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

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Microsoft Corporation 



http://www.archive.org/details/diagnostictherapOOmorruoft 



BOOKS 



BY 



ALBERT S. MORROW, M. D. 



Diagnostic and Thcrapctttic Tcchnic 

Pctavo of 894 pages, with 892 line- 
drawings. Third Edition. 



Immediate Care of the Injured 

i2mo of 355 pages, with 242 illus- 
trations. Cloth, $2.75 net. 
The New {2d) Edition 



DIAGNOSTIC 



AND 



THERAPEUTIC TECHNIC 

A Manual of Practical Procedures 
Employed in Diagnosis and Treatment 



BY 

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

LATE LIEUT.-COLONEL, M. C, U. S. A.", ATTENDING SURGEON TO 
THE CITY HOSPITAL, AND TO ST. BARTHOLOMEW'S HOSPITAL; 
CONSULTING SURGEON TO THE NASSAU HOSPITAL, MINEOLA, L. I. 



Ml") I S' 



THIRD EDITION, ENTIRELY RESET 
WITH 892 ILLUSTRATIONS, MOSTLY ORIGINAL 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1921 



Copyright, 191 1, by W. B. Saunders Company. Reprinted January, 

19 1 2, and January, 1913. Revised, entirely reset, reprinted, 

and recopyrighted January, 1915. Reprinted July, 1915, 

and April, 191 7. Revised, entirely reset, reprinted, 

and recopyrighted January, 1921 



Copyright, 192 1, by W. B. Saunders Company 



PRINTED IN AMERICA 

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 THIRD EDITION 



In the desire to have the third edition of this book conlorm to 
the latest advances in methods of diagnosis and treatment, a very 
careful revision of the text has been made and the book has been 
entirely reset. While the general plan of the original work has been 
followed without change, several sections have been rewritten and 
considerable new material has been added. Additional illustrations 
have been supplied to elucidate the new text, and some of those 
that appeared in previous editions have been redrawn. This work 
has been efficiently performed by Mr. Howard J. Shannon under 
the author's supervision. Every effort has been made to bring the 
present volume up-to-date and maintain the practical character of 
the previous editions, and it is hoped that the changes and addi- 
tions that appear in this new edition will add materially to the 
usefulness of the book. 

A. S. M. 

New York City, 
January, 1921. 



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 7. 

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

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

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

S 



6 PREFACE. 

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

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

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

A. S. M. 

New York City. 



CONTENTS 



CHAPTER I 

Page 

The Administration of General Anesthetics 17 

Preparations of the patient for general anesthesia 18 

Stages of anesthesia 22 

Ether anesthesia 24 

Chloroform anesthesia 34 

Nitrous oxid anesthesia 39 

Nitrous oxid and oxygen anesthesia 44 

Nitrous oxid and ether sequence 45 

Ethyl chlorid anesthesia 47 

Anesthetic mixtures 49 

Intubation anesthesia 51 

Intratracheal insufflation anesthesia * 52 

Anesthesia through a tracheal opening 56 

Intravenous general anesthesia 58 

Rectal anesthesia 61 

Oil-ether colonic anesthesia 64 

Scopolamin-morphin anesthesia 65 

Accidents during anesthesia and their treatment 65 

4fter-effects of anesthetics 72 

After-treatment of cases of general anesthesia 74 



CHAPTER II 

Local Anesthesia 76 

Advantages and disadvantages of local anesthesia 77 

Methods of producing local anesthesia 80 

Drugs employed for local anesthesia 81 

Preparation of patient for local anesthesia 84 

Conduction of an operation under local anesthesia 85 

Local anesthesia by cold 86 

Surface application of anesthetic drugs 87 

Infiltration anesthesia 88 

Endo- and perineural infiltration 93 

Practical application of infiltration, endo- and perineural methods of anesthe- 
sia to special localities 95 

Operations on inflamed tissues under local anesthesia 109 

Bier's venous anesthesia no 

Arterial anesthesia ii4 

Spinal anesthesia i^S 

Sacral anesthesia 122 

Parasacral anesthesia ^25 

7 



8 CONTENTS 

CHAPTER III 

Page 

Sphygmomanometry 127 

Normal blood-pressure 128 

Instruments for estimating blood-pressure 129 

Technic of estimating blood-pressure 132 

Variations of blood-pressure in disease 134 



CHAPTER IV 

Transfusion OF Blood 137 

Indications and contraindications 138 

Selection of the donor 139 

Hemolysis 139 

Method of determining blood groups 141 

Direct artery to vein transfusion 143 

Technic by Crile's method 145 

Brewer's method 148 

Elsberg's method 148 

Indirect transfusion, 149 

Lindeman's method 150 

Unger's method 152 

Paraffined tube method * 153 

Sodium citrate method 156 

Transfusion of preserved red cells 161 

Injections of Human Blood Serum 164 



CHAPTER V 

Infusions of Physiological Salt Solution 167 

Indications . 167 

Preparation of normal salt solution 168 

Artificial sera for infusions 169 

Gum acacia solutions for infusions . . v 170 

Intravenous infusion 170 

Intraarterial infusion . . " 177 

Hypodermoclysis 180 

Rectal infusion 183 



CHAPTER VI 

Acupuncture 184 

Venesection 185 

Scarification . 1 90 

Subcutaneous Drainage for Edema . . . . • 192 

Cupping 194 

Leeching 197 



CONTENTS 9 

CHAPTER VII 

Page 

Hypodermic AND Intramuscular Injection OF Drugs 201 

Administration ofArsphenamin and Neoarsphenamin 206 

Administration OF Diphtheria Antitoxin 214 

Vaccination 219 



CHAPTER VIII 

The Treatment of Neuralgia BY Injections 225 

Trifacial neuralgia 225 

Sciatica 231 



CHAPTER IX 

Disinfection of Wounds by the Carrel-Dakin Technic 234 

Preparation of Dakin's solution by Daufresne's method 235 

Mechanical cleansing of the wound 242 

Arrangement of the tubes 243 

Dressing the wound 246 

Bacteriological examination of the wound 247 



CHAPTER X 

Bier's Hyperemic Treatment 250 

Passive hyperemia 250 

Effects of hyperemia 251 

Indications 253 

General principles underlying hyperemic treatment 253 

Passive hyperemia by means of constricting bands 255 

Passive hyperemia by means of suction cups 261 

Active hyperemia 267 

The Proituction of an Artificial Pneumothorax 270 

Effects of 271 

Indications 271 

Method of inducing 274 

Complications 275 

The Diagnosis and Treatment of Fistulous Tracts by Means of Bismuth 

Paste 276 



CHAPTER XI 

Collection and Preservation of Pathological Material 279 

Method of making smear preparations for microscopical e^camination . . .279 

Method of inoculating culture tubes 287 

Collection of discharges and secretions for bacteriological examination ... 290 

Collection of blood for microscopical examination 297 

Collection of blood for bacteriological examination 302 



lO CONTENTS 

Page 

Collection of sputum 3^4 

Collection of urine 3^5 

Collection of stomach contents 3o<^ 

Collection of feces 307 

Removal of a fragment of solid tissue for examination 307 

CHAPTER XII 

Exploratory Punctures 3" 

Exploratory punctures in general 311 

Exploratory puncture of the pleura 312 

Exploratory puncture of the lung 317 

Exploratory puncture of the pericardium 318 

Exploratory puncture of the peritoneal cavity 321 

Exploratory puncture of the liver 322 

Exploratory puncture of the spleen 324 

Exploratory puncture of the kidneys 325 

Exploratory puncture of joints 326 

Spinal puncture 329 

Spinal puncture as a means of administering therapeutic sera 336 



CHAPTER XIII 

Aspirations 339 

Aspiration of the pleural cavity $39 

Aspiration of the pericardium 34 7 

Aspiration of the abdomen for ascites 350 

Aspiration of the tunica vaginalis 354 

Aspiration of the bladder 357 



CHAPTER XIV 

The Nose AND Accessory Sinuses 358 

Anatomic considerations 358 

Diagnostic methods 363 

Rhinoscopy 363 

Inspection of the nasophar3aix by means of Hays' pharyngoscope 37a 

Palpation by the probe 373 

Digital palpation of the nasopharynx 375 

Transillumination of the accessory sinuses 376 

Skiagraphy 378 

Therapeutic measures 37g 

Nasal douching 379 

The nasal syringe 382 

The nasal spray . 383 

Direct application of remedies 386 

InsuflSations 388 

Lavage of the accessory sinuses. . " 389 

Passive hyperemia in diseases of the nose and accessory sinuses 396 

Tamponing the nose for the control of hemorrhage 397 



CONTENTS II 

CHAPTER XV 

Page 

The Ear 401 

Anatomic considerations 401 

Diagnostic methods 405 

Direct inspection . • 407 

Otoscopy 407 

Determination of the mobility of the drum membrane -411 

Hearing tests 413 

Inflation of the middle ear for diagnosis 415 

Therapeutic measures 423 

The ear syringe 423 

Instillations 425 

Application of caustics 427 

Inflation of the middle ear for therapeutic purposes 428 

Inflation with medicated vapors 428 

Injection of solutions into the Eustachian tubes 429 

The Eustachian bougie 430 

Massage of the drum membrane 432 

Incision of the drum membrane 432 



CHAPTER XVI 

The Larynx and Trachea 436 

Anatomic considerations 436 

Diagnostic methods 439 

Laryngoscopy and tracheoscopy 440 

Direct laryngoscopy 417 

Autoscopy 450 

Suspension laryngoscopy 450 

Direct tracheo-bronchoscopy 453 

Palpation by the probe • 460 

Skiagraphy 460 

Therapeutic measures 461 

The laryngeal spray 461 

Direct apphcation of remedies 462 

Insufflations 465 

Steam inhalations 465 

Dry inhalations 468 

Intubation 468 

Tracheotomy 477 



CHAPTER XVII 

The Esophagus 488 

Anatomic considerations 488 

Diagnostic methods 488 

Auscultation ■ 489 

Percussion 49° 

Palpation 49° 

Examination by sounds and bougies • . 49° 



12 CONTENTS 

Page 

Esophagoscopy. . . ' 498 

Skiagraphy 502 

Therapeutic measures 502 

Lavage of the esophagus 502 

Dilatation of esophageal strictures by the bougie 504 

Intubation of the esophagus 508 



CHAPTER XVin 

The Stomach 513 

Anatomic considerations 513 

Diagnostic methods 514 

Inspection .• • • 5^6 

Palpation 518 

Percussion 521 

Auscultation 523 

Inflation of the stomach 524 

Examination of stomach contents 526 

Fractional method of gastric analysis 533 

Test of motor function 536 

Test of absorption power 536 

Gastrodiaphany 537 

Gastroscopy 539 

Skiagraphy 546 

Exploratory laparotomy 547 

Therapeutic measures 547 

Lavage of the stomach 547 

The stomach douche 552 

Gavage 555 

Duodenal feeding 559 

Massage 561 

Electrotherapy 563 



CHAPTER XIX 

The Colon and Rectum 566 

Anatomic considerations 566 

Diagnostic methods •. . . 570 

I. Abdominal Examination 571 

Inspection 571 

Palpation -572 

Percussion 573 

Auscultation 573 

Inflation of the colon 573 

Skiagraphy 576 

II. Internal Examination 577 

Inspection 579 

Palpation by the finger 579 

Manual palpation 582 

Examination by the speculum or proctoscope 583 



CONTENTS 13 

Page 

Examination by sounds and bougies 590 

Examination by the bougie £L boule. . 591 

Examination by the probe 592 

Lavage of the bowel 593 

Examination of the feces 594 

Therapeutic measures 594 

Enemata 594 

Enteroclysis 594 

Saline rectal infusion 607 

Continuous proctoclysis 609 

Nutrient enemata 613 

Injection of fluids or air into the bowel in intussusception 616 

Dilatation of rectal strictures by the bougie 618 

Colonic massage 621 

Auto-massage 623 

Application of electricity to the rectum and colon 624 



CHAPTER XX 

The Urethra and Prostate 627 

Anatomjc considerations 627 

Diagnostic methods 631 

Glass tests for locating urethral pus 632 

Injection test for locating urethral pus 634 

Inspection 634 

Palpation 636 

Examination by sounds and bougies 638 

Examination by the bougie a boule 647 

Urethrometry 650 

Estimation of the urethral length 651 

Urethroscopy in the male 652 

Urethroscopy in the female 658 

Therapeutic measures 661 

Urethral injections 661 

Irrigations of the urethra 664 

Instillations 669 

Application of ointments 672 

Urethroscopic treatment 673 

Direct application of cold to the urethra . 676 

Prostatic massage 677 

Meatotomy 679 

Treatment of strictures by gradual dilatation 680 

Treatment of strictures by continuous dilatation 693 



CHAPTER XXI 

The Bladder 696 

Anatomic considerations 696 

Diagnostic methods 698 

Urinalysis 699 

Inspection 7^4 



14 CONTENTS 

Page 

Percussion 705 

Palpation • • • 7oS 

Sounding for stone 707 

Test of bladder capacity , 711 

Estimation of residual urine 712 

Test for absorption from the bladder 713 

Cystoscopy in the male 713 

Cystoscopy in the female 719 

Skiagraphy 725 

Therapeutic measures 725 

Irrigations 725 

Auto-irrigations 729 

Instillations 730 

Cystoscopic treatment 731 

Fulguration of vesical growths by the high frequency current 732 

Catheterization in the male 734 

Catheterization in the female .- 741 

Continuous catheterization 743 

Aspiration of the bladder 746 



CHAPTER XXII 

The Kidneys and Ureters " 749 

Anatomic considerations 749 

Diagnostic methods 752 

Inspection 752 

Palpation of the kidney 753 

Palpation of the ureters 755 

Percussion 757 

Urinalysis 758 

Catheterization of the ureters in the male 759 

Catheterization of the ureters in the female 768 

Pyelometry 774 

Segregation of urine 775 

Tests of kidney function 779 

Skiagraphy 791 

Pyelography 792 

Exploratory incision 792 

Therapeutic measures 793 

Medication of the renal pelvis and ureters 793 

Dilatation of ureteral strictures . . . ' 794 



CHAPTER XXIII 

The Female Generative Organs 796 

Anatomic considerations 796 

Diagnostic methods 798 

I. Examination of the abdomen. 

Inspection 803 

Palpation ' 804 

Percussion 806 



CONTENTS 15 

Page 

Auscultation 808 

Mensuration 808 

II. Examination of the pelvic organs. 

Inspection 809 

Examination of discharges 810 

Digital palpation 811 

Bimanual palpation 813 

Examination by means of specula 820 

Sounding the uterus 825 

Digital palpation of the uterine cavity 827 

Examination of sections and scrapings from the uterus 829 

Exploratory vaginal incision 829 

Therapeutic measures 832 

Vaginal irrigations 832 

Local applications to the vagina and cervix 835 

Application of powders to the vagina 836 

Vaginal tampons 837 

Intrauterine douche 840 

Intrauterine applications 844 

Tamponing the uterus, . 847 

Bier's hyperemic treatment in gynecology 850 

Pelvic massage , 850 

Scarification of the cervix 852 

Pessary therapy 853 

Dilatation of the cervix 864 

Curettage 868 



Index 873 



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 state. Anes- 
thetics 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 general anesthesia the patient is brought practically to the 
border-line between life and death, and, in many case, the life of the 
patient depends upon the selection of the anesthetic, as well as 
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 selected 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 statis- 
tically 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 ejffects 
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 17 



1 8 THE 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 may be necessary to subject the patient to a 
very careful regime, beginning even some weeks before operation in 
order to put him in the best 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 moderate in amount to 
prevent overloading the alimentary canal. If the operation is set 
for early in the morning, no food should be given after a light supper 
the previous night; if it is fixed for the afternoon, a very light break- 
fast 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 
danger of the anesthetic, but to the subsequent distress of the pa- 
tient. In some cases of special gravity on account of shock or 
marked feebleness, a nutrient enema (see page 75), with the addi- 
tion 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 



THE ADMINISTRATION OF GENERAL ANESTHETICS 1 9 

anesthetic. To avoid undue excitement, the lavage may be per- 
formed 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. In the case of some patients simply a rub-down with 
alcohol at bedtime suffices to induce sleep; for others, especially if 
nervous, the administration of a sedative 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. J^foo (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 preliminary to general anesthesia, for 
exact knowledge as to the state of health is essential to an intelKgent 
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, 
and respirations, a physical examination of the heart, arteries, and 



20 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 operation- 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 quite important. 
A nornial adult male will pass 460 to 525 gr. (30 to 34 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 with ether. In the pres- 
ence of large quantities of albumin and casts the operation should be 
postponed or local anesthesia substituted. 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 hypodermic before the anesthetic is 
begun. In the presence of hypotension, cardiac stimulants for sev- 
eral days previous to the operation are indicated. 

Care 0] the Patient. — While the patient is on the operating-table 
care should be taken to maintain the bodily heat and prevent chilling 
by a proper amount of covering. The habit of washing patients with 
quarts of solution and leaving them lying in a pool of chilly water is 
to be condemned. It is preferable to arrange the patient upon the 
table before the anesthetic is begun. Anesthetizing a patient in one 
room and then moving him 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. 

The position assumed by the patient upon the operating-table 
should be unconstrained and as comfortable as is consistent with the 
needs of the case. A supine position, with the head elevated suffi- 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



21 



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 any anesthetic. 

Before administering the anesthetic, anything that interferes with 
or obstructs the respiration in the slightest degree should be removed. 
Tight collars, bandages about the neck, clothing, belts, straps, braces, 
etc., should invariably be loosened, no matter how short the anes- 




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

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 Anesthetists Supplies. — Besides the apparatus necessary for 
the actual administration of the anesthetic, the anesthetist should 
be provided with the following: a mouth gag, a wedge or screw- 
shaped piece of hard rubber to force the jaws apart, tongue forceps, 
a 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. 



22 



THE ADMINISTRATION OF GENERAL ANliSTHETICS 



i). A cylinder of oxygen should be ready for use, and an infusion 
set and tracheotonay tube should be accessible. 

Duration oj 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 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 
anesthetics passes through four stages: (i) The initial, or stage of 
irritation; (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 
absent, 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 ether or chloroform produces 
irritation of the mucous membrane of the respiratory tract and a 
profuse secretion of mucus with some coughing and frequent acts of 
swallowing. To some persons, the odor and taste of the anesthetic 
are exceedingly unpleasant, so that temporary holding of the breath 
is not uncommon. If the vapor is given in too concentrated a form, 
violent coughing will be induced, accompanied by cyanosis, and 
frequently a sense of suffocation is experienced and the patient tries 



THE ADMINISTRATION OF GENERAL ANESTHETICS 23 

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 0] 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 skin be- 
comes cool, pale, and moist. The pupils contract but still react 
slowly to light, and the conjunctival reflex disappears. 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 
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 



24 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 light at all times. 

Stage o] 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, with laughing, crying, or incoherent 
speech follow, and it is usually some hours before the mental equilib- 
rium is completely regained. Hyperesthesia is marked in the period 
of recovery, and general irritability, complaints of discomfort, 
and pain are to be expected. Some, however, especially children, 
pass into a deep sleep lasting for several hours. 

ETHER ANESTHESIA 

Ether is a very volatile, colorless liquid, with a strong, pungent 
odor and a burning, sweetish taste. It is very inflammable, and 
should not be used near a flame, cautery, or X-ray apparatus. 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 
anesthetic purposes, and it should be kept in hermetically sealed 
tin cans, as exposure to light 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 saliva, often accompanied by 
coughing. Lesions of the lungs are thus apt to follow its use, and 
may be due to the aspiration of saliva as well as to the direct 
irritation of the ether vapor. Ether is a distinct cardiac stimu- 
lant, accelerating the heart action and raising blood-pressure; this 
effect is well shown when ether is administered to a very ill person, 
the character of the pulse often showing immediate improvement 
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, es- 



ETHER ANESTHESIA .25 

pecially 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 recognized and proper treatment insti- 
tuted with more chance of success than with the latter. Upon the 
kidneys it acts as an irritant, and prolonged anesthesia often results 
in postoperative albuminuria. Ether produces a distinct leukocy- 
tosis, a slight diminution of the hemoglobin,- and a marked decrease 
in the coagulation-time of the blood (Hamburger and Ewing). Ac- 
cording 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, differing in this respect from the administra- 
tion of chloroform. The administration of ether is rendered safer if 
preliminary anesthesia is induced by some quick anesthetic, as nitrous 
oxid or ethyl chlorid; furthermore, oxygen and ether is a safer mix- 
ture 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, ether is preferable to chloro- 
form unless direct contraindications to its use are present. In the 
hands, of an expert, many of the dangers attributed to chloroform are 
absent, but it must be remembered that under the same conditions 
ether is also less dangerous. In unskilled hands, however, there 
can be no doubt that ether is always the safer. 

For the stimulating effects in cases of shock or hemorrhage, or 
when it is necessary to obtain a profound degree of narcosis with 
abolition of the reflexes, ether is by all means the best agent to use. 
In anemia ether is preferable to chloroform, as it has 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 
bronchitis or acute lung troubles, and, for the same reason, in 
advanced Bright's disease. In individuals over sixty years old, 
ether, as a rule, is to be avoided, as they are very likely to be afflicted 



26 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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 
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 




Fig. 3. — ^The Esmarch mask. 

forms of inhalers are used, according to the method 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 
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 



ETHER ANESTHESIA 



27 



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, the Davis, 





Fig. 4. — The Schimmelbusch mask. Fig. 5. — Chloroform dropper 

etc. These consist essentially of a metal face-piece surrounded by an 
inflatable rubber rim, an ether chamber filled with gauze, and a 
closed rubber bag into and out of which the patient breathes. They 
are also provided with suitable openings for the entrance of air.^ 
With such inhalers, the temperatijre of the ether vapor is raised by the 




Fig. 6. — The Allis inhaler. 

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. 

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



28 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



To obtain the benefit of the warm vapor without the disad- 
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 or two nasal tubes without inter- 





FiG. 7. — Towel cone. 

fering with the operation. The curved glass nasal tubes divised by 
Lumbard (Fig. 10) are admirable for this purpose. There are a number 
of inhalers suitable for the vapor method of etherization, of which 
Gwathmey's apparatus is a type. Gwathmey's vapor apparatus (Fig. 




Fig. 8. — The Clover ether inhaler. 



11), as described by him {Journal of American Medical Association j 
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 boiling 
water for three minutes, will remain warm for over one and a half hours. 



ETHER ANESTHESIA 



29 



If the heat is to be continued, this can be accomplished by simply 
taking the stoppers out, thus exposing the thermolite to the atmos- 
phere. The liquid then begins to recrystallize, and on turning to 




f 



Fig. 9. — The Bennet ether inhaler. 

a solid form gives off heat for another hour and a half. In each of 
the bottles there are three tubes, varying in length from one that 
reaches to the bottom of the bottle to one that penetrates only the 



I 




Fig. 10. — ^Lumbard's glass nasal tubes for anesthesia (Warbasse). 

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 



30 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



desired. In addition, by simply turning a small lever, without 
removing the mask, the patient receives pure air or a mixture of 
oxygen and air. By compressing the hand 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 
after use. Disregard of this precaution has been the cause of many 
of the cases of postoperative pneumonia. Metal portions of the 
inhaler should be boiled and the rubber parts soaked in a i to 20 
solution of carbolic acid after each administration. The parts are 
then dried, and fresh gauze packing is supplied for the closed inhalers 
and the open ones are covered with new gauze or canton flannel. 




Fig. II. — Gwathmey's vapor apparatus. 



Administration. — Drop Method. — The usual precautions already 
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 with the request that the patient breathe naturally and regu- 
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 reduced for the time being. In from five to six minutes the 
stage of excitement and struggling 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 minutes. By 
the drop method an even anesthesia without cyanosis is produced- 



ETHER ANESTHESIA 



31 



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

During the anesthesia the breathing must be carefully watched, 
together with the pulse and the eye reflexes. Under the stimulation 




Fig. 12. — Showing the administration of ether by the drop method. 

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 




Fig. 13. — Proper method of holding the jaw forward. 

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. 13). 
This prevents the relaxed epiglottis from being forced back by the 



32 THE ADMINISTRATION OF GENERAL ANESTHETICS 

tongue over the opening in the larynx, since, if the jaw is pushed for- 
ward, the tongue goes with it, giving a clear passage. In holding the 
jaw forward, care should be taken not to use force or bruise the 
tissues. If this maneuver does not overcome the obstruction 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 to allow the mucus and saliva to flow 
out through the corner of the mouth. Should vomiting occur, the 
inhaler must be removed and the patient's head turned to one side so 
that the vomited matter can escape; and, before the mask is reap- 
plied, 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 light in the. 
absence of the conjunctival reflex, it is a sign of overnarcosis. Other 
danger signs are a weak, thready, or irregular pulse, and marked 
pallor or cyanosis. Hiccough usually means that the patient is 
getting ready to vomit. Rolling of the eyes and repeated acts of 
swallowing are preliminaries to the patient coming out. Both 
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 wall 
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 ap- 
plied and the patient is instructed to take regular breaths, breathing 
back and forth through the bag. As soon as he becomes accus- 



ETHER ANESTHESIA 



33 



tomed to the apparatus, ether is slowly turned on during an inspira- 
tion by gradually revolving the drum of the ether chamber (Fig. 14). 
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 




Fig. 14. — Showing the administration of ether with a closed inhaler. 

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

Vapor Method. — It is preferable to start the anesthesia by some 
of the quick methods, as nitrous oxid gas followed by ether, or by 
ethyl chlorid followed by ether, and, when the patient is well under 



34 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 
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 a,pproaches 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 
sweetish taste and characteristic odor. When used for anesthetic 
purposes, it should be absolutely pure and neutral to litmus. Under 
the influence 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 blisters. For this 
reason the lips, nose, and cheeks with which it may come in contact 
during anesthesia should be well protected with vaselin. 

When inhaled, chloroform vapor has a depressant effect upon all 
the vital functions, but especially upon the circulation, lowering 
blood-pressure to a marked degree through vasomotor depression. 
Like ether, it produces. a leukocytosis. It is less of an irritant to the 
respiratory tract and more agreeable to take than ether, hence the 
primary stage of excitement is milder. Upon the kidneys, it is 
likewise less irritating. It causes slight temporary fatty changes in 
the kidneys, heart muscle, and liver (more marked upon the latter) 
which may be severe and later lead to fatal results if these organs 
are already diseased. 

Death from chloroform is usually sudden and with few premoni- 
tory signs. Vasomotor paralysis causing dilatation of the vessels 
and capillaries and fatal syncope is the primary cause, though the 
inhibitory action of the drug upon the heart itself may contribute. 



CHLOROFORM ANESTHESIA 35 

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 realized, or it is pushed too rapidly in an attempt to overcome 
the struggling. With a trained and watchful anesthetist, chloroform 
is robbed of many of its dangers, but in inexperienced hands it is a 
most dangerous drug, being estimated to be about five times more 
fatal than ether. 

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 
frequent. 

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

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 is also to 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 suffer- 
ing from 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 preferable to 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 



^6 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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, 
it 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 anes- 
thetic. 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 




Fig. 15. — Chloroform mask improvised from the corner of a towel. 

incomplete anesthesia, chloroform is contraindicated. In ophthal- 
mic operations, where the condition of the pupil cannot be ascer- 
tained, 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 are employed. For the former, a handker- 
chief, the corner of a towel (Fig. 15), or a piece of gauze will suffice, 
but a mask, such as Skinner's, Esmarch's (see Fig. 3), or Schim- 
melbusch'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 wifl be required. 

Different forms of apparatus for accurately estimating the 
strength of vapor, as Junker's (Fig. 16), Braun's, Gwathmey's (see 
Fig. 11), 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 



CHLOROFORM ANESTHESIA 



37 



and air is administered. By attaching the inflow tube to an oxygen 
cylinder, oxygen may be readily administered instead of air. 




Fig. i6. — Junker's chloroform inhaler. 

The same care should be taken as to the cleanliness of the chloro- 
form mask as would be observed with any inhaler. After each 
anesthesia the metal framework should be boiled and then recovered. 




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

« 

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- 
form 4 or 5 inches (10 to 12 cm.) from the face (Fig. 17), the patient 



38 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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 lo to 30 drops a minute, and the mask is brought nearer the 
face, being careful, however, not to touch the skin with portions of 
the mask wet with chloroform (Fig. 18). When given gradually in 
this way, the struggling is not usually prolonged or violent. The 
anesthetic should never be poured on suddenly in large quantities; 
it must always be administered well diluted with air. In the stage of 
excitement, chloroform must he given with extreme care; if the patient 
struggles, the drug should not be pushed, otherwise, when the patient 




Fig. 18. — Showing the method of administering chloroform (second step). 

holds his breath, as he will in such cases, a large quantity of the anes- 
thetic is retained in the lungs, and, when he takes a deep breath, a 
dangerous amount may be inhaled from the already oversaturated 
mask. Coughing and vomiting mean that the vapor is too strong, 
and it should be promptly 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 to free respiration from the 
tongue. When the patient is fully anesthetized, only small quan- 
tities of the anesthetic should be administered, just sufficient to keep 
him under. 

With chloroform anesthesia, we have practically the same stages 



NITROUS OXID ANESTHESIA 39 

as with ether, but they 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 light; conjunctival reflex just abolished; 
full muscular relaxation; and a good color without blueness of the 
lips or cheeks. The latter is an indication for a weaker vapor and 
more air or oxygen. With the ordinary chloroform mask, oxygen 
may be administered by simply inserting the tube leading from the 
oxygen cylinder under the edge of the mask. 

During the entire anesthesia, careful and close watch must 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 dilata- 
tion 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 33), 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 cylinders or containers, from which, when liberated, 
it escapes as a gas. It has a pleasant odor and a slightly sweetish 
taste. 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 



40 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 asphyxia. 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 
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 enormously 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 



NITROUS OXID ANESTHESIA 4I 

children, the mask and formidable appearing apparatus frequently 
cause such 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 opera- 
tions about the rectum and perineum, it is sometimes unsatisfactory, 
as the patient may stiffen up or straighten out the limbs, thus inter- 
fering with the operator. The same may be said of its use in alco- 
holics, or strong, robust, or fat individuals, though, according to 
Gwathmey, by preliminary medication with morphin alone, or with 
morphin and chloretone, 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. 19), etc. In general these consist 




Fig. 19. — The Bennett nitrous oxid gas inhaler, 

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. 

When a definite amount of oxygen is to be given, a special 
apparatus, as that of Hewitt (Fig. 20), Gwathmey (Fig. 21), Teter, 
Cunningham, or Gatch, is essential. With these inhalers any desired 
combination of nitrous oxid gas and oxygen may be obtained by 
regulating special switches, which are provided with indicators 
showing the exact strength of the vapor which the patient receives. 



42 THE ADMINISTRATION OF GENERAL ANESTHETICS 

Carbon dioxid, which is valuable as a respiratory stimulant, is 
provided by rebreathing or by connecting the apparatus with a 
tank of CO2. 

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




Fig. 20. — The Hewitt nitrous- oxid gas and oxygen inhaler. 

Administration. — In giving pure nitrous oxid, the apparatus is 
properly connected with the supply cylinder, and the rubber balloon 
is about three-fourths filled with gas. 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 applied over the mouth and nose, so 
that air cannot be drawn in around the rubber rim. The expiratory 
valve is opened and the patient is told to breathe regularly. After 
two or three breaths of air, during which the patient becomes 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 



NITROUS OXID ANESTHESIA 



43 



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 gas are soon followed by a change 
in the color of the face — it becomes dusky, and finally a deep livid 
hue. There is at first incoherent speech, but this is soon followed by 
the anesthetic snoring, rapid respiration, and 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 anesthesia cannot be continued 




Fig. 21. — Gwathmey's nitrous oxid gas and oxygen inhaler. 



beyond this point without danger of asphyxia. 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 considerably prolonged, pro- 
vided sufficient air is admitted to avoid extreme cyanosis, stertor, 
and muscular twitching, 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- 



44 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 
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 



Fig. 22. — Showing the method ot administering nitrous oxid gas. 

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 adminis- 
tering this combination. Success depends upon the ability of the 
anesthetist 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. 



NITROUS OXID AND ETHER SEQUENCE 45 

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 




Fig. 23. — The Bennett gas and ether apparatus. 

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. 23), Gwathmey's (Fig. 24), 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 



46 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



have an ether chamber containing gauze upon which the ether is 
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 
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 
a single bag is used for both gas and ether. As with all apparatus 
having mechanism likely to get out of order, the inhalers should 




Fig. 24. — Gwathmey's gas and ether apparatus. 

always be tested before using. The same inhaler should never be 
used upon a second patient without being sterilized and freshly 
packed with gauze. 

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 in- 
structed to breathe naturally. As soon as it is seen that the patient 
is breathing properly, the expiratory valve is opened and the nitrous 
oxid is turned on. After a few breaths the expiratory valve is closed 
and the patient breathes the gas back and forth, gradually going 
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 



ETHYL CHLORID ANESTHESIA 



47 



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 established, 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. 




Fig. 25. — Ethyl chlorid tube. 

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. 25), or in hermetically sealed glass tubes containing about 
1 3^ drams (5 c.c.) of the drug. The latter is best suited for the 
closed inhalers, the whole amount being emptied into the inhaler at 
once. Ethyl chlorid is decomposed by light and air, hence it should 
be kept in a dark place and in tightly stoppered tubes. Being in- 
flammable it should not be used near a flame or cautery. 

When inhaled, it is very rapidly absorbed and is quickly elimi- 
nated, anesthesia being produced in from thirty seconds to a minute 
or so, and lasting two to three minutes after the withdrawal of the 



48 



THE ADMINISTRATION OF GENERAL ANESTHETICS 




Fig. 26. — Showing the Schimmel- 
busch mask covered with gauze and oil 
silk for the administration of ethyl 
chlorid. 



anesthetic. Recovery is not quite so rapid as from 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 pleasant an anesthetic to take. It has the advantage, how- 
ever, of not producing cyanosis, and the anesthetic effects are more 

prolonged; furthermore, it may be 
administered without special ap- 
paratus. It stimulates both the 
heart and respiration, increasing 
the rate and the depth of the 
latter, but it lowers blood-pres- 
sure through dilatation of the 
peripheral vessels. 

Suitable Cases. — Ethyl chlorid 
is employed mainly for brief opera- 
tions or examinations not requir- 
ing full muscular relaxation, and as a preliminary to ether to get the 
patient under rapidly without struggling and excitement. It acts 
especially well in children on account of its rapidity of action. It 
should never be immediately followed by chloroform, as both are 
circulatory depressants. Its use is contra- 
indicated when there is any respiratory 
obstruction. 

Apparatus. — Owing to its great volatil- 
ity, ethyl chlorid is most satisfactorily 
administered by means of a closed inhaler, 
though the semiopen method may be em 
ployed, and is preferred by many as being 
safer. For the latter, one may employ an 
Esmarch or Schimmelbusch 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. 26); or an AWis inhaler 
may be used, leaving a small opening in 

the top. Any of the ordinary closed inhalers 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. 27) consists 
of a pliable rubber mouth-piece, to the top of which is fitted a metal 




Fig. 27.- 



Ware's ethyl chlorid 
inhaler. 



ANESTHETIC MIXTURES 49 

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 chamber 
which is provided with a valve and a small opening through which 
the anesthetic may be sprayed. 

Administration. — In administering ethyl chlorid by the closed 
method, the inhaler is placed over the patient's face during expira- 
tion in order to fill the bag, and, as soon as the patient is breathing 
regularly, from i to i)^ 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 pre- 
vent the entrance of air, signs of anesthesia appear in from thirty 
seconds to one minute. As soon as anesthesia is produced, the pa- 
tient should be allowed to have air. 

Full anesthesia is characterized by rapid and slightly stertorous 
breathing, dilated pupils, absence of the 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 recovers 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 
anesthesia may be obtained, though at times muscular relaxation is 
not complete and the patient is apt to remain partly conscious. 
Danger signs from ethyl chlorid anesthesia are gasping, shallow res- 
pirations, pupils widely dilated and not reacting to light, and general 
pallor of the skin. 

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



50 THE ADMINISTRATION OF GENERAL ANESTHETICS 

and avoiding the dangers of the latter. There are a large number of 
such mixtures, varying both in composition and in the relative pro- 
portion 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. 

In point of safety, mixtures occupy a place between chloroform 
and ether, the added safety over chloroform depending mainly 
upon the stimulating effect of the ether. The complications and 
dangers that may arise during the administration of these mixtures, 
however, are those met with from chloroform rather than from ether, 
and, as a general principle, mixtures should be given with as much 
caution as would be observed in the administration of the most 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 



SPECIAL METHODS OF ANESTHESIA 5 1 

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 26), 
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 ANESTHESU 

Intubation Anesthesia. — In operations about the mouth, such 
as is required, for instance, in removal of the tongue, repair of a cleft 
palate, resection of the jaw, etc., the administration of the anesthetic 
by means of tubes passed into the pharynx through the nose, known 
as 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 at frequent intervals in order to get the 
patient well under, as is the case when the ordinary interrupted form 
of anesthesia is employed. As the pharynx is packed with gauze, 
aspiration of mucus or blood from the site of operation is avoided, 
nor is there 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 
(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 



52 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



arm of which is attached by means of a third piece of rubber tubing 
a funnel lightly packed with gauze. 

Technic. — After full anesthesia has been obtained in the 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 
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. 28). Care 




Fig. 28. — Showing the method of inserting the tubes and packing the pharynx for 

intubation anesthesia. 



should be taken at this stage to listen at the ends of the tubes in order 
to make sure that the patient is breathing properly. If he is not, 
the gauze should be promptly removed and the pharynx repacked. 
As soon as regular breathing is established through the tubes, the 
funnel is connected and the anesthetic is continued by the drop 
method. 

Intratracheal Insufflation Anesthesia. — Intratracheal in- 
sufflation anesthesia, first 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 permitting the return of air 



I 



SPECIAL METHODS OF ANESTHESIA 53 

from the lungs. This method of anesthesia was originally adopted to 
supply a positive pulmonary pressure for operations upon the thora- 
cic 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 purpose it has largely replaced the various dif- 
ferential pressure chambers. 

Intratracheal insufflation is, furthermore, of special value in 
operations about the mouth, tongue, throat, jaws, and nose as the 
continuous reflux air current prevents the aspiration of blood, mucus, 
vomitus, 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 anes- 
thesia produced 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. • 

While 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 always be provided with a safety 
valve to guard against overpressure and there must be no chance of 
liquid 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- 
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 Booth- 
by's, which are elaborate in their completeness. A very simple and 
inexpensive apparatus (Fig. 29), which answers all purposes, is de- 
scribed 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 pur- 
pose 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.) 



54 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



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 interruption. The second branching of the tubes is 
introduced for the purpose of regulating the anesthesia. The ether 
bottle (E) is interpolated 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 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 




Fig. 29. — Apparatus for intratracheal insufflation anesthesia (Meltzer in Keen's 

Surgery). 

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 stop- 
cocks 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 



SPECIAL METHODS OF ANESTHESIA 



55 



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 
insufflation. 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 
(35 cm.) long, with a mark io>^ inches (27 cm.) from the distal end 




Fig. 30. — Jackson's direct view laryngoscope. 



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. 30). Elsberg has 
devised a special bit or holder to keep the tube from slipping 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 18) and is given morphin gr. }^ (0.0108 gm.) 
and atropin gr. Koo (0.00065 g^-) t>y 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. 452), 



56 THE ADMINISTRATION OF GENERAL ANESTHETICS 

the patient's mouth being held open by a mouth-gag. The Jackson 
laryngoscope is then introduced (for the technicof this see page 449), 
and, with the epiglottis pulled forward by the beak of the instru- 
ment 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 2j^^ inches (5 to 6 cm.) until the 
mark on the catheter is level with 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 slight 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 uniform, as the degree of anesthesia from a certain dose is prac- 
tically 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 con- 
dition. 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. 

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. 



SPECIAL METHODS OF ANESTHESIA 57 

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 




Fig. 3 1 . — The Trendelenburg apparatus for tracheal anesthesia. 

surrounded by a flat dried sponge fastened securely in place, which, 
when wet, swells up and acts as a tampon, preventing blood from 
descending along the side of the tube. The same result is obtained 
with the Trendelenburg instrument (Fig. 31) by surrounding the 




Fig. 32. — Showing the tracheal cannula in place. 

lower portion of the cannula with a delicate air bag, which is gently 
inflated by compressing an inflating bulb supplied with the apparatus 
as soon as the tracheotomy tube is in place (Fig. 32). 

Technic. — A preliminary tracheotomy is first performed (see 
page 447). The tracheal tube is then introduced into the opening, 



58 THE ADMINISTRATION OF GENERAL ANESTHETICS 

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 normal salt solution. Since then the method 
has been given a trial by a number of operators abroad and by a few 
in this country, but it has never become popular. 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 
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 infused and the flow was 
then stopped, the infusion 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 capacity of 3 pints (1500 c.c.) supported 
upon a stand at a height of 8 feet (240 cm.) from the floor, (2) a glass 

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



SPECIAL METHODS OF ANESTHESIA 



59 



dripping chamber with a capacity of 8 ounces (250 c.c), and (3) a 
warming chamber surrounded by a jacket containing water at a tem- 
perature of ioo°F. (38*^0.) (Fig. 33). When the apparatus is working 
the solution drips from the pipette leading from the reservoir into 
the indicator, the lower half of which is filled with solution and the 
upper half with air. A screw pinch cock 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. 34). 

Solutions. — Ether is used in a 5 per cent, 
solution in normal salt solution by Burkhardt 
and in a 7.5 per cent, solution by Rood. 
Hedonal 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 Souttar 
(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 paralde- 
hyde 2j^ per cent, and ether 3 per cent, in nor- 
mal salt solution. 

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

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

Preparations of Patient. — It is advisable to give the patient hypo- 
dermically an hour before the operation morphin gr. }^ (0.0108 gm.), 
atropin gr. 3^jloo (0.00065 gm.), and scopolamin gr. j^foo (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 



Fig. 33.— Appara- 
tus for intravenous an- 
esthesia. 



6o 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



that the infusion cannula cannot be disturbed by movements of the 
patient. 

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

Asepsis. — The solution must be absolutely sterile. The instru- 
ments are sterilized by boiling. The site for the infusion is shaved 
and the skin is sterilized by painting 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, procain solution the median cephalic or the 
median basilic vein is exposed through a small incision. The 




1 -a ^ 

Fig. 34. — 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. 



distal portion 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 170). The constriction is then 
removed Jrom the arm and the ether solution is allowed to run, at first 
fairly 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. 



SPECIAL METHODS OF ANESTHESIA 6l 

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. If a large quantity of solution has been infused, it 
is a wise precaution to have that patient's position in bed changed 
from time to time, otherwise edema of the lungs or of dependent por- 
tions of the body may develop. 

Rectal Anesthesia. — It consists in producing narcosis by means 
of warm ether vapor slowly forced into the rectum. This method 
was employed in 1847 ^Y Roux. Later, in 1884, it was taken up by 
Molliere and in this country by Weir and Bull, but it never came 
into general use. In tUe early cases colicky pains, diarrhea, bloody 
stools, and painful distention of the intestine were frequently ob- 
served. These symptoms, no doubt, were in many instances due 
to faulty methods of administering the anesthetic, and with the 
improved technic of Cunningham and others 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 dis- 
posal. Its greatest field of usefulness is in cases of extreme pulmo- 
nary or bronchial involvement and empyema, and in operations 
about the face, mouth, and larynx, where other means of anesthesia 
are unsuited. To the former class of cases it is especially suited on 
account of the -absence of pulmonary or bronchial irritation from the 
ether. While it is true that the greater part of the ether is eliminated 
from the lungs, the direct irritation of concentrated vapor is over- 
come, as is shown by the absence of the bronchial secretion, cough, 
etc. The method also has the advantage of requiring but little ether 
to induce and maintain anesthesia, and there is practically no stage 
of excitement or postoperative nausea and vomiting. On the other 
hand, the induction of narcosis is slow, and, in some cases where the 
absorptive power of the rectum is limited, sufficient 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 disten- 
tion produced, nor should it be used if the intestines are inflamed or 
their walls weakened. 

Apparatus. — A simple apparatus consists of the following: 
A wash bottle to hold the ether, about 8 inches (20 cm.) high and 4 



62 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



inches (lo cm.) in diameter, supplied with a tight stopper in which 
are two perforations. Through one of these openings a glass tube 
leads to the bottom of the bottle, and through the other a glass tube, 
cut off flush with the under surface of the stopper, leads out. A 
double cautery bulb is attached to the afferent tube by a piece of 
rubber tubing, while to the 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. The efferent 
tube is opened or closed by means of a small pinch cock. In addi- 
tion, a short rubber exhaust tube is connected to the efferent tube 
by means of a Y shaped glass tube and is likewise supplied with a 




Fig. 35. — Apparatus for rectal anesthesia. 

pinch cock. The free end of the exhaust tube is placed in a bottle 
of water in order to readily recognize the escape of gas from the 
rectum when the exhaust is opened. Both the afferent and the 
efferent tubes should be of sufficient length to permit the apparatus to 
be moved to a distance from the patient if necessary. The ether 
bottle is surrounded by a metal container holding warm water. 
This should be kept at a temperature of about 90°F. (32°C.), but not 
much above, as the ether will boil at 96°F. (ss'^C). A thermom- 
eter should be provided for the purpose of regulating the tem- 
perature. By compressing the cautery bulb air is forced into the 
ether through the long tube and leaves the apparatus saturated with 
warm ether vapor. 

More elaborate forms of apparatus have been devised, such as 



SPECIAL METHODS OF ANESTHESIA 63 

Sutton's, in which oxygen takes the place of air as a vehicle for the 
ether vapor and the degree of distention of the bowel is controlled 
by means of a manometer. 

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 exhaust tube is 
opened and the clip on the tube leading from the ether chamber is 
closed to permit the gases already present to escape, otherwise the 
absorption of the vapor is interfered with ; on complaints of disten- 
tion, the superfluous vapor must, likewise, be allowed to escape. 
The exhaust tube must also be opened when violent coughing occurs, 
otherwise the rectal tube is liable to be expelled. 

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 ability of the bowel to absorb. 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 forw^ard should be observed. 
At the completion of the anesthesia, the rectal tube is disconnected 
from the apparatus, and, by gentle abdominal massage of the colon, 
the vapor remaining unabsorbed is forced out. This should be fol- 
lowed by a cleansing enema. 



64 THE ADMINISTRATION OF GENERAL ANESTHETICS 

Oil=ether Colonic Anesthesia. — 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, 1913). This form of anesthesia has been used by its origi- 
nator in a large number of cases and is a most valuable addition to 
the field of rectal 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 contra- 
indicated in colitis, hemorrhoids, fistula in ano, or other pathological 
conditions of the lower bowel, and in most cases where ether is con- 
traindicated. 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 }yi to 
yi gr. (0.0081 to 0.0162 gm.) of morphin and }ioo S,^- (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, 
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 



ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT 65 

required for an adult of ordinary size. The tubes should be left in 
place until the patient is partially unconscious. In from five to 
twenty minutes the anesthesia is established. 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. }yioo (0.00065 gm.) and morphin, gr. J.^ to J^ 
(0.0108 to 0.0162 gm.) by hypodermic, one hour to two hours before 
operation. This combination is more efficacious than morphin alone, 
and has the effect of producing a drowsy state and even sleep, which 
may last five to six hours after the operation. It is contraindicated 
in patients with heart disease or when there is a tendency to 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 circula- 
tory 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 respira- 



66 THE ADMINISTRATION OF GENERAL ANESTHETICS 

tory centers, while the accidents from chloroform narcosis are pri- 
marily those occurring as the result of the depressing effects of the 
drug upon the circulation. Practically, however, in severe cases 
failure of the respiratory center and circulatory paralysis, if not 
coincident, precede or follow one another in such rapid sequence that 
it is often impossible to distinguish between the two or to determine 
which is the primary cause, and treatment must be directed toward 
both conditions. 

Accidents may be avoided in the great majority of cases if proper 
precautions are taken beforehand in the preparation of the patient 
and due care is observed in the administration of the anesthetic. 
These points have already been considered, but it may not be out of 
place to emphasize by repetition the most important of them. 
Never allow the patient to have food within three hours of the time 
of anesthesia. See that all foreign bodies, false teeth, plates, etc., 
which might fall into the throat and obstruct the respiratory passages 
are removed beforehand, and that tight bandages or clothing that 
might constrict the neck or chest are loosened. When relaxation 
occurs, turn the patient's head to one side to allow mucus and saliva 
to flow from the mouth, and see that the tongue does not fall back 
in the throat and act as an obstruction. The anesthetist must 
devote his entire attention to the anesthesia, taking particular care 
to watch the respirations, at the same time not forgetting to give 
due attention to the pulse, the condition 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 danger- 
ous, 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 removal of the 
cause which will be found to be some one of the following: coughing, 
struggling, locking of the jaws, awkward position of the patient, 
an improper holding of the cone, the so-called *' forge tfulness to 
breathe," falling back of the tongue and epiglottis, obstruction to- 
the air passages by blood, mucus, saliva, or foreign bodies, partial 



ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT 



67 



or complete occlusion of the nose from deformities of the bones and 
nasal growths, or from collapse and falling in of the alae 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 
to get a breath of fresh air. When the position of the patient is 




Fig. 36. — Method of holding the jaw forward. 



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, 
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 mo- 
mentary compression of the ster- 
num is frequently all that is neces- 
sary. Failing by these means, the 
jaws should be held apart and rhy- 
thmic traction exertod upon the 
tongue to excite a reflex inspiration. 
Obstruction caused by the fall- 
ing back of the tongue and epiglot- 
tis is corrected by properly holding 
the lower jaw forward (Fig. 36), or 
by traction upon the tongue by 
means of tongue forceps or a silk 

suture. An effective temporary 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. 37). In persistent cases the use of a pharyngeal breathing 




Fig. 37. — Showing the method of 
drawing the tongue and epiglottis for- 
ward. 



68 



THE ADMINISTRATION OF GENERAL ANESTHETICS 



tube is of the greatest aid in obtaining an unobstructed airway. 
This mechanical device (Fig. $S) consists essentially of a hollow rigid 
rubber or metal tube curved to conform to the shape of the base of 
the tongue through which the patient breathes when the tube is 
placed in the pharynx. 




Fig. 38.— Connell's pharyngeal breathing tube. 

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. Solid bodies may be removed by the finger or forceps. If 
this is not possible, tracheotomy (page 447) should be performed 
without hesitation. 




Fig. 



39- 



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



ready 



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



ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT 69 

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 
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. 39). This thoroughly expands the chest and pro* 
duces an inspiration. The arms are maintained in this position for 




Fig. 40. — Artificial respiration (expiration). The operator brings the patient's 
arms firmly against the chest while the assistant makes counterpressure. 

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 
upward toward the diaphragm (Fig. 40). 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 



70 THE ADMINISTRATION OF GENERAL ANESTHETICS 

as possible at the rate of normal respiration, certainly not over twenty 
times a minute. As an adjunct to the above, forcible dilatation of 
the sphincter ani may be perforrned 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 
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 69). 

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 large proportion of the deaths from chloroform anesthesia 
occur in the early stages, when only a small quantity of the anesthetic 



ACCIDENTS DURING ANESTHESIA AND THEIR TREATMENT 7 1 

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 sufTering from severe anemia or shock. But fatal syncope 
has occurred in many cases after only a few inhalations of chloroform, 
when the patient was in strong physical condition and exhibited no 
fear of the operation whatever. Such cases and those occurring after 
full anesthesia has been established can only be ascribed to the toxic 
action of the drug from sudden 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 abdomen, 
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 may be readily carried out with the 
hand placed over the precordium by elevating and depressing the 
wrist-joint at about the rate of the normal beat. In abdominal 
operations the heart may be massaged by grasping it between the 
thumb and forefinger, through the relaxed diaphragm, and alter- 
nately compressing and relaxing it twenty to forty times a minute. 
Direct cardiac massage can be practised through an incision in the 



72 THE ADMINISTRATION OF GENERAL ANESTHETICS 

fourth intercostal space and opening the pericardium. This opera- 
tion has been successfully performed in some seemingly hopeless 
cases, and is worthy of trial. 

Cardiac stimulants, such as strychnin, are of little use until the 
circulation is reestabHshed; a hypodermic of some rapid acting drug^ 
however, as adrenalin chlorid, 5 to 2oTf[ (0.30 to 1.25 c.c.) injected 
into a vein, camphorated oil, 2olTt (1-25 c.c), whisky, 20'ni (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 30TII 
(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 adrenalin in salt solution injected toward the heart (see 
page 177) 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 1.3 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 [3-^2 gr. (0.0054 gm.)] of cocain every half 
hour up to I gr. (0.065 g^O may be used in the more troublesome 
cases. If the condition becomes persistent and severe, lavage of the 
stomach (see page 547) should be carried out and repeated as often 
as necessary. In fact, it is the best means of preventing vomiting 



I 



THE AFTER-EFFECTS OF ANESTHESIA 73 

in any case, and some surgeons employ it as a routine 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- 
chitis, bronchopneumonia, and lobar pneumonia. They should be 
treated along the line^ 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 pa- 
tient should always be carefully protected against chilling, both dur- 
ing 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 pe- 
ripheral from pressure upon some nerve during the period of uncon- 
sciousness, though paralysis of central origin may take place as the 
result of cerebral embolism or hemorrhage, especially in those with 
high arterial tension and degenerative changes in the blood-vessels. 
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 



74 THE ADMINISTRATION OF GENERAL ANESTHETICS 

appear until the patient has recovered from the anesthesia develop- 
ing in from lo to 150 hours (Bevan and Favill). 

The condition is characterized by persistent vomiting, jaundice, 
sweetish breath, rapid pulse, Cheyne-Stokes respiration, in some 
cases extreme restlessness and excitability, in others delirium, 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 liver, most marked 
in the latter, and at times actual necrosis of the liver is seen. This 
condition is the result of the destructive action of chloroform upon the 
cells. The insufficiency of the liver results in the accumulation of 
toxins, and acetone, diacetic acid, and oxybutyric acid appear in the 
blood and urine as by-products. 

Bicarbonate of soda given by mouth in mild cases, and in salt 
solution by rectum, by hypodermoclysis, or intravenously in the 
severer ones, is a most valuable remedy for this condition. For 
intravenous injection ij^^ ounces (45 gm.) of bicarbonate of soda 
is dissolved in i quart (liter) of normal salt solution [salt 3 ii (8 gm.) 
to the quart (1000 c.c.) of water], and \^ pint (250 c.c.) is admin- 
istered every three or four hours until the entire amount is injected. 
Glucose is also frequently employed. It may be given in doses of 
3^ to I dram (2 to 4 gm.) to children and J-^ ounce (15 gm.) to adults 
by mouth, rectum, or intravenously. In addition, free elimination 
by the skin should be encouraged, and the bowels should be kept 
freely open. 

THE AFTER-TREATMENT OF CASES OF GENERAL 
ANESTHESIA 

Before moving a patient from the operating-table to his bed, it 
should be seen that he is well protected and properly wrapped in 
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, how- 
ever, when the patient is received, unless there is some special indi- 
cation for their use, as in shock or collapse. 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 AFTER-TREATMENT OF CASES OF GENERAL ANESTHESIA 75 

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 
by an attendant until consciousness returns, for, if left alone, he may 
choke from mucus or vomited material collecting in the tliroat, or 
attempt to sit up, remove his dressings, or in other ways do himself 
harm. DeUrious 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. 




^ri:^ 



Fig. 41. — The ether bed. 



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 
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 imtil food can be taken. 
The first food taken by mouth should be liquid in character, consist- 
ing 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 anes- 
thesia, 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 anes- 
thesia, 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, previously, com- 
pression 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. A further impetus was 
given to the development of local anesthesia by the discovery that 
in&ltration with cocain, or similar local anesthetics, into or around a 
nerve trunk in any part of its course effectually blocked the sensa- 
tion in the region suppHed 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 enlarging 
the field of local anesthesia until it can now be employed with entire 
success in a large number of major operations, as well as the usual 
minor ones. Indeed, it is safe to say that fully half the operations 
performed at the present time under general narcosis could be as 
satisfactorily carried out under local methods intelligently 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 abolished and, at the same time, 
sufficient muscular relaxation be obtained to insure the proper per- 
formance of the procedures contemplated. If these conditions can 
be satisfactorily obtained, and if the operator possess the necessary 
experience and skill in its use, then local anesthesia should be offered 
to the patient, if for no other reason, simply to avoid the well-known 
unpleasant after-effects of general narcosis, and to obtain a less dis- 

76 



LOCAL ANESTHESIA 77 

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 life 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 or drugs with 
similar anesthetic properties 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 a local anesthetic into nerve trunks 
supplying a region of operation is frequently performed for the pur- 
pose of preventing shock even where general anesthesia is employed, 
as, for example, the preliminary blocking of the sciatic nerve in hip 
amputations and the preliminary infiltration of the field of operation, 
the so-called *'anoci-association" of Crile. 

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 minimum. 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- 



78 LOCAL ANESTHESIA 

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 observes, ^'it is this tax upon the operator's attention, and the 
vigilance required to keep the inhibitory powers of the patient under 
control, and the time consumed in the anesthetizing procedure that 
will prevent cocain and the local analgesics from gaining ascendency 
in the crowded 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 
unfamiliarity with the proper technic, probably accounts for the fact 
that the wide scope of local anesthesia is not more generally taken 
advantage of at the present time. 

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

For the removal of practically all benign growths such as Kpo- 
mata, wens, cysts, benign tumors of the breast, and for the removal of 
superficial isolated glands, local anesthesia is quite sufiEcient. Whe- 
ther 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 when 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 



LOCAL ANESTHESIA 79 

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. 

Many 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 complications 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 
procedures, such as colostomy, gastrostomy, gastrotomy, simple 
drainage of the. gall-bladder and appendiceal abscess, suprapubic 
cystotomy, suture of the intestines following typhoid perforation, 
appendicostomy, and some interval operations for appendicitis, requir- 
ing 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 
pulling upon the mesentery, local anesthesia is contraindicated. 
Furthermore, 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 operation 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 



8o LOCAL ANESTHESIA 

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 stretch- 
ing of the sphincter ani is essential, and this cannot be performed 
painlessly by this m.ethod; 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 
uncompKcated 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 classes of local anesthetics are recognized: (i) Agents which 
freeze the tissues, and (2) 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: (i) Where the drug is used in such a way that the endings 
of the sensory nerves are paralyzed (terminal anesthesia) ; and (2) 



LOCAL ANESTHESIA 8 1 

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 is a combination of the terminal 
and regional methods of anesthesia. 

Drugs Employed for Local Anesthesia. — Of the many local 
anesthetics cocain was the first employed and, being the most power- 
ful of all local anesthetics, holds the most important place. In the 
early history of its development cocain was used in solutions as 
strong as lo and 15 per cent., with the result that frequently a set of 
dangerous symptoms, and in some cases death, were the sfequels. 
To avoid these untoward effects a number of drugs, as eucain B, 
tropacocain, stovain, alypin, novocain (procain), acoin, nirvanin, 
orthoform, anesthesin, subcutin, propasin, quinin and urea hydro- 
chiorid, etc., which are less toxic, but have in varying degrees the 
same action as cocain , have been introduced as substitutes. Of these 
eucain B., procain (novocain), and quinin and urea are probably 
most frequently used. 

Cocain. — 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 com- 
plete insensibihty 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 become capable of producing suppuration. A 
medium isotonic with the fluids of the body, as normal salt solution, 
is the best for dissolving the cocain. Such a solution, producing 



82 



LOCAL ANESTHESIA 



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 
glass tubes of sterilized salt and cocain according to Bodine's for- 
mula, each tube containing 2% gr. (0.18 gm.) of sodium chlorid and 
I gr. (0.065 g"^-) o^ cocain muriate. The contents of one of these 
tubes dissolved in an ounce (30 c.c.) of sterile water gives approxi- 
mately 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 (J^ 
of I per cent.) solution; for deeper infiltration, a i to 1000 (J-^o of 

1 per cent.) solution; for massive infiltration, a i to 3000 (J^-^q of i 
per cent.) solution; and for endoneural injections, 10 to 3oTTt (0.6 to 

2 c.c.) of a I to 200 (3-^ 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 1 No. 3, weak 



Cocain hydrochlorate. . . 
Morphin hydrochlorate. 

Chlorid of sodium 

Distilled sterilized water 



gr. 3 (0.2 gm.) I gr. i3^ (o.i gm.) 
gr. K (0.02 gm.) j gr. >^ (0.02 gm.) 



gr. yi (o.oi gm.) 
gr. K2 (0-005 
i I gm.) 

gr. 3 (0.2 gm.) I gr. 3 (0.2 gm.) gr. 3 (0.2 gm.) 
oz. 33^ (100 c.c.) I oz. 3^^ (100 c.c.) oz. 2>yi (100 c.c.) 



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 

^ Park, Davis & Co., and Squibbs. 



LOCAL ANESTHESIA 83 

to the Schleich formulae may be obtained from most pharmacists, 
with full directions for the preparation of a solution of any given 
strength. Schleich's solutions find favor with many operators, but 
personally the writer prefers to administer the morphin separately 
in a definite dose by hypodermic half an hour before operation. 

The addition of adrenalin chlorid to the cocain solution, as 
advocated by Braun, is of distinct advantage. Adrenalin is a vaso- 
constrictor and has the same 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 field 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 adrenalin. 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. 

The high toxicity of cocain has already been referred to. 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 % 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. 

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- 
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 3^ per cent, solution with adrenalin. 

Procain. — Procain, one of the more recent and at the present 
time the most popular substitute for cocain, was introduced in 1905 



84 



LOCAL ANESTHESIA 



under the trade-name ^'novocain." It is estimated to be one-sixth 
to one-seventh as toxic as cocain, thus permitting the use of fairly- 
large quantities without danger. It is non-irritating to the tissues 
and is not a vaso-dilator. 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 is somewhat 
slower in its action. As a local anesthetic for mucous surfaces it is 
far inferior to cocain, and has never become popular in nose and 
throat work. Solutions of this drug, like those of cocain should be 
isotonic with the body fluids and freshly prepared. 
Braun employs four novocain solutions: 



Novocain 

Normal salt solution 
Adrenalin 

i-iooo or 
Homorenon 

4 per cent. 



No. I 



sHer. (0.25 gm.) 
3H oz. (100 c.c.) 



5 drops 



No. II 



No. Ill 



No. IV 



ZH ST. (0.25 gm.) 
1% oz. (50 c.c.) 



5 drops 



iH gr. (o.i gm.) , i>'2 gr. (o.i gm.) 
2>2 dr. (10 c.c.) I i}i dr. (5 c.c.) 



S drops 



10 drops 



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

Procain is supplied in tablet form and in strengths corresponding 
to the above. 

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 las ing 
four or five days. In its early use solutions of i per cent, were em- 
ployed, 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 3^^ to J^ per cent, solutions. Upon 
mucous membranes, solutions of 10 to 20 per cent, may be used. 
It, however, 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 pre- 



LOCAL ANESTHESLA 85 

cautions should be taken as for general anesthesia (see page i8). 
Apprehensive anticipation on the part of the patient should be pre- 
vented 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 J^ to J^ 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 
}4: gr- (0.0162 gm.) combined with Jf oo gr. (0.00065 g°i-) of hyoscin 
may be administered hypodermically two hours before operation. 

The Conduction of the Operation. — The successful and satisfac- 
tory employment of local anesthesia depends upon an intelligent 
appreciation of its b'mitations, upon the experience and skill of the 
operator, and upon an accurate knowledge of the sensory nerve supply 
in any 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 
solution and leave him lying in a chilly pool for the remainder of the 
operation. 



86 LOCAL ANESTHESIA 

With very nervous individuals, it is well to keep the instruments 
covered from view and to avoid all reference to knives, scissors, etc. 
In fact, strict silence should be enjoined upon all. The patient's 
mental attitude can be further influenced to advantage by observing 
a quiet demeanor in the operating-room, by the avoidance of haste, 
and by a most careful handling of the tissues. Clean-cut dissection 
only is allowable in operations under local anesthesia. Rough 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, necessitating the use 
of a general anesthetic for completion of the operation. Rough 
wiping of the wound is likewise to be avoided. In fact, in every 
move and step the aim of the operator should be extreme gentleness. 
Neglect in observing these small and apparently trivial details is 
responsible for many of the failures with local anesthesia, and often 
results in condemnation of the method, though the fault lies with 
the operator. 

THE 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 application of salt 

and ice, or by spraying the part with 
some rapidly evaporating chemical, 
such as ether, rhigoline, or ethyl 
chlorid. The tissues as a result be- 
FiG. 42. — Ethyl chlorid spray tube, come first red and then blanched, 

and a superficial anesthesia is pro- 
duced, which persists but a few minutes. This form of anesthesia 
has a very small field of usefulness, and is only suitable for small 
incisions or punctures; even in these cases the method is open to 
the objection that the tissues become so hard that it is difficult to 
cut through them at times, and any dissection is out of the ques- 
tion. Furthermore, the thawing out process is attended with more 
or less pain. Freezing often lowers the vitahty of the tissues to 
such an extent that sloughing results; especially is this so when ap- 
plied to the tissues of poorly nourished individuals. 




THE SURFACE APPLICATION OF ANESTHETIC DRUGS 87 

Ethyl chlorid is now used almost exclusively for the purpose of 
freezing, and is both quick and effective. It is obtained in glass 
tubes with one end drawn out to a fine point and furnished with a 
spring tip (Fig. 42) or with a screw cap. The method of applica- 
tion 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 thi§ way, but a number of operations not involving the deeper 
tissues, such as the removal of polypi or small tumors, and opening 
of infections may thus be performed. 

For operations about the eye, a drop or two of a 2 to 4 per cent, 
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 liable to run down into the pharynx 
through the posterior nares and produce a very unpleasant sensa- 
tion in the throat, and, at the same time, the amount of solution 
necessary to produce anesthesia being larger, the danger of poisoning 
is greater. To increase the effectiveness of the cocain and obtain a 
bloodless field of operation, a spray of a i to 1000 adrenalin solution 
may be employed after the cocainization. 

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

The anterior urethra may be sufficiently anesthetized by filling it 
with a 0.2 per cent, cocain and adrenaHn solution, introduced by 



88 LOCAL ANESTHESIA 

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, 
procain 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 
edemati^ation 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 station- 
ary by some form of constriction applied to the part, centrally to the 
seat of injection, or by incorporating in the fluid infiltrated vaso- 
constrictor 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 solu- 
tion employed would be worthless. 

Apparatus. — For the purposes of ordinary infiltration the 60ITI 
(4 c.c.) or the 10 c.c. (2)-^ dram) sub-Q syringe is very satisfactory. 
This syringe has a soKd glass barrel and glass piston with asbestos 
packing, and can be readily sterilized, and is cheap. Several of these 
syringes should be on hand for the operation, and are to be kept filled 
in readiness, so that the infiltration may be carried on rapidly without 
waiting to recharge the same syringe. The needles should be sharp 



INFILTRATION ANESTHESIA 



89 



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 
needle, i inch (2.5 cm.) long, for skin infiltration, and a second one, 
2 to 23-^ inches (5 to 6 cm.) long, for infiltration of the deeper 
tissues. 




Fig. 43. — 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. 

For massive infiltration a large syringe or a special apparatus 
which will allow a continuous and rapid infiltration of the tissues is 
more satisfactory. The Matas infiltrator (Fig. 44) 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 




Fig. 44. — The Matas massive infiltrator. 

for the introduction of air, and one for the escape of the fluid. A 
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 



90 



LOCAL ANESTHESIA 



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 bottom and a rubber stopper fastened in the top by a clamp. 
A small glass tube connected with an inflating bulb passes through 

this stopper (Fig. 45). The reser- 
voir 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. 3-^ (0.0162 
gm.), should be given hypodermic- 
ally half an hour beforehand, unless 
contraindicated. For the skin in- 
filtration, a warm 0.2 per cent, solu- 
tion of cocain and adrenalin or a i 
per cent, procain-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 imme- 
diately below the skin surface. A few drops of solution are in- 
jected and the skin becomes blanched and raised into a wheal about 
the size of a ten-cent piece (Fig. 46). The needle is then reinserted 
into the edge 0] the wheal and more solution injected in the same 




Fig. 45. — The author's apparatus for 
massive infiltration. 



I 



INFILTRATION ANESTHESIA 



91 



manner, until the entire line of the proposed incision is one continuous 
wheal (Fig. 47). 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. 46. — 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. 

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 34 to }{ per cent, procain-adrenalin solution may 




Fig. 47. — Showing the reinsertion of the needle into the edge of the wheal. 

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 anes- 
thetic solution. Special care is taken to thoroughly infiltrate known 



92 



LOCAL ANESTHESIA 



sensitive regions, as, for instance, in the operation for inguinal hernia 
about the external ring where the main nerve trunks break up into 
their terminal filaments. In the case of an operation 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 and 



3Kitt 
%3ubcutr 




JMuscIt 



i^^^^m 




jBone 



Fig. 48. — Showing the directions in which the needle should be inserted in massive 
infiltration of deep structures. 

muscles, down to or including the periosteum, may be infiltrated in 
a mass, after the method of Matas (Fig. 48), or each structure sepa- 
rately 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- 




FiG. 49. — Showing the application of a constricting band to the finger in order to 
prolong and intensify the anesthesia. 



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



ENDO- AND PERINEURAL INFILTRATION 93 

While the infiltration method is carried out without any attempt 
to specially anesthetize nerve trunks, 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 
by means of elastic constriction applied centrally to the seat of 
infiltration (Fig. 49). In such a case, where large quantities of 
solution are used and remain in the tissues when the operation is 
completed, it is a wise precaution to loosen the constriction gradu- 
ally and intermittently, so as not to rapidly flood the system with a 
large volume of cocain solution. 

ENDO- AND PERINEURAL INFILTRATION 

The discovery that injections of cocain and similar analgesics into 
the tissues surrounding a nerve (perineural infiltration) or directly 
into it (endoneural infiltration) will effectually block the particular 
nerve and produce anesthesia in the entire area of its distribution has 
made possible many operations of magnitude, such as those for hernia, 
amputations, etc. Successful nerve blocking presupposes an 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 anesthetic 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 adrenalin to the analgesic solution. 

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

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



94 LOCAL ANESTHESIA 

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, procain 
adrenalin 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- 




\ 

Fig. 50. — 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 rendered 
anesthetic below the point of injection. 

sanguinated by elevation and an elastic constriction is applied 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 procain as they are exposed. When the injec- 
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 



ENDO- AND PERINEURAL INFILTRATION 95 

the nerve so that an entire transverse section is thoroughly blocked 
(Fig. 50). 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 suffice; 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. 51). The 
small occipital and great occipital nerves supply the posterior part 
of the scalp as far forward as the vertex. The great auricular nerve 
supplies the mastoid region, as does also the small occipital. The 
parietal portion of the scalp receives its supply from the auriculo- 
temporal and a branch of the temporomalar. The supratrochlear 
branch of the frontal nerve supplies the integument of the lower part 
of the forehead on either side of the median line. The supraorbital 
supplies the cranium over the frontal and parietal bones. Blocking 
these nerves by cross strips of infiltration at the points where they 
penetrate the muscular fascia and become subcutaneous (Fig. 52), 
or performing a thorough circumscribed infiltration around the area 
of operation, with infiltration of the periosteum, if necessary, renders 
many cases amenable to local measures which are now performed 
under general narcosis. Constriction by means of a rubber tourm*- 



96 



LOCAL ANESTHESIA 



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 
of the lower lip of the same side (see Fig. 52). In like manner the 
upper lip may be anesthetized by blocking the infraorbital nerves. 




Fig. 51. Fig. 52. 

Fig. 51. — The superficial nerves 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. 52. — Showing the area of anesthesia after blocking the supratrochlear, supra- 
orbital, and mental nerves. The dots indicate the points for infiltration. 



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 half an inch (i cm.) above the upper surface 
of the last molar tooth (Fig. 53). The lower jaw may be thus anes- 
thetized and teeth may be painlessly extracted. The lingua] nerve 
may be perineurally infiltrated at about the same point, as it lies 
close to the inferior dental. The floor of the mouth and the tongue 
are thus rendered insensitive, and quite extensive operations may 



ENDO- AND PERINEURAL INFILTRATION 



97 



be performed. Infiltration alone, however, is often sufficient 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 
jaws after cocainization of the second division of the fifth nerve. 
More recently Braun and others have reported extensive operations 




Fig. 53. — Showing the method of blocking the inferior dental nerve. 

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 228). 

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 
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- 



98 



LOCAL ANESTHESIA 



mastoid muscle at or about its middle will be of great aid (Fig. 55), 
Operations upon the larynx may be performed under infiltration 
anesthesia combined with blocking of the superior laryngeal nerve 
at the tip of the greater cornu of the hyoid bone. 

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 




Fig. 54. Fig. 55. 

Fig. 54. — The superficial cervical plexus. The dotted lines indicate the course 
of the sternomastoid muscle. 

Fig. 55. — Showing the area of anesthesia after blocking the superficial cervical 
plexus. The dots indicate the points for infiltration. 

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 
then commenced and is continued as the needle is carried inward 
and toward the median line well into the subcostal angle for a distance 
of 3-^ to 1-^ an inch (6 to 12 mm.). As many of the other inter- 



ENDO- AND PERINEURAL INFILTRATION .99 

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. 56) and blocking each branch sepa- 
rately by direct injection with a 0.5 per cent, solution of cocain or a 
2 per cent, solution of procain, 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 




Fig. 56. — 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. 

nserted just outside this point immediately above the clavicle in 
an oblique 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 3^ inches (3 cm.) the needle should reach 
the nerve trunks. Paresthesia throughout the arm and motor phe- 
nomena indicate when this has been accomplished.^ If the needle 
strikes the first rib it has been introduced too far. Kulenkampff in- 
jects 2 3-2 drams (10 c.c.) of a 2 per cent, solution of novocain (pro- 
cain) and adrenalin. In 10 to 30 minutes all sensation in the area 
below the point of injection is destroyed, and amputations or other 

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 in- 
jection and not to anesthetize both sides at the same time. 



100 



LOCAL ANESTHESLV 



operations may be performed at any level below the seat of injection. 
In shoulder-girdle amputations, however, infiltration of the lines of 
incision also should be performed in order to block small branches 
from the cervical plexus, i.e,, the supraacromial and suprascapular 
nerves. 

Operations upon the 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 
portion of the arm, or by separately exposing and blocking each nerve 
just above the elbow. In following the latter method, the median 






Fig. 57. Fig. 58. 

Fig. 57. — Exposure of the musculospiral and median nerves at the elbow. I, 
Musculospiral nerve; 2, median nerve. 

Fig. 58. — Exposure of the ulnar nerve just above the internal condyle. 

nerve is exposed by an incision across the elbow to the inner side of 
the biceps muscle, the brachial artery lying just external to it; the 
ulnar, in the groove between the internal condyle and the olecranon; 
and the 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 procain 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 
nerves. A circular area of subcutaneous infiltration at the elbow, 
however, as advised by Matas, abolishes any remaining sensibility 
in this region (Fig. 59). 



ENDO- AND PERINEURAL INFILTRATION 



lOI 



Just above the wrist, the median, ulnar, and radial nerves are 
available for perineural injection. The median is reached by intro- 
ducing the needle to the ulnar side of the tendon of the palmaris 
llongus and inserting it obliquely for a distance of '^i to % inch 
i^i to 2 cm.) in the direction of the radius. The ulnar nerve may be 




Fig. 59. — Showing the method of anesthetizing the small superficial nerves by cir- 
cular strips of subcutaneous infiltration. 

anesthetized perineurally a little above the head of the ulna by insert- 
ing the needle to a depth of about % 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- 




FiG. 60. — 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, Interosseous nerve; 2, radial nerve; 3, radial artery; 4, median nerve; 5, ulnar nerve; 
6, areas of skin infiltration; 7, flexor carpi ulnaris tendon; 8 palmaris longus tendon; 
9, flexor carpi radialis tendon. 

tion just above the styloid process of the radius (Fig. 60). Perineural 
injection alone for operations upon the wrist is not satisfactory, as 
[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. 59). 



I02 



LOCAL ANESTHESIA 



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. 6i). 




Fig. 6i. — Points for inserting the needle in perineural infiltration of the digital nerves. 

Through these points the needle is inserted toward each of the four 
digital nerves, and the anesthetic solution injected (Fig. 62). All 
nerve communication is thus blocked and the finger may be incised, 
amputated, etc., without pain. By injecting in the known location 




Fig. 62. — Cross-section of the finger showing the direction of the needle for peri- 
neural infiltration of the digital nerves. (After Braun.) i, Extensor tendons; 2, bone; 
3, flexor tendons; 4, areas of skin infiltration. 

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 



ENDO- AND PERINEURAL INFILTRATION IO3 

they are exposed. The skin, the subcutaneous tissues, the fascia?, 
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 % in. (3.5 cm.) from the 
median line on a level with the lower border of the rib and is inserted 
for a distance of i % 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 3-:^ to J^ in. 
(6 to 12 mm.) 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 79). 

Hernia. — While operations for hernia of any variety may be 
carried out under local anesthesia, the inguinal will be found esp>e- 
•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 
ilioinguinal, 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 ihohypogastric, 
running downward in the long axis of the hernia (Fig. 63). 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 genito- 
crural will be found after reflecting the aponeurosis of the external 
oblique lying among the structures of the cord, and frequently it 
lies behind the cord. Infiltration anesthesia is employed until the 
aponeurosis of the external obKque is reflected, when the above nerves 



I04 



LOCAL ANESTHESIA 



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 painlessly 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. 

Femoral hernia may be operated on under simple infiltration of 
the skin, subcutaneous tissues, and sac; or, preferably, by a combi- 




FiG. 63. — Showing the nerve supply of the inguinal region. (After Gushing.) 
1, Iliohypogastric nerve; 2, ilioinguinal nerve; 3, conjoined tendon; 4, cremaster 
muscle; 5, aponeurosis of the external oblique incised and edges reflected. 

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 oblique 
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 
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. 



ENDO- AND PERINEURAL INFILTRATION 



lOS 



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 




Fig. 64. — Showing the method of infiltrating about the cord in operations upon the 

testicle. 

escapes from the external ring (Fig. 64), combined with infiltration 
along the site of incision. 

Penis and Urethra. — Circumcision may be performed by infiltrat- 
ing the skin and mucous membranes along the lines of proposed 



1 




Fig. 65. — Points for injection in infiltration about the anus. 

incision, being careful to infiltrate the frenum thoroughly. More ex- 
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- 



io6 



LOCAL ANESTHESIA 



nal urethrotomy may be performed under infiltration combined 
with topical anesthesia of the mucous membrane (see page 87). 

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. 65) — 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 




Fig. 66. — Exposure of the anterior crural and external cutaneous nerves for injec- 
tion. I, Anterior crural nerve; 2, external cutaneous nerve; 3, femoral artery; 4, femo- 
ral vein. 



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. 66), or it may be blocked by a perineural injec- 
tion, the needle being inserted just to the inner side of the anterior 



ENDO- AND PERINEURAL INFILTRATION 



107 



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 ex- 
posed by an incision placed about J^ 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 peri- 
neural injection by inserting the needle at a point where a horizon- 
tal 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 required. It is introduced directly 
backward until bone is reached and is then withdrawn for a distance 
of 3^^5 inch (i mm.). After injection of the anesthetic solution about 




Fig. 67. — 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. 



J-^ an hour is required for complete anesthesia. The sciatic may also 
be blocked after exposure under infiltration anesthesia at the lower 
border of the gluteus maximus muscle, or at the upper border of the 
popliteal 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 
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 
the outer edge of the biceps muscle (Fig. 67). In the upper portion 
of the popliteal space the nerve may be exposed by a vertical incision 
in the mid-line; it will be found lying between the biceps and semi- 
membranosus muscles. It should be injected before it divides, or 
€lse both the internal and external popliteal nerves are to be blocked. 



io8 



LOCAL ANESTHESIA 



In operations below the tubercle of the tibia, it is unnecessary to block 
the anterior crural and external cutaneous; blocking the sciatic in 
the popliteal space and the external saphenous as it passes to the 
inner and posterior aspect of the knee-joint is sufficient (Fig. 68). 




Fig. 68. — Exposure of the internal saphenous nerve for injection, i, Internal saphe 
nous nerve; 2, internal saphenous vein. 

Below the knee, the large nerves are not available for injection 
until the ankle is reached. Behind the ankle the posterior tibial may 
be perineurally injected by inserting the needle on the inner side of 




Fig. 69. — 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 nerve; 5, anterior tibial nerve; 6, tendo achillis; 7, peronei muscles; 
8, flexor longus hallucis; 9, extensor longus digitorum; 10, extensor longus hallucis; 

II, tibialis anticus; 12, tibialis posticus; 13, flexor longus digitorum. 

the tendo achillis directly forward almost to the posterior surface of 
the tibia (Fig. 69). The anterior tibial may be likewise perineurally 
injected by inserting the needle on the dorsum of the ankle between 



ENDO- AND PERINEURAL INFILTRATION 



109 



the tendons of the tibialis anticus and the extensor longus hallucis 
and the innermost tendon of the extensor longus digitorum. By a 
circular strip of subcutaneous infiltration, the remainder of the 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. 70. — 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. 70), thus cutting off all sensory communication with the 
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. 



no • LOCAL ANESTHESLA. 

BIER'S VENOUS ANESTHESIA 

The idea of using the blood vessels for the purpose of diffusing 
local anesthetics through the tissues for surgical operations orginated 
with Bier, who described the method before the 37th German Sur- 
gical Congress in 1908. Previous to this the first record of the in- 
jection of local anesthetics into the circulation was in 1886, soon 
after the introduction of cocain, when Alms injected cocaine experi- 
mentally into the iliac artery of a frog and obtained complete 
anesthesia of the lower limb. Venous anesthesia consists essentially 
in rendering the limb bloodless and, after isolating the field of opera- 
tion from the circulation by means of tourinquets 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." 

While venous anesthesia is suitable for any operation upon an 
extremity which will permit of ischemia of the limb, 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 opera- 
tions upon bones, muscles, tendons, etc. It is especially indicated 
in cases with heart and lung complications which are poor risks for 
general anesthesia; and for cases of severe traumatism of the limbs 
with the patient deeply shocked it is invaluable. According to its 
originator, diabetic and senile gangrene and arteriosclerosis are con- 
traindications to its use. 

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- 
trating the site of operation, a gJass graduate for the vein solution, 
and three rubber bandages, each 23^^ inches (6 cm.) wide and 6 
feet (180 cm.) long (Fig. 71), will be required. 

Bier's cannulas are Ke iiich (1.5 mm.) in diameter for children and 
M4 to H2 iiich (1.75 to 2 mm.) in diameter for adults. The distal 
end of the cannula is provided with grooves into which fit the liga- 
tures with which it is tied in the vein, and at the other end there is 



bier's venous anesthesia 



III 



a stopcock and a bayonet connection (Fig. 72). 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. 

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 




Fig. 71. — Apparatus for venous anesthesia, i, Rubber tourniquets; 2, medicine 
glass; 3, glass graduate; 4, large glass syringe and Bier's cannula; 5, ampule of anes- 
thetic; 6, syringe for preliminary infiltration of the skin at the site of operation. 

curved needles with a cutting-edge, No. 2 plain catgut, and a few 
artery clamps (Fig. 73). 

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

Quantity Used. — From 5 drams to 2 ounces (20 to 60 c.c.) of 
solution are ordinarily injected, depending upon the extent of the area 




Fig. 72. — Enlarged view of Bier's cannula for venous anesthesia. 



to be injected. The quantity employed should not, however, 
exceed 2% ounces (80 c.c). 

Site of Injection. — The vein selected for the injection should 
preferably be one of the larger main subcutaneous veins which follow 
a definite course, rather than a tributary. Likewise veins imbedded 
in scar tissue are to be avoided. For the arm, the basilic vein and 
for the leg the internal saphenous vein is usually chosen. 



112 



LOCAL ANESTHESLA. 



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

Technic. — Before rendering the limb bloodless, it is well to make 
a small scratch with a scalpel in the skin over the vein in order to 
mark its site, as it is sometimes a difficult matter to recognize an 
empty vein in bloodless tissues. The limb is then elevated and ren- 
dered ischemic by the application of an Esmarch bandage applied 
from the extremity of 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 



h 




I n. ^ -^ s 7 * 

Fig. 73. — 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. 

is then applied at the upper limit of the bandage used to exsanguinate 
the part by wrapping a soft rubber bandage about the limb in 
broad bands so as not to cause the patient any unnecessary discom- 
fort, and the first bandage 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. 74). 
The appearance of the limb after the removal of the expulsion 
bandage is important. Mottling or cyanosis of the skin indicates 
that the veins have not been completely emptied, whereas, if the 
expulsion bandage has been properly applied, the skin will appear 
perfectly white and there will be a segment of the limb lying between 
the two bandages in which the vessels are entirely empty of blood. 



BIER S VENOUS ANESTHESIA 



"3 



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 forearm or leg. Under infiltration anesthesia with 
a 0.2 per cent, solution of cocain or a i per cent, solution of procain, 
one of the main subcutaneous veins, 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 off, 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 considerable 
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. 




Fig. 74. — Bier's venous anesthesia. Showing the application of the bandages and 

the site of injection +. 

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- 
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 necessary that the operation, 
including hemostasis and suturing, be completed before the bandages 
are removed. If difficulty is experienced in recognizing cut vessels, 
saline may be injected into the cannula and it will spurt from the open 

^ 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. 



114 ■ LOCAL ANESTHESIA 

ends. The danger of poisoning from absorption of the drug em- 
ployed for anesthesia may be disregarded. This apparent danger 
was formerly guarded against by washing out the veins with saline at 
the end of the operation. This precaution is now regarded as unnec- 
essary, 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 CO.) of a 0.5 per cent, solution of novocain (procain) in normal 
salt solution, colored with a few drops of concentrated methylene 
blue solution so that the operator may note the penetration of the 
tissues by the anesthetic, are slowly injected by means of a fine 
needle inserted obliquely into the vessel between Esmarch bandages 
in a manner very similar to the method of Bier. 

Ransohofif {Annals of Surgery, April, 19 10) 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 



SPINAL ANESTHESIA I15 

through the capillary walls into the surrounding tissues so that little, 
if any, solution is returned to the general circulation. 

It has not been shown that arterial anesthesia possesses any ad- 
vantages over venous anesthesia, and the arterial method is far more 
difficult to carry out and on account of the deep situation of the vessels 
which have to be exposed for the purpose of making the infection. 

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. — ^AU 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 4oTri (0.6 to 2.5 c.c.) of such a solution, 
containing between 3^ and i gr. (0.01296 and 0.065 g^O ^^ cocain, 
are injected. The addition of a few drops of a i to 1000 solution of 



Il6 LOCAL ANESTHESLA. 

adrenalin chlorid to the cocain is said to be of great benefit, prevent- 
ing the rapid diffusion of the anesthetic, and many of the unpleasant 
after-effects. 

S to vain is less toxic than cocain and is very highly recommended 
by many authorities. A 5 per cent, solution is used, the dose being 
?i to I gr. (0.0486 to 0.065 g^-)- 

Procain (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 ^"i to 
iM 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 3^^ to 
I gr. (0.0324 to 0.065 g^-) ill ^ 5 P^r 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 
solution lighter or more diffusible alcohol is added. Babcock (/. A. 
M. A., Oct. II, 1913) gives the following formulae for light solutions: 







(Approximately) 


A. Stovain, 


0.08 gm. 


iMgr. 


Lactic acid, 


0.04 c.c. 


%gr._ 


Absolute alcohol, 


0.2 c.c. 


3 minims 


Distilled water, 


1.8 c.c. 


30 minims 


B. Tropacocain, 


0.1 gm. 


iKgr. 


Absolute alcohol, 


0.2 c.c. 


3 minims 


Distilled water, 


1.8 c.c. 


30 minim? 


C. Novocain (procain). 


0. 16 gm. 


2K gr. 


Absolute alcohol, 


0.2 c.c. 


3 minims 


Distilled water, 


1.8 c.c. 


30 minims 



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 



I 



SPINAL ANESTHESIA 



117 



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

Apparatus. — A special stylet needle and an appropriate syringe 
with a capacity of about i J^ drams (5 c.c.) should be provided. The 
needle should be of platinum or nickel, ^^^5 inch (i mm.) in diameter,' 
and about 3% 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 




Fig. 75. — 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. 

[transversely it is ground the better. With a short-pointed needle 
the liabihty of injecting only a portion of the solution into the canal 
land part outside the subarachnoid space is quite remote. In addi- 
tion, a scalpel for making the preliminary puncture and sterilized 
; medicine glasses for holding the solution to be injected should be 
provided (Fig. 75). 

Location of the Puncture. — Any of the spaces between the second 
j lumbar and the first sacral vertebra is available for the puncture, but 
fthe usual site is between the third and fourth, or the fourth and 
fifth lumbar vertebra (Fig. 76). The spaces may be identified by 
counting down from the seventh cervical vertebra. If this is difficult 
ron account of excess of fat, the fourth lumbar spinous process may be 
[Teadily located, and from it the other vertebrae, by passing a line 



ii8 



LOCAL ANESTHESLA. 



between the highest points of the iliac crests. Such a line passes 
through the tip of the spinous process of the fourth lumbar vertebra 
(Fig. 77). Puncture in the mid-line is generally practised, as it 




Fig. 76. — Points for injecting the anesthetic solution in spinal anesthesia. 

insures the solution being more evenly distributed on both sides of 
the cord and lessens the chance of a one-sided analgesia. A point 
between the two spines in the mid-line is chosen, and starting from 




Fig. 77. — Showing the method of locating the fourth spinous process by passing a 
line through the highest points of the iliac crests. 

this point the needle is passed slightly upward and forward between 
the spinous processes. The average space available for the puncture 
between the bones in the lumbar portion of the cord is i%5 to % 



SPINAL ANESTHESIA 



119 



inch (18 to 20 mm.) in the transverse, and % to % inch (10 to 
15 mm.) in the vertical diameter. 

Preparation of the Patient. — This should be the same as for an 
operation under general anesthesia (see page 18). If the operation 




Fig. 78. — Sitting position for spinal puncture. 



is to be a prolonged one, morphin gr. 3^ (0.0162 gm.) should be 
given hypodermically half an hour beforehand. 

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 




Fig. 79. — Lateral position for spinal puncture. 

back to the operator (Fig. 78), or else lies upon one side with the 
back in the form of an arch (Fig. 79). 

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 



I20 



LOCAL ANESTHESIA 



hands and site of operation should be prepared with all the care that 
would be observed in any operation. 

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. 80), 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. 81) . Lessened resist- 
ance, followed by the escape of the fluid from the needle, determines 





Fig. 80. — Spinal anesthesia. First 
step, nicking the skin at the site of 
puncture. 



Fig. 81. — Spinal anesthesia. Second 
step, inserting the needle. 



when this is accomplished. The distance necessary to be traversed 
varies from i to iK inches (2.5 to 4 cm.) in a child, 2 3-^ to 3 inches 
(6 to 7.5) 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. 
83). This will vary from 10 to 40IU (0.6 to 2.5 c.c), according to 



SPINAL ANESTHESIA 



121 



the strength of the solution to be used. As soon as the desired 
quantity of cerebrospinal fluid has escaped, the flow is stopped by- 
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 withdrawn 
and reinject the solution thus formed. 
The solution should always be slowly intro- 
duced (Fig. 84). The needle is then with- 
drawn and the puncture sealed with collo- 
dion and cotton, or is 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 Ught 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 




Fig. 82. — Showing the 
direction of the needle in 
entering the spinal canal. 




Fig. 83. — Spinal anesthesia. Third 
step, allowing the cerebrospinal fluid 
to escape. 




Fig. 84. — Spinal anesthesia. Fourth 
step, injecting the anesthetic solution. 



their conductivity, and in from ten to fifteen minutes loss of sensa- 
tion, often accompanied by muscular paralysis, takes place. The 



122 LOCAL ANESTHESIA 

anesthesia becomes marked first in the anal and perineal regions, and 
then in the lower extremities, being limited above, as a rule, to a zone 
not higher than the waist line. With a successful injection, any op- 
eration 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 OR EPIDURAL 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 ob- 
stetrics for the purpose of obtaining painless deliveries, but it never 
came into general use. More recently sacral anesthesia has been 
revived and the technic improved by La wen 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. 

The injection into the sacral canal of normal salt solution alone 
or in combination with drugs has also been employed extensively as a 
therapeutic measure for eneuresis and pelvic neuralgias and neuroses. 

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 % 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 vertebrae, 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 sacraHs, is thus formed through 
which a needle may be readily passed into the sacral canal. The 
lower margins of this opening are prolonged downward as two tuber- 
cles, the sacral cornua (Fig. 85). 



SPINAL ANESTHESIA 



123 



The sacral canal contains the lower end of the cauda equina, the 
filum terminale, and the spinal dura. The latter extends to the level 
of the second sacral vertebra or to within 23^^ inches (6 cm.) of the 
hiatus (Fig. 86). 

Instruments. — The instruments required are the same as for 
spinal anesthesia (page 117), except a larger syringe — one with a 
capacity of about 5 drams (20 c.c.) — will be found preferable. 

Solutions Used. — Cocain, procain, and quinin and urea have all 
been used for sacral anesthesia, but procain is the drug generally 
employed. It is claimed that the addition of sodium bicarbonate to 



Sacral carta/ 





Socrol N. 



Coccygeal N. 



F'llum terrti'na/» 



Fig. 85. — The posterior sur- 
face of the sacrum, showing the 
hiatus sacralis. 



Fig. 86. — Showing the interior of 
the sacral canal. 



the procain solution adds to the anesthetic effect. The solution is 
made up as follows: 



Sodium bicarb., puriss., 
Sodium chlorid, 
Procain, 



0.25 gm. (3^ gr.) 
0.5 gm. (8gr.) 
I gm. (is gr.) 



This is dissolved in 100 c.c. (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 
procain used at a dose is from 0.4 to 0.6 gm. (6 to 9 gr.). 

Preparation of Patient. — The patient is given by hypodermic half 
an hour before the operation morphin gr. J^ (0.0108 gm.) and atro- 
pin gr. 3^^oo (0.00065 gm.). To this may be added scopolamin 



124 



LOCAL ANESTHESIA 



gr. Moo (0.00065 gm.), if the operation is especially difficult or 

prolonged. . , ^. 

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

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. 

Technic. — The point of proposed 
puncture is located and the skin is in- 
filtrated with a 0.2 per cent, solution 
of cocain or a i per cent, solution of 
procain. 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. 87). 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 dis- 
tance of about an inch (2.5 cm.). If 
the needle is in the canal its point may 
be freely moved about, and, upon mak- 
ing 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. 

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, 
of 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 
injected very slowly, and, when the desired quantity has been intro- 
duced, the needle is removed and the point of puncture is sealed witli 




Fig. 87. — Direction taken by 
the needle in entering the sacral 
canal. 



PARASACRAL ANESTHESIA 



125 



collodion and cotton. The patient is then brought into p>osition for 
operation, and in from 3 to 5 minutes the anesthesia is complete. 

PARASACRAL ANESTHESIA 

Another method of securing anesthesia for operations in the 
region of the perineum is the parasacral blocking of the sacral nerves 
as they emerge from the sacral foramina. When properly per- 
formed, paralysis of the sphincter ani is produced, and the prostatic 
urethra and the bladder are anesthetized. The anesthesia is thus 
sufficient for vaginal, prostatic, and rectal operations, but does not 
extend sufficiently high for operations involving the uterus and 
adnexa. The anesthesia is more certain than that following an 
epidural sacral injection and is without after effects. 

Anatomy. — Examination of the anterior surface of the sacrum 
shows that the distance between the adjoining sacral foramina from 
the 5th t» the 2nd measures ^^ of an inch (2 cm.) and between the 
2nd and ist one inch (2.5 cm.), and that a straight line between the 
5th and ist sacral foramina will pass directly over the intervening 
foramina. Such a line starts at the lower free margin of the sacrum 
% of an inch (2 cm.) from the median line and diverges slightly, 
about }i of an inch (0.3 cm.), as it passes up to the ist sacral foramen. 

Viewed laterally, the anterior surface of the sacrum is practically 
flat between the 5th and 2nd sacral foramina, but from the 2nd to the 
ist it is curved anteriority. 

The sacral foramina may thus be readily reached by a needle and 
the nerves blocked as high as the 2nd sacral by passing a needle 
upward in a straight line with a slight outward divergence from a 
point % of an inch (2 cm.) from the median line on the lower edge of 
the sacrum. The needle cannot be advanced further without strik- 
ing bone, owing to the forward curve of the sacrum, and to reach the 
ist sacral foramen and nerve, the point of the needle must first be 
elevated about half an inch (i cm.) and then inserted along the same 
line as before an inch (2.5 cm.) further. 

Instruments. — ^A syringe with a capacity of 5 drams (20 c.c), a 
fairly fine needle 5 inches (12 cm.) long, and a glass graduate with a 
capacity of 3 ounces (100 c.c.) will be required. 

Solution. — A I per cent, procain-adrenalin solution in normal 
salt solution is employed. 

Quantity. — For blocking the nerves on both sides about 3 ounces 
(100 c.c.) of solution will be required. 



126 



LOCAL ANESTHESIA 



Preparation of the Patient. — The patient's rectum should be 
empty. Half an hour before the operation the patient is given mor- 
phine gr. H (0.0108 gm.) and atropin gr. Koo (0.00065 gin.) 
hypodermically. 

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

Site of Puncture. — The needle is inserted into the tissues at a, 
point ^i of an inch (2 cm.) from the median line on the right and 
left of the sacro-coccygeal articulation. 

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

Technic. — If a fairly fine needle is employed, preliminary anes- 
thesia of the skin at the point of proposed puncture may be dis- 
pensed with. Braun's technic for block- 
ing the nerves is as follows : Th« needle is 
inserted on a level with the sacro-coccy- 
geal point % of an inch (2 cm.) from the 
median line parallel to the anterior sur- 
face of the sacrum. The lower edge of 
the sacrum is sought for, and from this 
point the needle is passed 2j''2 to 3 inches 
(6 to 7 cm.) along the inner surface of the 
sacrum on a line diverging slightly from 
the midline until bone is reached. This 
will be at the 2nd sacral foramen. Five 
drams (20 c.c.) of the anesthetic solution 
is injected as the needle is withdrawn 
from the 2nd to the 5th sacral foramina. With the needle withdrawn 
to the lower edge of the sacrum its direction is changed by elevat- 
ing its point toward the innominate line, and it is again inserted 
nearly parallel to the mid-line to a depth of 3^^ to 4 inches (9 ta 
10 cm.) from the edge of the sacrum, when it should strike bone at 
the ist sacral foramen. Here 5 drams (20 c.c.) more solution is in- 
jected. Finally i}.i drams (5 c.c.) of the solution is injected be- 
tween the rectum and coccyx. The same procedure is carried out 
on the opposite side. 

^ If the rectum is empty and the needle is kept in close contact 
with the sacrum while it is being inserted, there is little danger of 
injuring the bowel, but, as a precaution, the index finger may be 
inserted into the rectum as a guide. 




Fig. 88.— Method of in- 
serting the needle for para- 
sacral anesthesia (Warbasse). 



CHAPTER III 
SPHYGMOMANOMETRY 

Sphygmomanometry is the instmmental 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 20) 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 estimated 
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, 
connected with a manometer and inflating bulb. The amount of 
pressure 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 
pressure is of most importance, as pathological conditions affect it 

more than the diastolic. 

127 



128 SPHYGMOMANOMETRY 

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

For children up to two years, 75-9° 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 important, the narrow bands giving a higher reading than the 
broad ones. Furthermore, as the estimation of pressure depends on 
the tactile sense of the individual palpating the pulse, the pressure 
readings in the same patient will vary somewhat with different 
observers. Therefore, to avoid these sources of error and obtain 



SPHYGMOMANOMETRY 



129 



readings of value for comparison, the determination of pressure 
should always be made by the same observer, under the same con- 
ditions, 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. 89. — The Riva-Rocci Sphygmomanometer. 

The Riva-Rocci sphygmomanometer (Fig. 89), 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 4J2 
inches (11. 5 cm.) wide by 16 inches (40 cm.) long, covered with can- 
vas, and supplied 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 
suppHed with a pinchcock, for the purpose of releasing the pressure. 

Stanton's instrument (Fig. 90) consists of a rubber compression 
armlet 4H inches (11.5 cm.) wide by 16 inches (40 cm.) long, in- 
9 



I30 



SPH YGMOMANOME TRY 




Fig. 90. — Stanton's Sphygmomanometer. 




Fig. 9i.--Janeway's Sphygmomanometer. 



SPH YGMOMANOMETRY 1 3 1 

closed in a cuff of leather or thick canvas reinforced by tin strips. 
In the center of the cuff is cemented a glass tube \i 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 "B " 
for the gradual release of pressure, and on the arm connected with the 
inflating apparatus is a stopcock "A" to shut off the inflation. 

^ Janeway's instrument (Fig. 91) 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 




Fig. 92. — Rogers' Sphygmomanometer. 

inflation. The armlet is a closed rubber bag measuring 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 slid 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 'X." 

Rogers' Sphygmomanometer (Fig. 92) 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. 
The dial registers from o to 260 mm. of mercury. Upon the tube 



132 



SPHYGMOMANOMETRY 



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% to 
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. 

Stafitm's Instrument. — ^The armlet is buckled in place and is 
connected with the manometer, the scale of which is adjusted so that 
the mercury registers zero. With the valve "B " closed and cock "A" 
open, and with the fingers of the operator on the patient's pulse, the 
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 systolic 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 diastolic pressure, which is 
normally 25 to 40 mm. below the systolic pressure. 

Janeway's Instrument.— The armlet is properly secured about the 
limb as described above and the scale is so adjusted that the level of 



SPHYGMOMANOMETRY 



133 



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 described. The diastolic pressure is ob- 
tained in the same manner as described under the technic with the 
Stanton sphygmomanometer. 




Fig. 93. — 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 reappears. 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. 



SPHYGMOMANOMETRY 

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 appHed and the pulse obliterated m the usual 
way The operator then places a stethoscope over the brachial 
artery below the cuff and Ustens for the reappearance of the first 
sound (Fig. 94). The height of the column of mercury when this 
occurs represents the systolic pressure. K the armlet be further 
deflated there will stiU be heaxd murmurs which rapidly disappear 
when the mercury drops 30 to 45 mm. below the systoHc reading. 
The point at which all sounds disappear represents the diastolic 
pressure. 




Fig. 94. — 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.— Pam 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. 

Wasting diseases, or cachetic conditions, as cancer, tuberculosis, 
etc., are as a rule accom.panied by low pressure. In tuberculosis, if 



SPHYGMOMANOMETRY I35 

the pressure is normal or increased, it is looked upon as a good prog- 
nostic sign. 

In injections 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 
nephritis, 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 tlie 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 
perforation. 

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



1^6 SPHYGMOMANOMETRY 

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 impractic- 
able and dangerous for the purpose of introduction into the human 
circulation, and that direct transfusion from artery to vein or vein to 
vein only was permissible. Furthermore, it was contended by many 

^37 



138 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

that transfusion was a failure outside of increasing the volume of fluid 
• in the circulation, as the blood elements did not retain their vitality, 
and quickly died in the vessels of the receiver. Added to this, the 
uncertainty of blood-vessel 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 fifteen years, largely through the work of Carrel, 
Crile, and others in this country, transfusion was revived, and 
with the development of improved methods of blood-vessel anasto- 
mosis it became a practical operation, the value of which in cer- 
tain cases even outside of hemorrhage and shock is well established, 
both experimentally and clinically. More recently still attention has 
been again focused upon indirect transfusion through improvements 
in the syringe cannula method by Lindeman, Unger, and others, 
and the use of paraffin coated tubes. Success with these methods, 
however, depends upon the ability of the operator to transfer the 
blood from the donor to the recipient before coagulation takes place. 
A further step in simplifying indirect transfusion was the addition to 
the blood of sodium citrate, which prevents coagulation and at the 
same time does not alter the normal properties of the blood. The 
development of this method was largely the work of Weil and Lewis- 
ohn, and at the present time, owing to its simplicity, transfusion of 
citrated blood enjoys the widest popularity and is the method of 
choice. 

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 hemophilia, hemorrhage 
of the new born, 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, 
though more than one transfusion may be required before permanent 
improvement is noted. 

For shock, transfusion is at times of the greatest value. It 
exerts far greater influence on blood-pressure than does saline solu- 



TRANSFUSION 1 39 

tion. 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 secondary anemia transfusion has given good results where the 
-cause has been removed. In pernicious anemia transfusion causes 
temporary improvement, but it is extremely doubtful if it effects a 
cure. For acute leukemia it seems to be of no value. 

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 effects are probably the result of an in- 
creased resistance on the part of the patient, due to the restoration 
of the blood to a more normal condition. For the same action, 
transfusion is indicated in subacute forms of sepsis associated with 
anemia, emaciation, and devitalized tissues such as is frequently seen 
in war surgery in patients with large suppurating wounds and in- 
fected compound fractures. Repeated transfusions of small amounts 
of blood is of undoubted value in this class of cases for the purpose of 
increasing their resistance. 

Transfusion has been employed in many other conditions, such 
as tuberculosis, acute suppuration, acute infectious diseases, etc., 
but the results have not been encouraging. It is contra-indicated 
in patients with organic heart disease as there is danger of overtax- 
ing the heart by a sudden increase in the amount of fluids in the 
circulation. 

Selection of the Donor. — ^A young, healthy, vigorous adult should 
be selected to supply the blood as the value of a transfusion depends 
to a large extent upon the type of donor. 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 
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. 

Hemolysis. — Of the greatest importance is the selection of a 
donor whose blood is compatible with the blood of the recipient. 
Unless the delay is considered more dangerous than the risk of 



I40 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

hemolysis, the blood of the donor and recipient should always be 
tested for hemolysis. An exception to this is in the case of a new 
born infant, as it has been shown by Cherry and Langrock that the 
mother is always a safe donor. 

Moss' work on grouping the blood according to the power of 
agglutination has proved of great practical value in transfusion. He 
found that every individual riiay be arbitrarily classified in one of 
four groups according to the ability of his serum to agglutinate the 
corpuscles of other individuals, and according to the ability of his 
corpuscles to be agglutinated by the sera of other individuals. Ag- 
glutination may occur independently of hemolysis, but if agglutina- 
tion is absent hemolysis never occurs; hence, from the agglutination 
reaction it is possible to determine whether hemolysis will occur. 

Moss classifies the four groups as follows: 

Group I. — Serum agglutinates no corpuscles. 
Corpuscles agglutinated by sera of Groups II, III, and IV. 

Group II. — Serum agglutinates corpuscles of Groups I, and III. 
Corpuscles agglutinated by sera of Groups III, and IV. 

Group III. — Serum agglutinates corpuscles of Groups I and II. 
Corpuscles agglutinated by sera of Groups II and IV. 

Group IV. — Serum agglutinates corpuscles of Groups I, II and 
III. Corpuscles are not agglutinated by any serum. 

The above may be conveniently tabulated as follows : 

Serum of Group 

I II III IV 

Corpuscles of Group I o + + + 

Corpuscles of Group II o o + -|- 

Corpuscles of Group III o + o + 

Corpuscles of Group IV o o o o 

(+ = Agglutination) 

(o = No agglutination or hemolysis) 

It has been estimated that 5 per cent, of all individuals belong^ 
to Group I; 40 per cent, to Group II; 10 per cent, to Group III; and 
45 per cent, to Group IV. 

While it is preferable that the donor and recipient belong to the 
same group, it is not imperative, and, in the case of patients belong- 
ing to the less common groups I and III, this is often difficult. The 
important thing is to choose a donor whose corpuscles are not ag- 
glutinated or hemolyzed by the serum of the recipient. The fact that 
the donor's serum may agglutinate or hemolyze the patient's cor- 
puscles may be disregarded, as the high dilution of the donor's serum 



TRANSFUSION 141 

that results when it is added to the blood volume of the recipient, 
prevents any harmful action. The groups, whose blood may be 
safely mixed, is shown by the following table: 

// the recipient belongs to Group /, the donor may be selected from 
Groups I, II, III, or IV. 

// the recipient belongs to Group II, the donor may be selected from 
Groups II or IV. 

If the recipient belongs to Group III, the donor may be selected 
from Groups III or IV. 

// the recipient belongs to Group IV, the donor should be from 
Group IV. 

Members of Group I are thus termed universal recipients, as the 
serum of this group does not agglutinate the corpuscles of any of the 
other groups, while members of Group IV are termed universal donors 
as their blood may be transfused with safety into any patient. 

Method of Determining Blood Groups. — Vincent [Journal of the 
American Medical Association , April 27, 19 18), describes a rapid and 
simple method of determining blood groups by testing the individ- 
ual's blood against known citrated sera^ of Groups II and III. Ci- 
trated sera are employed to avoid coagulation of the fresh blood 
which is mixed with the sera in making the test, otherwise the reac- 
tion might be confusing. 

The technic is as follows : A drop of the Group II serum is placed 
upon one half of a clean glass slide and a drop of Group III serum 
upon the other half. The lobe of the ear of the individual to be 
tested is then punctured, and by means of glass rods about 3^^ of a 
drop of the blood is added to each serum, thoroughly mixing the 
blood and serum. Separate glass rods should be used for each trans- 
fer of blood so that there will be no mixing of the two sera, and care 
must be taken to make the transfer before the blood coagulates. 

The red cells at first show a uniform suspension in the serum which 
persists if there is no agglutination. Agglutination, if it occurs, is 
recognized by the formation of masses of agglutinated cells, and can 
be distinguished by the naked eye. The reaction usually occurs 
in about a minute. If there is any doubt as to the reaction, the slide 

1 The serum is prepared by collecting 5 drams (20 c.c.) of blood from individuals of 
Groups II and III, under aseptic precautions. The serum resulting from each, when the 
blood has coagulated and the clot contracted, is drawn oflF by means of separate pipettes 
into sterile flasks, and sufficient sodium citrate is added to each serum to give a 1.5 
per cent, citrated serum. Tricresol 0.25 per cent, is also added to each bottle of serum 
as a preservative. 



142 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

should be examined under the microscope. Rouleaux formation 
sometimes occurs and must not be mistaken for agglutination. 
According to the reactions obtained, it is possible to determine 
to which of the four groups the individual belongs . The accompanying 
illustrations (Fig. 95) readily explain the reactions. 

Quantity of Blood Transfused.^ — The quantity of blood transfused 
will vary according to the age of the patient and the condition for 
which the transfusion is performed. Between 20 and 25 ounces 
(600 and 750 c.c.) of blood for an adult, and from 2 3-^ to 5 ounces 
(75 to 150 c.c.) for an infant is an average dose. 

In direct transfusion it is impossible to estimate the exact amount 
of blood transfused and the guides should be the the condition of 



Serum n 


Se r urn m 


IT 

• 


JU 

• 



Sera 



m n 



Se rum in 






G 


roup I 




n 






111 









§ 



Group n 




JT 




nr 





Groupnr Groupnr 

Fig. 95. — Agglutination test as seen macroscopically. 

the donor and the recipient; the amount should also vary according 
to the condition for which the transfusion is performed. Twenty 
to forty-five minutes' flow in a good anastomosis is usually sufficient. 
As soon as the donor shows signs of loss of blood — indicated by a 
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 amounts of blood niay cause ser- 
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 



DIRECT ARTERY TO VEIN TRANSFUSION 143 

should be placed in a reverse Trendelenburg position with the feet 
lowered, and external massage of the heart (page 71) performed to 
assist in emptying it. 

Rapidity of Flow. — The rate with which the blood is injected into 
the recipient or flows from the donor to the recipient should be care- 
fully regulated, for fear of overcharging the heart and producing an 
acute cardiac dilatation. In direct transfusion this may be deter- 
mined by noting the strength of the pulsation in the veins. If too 
strong, the flow may be controlled by partially compressing the 
lumen of the artery by means of the fingers. 

Repetition of Transfusion. — The blood picture and the general 
condition of the patient will indicate the need for repetition of a 
transfusion. Often repeated transfusions of moderate amounts of 
blood give better results than a single large transfusion. Intervals 
of seven days may be taken as an average for repeated transfusions, 
and the same donor should not be employed more frequently than 
this. 

DIRECT 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- 
ture. In addition, there is frequently a contraction of the vessels 
at the point of suture, and thrombosis is more likely to occur. 

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. 16 cambric needles 
and fine strands of silk (Fig. 96). The silk should be thoroughly 
impregnated with vaselin and should be threaded into the needles 
before the operation is begun. 



144 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

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. 98). At least four sizes of these tubes should be 




Fig. 96. — 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 cannulse; 9, needles threaded with fine strands of silk. 

at hand, and the largest size that can be used without injury to the 
arterial coats by undue stretching should be employed. 

Position of the Donor and Recipient. — The donor should lie upon 
an operating-table of a type that will permit his head to be quickly 




mn 



Fig. 97. — Enlarged view of Crile's Fig. 98. — Enlarged view of 

clamps. (After Fowler.) i, Clamp Crile'-^ cannula, 

without rubbers; 2, rubber tubes to fit on 
jaws of clamps; 3, clamp applied to 
artery. 

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 



DIRECT ARTERY TO VEIN TRANSFUSION 



145 



during the operation. Between the two operating- tables is placed a 
small square table upon which the arms of the donor and recipient 
rest during the operation. The operator is seated upon a stool in 
front of this table, and his assistant opposite (Fig. 99). 

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



UperaTirt^ Tahle 
I /lecipient~ I 



©. © 



Operating • Table 
Z JPonor 



Fig. 99. — 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. 



of procain for the skin and a o.i per cent, cocain solution or a 0.5 
per cent, solution of procain for deeper infiltration. 

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

The area of incision is anesthetized, and about i J^ 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 



10 



146 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

applied as high as possible to the proximal end of the artery, or, in the 
absence of a special clamp, a piece of tape may be placed around the 
artery and clamped sufficiently tight to compress the vessel and 
shut off the circulation. The distal end of the artery is thenligated 
and the vessel is cut. The adventitia is pulled over the end of the 
vessel and is snipped off as clean as possible. The field of operation 
is now covered with a compress well soaked with hot saline solution. 
The vein of the recipient is then exposed in the same manner, and 
about i}i 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 (Fig. 100), 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 




Fig. 100. — Transfusion by Crile's method. First step, exposure of the vein and 
artery with Crile's clamps applied. 



the vein. A suture inserted in the edge of the vein, as shown in Fig. 
loi, 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. 102), and is tied in the second groove of 
the cannula. The forearms of the donor and the recipient are then 
placed so that the hand of the donor is directed toward the elbow of 
the recipient. The cuffed portion of the vein is lubricated 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. 103) 
and is tied in place by a silk ligature which fits into the first groove on 
the cannula. The clamp is removed from the vein first. The 
clamp upon the artery is then very gradually opened, allowing the 
blood to flow into the vein of the recipient (Fig. 104). At the com- 



DIRECT ARTERY TO VEIN TRANSFUSION 



147 



pletion of the operation the vessels are ligated, the tube is excised 
and the skin incision is sutured and dressed with sterile gauze. 

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




Fig. 103. 
Second step, 



draw- 



FiG. loi. Fig. 102. 

Fig. ioi. — Transfusion by Crile's method. (After Crile.) 
ing the vein through the cannula. 

Fig. 102. — Transfusion by Crile's method. (After Crile.) 
of cuffing back the vein. 

Fig. 103. — 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. 



Third step, method 



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- 




FiG. 104. — Transfusion by Crile's method. Fifth step, showing the anastomosis 

completed. 

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 



»I48 TRANSFUSION AND INJECTION OF HUMAN. BLOOD SERUM 

*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. 

Variations in Technic. — Brewer has simplified Crile's method 
of making an anastomosis by employing long glass tubes lined with 
paraffin (Fig. 105). These tubes are about 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 parafiin, shaken out, and allowed to cool. The vein and 
artery are exposed and isolated in the usual way and two Crile clamps 




Fig. 105. — Brewer's glass tubes lined with parafi&n for transfusion. 

are applied as shown in Fig. 100. The artery is drawn over one end 
of the tube and is secured by a ligature. A longitudinal or a trans- 
verse cut is made in the wall of the vein (see Fig. 131), 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. 132, and is secured in place by a ligature. The 
clamps are then removed and the blood is allowed to flow. 
Elsberg {Journal of the American Medical Association, March 
i3> 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. 106) 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- 



INDIRF.CT TRANSFUSION 1 49 

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 
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 
J-^ 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. 130). 




Fig. 106. — Elsberg's transfusion cannula. 

The vein is opened by means of a small transverse slit in the same 
manner as for an intravenous infusion (see Fig. 131), 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. 

INDIRECT TRANSFUSION 

In indirect transfusion the blood, instead of passing directly from 
the vessels of the donor into those of the recipient, is withdrawn into a 
syringe or receptacle and is then injected into the vessels of the re- 
cipient. Its success depends upon making the transfer of blood from 
the donor to the recipient without coagulation taking place. This 
may be accomplished by: (i) making the transfer with such rapidity 
that the blood has not time to clot; (2) coating the receptacle through 
which the blood flows with paraffin, and (3) mixing with the blood 
sodium citrate, which prevents coagulation. 

Transfusion by some of the indirect methods is preferred at the 
present time to direct transfusion for the reason that it is simpler, 



150 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

and requires less skill in its performance and at the same time is 
quite as effective; furthermore, indirect transfusion has this ad- 
vantage, that the quantity of blood transfused may be accurately 
measured. 

Indirect Transfusion by the Syringe Method of Lindeman. 
In 1892 von Zienjssen reported having performed transfusions by 
means of venous puncture upon the donor and recipient and with- 
drawing syringesful of blood from the donor and injecting them into 
the recipient. The method did not receive much attention, how- 
ever, until 1 9 13 when Lindeman improved upon it and made it 
suitable for transfusing large quantities of blood by using numerous 
syringes and special cannulas with which injury to the interior of 
the vein during manipulation of the syringes was avoided. Two 
of>erators and an assistant are necessary; and they should be 
specially trained, as success with the method depends upon dexterity 
and speed in handhng the syringes to avoid clotting of the blood. 
For this reason the syringe method is sometimes disappointing in the 
hands of those of limited experience. 

As no skin incision is made, the only discomfort to the donor and 
recipient is from the puncture of the skin by the needles entering the 
veins. The same vein may thus be utilized for subsequent trans- 
fusions if desired. 

Apparatus. — There will be required (i) two sets of cannulas — one 
for the donor and one for the recipient, (2) two tourniquets, (3) 
twelve record syringes with a capacity of 5 drams (20 cc.) each, and 
(4) three basins for rinsing the syringes — two for sterile water and one 
for saline solution. 

The cannulas consist of three to each set, which telescope one 
within the other. The innermost cannula is of small calibre and 
sharp pointed. It closely fits cannula No. 2, which in turn fits No. 
3. The distal ends of cannulas No. 2 and 3 are smooth and rounded 
so as not to injure the intima of the veins. On the proximal end of 
cannulas No. i and 2 are stationary thumb screws. The proximal 
end of No. 3 is made to fit a record syringe. 

Asepsis. — Before using, the syringes are cleaned in peroxide of 
hydrogen, then washed in a 10 per cent, sodium carbonate solution, 
rinsed, and sterilized with the cannulas in 95 per cent, alcohol. The 
arms of donor and recipient are sterilized by painting with iodin, 
and the hands of the operators and assistant are prepared as for any 
operation. 



INDIRECT TRANSFUSION 15I 

Technic. — A tourniquet is placed about the arm of the recipient 
and a cannula, lined with a thin coating of liquid petrolatum, is in- 
serted into the vein held almost parallel with the skin surface. 
As soon as the first joint ''A" enters the vein, cannula No. i is 
withdrawn J^ an inch (i cm.). This prevents'any injury to the vein 
wall from a sharp pointed cannula and leaves No. 2 only, in contact 
with the vein. Cannula No. 3 is now inserted % of an inch (2 cm., 
into the vein and No. i and 2 are removed. If the vein has been 
successfully entered blood quickly flows from the cannula. When 
this occurs, the tourniquet is removed, and a syringe containing 
warm saline solution is attached to the cannula and the solution is 
slowly injected. In the same manner the cannula is inserted into the 
vein of the donor and an empty syringe attached. A syringeful 
of blood is now rapidly withdrawn from the donor and is passed by 
the assistant to the operator on the recipient, who, after removing 

3 * * 



Fig. 107. — ^Lindeman's cannula assembled and separated. 

the saline syringe, attaches the one containing blood and quickly 
injects the contents of the syringe into the recipient. While this is 
being done, the operator on the donor attaches another syringe and 
fills it with blood. Syringesful of blood are rapidly withdrawn from 
the donor and injected into the recipient until the desired quantity 
has been transferred. A Httle saline solution is injected through the 
cannula of the recipient to keep it free of blood and prevent clotting 
every 2d, 3d, 4th, or 5th syringeful of blood according to the speed 
of flow from the donor. 

Syringes are not used a second time without being thoroughly 
cleaned. This is done by a nurse who rinses the syringes through 
two basins of sterile water and then in saline solution. It is empha- 
sized by the author of this method that only syringes and cannula 
with bright polished surfaces should be used. 



152 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 



Unger's Instrument for Syringe Transfusion. — linger {Jour. 
Amer. Med. Assoc, Feb. 13, 191 5) describes a cock for use in the 

C 




Fig. 108. — Unger's instrument for syringe transfusion. 
B. Blood syringe connected to blood outlet, C. stop-cock, D. donor's cannula. 
P. pedestal by which the stop-cock is raised or turned, R. recipient's cannula, S. saline 
syringe connected to saline outlet, and St. stand. 

syringe cannula method of transfusion whereby the number of syringes 
is reduced to two, the handling of the cannulas necessitated by fre- 



D 5 





^^iG. 109. Fig. 1 10. 

Fig. 109.— Unger's instrument. Donor's position {Mter Vngtr J ournal of Ameri- 
can Medical Association, July 17, 1916.) 

Fig. lie— Unger's instrument. Recipient's position. (After Unger, Journal of 
American Medical Association, July 17, 1916.) 

querit changing of syringes is avoided, and clotting is prevented 
by regular flushing of the apparatus with saline solution. With this 



INDIRECT TRANSFUSION 



153 



instrument blood may be withdrawn from the donor and injected 
into the recipient without making any disconnections. 

The instrument (Fig. 108) has four outlets: (i) blood outlet (B), 
(2) saline outlet (S), (3) , recipient outlet (R), and (4) donor outlet (D). 
A 5 dram (20 c.c.) Record syringe is attached to B and through it 
blood is aspirated and injected, while to S a second syringe for saline 
is attached by means of a piece of rubber tubing. To R and D 
the recipient's and donor's cannulas are connected by means of two 
paraffined rubber tubes i^^ inches (4 cm.) long. The cock is arranged 
to rotate through an arc of 45 degrees. When rotated so that the 
blood syringe operates upon the donor, saline 
may be injected into the recipient (Fig. 109), 
and while blood is being injected into the re- 
cipient saline solution may be injected into the 
donor (Fig. no). 

Indirect Transfusion by Paraffined Tubes. 
— ^As is well known, coagulation of blood is 
considerably retarded when the blood is col- 
lected in a receptacle lined with paraffin, and 
there is time to fill a container of moderate 
size with the donor's blood and empty it into 
the recipient before coagulation occurs if the 
blood is not shaken. Among the numerous 
devices for performing transfusion by this 
method may be mentioned the paraffined 
tubes of David and Curtis, ELimpton and 
Brown, and Vincent. 

Success in their use requires most careful 
preparation of the tubes, as it is essential that 
every portion of the apparatus with which 
the blood comes in contact be completely 
coated with a thin, smooth lining of paraffin to avoid clotting. 

Apparatus. — The tubes of Kimpton and Brown consist of glass 
cylinders with a capacity of 5 to 8 ounces (150 to 250 c.c.) closed at 
the upper end by a cork. A cannula leads from the bottom of the 
cylinder downwards and then at right angles to the axis of the 
cylinder. From the last bend the cannula measures 2 to 3 inches 
(5 to 7.5 cm.) and gradually tapers to a point K2 to >^ of an inch 
(2 to 3 mm.) in diameter. A side tube opens into the Cylinder on the 
same side as the cannula a little below the cork, to which a cautery 
bulb is attached (Fig. iii). The apparatus of David and Curtis con- 




FiG. Ill . — Kimpton- 
Brown indirect transfu- 
sion tube. 



154 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

sists of a 3 ounce (loo ex.) glass syringe with rubber tube and two- 
way valve and a double cannula tipped glass bulb of 13 ounces 
(4CX) c.c.) capacity (Fig. 112). 

Vincent's apparatus is very similar to Kimpton's and Brown's 
except that the lower end has a ground glass joint which fits a 
needle and thus permits its use without preliminary exposure of 

the veins. 

Preparation of the Tubes.— Paraffining the tubes must be done 
under rigid asepsis. A mixture of stearin i part, paraffin 2 parts, 
and vaseUne 2 parts is sterilized in an autoclave or by boiling, and the 
glass tubes are likewise sterilized in an autoclave. The paraffin 
mixture is melted in a water bath, and after first moderately heating 
the tube equally over an alcohol flame, the cork is removed and 
about iM ounces (50 c.c.) of the melted paraffin mixture is poured 
into it and is allowed to run over the entire interior of the tube, in- 




FiG. 112. — David and Curtis apparatus for indirect transfusion. 

eluding the cork which has been replaced in the tube, forming a 
uniform coat, and some of it is allowed to escape through the cannula. 
The tube is then turned so that the excess of paraffin runs back and 
out of the side opening. In the David and Curtis apparatus the 
excess of paraffin is drained off through the cannula tips. The 
junction of the cork and glass is finally sealed with paraffin on the 
outside. The tubes are then wrapped up in a sterile towel and are 
ready for use. 

Another method of coating the tubes is described by Alton {Jour- 
nal of the American Medical Association, Aug. 16, 1919.) The 
tubes are sterilized by dry heat and are then rinsed out with a small 
amount of alcohol and then ether. A mixture of paraffin with a 
melting point of 53° C. i part and ether 80 parts is sterilized in an 
autoclave and an ounce (30 c.c.) of this is poured into the tube, and 
the tube is shaken and rolled so that the entire inner surface is coated 
with the solution. A small amount of the solution is allowed to 



INDIRECT TRANSFUSION 1 55 

escape through the cannula to coat its interior, the excess solution 
being emptied out. As the ether evaporates it leaves a thin even 
coating of paraffin. It is advisable to wait several hours for the 
paraffin to harden before using the tubes. 

Asepsis. — Syringes and rubber portions of the apparatus are 
sterilized by boiling. The arms of the donor and recipient are 
sterilized by painting with tincture of iodin and the hands of the 
operator and his assistant are prepared as for any operation. 

Technic with the Kimpton and Brown Apparatus. — A tourniquet 
is placed upon the donor's arm with sufficient tension to produce 
venous obstruction, but not obliterate the pulse. Under local 
anesthesia with a 0.5 per cent, procain-adrenalin solution one of the 
prominent veins at the bend of the elbow is then exposed through 
an incision i inch (2.5 cm.) long. The vein is tied proximally and 




Fig. 113. — Method of holding the filled tube in carrying to the recipient. 

a ligature is placed around it distally, but is not tied. This ligature, 
held taut by an assistant, acts as a clamp and the vein is opened. 
The vein of the recipient is similarly exposed without using a tourni- 
quet and is tied off distally, the proximal ligature being used as a 
clamp. The vein is then opened, and, with the tube held upright, 
the cannula is inserted into the donor's vein, and the tube fills 
with blood under the venous pressure, which may be augmented by 
having the donor open and close his hand. When filled, the tube is 
taken to the recipient in a horizontal position with the side opening 
uppermost (Fig. 113) and the cannula is inserted into the vein of the 
recipient with the tube held upright. A cautery bulb is attached 
to the side opening of the tube and enough pressure is made on the 
cautery bulb to empty the tube. The cannula is withdrawTi while 



156 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

there is still a little blood left in it. More tubes may be filled and 
emptied in this manner, utilizing the same veins. At the conclusion 
of the transfusion the veins are ligated, the incisions closed with a 
few stitches, and a sterile dressing is applied. 

Transfusion of Citrated Blood. — The development of the 
method of transfusing blood to which sodium citrate is added to 
prevent coagulation is mainly the result of experimental work by 
Weil and Lewisohn. It was found that citration of blood to 0.2 
per cent, was sufficient to prevent coagulation, and that the trans- 




FiG. 114.— Transfusing blood with the Kimpton-Brown tube. 

fusion of such blood is apparently just as effective as whole blood, if 
the blood is injected within an hour after it is withdrawn from the 
donor. Contrary to what would be supposed, the coagulation time 
of the recipient's blood after the introduction of citrated blood is not 
retarded, but is shortened immediately after such transfusion. 
If used in proper strength citrated blood is without danger. Ac- 
cording to Lewisohn 75 grains (5 grams) can be injected into an 



INDIRECT TRANSFUSION 1 57 

adult intravenously with safety. The injection of unlimited quan- 
tities into the circulation, however, is toxic, depriving the blood and 
tissues of calcium and producing dyspnoea, tonic and clonic con- 
vulsions, tetany, paralysis, etc. There is no doubt that a reaction 
follows the transfusion of citrated blood more frequently than when 
whole blood is used. This is manifested by chills and fever, but, 
while unpleasant for the patient, it is not harmful. Many theories 
have been advanced to explain these reactions, but up to the present 
a satisfactory reason has not been found. 

Transfusion by the citrate method possesses a distinct advantage 
over other methods in permitting the transfer of blood from one 
place to another without detriment, so that the donor and recipient 
need not be in the same room. Furthermore, it requires none of the 
skill essential for the successful transfusion by other methods, and 
only the simplest form of apparatus is needed. In fact, the method 
is about as simple as an intravenous saline infusion. 

Strength of Citrate Solution. — A 0.2 per cent, citrate blood was 
the strength originally employed, but as an added factor of safety 
against clotting it is of advantage to employ a slightly higher per- 
centage of citrate — a 0.25 per cent., or 0.3 per cent. In the U. S. 
Army a 0.7 per cent, was used. Ampules containing 1% ounces 
(50 c.c.) of a 2.5 or 3 per cent, sterile sodium citrate in a 0.9 per cent, 
saline solution may be obtained. One ampule of the 2.5 or 3 per 
per cent, sodium citrate in 15 ounces (450 c.c.) of blood gives a 
citrated blood solution of 0.25 or 0.3 per cent. 

Apparatus. — Transfusion of citrated blood may be performed with 
a very simple apparatus. There will be required : (i) a graduated 
salvarsan flask, to which is attached a piece of rubber tubing >^ inch 
(6 mm.) in diameter and 4 feet (120 cm.) long supplied with a glass 
indicator; (2) ampules of sterile citrate solution; (3) two glass 
graduates of i pint (500 c.c.) capacity, for collecting the blood, 
and a glass stirring rod; (4) a small measuring glass graduated in 
cubic centimeters up to 50; (5) a large gauge Kaliski transfusion 
needle for collecting the blood, and one of smaller calibre for in- 
fusing the citrated blood into the donor; (6) two pieces of rubber 
tubing for tourniquets; (7) two artery clamps for holding the tourni- 
quets in place (Fig. 115). An ordinary glass irrigating jar or a 
large glass funnel may be used in place of the salvarsan flask. 

The Medical Department of the U: S. Army supplied an excellent 
apparatus whereby the blood is collected in, and injected from, the 
same container. It consists of a quart (litre) bottle graduated in 



158 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

icx> c.c, 4CX) c.c, and 700 c.c, two rubber stoppers having two perfora- 
tions, two transfusion needles, and glass and rubber tubing. Tubes 
for applying suction in withdrawing the blood and pressure to fill the 




Fig. 115. — Apparatus for transfusing citrated blood, i. Graduated reservoir with 
rubber tubing; 2. ampules of sterile sodium citrate; 3. two glass graduates and glass 
rod for stirring; 4. small glass graduate; 5. large and small calibre needles; 6. rubber 
tourniquet; 7. artery clamps. 

tubing of the injection apparatus are also provided (Figs. 117 
and 118). 

Asepsis. — The apparatus is sterilized by boiling or in an autoclave, 
the arms of the donor and recipient are sterilized by painting with 




Fig. 116. — Enlarged view of the Kaliski needle. 



tincture of iodin, and the operator's hands are prepared as carefully 
as for any operation. 

Technic. — A tourniquet, consisting of a piece of rubber tubing, is 
applied to the arm of the donor with sufficient tension to produce sl 



INDIRECT TRANSFUSION 



159 




Fig. 1 1 7. — Apparatus for transfusing citrated blood used by the Medical Department 
of the U. S. Army assembled for withdrawing blood from the donor. 



r 




Fig. 118.— Apparatus for transfusing citrated blood used by the Medical Depart- 
ment of the U. S. Army assembled for infusing blood. 



l6o TRANSrUSIOX AND INJECTION OF HUMAN BLOOD SERUM 

marked venous stasis, and is secured by clamping with an artery 
clamp. A tube of citrate solution is broken at the file mark, the 
open end is passed through a flame and 25 c.c. (6% drams) of the 
citrate solution is placed in the graduate in which the blood is to be 
collected, and the blood is drawn into it by inserting the large needle 
into one of the prominent veins at the bend of the elbow directed 
toward the hand. As the blood is withdrawn, the blood and citrate 
are stirred together with a glass rod to obtain a thorough mixing 
(Fig, 119). Blood is withdrawn up to the 250 c.c. mark on the 
graduate. Another 25 c.c. (6% drams) of citrate solution is poured 
into the graduate and more blood is withdrawn until the 500 c.c.', 




Fig. 119.— Withdrawing the blood from the donor into a graduate containing sodium 

citrate solution. 

mark is reached. If more than 500 c.c. ( i pint) of blood is required 
the second graduate is used to collect it, employing the citrate solu- 
tion as before in the proportion of 25 c.c. (6^ drams) to each 225 c.c. 
(jH ounces) of blood. When the desired amount has been 
collected,^ the tourniquet is removed and the needle withdrawn from 
the recipient's vein. Pressure is applied over the site of puncture 
a moment or two and the wound dressed with sterile gauze. 

Introduction of the citrated blood is accompHshed by first 
placing a tourniquet about the arm of the recipient to make the veins 
stand out prominently. The citrated blood is then transferred to 
the flask, into which about 2 ounces (60 c.c.) of normal salt solution 



TRANSFUSION OF PRESERVED RED CELLS 



l6l 



has been previously placed, and care is taken to see that the rubber 
tubing is completely filled with salt solution and that it contains no 
air. The needle is then introduced into the recipient's vein directed 
toward the heart, and, as soon as blood flows from it, the rubber 
tubing of the injection apparatus ^//e^/ with the salt solution is quickly 
attached and the tourniquet is removed. The reservoir is then elevated 
about 3 feet (90 cm.) and the blood allowed to flow by gravity (Fig. 





Fig. 120. — Method of introducing citrated blood into the recipient. 

120). It should run in slowly, care being taken not to suddenly 
overcharge the right heart, and the needle should be removed before 
the reservoir is completely drained. Upon completion of the trans- 
fusion the puncture is dressed as described above. 

TRANSFUSION OF PRESERVED RED CELLS 

Experimentally it was shown by Rous and Turner in 1916 that 
red blood corpuscles suspended in a fluid isotonic with blood plasma 
11 



1 62 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

may be kept for several weeks in a cool place and when injected 
into an animal of the same species will still functionate. They 
employed as an isotonic medium a 5.4 per cent, dextrose and a 3.8 per 
cent, sodium citrate solution in the proportion of roughly 3 parts 
blood, 2 parts isotonic citrate solution, and 5 parts isotonic dextrose 
solution. 

This method has been successfully applied to humans by Robert- 
son {British Medical Journal, June 22, 19 18) who employed it at the 
front, using for the purpose the blood of Group IV donors, and it 




Fig. 121.— Robertson's apparatus for collecting the blood for rtansfusion of preserved 

red cells. 

seems that blood lost through hemorrhage may be as effectively 
replaced by this means as by fresh whole blood. The advantages 
of a method of transfusion that permits the use of blood collected 
beforehand and kept stored in any desired quantity are obvious, 
and as an emergency method, where a suitable donor is not available, 
it is invaluable. 

Preparation of the Isotonic Preserving Fluid.— The isotonic med- 
ium is a 5.4 per cent, dextrose and a 3.8 per cent, sodium citrate 
solution. The solutions are made separately from freshly distilled 



TRANSFUSION OF PRESERVED RED CELLS 



163 

For preparing 



water, and are sterilized separately in an autoclave, 
the dextrose solution powdered dextrose is employed. 

For 500 c.c. (i pint) of blood, 350 c.c. (12 ounces) of isotonic 
citrate solution and 850 c.c. (28 ounces) of isotonic dextrose solution 
are required. 

Apparatus.— The apparatus employed by Robertson {British 
Medical Journal, July 22, 1918) for collecting the blood consists of a 
2 quart (2 Htre) glass bottle, with a stopper containing two perfora- 




FiG. 122. — Robertson's apparatus arranged for syphoning off the supernatant fluid. 



tions. One of these gives passage to a short right angled piece of 
glass tubing, to the free end of which a suction bulb is attached. 
Through the other passes a piece of right angled glass tubing with a 
long arm reaching nearly half way down the bottle and a short arm, 
to which is attached by means of a short rubber tube a vein needle 
(Fig. 121). 

Asepsis. — The apparatus is sterilized in an autoclave, and the 
usual preparations of the patient's skin and operator's hands are 
followed. 



l64 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

Technic— The blood is collected in the usual way by venous 
puncture (page 302) in the bottle containing the " isodextrose " 
and "isodtrate" solutions. The glass tube through which the blood 
enters should extend down to the citrate solution so that the blood 
does not fall into the solution through the air. Slight negative 
pressure may be produced in the bottle by means of the suction bulb 
to aid the flow of blood, and, as the blood is being withdrawn, the bot- 
tle is gently rotated so as to mix it with the solution. When 500 c.c. 
(i pint) of blood has been collected, the stopper is removed and the 
bottle is plugged with sterile cotton and placed in an ice box. 

The red cells slowly gravitate to the bottom and in 4 or 5 days 
they will have settled to 800 or 900 c.c. (26 to 30 ounces), and, after 
the supernatant fluid has been syphoned off, the blood can be used. 
If the supernatant fluid has a pinkish tint, the blood should be dis- 
carded as this is indicative of hemolysis. When the blood has been 
stored for some time, the red cells may sink to a level lower than that 
of the original blood, and, in such a case, Robertson employes a 
2.5 per cent, solution of gelatin in normal salt solution to bring the 
blood up to the required amount. 

Before transfusing, the blood is poured through two layers of 
sterile gauze into the transfusion apparatus in such a way that it 
flows down the side of the container and does not fall into it. The 
container is stoppered and placed in a water bath so as to bring its 
temperature up to 41° to 42°C. (106° to loy^F.). It is then ready 
for use. 

INJECTIONS OF HUMAN BLOOD SERUM 

For many years it has been known that blood serum contained 
some agent that hastened the coagulation of blood. In 1882 Hay em 
established 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. 



INJECTIONS OF HUMAN BLOOD SERUM 



165 



Blood serum is, likewise, claimed to be of value in septic conditions 
on account of its bactericidal action. 

While 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 
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 Jour- 
nal 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 aspirat- 
ing 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 prevent 
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. 

123). 

A 30 to 60 c.c. (i to 2 ounces) glass syringe with a glass piston 

should be provided for injecting 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. 
12 




Fig. 123. — Welch's 
apparatus for collecting 
blood serum. 



1 66 TRANSFUSION AND INJECTION OF HUMAN BLOOD SERUM 

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 day beginning two days before the 
operation 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 
abdomen 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 
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 — 
preferably the median basilic — is then identified and the needle of 
the collecting apparatus is thrust into it, holding the needle almost 
parallel with the skin surface. About 10 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 posi- 
tion 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 
expelled 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 swell" 
ing is very gently massaged until the serum is all absorbed. After 
withdrawal of the needle, the point of puncture is sealed with col- 
lodin and cotton. Usually within twenty-four to forty-eight hours 
after beginning the injections the bleeding will be controlled. 



I 



CHAPTER V 
INFUSION 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 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 still exten- 
sively employed in place of transfusion. This may be readily under- 
stood when we consider that the methods of administering salt 
solution can be carried out on short notice, that they require but 
little preparation, that they are marked by simplicity in technic, 
and that they are within the reach of all. 

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 cir- 
culation will not avail — only the transfusion of blood can avert a 
fatal issue in such cases. 

(2) In the prophylaxis and treatment of mild surgical shock, 
for the purpose of restoring heat to the body and raising arterial 
tension. As shown by Crile, however, in severe shock, unless due 
to hemorrhage, the rise of blood-pressure is so temporary^ that the 
first benefits derived from the infusion are not maintained. In 

167 



1 68 INFUSION OF PHYSIOLOGICAL SALT SOLUTION 

such cases, the combination with salt solution of drugs which raise 
blood-pressure, such as adrenalin chlorid, is followed by more 
marked and beneficial results. For a single infusion, lo to 30 V([ 
(0.6 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 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 
and in the presence of high blood pressure or secondary anemia 
with greatly reduced hemoglobin it should be employed with caution. 

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 



INFUSION OF PHYSIOLOGICAL SALT SOLUTION 1 69 

is to have a sterilized and very concentrated solution put up in 
hermetically sealed tubes, in such strength that the contents of 
one tube emptied into a quart (looo c.c.) of sterile water gives a 
normal salt solution (Fig. 124). In hospital practice it is customary 
to keep the solution in stock bottles ready for use. The solution is 
made up in the proper strength from sterile salt dissolved in sterile 
water, and is then prepared as follows.^ "Filter into flasks (sterilized 
by washing with bichlorid solution, then rinsing with sterile water) 
stoppered with nonabsorbent cotton, sterilize for one hour for three 
successive days at a temperature of 220° F., and cover the cotton 
stoppers with a small square of rubber tissue held in place by a 
rubber band. When needed, place the flask in a deep basin filled 
with hot water until raised to the proper temperature/' A more 




Fig. 124. — A tube of concentrated sterile salt solution. 

convenient method of bringing the solution to the required tempera- 
ture when 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 suflS- 
cient of the hot solution is then added to bring the contents of the 
reservoir to the proper temperature. 

Artificial Sera. — Some operators prefer to employ artificial sera 
prepared according to certain formulae, the object being to obtain 
a salution as nearly identical to the blood serum as possible. Some 
of those most frequently used are as follows: 

Hare's formula: 
Calcium chlorid, 
Potassium chlorid, 
Sodium chlorid, 
Distilled water, 

Ringer's formula: 
Potassium chlorid. 
Calcium chlorid, 
Sodium chlorid, 
Distilled water, 

1 Fowler. "The Operating-room and the Patient. 





(Approximately.) 


0.25 gm. 


gr. IV. 


o.io gm. 


gr. iK 


9 gm. 


dr. 2>i 


1000 c.c. 


qt.i. 


0.2s gm. 


gr. iv. 


0.3 gm. 


gr.4M 


7 gm. 


dr. iK 


1000 c.c. 


qt.i. 







(Approximately.) 


0.2 


gm. 


gr. iii. 


0.42 gm. 


gr. vi. 


0.3 


gm. 


gr. aH 


I 


gm. 


gr. XV. 


9 


gm. 


dr. 2M 


1000 


c.c. 


qt. i. 


6 


gm. 


dr. i3^ 


I 


gm. 


gr. XV. 


1000 


c.c. 


qt. i. 



170 INFUSION 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 

Gum Acacia Solutions. — For the purpose of providing a solution 
of the same viscosity as blood which would remain in the tissues 
and produce a more lasting elevation of blood pressure in shock and 
hemorrhage than is possible to obtain from salt solution, solutions of 
gum acacia have been advocated. The English shock committee 
first used a 6 per cent, gum acacia in 2 per cent, bicarbonate of 
soda solution, but later a 6 per cent, gum acacia in 0.9 per cent, 
salt solution, as recommended by Bayliss, was employed.^ While 
the gum salt solution was used both in the American and British 
armies during the recent war in the treatment of shock, there is 
still considerable difference of opinion as to its value ; some observers 
being very enthusiastic, claiming that it is an effective substitute 
for blood, while others assert that at best it is of no more benefit 
than ordinary salt solution. That gum salt solution is not without 
danger, in certain cases at least, is evident from the alarming and 
in some cases fatal reactions that have been reported following its 
use, for which a satisfactory explanation has not been offered. 

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 
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 

1 More recently ErJanger and Gasser {Annals of Surgery, April, 1919 and American 
Journal of Physiology, Oct., 19 19) report results from the intravenous injection of a 
hypertonic solution of gum acacia and glucose. They recommend a 25 per cent, gum 
acacia and 1 8 per cent, glucose solution. This makes a very viscid solution and must be 
administered slowly. jY^ drams (5 c.c.) of the solution for each 2K lbs. (Kilo) of 
body weight is given in an hour. The writers have used this solution in the treatment 
of shock and hemorrhage in humans as well as in experimental work on animals with 
apparent beneficial results. The work is still in the experimental stage, however. 



INTRAVENOUS INFUSION 



171 



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. 

Apparatus. — There should be provided a thermometer, a gradu- 
ated glass irrigating jar, about 6 feet (180 cm.) of rubber tubing, 
3.^ inch (6 mm.) in diameter, and a blunt-pointed metal infusion 
cannula (Fig. 125). In addition, a constrictor for the arm, a gauze 
compress, and a bandage will be required. 

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




Fig. 125. — Apparatus for giving an intravenous infusion. (Ashton.) 



Instruments.— The operator will require a scapel, a pair of 
blunt-pointed scissors, mouse-toothed thumb forceps, an aneurysm 
needle, a needle holder, two curved needles with a cutting efdge, 
and No. 2 plain catgut (Fig. 126). 

Asepsis.— Strict asepsis should be observed. The instruments 
and apparatus should be boiled, the thermometer should be im- 
mersed 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 prepared as for any operation. 



172 



INFUSION OF PHYSIOLOGICAL SALT SOLUTION 



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 
used at a temperature of 115° to 118° F. (46° to 48*^ C.) without 
harmful affects. 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. 




2 Z ' J 

^ Fig. 126.— Instruments for intravenous infusion, i, Scalpel; 2, blunt-pointed 
scissors; 3, thumb forceps; 4, aneurysm needle; 5, needle holder; 6, curved needles; 
7, No. 2 plain catgut. 

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 con- 
tinuously. By watching the thermometer and adding hot solution 
from time to time, as that in the reservoir cools, a uniform temper- 
ature may be maintained. 

^ Rapidity of Flow.— The speed of the flow may be regulated by 
raising or lowering the reservoir, or compressing the rubber 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 the action of 
the heart the slower must the fluid he introduced. Acute dilation 



INTRAVENOUS INFUSION 



173 



of the heart may be produced by disregard of this caution. Further- 
more, 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 . infusion must be discontinued until the 
dangerous signs have passed. 

Quantity Given. — It has been shown that only a certain amount 
of the solution will be retained in the circulation; after a time it 
escapes into the tissues and produces edema. 
Hence there is no object in infusing enor- 
mous quantities. The average amount ad- 
ministered 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 re- 
quired in cases of severe hemorrhage, or after 
venesection. The operator will be guided as 
to the requisite quantity chiefly by the re- 
turn of the pulse, the increase in its volume, 
and by the improvement in the color of the 
patient's skin. In severe cases it may be 
advisable to repeat the infusion two or three 
times within twenty-four hours rather than 
to infuse an enormous quantity at one time. 
Site of Operation. — One of the most 
prominent veins at the bend of the elbow is 
usually chosen (Fig. 127), preferably the 
median basilic which runs across the bend of 
the elbow from without inward. The infu- 
sion may also be performed through the in- 
ternal saphenous. At times a vein exposed 
in the course of an operation may be con- 
veniently utilized. 

Preparation of the Patient.— AU clothing should be removed 
from the area selected for the infusion, and that about the axilla 
loosened if the arm is chosen for the infusion. The bend of the 
elbow is shaved, if necessary, and is then pamted with tmcture 
of iodin. A sterile bandage is tightly ^vrapped above the elbow to 
compress the veins and make them more prominent (Fig. 128). 
If the circulation is very feeble, even this expedient may fail to 
make the veins stand out conspicuously. 




Fig. 127.— The super- 
ficial veins of the forearm. 
(Ashton.) 



174 



INFUSION OF PHYSIOLOGICAL SALT SOLUTION 



Anesthesia. — ^Anesthesia of the skin is obtained by infiltration at 
the site of the incision with a 0.2 per cent, solution of cocain freshly 
prepared or a i per cent, solution of procain, 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. 129). The vein is dissected 
from its bed for a distance of i to iK 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 




Fig. 128. — Showing the application of the bandage to the arm to constrict the veins 

(Ashton.) 

around the portion of the vein nearest the heart, ready to be tied 
(Fig- 130)- A portion of the exposed vein is now grasped in a mouse- 
toothed forceps at a short distance from the distal Hgature, and, 
while the vein is put upon the stretch, a cut directed obHquely up- 
ward is made with scissors through half the vein, exposing its lumen 
(Fig. 131). The solution is first allowed to flow through the cannula 
held elevated to expel any au: 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. 132) and is secured in place by 
tying the second ligature. It is well to tie this ligature in a bow knot 
so that it may be easily loosened when the cannula is to be withdrawn 



INTRAVENOUS INFUSION 



175 



at the end of the operation (Fig. 133). The bandage is now removed 
from above the elbow, and the saline solution is allowed to enter the 



I 



Fig. 




129. 



-Intravenous saline infusion. (Ashton.) First step, showing the vein 
exposed by a small incision. 




Fig. 130. — 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. 

circulation, the reservoir being raised 2 to 6 feet (60 to 180 cm.) 
above the patient. During the infusion the temperature of the 



176 



INFUSION OF PHYSIOLOGICAL SALT SOLUTION 



solution must be kept uniform, the thermometer in the reservoir 
being constantly watched, and care must he taken to replenish the 
fluid in the reservoir before it has all escaped, otherwise air will enter the 
vein when a fresh supply is added. 





Fig. 132. 
Third step, showing the method of 



Fig. 131. 

Fig. 131. — Intravenous saline infusion 
incising the vein. 

Fig. 132. — Intravenous saline infusion. (Ashton.) Fourth step, showing the 
cannula being inserted into the vein. 




Fig. 133. Fig. 134. 

Fig. 133. — Intravenous saline infusion. Fifth step, showing the cannula tied 
in place. 

Fig. 134.— Intravenous saline infusion. (Ashton.) Sixth step, showing the 
infusion cannula removed and the proximal end of the vein ligated. 

When sufficient solution has beeh 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 
(^^g- 134)- The edges of the skin wound are united with several 



INTRAARTERIAL INFUSION 177 

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- 
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, or when the veins are collapsed, as is 
sometimes the case following a hemorrhage, 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 
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. 

Crile and DoUey {Journal of Experimental Medicine, Dec., 
1906) have shown that the infusion of normal salt solution and 
adrenalin into an artery against the blood current in suspended ani- 
mation from the effects of anesthesia or other causes is the most 
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 
12 



178 



INFUSION OF PHYSIOLOGICAL SALT SOLUTION 



shown that it is possible by this method to resuscitate animals that 
were apparently dead. 

Apparatus. — ^The same apparatus described on page 171 for intra- 
venous infusion, or an infusion cannula attached to a large glass 
funnel by a piece of rubber tubing, may be employed. In addition, 
a hypodermic syringe will be required. 

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

Technic. — Crile (American Journal of Medical Sciences, April, 
1909) gives the following technic for employing arterial infusion in 




Fig. 135.— Showing the method of infusing salt and adrenalin solution into the carotid 
artery. (After Da Costa.) 

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 artificial respiration and a moderate artificial circulation. 
A cannula is inserted toward the heart into an artery. Normal sa- 
line. 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 adrenaUn chlorid and 15 to 30m (i to 2 c.c.) are at once injected. 
Repeat the injection in a minute, if needed. Synchronously with 



INTRAARTERIAL INFUSION 1 79 

the injection of the adrenalin, the rhythmic pressure on the thorax is 
brought to a maximum. The resulting artificial circulation distributes 
the adrenalin that spreads its stimulating contact with the arteries, 
bringing a wave of powerful contraction and producing a rising arterial, 
hence coronary, pressure. When the coronary pressure rises to, 
say, 40 mm. or more, the heart is liable to spring into action. The 
first result of such action is to spread still further the blood-pressure- 
raising adrenalin, causing a further and vigorous rise in blood-pres- 
sure, 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 




Fig. 136. — Apparatus for infusing salt solution into an artery in Dawbam's emergency 

method. 

hypodermic, or a long fine 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- 
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. 136) are all that are 
required. 

Technic. — The femoral artery is first carefully defined just 
below Poupart's ligament. The aspirating needle is then forced by 
a slow rotary movement directly into the artery, entering it at right 
angles. As soon as the needle enters the vessel, bright red blood 
will fill its lumen. The rubber tubing of the syringe, which has been 



l8o INFUSION OF PHYSIOLOGICAL SALT SOLUTION 

previously filled with saHne fluid, is then sUpped 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. 137). 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. 




Fig. 137. — Showing the method of infusing salt solution into the femoral artery. 

HYPODERMOCLYSIS 

The subcutaneous method of infusion does not permit as rapid 
an introduction of large quantities of solution as the intravenous, 
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, >^ inch (6 
mm.) in diameter, and an aspirating needle of fair size (Fig. 138). 
When it is desired to introduce the fluid under both breasts at once, 
two needles fastened to the rubber tubing by means of a Y-shaped 
glass connection, as shown in Fig. 139, may be employed. 

In an emergency, a glass funnel or a fountain syringe, to which is 



HYPODERMOCLYSIS 



l8l 



attached an ordinary hypodermic needle by several feet of rubber 
tubing, may be utilized. 

Temperature of the Solution. — The solution should enter the 
body at about iio° F. (43° C). When using a large aspirating 
needle the fluid in the reservoir should be kept at a constant tempera- 




FiG. 138. — Apparatus for giving hypodermoclysis. (Ashton.) 

ture of about 3 degrees higher. If a hypodermic 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. 139. — Showing two needles arranged for hypodermoclj^sis. 

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. When a hypodermic needle is employed, 
the needle being so small in caliber, it will be necessary to raise the 
reservoir 5 or 6 feet (150 to 180 cm.) to get sufficient force. 

Quantity Given. — Injections of small quantities of solution, re- 
peated several times, give better results than a single large injection. 



1 82 INrUSION OF PHYSIOLOGICAL SALT SOLUTION 

As a rule, 8 to i6 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 he injected into one area, as it may 
produce undue distention of the tissues and consequent sloughing 
from the prolonged anemia. 

Sites of Injection. — The area chosen for the injection should be 
in a region free from large blood-vessels and nerves and where there 
is an abundance of loose connective tissue. The usual sites are: 
(i) under the mammary glands; (2) in the subcutaneous tissue be- 
tween the crest of the ilium and the last rib ; (3) in the subcutaneous 




Fig. 140. — Sites for hypodermoclysis. 

tissue in the axillary space; (4) in the subcutaneous tissue on the inner 
surfaces of the thighs (Fig. 140). 

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. 

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

Technic. — The reservoir is raised from 3 to 4 feet (90 to 120 cm.) 
above the patient, and some of the fluid is allowed to escape from the 
needle, to expel any air or cold solution. With the solution still 
flowing, the operator, using steady pressure, inserts the needle ob- 
liquely well into the subcutaneous tissue. As the solution enters, a 



HYPODERMOCYLSIS 1 83 

swelling appears in the subcutaneous tissues which, however, slowly 
subsides as the fluid is absorbed (Fig. 141). If , as soon as the tissues 
in one area become distended, the needle be partly withdrawn and 
its direction be changed slightly, a large amount of solution may be 
infiltrated over a wide area without producing too great tension at 
any one spot. The absorption of the solution may be hastened by 
gentle massage over the infiltrated area. During the operation, the 




Fig. 141. — Giving hypodermoclysis under the left breast. (Ashton.) 

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 607.) 



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 punctures may be made 
with triangular-pointed surgeon's needles or with a very narrow- 




FiG. 142. — Instruments for acupuncture. 

bladed bistoury (Fig. 142). Employed for the relief of the pain of 
muscular rheumatism or neuritis, half a dozen cylindrical 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^ 

184 



VENESECTION 1 85 

and the operator's hands are cleansed as for any operation. It is 
especially important to observe all aseptic precautions both during 
and after puncture of dropsical effusions, as the tissues in such cases 
have poor resistance and are a good soil for infection. 

Anesthesia. — There is but little pain connected with this 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}i 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, 



1 86 



ACUPUNCTURE, V;ENESECTI0N, SCARIFICATION, ETC. 



furthermore, often prevents its employment, so thai 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 
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, 




Fig. 143.— Instruments for venesection, i, Glass graduate; 2, ethyl chlorid; 3, scalpel; 
4, stick for patient to grasp; 5, bandages. 

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 
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 evi- 
denced by a rapid, strong, full, incompressible pulse, while low arte- 
rial tension and circulatory depression with a slow, soft, irregular, and 
compressible pulse are, as a rule, contraindications. Thus in sthenic 
types of croupous pneumonia with dilated right heart, dyspnea, and 



VENESECTION 



187 



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 
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. Largo 
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. 143). 

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, however, if the 
venesection is to be supplemented by trans- 
fusion or saline infusion. Under such con- 
ditions 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. 144), but the internal jugular or 
internal saphenous may be utilized. 

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




Fig. 144. — Superficial veins 
of the forearm. (Ashton.) 



i88 



ACUPUNCTURE. VENESECTION, SCARIFICATION, ETC 



patients iDst 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. 

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, procain solution, or by freezing with ethyl chorid 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 




Fig. 145. — Venesection. First step, showing the application of the bandage to the 

arm. (Ashton.) 

the venous circulation and make the veins stand out prominently 
(Fig. 145). 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 
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. 146), which is exposed by 
dissection and a small opening made in its anterior wall (Fig. 147). 
The arm is then turned over, the thumb removed, and the blood is 
permitted to escape into a glass graduate (Fig. 148). 



VENESECTION 



189 



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 
result that the blood will escape under the skin into the subcutaneous 
tissues. If the median basilic vein is utilized, the incision into its 
wall must not be made too deeply for fear of wounding the brachial 
artery. 




Fig. 146. Fig. 147. 

Fig. 146. — Venesection. Second step, vein exposed and operator's finger compressing 
the distal portion of the vessel. 

Fig. 147. — Venesection. Third step, sho\ving incision into vein's wall. 

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 bleeding, both ends of the vein should be 
sought and ligated with fine catgut. The patient should be in- 
structed to carry the arm in a sling for a few days following this 

operation. 

CompUcations.— 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 



igo ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 

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 




Fig. 148. — Venesection. Fourth step, showing the operator's finger removed from 
the vein and the blood being collected in a glass graduate. 

is done in withdrawing blood for bacteriological examination (see 
page 302). 

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 application. Thus in inflamed 
ulcers, threatened gangrene from extreme tension, phlegmonous ery- 
sipelas, etc., prompt rehef often follows its use. Scarification may 



SCARIFICATION 



191 



also be employed in the place of multiple punctures for the relief of 
tension in marked edema of the extremities, labia, and scrotum. 
In urinary infiltration deep scarification becomes necessary to allow 
the escape of the extravasation and to prevent sloughing. In inflam- 
matory affections and edemas of the pharynx, uvula, tonsils, and 
glottis it is often indicated; in involvement of the latter with progres- 
sive dyspnea and cyanosis the scarification should be performed with- 
out any delay. 

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



Pig. 149. — Knife wrapped with adhesive plaster. 

For incising the tonsil, glottis, etc., a sharp-pointed curved bis- 
toury wrapped with adhesive plaster to within J^ inch (6 mm.) of its 
point (Fig. 149) should be employed in the absence of a protected 
laryngeal knife (Fig. 150). 

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




Fig. 150. — Protected laryngeal knife. 

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, procain 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 in- 
flamed 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. 151) and in other regions 



192 ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 

paraUel to the lines of cleavage, care being taken not to wound the 
superficial nerves or large veins. Warm fomentations applied to the 
scarified area assist in maintaining the escape of blood and serum. 
Scarification of the larynx is performed with the aid of laryn- 
goscopy (page 440). When a clear view of the edematous parts has 
been obtained, incisions about >i 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 477) must be per- 
formed without hesitation. 




Fig. 151. — Showing the method of scarifying a limb. 

DRAINAGE IN EDEMA OF THE LOWER EXTREMITIES 



Three operative procedures may be employed for relieving edema 
of the lower extremities when the tension becomes too great, namely, 
multiple punctures (page 184), incision (page 190), 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 cannulae may be employed at a time, and con- 
siderable fluid may be drained off in this way. When more than one 
cannula is used several quarts may be abstracted in twenty-four 
hours, but the operator should be cautious about withdrawing too 
great a quantity for fear of inducing a condition of cerebral anemia. 
Should such a condition be produced, the drainage should, of course, 
be immediately stopped and stimulants administered. 

Apparatus.— -Southey's tubes (Fig. 152) or those of Curschmann 
may be employed. The former are made in a set consisting of one 



DRAINAGE IN EDEMA OF THE LOWER EXTREMITIES 



193 



trocar and four cannulae. Each cannula has lateral openings as well 
as a distal opening. The lumen of the cannula is about J^s 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 for 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. 



I 



O 




Fig. 152. — Southey's trocars and cannula. 



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 filled 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. 153). Three or more cannulae are introduced in this manner. 
The cannula should be secured in place by means of adhesive plaster, 
and sterilized dressings should be placed about them. Elevation of 
the 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 

13 



194 



ACUPUNCTURE, VENESECTION, SCARIEICATION, ETC. 



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 the removal of the cannulae, the sites of the punctures 
should be sealed with collodion and cotton. 




Fig. 153. — Showing the method of draining an edematous limb with Southey's cannula. 

(After Gumprecht.) 



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

Apparatus. — Special cupping glasses supplied with 
rubber bulbs for exhausting the air (Fig. 154) are 
Fig. 154.— obtainable and will be found very convenient, but 
Uib form of ^^q ordinary cupping glasses in which the vacuum is 

cupping glass. , . irir o o 

created by igniting a little 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 




CUPPING 



195 



rounded edges will answer equally well. From 8 to 12 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. 




Fig. 155. — Instruments for wet cupping, i, Cupping glasses; 2, swab in alcohol; 

3, alcohol lamp; 4, scalpel. 

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 
or an alcohol flame. If wet cupping is to be employed, there will 
also be required a sharp scalpel or lancet (Fig. 155). 




Fig. 156.— Cupping. First step, swabbing the interior of the cupping glass with 

alcohol. 



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 bony or irregular surfaces on 
account of the impossibility of excluding air. Where the brain is the 



196 



ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 



seat of the trouble, the cups are applied to the back of the neck; in 
pericarditis, to the precordial region; in involvement of the lungs or 
pleura, to the chest between the vertebral column and scapular line; 
in renal 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. 

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




Fig. 157. — Cupping. Second step, igniting the alcohol in the cupping glass. 

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. 156), 
care being taken not to leave any excess of alcohol that may run down 
over the edges. The alcohol is then ignited (Fig. 157), and the cup is 
quickly and tightly appHed 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. 158) 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 swelhng 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. 



LEECHING 197 

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. 

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 }4 
inch (8.5 mm.) apart are made, care being taken to incise the skin 
only, for, if the subcutaneous tissues are cut into, particles of fat will 
be drawn up into the cuts when the cups are reapplied. The cups are 
then immediately applied for the second time. Blood will be drawn 




Fig. 158.— Cupping. Third step, the application of the cups. 

from the scarified area into the cups until the vacuum is exhausted 
and the cups fall oiff. 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 



198 ACUPUNCTURE, VENESECTION, SCARIFICATION, ETC. 

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 Swedish 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 
affected, and to the coccyx for the relief of congested or inflamed 
hemorrhoids. 

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

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



LEECHING 



199 



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 




Fig. 159. — Artificial leech. 

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 




Fig. 160.— Application of the artificial leech to the mastoid, (.\fter Ballenger.) 
First step, showing the method of scarifying. 

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 



200 



ACUPUNCTURE, VENESECTION, SCARLFICATION, ETC. 



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. 159). 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 




Fig. 161.— Application of the artificial leech to the mastoid. (After Ballenger.) 
Second step, withdrawing blood. 

lancet to rapidly rotate, as shown in the accompanying illustration 
(Fig. 160), the blades of the instrument being adjusted so as to cut 
to the desired depth. Then the cupping tube is applied and blood 
abstracted by withdrawing the piston and creating a vacuum (Fig. 
161). 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 ARSPHENAMIN AND NEO- 
ARSPHENAMIN, 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 contraindi- 
cated. 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 affording a method whereby 
it is possible to administer remedies in the presence of nausea and 
vomiting, or inability or unwillingness on the part of the patient to 
swallow; furthermore, the absorption of the drug is not dependent 
upon the functional activity of the gastrointestinal tract. 

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



Fig. 162. — Ordinary glass and metal hypodermic syringe. 

with a leather-covered piston (Fig. 162). 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 
attended to. Syringes of solid metal (Fig. 163) or those consisting 
of a glass barrel and solid glass piston, as the Luer CFig. 164), or 
with an asbestos-covered piston, as the "Sub-Q,'* will be found pref- 
erable, and may be easily cleaned and repeatedly boiled without 
harm. A syringe with a capacity of 30m (2 c.c.) is amply large for 

ordinary use. 

201 



202 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

The needles should be as fine as possible (28 to 27 gauge) and 
very sharp, and for injection beneath the skin they should be about 

1 inch (2.5 cm.) in length. For the administration of liquids of a 
heavy consistency a needle of somewhat larger caliber will be re- 
quired. For intramuscular injections, the needle should be i J-^ 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 corre- 
pondingly large. To prevent the needles rusting. and the lumen be- 
coming plugged, they should be first well cleaned out with water 
after using, followed by alcohol and ether to remove any remaining 




Fig. 163. — All metal hypodermic syringe. 

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

Preparation of the Solution. — The drugs most frequently used 
for hypodermic medication are morphin, atropin, strychnin, hyoscin, 
pilocarpin, caffein, cocain, apomorphin, quinin, mercury, digitalis, 
ergotin, nitroglycerin, adrenalin, alcohol, ether, etc. As the major- 
ity 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 




Fig. 164. — ^Luer's hypodermic syringe. 

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 idni (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 
sealed glass ampules, each containing sufficient 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 



HYPODERMIC AND INTRAMUSCUI.AR INJECTION OF DRUGS 203 

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 
selected, the spot chosen, of course, being distant from the immediate 
neighborhood of large blood-vessels or nerves, bony prominences, or 




Fig. 165.— Sites for hypodermic injections. 

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 Hne through the upper margin of the great trochan- 
ter, is usually chosen (Fig. 165). Where numerous injections are 
given care should be taken to alternate between the two sides and to 
avoid 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 



204 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



more rapid than from the glutei. The spot chosen is at the junction 
of the inner and middle thirds of a line uniting the highest 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. 




Fig. i66. — Showing the method of giving a hypodermic injection. 

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




Fig. 167. — Deep intramuscular injection. First step, inserting the needle. 

Technic. — The required amount of solution is drawn into the 
barrel of the syringe with the needle in place and any air is expelled 
by elevating the needle end and depressing the piston. The skin 
over the site of the proposed injection is then pinched up between 
the thumb and forefinger of the left hand, while with the right hand 
the needle is quickly thrust at an angle of 45 degrees into the sub- 
cutaneous tissues at the base of this fold (Fig. 166). If the needle 



HYPODERMIC AND INTRAMUSCULAR INJECTION OF DRUGS 205 

is sharp and it be quickly plunged through the skin, but Httle, if any, 
pain will be experienced. The solution should be injected slowly to 
avoid too sudden distention of the tissues. When the required 




Fig. 168. — Deep intramuscular injection. Second step, showing the syringe removed 
and inspection of the needle for the flow of blood. 

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. 




Fig. 169.— Deep intramuscular injection. Third step, injecting the soluUon. 

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 



2o6 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

into the glutei muscles up to its hilt (Fig. 167) . 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. 168); 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. 169), 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 ARSPHENAMIN AND 
NEOARSPHENAMIN 

ARSPHENAMIN 

Arsphenamin is a yellowish crystalline powder containing about 
}^i of its weight of arsenic. It was introduced under the name of 
salvarsan or "606" by Ehrlich in 1910 for the cure of syphilis after 
years of experimental work upon animals with spirillicidal drugs. 
Although arsphenamin 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 unfortu- 
nately this early promise has not been realized in the majority of 
cases. There is no doubt that it 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. 

Arsphenamin is indicated in all stages of syphilis. It gives the 
best results, however, the earHer 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 
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, unless as 



ADMINISTRATION OF ARSPHENAMIN AND NEOARSPHENAMIN 207 

shown by Swift and Ellis it is administered intraspinously in the 
fonn of salvarsanized (arsphenaminized) serum (see page 338). 
It is contraindicated in advanced degenerative processes of the 
central nervous system and in long-standing cardiac and vascular 
degenerations, and in nonsyphilitic retinal and optic nerve affections. 
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. 

Arsphenamin has also been employed in the treatment of other 
diseases due to spirilla with excellent results. In relapsing fever, 




Fig. 170. — Apparatus* for intravenous injection of arsphenanun. i, Graduated 
reservoir, rubber tubing, and vein needle; 2, graduate and glass rod for miring the 
solution; 3, decanter for distilled water; 4, glass funnel; 5, medicine dropper; 6, bottle of 
sodium hydroxid solution; 7, tube of arsphenamin; 8, file; 9, catheter for constricting 
arm; 10, artery clamp. 

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. 

Arsphenamin was at first given subcutaneously. Then intra- 
muscular 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. 



208 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

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 arfe 
less likely to occur ii 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 
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 
with a capacity of about 10 ounces (300 c.c), (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 3-^ 
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. 171. — 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 arsphenamin and a file to open it with (Fig. 
170). 

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 arsphenamin 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 ampule of arsphenamin 
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>^ ounces) of hot 



ADMINISTRATION OF ARSPHENAMIN AND NEOARSPHENAMIN 209 

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 by 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. (73^^ gr.) of arsphenamin per- 
fectly clear. Having obtained an absolutely clear solution, it is 
diluted with sterile 0.5 per cent, saline solution, made from chemically 
pure sodiurh chlorid and sterile, freshly distilled water, up to 250 c.c. 
(8 ounces) if, for example, 0.5 gm. (73^^ gr.) is the dose, that is, 50 c.c. 
(1% ounces) of fluid is used for every o.i gm. (i3-^ gr.) of arsphenamin. 
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)-^ 
gr.), for women 0,3 to 0.4 gm. (4^^ to 6 gr.), for children 0.2 to 
0.3 gm. (3 to 43-^ gr.), and for infants 0.02 to 0.05 gm. {}/^ to % 
gr.). In this country it is becoming customary to employ smaller 
initial doses, that is, 0.2 and 0.3 gm. (3 and 4}^ gr.) doses and, if 
no unpleasant symptoms follow, the second dose may be increased 
0.1 gm. {i}i 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 
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. — ^AU 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 applied about the fore- 
arm, the operator identifies the vein into which he wishes to insert 

14 



2IO 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



the needle and instructs the patient to work his fingers until the 
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. 172). 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 




Fig. 172. — Method of inserting needle into the vein. 



the tubing of the intravenous apparatus, the latter is connected 
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 arsphenamin 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 
30 inches (60 to 75 cm.) above the level of the patient. It takes 
about ten minutes for the entire quanity 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. 



NEOARSPHENAMIN 



211 



NEOARSPHENAMIN 

The general properties of neoarsphenamin (neosalvarsan) are simi- 
lar to those of arsphenamin and it is claimed to be just as efficacious. 
It, however, possesses certain decided advantages over arsphenamin in 
that it is better tolerated and is less often followed by a systemic reac- 
tion, so that larger doses can be employed and the dose may be repeated 
more frequently. Furthermore, the preparation of the solution is very 




Fig. 173. — Method of giving arsphenamin intravenously. 

simple, the drug being quite soluble in water and not requiring to be 
neutralized with caustic soda. 

Neoarsphenamin is given intravenously or by intramuscular 
injection — preferably by the former method. 

Apparatus. — For the intravenous administration of dilute solu- 
tions of neoarsphenamin the same apparatus described for the admin- 
istration of arsphenamin (page 208) will be required. 



212 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



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 lo to 20 c.c. (2}4 to 5 dr.), (2) 
a needle about 2}i 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 neoarsphenamin and a file to open it with, and 
(6) a glass rod for stirring (Fig. 174). 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 neoarsphenamin 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 




1 . ' S. 3 6 

Fig. 174. — Apparatus for intramuscular and intravenous injections of concentrated 
solutions of neoarsphenamin. i, Decanter of distilled water; 2, medicine glass; 3, all 
glass syringe and needle; 4, tube of neoarsphenamin; 5, small file. 



dissolving each 0.15 gm. (2 }{ gr.) of neoarsphenamin in 25 c.c. 
(6^ dr.) of freshly distilled sterile water. The water should not be 
heated, but should be at 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% to 9 gr.) of neoarsphenamin in 10 c.c. (2% dr.) 
oi freshly distilled sterile water, or 0.75 to 0.9 gm. (ii3^^ to 14 gr.) 
of neoarsphenamin 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}^ gr.) of neoarsphenamin 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 neoarsphenamin for men is 0.6 to 
0.75 gni. (9 to ii3^ gr.), for women 0.45 to 0.6 gm. {6^i to 9 gr.), 



NEO ARSPHENAMIN 2 1 3 

for children 0.15 to 0.3 gm. (23-^ to 4% gr.), and for infants 0.05 gm. 

m gr.). 

Repetition of the Dose. — Injections of neoarsphenamin 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 203). 

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 arsphenamin (see page 209) . When the concentrated solution 
is employed, however, the injection is more conveniently made with 
a syringe instead of a gravity apparatus. 

(2) Intramuscular Injection. — ^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, procain solution is injected into the region in 
order to diminish the sensibility. Then, after waiting a few moments, 
the desired quantity of neoarsphenamin 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 205.) Following the injection, the patient is 
kept in the recumbent position on his side or abdomen for 15 to 20 
minutes. 

The Rectal Administration of Arsphenamin and Neoars- 
phenamin. — Arsphenamin and neoarsphenamin have been adminis- 
tered in an enema by rectum, and reports would seem to show that 
the results are about as prompt as when the intravenous method is 
employed. The method is especially useful in children. Reactions, 
such as chills, fever, gastric irritation, diarrhoea, etc., which may 
follow the intravenous administration are claimed to be absent. 

Apparatus. — Any of the forms of apparatus described on page 595 
may be used, or a salvarsan flask, attached by a piece of rubber 
tubing to a rectal tube, may be employed. 



214 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

Preparation of Solution. — The solution is prepared in the usual 
way (see pages 208, 212), the appropriate dose being diluted in 150 
to 250 c.c. (5 to 8 ounces) of saline solution. 

Preparation of the Patient. — The rectum should be empty. 
Inability to retain the enema may be overcome by giving a dose 
of paregoric or tinct- of opium by mouth. 

Technic. — The enema is administrated with the patient in the 
knee chest or the Sims position. (For a full description of the 
technic see page 598.) Following the injection the patient should 
remain in bed 4 or 5 hours, with the foot of the bed elevated. 

Enemata are given once or twice a week. 

THE ADMINSTRATION OF DIPHTHERIA ANTITOXIN 

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

The Serum. — The serum 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 will depend upon 
the age of the patient and the severity and the stage of the disease. 
It should always be large for the serum is harmless and it is better to 
administer too much than not enough. According to Holt "for a 
child over two years, an initial dose for a severe attack, including all 
laryngeal cases, should not be less than 4000 to 5000 units; and the 
dose should be repeated in six or eight hours provided no improve- 
ment is seen. Children under two years should receive from 2000 

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



ADMINISTRATION OF DIPHTHERIA ANTITOXIN 21$ 

to 3000 units. Cases of exceptional severity where the injection is 
given late should receive from 8000 to 10,000 units, to be repeated iu 
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." 

Schick, who has done considerable experimental work on the 
dosage of diphtheria antitoxin, recommends giving 100 units of 
antitoxin in mild cases and in severe cases 500 units for each kilo- 
gram (2}i lbs) of weight. 

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. 

The Syringe. — The simpler the s)n*inge, the better. The 
syringe should have a capacity of about i}i to 2}^ drams (5 to 10 
c.c). Glass syringes with asbestos packing or those with the solid 




Fig. 175. — The record antitoxin syringe. 

glass piston, as the Luer, are most easily sterilized. The record 
syringe (Fig. 175) is also an excellent instrument. A moderately 
fine needle or the smallest through which the serum will flow is 
preferable to one of very large caliber. In charging the syringe it 
is better to remove the piston and pour the antitoxin into the syringe, 
as it is difficult to draw it up through the needle. The piston is 
then inserted and, with the syringe elevated, any air is expelled. 
Many of the manufacturers at the present time supply a syringe 
already sterilized and filled with antitoxin (Fig. 176). The advant- 
ages of this in the saving of time are obvious. 



2l6 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

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. 177). 

Asepsis. — The syringe and needles should 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. 176. — The New York Board of Health Antitoxin Syringe. The syringe comes 
sterilized and already loaded with antitoxin and, upon inserting the needle into the 
distal end, is ready for use. 

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 Httle. A fold of the skin from the area 
previously sterilized is then raised up betv/een the thumb and fore- 
finger of the left hand, and with the right hand, the needle is quickly 
plunged into the subcutaneous tissue (Fig. 178). If done quickly 
with a sharp-pointed needle, preliminary local anesthesia of the skin 




Fig. 177. — Sites for antitoxin injection. 

is unnecessary. The serum is then injected very slowly and the 
swelling produced is not massaged, being allowed to subside as the 
serum is absorbed. After withdrawal of the needle the puncture is 
sealed with collodion and cotton. Following the injection there may 
be a slight reaction 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 



ADMINISTRATION OF DIPHTHERIA ANTITOXIN 



217 



antitoxin. In a few hours the pseudomembrane begins to lose its 
dirty (^olor and becomes blanched and somewhat swollen. Within 
twelve to twenty-four hours the membrane loosens at the edges and 
rolls up, becoming detached in a mass, or in small pieces. , This seems 
to take place more rapidly about the tonsils than elsewhere. The 
usual time for 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 




Fig. 178. — Showing the method of injecting diphtheria antitoxin in the subcutaneous 

tissue of the axilla. 



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. 

The effects upon the constitutional symptoms are likewise 
impressive. 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 



2l8 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



the injection, and the pulse may be accelerated at the same time, but 
this is followed in favorable cases by a fall of the fever either by crisis 
or by lysis, the temperature becoming practically normal in two or 
three days. The persistence of fever is an indication for a second 
dose of antitoxin. 

The reduction in the mortality rate since the introduction of anti- 
toxin is well shown in the following table (Fig. 179) 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. 





YEAR 

We 89 So 91 92 93 9*fr 95 9fe 97 96 99 Oo" 01 02 03 01- OS 06 OT 08 


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'case fatauty " 1 

DEATH RATE. | 



Fig. 179. — 
tion 



Chart prepared by the New York Board of Health, showing the reduc- 
in the mortality from diphtheria since the introduction of antitoxin. 



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 
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 



VACCINATION 219 

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 
vaccinated. 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 understood, but the results 
of vaccination are unquestionable and admirably attest its efficiency. 
Localities in which vaccination is systematically carried out develop 
fewer cases and present the lowest death rate from smallpox. 

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

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

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 six months old before vaccination. The operation 
should be avoided if possible in dentition; and children who are 
delicate or suffering from malnutrition, syphilis, 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, 



220 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

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

The New York Department of Health supplies with each capillary 
tube of vaccine virus, a needle, a flat tooth pick for spreading the 
virus, and a piece of small rubber tubing which fits over one end of 
the capillary tube and is used to force the vaccine out of the tube 
(Fig. i8o). 



1 — -— ^—^ 














p _ 












/l « A 






6 \^ 


-=^ 





Fig. i8o. — New York Department of Health vaccination outfit, i, Instruments 
in case; 2, rubber tube for forcing the virus out of the tube; 3, tube containing virus; 
4, needle for scarification; 5, stick for spreading the virus. 

Site of Vaccination. — The vaccination is performed either upon 
the arm or leg. As a rule, the arm is preferred as a site, especially in 
children who are running about, as being more easily kept at rest and 
less likely to be injured. Mothers often prefer to have their girls 
vaccinated upon the leg to avoid the disfiguring effect of the scar. 
If the arm is chosen, the point selected is at about the insertion of the 
deltoid muscle; in the leg a spot on the outer aspect at the junction 
of the middle and upper third is selected. 

Asepsis. — 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 
iiKtrument 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 



VACCINATION 



221 



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 niay be lessened. 




Fig. i8i. — Vaccination. First step, scarifying the arm. 

Technic. — (i) By Scarification. Vaccination by the scarifica- 
tion method is generally practised in this country. A proper spot is 




Fig. 182. — Vaccination. Second step. Rubbing the virus into the scarified area. 

chosen upon the arm or leg, and an area M to J^ inch (3 to 6 mm.) in 
diameter is scarified by making a number of scratches at right 



222 



HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 



angles to each other in the skin with the point of the instrument 
just deep enough to draw serum, but no blood (Fig. i8i). If more 
than one inoculation is to be made, as is frequently done, the area 
scarified should be at a distance of at least i inch (2.5 cm.) apart. 
The virus is then deposited upon the scarified area, being rubbed in 
with some sterile instrument for a full minute and allowed to dry 
(Fig. 182). The site of vaccination is 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. 183) may be used, provided it is 
applied in such a way as not to constrict the arm (Fig. 184). After 
the vesicle has formed, the part should be gently washed with sterile 





Fig. 183. — Vaccination shield. Fig. 184. — Showing the shield in place. 



water once a day and dressed with fresh gauze or covered with a 
shield to prevent contact with the clothing. 

(2) By Acupuncture or Epidermic Puncture, — By some this 
method of vaccination is preferred to scarification. Hill {Canadian 
Medical Association Journal ^ March, 191 6) describes the method as 
follows: The arm is washed with soap and water, then with alcohol, 
and finally with ether. Drops of the virus are deposited upon the skin 
at three points so that each drop forms one of the angles of a triangle 
with sides 2 inches (5 cm.) long. The skin is then drawn tight by the 
operator's left hand which grasps the part from behind, while with 
the tip of a sterile needle, held almost parallel with the surface, 
punctures are made through the virus into the superficial layer of the 
skin to the depth of Kooo of an inch (.025 mm.). Six punctures 



VACCINATION 223 

are made close together at the site of each drop. The excess of the 
virus is then wiped off, no dressing or shield being required. 

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, 3^^ to ^i inch 
(6 to 1 2 mm.) in diameter, and full of limpid fluid. ' The center of the 
vesicle is depressed, while the margins are elevated and slightly 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 until the eighth or ninth day, when it drops 
gradually to normal. In children irritability, loss of appetite, and 
restlessness at night may accompany the fever. The axillary or 
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. 

Syphilis 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. 



224 HYPODERMIC AND INTRAMUSCULAR INJECTIONS, ETC. 

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 with 80 per cent, alcohol of the different 
branches of the fifth nerve 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 
necessitates exposure of the affected nerve or nerves and, for this 
reason, it has been largely discarded in favor of alcohol alone or in 
combination 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, but, 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 
the anterior convex border of the ganglion the sensory portion emerges 

^ More recently injections have been made directly into the Gasserian ganglion. 
15 225 



226 



TiiEATMENT OF NEURALGIA BY INJECTIONS 



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 sensory 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 rotun- 
dum, crosses the spheno-maxillary fossa, and, after entering the orbi- 




FiG. 185. — Anatomy of the trifacial nerve. (After Campbell.) 

tal cavity through the spheno-maxillary fissure, passes to the f ac by 
way of the infraorbital groove. It is also a sensory nervfe, supplying 
the cheek, anterior portion of the temporal region, the lower eyelid, 
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 nerve formed from a sensory and 
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 membrane of the mouth, 
tongue, and mastoid cells, and salivary glands. The motor portion 
supplies the muscles of mastication. 



TIC DOULOUREUX 



227 



Instruments. — There will be required a special needle 4^ inches 
(12 cm.) long and ^4 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>^ 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. 186). 




1 



1 54 a ^ 5 4 

Fig. 186. — Apparatus for injecting the branches of the fifth nerve, i, Two medicine 
glasses; 2, Luer syringe; 3, Levy and Baudouin needle; 4, small hypodermic needle; 
5, ampule 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 distal portion of the needle 
is graduated in centimeters up to five. The proximal end of the 
needle should be made to accurately fit the end of the syringe (Fig. 

187). 



Fig. 187. — Enlarged view of the Levy and Baudouin needle and stylet. 



Solution Used. — The solution originally used was a mixture of 
cacain, 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 reaction at the 
site of injection and the formation of scar tissue. Patrick {Jour- 
nal of the American Medical Association, Jan. 20, 191 2) uses the 
following: 

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. 



228 TREATMENT OF NEURALGIA BY INJECTIONS 

Quantity Used. — For a deep injection 3otTl (2 c.c.) of solution 
are generally injected into each branch. Eight minims (0.5 c.c.) is 
suflSicient 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 boiHng, 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. 188. — Showing the method of injecting the supraorbital branch of the first division 

of the fifth nerve. 

Inesthesia that results over the area of distribution of the nerve 
anfiltration of the skin with a few drops of 0.2 per cent, cocain solu- 
tion or a I per cent, procain solution at the point through which 
the needle enters is usually sufficient. 

Technic. — The site of injection and the direction in which the 
needle is inserted will vary according to the branch injected. 

First Division. — Deep injection of this nerve at the sphenoidal 
fissure is rarely practised on account of its dangers; instead, the 
supraorbital 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- 



TIC DOULOUREUX 229 

ball being protected by the index finger of the operator's left hand 
(Fig. 188). When the needle strikes the nerve a sharp shooting pain 
extending up the forehead will be felt by the patient. If possible, 
the needle should be inserted for a distance of }^i to % 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 vertical line to the lower border of the zy- 
goma; yi inch (0.5 cm.) behind the point where this perpendicular 
line crosses the zygoma is the point for entrance of the needle. The 




Fig. 189. — 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 strikes the 
coronoid process of the lower jaw, it will have to be re-inserted at a 
point slightly 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 



230 TREATMENT OF NEURALGIA BY INJECTIONS 

the needle introduced the correct distance, the stylet is withdrawn 
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 slightly 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 following the 
injection. 

If it is found impossible to reach the nerve at its exit from tne 
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 des- 
cending root of the zygoma is identified, and at a point i inch (2.5 




Fig. 190.— Needle in place for injecting the third division of the fifth nerve. 

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 sub- 
cutaneous tissues in a direction slightly upward and backward. 
The stylet is then pushed home, and needle is carried in through the 
deeper tissues, still sHghtly upward and backward, until it reaches 
a depth of i}^ 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 



TIC DOULOUREUX 



231 



of the operation, the needle is withdrawn and the skin puncture is 
sealed with collodion and cotton. 

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 destruc- 
tive action upon nerves and which have been effectively employed in 
neuralgia of the fifth nerve should be avoided in sciatica, as the 




Fig. 191. — Apparatus for injecting the sciatic nerve, i, Medicine glass; 2, glass 
graduate; 3, large glass syringe and blunt needle for injecting the nerve; 4, ampule of 
cocain; 5, small syringe and needle for the preliminary infiltration of the site of puncture; 
6, scalpel. 



I 



sciatic is a mixed nerve and the use of such drugs has produced grave 
motor changes in the nerve. The injection of physiological salt 
solution, however, has given good results in relieving the pain of scia- 
tica without 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 relief. Fre- 
quently 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 4^^ inches (12 cm.) 
long and J-fg 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 



232 



TREATMENT OF NEURALGIA BY INJECTIONS 



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. 191). 

The needle is of a type similar to that used for trifacial injections 
(see Fig. 187). 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). 




Fig. 192. — Showing the method of locating the point for injecting the sciatic nerve. 

(After Hoecht.) 

Quantity. — Two to 4 ounces (60 to 120 c.c.) of the warm solution 
and 23^^ to 5 drams (16 co 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 ad- 
vised. That used by D'Orsay Hoecht and one that gives access to 
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. 192). 

The nerve may also be reached by inserting the needle at a point 
where a horizonal line through the tip of the great trochanter cuts a 



SCIATICA 233 

vertical 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. 

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 procain. 

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 3^^5 inch (i mm.) and should be in close 
proximity to the nerve. The moment the nerve is reached the pa- 
tient 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 in- 
jected. 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 
quite for several days. For the first few days there may be some 
soreness, and not infrequently there is a slight rise of temperature 
for the first 24 to 48 hours. 



CHAPTER IX 

DISINFECTION OF WOUNDS BY THE CARREL-DAKIN 

TECHNIC 

The Carrel method of treating infected wounds is based on the 
belief that a non-toxic and non-irritating antiseptic, applied to, and 
kept in contact with all parts of a wound during a certain period of 
time and in a constant concentration, is capable of destroying 
microorganisms and eventually sterilizing the wound. The oppor- 
tunity to employ the Carrel technic during the recent war has fully 
demonstrated the soundness of Carrel's teachings, and the value of 
the method not only in preventing, but in suppressing, suppuration. 
Under this treatment wound complications are greatly diminished, 
convalescence is more rapid than under the old methods of treatment, 
and the period of incapacity is reduced to a minimum. Favorable 
results, however, depend upon the strict adherence to all the details 
of the technic so carefully developed by Carrel, for, as he emphasizes 
"the success of the method which enables us to render aseptic an 
infected wound is not due to the marvellous properties of a new drug. 
It should rather be attributed to a combination of means, which 
enables us to make use of a definite antiseptic substance, under such 
conditions of concentration and duration that its action becomes 
eflSicacious. This method is a combination of which each single 
part is essential to the rest. The antiseptic cannot be altered without 
changing the manner of using it. In the same way, a modification of 
the technic demands an antiseptic endowed with different chemical 
properties." 

Dakin's hypochlorite solution, having powerful bactericidal 
powers and at the same time being but slightly irritating to the 
tissues, was chosen as the antiseptic best meeting the requirements of 
the Carrel method after an exhaustive examination of many sub- 
stances with regard to their bactericidal action and effect upon 
normal tissues. The solution is instilled into the wound at frequent 
intervals, the object being not to irrigate the wound, but to keep it 
constantly bathed in the solution. Frequent instillations are 
necessary, because, in contact with wound fluids, the solution 
rapidly loses its chlorin. If the solution is used early in a wound, 

234 



DISINFECTION OF WOUNDS 235 

before the microorganisms have time to multiply and spread, 
infection may be aborted and the wound closed by suture without 
suppuration, while, if suppuration is already present, it can be 
controlled, provided the focus is reached by the solution, the wound 
being gradually freed from infection and put in such condition that 
it can be early closed by suture. Favorable response to the treat- 
ment is not gauged only by the clinical appearance of the wound, 
but is determined first by a diminution, and finally the disappearance 
of microorganisms demonstrated by microscopical examination of 
the secretions. 

Properties of Dakin's Solution. — Dakin's solution is a 0.5 per 
cent, neutral hypochlorite of soda solution. It differs from Javel 
water, Labarraque's solution, and other hypochlorites in that it 
contains no free alkali and so is non-irritating to the tissues. The 
effects are entirely local and, regardless of the amount used, there 
is no danger of toxemia from absorption. It has the property of 
disintegrating necrosed tissue, blood clots, etc., but does not harm 
the tissues undergoing repair or normal tissues with blood supply. 

The solution of sodium hypochlorite for the treatment of wounds 
should meet the following requirements. It must contain no 
caustic alkali and the hypochlorite content must be between 0.45 per 
cent, and 0.5 per cent. Solutions of hypochlorite with a strength 
below 0.45 per cent, are not active enough, while above 0.5 per cent, 
the solution is irritating. The solution must be carefully prepared, 
preferably by a trained chemist, and should be tested regularly. 
It should be kept in a cool place, free from exposure and light. 
It should never be heated, as by so doing its composition is altered 
and it loses its antiseptic properties. 

Preparation of Dakin's Solution by Daufresne's Method ^ — For 
the preparation of the solution three chemicals are necessary: 
calcium chlorid, sodium carbonate (dry, obtained in the market 
under the name of Solvay's soda), and sodium bicarbonate. The 
last two ingredients are fairly uniform in compositions, but the 
commercial chlorid of lime is subject to wide variations as to the 
amount of active chlorin it contains, and, for this reason, it is 
essential to determine by titration the percentage of active chlorin 
in the calcium chlorid employed. 

Titration of the Calcium Chlorid — For this purpose there will be 
required a 25 c.c. buret, graduated in tenths of a cubic centimeter, a 
10 c.c. pipet, and a decinormal solution of sodium hyposulphite. 

1 Infected Wounds, Carrel and Dehelly. 



236 



DISINFECTION OF WOUNDS 



An average sample of the calcium chlorid is obtained by select- 
ing small amounts from different parts of the stock and mixing them 
carefully. Twenty grams of this average sample are then weighed 
out and are dissolved in one liter of tap water. This solution is 
allowed to stand for several hours. Ten c.c. of the clear fluid is then 
measured off and to it is added 20 c.c. of a 10 per cent, solution of 
potassium iodid and 2 c.c. of acetic or hydrochloric acid. To the 
resultant mixture a decinormal solution of sodium hyposulphite is 
added drop by drop until the mixture is decolorized. The number of 
cubic centimeters of the hyposulphite solution employed to decolor- 
ize the mixture, multiplied by 1.775, gives the weight of active 
chlorin contained in 100 grams of calcium chlorid. The estima- 
tion of the chlorin must be carried out for each new sample of cal- 
cium chlorid employed. 

Daufresne gives the following table of the quantities of the 
chemicals required to obtain a correct solution, according to the 
amount of active chlorin contained in the calcium chlorid : 





Quantities to be used to obtain lo liters of solution of hypo- 




chlorite of 0.475 per cent. 


Titration of chlorid 








of lime (CI per 


Chlorid of lime, 


Carbonate of soda 


Bicarbonate of soda, 


cent.) 


grams 


anhydrous, grams 


grams 


20 


230 


115 


96 


21 


220 


no 


92 


22 


210 


los 


88 


23 


l^OO 


100 


84 


24 


102 


96 


80 


25 


184 


92 


76 


26 


177 


89 


72 


27 


170 


85 


70 


28 


164 


82 


68 


29 


159 


80 


66 


30 


154 


77 


64 


31 


148 


74 


62 


32 


144 


72 


60 


33 


140 


70 


59 


34 


135 


68 


57 


35 


132 


66 


55 


36 


128 


64 


53 


37 


124 


62 


52 



Preparation of Dakin's Solution,— (1) To make ten liters of the 
solution, weigh the exact quantities of the calcium chlorid, sodium 



DISINFECTION OF WOUNDS 237 

carbonate, and sodium bicarbonate determined by titration of the 
calcium chlorid. For example, if the calcium chlorid contains 25 per 
cent, active chlorine there will be required: 

Calcium chlorid 184 grams 

Sodium carbonate, dry, Solvay 92 grams 

Sodium bicarbonate 76 grams 

(2) Place the calcium chlorid in a 12 liter flask with 5 liters of 
tap water and, after shaking thoroughly for several minutes, allow 
it to stand over night. 

(3) Dissolve the carbonate and bicarbonate of soda in another 
5 liters of cold water. 

(4) Pour the solution of soda salts into the flask containing 
the super-saturated solution of calcium chlorid and, after shaking 
vigorously for a few moments, allow it to stand so that the carbonate 
of calcium, which is formed, can settle. 

(5) At the end of half an hour syphon off the clear fluid and 
filter it through two thicknesses of filter paper. A perfectly clear 
fluid should be the result. 

The fluid is now ready for use. To avoid mistaking it for other 
solutions permanganate of potash, (5 mgm. to the liter of filtered 
solution), may be added for the purpose of coloring it. 

Titration of Bakings Solution. — The strength of the solution 
should be determined from time to time by titration. It is performed 
as follows. To 10 c.c. of Dakin's solution add 20 c.c. of a 10 per cent, 
solution of potassium iodid and 2 c.c. of acetic or hydrochloric acid. 
To this mixture is added drop by drop, a decinormal solution of 
sodium hyposulphite until it is decolorized. The number of cubic 
centimeters of the sodium hyposulphite solution used, multiplied 
by 0,03725, will give the weight of hypochlorite of soda contained 
in 100 c.c. of solution. 

Test of Alkalinity of Dakin's Solution. — Place 20 c.c. of the solu- 
tion in a glass and drop a few centigrams of powdered phenol- 
phthalein on the surface of the liquid. If the solution is properly 
prepared, it will remain colorless, while a red tint indicates the 
presence of free caustic soda. 

Apparatus. — For instilling the solution into a wound there will 
be required: (i) A glass reservoir with a capacity of i quart (liter), 
(2) a red rubber irrigating tube J^ inch (6 mm.) in diameter and 6 
feet (2 m.) long, (3) a glass drop counter, (4) a clamp for controlling 
the flow of the solution, (5) glass connections and distributing tubes, 
and (6) rubber instillation tubes about 16 French in diameter and 



238 



BISINFECTION OF WOUNDS 



12 to 1 6 inches (30 to 40 cm.) long. For intermittent instillations 
with numerous tubes, which is the usual method employed, the 
apparatus is assembled without the "drop-counter" (Fig. 193). The 
latter is essential only when continuous instillations with a single tube 




Fig. 193. — Carrel apparatus assembled for intermittent instillation with numer- 
ous tubes. Small figure shows the arrrangement of the perforations and the end of the 
tube tied oflf. 

is used, a screw pinch cock regulating the flow of the solution (Fig. 
194). 

The instillation tubes are of two varieties — (i) non-perforated, 
with ends open and a large flat lateral opening 3^ of an inch (5mm.) 



BISINTECTION OF WOUNDS 



239 



from the distal end (see Fig. 194), and (2) perforated tubes, with 
the distal end closed with a ligature (see Fig. 193). A punch pro- 
ducing a hole with a diameter of about J-^s of an inch (i mm.) (Fig. 
195) is used to make the perforations. The tubes are perforated over 




Fig. 194. — Carrel apparatus assembled for continuous instillations. Note the 
single tube, drop-counter, and screw pinch-cock for regulating the flow. The small 
figure shows an enlarged view of the distal end of the tube with lateral opening. 

a space of from 2 to 8 inches (5 to 20 cm.) from the closed end, 
about eight perforations being made in each 2 inches (5 cm.) of 
space. For use on a large circular area such as an amputation 



240 



DISINFECTION OF WOUNDS 



stump, tubes may be employed in which the perforations are made 
in the middle third of the tube, leaving both ends open. For super- 




FiG. 195. — Punch for making the perforations in the tubes. 




M 







It <^^: 



Fjg 106.— Carrel tubes. A. Two way tube with perforations in the center. B. 
Perforated tubes covered with Turkish towelling. 

flcial wounds where it is desired to distribute the fluid over a large 
surface and for wounds with dependent openings, perforated tubes 



DISINFECTION OF WOUNDS 24 1 

are covered with Turkish towelling, and threads are fastened to the 
towelling and left long, to act as guy ropes and maintain the tubes 
in position. The threads may be sutured to the skin edges, or they 
can be held sufficiently fixed if covered by the vaseline gauze used to 
protect the skin edges. 

The glass distributing tubes are employed for connecting the 
instillation tubes with the main conducting tube. They are pro- 
vided with I, 2, 3, or 4 branches, so that the instillation may be 
carried out through one tube or through groups of 2, 3, or 4 tubes. 
When more than four tubes are required, a Y shaped glass tube is 
inserted into the conducting tube, thus allowing two sets of instilla- 
tion tubes to be connected with one reservoir. 

Dressings, etc. — For protection of the skin in the neighbor- 
hood of the wound, strips of gauze bandage, 2j^ by 5 inches (6 by 
12 cm.) in size, impregnated with sterile vaseline, are employed. 
These may be conveniently prepared by laying the strips of gauze 

^ P 



TMmmmm^Mmw'X^H^mmmumm^^^^^^^^^ 



B \C 

Fig. 197. — Cross section of large pad, showing n. and D. gauze, B. non-absorbent 
cotton, and C. absorbent cotton. (After Carrel and Dehelly.) 

m a shallow tin wafer box and pouring yellow vaseline melted to a 
liquid over them, so that the vaseline soakes into all portions of the 
gauze. The box is then covered and the whole is sterilized in an 
autoclave. Sterile gauze tampons for holding the tubes in place in the 
wound, are also required. 

The dressings are in the form of pads, of three sizes: one large 
enough to encircle the thigh, one for the arm or leg, and a smaller 
size. These pads consist of a layer of absorbent cotton and then a 
layer of non-absorbent cotton wrapped in a layer of gauze, which is 
carefully folded over the back of the pad. Secretions are thus 
absorbed, yet do not escape to the exterior. For holding these 
outside dressings in place web straps, safety pins, or clamps may be 
utiKzed. 

In addition to the above, scissors, dressing forceps, and rubber 
gloves are required. 

Asepsis. — The instillation tubes are sterilized by boiling or in 
an autoclave and the dressings are sterilized in an autoclave. In 
dressing the wounds everything that comes in contact with the 

16 



242 



DISINFECTION OF WOUNDS 



wound is handled with sterile forceps, and not even the gloved 
hands are allowed to touch the dressings or tubes. The instruments 
must thus he freshly sterilized for every case, and it is sometimes 
necessary to use newly sterilized instruments in dressing different 
wounds on the same patient. 

Frequency of Instillations. — Intermittent instillation, the method 
applicable to the great majority of wounds is practiced every two 
hours day and night. 

Quantity of Solution Instilled. — The length of time the solution 
flows should be sufficient to thoroughly bathe the wound and yet not 
flood it and wet the patient. The quantity of solution necessary tp 
fill the wound may be determined at the first dressing by allowing 
the solution to flow after the tubes are in place before the wound is 
covered. Usually the pinch cock is opened from a half to three 
seconds, depending on the size of the wound. The amount of solu- 
tion that escapes will thus vary from % to 3 ounces (20 to 100 c.c), 
and from 8 ounces to 23^^ pints (250 to 1200 c.c.) in the twenty-four 
hours. 

For continuous instillations the pinch cock should be so regu- 
lated that the solution flows at the rate of 5 to 6 drops per minute. 

Height of Reservoir. — The pressure under which the solution 
enters the wound is regulated by the height of the reservoir, and 
will vary according to the sensitiveness of the patient and the type 
of wound. The pressure should not exceed three feet (i meter) and 
often 16 inches (40 cm.) is sufficient. The entrance of the fluid 
should not cause the patient pain; if it does, the cause is either ex- 
cessive pressure or an inability of the solution to escape from the 
wound from a small opening. 

Duration of Instillations. — The instillations are maintained 
day and night until all microorganisms disappear from the wound. 
This usually requires from 5 to 8 days in moderate sized wounds of 
the soft parts, and longer if there is bone involvement. 

Technic. (i) Mechanical Cleansing of the Wound, — The first 
essential of the treatment is the preparation of the wound for the 
penetration of the Hquid by a thorough mechanical cleansing. 
This should be carried out at the earliest possible moment before 
the inflammatory stage sets in. It consists of a careful and thorough 
debridement of the wound and the removal of any shell fragments, 
pieces of clothing, dirt, etc. It must be thoroughly and methodi- 
cally done with all aseptic precautions under a general anesthetic. 

The field of operation is sterilized with tincture of iodin. The 



DISINFECTION OF WOUNDS 243 

wound must be opened up sufficiently to enable the operator to ex- 
plore hy sight the entire tract of the missel. The incisions should 
therefore, be free and one should not hesitate in this respect, as 
closure is readily effected when the wound is sterilized. The in- 
cisions are made, as far as possible, in the long axis of limbs or par- 
allel with underlying muscle fibers, large vessels, and nerves. The 
debridement is commenced by cutting away with the aid of a scal- 
pel and thumb forceps the bruised edges of the skin. The instru- 
ments used for this are then discarded for clean ones, and the same 
procedure is applied to the subcutaneous and muscular tissues. 
The incision exposing the tract through the muscles is of the same 
extent as the skin incision so that the depths of the wound may be 
laid open. The entire tract is then carefully explored, removing 
infiltrated blood, all tissues contaminated with particles of clothing, 
dirt, grass, or other foreign bodies, and tissues of doubtful vitality. 
All pockets are carefully explored for foreign substances. The 
same mechanical cleansing is applied to injured bone, removing 
splinters lying free but preserving those adherent to periosteum. 

If drainage of the wound is required, counter openings at depen- 
dent portions should be avoided as far as possible, for the success 
of the instillation treatment depends upon keeping the solution in 
contact with the wound and not allowing it to escape through the 
bottom. 

In the handling of the tissues gentleness is essential to avoid 
bruising and additional traumatism. Rough wiping of the wound 
and the careless use of retractors frequently aggravate the preex- 
isting damage and increase the chances for injection. 

Before completing the operation it should be seen that there is 
complete hemostasis and no oozing. Tissues infiltrated with blood 
are prone to infection and, furthermore, carelessness in this re- 
spect may invite secondary hemorrhage, as Dakin's solution has the 
power to dissolve fresh blood clots. 

(2) Arrangement of the Tubes. — The tubes are so placed in the 
wound that the solution will come in contact with every portion of 
it. They are placed directly in contact with the wound surface 
with a gauze compress over them (Fig. 198). Gauze should not be 
placed between the wound and the tubes, as the gauze quickly be- 
comes impregnated with wound secretions and prevents the solution 
from reaching the wound. 

In superficial wounds one or more perforated tubes according to 
the size of the wound are placed on the wound surface, the tubes 



244 



DISINFECTION OF WOUNDS 



being prevented from slipping by gauze compresses laid over them, 
or a two-way flow tube in the form of a ring with perforations in the 
center may be employed (Fig. 199). By means of rubber cuffs 




Fig. 198. — Method of placing the tube in a wound and covered with a gauze compress. 

(After Carrel and Dehelly.) 

and threads the tube may be arranged in any desired shape. If the 
wound is on the lateral aspect of the body so that the wound surface 




Fig. 199. — Arrangement of a perforated two-way tube on a large superficial wound. 
(Carrel and Dehelly modified.) 

is inclined, the tubes are placed along the superior border so the 
solution will spread by gravity over the surface (Fig. 200). 




Fig. 200.— Method of placing tubes in a wound with an inclined surface (After Carrel 

and Dehelly.) 

Penetrating wounds with the opening situated above require 
but a single tube. A tube without perforations, the opening being 



DISINFECTION OF WOUNDS 



245 



at the extremity, is introduced to the bottom of the wound, and the 
wound filled with solution (Fig. 201). It is to this type of wound 
that continuous instillation drop by drop is apphcable. When the 




Fig. 201. — Single tube in cup-shaped wound (Carrel and Dehelly modified.) 

opening is on the lateral aspect of a part, perforated tubes are em- 
ployed and retention of the fluid is attained by placing a light com- 
press about the orifice of the wound. A wound with the opening 




Fig. 202. — Method of using a tube covered with Turkish towelling in a wound of the 
soft parts in a dependent portion of a limb. 

located dependently is more difficult to sterilize. In such a case a 
tube covered with Turkish towelling, which tends to spead the 
solution over the wound and keeps it in contact for a longer period is 



246 DISINFECTION OF WOUNDS 

i 

employed (Fig. 202), or in large wounds several perforated tubes 
may be used, the solution being introduced under slightly greater 
pressure. 

I Perforating wounds with the openings on the anterior surfaces 
of the body present no great difficulty in the arrangement of the 
tubes. When one of the openings is dependent, the fluid tends to 
escape by gravity from the lowest opening, and the tubes must be 
arranged in such a way that the solution will escape at the highest 
point and flow back over the wound surface. Retention of the 
solution is favored by lightly tamponing the wound orifices (Fig. 
203). 




Fig. 203. — Method of placing the tubes in a large irregular perforating wound. (Carrel 

and Dehelly modified.) 

(3) Dressing the Wound. — When the tubes are properly arranged, 
they are fixed in position by small gauze compresses soaked in 
Dakin's solution. Care must be taken to see that all of the perfora- 
ted portion of the tubes Hes in the wound, otherwise the solution 
will escape outside the wound. Squares of vaseline gauze are 
placed on the skin adjoining the wound for its protection, and readi- 
ly adhere in place. (Fig. 204). The dressing is completed by apply- 
ing a cotton pad with the absorbent layer next to the wound. The 
dressing is secured in place by web straps or by safety pins. The 
ends of the instillation tubes which emerge from the dressing at different 
points are grouped in twos or fours and are attached to the branched 



DISINFECTION OF WOUNDS 



247 



unions. The tube from the reservoir is then attached and the 
branched cannula is fixed in place by safety pins to the highest 
point of the dressing (Fig. 205). Motion of the injured part 
must, of course, be guarded against by proper splinting. 




-,1^ 



Fig. 204, — Wound paniy dressed. Instillation tubes held in place by gauze and 
skin protected by squares of vaseline gauze. (Carrel and Dehelly modified.) 

Dressings are renewed every twenty-four hours, at which time 
the wound is carefully inspected and the tubes renewed. 

Bacteriologic Examination of the Wound. This consists of an 
examination of smears from the wound at regular periods and the 





?yi''^yysWMk:i;i^ii''lP 



Fig. 205. — Dressing completed. Large gauze pad in place and distributing tube pinned 
to the dressing by safety pins. (After Carrel and Dehelly.) 

estimation of the number of bacteria in the wound. Such exam- 
ination, carried out from the beginning during the course of the 
treatment, not only enables the surgeon to determine the proper 



248 



DISINFECTION OF WOUNDS 



time for closure of the wound without danger of the infection re- 
curring, but it also shows the progress of the sterilization. The 
method of examination is simple and consists in transferring one 
or more specimens of the secretions from the wound by means of a 
standard platinum wire loop, previously sterilized by passing through 
an alcohol flame, to a slide and counting the number of microor- 
ganisms to the microscopic field. This is done every other day and 




Fig. 206. — Showing the arrangement of the irrigating apparatus in an injury of the 
lower extremity. (Da Costa, modified from Carrel and Dehelly.) 

the results entered on a chart kept for the purpose to show at a 
glance the progress of the disinfection. The specimens should not 
be taken within less than two hours after fluid has been instilled 
into the wound, and care should be taken to obtain specimens of 
secretion from those parts of the wound which seem to be most in- 
fected, such as the deeper portions, necrosed points, pockets under 
exposed bone, cul de sacs, or small tracts less likely to be reached by 
the solution. 



DISINFECTION OF WOUNDS 249 

Under the treatment the number of microorganisms should 
diminish. If the count remains stationery for several days or in- 
creases the wound should be carefully examined with a view to 
modifying the treatment. The failure to obtain favorable results 
may be due to errors in the preparation of the solution, to insuffi- 
cient distribution of the solution from too few tubes, to the fluid not 
reaching all parts of the wound, to the presence of necrotic tissue, 
sequestra of bone, and foci of infection around foreign bodies that have 
been overlooked, etc. When the bacteria are absent from the wound 
or the number is reduced to one in every four or five fields, and this 
is verified by three successive examinations at intervals of two days, 
the wound is considered surgically sterile and may be closed. In 
streptococcic infections, however, the wound should not be closed 
until there is a complete absence of bacteria. 

As a rule, moderate sized wounds of soft parts may be closed in 
from five to eight days. Large, badly traumatized wounds may re- 
quire twelve days or more to sterilize. Compound fractures re- 
quire a longer period — from two to four weeks. In these cases it 
will be found that sequestra of bone are a frequent obstacle to ster- 
ilization and require removal before success is attained 



CHAPTER X 

BIER'S HYPEREMIC TREATMENT, THE PRODUCTION 

OF AN ARTIFICIAL PNEUMOTHORAX, AND 

THE DIAGNOSIS AND TREATMENT OF 

FISTULOUS TRACTS BY MEANS 

OF BISMUTH PASTE 

HYPEREMIC TREATMENT 

While the value of artifically producing hyperemia with the 
definite purpose of increasing the inflammatory reaction has only 
been recognized comparatively recently, 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 hyperemia 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 an 
active flow of arterial blood through the parts, and is especially 
useful for the absorption of the products of chronic, nontuberculous 
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 

250 



PASSIVE HYPEREMIA 251 

Rokitansky. Impressed by these observations, Bier conceived the 
idea of artifically producing a hyperemia for the cure of tuberculous 
affections in other parts of the body. Encouraged by the results 
obtained in the treatment of tuberculous 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 relief of these 
symptoms. According to Bier, however, the redness, heat, and 
swelling of an inflammation are but the outward signs of the effort on 
the part of nature to overcome noxious influences and produce a cure; 
and these are to be encouraged as beneficial instead of combated. An 
attempt was accordingly made to artifically 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 Hjrperemia. — The beneficial effects of hyperemia are 
most striking — the more marked, the earHer the treatment is begun. 

Diminution of Pain. — The prompt rehef 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 



252 bier's hyperemic treatment 

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 
probably at fault. The patient should always be impressed with the 
necessity of reporting any discomfort in the part subjected to the 
h3^eremia, 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 earHer 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 clin- 
ical course be greatly shortened. Accidental soiled wounds, which 
from experience we have every reason to believe will become infected, 
under the influence of hyperemia can often be made to heal without 
infection, and not 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. 

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



PASSIVE HYPEREMIA 253 

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 tuberculous 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 contains numerous favorable reports of its use, 
not only in purely surgical affections, but in the specialties and in 
medicine as well. 

The surgical conditions in which it has been found to be especially 
beneficial may be summarized as follows: Acute infections and in- 
flammations, such as furuncles, carbuncles, felons, infected wounds, 
infection of tendon sheaths, lymphangitis, lymphadenitis, mastitis, 
gonorrheal arthritis, and other forms of acute infections of joints, 
acute bone infections, burns; as a prophylactic measure in soiled or 
dirty wounds, compound fractures; in chronic affections, such as 
tuberculosis of bones, joints, glands, tendon sheaths, testicles; de- 
layed union of fractures; fistulas; old discharging sinuses; and 
infected leg ulcers uncomplicated by varicose veins. Its use is, 
however, contra-indicated in lesions complicated by thrombosis of 
veins. In erysipelas its value is doubtful; in fact, erysipelas has 
been known to develop under prolonged hyperemia in tuberculous 
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 idduces a suction hyperemia. 
In a host of other affections falling within the domain of rhinology, 
otology, gynecology, obstetrics, and dermatology, passive hyperemia 
has been recommended and applied with varying degrees of success. 

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 must always be promptly evacuated, and cold abscesses likewise 



254 bier's hyperemic treatment 

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 occureed. If incisions are not 
made, the hyperemia may do harm and the local inflammation 
become worse, for the transudate which is induced by the hyperemia, 
added to the exudate already present, has no outlet and may drive 
the bacteria and their toxins into healthy tissue and favor the exten- 
sion of the infection. 

In inflammations involving joints or tendon sheaths, mild active 
and passive motion are carried out from the first 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- 
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. SweUing 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 tuberculous 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- 



PASSIVE HYPEREMIA 255 

able, and mobility gradually increases; secretions from sinuses be- 
come serous instead of purulent, the sinus takes on a healthy appear- 
ance and finally closes. In tuberculous 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- 
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 produced 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 



256 bier's hyperemic treatment 

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 
must be observed not to exceed the proper grade of hyperemia, and 
in tuberculous cases not to lower the vitality of the tissues by too pro- 
longed obstruction. Only a mild hyperemia is necessary to produce 




Fig. 207. — Esmarch elastic bandage for obstructive hyperemia. 

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 2j^ inches (6 cm.) in breadth, is 
employed (Fig. 207). 

For the shoulder-joint and testicles, rubber tubing is used in place 
of a bandage. That used about the shoulder should be of fairlyj 




Fig. 208. — Elastic garter for producing obstructive hyperemia of the neck. (After 

Meyer-Schmieden.) 

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^i inches (3 cm.) in width may be used, or a 
special neck-band made for the purpose may be obtained. A garter 
elastic, about i inch (2.5 cm.) in width and provided with hooks and 
eyes so that it may be adjusted to any size, as shown by the ac- 
companying illustration (Fig. 208,) answers the purpose admirably. 



PASSIVE HYPEREMIA 257 

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. 

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 tuberculous affections the applications are of shorter dura- 
tion, the bandage being applied once or twice a day from one to four 
hours at a time. In his early work on tuberculous affections. Bier 
first employed short periods of hyperemia, and then prolonged 
and almost continuous hyperemia, but he experienced many fail- 
ures 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 re- 
turned to the short applications of from one to four hours a day. In 
cases of acute hot abscess formation, however, due to a mixed infec- 
tion 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 
sufficiently to make it adhere to the skin and prevent it from slipping. 
The bandage is wound around the limb with moderate tension six or 
eight times well above the seat of disease, each layer overlapping the 
preceding by about 3^^ inch (i cm.). The bandage is then made 
secure by adhesive plaster or tapes previously sewed to the terminal 
end (Fig. 209). 

The degree of hyperemia 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 

17 



258 



bier's hyperemic treatment 



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 
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 hyperesthesia of the part. If too great a degree of 
compression is employed, nutritional disturbances from the increased 




Fig. 209. — Showing the method of applying the elastic bandage to the arm. 



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. 

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 (see page 132). 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 difficult to obtain the proper 
amount of hyperemia, and several procedures have been advised to 



PASSIVE HYPEREMIA 259 

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 interfere with the hyperemia. If open wounds or sinuses 
be present, they are simply covered loosely with sterile or antiseptic 
gauze. 

A marked edema results from the hyperemia, extending up to the 
seat of constriction, and this has to be kept within proper limits. 
When the application is only for short periods of a few hours each 
day, the edema 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 h3rperemia 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 256), is used. It should be applied about the root of 
the neck, well below the larynx, with only moderate tension. To ob- 
tain the greatest degree of hyperemia with least constriction, small 
pieces of felt or wadding may be placed under the constricting band 
on either side of the larynx over the great veins (Fig. 210). 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 throb- 
bing or a feeling of marked fullness in the head is complained of, the 
bandage should be removed and reapplied. 



26o beer's hyperemic treatment 

Shoulder. — A soft bandage or cravat is placed loosely about the 
patient's neck and tied. Through the loop a stout piece of rubber 




Fig. 2IO. — Showing the application of the neck band. 

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. 211. — Showing the method of obtaining obstructive nyperemia of the shoulder. 

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 



PASSIVE HYPEREMIA 



261 



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 oppo- 
site axilla, and around the back, where it is secured to the portion of 
the rubber ring behind the joint (Fig. 211). By adjusting the band- 
age 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 




Fig. 212. — Showing the method of producing obstructive hyperemia of the testicleSo 

(After Meyer-Schmieden.) 



twenty-four hours, with correspondingly longer intermissions, in 
preference to the ten or eleven hour applications. 

Scrotum. — Tuberculous and other affections of the testicle may be 
treated by means of constriction about the root of the scrotum. A 
small piece of rubber tubing or catheter is wound several times about 
the base of the scrotum over a layer of cotton and is secured in place 
by tying with a piece of tape or cord (Fig. 212). 

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. 



262 



BIER S HYPEREMIC TREATMENT 



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




Fig. 223 

Fig. 213. — Cup for sty. 214. Cup for small abscess. 215. Cup for large 
abscess. 216. Cup for gums. 217. Cup for carbuncle. 218. Cups for tonsils. 
219. Breast cup. 220. Cup for cervix. 221. Cup for nose. 222. Finger suction 
glass. 223. Hand suction glass. 

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 



PASSIVE HYPEREMIA 263 

in the skin and deeper layers results. Besides producing hyperemia, 
the mechanical effect of the cupping glass is also of distinct advan- 
tage. 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 sinus under the 
influence of the hyperemia combined with suction. In the presence 
of tuberculous sinuses, daily applications of the suction cups may be 
employed in conjunction with the rubber bandage. 




Fig. 224. — Pump for producing a vacuum in the larger cups and suction glasses. 

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. 
213 to 223). If there is considerable discharge, a type of cup shown 
in Fig. 213 will be found most useful. 




Fig. 225. — Showing the method of obtaining motion in a stiff wrist by the aid of 

passive hyperemia. 

In selecting the cup, one should be chosen of sufficiently 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. 
224). A further convenience for use with the larger apparatus is a 
three-way stopcock inserted between the glass chamber and the 



264 



BIER S HYPEREMIC TREATMENT 



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. 225. Here the arm 
is drawn firmly in the glass case as the air is exhausted until the hand 
meets the obstacle at the lower end of the chamber, when the wrist 
turns in the direction of least resistance. Other joints of the body 
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 
ankylosed joint. Upon exhausting the air in the apparatus, the 




Fig. 226. — Showing tne method of obtaining motion in a stiff knee-joint by the aid of 

passive hyperemia. 



rubber bag descends and exerts an evenly regulated pressure upon 
the part to be treated, as shown in Fig. 226. 

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 
used. They should be again boiled and well cleaned before being 
put away. 

Duration of Application.— In the use of cups, brief applications 
often repeated are essential. Accordingly the cup is applied for five 
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. 



PASSIVE HYPEREMIA 265 

Technic, — Pus, if present, is always to he 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 
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. 227). If the application is made over an open infected wound, 
pus will be drawn out, accompanied by some blood. 




Fig. 227. — Showing a cup applied to a carbuncle. 

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. 
A 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 
withdrawal and reapplication of the cup. Pain should never be 
produced even in acutely inflamed regions. Sometimes more than 
one application of the cup is necessary before the proper degree of 
hyperemia is obtained. With the suction pump, the degree of 
hyperemia may be more nicely regulated. In this case, the cup with 
the edges well lubricated is simply applied to the affected region. 



266 

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 hyperemia 
is first coated with soap or vaselin so that the rubber sleeve will more 
easily slip over the skin and at the same time leakage of air may be 
avoided. The patient then thrusts the arm or foot into the appara- 
tus, and the rubber sleeve is bandaged securely about the limb with 
a rubber bandage (Fig. 228). A partial vacuum is then produced. 
This causes the part to be drawn more deeply into the chamber, and 




Fig. 228. — 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 applied. At the next sitting, if a crust 
has formed over the opening or sinus, it is gently removed with 
forceps and the treatment is continued as outlined above. 

The suction treatment should be applied daily at first. The 
amount of pus usually rapidly decreases each day, first becoming less 
purulent and more serous, until finally only a little serum is with- 
drawn with each application. The swelling diminishes and the part 



ACTIVE HYPEREMIA 267 

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 HYPEREMU 

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 
poultices, hot sand, etc., are all familiar examples of active hyperemia 
Hot air in a dry form, however, is the most effective means for 
inducing such a hyperemia on account of the high degrees 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 exudates, infiltrations, adhesions, etc., and a marked 
analgesic effect, causing a sensitive part to become less so or to be 
entirely relieved soon after the application is begun. It thus acts 
favorably in chronic rheumatism, chronic arthritis, chronic synovitis, 
and arthritis deformans. It aids greatly in promoting the absorption 
of edemas and of effusions of blood into the soft parts, and in synovial 
sacs — as in traumatic synovitis. Other affections in which active 
hyperemia has given good results are neuralgia, sciatica, neuritis 
lumbago, gout, varicose veins, varicose ulcers, etc. 

In fractures near a joint with painful involvement of the joint 
itself, it is of great value in reducing the edema and at the same 
time hastening the repair, thus increasing the chances of obtaining a 
more useful limb through the ability to perform early passive motion. 
In a Colles' fracture, for example, the bones should be properly re- 
duced and within a few days the part should be daily subjected to . 



268 



bier's hyperemic treatment 



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. 

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 




Fig. 229. — Apparatus for applying active hyperemia to the hand and wrist and the 

method of its application. 

form an important part of the treatment. Too much stress cannot 
be laid on the value of massage when judiciously used in appro- 
priate 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 leak- 
age of air. They are provided with a lid and have openings at one or 
both ends for receiving a limb. These openings are lined with cuffs 
of felt to avoid any danger of burning the skin, and are provided with 
straps so that the cuffs may be securely fastened to a limb. Open- 



ACTIVE HYPEREMIA 



269 



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 
is thus constantly in motion, which is important in order to permit 
evaporation of the perspiration upon the part and to maintain the 
dryness of the air. A thermometer is also provided with each box 
for indicating the temperature. Such boxes are made to fit various 
parts of the body, as the arm, hand, shoulder, foot, knee, hips, etc. 




Fig. 230. — 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.) 

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. 230). 

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- 
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- 



270 



BIER^S HYPEREMIC TREATMENT 



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 com- 
fortably 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 neces- 
sary 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 PRODUCTION OF AN ARTIFICIAL 
PNEUMOTHORAX 

The production of an artificial pneumothorax by the repeated 
injections into the pleural cavity of a slowly absorbable gas for the 
purpose of collapsing a tuberculous lung, orginated with Forlanini 
of Italy in 1894. Independently of Forlanini, the same operation 
was performed in 1898 by Murphy of Chicago, but at the time it 
did not excite a great deal of attention in this country, in spite of 
its successful use abroad by Brauer, Spengler, Saugmann and others. 
Today, however, it is recognized as a therapeutic measure of the 
greatest value for certain cases of pulmonary tuberculosis, and a 
procedure that is reasonably safe if performed under rigid asepsis 
and with proper precautions. 



PRODUCTION OF AN ARTIFICIAL PNEUMOTHORAX 27 1 

The aim of the treatment is to collapse a diseased lung and put 
it at rest on the same theory that a tuberculous joint or other tuber- 
culous process is immobilized. With reduction in the volume of the 
lung, its contents, such as the pus and cheesy collections in cavities 
and inflammatory exudates in the alveoli and small bronchial tubes, 
are gradually evacuated, so that toxic absorption is lessened. At 
first, while the cavities are undergoing collapse, expectoration may 
be temporarily increased, but it rapidly decreases in amount if the 
operation is successfull. As the cavities collapse and become ob- 
literated, the diseased parts are brought into apposition so that 
cicatrization is favored and the extension of the disease is limited. 

The effects of compression on the circulation of the blood and 
lymph is also important. In a collapsed lung the circulation of the 
blood is impeded and a condition of venous stasis results, which, 
as is well known, is an important factor in increasing the resistance of 
the tissues against the tubercle bacilli. Likewise, through com- 
pression of the lymph channels, toxic absorption rapidly decreases, 
and the fever, nightsweats, general weakness, and other symptoms 
of toxemia disappear. 

The operation is comparatively simple and consists in puncturing 
the chest with a needle which is connected with a reservoir of nitro- 
gen gas and a water manometer, and allowing the gas to flow into 
the pleural cavity in small amounts at a sitting. By some operators 
the parietal pleura is first exposed by an incision as an aid to the proper 
placing of the needle in the pleural cavity, but this method is formid- 
able in comparison with simple puncture and is generally reserved 
for those cases when the simpler technic fails. 

Indications. — Success in creating an artificial pneumothorax 
requires that the pleura be permeable, as the lung will not collapse 
if there are adhesions. 

The cases best suited to this treatment are those with an active 
involvement of a considerable portion of one lung with little or no 
involvement on the other side. Bilateral involvement, however, is 
not a contra-indication if less than a third of the good lung is affected. 
In rapidly progressive cases and in cases that do not improve under 
the usual hygienic and climatic treatment, it is also indicated. It 
gives excellent results in those cases where there is persistent and 
copious hemoptysis if its source can be definitely traced to one or 
the other lung. 

In cases where there are cavities with very rigid walls, the results 
are often uncertain, as, while healthy parts of the lung may collapse, 



272 



BIER S HYPEREMIC TREATMENT 



the lung at the site of the disease does not and outside of a slight 
temporary improvement the operation is a failure. In bronchiectasis 
the same difficulty is met in collapsing the thick walled dilated 
bronchioles, and, while use of the method has been followed by 
improvement, permanent benefit is doubtful. 

Artificial pneumothorax is contra-indicated in the presence of 
extensive involvement of both lungs, dry pleurisy, pleurisy with 
effusion, where there is such extensive cavity formation that there is 
danger of the needle entering the lung, in myocarditis or other serious 
cardiac, renal, or constitutional disease that would in itself be 
sufficient to prevent recovery, and in early favorable cases. 




Fig. 231. — Robinson apparatus for artificial pneumothorax. 

Apparatus. — There are various makes of apparatus on the market 
which are all much the same in principle. The manometer is the 
most important part of any apparatus, as it demonstrates the location 
of the needle during its insertion and registers the pressure in the 
thorax before and after the injection. 

The Robinson apparatus consists of two bottles with a capacity 
of 2 quarts (2000 c.c.) each, connected with a manometer. One 
bottle 'A" is stationary while the other ''B'' is arranged so it can 
be elevated or lowered. The stationary bottle is filled with sterile 
water containing two drams (8 c.c.) of pyrogallic acid to take up 
any oxygen that may enter with the nitrogen. Nitrogen gas is 



PRODUCTION OF AN ARTIFICIAL PNEUMOTHORAX 273 

then forced into bottle "A" forcing the solution into bottle ^'B". 
The apparatus is then ready for use, and, on opening the proper 
cock, the solution in bottle ''B" forces the nitrogen out of bottle "A" 
under pressure regulated by the height of bottle "B". As the water 
levels in the two bottles approach one another, bottle "B" is elevated 
to maintain the desired pressure. When cock "D" is closed and 
"E" & *T'' are open a direct connection between the needle and 
the manometer results. With cock ^'F" closed and ^'C" and ^'D" 
open connection is established between the manometer and the 
nitrogen, the pressure recorded being the difference in the water 
levels of bottles "A" and "B.'' With cock "E" closed and the other 
two open the nitrogen passes directly from bottle "A" into the needle. 
The needle should preferably be provided with an obturator and 
arm for connection with the tube to the gas bottle. The needle 
should be H5 inch (i mm.) in diameter and about i}^"^ inches 
(4 cm.) long. 




Fig 232. — Floyd needle for artificial pneumothorax. 

Gas Used. — Nitrogen gas is generally employed, as it is claimed 
to be more slowly absorbed than atmospheric air and is non-irritating. 
It should be chemically pure and should be filtered through sterile 
cotton on the way to the chest. 

Temperature. — The gas should be at about the temperature of 
the body. It may be warmed by immersing the tube through which 
it passes to the patient in a basin of hot water. 

Quantity Injected. — The injection of small amounts of gas 
is preferable. Two hundred to 400 c.c. (12 to 24 cubic inches) 
are introduced at the first sitting and this is increased to from 300 to 
600 c.c. (18 to 2)^ cubic inches) at the second, and to from 800 to 
1000 c.c. (48 to 60 cubic inches) at the third operation. 

Frequency of Injections. — Injections are given at intervals of 
from 2 to 5 days until complete collapse of the lung is obtained, 
demonstrated by disappearance of the respiratory murmur and 
X-ray examination. To insure permanency of the pneumothorax, 

18 



274 

further injections are made once or twice a month depending on the 
rapidity with which the gas is absorbed. 

Point of Puncture. — A point as far away from the seat of the 
disease as possible should be selected in order to avoid adhesions. 
For lesions of the apex the needle is inserted in one of the intercos- 
tal spaces between the 6th and 9th ribs, between the anterior 
and posterior axillary lines. For lesions of the lower lobe the third 
space outside the mamillary line is selected. 

Preparation of Patient. — The patient should be given morphin 
gr. 3-^ (0.0108 grams) by hypodermic half an hour before the operation. 

Position of Patient. — The patient should lie on the side with 
the diseased side uppermost and the arm elevated above the head 
so as to widen the intercostal spaces as much as possible. 

Asepsis. — The bottles, tubing and needles are sterilized and the 
operator's hands cleansed as carefully as for any operation. The 
skin at the site of puncture is sterilized by painting with tincture of 
iodin. 

Anesthesia. — A 0.5 per cent, procain-adrenalin solution is used. 
The skin at the point of puncture is first anesthetized and then the 
tissues of the intercostal space down to and including the pleura are 
infiltrated. 

Technic. — A point on the skin over the interspace through which 
the injection is to be made is selected at a little distance from the 
upper margin of the lower rib bounding the space, and, after being 
anesthetized, a small nick is made in the skin with a scalpel. The 
thumb and forefinger of the left hand are used to steady the tissues 
while the needle is introduced with the right hand, the forefinger 
being placed on the needle to guard against its being inserted too 
deeply. The needle is then pushed through the intercostal muscles 
into the pleura, which is usually entered at a depth of about 
one inch (2.5 cm.) and is recognized by the added resistence offered 
to the needle. The needle is now connected with the manometer, the 
trocar being withdrawn and the connection with the nitrogen 
bottle remaining closed, as the manometer is the only means of 
determining whether the needle has entered the pleura. While the 
needle remains outside the endo-thoracic fascia, the manometer 
registers zero, but as it reaches this structure there is a slight oscilla- 
tion between o and 3, due to the respiratory movements of the 
pleura. The entrance of the needle within the two layers of the 
pleura is indicated by a negative pressure of from 5 to 10 cm., 
and there will be observed distinct oscillations of the fluid in the 



PRODUCTION OF AN ARTIFICIAL PNEUMOTHORAX 275 

manometer corresponding to inspiration and expiration. Should 
the needle enter a blood vessel or adherent pleura negative pressure 
and the respiratory oscillations are absent. If the lung is entered 
respiratory oscillations may be present, but there is no negative 
pressure. Unless the negative pressure registers 3 cm. or over, the 
injection of the gas should not be attempted, and another site should 
be chosen. 

When it is certain that the needle is in the pleural cavity, the 
manometer is closed, and the gas is allowed to enter, which it does 
under the influence of the negative pressure in the cavity or under 
positive pressure in the gas reservoir, if necessary. After 100 c.c. 
(6 cubic inches) of gas has been introduced, the gas is shut off and the 
pressure in the pleural cavity is taken, and, if the manometer still 
registers a negative pressure, 100 c.c. (6 cubic inches) more gas may 
be introduced: The final reading of the manometer should indicate 
only a slight negative or a positive pressure of from 0.5 to 3 cm. At 
the completion of the operation the needle is withdrawn, pressure being 
made over the site of the puncture for a few moments to prevent 
leakage of gas into the subcutaneous tissues, and the wound is 
sealed with collodion and cotton. The patient should be kept in 
bed for twenty-four hours subsequent to the operation, and any 
tendency to cough should be controlled by small doses of 
codein. 

At subsequent operations the same site is chosen for inserting 
the needle as at the first operation, and the needle is introduced with 
the same precautions. 

Complications. — Some pain may be felt during the introduction 
of the needle through insufficient anesthesia. When it occurs 
during or following the injection of the gas, it is usually the result of 
breaking up of adhesions. A slight dyspnoea is not uncommon 
immediately following the injection, but soon passes off. Should 
severe dyspnoea and pain occur during the inflation, it should be 
stopped at once. 

Occasionally a condition known as ^^ pleural shock, ^^ which is 
manifested by an increase in the pulse rate and respirations, 
pallor, and dyspnoea, is observed. It usually passes off quickly, 
but may result fatally. 

Gas embolism J the result of gas entering a vessel, may occur if 
the precaution of demonstrating the location of the needle by the 
manometer before making the injection is not followed. It is 
characterized by rapid pulse, irregular respirations, faintness, 



276 

collapse, inequality of the pupils, etc. If a large quantity of gas 
enters a vessel, it may produce fatal results. 

Subcutaneous emphysema is sometimes observed in the neighbor- 
hood of the puncture from the escape of the gas into the tissues 
through the puncture. It is more apt to occur with the open 
method. 

Pleural efusions are a frequent complication. It is serious as 
it may result in a pyothorax. 

Accidental pneumothorax sometimes occurs as the result of 
injury to the lung by the needle, or from tearing of the lung when 
adhesions are broken up. 

THE DIAGNOSIS AND TREATMENT OF FISTULOUS 
TRACTS BY MEANS OF BISMUTH PASTE 

The injection of a mixture of bismuth and vaseHn for the 
diagnosis and treatment of fistulae, tuberculous sinuses, and abscess 
cavities was deyised 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. 

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 of the fistula and all its ramifications is obtained. 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 
from the fresh Hning of the walls. In old sinuses and abscess cavities 



BISMUTH PASTE INJECTIONS 277 

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, albuminura, 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 channels for 
absorption. 






Fig. 233.— Types of syringe for bismuth paste injections. 

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 fistulae 
Beck has devised a syringe with a nozzle of special shape and curve 
(Fig. 233). 

Formulary. — Two mixtures are used by Beck: 

No. I. Bismuth subnitrate 33% 

Vaselin, 67% 

No. II. Bismuth subnitrate, 3°% 

White wax, S% 

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 efficiency of the paste is 
increased by adding 0.5 to i per cent, formalin. 



278 

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 
sufficient 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 
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 XI 

THE 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 oft6n 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, and the clinical diagnosis and a short 
cUnical history of the case, together with a statement of from what 
part of the body or from what organ the pathological material 
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 slides, 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 slides are very dirty, the following method of cleansing 
the glass will suffice: First wash off the slide with soap and water, 
then wipe with alcohol and ether and rub dry with an old Unen or 
silk cloth; finally pass the slide through an alcohol flame. When 

279 



28o 



COLLECTION OF PATHOLOGICAL MATERIAL 



once 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 film 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- 



FiG. 234. — 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. 234) and is then tightly wrapped with a small roll of 
cotton (Fig. 235). The swab is then loosely laid in the test-tube and 
the mouth of the tube is plugged with sterile cotton (Fig. 236), and 





Fig. 235. — 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. 236. — Sterile swab in a glass test-tuoe. 

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 sHdes so as to spread the material in a thin transparent 
film (Fig. 237). 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 



SMEAR PREPARATION FOR MICROSCOPICAL EXAMINATION 281 

secured one upon another, but with their surfaces separated by 
matches or tooth-picks, as shown in Fig. 238. 




Fig. 237. — Method of making a smear. 

From the Mouth and Pharynx. Equipment. — Sterile 
swabs, glass slides, and a tongue depressor will be required (Fig. 239). 




Fig. 238. — Glass slides separated by match sticks and held together with rubber 
bands ready for shipment to the laboratory. (Ash ton.) 

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 hs 




Fig. 239. — 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 



282 



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. 240). In removing the swab the same care against 
contamination from contact with the tongue, etc., should be ob- 
served. 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. 




Fig. 240. — Showing the method of taking a smear from the pharynx. 

From the Nose. Equipment. — Swabs, slides, a nasal specu- 
lum, a head mirror, and an angular pipette (Fig. 241) will be required. 

Technic. — Ordinarily, for microscopical examination, a smear 
made in the usual way from secretions blown from the nose into a 
piece of sterile gauze is sufficient. If, however, it is desired to obtain 
a smear from any one locality, the secretion should be first removed 
by means of a pipette (page 294), and from this the smear is made. 

From the Eyes. Equipment. — Slides, a sterile swab, a 
platinum needle, and an alcohol lamp (Fig. 242) 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 283 

flame, and when it has cooled the lids are separated, the loop is 
brought into contact with the pus and sofne of it is transferred 
to a slide. A smear is then made by means of the swab. 




Fig. 241. — 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, 

(Fig. 243) should be provided. 



-Slides and sterile swabs 





Fig. 242. — Instruments for taking a smear from the eyes, i, Sterile swab; 2, 
slides; 3, alcohol lamp; 4, platinum needle. 

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



284 



COLLECTION OF PATHOLOGICAL MATERIAL 



Fig. 243. — Instruments for taking a smear from the urethra, i, Sterile swab; 2, slides. 




Fig. 244. — Forcing the discharge out of the urethra by pressure against the canal 
with the tip of the finger in the vagina. (Ash ton.) 



SMEAR PREPARATION FOR MICROSCOPICAL EXAMINATION 285 



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. 244). 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. 245) 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 



.n 




Fig. 245. — Instruments for taking a smear from the vagina. 
slides; 3, vaginal speculum. 



I, Sterile swab; 2, glass 



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. 246) 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. 247), 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. 



286 



COLLECTION OF PATHOLOGICAL MATERIAL 




Fig. 246. — Instruments for taking a smear from the uterus, i, Sterile swab; 2, tena- 
cula; 3, Simon's speculum; 4, glass slides; 5, sponge holder. 




Fig. 247. — Method of collecting the secretions from the uterus. (Ashton.) 



METHOD OF INOCULATING CULTURE TUBES 287 

METHOD OF INOCULATING CULTURE TUBES 

Equipment. — Culture tubes, sterile swabs, platinum needles, 
thumb forceps, and an alcohol lamp (Fig. 248) 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 




Fig. 248. — Instruments for making a culture, i, Alcohol lamp; 2, thumb forceps; 
3, sterile swabs; 4, culture tubes; 5, platinum needle. 

of bacteria to be cultivated. The culture media are sold in sterile 
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. 



3 



. 



Fig. 249. — Platinum needles. 

The inoculation of the tubes is performed by means of a swab 
or a platinum needle. The method of making and sterilizing the 
former has been described above (page 280). 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 



288 COLLECTION OF PATHOLOGICAL MATERIAL 

into the form of a loop or it may be simply left straight (Fig. 249), 
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. 250). The culture tube is held between 
the thumb and forefinger of the left hand, with the mouth of the 




Fig. 250. — 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 th^ 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. 251). The platinum needle is again passed through the flame 



METHOD OF INOCULATING CULTURE TUBES 



289 



and is then laid aside. The tube is finally closed with the cotton 
plug, first singeing the cotton, however, in the flame while held with 
the thumb forceps. 




Fig. 251. — Method of making a streak culture. (Levy and Klemperer.) 




Fig. 252. — 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. 

19 



290 COLLECTION OF 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. 253). The swab is then replaced in its 
container and the cotton plug is singed and reinserted into the mouth 
of the culture tube. 




Fig. 253. — The method of making a smear culture. 

When a number of cultures are being made, care should be taken 
to immediately number each tube as it is inoculated. 

COLLECTING DISCHARGES A^D SECRETIONS FOR BAC- 
TERIOLOGICAL 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. 
254) will be required. 



COLLECTING DISCHARGES A^ SECRETIONS 



291 



The pipettes may be easily made from thin glass tubing of an ex- 
ternal diameter of about J^ inch (6 mm.)- The center of a piece of 
such tubing about 6 inches (15 cm.) long is heated over a flame, the 





Fig. 254. — Apparatus for collecting discharges for bacteriological examination, i, Alco- 
hol lamp; 2, scissors; 3, suction syringe; 4, pipettes. 

tube continually being turned the while, until the glass is softened 
over about J^ inch (i cm.) of space (Fig. 255). 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. 255. — Heating the glass tube at its center over a Bunsen flame. (Ashton.) 

into a capillary tube several inches long Fig. (256). The center of 
this capillary tube is again heated in the flame until it melts, and, by 
drawing upon the ends, it parts in the center, leaving two pipettes, 



292 



COLLECTION OF PATHOLOGICAL MATERIAL 



each with one sealed end (Fig. 257). 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 



F'iG. 256. — 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. 258). The pipettes are 




Fig. 257. — 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. 259), 
but not so hot as to melt the glass or burn the cotton plug. Thus 




Fig. 258. — 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. 259. — ^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 Hps or a small suc- 
tion syringe to the free end of the rubber tubing. 



COLLECTING DISCHARGES AND SECRETIONS 



293 



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. 260) and should be then rounded off 




Fig. 260. — Snipping off the fused point of the slender end (a) of the pipette with 

scissors. (Ashton.) 




Fig. 261. — 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. 261). 

The pipette is then slowly passed through the flame so as to 
sterilize the entire outer surface of the tube (Fig. 262). When the 




Fig. 262. — Sterilizing the outer surface of the slender end (a) of the pipette. 

(Ashton.) 




Fig. 263. — Hermetically sealing the secretions in the bulbous portion of the pipette 
by fusing it in the flame at a and c. (Ashton.) 

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, 
which is then drawn up into the pipette by suction. The suction 



294 



COLLECTION OF PATHOLOGICAL MATERIAL 



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. 263). In this way the discharge is hermetically sealed in small 
glass tubes (Fig. 264) and can be sent to any distance for later bac- 
teriological examination. Each tube as it is prepared should be 
carefully labeled with a distinguishing number. 



Fig. 264. — Showing the bulbous portion of the pipette sealed and containing the 

secretion. (Ashton.) 

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 to 




Fig. 265. — 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. 

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 (Chapter 
XII). 

From the Nose and Accessory Sinuses. Equipment. — An 
angular pipette will be required, as well as an alcohol lamp, scissors, a 



COLLECTING DISCHARGES AND SECRETIONS 



295 



nasal speculum, suitable illumination, and a head mirror (Fig. 265). 

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 
followed. The patient is seated as for an anterior rhinoscopic exami- 
nation (page 366), the nasal speculum is introduced, and the light is 




Fig. 266. — Method of sucking secretion into a pipette from the female urethra. 

(Ash ton.) 

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 instru- 
ment 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, course, be avoided. 

From the Urethra. Equipment. — Pipettes and the other ap- 
qaratus necessary for collecting discharges (see Fig. 254) will be 
repuired. 



296 



COLLECTION OF PATHOLOGICAL MATERIAL 



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. 266). 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. 244). 
When a specimen has been obtained, the ends of the pipette are 
sealed and the tube is properly labeled. 





Fig. 267. — 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. 267) 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.. 268) will be required. 

Technic. — The speculum is introduced into the vagina and the 
cervix is well exposed to view. Any vaginal secretions are removed 
by means of sponges on holders, tenacula are inserted in the anterior 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION 297 

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. 268. — 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 




D 




Fig. 269. — ^Instruments for collecting blood for microscopical examination, i. 
Thumb forceps; 2, spear-pointed needle; 3, cover-glasses; 4, glass slides; 5, alcohol lamp. 

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. 



298 COLLECTION OF PATHOLOGICAL MATERIAL 

Equipment. — Slides, cover-glasses, an alcohol lamp, thumb for- 
ceps, and a spear-pointed needle or a lancet (Fig. 269) are necessary. 
The cover-glasses and slides should be of the best material. The 
former should be very thin and about % inch (22 mm.) square. 
Both should be absolutely clean and free from grease; the cleansing 
may be performed after the method described on page 279. 

Location of Puncttxre. — The blood may be withdrawn from a 
prick in the lobe of the ear or in the tip of the finger. The former 
region is preferable, however, as it is not so sensitive as the finger, 
and it is usually cleaner, so that the chances of infection are less. 




Fig. 270. — Making a fresh blood smear. First step, puncturing the ear. 

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 childern and nervous individuals. 

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. 

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 
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 
lobe is punctured (Fig. 270). The blood should be allowed to flow 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION 



299 



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 
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 




Fig. 271. — Making a fresh blood smear. Second step, collecting the drop on a cover- 
glass. 

apex of the drop (Fig. 271), but is not allowed to touch the skin. 
The cover-glass is then gently lowered upon the warmed slide (Fig. 
272) and the drop of blood is thus caused to spread out in a thin 
circular layer between the slide and the cover-glass. If the drop is 
not too large, the blood will not spread beyond the margins of the 




Fig. 272. — Making a fresh blood smear. Third step, placing the cover-glass holding 

the blood drop on a slide. 

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 
in the manner described above, and, after the first drop of blood has 



300 



COLLECTION OF PATHOLOGICAL MATERIAL 



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 
first slide, spreading out the drop in a broad thin smear (Fig. 273). 
To be of any value the smear must be spread out evenly and thinly. 




Fig. 273. — Method of making a dry blood smear with two slides. 

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. 270), and the 
first drop of blood is removed. One cover-glass is then held by its- 




Fig. 274. — Making a dry blood smear with two cover-glasses. Second step, collecting 
the drop on a cover-glass. 

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. 274), and is quickly placed upon the second 
glass, with the angles of the two not coinciding (Fig. 275), so that the 



COLLECTION OF BLOOD FOR MICROSCOPICAL EXAMINATION 



301 



drop spreads out by its own weight in a thin film between the two 
covers (Fig. 276). If too large a drop is taken, the upper cover will 
simply float around upon the lower. The upper cover is finally 
seized between the thumb and forefinger of the right hand and, still 




Fig. 275. — 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. 




Fig. 276. — 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. 277. — Making a dry blood smear with two cover-glasses. Fifth step, showing 
the method of drawing the two covers apart. 

holding the lower cover in the left hand, the two covers are drawn 
apart in the same plane (Fig. 277). Unless too small a drop has 
been taken, this is readily accomplished. The films thus obtained are 
then allowed to dry, and later they may be fixed and properly stained. 



302 



COLLECTION OF PATHOLOGICAL MATERIAL 



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 




Fig. 278. — Apparatus for collecting blood for bacteriological examination. 




Fig. 279. — Showing the method of making a venous puncture. 

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 ven- 
ous puncture is harmless and gives the patient but little discomfort. 



COLLECTION OF BLOOD FOR BACTERIOLOGICAL EXAMINATION 303 

Equipment. — A glass syringe with a capacity of 2>^ drams 
(about 10 c.c.)j a moderately large needle with a sharp point, broth 
and agar-agar culture tubes, and a bandage (Fig. 278) are necessary. 

Site of Puncture. — The median cephalic or median basilic vein is 
usually chosen (see Fig. 127), 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. 




Fig. 280. — Method of transfixing wall of vein with sewing needle to steady it and en- 
large its lumen to receive an aspirating needle. (Warbasse.) 

Asepsis. — The skin at the site of puncture is painted with iodin, 
the hands of the operator are as carefully sterilized as for any opera- 
tion, and the instruments are boiled. 

Anesthesia. — In ordinary cases anesthesia is unnecessary. If it 
is necessary to expose the vein by an incision, as in the case of an 
individual with much fat or whose tissues are edematous, infiltration 
with a 0.2 per cent, solution of cocain or a i per cent, procain 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 



304 COLLECTION OF PATHOLOGICAL MATERIAL 

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 
through the skin into thje vein (Fig. 279), 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 ij^^ drams (5 c.c.) of blood may be taken 
from a child, aijd about 2Y2 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. 

Watson {Journal of the American Medical Association, July 29, 
191 1) describes the following method as an aid in introducing the 
needle into the vein : A fine sewing needle is passed through the skin 
overlying the vein so as to transfix the anterior wall of the distended 
vein transversely to its long axis. This is then lifted forward, and 
the vein needle is introduced into the vein just behind the transfixion 
needle (Fig. 280). 

During the inoculation of the tubes the greatest care should be 
taken to avoid contamination; the needle is removed from the syringe 
as it is very apt to be contaminated with staphylococci from the 
skin, no matter how carefully the sterilization may have been carried 
out, and the inoculation is made through the sterile end of the 
syringe. In doing this, the same technic described on page 287 
should be followed. Inoculations are usually made with i6TTl (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. 
281), so that there can be no leakage during transportation. Suit- 
able bottles may be obtained from any laboratory or from most drug 
stores. The specimen should be obtained from the sputum coughed 



THE COLLECTION OF URINE 



305 




Fig. 281. — Spu- 
tum bottle. 



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 par- 
ticles 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 impossible 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, 1910) the following method: The child 
is made to cough by irritating the pharynx with a bit of gauze or 
cotton held in the jaws of an artery clamp, and 
any secretion which is brought into \dew is then 
secured on this swab. 

THE COLLECTION OF URINE 

When a simple chemical examination of urine 
is called for, it is only necessary to collect the 
specimen in some perfectly clean receptacle, the 
tirst portion as it comes from the meatus being re- 
ceived 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 anti- 
septic solution, and the catheter is gently inserted 
into the bladder without touching the adjacent 
parts (see also page 741). The first portion of the 
urine is to be discarded, and then from i}^^ to 2^^ drams (about 5 
to 10 CO.) are collected in a sterile test-tube, which is immediately 

plugged. 
29 




Fig. 282.— Cha- 
pin's urine collector. 



3o6 COLLECTION OF PATHOLOGICAL MATERIAL 

When it is desired to obtain a separate specimen from each kid- 
ney, the ureters may be catheterized (see page 759) or a urinary 
separator may be employed (see page 775). 

To obtain a twenty-four-hour specimen, as, for example, when 
it is desired to determine the total daily amount of urine secreted 
or to estimate the total solids, it is necessary to begin and end with 
an empty bladder. The patient is therefore instructed to empty the 
bladder at a certain hour and to discard this specimen. All the 
urine passed for the following twenty-four hours, including that 
voided at the end of this period, is saved in a large clean bottle. 
For cases of incontinence, a retained catheter must be used (see 
page 743). 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 g^^O ^^ ^^^^ ounce (30 c.c), formalin in the pro- 
portion of I drop to each 4 ounces (120 c.c), or a few drops of chloro- 
form to each 4 ounces (120 c.c.) may be added to the specimen. If 
cultures or inoculations are to be made, preservatives 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. 282) 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 
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, catheterization must be resorted to, 
employing a small catheter (9 to 11 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 529) 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 



REMOVAL OF SOLID TISSUE FOR EXAMINATION 



307 



the stomach, the gastric contents an hour after a test-meal will be 
required (see page 527). 

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 con- 
veniently 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 




Fig. 283. — 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; 
lo, specimen bottle. 

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 ordinaly cases there will be required: a scalpel, 
scissors, a cutaneous punch, artery clamps, plain thumb forceps, 



3o8 



COLLECTION OF PATHOLOGICAL MATERIAL 



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. 283). 

For regions which are not readily accessible, as, for example, the 
female genitals, volsellum forceps and suitable specula are necessar} . 

For collecting material from the interior of the uterus, curettage 
instruments, etc., will be required (see page 868). 




Fig. 284. — Excision of a piece of tissue from the cervix. (Ashton.) 

Asepsis. — The instruments are boiled, the hands of the operator 
are sterilized, and the site of operation is cleaned as for any operation. 

Anesthesia. — As a rule, local anesthesia by infiltration with a 
0.2 per cent, solution of cocain or i per cent, solution of procain in 
normal salt solution is sufficient. For skin tumors, freezing with 
ethyl chlorid usually suffices. 

Technic. — The line of proposed incision is first anesthetized. 
Then, with the tissues well retracted so as to expose the growth, a 
wedge-shaped piece of tissue is removed by means of a scalpel from 
the portion of the growth where the pathological changes are most 



REMOVAL OF SOLID TISSUE FOR EXAMINATION 



309 



marked or the tumor is nodular (Fig. 284). 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 controlled, the incision 
is closed, and a sterile dressing is finally applied. 




Fig. 285. — Removal of a fragment of a superficial growth with a skin punch. 

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. 285). The punch is then removed and 




"^^^^^^^^^^ 



Fig. 286. — Removal of a fragment of a superficial growth with a skin punch, 
step, cutting loose the base of the section. 



Second 



the circular core is seized in thumb forceps and is freed from its 
base by cutting with a pair of curved scissors (Fig. 286). 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. 



3IO COLLECTION OF PATHOLOGICAL MATERIAL 

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 870. 



CHAPTER XII 
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 difiicult of access may thus be tapped and explored with 
comparative safety. 

When fluid is detected, a quantity sufiicient for examination 
should be withdrawn. Frequently by a gross examination of the 
fluid sufflcient information may be obtained as to its character. 
With the naked eye, one can often make a diagnosis between a serous, 
bloody, or-purulent fluid, by carefully noting the color, clearness, and 
consistency of the material withdrawn. Valuable information can 
likewise be obtained from the odor. 

For more definite and exact information, a chemical, microscopi- 
cal, and bacteriological examination will be necessary. In prepara- 
tion for such an examination a few drops of the liquid should be 
injected into culture tubes, and the remainder placed in a sterilized 
test-tube, 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. 

311 



312 EXPLORATORY PUNCTURES 

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 indentified 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 THfi PLEURA 

This is a safe and simple operation employed, to confirm the 
diagnosis of a pleural effusion or to as certain 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 will be found convenient to have an assort- 
ment of needles of different lengths and diameters. They should 
measure in length 2>^ inches (6.5 cm.), 3 inches (7.5 cm.), sM 
inches (9 cm.), and- 4 inches (10 cm.); and in diameter >^o inch (0.5 
mm.), K5 inch (i mm.), }{^ inch (1.5mm.), and K2 inch (2 
mm.). For ordinary use the needle should be at least 3 inches (7.5 
cm.) long and about 3^^ 5 inch (i mm.) in diameter, so that it will 
readily give 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 



EXPLORATORY PUNCTURE OF THE PLEURA 



313 



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. 287). 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. 287. — Aspirating syringe and needles. 

by its evacuation, the aspirating apparatus of Potain or Dieulafoy 
(see page 340) may be used for the exploration, thus sparing the 
patient a subseqeunt 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 
by withdrawing the piston with the finger held over the end, to see if 






y 



U 



Fig. 288. — Apparatus for making smears and cultures from fluids removed by explora- 
tory puncture, i, Glass slides; 2, sterile test-tube; 3, culture tubes. 

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. 



314 



EXPLORATORY PUNCTURES 



In cases where a complete chemical, microscopical, and bac- 
teriological examination is desired, sterilized test-tubes for collecting 
and transporting the material aspirated, glass slides, and agar-agar 
culture tubes (Fig. 288) 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. 289. — 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 general thing, entrance of the needle in 
the sixth interspace in the anterior axillary line, in the sixth or seventh 
interspace in the midaxillary line, or the eighth interspace below 
the angle of the scapula will reveal the presence of fluid if such exists 
(Fig. 289). 

Position of the Patient. — If too weak to sit upright, the patient 
may lie semirecumbent for a lateral puncture, and for a posterior 
puncture in a lateral prone position, with the body curved forward 
and the arm of the affected side elevated (Fig. 290). In uncom- 
plicated cases, an upright sitting posture should be assumed, with the 



EXPLORATORY PUNCTURE OF THE PLEURA 



315 



arm of the affected side elevated for the purpose of widening the 
intercostal spaces (Fig. 291). 




Fig. 290. — ^Lateral position for exploratory puncture of the pleura. 




Fig. 291. — Exploratory puncture of the pleura with the patient sitting upright. 

Asepsis. — The strictest regard to asepsis must be observed in mak- 
ing any exploratory puncture, otherwise there is great risk of in- 
fection and of converting a simple serous exudate into a purulent one. 



3i6 



EXPLORATORY PUNCTURES 



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, syringes, 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 procain, will be all that is required. In 
employing 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. 292. Fig. 293. 

Fig. 292. — ;Showing the failure to withdraw fluid from the needle being inserted 
too far. (After Gumprecht.) 

Fig. 293. — 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 J^ inches (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 en- 
tering the pleural cavity. The lack of resistance and the mobility 
of the needle will demonstrate its entrance into a cavity. 

If fluid is not immediately obtained, the direction of the needle 
may be changed slightly, or it may be entirely withdrawn and inserted 



EXPLORATORY PUNCTURE OF THE LUNG 



317 



in other locations before the attempt is abandoned. Failure to 
withdraw fluid may be due to the needle entering the lung (Fig. 293) 
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. 294), 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 resist- 
ance offered to the entrance of the needle. Upon completion of the 
aspiration, the needle is quickly with- 
drawn, and the site of the puncture is 
closed with collodion and cotton. 

EXPLORATORY PUNCTURE OF THE 
LUNG 

Previous to undertaking any opera- 
tive procedure upon a pulmonary cavity, 
such as a tubercular, bronchiectatic, 
echinococcic, or abscess cavity, an ex- 
ploratory puncture will be of great ser- 
vice, not only as an aid to a physical ^ig. 294.— Showing the fail- 

, . • J 1. i.« u V ure to withdraw fluid from the 

examination in detecting such a cavity, . ^ . .u j, u 

° -^ point of the needle becoming 

but likewise in determining its size and imbedded in a thickened pleura, 
exact location, and its character by an (After Gumprecht.) 
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 312). 

Location of the Puncture. — This will depend entirely upon the 
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. 




3l8 EXPLORATORY PUNCTURES 

Anesthesia. — Infiltration of the site of puncture with a 0.2 per 
cent, solution of cocain or a i per cent, procain 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 316). 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, Httle 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 
imdertaken Hghtly, and the dangers of injuring the internal mam- 
mary vessels or pleura, or of puncturing the thin-walled auricles of 
the heart, should impress upon the operator the necessity of extreme 
care when performing this operation. 

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 312). 



EXPLORATORY PUNCTURE OF THE PERICARDIUM 



319 



Location of the Punctiire. — 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 sternal margin or i inch (2.5 cm.) to the left of it. Either 
of these points will avoid the internal mammary artery and veins 
which run vertically downward 3^^ 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 




Fig. 295. — Points for puncturing the pericardium. The dotted line indicates 
a distended pericardial sac. The course of the internal mammary vessels is also shown. 



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, 
Romberg, Kussmaul, and others, may be employed. The puncture 
is made in the fifth or sixth left interspace outside the nipple line 
between the apex beat and the outer limit of dullness (Fig. 295). 
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. 



320 



EXPLORATORY PUNCTURES 



Asepsis. — All aseptic precautions must be observed. The 
instruments are boiled and the hands of the operator are prepared 
as for any operation. If the patient be a male, the chest should be 
shaved, and, in any case, the skin must be sterilized by painting with 
tincture of iodin before making the puncture. 

Anesthesia. — Infiltration cocain or procain anesthesia or freezing 
with ethyl chlorid will suffice. 

Position of the Patient. — The operation may be performed with 
the patient semirecumbent or in the upright sitting posture. 

Technics — 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 




Fig. 296.' — Showing the method of inserting the needle in an exploratory puncture 

of the pericardium. 



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. 296). The 
needle should be introduced slowly and with great care almost in the 
sagittal plane and directed sHghtly toward the median line. En- 
trance into the pericardial sac is recognized 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 
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. 



EXPLORATORY PUNCTURE OF THE PERITONEAL CAVITY 32 1 

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 diag- 
nostic measure, but the dangers 
of producing serious complica- 
tions through puncture of the in- 
testine or other organs, or from 
leakage of fluid, especially if it 
be purulent, into the peritoneal 
cavity stamps it as an unsafe 
method except in those cases 
where the tumor is in close rela- 
tion to the abdominal wall. 
When the presence of pus is sus- 
pected, it is not wise to perform 
an exploratory puncture unless 
everything is in readiness for an 
immediate operation. The com- 
parative safety of an exploratory 
laparotomy and the fact that much more valuable information 
can be thus obtained renders this the operation of choice. 

Apparatus. — A long exploring needle, a glass aspirating syringe, 
a scalpel, a cocain syringe, test-tubes, etc., should be provided (see 
page 312). 

Asepsis. — The instruments and the hands of the operator are 
sterilized as for any operation. 

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 

21 




Fig. 297. — Points for puncture of the 
peritoneal cavity. 



32 2 EXPLORATORY PUNCTURES 

for the insertion of the needle. Both these sites will escape the 
deep epigastric artery (Fig. 297). 

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. 

Anesthesia. — Infiltration cocain or procain anesthesia or freezing 
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. 



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 (see page 312), 
should be provided. 

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. 298). Puncture may also 
be made anteriorly directly into the area of liver dullness below the 
hne of the pleura. 



EXPLORATORY PUNCTURE OF THE LIVER 



323 



Asepsis. — The operation is performed under all aseptic precau- 
tions (see page 315). 

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. 
If fluid is not obtained, the needle is 
slowly withdrawn, a vacuum being 
maintained in the syringe in the mean- 
time, so as to withdraw pus in case 
the point of the needle has previously 
passed through a cavity into healthy 
tissue. Near the surface of the liver 
the direction of the needle is altered, 
and it is inserted again in a different 
plane. In this manner a large area 
of the liver may be explored in all 
directions from one external punc- 
ture, 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% (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 i reely with the liver as it rises or descends during 
respiration. If fluid is not immediately found, a number of punc- 
tures should be made before the operation is abandoned. Failure 
to draw pus into the syringe does not necessarily signify absence 
of an abscess, for at times the material forming the abscess is so 
thick that it will not pass into the needle, and only a drop or two of 
pus will be discovered on close examination, clinging to the needle 
point. 

Having located an abscess, the needle should be left in situ as a 
guide, for it is not an uncommon experience, when pus is discovered 




Fig. 298. — Points for puncture 
of the liver. 



3^4 



EXPLORATORY PUNCTURES 



by aspiration and the needle removed, to fail to locate the abscess at a 
subsequent operation. 

EXPLORATORY PUNCTURE OF THE SPLEEN 

As a diagnostic measure, puncture of the spleen may be performed 
without danger if the organ is hard, as is found in chronic malaria, 
but in infectious diseases with a large, soft, and friable spleen it is 
an unjustifiable procedure. Laceration of the capsule followed by 
hemorrhage, suppuration in the spleen, and peritonitis have been 
known to result. Likewise puncture of the spleen in suspected cases 

of typhoid fever is no longer warranted, 
since we have other methods of diag- 
nosis, such as Widal's test, which are 
both safe and adequate. When fluctua- 
tion has been demonstrated, as in 
splenic abscess or hydatid disease, ex- 
amination of the fluid obtained by as- 
piration may give conclusive informa- 
tion; but here again, as in exploratory 
punctures of the liver or lungs, prepara- 
tions 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 instru- 
ments necessary for any exploratory 
puncture (see page 312) should be 
provided. 

Location of Puncture .^ — The spleen 
can be reached by inserting the needle 
through the tenth intercostal space in the midaxillary line on the left 
side (Fig. 299). If the organ is markedly enlarged, some point be- 
low 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- 
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 

315). 

Anesthesia. — ^Local infiltration anesthesia or freezing will suffice. 




Fig. 299. — Point for puncturing 
the spleen. 



EXPLORATORY PUNCTURE OF THE KIDNEYS 



325 



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 little 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 

Exploratory aspiration may be employed to detect collections of 
pus or other fluids in the region of the kidney. An exploratory 




Fig. 300. — ^Showing the relations of the kidneys from behind. 

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 
312) should be at hand. 

Location of the Puncture. — The needle should be introduced at a 
point about 2 3-^ inches (6 cm.) from the median line, to avoid the 
erector spinas muscles, and a little below the last rib on the left side, 
and, on the right side, between the last rib and the crest of the ilium. 

Position of Patient. — The patient may sit up, with the back bent 



326 EXPLORATORY PUNCTURES 

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 315). 

Anesthesia. — Local infiltration anesthesia or freezing will suffice. 

Technic. — A long fine needle should be employed. After nicking 
the skin with a scalpel at the site chosen for the puncture, the needle 
is slowly introduced forward and slightly inward toward the median 
line, frequent tests at aspiration being made as the needle is advanced. 
When fluid is discovered,- a sufficient quantity for diagnosis is with- 
drawn, and the site of puncture is sealed with a cotton and collodion 
dressing. 

EXPLORATORY 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 312). 

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 anesthesia 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, procain 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 applied are as follows: 

The ShouIder=Joint. — Entrance to the joint best effected by 
introducing the needle from the side through the groove between the 



EXPLORATORY PUNCTURE OF JOINTS 



327 



acromion process and the head of the humerus. The direction of the 
needle should be somewhat downward and backward (Fig. 301), if it 
is inserted straight in from the side it is apt to enter the subacromial 
bursa. 

The El bow- Joint. — Puncture of the joint may be made from 
behind or from. the outer side. 

To enter the joint behind, the forearm is flexed to an angle 
of 135 degrees, and the needle is inserted downward and forward 
behind the olecranon (Fig. 302). 

To puncture the joint from the outer side, the arm is flexed and 
the radial head is identified by the finger as the forearm is rotated. 




r 

I 



Fig. 301. — Point for puncturing the P'iG. 302. — Point for puncturing the 
shoulder- joint. elbow- joint. 

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 
extensor indicis and the extensor longus poUicis at the level of a Hne 
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 Bungner'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. 303), and, with the femoral artery identified by the 



328 



EXPLORATORY PUNCTURES 



forefinger of the left hand to avoid injuring it, the needle is pushed 
directly back into the joint. 




Fig. 303. — Points for puncturing the hip-joint (modified from Pels-Leusden). 

For a lateral puncture the leg should be slightly adducted. The 
needle is then pushed into the joint toward the median line of the 
body from the side just above the great trochanter (see Fig. 303). 

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




Fig. 304. — Point for puncturing the knee-joint. 

point where fluctuation or distention is most in evidence. When the 
swelling is more marked above the patella, the needle may be intro- 
duced from above downward behind the bone (Fig. 304), the opera- 



SPINAL OR LUMBAR PUNCTURE 



329 



tor's left hand grasping the joint below the patella and forcing the 
intraarticular 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- 
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 J^ inch (i cm.) above the malleolar 
process in a direction obliquely outward and backward; on the outer 
side the needle enters % of an inch (2 cm.) above the malleolar 
process in a direction obliquely inward and backward. 



SPINAL OR LUMBAR PUNCTURE 

Lumbar puncture, an operation first proposed by Quincke for 
the withdrawal of cerebrospinal fluid from the spinal canal, has 
both diagnostic and therapeutic , 

value. This procedure is of diag- 
nostic importance in cerebro-spinal 
lues, intracranial hemorrhage, 
tumors of the cord, meningitis, 
poliomyelitis, etc. through the in- 
formation that may be obtained in 
estimating the pressure of the cere- 
brospinal fluid and determining its 
characteristics by physical, chemical, 
microscopical, and bacteriological 
examination. 

Among its therapeutic uses is 
its employment as a ''decompressive 
agent," in cases of meningitis, hy- 
drocephalus, intracranial tumors, 
cerebral abscess, uremia, delirium tremens, etc., etc. On account 
of the continuity of the spaces in the brain and spinal column, 
temporary relief 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 em- 
ployed with great caution, however, in cases of brain tumor, for 
sudden death may follow removal of a large amount of fluid, the in- 
creased intracranial tension causing the medulla to be forced against 
the foramen magnum when the intraspinal pressure is relieved. In 
cerebrospinal meningitis, drainage by lumbar puncture is often folio w- 




FiG. 305. 



-Anatomy of the lumbar 
vertebrae. 



330 



EXPLORATORY PUNCTURES 



ed by good results, as not only is the pressure upon the cord and cere- 
bral centers lessened, but pus is withdrawn, and the toxicity of the 
spinal fluid is thereby diminished. 

It is in the administration of antitetanic serum and antiserum 
in cerebrospinal meningitis, the treatment of cerebral syphilis, and 
the production of spinal anesthesia, however, that lumbar puncture 
finds its chief therapeutic appHcations. 




Fig. 306. — Stylet needle for spinal puncture. 

Anatomy. — In the lumbar portion of the vertebral column the 
spinous processes do not project downward to such a degree as in 
other portions, and there is a distinct space (about % inch (22 mm.) 
in the transverse and % inch (15 mm.) in the vertical diameter) 
between the vertebral arches filled with ligaments through which a 




LiiLill 





Fig. 307. — Apparatus for spinal puncture, i, Scalpel; 2, ethyl chlorid tube; 3, small 
glass graduate; 4, hydrometer; 5, sterile test-tube; 6, culture tubes. 

needle may be readily passed into the spinal canal (Fig. 305.) The 
spinal cord reaches only to the second lumbar vertebra, so if the 
puncture be made below that point, and the introduction of the needle 
be carried out under rigid asepsis the operation is practically 
harmless. 



SPINAL OR LUMBAR PUNCTURE 33 1 

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 $}i inches (9 cm.) long and about j^i^ of an inch (i mm.) in 
diameter, and the point should be short and ground almost squarely 
across (Fig. 306) . In addition, a scalpel, a sterilized graduated test- 
tube, culture tubes, and an ordinary hydrometer (Fig. 307) 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. 308), though, if the puncture is performed for 
diagnostic purposes, it may be made lower — between the fifth lum- 
bar and first sacral vertebrae in order to withdraw any sediment that 



[ 



Fig. 308. — Points for spinal puncture. 

may be present. A point just below the tip of the spinous process of 
the vertebra forming the upper boundary of the chosen interspace 
at a distance of about H 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 



332 



EXPLORATORY PUNCTURES 



through the tip of the spinous process of the fourth lumbar vertebra 
(Fig. 309). 

Position of the Patient. — The operation may be performed with 
the patient sitting in a chair, with the body bent well forward in the 




Fig. 30Q. — Showing the method of locating the fourth spinous process by passing a 
line through the highest points of the iliac crests. 




Fig. 310. — Sitting posture for spinal puncture. 

form of a curve (Fig. 310), so as to widen the intervertebral spaces as 
much as is possible. If this is impracticable, the patient may lie on 
his left side with his knees drawn up, shoulders forward, and body 
bent forward in an arch (Fig. 311). 



SPINAL OR LUMBAR PUNCTURE 



333 



Asepsis. — The site for the puncture should be painted with 
iodin, and thorough asepsis must be observed during the entire 
operation. The needle should be boiled and the operator's hands 
should be properly sterilized. 




Fig. 311. — ^Lateral position for spinal puncture. 

Anesthesia. — With children general anesthesia may be necessary. 
In other cases, local anesthesia with a 0.2 per cent, solution of cocain 
or a I per cent, procain solution, or by freezing, as for any puncture, 
will answer all purposes. 





Fig. 312. — Spinal puncture. First step, 
nicking the skin at the point of puncture. 



Fig. 313. — Spinal puncture. Second 
step, inserting the needle. 



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 
the chosen spot (Fig.312). The operator's left thumb or index finger 
is then placed between the two spinous processes as a guide, and the 



334 EXPLORATORY PUNCTURES 

point of the needle is inserted on the same level as the finger about J^ 
inch (i cm.) from the median line, in an upward and inward direction 
(Fig. 313), until it enters the spinal canal. In a child this will usu- 
ally occur at a depth of from % to i J-^ inches (about 2 to 4 cm.) 
and in an adult from 2 3-^ to 3 inches (about 6 to 7.5 cm.). If the 
needle strikes bone, it should be slightly 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. 314). The first few drops are usually blood stained, 
and, if so, they should be discarded. Not more than i}^ drams 
(about 5 CO.) of fluid should be withdrawn from the spinal canal of a 




Fig. 314. — Spinal puncture. Third step, collecting the cerebrospinal fluid. 

child, nor more than }i 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 ij^^ 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 
by blood clot, 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. 



SPINAL OR LUMBAR PUNCTURE 335 

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- 
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 means of a 
small rubber tube, 8 to 16 inches (20 to 40 cm.) long, filled with a i 
per cent, solution of carbolic acid. This, of course, is to be done be- 
fore 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-Uke in clearness, 
does not change color on standing, and shows no sediment. It is 
sterile and gives a negative Wassermann reaction. It has an al- 
kaline reaction, a specific gravity of from looi to 1008, a freezing 
point of —56° to — 58°, and exists in the spinal canal in but small 
amounts, varying between J-^ and 2 ounces (15 and 6oc.c.) in adults 
and in infants between 2^/2 and 5 drams (10 and 20 c.c). The total 
quantity in the ventricles and subarachnoid space is estimated by 
different observers as anywhere from 2 to 5 ounces (60 to 150 c.c). 
It contains traces of protein (0.013 ^^ 0.07 per cent.), the greater 
proportion of which is globulin, some chlorides (0.7 per cent.) a 
copper-reducing body claimed to be glucose (0.07 to o.i per cent.), 
and traces of urea (0.035 ^^ o-04 per cent.). Some endothelial cells 
and small lymphocytes are present in the fluid, but these cellular 
elements normally do not exceed 5 per cubic, mm. 

Under pathological conditions the fluid may undergo marked 
modifications. In certain infectious diseases, intracranial tumor, 
meningitis, hydrocephalus, general paresis, etc., the amount may be 
greatly increased. In nephritis and uremia the urea is largely in- 
creased and there may be a rise in the chlorides; in hydrocephalus 
there may likewise be an increase in the urea. Sugar is increased in 
diabetes, but is usually absent in cases of meningitis. In apoplexy, 
meningitis, paresis, hydrocephalus, and brain tumor, the quantity 
of globulin may be markedly increased. Both the globulin content 
and the cell count are increased in cerebrospinal syphiUs, but by the 
reaction to the colloidal gold test it is possible to differentiate be- 



236 EXPLORATORY PUNCTURES 

tween general paresis and other forms of syphilis. A bloody or 
blood-stained fluid will be found in intrameningeal cranial hemor- 
rhages and in injuries of the skull extending through the dura, but in 
extradural injuries 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. In tuberculous men- 
ingitis, however, the fluid is clear and limpid. The cell count is in- 
creased in all inflammations of the meninges, but the character of 
the cells will differ according to the t3rpe of inflammation. Poly- 
nuclear cells predominate in acute inflammations, while, as a rule, 
in the subacute and chronic forms lymphocytes are found. It is 
only possible to determine the specific form of infection by bacterio- 
logical examination. Identification of the diplococcus intracellu- 
laris, pneumococcus, streptococcus, staphylococcus, bacillus of 
influenza, or tubercle bacilli will definitely settle the nature of the 
infection. 

Lumbar Puncture as a Means of Administering Therapeu= 
tic Sera. — When lumbar puncture is employed for the purpose of ad- 
ministering therapeutic sera in tetanus and cerebrospinal menin- 
gitis, a fairly large syringe, one with a capacity of at least i ounce 
(30 c.c), is required in addition to the other instruments necessary 
for spinal puncture. 

Meningococcus Meningitis. — The value of the administration 
of antimeningococcus serum intraspinously in meningococcus 
meningitis is now generally recognized. The early administration 
of the serum is of prime importance and in suspected cases, if the 
cerebro-spinal fluid drawn by the first puncture shows any tur- 
bidity, it is advisable to give the serum at once without waiting for 
the results of a bacteriological examination. Much valuable time may 
be thus saved without doing the patient any harm. One to ij^ 
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 evac- 
uated. Subsequent 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 
or small glass reservoir holding about 2 ounces (60 c.c.) attached to 
the needle by rubber tubing may be employed, the serum being 
allowed to flow into the subarachnoid space by gravity (Fig. 315). 



SPINAL OR LUMBAR PUNCTURE 



337 



It takes usually from lo to 15 minutes to administer the required 
amount in this manner. 

Tetanus. — Anti tetanic serum may be given intramuscularly 
or intravenously, but the best results seem to follow large doses 
given by intraspinous injection — i6cxx) units of high potency serum 
may be administered at a dose and repeated at 24 hours intervals 
for several days. 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 allowed to flow by gravity or is slowly injected 
through the same needle employed for the puncture. 

Rogers {Journal of the American Medical Association, July i, 
1905), injects 2 H to 5 drams (10 to 20 c.c.) of antitetanic serum into 




Fig. 315. — Gravity method of administering serum by lumbar puncture. 



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 in- 
serted 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 mani- 
fested by twitching of the legs; 2 J^^ to 5 drams (10 to 20 c.c.) of 
serum are then injected into and around these injured nerves. 

Poliomyelitis. — Favorable reports have followed the treatment 
of epidemic poliomyehtis with a serum prepared by Nuzum and 
Willy. There is some difference of opinion, however, as to its 



22 



338 EXPLORATORY PUNCTURES 

value and further trial will be necessary before this can be deter- 
mined. When administered early, it is apparently capable of 
preventing and arresting paralysis, but is of questionable value in 
clearing up paralysis already present. 

Cerebral Syphilis.- — Recently, Swift and Ellis of the Rockefeller 
Institute have developed a new line of treatment for syphilis of the 
central nervous system, employing intraspinous injections of sal- 
varsanized (arsphenaminized) 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 (arsphenamin) 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° F. (56° C). 
This serum is then injected by lumbar puncture, after withdrawing a 
'small quantity of the cerebrospinal fluid. 



CHAPTER Xm 

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 nor 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- 

339 



340 ASPIRATIONS 

moved without the necessity of withdrawing the cannula by simply 
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 ^i^ inch (i mm.) to ^2 
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. 316). 




Fig. 316. — 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 
syphonage. 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. 317) 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 



341 



trocar. By means of the second tubing the exhausting S3ninge is 
connected with stopcock b. The instrument should be carefully 
tested before using to see that all the connections are air-tight. To 
produce a vacuum, stopcock a is closed and stopcock b is opened, 




Fig. 317. — ^Potain aspirator. 

when, by pumping from thirty to fifty strokes, the air will be sujfi- 
ciently exhausted. Stopcock b is then closed, and the needle is 
inserted into the chest. As soon as its point enters the tissues, the 
vacuum is extended to the point by opening stopcock a, so that the 




Fig. 318. — The Dieulafoy aspirator. 

moment fluid is reached it will be drawn by suction into the bottle. 
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. 



342 



ASPIRATIONS 



The Dieulafoy apparatus (Fig. 318) consists of a glass syringe, 
with a capacity of 3 to 4 ounces (90 to 120 ex.), 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 5 to a basin 
to carry off 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. 319. — Connell's heat vacuum aspirator. 

aspirating needle is then introduced into the skin at 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 aspirator is filled, stopcock a is closed and stopcock h opened, and 
the fluid is discharged from h 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 



ASPIRATION OF THE PLEURAL CAVITY 



343 



Record, July 4, 1903). It consists of a strong glass bottle with a 
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. 319). A vacuum is thus produced which 
is amply sufficient to aspirate a chest. 

Removal of an effusion by syphonage may be readily accom- 
plished by means of a very simple apparatus. A piece of heavy 




Fig. 320. — Syphonage aspirator. 



tubing about 3 feet (90 cm.) long, a clamp to close one end of the 
tubing, a funnel, sterile water or saline solution to fill the tubing, and 
a receptacle to collect the fluid are the necessary requisites. One 
end of the tubing is fastened to a large caliber needle or the side out- 
let of the trocar and the other to the glass funnel (Fig. 320). 

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 facilitated as far as possible by the action of gravity. 
The sixth intercostal space in the anterior axillary line, the sixth or 
seventh space in the midaxillary line, and the eighth space below 
the angle of the scapula are the points of election (Fig. 321). 



344 



ASPIRATIONS 



Quantity Withdrawn.— It is not essential to empty the chest en- 
tirely at one sitting. The amount of fluid evacuated should be deter- 
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 effusion follows the removal of even small 
quantities. 




Fig. 321. — Sites for aspiration of the pleura. (The large dots represent the points 

of election.) 

Position of the Patient. — The aspiration is preferably performed 
with the patient on a bed so as to avoid the extra exertion of moving 
after the operation. When possible, an upright sitting position 
should be assumed, with the arm of the affected side raised, and the 
hand placed on some support or on the opposite shoulder to increase 
the breadth between the intercostal spaces (Fig. 322). 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. 290). 

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 boiling. 



ASPIRATION OF THE PLEURAL CAVITY 



345 



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 procain at the point of puncture will be 
sufficient. 




Fig. 322. — 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. 323. — 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. 323). As soon as the point of the needle 
enters the tissues, the vacuum already present in the aspirator is 
extended to the needle point by opening the proper stopcock, and the 



346 



ASPIRATIONS 



needle is steadily pushed in until it enters the pleural sac, which will 
usually be at a depth of i to i}i inches (2.5 to 3.5 cm.). The fluid 
should be withdrawn rather slowly in order that the structures may 
have time to adjust themselves to the changed conditions in the 
chest; at least twenty minutes to half an hour should be consumed in 
removing 2 pints (1000 c.c). 

Should the patient feel faint or suffer from vertigo or dyspnea 
the operation should be temporarily interrupted and the patient's 
head lowered. Complaints of severe pain, persistent cough, or expec- 
toration of blood also demand that the aspiration be discontinued. 




Fig. 324. — Aspiration of the pleura with the Potain apparatus. 

•At the completion of the operation the tissues are pinched up 
around the shaft of the needle which is quickly withdrawn. The 
site of puncture is then dressed with collodion and cotton, or with a 
sterile pad of gauze held in place by adhesive strips. 

In employing the syphonage apparatus the tubing is 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- 
ing the clamp from the tube the column of water is released and the 
fluid withdrawn by a process of syphonage. 



ASPIRATION OF THE PERICARDIUM 347 

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 yellowish, 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. Embolism, cerebral anemia, from the sudden 
rush of blood to the expanding lung, hemorrhage into the pleural 
cavities from injury to the lung, and irritation of the terminations of 
the pneumogastric nerve have been suggested as explanations. 

The occurrence of these complications may be reduced to a 
minimum by the employment of rigid aspesis, 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 effusion is sufficiently large to endanger life 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. 

In the presence of a purulent exudate, though temporary relief 



348 



ASPIRATIONS 



may be obtained by aspiration, the condition is one that should be 
treated by incision and free drainage, 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 




Fig. 325. — 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 318). 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. 

4. In the fifth or sixth left interspace outside the nipple line be- 
tween the apex beat and outer border of dullness (Fig. 325). 



ASPIRATION OF THE PERICARDIUM 349 

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. This 
may be followed by absorption of the rest of the fluid, as is often the 
case in pleurisy. If there is no improvement at the end of a day or 
two, however, it will be necessary to perform a second tapping. 

Position of Patient. — The operation may be performed either with 
the patient recumbent or sitting upright. 

Asepsis. — The greatest regard to aseptic precautions should be 
observed. The area of operation should be shaved, if necessary, and 
the skin 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 procain 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. 323. The direction of the needle as it is introduced 
should be at first backward, until it enters the thorax, and then 
slightly inward into the pericardium; but if the approach is made 
in the left seventh costoxyphoid angle, the needle is introduced 
directly upward and backward. The introduction of the needle 
must be performed slowly, steadily, and with great care. The 
vacuum previously produced in the aspirator is extended to the 
needle, by opening the proper valve, as soon as the needle point enters 
the tissues, so that fluid will be 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 
is quickly withdrawn, and the seat of puncture is occluded wdth 



350 



ASPIRATIONS 



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. 326. — 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 }{q to }i ii^ch (1.5 to 3 mm.) in diameter 
— should be used. The trocar is spear-pointed and should fit the 
cannula perfectly so as to prevent the point of the latter catching 
in the tissues during its introduction (Fig. 326) . An excellent form of 
cannula, and one frequently used, contains a lateral opening about 



ASPIRATION FOR ASCITES 



351 



J^ 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 
340) 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. 327. — 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. 327). 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. 

Quantity Withdrawn. — Whether all the fluid should be removed 
at once will be determined by the condition of the patient and the 



352 



ASPIRATIONS 



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 
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. 




Fig. ^28. — Aspiration of the peritoneal cavity. First step, application of the abdomi- 
nal binder. 



Preparations. — The 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 procain 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. 328) and 
is to be tightened at intervals during the operation, so that uniform 
pressure may be applied while the fluid is flowing off and a sudden 
overfilling of the abdominal vessels with blood prevented. With a 



ASPIRATION FOR ASCITES 



353 



scalpel the skin is incisea for a distance of yi ii^ch (6 mm.) at the 
spot chosen for the puncture (Fig. 329), 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. 330). As soon as it is judged that the 
peritoneal cavity has been reached, the trocar is withdrawn and the 
fluid is permitted to escape. 

The fluid should be evacuated slowly, and, if it flows too freely, 
it is well to stop the flow at intervals by placing the finger over the 
end of the trocar, in order to allow the abdominal contents to adapt 
themselves to the changed conditions. If the stream is suddenly 




I 



Fig. 329. — Aspiration of the peritoneal cavity. Second step, nicking the skin at 

the point of puncture. 

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 
sufficient to relieve 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- 
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 cannula 
while this is being done. 

23 



354 



ASPIRATIONS 



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 
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. 




Fig. 336. — Aspiration of the peritoneal cavity. Third step, showing the method of 

inserting the trocar. 



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 carbolic acid. The former is rarely more 
than a palHative measure, as the fluid usually promptly recurs. 

The treatment by a combination of aspiration and the injection 
of 95 per cent, carbolic acid is, however, successful in more than 80 
per cent, of cases (Bevan) . . It is especially applicable to hydroceles 
with thin sacs; in the old, chronic cases with thick sacs it is not often 
successful. 



ASPIRATION OF THE TUNICA VAGINALIS 



355 



The operation is practically without danger, if performed with 
proper technic and care is taken to prevent injury to the structures 
of the cord and the testicle. The latter usually lies posterior to 
the tumor, though in rare cases it may be in front. Its position 
should always be ascertained first, if possible, by palpation and 
transillumination. 




Fig. 331. — Trocar and syringe for aspirating and injecting a hydrocele. 

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. 331). 

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. 




Fig. 332. — Aspirating a hydrocele. Showing the method of grasping the scrotum 
and the trocar being inserted. 



Asepsis. — The usual aseptic precautions should be observed. 
The skin at the site of puncture should be shaved and then painted 
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 
by the injection of a few drops of a 0.2 per cent, solution of cocain 
or a I per cent, solution of procain, or frozen by ethyl chlorid. 



356 



ASPIRATIONS 



Technic. — The operator places his left hand behind the scrotum 
and grasps the neck of the hydrocele between the thumb and fore- 
finger, thus making the tumor tense by compression. Holding the 




Fig. S33- — Aspirating a hydrocele. Showing the cannula in place. 

trocar and cannula in the right hand with the index finger placed 
about I inch (2.5 cm.) from its tip so as to prevent the instrument 
being introduced too deeply, the operator thrusts it into the tunica 




Fig. 334. — Method of injecting a hydrocele. 

vaginalis in an upward and backward direction (Fig. 332). 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 



ASPIRATION OF THE BLADDER 357 

depressing the free end and the trocar is removed (Fig. sss). 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. 334). 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 sub- 
sides 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 746). 



CHAPTER XIV 
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 J^^ 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. 335). 

358 



ANATOMIC CONSIDERATIONS 



359 



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. 

The middle meatus lies between the middle and inferior turbinates, 
and is more capacious than the superior, extending along the pos- 




FiG. 335. — Transverse section of the nasal cavities. (After Zuckerkandl.) 

terior two-thirds of the outer wall of the nose. Opening into the 
middle meatus on the outer wall is a crescentic sUt-like aperture, 
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 




Fig. 336. — Showing the structures in the outer wall of the nasal cavity, i, Opening 
of the sphenoidal sinus; 2, superior meatus; 3, middle meatus; 4, inferior meatus. 

of the middle meatus and extending from the hiatus semilunaris up- 
ward and forward, is a curved groove bounded internally by the un- 
cinate process of the ethmoid, known as the infundibulum. From 



360 



THE NOSE AND ACCESSORY SINUSES 



this a closed duct leads into the frontal sinus. At the deepest por- 
tion of the infundibulum near the posterior end, is the opening of the 
maxillary sinus, and behind this at times is found an accessory 
opening. The anterior ethmoidal cells also open into the infundibu- 
lum 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, 
discharges from the latter being very apt to find their way into the 
ostium of the maxillary sinus. 




Fig. 337. — ^Lateral wall of the right nasal cavity showing the orifices of the accessory 
sinues. (After Schultze and Stewart.) The dotted line indicates the outline of the 
middle 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 turbi- 
nate; 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. 

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 vdth the integument and also with the mucous membrane 
of the pharynx. Eustachian tubes, and accessory sinuses In the 
upper portion of the nose the mucous membrane is of the columnar 
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 Hned with 



ANATOMIC CONSIDERATIONS 



361 



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 fossae are four cavities filled with air, known as the 
maxillary, frontal, ethmoid, and sphenoid sinuses. These accessory 
sinuses are lined with a thin, pale, mucous membrane continuous 
with that of the meatus into which each sinus respectively opens. 




Fig. 338. — 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.) 



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, Hes 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 wall is directed toward the face and corresponds to the 
canine fossa externally. The floor, which is directed toward the 
mouth, is formed by the alveolar margin and outer portion of the hard 
palate. The roots of the molar teeth almost protrude through the 
floor into the antrum (Fig. 337), being often separated from the 
cavity by a thin shell of bone, or merely mucous membrane, so that 



362 THE NOSE AND ACCESSORY SINUSES 

ulceration 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 l)ang 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 bones 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 flooc 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, Hke the frontal sinuses, they may be asymmetri- 
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 



RHINOSCOPY 363 

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, syphilis, 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 breaths through the mouth, and the patency of the nose 
should be tested by alternately closing each nostril with the finger 
while the patient breaths through the opposite one. The odor of the 
breath, the presence or absence of marked movement of the alae nasi, or 
any sounds produced during nasal breathing, and the character of the 
voice should also be 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 cavity 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 Hght. 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 
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 



3^4 



THE NOSE AND ACCESSORY SINUSES 



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. 339). Electric light from a frosted 
lamp is also much used and has an advantage in that it does not 
give out much heat. 

Whatever the form of light, it should be so arranged upon a 
suitable bracket that it may be raised, lowered, or turned from side 




Fig. 339. — Gas lamp upon an adjustable stand fitted with a Mackenzie condenser. 

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. 340). Such a hght, with the current furnished from 
a small pocket storage battery will be found a great convenience 
outside the examining room. 

Instruments. — In addition to a suitable light, there will be re- 
quired: a concave head mirror, about $}yi to 4 inches (9 to 10 cm.) 
in diameter, with a large central eye-hole, and secured to a soft 
leather headband by a ball-and-socket joint; a rhinoscopic mirror 



RHINOSCOPY 



3^5 



}i inch (i cm.) in diameter, set at an angle of loo to no degrees 
with the shaft, which is curved to follow the line of the tongue; a 
Myles solid-blade nasal speculum; a Fraenkel tongue depressor; a 
White palate retractor; and a nasal applicator with a triangular- 
tipped shaft (Fig. 341). 




Fig. 340. — Electric head light. 




Fig. 341. — Instruments for rhinoscopy, i, Alcohol lamp; 2, rhinoscopic mirror; 
3, White's palate retractor; 4, Myles' nasal speculum; 5, head mirror; 6, nasal appli- 
cator; 7, Fraenkel's tongue depressor. 

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. 



Z(>6 



THE NOSE AND ACCESSORY SINUSES 



Position of the Patient. — The patient is seated upright upon a 
firm, straight-backed chair. The examiner sits, facing the patient, 
upon an adjustable seat, such as a piano stool, which may be readily 
raised or lowered according to the height of the patient. 

Technic. — i. Anterior Rhinoscopy. — The operator adjusts the 
head mirror in such a way that the central opening is opposite his 
left eye and the light is reflected into the nostrils of the patient. * The 
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 
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 slid- 
ing them apart, the necessary am.ount 
of dilatation is obtained (Fig. 342). 

The inspection of the cavity should 
proceed from before backward, the 
light being thrown into all recesses. By 
slightly elevating the tip of the nose, 
the floor of the nose, the inferior turbi- 
nate, 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 naso- 
pharynx. By bending the patient's head backward and raising 
the chin, the middle meatus and the middle turbinate may be seen ; only 
when the latter has been removed, or is very much atrophied, 
however, is it possible to obtain a view of the apertures leading to 
the accessory sinuses. Tilting the patient's head still further back- 
ward 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 
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 hyper trophied. 




FiQ. 342. — Myles' speculum in 
place. 



RHINOSCOPY 



367 



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- 
terior ethmoidal cells. To ascertain exactly which sinus is involved. 




Fig. 343. — Showing the method of performing anterior rhinoscopy. 



frequently other aids to diagnosis, as probing, transillumination, or 
skiagraphy, must be employed. 

The attention of the examiner is finally directed to the bony and 
cartilaginous portions of the nose. Deviations, ulcerations, perfora- 
tions, and spurs of the septum, contracture or hypertrophy of the 
turbinal bodies, the presence of foreign bodies, the presence of new 
growths and their point of attachment, etc., etc., are in a general 
way the conditions to be looked for. 

2. Posterior Rhinoscopy. — The operator adjusts the head mirror 
over his left eye so that the light is thrown upon'the patient's mouth. 
The patient is instructed to open the mouth, and a tongue depressor 
held between the thumb and the index and middle fingers of the left 



368 



THE NOSE AND ACCESSORY SINUSES 



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. 
344). If care be taken not to insert the depressor too far and to avoid 
pushing back on the tongue, gagging will be prevented. A mirror of 
suitable size is then warmed and, with the light reflected upon the 
posterior pharyngeal wall, the mirror is gently introduced into the 
mouth, lightly held between the thumb and forefinger of the right 
hand with its metal surface directed toward the tongue. The mirror 




Fig. 344. — First step in posterior rhinoscopy, inserting the tongue depressor. 

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 slightly so 
that the upper border of the mirror lies behind the soft palate. At 
the same time, the handle of the mirror should be so held toward 
the left angle of the patient's mouth that illumination is not interfered 
with (Fig. 345). 

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 



RHINOSCOPY 



369 



various directions by rotating its handle, different portions may be 
brought into view and the entire space may thus be examined in 
detail. By first holding the handle of the instrument well up, the 
vault of the pharynx will be brought into view, and the presence or 
absence of adenoids or other tumors may be ascertained. The 
pharyngeal vault is usually smooth and dome-shaped, but it may be 
almost completely filled up and show depressions and elevations 
depending on the size and condition of the pharyngeal tonsil. On 
depressing the handle slowly, the posterior nares may be examined 
in detail from above downward. In the median line is seen the sep- 




FiG. 345. FiG. 346. 

Fig. 345. — Showing the rhinoscopic mirror in place. 

Fig. 346. — Posterior rhinoscopic image, i, Roof of pharynx; 2, uvula; 3, soft 
palate; 4, opening of Eustachian tube; 5, superior turbinate; 6, middle turbinate; 7, 
inferior turbinate. 



tum; on either outer wall from above downward will be seen the 
ridge of the superior turbinate, with the superior meatus lying just 
below as a darkened depression. Below this will be observed the 
middle turbinate as a pinkish- white fusiform body, and, underlying 
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. 

In some cases it may be almost an impossibility to make a satisfac- 
tory posterior rhinoscopic examination. This may be from the for- 



24 



370 



THE NOSE AND ACCESSORY SINUSES 



mation 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 with a long uvula, or it may be due to the presence 
of a growth in the nasopharynx. The most common obstacle, 
however, is the involuntary elevation of the soft palate on the introduc- 
tion of the mirror, so that the view of the parts above is blocked. In- 
structing the patient to breathe through the nose with the mouth open, 
or to pronounce "en" with strong nasal sound, often suffices to over- 
come this impediment. In other cases it will be necessary to use a 
palate retractor, such as White's. After applying cocain to the palate, 
the wire palate loop of the instrument is passed behind the soft palate 




Fig. 347. — White's palate retractor in place. 

and the stem of the instrument so adjusted as to draw the palate well 
forward into the desired position. The instrument is maintained in 
position by means of the wire loops which rest within the nose 
(Fig. 347)- 

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 



INSPECTION OF THE NASOPHARYNX 



371 



pharyngoscope.^ With this instrument, the use of which requires 
none of the skill necessary for the ordinary posterior rhinoscopic 
examination, it is possible to obtain a clear picture of the nasophar- 
ynx, posterior nares. Eustachian tubes, as well as the larynx with- 
out 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. — ^AU that is required is the pharyngoscope and a six- 
dry-cell battery. The instrument is made in the form of a tongue 




Fig. 348. — Hays' pharyngoscope. 



depressor, the horizontal portion of which is flattened in its inner 
two-thirds, and in its widest part measures less than J^ 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 cir- 
cumference of the eye-piece of the telescope is a small metal guide, 
to indicate the direction 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 off the current (Fig. 348) . 

Asepsis.^The instrument must be thoroughly sterilized before 
use. This is accomplished by means of formalin vapor or by immer- 

1 Harold Hays, in the New York Medical Journal^ April 19, 1909, and the 
Laryngoscope July, 1909. 



372 



THE NOSE AND ACCESSORY SINUSES 



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, gaging be in- 
duced 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 }{q inch (1.5 mm.) from the 
pharyngeal wall (Fig. 349). The instrument 
is kept steadily in place upon the tongue, 
and the patient is told to close' the mouth 
and breathe through his nose. This produces 
relaxation and consequent widening of the 
pharynx and nasopharynx. The light is then 
turned on, and the examiner inspects the 
structures as they are separately brought to 
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. 




Fig. 349. — Showing 
the method of inserting 
the Hays pharyngoscope 
(after Hays Am. Jour. 
Surg. J May, 1909). 




Fig. 350. — Showing the pharyngoscope in place with the examiner inspecting the 

postnasal space. 



and, by tilting the distal end of the instrument slightly upward, 
the posterior nares are viewed. 



PALPATION BY THE PROBE 



373 



To inspect the region of the Eustachian tubes, the lens is rotated 
about 30 degrees to one side, when the orifices of the tubes, Rosen- 
muUer'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. 



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 norm- 
ally present, as well as the presence of abnormal growths, adhesions, 
foreign bodies, and the patency or obstruction of the openings lead- 
ing 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. 351). 




Fig. 351. — Instruments for palpating the interior of the nose, i, Nasal applicator; 
2, nasal probe; 3, sinus probe; 4, Myles' nasal speculum; 5, head mirror. 

The nasal probe should be of silver, fairly stiff, but at the same 
time capable of being bent. It should be about 8 inches (20 cm.) 
long, and set into its handle at an angle of 135 degrees. 

The instrument employed for examination of the sinuses must be 
of pure soft silver and fine in size so that it may be readily bent to 
any curve or be adjusted to the shape of the region through which it 
has to pass. 

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 



374 



THE NOSE AND ACCESSORY SINUSES 



sufficient time to elapse for the cocain to take effect before proceeding 
with the examination. 

. Position of Patient. — The positions of the patient and operator 
are the same as for a rhinoscopic examination (see page 366). 

Technic. — By means of a- speculum and reflected light the inter- 
ior of the nasal cavity is brought into view and is then systemati- 
cally explored by the probe. Any growths are palpated to determine 
their consistency, and masses that may be hidden beneath the turbi- 
nates 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 




Fig. 352. — Showing the steps in the passage of a probe into the frontal sinus. 

condition and the patency of their ostia as a preliminary to irrigation. 
On account of the anatomical arrangement of the parts, probing is 
practically limited to the sphenoidal and frontal sinuses unless the 
middle turbinate is first removed. Before making any exploration of 
these cavities, any visible pus or discharge is wiped away and the 
nasal cavity cleansed by syringing. 

To enter the frontal sinus, the distal end of the probe, bent to an 
angle 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 
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 



DIGITAL PALPATION 



375 



this maneuver, and no attempt should be made to force the instru- 
ment if any obstruction to its passage exists. 

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. 




Fig. 353. — Showing the steps in the passage of a probe into the sphenoidal sinus 



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 
information as to the condition of these parts when the latter is not 
possible. No instruments are needed, except in the case of unruly 
children, when a mouth gag may be required. WTiile digital palpa- 
tion is a rather unpleasant procedure for the patient, if performed 
rapidly and skilfully many of the disagreeable features may be 
eliminated. 

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 



376 



THE NOSE AND ACCESSORY SINUSES 



the cheek in between the open jaws to prevent the examining finger 
from being bitten (Fig. 354). 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, 




Fig. 354. — Showing the method of palpating the postnasal space with the finger. 

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. 



TRANSILLUMINATION 

Transillumination is a valuable aid for determining the condition 
of the frontal or maxillary sinuses. Its use in connection with other 




Fig. 355. — Coakley's transilluminator. a, Apparatus assembled for transillumina- 
tion of the antrum; b, glass hood for use in transillumination of the antrum; c, hood for 
use in transillumination of the frontal sinus. 

sinuses is futile. This method of diagnosis becomes possible from the 
fact that the air spaces, when in a healthy state, transmit light 



TRANSILLUMINATION 377 

through their thiri walls, which power is diminished when pus is 
present or the mucous membrane lining the cavity is much thickened. 
Transillumination is not an infallible method, 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 therefore 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. 




Fig. 356.— Transillumination effect in a Fig. 357. — Transillumination effect in a 
ngrmal right frontal sinus. diseased left frontal sinus. 

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 
hood to fit over the lamp in place of the glass one, for use about the 
frontal sinus (Fig. 355). The lamps are of about four or five candle- 
power, the electricity being supplied by a small battery or the street 
current. In employing the latter, a current controller, by which the 
amount of current may be regulated, will be necessary. 

Technic. i. Transillumination of the Frontal Sinus, — The pa- 
tient is seated in a dark room. The black hood is drawn over the 
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 
opposite side is treated in the same manner, and the two are com- 
pared as to the intensity with which the light is transmitted. 

Through a large sinus in a normal condition the light is trans- 



378 THE NOSE AND ACCESSORY SINUSES 

iiiitted 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 checks, 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 




Fig. 358. — Transillumination effect Fig. 359. — Transillumination effect 

in the normal case. (After Harmon in sinusitis of the right antrum. (After 
Smith, in Keen's Surgery.) Harmon Smith, in Keen's Surgery.) 

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 Hning mucous membiane. 

^ 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 



NASAL DOUCHING 



379 



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 
the 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 douchirig is employed for the purpose of cleansing the nasal 
cavity prior to operative procedures or for the purpose of removing 
secretions or crusts preparatory to the application of other remedies. 




Fig. 360. — Nasal douche apparatus. 

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 
injection 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. For the 



380 THE NOSE AND ACCESSORY SINUSES 

patient's 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 CO.), 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. 360. 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. 361), known as the "Bermingham douche," is useful 
where the cleansing is to be carried out by the patient. 

Solutions. — For ordinary cleansing purposes the solution should 
be alkaline and as unirritating as possible. 

One of the following formulae may be employed. 

I^. Sodii bicarbonatis, 

Sodii biboratis, aa. dr. i (4 gm.) 

Acidi carbolici, lUxv (i c.c.) 

Glycerini, oz. i (30 c.c.) 

Aquae, q. s. ad. Oi (500 c.c.) M. 

R. Sodii bicarbonatis, dr. i (4 gm.) 

Acidi salicylici, gr. x. (0.65 gm.) 

Aquse, q. s. ad. Oi (500 c.c.) M. 

R. Sodii bicarbonatis, " • 

Sodii biboratis, 

Sodii chloridi, aa. oz. i (30 c.c.) M. 

Sig. A teaspoonful to a pint of warm water 

Some of the proprietary preparations, such as listerin, borolyptol, 
glycothymolin, alkalol, etc., will be found of value where an antiseptic 



Fig. 361. — 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, • gr. i— ii (0.06-0.1 gm.) 

Aquae, ad. oz. i (30 c.c.) M. 



NASAL DOUCHING 



381 



Temperature. — ^All solutions should be used warm, at a tempera- 
ture of about 100° F. {sS° C). 

Quantity. — For ordinary cleansing purposes or for the removal 
of free secretion from the nose, a few ounces of solution are sufficient. 
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, 




Fig. 362. — Showing the method of using the nasal douche. 

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 slighly 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 pre- 
vent 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 pa- 
tient's head is bent forward, the fluid does not escape into the 



382 THE NOSE AND ACCESSORY SINUSES 

pharynx, but passes through one nostril back into the nasopharynx 
and out through the other nostril (Fig. 362). 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 
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. 363. — Nasal syringe 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. 363). 

Solutions. — ^Any of the cleansing solutions mentioned on page 
380 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 NASAL SPRAY 



383 



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 accumula- 
tion in the postnasal space and lessening the dangers of infecting 
the Eustachian tubes. 

To syringe from the posterior nares, a tongue depressor is intro- 
duced into the mouth to keep the tongue out of the way, while the 
distal end of the postnasal tip is introduced behind the soft palate. 




(Fig. 364. — Showing the method of syringing the nose from behind. 



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 
postnasal space and nose from behind forward (Fig. 364). 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. 

Apparatus. — The simplest form of atomizer usually proves most 
satisfactory, and is less liable to get out of order. The Whitall 



384 



THE NOSE AND ACCESSORY SINUSES 



Tatum (Fig. 365), the Davidson, or the De Vilbiss (Fig. 366) are 
all good atomizers. The latter is especially serviceable, and the 
spray part, being of metal, may be readily sterilized. The instru- 
ment should be provided with a straight nasal tip as well as with a 
postnasal tip. The air current may be suppHed by a rubber com- 
pression bulb or from a compressed air tank (Fig. 367). The latter 
will be found more convenient for office work. 




Fig. 365. — Whitall Tatum atomizer. 

For cleansing purposes, the spray should be rather coarser than 
that employed for medication. Oily preparations may be sprayed 
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 380 
may be employed in a spray. 




Fig. 366. — De Vilbiss atomizer. 



When a mild antiseptic action is desired, the solutions given on 
page 380 or the following may be used: 



I^. Acid! carbolici 
Glycerini, 
Aquae 



gr. V (0.3 gm.) 
dr. i (4 c.c.) 
q. s. ad. oz. i (30 c.c.) M. 



THE NASAL SPRAY 



38; 



I^. Resorcini, 
Glycerini, 
Aquae, 



gr. iii (0.2 c.c) 
dr. i (4 c.c.) 
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 pur- 
pose 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 




Fig. 367. — Compressed-air atomizing apparatus. 

to 0.3 gm.) or more ta the ounce (30 c.c.) for the sedative effect, as 
in the following: 



I^. Eucalyptol, 
Menthol, 
Benzoinol, 

I^. Thymol, 
Menthol, 
Albolene, 

I^. Camphorae. 
Menthol, 
Albolene, 



nix (0.6 c.c.) 
gr. V (0.3 gm.) 
oz. i (30 c.c.) M. 



fia gr. ii (o.i gm.) 
oz. i (30 c.c.) M. 



aa gr. v (0.3 gm.) 
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 



25 



^86 THE NOSE AND ACCESSORY SINUSES 

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 383). 

THE DIRECT APPLICATION OF REMEDIES 

This method is employed for the application of strong solutions or 
solid caustics, or when it is desired to confine the action of the remedy 
to any particular area. 




Fig. 368. — Fusing chromic acid on a probe. First step, heating the probe. (Gleason.)" 

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. 368) 
and is then dipped into crystals of the acid (Fig. 369). 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 



THE DIRECT APPLICATION OF REMEDIES 



387 



(Fig. 370), and, upon cooling, they recrystallize in the form of a bead 
on the end of the instrument (Fig. 371). 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 (30 c.c.) — should be at hand to 
neutralize any excess of acid. 




Q 

Fig. 369. Fig. 370. Fig. 371. 

Fig. 369. — Fusing chromic acid on a probe. Second step, dipping the hot probe in 
the crystals. (Gleason.) 

Fig. 370.— Fusing chromic acid on a probe. Third step, heating the crystals 
into a bead. (Gleason.) 

Fig. 371. — Fusing chromic acid on a probe. Showing the finished probe. (Gleason.) 



Anesthesia. — The parts should be cocainized by the application of 
a 4 per cent, solution of cocain. 

Technic. — The mucous membrane is well cleansed, and, when 
using caustics, the area to be treated is rendered as dry as possible to 
prevent the caustic spreading over too large a surface. The appli- 
cation is then made to the diseased spot under guidance of the nasal 
speculum, being careful not to allow the applicator to touch any other 
points. If acid is employed, any excess is immediately neutrahzed 
with the strong solution of bicarbonate of soda by means of an appli- 
cator previously prepared and in readiness. 



388 



THE NOSE AND ACCESSORY SINUSES 



' 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 powered 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., 




Fig. 372. — Powder blower. 

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. 372 or that shown in 
Fig. 373 may be used. The former is made on the same principle 
as a hand spray, but with larger tubes. It, however, requires the 




373. — Scoop powder blower. 



use' of both hands in its manipulation. The latter instrument con- 
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 
kiT through the apparatus, blowing the powder out in front of it. This 
insjtrument may be manipulated with one hand, and the quantity of 
powder used can be accurately measured. Insufflators are supplied 



LAVAGE OF THE ACCESSORY SINUSES 389 

with straight tips for the anterior nares, and with curved tips for 
making appUcations to the posterior nares. 

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. I 

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* 
to whether the anterior or the posterior portions of the nose are ta' 
be medicated, and, with two or three rapid compressions of the bulb, 




Fig. 374. — Sajous' powder blower. 

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 pur-, 
pose 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 byj 
irrigation is most successful in the early cases of empyema; in those 
complication 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 5i (4 gm.) to the> 
pint (500 c.c.) of boiled water), a saturated solution of boric acid,) 
or any of the solutions mentioned on page 380 may be used. 



390 



THE NOSE AND ACCESSORY SINUSES 



Temperature. — ^All solutions employed in irrigating should be 
warm — at about ioo° F. {;^S'^ 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 of its hidden position and the fact that the opening is 
directed somewhat downward and forward from the infundibulum. 
If an accessory opening be present, however, it may be possible to 
irrigate through it, but in most cases an artificial opening will have to 
be made through the inferior turbinate, or through the alveolus after 
removal of the second bicuspid, or the first or second molar tooth. 
The former approach should be chosen when the teeth are sound and 




Fig. 375. — 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; 
S, tubing to connect the syringe and cannula; 6, Myles' trocar and cannula. 



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-pulling forceps, an alveolar drill, a syringe, and a silver or 
aluminum tube of the same caliber as the drill, 3^^ to % inch (i to 2 
cm.) long and provided with a flange to prevent its slipping into the 
antrum. 



LAVAGE OF THE ACCESSORY SINUSES 



391 



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. 




Fig. 376. — ^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. 

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 




Fig. 377. — Showing the method of puncturing the antrum through the inferior meatus. 



reflected light, a point is selected just beneath the inferior turbinate 
and about J^ inch (i cm.) behind its anterior extremity, and the 
trocar is introduced, pushing it in an outward, backward, and sHghtly 



392 



THE NOSE AND ACCESSORY SINUSES 



upward direction, through the thin bony wall into the antrum (Fig. 
377). 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. 378). 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- 




M'ddle^&ifas, 



^ntfum of 



/nfer/oryl^eaJus 



Fig. 378. — Transverse section through the nose, showing cannula, a, Entering 
antrum through inferior meatus; and h, cannula entering the orbit through the middle 
meatus. (After Cofl&n.) 



cated. Usually there is no great difficulty in reinserting the cannula 
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 
socket of the second bicuspid or the inner root socket of the first or 
second molar tooth (Fig. 379). 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 
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- 
trum has been entered the cavity is irrigated by means of a syringe^ 



LAVAGE OF THE ACCESSORY SINUSES 



393 



the solution escaping into the nose through the natural opening. 
To aid its escape, the patient's head should be inclined forward. 




Fig. 379. — Showing drills entering the antrum through the alveolus. (.Vfter Schultze 

and Stewart.) 

Finally, a metal drainage-tube of the proper size is inserted, through 
which subsequent irrigations may be made. 




Fig. 380. — 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. 

The irrigations may be performed once or twice a day, and later 
they may be carried out by the patient himself. When the discharge 



394 



THE NOSE AND ACCESSORY SINUSES 



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- 
nasal duct. In some cases, where the opening is occluded by the 
middle turbinate or an enlarged bulla ethmoidalis, 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 cannula that may be easily bent to 
accommodate itself to any curve — such as Hartmann's — and a syr- 




FiG. 381. — Showing the steps of passing a cannula into the frontal sinus. 



inge that can be attached by means of rubber tubing will be required 
(Fig. 380). 

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. 

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 
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 fron to-nasal duct (Fig. 381). 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 ACCESSORY SINUSES 



395 



Lavage of the Sphenoidal Sinus. Instruments. — A head mirror, 
a nasal speculum, a nasal applicator, a sinus probe; a sphenoidal 




« A. ^ 6 

Fig. 382. — Instruments for lavage of the sphenoidal sinus, i, Myles' nasal specu- 
lum; 2, head mirror; 3, syringe; 4, tubing to connect the syringe to cannula; 5, sinus 
probe; 6, nasal applicator; 7, sinus cannula. 



curved cannula, and a syringe with rubber-tubing attachment will 
be required (Fig. 382). 




Fig. 383. — Showing the steps of passing a cannula into the sphenoidal sinus. 

Asepsis. — The instruments are boiled, and the patient's nose is 
cleansed by gentle syringing. 



396 THE NOSE AND ACCESSORY SINUSES 

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 
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. 383). The depth of the sinus is only about 
% inch (1.5 cm.), and care should be taken not to force the instru- 
ment 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 AND 
ACCESSORY SINUSES 

The beneficial effects of passive hyperemia in the treatment of 
inflammations have already been discussed in Chapter X, 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 256) or by a special form of suction apparatus. 
The latter is more efficacious 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. 221 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. 

1 Ballenger: "Diseases of the Nose, Throat, and Ear." 



TAMPONING THE NOSE FOR CONTROL OF HEMORRHAGE 397 

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 in- 
if actions, diseases of the blood, etc. Usually the bleeding ceases 
spontaneously or under simple treatment which aims at lessening 
the congestion of the nasal mucous membrane and favoring the for- 
mation of a clot, such as the application of cold over the nose and 
at the base of the neck, removing tight collars, etc., from the neck, 
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. 

K these simple measures are insufficient, a speculum should be 
introduced and the interior of the nose inspected for the source of 
the hemorrhage. If the bleeding point is within reach, it should 




Fig. 384. — Instruments for tamponing the anterior nares. i, Nasal applicator; 
2, head mirror; 3, narrow strip of gauze; 4, Myles' nasal speculum. 

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 1000 solution of adrenaHn 
chlorid should be applied to the part upon a pledget of cotton. It 
may be impossible to locate the bleeding point, or the hemorrhage 
may continue in spite of such treatment, so that in the presence of 
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- 
ror, a nasal speculum, a nasal applicator, and a single narrow strip 
of gauze should be provided (Fig. 384). 



398 



THE NOSE AND ACCESSORY SINUSES 



For packing the posterior nares a tampon about i inch (2.5 cm.) 
long and 3^^ 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 
18 inches (45 cm.) long, being left free. For the purpose of adjusting 
the tampon in place, a rubber urethral catheter of a size that will 
readily pass through the nose into the mouth (Fig. 385), or an instru- 




FiG. 385. — Catheter for drawing plug into the posterior nares. 

ment especially made for this purpose, known as Bellocq's sound 
(Fig. 386), will be necessary. This latter consists of a curved 
metal cannula containing a concealed steel spring, which is protruded 
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. 386. — Bellocq's cannula. 

Technic (i) (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 
and the hemorrhage controlled (Fig. 387). This packing should 
always be removed within forty-eight hours. Only a single strip of 



TAMPONING THE NOSE FOR CONTROL OF HEMORRHAGE 399 

gauze should be used, as it will be less difficult to remove and there is 
no danger of leaving any behind in the nose. As a further aid in 
removal, the end of the gauze should be left within easy reach. 




Fig. 387. — Showing the method of tamponing the anterior nares. 




Fig. 388. — Showing the method of drawing a plug into the posterior nares by the aid 

of Bellocq's cannula. 

(2) {Posterior Nares). — The tampon, as already described, should 
be well lubricated with sterile vaselin and placed near at hand. The 



400 



THE NOSE AND ACCESSORY SINUSES 



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. 388), the 
spring is returned within the cannula, and the latter is 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 lightly into the posterior nares (Fig. 389). 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 




Fig. 389. — The posterior nasal plug in place. 

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 XV 



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 
consideration 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 fibrocarti- 
lage, covered by perichondrium, connective tissue, and skin, which 

projects from the side of the head. It has the 

function of collecting sounds and reflecting them 
to the external auditory meatus. The central 
depressed portion, resembling a shell in form, 
is called the concha. It is bounded by a rim, 
the antihelix, which runs at first backward and 
then upward and forward, finally dividing into 
two arms. The space between these two arms 
is known as the fossa of the antihelix. From 
the front portion of the concha extends a ridge,- 
known as the helix, at first in a forward and 
upward direction and then around the circum- 
ference of the auricle toward the lowest por- 
tion. The space between the antihelix and 
the helix is designated the fossa of the helix. 
The small backward projection lying in front 
of the concha 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 ij^ 

inches (4 cm.) in length, the floor being slightly longer than the roof 

26 401 




Fig. 390.— The left 
auricle, i, Concha; 2, 
antihelix; 3, fossa of 
antihelix; 4, helix; 5, 
fossa of the helix; 6, tra- 
gus; 7, antitragus; 8, 
lobule. 



402 



THE EAR 



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 in- 
terior is lined with thin skin, which contains hair follicles and 
cerumenous glands, the latter being most abundant at the junction 
of the cartilaginous and bony portions. The widest portion of the 
canal is near the external 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- 



Sead 1/ Malleus 

Jiof^ cf T1//npanxun> 

! Semicircular Ccuuds 



Cerumenous 
Glands 




/octal Airve 



laiclopen 



Fig. 391. — Front view of the organ of hearing. (Randall.) 

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. 

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 



ANATOMIC CONSIDERATIONS . 403 

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 
is practically divided by the chain of ossicles into two portions, an 
upper epi tympanic 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 



_____ MallexiS 

\ j^m^, M.Mi}\ 

Stapes 




Fig. 392. — Anatomy of the ossicles. (Pyle.) 

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 
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 proc- 




404 ^ THE EAR 

ess 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 memhrana tympani, or ear-drum, is a thin elastic membrane 
stretched obliquely downward and inward across the inner end of the 
external auditory canal forming the outer wall of the tympanic 
cavity. The drum membrane is made up of three layers, an outer 
one of skin, a middle of fibrous tissue, and an inner formed by the 
reflection of the mucous membrane of the 

n. 

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 
surface* of^'the right normally smooth. By the aid of a speculum 
membrana tympani. and suitable illumination there will be noted a 
(Gleason.) ^ «, Mem- whitish ridge formed by the handle of the 

brana flacdda; b, pos- jj^^^eus, running from a tubercle near the upper 

tenor fold; c, snort . . 

process; d, incudosta- ^^^ anterior periphery downward and back- 

pedial articulation; e, ward toward the center of the membrane. This 

To^^^^cone of H hr""' ^^^^^^^^ 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 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 membrane 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^i 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. 



DIAGNOSTIC METHODS 405 

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, foreign 
bodies, acute infectious diseases, syphilis, tuberculosis, etc. The 
symptoms or symptom complained of should then be investigated 
more in detail. 

Deafness and tinnitus are the Common complaints for which relief 
is sought, and are frequently associated. In the presence of the 
former it should be 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 



4o6 THE EAR 

as well as affections of the internal ear, in neurasthenic conditions/ 
arteriosclerosis, and may follow the taking of certain drugs, as, for 
example, quinin or the salicylates. They may be described by the 
patient as singing, whistling, buzzing, loud and roaring or musical 
in character, or they may resemble voices. When present, it should 
be learned whether they are located in the ear or in the head, whether 
unilateral or bilateral, and whether they are modified by mental or 
physical exertion or by the time of day. As a rule they are worse at 
night, and in some cases they may be entirely absent during the day. 

In the presence of pain or earache, its character, the duration, 
and whether constant or intermittent should be noted. Pain may be 
the result of morbid conditions in the ear or it may be reflex, as, for 
example, from a decayed tooth, or from an inflammation of the 
pharynx, tonsils, etc. When it suddenly develops in an ear pre- 
viously 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 collection of fluid in the middle ear 
or destruction of bone may be suspected. Pressure tenderness is 
also of diagnostic importance in determining the origin of the trouble. 
Thus, pain caused by traction upon the auricle or by pressure on the 
tragus points to an inflammation involving the external auditory 
canal, tenderness elicited by pressure in the depression below the 
lobule of the ear to middle-ear inflammation, and pressure tenderness 
over the mastoid to involvement of that bone. 

The presence or absence of a discharge is next determined. With 
a history of a discharging ear, the length of time the discharge has 
lasted, the character of the discharge, whether serous, bloody, or 
purulent, whether scanty or in large amounts and whether continuous 
or intermittent should be noted. It is also important to ascertain if 
the discharge is accompanied by pain, and the relation the pain and 
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 XIV. The parts in the vicinity of the ear 
should likewise be inspected as well as palpated for signs of inflamma- 



OTOSCOPY 407 

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. In 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 w^ay 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. 340) , or 
by means of light reflected upon the part by a head mirror. 

Position of Patient. — The patient is seated upon a stool with the 
ear to be examined turned toward the surgeon, who is also seated 
upon a stool of such height that his eyes are on a level with the ear of 
the patient. If reflected light is employed, the source of illumination 
should be a little above the level of the patient's ear and upon the 
examiner's left side. 

Technic. — Under full illumination the auricle is first carefully 
inspected, noting the presence or absence of excoriations from dis- 
charges, eczema, swellings, deformities, new growths, etc. Then by 
means of traction upon the auricle in an upward and backward direc- 
tion, the external auditory canal is straightened out and a view of a 
considerable portion of its interior becomes possible. The examiner 
should note especially the color of the canal for signs of inflammation, 
the presence or absence of swellings, fissures, foreign bodies, new 
growths, etc. 

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- 



4o8 



THE EAR 



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, 
mounted upon an adjustable bracket so that it may be raised to any 




s " 



Fig. 394.- 



-Instruments for otoscopy, i, Head mirror; 2, aural specula; 3, ear probe; 
4, ear curet; 5, angular ear forceps; 6, ear syringe. 



desired height, a concave head mirror 33^^ 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 Politzer 
angular ear forceps, and an ear syringe (Fig. 394). If desired, in 
place of reflected light, illumination from an electric head Hght may 
be substituted. 





Fig. 395. — Gruber's speculum. 



Fig. 396. — Boucheron's speculum. 



For purposes of examination Gruber's specula (Fig. 395) are most 
satisfactory, as they are elHptical 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 
instruments, such as Boucheron's (Fig. 396) or Toynbee's is prefer- 



OTOSCOPY 



409 



able. Electric-lighted specula (Fig. 397) 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 
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 
plane with the external auditory canal. If reflected light is em- 
ployed, the source of illumination should be a little above the level of 
the patient's ear and upon the examiner's left. 




Fig. 397. — Electric-lighted speculum. 

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 Ht- 
tle downward, as the wall of the canal has no bony support at this 
time and Hes 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 
parts illuminated at the distal end of the speculum until the drum 



4IO 



THE EAR 



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. 

(398)- 

Before examining the drum menbrane, 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 
solution or a saturated solution of boric acid (see page 423). Small 




Fig. 398. — Otoscopy with the reflector and ear speculum. 

course of light. (Gleason.) 



The arrows represent 



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 an- 
terior portion, about J-^5 inch (i mm.) from the superior wall, is 
the short process of the malleus, and running forward and backward 



DETERMINATION OF MOBILITY OF DRUM MEMBRANE 



411 



above the short process are two folds of membrane above which lies 
Sharpnell's membrane. Extending from the tip of the malleus to- 
ward the periphery, in the lower and anterior quadrant, will be noted 
the bright cone of reflected light. In addition to these landmarks 
normally to be observed, if the membrane is very thin and retracted, 
there may be seen the long process of the incus as a whitish line run- 
ning 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 shortened, and the con- 
ical folds are deepened. At the same time 
the cone of reflected light will appear altered 
in shape and displaced. If bulging is pres- 
ent, its location should be noted. As a rule, 
bulging occurs in the posterior portion of the 
membrane, or the entire drum may be dis- 
tended. 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 in- 
formation as to the conditions found is desired. In all manipula- 
tions of the speculum or instruments great gentleness should be 
observed. 




Fig. 399. —The appear- 
ance of the drum mem- 
brane as. seen through the 
speculum. 



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 
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. 



412 



THE EAR 



Apparatus. — Siegle's pneumatic otoscope (Fig. 400) 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 suppHed by an 
electric head light or reflected from a head mirror. 

Position of Patient. — The patient and the operator occupy the 
same relative positions as employed for an ordinary otoscopic exam- 
ination (see page 409) . 

Asepsis. — The speculum portion of the instrument should be 
sterilized by boiHng. 




Fig, 400. — Siegle's pneumatic otoscope. 



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 413 

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 fol- 
lowing are sufficient for all practical purposes: (i) testing the acuteness 
of hearing by means of the watch and voice, (2) testing the percep- 
tion 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 W^eber's and Rinne's tests. Galton's whistle gives tones 
ranging from about 7000 vibrations per second to the highest per- 
ceptible tone limit. The instrument is provided with a scale and 
screw whereby the number of vibrations may be regulated so as to 
give any tone within the limits stated above. 

Tests of Acuteness of Hearing. — i. The Watch Test. — The 
test is made in a room free from noise and with a watch that ticks 
rather loudly. Since the ticking of different watches varies con- 
siderably, the distance at which the particular watch is heard by a 
normal ear must be determined by experience. Each ear is tested 
separately in the following manner: The patient is seated in a chair 
with his eyes closed, and with his forefinger closing the ear not under 
examination. The examiner first holds the ticking watch close to 
the ear being tested so that the patient can hear it distinctly and then 
slowly brings it from a distance beyond the lange of hearing power 
toward the ear in a line perpendicular to the auricle until the patient 
again recognizes the ticking. The distance from the ear at which 
the ticking is heard is then accurately measured, and the result is 
expressed in a fraction of inches, the denominator of which represents 
the number of inches at which the particular watch is normally heard 
and the numerator the number of inches it is heard by the ear under 
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 



414 



THE EAR 



in an ordinary voice and also in a whisper at the end of expiration 
with the residual air from various distances, and measures the dis- 
tance at which the patient can hear and repeat them correctly. The 
result is expressed in a fraction of feet, the denominator of which rep- 



n 



3 



\Y/ 



^yy 



?y 



Vc7 



\ 



c 



Fig. 401. — Hartmann's set of tuning-forks varying from 128 vs. to 2048 vs. 

resents 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 Hps of the examiner and that the 




P'iG. 402. — Edelmann's modification of Galton's whistle. 

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 



INFLATION OF THE MIDDLE EAR 415 

a more limited range than this/varying from about 24 to 16,000 vibra- 
tions per second. In this test the hearing is tested for low tones with 
a low-toned fork and for high tones with the Galton whistle. The 
test is of diagnostic value in 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 ad- 
vancing age the upper tone limit is lowered. 

Weber's Test. — It is employed for the purpose of locating the 
seat of unilateral deafness. In this test a C 2 (512 vs.) fork is set 
vibrating and the handle is placed on the incisor teeth or upon the 
cranium in the mid-line. If the sound is heard best in the affected 
ear, it is indicative of some affection of the conduction apparatus, as 
middle-ear disease, impacted cerumen, or occlusion of the Eustachian 
tube, while if the perceptive apparatus is at fault, it will be heard 
better in the normal ear. 

Rinne'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 
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.^., 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- 
ency 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 428). 



4l6 THE EAR 

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 will 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 will be distant. When the middle ear contains an exudate, the 
sound will vary according to the character of the fluid; if it is thin 
and watery, a fine bubbling sound will be heard; if it is thick and 
viscid, the sound will be a coarse bubbling one. In the presence of a 
perforation of the membrana tympani, inflation causes a characteris- 
tic hissing or whistling 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 effect of the infla- 
tion upon it noted and the mobility determined. 

There are three methods by which the middle ear may be inflated : 
(i) Valsalva's method, (2) Politzer's method, and (3) catheteriza- 
tion. Before practising inflation it is a wise precaution to inspect the 
ear-drum to see if it is sufficiently strong to stand the strain, as cases 
have been reported where a diseased drum has been ruptured by the 
Politzer bag. 

Position of Patient. — The patient should be seated upon a chair. 
The examiner is also seated, facing the patient. 

Preparations of Patient. — In 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 ^St,). 

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 frequently, with the risk of producing a flaccid con- 
dition of the drum unless the patient is cautioned against its 
overuse. 

Apparatus. — There will be required a head mirror and some 
source of illumination, or an electric head light, aural specula, and an 
aural stethoscope. The latter instrument (Fig. 403) 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. 



INFLATION OF THE MIDDLE EAR 



417 



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 




Fig. 403. — Aural stethoscope. 

forced through the tubes into the middle ear. As this occurs the 
patient will have a feeling 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. K the drum membrane is inspected as the 
inflation is performed, it will be noticed that the membrane moves 
outward and becomes somewhat congested. 




Fig. 404. 



/ ^ 

-Instruments for Politzer's method of inflation, i, Head mirror; 
specula; 3, aural stethoscope; 4, Politzer inflation bag. 



aural 



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 Politzer air-bag (Fig. 404). 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, supplied with a piece of 



27 



4i8 



THE EAR 



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 teaspoonf ul is sufficient — which he is instructed to hold in his 
mouth until told to swallow. The examiner then inserts the nose- 
piece of the Politzer bag into one nostril for a distance of about 
^"2, iiich (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 




Fig. 405. — Inflation by Politzer's method. 

of swallowing, the examiner compresses the air-bag with his right 
hand (Fig. 405). The act of swallowing causes the soft palate to rise 
upward and shut off 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 
effect as swallowing. 

With the auscultatory tube the character of the sound produced 
is recognized. When it is desired to inflate only one ear, the patient's 
head should be turned to one side, so that the affected ear Hes upper- 
most, while at the same time the opposite ear is closed by the fingers 
pressed against the external auditory meatus. In using Politzer's 
bag care should be taken not to use a great amount of force and 
thereby avoid causing the patient pain. 



INFLATION OF THE MIDDLE EAR 



419 



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. 
In certain cases it may be impossible to perform catheterization, 
as, for example, in the presence of marked deviations of the septum, 
considerable narrowing of the nasal fossae, tumors, or adenoids, 
and in nervous or hysterical individuals or in those upon whom 
attempts to pass the catheter excite coughing, retching, or spasm of 
the pharyngeal muscles. 




Fig. 406. — 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. 



Apparatus. — There will be required a head mirror and suitable 
illumination or an electrical head light, aural specula, an aural stetho- 
scope, a Politzer air-bag with an Eustachian catheter tip, and several 
sizes of Eustachian catheters (Fig. 406). The catheter is a metal 
tube 6J^ inches (16 cm.) long, curved at its distal end, the extreme 
tip of which is slightly bulbous, and with an expanded proximal end 
into which the tip of a Politzer bag may be fitted. It should be of 
pure silver so that its curve may be changed to fit the 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 }i^, ^{27 }i iiich (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, 



420 



THE EAR 



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 
applied by means of a cotton-tipped probe to the inferior meatus. 

Technic. — The operator first 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. Lowenberg Method. — The proximal end of the lubricated cathe- 
ter is grasped lightly between the thumb and forefinger of the right 
hand, while by means of the thumb of the left hand, the tip of the 




Fig. 407. 



-Catheterizing the Eustachian tube. First step, showing the position of the 
catheter for its introduction. 



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. 
407). 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 with the pos- 
terior wall of the pharynx (Fig. 408). The beak is then rotated 
through an angle of 90 degrees toward the median line, until the guide 
ring lies horizontal, and the catheter is drawn forward until its beak 
is found to impinge upon the nasal septum (Fig. 409). The beak is 
then rotated downward and outward through an angle of a little 



INFLATION OF THE MIDDLE EAR 



421 



more than 180 degrees until the guide ring points toward the outer 
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- 




FiG. 408. — Catheterizing the Eustachian tube. Second step, catheter being 

along the floor of the nose. 



stachian tube (Fig. 410). In all these manipulations care should be 
taken to employ the greatest gentleness. The entrance of the 




Fig. 409. — Showing the different positions of the beak of the catheter in its insertion 
into the orifice of the Eustachian tube. (After Barnhill and Wales.) 

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 
in place by the thumb and forefinger of the left hand, the other fin- 



422 THE EAR 

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- 
formed by compressing the bag in the fingers of the right hand (Fig. 




Fig. 410. — Catheterizing the Eustachian tube. Third step, shomng the position 
of the guide when the catheter tip is entering the orifice of the tube. 

411). While this is done the examiner notes the sound produced by- 
means of the auscultation tube. 




Fig. 411. — Inflation through an Eustachian catheter. (Gleason.) 

In removing the catheter it is first rotated until its beak points 
downward and is then gently withdrawn by a reversal of the move- 
ments employed in its insertion. 



THE EAR SYRINGE 



423 



2. Binnafont 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 
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 from 1/4 to 3/8 inch (6 to 9 
mm.) . The catheter isr 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 
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 solu- 
tions of the proper temperature, otherwise the 
procedure is not only rendered painful, but is 
capable of causing harm. Especially is it neces- 
sary 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 ^ »„ , 

•^ , \TiiJi- Fig. 412. — Allport's 

of I or 2 ounces (30 to 60 c.c). It should be pro- ^^j. syringe. 

vided with a blunt conical nozzle — the ordinary 

olive-shaped tip is not to be commended, as it interferes with a 

free return flow. A syringe with a long-pointed nozzle, such as is 

shown in Fig. 413, 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. 414), with a capacity of 1/2 

dram (2 c.c), provided with specially bent tips, is used. There will 




424 



THE EAR 



be required, in addition, suitable illumination, aural specula, and an 
aural applicator. 

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 (5i (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. 




Fig. 413. — Metal ear syringe with a small nozzle 

Temperature. — The solution should be injected warm — at about 
a temperature of 100° F. (38° C). Cold solution should never be 
used, as it is apt to cause vertigo or fainting. 

Quantity. — For tjie purpose of removing foreign bodies or wax, 
I to 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. 




Fig. 414. — Blake's tympanic syringe. 

Frequency. — This will depend upon the virulence of the infection 
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 



INSTILLATIONS 



425 



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 
solution, as it is injected, will pass along the upper wall and wash out 
purulent matter or foreign material below (Fig. 415). The solution 
is then injected with only a small amount of force in sufficient quanti- 
ties for the purpose of the operation. Should dizziness or syncope 
supervene, the operation should be immediately stopped. 




Fig. 415. — Washing impacted cerumen from canal. Showing how to hold auricle 
to straighten the canal and where to direct the stream of water. (Gleason.) 

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 
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 



426 



THE EAR 



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 granula- 
tion tissue. 

Instruments. — To instil a solu- 
tion into the external auditory canal, 
an ordinary glass medicine dropper 
may be employed. For tympanic 
instillations a pipette glass dropper 
with a small curved tip, a head 
mirror and illumination, and an 
aural speculum will be required 
(Fig. 416). 

Asepsis. — The instruments 
should always be sterilized before 




Fig. 416. — Instruments for tym- 
panic instillation, i, Head mirror 
2, aural specula; 3, glass instillator. 



use. 



Solutions. — Solutions of silver nitrate 5 to 20 per cent., copper 
sulphate 5 per cent., zinc sulphate 5 per cent., and alcohol 25 to 95 
per cent, may be used. 

Temperature. — The solutions 
should be warm — at about 100° F. 
(38° C). . 

Position of Patient. — The patient 
should be seated with the head bent 
sideways so that the affected ear lies 
uppermost. 

Technic. — The ear is first cleansed 
and all secretion or fluid removed 
by means of a cotton-tipped probe. 
The operator then straightens out 
the external auditory canal by grasp- 
ing the auricle between the thumb 
and forefinger of the left hand and 
exerting traction in an upward and 

backward direction. With the right hand he then instils 5 to 10 
drops (0.3 to 0.6 c.c.) of the desired solution into the auditory canal. 




Fig. 417. — Showing nozzle of a 
pipette inserted for a tympanic in- 
stillation. 



APPLICATION OF CAUSTICS 



427 



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. 417). 

APPLICATION OF CAUSTICS 

The application of chemical caustics to the ear may be required 
for the purpose of destroying granulations or small polypi. The most 
frequently employed agents for this 
purpose are chromic acid or silver 
nitrate. They are applied fused 
upon the tip of a delicate ear probe. 
In making such applications with 
strong chemicals great care must be 
taken that the caustic only comes in 
contact with, the area to be treated. 
They should, therefore, only be ap- 
plied by the aid of a speculum and 
good illumination. 

Instruments. — There will be re- 
quired a head mirror and a strong 
light, aural specula, a delicate aural 
probe, and an aural applicator (Fig. 
418). 

. The method by which the acid 
or silver nitrate is fused upon the 
probe has been previously described 
(see page 386). 

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 exami- 
nation. 

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 appUed. The 
caustic is then carefully applied to the area it is desired to destroy. 




Fig. 418. — Instruments for ap- 
plying caustics to the ear. i, Head 
mirror; 2, aural specula; 3, aural 
probe; 4, applicator. 



428 



THE EAR 



INFLATION OF THE MIDDLE EAR 

The value of inflation in diagnosis has been previously considered 
(see page 415). 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 416. 

INFLATION WITH MEDICATED VAPORS 

In certain cases of subacute or chronic nonsuppurative otitis 
media, inflation with medicated vapors is often employed to better 




Fig. 419. — Dench's vaporizer and Eustachian catheter. 

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- 
eter, forms the necessary apparatus. There are a number of con- 
venient vaporizers, such as Hartmann's, Pynchon's, or Dench's 
(Fig. 419). 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. 



INJECTION OF SOLUTIONS INTO THE EUSTACHIAN TUBES 429 

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 
416). 

Position of Patient. — Same as for catheterization (seepage 416). 

Technic. — The Eustachian " catheter is passed by one of the 
methods described on pages 420 and 423 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 mucous 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- 




FiG. 420. — Eustachian catheter and syringe for medication of the Eustachian tubes. 

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. 

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. 420), and aPolitzer 
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), silve nitrate 2 to 5 gr. (0.13 to 0.32 gm.) to the ounce 



43 O THE EAR 

(30 c.c), sulphate of zinc i gr. (0.065 g^^-) 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 eraployed. 

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 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 416). 

Position of Patient. — Same as for catheterization (see page 416). 

Technic. — The catheter is introduced into the tube by one of the 
methods described on pages 420 and 423 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 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 1}^ inches (3 cm.) beyond the tip of the catheter. 

Instruments. — There will be required an Eustachian catheter, 
Eustachian bougies, and a Politzer air-bag (Fig. 421). The bougies, 
are made of silkworm gut or whalebone, with tips conical or bulbous 
in shape, and varying in diameter from ^-q^ to ^^5 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. 



THE EUSTACHIAN BOUGIE 43 1 

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 

416). 

Position of Patient — Same as for catheterization (see page 416). 

Technic. — The bougie is lubricated and is introduced within the 
catheter until the tip is level with the distal end of the catheter (Fig. 
422). The catheter, with the bougie in place, is then introduced 




Fig. 421. — Instruments for dilatation of the Eustachian tubes, i, Eustachian cathe- 
ters; 2, Eustachian bougies; 3, Politzer's inflation bag. 

into the tube in the manner described on page 420. The bougie is 
then carefully passed into the tube for not more than i 3^^ inches 
(3 cm.) which can be accomplished in a normal tiibe' without difficulty. 
As 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; 



r 




Fig. 422. — Showing the bougie inserted in the catheter ready to be passed into the 

Eustachian tube. 

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 efifect than the plain bougie in overcoming a stenosis due 



432 THE EAR 

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 pro- 
duces 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 
mstrument (see Fig. 400), by means of which the drum membrane 
may be observed and the effect of the massage noted. 

Asepsis. — The speculum portion of the instrument should be 
sterile. 

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 412, 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 



INCISION OF THE MEMBRANA TYMPANI 



433 



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 is present, 
extensive destructive changes may have occurred and the process 
may rapidly extend to the mastoid antrum or to the cranial cavity. 




Fig. 423. — Instruments for incising the drum membrane, i, Head mirror; 2, aural 
specula; 3, angular paracentesis knife; 4, Allport's ear syringe. 



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. As a rule simple punc- 
ture, or paracentesis, is not enough; 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 3^^ to % i^^ch 
(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. 

423). 

Asepsis. — The instruments should be sterilized by boiling, and 
the operator's hands cleansed as thoroughly as for any operation. 



434 



THE EAR 




Fig. 424. — Incision of the membrana tympani in acute otitis media involving the 
lower portion of the tympanic cavity. (Dench.) 




Fig. 425. — Incision of the membrana tympani in acute otitis media, involving the 
upper portion of the tympanic cavity. (Dench.) 



INCISION OF THE MEMBRANA TYMPANI 435 

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. 

Anesthesia. — The operation is quite painful. In children genial 
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: 

I^. Cocain hydrochlorate, gr. vi C0.4 gm.) 

Anilin oil, 
Alcohol, aa 5i (4 c.c.) 

A small amount of this solution is instilled into the external auditory 
canal and is allowed to remain for fifteen minutes. It must be used 
with care if a perforation be present, as it will thus enter the tym- 
panic 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. 424). 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 K2 to 
J^ inch (2 to 4 mm.). Of course, if there is any localized bulg- 
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 withdrawn, the tissues of the posterior 
wall of the auditory canal are incised down to the bone for a distance 
of about }i inch (3 mm.) from the drum (Fig. 425). 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 satur- 
ated solution of boric acid or a i to 5000 bichlorid of mercury 
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 XVI 
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 Hes 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 alae joined in front at an acute angle. Above, it is 
joined to the hyoid bone by the thyrohyoid membrane, and, below, to 
the cricoid cartilage by the cricothyroid membrane. The space 
between the thyroid and cricoid cartilages in an adult measures 
about half an inch (i cm.) in height; 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 J^ 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. 

436 



ANATOMIC CONSIDERATIONS 



437 



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. 426. Fig. 427. 

Fig. 426. — Anterior view of the larynx. (After Deaver.) i, Epiglottis; 2, lesser 
comu of hyoid bone; 3, greater cornu of hyoid bone; 4, thyrohoid membrane; 5, thyroid 
cartilage; 6, cricothyroid membrane; 7, cricoid cartilage; 8, trachea. 

Fig. 427. — 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. 

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 



438 



THE LARYNX AND TRACHEA 



measure about % inch (2 cm.) in length in the male, and ^i inch 
(i cm.) in the female. Between the two cords is a long narrow 
chink, the glottis. Above and parallel to the vocal cords are two 
second folds of mucous membrane enclosing ligamentous tissue, 
attached to the thyroid cartilage in front and to the two arytenoids 
behind, 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- 



'Hubert, 
Cbrnu 



rTi/a^e 



Ri'^hf" Cont/tfO' 

canT/c/£ftK 



crr/e/y 




Tnembrane 



Inf.thyr.arf: 
7-ocAea. 









Fig. 428. — Anatomy of the trachea and its relations. 

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. 

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 



DIAGNOSTIC METHODS 439 

(10 to 12 cm.) long in males, and from 3 2/3 to 4 1/2 inches (9 to ii 
cm.) long in females. Its transverse diameter measures on an aver- 
age 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 
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. 

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- 
nate vein, the arch of the aorta, and the innominate and the left 
common carotid arteries. Behind lies the esophagus. Laterally, 
the trachea is in relation with the common carotid arteries, the 
lateral lobes of the thyroid, the 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 prehminary to the local examination, attention should first 
be given to the general condition of the patient, and the history of 
other afifections that may have a bearing upon the conditions should be 



440 • THE LARYNX AND TRACHEA 

inquired into. This is important, for, while the symptoms of proc- 
esses involving this portion of the respiratory tract are characteris- 
tic ( 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 symtoms are secondary to 
other conditions, such as gout, diphtheria, rheumatism, diabetes, 
nephritis, tuberculosis, syphilis, diseases of the nervous system, etc. 
Thus it becomes of the utmost importance to examine other organs 
as well and not to limit 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, swellings, new growths, enlarged 
glands, fractures of the cartilages, etc., may be determined, and the 
mobility or fixation of the parts during swallowing and respiration 
may be noted. 

LARYNGOSCOPY AND TRACHEOSCOPY 

By this method the interor of the larynx and trachea are in- 
spected by means of a laryngoscopic mirror and reflected light. The 
technic is not difficult, 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 
[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, 3/4 
and I inch (i, 2, and 2.5 cm.) in diameter, that they may be adapted 
to the size of the individual fauces; and an alcohol lamp (Fig. 429). 
The light should be placed upon a suitable bracket, that it may be 
raised or lowered to any desired height (see Fig. 339). 

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. 



LARYNGOSCOPY AND TRACHEOSCOPY 



441 



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 raided and 




Fig. 429. — Instruments for laryngoscopy, i, Laryngeal mirrors; 2, head mirror; 

3, alcohol lamp. 




Fig. 430. — ^Laryngoscopy. First step, showing the method of grasping the tongue* 



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 



442 THE LARYISTX AND TRACHEA 

side of the patient's, and with his eye on a level with the patient's 
mouth, at a distance of about a foot (30 cm.), or the focal length of 
the mirror. 

Anesthesia. — Ordinarily, cocainization of the parts is unneces- 
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. 

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 Hght will be reflected in a circle upon the mouth of 
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- 




FlG. 431. — ^Laryngoscopy. Second step, heating the mirror. 

tor's left hand (Fig. 430). Light traction is made outward and 
slightly upward rather than downward, so as to avoid forcing the 
under surface of the tongue against the lower incisor teeth. The 
laryngeal mirror is then warmed to avoid condensation "of moisture 
upon its reflecting surface, by holding it at a Httle distance above a 
flame for a few seconds (Fig. 431), the precaution being taken to test 
the temperature of the mirror hejore 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 between the thumb and forefinger of the right hand 
with its reflecting surface downward (Fig. 432), 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 



LARYNGOSCOPY AND TRACHEOSCOPY 



443 



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 sufl&cient time must be al- 




Fig. 432. — Showing the method of holding the mirror. 

lowed for the patient to recover his breath and the irritability to 
subside before it is reintroduced. As soon as the instrument is in 
proper position, the handle is moved to one side of the patient^s 
mouth so as to be well out of the line of vision. The mirror is then 
slowly and gently turned until a view of the base of the tongue is 




Fig. 433. — ^Laryngoscopy. Third step, showing the mirror being introduced 
and also the relative position of the patient and examiner and the position of the light. 

obtained, and any abnormalities 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. 434). 

It should be remembered that the laryngeal image will be in- 



444 



THE LARYNX AND TRACHEA 



verted — that is, the structures of the front part of the larynx appear 
on the upper part of the mirror, and vice versa; the right and left 




Fig. 434. — ^Laryngoscopy. Fourth step, showing the mirror in place. (J. M. Anders.) 





Fig. 435. Fig. 436. 

Fig 435. — The laryngoscopic image, i, Epiglottis; 2, false vocal cords; 3, vocal 
cords; 4, glossoepiglottic fossa; 5, interarytenoid space; 6, cartilage of Santorini and the 
location of the arytenoid cartilage; 7, cartilage of Wrisberg. 
Fig. 436. — The larynx during gentle respiration. 

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 



LARYNGOSCOPY AND TRACHEOSCOPY 



445 



color traversed by its pink blood-vessels; extending backward across 
the mirror back of the epiglottis are a pair of pearly-white bands, 
the vocal cords; parallel to the vocal cords, but lying anteriorly and 
outside, are a second pair of bands with a 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 
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 
arytenoid cartilages; on either side of the image will be noted the 
glossoepiglottic fossae. 

To make a complete examination, the larynx should be inspected 
during quiet respiration, deep respiration, and phonation. During 





Fig. 437. — The larynx in phonation. 



Fig. 438. — The latynx during deep 
respiration. 



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. 436). By requesting the patient to say "ee'' or ^'he," a 
view is obtained of the larynx with the cords almost in apposition and 
the interarytenoid space obliterated (Fig. 437). 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. 438). 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 in favorable cases may be brought into view. To obtain 
the most favorable position for inspection of the trachea, the pa- 
tient's neck should be held straight and the chin extended somewhat 
forward. The mirror will also require a different adjustment, being 



446 THE LARYNX AND TRACHEA 

held more horizontally than for laryngoscopy, and the surgeon 
should be seated lower. 

The examiner should first note the color of the various parts 
brought to view for signs of congestion or inflammation, bearing in 
mind that if cocain has been employed the parts will appear anemic, 
and that gagging or retching may be responsible for congestion He 
should look for the presence of exudations, foreign bodies, and any 
structural changes, such as ulcerations, swellings, abscesses, edema, 
new growths, malformations, and dislocations of the arytenoid car- 
tilages, etc. Finally, the condition and mobiHty of the vocal cords 
during respiration and phonation are observed. They should 
approximate symmetrically in the mid-line during phonation, and 
separate equally with inspiration. 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 struc- 
tures may be thus obtained, it may be necessary to make more than 
one inspection before the whole examination is completed in a 
satisfactory manner. 

Difficulties in Laryngoscopy. — It is sometimes a difficult matter 
for a beginner to inspect the parts, owing to faulty technic or to 
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 examiation 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 made in. the usual way. If 



DIRECT LARYNGOSCOPY 



447 



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 




Fig. 439. — Jackson's self-illuminated tube spatula for direct laryngoscopy. 

difficult, and it may also be performed upon a patient under general 
anesthesia. It is, however, more uncomfortable for the conscious 
patient than ordinary laryngoscopy. 

Instruments. — ^A tubular spatula, self -illuminated, such as Jack- 
son's (Fig. 439), 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. 440) and an electric head 
light (Fig. 441). In addition a mouth-gag and a Sajous applicator 
are required (Fig. 442). 

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 



448 



THE LARYNX AND TRACHEA 



raised and thrown back so that a direct view from above downward 
is possible. An assistant stands or sits behind, supporting the 
patient's head, and holding the mouth-gag in proper position. The 
operator stands in front. 

A child should be seated upon the lap of a nurse, who encircles 
its body with her arms, confining the child's arms closely to its sides 





Fig. 440. — Kirstein's tongue depressor. 

and clasping its legs between her knees. The child's head rests upon 
the nurse's shoulder, being held in the proper position from behind 
by an assistant. 

Anesthesia. — Cocainization of the parts is usually necessary to 
avoid unpleasant gagging and retching. This is accomplished by 




Fig. 441. — Kirstein's head light. 

the application to the larynx and neighboring parts of a 4 per cent, 
solution of cocain by means of a cotton swab held by a Sajous appli- 
cator. This should be performed by the aid of a laryngeal mirror. 
If operative procedures are required, the application of a 20 per cent, 
solution of cocain should follow the preliminary cocainization. In 



DIRECT LARYNGOSCOPY 



449 



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 




Fig. 442. — Sajous' applicator and mouth-gag. 

regurgitation of the stomach contents. The parts having been co- 
cainized, and with the patient seated in the proper position, a mouth- 
^ag is inserted in one side of the mouth and is held in place by the 




Fig. 443. — 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; dj conduit for removing 
secretions, etc., by aspiration during the examination. 

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 Ut and adjusted so as to throw the light into 

29 



450 THE LARYNX AND TRACHEA 

the mouth, if a nonilluminated tube is used, the tubular speculum is 
introduced past the base of the tongue until the epiglottis appears. 
Its tip is passed to a point about 1/2 inch (i cm.) below the free edge 
of the epiglottis, which is then drawn forward, and with it the base 
of the tongue out of the line of vision by exerting pressure upon the 
handle of the instrument in an upward and backward direction 
(Fig. 443). 

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 
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 
the back of the tongue. With the head light properly adjusted the 
operator looks down this groove and inspects the larynx. The 
posterior walls of the larynx and trachea are clearly viewed by this 
method, but the anterior parts are not seen so well as with the 
laryngoscopic mirror. 

SUSPENSION LARYNGOSCOPY 

A method of laryngoscopy of great value for certain cases has 
been devised by Killian under the name of suspension laryngoscopy. 
It is performed with the patient in the dorsal position, his head sus- 
pended by means of a specially made spatula introduced over the 
tongue. The curved region from the teeth to the larynx is thus 
converted into a straight line, and it is possible to obtain a direct 
view of the larynx and surrounding parts not possible under other 
methods. 

Suspension laryngoscopy is not intended to take the place of 
indirect laryngoscopy for routine oihce examinations, and, as a 
diagnostic measure, should be reserved for cases in which difficulty 
is met in making a satisfactory examination by the usual methods. 



SUSPENSION LARYNGOSCOPY 



451 



It is of special value for operative procedures, such as the removal of 
foreign bodies or growths from the larynx, the cauterization or 
curettage of ulcerations, etc., and as an aid in introducing thebron- 
chosc9pe or esophagoscope. Its advantages over the other methods 
of laryngoscopy for operating is that the operator is brought near 
the field of operation and both of the operator's hands are left free. 
Futhermore, on account of the position of the patient's head, blood 
and secretions escape toward 
the vault of the pharynx and 
do not obscure the operative 
field or enter the larynx. 

Supension laryngoscopy 
has certain limitations, how- 
ever, and is not suitable for 
all cases. Rigidity of the 
cervical portion of the verte- 
bral column, a very thick 
tongue, very prominent upper 
teeth, and any condition that 
prevents the mouth being 
opened to the fullest extent 
are contra-indications. The 
method thus has a wider field 
of usefulness in children than 
in adults. It is claimed that 
the suspension causes only 
slight discomfort and that the 
after effects are mild. 

Apparatus. — Killian's 
original instrument, as modi- 




FiG. 444.- 



-Travelling crane for 
laryngoscopy. 



suspension 



fied by Lynch, consists essentially of a travelling crane, or ''gallows," 
and a hook spatula. The gallows (Fig. 444) can be raised or lowered, 
or moved in a horizontal direction. The horizontal arm of the gal- 
lows is provided with notches to receive the handle of the hook 
spatula. 

The hook spatula consists of a handle, tongue holder, and mouth 
gag. The handle consists of a vertical arm with a joint in the center, 
by manipulation of which, the arm may be bent or straightened. One 
end of the arm terminates in a hook and to the other end a tongue 
holder and mouth gag is attached. The mouth gag, which may be 
opened or closed by means of a screw, has a plate which engages the 



452 



THE LARYNX AND TRACHEA 



upper teeth and prevents the spatula from slipping out of the mouth 
(Fig. 445). 

Illumination is furnished by a Kirstein head lamp, reflected 
light from a head mirror, or by a lamp designed to be fastened to one 
of the bars of the mouth gag. 

An operating table that can be raised or lowered to suit the 
height of the operator is necessary. 

Asepsis. — The operation should be performed under the usual 





Fig. 445, — ^Lynch's modification 
of Killian's hook spatula. 



Fig. 446. — Suspension laryngoscopy. 
(Modified from Lynch.) 



aseptic precautions. The hook spatula and mouth gag are boiled 
and the operator's hands are prepared as for any operation. 

Position of the Patient. — The patient should be in the dorsal 
position on a table, with the shoulders brought to the edge of the 
t3<ble and the head supported by an assistant. 

Anesthesia. — In this country general anesthesia is usually em- 
ployed for adults and always for children. If local anesthesia 
is used, the patient is given, two hours before the operation, i/ioo 
of a grain (.00065 gi^-) of scopolamin and 1/4 of a grain (0.0162 
gm.) of morphin hypodermically. Anesthesia is obtained by ap- 
jplying a 20 per cent, solution of cocain to the base of the tongue, 
pharynx, epiglottis, and larynx. 



DIRECT TRACHEO-BRONCHOSCOPY 453 

Technic. — The patient is placed on the table, with his shoulders 
at the edge and his head supported by an assistant, and the crane 
is secured to the table on the right side. Then under illumination 
from a head light, the tongue spatula, with the mouth gag closed, is 
carefully passed well over the base of the tongue in the median line 
until its tip engages in front of the epiglottis. Pressure of the tongue 
against the lower teeth should be prevented by means of a small wad 
of gauze previously placed between the inner surfaces of the teeth , 
and the tongue. The tooth plates are adjusted and the mouth gag is 
then opened to its fullest extent and securely locked. The operator 
brings the vertical arm of the hook toward him, thereby crowding 
the tongue forward and at the same time elevating the epiglottis. 
The hook is finally hung on the horizontal arm of the crane, the 
assistant slowly releasing the head until it hangs by its own weight 
supported by the hook spatula. Any additional adjustment that 
may be necessary may be made by moving the crane in a vertical 
or horizontal direction. The illumination is finally turned on ex- 
posing to direct view the larynx and the neighboring parts. 

DIRECT TRACHEO-BRONCHOSCOPY 

In 1897 Killian devised long endoscopic tubes that could beintro- .- 
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 eletric head light. This operation is designated 
respectively as *' upper direct tracheo-bronchoscopy, " and *4ower 
direct tracheo-bronchoscopy. " In this country, Chevalier Jackson 
has perfected similar tubes, in which, however, the illumination is 
supplied 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 
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 speciaHst; 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 tubes may be employed/' 



454 



THE LARYNX AND TRACHEA 



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. 

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 



^ 



=^ 



~^W1 ' 



Fig. 447. — Killian's bronchoscope. 

the smallest sized tubes should be used for the bronchi. Jackson 
employs for lower tracheo-bronchoscopy a tube J^ incli (8 mm.) in 
diameter by 8 inches (20 cm.) long for adults, and one 3^^ inch 
(5 mm.) in diameter by 53-^ inches (14 cm.) long for children; and 
for upper tracheo-bronchoscopy a tube %5 inch (7 mm.) in diame- 
ter by 18 inches (45 cm.) long for adults, and one }i inch (5 mm.) 
in diameter by 8 inches (20 cm.) long for children. 



^^\ 




Fig. 448. — ^Jackson's bronchoscope. 

In Killian's instruments (Fig. 447) illumination is supplied from 
an electric head light. In 'the Jackson tubes (Fig. 448) the illu- 
mination is suppHed by a small electric light at the distal end of 
Ithe instrument. These latter are somewhat easier to use than 



DIRECT TRACHEO-BRONCHOSCOPY 



455 



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. 449). For inserting these 
instruments, a special split tube (Fig. 450), resembling that used 
in direct laryngoscopy, is supplied which is, removed in two halves 
after the bronchoscope has entered the glottis. 




Fig. 449. — Jackson's secretion aspirator. 

A portable battery with rubber-covered cords, a mouth-gag, a 
Sajous applicator, variously shaped forceps, applicators for applying 
cocain or drugs to the mucous membrane, hooks, etc., for the removal 
of foreign bodies through the instrument, and a tracheotomy set 




Fig. 450. — 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. 

(see page 479) 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 necessary. The tubes and 
accessory instruments are boiled, the lighting apparatus is sterilized 
by immersion in alcohol or in a i to 20 carboHc acid solution followed 
by rinsing in alcohol, and the rubber-covered battery cords are wiped 
off with bichlorid solution. The hands of the operator and assistants 



456 



THE lary:nx and trachea 



should be as thoroughly cleansed as for any operation. On account 
of the danger of sepsis from the mouth, the patient's teeth should 




Fig. 451. — Accessory instruments for tracheo-bronchoscopy. 

be brushed and the mouth well cleansed with an antiseptic wash 
before passing the instruments. A tube employed in the upper 




Fig. 452. — The position of the patient and the assistant for upper tracheo-bron choscopy, 

(After Ja;ckson.) 

operation should not be used for lower bronchoscopy without 
resterilization. 



DIRECT TRACHEO-BRONCHOSCOPY 



457 



Preparation of the Patient. — If general anesthesia is to be em- 
ployed, the patient should be prepared according to the usual method 
(page 1 8). 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 
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- 




SUD£ or SPECULUM KtMOi/SO 



SePARABie SPICULUM RCMOVCD LLAVINS BKOMCHOJCOPt M f>OSITmM. 



I 



Fig. 453. — Showing the various steps in upper bronchoscopy. (After Jackson.) 

gag, while the operator stands in front. When a general anesthetic 
is employed, and in all cases of lower bronchoscopy, the patient 
should be in the dorsal position on a table, the front of which is 
slightly elevated, with the head hanging over the edge of the table, 
in which position it is supported by an assistant who takes care of the 
mouth-gag, as shown in Fig. 452. 

Anesthesia. — In children, general anesthesia is necessary. In 
adults, preliminary cocainization of the pharynx and larynx with a 4 
per cent, solution of cocain, followed by a 20 per cent, solution of 
cocain, applied to the larynx and trachea is in most cases sufficient, 



458 



THE LARYNX AND TRACHEA 



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. 

Technic. — i. Upper Tracheo-hronchoscopy. — 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 
449). The bronchoscope, well lubricated with sterile vaselin, and 
with the illumination properly turned on, is passed through the split 
tube as far as the epiglottis under the guidance of the operator's eye. 




Fig. 454. — ^Lower bronchoscopy. (Modified from Ballenger.) 



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 
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 



DIRECT TRACHEO-BRONCHOSCOPY 459 

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. 

2. Lower Tracheo-hronchoscopy. — ^Low tracheotomy is first per- 
formed as described on page 486. 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 introduced, and the instrument is 
advanced under the guidance of the operator's eye, which is applied 
at the end of the instrument. As soon as the bifurcation of the 
trachea is reached, the tube may be directed into either bronchus 
by gentle 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 anes- 
thetized, as before, in advance of the instrument with cocain applied 
upon long applicators through the instrument, and the examination 
proceeded with as above. 

The after-treatment of the patient consists in inserting a tracheot- 
omy tube which is worn for several days. After the removal of this 
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. 455). 

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. 



460 



THE LARYNX AND TRACHEA 



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 10 per cent, solution of cocain. 

Technic. — The tongue is protruded and held by the patient v/ith 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 
posterior pharyngeal wall (see Fig. 
456). It is then brought into the 
natural position, with the laryngeal 
portion vertical and the handle in 
the mid-line, the point of the instru- 
ment 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 
Fig. 455-— Instruments for probing ™age in the mirror, the diseased 

the larynx, i, Laryngeal probe; 2, laryn- areas are then explored (see Fig. 

geal mirror; 3, alcohol lamp; 4, head -.N In performing this manipu- 

mirror. , . . , , i ^i ^ 

lation, it must be remembered that 
the image in the mirror is reversed, so that movements of the instru- 
ment will likewise appear reversed, and that the distance between the 
arytenoids and the vocal cords is much greater than appears in the 
image. 




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. 



THE L.\RYNGEAL SPRAY 46 1 

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 syphilitic or tubercu- 
lous 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 man- 
ner. If this is not feasible, the patient must be very carefully in- 
structed 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. 365), and the De Vilbiss atomizers (see Fig. 366) 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. 367). 

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 380 for use in the nose may be employed. For 
topical applications to the larynx, the formulae of antiseptic, astrin- 
gent, sedative, and stimulating solutions given on page 385, 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. {2>^° C). 

Anesthesia. — When the parts are very sensitive, preliminary 
spraying with a 10 per cent, solution of cocain may be required. 



462 THE LARYNX AND TRACHEA 

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 light 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 compressed. 
In employing oily preparations, the patient should take an inspira- 
tion 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 applied by means of swabs or brushes. 
Solid caustics should be fused on a probe. The application should 
be made with the aid of a laryngeal mirror, and great care must be 
taken to avoid bruising the tissues or causing trauma. 

Instruments. — For the application of liquids, a cameFs-hair 
brush, mounted on a wire which is bent at right angles about 2 3-^ 
to 3- inches (6 to 7 cm.) from the end and inserted into a handle, a 
Sajous applicator (see Fig. 442), or an ordinary laryngeal applicator 
wrapped with cotton may be employed. In making use of the latter, 
care should be taken that the cotton is wrapped tightly about the end 
of the instrument, so that there is no danger of its falHng off and slip- 
ping into the larynx. 



THE DIRECT APPLICATION OF REMEDIES 



463 



Solid caustics, as silver nitrate and chromic acid, may be applied 
fused on the end of a laryngeal probe, as described on page 386. 




Fig. 456. — Method of inserting the lar5rQgeal applicator. 




Fig. 457. — Shows the method of making direct applications to the lar3rnx by the aid 

of the laryngeal mirror. 

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. 



464 



THE LARYNX AND TRACHEA 



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. 456), and then, as soon 




Fig. 458. — Instruments for applying powders to the larynx, i, Powder blower; 2, 
laryngeal mirror; 3, alcohol lamp; 4, head mirror. 



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 miiror (Fig. 457). 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. 



STEAM INHALATIONS 465 

INSUFFLATIONS 

Powders may be applied to the larynx by means of a special 
insufilator. 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, stear- 
ate of zinc, or powdered acacia as a base, are usually employed in the 
proportion 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 reHef 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. 458 is very convenient, as with it the 
amount of powder may be accurately measured, and the instrument 
may be manipulated with one hand. 

Technic. — The laryngeal mirror is warmed and properly inserted 
into the pharynx, so that a good view of the parts to be medicated is 
obtained. The insufflator, filled with the desired amount of powder, 
is inserted in the mouth and carried back to the 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. i 

STEAM INHALATIONS 

By means of steam inhalations the active principle of certain 
drugs that are readily volatilized by heat may be brought into con- 
tact 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 membranes by supplying moisture and so relieving the heat 
and dryness of congestion. In the latter stages of an inflammation 
the steam, furthermore, dilutes and assists in removing secretions. 
Steam inhalations are thus of great value in congestion and edema of 
the larynx, croup, membranous laryngitis, and bronchitis. They 
are especially serviceable in softening the thick tenacious secretion of 
chronic laryngitis. 

The 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 



466 



THE LARYNX AND TRACHEA 



shown in Fig. 459, is most convenient. For direct inhalation, more 
or less elaborate forms of apparatus are manufactured (Fig. 460), but 




Fig. 459. — Croup kettle. 





Fig. 460. — Steam atomizer. Fig. 461. — Steam inhaler impro- 

vised from a coffee-pot. 

a coffee-pot with a funnel of heavy paper placed in the top makes a 
simple and efficient inhaler (Fig. 461). 



STEAM INHALATIONS 



467 



Formulary. — Sedative, stimulating, or antiseptic drugs are the 
ones usually employed for inhalation. These include tincture of 
benzoin compound in the strength of i5 (4 c.c.) to the pint (500 
c.c.) ; creosote, 5 to 10 TH, (0.3 to 0.6 c.c.) to the pint (500 c.c.) ; ol. 
cubebae, 5111 (0.3 c.c.) to the pint (500 c.c); spirits camphori, 5TU 
(0.3 c.c.) to the pint (500 c.c); ol. pinus sylvestris, 5Tn, (0.3 c.ci) 
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 too hot irrita- 
tion of the mucous membrane may be produced and there is danger 
of the steam scalding the face. 




Fig. 462. — Crib arranged for steam inhalations. (After Kerley.) 

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 
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 



468 THE LARYNX AND TRACHEA 

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. 462). 

DRY INHALATIONS 

These are useful in diseases of the upper respiratory tract for those 
who cannot tolerate the steam inhalations. 

The Inhaler. — A special mask made of woven metal, which accu- 
rately fits the mouth and which is pro\aded with a sponge upon which 
the medication is dropped, is employed (Fig. 463). 




Fig. 463. — Inhalation mask. 

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 
or upper portion of the trachea. It is an operation which gives 
prompt relief without the necessity of cutting and without producing 



INTUBATION OP THE LARYNX 



469 



any loss of blood or shock. It is less terrifying to the patient 
than tracheotomy and the after-care is not so troublesome. 
Anesthesia is not necessary nor is any previous preparation of the 
patient required. Special instruments, however, are essential, and 
the feeding of the patient 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. 

Indications. — The operation was originally devised for the relief 
of obstruction to respiration in cases of laryngeal diphtheria and has 




O 



fQOOOOOo\ 





Fig. 464. — 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. 

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, 
an extractor, a mouth gag, and a gauge indicating the size of the 
tubes according to the age of the patient (Fig. 464) . Although these 



470 THE LARYNX AND TRACHEA 

instruments 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 head as far as possible (Fig. 465). Some opera- 
tors, 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 with a piece of silk 2 or 3 feet 
(60 to 90 cm.) long. Then, with the obturator in place, the tube is 
screwed on the introducer in such a manner that its projecting 
flange lies behind and faces away from the operator. The mouth gag 
is next inserted between the patient's jaws on the left side and is held 
in place by the assistant who supports the child's head. The opera- 



INTUBATION OF THE LARYNX 



471 



tor, with his eyes, nose, and mouth protected against possible infec- 
tion in diphtheria cases, faces the patient and inserts his left index- 




FiG. 465. — Position of child for intubation and method of holding. 

finger into the mouth, hooking up the epiglottis (Fig. 466) . 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 




Fig. 466. — Intubation. First step, showing the method of drawing the epiglottis 

forward. 

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 



472 



THE LARYNX AND TRACHEA 



index-finger around the hook on the under surface of the instrument^ 
and the loop of silk wound over his little finger, as shown in Fig. 
467. He then slowly introduces the tube into the mouth in the me- 




FiG. 467. — Showing the intubation tube on the introducer and the method of holding 

the latter. 

dian line, hugging the center of the tongue and keeping the handle of 
the instrument at first well down on the chest of the patient (Fig. 
468). When the end of the tube reaches the epiglottis (Fig. 469), the 




Fig. 468. — 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. 470) . 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. 471) . At 



INTUBATION OF THE LARYNX 



473 



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. 




'I ^ 




Fig. 469. — Third step in intubation. 



Fig. 470. — Fourth step in intubation. 



As soon as the tube is in proper position, the operator's forefinger 
is placed on its head helding it in place while the button on the handle 
of the instrument is pushed forward, thus disengaging the obturator 
from the tube (Fig. 47 2) . The intubator with the obturator attached 
is then removed, and the tube is pushed well in to. the larynx by 




Fig. 471. — Showing a faulty position 
of the tube, due to the handle of the in- 
troducer not being raised sufficiently high. 




Fig. 472. — Fifth step in intubation 
withdrawing the introducer while index- 
finger holds the tube in place. 



the finger (Fig. 473). No.t 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. 



474 



THE LARYNX AND TRACHEA 



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 positipn, it is well to wait for ten or 
fifteen minutes, to make sure that there is no obstruction to free 





Fig. 473. — Sixth step in intubation, 
showing the index-finger pushing the tube 
well into the larynx. 



Fig. 474. — 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. 475). Some 




Fig. 475. — 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 a disadvantage, how- 



INTUBATION OF THE LARYNX 



475 



-ever, in that it is possible for the child to remove the tube if it 
gets hold of the string. 

Should the tube be placed in the esophagus by mistake, there will 
be no relief to the dyspnea and the cyanosis, there will be an absence 
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 
for the patient to recover from the excitement attending the opera- 
tion, it should be reintroduced. 




Fig. 476. — Method of feeding an intubation patient with the head lowered. 



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 im- 
minent, 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- 



476 



THE LARYNX AND TRACHEA 



solid food. As a rule, by having the patient lie with the head lowered^ 
fluids will pass along the roof of the mouth to the posterior pharyn- 
geal wall, and will enter the esophagus, and, if given slowly, sufficient 
food may be administered in this way (Fig. 476); or food may be 
administered 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 555). Rectal feeding may be combined with the above if 
indicated. 

When to Remove the Tube. — The tube should always be re- 
moved as soon as possible, as its prolonged use may produce ul- 




FiG. 477. — Extubation. 

ceration of the larynx. In cases of diphtheria, where antitoxin has- 
been administered, the tube may be removed in three to seven days, 
depending to some extent upon the age of the patient, being left in 
for longer intervals in very young children. If the tube becomes 
occluded at any time, it must be removed without delay, cleaned, 
and then reintroduced. When the tube is to be permanently re- 
moved, the physician, after extracting it, should wait sufficiently 
long to see that respiration does not become impeded and neces- 
sitate 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 



TRACHEOTOMY 477 

€xtubator, held in the operator's right hand, is then introduced with 
its jaws closed, by the same maneuvers employed in introducing the 
intubator, until its tip is felt by the finger on the tube. It is then 
carefully guided into the lumen of the tube. By pressing the lever on 
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. 
477). 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 laryn- 
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 obstru- 
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, 
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 mouth, pharynx, jaws, 



478 



THE LARYNX AKD TRACHEA 



or larynx, and as a preliminary to laryngectomy and lower tracheo- 
bronchoscopy. 

Choice of Operation. — The choice betwen 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^ 




Fig. 478.— The location of the incisions in laryngotomy and tracheotomy. (After 

Bickham.) 
a, Thyroid cartilage; b, incision for laryngotomy; c and e, branches of superior 
thyroid arteries; d, cricoid cartilage;/, incision for high tracheotomy; g, thyroid gland j 
h, incision for low tracheotomy; i, pneUmogastric nerve; j, sterno-mastoid muscle;. 
k, inferior thyroid veins; I, 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 re- 
quiring the wearing of a tube for any length of time, on account of 
the proximity of the vocal cords and their liability 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 



TRACHEOTOMY 



479 



trouble permits. It is the operation of choice for children and in 
cases of diphtheria where a tube has to be worn for some time. 

Low tracheotomy may be required for the removal of foreign bod- 
ies from the bronchi, for lower tracheo-bronchoscopy, for the relief 
of threatened suffocation from occulsion 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. 479. — 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, tracheo- 
tomy tube; II, catheter; 12, tracheal forces; 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. 479). 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 



48o 



THE LARYNX AND TRACHEA 



in the shape of a hook to hold the trachea open until the proper tube 
can be obtained. 

Tracheotomy tubes of several sizes and with different curves 
should be provided so that one suitable for the individual case may be 
at hand. A silver tube, somewhat flattened from side to side, with- 




FiG. 480. — Tracheotomy tube. 




481. — Tracheotomy tube impro- 
vised from rubber tubing. 



out fenestras, and with a movable inside tube, is preferable (Fig. 480). 
With some tubes an obturator is supplied as an aid to insertion. For 
an adult, a No. 5 or 6 tube will usualy suffice; for a child under two, 
a No. 2, tube should be provided; for a child from two to four, a 




Fig. 482. — Position of patient for laryngotomy and tracheotomy. 

No. 3 ; and for one over four, a No. 4. In an emergency a tube may 
be improvised by bending a piece of rubber tubing into the required 
shape, as shown in Fig. 481. For laryngotomy, a tube shorter than 
the ordinary tracheotomy tube, and flattened from before backward, 
is employed. 



TRACHEOTOMY 48 I 

Asepsis. — The instruments are sterilized by boiling or, in an 
emergency, by immersion in a i to 20 carbolic acid solution. The 
hands of the operator and his assistants should be prepared with the 
same care as for any operation. 

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 fiat 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. 482). In an emergency, the patient's head may be simply 
allowed 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 procain 
is sufficient. A 0.2 per cent, solution of cocain or a i per cent, pro- 
cain solution is employed for the skin, and a o.i per cent, solution 
or a 0.5 per cent, procain solution for deeper infiltration. When 
there is occasion for great haste in the presence of unconsciousness 
or dyspnea with marked and increasing cyanosis, an anesthetic may 
be dispensed with, as in such cases the sense of pain is much blunted 
or abolished. 

In young children, local anesthesia is not followed by good results, 
as the infiltration alone terrifies the child and produces struggling, 
which adds to the dyspnea. If air enters the lungs at all, chloro- 
form 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 1% 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 ligated before division. The 
cricothyroid membrane is thus brought into view. The thyroid 

31 



452 THE LARYNX AND TRACHEA 

cartilage is steadied with a tenaculum, while the cricothyroid mem- 
brane is transversely incised by means of a sharp, narrow-pointed 
bistoury near the upper border of the cricoid cartilage, so as to avoid 
the cricothyroid artery, which runs along the upper border of the 
space below the thyroid cartilage (Fig. 483). 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 




Fig. 483. — Opening the cricothyroid membrane in laryngotomy. 
(After Bickham.) 

a tracheal dilator, and the foreign body which may be causing the 
obstruction is removed by means of tracheal forceps. If there is not 
sufficient room to remove the foreign body through this incision, the 
cricoid cartilage may be cut. The laryngotomy tube is then 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. 



TRACHEOTOMY 



483 



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 1)2 to 2 inches (4 to 5 
cm.) long is made exactly in the median line, extending from the cri- 
coid cartilage to a little below the isthmus of the thyroid gland (Fig. 
484). 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 muslces are thus exposed, and should be separated 
along their inner borders and retracted to the sides. As these muscles 




Fig. 484. — Exposing the trachea in high tracheotomy. 

are pulled apart, the isthmus of the thyroid gland and the deep cervi- 
cal fascia covering the trachea appear. This fascia is 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 downward, and with it the isthmus of 
the thyroid gland, thus exposing the rings of the trachea. If the 
thyroid isthmus is very large, two ligatures may be placed about it, on 
each side of the median line, to control the hemorrhage, and the isthmus 
with the deep fascia is incised vertically and each half retracted to the 
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 



484 



THE LARYNX AND TRACHEA 




Fig. 485. — Opening the trachea in high tracheotomy. (After Bickham.) 




Fig. 486. — Method of inserting the tracheotomy tube. 



TRACHEOTOMY 485 

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 sharp narrow bistoury, with its cutting edge up, is in- 
serted through the membrane below the second ring of the trachea, 
and the latter is incised in the median line as far up as the cricoid 
cartilage, care being taken to include the mucous membrane of the 
trachea in this incision (Fig. 485). 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. 486) . If there is no great urgency, 




Fig. 487. — Showing the tracheotomy tube in place. (Stoney.) 

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. 487). 

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 
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 



486 THE LARYNX AND TRACHEA 

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 yi inch (i cm.) of the sternal notch. 
The skin and superficial and deep fascia are incised, and the inferior 
thyroid veins, or other vessels that may be in the way, are ligated and 
divided. The sternohyoid and sternothyroid muscles are separated 
in the median line and are retracted to each side. The deep cervical 
fascia is divided vertically downward from the lower border of the 
isthmus of the thyroid gland, and is retracted laterally, notching it 
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 




Fig. 488. — Intracannular alligator forceps. (Fowler.) 

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 
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 465). 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 
collect at the mouth of the tube should be promptly removed. Secre- 



TRACHEOTOMY 487 

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 alligator forceps (Fig. 488) introduced through the 
cannula. If this is not possible, the tracheotomy tube should be 
withdrawn 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 
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 celluHtis; 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 XVII 
THE ESOPHAGUS 

Anatomic 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 sixth cervical verte- 
brae to the tenth dorsal vertebra. Its entire length is about lo inches 
(25 cm.), while the distance from the upper incisor teeth to the car- 
diac end measures about 16 inches (40 cm.). Antero-posteriorly the 
esophagus presents a sUght curve with the concavity forward, as it 
follows the direction of the spinal column. Laterally, it has the fol- 
lowing curves: from its starting point it turns slightly to the left, 
projecting as much as 3^^ 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, 
and a little to the left, of the aorta to pass through the diaphragm 
(Fig. 489) . In its course, the esophagus has in front of its upper por- 
tion 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 f^i^ inch (19 mm.) in diameter, 
but a number of constrictions in its caliber have been described, the 
most marked being as follows: (i) at its commencement, 6 inches 
(15 cm.) from the incisor teeth; (2) at a point 10 inches (25 cm.) 
from the incisor teeth, where it is crossed by the left bronchus; and 
(3) at a point 16 inches (40 cm.) from the incisor teeth, where it 
passes through the diaphragm (Fig. 490) . At these points the caliber 
of the tube measures about 3^^ 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. 

Diagnostic Methods 

The methods available for examination of the esophagus include: 
(i) auscultation, (2) percussion, (3) external palpation, (4) instru- 

488 



AUSCULTATION 



489 



mental examination, (5) inspection through the esophagoscope, and 
(5) the use of the X-rays. The first three of these methods are of 
very limited clinical 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. 





Fig. 489. Fig. 490. 

Fig. 489. — The course and relations of the esophagus viewed from behind. 

Fig. 490. — 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. 

As in examination of other regions, a careful history of the case 
should precede any local examination. 

AUSCULTATION 

Auscultation is performed by listening with a stethoscope over the 
course of the esophagus while the patient swallows liquids. The 



490 THE ESOPHAGUS 

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 
only should be employed in manipulation, however, since, if due care 
is not exercised in this direction, a false passage may be readily made 
through the esophagus into the mediastinum; especially is such an 



EXAMINATION BY SOUNDS AND BOUGIES 



491 



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 recent 



Fig. 491. — Cylindrical esophageal sound. 

ulceration, the use of esophageal instruments is contraindicated. 
In cases of advanced pulmonary or cardiac disease and cirrhosis of the 
liver, instruments, if used, should be employed with gieat caution. 
Instruments. — For ordinary examination, graduated esophageal 
bougies and bougies a boule are employed. These instruments vary 
in length from 24 to 32 inches (60 to 80 cm.). The best bougies are 




Fig. 492. — Conical esophageal sound. 

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. 491) or conical (Fig. 492) 
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, 



Fig. 493. — Olivary bougies k boule for the esophagus. 

to the end of which metal or ivory olive-shaped tips of different sizes 
may be screwed (Fig. 493). The shaft should be marked off 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 permeable. They may be introduced into the stricture through 



492 



THE ESOPHAGUS 



a hollow bougie which is first passed to the face of the stricture, or 
they may be inserted through an esophagoscope. 

Asepsis. — Rubber bougies and tubes may be sterilized by boiling. 
The gum-elastic instruments, unless of the very best material, are 
ruined by boiling or by the use of strong antiseptics. They may be 
rendered sufficiently aseptic by immersion in a saturated solution of 
boracic acid, after first thoroughly washing with soap and water. 
The hands of the operator should also be clean. 

Position. — The patient is seated in a chair with the head thrown 
back against the back of the chair, and with the chin raised suf- 
ficiently to make the passage between the mouth and the esophagus 
as straight a line as possible. The surgeon stands in front of the 




Fig. 494. — Shows the first step in introducing an esophageal bougie. 

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 having them held by a nurse or by including them in a 
sheet wrapped about the child's body. 

Anesthesia. — In an adult general anesthesia is only necessary in 
exceptional cases, but the pharynx and larynx, if very irritable or sen- 
sitive, may be brushed over with a 5 or 10 per cent, solution of cocain. 

Technic. — The patient is seated in the proper position with a 
towel about the neck for protection, and is given a basin to catch 
vomitus or saliva. A soft, flexible sound is passed as follows: the 
bougie, 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 



EXAMINATION BV SOUNDS AND BOUGIES 



493 



pharynx. The patient is then requested to swallow and the instru- 
ment is thus advanced, partly by the act of swallowing and partly by 
the operator, until an obstruction is reached or the sound enters the 
stomach (Fig. 494). 

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 




Fig. 495. — Introduction of an esophageal bougie with the finger holding the tongue 

and epiglottis forward. 

draws the latter forward, and with it the larynx, so that the esophagus 
may be more easily entered (Fig. 495). The bougie is then passed 
on the finger as a guide straight back in the median line to the 
pharynx, and, hugging the posterior wall of the pharynx, it is pushed 
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 wiU 



494 



THE ESOPHAGUS 



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. 496.) 

If dyspnea and cough are induced, the instrument has probably 
entered the larynx. To settle this point, the patient should be told to 
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 




Fig. 496. — Shows second step in introducing an esophageal bougie. 



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. 490). If a large tube 
can be passed into the stomach, the existence of a stenosis may be 
ruled out, while if the tube passes very easily without any sense of 
resistance, atony or paralysis of the canal is presumable. 

Any evidences of pain, however, produced by the bougie in it3 
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- 



EXAMINATION BY SOUNDS AND BOUGIES 



495 



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, 
the bougie is removed and a smaller one is inserted; and, if necessary, 
smaller sizes are successively introduced until one is found 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 



111 



Fig. 497. Fig. 498. 

Fig. 497. — Method of estimating the length of an esophageal stricture. The 
bougie a boule at the face of the stricture. 

Fig. 498. — 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. 



making the 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. 497), and the 
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. 498), and the dis- 
tance of this point from the mouth is also estimated. By subtracting 



496 



THE ESOPHAGUS 



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 
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 distinguised when the two come in contact. 

If the bougie has entered a diverticulum, it will be possible to 
move its end freely in different directions, and, if the diverticulum be 






Fig. 499. Fig. 500. Fig. 501. 

Fig. 499. — Shows a sound passing the opening of a diverticulum. (After 
Gumprecht.) 

Fig. 500. — Shows the ease with which a sound will enter a diverticulum when 
the latter is full. (After Gumprecht.) 

Fig. 501. — Shows the ease with which a sound follows the esophagus when the 
diverticulum is empty. (After Gumprecht.) 

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. 499), it can frequently be 
passed by the diverticulum into the stomach. A bougie will be more 
apt to enter a diverticulum if the sac be full (Fig. 500) and pass to the 
stomach when the sac is empty (Fig. 501). This intermittent 
obstruction to the passage of a bougie is characteristic of a diver- 
ticulum, 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: 



EXAMINATION BY SOUNDS AND BOUGIES 



497 



The patient is instructed to swallow with a little water before bed- 
time 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- 
ach and intestines a sufficient distance to withstand moderate trac- 
tion without being withdrawn. A whalebone bougie with an oHve 
tip, through which is an opening sufficiently large to accommodate 
the thread, is then passed down the esophagus on the thread, which 
is held loosely, until an obstruction is encountered. If this obstruc- 





FiG. 502. Fig. 503. 

Fig. 502. — Esophageal sound passed over a swallowed thread into a diverticulum. 
(After Plummer.) 

Fig. 503. — Sound lifted out of the diverticulum by tightening the thread. (After 
Plummer.) . 



tion 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. 502), 
the bougie will be elevated to the level of the opening into the esoph- 
agus (Fig. 503). The depth of the diverticulum may be readily 
determined by the distance the bougie is elevated when the thread is 
made taut. 

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 



32 



498 THE ESOPHAGUS 

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 di- 
rect inspection of the interior of the esophagus by the aid of a long 
endoscopic tube illuminated by electricity. By the use of the esopha- 
goscope 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 exami- 
nation. 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 instrument. The con- 
traindications to its use are practically the same as those mentioned 
for the sound or bougie, viz., aortic aneurysm, recent hemorrhage 
from the esophagus, advanced pulmonary or cardiac disease, etc. 

Instruments. — Von Mikulicz's instruments (Fig. 504) are cylin- 
drical tubes about % to 3-^ inch (10 to 13 mm.) in diameter, bevelled 
at the end and supplied with an obturator to aid in their introduc- 
tion. 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. 505) 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 for- 
mer it is difficult to direct the light 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 
% inch (10 mm.) thick, and for children, a tube 18 inches (45 cm.) 
long and %5 inch (7 mm.) thick. In addition to the esophago- 
scope, a Sajous applicator, swabs on holders, various shaped forceps 
for removing foreign bodies or sections of tissues for examination, etc., 
are required. 



ESOPHAGOSCOPY 



499 



Asepsis. — The tubes and accessory instruments may be sterilized 
by boiling and the lights by immersion in alcohol. 

Preparation of Patient. — The patient's stomach should be empty, 
to avoid regurgitation of its contents. Where there is a marked 




Fig. 504. — Von Mikulicz set of instruments for esophagoscopy. (Gottstein in 

Keen's Surgery.) 

dilatation of the esophagus, a preliminary lavage (see page 502) may 
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. 




c^^ fe 



Fig. 505. — Jackson's esophagoscope. 

Position of Patient. — Some operators perform esophagoscopy 
with the patient sitting up; others, with the patient on a table in a 



500 



THE ESOPHAGUS 



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 




Fig. 506. — The position of the patient and assistant for esophagoscopy. 
(After Jackson.) 

table, supported by an assistant, who raises, lowers, or turns the head 
at will {Fig. 506) , is preferable. 

Anesthesia. — General anesthesia may be required in children. 
For adults, painting the pharynx, larynx, and entrance of the esopha- 




FiG. 507. — Shows the method of holding the esophagoscope. (After Jackson.) 

gus with a 10 per cent, solution of cocain by means of a cotton swab 
held in a Sajous applicator some minutes before the introduction of 
the tube will suffice. This may be very effectually done through a 



ESOPHAGOSCOPY 



501 



short split-tube spatula, such as is used in direct laryngoscopy (see 

Fig. 450)- 

Technic. — The seat of trouble should have been previously deter- 
mined by means of a bougie, and if the operator possesses tubes of 
different lengths this will enable him to select one of the proper length. 
The tube is lubricated, the patient's mouth is well opened, and, with 




Fig. 508. — First step in esophagoscopy, the left index-finger guiding the instrument 
into the esophagus. (After Jackson.) 

the index-finger of the left hand, the base of the tongue is drawn 
forward (Fig. 508) . The operator then introduces the tube, with the 
obturator inserted in place, backward to the posterior part of the 
pharynx and then downward, the assistant at the same time extending 
the patient's head so as to bring the mouth and esophagus nearly 
in the same straight line. The patient is directed to aid the passage 




Fig. 509. — Shows the esophagoscope in place. 



of the tube by swallowing. As soon as the esophagus has been well 
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. 509). 
Under direct inspection the direction of the esophagus can be dis-' 
tinguished and the tube advanced accordingly, care being taken to 



502 THE ESOPHAGUS 

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 sh*t 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. Follow- 
ing the operation, if there is pain or difficulty in swallowing, cracked 
ice in small quantities may be administered. 

SKIAGRAPHY 

The X-rays are useful in locating bones, coins, and other imper- 
vious foreign bodies. By having the patient first swallow bismuth or 
similar metafile substances, which offer resistance to the penetration 
of the X-rays and are capable of casting a shadow, the presence of 
a diverticulum, constrictions, or dilatations is readily recognized, 
and the size and shape may be outlined. 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- 
quently employed to remove foul and decomposed products of the 
ulceration, and gives much refief 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 smafi glass funnel at its proximal end, 
forms the necessary apparatus (Fig. 510) . More elaborate apparatus 



LAVAGE OF THE ESOPHAGUS 



503 




Fig. 510. — Apparatus for esophageal lavage. 
^f Fenestra in the tip of the tube; b, glass funnel; c, mark to indicate the distance 
from the teeth to the stomach. 




Fig. 5ii.-^Boas* apparatus for esophageal lavage. (After Gumprecht.) 



504 THE ESOPHAGUS 

has been devised for esophageal lavage, such as, for example, Boas' 
tube (Fig. 511), 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 
eFevated. The operators 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 
21/2 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, 
and, when the stricture is impassable, gastrostomy. Gradual dila- 
tation by 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 



DILATATION OF ESOPHAGEAL STRICTURES 



505 



intervals during the remainder of the patient's life. When the 
stricture involves the greater part of the canal, dilatation is fre- 
quently unsuccessful. Dilatation is con- 
traindicated in very recent burns of the 
esophagus. Moderate and carefully per- 
formed dilatation, however, is not contra- 
indicated by carcinoma. 

Strictures may be located in any part 
of the esophagus, but the majority are situ- 
ated near the points of normal constriction 
of the canal (Fig. 512). 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 accumula- 
tion of food; especially is this the case if 
the stricture is low in the canal, and as a 
result inflammation or suppuration may 
develop. In such cases there is great 
danger of perforating the walls of the eso- 
phagus unless extreme gentleness in mani- 
pulation is observed. /' 

The danger of passing a bougie through 
an aneurysmal sac should also be kept in 
mind, and to avoid such an accident a 
careful physical examination should be 
made in every case before inserting any 
esophageal instrument. By such examina- 
tion the discovery of other growths within ^^^f^ ^^^ ^^ the pharynx and 
the neck or mediastinum producing com- ^^^^^^^^ o t e esop agus; 

■V *^ 2, stenosis from pressure of 

pression is often possible. It is next neces- tumors of the neck; 3, stenosis 
sary to determine by means of a bougie ^^^ to aneurysm of the arch 
the location, the degree, the approximate ^^ the aorta; 4, stenosis as the 

, , ... Mil 1 r result of caustic or lye burns; 

length,^ and, if possible, the character of 5^ stenosis as result of carci- 
the stricture before any attempts at dilata- noma of lower end of the eso- 

tion are made. phagus and cardiac end of 

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 K2 to % inch 




Fig. 512. — The most fre- 
quent seats of stricture of the 
esophagus. (Eisendrath.) 

A, Aorta, D, Diaphragm. 
I, Stenosis from carcinoma of 



5o6 



THE ESOPHAGUS 



(2 to 14 mm.). In a normal esophagus, a bougie Yi to % inch (13 
to 14 mm.) in diameter will pass the narrow portions without 
difficulty. 

For strictures of fair size, say the size of a lead pencil, cyHndrical 
bougies (Fig. 513) may be employed; for smaller strictures the con- 
ical (Fig. 514) or bulbous instruments (Fig. 515) are used. 




Fig. 513. — Cylindrical esophageal bougie. 

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 esopha- 
goscope or through a special hollow sound. 

Other more complicated instruments are sometimes used, such 
as Schreiber's and Billroth's sounds. The former (Fig. 516) consists 




Fig. 514. — Conical esophageal bougie. 

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. 515. — Bulbous esophageal bougie. 

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 502), is indicated. 

Rapidity of Dilatation. — The stretching should be done gradually. 
Rapid dilatation or divulsion is dangerous and inadvisable. 



DILATATION OF ESOPHAGEAL STRICTURES 507 

Frequency. — As a rule, the bougies may be inserted every second 
or third day. If the bougies 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 lo per cent, solution 
of cocain renders the operation easier. 

Technic. — A bougie of a size that will enter the stricture is 
chosen. This is determined from the examination of the stricture 



•B h 




Fig. 516. — Schreiber's esophageal sound. (Gottstein in Keen's Surgery.) 

previously 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. 494). If difficulty 
is encountered in entering the esophagus, the tongue may be drawn 
forward by the left index-finger, as shown in Fig. 495. 

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 
inserted, and, if the stricture seems very tight, this same instrument 



5o8 



THE ESOPHAGUS 



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 




Fig. 517. — 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}, 

through the stricture as a guide, over which are passed small olivary 
bougies or conical sounds (see page 497), by means of filiform 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 similar to 
the method used for tight urethral strictures (Fig. 517). 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 



INTUBATION OF THE ESOPHAGUS 509 

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 to 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 



Fig. 518. — Symonds' short tube for intubation of the esophagus. 

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- 
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 complications. 

Instruments. — When long tubes are indicated, an ordinary hollow 
cylindrical esophageal tube (see Fig. 491) or a rubber stomach-tube 
of appropriate size may be employed. For the purpose of feeding 
the patient, a glass funnel that will fit into the proximal end of the 
tube will also be required. 

Short tubes of gum elastic and hard rubber have been devised 
hy Symonds, von Ley den, and others. Symonds' tubes (Fig. 518) 
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 



5IO THE ESOPHAGUS 

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. 518, for 
the purpose of extracting the tube. A special whalebone guide for 
inserting the tube is also required (Fig. 519). 

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. 

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. 




Fig. 519. — Symonds' tube on introducer. 

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. 

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 492). 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 



INTUBATION OF THE ESOPHAGUS 



511 



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. 



I 




Fig. 520. — Shows long esophageal tube passed through the nose. 




Fig. 521 — Showing the method of introducing Symonds' short tube. 

Instead of passing the tube through the mouth it may be in- 
serted through the nostril (Fig. 520). The free end, corked as above, 
is then secured in place by means of adhesive plaster. 

2. Short Tubes. — A tube of the proper size is selected and placed 



512 THE ESOPHAGUS 

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 
same steps as for the passage of a bougie (Fig. 521). 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. 

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 XVTII 

THE STOMACH 

Anatomic Considerations 

The stomach may be described as a hollow, inverted, pear-shaped 
organ, the greater part of which lies 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. 522. — 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 wall is triangular in shape, 
bounded on the right by the lower border of the liver, on the left 
by the eighth, ninth, and tenth costal cartilages, and below by the 
transverse colon. 

The upper limit of the stomach, the fundus, reaches the level of 
the lower border of the fifth rib in the mammary line, being in rela- 
33 513 



514 THE STOMACH 

tion with the diaphragm above and the concave surface of the spleen 
to the left. The lower limit or greater curvature extends to the level 
of a 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 cur- 
vature may be modified to a marked degree. The cardiac or superior 
opening lies about }^i 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 3^ 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 di- 
rected 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 downward; 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 23^^ pints (1200 c.c). When the stomach is 
empty, the longest diameter me^-sures 7 3^ to 8 inches (18 to 20 
cm.) and' the transverse diameter 2%^ to 2>yi 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 2>yi 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 METHODS 515 

diagnostic importance is a history of gastric pain, vomiting, or the 
vomiting of blood. 

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 reHeved by eating. On the other hand, the pain of an ulcer 
or cancer comes on after eating, and the seat of pain is usually local- 
ized. 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 vertebras 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 uni- 
formly 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 usually relieves the 
pain complained of. In cancer of the stomach, vomiting may not 
appear until late in the disease and, as a rule, the attacks of vomiting 
do not come on at such short intervals after feeding as in the case of 
ulcer. In dilatation, on the other hand, vomiting occurs at com- 
paratively long intervals, and the amount brought up is correspond- 
ingly large. Blood in the vomitus is always of diagnostic importance. 
A profuse hermorrhage from the stomach generally signifies an ulcer, 
while the constant vomiting of blood-streaked material points more 
toward cancer; especially is this true if the vomited matter has a 
foul odor. 

It has been possible here to point out the importance and the 
significance of but a few symptoms, and for further details the reader 



5i6 THE STOMACH 

is referred to works on diagnosis where these will be found fully 
discussed. The writer simply wishes to emphasize the importance 
of a careful history and to point out in a general way the lines of 
questioning. 

A general physical exmination 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 use. 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 preHminary inflation of the organ (page 
524). When thus distended the stomach becomes separated from the 
surrounding organs and its contour is more easily made out. At the 
same time abnormal positions or new growths may be better recog- 
nized. 

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 
outUnes from the shadows cast by the inequalities of the abodminal 
wall produced by the stomach beneath (Fig. 523). 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 



INSPECTION 



517 



empty. If there be obstruction of the pylorus with dilatation and 
hypertrophy of the walls, peristaltic movements of the stomach may 
be observed after taking food. These waves may be seen extending 




Fig. 523. — Inspection of the stomach. 




Fig. 524. — Showing the shape of: (i) A dilated stomach, (2) an hour-glass stomach, 

(3) the stomach in gastroptosis. 

toward the pylorus from under the ribs in the left upper quadrant to 
the right lower quadrant. Peristalsis may be excited by tapping the 
abdomen or by the application of cold. A dilated stomach may be 



5l8 THE STOMACH 

determined from the great bulging in the epigastrium and by trac- 
ing the greater curvature to a point considerably below the umbili- 
cus, and at times an hour-glass contraction may be recognized (Fig. 
524). 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 




525. — 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 



PALPATION 



519 



greater relaxation than is possible by this posture, the knees should be 
drawn up and the head and thorax should be slightly raised upon a 
pillow. Where there is considerable rigidity of the abdominal muscles 
or in fat individuals, relaxation may be secured by placing the patient 
in a warm bath. 

Technic. — The examination should be performed in a warm 
room and the physician's hands should be warmed to avoid the 
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 flat upon the abdomen, with the 




Fig. 526. — Palpating a tumor of the stomach between the fingers of the two hands. 

palms down and the fingers slightly flexed, and palpates with the 
finger-tips. Only gentle manipulations should be employed, as 
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. 525). 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 palpation tumors, one hand is used to fix the growth and the 



520 



THE STOMACH 



other outlines its size and determines its consistency, fixity, or 
mobility, and the presence or absence of pulsation, tenderness upon 
pressure, etc. (Fig. 526). 

The examiner should first determine the size and position of the 
stomach. Inflation (page 524) 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 




^ite oftendenress, 
in. ulcer ofpylo. ' 

jSiie of tenderness 
Mleer of the cLwdenuin. 



Usual sites of 
tenderness t/u 
Uleer o^jtomaek. 



Fig. 527. — Points of pressure tenderness in ulcer of the stomach. (Mayo Robson in 

Keen's Surgery.) 



next carefully palpated with the purpose of determining the presence 
or absence of new growths, painful spots, etc. Tumors of the 
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 



PERCUSSION 



521 



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 
spontaneous and is increased upon pressure, while in nervous condi- 
tions it is generally diminished or relieved by 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. 527); 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 (Fig. 528). In 



jS)ites of tender/tes} 
in ulcer of — 
the tstomaeh 




Fig. 528. — Points of pressure tenderness found posteriorly in ulcer of the stomach. 
(Mayo Robson in Keen's Surgery.) 

affections of the gall-bladder similar tender points will be frequently 
found more to the right of the spinal column. 



PERCUSSION 



Only the greater curvature and the portion of the anterior surface 
of the stomach in contact with the anterior abdominal wall are access- 
ible for percussion, consequently the chief use of this method is to 
determine the shape and size of the 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 



522 



THE STOMACH 



source of error is the resonance of the transverse colon, which may be 
confused with that of the stomach. To avoid this the stomach may 
be distended with gas and the colon with fluid, or the colon may be 
inflated and the patient may drink one or more glasses of water. In 
either case a contrast between the tympany of the one and the dulness 
of the other will be obtained on percussion. The percussion note 
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 




rr^i 



Fig. 529. — Percussion of the stomach. 

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 
against the surface, while with the flexed middle finger of the right 
hand a number of sharp taps or blows are struck (Fig. 529). The 
force of the percussion should, as a rule, be very Hght, 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 



AUSCULTATION 523 

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 
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 follows the act of swallowing, and 
a second sound, more rattling 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 Hes recumbent and the operator listens with his ear near 
the abdomen while he taps the abdominal wall in the region of the 
stomach with his finger-tips. Succussion sounds may also be elicited 
by moving the patient quickly from side to side. These sounds 
should be differentiated from other gurgling sounds which are heard 
when the stomach contains only air or is empty. Succussion in 
itself is of no diagnostic importance, for it may be heard in a normal 
stomach containing a quantity of fluid. It is pathological, however, 
if obtained when the stomach should normally he empty, that is, in the 
morning before breakfast, three hours after a test breakfast, or seven 
hours after a test dinner. It then indicates a condition of atony or 
deficient motihty. 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 



524 THE STOMACH 

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. 

The inflation may be performed by means of effervescent 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 sufflcient gas 
in a capacious stomach or, if too much gas is formed, it may produce 
pain and vomiting. With either method some caution must be 
observed and the inflation must be immediately stopped if pain be 
produced. Inflation is contraindicated in recent hemorrhage of the 
stomach, in suspected gastric ulcer, in advanced cardiac disease, and 
in advanced arterial disease. 

Under distention the stomach is raised from the neighboring 
organs and its limits thus become more clearly outlined, so that con- 
ditions of dilatation, gastroptosis, and hour-glass contractions may be 
distinguished and tumors 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. 



INFLATION OF THE STOMACH 525 

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. 530). 

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 
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.) 




Fig. 530. — Stomach-tube and Davidson syringe for inflating the stomach. 

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. 

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, 



526 THE STOMACH 

is passed along the roof of the mouth to the pharynx. From this 
point it is advanced partly by swallowing efforts 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 
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. 

EXAMINATION OF THE STOMACH CONTENTS 

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 both diagnostic and prognostic value,, 
but, while gastric analysis is of great importance, the information 
obtained hy such examination must not he relied upon to the exclusion 
of other methods of diagnosis, as it is hy no means final. In all cases 
the history and the results of the 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 hypersecretion or disturbance of the motor power of the 
stomach is suspected, the contents of the fasting stomach should be 
examined. Normally, the stomach should be empty of food within 
eight hours after a full meal. According to Rehfuss, after an all 
night fast the residuum in the stomach averages between 30 and 
50 c.c. (i and 1% ounces) in amount. It is thin and opalescent, and 
contains bile in about 50 per cent, of the cases. It has an average 
total acidity of 30 and an average free acidity of 18. 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 containing free hydro- 
chloric acid is obtained, it points in the former case to motor insuf- 
ficiency and in the latter to hypersecretion. 



EXAMINATION OF THE STOMACH CONTENTS 527 

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 35 and 70 gm. (i and 2}/^ ounces), a cup of tea without sugar or 
milk, or 300 to 400 c.c. (10 to 14 ounces) 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 — • 
400 c.c. (about 14 ounces), a large portion of beefsteak or other meat, 
weighing 150 to 200 c.c. (5 to 7 ounces), mashed potatoes — 50 gm. 
(ij^ ounces), and a roll 35 gm. (i ounce). 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 23^ 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 presence of soluble 
albumin, the products of digestion, the presence of rennin and pepsin, 
and the character of the carbohydrates. 

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 



528 



THE STOMACH 



cancer except in cases where an ulcer is undergoing malignant 
change. 

Hypochlorhydria. — A diminished secretion of hydrochloric acid 
occurs in the late stages of chronic gastritis, in gastric neuroses, in 
gastric atrophy, in dilatation of the stomach, in the early stages of 
gastric cancer, and sometimes in ulcer when 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. 




Fig. 531. — Stomach- tube and funnel for expressing the stomach contents, a, 
Showing the lateral fenestras; h, funnel; c, mark to indicate the distance from the 
ncisor teeth to 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 deficiency in 
the amount of hydrochloric acid, the significance of which has been 
mentioned above. 

Lactic acid is the result of bacterial fermentation. It is found in 
appreciable amounts only when hydrochloric acid is absent and in 
general signifies insuihciency of the motor power and stagnation of 
the stomach contents, as is found in dilatation, obstruction of the 
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 



EXAMINATION OF THE STOMACH CONTENTS 529 

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 ondition. 

Extraction of the Stomach Contents. — The stomach contents 
may be- removed through a stomach-tube either by the aspiration or 
expression method. The expression method answers in the great 
majority of cases, but it may fail where the contents of the stomach 
are not fluid enough to flow through the tube. The use of the 
stomach-tube is contraindicated in the presence of aortic aneurysm, 
in patients liable to cerebral hemorrhage, or in those who have recently 
suffered from gastric or pulmonary hemorrhages, in those who are 



Fig. 532. — Boas' aspirating bulb. 

very weak, in those suffering 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 y^i of an inch (6 mm.) in caliber, with two smooth-edged lateral 
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. 531). 

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* apparatus (Fig. 532). The bottle- 
aspirator (Fig. 533) consists of a large glass bottle supplied with a 
34 



530 



THE STOMACH 



tightly fitting rubber stopper through which two glass tubes pass; 
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. 



'frs/>umjo 




/S'/o/nacJ? /uie 



Fig. 533. — Bottle arranged for aspirating the stomach contents, a, Large glass, 
bottle; b, tubing connected with a Potain aspirator; c, the stomach tube. 




Fig. 534. — Introducing the stomach-tube. First step, imparting a curve to the end 
of the tube for its more easy passage. 

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. — Artificial teeth or plates should be removed from 



EXAMINATION OF THE STOMACH CONTENTS 



531 



the patient's mouth and he should be protected by a towel or an 
apron fastened about the neck. A small bowl should be provided 
for the purpose of receiving excessive secretion of mucus or 




Fig. 535. — Introducing the stomach-tube. Second step. 

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 




Fig. 536. — Introducing the stomach-tube. Third step. 

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. 535). During this ma- 



S2>^ 



THE STOMACH 



neuver the patient is instructed to breathe regularly and deeply, even 
if a sense of suffocation is produced, and to hold the head slightly 
forward to allow the escape of the saliva which collects in the throat 
(Fig. S3^)' ^^ 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 1 6 inches (40 cm.) and to the lower border of the healthy 
stomach about 22 inches (55 cm.), but in pathological conditions, as 



Fig. 537. — Aspiration of the stomach contents. First step. 

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. 



EXAMINATION OF THE STOMACH CONTENTS 



533 



Aspiration with the Boas aspirator is performed as follows: With 
the clamp closed the operator compresses the bulb (Fig. 537) 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. 538). 

The Fractional Method of Gastric Analysis. — In the frac- 
tional method of gastric analysis samples of the stomach contents are 
withdrawn and examined at frequent intervals during the whole 




Fig. 538. — Aspiration of the stomach contents. Second step. 

cycle of gastric digestion. For the purposes of this examination 
Rehfuss has devised a special tube of small size, which may be left 
in the stomach for a considerable time without discomfort to the 
patient. Samples of the stomach contents are removed every 15 
minutes after the administration of a test meal till the close of diges- 
tion, and the results of the analyses are plotted in a graphic chart or 
curve. In this way the chemical composition of the gastric juice 
during every phase of gastric digestion, and the progress of digestion 
at any time after the ingestion of food may be studied. This method 



534 



THE STOMACH 



consumes more time than the older methods of gastric analysis, but 
more exact information as to the secretory and motor power of the 
stomach is thus obtained than is possible from the customary single 
examination one hour after a test meal. 

Apparatus. — The Rehfuss tube is 40 inches (100 cm.) long and No. 
10 to 12 French in size. The proximal end is adapted to fit an as- 
pirator, while to the distal end is fitted a metal tip heavy enough to 
cause it to gravitate to the bottom of the stomach. The tip is pro- 
vided with slots of the same size as the tubing so that any material 
which enters the tip will pass through the tube. A glass syringe is 
employed for aspirating (Fig. 539). 




rig. 539. — The Rehfuss tube for fractional gastric analysis. 

Asepsis. — The apparatus should be sterilized by boiling. 

Position of the Patient. — The patient is seated upright in a chair 
or in bed. 

Technic— The patient is given an Ewald test meal (2 slices of 
bread or toast and 2 glasses of water) on a fasting stomach after re- 
moval of the residium. The tube is inserted in the following manner: 
The patient is directed to open his mouth, and the tip of the tube, 
lubricated with glycerin, is placed back of the tongue in the pharynx 
by the examiner. The tube is then carried into the stomach by the 
patient swallowing. In this he may be aided by. swallowing a 
Jittle water if any difficulty is met in getting the tube down. About 
22 to 24 inches (55 to 60 cm.) of tubing is passed. From i}i to 2^^ 



EXAMINATION OF THE STOMACH CONTENTS 535 

drams (5 to 10 c.c.) of the stomach contents are then removed at 15 
minute intervals, or 30 minute intervals if digestion is very slow, 
until the end of digestion, that is, until aspiration shows no further 
food particles. The specimens are collected in separate containers 
and are labelled and later examined, and the results are tabulated in a 
curve. 

Variations in Curves in Health and Disease. — -There is no one 
form of secretory curve common to all normal stomachs. Rehfuss, 
Bergeim, and Hawk {Journal American Medical Association, Sept. 
12, 1914) describe three normal types of curve: 

1. The Isosecretory Type. — The curve shows a steady rise, reach- 
ing a high point of 60 for total acidity and 40 for free acidity. The 
high point is maintained for from J^ to i hour and then gradually 
dechnes. Food residue disappears in 2 to 23^ hours. 

2. The Hypersecretory Type. — There is a rapid rise of the curve, 
reaching a high point of 70 to 100 for acidity. The curve shows a 
very slow or no decline in the usual time. Food remnants disappear 
in 2 to 2^-^ hours, but the gastric secretion often continues for half an 
hour or longer. 

3. The Hyposecretory Type. — This type is rare. The curve 
slowly rises, reaching a high point of 40 to 50 for acidity. Digestion 
is complete in 2 to 2 3-^ hours. 

Some of the variations in the curves in disease are, according to 
Kahn {N. Y. Medical Journal, Jan. 18, 191 9), as follows: 

In Gastric ulcer the ascent of the curve is rapid and its height is 
reached within an hour or slightly after. The high point for total 
acidity is between 100 and no and for free acidity between 60 and 
70. The decline is gradual or sudden. Blood may be present. 

In Duodenal ulcer the curve shows a gradual ascent. The height 
of the curve is not reached until 2 3-^ hours when the stomach begins 
to empty. The high point for total acidity reaching no or over and 
for free acidity between 90 and 100. 

In Gastric carcinoma with obstruction the total acidity may be 
normal or slightly above normal, while the free acidity is entirely 
absent or rises to 10 or 15 after an hour. Blood and lactic acid are 
also found. In carcinoma of the cardia with no obstruction, both the 
total and free acidity are subnormal. 

Kahn points out that reflex irritation due to gall-stones, appendi- 
citis, colitis, or renal colic may produce a marked influence upon the 
gastric curve, and results similar to those observed in duodenal ulcer 
may be obtained. 



53^ 



THE STOMACH 



TEST OF THE MOTOR FUNCTION OF THE STOMACH 

By the motor power of the stomach is meant the abiHty 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 ap- 
pears in the urine. Salol is unaffected by the gastric juice, but is 
spHt into salicylic acid and carbolic acid in the intestine. In per- 
forming 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 spHt up and iodin is absorbed and eliminated in 
the saliva. Fifteen grains (i gm.) of iodipin are administe ed 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. 

TEST OF THE ABSORPTION POWER OF THE STOMACH 

The usual method of determining this is by the test of Penzoldt 
and Faber. It is performed as follows: 3 grains (0.2 gm.) of chemi- 



TRANSILLUMINATION OF THE STOMACH 537 

cally pure potassium iodid are given in a gelatin-coated capsule on 
an empty stomach, and the urine or the saliva is then tested with 
starch-paper and fuming nitric acid every few minutes for iodin. Its 
presence is indicated by a blue or a violet reaction. Iodin should 
normally be detected in the saliva and urine in from six and a half 
to fifteen minutes after the ingestion of the iodid of potassium, while 
its appearance is considerably delayed if the absorption power is 
interfered with. 



TRANSILLUMINATION OF THE STOMACH, OR GASTRO- 

DIAPHANY 

A method introduced by Einhorn, which consists of transillumi- 
nating the stomach by means of a small electric light fastened to the 
end of a rubber tube. By this method of diagnosis the position and 
size of the stomach may be determined, and the presence and 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 differentiation of this condi- 
tion from gastroptosis. In the former the illuminated area is larger 
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 is that the organ is seen in its natural 
condition, whereas under inflation it is apt to be stretched beyond 
the normal. To employ the method successfully it is necessary that 
the patient be accustomed to the insertion of the stomach 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. 540). 

Asepsis. — The instrument should be sterilized before use. 



538 



THE STOMACH 



Position of the Patient. — The examination is performed with the 
patient in the erect position. 

Technic. — Transillumination must be performed upon an empty 
stomach; if necessary, the stomach should be first emptied by means 
of the stomach-tube. The patient is then given two glasses of water 
to drink to prevent overheating the stomach from the lamp. The 
tube is 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, while the results 




Cross section.'-^ (ei^ldrged) 
Shouring inner txthe. 
ex.tending throughout 



Fig. 540. — Lynch's gastrodiaphane. (Lynch.) 

of the transillumination are noted. A bright luminous area will be 
noted on the anterior abdominal wall which corresponds in size to 
the outlines of the stomach. In the case of a tumor of the anterior 
stomach wall, even if too small to be felt, a dark patch will appear in 
the 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- 
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 ttij (0.30 c.c.) of dilute 



I 



GASTROSCOPY 539 

phosphoric or sulphuric acid to increase the acidity and §o 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 
}^i to J4 grain (0.008 to 0.016 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 1 881, 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 the fact that they were 
inserted blindly and not under the sight of the operator proved a 
serious drawback. Chevalier Jackson, in 1906, designed a gastro- 
scope on entirely different principles employing large tubes with 
the illumination at the distal end, similar to those used in direct 
tracheo-bronchoscopy and esophagoscopy, and he thus made it pos- 
sible to explore 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 or- 
gan is placed the less of it will be available for examination. Further- 
more, under 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 sec- 
tions of tumors may be excised for microscopical examination. A 
further advance in gastroscopy was made in 1 910 by Hill in conjunc- 
tion with Herschell, who combined a direct and indirect view esopha- 
gogastroscope and added to the instrument a tap for inflating the 
stomach with air. 



540 THE STOMACH 

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 
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, inter- 
fere with or render gastroscopy out of the question. 




Fig. 541. — Jackson's gastroscope. 

Apparatus. — ^Jackson's gastroscope (Fig. 541) consists of a cylin- 
drical tube about 32 inches (80 cm.) long with a lumen 2/5 inch 
(10 mm.) in diameter, and with a thickened distal end. In the wall 
of the instrument are two small accessory tubes; one through which 
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. 

The Hill-Herschell esophagogastroscope (Fig. 542) for combined 
direct and indirect gastroscopy consists of a direct view tube with the 
illumination supplied at the proximal end from a Briinings 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 



GASTROSCOPY 



541 



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. 




a b c 

Fig. 542. — Hill-Herschell esophagogastroscope. a, Direct view esophagoscope 
with Briinings lamp; b, indirect view periscope; c, shows instrument assembled for 
gastroscopy. 

Preparations. — These should include the ordinary preparations 
for a general anesthetic; that is, the patient is given a cathartic the 
night before the operation and food is withheld for a period of .twelve 
hours before the operation (see also page 18). It is essential that 
the 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. 



542 



THE STOMACH 



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 
the edge of the table and the head supported by an assistant seated 




Fig. 543. — Position of patient for gastroscopy. (After Jackson.) 

at the head of the table and to the right, after the manner shown in 
the accompanying illustration (Fig. 543). This assistant also con- 
trols the mouth gag. Jackson recommends that, as soon as the tube 




Fig. 544. — Method of inserting the gastroscope. (After Jackson.) 

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 



GASTROSCOPY 



543 



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 in- 
serted and the operator introduces the left forefinger into the patient's 
mouth to the base of the tongue or behind the epiglottis and draws 
the tongue downward. 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. 544). At 
this stage the assistant who controls the patient's head should bend 
the patient's neck well backward so as to bring the mouth and 
esophagus in as straight a line as possible. As soon as the instru- 
ment has been passed beyond the entrance of the esophagus, the 
obturator is withdrawn and the light is turned on. The instrumeut 




Fig. 545. — 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 way entirely by sight, care being taken to 
avoid compressing the trachea by the point of the instrument. To 
pass the hiatus at the diaphragm, the instrument is rotated in such a 
way that the long axis of a cross section of the tube corresponds to 
that of the hiatus (this extends from behind and the right to the front 
and the left). To pass the abdominal esophagus as it bends to the 
left, the head and neck of the patient are turned to the right (Fig. 
545). When the tube has entered the stomach, the interior of the 
organ should be systematically explored according to the technic 
described by Jackson,^ which the writer takes the liberty of quoting : 

ijackson. Trpcheo bronchoscopy, Esophagoscopy, and Gastroscopy, page 149. 



544 



THE STOMACH 



"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- 
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. 546). 

"After the whole possible range has been covered in this way 
we proceed to the second plan. The tube is passed down until the 




Fig. 546. — Showing the patient's head and neck turned to the left to allow the instru- 
ment to reach the pyloric end. (After Jackson.) 

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 
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 accompHshed 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 



QASTROSCOPY 



545 



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 





Fig. 547- Fig. 548. 

Fig. 547. — The passage of the outer tube of the Hill-Herschell esophagogastroscope 
through the esophagus under direct vision, (Mayo Robson in Keen's Surgery.) 

Fig. 548. — Method of performing' indirect view gastroscopy with the Hill-Her- 
schell instrument. (Mayo Robson in Keen's Surgery.) 

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 

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- 
35. 



546 THE STOMACH 

ing it if the sense of touch is reHed 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, 
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 (Fig. 547) in the manner previously described for the pass- 
age of Jackson's gastroscope (page 543). 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 soiled from contact with the mucous membrane. 
The pylorus is. first located (Fig. 548) 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, 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 stomach 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 



LAVAGE OF THE STOMACH 547 

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- 
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 indi- 
cated, since an early recognition of the trouble furnishes the only hope 
of cure. The surgeon must be convinced, however, that he can ac- 
complish 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 is unjustifiable. 

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 



548 THE STOMACH 

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 h 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 
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 arterio- 
sclerosis and in general weakness or prostration it should be used 
with caution. 

Apparatus. — The employment of a stomach-pump is not advis- 
able on account of the danger of injuring the mucous lining of the 
stomach; instead, an ordinary siphonage apparatus should be em- 
ployed. This consists of a soft-rubber stomach-tube joined by 
means of 3 to 4 inches (7.5 to 10 cm.) of glass tubing to a piece of 
rubber tubing 2 to 3 feet (60 to 90 cm.) loiig, to the free end of which 
a glass funnel having a capacity of about a pint (500 c.c.) is fitted 
(see Fig. 531). The stomach-tube should be about 30 inches 
(75 c.c.) long, yi to 3-^ 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. 549). 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.) 



LAVAGE OF THE STOMACH 



549 



of rubber tubing, to the free end of which an 8-ounce (250 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 be- 
fore using. After use it should be thoroughly cleansed, care being 
taken to see that particles of food are not left adher- 
ing to the interior of the tube, especially about the 
lateral windows. 

Solutions Employed. — For cleansing purposes 
boiled lukewarm water is generally employed. To 
rid the stomach of mucus, alkaline mineral waters, 
as Carlsbad or Vichy, or Carlsbad salt, i dr. (4 gm.) 
to I quart (1000 c.'c.) of water, or sodium bicarbo- 
nate (i to 5 per cent.), may be employed. 

Temperature. — The solution should be of a tem- 
perature of from 90° to 100° F. (32° to sS° C). 

Quantity. — The stomach should not be over dis- 
tended with solution, about a pint (500 c.c.) being 
introduced at a time. The washing-out process is 
to be continued, however, until the contents of the 
stomach return clear, provided the patient's con- 
dition permits it. In some cases the process must 
be repeated ten or twelve times before this is at- 
tained. 

Time for Lavage. — When employed to remove 
stagnated food from a dilated stomach, lavage may 
be performed either in the morning before the first 
meal or at night, three or four hours after the last 
meal. The former time is preferable, as the stomach 
is thus given all possible opportunity for assimila- 
tion of its contents and no nourishment is with- 
drawn. . 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 neces- 
sary to wash out the stomach twice a day, night and morning. 

Position of Patient. — The patient sits in a chair facing the opera- 
tor, 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 for- 



Fig. 549.— 
Enlarged view of 
the tip of a 
stomach-tube 
with a closed end 
and lateral fen- 
estras. 



550 



THE STOMACH 



ward 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. — 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 



J^ 


j^y 




\ \ 


\ 1 
\ 1 


^ y 


_V I . 


\ "'"^ 


f ._. 


^ 


V"^^— 






"'' 


1 




'; 




'/ 




1 




// 




// 




.0 






Fig. 550. — Showing the method of washing out the stomach. (After Boston.) 

or saHva 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 fingers. The tube is 
simply passed along the roof of the patient's mouth until the pharynx 
is reached, when the patient is instructed to swallow and the instru- 



LAVAGE OF THE STOMACH 



551 



ment, grasped by the pharyngeal muscles, is carried on into the 
esophagus (see Fig. 535). At first there may be some irritation and 
gagging, but by having the patient breathe in deeply and regularly 
this rapidly subsides. When a patient becomes accustomed to the 
passage of the tube there is very little if any discomfort produced. 

As soon as the tube enters the esophagus it is rapidly pushed on 
into the stomach. Frequently when the tube enters the stomach the 
contents immediately escape into the funnel; if not, the funnel 
should be lowered and the contents drained off. To accomplish this 




Fig. 551. — Showing the passage of a stomach-tube through the nose in performing 

gastric lavage upon infants. 



it may be necessary, however, to apply some slight pressure over the 
epigastrium, after the method employed in expressing a test-meal 
(seepage 532). 

Having removed the contents of the stomach, or being sure that 
it is empty, the tube is pinched close to the patient's mouth, and the 
funnel is elevated slightly and filled with about a pint (500 c.c.) of 
solution (Fig. 550). 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 



552 THE STOMACH 

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 
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's position changed during 
the lavage; for example, after one or more washings in the upright po- 
sition 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 is removed as follows: 
A small quantity of fluid is allowed to remain in the funnel and, as 
the tube is slowly withdrawn, this is permitted to flow back into the 
stomach until the end of the tube is in the esophagus. The tube is 
then tightly pinched to prevent the solution from escaping as the 
tube is withdrawn over the larynx and through the mouth. The 
important point is that the tube should not be removed from the 
stomach empty, as portions of mucous membrane may be drawn into 
the fenestras 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 bitting the instrument, the tube may be passed through 
a nostril (Fig. 551). As a rule, this method of introduction is not 
difficult, as the tube hugs the posterior wall of the pharynx and read- 
ily 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- 



THE STOMACH DOUCHE 



553 



necting tube 3 to 4 inches (7.5 to 10 cm.) long, and a stomach-tube 
about 30 inches (75 cm.) long, with a large number of side openings 
H5 to K2 inch (i to 2 mm.) in diameter and a terminal opening 
H to }i inch (3 to 4 mm.) in diameter, should be provided (Fig. 
552). The 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 H inch (9 mm.) in diameter, 




Fig. 552. — An enlarged view of a stomach- Fig. 553. 
douche tube. 



-Einhorn 's apparatus for giv- 
ing a stomach douche. 



terminating at the stomach end in a hard-rubber cap with numerous 
side openings and a large end opening (Fig. 553). Within the tip of 
this cap lies a freely movable aluminum ball which is prevented by 
two crossbars from entering the main portion of the tube. This ball 
falls over the terminal opening as the solution flows into the stomach 
and causes the fluid to flow out through the small openings. When 
the current is reversed, the ball is driven upward and the solution is 
carried off through the large opening. 



554 THE STOMACH 

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- 
ing: sahcyhc 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 38° C). Occasion- 
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 or 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. 

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 dis- 



THE STOMACH DOUCHE 



555 



tance to bring the perforated tip within the cardia (Fig. 554), which 
is determined 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 
solution is then allowed to flow into the stomach, the funnel end being 
elevated high enough to obtain the necessary pressure. 

To remove the solution, the tube is pinched while there is still 
some liquid in it and is inserted some 4 to 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. 




Fig. 554. — Showing the mechanism of the stomach douche. (After Gumprecht.) 

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 



556 



THE STOMACH 



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 
difficult matter to give sufficient food. 

Apparatus. — The same sort of apparatus as is employed for gastric 
lavage will be required, yiz., a soft stomach-tube 30 inches (75 cm.) 
long, 2 feet (60 cm.) of rubber tubing joined to the stomach-tube by a 




Fig. 555. — Apparatus for nasal gavage. 

glass connecting tube 3 or 4 inches (7.5 to 10 cm.) long, and a glass 
funnel with a capacity of about i pint (500 c.c.) (see Fig. 531). If 
it is intended to employ the apparatus for nasal feeding, a tube of 
smaller cahber 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. 555). 

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 
diphtheria, for example, the apparatus should always be boiled. 



GAVAGE 



557 




Fig. 556.— Gavage. First step, introduction of the tube. 




Fig. 55 /-—Gavage. Second step, administering the 



food. 



558 



THE STOMACH 



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 
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 fiat on its back 
across the nurse's knees with the head slightly elevated. Its arms 




Fig. 558. — Gavage. Third step, showing the tube being compressed as it is removed 

to prevent leakage. 

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. 556). In an infant at 
birth the distance from the alveolus to the cardia is 6^-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 



DUODENAL FEEDING 559 

the required amount of food introduced (Fig. 557). The tube is then 
rapidly withdrawn, pinching it the while, so as to prevent any drip- 
ping of food into the pharynx and larynx (Fig. 558). The patient 
should be kept quietly in the recumbent position for some time after 
the introduction of the food. In cases complicated by gastroenteri- 
tis, etc., a preliminary lavage of the stomach with warm water, just 
before giving the food, is often advisable. It removes mucus and any 
food remnants of a previous feeding, cleanses the mucous membrane, 
and at the same time stimulates it to a better absorption of the freshly 
introduced food. 

DUODENAL FEEDING 

Duodenal feeding consists in the administration of food through a 
small tube introduced into the duodenum through the stomach. 




^1^^ 

Fig. 559. — Einhorn's duodenal pump, a, Metal capsule, lower half provided 
with numerous holes, the upper half communicating with tube h; i, 11, 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, col- 
lapsible connecting tube; /, -aspirating syringe. (Kemp.) 

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 
duodenal ulcer and gastric dilatation not due to organic obstruction^ 
It has also been employed in cases where difficulty is found in admin- 
istering 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. 559). 



560 THE STOMACH 

Palefski has modified Einhorn's tube by employing 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 No. 
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 mixture: 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). 

Frequency of Feedings. — Eight feedings are given a day at 2-hour 
intervals. 

Position of Patient. — The patient is seated in a chair with the 
head thrown back. 

Technic. — The operator places the bulb in the patient's open 
mouth and instructs him to swallow it. When the 40 cm. (16 in.) 
mark is at the patient's teeth, the metal 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. The tube is then 
slowly pushed onward, and when the 56 cm. (22 ins.) mark is at the 
teeth the bulb should be at the pylorus. From this point the tube is 
left to work its way into the duodenum, which is indicated when the 
70 cm. (28 in.) mark is at the teeth. From time to time test aspir- 
ations are made to determine more certainly 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 consider- 
able 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 



f 



MASSAGE OF THE STOMACH 56 1 

from becoming clogged. The tube is left in place during the course 
of 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 lo 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 imparied 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 
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 purpose 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, 
however, the object is to propel the contents of the stomach into the 
intestines, and the massage is then performed upon a full or partly 
full stomach. The best time for 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 five to ten minutes. 

36 



562 



THE STOMACH 



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. 

Technic. — Stroking movements (effleurage) and kneading (petris- 
sage) are the manipulations most employed. In performing effleur- 




-^ 1 ^ ^ 

Fig. 560. — Stroking massage applied to the stomach. (After Gant.) 

age the operator places his left hand upon the right hypochondriac 
region for the purpose of counterpressure and with his right hand, the 
fingers of which are outstretched, he performs stroking movements 
from the fundus toward the pylorus; i.e., from left to right (Fig. 560). 




Fig. 561. — Kneading massage applied to the stomach. 

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 



ELECTROTHERAPY IN DISEASES OF THE STOMACH 563 

kneaded by alternately squeezing and relaxing the fingers (Fig. 561). 
The force used in the various movements of massage will depend upon 
the sensitiveness of the patient, the thickness of the abdominal walls, 
and the rigidity of the muscles. The manipulations, however, should 
never produce pain or be disagreeable to the patient. 

To accelerate the passage of the stomach contents into the 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 clij^ically. It seems probable, however, that electricity 
increases the motor activity, stimulates the secretion of the gastric 
juice, and increases the absorption power of the stomach. According 
to clinical experience, at any rate, its use is followed by favorable 
results in simple atony, dilatation from atony, hypochlorhydria, 
nervous anorexia, nervous vomiting, paresthesia, hyperesthesia, and 
gastralgias. 

Both the faradic and the galvanic currents are employed and they 
may be used percutaneously or intraventricular^. As to the choice 
of current and the method of its application, authorities again dis- 
agree. 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 intraven- 
tricular method seems more desirable when the necessary apparatus 
is at hand, as the stomach is thus directly treated. External appli- 
cation 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. 562). For intrastomachic 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. 563) consists of a hard- 
rubber shell, shaped like an egg, with numerous small perforations 



5^4 



THE STOMACH 



piercing its surface, and within this capsule is a button of copper or 
brass. A small rubber tube K5 inch (i mm.) in diameter carries 
fine wires leading from the button to the instrument. A curved plate 
electrode is connected with the other pole of the battery. 







I 



[ 




Fig. 562. — ^Large flat sponge electrode. 

Duration of Application. — Each treatment should consume about 
ten minutes. 

Frequency. — At first treatments are employed daily; after two or 
three weeks, twice weekly; and, finally, applications are made at 
weekly intervals until the treatments are discontinued. 




Fig. 563. — Einhorn's deglutible electrode. 

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 sufficient, however, to 
produce strong and visible contractions of the abdominal wall and 
back muscles without causing pain. 



ELECTROTHERAPY IN DISEASES OF THE STOMACH 565 

Position of Patient. — The patient should be in the recumbent 
position with the head slightly elevated and the legs flexed so as to 
relax the abdominal muscles. 

Technic. — i. 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. Intrastomachic Application. — The treatment should be given on 
an empty stomach, preferably one or two hours after a light breakfast. 
If necessary, the stomach should be emptied by means of a stomach- 
tube. When an electrode, such as Wegele's or Stockton's, is 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 re- 
quested to open the mouth widely and the electrode is placed well 
back in the patient's mouth and the patient is then instructed to 
swallow. If there is any difficulty in accomplishing this, drinking a 
glass of water will be of material assistance. 

The gastric electrode is connected with the negative pole of the 
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 apphed 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 XIX 
THE COLON AND RECTUM 

Anatomic Considerations 

The Colon. — The colon is that portion of the alimentary 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 
2,% inches (8 cm.) in diameter. The average capacity of the colon 
in infants is i pint (500 c.c), at 2 years 2)'^ pints (1.25 liters), and in 
adults 9 pints (4.5 liters). 



' Fig. 564. — 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 2>\i inches (8 cm.) broad and 2^^^ inches (6 cm.) long. It is usually 
completely covered by peritoneum. From its inner and posterior 
portion is given off the vermiform appendix, a small blind tube 
with an average length of 33-^ inches (8 cm.). The ileum opens into 

566 



ANATOMIC CONSIDERATIONS 567 

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 ver- 
tically up the right side of the abdomen from the cecum to the infe- 
rior surface 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 
abdominal muscles and the lower pole of the kidney, and is bound to 
the former by connective tissue. Anteriorly and laterally it is cov- 
ered 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 fastened to the posterior abdominal wall by a long 
mesentery. 

The descending colon is 83^^ 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^^ inches (44 cm.) long and extends from the left iliac crest 
in an S-shaped curve to the third sacral vertebra. In the first por- 
tion 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 ot 
the pelvic floor as the anal canal (Fig. 565). The antero-posterior 



568 



THE COLON AND RECTUM 



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. 565. — 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 lie anteriorly. 

The anal canal is about i^i 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 



ANATOMIC CONSIDERATIONS ' 



569 




Fig. 566. — The rectal valves as 
seen through the proctoscope. (After 
Gant.) 



supported by the levatores ani muscles. At the anus the skin is dark 

brown in color and puckered up into radiating folds. The anal canal 

is in relation anteriorly in the male with the bulb and membranous 

portion of the urethra; and in the fe- 
male 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 like 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 

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. 566). These valves 
are attached to the walls of the rectum 
for a distance of from y^ to J-^ its cir- 
cumference and protrude into its cavity 
to varying degrees. Their function 
seems to be to assist the sphincters and 
to serve to support the fecal mass. 
They may be the cause of difficulty in 
making digital examinations and they 
may act as obstacles to the passage of 
a rectal tube. 

In the anal canal the mucous mem- 
brane is thrown into a series of longi- 
tudinal folds, five to twelve in number, 
called the columns of Morgagni. They 

are about H inch (i cm.) in length, and are prolonged upward 

from the radiating folds about the anus. Stretched between these 




Fig. 567. — The anal canal, 
showing the columns and valves 
of Morgagni. 



570 



THE COLON AND RECTUM 



columns at their inferior ends are semilunar folds of mucous mem- 
brane forming pouches that open upward, known as the valves of 
Morgagni (Fig. 567). 

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- 
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, 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. 

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- 
structon. 

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. 



i 



INSPECTION 571 

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 refiexly 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, skiagrapy, 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. 

Position. — The patient lies with the body symmetrically placed 
upon a firm flat table with the light falling obliquely from the head 
toward the foot (see Fig. 523). It is of advantage when examining 
for ptosis to have the patient also assume the erect positon. 

Technic. — The patient's abdomen being fully exposed, inspection 
is performed from the side and from the foot of the table (see Fig. 
523). The examiner notes first the general appearance of the abdo- 
men, whether distended or flat and whether the abdominal walls are 
well developed and capable of supporting the contents. In entero- 
ptosis 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 
umbilicus. This characteristic appearance is accentuated with the 
patient in the erect position — the abdomen appears more pendulous 



5^2 THE COLON AND RECTUM 

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 
573) 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 fiat 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 
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, 



INFLATION OF THE COLON 573 

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 a