. Various scales have
been devised for determining the approximate size of the urethra from
comparison with the circumference of the penis, but they are not
accurate. As a general rule, dilatation of the stricture to the size of
the meatus, provided it is of normal caliber, is sufficient.
Position of Patient. — The patient should be in the dorsal position
with his shoulders slightly raised and thighs a little flexed and rotated
outward. The operator takes his place just above the patient's hips
and facing toward the patient's body, upon whicliever side is most
convenient for him.
Anesthesia. — Local anesthesia is only necessary where the patient
is nervous and the urethra hyperesthetic, or upon the first passage of a
sound after urethrotomy, as properly introduced instruments should
ordinarily cause little or no pain. In such cases the urethra is well
distended with a 0.2 per cent, solution of cocain and adrenalin solu-
tion and the solution is confined in the urethra for fifteen minutes by
holding the meatus closed.
Technic. 1. Large Strictures. — Under this heading will be con-
sidered strictures above 15 French in size.
THE TREATMENT OF STRICTURES
633
With Sounds. — A sound of a size that will easily pass through the
stricture — determined by previous exploration — is warmed, well
lubricated with lubrichondrin or other Irish moss preparation, and
Fig. 666. — First step in passing a sound.
is very gently introduced in the following manner: The operator
grasps the penis behind the corona between the ring- and middle
fingers of the left hand and with the thumb and index-fingers of the
Fig. 667. — Second step in passing a sound.
same hand he retracts the foreskin and separates the lips of the mea-
tus. The sound is grasped hghtly between the thumb and first two
fingers of the right hand and is carefully inserted into the urethra.
634
THE URETHRA AND PROSTATE
At this stage the handle of the instrument should be parallel to the
abdominal wall and in line with fJie folds of the groin (Fig. 666). As
the sound is pushed onward and downward, the handle of the instru-
ment is gradually swept to the center line (Fig. 667) and is then slowly
raised to a perpendicular so that its beak passes beneath the pubic
arch (Fig. 668) into the membranous urethra. Unless the stricture
be in the deep urethra, it is not necessary to insert the sound into the
.--^
Fig. 668. — Third step in passing a sound.
bladder — the instrument should simply be passed through the stric-
ture. To insert the instrument the full distance, the handle is
brought forward and downward between the thighs (Fig. 669).
When the point of the sound reaches the stricture, the utmost
gentleness in manipulation should be used in engaging it in the
stricture, and no attempt to enforce the instrument along should be
made, until it is certain that its point has entered the opening in the
stricture. Having passed the sound entirely through the stricture,
it is removed by a reversal of these steps and a second one is intro-
duced. If this causes pain or spasm, it is immediately withdrawn,
and no immediate further attempt to dilate is made. If, however,
the urethra tolerates the second instrument, a third one may be
introduced.
THE TREATMENT OF STRICTURES
635
At the next sitting the dilatation is begun by inserting a sound one
size larger than the first instrument used at the previous treatment,
and the dilatation is increased one or two sizes as before. In this way
the treatments are continued until the desired degree of dilatation is
obtained.
The passage of the sound will cause more or less smarting, but it
is only transitory. At times a few drops of blood may follow the
removal of the instrument. The next act of urination is apt to be
Fig. 669. — Fourth step in passing a sotind
painful, and not infrequently the gleety discharge is increased for
twenty-four or forty-eight hours. The patient should be warned of
these symptoms beforehand.
With the Kallmann Dilator. — The rubber sheath is drawn over the
instrument. The dilator, closed and well lubricated, is then intro-
duced to the seat of constriction and dilatation of the canal is then
produced to any desired extent by turning the wheel at the end of the
instrument. The stretching must be performed very gradually and
with great care, as these instruments are so powerful that severe
trauma may be caused by a too rapid dilatation. If the patient
complains of pain, or if an undue amount of resistance is felt, the
dilatation should be stopped. Having effected the desired amount
of dilatation, the instrument is left in place for several moments
before it is closed and removed. At subsequent treatments the dila-
tation is increased one or two numbers each time.
636 THE URETHRA AND PROSTATE
2. Small Slrictiires. — For small strictures, that is, below 15
French, soft bougies are employed. A bougie of a size that will read-
ily enter the stricture is selected. The penis is held straight up and
upon the stretch in the fingers of the left hand after the manner de-
scribed above, and the bougie, well lubricated, is carefully passed
straight down to the seat of obstruction (Fig. 670), provided the
latter is in the anterior urethra. An instrument can thus be readily
Fig. 670. — Method of inserting a flexible bougie through a urethral stricture.
passed straight as far as the bulbomembranous junction, but here it
is apt to be obstructed. To pass this point and enter the deep ure-
thra, the bougie should be introduced bent as much as possible to
the shape of a curved sound, and, when the point reaches the bulb,
slight pressure should be made with the fingers on the perineum (see
Fig. 608). When the instrument strikes the face of the obstruction,
gentle attempts are made to engage its point in the stricture. This
accomplished, the instrument is pushed on entirely through the
stricture, and the dilatation is proceeded with in the same manner as
when using sounds. Steel instruments may be substituted for the
bougies when the dilatation has been carried as high as 15 French.
3. Filiform Strictures. — In the beginning of the treatment of a
filiform stricture it often requires the greatest perseverance and skill
to enter the bladder, as frequently the stricture is of such small caliber
or the opening is so situated that it is extremely difl&cult to engage
even a fine filiform. Once, however, the filiform is inserted, the main
difficulty is surmounted. In introducing fihforms the same method
is employed as for straight bougies. The penis, grasped in the fingers
THE TREATMENT OF STRICTURES
637
of the operator's left hand, is put upon the stretch and the filiform,
•vO-ell lubricated, is inserted along the floor of the canal. If the point
of the instrument is obstructed by a fold of mucous membrane or the
opening of some lacuna, it should be withdrawn slightly and then
slowly reinserted. When the face of the stricture — the location of
which has been previously determined — obstructs the further advance
of the filiform the instrument should be slowly rotated making
attempts to engage its point in the stricture the while, but without
using any force. Sometimes by distending the canal with warm oil it
Fig. 671. — Method of passing a filiform bougie through a stricture by first filling
the canal with filiforms.
is possible to enter the filiform in the opening of the stricture. Fail-
ing with one filiform, a second may be inserted beside the first one and
the same manipulation is carried out as with the first. If still un-
successful, additional filiforms are inserted until the urethra contains
six or seven of them. Then gentle attempts are made to pass each in
turn, and usually one will finally slip into the opening (Fig. 671),
whence it can be readily passed into the bladder. If, after a fair
trial, it is impossible to insert an instrument, it is better to give up the
attempt for the time being, and try again a few days later. Some-
times upon a second or third trial the opening will be readily located.
Gentle manipulation combined with perseverance will result in suc-
cess in the great majority of cases, but, if it is impossible to pass the
instrument by these means, a urethroscope may be introduced as far
as the obstruction and the filiform inserted by direct sight.
6 -.8
THE URETHRA AND PROSTATE
Having finally passed a filiform, the smallest size tunneled sound
should be inserted over it as a guide (Fig. 672). If there has been
much manipulation in passing the filiform, the operator's efforts had
best stop at this, or, at the most, a second sound is introduced. At
the next sitting the filiform is again inserted and the dilatation in-
creased by inserting larger instruments over it as a guide. After some
dilatation has been thus obtained, soft bougies may be substituted
for the filiforms and tunneled sounds, and the treatments may be
carried out as outlined above.
Fig. 672. — Method of passing a tunneled sound over a filiform.
Accidents and Complications Attending Dilatation. — There are
several troublesome as well as serious complications that may follow
the passage of urethral instruments.
Shock: — In some cases, in spite of the utmost gentleness in manipu-
lation, the passage of a sound produces sufficient shock to cause the
patient to faint or collapse. It is more likely to occur in patients
upon whom an instrument is passed for the first time, especially if
they are of a distinctly nervous type and look upon the operation
with fear and apprehension.
Much may be done in preventing such a complication when the
nervous element is in evidence by avoiding pain through the use of
local anesthesia. Should fainting occur, the patient's head is to be
immediately lowered and stimulants administered if necessary.
Urethral Chill and Fever. — A form of urinary septicemia spoken of
as urethral chill and fever is liable to follow urethral instrumentation.
THE TREATMENT OF STRICTURES 639
It may be the result of absorption of toxic elements which are present
in the urine, in the urethra, or are introduced from without with the
instrument, or it may be the result of shock to the kidneys. The
condition may be of a mild type — in which case a few hours after
the passage of the instrument the patient is seized with a chill fol-
lowed by fever, more or less prostration, and within twenty-four
hours recovery — or it may be severe and progressive and eventually
result in the death of the patient.
Preventive treatment, which is of the greatest importance, should
consist in rigid asepsis, gentle manipulation of urethral instruments,
and antiseptic irrigations or instillations after any instrument has
been used. Actual treatment comprises rest in bed, quinin in 5- or 10-
grain (0.3 to 0.6 gm.) doses, and the administration of genitourinary
antiseptics. In the presence of urinary suppression, hot baths or
hot packs and stimulants are indicated.
Inflammation of the Urethra, Prostate, or Bladder.- — Inflammation
of the stricture, prostatitis, or cystitis may follow as a result of injury
to the urethra or vesical neck from rough or careless introduction of
instruments or from failure to pay due regard to cleanliness. The
inflammation may extend, in addition, from the urethra down the
ejaculatory ducts and set up an epididymitis. In the presence of
such complications, attempts at dilatation should cease until the
acute period is passed and appropriate treatment should be directed
to the cure of the complication.
Hemorrhage, — At times considerable hemorrhage may result from
the passage of instruments. This, as a rule, indicates a false passage
or an attempt at too great a degree of dilatation at one sitting. Bleed-
ing may occur, however, in some cases where the urethra is markedly
congested with scarcely any injury to the tissues. The bleeding
usually stops of its own accord. If excessive, the patient should be
kept quietly in bed and cold applications should be applied to the
perineum.
False Passage. — Another accident that may result from the use of
urethral instruments is the formation of a false passage by forcing
the instrument through the urethral wall into the surrounding tissues.
It is more liable to happen when using rigid instruments of small size
and probably occurs more frequently than is recognized. When a
false passage is made, there will generally be free hemorrhage at the
time or upon withdrawal of the instrument, and the patient will com-
plain of severe pain and may show signs of shock. At the same time,
the operator, while conscious that the instrument has passed the
640 THE URETHRA AND PROSTATE
obstruction, will recognize that the point is not in the urethra from the
direction of the handle. In such a case, if an examination is made by
the rectum, the point of the instrument will be found in the perineum
near the rectal wall. Furthermore, the instrument, if it be a rigid
curved one, cannot be rotated about its own axis as would be the case
were its point in the bladder.
Following such an accident, if the patient can urinate, the treat-
ment should be expectant in the main; that is, he should be put to bed
and given urinary antiseptics and carefully watched. Should extrava-
sation of urine occur or an abscess develop, prompt and free drainage
should be estabUshed and perineal urethrotomy should be performed.
CONTINUOUS DILATATION
Continuous dilatation consists in inserting a fiUform or small
bougie through a stricture and leaving it in place for twenty-four or
forty-eight hours. By the end of this period more or less absorption
of the stricture has taken place, so that there is some dilatation, and
a larger instrument may then be inserted. It is a method that may
be sometimes employed for securing dilatation of tight strictures not
amenable to gradual dilatation, and is worthy of trial in such cases
before resorting to a radical cutting operation. The method has its
objections, however, in that it is necessary to keep the patient under
constant observation and in bed; furthermore, irritation from the
instrument in the urethra is apt to cause urethritis which may in turn
lead to cystitis. The method is contraindicated in the presence of
cystitis or if renal complications exist.
Instruments. — Filiform (see Fig. 599) or soft bougies (see Fig. 598)
may be employed.
Asepsis.^ — Rigid asepsis is, of course, imperative. The instru-
ments are to be sterilized as already described (page 587). The penis
and meatus are washed with soap and water, followed by a i to 5000
bichlorid of mercury solution. The urethra should be irrigated with
a I to 5000 permanganate of potash or saturated boric acid solution,
and the bladder should be likewise irrigated with boric acid solution,
if possible, upon changing the instruments.
Technic. — The instrument is passed through the stricture after the
method already described for intermittent dilatation (page 636), and
is then securely fastened in place. There are several methods of do-
ing this, but the following is the simplest and most effective: Four
pieces of adhesive, each about 4 inches (12 cm.) long and 1/4 inch (6
CONTINUOUS DILATATION
641
mm.) wide are secured to the bougie (which for a space of an inch (2.5
cm.) in front of the meatus has been thoroughly dried and from which
all grease has been removed) in such a way that one strip lies upon
the dorsum, one on the ventral surface, and one on either lateral sur-
face of the penis. When a foreskin is present, it is drawn down over
the glans and each strip is carried over it and caused to adhere to •
the penis. An additional strip of adhesive i inch (2.5 cm.) wide
is placed horizontally about the penis just behind the corona cover-
ing the four small strips (Fig. 673). This strip should not entirely
encircle the penis, thus avoiding any danger of constricting it. Where
Fig. 673. — Showing the method of securing a bougie or catheter in the urethra.
(After Sinclair, Polyclinic Journal, July, 1908.)
there is no foreskin, a piece of gauze should be interposed between the
glans and the small strips. A liberal sterile gauze dressing is then
wrapped about the penis and the protruding instrument, and the
whole is supported by means of a T-bandage. The urine escapes
along the side of the bougie into the gauze, which should be changed
when saturated. Within twenty-four or forty-eight hours the bougie
is removed, and the stricture will be found sufficiently stretched to
permit the easy introduction of a larger instrument. This is left in
for the same length of time, and upon its removal gradual dilatation
may be begun.
When there is retention of urine, the filiform is passed as before and
a tunneled catheter is passed over it as a guide into the bladder (page
638), and the urine is drawn off. The bladder is then irrigated and
the catheter removed, but the filiform is secured in place as described
above. Usually urine will begin to pass along the bougie in a short
while, but if not it may be withdrawn as often as necessary by means
of a tunneled catheter.
41
CHAPTER XX
THE BLADDER
Anatomic Considerations
The bladder is a musculomembranous reservoir tor the reception of
urine, lying behind the pubes and in front of the rectum in the male
and the uterus in the female. The bladder may be described as hav-
ing (i) a summit, or apex; (2) a base, or fundus, which rests upon the
rectum and into which open the ureters ; (3) a body, or middle portion ;
and (4) a neck, or constricted portion, opening into the urethra. It
has an average physiological capacity of from 6 to 9 ounces (180 to
270 c.c), and a normal maximum capacity of 24 ounces (720 c.c), but,
under certain pathological conditions, it may become enormously
distended without rupture. Its shape and position depend to a cer-
tain extent upon whether it is empty or full. When empty, it lies well
behind the pubes, and upon median section appears triangular in out-
line; when partially filled, it becomes rounded in outline; and, when
completely distended, it becomes oval and rises partly from the pelvis
into the abdominal cavity.
The peritoneum partially covers the anterior surface and sides of
the bladder, and entirely covers the superior surface, extending pos-
teriorly as far as the level of a transverse line passed between the upper
limits of the seminal vesicles, whence it is reflected to the rectum in
the male, while in the female it is reflected to the uterus. When the
bladder becomes distended, the peritoneum is carried from the ante-
rior abdominal wall with it, so that in retention of urine with disten-
tion it becomes possible to empty the viscus by passing an aspirator
into it above the pubes without fear of entering the peritoneal cavity
(Fig. 674).
Beneath the peritoneal coat lies the muscular layer. It consists
of three coats: external, middle, and internal. The external is com-
posed of fibers arranged longitudinally and in thick bundles over the
anterior and posterior surfaces, but forming a comparatively thin
layer at the sides. The fibers of the middle coat have a circular
arrangement. They are thickest at the neck where they form the
internal vesical sphincter. The internal layer is thinner than either
642
ANATOMIC COXSLDEIL\TIONS
643
Fig. 674. — Showing the space above the pubes through which it is possible to enter
the bladder without opening into the peritoneum.
Fig. 675. — The interior of the bladder, i, Trigone; 2, orifice of ureter; 3, mus-
cular layer; 4, mucous membrane; 5, interureteric line; 6, prostate gland.
044 THE BLADDER
of the others. Some of its fibers are arranged longitudinally and
others circularly.
The mucous coat is composed of stratified pavement epithelium.
It is of a pale salmon color. When the bladder is distended, the
mucous membrane forms a smooth lining for the interior, but is thrown
up into thick folds when the viscus is empty, except over the portion
known as the trigone where it is always smooth. The mucous mem-
brane of the bladder is comparatively insensitive to touch when in a
normal condition, as it has a scant nerve supply, the most sensitive
portion being over the trigone. The trigone is a smooth triangular
space at the base of the bladder, the apex of which corresponds to the
opening of the urethra and the base to a line passing between the
orifices of the two ureters (Fig. 675).
The ureters pierce the bladder wall obliquely and appear upon the
mucous membrane as round openings or oval slits directed forward
and inward. These orifices are from i to i 1/2 inches (2.5 to 4 cm.)
apart and about i inch (2.5 cm.) from the beginning of the urethra.
Diagnostic Methods
When examining a case of suspected bladder disease the symptoms
complained of should first receive careful attention. In addition to
the usual questions, information bearing upon the act of urination
should be sought, ascertaining whether there is frequency of urination,
whether there is urgency, whether the act is difficult, whether pain is
present and, if so, its relation to the passage of urine, whether the
force or caliber of the stream is changed, etc., etc.
Frequency of urination is common in all bladder affections where
the mucous membrane is inflamed. It is also a symptom of vesical
stone, tumor, foreign body, or an enlarged prostate. In the presence
of stone this symptom is more marked when the patient is up and
about or after exertion, while in the case of an enlarged prostate it is
more pronounced at night. Frequent micturition may, however,
occur when the bladder is healthy, as in diabetes, in hysteria, in those
who drink large quantities of water, in those whose urine contains
excessive amounts of uric acid or oxalates, etc.
Urgency of micturition, or the feeling of being compelled to pass
urine the instant the desire is felt, points strongly to inflammation of
the bladder or the prostate. Inflammation or irritation of the urethra
may also cause it. It is, however, sometimes observed as the result
ANATOMIC CONSIDERATIONS 645
of certain mental emotions, as fright or apprehension, or mental sug-
gestions, such as the sound of running water. Irritating urine and
diseases of the nervous system are also causes.
With a history of painful micturition, it is important to determine
the seat of the pain and the exact relation it bears to the act of urina-
tion. Pain from prostatitis is generally felt in the perineum or rec-
tum, pain in bladder disease is felt over the pubes, in kidney disease in
the loins. A vesical calculus, however, will frequently cause pain in
the head of the penis. Pain at the beginning of urination, as a rule,
points to some obstruction to the outflow of urine or to inflammation
of the urethra, or it may be the result of very irritating urine. If it
occurs during micturition, it may be caused by inflammation of the
urethra, prostate, or bladder wall. Pain at the end of urination occurs
when a vesical calculus is present or when there is inflammation in-
volving the neck of the bladder or the prostate. In acute prostatitis
pain is also present upon defecation. When pain is present in the
intervals between the acts of urination, it may be caused by a vesical
calculus, tumors, or prostatic abscess. When such pain is increased
upon exertion and entirely relieved by rest in the dorsal position, it is
believed by some writers to be pathognomonic of vesical calculus.
Difficulty of urination, as a rule, indicates stricture of the urethra
or an enlarged prostate. Changes in the caliber of the stream gener-
ally point to stricture. In the presence of enlarged prostate, disease
of the bladder wall, and in some nervous affections, the force of the
stream may be greatly diminished, so much so as to amount to a mere
dribbling. A vesical calculus may at times cause a sudden stoppage
of the stream, and this is frequently accompanied by sharp
pain.
While a complete history should always be obtained, at the same
time too much importance should not be placed upon symptomatology
in the diagnosis of vesical affections. The symptoms are often decep-
tive, as they may be common to diseases involving the bladder, kid-
neys, or urethra. Even when they clearly point to the bladder as
their seat of origin, they are sometimes of but little value in differen-
tiating between the various morbid conditions that may affect this
organ. An accurate diagnosis can only be arrived at by a physical
examination along the lines detailed below.
The methods available for examination of the bladder include
urinalysis, inspection, percussion, palpation, sounding, cystoscopy,
tests of the capacity, the sufficiency, and the absorption power of the
bladder, and the X-rays.
646 THE BLADDER
EXAMINATION OF THE URINE
A complete chemical, microscopical, and bacteriological examina-
tion of the urine should be made in all cases of suspected disease of
the bladder or kidneys. The proper method of collecting the speci-
men for such examination has been previously described (page 252).
but it is outside the province of this work to describe urinalysis; for
this the reader is referred to some of the numerous works devoted to
the subject. The diagnostic significance of modifications in the nor-
mal condition of the urine as far as applies to vesical and renal disease
will, however, be briefly considered.
The quantity of urine passed normally by a healthy adult amounts
on an average to 50 ounces (1500 c.c.) in twenty-four hours, but this
may be greatly modified even in health, depending upon the season of
the year, the quantity of water imbibed, the amount of exercise taken,
the condition of the nervous system, etc., etc. In certain diseases, as
fevers, in affections accompanied by night-sweats or diarrhea, chronic
parenchymatous and acute nephritis, in blockage of a ureter by an
impacted stone or by a twist, in shock, hemorrhage, etc., the output
of urine may be greatly decreased (ohguria). On the other hand, an
increased quantity of urine (polyuria) will be found in hysteria, in
the presence of interstitial changes in the kidney, from the use of
diuretics, in diabetes, in renal tuberculosis, in pyelitis, etc.
In bladder affections the daily output of urine generally remains
unchanged and, in the presence of marked changes in this respect,
involvement of the kidneys or some constitutional disease may be
implied.
The specific gravity of the urine for a normal individual is fixed at
1. 018 to 1.025 ^t 60° F. (16° C). The specific gravity is closely
related to the amount of solids excreted, so to be of value the test
should be applied to a mixture of the urine voided during twenty-four
hours.
In diseases of the bladder the specific gravity is unaffected, but in
renal disease it may be markedly changed. A low specific gravity
and an increased output of urine, when the bladder is diseased, points
strongly to pyelitis or pyelonephritis.
The odor of urine is faintly aromatic, the more marked the greater
the proportion of solids. The taking of such drugs as copaiba, cubebs,
turpentine, and sandalwood modify this characteristic odor. In dia-
betic coma the odor of the urine resembles that of chloroform from
the presence of acetone and diacetic acid. Urine that has undergone
EXAMINATION OF THE URINE 647
ammoniacal decomposition, as is frequently the case in chronic cysti-
tis, has the characteristic and offensive odor of stale urine. Urine
coming from a bladder which communicates with the rectum by a
rectovesical fistula has an odor of skatol. In the presence of ulcera-
tions within the bladder, especially ulcerating tumors, the urine will
be foul-smelling and may even have a distinct odor of putrefaction.
The color of the urine is a hght or dark amber depending upon the
concentration. The presence of blood gives the urine a bright red or
reddish black hue, depending upon whether the hemorrhage is recent
or old. Bile gives a dark yellow or brownish color with a greenish
tinge. In chyluria the urine appears milky. Fevers render the urine
darker than normal. Various drugs may also modify the color, thus
senna, rhubarb, and santonin may color the urine a golden-yellow
or deep red hue, methylene blue gives a greenish-blue color, and
poisoning from carbohc acid, chlorate of potash, or creosote makes
the urine smoky or black.
Transparency. — Normal urine should be clear and transparent
when voided. In bladder diseases the urine is, as a rule, turbid.
Turbidity may be caused by urates, phosphates, blood, pus, epithe-
lium, chyle, or bacteria. The turbidity caused by urates disappears
upon heating the urine, that due to phosphates clears up upon the
addition of one or two drops of acetic acid.
In bacteriuria, as is seen after the passage of unclean instruments,
the turbidity is slight and remains unchanged upon standing, upon the
application of heat, or in the presence of acetic acid. The condition
is readily recgonized by the aid of the microscope.
The turbidity produced by pus is increased upon heating the urine,
and does not disappear upon the addition of an acid. Furthermore,
upon allowing such a specimen to stand a few hours, it will be found
that the pus settles to the bottom leaving the rest of the fluid clear.
A simple test for the presence of pus is to add a little solution of potas-
sium hydrate to the suspected specimen; in the presence of pus a
gelatinous precipitate is formed.
The reaction of urine is normally slightly acid. The acidity is
increased in fevers, gout, lithemia, rheumatism, chronic B rights dis-
ease, etc., and upon a diet composed chiefly of proteids. A vegetable
diet and large quantities of fluids render the urine neutral or alkaline.
In diseases of the bladder the urine may be acid or alkaline, thus
in acute cystitis the urine is usually acid. In chronic cystitis it may
be either acid or alkaline, always the latter in the presence of ammoni-
acal fermentation, but when due to the gonococcus, tubercle baoillus.
648 THE BLADDER
or colon bacillus it is acid. In uncomplicated cases of pyelitis and
pyelonephritis the urine also has an acid reaction.
Alhiiminuria. — Albumin in the urine is not to be considered an
invariable sign of kidney disease. It may result from a number of
local causes, such as blood, pus, prostatic secretion, etc., due to an
inflammation involving the kidney pelvis, ureter, bladder, prostate,
or urethra, without the existence of organic disease of the kidney.
Furthermore, a transient albuminuria is not infrequently the result
of the diet, the amount of exercise taken, ner\-ous shocks, toxins in
the blood, etc. So that it becomes of the greatest importance to
decide whether an albuminuria is of renal origin or is the result of
other pathological conditions, and sometimes this is a difficult matter.
The two may exist together.
Hematuria. — Blood in the urine may have its source in any part of
the genitourinary tract, as the urethra, prostate, bladder, ureters, or
kidneys. While it is not always possible to determine the source of
the hemorrhage from an examination of the urine, there are certain
characteristic differences in hemorrhages from these different regions.
Urethral hemorrhage may arise from acute urethritis or inflamed
strictures, or may follow traumatism to the canal, the passage of in-
struments, etc. In urethral hemorrhage, if the source is from in front
of the compressor urethras muscle, the blood appears independently
of urination, and may escape from the meatus freely, in drops, or in
the form of long clots. If from the posterior urethra, the blood finds
its way backward into the bladder and. when of considerable quantity,
uniformly discolors the urine. If, however, the posterior hemorrhage
is sHght, the first and last portions of the urine passed may be blood-
tinged while the intermediary portion will be clear.
Vesical hemorrhage may follow the sudden and complete empty-
ing of the bladder in retention, or it may be due to trauma, the pass-
age of instruments, varicosities, stone, inflammation, ulcer, tubercu-
losis, tumors, etc. The urine in a recent vesical hemorrhage may be
comparatively clear at first, or only slightly discolored, becoming
more so as the bladder is emptied, until it finally has a bright red color
or consists of almost pure blood. It may contain large clots which
have no definite shape, and. if long retained, they appear black and
tarry. The reaction of the urine is generally alkaline.
Renal hematuria may be due to inflammation, congestion, trauma,
stone, tuberculosis, tumors, the use of strong diuretics, etc., etc. The
blood will be thoroughly mixed with the urine, imparting to the latter
a smoky tint or deep red-brown color. It will be found that the cor-
EXAMINATION OF THE URINE 649
puscles are greatly changed and without coloring matter, often appear-
ing as mere shadows, but in cases of ruptured kidney or in severe renal
hemorrhage from other cause, they may remain unaltered and the
urine will be much lighter in color. The urine during renal hemor-
rhage and just after is generally acid in reaction unless the bleeding
has been severe or pus is present. Large clots are seldom formed un-
less the blood coagulates after reaching the bladder, but there may be
found casts of the kidney tubules or cylindrical-shaped clots from the
ureters.
A more positive diagnosis between hematuria of renal origin and
that of the bladder may be made by introducing a catheter and thor-
oughly washing out the bladder with a warm normal salt solution,
being careful to wash out all the clots. If the blood is of renal origin,
the last washings will consist of clear fluid and will remain clear until
more blood flows from the ureters. If, on the other hand, the bleed-
ing arises from the bladder, it will be found impossible to completely
free the fluid from blood.
By means of a cystoscopic examination (page 659) the bladder may
be excluded as the source of the blood if it is found free from disease,
or it may be possible to see blood escaping from one or other ureter.
(See also the absorption test, page 659.)
Pyuria. — Pus in the urine is a common accompaniment of bladder
diseases and also those affecting the urethra and kidneys. Pyuria is
a symptom of suppuration or catarrh in the genitourinary tract; thus
it will be found in pyonephritis, pyelitis, tuberculosis, cystitis, ure-
thritis, etc. It is characterized by cloudy urine in which a thick
yellow sediment settles upon standing.
A differential diagnosis between urethral pus and bladder pus may
be made by having the patient void his urine in two glasses (page 580) .
If the urethra is the source, the first glass of urine will be found cloudy
and the contents of the second glass clear or nearly so. When the
bladder is affected the contents of both glasses will be equally cloudy.
In deciding between vesical and renal pyuria, it should be borne in
mind that in the former condition the amount of albumin will be
slight and there will be no renal casts, but bladder epithelium will be
found; while in urine containing pus from the kidney albumin will be
found in a greater proportion than can be accounted for by the
amount of pus, and casts may be present. The use of the catheter or
cystoscope will, however, furnish more exact evidence as to the sourc3
of the pyuria.
To apply the first test, the bladder is thoroughly washed with a
6^o
THE BLADDER
warm normal salt or boric acid solution through a catheter until the
fluid returns clear. The catheter is then clamped and allowed to
remain in place ten or fifteen minutes, and what urine has entered the
bladder in the meantime is drawn off. If this last specimen is again
turbid we may conclude that the pus comes from the kidneys.
On cystoscopic examination, if the bladder be found free from
disease, this evidence points to the kidney as the source of pus. The
diagnosis may be made absolute if pus is seen exuding from the ure-
ters or a sample of urine obtained by ureteral catheterization contains
pus.
INSPECTION
Inspection of the bladder without the aid of instruments is ex-
tremely limited in value. By inspection of the abdomen, it is possi-
FiG. 676. — Vaginal inspection of the bladder. (Ashton.)
ble to recognize a distention of the bladder, and, in the female, hy
means of a vaginal inspection, some information as to the condition
of the floor of the bladder may be gained.
Position of Patient. — For ordinary abdominal inspection the
patient Hes flat on the back with the body uncovered from the um-
bilicus to the knees, and with the legs extended in the same plane as
the body.
For inspection through the vagina the patient should be in the
dorsal posture.
Technic. — i. Abdominal Inspection. — The examiner takes his
position upon one side of the patient and carefully notes any change
PALPATION 651
in the size or shape of the hypogastrium. A distended bladder
appears as an ovoid tumor with the narrow end down, situated above
the symphysis generally in the median line.
2. Vaginal Inspection. — The examiner sits facing the vulva, and,
by retracting the perineum with the index-finger of the left hand in-
troduced within the vagina (Fig. 676), the anterior vaginal wall is ex-
posed for inspection. In this way a displacement of the bladder, pro-
trusion from distention, or a vesicovaginal fistula may be recognized.
PERCUSSION
Percussion of the bladder is chiefly of use in determining the pres-
ence or absence of distention. The percussion note over the hypo-
gastrium is normally tympanitic. When the bladder becomes dis-
tended with fluid, there will be a fluctuating tumor above the symphy-
sis which gives a fiat percussion note and tympany at the sides. If,
however, coils of intestine fill the space between the bladder and the
abdominal wall, as is sometimes the case where the intestines become
adherent as the result of pelvic peritonitis, percussion will furnish but
imperfect information, as a tympanitic note may be obtained and
yet the bladder be distended. Any doubt as to the presence of
distention should be immediately settled by passing a catheter into
the bladder.
PALPATION
In the case of thin individuals with relaxed abdominal walls pal-
pation will often give valuable information, but in fat or very muscu-
lar patients it is of limited use. The palpation may be performed
abdominally or bimanually. The latter method yields the most
valuable information. Distention, foreign bodies, calculi, tumors,
and tender areas may be thus recognized, and an idea as to the thick-
ness and sensibility of the bladder walls may be obtained. It is an
especially useful method to employ in examining the bladders of
children.
Digital palpation of the bladder by means of a finger introduced
through a perineal or suprapubic wound or through the urethra in the
female are methods now rarely employed for diagnosis alone, as we
have other equally efficient and more simple means of examination.
Position of Patient.- — For abdominal palpation the patient should
be in the dorsal posture with the thighs flexed and the body uncovered
from the umbilicus down. This or the knee-chest posture may be
employed for bimanual examination.
652
THE BLADDER
Anesthesia. — In stout individuals or those with rigid abdominal
walls, it may be impossible to make a satisfactory bimanual examina-
tion without the aid of general anesthesia.
Fig. 677. — Abdominal palpation of a distended bladder.
Fig. 678. — Bimanual palpation of the bladder.
Technic. i. Abdominal Palpation. — The examiner stands upon
the left side of the patient, and, placing his right hand flat upon the
abdomen just above the pubes, gently palpates the hypogastric region
by means of his finger tips. In thin individuals, if distention is
SOUNDING 653
present, a fluctuating tumor will be recognized. By requesting the
patient to breathe deeply with the mouth open and at the same time
pressing the ulnar border of the hand deeply toward the pelvis, it is
often possible to outline the swelling of a distended bladder more
distinctly (Fig. 677). Such manipulation will frequently cause the
patient to evince a desire to urinate.
2. Bimanual Palpation. — The bladder should be first emptied.
The index-finger of the right hand or the index and middle fingers, if
possible, are introduced into the rectum in the male or the vagina
in the female, after first being well lubricated. The four fingers of
the left hand are then placed above the symphysis, and, while they
make counter pressure toward the base of the bladder, the entire
viscus is palpated bimanually (Fig. 678).
SOUNDING
Palpation of the interior of the bladder by means of a suitable
sound is a method of exploration employed in cases of suspected
stone, foreign bodies, or tumors. The sound is also of value in
testing the sensitiveness of the bladder walls and in estimating the
Fig. 679. — Thompson stone searcher.
amount of intravesical enlargement of the prostate (page 585) and in
the diagnosis of cystocele in the female.
While sounding is a fairly reliable method in searching for a stone,
there are certain difficulties and sources of error that should be borne
in mind. A stone may be encrusted with blood and mucus and so be
missed entirely, or it may be encysted with only such a small por-
tion exposed that it may be difficult to reach it, or it may lie behind
an enlarged middle lobe of the prostate. Very small stones may like-
wise be missed or they may be so light that the slight shock imparted
by contact of the instrument is unnoticed. A tumor or a contracted
thick bladder wall encrusted with lime salts or phosphates may give
a sensation that is confused with the click of a stone.
Instruments. — For sounding the male bladder a Thompson metal-
lic searcher (Fig. 679) is employed. This instrument has a fairly
large beak, flattened from side to side, which joins the shaft at an
654 THE BLADDER
angle of 120 degrees. The shaft should be slender — 12 to 15 French
scale — so it can be readily moved back and forth or rotated from
side to side within the urethra. The handle of the instrument is
supplied with a guide which indicates the direction of the beak.
Asepsis. — The sound is boiled for five minutes in a i per cent,
sodium carbonate solution. The external genitals are cleansed with
soap and water followed by a i to 5000 bichlorid of mercury solution.
The hands of the operator should be sterilized in the usual way. The
urethra should be irrigated with a saturated solution of boric acid or
a I to 5000 permanganate of potassium solution. The bladder is
emptied and irrigated with boric acid solution.
Position of Patient. — The patient should be in a recumbent posi-
tion with the hips raised several inches higher than the head and the
thighs extended fiat.
Preparations of the Patient. — The rectum should be empty.
About 4 ounces (120 c.c.) in an adult and 2 ounces (60 c.c.) in a child
of a saturated boric acid solution or a normal salt solution should
be introduced into the bladder, so as to permit easy movement of
the searcher and to prevent the stone from being concealed in the
folds of mucous membrane.
Anesthesia — As a rule, no anesthesia is necessary. In sensi-
tive cases the instillation of a few drops of a 2 per cent, solution of
cocain into the posterior urethra vriR suffice, or the bladder may be
filled with 5 ounces (150 c.c.) of a warm o.i per cent, solution of
cocain to which is added 20 drops (1.25 c.c.) of adrenalin chlorid.
This is to be retained fifteen to twenty minutes. If the bladder is
extremely irritable and the patient nervous, a general anesthetic
may be administered. In children a general anesthetic is usually
necessary.
Technic. — The instrument is well lubricated with lubrichondrin
or one of the other Irish-moss preparations and is introduced in the
same manner as a sound (page 587). When the beak of the instru-
ment reaches the triangular ligament, the fingers of the left hand are
appHed to the perineum and assist in guiding the point into the open-
ing. The handle of the sound is then brought dowTi between the
thighs and the instrument is at the same time gently pushed into
the bladder. As the instrument traverses the fixed curve of the
urethra, pressure should be made over the region of the pubes to
relax the suspensory ligament of the penis (see Fig. 605). To be
sure the point is within the bladder, the instrument should be intro-
duced a distance of about 8 inches (20 cm.).
SOUNDING
655
A systematic examination of the entire bladder is then per-
formed. The instrument, being held lightly between the thumb
and the forefinger of the right hand, is first inserted to the full length,
and is then slowly withdrawn, rotating the beak from side to side,
so that the point of the sound is brought into contact with every por-
tion of the bladder wall. In this way any thickness or rigidity of
the bladder wall, as is found in hypertrophy, chronic inflammatory
conditions, and in the presence of firm growths, may be recognized.
In the same manner the sensitiveness of the organ may be tested.
Normally, the bladder has but little sensation to touch except in the
region of the trigone. In cases of posterior urethritis this region may
Fig. 680. — Palpation of a stone lodged above the vesical. opening.
be markedly hyperesthetic. Local areas of increased sensitiveness
point to ulceration or new growths, while in cases of cystitis the entire
bladder will be sensitive.
In examining for suspected stone the search should be carried out
in the same systematic manner, carrying the instrument to the fun-
dus first and then tapping each lateral wall in succession as the in-
strument is withdrawn to the vesical neck. The upper wall of the
bladder is then palpated by depressing the handle of the instrument
well down between the thighs, and as an aid the bladder wall may be
depressed toward the instrument by means of the free hand placed
above the pubes. In this way a stone located above the vesical open-
ing may be located (Fig. 680). The beak of the sound is then rotated
and turned downward. In doing this, if the point catches in the
mucous membrane, the handle should be depressed so as to lift the
beak clear of the floor. The posterior prostatic region is then ex-
6;;6
THE BL.ADDER
plored. Should the prostate be enlarged, the handle of the instru-
ment should be raised somewhat, and, with a finger in the rectum,
it will be possible to bring a stone, if one is present, within reach of
the instrument (Fig. 68i).
WTien the sound strikes a stone, the examiner will recognize the
fact by a distinct click that may be heard as w^ell as felt. Some
idea as to the consistency of the stone may be gained from the sharp-
ness of the ring; a high-pitched metallic click generally indicates a
hard stone (oxalate), while a dull low-pitched sound would indicate
a soft stone (urate). It is also possible to determine whether a
Fig. 68 1. — Palpation of a stone lodged behind the prostate with the aid of a finger
in the rectum.
stone is rough or smooth from the sensation imparted as the beak
of the instrument is drawm over its surface. If possible it should
be ascertained w^hether a stone is movable or fixed by attempting to
dislodge it with the beak of the instrument or by changing the posi-
tion of the patient, that is, after the stone is located, the sound is
withdrawn and the patient is put in the knee-chest posture; on re-
suming the dorsal position, the instrument is again inserted and any
change in the position of the stone is noted.
To determine the size of the stone, the beak of the instrument is
carried over the posterior surface and the position of the meatus is
marked on the shaft. The instrument is then slowdy w^ithdrawn,
tapping the stone the while, until the anterior border is reached and
the relation of the meatus to the shaft is again noted. Subtracting
the latter measurement from the first one gives approximately the
TEST OF THE BLADDER CAPACITY
657
length of the stone in its antero-posterior diameter. The transverse
diameter may be Kkewise estimated by tapping the stone from side
to side.
At the completion of the operation the instrument is removed by
a reversal of the steps taken in its insertion, and the bladder is
irrigated with a warm saturated solution of boric acid, followed by a
deep urethral instillation of i to 1500 silver nitrate solution.
TEST OF THE BLADDER CAPACITY
By distending the bladder with fluid its capacity is readily esti-
mated, and from this it mav be determined whether the bladder is
Fig. 682. — Catheter and syringe for estimating the bladder capacity.
Fig. 683. — Alethod of distending the bladder with fluid when estimating its
capacity.
normal, atonic, or contracted. If large quantities of solution can be
injected without inducing contractions, it may be inferred that atony
or paralysis exists; but if, on the other hand, the bladder is in an in-
flamed condition or is contracted, it vnil often not be possible to
inject more than an ounce (30 c.c.) or so without the patient com-
plaining of distention.
42
658 THE BLADDER
This test is also useful in the diagnosis of a ruptured bladder.
By injecting a definite amount of solution into the bladder and noting
the quantity that returns, the presence or absence of rupture may be
readily recognized. In performing this test, however, it is neces-
sary to inject 6 to 8 ounces (180 to 250 c.c.) of fluid, as small amounts
may give misleading results.
Apparatus. — An ordinary soft-rubber catheter for the male or a
glass catheter for the female and a large syringe, such as a Janet or
Record (Fig. 682), are required.
Asepsis. — The apparatus is sterilized by boiling and the exami-
ner's hands are to be thoroughly cleansed. The external genitals
are washed with soap and water, followed by a i to 5000 solution
of bichlorid of mercury, and the urethra is irrigated with a satu-
rated solution of boric acid or a i to 5000 solution of potassium
permanganate.
Position of Patient. — The patient should be in the dorsal position
upon a flat table.
Technic. — The catheter, well lubricated with lubrichondrin, is
introduced into the bladder and all the urine is drawn off. The
syringe is then filled with a warm (100° F. (38° C.)) saturated solution
of boric acid or normal salt solution, and the solution is slowly in-
jected into the bladder (Fig. 683). As soon as the patient complains
of distention, the injection is stopped and the quantity of fluid that
has entered the bladder is estimated. The syringe is then discon-
nected from the catheter and the fluid is allowed to escape from the
bladder through the catheter.
ESTIMATION OF RESIDUAL URINE
Normally, with micturition the bladder empties itself almost
completely, but, if the evacuation of urine is interfered with by
obstruction from a stricture or an enlarged prostate or from the con-
dition of the bladder itself, as, for example, in atony, cystocele, etc.,
the evacuation will be incomplete and more or less residual urine
will remain. The amount of residual urine often has a bearing upon
the prognosis as well as the treatment to be pursued in a given case,
and its estimation is thus of some importance.
Apparatus. — All that is required is a ^Mercier catheter with a
coude curve and a glass graduate.
Asepsis. — The catheter is sterilized by immersion in a i to 20
carbolic acid solution followed by rinsing in sterile water. The
THE ABSORPTION TEST 659
external genitals are cleansed in the usual way, and the urethra is
irrigated with a mild antiseptic solution. The hands of the operator
should likewise be sterile.
Technic. — The patient is instructed to empty his bladder as
completely as possible while in the upright position. He is then
placed in the dorsal position. The catheter, well lubricated, is in-
troduced into the bladder, and any urine that remains is drawn off
into the graduate and is measured. This may amount to from i
dram (4 c.c.) to several ounces. If there is more than 2 ounces
(60 c.c.) of residual urine, it is certain that some interference with
the voluntary evacuation of the bladder exists. Observation of the
flov/ of urine from the catheter may also furnish valuable information.
If the urine is expelled in a strong gush, it indicates that the muscu-
lar structure of the bladder is competeni , while, if it simply escapes
by gravity, an atonic condition is probably present.
THE ABSORPTION TEST
A test sometimes employed to determine whether blood in the
urine has its source in the bladder consists in injecting a solution of
iodid of potassium into the bladder and later testing the saliva for
iodin. Ordinarily there will be no absorption from the healthy
bladder, but, if raw or ulcerated surfaces are present, absorption of
the iodid of potassium is quite rapid and iodin will be eliminated in
the saliva.
Apparatus. — There will be required an ordinary soft-rubber irri-
gating catheter, a Janet syringe, and a test-tube.
Asepsis. — The usual aseptic precautions employed when intro-
ducing an instrument into the bladder should be observed.
Technic- — The patient first empties his bladder. The soft
catheter is then introduced and the bladder is well irrigated with nor-
mal salt solution. From 2 to 3 ounces (60 to 90 c.c.) of a i per cent,
solution of potassium iodid are then injected into the bladder and the
catheter is removed. At the end of ten or fifteen minutes some of
the patient's saliva is collected in a test-tube and is tested for iodin.
This is readily done by adding a few drops of a dilute solution of
cooked starch and stirring with a glass rod dipped in fuming nitric
acid. If iodin is present in the saliva, the mixture will turn blue.
CYSTOSCOPY
Cystoscopy is the inspection of the interior of the bladder by the
aid of an instrument especially devised for the purpose, the cysto-
66o THE BLADDER
scope. It is a method of examination that may be of the greatest
value when employed by an expert, but it is of limited use in the
hands of the inexperienced, for it is absolutely essential that the
examiner be familiar with the appearance of the normal bladder be-
fore he can recognize and correctly interpret pathological conditions,
and this can only be learned by practical experience.
By a cystoscopic examination properly carried out it is possible
to obtain an accurate picture of the interior of the bladder and to
study the appearance of the ureteral orifices as well as the condition
of the urine that escapes from them; that is, whether it contains pus
or blood. Cystoscopy thus becomes of service not only for diagnosis
of obscure vesical affections that may escape recognition by other
means, but also in the diagnosis between a possible vesical and kidney
lesion.
The method has, however, certain limitations. It cannot be
employed with success in the presence of marked hypertrophy of the
prostate, when the bladder is greatly contracted, or when there is
an active vesical hemorrhage going on which obscures the view. It
is contraindicated in the presence of acute urethritis, acute prosta-
titis, epididymitis, or acute cystitis. The urethra must, as a rule,
be of a caliber of 22 to 24 French, and, if the meatus is narrow, it
must be first cut, or, if strictures are present, they must be suffi-
ciently dilated before the instrument can be introduced.
Instruments. — Cystoscopes are of two types, the direct view, in
which the light is on the convex side of the beak and the eye looks
down a straight tube through a window in the distal end, and the
indirect view, in which the light is placed on the concave side and the
image is reflected at right angles to the eye-piece, thus giving an
inverted picture. Some of the newer indirect view instruments,
however, give an upright picture.
For the simple examination of the bladder the use of an indirect
view cystoscope gives the best results, as with such an instrument the
roof, floor, and walls of the bladder — excepting a part of the posterior
wall — may be readily inspected. The examination may be satisfac-
torily performed either by means of a special exploring cystoscope,
such as the Nitze, Otis, Schapira, etc., or by means of one of the
ureter-catheterizing cystoscopes to be described later on (see page
705). The exploring cystoscope has an advantage over the cathe-
terizing instruments, however, in that its shaft being small the exam-
ination is less painful.
The Nitze instrument (Fig. 684) is the oldest type of the indirect
CYSTOSCOPY
66l
or right-angled view cystoscope. It consists essentially of a metal
tube 9 inches (23 cm.) long and from 15 to 24 French scale in size,
having at the distal end a short beak fitted with a small electric lamp
and on the concave side of the instrument at the point where the beak
joins the shaft a lens, beneath which is placed a prism. From the
prism the image is reflected at right angles through a series of lenses
to the eye-piece. A small knob soldered on the circumference of the
eye-piece indicates the position of the cystoscopic window. The
instrument is fitted with two-way stopcocks for irrigation should the
lens become cloudy. Space does not permit a description of the
many modifications of the Nitze instrument, each of which has ad-
vantages of its ovm.
The illumination for cystoscopes may be furnished from a six-
er eight-cell battery or from the street current provided a controller is
employed.
Fig. 684. — Nitze's cystoscopes.
Additional instruments required are a Janet syringe, holding
from 3 to 4 ounces (90 to 120 c.c), or an irrigating jar, and a catheter.
Asepsis. — Formalin vapor may be employed or the instrument
may be immersed in a i to 20 carboHc acid solution for ten minutes
followed by rinsing in alcohol and then sterile water. The external
genitals should be cleaned with soap and water followed by a i to
5000 bichlorid solution. The examiner's hands are to be likewise
steriHzed.
Position of the Patient. — The examination is performed with the
patient in the Hthotomy position and with his buttocks close to the
edge of the table or, as preferred by some operators, in the semi- .
recumbent posture. The best form of table to use is one pro\^ded
with uprights which are surmounted with double inchned rests about
15 inches (37 cm.) above the level of the table for the support of the
patient's thighs and knees (Fig. 685). It is a great convenience to
662
THE BLADDER
have a table provided with a wheel within reach of the operator, by
turning which it may be raised or lowered at will.
Anesthesia, — Local anesthesia of the urethra is generally neces-
sary, though in exceptional cases cystoscopy may be performed with-
out anesthesia. The instillation into the deep urethra of a few drops
of a 2 per cent, solution of cocain may be sufficient. A sensitive
bladder may be rendered anesthetic by first emptying it and then
filling it with 5 ounces (150 c.c.) of a warm o.i per cent, solution of
cocain to which is added 20 drops (1.25 c.c.) of adrenalin and having
Fig. 685. — Table with Bierhofl's leg supports for cystoscopy. (Greene and
Brooks.)
the whole amount retained for fifteen to twenty minutes. Guyon's
method of obtaining local anesthesia consists in injecting into the
rectum three-quarters of an hour beforehand a mixture containing:
Antipyrin,
Laudanum,
Water,
gr. xiv (0.9 gm.)
TTlx (0.6 c.c.)
5iii (90 c.c.)
In some adult cases, where the urethra, bladder, or prostate are
extremely sensitive, and in children general anesthesia may be
required.
Preparations. — The bladder should first be emptied and should
then be thoroughly irrigated with a saturated solution of boric acid
by means of a catheter and Janet syringe until the fluid returns clear,
as a satisfactory examination can be made only in a clean bladder. If
CYSTOSCOPY
663
an irrigating cystoscope is employed, the irrigation may be performed
through the sheath of the instrument. Four to 6 ounces (120 to
180 c.c.) of a saturated solution of boric acid or normal salt solution
are then injected into the bladder and allowed to remain so as to
smooth out the folds of mucous membrane and furnish space for the
cystoscope to be moved about.
If there is sufficient bleeding from the bladder to interfere with
the examination, a solution of i to 3000 adrenahn chlorid may be
injected through the catheter and allowed to remain for about ten or
fifteen minutes, when it is drawn off and the bladder is distended.
Pig. 686. — Position of the cystoscope for inspection of the roof of the bladder.
Everything that will be required during the examination should
be placed near at hand, and the cystoscope light should be tested
under water before the instrument is introduced.
Technic. — The instrument after being thoroughly tested, is lubri-
cated with glycerin or lubrichondrin and is gently passed into
the bladder in the same manner one would pass a sound. Great care
should be taken not to use any force in introducing the instrument.
If there is any difficulty in making the beak enter the opening in the
triangular ligament, pressure applied on the perineum by the fingers
of the free hand will assist in its passage into the membranous urethra
(see Fig. 608). As soon as the instrument has entered the bladder, it
can be freely moved about.
The operator then takes his seat with his eyes on a level with the
ocular end of the instrument, the light is turned on, and the interior of
664
THE BLADDER
the bladder is systematically inspected, care being taken not to touch
the mucous membrane with the light. It should be remembered that
in using a prism form of indirect view cystoscope the image will be
reversed, as in the laryngoscope. The instrument being introduced
with its beak turned up, the roof of the bladder will first come into
view (Fig. 686). In order to see as much of this portion of the blad-
der as possible, the instrument should be rotated first in one direction
and then in the other and then pushed farther in, repeating these
movements until the entire roof has been inspected. By depressing
or elevating the shaft a more complete view of the anterior or poste-
rior wall is obtained. The beak of the instrument is then rotated so
that it faces toward the floor of the bladder (Fig. 687), and the instru-
ment is withdrawn until the prostate appears as a clear dark red cres-
cent. If hypertrophied, it will appear deformed in the picture, and
Fig. 687. — Position of the cystoscope for inspection of the floor of the bladder.
the degree of its enlargement and its location may be recognized.
The instrument is next pushed slowly backward in the median line
as far as the fundus, the examiner carefully inspecting the floor of the
bladder as the instrument is advanced. By slightly rotating the
instrument first to one side and then to the other a large extent of the
floor may be viewed.
The mucous membrane normally has a salmon or grayish-pink
tint and is smooth and glossy with the superficial vessels standing
out here and there. When acutely inflamed, it becomes a dark red
color and has a velvety appearance and there is a general hyperemia
so that the smafl blood-vessels disappear. In chronic inflammation
the mucous membrane may take on a grayish tint and the folds
CYSTOSCOPY IN THE FEilALE 665
appear much thickened. This region should be carefully examined
for small stone, tubercular ulcers, and new growths.
Having inspected the floor, the instrument is turned 45 degrees to
one side and is gradually withdra^^^l from the fundus. In this way
the opening of the ureter on that side will come to view as an oblique
slit or as a small dimple (Fig. 688) in a prominent papilla, and, if it is
watched, it will be seen to emit a gush of urine every ten to fifteen
seconds. If not immediately found, the interureteric line, which runs
transversely across the central field between the two ureters, should
be identified and, by tracing this to one side or the other, the ureteral
orifice may be located. The appearance of the ureteral orifice should
be carefully inspected for signs of ulceration, erosions, or inflammation
which might indicate a diseased kidney on that side, and likewise the
character of the urine which escapes should be noted, i.e., whether
clear, purulent, or bloody.
Fig. 688. — Appearance of the ureteral orifices.
The lateral wall is carefully inspected as far as the vesical neck.
The instrument is then rotated 90 degrees to obtain a view of the
opposite side and it, including the ureter of that side, are examined
while the instrument is slowly passed to the fundus again. Follow-
ing some such scheme, the entire bladder may be inspected except
a portion of the posterior wall which is invisible with an indirect view
instrument. During the examination it is well to shut oft" the fight
at intervals so as to allow the instrument to cool.
At the end of the examination the Hght is turned oft" and the instru-
ment is carefully withdrawm, taking care to see that the beak is again
turned up before this is done. The patient's bladder is then
emptied and irrigated with boric acid solution.
CYSTOSCOPY IN THE FEMALE
The examination of the female bladder may be performed by
using an ordinary male cystoscope or a somewhat shorter female
666
THE BLADDER
instrument. Such examination, which is less difficult than in the
male on account of the short length of the urethra, requires no separate
description, as the technic differs in no essential way from the method
Fig. 689. — Instruments for cystoscopy in the female, i, Electric-lighted
open-tube cystoscope; 2, urethral dilator; 3, urine evacuator; 4, alligator- jawed
forceps; 5, ureteral searcher.
Fig. 690. — Kelly's open-tube cystoscope.
used in the male. Another method of vesical inspection is by means
of Kelly's open straight tubes and atmospheric distention of the
bladder.
Instruments. — For cystoscopy according to Kelly's method there
will be required: Kelly's specula, or some of their modifications,
an electric head light or head mirror, a Kelly dilator to stretch the
CYSTOSCOPY IX THE FEiLA.LE
667
external urethral orilice, a urine evacuator to draw off residual urine,
alligator forceps for holding cotton swabs, and a ureteral probe for
probing the mucous membrane or locating the ureteral orifices
(Fig. 689).
The specula consist of cylindrical tubes 3 1/5 inches (8 cm.) long,
of equal length throughout, and in sizes of from 1/5 inch (^5 mm.)
in diameter up to 4/5 inch (20 mm.). Those below Xo. 12 are gen-
erally employed for diagnostic purposes. The tubes are of German
silver or nickel-plated, each having a conical expansion at the ocular
end to which is fastened a strong handle (Fig. 690). Each tube is
supplied with an obturator having a conical end-piece. The illumina-
FiG. 691. — Enlarged view of an electric-lighted open-tube cystoscope.
tion is furnished by reflected light or from an electric head light, the
latter being preferable. These specula, however, may be obtained
furnished with an electric Hght at the distal end^ (Fig. 691), an instru-
ment which simplifles the operation for one not accustomed to the use
of a head light.
The urethral dilator is a cone-shaped metallic instrument which
gradually increases in size from the point until at the base it measures
16/25 inch (16 mm.) in diameter. The instrument is graduated
so that the examiner can determine the required amount of dilatation.
The urine evacuator is necessary for the purpose of removing the
^They are made by the Electro-Surgical Instrument Company of Rochester,
New York.
668
THE BLADDER
urine that collects in the floor of the bladder which would otherwise
interfere with the examination. It consists of a suction bulb attached
by means of a long delicate rubber tube to a small perforated glass
bulb. In the Luys' open tube cystoscope an aspirating tube is incor-
porated in the instrument.
Asepsis. — All the instruments with the exception of the light car-
rier may be boiled for five minutes in a i per cent, soda solution.
The latter may be sterilized by immersion in a i to 20 carbolic acid
solution followed by rinsing in sterile water. The operator's hands
Fig. 692. — Method of dilating the itrethra. (Ashton.)
should be carefully sterilized and the external genitals and mouth
of the urethra should be cleansed with soap and water, followed by
a I to 5000 solution of bichlorid of mercury.
Position of Patient. — Two positions are employed, the dorsal and
the knee-chest. In the dorsal position the patient lies with the head
and thorax resting on the table and the hips elevated 8 to 12 inches
(20 to 30 cm.) upon cushions so as to raise the pelvis and permit the
bladder to distend with air when the cystoscope is introduced. While
the dorsal posture is the least wearing on the patient, it is not suited
for stout persons. In such cases, the knee-chest posture, with the
knees separated 10 or 12 inches (25 or 30 cm.), is more suitable.
Preparations of Patient. — Before the patient is placed upon the
table the rectum and bladder should be emptied.
Anesthesia. — ^Local anesthesia is generally sufficient except in
very nervous women. A pledget of cotton saturated with a 2 per
CYSTOSCOPY IX THE TEilALE
cent, solution of cocain introduced upon an applicator within the
meatus and alloAved to remain for five minutes will anesthetize the
urethra sufficiently to allow it to be dilated.
Technic. — As a rule, it is first necessary to dilate the urethral
Fig. 693. — ^.lethod of holding the open-tube cystoscope during its introduction
into the bladder.
orifice; the rest of the canal, being very dilatable, is easily stretched
by the cystoscope in its passage. The dilator is lubricated with one
of the Irish-moss preparations and is introduced into the urethra with
a slight boring motion until the required amount of dilatation is
Fig. 694. — Inspection of the female bladder through an open-tube cystoscope.
reached (Fig. 692). Dilatation to about X0.12 on the dilator is
generally sufficient. A speculum of a size from 7 to 10, depending
upon the age of the patient, is then selected. It should be grasped in
the operator's right hand, the cylinder lying between the index and
670
THE BLADDER
middle fingers, with the thumb against the obturator, as shown in
Fig. 693. With the fingers of the left hand the labia are separated
and the speculum, well lubricated, is introduced through the urethral
orifice, whence it is gradually pushed into the bladder following the
urethral curve under the pubic arch. Upon removal of the obturator,
air rushes in distending the bladder. If, when the patient is in
the knee-chest position, the bladder does not balloon up, two
Fig. 695. — -Method of removing residual urine during a cystoscopic
examination.
fingers may be introduced into the vagina so as to distend it with
air. The illumination is then turned on, or, in the absence of a self-
illuminated speculum, the light from the electric head light or head
mirror is thrown into the bladder through the speculum, and the
bladder is systematically examined (Fig. 694).
By alternately moving the speculum from side to side and depress-
ing or elevating the handle all portions of the bladder may be
inspected. If the patient is in the dorsal posture, urine soon collects
in a pool on the base of the bladder, and this must be removed as
often as required by means of the evacuator (Fig. 695). By means of
the cotton mops held in the alHgator forceps, mucus, blood, or pus
that may obscure a clean view of the mucous membrane may be
wiped away.
IRRIGATIONS 67 1
SKIAGRAPHY
The X-rays are sometimes used in locating a vesical stone which,
from being buried in a pocket or being situated behind the prostate,
may escape detection by other means. The success of the skiagraph
depends to a large extent upon the composition of the calculus. Oxa-
late and phosphate stones cast a dense shadow, but those composed
of urates and uric acid cast very faint shadows, and so may be
missed entirely. The bony walls of the pelvis may likewise interfere
and give a negative result. To secure a satisfactory radiograph it
is essential that the bowels be emptied by a purge administered the
night before followed by an enema in the morning.
By injecting into the bladder a solution of bismuth or one of the
silver salts and taking a radiograph immediately, much valuable
information as to the size and position of the bladder and the presence
or absence of diverticula, sacculations, tumors, or obstruction at the
vesical neck may be obtained.
Bismuth is used in a loper cent, watery solution. Of the silver
salts, collargol in 2 to lo per cent, solution and argyrol in 25 per cent,
solution are generally employed. Eight ounces (250 c.c.) of solu-
tion will be sufficient.
Therapeutic Measures
IRRIGATIONS
Irrigation of the bladder maybe employed either for simple cleans-
ing purposes, as is required in preparation for an instrumental
examination or operative procedure, or to produce a local effect upon
the mucous membrane. Irrigations are thus of the greatest value in
the treatment of various inflammatory affections of the bladder. In
acute cystitis, however, on account of the distention produced, they
often increase the pain and may aggravate the trouble. They should
be employed, however, in acute cases if the bladder does not com-
pletely empty itself and there is decomposition of urine. Irrigations
are also contralndicated where the bladder cannot hold more than i
ounce (30 c.c.) of fluid without exciting a desire to urinate; in such
cases, instiUations should be substituted.
There are two methods of performing vesical irrigation; (i) by
injecting the fluid in sufficient quantity to distend the bladder and
having it retained a short time before allowing it to escape, and (2)
by using a double-flow catheter which allows the fluid to escape as fast
672
THE BLADDER
as it flows ill. In the majority of cases the former is the preferable
method as a certain amount of distention of the bladder is necessary
in order to wash out pus, bacteria, and debris from the folds of mucous
membrane.
Apparatus. — A large glass funnel, 4 feet (120 cm.) of rubber
tubing, a soft-rubber catheter, a large glass graduate, a thermometer,
and a waste-pail are required (Fig. 696).
A double-flow soft catheter (Fig. 697) may be employed in place of
the ordinary catheter if desired. When this is used a graduated glass
irrigating jar should take the place of the funnel.
Fig. 696. — Apparatus for bladder irrigations.
Asepsis. — The apparatus is boiled and the thermometer sterilized
by immersion for 10 minutes in a i to 500 bichlorid of mercury solu-
tion followed by a thorough rinsing in sterile water. The operator's
hands should be thoroughly scrubbed.
Solutions Used. — Normal salt solution (oi (4 gm.) of salt to the
pint (500 c.c.) of water), a saturated solution of boric acid, silver
nitrate i to 15,000 to i to 5000, potassium permanganate i to 8000 to
I to 4000, bichlorid of mercury i to 100,000 to i to 5000, formalin
I to 5000, oxycyanid of mercury i to 5000 to i to 2000, carbolic acid,
etc., are among the numerous agents employed.
It is always well to begin the treatment with the weaker solutions
and gradually increase the strength as indicated. After an irrigation
with a poisonous drug, the bladder should be douched with normal
salt solution to prevent absorption.
Temperature. — The irrigating fluid should be at a temperature of
100° to 105° F. (38° to 41° C).
IRRIGATIONS
673
Quantity. — The irrigations should be continued until the fluid
returns clear. As a rule about i pint (500 c.c.) of solution will be
suflScient.
Fig. 697. — Return-flow soft-rubber catheter.
Fig. 698. — Irrigation of the bladder by the single-catheter method.
Frequency. — When there is profuse suppuration and rapid decom-
position of urine, the irrigations are employed twice a day. In a
mild case daily irrigations or on alternate days will sufl&ce. A lapse of
one or two days, however, should intervene when very strong solu-
tions are employed.
43
674 THE BLADDER
Position of Patient.— The patient should be in the dorsal position.
Preparation of Patient.— The bladder should be empty. The
external genitals are washed with soap and water followed by a i to
5000 bichlorid of mercury solution, and the urethra is irrigated with a
boric acid or i to 5000 potassium permanganate solution.
Technic. i. Single Catheter Method. — The catheter, well lubri-
cated, is gently passed into the bladder, and any residual urine is
Fig. 699. — Irrigation of the bladder with a double-flow catheter.
allowed to escape. The funnel is filled with from 3 to 6 ounces (90
to 180 c.c.) of the solution, and the tubing leading from the funnel is
attached to the catheter, first taking care to see that air or any cold
solution is expelled from the tube. The funnel is then raised 2 or 3
feet (60 to 90 cm.) above the patient and the solution is permitted to
slowly flow mto and distend the bladder. As soon as the patient
complains of the distention, the flow is shut off. After allowing the
solution to remain in the bladder a few moments, the funnel is lowered
below the level of the bladder and the fluid is allowed to escape into
AUTO-IRRIGATIONS 675
the waste-pail (Fig. 698). The funnel is then refilled and the process
repeated until the fluid returns clear.
In performing the irrigation care must be observed not to overdis-
tend the bladder. Just how much can be injected at a time depends
upon the individual case, but it should not be sufficient to cause any
pain. Entrance of air into the bladder should also be guarded
against.
2. Double- fl'Oiv Catheter Method. — The technic varies a little from
that just described. The catheter is passed into the bladder and the
irrigating tubing is attached to the inflow tube of the catheter. The
reservoir, filled mth the entire amount of fluid to be used during the
irrigation, is then raised 2 to 3 feet (60 to 90 cm.) above the bladder
and the solution is allowed to flow. As fast as it enters the bladder, it
is carried off again through the outflow tube (Fig. 699); but, by
occasionally compressing the outflow tube, the bladder may be more
or less completely filled before the fluid is permitted to escape.'
AUTO -IRRIGATIONS
While it is not advisable to allow a patient to irrigate his own
bladder in the presence of a severe cystitis, auto-irrigation may be
safely performed for the purpose of keeping the bladder clean by those
who are compelled to lead a catheter Hfe. The patient should, how-
ever, be carefully instructed how to sterilize the catheter, his hands,
etc., and in the proper method of performing the irrigation, and he
should be fully warned of the dangers of neglecting to follow the strict-
est rules of cleanhness.
Apparatus. — A douche bag with a capacity of i quart (i liter), 4
feet (120 cm.) of rubber tubing, a T-shaped glass tube, a soft-rubber
catheter, and a waste-pail comprise the necessary outfit. The
T-shaped glass connection is placed between the catheter and the
tubing of the reservoir and to its long arm is attached another piece
of tubing that leads to the waste-pail. A shut-ofl' chp is placed on the
tube leading from the irrigator and another upon the waste tube
(Fig. 700).
Solution Used. — It is better not to entrust the patient vnih strong
antisepric solutions; instead a saturated (4 per cent.) solution of boric
acid should be used. It is prepared by dissolving about 5 teaspoon-
fuls (20 gm.) of boric acid crystals in i pint (500 c.c.) of hot water.
Position of Patient. — The irrigation is most conveniently given
with the patient sitting in a chair and with the waste-pail on the floor
between the legs.
676
THE BLADDER
Technic. — The reservoir is filled with i pint (500 c.c.) of warm
(105° F. (41° C.)) boric acid solution and is hung on a hook about 3
feet (90 cm.) above the level of the bladder. The patient then intro-
duces his catheter into the bladder and draws off the urine. The
solution is allowed to flow from the tubing to expel any air or cold
fluid, and the tubing is then connected with the catheter. The
solution is allowed to flow into the bladder until there is a feeling of
distention, when the flow is shut off and the outflow pipe is opened
Fig. 700. — Apparatus for auto-irrigation of the bladder.
allowing the fluid to escape into the waste-pail. The process is
repeated until the reservoir is emptied.
INSTILLATIONS
Instillations dift"er from irrigations in that a smaller quantity of
solution is used and the fluid is allowed to remain in the bladder.
Stronger solutions can thus be employed and it is possible to obtain a
more lasting effect upon the mucous membrane than from an irriga-
tion. Instillations are very useful in all cases of cystitis, but espe-
cially those in which the inflammation is particularly severe about the
trigone and vesical neck.
The immediate effect of the instillation is to induce a moderate
congestion accompanied by an increased desire to urinate and some
pain, but this soon passes off and is followed by reaction and a gradual
relief of the symptoms.
Syringe. — A Keyes-Ultzmann syringe will be required (Fig. 701).
When, however, it is desired to inject more than 1/2 dram (2 c.c.)
INSTILLATIONS
677
of solution, a soft-rubber catheter and glass syriDge of the desired
capacity should be substituted for the above.
Solutions Used. — Silver nitrate beginning with a i to 1500 solu-
tion increased to 5 per cent., protargol i to 20 per cent., bichlorid of
mercury i to 10,000 to i to 5,000, a 10 per cent, emulsion of iodoform
and glycerin, etc., are often employed.
Quantity. — As a rule about 15 to 30 HI (i to 2 c.c.) are injected,
but when it is desired to medicate a large surface, as much as i dram
(4 c.c.) or more may be used.
Frequency. — Instillations may be employed every other day to
every third or fourth day according to the reaction they provoke.
Position of Patient. — The dorsal position is used.
Preparations of Patient. — The bladder should be empty, and if
there is residual urine it should be drawn off by a catheter. The
external genitals are cleansed and the urethra is irrigated with a
boric acid solution.
Technic. — The syringe is first filled with the desired amount of
solution. The nozzle, after being well lubricated with lubrichondrin ,
Fig. 701. — Keyes-Ultzmann instillation syringe.
is then introduced in the same manner employed in passing any
curved urethral instrument (see page 587) until its point Hes in the
prostatic urethra. This will be when the shaft of the instrument has
been depressed between the legs to an angle of a little less than 45
degrees with the horizon. The required amount of medication is
then slowly injected into the prostatic urethra, whence it flows over
the vesical neck and trigone. In removing the syringe the piston
should be first withdrawn a little so as to prevent any solution leaking
from it along the urethra.
When using the catheter method of instillation, the same technic
as for a posterior urethral irrigation (page 614) is followed.
CYSTOSCOPIC TREATMENT
In the hands of an expert the cystoscope becomes an instrument
of great value in treating vesical lesions. While cystoscopic treat-
6/8
THE BLADDER
ment is more difficult in the male than in the female, such procedures
as removing small calculi and foreign bodies, dilating the ureteral
openings, snaring small growths, the curettage of ulcers, the direct
application of strong solutions of silver nitrate to diseased areas by-
means of a cotton- tipped probe, etc., may be satisfactorily per-
formed, even in the male, by a physician of skill and experience.
Instruments. — For male cases, a direct-view-air-distention cysto-
scope provided with a perforated window and bulb-aspirator (Fig.
702) is necessary. In the female, Kelly's tubes (page 666) or some
of their modifications are employed.
^-^^
Fig. 702. — Bransford Lewis operating cystoscope. (Lewis in Keen's Surgery.)
Technic. — The method of exposing and treating diseased areas is
performed in the same manner in which the bladder is inspected
(pages 663, 669) and requires no further description here. In
making applications of strong solutions, however, care should be
taken to bring the solution only in contact with the diseased area and
not to saturate the applicator with an excess of solution.
THE DESTRUCTION OF VESICAL GROWTHS BY
THE HIGH FREQUENCY CURRENT
While the use of the high frequency (Oudin) current for the
destruction of neoplasms has been employed for a number of years
in the treal ment of superficial and cutaneous growths, the adaptation
of this method of treatment to the destruction of vesical papillomata
is of comparatively recent date. Beer of Xew York in 19 10 being the
DESTRUCTION OF VESICAL GROWTHS 679
first to suggest it. Since then Keyes, Jr., and others have reported
upon the use of this form of treatment in vesical growths, both
benign, and mahgnant, and in the benign papillomata the results
have been uniformly successful. Against malignant growths, how-
ever, unless very small, the high frequency current has not proved
more than a palliative measure.
Briefly the method of treatment consists in the repeated applica-
tion of the high frequency current to the tumor by means of an insul-
ated wire introduced into the growth through the aid of a cystoscope.
The current produces an intense reaction in the tissues to which it
is applied followed by necrosis and the gradual sloughing away of the
growth.
Properly applied the treatments are practically painless unless
the electrode comes in contact with the bladder wall.
Apparatus. — An ordinary direct or indirect ureter catherizing
cystoscope (see page 705), a Janet syringe, a catheter, a heavily
insulated 6-ply copper wire cable to fit into the catheter chamber of
the cystoscope, and a high frequency machine with a Oudin resonator
are required.
Asepsis. — The same as for a cystoscopic examination (see page
661).
Position of Patient. — The same as for a cystoscopic examination
(see page 661).
Anesthesia. — General anesthesia is not required. The methods
of obtaining local anesthesia have been fully described (see
page 662).
Strength of Current. — The spark gap should be 1/8 to 1/4 of an
inch (3 to 6 mm.). A wider gap gives greater voltage and produces
too strong a reaction.
Duration of Each Treatment. — The current is appHed to one spot
for from 15 to 30 seconds at a time, and the number of applications
will depend upon the size of the growth. Each treatment should not
average more than from 3 to 5 minutes.
Frequency of Treatments. — Ordinarily treatments are given at
intervals of from 4 to 7 days. In very sensitive bladders an interval
of from 10 days to 2 weeks may elapse between treatments.
Preparations of the Patient. — The external genitals are cleansed
with soap and water, followed by a i to 5000 bichlorid of mercury
solution. The bladder is emptied and thoroughly irrigated and from
4 to 6 ounces (120 to 180 c.c.) of sterile water are allowed to remain
for purposes of distention.
68o THE BLADDER
Technic. — Having tested the cystoscope and the high frequency
current, the cystoscope, well lubricated and with the electrode in
one of the catheter chambers is introduced into the bladder (see page
663). The end of the wire to be introduced into the tumor, should
have been previously cut off flush with the insulation. The tumor
is located and the electrode is inserted into it as near the base as
Fig. 703.— Destruction of vesical growth by means of the high frequency current
(After Oudin.)
possible (Fig. 703). The current is then turned on for 15 to 30 sec-
onds and a rapid blanching of the tissues at the point of contact
occurs. The wire is then allowed to cool and is reinserted into
another portion of the tumor and the dessication continued until the
whole mass has been treated. At subsequent treatments portions of
the growth that remain viable are similarly dealt with. When the
entire mass has sloughed away the base is likewise treated.
CATHETERIZATION OF THE BLADDER
Catheterization of the bladder is indicated in all cases of complete
retention of urine and in some cases of partial retention, as, for
example, in prostatic hypertrophy when the residual urine amounts
to more than 2 ounces (60 c.c). Retention may be the result of
obstruction from stricture, spasm of the compressor urethrse muscle,
hj-pertrophy or congestion of the prostate, clots of blood, calculi,
foreign bodies or tumors in the bladder or urethra, perineal abscess,
traumatism, etc., etc., and as the result of defective expulsion power
of the bladder through impairment of the nervous mechanism, as in
hysteria, certain diseases of the brain and spina] cord, shock, fevers,
CATHETERIZATION OF THE BLADDER
68l
after the use of certain drugs, following rectal operations, etc., etc.
The probable cause of the retention should, if possible, be ascertained
before attempts to pass a catheter are made.
Retention may come on suddenly or gradually. In the presence
of acute retention there is great desire, but inability, to urinate, ac-
companied by a severe and aching pain in the abdomen and perineum. '
Fig. 704. — Soft-rubber catheter.
Unless the condition is reheved, the symptoms rapidly grow worse
and the patient lapses into a comatose state. When the retention is
gradual in onset, these severe symptoms are sometimes absent even
in cases of enormous distention, and it may be only the dribbling of
the overflow from the overdis tended bladder that the patient com-
plains of, the so-called "false incontinence." Physical examination
will, however, reveal an elastic fluctuating tumor occupying the
Fig. 705. — Silver catheter.
and becomes more
hypogastrium, which is dull on percussion
prominent with the patient standing erect.
Instruments. — An assortment of the various forms of catheters
should be on hand. For the ordinary cases of retention, uncompli-
cated by stricture or an enlarged prostate, a soft-rubber Nelaton
(Fig. 704) or a blunt silver catheter with a short curve (Fig 705) may
be employed.
682
THE BLADDER
In the presence of strictures a gum elastic olivary catheter (Fig.
706) and a set of Gouley's tunneled catheters and filiforms (Fig. 707)
will be required. In place of the latter a whip catheter (Fig. 708)
may be employed. This consists of a flexible gum elastic catheter
tapering off for several inches into a filiform.
Fig. 706. — Gum-elastic olivary catheter.
Fig. 707. — Gouley's tunneled catheter and filiform.
Fig. 708. — Whip catheter.
The best form of catheter to use when the prostate is enlarged is a
Mercier coude catheter (Fig. 709) . The slight angle at the end of this
instrument permits it to override an obstruction. Guyon's mandarin
coude catheter (Fig. 710) and a long-curved silver prostatic catheter
(Fig. 711) should also be provided. The caUber of the instruments
CATHETERIZATION OF THE BLADDER
683
for this class of cases should be fairly small, say from 15 to 18 French.
Asepsis. — The greatest care should be taken to avoid infection of
the bladder. Metal and rubber catheters, as well as the better make
Fig. 709. — Catheters with a coude and bicoude curve.
gum elastic instruments are boiled for five minutes. Instruments
that will not stand boiling are sterilized by formalin vapor (page 587)
or by immersion in a i to 20 carbolic acid solution followed by rinsing
Fig. 710. — Guyon's mandarin coude catheter.
in sterile water. The operator's hands are to be sterilized as carefully
as for any operation.
Quantity of Urine Withdrawn. — Except when the distention is
slight and of short duration, the bladder should not be emptied com-
FiG. 711. — Silver prostatic catheter.
pletely at the first catheterization. As the result of long-standing
vesical distention there occurs a dilatation of the ureters and renal
pelvis with changes in the kidney structure, and a sudden evacuation
of the urine is apt to be followed by suppression of urine; or hemor-
684
THE BLADDER
rhage from the vesical mucous membrane or kidneys may result from
the sudden relief of pressure upon the distended veins. Therefore,
not more than 8 ounces (240 c.c.) of urine should be withdrawn at the
lirst catheterization, gradually increasing the amount at subsequent
catheterizations.
Fig. 712. — Showing the method of passing a soft-rubber catheter.
Fig. 713. — Showing soft-rubber catheter passed into the bladder.
Frequency. — As a rule, in complete retention the bladder requires
emptying every four to eight hours. When the catheter is employed
for withdrawing the residual urine of prostatic hypertrophy the
frequency will depend upon the amount of residual urine. Thus, if
Ihis amounts to from 2 to 4 ounces (60 to 120 c.c), one daily catheter-
CATHETERIZATION OF THE BLADDER
685
ization before the patient retires in the evening will suffice; if it
amounts to from 4 to 6 ounces (120 to 180 c.c), the catheter should
be used twice a day, i.e., in the evening and morning; larger quanti-
ties of residual urine demand that the bladder be emptied three or
four times a day.
Position of Patient. — Catheterization should always be performed
with the patient recumbent, as shock or other unexpected symptoms
may appear at any time during the operation. The patient is there-
PiG. 714. — Showing an ordinary catheter obstructed by an enlarged middle lobe of
the prostate gland.
fore placed in the dorsal position with his shoulders slightly raised
and thighs somewhat flexed and rotated slightly outward.
Preparation of Patient. — The glans penis and meatus should be
washed with soap and water, followed by a i to 5000 bichlorid of
mercury solution and then sterile water. The urethra is irrigated
with a warm saturated solution of boric acid or a i to 5000 solution
of potassium permanganate.
Technic. — i. In Cases Uncomplicated by Stricture or Enlarged
Prostate. — A full-sized soft-rubber catheter is tried first. It is well
lubricated and, while the penis is held upright, is slowly fed into the
urethra a little at a time (Fig. 712). If the catheter becomes ob-
structed, the penis should be put upon the stretch to obliterate any
wrinkles in the mucous membrane, and the instrument is again
advanced as before or by rotating it while the attempt is made to
686
THE BLADDER
make it pass. In this way a soft instrument can usually be made to
enter the bladder when the retention is simply due to defective expul-
sive power. In withdrawing a catheter the instrument should be
compressed between 1 he thumb and forefinger, or the tip of the finger
should be placed over the opening at the proximal end to prevent
the urine which remains in the catheter from dripping out and wetting
the patient's clothes.
In cases of spasmodic stricture, failing in attempts to pass a soft
instrument, a full-sized metal catheter should be resorted to. Such
a catheter is passed precisely as one would a sound (see page 587).
Fig. 715. — Showing a coude catheter passing the obstruction.
When the point of the instrument has been introduced as far as the
obstruction, it should be held pressing steadily against the face of
the stricture for a few minutes until the spasm passes off, when it
may be easily slipped into the bladder.
2. In the Presence of Stricture. — In dealing with a retention due to
stricture a small soft-rubber catheter should be given first trial. If
unsuccessful, attempts may be made to pass an olivary pointed
catheter. If this fails, a filiform should be introduced through the
stricture (see page 636) and a Gouley tunneled catheter passed over
this as a guide, or, in its stead, a whip catheter may be employed.
Should the stricture be of such small caliber that it is only possible
to insert a filiform, the latter should be left in place to act as a capillary
drain, taking care, however, to fasten it in such a way that it cannot
slip out (page 691). In this way the bladder will empty itself in a
CATHETERIZATION IN THE FEMALE 687
few hours and, by the end of twenty-four hours, sufficient dilatation
wiJl usually have taken place to allow the passage of a tunneled
catheter. Failing to pass even a filiform the bladder should be
aspirated (page 692).
3. In the Presence of Prostatic Hypertrophy. — A soft flexible cath-
eter should be tried and then a coude catheter. The latter will often
succeed where a soft catheter fails because the bend of the tip of this
instrument keeps the point in contact with the upper wall of the ure-
thra and thus permits it to more easily override a median prostatic
enlargement (Fig. 715). Sometimes, if an ordinary coude catheter
will not pass, an elbowed catheter with a stylet can be made to do so.
With this instrument it is possible to elevate the point more sharply,
when obstructed, by withdrawing the mandarin a little, so that the
point of the instrument passes upward over the obstruction into the
bladder.
After repeated and unsuccessful efforts with the above instrument
a metal prostatic catheter should be tried before resorting to aspira-
tion. Great gentleness should be employed in its introduction to
avoid making a false passage. Sometimes assistance in guiding its
point may be derived from placing a finger in the rectum.
CATHETERIZATION IN THE FEMALE
Catheterization of the female bladder is a simple procedure. It
should always be done, however, by direct sight; the old method of
passing a catheter by touch carries with it the great risk of infection.
Fig. 716. — Glass female catheter. (Ashton.)
Instruments. — A glass female catheter, 5 inches (13 cm.) long and
1/5 of an inch (5 mm.) in diameter with a gentle curve in opposite
directions at both ends (Fig. 716), is the best instrument to employ.
Asepsis. — The catheter is boiled for five minutes and the opera-
tor's hands are carefully scrubbed in soap and water, followed by
immersion in an antiseptic solution.
Position of Patient. — The patient should be in the dorsal position
with the thighs flexed and the legs well separated.
Preparations of Patient. — The external genitals and meatus are
cleansed with soap and water followed by a i to 50C0 bichlorid of
mercury solution.
688
THE BLADDER
Technic. — The operator separates the labia with the thumb and
forefinger of the left hand so as to expose the meatus. The catheter,
held near the proximal end in the fingers of the right hand, is then
Fig. 717. — Method of passing a catheter in the female. (Ashton.)
Fig. 718. — Showing the method of preventing urine dripping from the catheter as
it is withdrawn. (Ashton.)
introduced through the urethra into the bladder (Fig. 717). When
the bladder has been emptied, the forefinger is first placed over the
proximal end of the catheter to prevent the escape of the urine it
contains (Fig. 718) and the instrument is then withdrawn.
CONTINUOUS CATHETERIZATION
689
CONTINUOUS CATHETERIZATION
A catheter may be introduced into the bladder and left in place in
cases where drainage of the bladder for a brief period is desired. It
may be employed in chronic cystitis accompanied by the presence of
large amounts of pus, frequent urination, and tenesmus, in vesical
^.
Fig. 719. — The Pezzer retention catheter.
hemorrhage, and in cases of obstruction from an enlarged prostate
where the constant introduction of a catheter causes spasm or hemor-
rhage, or where catheterization is difhcult. The bladder is thus put at
rest and at the same time is kept constantly emptied, the beneficial
^^
Fig. 720. — The Malecot retention catheter.
effects of which are shown by a rapid decrease of the inflammation
and congestion, decline of the fever, and relief of the pain and tenes-
mus. Continuous catheterization is also indicated in wounds of the
urethra or after certain operations upon the urethra when it is desir-
able to prevent the contact of infected urine with raw surfaces.
Fig. 721. — Stylet in place in Malecot catheter, a, Mandarin pushed forward; b,
mandarin withdrawn.
At first, when the catheter is inserted, there may be a feeling of
weight in the perineum, but this soon passes off. In some instances a
mechanical urethritis is set up which may persist until the instrument
is removed and, if neglected, urethral abscess or extension of the
infection backward into the bladder may result.
44
690 THE BLADDER
Instruments. — A simple soft-rubber catheter of about 18 French
with the eye near the end or the retention catheters of Pezzer or
Malecot may be employed. The Pezzer catheter (Fig. 719) has a
flange to rest against the vesical neck, while the ]\Ialecot instrument
(Fig. 720) has wings on either side. When introduced over a stylet
(Fig. 721), these projections are made to disappear, but reappear
when the stylet is removed.
Asepsis. — The catheter should be thoroughly sterilized by boiling
or by formalin vapor and, if the latter method is employed, care must
be taken to remove all trace of the formalin by thoroughly rinsing the
catheter in sterile water. The operator's hands should hkewise be
perfectly sterile.
Duration. — This will depend upon the toleration of the urethras
In some cases, continuous drainage may be kept up for over two week.
Fig. 722. — Showing the method of securing a catheter in the bladder. (After
Sinclair, Polyclinic Journal, July, 1908.)
without the catheter causing much irritation; in others, the presence
of an instrument in the bladder produces so much irritation and ves-
ical spasm thai it cannot be used at all.
Preparation of Patient. — The glans penis and meatus are washed
with soap and water followed by a i to 5000 solution of bichlorid of
mercury, and the urethra is thoroughly irrigated with a mild anti-
septic solution.
Technic. — i. By the Ordinary Catheter. — If a simple rubber
catheter is employed, it is well lubricated and is then introduced in
the usual way until its eye lies just within the bladder. It is quite
important that the point of the catheter be not introduced too far,
for, if so, it will not only fail to drain the bladder properly, but will
irritate the vesical floor. To insure that the instrument is properly
placed, it should first be introduced into the bladder imtil the urine
flows freely and then slowly withclra^vn until the flow just stops,
when it is pushed into the bladder again, this time for a distance of
1/4 inch (6 mm.). It is then secured in place as follows:
CONTINUOUS CATHETERIZATION
691
The portion of the catheter protruding from the meatus is thor-
oughly dried and all grease is removed. Then four pieces of adhesive
plaster, each about 4 inches (12 cm.) long and 1/4 inch (6 mm.) wide,
are secured to the catheter at the point it emerges from the meatus in
such a way that one strip lies upon the dorsum, one on the ventral
surface, and one on either side of the penis. Each strip is carried
back over the foreskin and is made to adhere to the body of the penis.
An additional strip of adhesive i inch (2.5 cm.) wide is placed hori-
zontally about the penis back of the corona, covering the four small
strips (Fig. 722). Care should be taken, however, not to have this
strip entirely encircle the penis. The penis is then wrapped in sterile
gauze and is supported over one groin by a T-bandage. If upon
Fig. 723. — Malecot retention catheter in place in the bladder.
inspection it is found that the urine escapes freely, the free end of the
catheter is finally connected with a drainage-tube which conducts
the urine to a receptacle at the side of the bed. The receptacle
should be half-full of some antiseptic solution.
If the retained catheter is employed in a case of long-standing
retention where it is dangerous to empty the bladder at once, an
intermittent form of drainage may be employed by discarding the
drainage-tube and simply inserting a plug in the end of the catheter,
which is removed at definite intervals and an increasing quantity of
the urine drawn off each time until it is considered safe to empty the
bladder completely, when the above method is used.
2. By the Self -retaining Catheter. — In inserting a special self-retain-
ing catheter, a stylet curved to the shape of a sound is introduced
within the instrument so as to obliterate the projecting collar or
wings (see Fig. 721). When the catheter is in place, the stylet is
692 THE BLADDER
withdrawn, thus allowing the bladder end of the catheter to expand
again so that the catheter is retained in place unless some force is
used in withdrawing it (Fig. 723). In spite of this, however, it is
safer to fix the catheter in place by the method above described,
after first withdrawing it until the resistance shows that the terminal
enlargement is at the vesical neck.
After-care. — The catheter rapidly becomes encrusted with lime
salts, blood, or pus and should, therefore, be changed every two or
three days to permit of its being cleansed. At this time the urethra
and bladder should be thoroughly irrigated with a mild antiseptic
solution and the catheter thoroughly sterilized before it is reinserted.
In the presence of pus or blood the bladder may be irrigated through
the catheter as frequently as seems indicated.
If urethritis develops, the urethra should be irrigated once or
twice daily with a saturated solution of boric acid. This may be
accomplished by withdrawing the catheter until its extremity lies
in front of the bulbous urethra and then flushing out the urethra
from behind through the instrument by means of an irrigating appa-
ratus. The catheter is then pushed back to its original position.
Constant watch should be kept lest ulceration of the urethral wall
develop at the penoscrotal junction from pressure of the catheter.
To avoid this, the penis should be supported in such a position that
the sharp angle formed at the penoscrotal junction when the organ
hangs vertically is obliterated.
ASPIRATION OF THE BLADDER
Suprapubic aspiration of the bladder is indicated as a temporary
expedient when there is complete retention of urine and catheteriza-
tion is impossible from the presence of a tight stricture, prostatic
enlargement, or from any other cause. The operation is easily
performed and, if properly done, is a safe procedure. At times after
a single aspiration the congestion is so much lessened that within a
few hours it becomes possible to pass a catheter, or the patient voids
spontaneously, but, if necessary, the bladder may be emptied several
times a day for several days by this method without danger.
Where a permanent drainage for some time is desired, suprapubic
puncture by means of a trocar and cannula may be performed.
Puncture through the perineum or rectum, on the other hand, should
be avoided as unsafe.
Instruments. — For temporary relief an aspirating needle and
syringe should be employed. The needle should be fairly fine and
ASPIEATON OF THE BLADDER
693
about 3 inches (7.5 cm.) long. The Potain aspirator (Fig. 724) is
the best to use. This instrument has already been described
(page 286).
When a trocar and cannula are used, a curved instrument with
the convexity of the curve upmost should be obtained. A scalpel to
nick the skin is also required.
Asepsis. — The instruments are boiled for five m.inutes in a i per
cent, sodium carbonate solution and the operator's hands are sterilized
in the usual way as for any operation.
Site of Puncture. — The puncture is made in the median line about
1/2 inch (i cm.) above the pubes. The extraperitoneal space above
Fig. 724. — Potain aspirator.
the pubic bone is increased when the bladder is distended and a needle
or trocar may be inserted here without danger of entering the perito-
neum. When a number of punctures are made, the site may be
changed a little each time.
Position of Patient. — The operation may be performed with the
patient recumbent or sitting partly up.
Preparations of Patient.^-^The pubes should be shaved and then
painted with tincture of iodin.
Anesthesia. — Sufficient anesthesia is obtained by freezing the
surface tissues with ethyl chlorid or salt and ice to render the opera-
tion painless.
Technic. — i. By the Aspirator. — The suprapubic region is first
carefully percussed to make sure that there are no coils of intestine
694 THE BLADDER
lying in front of the bladder. The aspirator is assembled, tested, and
the air in the bottle exhausted. A small nick is then made in the
skin at the spot chosen for the puncture and the needle, held in the
right hand with the index-finger placed on its shaft as a guide, is
introduced through the tissues, directed downward and backward,
until a lessened resistance signifies that the bladder has been entered
This will usually be when the needle has entered from i 1/2 to 2 1/2
inches (4 to 6 cm.), depending upon the thickness of the abdominal
wall. The aspirator is then attached and the vacuum is extended to
the needle-point by opening the inflow cock. If no urine is with-
drawTi, the needle is introduced still further until fluid is reached.
The contents of the bladder are then partly or completely emptied,
depending upon the duration of the retention and the amount of the
distention (see page 683).
In removing the needle, care should be taken to keep up the suc-
tion until the needle is completely withdrawn, otherwise some urine
may escape from the tip of the needle as it traverses the prevesical
space and cause an infection. The site of the puncture is finally
covered with a piece of sterile gauze held in place by adhesive plaster.
2. By the Trocar and Cannula. — A small nick is made in the skin
as before at the chosen site and through this the trocar and cannula
with the convexity up is inserted into the bladder, care being taken to
guard against the instrument entering too deeply by placing the index-
finger on the shaft of the instrument as a guide. The trocar is then
removed and the cannula is secured in place for permanent drainage
by means of tapes. A rubber drainage-tube leading to a receptacle
half filled with an antiseptic solution is fastened to the cannula.
The bladder may be irrigated through the cannula once or twice
daily if it contains much pus. The cannula should be removed and
sterilized every few days. To do this a small catheter is passed
through the lumen of the cannula into the bladder where it is main-
tained while the catheter is being cleansed. The cannula is then easily
reintroduced over the catheter as a guide.
The permanent cannula should be removed as soon as it is possible
to pass a catheter through the urethra without difficulty. The sinus
remaining is allowed to close by granulation.
CHAPTER XXI
THE KIDNEYS AND URETERS.
Anatomic Considerations
The Kidneys. — The kidneys are two bean-shaped organs, each
measuring on an average from 4 to 4 3/4 inches (10 to 12 cm.) in
length and 2 1/2 inches (6 cm.) in breadth. They he deeply situated
in the abdominal cavity on each side of the vertebral column, behind
the peritoneum embedded in a loose layer of areolar tissue, the peri-
renal fat, resting upon the diaphragm, the quadratus lumborum,
Fig. 725. — The position of the kidneys and course of the ureters from behind.
and psoas muscles. Surrounding the perirenal fat is a layer of fascia,
complete except along the inner border of the kidney and at its lower
pole, which is firmly attached to the spine and diaphragm, and serves
to anchor the kidney in place.
The position of the kidneys from behind corresponds to the space
between the upper border of the twelfth dorsal vertebra and the first
and second, or third, lumbar vertebrae. The right kidney generally
lies about 1/3 to 1/2 inch (0.7 to i cm.) lower than the left on
69s
696
THE KIDNEYS AND URETERS
account of the position of the hver above it. the upper extremity of
the right kidney usually reaching to the level of the lower border of
the eleventh rib and that of the left to the upper border of the eleventh
rib. The inferior poles of the kidneys reach to within i 1/2 inches
(4 cm.) on the right and to within 2 inches (5 cm.) on the left of the
crest of the ilium. During deep inspiration or when the patient
stands erect the kidney will descend to a somewhat lower level. The
long axis of the kidney is directed obliquely downward and outward,
Fig. 726. — The kidneys and ureters from the front.
so that the superior poles lie from 1/2 to i inch (i to 2.5 cm.) nearer
the median line than the lower poles.
Anteriorly, the position of the kidney may be mapped out b}^ pass-
ing a horizontal line through the umbihcus and a vertical line from
the middle of Poupart's ligament to the costal border perpendicular
to the horizontal line — the former passes just below the lower poles
of the kidneys, while the latter cuts the long axis of the kidney at the
junction of its middle and outer thirds. If the kidney lies to the outer
side of the vertical line or below the horizontal umbilical line, it is
indicative of enlargement or a displacement.
Relations of Kidneys. — Behind, the kidneys are in relation with
the diaphragm, quadratus lumborum, psoas muscles, and with the
last dorsal, iliohypogastric, and ilioinguinal nerves. The close
ANATOMIC CONSIDERATIONS 697
relations of these nerves account for the referred pains sometimes
encountered in diseases of the kidneys.
In front of the right kidney are the under surface of the right lobe
of the liver, the second portion of the duodenum, the ascending colon,
and the hepatic flexure. The left kidney is in relation in front with
the spleen, the fundus of the stomach, the tail of the pancreas, the
splenic vessels, and the descending colon.
Ureters. — The ureters are two in number, one for each kidney.
They are about 12 inches (30 cm.) in length and have a caliber equal
to that of a goose quill. The ureter begins at the neck of the renal
pelvis opposite the lower pole of the kidney and passes down on the
psoas muscle behind the peritoneum to the brim of the pelvis. A line
drawn on the abdominal wall vertically upward from the junction of
the middle and inner thirds of Poupart's ligament roughly represents
the course of the ureter from the kidney to the pelvic brim.
The ureter in the male, after crossing the pelvic brim and the
common ihac vessels, passes downward and backward in front of the
sacroiliac joint and enters the parietal attachment of the posterior
false ligament of the bladder. It then passes forward and inward to
the base of the bladder which it enters just above the seminal vesicle,
first passing under the vas deferens.
The ureter in the female, after crossing the pelvic brim and iliac
vessels, passes downward and backward along the lateral wall of the
pelvis as in the male. It then enters the base of the broad ligament
and passes down parallel with the cervix and upper portion of the
vagina, at a distance of about 1/2 inch (i cm.) external to the cervix
and posteriorly to the uterine artery. After crossing the upper third
of the vagina the ureter enters the bladder opposite the middle of the
vagina. The pelvic portion of the ureter in the female is thus readily
palpated through the vagina or rectum.
The ureters enter the bladder i 1/2 to 2 inches (4 to 5 cm.) apart
and, after passing obliquely forward and inward for a distance of 3/4
of an inch (2 cm.) through the bladder wall, they appear on the
mucous membrane about i 1/4 inches (3 cm.) apart and the same dis-
tance posterior to the internal urethral orifice. Through this oblique
insertion of the ureters into the bladder regurgitation of urine when
the bladder is distended is effectually guarded against.
The ureters are composed of three coats, an outer fibrous, a middle
or muscular, and an internal or mucous. Normally the walls are
collapsed and lie in contact. The lumen of the ureter presents three
constrictions and two intermediate dilated portions. The constric-
698 THE KIDNEYS AND URETERS
tions are: First, about 2 1/2 inches (6 cm.) from the hilum of the
kidney; second, at the point where the ureter crosses the pelvic
brim; and, third, at its entrance into the bladder.
Diagnostic Methods
In suspected disease of the kidney or ureter a careful history of the
past ailments and present symptoms should first be obtained. Fre-
quently pain will be the only symptom complained of. In such case
its exact location should be determined; that is, whether limited to
the loin or radiating along the course of the ureter, and whether
unilateral or bilateral. Severe attacks of pain radiating from the loin
down toward the bladder, testicle, and thigh are strongly suspicious
of calculus. The character of the pain should also be ascertained;
whether it is dull or aching, or paroxysmal and lancinating, and
whether continuous or periodic. Periodic attacks of sharp pain
accompanied by a considerable diminution in the amount of urine
secreted, followed by relief of the pain and an abundant flow of urine
are characteristic symptoms of hydronephrosis due to a movable
kidney. The patient should also be questioned as to the character
of his urine, i.e., whether bloody, etc., supplemented by inquiry as to
special points along the lines mentioned in the sections upon the
urethra and bladder. This is followed by a thorough physical
examination.
Having obtained all the information possible by these means, the
actual examination of the organ under consideration may be taken up.
The methods available for examination of the kidneys and ureters
include inspection, palpation, percussion, urinalysis, cystoscopic
examination, ureteral catheterization, pyelometry, segregation of
urine, determination of the functional capacity of the kidneys,
skiagraphy, and exploratory incision.
INSPECTION
On account of the deep situation of the kidney in the abdomen,
inspection gives no information if the kidney is normal. When, how-
ever, the kidney is greatly enlarged it may produce a visible swelling
in the loin or protrude anteriorly and cause a bulging of the lower
ribs upon the side affected.
Inspection should be performed from in front -with the patient
lying flat on the back, and also from behind and laterafly with the
PALPATION OF THE KIDNEYS
699
patient standing and bending forward, so as to make any bulging
more prominent through relaxation of the abdominal muscles.
PALPATION OF THE KIDNEYS
Palpation is by far the most valuable of the methods of physical
diagnosis for determining the presence of enlargement or displace-
ments of the kidney. While the normal kidney can seldom be felt,
unless the individual is very thin and the abdominal wall is lax, and
then it is only possible to palpate the lower pole of the kidney, an
increase in the size of the organ or undue mobility is readily recog-
nized. By palpation it is also possible to determine the sensitiveness
of the kidney and in the presence of a tumor, its characteristics —
namely, its size, sl^ape, and whether soft, hard, or fluctuating.
Palpation is sometimes performed with one hand, so placed that
the fingers press in the loin while the thumb lies on the abdomen
beneath the costal arch, but a more satisfactory method is the
bimanual.
Fig. 727. — Palpation of the kidney with the patient in the dorsal position.
Position of Patient. — The patient should lie flat on the back with
the head and shoulders elevated upon a small pillow and the lower
extremities flexed so as to thoroughly relax the abdominal walls.
Sometimes in cases of movable kidney additional information may be
elicited by palpating with the patient standing, his body bcDt forward
from the hips, and with his hands resting on the arm of a chair for
support; or else the patient may assume the lateral position, lying on
the sound side, and with the thighs slightly flexed (see Fig. 728).
?oo
THE KIDNEYS AXD URETERS
Preparations of Patient. — Care should be taken to have the colon
empty at the time of the examination; if necessary a cathartic should
be administered the night before for this purpose. All clothing that
is likely to interfere with the examination should be removed.
Anesthesia. — If palpation is difficult through rigidity of the ab-
dominal muscles or from increased sensitiveness, a general anesthetic
may be required in order to make a satisfactory examination.
Technic. — The examiner should stand upon the side he wishes to
examine. When palpating the right kidney the fingers of the left
hand are placed under the loin just below the last rib and the right
hand is placed flat on the abdomen below the costal arch (Fig. 727);
Fig. 728. — Palpation of the kidney with the patient on the side.
to palpate the left kidney the position of the hands is reversed. The
patient is instructed to breathe deeply but quietly, and any manipula-
tions should be gentle in character to avoid inciting muscular con-
traction. The kidney descends during inspiration and, if at this time
forward pressure is made with the hand under the loin and the hand
upon the abdomen is pressed backward under the ribs, the kidney, if
enlarged, will be felt. If the kidney is displaced, it may be caught
between the two hands as it descends during deep respiration and
may be prevented from returning to its former position. In the
presence of a tumor, the size, shape, and consistence of the growth
should be determined and its sensitiveness ascertained. Palpation
of the normal kidney causes a peculiar sensation which has been
likened to pressure on the testicle; actual pain will be elicited, how-
ever, in the presence of some tumors, kidney calculus, or pus
formation.
Tumors of the colon, gall-bladder, pylorus, spleen, or a peduncu-
PALPATION OF THE URETERS 701
lated ovarian or uterine growth may be mistaken for a renal tumor
or a movable kidney. The symptoms complained of and the relation
of the colon of the tumor, however, will usually settle the diagnosis.
The colon lies in front or to the inner side of the kidney and, if neces-
sary, it should be inflated to more accurately map it out.
At times the so-called "ballottement of the kidney" may be
obtained if the kidney is freely movable. To elicit this sign sudden
sharp pressure is applied to the loin by the posterior hand, when, if
movable or enlarged, the kidney will be driven forward with a slight
impact against the hand on the abdomen in front.
PALPATION OF THE URETERS
The ureters may be palpated through the abdominal wall, through
the vagina, or through the rectum. Abdominal palpation is only of
value if the patient is thin and the abdominal walls lax, and then it is
only possible to palpate the ureter if thickened or if it contains a
calculus. In some cases, however, if inflamed and painful, the ureter
may be traced from the kidney pelvis to the pelvic brim from the
pain elicited on palpation. Through the vagina it is possible to
palpate the ureter from the base of the broad ligament to its entrance
into the bladder. Calculi, thickening, or inflammation of this por-
tion of the ureter is thus readily recognized. In the male by rectal
examination the ureter may be palpated in its course from the pelvis
to the bladder.
Positions of Patient. — For abdominal palpation the patient should
lie flat on the back with the head and shoulders slightly elevated and
the thighs flexed.
Vaginal or rectal palpation is performed in the dorsal position
with the thighs flexed.
Preparations of Patient. — The bladder and bowels should be
empty at the time of examination.
Technic. — i. Abdominal Palpation. — The examiner stands on the
side to be palpated and first locates the promontory of the sacrum by
deep palpation with the examining hand. The ureter crosses the
pelvic brim at a point about i 1/4 inches (3 cm.) to the side of the
promontory and a little below it. A thickened ureter may be
palpated at this point if the patient has thin, relaxed abdominal mus-
cles. Beginning at this point, the ureter maybe traced upward along
its course by making deep pressure along the outer border of the rectus
muscle (Fig. 729). If the ureter is inflamed, palpation will elicit
702
THE KIDNEYS AND URETERS
pain. On the right side such pain must be differentiated from that
of cholecystitis or appendicitis.
2. Vaginal Palpation. — The right hand is employed to palpate
the right ureter and the left hand for palpation of the left ureter.
Fig. 729. — -Abdominal palpation of the ureter.
Fig. 730. — Vaginal palpation of the ureter. (Ashton.)
The index-finger is inserted in the vagina and is carried to the vaginal
fornix corresponding to the ureter to be palpated. From this point
it is pushed upward and outward toward the pelvic wall, and a careful
PERCUSSION
703
search is made for the ureter which will be recognized as a flat cord
passing forward and inward from the pelvic wall around the cervix to
the bladder (Fig. 730). Sometimes, by means of a bimanual exam-
ination, with one hand placed on the abdominal wall and exerting
downward pressure the ureter may be more satisfactorily examined.
3. Rectal Palpation. — The right hand palpates the right ureter
and vice versa. The index-finger well lubricated is inserted into the
rectum and is carried upward a little higher than the level of the base
of the seminal vesicle. The finger is then turned toward the lateral
wall of the pelvis and the ureter is sought by moving the finger
backward and forward. It will be recognized as a flat cord-hke
structure passing at first downward along the side of the pelvis and
Fig. 731. — Palpation of the ureter per rectum.
then forward. It may be traced as far as the bladder and will be
recognized passing forward and inward from the pelvic wall to the
base of the bladder, where it will be felt a little above the seminal
vesicle.
PERCUSSION
Percussion of the kidney is of slight value unless the organ is
greatly enlarged. At best it is diflicult on account of the thick layer
of muscles in the dorsal and lumbar regions and the depth of the
kidney from the anterior abdominal wall. In fat individuals the
difiiculties are increased in proportion. Percussion is important,
however, for the purpose of showing the position of the colon in
704
THE KIDNEYS AND URETERS
relation to a tumor occupying the region of the kidney and in
differentiating growths of the kidney from the spleen and liver.
Position of Patient. — To percuss from behind the patient should
lie face downward with a firm cushion or several pillows under the
abdomen to make the lumbar region more prominent (Fig. 732).
For anterior percussion the patient lies in the dorsal posture with
the legs extended.
Preparations of Patient. — The colon must be emptied so as not to
obscure the results.
Technic. — It is necessary to employ very strong percussion to out-
line the organ, but in fat individuals even this may yield unsatis-
factory results. In a normal case the kidney dulness will be found
to extend about 2 inches (5 cm.) below the last rib. merging above
17 •••;
Fig. 732. — Position of the patient for percussion of the kidneys from behind.
into that of the liver or spleen. In a large renal growth percussion
will give dulness extending outward and downward beyond the nor-
mal limits, with colon resonance in front or internal to the tumor.
Tumors of the spleen or liver may give much the same area of
dulness, but the colon resonance will be behind. Inflation of the
colon (page 521) may be necessary before its position can be accur-
ately determined.
URINALYSIS
The examination of the urine is of the greatest importance. It
should comprise a complete physical, chemical, microscopical, and
bacteriological analysis. Abnormality may be due to general
diseases, renal diseases, or to lesions in 1 he lower genitourinary tract,
so that it is not sufficient to simply recognize a departure from the
normal, but the seat of the trouble, i.e., whether in the bladder, ureter,
or kidney, must be determined and, if the ureters or kidneys are
affected, which side is involved as well. For this purpose the cysto-
CATHETERI2IXG THE URETERS 705
scope and ureteral catheter are of the greatest aid. Other methods
for determining the source of abnormal urinary constituents have al-
ready been described (see page 646).
CYSTOSCOPY (See page 659)
CATHETERIZING THE URETERS
The use of the ureteral catheter is of the greatest diagnostic aid in
diseases of the kidney or ureter, as it is possible by this means to
collect urine separately from each kidney for analysis uncontami-
nated by contact with the bladder or urethra, and to explore the
entire length of the ureter from the bladder to the kidney pelvis.
This method of examination is thus of value in determining whether
both kidneys are present, in estimating the functional capacity of
either kidney, and in the presence of blood or pus in the urine in
determining whether its source is the kidney or the ureter and from
which side it comes. It is also of the greatest aid in recognizing stric-
ture or calculus of the ureter, hydroureter, hydronephrosis, etc.
Ureteral catheterization has certain drawbacks that should be
mentioned. Under the most favorable conditions it requires con-
siderable skill to catheterize the ureters, and in some cases, compli-
cated by the presence of tight urethral strictures, enlargement of the
prostate, tumors, or thickening of the bladder mucous membrane it
may be impossible. Then there is always present the danger of
carr)dng infection from the bladder into a healthy ureter or kidney.
With proper aseptic precautions in performing the operation, how-
ever, this danger may be disregarded.
Fig. 733. — Bransford Lewis cystoscope.
Instruments. — Catheterizing cystoscopes, like the exploring
cystoscopes, are of two t}^es, the direct view and the indirect \aew.
The direct view cystoscope, of which the Brenner, BroT\Ti.
Bransford Lewis, Eisner, etc., instruments are t\-pes. are arranged
with the light either on the convex side of the beak, or with a wdndow
both on the convexity and concavity so that the hght is shed in both
45
706 • THE KIDNEYS AND URETERS
directions, and are provided with a straight observation telescope
having a window at the distal end. The catheter chambers are placed
on the under surface of the telescope so that the catheters protrude at
the lower part of the field of vision in a straight Hne. An obturator
takes the place of the telescope when the instrument is being inserted
into the bladder.
The indirect catheterizing cystoscope, such as the Nitze, Casper,
Albarran, Bierhoff, Buerger, etc., have the Hght upon the concave side
of the beak, while the image is reflected at right angles, by means of a
prism, to the eye-piece at the proximal end. The catheter chambers
are enclosed within the sheath of the instrument lying above the
telescope. A small movable tongue or finger, which can be raised or
lowered by means of a screw at the ocular end of the instrument, is
provided for the purpose of changing the angle of the catheters as
they emerge from the instrument. Irrigating cocks are provided
with both styles of cystoscope.
Instruments may also be obtained with which it is possible to
employ either the direct or indirect methods of observation and
catheterization, as McCarthy's composite cystoscope, which has
Fig. 734. — The Bierhoff cystoscope. a, Showing the instrument with the tele-
scope in position for catheterization; b, showing the telescope rotated within the
sheath to facilitate removal of the instrument.
both indirect and direct view telescopes and an indirect double
catheterizing attachment, and the universal cystoscopes of Tilden
Brown and Bransford Lewis, which combine in one instrument direct
and indirect observation and double catheterization by either the
direct or indirect method.
While the choice of the make of instrument must rest with the
individual operator, there is no doubt that in the majority of cases it
is easier to catheterize with the direct view instrument, exceptions
being the presence of intravesicular hypertrophy of the prostate and
a trabeculated bladder, in which class of cases the indirect view
instrument is essential; on the other hand, it is far easier to locate
the ureteral orifices by indirect view.
CATHETERIZING THE URETERS
707
The catheters, which are of silk elastic material about 24 inches
(60 cm.) long and 5 to 7 French in size, should be of different colors
to differentiate them. The distal end is either blunt or ohve pointed.
Before using, it should be seen that the catheters are smooth and the
eyes perfect; the patency of the catheters should also be tested by
injecting water through them. They are best kept at full length in
glass tubes plugged with cotton at either end.
For the purpose of recognizing calculi the end of the catheter may
be dipped in melted wax (2 parts of dental wax and i part of ohve oil)
and allowed to harden in the air (Fig. 735). On coming in contact
with a stone scratch marks will be produced on the wax tip. The
wax catheters can only be used, however, with the direct view instru-
ment and to avoid scratching the wax they should be threaded
through the instrument from the vesical end backward.
Fig. 735. — Wax-tipped ureteral catheter.
In addition to the ureteral catheters an irrigating jar or a Janet
syringe holding 3 to 4 ounces (90 to 120 c.c.) of solution and a soft-
rubber catheter should be provided for irrigating the bladder.
Illumination for the cystoscope may be obtained from a six- or
eight-cell battery or from the street current provided a controller is
employed.
Asepsis. — The cystoscope should be well cleaned with tincture of
green soap and water and is then placed in a i to 20 carbohc acid
solution or 95 per cent, alcohol, or it may be sterilized by formahn.
Before using, it should be rinsed oh in a saturated solution of boric
acid. The catheters are sterilized by formalin vapor or by boihng
for one or two minutes in plain water, care being taken to wrap
them separately in gauze to prevent their sticking together and to
place them at full length in the sterilizer. The examiner's hands are
carefully sterilized in the usual way.
Position of Patient. — The patient may be in the hthotomy posi-
tion with the buttocks close to the edge of the table, or as preferred
by some operators in a semirecumbent posture. The table should be
provided with uprights which are surmounted with double inchned
rests for the thighs and knees. (See Fig. 685)
Anesthesia. — If any anesthesia is necessary, local anesthesia
usually suffices. It may be obtained by the instillation into the deep
7o8
THE KIDNEYS AND URETERS
urethra of a small quantity of a 2 per cent, solution of cocain or by
filling the empty bladder with 5 ounces (150 c.c.) of a warm o.i per
cent, solution of cocain to which is added 20 drops (1.25 c.c.) of
adrenalin. This must be retained for at least fifteen to twenty
minutes. Guyon's method may also be employed (see page 662).
In some few cases it may be necessary to employ general anesthesia;
for children general anesthesia should always be used.
Preparations of Patient. — The external genitals should be cleansed
with soap and water followed by a i to 5000 bichlorid of mercury
solution. The bladder is then emptied and thoroughly irrigated
with a saturated solution of boric acid by means of a catheter and a
large syringe or through the sheath of the cystoscope if the instru-
ment is supplied with an irrigating cock, until the fluid returns clear.
Four to 6 oimces (120 to 180 c.c.) of a saturated boric acid or normal
salt solution are then injected into the bladder and allowed to remain
for the purpose of distention.
Fig. 736. — Catheterization by the direct method, showing the cystoscope as
introduced and with the vesical end deflected toward the ureter.
If hemorrhage from the bladder is sufficient to interfere with the
operation, a i to 3000 adrenalin chlorid or i to 15.000 silver nitrate
solution should be injected through the catheter and allowed to
remain in the bladder for ten to fifteen minutes before it is distended.
Technic. — i. Direct Catheterization. — The cystoscope and cathe-
ters having been thoroughly tested, the instrument, well lubricated
with glycerin or lubrichondrin and with the obturator in place, is
introduced into the bladder. The obturator is then removed and the
CATHETERIZING THE URETERS
709
catheterizing telescope is inserted in its place, after which the light
is turned on and the ureteral orifices are sought for. They are located
at the upper angles of the trigone about 3/4 inch (2 cm.) from the
median line and i inch (2.5 cm.) from the internal opening of the
urethra. By first locating the apex of the prostate and then pushing
the instrument in about i inch (2.5 cm.) the interureteric line which
passes between the two ureters, forming the base of the trigone, will
come to view and if this is traced to one side or the other the orifice
of the ureter will be recognized in the lateral angle of the trigone. It
may appear either as a slit or as a dimple on the apex of a papilla, and,
if carefully watched, urine will be seen coming from it in intermittent
spurts. It may be extremely difi&cult to locate the ureter, but a
careful search will usually reveal it. In all manipulations of the
cystoscope it is of the utmost importance to employ extreme gen-
tleness otherwise bleeding will supervene and interfere with the
examination.
Fig. 737. — Catheterization by the direct method, showing the heel of the cysto-
scope brought close to the mouth of the ureter.
With the direct view cystoscope the instrument is not rotated
about an axis, but the beak is kept constantly pointing upward while
the vesical end is turned from one side to the other or up and down
as the case may be (Fig. 736). The mouth of the ureter having been
located, the heel of the cystoscope is brought close to it (Fig. 737) and
an attempt is made to engage the catheter in its lumen. The catheter
7IO
THE KIDNEYS AND URETERS
is then slowly and gently threaded up the ureter to the desired dis-
tance (Fig. 738). If the purpose of the catheterization is simply to
withdrawurine from the ureter, the catheter is introduced 3 to 4 inches
(7.5 to 10 cm.); in exploring the ureter for stone or stricture, or to
determine whether pus has its origin in the ureter or kidney pelvis,
the catheter should be passed as far as the renal pelvis — 13 to 15
inches (32 to 37 cm.). If less than 11 inches (27 cm.) of catheter
can be inserted, an obstruction must be inferred (Braasch). The
other ureter is located and catheterized in the same manner.
Fig. 738. — Catheterization by the direct method, showing the catheter entering
the ureter.
The Hght is then extinguished and the catheterizing attachment is
first carefully removed and then the sheath, keeping the catheters in
position in the ureter by threading them through the instrument as
it is withdrawn. Unless the catheters are of different colors, they
should be labeled 'Meft" or "right" in order to distinguish them.
The first urine that flows is discarded and the ends of the catheters
are then wiped off and inserted into sterile bottles plugged with
cotton. A catheter may become plugged with mucus, blood clots,
or pus. If so about 15 TTt (i c.c.) normal salt solution may be in-
jected through it by means of a syringe.
From 2 to 4 ounces (60 to 120 c.c.) of urine are, as a rule, suffi-
cient for examination. While the urine is being collected, the
patient's legs should be released from the crutches holding them and
CATHETERIZING THE URETERS
711
he should be allowed to assume as comfortable a position as possible.
At the completion of the operation the catheters are carefully re-
moved and the bladder- is irrigated with a saturated solution of boric
acid.
Fig. 739. — Catheterization by the indirect method, showing the cystoscope in
position.
Fig. 740. — Catheterization by the indirect method, the catheter being pushed into
the instrument until its tip passes shghtly beyond the ureteral orifice.
2. Indirect Catheterization. — The instrument, well lubricated, is
introduced into the bladder and is then rotated completely around so
that its beak looks posteriorly. The prostate is thus located and by
712 THE KIDNEYS AND URETERS
rotating the instrument through an angle of 30 to 45 degrees the lat-
eral ridge of the trigone may be traced running backward at an angle
Fig. 741.— Catheterization by the indirect method, showing the tip of the catheter
being deflected toward the ureteral orifice by elevating the director.
Fig. 742. — Catheterization by the indirect method, showing the catheter inserted
in the ureter.
from the prostate. At the point of the junction of this ridge with the
interureteric line will be found the ureteral orifice. It should be
CATHETERIZING THE URETERS
713
remembered that with this form of instrmnent the image will appear
inverted, that is, the prostate will appear at the upper portion of the
field instead of at the lower. Having located the ureteral orifice the
instrument is brought close to it (Fig. 739) and the catheter is pushed
gently forward until its tip passes slightly beyond it (Fig. 740). The
small director is then elevated slightly (Fig. 741) and the catheter is
again pushed forward. If it misses the orifice, the catheter is with-
drawn a Httle and a second attempt made to introduce it. By
pushing the catheter forward a little or withdrawing it and changing
its angle of deflection slightly, it is finally introduced into the ureter
(Fig. 742). The other ureter is then located and the catheter is
Fig. 743- Fig. 744.
Fig. 743. — Removal of the sheath. First step, showing the telescope removed
and the catheters lying loosely in the sheath. (After Buerger, Annals of Surgery,
Feb., 1909.)
Fig. 744 — Removal of the sheath. Second step, showing the ocular end de-
pressed and carried to the left until clear of the catheters. (After Buerger,
Annals of Surgery, Feb., 1909.)
introduced in the same way. The catheterizing telescope is then
carefully removed, first turning the deflector down and extinguishing
the lamp. It is sometimes a difficult matter to remove the sheath of
the cystoscope and still leave the catheters in place when using this
form of instrument. The following manipulations, however, de-
scribed by Buerger {Annals of Surgery, February, 1909), simplify
this portion of the operation:
" After having introduced the catheters a httle higher than we
would if the instrument were to remain in the bladder, and after
714
THE KIDNEYS AND URETERS
removal of the telescope, the following movements should be carried
out: first, the ocular is depressed and carried a little to the left, thus
separating the beak from the line of the catheters (Fig. 744); second,
the whole instrument is rotated to the right on its longitudinal axis
through an arc of 190 degrees, retaining the relative position just
described, thus making the beak point upward (Fig. 745); third
(still in the same plane, with the ocular a little to the left), the ocular
is raised and brought back to the median line in order to bring the
convexity of the beak against the trigone of the bladder (Fig. 746);
and fourth, the sheath is removed, its inferior aspect being made to
hug the posterior wall of the urethra."
Removal of the Bierhoff instrument is comparatively simple, as
it is arranged so that the telescope may be rotated within the sheath
until the beak points upward without disturbing the catheters (see
Fig. 734)-
Fig. 745.
Fig. 745. — Removal of the sheath. Third step, showing the beak being turned
upward. (After Buerger, Annals of Surgery, Feb., 1909.)
Fig. 746. — Removal of the sheath. Final step, the beak in position for re-
moval of the sheath. (After Buerger, Annals of Surgery, Feb., 1909.)
URETERAL CATHETERIZATION IN THE FEMALE
Ureteral catheterization in the female has the same field of
usefulness as when applied to the male (see page 705). In addition,
catheters are often inserted into the ureters as a guide to their posi-
tion so as to avoid injuring them in difficult pelvic operations.
Catheterization may be performed, as in the male, by means of
URETERAL CATHETERZATION IN THE FEMALE
715
one of the catheterizing cystoscopes, the method of performing
which requires no further explanation than that given above, or
by means of open tubes under air distention after the method of
Kelly. This latter method requires separate description.
Instruments. — The ordinary Kelly speculum with illumination
furnished by reflected light or some of the modifications of Kelly's
tubes with the Hght at the distal end may be employed. The latter
are preferable.
In addition there will be required a cone-shaped urethral dilator,
alligator-jaw-shaped forceps, a residual urine evacuator, Kelly's
ureteral searcher, silk flexible catheters, a metallic catheter, and
hard-rubber flexible sounds (Fig. 747).
Fig. 747. — Instruments for catheterizing the ureters in the female, i, Open-
tube cystoscope; 2, Kelly urethral dilator; 3, residual urine evacuator; 4, alligator-
jawed forceps; 5, ureteral searcher; 6, metal ureteral catheter; 7, flexible ureteral
catheters with stylets; 8, ureteral bougies.
The cystoscope, alligator-jaw forceps, urethral dilator, and
searcher have been previously described (page 666).
The flexible silk catheters are made in two lengths: 12 inches
(30 cm.) long for ordinary ureteral catheterization and 20 inches
(50 cm.) long for catheterization of the kidney pelvis. The tips
are blunt or olivary and have an oval eye about 3/4 inch (2 cm.)
from the distal end. They may be obtained in sizes running from
1/16 to 1/8 inch (1.5 to 3 mm.) in diameter. A wire stylet is in-
troduced within the catheter to furnish it with the necessary stift'-
•Jl6 THE KIDNEYS AND LTiETERS
ness for passage into the ureter, or forceps, such as Ashton's (Fig.
748), may be employed for this purpose. As an aid in recognizing
a calculus the ends of the catheters may be wax- tipped (see Fig. 735).
Metal catheters are 12 inches (30 cm.) long and i '12 inch (2 mm.)
in diameter and are supplied with three eyes situated back of the
point which is conical in shape and slightly curved. They are
employed when a stricture low down in the ureter interferes with the
passage or a flexible catheter.
Fig. 748. — Ashton's forceps for guiding the catheter into the ureter. (Ashton.)
Solid, flexible, hard-rubber bougies are employed in exploring the
ureters or dilating strictures. They are 20 inches (50 cm.) long and
1/12 inch (2 mm.) in diameter. When warmed they become flexible
and in this state may be passed the entire length of the ureter without
danger. For the purpose of locating stone they may be wax-tipped
(Fig. 749).
:i
Fig. 749. — Wax-tipped bougie. (Ashton.)
Asepsis. — Great care should be taken to observe aU aseptic details.
The operator's hands should be thoroughly cleansed, and precautions
should be taken not to allow the sterile catheters to touch the table
or patient's body during their introduction. Metal instruments and
hard-rubber bougies are sterilized by boiling for five minutes in a i
per cent, soda solution. The light carrier may be sterilized by
immersion in a i to 20 solution of carbolic acid followed by rinsing
in alcohol. Silk catheters are sterilized by formalin vapor or are
boiled for not over two minutes in plain water and are then placed in
cold sterile water to make them stift'. Care should be taken when
boihng the catheters to place them in the sterilizer at full length and
to wTap them separately in gauze so as to keep their surfaces from
becoming glued together.
After use the catheters should be thoroughly cleaned inside and
outside with warm water and tincture of green soap and then put
away at full length in a glass receptacle.
Position of the Patient. — As for cystoscopy two positions are
employed, namely, the dorsal elevated and the knee-chest. In the
URETERAL CATHETERIZATION IN THE FEMALE 717
former the patient lies with the head and thorax resting on the table
and the hips elevated 8 to 12 inches (20 to 30 cm.) upon a cushion so
as to raise the pelvis sufficiently to allow the bladder to distend with air
when the cystoscope is in place. If the bladder does not inflate with
the patient in the dorsal position, the knee-chest posture is employed.
The latter position is usually necessary in stout people.
Preparations of Patient. — It should be seen that the rectum and
bladder are empty before beginning the examination. The external
genitals are then washed with soap and water followed by a i to
5000 solution of bichlorid of mercury, and the bladder is irrigated with
a warm saturated solution of boric acid until the fluid returns clear.
The solution is then all drained off before the cystoscope is inserted.
Anesthesia. — ^Local anesthesia, obtained by inserting into the mea-
tus a small pledget of cotton saturated with a 2 per cent, solution of
cocain and allowing it to remain for fi.ve minutes, is generally suffi-
cient. In extremely nervous patients general anesthesia may be
required.
Technic. — The urethra is first dilated and the cystoscope is intro-
duced in the manner already described (page 669). The obturator is
then removed, when, if the patient is in the proper position, air rushes
in and distends the bladder. The Hght is then adjusted and a search
is made for the ureteral orifices. In doing this it is well to first with-
draw the instrument until the mucous membrane of the internal
urethral orifice begins to close over the end of the instrument, and
then to advance it 1/2 to 3/4 inch (i to 2 cm.) turned either to the
right or left about 30 degrees from the center line along the dark
lateral ridge of the trigone. The distal end of the instrument is then
brought close to the base of the bladder by raising the handle of the
cystoscope if the patient is in the dorsal position, or depressing the
handle if the knee-chest position is used. By moving the instrument
carefully about, the mouth of the ureter will be located somewhere
near the end of the cystoscope. It may appear as a small sHt or as a
distinct hole or as a dark point in the bladder mucous membrane.
If it is not readily found, the speculum should be directed toward its
normal location and a careful search made for it with a ureteral
searcher in the folds of mucous membrane.
Having located the orifice, the end of the cystoscope is brought
close to it and the catheter is introduced. Metal catheters or sounds
are not difficult to introduce. They should be well lubricated and,
while the cystoscope is maintained in position with the left hand, they
are guided by means of the right hand into the ureteral orifice.
7i8
THE KIDNEYS AND URETERS
Flexible catheters may be introduced in two ways, either by the
use of a stylet to give them stiffness or by the aid of a specially made
forceps, such as Ashton's (see Fig. 748). By the former method the
catheter, well lubricated, with the stylet in place, is gently inserted in
the same manner as a metal catheter into the mouth of the ureter
(Fig. 750). The stylet is then withdrawn and the catheter is pushed
on until it has entered the desired distance. For ordinary purposes
of catheterization this will be 3 or 4 inches (7.5 to 10 cm.). In intro-
FiG. 750. — Catheterization of the ureter in the female by means of a flexible
catheter armed with a stylet.
ducing these flexible catheters care must be observed that the portion
outside the cystoscope does not become contaminated by touching the
patient or the table, and for this purpose it is well to keep this part of
the catheter wrapped in sterile gauze.
If it is desired to catheterize both ureters, the mouth of the other
one is then located and the catheter introduced in the same manner.
The cystoscope is then withdrawn and the catheters are labeled right
and left to distinguish them. After wiping the ends of the catheters,
they are placed in two small sterile bottles plugged with sterile cotton,
and about 2 to 4 drams (8 to 15 c.c.) of urine are collected from each
kidney (Fig. 751).
URETERAL CATHETERIZATION IN THE FEIIALE
719
Variation in Technic. — The following method, devised by
Kelly, for collecting urine from one kidney without using a catheter
Fig. 751. — Method of collecting separate urine from each kidney. (Ashton.)
YiG, 7-2.— Kelly's method of collecting urine from a kidney without using a
catheter. (After Kelly.)
is sometimes employed when it is undesirable to introduce a catheter
into the ureter for fear of carrying an infection from the bladder or
720 THE KIDNEYS AND URETERS
from other causes. Briefly, it consists in placing the patient in the
knee-chest posture, introducing into the bladder a speculum with the
end cut on the slant, and exposing to view the ureteral orifice from
which it is desired to obtain a specimen of urine. The orifice of the
ureter is then wiped clean and the speculum is held close against the
bladder wall so that the urine escapes into the speculum whence it is
collected by means of a small glass graduate (Fig. 752). In this way
often in a short time sufiicient urine may be collected for purposes of
examination.
PYELOMETRY
By distending the renal pelvis with fluid its capacity may be meas-
ured, and from this it may be determined whether the pelvis is normal,
contracted, or dilated. The test is based. upon the fact that if the
kidney pelvis is overdistended an artificial renal colic is produced. A
normal pelvis will hold from i 1/4 to 4 drams (5 to 15 c.c.) of fluid
without pain. According to Braasch if the renal pelvis has a capa-
city of less than 50 TTt (3 c.c.) it indicates irritability or a con-
traction generally due to stone, tumor, acute or chronic pyelitis, or
spasm; a pelvis allowing distention up to i ounce (30 c.c.) may be
found in neurotic subjects, the condition being explained by the pres-
ence of a hysterical anesthesia; while a capacity of 10 drams (40
c.c.) and over indicates hydronephrosis.
Instruments. — A direct or indirect catheterizing cystoscope,
ureteral catheters, catheter and syringe for irrigating the bladder, a
small syringe with a capacity of 2 1/2 (10 c.c.) with a nozzle that will
fit the end of the ureteral catheter as the Record syringe, and a glass
measuring graduate will be required.
Asepsis. — See under ureteral catheterization (pages 707, 716).
Solution Used. — A 2 per cent, boric acid solution colored with a
drop or two of methylene blue is employed.
Temperature. — The solution should be at a temperature of about
100° F. (38° C).
Position of Patient. — Same as for ureteral catheterization (pages
707, 716).
Anesthesia. — (Seepages 707, 717).
Preparation of Patient. — Same as for ureteral catheterization
(pages 708, 717).
Technic— A catheter of sufficient size to occlude the ureter and
prevent the escape of the solution beside it is introduced into the
SEGREGATION OF URINE 72 1
ureter of the affected side as far as the pelvis (see ureteral catheteri-
zation pages 708, 717). The colored solution is then injected into
the catheter while the operator notices through the cystoscope if any
of it leaks back into the bladder; if not, the injection is slowly con-
tinued until colicky pain is produced in the region of the kidney,
showing that the pelvis is distended. The quantity injected indicates
the capacity of the pelvis.
SEGREGATION OF URINE
Special instruments, known as segregators, which separate the
bladder into two halves through the formation of an artificial dam,
may be employed to collect the urine separately from the kidneys
when a catheter cannot be passed into the ureter or ureteral catheter-
ization is contraindicated. They are easier to employ than the ure-
teral catheter and with their use there is no danger of carrying infec-
tion into the ureters, but, on the other hand, they are not so accurate,
as an incomplete watershed may be formed allowing the urine from
the two sides to mingle, and the introduction of the instruments may
incite vesical bleeding and give misleading results. Again, if the
bladder is diseased, the urine obtained is, of course, contaminated and
it is not possible to determine whether the source of blood or pus is
the bladder, ureter, or kidney. If the bladder is very irritable or
bleeds easily, as is the case in the presence of acute cystitis, vesical
calculus, tumors, and prostatic hypertrophy, a segregator should not
be used. In healthy bladders, however, segregation properly per-
formed is fairly reliable. '
Instruments. — There are several types of urine separators among
which may be mentioned the instruments of Harris and Luys.
The Harris segregator (Fig. 753) consists of two catheters having
a common sheath except at the distal and proximal ends. The intra-
vesical ends when in contact form a cylinder with a double curve and
are supplied with numerous small eyes which lead to the interior of
the catheter. The extravesical portions end in curved metal tubes to
which are connected by means of pieces of rubber tubing two aspirat-
ing bottles. A long lever, connected to the shaft of the instrument by
means of a fulcrum and spring, which is inserted into the rectum or
vagina for the purpose of raising up the bladder wall in the mid-line
in the form of a dam, is also provided.
Luys' instrument(Fig. 754) consists of two catheter tubes separated
by a metal partition, the vesical end of which has a Benique form of
722
THE KIDNEYS AND URETERS
curve. On the concave side of the intravesicalportion is a small chain
covered with a thin india-rubber membrane, so arranged that after the
instrument is within the bladder by turning a screw at the proximal
end of the instrument the rubber membrane is made to partition the
Fig. 753. — The Harris segregator. (Ashton.)
bladder into two halves. Near the proximal end are two discharge
tubes which empty into small bottles. In males this instrument
causes less discomfort than does the Harris segregator.
Asepsis. — The instruments and the bottles for collecting the urine
should be sterilized by boiling for five minutes, and the operator's
hands are cleansed as for any operation.
Fig. 754. — The Luys segregator.
Position of Patient. — In using the Harris instrument the patient
lies flat on the back with the feet, hips, and head on a level and with
the thighs flexed.
The same position is employed in inserting the Luys instrument,
but, when the instrument is in the bladder, the patient is elevated to a
semi-sitting position.
SEGREGATION OF URINE
723
Preparations of Patient. — The rectum should be empty. The
external genitals are cleansed with soap and water followed by a i
to 5000 solution of bichlorid of mercury. The urethra is irrigated
with a I to 5000 solution of potassium permanganate. The bladder is
emptied by means of a catheter and is then irrigated with a saturated
solution of boric acid or sterile water. About 5 ounces (150 c.c.)
of solution is left in place when using the Harris instrument to permit
manipulation of the instrument, less distention being necessary with
the Luys instrument.
Anesthesia. — Local anesthesia may be required if the urethra or
bladder are hyperesthetic.
Technic. — i. Harris^ Method. — The instrument, closed so the
catheters form a continuous tube, is well lubricated and is introduced
Fig. 755. — Segregation of urine by means of the Harris segregator. First step,
instrument in position in the bladder. (Ashton.)
into the bladder until its beak lies just within the vesical neck (Fig.
755). The proximal ends are then rotated outward so that the vesical
ends are made to lie on either side of the ureteral orifices and are fixed
in this position by the small spring at the proximal end of the instru-
ment (Fig. 756). The long lever, well lubricated, is then introduced
into the rectum of the male or the vagina of the female and is secured
by a clamp to the sheath of the catheters. By means of a spiral spring
the rectal or vaginal end is forced upward causing a longitudinal ridge
of bladder wall to be formed in the mid-line between the two ureteral
orifices with the end of each catheter lying at the bottom of the corre-
sponding compartment of the bladder. The fluid left in the bladder
is then allowed to escape from each catheter until it has all been
drained off. The aspirating apparatus is then attached and the urine
724
THE KIDNEYS AND URETERS
is gently sucked out of the viscus from time to time by means of the
suction bulb and is collected in two sterile bottles (Fig. 757). The
instrument must be left in place about half an hour to collect suillicient
Fig. 756. — Segregation of urine by means of the Harris segregator. Second step,
vesical ends of the instrument separated. (Ashton.)
Fig. 757. — Segregation of urine by means of the Harris segregator. Third step,
the instrument in place. (Ashton.)
urine for examination. Care must be taken to avoid too vigorous
aspiration or hemorrhage will be incited.
At the completion of the operation the lever is detached, the cath-
eters are folded back in place, and the instrument is carefully
THE FUNCTIONAL CAPACITY OF THE KIDNEYS
725
removed, following which the bladder is irrigated with a saturated
solution of boric acid.
2. Liiys^ Method. — The rubber dam is first carefully examined to
see if it is intact. The instrument, well lubricated, is then introduced
in the same manner one would insert a sound, depressing the handle
well between the thighs as soon as the tip enters the prostatic urethra
so as to carry the curved portion into the bladder. As soon as the
instrument is well within the bladder, the patient is raised to a semi-
sitting posture and the diaphragm is raised, carefully keeping the
instrument exactly in the median line. The handle of the instrument
is then elevated until resistance shows that the intravesical portion is
in contact with the base of the bladder. This should be confirmed
Fig. 758. — Showing the method of using the Luys segregator.
by vaginal or rectal palpation. After all solution has been drained
from the bladder, the urine, as it trickles into the bladder, is carried
off by a catheter on each side and is collected in the small tubes at the
proximal ends of the instrument (Fig. 758).
At the completion of the operation the diaphragm is lowered and
the instrument is withdrawn. This is followed by a vesical irrigation
of boric acid.
DETERMINATION OF THE FUNCTIONAL CAPACITY OF THE
KIDNEYS
By the functional capacity of the kidney is understood the ability
of that organ to perform its excretory functions. In surgical work
it is always important to determine whether the kidneys are doing
normal excretory work, but, unless a severe operation is to be under-
y26 THE KIDNEYS AND URETERS
taken, a careful urinalysis, including the total daily amount of urine,
the daily excretion of urea, etc., is sufficient. When the removal of
one kidney is contemplated, however, in addition to determining
whether the two kidneys are functionating properly, the functional
capacity of each kidney should be determined as far as possible. A
variety of procedures with this in view have been devised. These
include (i) estimation of the amount of urea excreted, (2) induc-
ing artificial glycosuria by phloridzin, (3) the methylene-blue and
indigo-carmin tests, (4) the phenolsulphonephthalein test, (5) cryos-
copy of the blood and urine, and (6) the experimental polyuria test.
While these tests are very valuable, none of them are infallible, for,
though they demonstrate which kidney is functionating best, they
do not absolutely prove that a particular kidney is healthy and cap-
able of doing sufficient excretory work after removal of its mate.
The Urea Test. — The average daily amount of urea excreted in
health amounts to from 250 to 450 grains (16 to 29 gm.). In the
presence of one diseased kidney, if it is found on repeated examina-
tions that the average total daily amount is not reduced to below 250
grains (16 gm.), it is evident that the sound kidney is compensating
for the other's inefficiency. Collection of the separate urine from
each kidney by ureteral catheterization and estimation of the amount
of urea in each specimen will, however, show exactly the proportion
of work each kidney performs.
The Phloridzin Test. — This test depends upon the property of
the healthy kidneys to form sugar from phloridzin. The bladder is
first emptied and then i6Tn, (i c.c.) of a i to 200 solution of phloridzin
are injected into the buttock. If the kidneys are healthy, glycosu-
ria should appear within fifteen minutes to half an hour after the ad-
ministration of. the phloridzin and should persist for about two to
four hours. Delay in its appearance or the excretion of only small
amounts of sugar points to renal insufficiency, while an entire absence
of sugar indicates that the kidneys are seriously affected. If the
functional activity of each kidney is to be determined, a catheter is
placed in each ureter and the relative proportion of sugar in the
separate specimens of urine thus obtained is estimated.
Methylene=blue and Indigo=carmin Tests. — Another method
of testing the functional activity of the kidneys is to inject drugs,
such as methylene blue or indigo-carmin, which color the urine after
entering the circulation. For this purpose i6Tn. (i c.c.) of a 5 per
cent, solution of methylene blue is given hypodermically or 6oTn,
(4 c.c.) of a 4 per cent, solution of indigo-carmin is injected intra-
THE FUNCTIONAL CAPACITY OF THE KIDNEYS 727
muscularly. If the kidneys are normal, upon cystoscopic examina-
tion within half an hour after administration of the methylene blue
and within ten to twelve minutes after the administration of the
indigo- carmin, stained urine will be seen escaping from the ureteral
orifices.
It is claimed for these tests that if the coloring of the urine is delayed
or its intensity lessened it tends to show that there is some impair-
ment of the renal function.
The Phenolsulphonephthalein Test. — In igioRowntree and
Geraghty proposed a new colorimetric test for estimating the renal
function by using phenolsulphonephthalein. As this drug is very
rapidly and almost exclusively eliminated from the body by the
kidneys, the test is one of the most delicate and reliable for determin-
ing the functional efficiency of the kidneys. When the kidney func-
tion is not impaired, the drug is present in the urine within five to
ten minutes after a subcutaneous injection, from 40 to 60 per cent, of
it being excreted within the first hour and from 20 to 25 per cent,
during the second hour. After an intramuscular injection, the drug
appears in the urine in about the same time as after a subcutaneous
injection, but from 5 to 10 per cent, more is eliminated during the first
hour. Following an intravenous injection, the drug appears in the
urine in from three to live minutes, and from 35 to 45 per cent, of it
is eliminated within the first half hour and 63 to 80 per cent, during .
the first hour. The quantity of the drug eliminated during a given
time indicates the excretory capacity of the kidneys, that is, the
quantity will be diminished according to the amount of kidney im-
pairment present.
Technic. — ^Twenty minutes to half an hour before making the test
the patient is given two or three glasses (300-400 c.c.) of water in
order to assure a free urinary secretion. Under the usual aseptic
precautions the patient is catheterized, the catheter being left in the
empty bladder. Sixteen minims (i c.c.) of the standard alkaline
solution of phenolsulphonephthalein containing 6 mg. (approxi-
mately yV gr.) of the drug are then injected subcutaneously, intra-
muscularly, or intravenously^ and the time of injection is noted.
The urine is allowed to flow into a test-tube containing a drop of a 25
per cent, solution of sodium hydroxid and the time of the first faint
pinkish tinge is noted. The catheter is now withdrawn, the patient
being required to urinate into a receptacle at the end of an hour after
^Rowntree and Geraghty (Journal of American Medical Association, Sept. 2,
191 1) advocate for general use the intramuscular injection in the lumbar muscles.
728 THE KIDNEYS AND URETERS
the first appearance of the drug and in a second receptacle at the
of the second hour. In the presence of urinary obstruction, the
catheter is left in the bladder, the hourly specimens being separately
collected. Twenty-five per cent, solution of sodium hydroxid is now
added to the urine in sufiicient quantity to render it strongly alkaline
and bring out the characteristic color — a brilhant purple red.
To determine the amount of dye present a Duboscq colorimeter or
a modified Hellige hemoglobinometer is employed. The solution con-
taining the urine is diluted with sufficient distilled water to make i
quart (i liter) and after thoroughly mixing a small filtered portion is
compared with a standard in the colorimeter. A simpler and fairly
accurate method is to prepare a series of standard solutions in test-
tubes containing 5, 10, 15, 20 per cent, etc., of the drug up to 60 per
cent., and then selecting the standard tube which matches the color
of the diluted urinary specimen.
To determine the functional efficiency of each kidney, the ureters
are catheterized and, as soon as the urine flows freely, the drug is
injected. The time of injection is recorded and the collection of urine
from each side is continued for one hour from" the time of the first
appearance of the drug. If the drug is given intravenously the urine
need only be collected for fifteen minutes after the appearance of
the drug. The quantity excreted in each specimen is then estimated
as described above.
Cryoscopy. — Cryoscopy is the determination of the freezing-
point of a liquid compared to that of distilled water. The underlying
principle of this test is that fluids containing a small amount of soUd
material give a high freezing-point while liquids with greater concen-
tration freeze at a lower temperature. Applied to the blood and
urine, cryoscopy is valuable in determining the renal activity of the
kidneys and in some cases may be of prognostic value when renal
impairment exists. For example, if the kidneys are doing an insuffi-
cient amount of excretory work, there will be an accumulation of
solid material in the blood which will, therefore, freeze at a lower
temperature than normal, and at the same time the urine in such a
case, through impairment of the power of the kidneys to eliminate
properly, will give a higher freezing-point than normal.
The freezing-point of normal blood is 0.56° C. below that of dis-
tilled water. In weakened anemic individuals, however, it may rise
to —0.55° C. or even as high as —0.53° C. or —0.52° C. If cryo-
scopy of the blood gives a freezing-point below —0.56° C, it is
regarded as indicating some impairment of the renal function with
THE FUNCTIONAL CAPACITY OF THE KIDNEYS 729
retention of waste products in the blood. According to Kummell, if
the freezing-point of blood falls to —0.60° C. it indicates such a degree
of renal impairment that nephrectomy is contraindicated.
Cryoscopy of the urine is of less value than when the test is applied
to the blood. Healthy urine freezes at —0.9° C. to —2° C, and if
the freezing-point is higher than —0.9° C. it is considered to be in-
dicative of insufficient renal activity. Cryoscopy of urine collected
separately from each kidney by ureteral catheterization will give
more information than when the test is applied to the bulk of
urine.
To carry out this test 2 1/2 drams (10 c.c.) of blood and urine are
required. For comparative examination the two should be collected
at the same time, the former by venous puncture (page 250) and the
latter by ureteral catheterization (page 705).
For the technic of cryoscopy, which requires a considerable
amount of skill to properly carry out, the reader is referred to some of
the manuals on clinical laboratory methods.
Experimental Polyuria Test.^ — Still another method of esti-
mating the functional activity of the kidneys is that known as the
experimental polyuria test, devised by Albarran, which consists
essentially in obtaining the urine from each kidney when the patient
is dry and comparing the two specimens and then having the patient
drink a large quantity of water and noting the effect upon the activity
of the two kidneys.
The test is based upon the following laws: First, a diseased kidney
has a more uniform function than a healthy one, and the more
extensively its parenchyma is destroyed the less will its function vary
from time to time; second, when one kidney alone is diseased or is
more diseased than the other, if the urinary function is disturbed, its
function is less modified than the other. In other words, if an
increased excretory demand is placed upon the kidneys through the
ingestion of large quantities of water and the urine is collected sepa-
rately, the less diseased organ should show a greater increase in activ-
ity, manifested by the excretion of a larger total amount of fluid and
solids, though the percentage of solids will be diminished, while the
disea,sed kidney will show a relatively small or no increase in activity.
The test thus becomes of value in determining which kidney is func-
tionating best and the power of each to accommodate itself to
increased demands for excretory work.
Technic. — The patient should not have eaten anything for four
hours or taken any liquids for three hours. A single catheter is placed
73 O THE KIDNEYS AND URETERS
in one ureter and the urine from the other side is collected by means or
a small catheter passed into the bladder. The urine which flows fof
the first ten or fifteen minutes is discarded in order to permit the re-
flex polyuria which may follow the introduction of the ureteral
catheter to subside, and the urine that then flows is collected for half
an hour. This is saved for comparison with specimens taken after
the administration of the fluid. At the end of half an hour the patient
is given two to three glasses of mineral water and the urine is collected
separately and examined at half hour intervals for one and a half
hours. Not only is the total quantity of urine noted, but the speci-
mens are tested as to the freezing-point, quantity of urea and sodium
chlorid, and, if phloridzin has been given, the amount of sugar is
estimated.
SKIAGRAPHY
The X-rays are of the greatest aid in the diagnosis of ureteral and
renal calculi. A good picture will give positive information as to the
position of a calculus, that is, whether it is located in the ureter or
kidney and w^ill demonstrate the number and size, as well as the
position of the kidneys. In order to interpret the results of the X-ray
correctly the plate should show the following anatomic landmarks.
The eleventh and twelfth ribs, the transverse processes of the verte-
brae, the crests of the ilia, and the psoas muscle. If these points are
shown, the position of a calculus may be determined with accuracy.
The shadows cast by tumors, fecal concretions, calcified retroperit-
oneal glands, buried sutures which have become calcified, phleboliths,
foreign bodies in the intestines, the thickened tip of an appendix, etc.,
are sometimes wrongly interpreted as calculi. Such errors may be
avoided if a catheter filled with a 30 per cent, bismuth paste or a
catheter in which a lead wire stylet has been placed is inserted into
the ureter and renal pelvis, and an X-ray is then taken. The shadow
of a calculus will be shown to be in close relation to that produced by
the wire in the ureter. Thus, while a positive picture can usually be
taken as proof of the presence of a calculus, this cannot always be
said of the negative evidence furnished by an X-ray. It must be
remembered that great thickness of the abdominal wall may interfere
with the success of a picture and that the chemical composition of the
stone is also an important element, for while oxalate and phosphate
stones give a deep shadow, those composed of uric acid furnish but
faint shadows and may escape recognition. In all cases to obtain a
EXPLORATORY INCISION 73 1
successful picture it is absolutely essential that the stomach be empty
and the bowels be thoroughly cleared by a purge given the night
before and an enema the morning of the examination.
Pyelography. — This consists in the injection of an opaque fluid
into the ureter and renal pelvis followed by an immediate radiograph.
This method of diagnosis is of the greatest value in demonstrating the
extent and character of dilatations of the renal pelvis and ureter,
distortions of the pelvis by tumors or stones and of the ureter by the
presence of stones or strictures.
A 10 to 15 per cent, solution of collargol or a 50 per cent, solution
of argyrol are the most frequently employed. Kelly and Lewis
advocate a 5 per cent silver iodid emulsion. The catheter is
inserted into the renal pelvis and the contents are allowed to run off.
A quantity of the warmed opaque silver solution sufficient to distend
the renal pelvis is then allowed to slowly flow in under the force of
gravity. The quantity of fluid used will depend upon the size of the
pelvis previously determined by pyelometry (see page 720) or by the
production of pain when the pelvis is distended. To study the
ureter the catheter is partly withdrawn so that the ureter may be
filled up and distended by the solution. The catheter is then
plugged to prevent the escape of the solution and the opposite side
is similarly injected, a radiograph being taken immediately. The
plugs are finally removed from the catheters and the solution is
allowed to drain off. To aid in removing the solution it is well to
induce a polyuria by giving the patient a glass of water to drink at
the completion of the operation.
EXPLORATORY INCISION
In cases of contemplated nephrectomy where other means of
diagnosis fail to give satisfactory results, an exploratory operation
will determine the exact condition of the second kidney. The kidney
requiring removal is first exposed and thoroughly explored. If its
removal seems indicated, it is replaced for the time being and the
kidney supposed to be healthy is then cut down upon by a lumbar
incision, the capsule is incised, and the organ is palpated and if neces-
sary inspected. If it is found to be healthy, the wound is closed and
the other kidney may then be removed. Should, however, such
exploration reveal serious disease of the second kidney, nephrectomy
is contraindicated.
732
THE KIDNEVS AXD URETERS
Therapeutic Measures
MEDICATION OF THE RENAL PELVIS AND CJRETERS
'Lavage of the kidney pelvis and ureter has been employed with
considerable success by Kelly and others in treating subacute and
chronic affections of the kidney pelvis and ureter. The procedure is
not difhcult for one skilled in the passage of the ureteral catheter, and
properly performed seems to be without danger. It is not a suitable
method of treatment, however, in acute infections, and in chronic
cases, even, other measures should be hrst given a trial.
Fig. 759. — Medication of the renal pelvis.
Instruments. — In addition to the apparatus necessary for ureteral
catheterization (see pages 705. 715) there will be required a glass
syringe with a capacity of 2 1/2 drams (10 c.c.) supplied with a blunt
nozzle sufficiently small to fit into the end of the catheter.
Asepsis. — The same precautions against infection should be
observed as detailed under ureteral catheterization (pages 707, 716).
Solutions Used.— Sterile water, a saturated solution of boric acid,
silver nitrate in the strength of i to 8000 increased in strength up to
I to 2000. protargol i to 500 to 2 per cent., argyrol 2 to 5 per cent.,
collargol4 per cent., bichlorid of mercury i to 150,000 to i to 16,000
may be employed. Too strong solutions will result in colic.
For the purpose of aiding the passage of an impacted calculus
injections of sterile olive oil have been employed.
THE DILATATION OF URETERAL STRICTURES 733
Temperature. — The solution should be at a temperature of 100"^
F. (38° C).
Quantity. — One to 2 drams (about 5 to 10 c.c.) of solution are
generally injected at a time. If large amounts are employed, over-
distention of the renal pelvis will result with consequent colic.
Frequency. — The treatments may be applied once or twice a
week.
Position of Patient.— Same as for ureteral catheterization (pages
707, 716).
Anesthesia. — (Seepages 707, 717.)
Preparations of Patient. — The same as for ureteral catheteriza-
tion (pages 708, 717^.
Technic. — The catheter is inserted into the renal pelvis as pre-
viously described (pages 708, 717). Any fluid or pus collection is
then allowed to drain off, and the tip of the syringe, charged with the
solution, is introduced into the end of the catheter and i or 2 drams
(about 5 to 10 c.c.) of solution are injected. Care must be taken to
see that the syringe contains no air and the injection must be given
very slowly and evenly to avoid a sudden distention of the kidney pel-
vis. The syringe is then disconnected, the patient is raised to a
semiupright position, and the solution is aU aUowed to escape; if a
small catheter is employed, the solution may, however, escape beside
it into the bladder. This washing-out process may be repeated
until the solution returns clear. The syringe is again connected
with the catheter which is slowly withdrawn, the solution being
injected the while so as to medicate the entire ureter. At the com-
pletion of the operation the bladder is irrigated.
To aid the passage of a ureteral calculus by the injection of olive
oil, the following technic is employed: a ureteral catheter is passed
beyond the stone if possible, and, if not, up to it, and a few drops of
sterile olive oil are injected. This acts as a lubricant and the stone
is often readily passed as a result.
THE DILATATION OF URETERAL STRICTURES
The gradual dilatation of ureteral strictures may be performed by
suitable bougies, introduced with the aid of the cystoscope. While it
is doubtful if a permanent cure can be obtained in many cases by this
method, as such strictures, like those of the urethra, rectum, etc., tend
to recontract in the majority of cases, the patient is greatly benefited
for the time being through relief of the distention of the ureter and
734
THE KIDNEYS AND URETERS
kidney pelvis caused b}- the obstruction. The majority of strictures
are located near the ureteral orifices, and these are most readily di-
lated, though the method may be applied with success to strictures in
any part of the canal.
Instruments. — Dilatation may be affected by means of flexible
whalebone bougies, flexible catheters or, if the stricture is near the
vesical end, by metal catheters. These instruments as well as the
cystoscopes have been already described (pages 705, 715).
Asepsis. — (See pages 707. 716.)
Fig. 760. — Showing the method of dilating a ureteral stricture.
(After Kelly and Noble.)
Frequency of Dilatation. — Treatments are employed every two or
three days.
Position of Patient. — Same as for ureteral catheterization (pages
707, 716).
Preparations. — (See pages 708, 717.)
Anesthesia. — (See pages 707, 717.)
Technic. — The ureteral orifice is located as already described and
the dilator is introduced into the ureter in the same manner as the
ureteral catheter (pages 708, 717). Choosing an instrument that the
stricture will readily admit, it is passed completely through the stric-
ture and is left in place for a few moments and then a larger size is
inserted. At the next treatment the stricture is dilated one or two
sizes more until finally it is stretched sufficiently to admit a No. 5 or
6 catheter with ease. Following each treatment lavage of the kidney
pelvis and ureter may be practised as described above.
CHAPTER XXII
THE FEMALE GENERATIVE ORGANS
Anatomic Considerations
The Vagina. — The vagina is a musculo-membranous canal ex-
tending from the uterus to the vulva, lying bet^Yeen the bladder and
urethra in front and the rectum behind. ^Mth the woman in an erect
posture it is directed downward and forward at an angle of 60 degrees
with the horizon. The anterior wall, which is shorter than the poste-
rior wall, due to the position of the cervix, measures 2 to 2 1/2 inches
(5 to 6 cm.; in length, while the posterior wall measures 3 to 3 1/2
inches (7.5 to 9 cm.). Xormally the walls are in contact, but when
distended the vagina becomes conical in shape and larger above than
below^ That portion surrounding the cervix uteri is spoken of as the
roof or fornix. It is divided for description into four parts: the ante-
rior fornix, in which is normally felt the body of the uterus; the pos-
terior forniX; the deepest portion, which is in close relation with the
cul-de-sac of Douglas; and the two lateral fornices.
Relations. — Anteriorly, in its lower portion the vagina is in relation
with the urethra and in its upper half with the neck and fundus of the
bladder. Posteriorly, it is in relation with the perineal body in its
lower quarter, in its upper quarter with the cul-de-sac of Douglas,
and between the two with the rectum.
Structure. — It consists of a mucous, muscular, and connective-
tissue coat. The mucous membrane, which is of the squamous va-
riety, exhibits on the anterior and posterior walls numerous ridges,
or rugse, which extend out transversely from a central column. They
are more distinct on the anterior wall.
The muscular coat is arranged in two layers, an inner longitudinal
and an outer circular.
The connective- tissue coat is a thin fibrous structure containing a
few smooth muscle fibers. In its meshes this layer gives support to a
plexus of veins.
The Uterus and Appendages. — The uterus, or womb, is a hol-
low pear-shaped organ lying in the pelvis between the bladder and the
rectum. It measures about 3 inches (7.5 cm.) in length, 2 inches
(5 cm.) in breadth, and i inch (2.5 cm.) in thickness.
735
736
THE FEMALE GENERATIVE ORGANS
Externally, it is flattened from before backward, and at the point
where the peritoneum is reflected from the uterus to the bladder there
appears a constriction, the isthmus, which corresponds with the posi-
tion of the internal os and divides the uterus into two portions. The
portion lying below the isthmus is the cervix, that part between the
isthmus and a line joining the entrance of the tubes is known as the
body, while the portion above the plane of the entrance of the tubes is
known as the fundus. The cervix in turn is also divided into three
portions: an infravaginal portion, below the attachment of the ante-
rior vaginal wall; a supravaginal portion, above the attachment of the
posterior vaginal wall; and an intermediate portion, lying between
the two.
Fig. 761. — The normal position of the uterus. (Ashton.)
The interior of the uterus measures about 2 1/2 inches (6 cm.) in
length and is divided into two portions by the internal os. That
portion of the canal above this point is triangular in shape with the
base upward and with the walls normally in contact. In the cervical
portion the canal is fusiform in shape. Ihe uterus opens into the
vagina through the external os, a transverse aperture having an ante-
rior and a posterior lip, while above it connects with the peritoneal
cavity through the Fallopian tubes.
Position of Uterus. — Normally the uterus lies in a slightly ante-
flexed position with the fundus pointing toward the umbilicus (Fig.
761). Its position, however, is modified from time to time by the
neighboring organs. Thus a distended bladder will push it toward
the sacrum, while a full rectum pushes it forward.
DIAGNOSTIC METHODS
737
structure. — The litems is made up of a mucous, muscular, and a
peritoneal coat. The mucous membrane of the body of the uterus is
smooth and pale in color, with the mouths of numerous tubular glands
opening upon its surface. The lining epithelium is of the ciliated
variety having a motion from within outward.
In the cervix it is firmer in structure and is thrown into numerous
folds, the arbor vitse. These are arranged in the form of a median
ridge on the anterior and posterior walls, from which branch second-
ary ridges in an upward and outward direction. Between these
ridges are located the openings of tubular and racemose glands. In
the upper portion of the cervix the mucous membrane is the same as
that found in the body of the uterus and below it is similar to that in
the vagina.
Extending out from either superior angle of the uterus are the two
Fallopian tubes. They measure 3 to 5 inches (7.5 to 12.5 cm.) in
length and lie in the free borders of the broad Hgaments between the
ovaries behind and the round ligaments in front. They are lined
with ciliated epithelium having a direction toward the uterus. Their
external apertures, the fimbriated extremities, open into the perit-
oneal cavity near the ovary. Internally, each tube opens into the
uterine cavity at its superior angle.
The ovaries, two in number, lie on either side of the uterus, about
on a level with the pelvic brim, near the abdominal extremities of the
tubes. Each ovary measures i 1/2 inches (4 cm.) in length, 3/4 inch
(2 cm.) in breadth, and 1/3 to 1/2 inch (0.8 to i cm.) in thickness.
Diagnostic Methods
In making a gynecological examination the investigation should
comprise an inquiry into the patient's general condition as well as an
examination of the pelvic organs. A clear and concise history of the
subjective symptoms should be the first step in every case. It is
preferable to allow the patient to first detail her own symptoms and to
supplement this by inquiry as to essential points. In doing this it is
well to follow a routine system in order to avoid omitting some impor-
tant point that may have direct bearing upon the case, and also that
the examiner may have a complete record for future reference.
In addition to the usual questions commonly asked in obtaining a
history, special information should be sought in regard to the follow-
ing points : First the menstrual history should be inquired into, ascer-
taining the age at which menstruation began, the precautions taken
during menstruation, the interval between the periods, the regularity
47
738 THE FEMALE GENERATIVE ORGANS
of the periods, the duration of the flow, and its character, whether
painful, whether accompanied by the passage of clots, and whether
scanty or profuse. The latter is especially important, as excessive
menstrual bleeding points to the presence of some pathological
condition.
With a history of painful menstruation the time the pain begins
and ceases in relation to menstruation should be ascertained. It
should also be found out whether there has been any bleeding between
the periods. If the menopause has occurred, its date and the presence
or absence of any bleeding since are to be noted. If the patient is
married, certain data relating to child-bearing should be sought, com-
prising the number of children, the dates of their births, a history of
the labors, whether easy, difficult, or instrumental, and whether they
were followed by a long and protracted convalescence.
With a history of abortions or miscarriages the period of preg-
nancy at which they occurred and their probable cause should be
ascertained. At times it is also important to know something of the
marital relations, that is, the frequency of coitus, whether the act is
painful and whether measures to prevent conception have been em-
ployed, and, if so, the methods used.
The patient is next questioned as to the presence or absence of a
vaginal discharge. If present, its character should be inquired into,
whether foul, blood-tinged, or having the characteristics of an ordi-
nary leucorrhea. The quantity of discharge is also to be noted, and
whether it is always present or only occurs midway between the
monthly periods.
Pain is another frequent and important complaint upon which full
information should be sought. The character and situation of the
pain should always be determined. The pain complained of may be
in the form of a headache, a bearing-down feeling, backache, or its
situation may be referred to some part of the pelvis, the coccyx, or the
inguinal region. Inguinal pain generally points to some disease of
the uterine appendages or ligaments; on the other hand, backache is
found as an accompaniment of a number of conditions, such as chronic
constipation, uterine displacements, pelvic tumors, etc., while pain
in the coccyx is often a symptom of neurasthenia. It should also be
ascertained if the pain is modified by menstruation, and if so, whether
it is worse before the flow begins, during the flow, or afterward, also
whether it is affected by exercise, any sudden jolt or jar, or by coitus.
Finally, since many gynecological patients have in addition to
their pelvic troubles other disorders, the general symptoms and the
PREPAEAT.ON OF PATIENT FOE. EXAMINATION 739
functions o^ other organs should be similarly inquired into. Thus
the patient should be questioned as to her appetite, loss of weight,
nausea and vomiting, and if the latter is present, its character and
relation to the taking of food, the condition of the bowels, and whether
she sleeps well or suffers from nervousness, hysteria, palpitation of the
heart, hot flashes, etc., etc.
Having obtained the above data, a thorough physical examina-
tion is then made. It should comprise a careful observation of the
patient's general condition, color, and nutrition, and an examination
of the heart, lungs, nervous system, urine, and blood. After this is
completed the patient is prepared for a general examination of the
abdomen and pelvic organs.
The methods available for such examination include abdominal
inspection, palpation, percussion, auscultation, and mensuration,
internal examination by inspection and palpation, the use of specula
and the uterine sound, digital exploration of the uterus, test excision,
test curettage, and exploratory incision.
Preparation of Patient. — Certain preparation of the patient is
essential for a thorough examination, otherwise the results will be
unsatisfactory. If an anesthetic is to be given, the preparations for
such, previously detailed (page 2), should be carried out. In any
case, the bowels should be thoroughly evacuated by means of a mild
purgative taken the day before, followed by an enema on the morning
of the examination. The bladder is emptied spontaneously just
before the patient presents herself for examination.
A suitable examining- table should be provided, and the simpler
it is the better. It should be about 3 feet (90 cm.) high, strong in
construction, provided with adjustable foot-rests, and capable of
being lengthened so that the patient may be placed upon it in the
horizontal position. A small step, to aid the patient in mounting,
is also necessary. A second small table should be placed near at
hand, upon which are placed solutions, instruments, etc., that may be
required during the examination.
When it is necessary to make a vaginal examination in the
patient's home, an ordinary kitchen table or the bed may be utilized.
In the latter case the patient is placed lengthwise across the bed, with
an ironing-board covered by several thicknesses of a sheet placed on
the mattress under the patient's hips, and with the patient's feet
supported on two chairs (Fig. 717).
With the patient in the desired position upon the table it should
be seen that the corsets and any constricting bands are removed from
740
THE FEMALE GENERATIVE ORGANS
about the waist and that the patient is so covered by sheets that only
the region to be examined is exposed. For an abdominal examina-
tion two sheets are employed, one draped over the pelvic region and
lower part of the abdomen and the other over the upper abdomen.
For a vaginal examination the sheet is thrown over the lower extrem-
ities and is then separated so as to expose the vulva. If the examiner
is provided with a nurse, these details may be left to her. While a
nurse is not absolutely necessary, it is always preferable to have some
woman present at the examination, not only for the greater comfort
of the patient, but for the protection of the physician against malici-
ous charges at the hands of unscrupulous females.
Fig. 762. — Position of the patient for an examination upon a bed. (Ashton.)
Gynecological Postures. — In examining the female pelvic organs
a number of postures are available. These include the dorsal, the
Sims, the knee-chest, the erect, and the squatting positions.
The dorsal position, which is the best for digital or bimanual
examinations, is obtained by placing the patient, facing the light, flat
on the back, with the hips near the edge of the table and with the
feet supported upon the foot-rests (Fig. 762).
The Sims position is obtained by placing the patient upon her
left side, with the left side of the face, the left shoulder, and left
breast resting upon a flat pillow. The left arm lies behind the back,
the thighs are well flexed upon the body, and the right knee is drawn
GYNECOLOGICAL POSTURES
741
up nearer the body than the left ('see Fig. 538). In this position an
excellent xiev: may be obtained of the vaginal fornices, the anterior
vaginal wall, and the cervix, but it is not satisfactory for a digital
Fig. 763. — The patient in the dorsal position. (Ashton.)
Fig. 764. — Examination with the patient standing erect. (Ashton.)
examination, as the pelvic organs are more diiScult to reach than
w-ith the patient in the dorsal posture.
The knee-chest position is obtained b}- having the patient kneel
upon a table, with the thighs at right angles to the legs, the chest
742 THE FEMALE GENERATRE ORGANS
resting upon a pillow placed upon the same level as the knees (see
Fig. 540). In this posture the intestines gravitate toward the dia-
phragm, and the vagina becomes distended so that the numerous folds
of mucous membrane are spread out smoothly.
The Erect Posture. — The patient, with her clothes elevated and a
sheet fastened about her hips, stands with one foot on the floor and
the other resting upon a stool 6 to 8 inches (15 to 20 cm.) high. The
examiner kneels in front of the patient and, passing his hand beneath
the sheet, makes a digital examination of the vaginal outlet and the
uterus (Fig. 764) . In this position a prolapse of the uterus or a relaxa-
tion of the vaginal outlet is more readily recognized than in the
dorsal posture.
The squatting posture is sometimes useful in ascertaining the degree
of a uterine prolapse and the relaxation of the vaginal walls. The
patient takes the same position as when at stool and, by a slight
straining effort, any tendency to prolapse is readily made visible to
the examiner.
Asepsis. — In all gynecological examinations every precaution
must be taken to avoid infecting a patient as well as to prevent infec-
tion of the examiner by the patient. All instruments that are used
are boiled for live minutes in a i per cent, soda solution, and no instru-
ment should be used on more than one patient without resterilization.
The examiner's hands are sterilized by a thorough scrubbing with
tincture of green soap and water, followed by immersion in an anti-
septic solution. The examiner should also see that his finger-nails
are cut short to avoid hurting the patient.
If the patient is suspected of having syphilis or gonorrhea, or in
the presence of a septic discharge, the examiner should protect him-
self by wearing rubber gloves previously sterilized by boiling. In
the majority of cases it is sufficient to wipe off the vulva with a swab
soaked in a i to 2000 bichlorid solution, but where a profuse or foul
discharge is present a vaginal douche should be given. When it is
desired to obtain a specimen of a discharge for examination, antisep-
tic solutions or douches should be omitted until this has been done.
/. Examination of the Abdomen
INSPECTION
From the appearance of the skin, the shape of the abdomen, and
the effect of respiration upon a tumor valuable information may be
obtained.
PALPATION
743
Position of Patient. — The patient should lie with the body sym-
metrically placed upon a firm flat table in the horizontal position,
Technic. — With the patient's abdomen entirely exposed and the
light falling obliquely upon the abdomen, the examiner inspects it
first from the side and then from the foot of the table (see Fig. 491).
The color of the skin of the abdomen, the presence or absence of
striae, eruptions, scars, edema, and dilated veins, the condition of the
abdominal walls, whether rigid or lax, and the shape and symmetry
of the abdomen should all be noted.
In enlargement of the abdomen due to obesity, the lower portion
of the abdominal wall usually hangs down over the patient's thighs.
In ascites the abdomen is more or less flattened, and the sides
bulge outward. In the presence of pregnancy or an ovarian cyst the
enlargement is smooth and regular, in the former case the abdo-
men being symmetrically enlarged, while an ovarian cyst, especially
if small, may distend one side only. Fibroid tumors may present as
irregular and nodular growths. If a tumor is discovered, the pres-
ence or absence of mobility with respiration and whether the ab-
dominal walls move over the growth should be noted. Evidence of a
weakened condition of the recti muscles or the presence of a hernia
should also be sought by having the patient strain and cough.
PALPATION
Palpation of the abdomen is the most satisfactory of the methods
of abdominal examination and should form a part of every routine
gynecological examination. By it the presence of tumors, rigidity,
fluctuation, or local tenderness that might escape notice by trusting
simply to a vaginal examination may be recognized, and, in the pres-
ence of an enlargement, its situation, origin, shape, mobility, and
consistency may be determined.
Position of Patient. — The patient lies in the dorsal position, with
the shoulders slightly elevated and the thighs somewhat flexed to
secure thorough relaxation.
Technic. — The examiner first thoroughly warms his hands.
Then, taking his place upon one side of the patient, he systematic-
ally palpates all portions of the abdomen. In doing this the pal-
pating hand — usually the right — is placed upon the abdomen, palm
downward, and firm but gentle pressure is made — sharp pressure
with the finger tips should be avoided as it incites the muscles to
contract. Local or general rigidity of the abdominal wall, sensi-
tive areas, and the presence of a tumor are thus ascertained.
744
THE FEMALE GENERATIVE ORGANS
To differentiate obesity from intraabdominal growths both hands
are employed and make deep pressure from the sides toward the
mid-line, at the same time lifting upward on the abdominal walls
Fig. 765. — Showing the method of estimating the thickness of the
abdominal walls.
(Fig. 765). The situation, origin, size, or mobility of a tumor is
determined by making deep pressure with both hands in all direc-
tiDns about the mass (Fig. 766). An enlarged uterus is mapped out
in the same manner. In examining the lateral regions of the abdo-
FiG. 766. — Bimanual palpation of an abdominal tumor. (Ashton.)
men bimanual palpation is often of service, one hand being placed
under the flank and making forward pressure while the other hand
palpates the antero-lateral surface of the abdomen.
PERCUSSION
745
Fluid collections are recognized by a thrill or wave produced by
placing one hand with the palm flat on one side of the abdomen and
tapping the abdomen from the opposite side with the fingers of the
other hand. To avoid confusing a wave produced by tapping a fat
abdomen with that of fluid the examiner should have an assistant
place the ulnar edge of his hand firmly on the summit of the abdo-
men while the tapping is performed (Fig. 767). In the case of fat
the wave is then absent.
Fig. 767. — Method of differentiating between a wave produced when tapping
fat abdomen and one containing fluid. (Ashton.)
PERCUSSION
Abdominal percussion is valuable when employed as an adjunct
to inspection and palpation in differentiating between tympany,
ascites, cystic and sofid tumors, and in determining the size and
shape of a tumor, and its origin. To avoid errors, the large intes-
tine should be emptied by an enema before the examination.
Position of Patient. — Percussion is performed, first, with the
patient lying on the back and, then, turned upon the side.
Technic. — The examiner places the palmar surface of the middle
finger of the left hand firmly upon the area to be percussed and,
using the tip of the middle finger of the right hand, bent at a right
angle, as a plexor, strikes quick, sharp blows (see Fig. 497)- The
normal resonance of the abdomen is tympanitic except in the regions
of the liver and spleen where it is dull. Fecal masses, cystic and solid
tumors, and fluid collections give dulness on percussion. When
746
THE FEMALE GEXERATR'E ORGANS
distended intestines overlie a growth, however, the note will be tym-
panitic, and it will be necessary to employ deep and strong percus-
sion to bring out the dulness. By carefully percussing around the
^tympanv^
Fig. 768. — Showing the area of dulness and tympany in ascites when the patient is
recumbent. (Ashton.)
margins of a tumor and noting where tympanitic resonance is absent,
it is often possible to determine the origin of the growth.
In the presence of ascites with the patient in the dorsal position,
dulness will be elicited in the flanks, while the center of the abdomen
^^UPANV^
Fig. 769. — Showing the area of dulness and tympany in ascites when the patient
lies on her side. (Ashton.)
will be tympanitic, as the intestines float to the highest point (Fig.
768). With a change in the patient's position the fluid gravitates to
the lowest point and the location of the dulness and tympany is like-
wise changed (Fig. 769). On the other hand, the area of dulness due
to tumors is not aft'ected by changes in the patient's position.
MENSURATION
747
AUSCULTATION
Auscultation is of limited use except in the differential diagnosis
between pregnancy and other tumors. In the former case the fetal
heart sounds and the funic souffle settle the diagnosis. Much impor-
tance cannot be attached to the uterine bruit, however, in the ab-
sence of other signs pointing to pregnancy, as it is also heard in large
fibroid tumors. In some cases of peritonitis it may be possible to
hear a friction note.
MENSURATION
Mensuration of the abdomen is useful in determining whether the
abdomen is symmetrically enlarged or not, in noting an}- increase of
ascites, and in recording the rapidity of enlargement in a tumor.
Position of Patient. — The measurements are taken with the
patient in the horizontal recumbent position.
Fig. 770. — Showing the measurements taken in recording the growth of an
abdominal tumor.
Technic. — An ordinary tape measure is employed and the follow-
ing measurements are taken: (i) the circumference of the abdomen
at the level of the umbilicus, (2) the distance from the ensiform carti-
lage to the pubes, (3) the distance from the umbilicus to each anterior
superior spine, (4) the distance between the two anterior superior
spines, and (5) the distance from the anterior superior spines to the
pubes (Fig. 770). To have any value for purposes of comparison,
these measurements should be taken from the same points each
time and with the patient in exactly the same position.
748 THE FEMALE GENERATIVE ORGANS
//. Examination of the Pelvic Organs
INSPECTION
A careful inspection of the external genitals and the vaginal
orifice should always be made as a routine before a digital examina-
tion, otherwise lesions involving the vulva and neighboring parts
may escape notice. Inflammations, new growths, the presence of
abnormal secretions, prolapse of the anterior or posterior vaginal
walls, lacerations of the perineum, and many other pathological con-
ditions are readily recognized by inspection.
Fig. 771. — Inspection of the vaginal outlet. (Bandler.)
Position of the Patient. — Inspection is performed with the pa-
tient in the dorsal posture with the feet toward the light.
Technic. — The examiner sits or stands facing the vulva and be-
gins his inspection without disturbing the relation of the parts. He
should first note the general appearance of the vulva, whether the
labia are closed or in apposition, and whether the vulva is the seat of
INSPECTION
749
inflammation, ulcerations, warts, swelling, edema, varicosites, erup-
tions, or excoriations, the latter a frequent accompaniment of a dis-
charge. If a discharge is present, its color, quantity, and other
characteristics should be noted.
The labia are next separated with the fingers of the left hand, and
the entrance to the vagina is inspected (Fig. 771), noticing the color
of the mucous membrane, the presence or absence of the hymen, the
condition of the openings of the ducts of Bartholin and the orifice of
the urethra, and the presence or absence of lacerations, cystocele,
or rectocele. By instructing the patient to bear down or strain
slightly, a prolapse of the anterior or posterior vaginal walls is made
Fig. 772. — Method of exposing the anterior and posterior vaginal walls for
inspection. (Ashton.)
more evident. The hood of the clitoris should also be retracted and
an examination made for adhesions or concretions that may be the
cause of nervous symptoms. By retracting the perineum with two
fingers inserted in the vagina, as shown in Fig. 772, the lower portion
of the anterior and posterior vaginal walls may be brought to view.
EXAMINATION OF DISCHARGES
If an abnormal discharge is present, specimens should be obtained
at this time for later microscopical or bacteriological examination.
The importance of such an examination cannot be too strongly
emphasized. The technic for collecting and preparing the speci-
mens has been previously detailed at length in Chapter X.
;:>
^o
THE FEMALE GENERATR^E ORGANS
DIGITAL PALPATION
Palpation by means of the linger is employed to obtain more
complete information as to abnormal conditions of the vulva or
vaginal outlet discovered on inspection, and to determine the condi-
tion of the vagina, vaginal fornices, and the cervix. For a satis-
factory examination of the other pelvic organs, bimanual palpation
is necessary.
Asepsis. — All the aseptic precautions previously detailed (page
742) should be observed.
Fig. 773. — The diagnosis of a cystocele by the aid of a bladder sound. (Ashton.)
Position of Patient. — The dorsal position is ordinarily employed,
but the erect posture will be found useful in estimating the degree
of a uterine prolapse.
Preparations. — (See page 739.)
Technic. — The examiner first palpates between the thumb and
forefinger of the right hand any abnormal conditions, such as swell-
ings, new growths, etc., about the vulva and the vaginal outlet, and
also the glands of Bartholin for signs of inflammation or thickening.
The labia are then separated between the thumb and index-
finger of the right hand, and the index-finger of the left hand, well
lubricated, is introduced into the vagina. The condition of the
vagina is then investigated, noting the presence or absence of
congenital malformations, its sensitiveness, its temperature, and
whether the vaginal walls have their normal roughness or are smooth
DIGITAL PALPATION
751
and unduly relaxed. By turning the examining finger palmar sur-
face up the anterior vaginal wall may be palpated and the presence
Fig. 774. — Method of estimating the thickness of the perineum. (Ashton.)
Fig. 775. — Digital palpation of the cervix. (Ashton.)
or absence of an urethrocele or a cystocele may be ascertained. By
introducing a sound into the bladder and palp.ating its point with the
finger in the vagina (Fig. 773) a cystocele, if present, may be more
752 THE FEMALE GENERATR'E ORGANS
readily recognized. The posterior vaginal wall is likewise examined
by rotating the examining finger, palmar surface back, and. by
placing the thumb of the same hand near the rectum the perineum
may be grasped between the two fingers and its firmness and thick-
ness estimated (Fig. 774). The vaginal fornices on all sides of the
cervix are next palpated, noting their depth, any rigidity, indura-
tion, or tenderness.
If the uterus is in a normal position, it will be possible to feel its
body through the anterior fornix, while, if retroverted, the latter will
be felt in the posterior fornix. The condition of the uterus is more
satisfactorily made out, however, by bimanual palpation.
Finally, the cervix is palpated (Fig. 775), noting especially its
size, whether closed or open, whether hard or soft, its mobility, and its
position, that is. whether pointing backward toward the sacrum, as in
retroflexion of the uterus, or pointing forward toward the symphysis,
as is found when the uterus is retroverted or anteflexed. The pres-
ence or absence of lacerations, erosions, cysts, etc., should also be
determined.
BIMANUAL PALPATION
Bimanual palpation by means of the fingers of one hand in the
vagina or rectum and the fingers of the other hand making counter-
pressure above the symphysis is the most valuable method for in-
vestigating the condition of the pelvic organs. By it one may map
out the size and shape of the uterus and determine its consistency,
position, mobility, and the presence or absence of new growths. The
tubes, ovaries, broad ligaments, etc., may likewise be palpated and
their condition ascertained.
Vagino-abdominal palpation is the most satisfactory and the
more generally employed method. It should be supplemented by
recto-abdominal palpation, however, in any doubtful cases. The
latter method is especially useful in exploring the posterior surface
of the uterus and the appendages in cases of posterior displacement of
the uterus, as these structures may then be more readily reached
from the rectum than from the vagina. Recto-abdominal palpa-
tion is also indicated in children, in the unmarried, and in cases
where the vagina is unduly sensitive or obstructed by tumors or an
imperforate hymen.
To perform a successful bimanual examination it is necessary
that the abdominal walls be thin, relaxed, and free from tenderness
upon pressure, and that the vagina be sufficiently large to admit
BIMANUAL PALPATION 753
the fingers of the examining hand. In the case of individuals with
very muscular, fat, or rigid abdominal walls or a small vagina the
examination is usually unsatisfactory without an anesthetic. In
any case, the examination must be performed with the utmost
gentleness. Rough manipulations accomplish nothing and are cap-
able of causing great harm, especially in cases where the pelvis
contains a tube filled with pus, a thin-walled cyst, an ectopic preg-
nancy, etc.
Asepsis. — For the necessary precautions against infection see
page 742.
Position of Patient. — Bimanual palpation is most satisfactorily
performed with the patient in the dorsal position.
Preparations. — (See page 739.)
Anesthesia. — General anesthesia is not often required in indi-
viduals with thin and relaxed abdominal walls, but in muscular, fat,
or nervous individuals or where the parts are tender and sensitive
an anesthetic may be necessary to secure relaxation. A general
anesthetic should also be employed if any doubt remains as to the
conditions found after an ordinary bimanual examination, and in
all cases where it is necessary to make a vaginal examination upon
virgins.
Technic. — i. Vagino-ahdominal. — The examiner stands facing
the patient a little to one side or the other depending upon which
hand he palpates with. The labia are then separated between the
thumb and forefinger of one hand and the index-finger of the other
hand, or the index- and middle fingers if the parts are sufficiently
relaxed to admit them, are well lubricated and are inserted into the
vagina, while the fingers of the free hand are placed on the abdomen
above the pubes. The external hand is used to steady or depress the
organs while the internal hand does the palpating. As a rule the
left hand is employed to palpate with, being the smaller of the two and
possessing greater tactile sensibility, but the examiner should be
equally proficient with either hand. The last two fingers of the in-
ternal hand should be folded back upon the palm, as shown in Fig.
776, so as to invaginate the pelvic floor and thereby permit the
greatest possible penetration. The palmar surfaces of the fingers of
the internal hand are brought in contact with the cervix and its con-
dition and position are first determined. With the internal fingers
in contact with the cervix and exerting upward pressure the external
hand locates the fundus of the uterus and makes gentle pressure from
above. The length, sensitiveness, consistency, and position of the
754
THE FEMALE GENERATIVE ORGANS
Uterus are thus determined, and likewise the mobihty by making a
series of gentle pushes from above and below (Fig. 777).
By placing the internal lingers in front of the cervix and the fingers
Pig. 776. — Method of inserting the examining fingers in bimanual palpation
Small figure shows the method of holding the fingers.
Fig. 777. — Method of determining Fig. 778. — Method of estimating the
the length and mobility of the uterus. thickness of the uterus. (Ashton.)
(Ashton.)
of the externa) hand behind the fundus the thickness of the uterus
may be estimated (Fig. 778). If the fundus is pressed well forward
by the external hand, the anterior and lateral surfaces may be pal-
pated and any irregularity of the surfaces which might be caused by
BIMANUAL PALPATION
755
fibroids or other growths is noted. By carrying the fingers of the
internal hand posterior to the cervix and pressing the fundus back-
ward the posterior surface is in hke manner explored. When the
Fig. 779. — Diagnosis of an anteflexion of the uterus by bimanual palpation.
(Ashton.)
Fig. 780. — Diagnosis of a posterio'r Fig. 781.— Shows the method of
displacement of the uterus by bimanual palpating the body of the uterus in a
palpation. (Ashton.) posterior displacement. (Ashton.)
fundus is not found in its normal position, it should be sought for
anteriorly near the symphysis, or posteriorly. To palpate for anterior
displacements, the internal finger is carried up in front of the cervix
756
THE FEMALE GEXERATR'E ORGANS
into the anterior fornix while the external hand exerts pressure down-
ward behind the symphysis. If antetiexed, the fundus will be readily
felt between the fingers of the external and internal hands (Fig.
779), while in posterior displacements the opposed fingers may be
brought together as shown in Fig. 780. In such case the fundus
should then be sought posteriorly by carrying the internal finger
up into the posterior cul-de-sac while external pressure is made by
the external hand from above (Fig. 781).
A posterior flexion will be readily differentiated from a version by
the bend or angle on the posterior aspect of the uterus (Fig. 782).
Fig. 782. — Diagnosis of a posterior flexion of the uterus by bimanual palpation.
(Ashton.)
In the presence of a posterior displacement it should be determined
whether the uterus is mobile or fixed through adhesions by passing
the internal fingers high up posteriorly and by the aid of the external
hand attempting to lift the uterus up.
After thoroughly examining the uterus the condition of the broad
and uterosacral ligaments should be ascertained. By carrying the
fingers up beside the cervix into the lateral fornices and making
counter-pressure from above the condition of the broad ligaments
may be determined, and any pain on pressure, thickening, or indura-
tion noted. Palpation of the uterosacral ligaments through the pos-
terior fornix may be performed in like manner.
The tubes and ovaries should also be examined with reference to
their size, shape, consistency, sensitiveness, position, and mobility.
It is of advantage to use the right hand in palpating the right side
BIMANUAL PALPATION
757
and the left hand for the left side. The examining fingers are in-
serted well up in the lateral fornix beside the cervix in an upward and
backward direction, while the external hand makes deep pressure
downward through the abdominal wall on the corresponding side.
By altering the position of the fingers of the two hands from time to
time the ovary and tube are finally grasped between the opposed
fingers (Fig. 783). Except where the abdominal walls are extremely
thin and the vagina is relaxed, the normal tube cannot be felt, but,
Fig. 783. — Examination of the uterine appendages by bimanual palpation.
(Ashton.)
when enlarged, it may be readily recognized at a club-shaped mass
gradually narrowing down as it approaches the uterus. The nor-
mal ovaries, however, are generally palpable as small, oval masses,
somewhat tender upon pressure, on each side of the uterus. When,
as the result of chronic inflammation, extensive adhesive formation
has taken place the tubes and ovaries are often matted together into
irregular masses, and it may not be possible to map them out sepa-
rately. Having examined one side of the pelvis, the same procedure
is repeated upon the other side.
2. Recto-abdominal. — The examiner stands facing the patient and
inserts the well-lubricated index-finger of the left hand high into the
rectum. At the same time the external hand placed on the abdomen
758
THE PEMALE GEXERATR'E ORGANS
above the symphysis makes counter-pressure, while the uterus and
appendages are carefully palpated fFig. 784). Care must be taken,
Fig. 784. — Recto-abdominal palpation of the uterus. (Ashton.)
Fig. 785. — Recto-abdominal palpation of the uterus with the latter drawn toward
the vaginal outlet by means of a tenaculum. (Ashton.)
however, not to exert too much force with the fingers in the rectum
for fear of lacerating or otherwise injuring the bowel.
EXAMINATION BY SPECULA . 759
By drawing the uterus well down by means of a pair of bullet
forceps caught in the cervix, and then performing recto-abdominal
palpation, a much more complete examination is possible (Fig. 785).
This method, however, should never be attempted when the uterus is
fixed by adhesions or the appendages are inflamed. As a rule, general
anesthesia is necessary. Care should always be taken to replace the
uterus in its normal position at the completion of such an examination
EXAMINATION BY SPECULA
By means of suitable specula the mucous membrane of the entire
vagina and cervix may be directly inspected. The use of specula
furnishes little information outside of the color and condition of the
Fig. 786. — Goodell's vaginal speculum. (Ashton.)
mucous membrane and the origin of a discharge, which is not as
readily obtainable by digital palpation. For gynecological treat-
ment and operative procedures, however, specula are indispensable.
Fig. 787. — Trivalve vaginal speculum.
Instruments. — Numerous specula have been devised, such as the
bivalve (Fig. 786), the trivalve (Fig. 787), the cyhndrical, the Sims
(Fig. 788), Simon's, the self-retaining weighted speculum, etc., etc.
760
THE FEMALE GENERATIVE ORGANS
For diagnostic purposes the bivalve and the Sims specula are prob-
ably most commonly employed. To prevent the anterior vaginal
wall from obscuring the view when using the Sims speculum a vag-
inal depressor is also required (Fig. 789). A sponge holder (Fig.
Fig. 788. — Sims' vaginal speculum. (Ashton.)
790) and cotton wipes should be provided for removing secretions.
Asepsis. — The speculum should be sterilized by boiling for five
minutes in a i per cent, soda solution before use.
Position of Patient. — When the bivalve or trivalve speculum is
Fig. 789. — Vaginal depressor. (Ashton.)
employed the patient should be in the dorsal position. In using the
perineal retractors, such as the Sims, the left lateral, or the knee-
chest position may be employed.
Preparations of Patient. — (See page 739.)
Fig. 790. — Sponge holder and swab.
Technic. — i. With the Bivalve Speculum. — The examiner stands
or sits facing the vulva. Then, with the labia well separated be-
tween the index- and middle fingers of the left hand, the speculum,
warmed and well lubricated, is inserted into the vagina with its
EXAMINATION BY SPECULA
761
blades parallel to the vulva opening (Fig. 791). The speculum is
introduced about 2 inches (5 cm.) and is then rotated so that the
Fig. 791. — Method of inserting the bivalve speculum. (Ashton.)
Fig. 792. — A'lethod of exposing the lateral walls of the vagina by means of the
bivalve speculum. (Ashton.)
blades lie parallel with the anterior and posterior vaginal walls. By
widely separating the blades (Fig. 792) a view of the cervLx and the
lateral walls of the vagina is obtained. For inspection of the ante-
76.
THE FEMALE GENERATIVE ORGANS
rior and posterior vaginal walls the blades of the speculum are turned
so that they lie parallel with the outlet of the vulva and they are
then opened (Fig. 793). The condition of the entire vaginal mucous
Fig. 793. — Method of exposing the anterior and posterior vaginal walls by means of
a bivalve speculum. (Ashton.)
Fig. 794. — Shows the method of inserting Sims' speculum.
membrane may be thus ascertained, and inflammatory conditions,
a fistulous opening, new growths, etc., will be readily recognized if
present. If a discharge is present, its origin should be determined.
EXAMINATION BY SPECULA
763
Fig. 795. — Showing the Sims speculum in place. (Ashton.)
Fig. 796. — Method of inspecting the cervix by the aid of the Sims speculum and a
vaginal depressor. (Ashton.)
764 THE FEMALE GENERATIVE ORGANS
The cervix is then inspected, noting its size and shape and whether
it is lacerated or is the seat of inflammation, erosions, cysts, or new
growths, and whether a discharge issues from the external os. If
secretions obstruct the view, they should be carefully wiped away by
means of cotton wipes held by a sponge holder. In some cases,
where the vagina is very long and narrow, a clear view of the cervix
can only be obtained by drawing it down into the vagina by means of
a tenaculum or bullet forceps.
2. With the Sims Speculum. — The shaft of the speculum is grasped
in the operator's right hand while with the left hand the upper
buttock is raised so that the vulva is well separated. The blade of
the speculum, which has been previously warmed and lubricated,
is then inserted into the vagina parallel with the cleft of the vulva
(Fig. 794). The blade is then rotated so that it lies parallel with the
anterior and posterior vaginal walls and is further introduced until
its distal end lies back of the cervix. By making traction backward
and outward the perineum is retracted so that an excellent view of
the anterior vaginal wall and cervix is obtained (Fig. 795). Should
the anterior vaginal wall obstruct the view, it may be drawn out of
the way by means of the vaginal retractor as shown in Fig. 796.
SOUNDING THE UTERUS
The uterine sound, which was formerly employed to a great ex-
tent in gynecological diagnosis, is now seldom used, as little informa-
tion is gained by its use, outside of determining the length, size, and
consistency of the uterine cavity, that is not as readily obtainable
by other and less dangerous means. The unskilled use of the uterine
sound has often led to the introduction of septic material into the
uterus carried from the vagina or cervix, as well as to the infliction
of serious injury upon the uterine mucous membrane and even per-
foration of that organ. To avoid these risks the position of the
uterus should be ascertained before an attempt is made to introduce
the sound, and, during the attempt, only gentle manipulations of
the instrument should be made; it should never be used as a means of
righting a displaced uterus. The sound should never be introduced
by touch alone, but always with the cervix clearly exposed by means
of a speculum, and in every case the date of the last menstruation
should be ascertained beforehand so as not to interrupt a possible
pregnancy. Its use is contraindicated if the uterus is infected or is
the seat of a malignant disease, or if the uterine appendages are
involved in a suppurative disease.
SOUNDING THE UTERUS
765
Instruments. — The operator will require a vaginal speculum, a
pair of bullet forceps, cotton wipes, a sponge holder, and a uterine
sound (Fig. 797).
The sound is made of flexible metal, about 12 inches (30 cm.)
long and from 1/12 to 1/8 inch (2 to 3 mm.) thick, with a bulbous
tip. The shaft is marked off in inches, and 2 1/2 inches (6 cm.) from
the distal end is a small protuberance to indicate the normal depth
of the uterus.
Asepsis. — The introduction of a sound or any instrument into the
uterus should be regarded as a surgical operation and should be carried
Fig. 797. — Instruments for sounding the uterus, i, Garrigues' weighted specu-
lum; 2, dressing forceps; 3, tenaculum; 4, uterine sound.
out with every aseptic detail. All the instruments should be boiled
for five minutes in a i per cent, soda solution. The external genitals
should be thoroughly cleansed with soap and water followed by a
I to 2000 bichlorid solution and the vagina should be douched with
some antiseptic. The operator's hands are cleansed as thoroughly
as for any operation.
Position of Patient. — The patient should be in the lithotomy
position.
Technic. — The operator sits facing the vulva and, after separating
the labia, introduces the speculum. The anterior lip of the cervix
is then seized by means of bullet forceps and, after being pulled down
into view, is thoroughly wiped off with a cotton swab soaked in a
7C6
THE PEMALE GENERATrv:E ORGANS
I to 2000 bichlorid solution. The sound with its distai 3 inches (7.5
cm.) bent in a slight forward curve is grasped lightly between the
thumb and forefinger of the right hand and is introduced into the
external os, being careful not to touch any portion of the vagina. By
gently depressing its handle the sound should readily glide up the
canal to the fundus. If the point is arrested by catching in a fold of
mucous membrane or at the internal os, gentle manipulation will
usually result in its passage — force should never he employed.
Fig. 798. — Showing the method of estimating the length of the uterus by means of
the uterine sound.
Sometimes, when the cervix is bent forward, the sound may be
more readily passed if it is started with the concavity of its curve
turned backward and, as soon as it becomes arrested, rotating it for-
ward. When the tip of the instrument reaches the fundus, the opera-
tor's right index-finger should be slid along the shaft of the instru-
ment until it comes in contact with the cervix for the purpose of in-
dicating the depth of the canal when the instrument is removed
(Fig. 798).
DIGITAL PALPATION OF THE UTERINE CAVITY
Digital exploration of the interior of the uterus is occasionally
required in the diagnosis of intrauterine growths or retained prod-
DIGITAL PALPATION OF THE UTERINE CAVITY 767
ucts of conception which are not revealed by other methods of
examination. With the finger in the cavity of the uterus it is possible
to determine whether the uterus is empty or not, the length and
direction of the canal, and the thickness, consistency, and other
characteristics of the endometrium.
Digital exploration necessitates a thorough preliminary dilata-
tion of the cervix, except in puerperal cases, and should, therefore,
be considered in the same light as a surgical operation. It should
not be attempted until the possibility of pregnancy has been excluded
by determining the date of the last menstruation and by a careful
examination.
Fig. 799. — Digital exploration of the uterine cavity. (Ashton.)
Instruments. — Instruments for dilating the cervix are required.
These include a vaginal speculum, a pair of dilators, sponge holders,
and two bullet forceps. (See Fig. 851.)
Asepsis. — Strict aseptic precautions should be observed. The
external genitals are washed with soap and water, followed by a
I to 2000 bichlorid of mercury solution. The vagina is scrubbed
with soap and water by means of a sponge on a holder and is then
douched with an antiseptic solution. The instruments are boiled
for five minutes in a i per cent, soda solution and the operator's
hands are prepared with the same care as for any operation.
Position of Patient. — The lithotomy position is employed.
768
THE FEMALE GENERATR^E ORGANS
Anesthesia. — General anesthesia is required except in postpartum
cases.
Technic. — The cervix is first dilated sufficiently to admit the
operator's finger (see page 803). The index-finger of the right hand
or, where possible, as in postpartum cases, the index- and middle
fingers are then passed into the uterus, while, with the left hand on
the abdomen, the operator presses down upon the fundus uteri, so
as to bring the uterus within reach of the internal fingers (Fig. 799).
The interior of the uterus is then systematically explored by the in-
ternal fingers.
Fig. 800. — Instruments for an exploratory vaginal section, i, Garrigues'
weighted speculum; 2, sponge holder; 3, tenaculum; 4, thumb forceps; 5, sharp-
pointed scissors; 6, artery clamps; 7, needle holder; 8, needles; 9, No. 2 catgut.
THE EXAMINATION OF SECTIONS AND SCRAPINGS FROM
THE UTERUS
To determine the nature of a suspicious growth a portion should
be excised for examination. The method of doing this has already
been described (page 254). Where the interior of the uterus is the
seat of suspected disease, scrapings from the endometrium should
be collected by a thorough curettage for examination (see page 807).
EXPLORATORY INCISION
Direct palpation of the pelvic structures is sometimes required in
the diagnosis of obscure pelvic conditions. It may be accomplished
EXPLORATORY INCISION
769
by means of an abdominal incision or through a small opening made
in the cul-de-sac of Douglas. The latter method is preferable, as it
is not a dangerous operation, and the recovery of the patient is more
rapid than when an abdominal section is performed. The operator
should be prepared, however, to perform any operative procedures,
such as draining a pus sac, removing suppurating tubes, or opening
the abdomen, if the findings indicate it.
Instruments. — There will be required a weighted vaginal specu-
lum, sponge holders, bullet forceps, toothed thumb forceps, sharp-
FiG. 801. — First step in performing a posterior vaginal section, opening into the
posterior cul-de-sac.
pointed curved scissors, artery clamps, curved cutting-edged needles,
a needle holder, and No. 2 catgut (Fig. 800).
Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The external genitals are scrubbed with soap
and water followed by a i to 2000 bichlorid solution, and the vagina
is cleansed by first washing with soap and water and then by means
of an antiseptic douche. The operator's hands are sterilized in the
usual way.
Position of Patient. — The patient should be in the lithotomy
position.
49
770
THE FEMALE GENERATIVE ORGANS
Fig. 802. — Shows the posterior cul-de-sac opened.
Fig. 803. — Shows the method of palpating a tumor through an incision into the
posterior cul-de-sac.
VAGINAL IRRIGATIONS 77 1
Preparation of Patient. — The patient is prepared for general
anesthesia (see page 2) and the bowels and bladder should be
empty at the time of operation.
Anesthesia. — General anesthesia is employed.
Technic. — The vaginal speculum is placed in the vagina and the
posterior lip of the cervix is seized in bullet forceps which are given
to an assistant to hold. The operator then picks up the posterior
vaginal wall by means of thumb forceps at a point in the mid-line,
just back of where it is reflected from the cervix, and with a pair of
scissors makes a transverse incision about i inch (2.5 cm.) long
through the vaginal wall (Fig. 801). The vaginal wall posterior to
the incision is then separated by blunt dissection from the under-
lying peritoneum for a short space (Fig. 802). The peritoneum thus
exposed is then picked up and a transverse opening, sufficiently
large to admit the fingers, is made in it. Through this opening the
pelvic structures may be thoroughly palpated by the finger (Fig.
803), and if desired the appendages may be brought down to view
and inspected.
At the completion of the operation the opening in the peritoneum
and that in the vaginal wall are closed by a few catgut sutures.
Therapeutic Measures
VAGINAL IRRIGATIONS
Vaginal irrigation, or douching, may be employed for simple
cleansing purposes, as in leucorrhea or in preparation for operative
procedures, for the purpose of bringing soothing, astringent, or anti-
septic solutions in contact with diseased vaginal or cervical mucous
membrane, and as a means of applying heat to the pelvic organs to
relieve congestion or inflammation, to hasten involution after labor,
to control uterine hemorrhage, etc. In pregnancy and during
m.enstruation douches should be used with caution.
Apparatus.— There will be required a large glass irrigating jar or
douche bag, a bath thermometer, 6 feet (180 cm.) of rubber tubing,
1/4 inch (6. mm.) in diameter, leading from the reservoir to the
douche nozzle, a glass vaginal douche nozzle, and a douche pan with a
spout to which is attached a piece of rubber tubing sufficiently long
to convey the waste fluid to a slop pail (Fig. 804).
The douche nozzle should preferably be of glass without any curve
and having perforations on the sides but with none at the end (Fig. 805) .
772
THE FEMALE GENERATWE ORGANS
With such an instrument there is little danger of the solution entering
the uterus in cases of a patulous cervix.
Asepsis. — The greatest care should be taken against infection
especially in puerperal cases. The apparatus should, therefore, be
boiled for five minutes in plain water and the thermometer should be
Fig. 804. — Apparatus for vaginal douching.
sterilized by immersion in a i to 500 bichlorid of mercury solution,
after which it is rinsed in sterile water. The attendant's hands should
be cleansed in the usual way and the external genitals should be
washed with soap and water followed by a i to 2000 bichlorid solution.
When the patient administers the douches herself, the dangers of
Fig. 805. — Enlarged view of a glass vaginal douche nozzle.
infection and the proper means of avoiding it should be carefully
explained to her.
Solutions Used. — Among the many solutions used for vaginal
injection are the following: Plain sterile water; normal salt solu-
tion— salt 5i (4 gm-) to the pint (500 c.c.) of boiled water — boric
acid, 2 per cent.; thymol i to 1000; lysol i per cent.; creolin i per
cent.; tannic acid o'l (4 gm.) to the quart (liter); alum acetate oi
(4 gm.) to the quart (liter); permanganate of potash i to 2000;
VAGINAL nmiGATIONS
773
bichlorid of mercury i to 5000; carbolic acid i per cent., etc. The
use of poisonous drugs, such as the latter two, should he followed by a
douche of sterile water or saline to avoid any danger of absorption.
Temperature. — Ordinarily the irrigation is given at a tempera-
ture of 100° to 105° F. (38° to 41° C). When the stimulating and
vascular constricting effect of heat is desired, however, the temp-
erature should be from 115° to 120° F. (46° to 49° C).
Quantity. — At least i gallon (4 liters) of solution should be used
at a time. If it is desired to obtain a prolonged effect from the heat,
Fig. 806. — Showing the correct (a) and the incorrect {b) method of giving a vaginal
douche. (Ashton.)
several gallons may be used over a period of fifteen to thirty minutes.
Height of Elevation. — This is important, since, if the reservoir is
elevated too high, the pressure will be so gre.at that solution may be
forced into the uterus. An elevation of 2 to 3 feet (60 to 90 cm.) is
amply sufficient.
Frequency. — This will depend upon the purposes of the douche
from once a day to three or more times daily.
Position of Patient. — The patient lies in bed on a douche pan in
the dorsal position, with the knees flexed, or else recumbent in a bath
tub. The douche should not be taken with the patient sitting on the
toilet.
Technic. — The labia are widely separated with the fingers of the
left hand and with the right hand the nozzle is introduced into the
vagina, first, however, allowing the solution to flow in order to expel
774 THE FEMALE GENERATIVE ORGANS
any air or cold fluid. The desired amount of solution is then per-
mitted to enter the vagina which balloons up under the influence of
the distention and thus allows the solution to come in contact with
its entire surface (Fig. 806).
In cases of a relaxed vagina, it is necessary to compress the vaginal
outlet about the douche tube in order to obtain this distention.
This procedure should, however, be used with caution in puerperal
cases, for, if the intravaginal pressure be too great, some of the
solution will necessarily be forced into the uterus. During the irri-
gation care must be taken to protect the patient's body from
cold by suitable covering.
LOCAL APPLICATIONS TO THE VAGINA AND CERVIX
Local appHcations are employed in treating inflammations of the
vagina and the vaginal portion of the cervix. They may be made by
means of cotton-tipped applicators or by tampons (see page 778).
Fjg. 807. — Instruments for making local applications to the vagina, i, Bivalve
speculum; 2, applicator.
The former method should be employed when it is desired to medi-
cate locahzed areas of inflammation or ulceration or to employ
strong solutions.
Instruments. — There will be required a bivalve vaginal speculum
and a metal applicator or a pair of dressing forceps (Fig. 807).
Asepsis. — The instruments are boiled in a i per cent, soda solu-
tion for five minutes and the external genitals are cleansed with soap
and water followed by a i to 2000 bichlorid of mercury solution.
The operator's hands should likewise be clean.
Solutions Used. — Tincture of iodin, silver nitrate gr. xx to xxx
(1.3 to 2 gm.) to the ounce (30 c.c), argyrol 50 per cent., copper
sulphate gr. v to xx (0.3 to 1.3 gm.) to the ounce (30 c.c), zinc sul-
phate gr. V to XX (0.3 to 1.3 gm.) to the ounce (30 c.c), etc., are
among the solutions generally employed.
LOCAL APPLICATIONS TO THE VAGINA AND CERVIX
775
Frequency.^ — Applications may be made every three or four days.
Position of Patient. — The patient should be upon a firm table in
the dorsal position.
Technic. — The diseased area is exposed by means of a speculum
and, after removing any mucus or secretion, the surface it is desired
to medicate is wiped dry. An applicator or dressing forceps wrapped
with cotton is then dipped in the solution and the saturated swab is
thoroughly rubbed over the diseased area. Following this a light
vaginal tampon is inserted and allowed to remain in place twelve to
twenty-four hours.
APPLICATION OF POWDERS TO THE VAGINA
Powders are sometimes employed with success in place of liquids
in the treatment of chronic vaginitis, especially if ulcerated surfaces
are present.
Fig. 808.
-Instruments for the application of powders to the vagina,
speculum; 2, dressing forceps; 3, powder blower.
I, Bivalve
Instruments.— A vaginal speculum, dressing forceps, and a
powder blower are required (Fig. 808).
Formulary.— Soothing or astringent powders, such as boric acid,
zinc oxid, bismuth subnitrate, calomel, tannic acid, glycerole of tannin,
acetanihd, alone or in combination, are frequently employed.
Position of Patient.— The patient should be in the dorsal posture.
776
THE FEMALE GENERATIVE ORGANS
Technic. — The vagina is first well cleansed with a douche. A
speculum is then inserted and, by means of a cotton swab held in a
dressing forceps, the mucous membrane is thoroughly dried. The
entire inflamed surface is then coated with the desired powder applied
by means of the powder blower. A light tampon is finally inserted
and is left in place for twenty-four hours.
VAGINAL TAMPONS
Vaginal tampons are used for a variety of purposes, namely, to
bring medication in contact with the vagina or the cervix in the treat-
FiG. 809. — Showing the method of making a cotton vaginal tampon.
(Kelly and Noble.)
ment of inflammations involving these structures, to protect and
keep separated inflamed or ulcerated vaginal walls, to apply glycerin
VAGINAL TAMPONS
777
for its depleting effect upon the uterus and pelvic organs, to support
a prolapsed ovary, for the purpose of stretching adhesions or sup-
porting the uterus by distention of the vagina and fornices, and alone
or in combination with the uterine pack to control hemorrhage from
the uterus.
Tampons should not be left in place more than twenty-four hours,
as they tend to become foul and offensive, and strings should always
be attached so that they may be removed by the patient. The
patient should, of course, be informed of the exact number of tam-
pons inserted.
Instruments. — Bivalve and Sims' specula and dressing forceps
are required.
The Tampon. — Tampons are made of absorbent cotton, lambs'
wool, or gauze. For carrying medication absorbent cotton is prefer-
FiG. 8io. — Vaginal tampons in position.
able, while for purposes of support lambs' wool or gauze, having more
body, are best.
The cotton tampon is made by cutting a flat layer of absorbent
cotton into an oblong shape, placing a heavy silk string about 14
inches (35 cm.) long, across one end as shown in Fig. 809, and rolling
the cotton about the string. On tying the string the two ends of the
cotton roll are brought together and, at the same time, the string is
buried in and securely fastened to the cotton.
Lambs' wool tampons may be made in the same manner or a silk
string may be simply tied to the center of a wad of the wool.
A gauze tampon should consist of a single piece of gauze .3 feet
(90 cm.) or more long, depending on the capacity of the vagina and the
778
THE FEMALE GENERATWE ORGANS
firmness with which it is to be packed, and folded to a width of about
2 inches (5 cm.").
The Medicated Tampon. — The tampon is made as above de-
scribed and is then saturated with the desired medication. For this
purpose the following drugs are employed: Ichthyol and glycerin 25
per cent., boroglycerid, glycerite of tannic acid 20 per cent., argyrol
10 to 25 per cent., protargol 2 per cent, etc. When indicated the
tampon may be covered with some of the powders mentioned on j^age
775 in place of these solutions.
Asepsis. — The instruments should be boiled and the tampons
thoroughly sterilized. The external genitals are washed with soap
Fig. 811. — Shows the method of packing the vagina with the patient in the Sims
position.
and water followed by a i to 2000 bichlorid of mercury solution. The
operator's hands are cleansed in the usual way.
Position of Patient. — For inserting the medicated tampon the
patient may be in the dorsal posture, but when it is desired to thor-
oughly pack the vaginal vault for the purposes of support and to con-
trol hemorrhage the Sims or the knee-chest posture is preferable.
Prepgirations of Patient. — The bladder and bowels should be.
empty. Any clots or secretions are \M*ped from the vagina and the
entire vagina is then swabbed out with a i to 2000 bichlorid of mer-
curv solution.
THE INTRAUTERINE DOUCHE 779
Technic. — For applying a medicated tampon a bivalve speculum
is inserted and the tampon, soaked in the medicament, is carried in
dressing forceps to the desired spot. A wool tampon is then inserted
to retain the first one in position and, while the tampons are held
securely in place by means of the dressing forceps, the speculum is
removed, care being taken that the strings attached to the tampons
are left hanging from the vagina (Fig. 8io).
The tampon is to be removed by the patient within twenty-four
hours, at which time a cleansing douche should be taken.
To thoroughly pack the vagina, as is necessary, for example, for
the control of hemorrhage, the patient being in the Sims or the knee-
chest posture, a Sims speculum is inserted and the posterior vaginal
waU is put upon the stretch. Then, by means of a pair of dressing
forceps, the entire vagina is thoroughly tamponed with a strip of
gauze, beginning with the posterior vaginal fornix, then filling the
lateral and anterior fornices, and, as the rest of the vagina is packed,
gradually withdrawing the speculum (Fig. 8ii). A T-bandage is
then applied to retain the pack in place. Such a pack properly
inserted wiU control any ordinary hemorrhage from a nonpuerperal
uterus, but in severe hemorrhages and in postpartum cases the
uterus also should be tamponed (page 786).
Removal of the packing in twelve or twenty-four hours should be
followed by a cleansing douche.
THE INTRAUTERINE DOUCHE
Uterine douches are employed in the treatment of septic condi-
tions affecting the uterus, to control hemorrhage, and for cleansing the
uterus after curettage and other intrauterine operations. They are
more dangerous than vaginal douches, and certain precautions in their
use are necessary. They should always be given by the physician
himself and in their use the same care and attention to cleanliness
should be observed as in any operative procedure. It is absolutely
essential that a free and unimpeded return of the solution be provided
by having the cervix well dilated or by employing a return-flow irri-
gating nozzle, otherwise there is danger of overdistention of the uterus
with resulting shock or of the fluid being forced into the uterus
through the tubes. Furthermore, the use of poisonous drugs, such as
carbolic acid or hichlorid of mercury, should always be followed by an
intrauterine irrigation of sterile water or of normal salt solution.
Apparatus. — There will be required a glass irrigating jar or a large
douche bag, a thermometer, 6 feet (180 cm.) of rubber tubing, 1/4
78o
THE FEMALE GENERATIVE ORGANS
inch (6 mm.) in diameter, connecting the reservoir and the douche
nozzle, a douche pan with a spout to which is attached a piece of rub-
ber tubing sufficiently long to convey the returning fluid to a waste
pail (see Fig. 804).
There are several forms of intrauterine douche nozzles. When the
cervix is widely dilated, as in postpartum cases, a curved glass nozzle
Fig. 812. — Glass intrauterine douche nozzle.
with the openings upon the sides, such as the Chamberlain tube (Fig.
812), is sufficient.
In other cases it is necessary to employ some form of return-flow
nozzle. The Fritsch-Bozeman nozzle (Fig. 813) is the safest of these.
Fig. 813. — Fritsch-Bozeman return-flow uterine douche nozzle. (Bandler.)
It consists of an outer tube fenestrated near the tip, with a second
opening upon the under surface of the instrument near its lower end
for the return flow. Inside this outer tube is a smaller inflow tube.
This instrument requires some dilatation of the cervix, however.
catheter. (Ashton.)
before it can be introduced and where this is lacking a smafler instru-
ment, such as Talley's intrauterine catheter (Fig. 814), may be
employed. The latter consists of a curved metal catheter with two
heavy wires on its under surface, which may be expanded or closed by
turning a small thumb-screw. The catheter is introduced into the
uterus with the wires lying close to the catheter and, when in the
THE INTRAUTERINE DOUCHE
781
uterus, the wires are expanded, thereby dilating the cervix sufficiently
to permit a return of the injected solution.
Instruments. — In addition to the above apparatus a vaginal
speculum, a sponge holder, and a pair of bullet forceps are required
(Fig. 815).
Asepsis. — The apparatus and instruments should be sterilized by
boiling and the thermometer by immersion in a i to 500 bichlorid of
mercury solution followed by rinsing in sterile water. The external
genitals are first washed with soap and water and then with a i to
2000 bichlorid of mercury solution. The vagina is cleansed by means
Fig. 815. — Instruments for intrauterine douching, i, Garrigues' weighted specu-
lum; 2, sponge holder; 3, tenaculum.
of a I to 5000 bichlorid of mercury douche, followed by sterile water.
The operator's hands are sterilized in the usual way.
Solutions Used. — Plain sterile water, normal salt solution— salt
3i (4 gm.) to the pint (500 c.c.) of water, i to 10,000 to i to 5000
bichlorid of mercury, 50 per cent, alcohol, 0.5 per cent, solution of
lysol, 0.5 per cent, solution of creolin, silver nitrate i to 1000, etc.,
etc., are among the solutions employed.
Temperature. — Ordinarily the temperature of the solution is
about 105° F. (41° C). Where the stimulating and constricting effect
of heat is desired the temperature of the solution should be 115° to
120° F. (46° to 49° C).
Quantity. — About i quart (i liter) of solution is used at a time.
78:
THE FEMALE GENERATIVE ORGANS
Rapidity of Flow. — The fluid should not be allowed to enter the
uterus more rapidly than it can escape, otherwise there is danger of its
Fig. 8i6. — Inserting the douche nozzle when the cervix is well dilated.
being forced into the tubes. Therefore, the reservoir should not be
elevated more than 2 feet (60 cm.).
Position of Patient. — The patient should be in the dorsal position.
Fig. 817. — Method of giving an intrauterine douche in a postpartum case.
Technic. — If the cervix is well dilated so that the entrance of the
douche nozzle is not interfered with, the latter may be inserted by
touch alone, as follows : One or two fingers of the left hand are passed
THE INTRAUTERINE DOUCHE
783
into the vagina and the external os is thus located. The douche
nozzle, with the solution flowing so as to avoid injecting any air, is
then inserted into the uterus by the right hand, being guided through
the cervix by the fingers of the left hand (Fig. 816). The nozzle is
then gently passed to the fundus of the uterus and the cavity is thor-
oughly irrigated. The return flow must be carefully watched to see
that it is not obstructed. It is well to place the left hand exter-
nally over the fundus uteri in puerperal cases to prevent any possible
overdistention of the uterus and opening up of the sinuses (Fig. 817).
Fig. 818.
-Shows the method of giving an intrauterine douche with a return-flow
nozzle.
To introduce the douche nozzle by sight, the posterior vaginal wall
is retracted by means of a speculum, and, if the cervix is not readily
accessible, it is drawn down into the vagina by means of bullet forceps
caught in its anterior lip. The cervix is then wiped off by means of a
swab on a sponge holder wet with a i tp 2000 bichlorid of mercury
solution, and a return-flow nozzle is inserted by direct sight, taking
care to have the solution first flowing (Fig. 818). In inserting the
nozzle extreme gentleness should be used to avoid injuring the tissues
or possibly perforating the uterus. The latter accident has happened
frequently enough to warrant this caution.
INTRAUTERINE APPLICATIONS
The application of drugs with an astringent or caustic action to the
mucous membrane of the uterus is employed in the treatment of endo-
■84
THE FEMALE GENERATWE ORGANS
metritis alone or in conjunction with curettage. The best results are
obtained, however, when intrauterine applications are used after a
preliminary curettage.
The indiscriminate employment of intrauterine applications
should be condemned, as they often do more harm than good. They
should only be employed in cases where thorough asepsis can be
obtained, and then only with the cervix sufficiently dilated to allow
thorough subsequent drainage. The procedure, therefore, is one that
rises to the dignity of an operation and should never be attempted
as a part of the office treatment.
Fig. 819. — Instruments for making intrauterine applications, i, Garrigues
weighted speculum; 2, sponge holder; 3, tenaculum; 4, applicator.
The position and size of the uterus and the condition of the other
pelvic organs must be determined by bimanual examination before-
hand. In the presence of adnexal involvement or other complications
intrauterine applications are contraindicated.
Instruments. — There should be provided a vaginal speculum,
sponge holders, bullet forceps, and two uterine applicators (Fig. 819).
Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The external genitals are washed with soap and
water followed by a i to 2000 bichlorid solution. The vagina is
douched with a i to 5000 bichlorid of mercury solution followed by
sterile water. The operator's hands are likewise sterilized as for any
operation.
INTRAUTERINE APPLICATIONS
78:
Solutions Used. — Sulphate of zinc 5 to 10 per cent., chlorid of zinc
5 to 10 per cent., silver nitrate 5 to 10 per cent., per chlorid of iron 5
per cent., ichthyol 5 to 10 per cent., tincture of iodin 50 per cent,
Chinrchill's solution of iodin, pure carbohc acid, etc., etc., may be
employed.
Position of Patient. — The patient is placed in the dorsal position.
Technic. — The vaginal speculum is inserted and the cervix is
drawn down into view by means of bullet forceps which seize the ante-
rior lip. Any secretion or collection of mucus is then wiped away
Fig. 820. — Shows the method of making an intrauterine application.
from the external osby means of a swab soaked in a i to 2000 bichlorid
solution, and the cervix is dilated if necessary (see page 803). A
small thin layer of dry cotton is then securely wound round an appli-
cator, taking care that the tip of the instrument is well covered. The
swab thus fashioned is to be of such size that it will readily pass the
cervix. The applicator is curved to the shape of the canal and is
passed into the uterus for the purpose of removing any secretions and
thus allow the solution to come in contact with all portions of the
mucous membrane. A second applicator, similarly wrapped with
cotton, is dipped in the solution. Any excess of fluid is squeezed
from the cotton and the appHcation is then made to the interior of the
uterus, carrying the cotton-tipped applicator well up to the fundus
and moving the instrument about in the cavity (Fig. 820). A vaginal
tampon is finally inserted, which is removed in twenty-four hours.
The patient should remain quiet for a day or two, and if a strong
50
786
THE FEMALE GENERATIVE ORGANS
caustic has been employed she should be warned that at first there will
be an increased discharge.
TAMPONING THE UTERUS
Tamponage of the uterus may be required to control severe uter-
ine hemorrhage, to secure dilatation of the cervix for the expulsion of
the uterine contents or in preparation for intrauterine manipulations,
and to aid in the separation of retained products of conception. The
technic of tamponing the uterus for the control of hemorrhage is
Fig. 821. — Instruments for tamponing the uterus. I, Garrigues' speculum; 2,
sponge holder; 3, tenaculum; 4, uterine dressing forceps; 5, uterine packer.
something with which every physician should be familiar, as occasions
may arise when the operation is demanded without delay as a life-
saving measure; at the same time it should be regarded as a surgical
procedure and one that should always be performed under thorough
aseptic precautions. The position and size of the uterus should be
ascertained by bimanual examination beforehand, otherwise the
uterus may be injured in attempting to insert the packing.
Instruments. — A Simon or a Garrigues speculum, sponge holders,
two bullet forceps, a pair of uterine dressing forceps, or a cannula and
packer are required (Fig. 821). In the majority of cases a pair of
curved dressing forceps may be employed for inserting the packing,
but, where the cervix is not well dilated, a special packer, such as is
shown in Fig. 822, by means of which the packing is pumped into the
uterus through the cannula, is more convenient.
TAMPONING THE UTERUS
787
Packing Material. — The most satisfactory material to pack with
is steriHzed gauze. This should be folded into strips 2 inches (5 cm.)
wide for use when the cervix is well dilated and into strips 1/2 inch
(i cm.) wide for an incompletely dilated cervix. Care should be-
Fig. 822. — Showing the cannula and plunger of the uterine packer separated.
taken to see that the strips are so folded that no frayed edges are
exposed. The gauze is best kept in long strips packed in sterile glass
tubes.
Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The patient's external genitals are washed with
Fig. 823. — Method of tamponing the uterus with a long strip of gauze inserted by
means of dressing forceps.
soap and water, followed by a i to 2000 bichlorid solution and the
vagina is first cleansed with soap and water and then douched with a
I to 5000 solution of bichlorid of mercury.
Position of Patient. — The patient should be in the hthotomy
position.
Preparations of Patient. — The patient's bladder and bowels should
be empty.
788
THE FEMALE GENERATIVE ORGANS
Technic. — Any clots are first wiped out of the vagina. The cer-
vix is exposed by means of the speculum and the anterior and pos-
terior lips are seized in bullet forceps which are given to an assistant
to hold. A strip of gauze is then seized in dressing forceps in such a
way that the gauze falls over the end of the forceps so as to avoid
inflicting any injury upon the tissues and is carried to the fundus.
Successive sections of the gauze are inserted in the same manner until
the cavity is filled (Fig. 823). Whenever possible, a single strip of
gauze should be employed. While inserting the gauze the operator's
Fig. 824. — Method of using the uterine packer.
free hand should be kept upon the abdomen in order to control the
uterus, and care should be taken that the gauze does not come in
contact with anything that is not sterile. The end or ends of the
gauze, if more than one strip is used, should be left projecting into
the vagina, so that it may be easily found, when the gauze is to be
removed, which should be within twenty-four hours of its insertion.
In cases of severe hemorrhage the vagina also should be packed
(see page 776), taking care, however, to tie the vaginal strip to that
within the uterus or else to bring the ends of both vaginal and uterine
strips to the vaginal outlet. Upon removal of the gauze a vaginal
douche should be given.
In tamponing the uterus by means of the special packer shown in
Fig. 822, the cervix is exposed as before and is drawn down by means
of bullet forceps. The cannula is then inserted into the uterus and a
PELVIC MASSAGE 789
narrow strip of gauze is caught on the sharpened end of the piston and
is carried into the uterus by a pumping motion of the piston (Fig,
824).
BIER'S HYPEREMIC TREATMENT IN GYNECOLOGY
Passive hyperemia by means of special forms of suction cups
appHed to the cervix uteri has been employed with good results in
cases of puerperal and other forms of infections of the cervix and
uteruSj in ulcerations of the cervix, in chronic metritis, and in amenor-
rhea. The use of cups is contraindicated, however, if the adnexa are
inflamed.
In dysmenorrhea there have been numerous favorable reports
from the application of large suction cups to the breast once or twice
a day for periods of fifteen to thirty minutes, beginning a few days
before the date of expected menstruation and continuing the treat-
ments till the end. Pelvic exudates have also been treated with
success by means of hot-air boxes in which the pelvis and hips rest.
The apparatus for obtaining active and passive hyperemia, as
well as the method of its use, have been previously described in
Chapter IX.
PELVIC MASSAGE
Pelvic massage after the method of Brandt has been employed for
the purpose of hastening the absorption of pelvic exudates through
stimulation of the circulation and lymph currents, to stretch or sepa-
rate old adhesions, to stimulate contractions in the uterus, and to
strengthen and tone up weakened or thickened pelvic ligaments. In
certain selected cases this method of treatment has value. Pelvic
massage must never he employed, however, in the presence of acute
i ■iflammation or with pus collections in the tubes or pelvis, so that the
diagnosis must be carefully made in every case before it can be safely
attempted, and then it should only be performed by the physician
himself. In individuals with erotic tendencies it should be avoided.
Duration of Treatments. — The massage is performed for about ten
minutes at a sitting.
Frequency. — Treatments are given daily.
Position of Patient. — The patient should be in the dorsal posture.
Preparations. — The bladder and bowels should be emptied before-
hand and the clothing should be loosened from the abdomen.
Technic. — Under all aseptic precautions two fingers of the left
hand are introduced into the vagina and are carried up to the part to
790
THE FEMALE GENERATIVE ORGANS
be massaged. Then, by means of the right hand placed on the abdo-
men, at first gentle circular movements and then deep pressure manip-
FiG. 825. — Showing the position of the hands in commencing pelvic massage.
Fig. 826. — Instruments for scarification of the cervix, i, Bivalve speculum; 2,
sponge holder; 3, tenaculum; 4, narrow-bladed bistoury.
ulations are made over the diseased part which at the same time is
raised and fixed within reach of the external hand by the internal fin-
SCARIFICATION OF THE CERVIX
791
gers. The manipulations should be begun each time over the per-
iphery of the diseased part and should always be made with the great-
est care and with the absence of any approach to roughness.
When employed for the purpose of gradually stretching adhesions
or contracted ligaments, gentle intermittent traction is applied to the
uterus through the internal and external hands in a direction opposite
to the point of the fixation (Fig. 825). By thus gradually stretching
the adhesions and through the stimulating effect of the manipulations
the fibrous tissue is gradually absorbed and the muscular and elastic
tissues become regenerated. Such manipulations are especially use-
ful when used in conjunction with hot douches and tampons in gradu-
ally replacing a uterus bound down by adhesions.
SCARIFICATION OF THE CERVIX
The withdrawal of blood from the cervix is a valuable therapeutic
measure in cases of chronic congestion of the uterus and pelvic organs.
Fig.
Fig. 827. — Method of scarifying the cervix by punctures. (Ashton.)
828. — Scarification of the cervix, showing the method of making the superficial
incisions. (Ashton.)
It is also employed with good results for the rehef of the pain and coHc
of delayed menstruation due to pelvic congestion.
Instruments. — A vaginal speculum, sponge holders, bullet forceps,
and a narrow-bladed bistoury are required (Fig. 826).
Asepsis. — All aseptic precautions should be observed. The
instruments are to be boiled for five minutes in a i per cent, soda solu-
79^ I'HE FEMALE GENERATIVE ORGANS
tion. The external genitals are cleansed with soap and water, fol-
lowed by a I to 2000 bichlorid solution, and the vagina is douched.
Position of Patient. — The patient should be in the dorsal posture.
Technic. — The cervix is exposed by the speculum and. after being
mopped off by means of a wipe moistened in a i to 2000 bichlorid
solution, is seized by the bullet forceps and is drawn well down toward
the vaginal outlet. Numerous punctures are then made by means of
the point of the bistoury to the depth of 1/4 to 1/2 inch (6 to 12 mm.)
around the circumference of the cervix (Fig. 827), or, instead of punc-
tures, cross cuts may be employed (Fig. 828). In this way from 1/2
ounce (15 c.c.) to 2 ounces (60 c.c.) of blood may be withdrawn. A
tampon of ichthyol and glycerin or tannin and glycerin is then inserted
into the upper portion of the vagina, to be removed within twelve
hours.
PESSARY THERAPY
Pessaries are employed for the purpose of maintaining a retrodis-
placed or prolapsed uterus in place and to support a cystocele. In
the case of a prolapse of the uterus or a cystocele a pessary is only of
value as a palliative measure where operative relief is refused or is
undesirable on account of the age or condition of the patient. In a
certain proportion of retrodisplacements, however, a properly fitted
pessary will in time produce a cure, the most favorable cases being
those in which the displacement is only of short duration as, for
example, after confinement. The only cases of displacement in which
pessary therapy is suitable are those where the pelvic floor has suffi-
cient tonicity to give support to the pessary and where the displace-
ment is not compUcated by pelvic lesions. Their use is contraindi-
cated in the presence of considerable enlargement or a prolapse of the
ovary, hydrosalpinx, pyosalpinx, or new growths, and where the
uterus is bound down by adhesions. Some cases of adhesions, how-
ever, under appropriate treatment by medicated tampons, hot
douching, etc., may be so stretched or even be made to disappear that
later a pessary may be satisfactorily employed.
Pessaries are not designed as a means of replacing a uterus, but
simply to hold the organ suspended in proper position after it has been
replaced. This it does by distending the vaginal walls, and not
through any force exerted by the instrument upon the uterus itself.
Every pessary should be fitted to the individual case, and it is here
that the experience of the physician counts for much. When properly
fitted, the pessary should never cause any pain or even make the patient
PESSARY THERAPY
793
conscious of its presence, and it may be worn for years, with certain
precautions as to cleanliness, to be mentioned later, without harm.
Fig. 829.— Hodge-Smith pessary.
Fig. 830. — Hodge pessary.
Fig. 831.— Ring pessary.
Fig. 832. — Gehrung's pessary.
Fig. 833.— Skene's pessary.
Fj^. 834.-CUP or ring (a) pessary with external support. (Ashton.)
On the other hand, an ill-fitting pessary «^ ,^^^^ ^^P/^^^, "";"';
not suitable for such treatment is distmctly harmful. It should,
therefore, always be impressed upon the patient that if the least pam
794 THE FEMALE GEXERATR'E ORGANS
or an undue amount of leucorrhea results from the insertion of the
pessary,, she should report to the physician immediately, or else
remove the pessary herself.
Pessaries. — Pessaries are made of hard rubber in a great variety
of shapes. For retrodisplacements the most commonly employed is
the Hodge-Smith (Fig. 829). If, however, the pelvic floor is relaxed,
a Hodge pessary (Fig. 830) is preferable, as its wide lower bar renders
it less liable to slip out. These act as levers in the vagina in such a
way that the force is exerted upon the posterior cul-de-sac and the
uterosacral ligaments, so that the cer\'ix is pulled backward and the
uterus is thus tipped forward.
Ring pessaries (Fig. 831) are also employed in retrodisplacements
where there is not sufficient support for the ordinary pessary. They
act by so distending the vagina in all directions that the uterus is
supported by the lower vaginal structures. The ring should be
smooth and fairly thick, at least 1/4 inch (6 mm.), so as to avoid any
danger of its eroding through the vaginal walls. The ring pessary
is also employed for retaining a prolapsed uterus in place; but in
many cases of prolapse, the perineum is so relaxed that the pessary
immediately slips out. and some sort of pessary held in place by an
abdominal support, such as is shown in Fig. 834, will be necessary.
For supporting a cystocele Gehrung's anteversion pessarj^ (Fig.
832) or Skene's pessary (Fig. St^t,) is often used with success.
As previously stated the pessary should be fitted to each individual
case. The shape of the pessary may be readily changed by first
coating the instriiment with oil or vaselin and then softening it by the
heat of an alcohol lamp. When it has been moulded to the desired
shape it is hardened again by immersion in cold water. The ten-
dency is to employ too large a pessary, which is dangerous, as it may
exert undue pressure upon the vaginal wall and produce excoriations,
or in time even ulcerate through. On the other hand, if the pessary is
too small, it will not remain in place. The safest plan is to measure
the vagina in each case and shape the pessary accordingly. The
depth of the vagina is determined by carrying two fingers as high as
possible into the posterior cul-de-sac and measuring the distance from
the inferior border of the symphysis, while the width is estimated by
noting the distance to which the two fingers in the vagina may be
separated. About 1/2 inch (i cm.) should be deducted from the
former measurement for the correct length of the pessary.
Asepsis. — The ring pessary may be sterilized by boiling, but the
others, if so treated, lose their shape; prolonged immersion in some
PESSARY THERAPY
795
antiseptic solution, such as i to 500 bichlorid of mercury, should be
employed instead.
Position of Patient. — For inserting the pessary the patient is ordi-
FiG. 835. — First step in replacing a retroverted uterus. (Ashton.)
narily placed in the dorsal posture, though in some cases the knee-
chest position may be used to better advantage.
Preparations of Patient. — The bladder and bowels should be
empty, and the clothing well loosened,
Fig. 836. — Second step in replacing a retroverted uterus. (Ashton.)
Technic. — i. Replacement of the Retroverted Uterus. — There are
two methods of replacement: (i) By bimanual manipulation, and
(2) with the patient in the knee-chest posture. The former method
is usually effective if the abdominal walls are not thick and rigid and
796
THE FEMALE GENERATIVE ORGANS
the vagina is sufficiently roomy. It is performed as follows: Two
fingers of the left hand are introduced into the vagina and are carried
up into the posterior cul-de-sac where they exert pressure in an
Fig. 837. — Third step in replacing a retroverted uterus. (Ashton.)
upward and forward direction upon the body of the uterus (Fig. 8^s)-
As the uterus is thus elevated, the right hand is placed upon the
abdomen, and an attempt is made to hook the fingers behind the fun-
FiG. 838. — Second method of replacing a retroverted uterus. First step.
(Kelly and Noble.)
dus (Fig. 836). The fundus is then pulled forward by the fingers of
the external hand while the internal fingers are shifted to the anterior
fornix, where they make backward pressure upon the cervix and the
PESSARY THEBAPY
797
lower segment of the uterus (Fig. 837). Sometimes, however, it is
not possible to raise the fundus past the promontory by this method.
In such a case the anterior lip of the cervix should be grasped in
Fig. 839. — Second method of replacing a retroverted uterus. Second step.
(Kelly and Noble.)
Fig. 840. — Second method of replacing a retroverted uterus. Third step.
(KeUy and Noble.)
bullet forceps, and the whole uterus is then puUed down toward the
vaginal outlet (Fig. 838). At the same time the index-finger of the
left hand covered with a glove is inserted into the rectum and the
"98
THE FEMALE GENERATR'E ORGANS
fundus is elevated past the promontory (Fig. 839). The cervix is
then pushed backward (Fig. 840), the bullet forceps are removed, and
reposition is completed bimanually as described above.
If these manipulations fail, the patient should be placed in the
knee-chest posture and the posterior vaginal wall retracted by means
of a Sims or Simon speculum. This frequently results in the uterus
falling forward through the effect of gravity. If it does not, the cer-
vix should be grasped with bullet forceps and pulled upward and out-
ward toward the vaginal outlet, while the fundus is pushed forward by
means of a pair of dressing forceps armed with a pledget of cotton
Fig. 841. — -Replacement of a posterior uterine displacement in the knee-chest
position. Showing the cervix drawn forward and the fundus swinging clear of the
promontory. Illustration a shows the fundus pushed anteriorly by direct pressure.
(Ashton.)
carried up into the posterior cul-de-sac (Fig. 841). The patient is
then slowly and carefully turned to the dorsal position, and a bi-
manual examination is made to determine if the uterus is still in posi-
tion before a pessary is inserted.
In all manipulations toward replacement of a uterus, the utmost
gentleness should he employed. If the patient is very sensitive or the
abdominal walls rigid, it is preferable to give a general anesthetic
rather than employ force.
PESSARY THERAPY 799
2. Introduction of Pessaries. — To insert the ordinary retroversion
pessary, the left index-finger is carried into the vagina and the vaginal
Fig. 842. — First step in introducing a retroversion pessary.
wall is retracted, while with the right hand, the pessary is introduced
at first obliquely (Fig. 842), and then turned so that it lies transversely
Fig. 843. — Showing the pessary in the vagina with the posterior bar in contact
with the cervix. (Ashton.)
in the vagina (Fig. 843). The index-finger of the left hand is then
shifted so that it lies under the anterior bar with its -tip resting upon
the posterior bar (Fig. 844). The posterior bar is then pressed down-
8oo
THE FEMALE GEXERATR'E ORGANS
ward and backward until it lies behind the cervix (Fig. 845). After
the pessar>' has been introduced, the patient is examined while in the
erect position to see if it fits properly. A properly fitting pessary
Fig. 844. — Second step in introducing a retroversion pessary, depressing the
posterior bar and inserting it behind the cervix. (Ashton.)
Fig. 845. — Showing the retroversion pessary in place. (Ashton.)
Fig. 846. — First step in introducing a ring pessary.
should hold the uterus in place and at the same time should not be
so tight that the examining finger cannot be passed between the
vaginal walls and the pessary on all sides.
PESSARY THERAPY
8oi
The ring pessary is introduced in much the same way, that is, the
left index-finger retracts the posterior vaginal wall while with the
fingers of the right hand the pessary is introduced obliquely into the
vagina (Fig. 846). It is then turned transversely and is manipulated
Fig. 847. — Shows the ring pessary in place.
Pig. 848. — Showing Skene's pessary in place. (Ashton.)
by the internal fingers until it hes in proper position with its opening
surrounding the cervix (Fig. 847).
Skene's cystocele pessary is introduced into the vagina in the same
manner as the retroversion pessary, with the posterior bar lying
behind the cervix, and the broad anterior bar supporting the bladder
(Fig. 848).
SI
802
THE FEMALE GENERATIVE ORGANS
Gehrung's cystocele pessary is more difficult to introduce. The
following method is employed: The pessary is placed upon a table in
such a way that it rests upon its inferior arch, with the two curves,
Fig. 849. — First step in introducing Gehrung's pessary.
right and left, facing toward the operator, who then grasps the curve
L between the thumb and forefinger of the right hand, and inserts
curve R into the right side of the vagina (Fig. 849) and then curve L
Fig. 850. — -Gehrung's pessary in position.
into the left side. The pessary is then manipulated into such posi-
tion, that the superior arch lies up in front of the uterus, the inferior
arch under the pubic arch, and the two curves R and L on the pos-
terior vaginal wall (Fig. 850).
DILATATION OF THE CERVIX
803
After-care. — Within three or four days after introduction of the
pessary, the vagina is inspected to determine whether there is any
erosion from undue pressure of the pessary. The patient is then
examined once every month or six weeks, at which time the pessary is
removed and well cleansed before re-insertion and the vagina is
examined for signs of ulceration, which, if present, necessitate the
removal of the pessary and the substitution of medicated tampons
until healing has been effected. Once a week and after each men-
strual period the patient should take a warm boric acid or soapsuds
douche for cleansing purposes, while, if there is irritation from the
presence of the pessary, a daily douche should be administered. In
cases where the displacement is accompanied by considerable uterine
congestion and enlargement, a hot vaginal douche should be given
night and morning (see page 771). In all cases the physician should
impress upon the patient the necessity of reporting if at any time the
pessary causes any pain or discomfort.
DILATATION OF THE CERVIX
Dilatation of the cervix, while a small operation, is one of con-
siderable importance, as it forms a part of many gynecological pro-
FlG.
4. 5 ' 6
851. — Instruments for dilating the cervix, i, Garrigues' speculum; 2,
sponge holder; 3, tenaculum; 4, uterine sound; 5, Goodell dilators; 6, Fritsch-
Bozeman return-flow irrigator.
cedures. Thus it may be required as a preliminary to exploration of
the interior of the uterus, intrauterine irrigations and applications,
8o4
THE FEMALE GENERATIVE ORGANS
curettage, and to secure sufficient dilatation for the extraction of
retained secundines following an incomplete abortion. Dilatation
of the cervix is also employed for the cure of dysmenorrhea and ster-
ility dependent upon cervical stenosis. The operation should always
be performed under all aseptic precautions and after the position of
the uterus and the condition of the appendages have been first deter-
mined by bimanual examination. Pelvic peritonitis, pelvic abscess,
pyosalpinx, etc., are contraindications to dilatation, unless the pro-
cedure is to be immediately followed by operative treatment of these
conditions.
There are two methods of performing dilatation: (i) Gradual
dilatation by means of sponge, laminaria, or tupelo tents, and (2)
rapid dilatation. The former method, besides being painful, is no
longer looked upon with favor on account of the dangers of infection
and will not be described.
Fig. 852. — Hegar's graduated dilators. (Bandler.)
Instruments. — A self-retaining speculum, a sponge holder, two
bullet forceps, a uterine sound, two pairs of Goodell's dilators (a
small and a large size), and a Fritsch-Bozeman return-flow irrigator
are required (Fig. 851). Some operators prefer to employ graduated
sound dilators, such as Hanks' or Hegar's (Fig. 852), in place of the
glove stretcher form of dilator, as producing less laceration of the
cervical tissue.
Asepsis. — The instruments are boiled in a i per cent, soda solution
for five minutes and the operator's hands are thoroughly cleansed.
Position of Patient. — The patient should be in the lithotomy
posture.
Anesthesia. — While the operation may be performed under local
anesthesia by infiltrating the cervical tissue with a 0.2 per cent,
solution of cocain or a i per cent, novocain solution, and inserting a
pledget of cotton saturated with a 4 per cent, solution of cocain into
the cervical canal, general anesthesia will be found preferable in the
majority of cases.
DILATATION OF THE CERVIX
80 !
Preparations of Patient.— The bladder and bowels are to be
empty. The hair is shaved or closely cut from the labia and the
external genitals are washed with soap and water followed by a i to
2000 bichlorid solution. The vagina is then washed with soap and
water by the aid of a swab on a sponge holder and this is followed by a
douche of i to 5000 bichlorid.
Technic. — The speculum is introduced into the vagina and the
anterior cervical lip is seized by bullet forceps and is drawn toward
Fig. 853. — First step in dilatation of the cervix. The cervix exposed and drawn
down bv a tenaculum.
the vaginal orifice (Fig. 853). The cervix is then swabbed with a
I to 2000 bichlorid solution. A sound is next introduced for the pur-
pose of determining the direction of the uterine canal, and this is
important in order to avoid perforating or otherwise injuring the
uterus with the dilators in case of a retrodisplacement or a sharp ante-
flexion. The small size Goodell dilator is then inserted into the cer-
vix, carefully manipulating it past any obstruction from the internal
OS, but above all avoiding the use of any force. With the instrument
through the internal os the dilators are gradually expanded, first in
one direction and then, after rotation of the instrument, in another,
8o6
THE FEMALE GENERATIVE ORGANS
until a moderate amount of dilatation has been obtained, when the
large size dilator may be substituted. The dilatation is thus con-
tinued, the operator being guided as to the force he may exert by the
amount of resistance offered by the cervix, until the cervLx has been
sufficiently stretched for the purposes of the operation.
At the comi)letion of the operation the uterus is irrigated through a
Fritsch-Bozeman double-flow tube. Following the operation the
patient should remain in bed three to four days during which time a
Fig. 854. — Second step in dilatation of the cervix. Shows the method of dilating
by means of Goodell's dilators.
daily vaginal douche of warm 4 per cent, boracic acid solution or ster-
ile water is given.
Dilatation by means of the Hegar style of dilator is comparatively
simple. The cervix is exposed and drawn down as above, and then,
beginning with the small ones, successive larger sizes of the dilators
are inserted into the cervix (Fig. 855), lubricating each sound with
sterile vaselin before its introduction. In using the smaller sized
sound great care must be observed against making a false passage in
case any obstruction is offered by the internal os.
CURETTAGE 807
When dilatation is performed for sterility due to stenosis, some
operators follow the operation by introducing into the cervix a hard-
rubber stem, such as is shown in Fig. 856, for the purpose of maintain-
ing the dilatation. The stem is from 22 to 25 French in size and is
Fig. 855. — Showing the method of dilating the cervix by means of the graduated
dilators of Hegar.
provided with a groove upon its lateral wall for the escape of dis-
charges. It has this objection, however, that it is liable to irritate the
cervical lining.
Fig. 856.— Intrauterine stem pessary. (Bandler.)
CURETTAGE
Curettage, or the scraping of the inner lining of the uterine cavity
may be performed for the purpose of removing diseased mucosa in
chronic endometritis, for the purpose of obtaining tissue for subse-
quent microscopic examination in suspected cancer of the uterus, and
as a preliminary to repair of the cervix and operations upon the uter-
ine appendages. In puerperal cases the operation is indicated for the
8o8
THE FEMALE GENERATIVE ORGANS
removal of pieces of decidua or placenta retained after labor or follow-
ing incomplete abortions.
The operation is contraindicated in cancer of the uterus except to
obtain tissue for examination and as a preliminary to a radical opera-
tion and likewise in pelvic peritonitis, pyosalpinx, pelvic cellulitis,
ectopic pregnancy, etc., unless as a preliminary to a laparotomy.
Curettage is dangerous in the presence of submucous fibroids, as
sloughing of the growths may result through injury from the curet. I n
streptococcus infections of the uterus, the operation, if performed at
Fig. 857. — Instruments for curettage, i, Garrigues' weighted speculum; 2
sponge holder; 3, tenacula; 4, uterine sound; 5, Goodell dilators; 6, Fritsch-
Bozeman nozzle; 7, Sims' curets; 8, Martin's curet; 9, blunt curet; 10, placental
forceps; ii, uterine dressing forceps.
all, should be done with caution, as new channels for infection are
opened up by the curet and extension of the process to the deeper
tissues is liable to follow.
A curettage should always be performed under the strictest asep-
sis and with care and gentleness, as a false passage may easily be
made through the wall of the uterus with the curet or dilator; espe-
cially is this liable to happen in septic conditions and in puerperal cases
where the uterine wall is soft. The position of the uterus and the
condition of the adnexa should be ascertained beforehand by means
of a bimanual examination.
Instruments. — A Simon or a Garrigues self-retaining speculum,
sponge holders, two bullet forceps, a uterine sound, a pair of large and
CURETTAGE
809
smal] Goodell dilators, Sims' curets, a Martin curet, a large blunt
curet, placental forceps, uterine dressing forceps, and a Fritsch-
Bozeman return-flow irrigator will be required (Fig. 857).
Asepsis. — All the instruments are boiled for five minutes in a i per
cent, soda solution, and the operator's hands are sterilized as for any
operation.
Position of Patient. — The patient should be in the lithotomy-
posture.
Anesthesia. — General anesthesia is necessary.
Fig. 858. — Dilatation and curettage of the uterus. Illustration a shows the
endometrium being removed with Sims' curet; illustration h shows the mucous
membrane on the fundus being removed with Martin's curet. (Ashton.)
Preparations of Patient. — The bladder and bowels are to be
empty. The hair is shaved or cut from the labia and the external
genitals are washed with soap and water followed by a i to 2000
bichlorid solution. The vagina is first thoroughly scrubbed with
soap and water by means of a swab on a sponge holder and is then
thoroughly douchedwith a i to 5000 bichlorid of mercury solution.
Technic. — i. Nonpuerperal Cases. — The cervix is exposed by
means of the speculum and the anterior or both the anterior and
posterior lips are caught by means of bullet forceps and are drawn
well down toward the vulva. The cervix is then wiped with a swab
soaked in a i to 2000 bichlorid solution and, after first determining
the direction of the canal, the cervix is dilated in the manner described
8io
THE FEMALE GENERATIVE ORGANS
on page 805. The entire uterus is then thoroughly scraped with a
sharp curet of the largest size that will pass through the cervix. This
should be done in a systematic manner — for example, beginning with
the anterior wall, the curet is carried to the fundus and is then with-
drawn along the front wall and out of the uterus in one sweep. Any
adherent tissue is wiped off the curet and the instrument is reinserted
and withdrawn over another section of the anterior wall. The proc-
ess is repeated until the entire anterior wall has been scraped, and
then the two side walls and the posterior wall are similarly dealt
Fig. 859. — Shows the uterine cavity being swabbed out with pure carbolic acid.
(Ashton.)
with. A Martin curet is then substituted for the Sims instrument
and the fundus is well scraped. The cavity is then irrigated with
sterile water or normal salt solution by means of the return-flow
catheter in order to remove any debris or loose shreds of tissue, and a
light packing is inserted for a few moments to dry the cavity. The
packing is then removed and the uterine cavity is swabbed with pure
carbolic acid introduced by means of a cotton swab on dressing forceps
(Fig. 859). In doing this care must be taken not to touch the vagina
with the carbolic acid and to remove any excess of acid from the swab
before inserting it in the cervix. The vagina is then cleansed, the
bullet forceps are removed from the cervix, and a light vaginal tampon
is placed in contact with the cervix. The vulva is finally covered
with a gauze pad.
2. Puerperal Cases. — Unless the cervix is already dilated, it should
be stretched sufficiently to admit one or, if possible, two fingers. The
CURETTAGE
>II
operator then inserts the index- and middle-fingers or, if this is not
possible, the index-finger of the right hand into the uterus and, while
counter pressure is made over the fundus with the left hand, he thor-
oughly explores the cavity and separates any retained material" by
means of the internal fingers (Fig. 860). Large pieces of tissue thus
loosened may be then removed by means of placental forceps. The
cavity of the uterus is then irrigated with normal salt solution or with
sterile water and is lightly scraped with a large dull curet. In doing
this great care and gentleness are necessary to avoid perforating the
Fig. 860. — Digital currettage of the uterus. (Ashton.)
Uterus. Sharp curets should never he employed in puerperal cases.
After a final exploration with the finger the cavity is again irrigated
and the operation is concluded by cleansing the vagina and covering
the vulva with a sterile gauze pad secured in place by a T-bandage.
Only in cases where the operation is accompanied by severe bleeding
or where it is desired to introduce contraction in a flabby organ is it
necessary to pack the uterus (see page 786) . If this is done, the pack-
ing should be removed in twenty-four hours.
After-care. — The vagina should be douched daily with a i to 5000
warm bichlorid solution followed by sterile water or normal salt so-
lution. In cases of curettage for simple endometritis the patient may
be allowed out of bed within a week, in other cases the duration of
the stay in bed will depend upon the condition of the patient.
INDEX
Abdomen, aspiration of, 296
auscxiltation of, 747
inspection of, 464, 518, 742
local anesthesia in operations on,
86
mensuration of, 747
palpation of, 743
percussion of, 745
Abdominal inspection of bladder, 650
massage, 568
palpation of bladder, 652
of ureters, 701
Abscess cavities, bismuth paste for,
223
Absorption power of stomach, Pen-
zoldt and Faber's test, 483
test of, 483
test of bladder, 659
Accessory sinuses, anatomy of, 307
.lavage of, 336
skiagraphy of, 325
Accidents during anesthesia and their
treatment, 48
A. C. E. general anesthetic mixture, 33
Acid intoxication, 56
Active hyperemia, 220
Acupuncture, 152
Administration of antiserum in cere-
brospinal meningitis, 283, 284
of antitetanic serum, 284
of chloroform, drop method, 20
vapor method, 23
of diphtheria antitoxin, 183
of ether, closed method, 16
drop method, 14
semiopen method, 16
vapor method, 17
of ethyl chlorid, 32
of general anesthetics, i
of neosalvarsan, 181
intramuscular, 183
intravenous, 182
of nitrous oxid, 26
and ether, 30
of salvarsan, 175
intravenous, 179
preparation of solution, 178
Adrenalin chlorid and saline solution in
shock, 136
as aid to local anesthesia, 65
After-effects of general anesthetics, 55
After-treatment of cases of general
anesthesia, 57
Air, hot, active hyperemia by, 220
inflation of colon with, 521, 563
of stomach with, 471, 473
Air-bag, Politzer's, 365
Albarran's cystoscope, 706
Albuminous expectoration after aspira-
tion of chest, 293
Albuminuria, 648
Alcohol injections in tic douloureux, 194
AUigator-jawed forceps, Kelly's, 667,
715
Allis' ether inhaler, 10
Allport's ear syringe, 371
Anachlorhydria, 475
Anal canal, anatomy of, 515
Anesthesia, arterial, 97
Bier's venous, 93
chloroform, 17
apparatus, 19
suitable cases, 19
ether, 8
apparatus, 10
suitable cases, 9
ethyl chlorid, 30
suitable cases, 31
general, i
A.C.E. mixture for, 33
accidents during, 48
after-efl'ects, 55
after-treatment following, 57
anesthol for, 33
asphyxiation from, 49
Billroth's mixture for, 33
C.E. mixture, 33
cardiac paralysis during, 53
delayed poisoning from, 56
intravenous, 41
postoperative paralyses follow-
ing, 56
precautions in, i
preparations of patient for, i
813
>i4
INDEX
Anesthesia, general, renal complications
of, 56
respirator^' complications of, 55
paralysis during, 53
Schleich's mixture, 33
stages of, 6
Vienna mixture, 33
vomiting after, 55
Gwathmey's oil-ether method, 47
infiltration, 64, 71
insufflation, intratracheal, 36
intravenous, general, 41
intubation, 34
local, 59
adrenalin chlorid as aid to, 65
advantages of, 60
by endoneural infiltration, 76
by freezing, 69
by infiltration, 71
by perineural infiltration, 76
by surface application of anes-
thetic drugs, 70
conduction of operation under, 68
disadvantages of, 60
drugs used for, 64
ethyl chlorid in, 70
in abdominal operations, 86
in hernia operations, 86
in operations on anus, 89
on bladder, 71
on eye, 70
on face, 79
on head, 78
on larjmx, 70
on lips, 79
on lower extremity, 89
on lower jaw, 79
on mouth, 79
on neck, 80
on nose, 70
on penis, 88
on rectum and anus, 89
on scalp, 78
on scrotum, 88
on thorax, 81
on upper extremity, 82
on urethra, 71, 88
methods of producing, 63
operations on inflamed tissues
under, 92
preparation of patient, 67
suitable cases, 61
lumbar, 98
nitrous oxid, 23
Anesthesia, nitrous oxid and ether, 28
apparatus, 28
apparatus, 24
suitable cases, 23
oil-ether colonic, 47
rectal, 44
regional, 64
sacral, 105
scopolamin-morphin, 48
spinal, 98
terminal, 64
tracheal, 40
venous, 93
Anesthetic mixtures, 33
Anesthetics, general administration of, i
local, 59
Anesthetist's supplies, 5
Anesthol, 33
Ankle-joint, exploratory puncture of,
276
Anterior crural nerve, cocainization of,
89
nares, 304
rhinoscopy, 312
tibial ner\-e, cocainization of, 92
Antiserum, administration of, in cere-
brospinal meningitis, 283
Antitetanic serum, administration of,
284
Antitoxic sera, lumbar puncture as
means of administering, 283
Antitoxin, diphtheria, administration
of, 183
after-effects of, 186
syringes, 184
Antrum of Highmore, 307
Anus, anatomy of, 515
dilatation of, 529
inspection of, 518, 526
local anesthesia in operations on,
89
palpation of, 527
Application of caustics to lar>'nx, 409
to riOS2, 332
intrauterine, 783
local to cer\'ix, 774
to vagina, 774
of powders to vagina, 775
to larynx, 409
Arterial anesthesia, 97
Artery to vein transfusion, 121
Artificial leech, 167
respiration, 51
sera for infusion, 137
INDEX
815
Artificial sera for infusion, Hare's form-
ula for, 137
Locke's formula for, 138
Ringer's formula for, 137
Szumann's formula for, 138
Arytenoid cartilages, anatomy of, 386
Ascites, aspiration of abdomen for, 296
Ashton's forceps for guiding ureteral
catheter, 716
Asphyxiation during general anesthe-
sia, 49
Aspirating bulb. Boas', 477
syringes, 259
trocar, 286
Aspiration of abdomen in ascites, 296
of bladder, 692
of pericardium, 293
of peritoneal cavity, 296
of pleura, 285
of stomach contents, 477
of tunica vaginalis, 300
Aspirator, bottle, for stomach contents,
477
Connell's heat vacuum, 288
Dieulafoy, 287
Potain, 286, 693
syphonage, 289
Atomizer, Davidson, 331
De Vilbiss, 331
steam, 413
Whitall Tatum, 330
Atropin as preliminary to general anes-
thesia, 3
Aural speculum, Boucheron's, 356
electric-lighted, 356
Gruber's 355
Toynbee's, 356
stethoscope, 364
Auricular nerve, great, cocainization
of, 78
Auriculotemporal nerve, cocainization
of, 78
Auscultation of abdomen, 747
of colon, 520
of esophagus, 437
of stomach, 470
of uterus, 747
Auscultatory method of determining
blood-pressure, 116
Auto-irrigation of bladder, 675
Auto-massage, 570
cannon ball for, 570
Automatic scarificator, 159
Autoscopy, 399
Bacteriological examination, collec-
tion of blood for, 250
of discharges and secretions for,
238
from abscess cavity, 242
from eyes, 243
from nose and accessory-
sinuses, 243
from serous cavities, 242
from urethra, 244
from uterus, 244
from vagina, 244
Ballottement of kidney, 701
Bandage, elastic, for passive hyperemia,
209
Bardet's stomach electrode, 511
Beck's bismuth paste for diagnosis and
treatment of fistulous tracts, 223
Bed, ether, 58
Bellocq's cannula, 345
Bennett's ether inhaler, 11
gas and ether apparatus, 28
nitrous oxid inhaler, 25
Bermingham nasal douche, 326
B-eucain, 66
Bicoude catheter, 683
Bierhoff's cystoscope, 706
supports for legs in cystoscopy, 662
Bier's active hyperemia, 220
cannula, 94
passive hyperemia, 203
by bands, 209
by cups, 215
in diseases of nose and acces-
sory sinuses, 343
in gynecology, 789
of head and neck, 209, 212
of scrotum, 214
of shoulder, 209, 213
of testicles, 209, 214
venous anesthesia, 93
Billroth's esophageal sound, 454
general anesthetic mixture, 33
Bimanual palpation of bladder, 653
of pelvic organs, 752
Binnafont method of catheterizing
Eustachian tubes, 370
Bismuth paste for diagnosis and treat-
ment of fistulous tracts, 223
Bivalve rectal speculum, 530
vaginal speculum, 759
Bladder, absorption test, 659
anatomy of, 642
8i6
INDEX
Bladder, aspiration of, 692
auto- irrigation of, 675
calculus in, Thompson's searcher
for, 653
X-ray in detection of, 671
capacity of, 642
test of, 657
catheterization of, 680
in presence of prostatic hyper-
trophy, 687
of stricture, 686
continuous catheterization of, 689
cystoscopic examination of, in male,
659
female, catheterization of, 687
growths of, destruction by high
frequency currents, 678
inflammation of, after passage of
urethral sound, 639
inspection of, 650
instillations for, 676
irrigation of, 671
palpation of, 651
papilloma of, destruction by high
frequency currents, 678
percussion of, 651
sound, Thompson's, 653
sounding of, 653
Blake's ear syringe, 371
Bleeding, 153
Blocking, nerve, 76
Blood, collection of, for bacteriological
examination, 250
for microscopical examination, 245
expectoration of, after aspiration of
chest, 293
in urine, 648
serum, human, injection of, 132
Welch's apparatus for collecting,
133
significance of, in vomitus, 463
smears, method of making, 246
transfusion of, 119. See also Trans-
fusion of blood.
washing, 155
Blood-pressure, determination of, 109
auscultatory method, 116
diastolic, 109
normal, no
systolic, 109
variations of, in disease, 116
in health, no
Boas' apparatus for esophageal lavage,
450
Boas' aspirating bulb, 477
rectal electrode, 572
Bodenhamer's rectal irrigator, 549
Bodine's formula for cocain and salt
solution, 65
Bottle aspirator for extracting stomach
contents, 477
Boucheron's ear speculum, 356
Bougies a boule, esophageal, 438
rectal, 538
urethral, 594
dilatation of esophageal strictures
by, 451
of rectal strictures by, 565
esophageal, 438, 453
Eustachian, 378
medicated, 380
examination of rectum by, 537
filiform, 586
urethral, 585, 586, 631
Wales', 538, 566
Boxes, hot-air, 221
Brachial plexus, cocainization of, 82
Braun's novocain solutions, 67
Brenner's cystoscope, 705
Brewer's method of transfusion of
blood, 127
transfusion tubes, 127
Bronchoscope, Jackson's, 401
Killian's 400
Brown's cystoscope, 705, 706
Buerger's cystoscope, 706
transfusion cannula, 122
Calculi in bladder, Thompson's
searcher for, 653
in kidneys, skiagraphy of, 730
ureteral, skiagraphy of, 730
X-ray in detection of, 671
Caliber of urethra, 576
Cannon ball fcr auto-massage, 570
Cannula, Bellocq's, 345
Bier's, 94
Brewer's transfusion, 127
Buerger's transfusion, 123
Crile's transfusion, 122
Elsberg's transfusion, 129
Hahn's tracheal, 40
Levin's transfusion, 128
Southey's, 161
Trendelenburg's tracheal, 40
Capacity of bladder, 642
test of, 657
of renal pelvis, 720
INDEX
;i7
Capacity of stomach, 462
Carbonic acid gas, inflation of stomach
with, 471, 473
Cardiac massage, 54
paralysis during anesthesia, 53
Carrel's method of transfusion of blood,
129
Cartilage, cricoid, anatomy of, 385
thyroid, anatomy of, 385
Cartilages, arytenoid, anatomy, of 386
Casper's cystoscope, 706
Catheter, bicoude, 683
coude, 682
female, 687
Gouley's tunneled, 682
Guyon's, 682
Malecot, 690
Pezzer, 689
prostatic, 681
silver prostatic, 681
ureteral, 715
wax-tipped, 707
whip, 682
Catheterization, continuous, of bladder,
689
of Eustachian tubes, 366
Binnafont • or Kramer method,
370
Lowenberg's method, 367
of female bladder, 687
of male bladder, 680
in presence of prostatic hyper-
trophy, 687
of stricture, 686
of ureters, 705
direct view method, 708
in female, 714
indirect view method, 711
Caustics, applications of, to ear, 375
to larynx, 409
to nose, 332
C. E. general anesthetic mixture, 33
Cecum, anatomy of, 513
Cerebrospinal fluid, normal, 282
pathological variations in, 282
meningitis, administration of anti-
serum in, 283, 284
pressure, 283
Cervical plexus, cocainization of, 81
Cervix, dilatation of, 803
local applications to, 774
scarification of, 791
Chloroform, administration of, drop
method, 20
52
Chloroform, administration of, vapor
method, 23
anesthesia, 17
apparatus, 19
suitable cases, 19
delayed poisoning from, 56
inhalers, 19
Chamberlain's uterine douche nozzle,
780
Chapin's urine collector, 253
Chetwood's alternating cut-off", 612
tubes, 599
urethral irrigating nozzle, 611
Chill, urethral, 638
Chromic acid, method of fusing, on
probe, 334
Clamp, Crile's, 122
Levin's transfusion, 128
Closed method of administering ether, 1 6
Clover's ether inhaler, 1 1
Coakley's transilluminator, 323
Cocain, 64
Bodine's formula for, 65
for sacral anesthesia, 107
morphin preliminary to, 68
Schleich's formula for, 65
solutions, preparation of, 64
sterilization of, 64
Cocainization of anterior crural nerve,
89
tibial nerve, 92
of auriculotemporal nerve, 78
of brachial plexus, 82
of branches of trifacial nerve, 80
of cervical plexus, 8 1
of digital nerves, 85
of external cutaneous nerve, 89
of frontal nerve, 78
of genitocrural nerve, 86
of great auricular nerve, 78
occipital nerve, 78
of iliohypogastric nerve, 86
of ilioinguinal nerve, 86
of inferior dental nerve, 79
of infraorbital nerve, 79
of intercostal nerve, 81
of lingual nerve, 79
of lumbar nerves, 86
of median nerve at wrist, 84
in arm, 83
of mental ner\^e, 79
of musculospiral nerve, 83
of posterior tibial nerve, 92
of radial neive, 84
of sciatic nerve, 89
8i8
INDEX
Cocainization of small occipital nerv^e,
78
of spinal cord, 98
of superior laryngeal nerve, 81
of supraorbital nerve, 78
of cervical plexus, 82
of temporomalar nerve, 78
of thoracic nerves, 86
of ulnar nerve at wrist, 84
in arm, 83
Cold, direct application, to urethra,
622
local anesthesia by, 69
Collection and preservation of patholog-
ical material, 227
of blood for bacteriological exami-
nation, 250
for microscopical examination, 245
of discharges and secretions for
bacteriological examination,
238
from abscess cavity, 242
from eyes, 243
from nose and accessory sinuses,
243
from serous cavities, 242
from urethra, 244
from uterus, 244
from vagina, 244
of feces, 254
of gastric contents, 254, 474
of sputum, 252
of urine, 252
Colon, anatomy of, 513
ascending, anatomy of, 514
descending, anatomy of, 514
inflation of, 563
for diagnostic purposes, 521
massage of, 568
sigmoid, anatomy of, 514
transverse, anatomy of, 514
tube, 543
Colonic anesthesia, oil-ether, 47
Color of urine, 647
Connell's aspirator, 288
Constipation, electrotherapy in, 571
Continuous catheterization of bladder,
689
dilatation of urethral strictures, 640
Coude catheter, 682
Cricoid cartilage, anatomy of, 385
Crile's clamps, 122
method of intraarterial infusion,
145
Crile's method of intubation anesthesia,
34
of transfusion of blood, 121, 125
transfusion cannula, 122
Croup kettle, 413
Crural nerve, anterior, cocainization of,
89
Cryoscopy of urine, 728
Cup pessary, 793
Cupped sound, 619
Cupping, 162
dry, 165
wet, 166
Cups for abstracting blood, 163
for passive hyperemia, 215
Curet, blunt, 808
Martin's, 808
Sims', 808
urethral, 622
Curettage, 807
Curves of urethra, 576
Cutaneous nerve, external, cocainiza-
tion of, 89
Cystoscope, Albarran's, 706
Bierhoff's, 706
Brenner's, 705
Brown's, 705, 706 •
Buerger's, 706
Casper's, 706
direct view, 660
Eisner's, 705
indirect view, 660
Kelly's female, 666, 715
Lewis', 678, 705
Luys' open tube, 668
McCarthy's, 706
Nitze's, 660, 706
Otis', 660
Schapira's, 660
Cystoscopic treatment, 677
Cystoscopy in female, 665
in male, 659
Davidson atomizer, 331
Dawbarn's method of intraarterial
infusion, 146
Death, sudden, after aspiration of
chest, 293
Deglutition murmur, 471
Dench's vaporizer, 377
Dental nerve, inferior, cocainization of,
79
Depressor, vaginal, 760
De Vilbiss atomizer, 331
INDEX
819
Dewitt's apparatus for regulating flow
in proctoclysis, 557
Diastolic blood-pressure, 109
Dieulafoy aspirator, 287
Digital nerves, cocainization of, 86
palpation of nasopharynx, 322
of pelvic organs, 750
of rectum, 528
of uterine cavity, 766
Dilatation, continuous, of urethral
strictures, 640
of cervix, 803
of esophageal strictures, 451
of rectal strictures by bougie, 565
of urethral strictures, 627, 640
Dilator, Goodell's uterine, 803
Hanks' uterine, 804
Hegar's uterine, 804
Kelly's urethral, 606, 666, 715
Kollmann's, 630
Diphtheria antitoxin, administration
of, 183
after-effects of, 186
Direct applications to nose, 332
laryngoscopy, 396
tracheo-bronchoscopy, 400
lower, 400, 406
upper, 400, 404
view cystoscope, 660
method of catheterization of
ureters, 708
Dorsal position for gynecologic exami-
nation, 740
Double current catheter, 672
Douche, Bermingham's nasal, 326
hot-air, 222
intrauterine, 779
nasal, 325
stomach, 499
Einhorn's, 499
vaginal, 771
Drainage in edema of lower extremities,
160
Drop method of administering chloro-
form, 20
ether, 14
Drugs as preliminary to general
anesthesia, 3
Drum membrane, ariatomy of, 351
determination of mobility of, 359
incision of, 381
massage of, 380
Dry cupping, 165
inhalations, 415
Duck-bill rectal speculum, 531
Duodenal feeding, 505
pump, Einhorn's, 506
Ear, anatomy of, 348
application of caustics to, 375
inspection of, 354
instillations for, 373
speculum, Boucheron's, 356
, electric-lighted, 356
Gruber's, 355
Toynbee's, 356
syringe, 370
AUport's, 371
Blake's, 371
syringing, 370
Edelmann's modification of Galton's
whistle, 361
Edema, acupuncture for, 152
of glottis, scarification in, 158
of lower extremities, drainage in,
160
Einhorn's duodenal pump, 506
esophagoscope, 445
gastrodiaphane, 484
stomach bucket, 481
douche, 499
electrode, 511
Elastic bands for passive hyperemia, 209
Elbow-joint, exploratory puncture of,
274
Electrode, Boas' rectal, 572
Electrotherapy in constipation, 571
in diseases of stomach, 509
in tumors of bladder, 678
Elsberg's method of transfusion of
blood, 129
transfusion cannula, 129
Eisner's cystoscope, 705
Endoneural infiltration, 76
Enemata, 541
nutrient, 560
Enteroclysis, 546
with double tube, 554
with single tube, 552
Epiglottis, anatomy of, 385
method of drawing forward during
anesthesia, 50
Epistaxis, tamponing nose for, 343
Epsom salts for spinal anesthesia, 99
Erect position for gynecologic examina"
tion, 742
Esmarch bandage for passive hyperemia,
209
)2C
INDEX
Esmarch mask, lO
Esophageal bougies, 438, 453
d boule, 438
lavage, 449
sounds, 437
Billroth's 454
Schreiber's, 454
strictures, dilatation of, 451
tube, Symonds', 457
Esophagogastroscope, Hill-Herschell,
487
Esophagoscope, Einhorn's, 445
Jackson's, 445
Mikulicz's, 445
Esophagoscopy, 445
Esophagus, anatomy of, 435
auscultation of, 437
dilatation of strictures of, 451
intubation of, 456
lavage of, 449
normal constrictions of, 435
palpation of, 437
percussion of, 437
skiagraphy of, 449
Ether, administration of, closed method,
16
drop method, 14
semi-open method, 16
vapor method, 17
anesthesia, 8
apparatus, 10
suitable cases, 9
bed, 58
inhalers, 10
Ethmoidal sinuses, anatomy of, 308
Ethyl chlorid, administration of, 32
anesthesia, 30
apparatus, 31
suitable cases, 31
as local anesthetic, 70
inhalers, 31
Eucain B, 66
Eustachian bougies, 378
medicated, 380
tubes, anatomy of, 352
catheterization of, 366
inflation of, by catheter, 366
Politzer's method, 365
Valsalva's method, 364
medication of, 377
Ewald-Boas test breakfast, 474
Ewald's test of motor power of stomach,
482
Expectoration, albuminous, after as-
piration of chest, 293
of blood after aspiration of chest,
293
Experimental polyuria test of functional
capacity of kidneys, 729
Exploratory incision for inspecting kid-
ney, 731
for palpating pelvic organs, 768
laparotomy, 493
punctures, 258
of ankle-joint, 276
of elbow-joint, 274
of hip-joint, 275
of joints, 274
of kidneys, 273
of knee-joint, 275
of liver, 269
of lung, 264
of pericardium, 265
of peritoneal cavity, 268
of pleura, 259
of shoulder- joint, 374
of spinal canal, 277
of spleen, 271
of wrist-joint, 275
Expression of stomach contents. 476
External cutaneous nerve, cocainiza-
tion of, 89
Extubation, 423
Extubator, O'Dwyer's, 417
Faber and Penzoldt's test of absorp-
tion power of stomach, 483
Fallopian tubes, anatomy of, 737
False passage from urethral instru-
mentation, 639
Feces, bacteriological examination, 541
chemical examination, 541
collection of, for examination, 254
examination of, 541
macroscopical examination, 541
microscopical examination, 541
Feeding by gavage, 502
duodenal, 505
intubation cases, 422
by rectum, 560
Fever, urethral, 638
Fifth nerve, anatomy of, 194
first division, injection of, 197
injection of, for neuralgia, 194
second division, injection of, 198
third division, injection of, 199
INDEX
821
Filariasis, salvarsan in, 176
Filiform bougies, esophageal, 454
urethral, 586, 631
Finger palpation of rectum, 528
Fingers, local anesthesia in operations
on, 85
Finger's ointment, 619
Fistulous tracts, bismuth paste for
diagnosis and treatment of, 223
Fluid, cerebrospinal, normal, 282
pathological variations in, 282
Fluorescein in gastrodiaphany, 485
Forceps, Ashton's, for guiding urethral
catheter, 716
KeUy's aUigator-jawed, 667, 715
placental, 808
uterine dressing, 808
Formalin sterilizer, 587
Fraenkel's tongue depressor, 311
Freezing, local anesthesia by, 69
Fritsch-Bozeman uterine douche noz-
zle, 780
Frontal nerve, cocainization of, 78
sinus, anatomy of, 308
lavage of, 340
transillumination of, 323, 324
Functional capacity of kidneys, deter-
mination of, 725
b5'' cryoscopy, 728
experimental polyuria test for,
729
indigo-carmin test for, 726
methylene-blue test for, 726
phenolsulphonephthalein test
for, 727
phloridzin test for, 726
urea test for, 726
Galton's whistle, 360
Edelmann's modification, 361
Garrigues' speculum, 765
Gastric contents, collection of, 254
juice, composition, 475
Gastrodiaphane, Einhorn's, 484
Lynch's, 484
Gastrodiaphany, 483
Gastroscope, Jackson's, 486
Mikulicz's, 485
Rosenheim's, 485
Gastroscopy, 485
combined direct and indirect view,
492
direct view, 488
Jackson's technic, 490
Gavage, 502
Gehrung's pessary, 794
General anesthesia, i. See also Anes-
thesia, general.
Generative organs, female, anatomy of,
735
Genitocrural nerve, cocainization of,
86
Geraghty and Rov/ntree's test for func-
tional capacity of kidneys, 727
Glass catheter, female, 687
test, three, 580
two, 580
GoodeU's uterine dilators, 803
vaginal speculum, 759
Gouley's tunneled catheter, 682
sound, 631
Goyanes' method of arterial anesthesia,
97
Great auricular nerve, cocainization of,
78
occipital nerve, cocainization of, 78
Gruber's ear speculum, 355
Guyon's catheter, 683
Gwathmey's gas and ether inhaler, 29
nitrous oxid gas and oxygen inhaler,
26
oil-ether colonic anesthesia, 47
.vapor apparatus, 12
Gynecologic examinations, 737
postures, 740
Gynecology, Bier's hyperemic treat-
ment in, 789
Hahn's tracheal cannula, 40
Hand injections for urethra, 607 '
Hanks' uterine dilators, 804
Hare's formula for artificial serum for
infusions, 137
Harris' segregator, 721
Hartmann's tuning-forks, 361
vaporizer, 377
HartweU's method of transfusion of
blood, 128
Hays' pharyngoscope, 317
Head lamp, electric, 311
Kirstein's, 397
local anesthesia in operations on,
78
passive hyperemia of, 209, 212
Hearing tests, 360
Heart, massage of, 54
paralysis of, during anesthesia, 53
Heat vacuum aspirator, Connell's, 288
822
INDEX
Hegar's uterine dilators, 804
Hematuria, 648
Hemolysis, tests for, in transfusion of
blood, 121
Hemorrhage after passage of urethral
sound, 639
tamponing nose for, 343
uterus for, 786
vagina for, 779
Hernia, local anesthesia in operations
for, 86
Herschell-Hill esophagogastroscope, 487
Hewitt's nitrous oxid gas inhaler, 25
Hiatus sacralis, 105
High tracheotomy, 429
Highmore, antrum of, 307
Hill-Herschell esophagogastroscope, 487
Hip-joint, exploratory puncture of, 275
Hodge pessary, 794
Hodge-Smith pessary, 794
Honan's apparatus for intravenous
anesthesia, 42
Hot a'r, active hyperemia by, 220
boxes, 221
douche, 222
Houston's valves, 516
Hydrocele, aspiration and injection of,
300, 301
Hyperacidity, 476
Hyperchlorhydria, 475
Hyperemia, active, 220
passive, 203
by bands, 209
by cups, 215
in diseases of nose and sinuses, 343
in gynecology, 789
of head and neck, 209, 212
of scrotum, 214
of shoulder, 209, 213
of testicles, 209, 214
Hypoacidity, 476
Hypochlorhydria, 475
Hypodermic injection of drugs, 170
syringes, 170
Hypodermoclysis, 148
Iliohypogastric nerve, cocainization
of, 86
Ilioinguinal nerve, cocainization of, 86
Illumination for rhinoscopy, 310
Incision, exploratory, for inspecting
kidney, 731
for palpating pelvic organs, 768
of drum membrane, 381
Indigo-carmin test of functional ca-
pacity of kidneys, 726
Infectious diseases, salvarsan in, 176
Inferior dental nerve, cocainization of,
79
Infiltration anesthesia, 64, 71
endoneural, 76
perineural, 76
Infiltrator, Matas', 72
Morrow's, 73
Inflamed tissues, operations on, under
local anesthesia, 92
Inflation of colon for diagnostic pur-
poses, 521
in intussusception, 563
of middle ear, 363, 376
Politzer's method, 365
through catheter, 366
Valsalva's method, 364
with medicated vapors, 376
of stomach, 471
by air, 471, 473
by carbonic acid gas, 471, 473
Infraorbital nerve, cocainization of, 79
Infusions of physiological salt solution,
135
intraarterial, 144
intravenous, 138
rectal, 554
subcutaneous, 148
Inhalations, dry, 415
steam, 412
Inhaler, Allis' ether, 10
Bennett's ether, 13
gas and ether, 29
nitrous oxid, 25
Clover's ether, 11
Esmarch chloroform, 10
Gwathmey's gas and ether, 29
nitrous oxid gas and oxygen, 26
vapor, 12
Hewitt's nitrous oxid gas, 25
Junker's chloroform, 20
Schimmelbusch chloroform, 11, 31
Injection, hand, for urethra, 607
of fluid or air into bowels in intus-
susception, 563
hypodermic, 170
intramuscular, 170
test for urethral pus, 581
treatment of neuralgia by, 194
of sciatica by, 200
of tic douloureux by, 194
Inspection of abdomen, 464, 518, 742
INDEX
823
Inspection of anus, 526
of bladder, 650
of ear, 354
of kidneys, 698
by exploratory incision, 731
of nasopharynx by Hays' phan,-n-
goscope, 317
of nose, 309
of rectum, 518, 526
of stomach, 464
of urethra in female, 581
in male, 581
of vagina, 748, 759
Instillation syringe, Keyes-Ultzmann,
616, 677
Instillations for bladder, 676
for ear, 373
for urethra, 616
Insufflation anesthesia , intratracheal,
36
Insufflations for larj^nx, 411
for nose, 334
Insufflator, laryngeal, 412
nasal, 334
Intercostal nerve, cocainization of, 81
Intestine, lavage of, 540
Intraarterial infusion of salt solution,
144
Crile's method, 145
Dawbam's method, 146
Intramuscular administration of neo-
salvarsan, 183
injections of drugs, 170
Intrastomachic application of elec-
tricity to stomach, 511
Intratracheal insufflation anesthesia, 36
Intrauterine applications, 783
douche, 779
Intravenous administration of neosal-
varsan, 182
of salvarsan, 179
general anesthesia, 41
infusion of salt solution, 138
Intubation anesthesia, 34
of esophagus, 456
of larynx, 415
tubes, O'Dw^^er's, 416
Intubator, O'Dwyer's, 417
Intussusception, injection of air and
fluids in, 563
lodipin test of motor power of stomach,
482
Irrigations, auto- of bladder, 675
bladder, 671
Irrigations, rectal, 546
urethral, 611
vaginal, 771
Irrigator, double flow rectal, 548, 549
Valentine's, 611
Iversen's apparatus for proctoclysis, 557
Jackson's bronchoscope, 401
esophagoscope, 445
gastroscope, 486
laryngoscope, 38, 396
technic of gastroscopy, 490
Janeway's sphygmomanometer, 113
Jaw, method of holding forward, during
anesthesia, 50
Joints, exploratory^ puncture of, 274
Junker's chloroform inhaler, 20
Kelly's aUigator-jawed forceps, 667,
715
cone-shaped urethral dilator, 606
female cystoscope, 666, 715
method of collecting urine from
ureter without ureteral catheter,
719
proctoscope, 531
rectal specula, 531
sigmoidoscope, 531
sphincteroscope, 531
ureteral bougie, 715
catheter, 715
searcher, 666, 715
urethral dilator, 606, 666, 715
tube-speculum, 605
urine evacuator, 666, 715
Kemp's double flow rectal irrigator, 548
Kettle, croup, 413
Keyes-Ultzmann instillation syringe,
616, 677
Kidneys, anatomy of, 695
baUottement of, 701
calculus in, skiagraphy of, 730
exploratory incision for inspecting,
731
puncture of, 273
functional capacity of determination
of, 725. See also Functional
capacity of kidneys.
inspection of, 698
by exploratory incision, 731
palpation of, 699
pelvic, capacity of, 720
medication of, 732
percussion of, 703
824
INDEX
Kidney, position of, 695
relations of, 696
skiagraphj- of, 730
Killian's bronchoscope, 400
larv'ngoscope, 396
Kirstein's head light, 397
tongue depressor, 396
Klotz's urethral tube, 600
Knee-chest position for gynecologic
examination, 741
for rectal examination, 525
Knee-joint, exploratory' puncture of,
275
Knife, urethral, 621
Kollmann's dilators, 630
urethral syringe, 622
Kramer's method of catheterizing Eus-
tachian tubes, 370
Kulenkampff's method of blocking
brachial plexus, 82
Lactic acid in stomach contents, 476
Laparotomy, exploratory, 493
Laryngeal insiifHator, 412
nerv'e, superior, cocainization of, 81
probe, 407
spray, 408
Laryngoscope, Jackson's, 38, 396
Killian's, 396
Lar\-ngoscopj-, 389
direct, 396
Lary-ngotomy, 428
Lar^-nx, anatomy of, 385
application of caustics to, 409
direct applications for, 409
dry inhalations for, 415
insufflations for, 411
intubation of, 415
palpation of, by probe, 407
skiagraphy of, 408
steam inhalations for, 412
Lavage of esophagus, 449
of frontal sinus, 340
of intestine, 540
of maxillary sinus, 336
of sphenoidal sinus, 342
of stomach, 494
of ureters and renal pelvis, 732
Leech, artificial, 167
Leeching, 166
Length of urethra, estimation of, 597
Leube's test of motor power of stomach,
482
Levin's transfusion clamp, 128
L^vy and Baudouin needle, 196
Lewis' operating cystoscope, 678
universal cystoscope, 705
Lingual nerve, cocainization of, 79
Lithotomy position in rectal examina-
tion, 525
Liver, exploratory puncture of, 269
Local anesthesia, 59. See also Anes-
thesia, local.
applications to cer\'ix, 774
to vagina, 774
Locke's formula for artificial serum for
infusions, 138
Locomotor ataxia, salvarsan in, 176
Low tracheotomy, 432
Lowenberg's method of catheterizing
Eustachian tubes, 367
Lower direct tracheo-bronchoscopy, 400,
406
extremity, local anesthesia in opera-
tions on, 89
Luer's hypodermic syringe, 171
Lumbar anesthesia, 98
ner\-es, cocainization of, 86
puncture, 277
as means of administering anti-
toxic sera, 283
Lung, exploratory puncture of, 264
Luys' open tube cystoscope, 668
segregator, 721
Lynch's gastrodiaphane, 484
Malaria, salvarsan in, 176
Malecot retention catheter, 690
Martin's curet, 808
Massage, abdominal, 568
auto-, 570
cannon ball for, 570
colonic, 568
of drum membrane, 380
of heart, 54
of prostate, 624
of stomach, 507
pelvic, 789
Matas' massive infiltrator, 72
Maxillary sinus, anatomy of, 307
lavage of, 336
transillumination of, 323, 325
McCarthy's cystoscope, 706
Meatome, Otis', 626
Meatotomy, 626
Median nerve, cocainization of, at
wrist, 84
in arm, 83
Medicated Eustachian bougie, 380
INDEX
82::
Medicated tampon, 778
Medication of Eustachian tubes, 377
of ureters and renal pelvis, 732
Meltzer and Auer's method of intra-
tracheal insufflation anesthesia, 36
Membrane, drum, anatomy of, 351
determination of mobility of, 359
incision of, 381
massage of, 380
Meningitis, cerebrospinal, administra-
tion of antiserum in, 283, 284
Mensuration of abdomen, 747
.Mental nerve, cocainization of, 79
Method of inoculating culture tubes,
235
of making smear culture, 238
preparation for microscopical
examination, 227
from eyes, 230
from mouth and pharynx,
229
from nose, 230
from urethra, 231
from uterus, 233
from vagina, 233
stab culture, 237
streak culture, 236
Methylene-blue test of functional ca-
pacity of kidneys, 726
Middle ear, inflation of, 376
with medicated vapors, 376
Mikulicz's esophagoscope, 445
gastroscope, 485
Mirror, head, 310
rhinoscopic, 311
Mixture, A. C. E-, 33
anesthetic, 33
anesthol, 33
Billroth's, 33
C. E., 33
Schleich's, 33
Vienna, 33
Mobility of drum membrane, determina-
tion of, 359
Morgagni's valves, 516
Morphin as preliminary to general anes-
thesia, 3
preliminary to cocain, 68
to general anesthesia, 3
Morrow's infiltrator, 73
Motor functions of stomach, tests for,
482
Murmur, deglutition, 471
Murphy's proctoclysis, 556
rectal specula, 532
Muscular rheumatism, acupuncture in,
153
Musculospiral nerve, cocainization of,
83
Myles' nasal speculum, 311
Nares, anterior, 304
posterior, 304
digital palpation of, 322
inspection of, 314
Nasal douche, Bermingham's, 326
douching, 325
spraying, 330
syringing, 329
Nasopharynx, digital palpation of, 322
inspection of, by Hays' pharyngo-
scope, 317
Neck, passive hyperemia of, 209, 212
Neosalvarsan, administration of, 181
intramuscular, 183
intravenous, 182
Nerve blocking, 76
Neuralgia, treatment of, by injections,
194
trifacial, treatment of, by injections,
194
Neuritis, acupuncture in, 153
Nitrous oxid, administration of, 26
and ether, administration of, 30
anesthesia, 28
apparatus, 28
anesthesia, 23
apparatus, 24
suitable cases, 23
inhalers, 24
and oxygen inhaler, 25
Nitze's cystoscope, 660, 706
Nose, anatomy of, 304
application of caustics to, 332
douching, 325
inspection of, 309
insufflations for, 334
passive hyperemia in diseases of, 343
probing, 319
spraying, 33b
syringing, 329
tamponing, 343
Novocain, 67
. Braun's formula for, 67
in sacral anesthesia, 107
in spinal anesthesia, 99
Nutrient enemata, 560
826
INDEX
Obstructive hyperemia, 203
by band, 209
Occipital nerve, great, cocainization
of, 78
small, cocainization of, 78
O'Dwyer's intubation instruments, 416
Odor of urine, 646
Oil-ether colonic anesthesia, 47
Ointment, application of, to urethra, 618
Finger's, 619
syringe, urethral, 619
Unna's, 619
Ossicles of ear, 350
Otis' cystoscope, 660
meatome, 626
urethrometer, 596
Otoscope, Siegle's, 359
Otoscopy, 355
Ovaries, anatomy of, 737
Palate retractor. White's, 311
Palpation, digital, of nasopharynx, 322
of abdomen, 743
of anus, 527
of bladder, 651
of esophagus, 437
of kidneys, 699
of larynx by probe, 407
of nose by probe, 319
of prostate, 584
of rectum, 519, 527
by finger, 528
by whole hand, 529
of seminal vesicles, 584
of stomach, 466
of ureters, 701
of urethra in female, 585
in male, 582
of uterus, 752
of vagina, 750
of vulva, 750
Papilloma of bladder, destruction, by
high frequency currents, 678
Paracentesis of abdomen, 296
pericardii, 293
thoracis, 285
Paralysis, cardiac, during anesthesia,
53
respirator^', during general anesthesia,
53
Paresis, salvarsan in, 176
Passive hyperemia, 203
by bands, 209
by cups, 215
Passive hyperemia in diseases of nose
and accessory sinuses, 343
in gynecology, 789
of head and neck, 209, 212
of scrotum, 214
of shoulder, 209, 213
of testicles, 209, 214
Pathological material, collection and
presen,-ation of, 227
Patrick's formula for alcohol injection
of trifacial nerve, 196
Pelvic massage, 789
organs, anatomy of, 735
bimanual palpation of, 752
digital palpation of, 750
Pelvis, renal, capacity of, 720
medication of, 732
Penis, local anesthesia in operations on,
88
Penzoldt and Faber's test of absorp-
tion power of stomach, 483
Pepsin in gastric contents, 476
Percussion of abdomen, 745
of abdominal tumors, 746
of bladder, 65 1
of colon, 520
of esophagus, 437
of kidneys, 703
of stomach, 469
Percutaneous application of electricity
to stomach. 511
Pericardicentesis, 293
Pericardium, aspiration of, 293
exploratory puncture of, 265
Perineural infiltration, 76
Peritoneal cavity, aspiration of, 296
exploratory puncture of, 268
Pessary, 794
cup, 793
Gehrung's, 794
Hodge, 794
Hodge-Smith; 794
ring, 794
Skene's, 794
stem, 807
therapy, 792
Pezzer retention catheter, 690
Pharjmgoscope, Hays', 317
Pharynx, inspection of, 314
Phenolsulphonephthalein test of func-
tional capacity of kidneys, 727
Phlebotomy, 153
Phloridzin test of functional capacity
of kidneys, 726
INDEX
827
Physiological salt solution, infusions of,
135
injection of, in sciatica, 200
Placental forceps, 808
Pleura aspiration of, 285
exploratory puncture of, 259
Pleurocentesis, 285
Pneumatic otoscope, 359
proctoscope, Tuttle's, 532
Pneumothorax after aspiration of chest,
293
Poisoning, delayed chloroform, 56
Politzer's inflation bag, 365
method of inflating middle ear, 365
Polyuria test, experimental, of func-
tional capacity of kidneys, 729
Position, dorsal, for gynecologic ex-
amination, 740
erect, for gynecologic examination,
742
for gynecologic examinations, 740
knee-chest, for gynecologic examina-
tion, 741
of kidneys, 695
Rose's, for esophagoscopy, 447
Sims', 525, 740
squatting, for gynecologic examina-
tion, 742
of stomach, 461
of uterus, 736
Posterior nares, 304
digital palpation of, 322
inspection of, 314
rhinoscopy, 314
tibial nerve, cocainization of, 92
Potain aspirator, 286, 693
Powder blower, laryngeal, 412
nasal, 335
Sajous', 335
vaginal, 775
Powders, application of, to vagina, 775
Probe, rectal, 540
urethral, 621
Probing larynx, 407
nose, 319
of rectum, 539
Proctoclysis, continuous, 556
Proctoscope, examination of rectum by,
530
Kelly's, 531
Murphy's, 532
Tuttle's, 532
Proctoscopy, 534
Prostate, anatomy of, 577
Prostate, inflammation of, after pas-
sage of urethral sound, 639
massage of, 624
palpation of, 584
Prostatic catheter, 681
Psychrophore, 622
Pump, Einhorn's duodenal, 506
Puncture, exploratory, 258
of ankle-joint, 276
of elbow-joint, 274
of hip-joint, 275
of joints, 274
of kidneys, 273
of knee-joint, 275
of liver, 269
of lung, 264
of pericardium, 265
of peritoneal cavity, 268
of pleura, 259
of shoulder-joint, 274
of spinal canal, 277
of spleen, 271
of wrist-joint, 275
lumbar, 277
as means of administering anti-
toxic sera, 283
spinal, 2"] "J
Pus in urine, 649
Pyelography, 731
Pyelometry, 720
Pynchon's vaporizer, 377
Pyuria, 649
QuiNiN and urea hydrochlorid, 67
for sacral anesthesia, 107
Radial nerve, cocainization of, 84
Ransohoff's method of arterial anes-
thesia, 97
Reaction of urine, 647
Rectal anesthesia, 44
bougie a boule, 538
Wales', 538, 566
electrode. Boas', 572
feeding, 560
infusion of salt solution, 554
irrigations, 546
irrigator, Bodenhamer's, 549
Kemp's, 548
Tuttle's, 549
palpation of ureters, 703
probe, 540
speculum, bivalve, 530
duck-bill, 531
828
IXDEX
Rectal speculum, fenestra ted-blade, 531
Kelly's, 531
Murphy's, 532
Sims', 530
Tuttle's, 532
strictures, dilatation of, by bougie,
565
valves, 516
Recto-abdominal palpation of pelvic
organs, 757
Rectum, anatomy of, 514
dilatation of, 529
examination of, by bougie a boule,
539
by bougies, 537
by probe, 539
by proctoscope, 530
by sounds, 537
by speculum, 530
feeding by, 560
inspection of, 518, 526
internal examination, 524
local anesthesia in operations on, 89
palpation of, 519, 527
by finger, 528
by whole hand, 529
probing of, 539
relations of, 515
skiagraphy of, 524
Regional anesthesia, 64
Relapsing fever, salvarsan in, 1 76
Relations of kidneys, 696
Removal of fragments of tissue for ex-
amination, 254
Renal complications following general
anesthesia, 56
Rennin in gastric contents, 476
Replacement of retroverted uterus, 795
Residual urine, estimation of, 658
evacuator, 715
Respiration, artificial, 51
Respiratory complications following
general anesthesia, 55
parah-sis during general anesthesia,
53
Retention catheter. 690
Retroverted uterus, replacement of, 795
Revaccination, 193
Rhinoscopic mirror, 311
Rhinoscopy, 309
anterior, 312
posterior, 314
Riegel test dinner, 474
Ring pessar>-, 794
Ringer's formula for artificial sera, 137
Rinn^'s test for deafness, 362
Riva-Rocci sphygmomanometer, 1 1 1
Rogers' sphygmomanometer, 113
Rood's apparatus for intravenous anes-
thesia, 42
Rosenheim's gastroscope, 485
Rose's posture for esophagoscopy, 447
Rowntree and Geraghty's test for func-
tional capacity of kidneys, ']2'j
Sacral anesthesia, 105
Sajous' powder blower, 335
Saline solution, administration of ad-
renalin chlorid in, 136
injection of, in sciatica, 200
intraarterial infusion, 144
intravenous infusion of, 138
preparation of, 136
rectal infusion of, 554
sterilization of, 137
subcutaneous infusion, 148
Salvarsan, administration of, 175
intravenous, 179
preparation of solution, 178
Saxon's apparatus for proctoclysis, 557
Scarification, 158
of cervix, 791
of glottis, 158
of larynx, 160
of tonsil, 159
Scarificator, automatic, 159
Schapira's cystoscope, 660
Schimmelbusch inhaler, 11, 31
Schleich's cocain solutions for local an-
esthesia, 65
general anesthetic mixture, 33
Schreiber's esophageal sound, 454
Sciatic nerve, cocainization of, 89
Sciatica, injection of saline solution in,
200
treatment of, by injections, 200
Scopolamin-morphin anesthesia, 48
Scrapings from uterus, examination of,
768
Scrotum, local anesthesia in operations
on, 88
passive hyperemia of, 214
Searcher, Kelly's ureteral, 666, 715
Sections from uterus, examination of,
768
Segregation of urine, 721
Harris' method, 723
Luys' method, 725
INDEX
829
Segregator, Harris', 721
Luy's, 721
Seminal vesicles, palpation of, 584
Semi-open method of administering
ether, 16
Serum, blood, human, injection of, 132
Welch's apparatus for collecting, 133
Shock after passage of urethral sound,
638
Shoulder-joint, exploratory puncture
of, 274
passive hyperemia of, 209, 213
Siegle's otoscope, 359
Sigmoid colon, anatomy of, 514
Sigmoidoscope, Kelly's, 531
Silver prostatic cathether, 681
Sims' curets, 808
position, 525, 740
rectal speculum, 530
vaginal speculum, 760
Sinus, ethmoidal, anatomy of, 308
frontal, anatomy of, 308
lavage of, 340
transillumination of, 323, 324
maxillary, anatomy of, 307
lavage of, 336
transillumination of, 323, 325
sphenoidal, anatomy of, 308
lavage of, 342
Sinuses, accessory, anatomy of, 307
tubercular, bismuth paste for, 223
Skene's pessary, 794
Skiagraphy of accessory sinuses, 325
of colon, 524
of esophagus, 449
of larynx, 408
of renal calculi, 730
of stomach, 493
of ureteral calculi, 730
of vesical calculi, 671
Small occipital nerve, cocainization of, 78
Smal'pox, vaccination against, 188
Smear, blood, method of making, 246
culture, method of making, 238
preparation for microscopical examin-
ation from eyes, 230
from mouth and pharynx,
229
from nose, 230
from urethra, 231
from uterus, 233
from vagina, 233
method of making, 227
Snare, urethral, 622
Sound, uterine, 765
Sounding bladder, 653
urethra, 585
uterus, 764
Sounds, Billroth's, 454
bladder, 659
cupped, 619
esophageal, 437, 454
examination of rectum by, 537
Gouley's, 631
Schreiber's, 454
urethral, 585, 586, 629
Southey's trocars and cannula, 161
Specific gravity of urine, 646
Specula, bladder, Kelly's, 666
ear, Boucheron's, 356
electric-lighted, 356
Gruber's, 355
Toynbee's, 356
examination of rectum by, 530
Garrigues', 765
nasal, Myles', 311
rectal, bivalve, 530
duck-bill, 531
fenestrated-blade, 531
Kelly's, 531
Murphy's, 532
Sims', 530
Tuttle's, 532
urethral, 620
Kelly's, 605
vaginal, bivalve, 759
Goodell's, 759
Sims', 760
trivalve, 759
Sphenoidal sinuses, anatom}^ of, 308
'avage of, 342
Sphincteroscope, Kelly's, 531
Sphygmomanometer, Janeway's, 113
Riva-Rocci, iii
Rogers', 113
Stanton's, 113
Sphygmomsnometry, 109
Spinal anesthesia, 98
canal, puncture of, ^TJ
cord, cocainization of, 98
Splashing sounds in stomach, 471
Spleen, exploratory puncture of, 271
Sponge holder, 760
Sprays, laryngeal, 408
nasal, 330
Sputum, collection of, 252
Squatting position for gynecologic ex-
amination, 742
830
INDEX
Squatting position in rectal examina-
tion, 526
Stab cultures, method of making, 237
Stanton's sphygmomanometer, 113
Steam atomizer, 413
inhalations, 412
Stem pessary, 807
Steri ization of cocain solutions, 64
of salt solutions, 137
Sterilizer, formalin, 587
Stethoscope, aural, 364
Stockton's stomach electrode, 511
Stomach, absorption power of, Pen-
zoldt and Faber's test, 483
test of, 483
anatomy of, 461
auscultation of, 470
bucket, Einhorn's, 481
capacity of, 462
contents, collection of, 254, 474
composition of, 474
examination, 475
extraction of, 474
aspiration method, 476
expression method, 476
lactic acid in, 476
pepsin in, 476
rennin in, 476
douche, 499
Einhorn's, 499
electrode, Bardet's, 511
Einhorn's, 511
Stockton's, 511
Wegele's, 511
electrotherapy in diseases of, 509
inflation of, 471
by air, 471, 473
by carbonic acid gas, 47 1 , 473
inspection of, 464
lavage of, 494
massage of, 507
motor power of, Ewald's test, 482
iodipin test, 482
Leube's test, 482
tests for, 482
palpation of, 466
percussion of, 469
position of, 461
skiagraphy of, 493
splashing sounds in, 471
succussion sounds in, 471
transillumination of, 483
tube, 477, 495
washing out, 494
Stomach, x-ray examination, 493
Stools. See Feces.
Stovain in spinal anesthesia, 98
Streak culture, method of making, 236
Strictures of esophagus, dilatation of,
451
of rectum, dilatation, by bougie,
565
of urethra, dilatation of, 627
continuous, 640
Subcutaneous drainage in edema, 160
infusion of salt solution, 148
Succussion sounds in stomach, 471
Suction cups for passive hyperemia, 215
Sudden death after aspiration of chest,
293
Superior laryngeal nerve, cocainization
of, 81
Supraorbital nerve, cocainization of,
78
Swinburne's urethroscope, 600
Symonds' esophageal tube, 457
Syphilis, salvarsan in, 175
Syphonage aspirator, 289
Syringe, antitoxin, 184
aspirating, 259
for bismuth paste injections, 224
ear, 370
hypodermic, 170
Kollmann's urethral, 622
nasal, 329
urethral, 608, 616, 619
Systolic blood-pressure, 109
Szumann's formula for artificial sera
for infusion, 138
Talley's intrauterine douche nozzle,
780
Tampon, medicated, 778
uterine, 786
vaginal, 776
Tamponing nose for control of hemor-
rhage, 343
vagina for hemorrhage, 779
Temporomalar nerve, cocainization of,
78
Terminal anesthesia, 64
Test, absorption, of bladder, 659
of absorption power of stomach,
483
of acuteness of hearing, 360
of bladder capacity, 657
breakfast, Ewald-Boas, 474
dinner, Riegel, 474
INDEX
831
Test, Ewald's, of motor power of stom-
ach, 482
experimental polyuria, of functional
capacity of kidneys, 729
for hearing, 360
indigo-carmin, of functional capacity
of kidneys, 726
injection, for urethral pus, 581
iodipin, of motor power of stomach,
482
Leube's, of motor power of stomach,
482
meals, 474
methylene-blue, of functional capacity
of kidneys, 726
of motor power of stomach, 482
Penzoldt and Faber's, for absorp-
tion power of stomach, 483
for perception of musical notes, 362
phenolsulphonephthalein, of func-
tional capacity of kidneys, 727
phloridzin, of functional capacity of
kidneys, 726
Rinne's, for deafness, 362
Rowntree and Geraghty's, for func-
tional capacity of kidneys, 727
three-glass, for urethral pus, 580
two-glass, for urethral pus, 580
urea, of functional capacity of kid-
neys, 726
voice, of hearing, 362
watch, of hearing, 360
Weber's, for deafness, 362
Wolbarst's three-glass, 580
Testicles, passive hyperemia of, 209,
214
Tetanus antitoxin, administration of,
284
Thompson's stone searcher, 653
Thoracentesis, 285
Thoracic nerves, cocainization of, 86
Thyroid cartilage, anatomy of, 385
Tibial nerve, anterior, cocainization of,
92
posterior, cocainization of, 92
Tic douloureux, alcohol injections in,
194
treatment of, by injections, 194
Tissues, inflamed, operations on, under
local anesthesia, 92
Tongue depressor, Fraenkel's, 311
Kirstein's, 396
method of drawing forward, during
, anesthesia, 50
Towel cone, 12
Toynbee's ear speculum, 356
Trachea, anatomy of, 387
Tracheal anesthesia, 40
cannula, Hahn's, 40
Trendelenburg's, 40
Tracheo-bronchoscopy, direct, 400
lower, 400, 406
upper, 400, 404
Tracheoscopy, 389
Tracheotomy, 424
high, 429
low, 432
tubes, 427
Transfusion cannula. Brewer's, 127
Buerger's, 123
Crile's, 122
Elsberg's, 129
Levin's, 128
of blood, 119
artery to vein, 121
Brewer's method, 127
Carrel's method, 129
Crile's method, 121, 125
Elsberg's method, 129
Hartwell's method, 128
selection of donor, 121
tests for hemolysis in, 121
vein to vein, 131
Transillumination of frontal sinus, 323,
324
of maxillary sinus, 323, 325
of stomach, 483
Transilluminator, Coakley's, 323
Transparency of urine, 647
Trendelenburg tracheal cannula, 40
Trifacial nerve, anatomy of, 194
branches, cocainization of, 80
first division, injection of, 197
injection of, for neuralgia, 194
second division, injection of, 198
third division, injection of, 199
neuralgia, treatment of, by injec-
tions, 194
Trivalve vaginal speculum, 759
Trocar and cannula for aspirating
bladder, 694
Southey's, 161
aspirating, 286
Tropacocain in spinal anesthesia, 99
Trousseau tracheal dilator, 426
Tube for esophageal lavage. Boas', 450
intubation, 416
Klotz's urethral, 600
832
INDEX
Tube, stomach, 477, 495
tracheotomy, 427
Tubercular sinuses, bismuth paste for,
223
Tube-speculum, Kelly's urethral, 605
Tumors of bladder, destruction, by
high frequency currents, 678
Tunica vaginalis, aspiration of, 300
Tuning-forks, Hartmann's, 361
Tuttle's proctoscope, 532
rectal irrigator, 549
Ulnar nerv-e, cocainization of, at wrist,
84
in arm, 83
Unna's ointment, 619
Upper direct tracheo-bronchoscopy,
400, 404
extremity, local anesthesia in op-
erations on, 82
Urea test of functional capacity of kid-
neys, 726
Ureteral bougie, Kelly's, 715
calculi, skiagraphy of, 730
catheter, Kelly's, 715
wax-tipped, 707
catheterization, direct view method,
708
indirect view method, 711
in female, 714
in male, 705
searcher, Kelly's, 666, 715
stricture, dilatation of, 733
Ureters, anatomy of, 697
catheterization of, direct view
method, 708 '
indirect view method, 711
in female, 714
in male, 705
medication of, 732
palpation of, 701
skiagraphy of, 730
Urethra, anatomy of, 574
application of cold to, 622
of ointments to, 618
caliber of, 576
collecting discharges from, for bac-
teriological examination, 244
for microscopical examination, 231
curves of, 576
estimation of length, 597
examination of, by bougie a boule,
594
by sounds and bougies, 585
Urethra, false passage of, from instru-
mentation, 639
hand injections for, 607
inspection of, 581
instillations for, 616
irrigations of, 611
local anesthesia in operations on, 88
palpation of, 582, 585
sounding of, 585
strictures, dilatation of, 627
continuous, 640
Urethral bougie a boule, 594
bougies, 585, 586, 631
chill, 638
curet, 622
dilator, Kelly's, 606, 666, 715
fever, 638
filiforms, 631
instillations, 616
irrigating nozzle, Chetwood's, 611
irrigations, 611
knife, 621
ointment syringe, 619
probe, 621
snare, 622
sound, blunt, 586
conical, 629
cupped, 619
double-taper, 629
speculum, 620
strictures, dilatation of, 627
continuous, 640
syringe, 608
Kollmann's, 622
tube, Klotz's, 600
tube-speculum, Kelly's, 605
Urethritis after passage of urethral
sound, 639
Urethrometer, 596
Otis', 596
Urethrometry, 596
Urethroscope, 599
in treatment of urethral diseases,
620
Swinburne's, 600
Urethroscopic treatment, 620
Urethroscopy, in female, 605
in male, 598
Urinalysis in bladder disease, 646
in kidney disease, 646, 704
Urine, albumin in, 648
blood in, 648
collection of, for examination, 252
from infants, 253
INDEX
833
Urine, collection of, in presence of in-
continence, 253
collector, Chapin's, 253
color of, 647
cryoscopy of, 728
estimating quantitj^ of, for twenty-
four hours, 253
evacuator, KeUy's, 666, 715
examination of, 646
in kidney diseases, 704
odor of, 646
pus in, 649
quantity of, passed in twenty-four
hours, 646
reaction of, 647
residual, estimation of, 658
segregation of, 721
Harris' method, 723
Luys' method, 725
specific gravity, 646
transparency of, 647
Uterine applications, 783
dilators, GoodeU's, 803
Hanks', 804
Hegar's, 804
douche, 779
nozzle, Chamberlain's, 780
Fritsch-Bozeman, 780
Talley's, 780
dressing forceps, 808
sound, 765
tampon, 786
Uterus, anatomy of, 735
applications to, 783
collection of discharges from, for
bacteriological examination, 244
for microscopical examination, 233
curettage of, 807
digital palpation of, 766
palpation of, 752
position of, 736
retroverted, replacement of, 795
scrapings from, examination of, 768
sections from, examination of, 768
sounding of, 764
tamponing, 786
Vaccination, 188
Vagina, anatomy of, 735
application of powders to, 775
collection of discharges from, for
bacteriological examination, 244
for microscopical examination,
233
53
Vagina, inspection of, 748, 759
local applications to, 774
palpation of, 750
relations of, 735
Vaginal depressor, 760
douche, 771
nozzle, 771
inspection of bladder, 651
irrigations, 771
palpation of ureters, 702
powder blower, 775
speculum, bivalve, 759
Goodell's, 759
Sims', 760
trivalve, 759
tampon, 776
medicated, 778
Vagino-abdominal palpation of pelvic
organs, 753
Valentine's irrigator, 611
Valsalva's method of inflating middle
ear, 364
Valves, Houston's, 516
Morgagni's, 516
rectal, 516
Vapor method of administering chloro-
form, 23
ether, 17
Vaporizer, Bench's, 377
Hartmann's, 377.
Pynchon's, 377
Vein to vein transfusion, 131
Venesection, 153
Venous anesthesia, 93
hyperemia, 203
Vesicles, seminal, palpation of, 584
Vienna general anesthetic mixture,
33
Voice test for hearing, 362
Vomiting after anesthesia, 55
Vomitus, blood in, 463
Von Hacker's method of dilating
esophageal strictures, 455
Von Mikulicz's esophagoscope, 445
Vulva, palpation of, 750
Wales' bougies, 538, 566
Washing out stomach, 494
Watch test for hearing, 360
Wax-tipped ureteral catheter, 707
Weber's test for deafness, 362
834
INDEX
Wegele's stomach electrode, 511
Welch's apparatus for collecting blood
serum, 133
Wet cupping, 166
Whip catheter, 682
Whistle, Galton's, 360
Edelmann's modification, 361
Whitall Tatum atomizer, 330
White's palate retractor, 311
Wolbarst three-glass test, 580
Wrist-joint, exploratory puncture of,
275
X-RAY examination
nuses, 325
of stomach, 493
of accessory si-
Yaws, salvarsan in, 176
SAUNDERS' BOOKS
on
Skin, Genito- Urinary,
Chemistry, Eye, Ear, Nose,
and Throat, and Dental
W. B. SAUNDERS COMPANY
WEST WASHINGTON SQUARE PHILADELPHIA
9, HENRIETTA STREET, COVENT GARDEN, LONDON
Davis* Accessory Sinuses
Development and Anatomy of the Nasal Accessory Sinuses in
Man. By AVarren B. Davis, M. D., Corinna Borden Keen Research
Fellow of the Jefferson 3*Iedical College, Philadelphia. Octavo of 172
pages, with 57 original illustrations. Cloth, $3.50 net.
ORIGINAL DISSECTIONS
This book is based on the study of two hundred and ninet)' lateral nasal walls,
presenting the anatomy and physiology of the nasal accessor}' sinuses from the
sixtieth day of fetal life to adva?iced maturity. It represents the original research
work and personal dissections of Dr. Davis at the Daniel Baugh Institute of
Anatomy of Philadelphia and at the Friedrichshain Krankenhaus of Berlin. It
was necessary for Dr, Davis to develop a new techiiic by which the accessor)'
sinus areas could be removed en masse at the time of postmortem examinations,
and still permit of reconstruction of the face without marked disfigurement.
Ninety -six cases in this series were thus obtained. The tables of averages, giving
you the age, size of ostia, origin, thickness of septum, and anterior and posterior
walls, vertical, lateral, and posterior diameters, and relation to the nasal floor,
form an extremelv valuable feature.
SAUNDERS' BOOKS ON
Stelwag»onV
Diseases of the Skin
A Treatise on Diseases of the Skin. By Henry W. Stelwagon,
M. D., Ph. D., Professor of Dermatology in the Jefferson Medical
College, Philadelphia. Octavo of 1250 pages, with 331 text-cuts and
33 plates. Cloth, $6.00 net; Half Morocco, 1^7.50 net.
THE NEW (7th) EDITION
There are two features in Dr. Stelwagon's work that stand out above all the
others : The special emphasis given the two practical phases of the subject —
diagnosis and treatment; and the wealth of illnstratiojis. These latter are of real
value. They teach you diagnosis as no description can. Many of these illustra-
tions are in colors.
Over 75 pages of the work are devoted to svphilis, giving you the Wassermann
test, the salvarsan ("606") treatment, and all the newest advances. Pellagra,
tropical affections, hookivorm disease. Oriental sore, ringworm, impetigo contagiosa
— all those diseases being so widely discussed to-day.
George T. Elliot, M. D., Professor of Dermatology, Cornell University.
" It is a book that I recommend to my class at Cornell, because for conservative judgment,
for accurate observation, and for a thorough appreciation of the essential position of derma-
tology, I think it holds first place."
Schamber£('s Diseases qf the Skin
and E^niptive Fevers
Diseases of the Skin and the Eruptive Fevers. By Jay F. Schamberg,
M. D. , Professor of Dermatology and the Infectious Eruptive Diseases, Philadel-
phia Polyclinic. Octavo of 585 pages, illustrated. Cloth, ^3.00 net.
NEW (3d) EDITION
*' The acute eruptive fevers constitute a valuable contribution, the statements made
emanating from one who has studied these diseases in a practical and thorough manner from
the standpoint of cutaneous medicine. . . . The views expressed on all topics are con-
servative, safe to follow, and practical, and are well abreast of the knowledge of the present
time, both as to general and special pathology, etiology, and treatment."— American Journal
of Medical Sciencts.
GENITO- URINAR V DISEASES
Norris*
Gonorrhea in Women
Gonorrhea in Women. By Charles C. Norris, M. D., Instructor
in Gynecology, University of Pennsylvania, with an Introduction by
John G. Clark, M. D., Professor of Gynecology, University of Penn-
sylvania. Large octavo of 5 20 pages, illustrated. Cloth, ^6.00 net.
A CLASSIC
Dr. Norris here presents a work that is destined to take high place among
pubhcations on this subject. He has done his work thoroughly. He has searched
the important literature very carefully, over 2300 references being utilized.
This, coupled with Dr. Norris' long experience, gives his work the stamp of
authority. The chapter on serum and vaccine therapy and organotherapy is
particularly valuable because it expresses the newest advances. Every phase of
the subject is considered.
Pennsylvania Medical Journal
" Dr. Norris has succeeded in presenting most comprehensively the present knowledge of
gonorrhea in women in its many phases. The present status of serum and vaccine therapy is.
given in detail."
Braasch's Pyelog(raphy
Pyelography. By William F. Braasch, M. D., The Mayo Clinic,
Rochester, Minn. Octavo of 323 pages, with 296 pyelograms. Cloth,
$5.00 net.
A NEW WORK
Dr. Braasch's new work is the first comprehensive collection of the various types of
pelvic outlines, both normal and pathologic. You get here 296 skiagrams of the renal pel-
vis and ureter, selected from several thousand plates made at the Mayo Clinic. These pye-
lograms, together with the clear descriptions, constitute an admirable aid to the differential
diagnosis of the various conditions affecting the renal pelvis. The characteristic pelvic out-
line in each disease is first shown you by the excellent pyelograms; then Dr. Braasch inter-
prets these pyelograms for you in diagnostic terms. You get the history of pyelography, the
exact technic (selection of the medium, preparation of solution, method of injection, sources
of error, results), the normal pelves, the various pathologic outlines, and the outlines in con-
genital anomalies. It is a most complete work.
SA UNDERS ' BOOKS ON
BarnhiU an^ Wales*
Modern Otology
A Text=Book of Modern Otology. By John F. Barnhill, M. D.,
Professor of Otology, Laryngology, and Rhinology, and Earnest
DE W. Wales, M. D., Associate Professor of Otology, Laryngology,
and Rhinology, Indiana University School of Medicine, Indianapolis.
Octavo of 598 pages, with 314 original illustrations. Cloth, $5.50 net;
Half Morocco, $7.00 net.
THE NEW (2d) EDITION
The authors, in writing this work, kept ever in mind the needs of the
physician engaged in general practice. It represents the results of personal
experience as practitioners and teachers, influenced by the instruction given by
such authorities as Sheppard, Dundas Grant, Percy Jakins, Jansen, and Alt.
Much space is devoted to prophylaxis, diagnosis, and treatment, both inedical
and surgical. There is a special chapter on the bacteriology of ear affections —
a feature not to be found in any other work on otology. Great pains have been
taken with the illustrations, in order to have them as practical and as helpful as
possible, and at the same time highly artistic. A large number represent the
best work of Mr. H. F. Aitken.
Coolidg(e on Nose and Throat
Manual of Diseases of the Nose and Throat. By Algernon Cool-
IDGE, M. D., Professor of Laryngology, Harvard Medical School.
Octavo of 360 pages, illustrated. Cloth, ;^i.50 net.
This new book furnishes the student and practitioner a guide and ready reference to the
important details of examination, diagnosis, and treatment. Established facts are empha-
sized and unproved statements avoided. Anatomy and physiology of the different regions
are included.
Frank Allport. M.D.
Professor of Otology, Northwestern University, Chicago.
" I regard it as one of the best books in the English language on this subject. The
pictures are especially good, particularly as they are practically all original and not the old
reproduced pictures so frequently seen."
DISEASES OF THE EYE.
DeSchweinitz's
Diseases of the Eye
Just Out— New (8th) Edition
Diseases of the Eye: A Handbook of Ophthalmic Practice.
By G. E. deSchweinitz, M.D., Professor of Ophthalmology in the Uni-
versity of Pennsylvania, Philadelphia, etc. Handsome octavo of 754
pages, 386 text-illustrations, and 7 chromo-lithographic plates. Cloth,
|6.oo net; Sheep or Half Morocco, $7.50 net.
THE STANDARD AUTHORITY
The new matter added includes: Walker's testing of visual field, squirrel
plague conjunctivitis, swimming bath conjunctivitis, anaphylactic keratitis, family-
cerebral degeneration with macular changes, ocular symptoms of pituitary
disease, sclerectomy with a punch, preliminary capsulotomy, iridotasis, thread
drainage of anterior chamber, extraction of cataract in capsule after subluxation
of lens with capsule forceps, capsulomuscular advancement with partial resection,
tenotomy of inferior oblique, window resection of nasal duct.
Bass and Johns' Alveolodental Pyorrhea
Alveolodental Pyorrhea. By Charles C. Bass, M. D., Professor
of Experimental Medicine, and Foster M. Johns, M. D., Instructor in
the Laboratories of Clinical Medicine, Tulane Medical College. Octavo
of 168 pages, illustrated. Cloth, ^2.50 net.
Drs. Bass and Johns present their subject from the viewpoint of infection by
the Endamoeba buccaUs. You get a full account of the Endamoeba buccalis, the
history of disease, the morbid processes, contagiousness, symptomatology, how
to make your diagnosis from the history and microscopic examination, prophy-
laxis, and the exact technic for using emetin hydrochlorid. You get the action
of emetin upon the Endamoeba, you get the exact dosage, you get the interval
between doses, the local effect, the urticaria produced, the technic of injection.
University of Pennsylvania Medical Bulletin
"Upon reading through the contents of this book we are impressed by tne remarkable
fulness with which it reflects the notable contributions recently made to ophthalmic literature.
No important subject within its province has been neglected."
SAUNDERS' BOOKS ON
GET A ^ • ^ *. •* "^"^ ^^^
THE BEST ^m***^riCC^n STANDARD
American
Illustrated Dictionary
New (8th) Edition— 1500 New Terms
The American Illustrated Medical Dictionary. A new and com-
plete dictionary of the terms used in Medicine, Surgery, Dentistry,
Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred
branches; with over 100 new and elaborate tables and many illustra-
tions. By W. A. Newman Borland, M.D., Editor of " The American
Pocket Medical Dictionary." Large octavo, with 1 137 pages, bound in
full flexible leather. Price, $4.^0 net; with thumb index, ;^5.oo net.
KEY TO CAPITALIZATION AND PRONUNCIATION— ALL THE NEW WORDS
This dictionary is the "new standard." It defines hundreds of the newest
terms not defined in any other dictionary — bar none. These terms are hve,
active words, taken right from modern medical hterature.
Howard A. Kelly. M. D.,
Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore
" Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient
sije. No errors have been found in my use of it."
Theobald's Prevalent Eye Diseases
Prevalent Diseases of the Eye. By Samuel Theobald, M. D.,
Clinical Professor of Ophthalmology and Otology, Johns Hopkins
University. Octavo of 550pages, with 219 text-cuts and several colored
plates. Cloth, ^4.50 net ; Half Morocco, ;^6.oo net.
THE PRACTITIONER'S OPHTHALMOLOGY
With few exceptions all the works on diseases of the eye, although written
ostensibly for the general practitioner, are in reality adapted only to the specialist ;
but Dr. Theobald in his book has described ver}' clearly and in detail those condi-
tions, the diagnosis and treatment of which come within the province of the general
practitioner. The therapeutic suggestions are concise, unequivocal, and specific.
It is the one work on the Eye written particularly for the general practitioner.
Charles A. Oliver, M.D.,
Clinical Professor of Ophthalmology, Woman s Medical College of Pennsylvania.
" I feel I can conscientiously recommend it, not only to the general physician and medical
student, for whom it is primarily written, but also to the experienced ophthalmologist. Mosi
surely Dr. Theobald has accomplished his purpose."
DISEASES OF THE EYE.
Haab and DeSchweinitz's
External Diseases qf the Eye
Atlas and Epitome of External Diseases of the Eye. By Dr. O.
Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz,
M. D., Professor of Ophthalmology, University of Pennsylvania. With
1 01 colored illustrations on 46 lithographic plates and 244 pages of
text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series.
THE NEW ;3d) EDITION
Conditions attending diseases of the external eye, which are often socoiHplicated.
have probably never been more clearly and comprehensively expounded than in
the forelying work, in which the pictorial most happily supplements the verbal
description. The price of the book is remarkably low.
The Medical Record, New York
" The work is excellently suited to the student of ophthalmology and to the practising
physician. It cannot fail to attain a well-deserved popularity."
Haab and DeSchweinitzV
Ophthalmoscopy
Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic
Diagnosis. By Dr. O. Haab, of Zijrich. Edited, with additions, by
G. E. deSchweinitz, M. D., Professor of Ophthalmology, University
of Pennsylvania. With 152 colored lithographic illustrations and 92
pages of text. Cloth, ^3.00 net. In Satmders' Hand- Atlas Series.
THE NEW (2d) EDITION
The great value of Prof. Haab's Atlas of Ophthalmoscopy and Ophthalmo-
scopic Diagnosis has been fully established and entirely justified an English
translation. Not only is the student made acquainted with carefully prepared
ophthalmoscopic drawings done into well-executed lithographs of the most im-
portant fundus changes, but, in many instances, plates of the microscopic lesions
are added. The whole furnishes a manual of the greatest possible service.
The Lancet, London
"We recommend it as a work that should be in the ophthalmic wards or in the library of
every hospital into which ophthalmic cases are received."
SAUNDERS' BOOKS ON
Cradle's
Nose, Pharynx, and Ear
Diseases of the Nose, Pharynx, and Ear. By Henry Gradle,
M.D,, late Professor of Ophthalmology and Otology, Northwestern
University Medical School, Chicago. Octavo of 547 pages, illustrated,
including two full-page plates in colors. Cloth, ^^3.50 net.
INCLUDING TOPOGRAPHIC ANATOMY
This volume presents diseases of the Nose, Pharynx, and Ear as the author
has seen them during an experience of nearly twenty-five years. In it are
answered in detail those questions regarding the course and outcome of diseases
which cause the less experienced observer the most anxiety in an individual case.
Topographic anatomy has been accorded liberal space.
Pennsylvania MediczJ Journal
"This is the most practical volume on the nose, pharynx, and ear that has appeared
recently. ... It is exactly what the less experienced observer needs, as it avoids the confusion
incident to a categorical statement of everybody's opinion."
Kyle's
Diseases of Nose and Throat
Diseases of the Nose and Throat. By D. Braden Kyle, M. D.,
Professor of Laryngology in the Jefferson Medical College, Phila-
delphia. Octavo, 825 pages; with 2^3 illustrations, 28 in colors.
Cloth, $4.50 net; Half Morocco, ^6.00 net.
THE NEW (5th) EDITION
The new {sth) edition of Dr. Kyle's work shows an increase of 100 pages zxi^
some 40 new illustrations. The following new articles have been added : vaccine
therapy ; lactic bacteriotherapy ; salvarsan in the treatment of syphilis of the upper
respiratory tract ; sphenopalatine ganglia neuralgia ; negative air-pressure in ac-
cessory sinus disease ; chronic hyperplastic ethmoiditis ; and congenital insuffi-
ciency of the palate. The tables of differential diagnosis and the prescriptions are
striking points of Dr. Kyle's book.
Pennsylvania Medical Journal
" Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat
knowledge in this book."
URINE AND IMPOTENCE.
Og'den on the Urine
Clinical Examination of Urine and Urinary Diagnosis. A Clinical
Guide for the Use of Practitioners and Students of Medicine and Sur-
gery. By J. Bergen Ogden, M. D., Medical Chemist to the Metro-
politan Life Insurance Company, New York. Octavo, 418 pages, 54
text illustrations, and a number of colored plates. Cloth, ^3.00 net.
THE NEW (3d) EDITION
In this edition the work has been brought absolutely down to the present day.
Urinary examinations for purposes of life insurance have been incorporated, because
a large number of practitioners are often called upon to make such analyses.
Special attention has been paid to diagnosis by the character of the urine, the
diagnosis of diseases of the kidneys and urinar)- passages ; an enumeration of the
prominent clinical symptoms of each disease ; and the peculiarities of the urine
in certain general diseases.
The Lancet, London
" We consider this manual to have been well compiled ; and the author's own experience,
sp clearly stated, renders the volume a useful one both for study and reference."
Pilcher*s
Practical Cystoscopy
Practical Cystoscopy. By Paul M. Pilcher, M. D., Consulting
Surgeon to the Eastern Long Island Hospital. Octavo of 504 pages,
with 299 illustrations, 29 in colors. Cloth, $6.00 net.
NEW (2d) EDITION
Cystoscopy is to-day the most practical manner of diagnosing and treating
diseases of the bladder, ureters, kidneys, and prostate. To be properly equipped,
therefore, you must have at your instant command the information this book gives
you. It explains away all difficulty, telling you ivhy you do not see something
when something is there to see, and telling you how to see it. All theor)- has
been uncompromisingly eliminated, devoting ever>' line to practical, needed-
every-day facts, telUng'you how and when to use the cystoscope and catheter-
telling you in a way to make you know. The work is complete in ever)' detail.
Bransford Lewu, M. D., St. Louis University.
" I am very much pleased with Dr. Pilcher's ' Practical Cystoscopy.' I think it is the best
in the English language now." — April 27, igii.
SAUNDERS' BOOKS ON
Goepp's
Dental State Boards
Dental State Board Questions and Answers — By R. Max Goepp,
M. D., author " Medical State Board Questions and Answers." Octavo
of 428 pages. Cloth, ^2.75 net.
NEW (2d) EDITION
This new work is along the same practical lines as Dr. Goepp's successful work
on Medical State Boards. The questions included have been gathered from reliable
sources, and embrace all those likely to be asked in any State Board examination
in any State. They have been arranged and classified in a way that makes for a
rapid resume of every branch of dental practice, and the answers are couched in
language unusually explicit — concise, definite, accurate.
The practicing dentist, also, will find here a work of great value — a work
covering the entire range of dentistry and extremely well adapted for quick
reference.
Haab and deSchweinitz's
Operative Ophthalmology
Atlas and Epitome of Operative Ophthalmology. By Dr. O.
Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz,
M. D., Professor of Ophthalmology in the University of Pennsylvania.
With 30 colored lithographic plates, 1 54 text-cuts, and 375 pages of
text In Saiindcrs Hand- Atlas Series. Cloth, $3.50 net.
Dr. Haab's Atlas of Operative Ophthalmology will be found as beautiful and
as practical as his two former atlases. The work represents the author' s thirty
years' experience in eye work. The various operative interventions are described
with all the precision and clearness that such an experience brings. Recognizing
the fact that mere verbal descriptions are frequently insufficient to give a clear
idea of operative procedures. Dr. Haab has taken particular care to illustrate
plainly the different parts of the operations.
Johns Hopkins Hospital Bulletin
" The descriptions of the various operations are so clear and full that the volume can well
hold place with more pretentious text-books."
GENITO- URINARY AND NOSE, THROAT, ETC.
Greene and Brooks*
Genito-Urinary Diseases
Diseases of the Genito=Urinary Organs and the Kidney. By
Robert H. Greene, M. D., Professor of Genito-Urinary Surgery at
Fordham University; and Harlow Brooks, M. D., Assistant Pro-
fessor of Clinical Medicine, University and Bellevue Hospital Medical
School. Octavo of 639 pages, illustrated. Cloth, ^5.00 netj Half
Morocco, ^^6.50 net.
THE NEW (3d) EDITION
This new work presents both the medical and surgical sides. Designed as a
work of quick reference, it has been written in a clear, condensed style, so that
the information can be readily grasped and retained. Kidney diseases are very
elaborately detailed.
New York Medical Journal
"As a whole the book is one of the most satisfactory and useful works on genito-urinary
diseases now extant, and will undoubtedly be popular among practitioners and students."
Gleason on Nose, Throat,
and Ear
A Manual of Diseases of the Nose, Throat, and Ear. By E.
Baldwin Gleason, M. D., LL. D., Professor of Otology, Medico-
Chirurgical College, Philadelphia. i2mo of 590 pages, profusely illus-
trated. Cloth, ^2.50 net.
THE NEW (3d) EDITION
Methods of treatment have been simplified as much as possible, so that in
most instances only those methods, drugs, and operations have been advised
which have proved beneficial. A valuable feature consists of the collection of
formulas.
American Journal of the Medical Sciences
" For the practitioner who wishes a reliable guide in laryngology and otology there are few
books which can be more heartily commended."
American Text=Book of Genito=Urinary Diseases, Syphilis, and
Diseases of the Skin. Edited by L. Bolton Bangs, M. D.. and
W. A. Hardaway, M. D. Octavo, 1229 pages, 300 engravings, 20
colored plates. Cloth, ;^7.oo net.
SAUNDERS' BOOKS OX
Holland's Medical
Chemistry and Toxicology
A Text-Book of Medical Chemistry and Toxicology. By James
W. Holland, M. D., Emeritus Professor of Medical Chemistry and
Toxicology, and Dean, Jefferson Medical College, Philadelphia. Octavo
of 678 pages, fully illustrated. Cloth, $3.CX) net.
FOURTH EDITION
Dr. Holland's work is an entirely new one, and is based on his forty years'
practical experience in teaching chemistry and medicine. It has been subjected to
a thorough revision, and enlarged to the extent of some sixty pages. The additions
to be specially noted are those relating to the electronic theory, chemical equilib-
rium, Kjeldahl's method for determining nitrogen, chemistr)- of foods and their
changes in the body, synthesis of proteins, and the latest improvements in urinary
tests. More space is given to toxicology than in any other text-book on chemistry'.
American Medicine
" Its statements are clear and terse ; its illustrations well chosen ; its development logical,
systematic, and comparatively easy to foliow. . . . We heartily commend the work."
Ivy's Applied Anatomy and
Oral Surgery for Dental Students
Applied Anatomy and Oral Surgery for Dental Students. By
Robert H. Ivy, M.D., D.D.S., Assistant Oral Surgeon to the Philadel-
phia General Hospital. i2mo of 280 pages, illustrated. Cloth, $1.50
net.
FOR DENTAL STUDENTS
This work is just what dental students have long wanted — a concise, practical
work on applied anatomy and oral surgery, written with their needs solely in
mind. No one could be better fitted for this task than Dr. Ivy, who is a graduate
in both dentistry and medicine. Having gone through the dental school, he
knows precisely the dental student's needs and just how to meet them. His
medical training assures you that his anatomy is accurate and his technic modern.
The text is well illustrated with pictures that you will find extremely helpful.
H. P. Kuhn, M.D., Western Dental College, Kansas City.
" I am delighted with this compact little treatise. It seems to me just to fill the bill."
CHEMISTRY, SKIN, AND VENEREAL DISEASES. 13
American Pocket Dictionary New rgth) Edition
The American Pocket Medical Dictionary. Edited by W. A.
Newman Borland, M. D., Editor " American Illustrated Medical
Dictionary." Containing the pronunciation and definition of the
principal words used in medicine and kindred sciences. 693 pages.
Flexible leather, with gold edges, ;^i.oo net; with thumb index,
$1.21 net.
James W. Holland, M. D.,
Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College
Philadelphia, '
" I am struck at once with admiration at the compact size and attractive exterior. ]
can recommend it to our students without reserve."
Stelwagon*s Essentials of Skin 7th Edition
Essentials of Diseases of the Skin. By Henry W. Stel-
wagon, M. D., Ph.D., Professor of Dermatology in the Jeffer-
son Medical College, Philadelphia. Post-octavo of 291 pages,
with 72 text-illustrations and 8 plates. Cloth, ;^i.oo net. In
Saunders' Question- Compend Series.
The Medical News
" In line with our present Icnowledge of diseases of the skin. . . . Continues to main-
tain the high standard of excellence for which these question compends have been noted."
Wolffs Medical Chemistry New (7th) Edition
Essentials of Medical Chemistry, Organic and Inorganic.
Containing also Questions on Medical Physics, Chemical Physiol-
ogy, Analytical Processes, Urinalysis, and Toxicology. By Law-
rence Wolff, M. D., Late Demonstrator of Chemistry, Jefferson
Medical College. Revised by A. Ferree Witmer, Ph. G., M. D.,
Formerly Assistant Demonstrator of Physiology, University of
Pennsylvania. Post-octavo of 222 pages. Cloth, ^i.oo net. In
Saunders' Question- Compend Series.
Bliss* Qualitative Chemical Analysis
Qualitative Chemical Analysis. By A. R. Bliss, Jr., Ph. G.,
M. D., Professor of Chemistry and Pharmacy, Birmingham
Medical College, Alabama. Octavo of 250 pages. Cloth, 32.00
net.
Vecki*s Sexual Impotence New (sth) Edition
Sexual Impotence. By Victor G. Vecki, M. D., Consulting
Genito-Urinary Surgeon to Mt. Zion Hospital, San Francisco.
i2mo of 405 pages. Cloth, ^2.25 net,
Johns Hopkins Hospital Bulletin
"A scientific treatise upon an important and much neglected subject. . . . The
treatment of impotence in general and of sexual neurasthenia is discriminating and
judicious."
14 SAUNDERS' BOOKS ON
Second
Edition
Wells' Chemical Patholos(y
Chemical Pathology. Being a discussion of General Path-
ology from the Standpoint of the Chemical Processes Involved.
By H. Gideon Wells, Ph. D., M. D., Assistam Professor of
Pathology in the University of Chicago. Octavo of 6i6 pages.
Cloth, ^3.25 net.
Wm. H. Welch, M. D., Professor of Pathology, Johns Hopkins University.
" The work fills a real need in the English literature of a very important subject, and
I shall be glad to recommend it to my students."
The New (2dj Edition
Saxe*s Urinalysis
Examination of the Urine. By G. A. De Santos Saxe, M. D.,
formerly Instructor in Genito-Urinary Surgery, New York Post-
graduate Medical School and Hospital. i2mo of 448 pages, fully
illustrated. Cloth, ^1.75 net.
Francb Carter Wood, M. D., Adjunct Professor of Clinical Pathology, Columbia Uni-
versity.
" It seems to me to be one of the best of the smaller works on this subject ; it is,
indeed, better than a good many of the larger ones."
deSchweinitz and Randall on the Eye, Ear»
Nose, and Throat
American Text-Book of Diseases of the Eye, Ear, Nose, and
Throat. Edited by G. E. de Schweimtz, M.D., and B. Alex-
ander Randall, M.D. Imperial octavo. 125 1 pages, with 766
illustrations, 59 of them in colors. Cloth, ;^7.00 net; Half Mo-
rocco, $8.50 net.
Griinwald and Grayson on the Larynx
Atlas and Epitome of Diseases of the Larynx. By Dr. L,
Grunwald, of Munich. Edited, with additions, by Charles P.
Grayson, M.D., ^University of Pennsylvania. With 107 colored
figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth,
;^2.50 net. /;/ Saunders Hand-Atlas Series.
Mracek and Stelwagon's Atlas of Skin f^^
Atlas and Epitome of Diseases of the 5kin. By Prof. Dr.
Franz Mracek, of Vienna. Edited, with additions, by Henry
W. Stelwagon, M.D., Jefferson Medical College. With yy col-
ored plates, 50 half-tone illustrations, and 280 pages of text. In
Saunders' Hand-Atlas Series. Cloth, $4.00 net.
EYE, EAR, NOSE, AND THROAT.
deSchweinitz and Holloway on Pulsating Exoph-
thalmos
_ Pulsating Exophthalmos. An analysis of sixty-nine cases not pre.
viously analyzed. By George E. deSchweinitz, M. D., and Thomas
B. Holloway, M. D. Octavo of 125 pages. Cloth, $2.00 net.
This monograph consists of an analysis of sixty-nine cases of this affection
not previously analyzed. The therapeutic measures, surgical and otherwise,
which have been employed are compared, and an endeavor has been made
to determine from these analyses which procedures seem likely to prove of
the greatest value. It is the most valuable contribution to ophthalmic liter-
ature within recent years.
British Medical Journal
"The book deals very thoroughly with the whole subject and in it the most complete account ot
the disease will be found."
Jackson on the Eye The New (2d) Edition
A Manual of the Diagnosis and Treatment of Diseases of the
Eye. By Edward Jackson, A. M., M. D., Professor of Ophthalmology,
University of Colorado. i2mo volume of 615 pages, with 184 beautiful
illustrations. Cloth, ^2.50 net.
The Medical Record, New York
" It is truly an admirable work. . . . Written in a clear, concise manner, it bears evidence of the
author's comprehensive grasp of the subject. The term ' multum in parvo' is an appropriate one to
apply to this work."
Grant on Face, Mouth, and Jaws
A Text-Book of the Surgical Principles and Surgical Diseases
of the Face, Mouth, and Jaws. For Dental Students. By H. Horace
Grant, A. M., M. D., Professor of Surgery and of Clinical Surgery,
Hospital College of Medicine, Louisville. Octavo of 231 pages, with
68 illustrations. Cloth, ^2.50 net.
Preiswerk and Warren's Dentistry
Atlas and Epitome of Dentistry. By Prof. G. Preiswerk, of
Basil. Edited, with additions, by George W. Warren, D.D.S., Pro-
fessor of Operative Dentistry, Pennsylvania College of Dental Surgery,
Philadelphia. With 44 lithographic plates, 152 text-cuts, and 343 pages
of text. Cloth, ^3.50 net. In Saunders' Atlas Series.
Asher*s Chemistry and Toxicology
Chemistry and Toxicology for Nurses. By Philip Asher, Ph.G.,
M. D., Dean and Professor of Chemistry, New Orleans College of Phar-
macy. 1 2 mo of 190 pages. Cloth, 1 1.25 net.
1 6 SAUNDERS' BOOKS ON
Wolfs Examination of Urine
A Laboratory Handbook of Physiologic Chemistry and
Urine-examination. By Charles G. L. Wolf, M. D., Instructor in
Physiologic Chemistry, Cornell University Medical College, New
York. 1 2mo volume of 204 pages, fully illustrated. Cloth, ;^ 1.25 net.
British MediceJ Journal
" riie methods of exLimining the urine are very fully described, and there are at the
end of the book some extensive tables drawn up to assist in urinary diagnosis."
Jackson's Essentials of Eye Third Revised Edition
Essentials of Refraction and of Diseases of the Eye. By
Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of
the Eye, Philadelphia PolycHnic. Post-octavo of 261 pages, 82 illus-
trations. Cloth, $1.00 net. In Saunders' Question-Compend Series.
Johns Hopkins Hospital Bulletin
" riie entire ground is covered, and the points that most need careful elucidation
are made clear and easy."
Gleason*s Nose and Throat Fourth Edition. Revised
Essentials of Diseases of the Nose and Throat. By E. B.
Gleason, S. B., M. D., Clinical Professor of Otology, Medico-
Chirurgical College, Philadelphia, etc. Post-octavo, 241 pages, 112
illustrations. Cloth, $1.00 net. In Saimders' Question Compends,
The Lancet. London
" The careful description which is given of the various procedures would be sufficient
to enable most people of average intelligence and of slight anatomical knowledge to
make a very good attempt at laryngoscopy."
Gleason*s Diseases of the Ear Third Edition. Revised
Essentials of Diseases of the Ear. By E. B. Gleason, S. B.,
M. D., Clinical Professor of Otology, Medico-Chirurgical College,
Phila., etc. Post-octavo volume of 214 pages, with 114 illustra-
tions. Cloth, $1.00 net. In Saujiders' Qiiestion-Compend Scries.
Bristol Medico-Chirurgical Joumzd
"We know of no other small work on ear diseases to compare with this, either in
freshness of style or completeness of information."
Wilcox on Genito- Urinary and Venereal Diseases
The New (2d) Edition
Essentials of Genito-Urinary and Venereal Diseases. By
Starling S. Wilcox, M. D., Lecturer on Genito-Urinary Diseases
and Syphilology, Starling-Ohio Medical College, Columbus. 1 2mo
of 321 pages, illustrated. Cloth, $1.00 net. Saunders' Compends.
Stevenson's Photoscopy
Photoscopy (Skiascopy or Retinoscopy). By Mark D. Stev-
enson, M. D., Ophthalmic Surgeon to the Akron City Hospital.
i2mo of 126 pages, illustrated. Cloth, ^1.25 net.
Edward Jackson. M. D.. University of Colorado.
"It is well written and will prove a valuable help. Your treatment of the emergent
pencil of rays, and the part falling on the examiner's eye, is decidedly better than any
previous account."
ct-n/s
RC73
Morrow
M83
1915
Copy 1
NOV 7
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