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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

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.

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 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

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

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

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.

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

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

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

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

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.

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

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

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.

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

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

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-

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.

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

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

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

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

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

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

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

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

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

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

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

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

6o LOCAL ANESTHESIA

to the patient, if for no other reason, simply to avoid the well-known
unpleasant after-effects of general narcosis, and to obtain a less dis-
turbed and more rapid recovery, regardless of whether the particular
operation be classified as a major or a minor one.

Advantages and Disadvantages of Local Anesthesia. — There are
certain advantages peculiar to local anesthesia that should be care-
fully considered when selecting the anesthetic in any given case.
Most important is the absolute safety to the Ufe of the patient when
this form of anesthesia is employed with proper precautions. With
the substitution of the weak for the old-time strong cocain solutions,
and the discovery of the newer less toxic analgesics, together with a
knowledge of the amount of these drugs that can be safely used, the
dangers of poisoning may be disregarded.

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

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

Another feature connected with an operation under local anes-

LOCAL AXESTHESLA. 6 1

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

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

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

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

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

62 LOCAL ANESTHESIA

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

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

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

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

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

LOCAL ANESTHESIA 63

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

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

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

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

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

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

64 LOCAL ANESTHESIA

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

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

Solutions of cocain should always be freshly prepared at the time of
operation, as it is well known that they are prone to decompose, and
in a short time such a solution becomes capable of producing sup-
puration. A medium isotonic with the fluids of the body, as normal
salt solution, is the best for dissolving the cocain. Such a solution,
producing neither swelling of the tissues, as water does, nor shrinkage
of the cells, as is the case with the more concentrated saline solutions,
has no injurious effects upon the tissues. The effectiveness of the
solution is also increased by using it warm.

As solutions of cocain will not stand prolonged boiling, the salt or
tablet should be previously sterilized by dry heat. An efficient
method is to place the cocain in a small test-tube plugged with cotton,
and then to sterilize it by means of dry heat at a temperature of 300°
F. for fifteen minutes. Several firms^ prepare hermetically sealed

' Parke, Davis & Co., and Squibbs.

LOCAL ANESTHESIA

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

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.)

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

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

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

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.

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

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

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

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

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

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

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

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

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

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.

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-

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

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

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-

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

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-

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~

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

gm.

gr. HI.

gm.

gr. VI.

gm.

gr. 4 1/2

gm.

gr. XV.

gm.

dr. 2 1/4

I coo

c.c.

qt. i.

gm.

dr. I 12

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

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.

623

1.6

1689

3 and 4

1871

127

6.7

5 and over

455

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.

4 J

YEAR I

58 Se So 91 92 93 94 95 9fe 97 98 99 00 1 02 03 04 05 06 07 08 1

64
60

56
52
48

/ V

J6
3Z
2S
24
20
16

V-

.'•n

N 5

'—

«!

-V

•-

— -

V-

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

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

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.

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.

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

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

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

/ A^'

-< ^ \

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— "'^\\\\\

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r^.

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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 ^

/ V

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-

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-

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-

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,

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

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

514 THE COLON AND RECTUM

the cecum at a point just above the origin of the appendix. Regurgi-
tation of fluids and gases into the small intestine is prevented by the
ileocecal valve, a slit-like opening at right angles to the long axis of
the bowel.

The ascending colon is 8 inches (20 cm.) long. It extends vertically
up the right side of the abdomen from the cecum to the inferior sur-
face of the liver to the right of the gall-bladder, where it turns to the
left as the hepatic flexure. It passes in front of the posterior abdom-
inal muscles and the lower pole of the kidney, and is bound to the
former by connective tissue. Anteriorly and laterally it is covered
by peritoneum.

The transverse colon is about 20 inches (51 cm.) in length. It ex-
tends from the hepatic flexure across the abdomen below the liver and
greater curvature of the stomach, with a slight downward curve at
its center, to the spleen, where it turns downward as the splenic
flexure. The transverse colon is the most movable portion of the
large gut, being connected with the posterior abdominal wall by a
long mesentery.

The descending colon is 8 1/2 inches (21 cm.) long. It extends down
the left side of the abdomen from the splenic flexure to the sigmoid,
lying in front of the left kidney and posterior abdominal muscles.
Anteriorly and laterally it is covered by peritoneum.

The sigmoid colon is the narrowest portion of the large gut. It is
about 17 1/2 inches (44 cm.) long and extends from the left iliac crest
in an S-shaped curve to the third sacral vertebra. In the first portion
of its course it passes downward almost to Poupart's ligament, then
turns from the left to the right to enter the pelvic cavity near the
mid-line, and passing to the right side, it turns upward as far as the
lower margin of the right iliac fossa. From this point it makes a
sudden turn and passes downward, backward, and inward to become
continuous with the rectum. The sigmoid is very movable, having
a complete peritoneal covering and mesosigmoid. At the junction
with the rectum the gut exhibits a marked narrowing from an increase
of the muscular fibers, known as the sphincter of O'Beirne.

The Rectum. — The rectum commences at the sigmoid flexure,
opposite the third sacral vertebra, and descends in the middle line of
the sacrum and coccyx. As it descends it forms a curve with the
concavity forward until it reaches a point about i inch (2.5 cm.)
below the tip of the coccyx where it turns, forming a sharp angle, and
is then continued downward and backward through the thickness of
the pelvic floor as the anal canal (Fig. 533). The antero-posterior

ANATOillC CONSIDERATIONS

515

curves of the rectum are distinct and a knowledge of their direction
is important for the proper introduction of the finger or instruments
in making an examination. There are also two slight lateral curves,
first to the right and then to the left, but of less practical importance.

For purposes of description the rectum may be divided into the
rectum proper and the anal canal.

The rectum proper extends from the middle of the third sacral
vertebra to the upper border of the internal sphincter muscle, or to
about the level of the apex of the prostate gland, and measures 3 to
4 inches (7.5 to 10 cm.") in length. This portion of the rectum is

Fig. 533. — Sagittal section of the rectum.

sacculated in form, exhibiting three pouches or dilatations, of which
the lowest and largest, called the ampulla, measures in some cases
nearly 10 inches (25 cm.) in circumference. The constrictions be-
tween which lie these dilatations are produced by an infolding of the
coats of the bowel in the formation of the so-called rectal valves. In
the male, the rectum is in relation anteriorly with the recto-vesical
pouch, the trigone of the bladder, the seminal vesicles, and the pros-
tate gland, while in the female, the vagina and the recto-vaginal
pouch with the small intestine therein contained He anteriorly.

The anal canal is about i 1/2 to 2 inches (4 to 5 cm.) long.
It extends downward and backward, terminating at the surface of the
body as the anus. This portion of the rectum has no peritoneal
covering. It is embraced by the internal sphincter muscle and is
supported by the levatores ani muscles. At the anus the skin is dark

5l6 THE COLON AND RECTUM

brown in color and puckered up into radiating folds. The anal canal
is in relation anteriorly in the male with the bulb and membranous
portion of the urethra; and in the female the perineal body separates
it from the lower end of the vagina.

The rectum is lined with a dark and vascular mucous membrane,
which is thrown into a series of folds, the most important of which are
known as Houston's valves, or the rectal valves. These are three —
sometimes two or four — semilunar folds, projecting Hke transverse
shelves into the cavity of the bowel when it is distended. According
to the usual arrangement the inferior fold projects from the left wall
of the rectum at a point about 2 inches (5 cm.) above the anal orifice;
the middle and most constantly present one projects from the right
wall at a point situated 3 inches (7.5 cm.) from the anus; while the

Fig. 534. — The rectal valve as seen thiuugh the proctoscope. (After Gant.)

superior fold projects from the left wall near the third sacral vertebra,
or at a point about i inch (2.5 cm.) above the middle fold (Fig. 534).
These valves are attached to the walls of the rectum for a distance
of from 1/3 to 1/2 its circumference and protrude into its cavity
to varying degrees. Their function seems to be to assist the sphinc-
ters and to serve to support the fecal mass. They may be the cause
of difficulty in making digital examinations and they may act as ob-
stacles to the passage of a rectal tube.

In the anal canal the mucous membrane is thrown into a series
of longitudinal folds, five to twelve in number, called the columns of
Morgagni. They are about 1/2 inch (i cm.) in length, and are pro-
longed upward from the radiating folds about the anus. Stretched
between these columns at their inferior ends are semilunar folds of
mucous membrane forming pouches that open upward, known as the
valves of Morgagni (Fig. 535).

DIAGNOSTIC METHODS

517

Diagnostic Methods

Assuming that the usual lines of inquiry common to all histories
have been followed and it having been ascertained whether there is a
past record of syphilis, gonorrhea, dysentery, typhoid fever, appen-
dicitis, peritonitis, pelvic inflammation, gall-stones, etc., which might
result in adhesions, ulceration, stricture, or tumor, inquiry is then
directed to special symptoms.

In the presence of pain, its location, whether in the abdomen,
rectum, pelvis, or neck of the bladder; its character, whether sudden
in onset, acute and cutting, or a dull ache; and the time of day it is
felt, that is, before or after stools or with every stool, will often fur-

FiG. 535. — The anal canal, showing the columns and valves of Morgagni.

nish a clue as to the cause. Pain in the upper part of the abdomen
is suggestive of gastric, duodenal, or gall-bladder affections. Pain in
the right iliac fossa may be due to appendicitis or to involvement of
the cecum. Pain situated in the central portion of the abdomen is
frequently caused by colic from gas, feces, or mechanical obstruction,
though not infrequently early in appendicitis the pain is in this local-
ity. Colic is characterized by short, sharp pains coming on suddenly
and often shifting in location; furthermore, the passage of gas or feces
usually gives relief. Constant or prolonged pain is more apt to
signify some organic lesion. Frequently in place of pain patients
will complain of more or less discomfort or tenesmus in the anus or
rectum. It is a frequent symptom in dysentery and in many other
affections of the rectum.

5l8 THE COLON AND RECTUM

If abdominal distention is complained of, it should be ascertained
whether it is general or localized and whether there is any passage
of gas from the bowels, and, if so, whether it relieves the condition,
A total absence of flatus with obstinate constipation suggests ob-
struction.

Finally, the habitual state of the bowels should be determined,
that is, whether they are normal, constipated, or loose, or whether
constipation and diarrhea are alternately present. The examiner
should also inquire as to the color, odor, and character of the move-
ments, whether soft or hard, large or small, and whether they contain
mucus, pus, or blood. The amount and contour will vary much in
health as well as in disease, depending upon the form of food taken,
the quantity of water imbibed, etc.

When all possible information has been obtained from a history
and general physical examination, a local examination is made to
determine more accurately the cause of the symptoms complained of
and the proper line of treatment to pursue. Especially is it import-
ant to make a systematic examination in the presence of rectal
symptoms. On account of the close relation and anatomic prox-
imity of other pelvic organs, as the uterus, tubes, and ovaries in the
female and the bladder, urethra, prostate, and seminal vesicles in the
male, it is necessary to be able to differentiate between many affec-
tions the symptoms of which may reflexly simulate an abnormal
condition of the rectum. It is not uncommon for a stricture of the
urethra, an enlarged prostate, a stone in the bladder, or a displace-
ment of the uterus, for example, to produce a set of symptoms which
point to the rectum as their seat.

The methods available for examination of the colon and rectum
include abdominal inspection, palpation, and percussion, ausculta-
tion, inflation of the colon, skiagraphy, rectal inspection and palpa-
tion, proctoscopy, examination by sounds and bougies, examination
by the probe, lavage of the bowel, and examination of the feces.

/. Abdominal Examination

INSPECTION

In a thin individual it is often possible to make a diagnosis of
ptosis, tumors, or constrictions of the colon from the appearance and
shape of the abdomen. Abdominal inspection is of but very limited
use in stout individuals.

PALPATION 519

Position. — The patient lies with the body symmetrically placed
upon a firm flat table with the hght falUng obliquely from the head
toward the foot (see Fig. 491). It is of advantage when examining for
ptosis to have the patient also assume the erect position.

Technic. — The patient's abdomen being fully exposed, inspection
is performed from the side and from the foot of the table (see Fig. 491).
The examiner notes first the general appearance of the abdomen,
whether distended or flat and whether the abdominal walls are well
developed and capable of supporting the contents. In enteroptosis
the upper part of the abdomen is concave and more or less of a "pot-
belly" is evident with a sulcus between the two recti above the um-
bilicus. This characteristic appearance is accentuated with the
patient in the erect position — the abdomen appears more pendulous
and the abdominal contents may project like a hernia through the
space between the two recti. The examiner then makes more careful
inspection for the presence of hernia, visible swelling, or tumor. A
tumor may produce sufficient bulging of the part affected to be recog-
nized by inspection. Likewise, if the individual is thin, in the pres-
ence of stenosis of the bowel it may be possible to recognize disten-
tion of the portion of the bowel proximal to the seat of obstruction
and the strong peristaltic waves. Inflation of the bowel (see page
521) is of considerable value in making more prominent a tumor or
the seat of an obstruction.

PALPATION

The cecum and parts of the ascending, transverse, descending, and
sigmoid colon are accessible for palpation, depending upon the stout-
ness of the individual. It is thus possible to recognize local tender-
ness, thickening of the gut, and a tumor, and, in the presence of the
latter, its size, mobility, and consistency.

Preparations of the Patient. — When feasible, the patient's bowels
should be emptied by a cathartic given the night before.

Position. — The examination is performed with the patient in the
dorsal position upon a flat table with the knees flexed and a small
pillow beneath the head and shoulders to secure relaxation of the
abdominal muscles. Shifting the patient from side to side will often
furnish more complete information in the presence of a tumor or other
mass.

Technic. — The examiner stations himself by the side of the pa-
tient and places his right hand, well warmed, flat upon the patient's

520 THE COLON AND RECTUM

abdomen, at first performing gentle circular palpation over all parts.
Gradually deeper palpation may be employed, but sudden poking of
any region should be carefully avoided. In performing deep palpa-
tion reinforcing one hand with the other is of great aid. Tender
spots, rigidity of the muscles, and the presence of masses should be
looked for. Tenderness suggests inflammation or ulceration of the
bowel. In eliciting tenderness it is well to watch the patient's face,
as this is often a better guide than questions as to his sensations.
Rigidity of one or both recti is of diagnostic importance signifying
some local peritoneal irritation in the first instance and general peri-
tonitis if both recti are involved. A rigid right rectus is not uncom-
mon, however, in right-sided pneumonia and pleurisy. The sensa-
tion a mass gives to the palpating hand is frequently a guide to its
character. Thus, a cancerous growth is generally hard to the touch,
cannot be indented, and is frequently uneven; a benign growth is
generally smooth; a fecal impaction is movable, has a doughy feel,
and can be indented with the fingers. In intussusception the mass is
smooth and has the characteristic sausage shape. Often more valu-
able information as to the source and mobility of a mass may be
elicited by changing the position of the patient from time to time and
by inflation of the bowel (see page 521).

PERCUSSION

The chief use of percussion is to confirm the results obtained by
palpation. The percussion note over the empty colon is tympanitic
and of a higher pitch and less volume than over the stomach, and
over the small intestine the note is of a still higher pitch and less
volume. When the bowel contains fluid or fecal matter or in the
presence of a solid tumor the percussion note is flat. Percussion is
thus of value in differentiating between the empty intestine and a
solid tumor, and, in the presence of the latter, in determining its size
and shape. By first inflating the bowel with air or fluid it is possible
to trace its course and thus recognize the presence and degree of
ptosis. This method is also of value in locating the seat of a stricture
of the bowel by the contrast between the percussion note obtained
over the inflated portion and that over the empty bowel.

AUSCULTATION

Auscultation is of but little diagnostic importance in diseases of
the large bowel. Various splashing, gurgling, and whistling sounds are

INFLATION OF THE COLON 52 1

to be heard normally in the intestines and are due to the movements
of gas and fluids. In chronic obstruction of the large bowel gurgling
sounds are also to be heard in the region of the obstruction, and, if
they are always heard in the same location, they are of considerable
diagnostic importance. An entire absence of intestinal sounds would
suggest intestinal paresis. By injecting into the bowel small quanti-
ties of fluid (about a pint (500 c.c.)) it is possible to map out the course
of the bowel by the splashing sounds heard on auscultation. This
procedure may be employed to advantage in cases of suspected
ptosis.

INFLATION OF THE COLON

This procedure is performed both as a diagnostic and as a thera-
peutic measure (for the latter see page 563). The bowel may be
inflated either by means of air or fluids. For diagnostic purposes,
however, air is preferable, as there is thus produced a contrast on
percussion between the tympany of the air-distended bowel and the
flatness of a tumor. It has the disadvantage, however, that the
amount injected cannot be measured as can fluids, and consequently
the degree of distention is not so well regulated.

The colon may be distended as far as the cecum, provided there
be no obstruction and the inflation be slowly and carefully performed.
When thus distended, the bowel is raised from the surrounding parts
and is caused to stand out against the abdominal wall so that it may
be readily mapped out by palpation and by percussion, and its size,
shape, position, and mobility may be determined. It thus be-
comes possible to locate the seat of a stricture or an obstruction by
noting the limits of the distended area — the part below the seat of
stenosis becomes prominent, while the portion of the bowel above will
be but slightly distended or not at all so, depending upon the degree
of occlusion. Under inflation, tumors of the large bowel are made
more prominent and it is frequently possible to recognize that a
growth is located in or is in connection with the colon by tracing the
distended bowel directly into the tumor mass. Finally, inflation is
also of great aid in determining the probable seat of other abdominal
tumors; the distention of the bowel causes a change in the position
of the tumor, displacing it in the direction of the normal position
of the organ from which it takes origin, so that tympany is obtained
where there was originally dulness; for example, a tumor of the
stomach is pushed upward; a tumor of the gall-bladder and liver is
pushed upward and forward; a tumor of the pancreas becomes less

;22

THE COLON AND RECTUM

noticeable; a tumor of the kidney is pushed upward toward the
normal position of the kidney and hes behind the distended colon;
a tumor of the spleen will lie in front of the colon and the growth
will become more readily palpable from being pushed forward, etc.,
etc.

"^ r j]Tnini'iiir'""'i'ii'""i""i"""''i"'"""'"iMiii7ii™^™™
Fig. 536. — Rectal tube and cautery bulb for inflating the colon.

Apparatus. — The injection of fluids is effected by means of a foun-
tain syringe or a graduated glass irrigating jar as a reservoir, and
a rectal tube attached to the reservoir by about 6 feet (180 cm.) of
rubber tubing 1/4 to '^IZ inch (6 to 9 mm.) in diameter.

Fig. 537. — Inflation of the colon with oxygen. (After Gant.)

For the injection of air a special inflation apparatus may be em-
ployed, but a rectal tube attached to a Davidson syringe, cautery
bulb (Fig. 536), hand bellows, or bicycle pump will answer equally
well. The pumping apparatus may be dispensed \A\h if oxygen
or carbonic gas is used. In the case of the former the rectal tube

INFLATION or THE COLON 523

is simply attached to the oxygen tank (Fig. 537), while, if the latter
gas be employed, the tube is attached to a syphon of carbonic, and
the latter is inverted so that the gas escapes without the water
following.

Media for Inflation. — Of fluids, warm normal salt solution (dr. i
(4 gm.) of salt to a pint (500 c.c.) of water) is best. Air, oxygen, or
carbonic acid gas may be used when gaseous distention is desired.

Amount Injected. — When inflating with gas there is no way to
determine accurately the amount of gas injected, and the patient's
sensations and the degree of distention of the bowel must be the
guide. Never inject sufiicient to cause pain, and care must be taken
not to endanger the gut.

As much as 3 quarts (3 liters) of fluid may be injected with
safety.

Rapidity. — Fluid or gas should be injected slowly and steadily;
rapid distention of the bowel is to be avoided. From fifteen minutes
to half an hour should be consumed in performing the operation. If
the reservoir be not elevated above 3 feet (90 cm.), the fluid will not
enter the bowel too rapidly.

Position of Patient. — The tube may be inserted with the patient
upon his side, but as soon as the inflation is begun the dorsal position
should be assumed.

Technic. — If there is any accumulation of fecal matter in the
bowels a simple enema should be given and an evacuation produced
before attempting the operation. The rectal tube is then well lubri-
cated with vaselin and is inserted 4 or 5 inches (10 to 12 cm.) within
the rectum. If fluid is employed, the reservoir is then elevated be-
tween 2 and 3 feet (60 to 90 cm.) and the solution is allowed to distend
the bowel slowly, cotton being tightly packed about the anus and the
buttocks being held in close apposition to prevent leakage. As the
rectum becomes distended there will be some spasm and an almost
irresistible desire on the part of the patient to expel the fluid, but if the
flow be temporarily stopped, or the reservoir lowered, and time be
given for the fluid to pass upward, this feeling soon passes off and the
inflation may be then continued. When the colon has been sufficiently
distended and the purposes of the examination are accomplished, the
fluid is allowed to escape from the bowel through the tube.

The technic of introducing gas is practically identical with the
above, great care being taken, however, not to force the gas in too
rapidly or in excess, and at the completion of the examination to draw
off as much of it as possible, so as to avoid unpleasant distention. Its

524 THE COLON AND RECTUM

escape may be aided by inserting two fingers into the rectum and
holding the anus open.

SKIAGRAPHY

The X-rays are of value in recognizing the presence of foreign
bodies in the intestinal tract, and for determining the position of the
colon and the seat of strictures, dilatations, angulations, or adhesions
that may be causing obstruction. For recognizing the latter condi-
tions a preliminary rectal injection of a bismuth mixture or the inges-
tion of a bismuth meal is essential. When the bismuth is given by
mouth, its passage may be traced through the intestinal tract by
means of repeated X-rays, and valuable information as to the motil-
ity of the intestinal contents may be secured.

In preparation for an X-ray examination of the large intestine,
the patient is given a purge for two nights before and an enema on
the day of the examination to thoroughly empty the colon. Two
oimces (60 gms.) of bismuth subcarbonate are mLxed with a little
starch in 2 quarts (2 liters) of warm water and are injected into the
bowel with the patient in the Sims position with the hips elevated, or
while in the knee-chest position, and a radiograph is immediately
taken; or, the patient may be given by mouth an ounce (30 gms.) of
bismuth subcarbonate or oxychlorid in 12 ounces (360 gms.) of milk or
koumiss, and the radiograph be taken at the end of 24 hours when all
the bismuth should be in the large bowel. A second picture should
be taken at the end of 48 hours in order to judge of the motility of
the bowel. Exposures should be made with the patient in the recum-
bent and in the upright posture.

//. Internal Examination

Preparation of the Patient. — In order to make a satisfactory
examination of the rectum the latter should be emptied of its con-
tents by means of a cathartic given the night before or by an enema
administered just before the examination is begun. In some cases,
however, more useful information as to the usual condition of the
rectum may be obtained by making a preliminary examination of the
patient in just the condition he presents himself. The presence of
blood, pus, or mucus will thus be revealed, of which there would often
be no trace after a cleansing enema. If necessary, an enema may
then be given and a more complete examination may be made later.
The bladder should likewise be evacuated, and tight clothing, such as

POSITIONS FOR INTERNAL EXAMINATION

525

bands, belts, or corsets, which tend to force the intestines into the
pelvis, should be loosened.

Position of the Patient. — -Four positions are employed for rectal
examinations, each of which has its own advantages under special
conditions. These are: (i) the Sims, (2) the lithotomy, (3) the knee-
chest, and (4) the squatting posture.

The Sims, or left lateral position, is obtained by placing the pa-
tient upon the left side with the left side of the face, the left shoulder,
and the left breast resting upon a flat pillow. The left arm lies be-
hind the back and the thighs are well flexed upon the body with the
right knee drawn up nearer the body than the left. The buttocks lie
near the edge of the table and are elevated upon a hard pillow (Fig.
538). This position will be found most useful for routine examina-

FiG. 538. — The Sims position.

tions, and probably will be found less objectionable to the patient
than the lithotomy or knee-chest positions.

The lithotomy position is secured by placing the patient flat on the
back and flexing the thighs upon the abdomen and the legs upon the
thighs. The buttocks, which are elevated upon a hard flat pillow,
project over the end of the table (Fig. 539) . In very stout individuals
this position will permit of a more satisfactory examination than will
the Sims.

The knee-chest position is obtained by having the patient kneel
upon a table with the thighs at right angles to the legs with the body
well flexed upon the thighs, the chest resting upon a pillow placed
upon the same level as the knees (Fig. 540). The knee-chest position
favors displacement of the coils of intestine upward, thus allowing the
rectum to be distended by the entrance of air upon the insertion of a
speculum or proctoscope. The mucous membrane of the rectum,
which in the dorsal position lies in folds, becomes expanded, and thus
a more thorough inspection of all portions of the canal is possible.

526

THE COLON AND RECTUM

The squatting posture is only suitable for digital examination.
The patient assumes an attitude similar to that taken while at stool.
Portions of the rectum may be thus palpated which in the Sims or the
dorsal position would be out of reach of the examiner's finger. By a

Fig. 539. — The lithotomy position.

'l7llll|||||||I U»l|l|l||l l l llll | l|ll l | l l|l|| ) l|l ) || ;| li ;) |||| )))| | ) || ||| | || | ||)||)|,|)| |i||| | ; |||[ | || |jy

Fig. 540. — The knee-chest position.

slight straining effort protrusions or moderate degrees of prolapse will
be revealed.

INSPECTION

The anus is first inspected. The presence of discharges from the
rectum, excoriations, eczema, thickening of the epidermis, scars,
ulcerations, fistulous openings, condylomata, the swelling of an abscess.

PALPATION

527

and external hemorrhoids, are carefully looked for. Then, by separ-
ating the buttocks and placing the thumbs on either side of the anus
and drawing it apart while the patient strains slightly, inspection of
the anal canal for at least an inch (2.5 cm.) will be possible (Fig. 541).
Shght degrees of prolapse, fissures, ulcers, hemorrhoids, and polypi
or other growths may be readily demonstrated in this way.

PALPATION

Palpation of the rectum may be performed by means of the finger
or by the whole hand. With the index-finger one may examine the
anus, the anal canal, and the ampulla of the rectum. The first 4
inches (10 cm.) of the rectum may be thus explored.

Fig. 541. — Inspection of the anus. (Ashton.)

Introduction of the whole hand into the rectum, as advocated by
Simon, for the purpose of palpation of portions of the canal out of
reach of the finger, may be practised if the hand is moderately small.
Tuttle states that a hand requiring a kid glove larger than 73/4 should
never be introduced into the rectum except in a life or death emer-
gency. Manual palpation is rarely required, being only necessary for
examining tumors high up that cannot be inspected by means of a
speculum or a proctoscope. In addition, it is a serious procedure, as
there is danger of rupture or undue distention of the bowel in careless
hands.

Anesthesia. — General anesthesia will be required for palpation by
the whole hand, as complete dilatation of the rectum is essential.

528

THE COLON AND RECTUM

Technic. — i . By the Finger. — No anesthesia will be required. The
direction of the rectum, which is at first slightly forward from the
anus, then back into the hollow of the sacrum, then to the right, and
finally to the left toward the sigmoid flexure, should be kept clearly in
mind. The index-finger of the right hand is covered with a rubber
finger cot. If, however, it is desired to preserve the tactile sense of
the finger, a covering is dispensed with, in which case soap should be
forced under the nail. The finger is well lubricated with sterile vase-
lin or with one of the preparations of Irish moss made for the pur-
pose and is then introduced slowly and with a rotary motion, the

Fig. 542. — Palpation of the rectum. (Gant.)

patient being requested to strain gently to f acihtateits passage through
the sphincter. Roughness in inserting the finger or disregard of the
natural direction of the canal will be liable to cause spasm of the
sphincter and give the patient such pain that a thorough examination
will be impossible.

As the finger passes through the anal canal the condition of the
sphincter should be noted, the examiner observing whether it is closed,
rigid, and resisting, or loose and patulous. When the internal sphinc-
ter has been passed, the finger is swept lightly over the mucous mem-
brane, palpating the rectal wall in all directions. The size and sensi-
tiveness of the rectum is thus ascertained. The examining finger will
readily detect the presence of impacted feces, polypi, large hemor-
rhoids, malignant growths, ulcerations, fissures, and strictures if a
systematic examination is made. In the male, enlargement, indura-
tion, degrees of sensitiveness, or softness of the prostate should be

PALPATION

529

carefully noted, and likewise information regarding the condition of
the seminal vesicles and bladder should be obtained. A vesical cal-
culus may frequently be discovered by such examination. In the
female, the uterus, tubes, ovaries, and broad ligaments are carefully
examined for displacements or signs of inflammation. Finally, the

Fig. 543. — Method of dilating the anus by means of one finger of each hand.

coccyx should not be overlooked, as this bone may be responsible for
considerable rectal disturbance.

If pus, blood, or mucus be present in the bowel there will be an
escape of the material from the anus when the finger is withdrawn or
the finger will come away coated. In all cases it is important to note

Fig. 544. — Method of dilating the anus by means of two fingers of each hand.

the odor of the examining finger upon its withdrawal. The foul odor
of cancer is characteristic and will not be mistaken for anything
else once it is recognized.

2. By the Whole Hand. — Stretching of the sphincters is commenced
by introducing into the anus the two forefingers with the palmar sur-

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 amoun