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BOOKS

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

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

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

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.

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

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

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.

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.)

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

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

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.

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

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

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.

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

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-

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

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

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

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

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.

INFILTRATION ANESTHESIA

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

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*-

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

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-

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

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

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

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

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

•

Sera

m n

Se rum in

roup I

111

Group n

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

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

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

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.

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.

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

gm.

gr. XV.

gm.

dr. 2M

1000

c.c.

qt. i.

gm.

dr. i3^

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

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.

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

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

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

6^
60
56

■ Ik

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36
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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 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.

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

230

115

220

210

los

l^OO

100

102

184

177

170

164

159

154

148

144

140

135

132

128

124

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.

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

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

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

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,

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

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.

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.

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

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

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

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.

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

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

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.

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-

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

^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.

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

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-

\Y/

^yy

Vc7

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

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;

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

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.

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

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

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

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.

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

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^y

\ \

\ 1
\ 1

^ y

_V I .

\ "'"^

f ._.

V"^^—

"''

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

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.

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.

[

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.

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 as to the source and mobility of a mass may be
elicited by changing the position of the patient from time to time and
by inflation of the bowel (see below) .

PERCUSSION

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

AUSCULTATION

Auscultation is of but little diagnostic importance in diseases of
the large bowel. Various splashing, gurgling, and whistling sounds
are to be heard normally in the intestines and are due to the move-
ments of gas and fluids. In chronic obstruction of the large bowel
gurgling sounds are also to be heard iii the region of the obstruction,
and, if they are always heard in the same location, they are of con-
siderable diagnostic importance. An entire absence of intestinal
sounds would suggest intestinal paresis. By injecting into the bowel
small quantities of fluid (about a pint (500 c.c.)) it is possible to map
out the course of the bowel by the splashing sounds heard on auscul-
tation. This procedure may be employed to advantage in cases of
suspected ptosis.

INFLATION OF THE COLON

This procedure is performed both as a diagnostic and as a thera-
peutic measure (for the latter see page 6i6). The bowel may be

574 THE COLON AND RECTUM

inflated either by means of air or fluids. For diagnostic purposes ^^
however, air is preferable, as there is thus produced a contrast on
percussion between the tympany of the air-distended bowel and the
flatness of a tumor. It has the disadvantage, however, that the
amount injected cannot be measured as can fluids, and consequently
the degree of distention is not so well regulated.

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

Apparatus. — The injection of fluids is effected by means of a foun-
tain syringe or a graduated glass irrigating jar as a reservoir, and
a rectal tube attached to the reservoir by about 6 feet (i8o cm.) of
rubber tubing >^ to % inch (6 to 9 mm.) in diameter.

For the injection of air a special inflation apparatus may be em-
ployed, but a rectal tube attached to a Davidson syringe, cautery
bulb (Fig. 568), hand bellows, or bicycle pump will answer equally
well. The pumping apparatus may be dispensed with if oxygen
or carbonic gas is used. In the case of the former the rectal tube

INFLATION OF THE COLON

575

is simply attached to the oxygen tank (Fig. 569), while, if the latter
gas be employed, the tube is attached to a syphon of carbonic, and
the latter is inverted so that the gas escapes without the water
following.

;gi!^''""^^''''''"i'"""'i"|''''''''''''''iiimiiilitiTTm™^^
Fig. 568. — Rectal tube and cautery bulb for inflating the colon.

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

Amount Injected. — When inflating with gas there is no way to
determine accurately the amount of gas injected, and the patient's

Fig. 569. — Inflation of the colon with oxygen. (After Gant.)

sensations and the degree of distention of the bowel must be the
guide. Never inject sufficient to cause pain, and care must be taken
not to endanger the gut.

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

576 THE COLON AND RECTUM

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

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

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

The technic of introducing gas is practically identical with the
above, great care being taken, however, not to force the gas in too
rapidly or in excess, and at the completion of the examination to draw
off as much of it as possible, so as to avoid unpleasant distention. Its
escape may be aided by inserting two fingers into the rectum and
holding the anus open.

SKIAGRAPHY

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

SKIAGRAPHY 577

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

II, Internal Examination

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

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

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

570). This position will be found most useful for routine examina-
37

578

THE COLON AND RECTUM

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

The lithotomy position is secured by placing the patient flat on the
back and flexing the thighs upon the abdomen and the legs upon the

Fig. 570. — The Sims position.

thighs. The buttocks, which are elevated upon a hard flat pillow,
project over the end of the table (Fig. 571). In very stout indi-
viduals this position will permit of a more satisfactory examination
than will the Sims.

The knee-chest position is obtained by having the patient kneel
upon a table with the thighs at right angles to the legs with the body

Fig. 571. — The lithotomy position.

well flexed upon the thighs, the chest resting upon a pillow placed
upon the same level as the knees (Fig. 572) . The knee-chest position
favors displacement of the coils of intestine upward, thus allowing the
rectum to be distended by the entrance of air upon the insertion of a

PALPATION 579

speculum or proctoscope. The mucous membrane of the rectum,
which in the dorsal position lies in folds, becomes expanded, and thus
a more thorough inspection of all portions of the canal is possible.
The squatting posture is only suitable for digital examination.
The patient assumes an attitude similar to that taken while at stool.
Portions of the rectum may be thus palpated which in the Sims or the
dorsal position would be out of reach of the examiner's finger. By a
slight straining effort protrusions or moderate degrees of prolapse will
be revealed.

"Tlll||||||||ll||))|l|)||lllllll|)|lll|!lllll|l|l)||>|ll))|||||/|||/|i|||||||)|)||||i)))|^|^^^^^^

Fig. 572. — The knee-chest position.

INSPECTION

The anus is first inspected. The presence of discharges from the
rectum, excoriations, eczema, thickening of the epidermis, scars,
ulcerations, fistulous openings, condylomata, the swelling of an
abscess, and external hemorrhoids are carefully looked for. Then,
by separating the buttocks and placing the thumbs on either side of
the anus and drawing it apart while the patient strains slightly,
inspection of the anal canal for at least an inch (2.5 cm.) will be
possible (Fig. 573). Slight degrees of prolapse, fissures, ulcers,
hemorrhoids, and polypi or other growths may be readily demon-
strated in this way.

PALPATION

Palpation of the rectum may be performed by means of the finger
or by the whole hand. With the index-finger one may examine the

58o

THE COLON AND RECTUM

anus, the anal canal, and the ampulla of the rectum. The first 4
inches (10 cm.) of the rectum may be thus explored.

Introduction of the whole hand into the rectum, as advocated by
Simon, for the purpose of palpation of portions of the canal out of
reach of the finger, may be practised if the hand is moderately small.
Tuttle states that a hand requiring a kid glove larger than 7^^ should
never be introduced into the rectum except in a life or death emer-
gency. Manual palpation is rarely required, being only necessary for
examining tumors high up that cannot be inspected by means of a
speculum or a proctoscope. In addition, it is a serious procedure, as
there is danger of rupture or undue distention of the bowel in careless
hands.

Fig. 573. — Inspection of the anus. (Ashton.)

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

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

PALPATION

581

through the sphincter. Roughness in inserting the finger or disre-
gard of the natural direction of the canal will be liable to cause spasm
of the sphincter and give the patient such pain that a thorough
examination will be impossible.

Fig. 574. — Palpation of the rectum. (Gant.)

As the finger passes through the anal canal the condition of the
sphincter should be noted, the examiner observing whether it is
closed, rigid, and resisting, or loose and patulous. When the internal
sphincter has been passed, the finger is swept lightly over the mucous

Fig. 575. — Method of dilating the anus by means of one finger of each hand.

membrane, palpating the rectal wall in all directions. The size and
sensitiveness of the rectum is thus ascertained. The examining
finger will readily detect the presence of impacted feces, polypi, large
hemorrhoids, malignant growths, ulcerations, fissures, and strictures

582 THE COLON AND RECTUM

if a systematic examination is made. In the male, enlargement,
induration, degrees of sensitiveness, or softness of the prostate should
be carefully noted, and likewise information regarding the condition
of the seminal vesicles and bladder should be obtained. A vesical
calculus may frequently be discovered by such examination. In the
female, the uterus, tubes, ovaries, and broad ligaments are carefully
examined for displacements or signs of inflammation. Finally, the
coccyx should not be overlooked, as this bone may be responsible for
considerable rectal disturbance.

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

Fig. 576. — Method of dilating the anus by means of two fingers of each hand.

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

2. By the Whole Hand. — Stretching of the sphincters is com-
menced by introducing into the anus the two forefingers with the pal-
mar surfaces out, and separating them slowly and gently in all direc-
tions, care being taken to avoid injury to the mucous membrane if
possible (Fig. 575). As soon as a little dilatation has been secured,
two and then three fingers of each hand may be introduced, carrying
them to a point well above the internal sphincter. The fingers are
then gradually separated until sufiicient dilatation is obtained to al-
low the hand to pass (Fig. 576). The hand is then well lubricated
and, with the fingers formed in the shape of a cone, it is gradually
introduced past the sphincter muscles until it enters the dilated am-
pulla. From this point on only two fingers should be used in palpa-

EXAMINATION BY THE SPECULUM OR PROCTOSCOPE

583

tion, and great care and gentleness are necessary to prevent injury, as
the canal gradually narrows down.

EXAMINATION BY THE SPECULUM OR PROCTOSCOPE

By the aid of suitable specula and reflected light, the whole inner
surface of the rectum up to the sigmoid flexure may be inspected.
The openings of glands and the condition of the valves and any altera-
tion in color or unevenness of the surface of the mucous membrane
are noted. Ulcers, polypi, new growths, malignant disease, stric-
tures, the internal openings of fistulous tracts, hemorrhoids, and
congestion or inflammation of the rectal mucosa may be distin-
guished by the experienced examiner.

Fig. 577. — The Sims rectal speculum. (Hirst.)

Instruments. — The ordinary rectal specula are made in various
shapes and styles, such as the Sims (Fig. 577), the bivalve, the duck-
bill (Fig. 578), the fenestrated-blade (Fig. 579), the conical, etc.
These are all useful instruments for inspection of the lower 4 or 5
inches (10 to 12 cm.) of the bowel, but their usefulness is limited to
that region.

For examination of points higher up Kelly has devised tubular
specula (Fig. 580) which permit a thorough inspection of the entire
rectum and the sigmoid flexure. This set of instruments consists of :
(i) a sphincteroscope, (2) a long and (3) a short proctoscope, and
(4) a sigmoidoscope. The sphincteroscope is short and slightly
conical; the diameter of the lower end of the tube is i inch (2.5 cm.)
and of the upper end 13^:5 inches (3 cm.). The cylinder of the short
proctoscope is 53^^ inches (14 cm.) long, and % inch (22 mm.) in

584

THE COLON AND RECTUM

diameter. The long proctoscope is 8 inches (20 cm.) long and of the
same diameter as the short proctoscope, and the sigmoidoscope is of
like diameter and 14 inches (35 cm.) long. Each speculum consists
of a cylindrical metal tube, at the outer end of which is a funnel-
shaped rim about 2 inches (5 cm.) in diameter to which a handle is-
attached. A blunt obturator is provided to faciHtate the introduc-
tion of the instrument into the bowel. Illumination is secured from
an electric light held close to the sacrum, which is reflected by a head
mirror into the speculum, or else an electric head light or the direct
sunlight may be employed.

Fig. 578. — Duck-bill rectal speculum.

Fig. 579. — Fenestrated-blade rectal
speculum.

Murphy has modified Kelly's instrument in such a way that the
specula telescope, the proctoscope fitting into the sphincteroscope,
etc. This does away with the necessity of withdrawing and inserting
a speculum through the anus each time a smaller size is used. The
sphincteroscope is used first, and into this the next smaller size is
passed without withdrawing the original instrument, until all have
been introduced in succession.

The pneumatic proctoscope, such as Tuttle's modification of
Law's instrument (Fig. 581), is not dependent upon atmospheric
pressure as a means of dilatation, this being accompHshed by a special

EXAMINATION BV THE SPECULUM OR PROCTOSCOPE

585

inflation apparatus connected with the instrument. Tuttle's procto-
scope consists of a long cylinder, to the circumference of which is
fitted a small metallic tube closed at its distal extremity by a flint-

FiG. 580. — Kelly's set of tubular specula, i, Swab and holder; 2, sigmoidoscope;
3, long proctoscope; 4, short proctoscope; 5, sphincteroscope.

Fig. 581. — Tuttle's pneumatic proctoscope, i, Proctoscope with obturator
removed; 2, obturator; 3, handle; 4, air-tight plug with glass window; 5, inflating
apparatus.

glass bulb. An electric light fitted upon a long metallic stem is car-
ried through the small accessory cylinder to the end of the speculum.

586

THE COLON AND RECTUM

An obturator fits into the distal end of the large cylinder to facilitate
the introduction of the instrument. In addition, there is an air-
tight-fitting plug containing either a plain glass window or a lens
focused to the length of the instrument to be inserted in the procto-

FiG. 582. — Method of holding the proctoscope.

scope when the obturator is removed. This plug is in connection
with an inflating apparatus. An adjustable handle is supplied with
the instrument. These specula vary in length from 4 to 14 inches
(10 to 35 cm.). Tuttle recommends a 4- and a lo-inch (10 and 25
cm.) tube for ordinary use. The light is furnished by a four or a six

Fig. 583. — Proctoscopy. First step, method of inserting the instrument.

dry-cell battery. In using the specula and proctoscope long dressing
forceps and cotton balls with which to swab out the bowel will be
required.

Asepsis. — The specula may be sterilized by boiling or by im-
mersion in a I to 20 carbolic acid solution. In case the latter is

EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 587

employed, the instrument should be rinsed off with alcohol or sterile
water before use.

Position of the Patient. — The patient should be placed in the
knee-chest position, so that the rectum will balloon up upon the
entrance of air through the instrument.

Fig. 584. — Proctoscopy. Second step, showing the direction of the instrument in

passing through the anus.

Fig. 585. — Proctoscopy. Third step, showing the direction of the instrument in

entering the ampulla.

Anesthesia. — An anesthesia is not required, as a rule, unless the
patient is extremely hyperesthetic.

Technic. — i. With the Kelly Instrument. — The instrument should
always be warmed and lubricated with sterile vaselin before its
introduction. In using the sphincteroscope the handle of the instru-
ment is grasped in the right hand with the right thumb pressing

588

THE COLON AND RECTUM

against the obturator, as shown in Fig. 582. The buttocks are then
drawn apart, and with the end of the obturator held against the canal
orifice (Fig. 583), the patient strains slightly and the speculum is
slowly pushed into the bowel in a direction downward and forward
(Fig. 584) until the funnel-shaped rim prevents its further progress.
The obturator is then removed, allowing air to pass in and distend
the bowel. The light is reflected into the instrument in such a way
as to thoroughly illuminate the interior, and, as the instrument is
slowly withdrawn, the whole of the anal canal is carefully inspected.

Fig. 586. — Proctoscopy. Fourth step, showing the instrument inserted to its full

extent.

The proctoscope is inserted in precisely the same manner, first
pushing the instrument in a direction downward and forward (Fig.
584) and then upward toward the sacral hollow (Fig. 585). As soon
as the tube enters the ampulla, the obturator should be withdrawn
allowing air to enter and expand the bowel. The light is then thrown
into the instrument and the ampulla is inspected. From this point
the instrument is advanced past the valves entirely hy sight. Some
difficulty may be experienced in following the direction of the canal
from a valve or fold of mucous membrane occluding the end of the
instrument. In such a case the distal end of the instrument should be
gently moved from side to side until the opening of the canal is found.
In this manner the whole interior of the rectum may be inspected.
As the instrument is withdrawn, the condition and character of the

EXAMINATION BY THE SPECULUM OR PROCTOSCOPE 589

mucous membrane as it falls over the end of the instrument is noted
(Fig. 587).

Fig. 587. — Showing the method of performing proctoscopy by the aid of a head mirror

and an electric light.

In introducing the sigmoidoscope it is to be remembered that the
upper portion of the canal gradually turns to the left, hence the point

Fig. 588. — Showing the method of inserting Tuttle's instrument with the finger in
the rectum and the auxiliary tube pressing against it.

of the instrument is turned in that direction as it slowly ascends the
bowel.

590

THE COLON AND RECTUM

2. With Tuttle^s Proctoscope. — The proctoscope, warmed and
well lubricated, is introduced in much the same manner as is Kelly's
instrument. To avoid causing the patient any discomfort from the
presence of the auxiliary tube, however, it is well to insert the index-
finger of the left hand into the bowel first and than to introduce the
instrument with the end of the auxiliary tube pressed against the
finger (Fig. s^^)^ ^s the tube enters the bowel the finger is withdrawn.
When the internal sphincter has been passed, the obturator is with-
drawn and the plug containing the glass lens is substituted. This
makes the instrument air-tight. Very slight pressure upon the bulb
of the inflating apparatus distends and straightens out the canal as
the instrument is advanced. Should the lamp become obscured by
feces or mucus, the plug is removed from the instrument and, with-
out removing the instrument, the glass is wiped off with a cotton
wipe held in long dressing forceps. At the completion of the exami-
nation the cap at the end of the tube is withdrawn and the air is
allowed to escape from the bowel before the instrument is removed.

EXAMINATION BY SOUNDS AND BOUGIES

The employment of the rectal sound or bougie for the diagnosis
of stricture has been superseded to a large extent by the use of the
proctoscope. The bougie, furthermore, is not a very reliable in-
strument, as strictures that do not exist may be imagined to be pre-
sent from the point of the instrument catching in the folds of muc-
ous membrane or in a diverticulum, or from being arrested by fecal
matter, the promontory of the sacrum, a retroverted uterus, or an
enlarged prostate. Again, the instrument may bend or curve
upon itself.

Instruments. — There are many varieties of sounds and bougies
made for diagnostic purposes, but the only instrument that should be
employed is a soft-rubber one, the Wales bougie (Fig. 589) being a
type. Metal or hard-rubber sounds are dangerous, even in the
hands of an expert, unless they are inserted by the aid of a procto-
scope, as they may easily be pushed through the rectal wall into the
peritoneal cavity, especially if the rectum is weakened by some
pathological condition. The Wales bougie is made of soft rubber
in different sizes, and in length measures about 12 to 14 inches (30
to 35 cm.). It is perforated by a canal running through its center
for the purpose of allowing fluid to be injected into the bowel to
aid in its passage. In using this instrumerit a Davidson syringe
should be provided.

EXAMINATION BY SOUNDS AND BOUGIES

591

Technic. — The bougie, well lubricated, is gently inserted into
the bowel until its further progress is impeded by some obstruction.
The Davidson syringe is then attached and a stream of warm water
or oil is forced through the instrument for the purpose of dislodging
any fecal matter or folds of mucous membrane that may be interfer-
ing with its passage. In this way the whole length of the bowel
may be explored without danger, and the instrument may be passed
into the sigmoid provided no stricture exists.

Fig. 589. — Wales' bougies.

EXAMINATION BY THE BOUGIE A BOULE

The rectal bougie a boule is made use of in diagnosis to deter-
mine the size and length of a stricture.

Instruments. — The bougie a boule consists of a flexible wire or
rubber shaft with a handle to the extremity of which acorn-tips of
various sizes may be screwed (Fig. 590). The bougie a boule is used
to best advantage in connection with a cylindrical speculum or a
proctoscope.

Fig. 590. — Rectal bougie a boule.

Technic. — A speculum is introduced into the anus and is carried
up to the seat of the stricture so that a clear view of its opening may
be secured. The examiner begins by selecting a large bougie and
passing it through the speculum to the opening in the stricture (Fig.
591). If it is found to be too large to enter the stricture, smaller
instruments are selected until one is found that will just pass through
the contracture. This is inserted entirely through the stricture,
using gentleness only in manipulation, and as it is withdrawn its

592

THE COLON AND RECTUM

base catches the distal opening of the stricture (Fig. 592). From
this examination the exact length and size of the contracture may be
readily ascertained.

Fig. 591. • Fig. 592.

Fig. 591. — Method of estimating the length of a rectal stricture, the bougie k
boule at the face of the stricture.

Fig. 592. — Method of estimating the length of a rectal stricture. The bougie
a boule is withdrawn until its base is arrested at the distal end of the stricture.

EXAMINATION BY THE PROBE

Probing has but little utility in the diagnosis of rectal diseases
except as a means of determining the situation and course of a r ecto-
vaginal or ischiorectal- fistula.

Instruments. — A silver probe 8 or 10 inches (20 to 25 cm.) long
with a flat handle is employed (Fig. 593). The probe should be fiex-

Fig. 593. — Rectal probe.

ible that it may be bent in any direction if desired. When examining
for a recto- vaginal fistula a Sims speculum will be required in addition
to expose the fistulous opening in the vagina.

Technic. — The index-finger of the left hand, well lubricated, is
first introduced into the rectum. The probe, grasped in the right

LAVAGE OF THE BOWEL

593

hand, is then passed through the external opening in the supposed
direction of the fistulous tract. The tract of the sinus is thus slowly
explored, removing the probe and bending it so as to alter its shape to
correspond with the direction of the sinus if necessary. The internal
finger at once recognizes the tip of the probe as it enters the rectum
(Fig. 594).

Fig. 594. — Showing the method of probing an ischiorectal fistula. (Ashton.)

LAVAGE OF THE BOWEL

As a diagnostic measure, irrigation of the bowel is sometimes
employed for the purpose of securing samples of the contents for
examination. The presence of blood, pus, amebae, tumor fragments,
etc., in the material thus obtained, will often lead to the recognition
of ulcerative or suppurative processes or malignant conditions which
from their location high up in the bowel might otherwise escape
notice.

Apparatus. — There will be required a rectal tube connected with
a glass funnel by about 3 feet (90 cm.) of rubber tubing.

Position of the Patient. — Irrigation may be performed with the
patient in the dorsal position or lying upon the left side with the
knees drawn up.

Technic. — The tube, properly lubricated, is inserted into the rec-
tum a short distance, and about a pint (500 c.c.) of warm boiled
water is slowly allowed to run into the bowel through the funnel,
which is elevated i to 2 feet (30 to 90 cm.) above the level of the
patient. As soon as any discomfort is felt by the patient, the funnel

594

THE COLON AND RECTUM

is lowered and the contents of the bowel are syphoned off and pre-
served for examination.

EXAMINATION OF THE FECES

Examination of the stools is of distinct diagnostic value in many
of the diseases of the digestive tract. Besides furnishing information
as to the functional activity of the various organs associated with the
process of digestion and absorption of food, it is a valuable aid in
the recognition of those diseases of the rectum and large intestine
which are due to infection by parasites and bacteria. Without
attempting fo enter into the technic of such examination, the details
of which will be found fully described in manuals on clinical labora-
tory methods, the lines along which the investigation should be
conducted may be briefly referred to. There are four methods of
examination available: macroscopical, microscopical, chemical, and
bacteriological.

Macroscopical examination. — The amount, color, odor, consist-
ency, and form of the stool and the presence or absence of mucus,
blood, or pus should be carefully noted.

Microscopical examination is made for the purpose of detecting
intestinal parasites or their ova, fat globules, undigested meat fibers,
blood, pus, or tumor fragments.

Bacteriological examination will identify pathogenic bacteria if
present.

Chemical examination should include tests for mucin, albumin,
carbohydrates, fat, blood, bile pigments, etc.

Therapeutic Measures

ENEMATA AND ENTEROCLYSIS

Hydrotherapy of the lower bowel may be carried out by means of
enemata or by enteroclysis. These two measures are often unneces-
sarily confused and, while in general they are employed for the relief
of much the same conditions, yet in practical application they are
quite distinct. By an enema is understood the introduction into the
bowel of clysters of fluid to be retained some little time at least. The
quantity of fluid so injected is usually small in amount, rarely ex-
ceeding I to 2 pints (500 to 1000 c.c). Enteroclysis, on the other
hand, is an irrigation of the lower bowel, the fluid returning almost

ENEMATA AND ENTEROCLYSIS 595

as rapidly as it is introduced. In this procedure, large quantities
of fluid are made use of — frequently several gallons at an irrigation.
The enema and the irrigation may be administered either low or
high, according to whether the fluid is introduced a few inches up
the rectum or high in the colon.

Enemata. — Enemata may be of several kinds, according to the
purpose for which they are employed. They may be designed
simply to secure an action of the bowels in ordinary constipation or to
unload the bowel of long-standing fecal accumulations or impactions
and at the same time relieve the accompanying tympanites. These
are known as purgative enemata. Such injections owe their action to
the stimulating effects upon intestinal peristalsis and to the softening
produced in the hardened fecal matter. In the treatment of consti-
pation, however, the use of enemata should be restricted as much as
possible; they should not be advised for long-continued use, as they
gradually lose their potency, and constantly increasing quantities are
necessary to produce an effect. For the local effects in colitis, dysen-
tery, catarrhal and ulcerative conditions of the rectum and colon,
small enemata of antiseptic, astringent, or sedative solutions to be
retained some little time are administered after each movement or
following a cleansing irrigation. While used mainly for purgative
and cleansing effects, enemata have other valuable uses in thera-
peutics. Rectal injections of saline solution are made use of in the
treatment of shock, hemorrhage, sepsis, etc. (see Saline Infusions,
p. 607). Rectal enemata are likewise employed as a means of intro-
ducing fluids and nutriment into the bowel (see Rectal Feeding,
p. 613) and for the administration of drugs which affect the general
system after absorption.

In employing the rectum as an avenue for the administration of
drugs, however, certain facts are to be kept in mind. The drug
should always be given in such a state that the active principle is in an
aqueous solution or else is capable of being dissolved in the fluids of
the rectum. It should also be remembered that, while the absorption
power of the rectum may be great, drugs are taken up but slowly and
if a rapid effect is desired, this method should not be employed. As a
rule, unless the drug is very powerful and is capable of being rapidly
absorbed, the dose is twice the amount given by mouth.

Apparatus. — The simpler the apparatus, provided it is efficient,
the better. A fountain syringe or a glass irrigating jar, capable of
holding a quart (1000 c.c.) of solution, will be required as a reservoir,
but in an emergency a large funnel will answer. A rubber tubing

596

THE COLON AND RECTUM

about 34 to % inch (6 to 9 mm.) in diameter and at least 6 feet
(180 cm.) long is connected with the outlet of the reservoir, and to the
free end an appropriate nozzle is attached (Fig. 595). For low
enemata the ordinary hard-rubber rectal nozzle provided with every
douche-bag will answer, but if the injection is to be given high up in
the bowel a flexible-rubber rectal tube about 20 inches (50 cm.) long
will be more convenient. The tube should be smooth and from %
to }^i inch (9 to 12 mm.) in diameter. A very simple apparatus
consists of a long colon tube and a funnel (Fig. 596).

Fig. 595. — Fountain syringe and nozzle Fig. 596. — Colon tube and funnel,
for giving a low enema.

Rectal tubes are made with the openings at the side, or with one
opening at the end (Fig. 597). The latter are better, as the fluid may
be injected directly through the tube for the purpose of dislodging
any feces or folds of mucous membrane that may obstruct the pas-
sage of the tube. In addition, a bed-pan or a douche-pan should be
provided.

Formulary. — For simple cleansing purposes or to produce an
evacuation in mild cases of costiveness an enema consisting of normal
salt solution (dr. i (4 gm.) of salt to i pint (500 c.c.) of warm water)
or the soap-suds enema, made by adding to i quart (1000 c.c.) of

ENEMATA AND ENTEROCLYSIS 597

hot water sufficient castile soap scrapings to make suds, may be used.
The continued use of the latter is not advisable, however, as some
irritation may be caused by the lye which is apt to result in proctitis
or skin eruptions.

In habitual constipation the injection of from 2 to 6 ounces (60 to
180 c.c.) of warm sweet oil into the bowel or the use of the flax-seed
enema will often give good results. The latter is prepared by adding
I ounce (30 gm.) of flax-seed to i pint (500 c.c.) of cold water and
then boiling the mixture for ten minutes. The resulting muci-
laginous mixture is strained and injected while warm. Another
good enema consists of equal parts of milk and molasses. When
a more profound effect is desired there are a number of drugs that

Fig. 597. — Rectal tubes.

may be incorporated in the enema. Of these may be mentioned
olive oil, castor oil, glycerin, ox gall, turpentine, magnesium sulphate,

Carlsbad salt, etc. The following combinations of the above will
be found useful :

I^ Olive oil or castor oil, oz. ii (60 c.c.)

Warm soapy water, oz. iv (120 c.c.)

I^ Glycerin, oz. i (30 c.c.)

Olive oil, . oz. iii (90 c.c.)

Warm soapy water, oz. iv (120 c.c.)

I^ Ox gall, • dr. ii (8 gm.)

Warm water, O i (500 c.c.)

I^ Ox gall, dr. ii (8 gm.)

Glycerin, ^ oz. iv (120 c.c.)

Warm water, O i (500 c.c.)

I^ Magnesium sulphate, oz. i (30 gm.)

Glycerin, • oz. ii (60 c.c.)

Warm water, oz. iii (90 c.c.)

I^ White of egg (beaten),

Oil of turpentine, dr. i (4 c.c.)

Olive oil, oz. i (30 c.c.)

Warm water, O i (500 c.c.)

598 THE COLON AND RECTUM

I^ Magnesium sulphate, oz. ii (60 gm.)

Oil of turpentine, dr. ii (8 c.c.)

Glycerin, oz. ii (60 c.c.)

Warm water, oz. iv (120 c.c.)

For the relief of tympanites a turpentine enema or an enema con-
sisting of 3 ounces (90 c.c.) of milk of asafetida may be used. For
irritability of the rectum the use of a small flaxseed enema or the
starch-water enema, to which 10 to 2oTrt (0.6 to 1.25 c.c.) of laudanum
are added, will often give great relief. The starch-water enema is
prepared by mixing an ounce (30 gm.) of starch and sufficient cold
water to form a thick paste; enough boiling water is then added to
dilute this mixture to the consistency of mucilage.

Temperature. — The enema should be given warm — at a tempera-
ture of about 100° F. (;^8° C.) — unless contraindicated.

Rapidity of Flow. — The solution should always be injected slowly
to avoid discomfort and spasm from a sudden distention of the bowel.
The reservoir is consequently elevated 2 to 3 feet (60 to 90 cm.)
above the patient.

Quantity. — To stimulate peristalsis and produce an evacuation
of the bowels a bulk of liquid sufficiently large to distend the walls of
the intestine should be injected. For this purpose between i pint
(500 c.c.) and i quart (1000 c.c.) of fluid is made use of at one injec-
tion. Enemata to be permanently retained for absorption, such as
those containing drugs or nutriment, should be small in amount, as a
rule containing only 2 to 3 ounces (60 to 90 c.c.) of fluid.

Position of the Patient. — The dorsal, the Sims, or the knee-chest
position may be utilized. When employing the dorsal or the Sims
position the hips should be elevated upon a hard pillow; especially
is this necessary if the enema is to be injected high into the bowel.
Infants can be best controlled lying on the back upon the atten-
dant's lap.

Technic. — The tube is first well lubricated with vaselin, and any
air is expelled. The left hand then separates the buttocks, and,
while the patient strains slightly to relax the sphincter, the tube is
inserted into the anus, guided by the right hand in which it i^ held at
a distance of about 2 inches (5 cm.) from its extremity, the operator
using a slight boring motion, and bearing in mind that the direction
of the anal canal with the patient recumbent is upward and slightly
forward. Having traversed the anal canal, the tube enters the rec-
tum proper, and is then slowly advanced in an upward and slightly
backward direction. From this point some difficulty may be met

ENEMATA AND ENTEROCLYSIS

599

with in passing the tube, as it often doubles upon itself from the
point catching in a fold of mucous membrane or one of the valves
or from being obstructed by feces. Withdrawing the tube slightly
and advancing it will often suffice to free it; in other cases allowing
the fluid to flow as the tube is advanced displaces or removes any ob-
struction and at the same time causes the tube to straighten out. In
this manner the tube may be passed into the colon, if desired, without
causing the patient any great discomfort, provided gentleness and no
force be employed.

When the tube is introduced to the desired height, the reservior is
elevated a distance of 2 or 3 feet (60 to 90 cm.), and its contents are
allowed to enter the bowel slowly (Fig. 598). The patient is apt to

Fig. 598. — Method of giving a low enema. (Macfarlane.)

complain of fulness in the rectum as the fluid enters and distends it,
but, by temporarily stopping the flow, this feeling soon passes off,
and, as the rectum becomes tolerant to the pressure, more fluid can
be injected. When the desired amount has been introduced, the
flow is shut off by pinching the tube, which is then withdrawn. The
patient is directed to hold the enema for five or ten minutes if possible
before using the bed-pan.

Enteroclysis. — ^Like enemata, irrigations are used mainly for
cleansing purposes, to remove putrefying material or toxins from the
bowels, and to bring medicated fluids into contact with diseased
mucous membrane. Large irrigations are not advised, however, in
the treatment of habitual constipation, the use of small enemata is
just as efficacious, and there is less danger of producing atony of the
bowel than where it is continually overloaded and distended with
large quantities of fluid. In the treatment of intestinal toxemia by
enteroclysis, the bowels are thoroughly cleansed and absorption of

6oO THE COLON AND RECTUM

the toxins from the decomposing contents is prevented. At the same
time, more or less fluid is absorbed, the activity of the skin, kidneys,
and liver is consequently stimulated and general absorption and
autointoxication are greatly lessened. For the same reasons entero-
clysis has a wide field of usefulness in the treatment of renal insuffi-
ciency, uremia, toxemia, general septic conditions, etc., producing
marked diuresis, and not only diluting the toxins in circulation, but
favoring their elimination.

Enteroclysis with hot normal salt solution, through the stimu-
lating effect on the circulation and the elevation of bodily tempera-
ture, produces marked and beneficial results in shock due to whatever
cause (see Saline Rectal Infusions, page 607).

In proctitis and in catarrhal, dysenteric, and ulcerative conditions
of the large bowel irrigations are employed for cleansing purposes,
removing foreign substances, mucus, and pus, and thus rendering
bacteria less active ; they also serve as a means of bringing medicinal
agents in contact with the diseased surfaces. For the local effect
upon diseases of the rectum or adjacent organs irrigations are used
either hot or cold; for example, in the treatment of internal hemor-
rhoids or hemorrhage from ulcers situated in the rectum or lower
bowel. Such irrigations are likewise employed in genitourinary and
gynecological practice for the treatment of congestion and inflam-
mation located in the bladder, prostate, and deep urethra, or the
uterus and its appendages.

Apparatus. — The reservoir for the solution may be either a
quart-glass irrigating jar or a fountain syringe, attached to which
is about 6 feet (180 cm.) of rubber tubing }/i to % inch (6 to 9
mm.) in diameter. Irrigating tubes are made in two styles: a single-
flow tube, in which the fluid enters and escapes through the same
opening, and a double-current tube, in which the inflow enters and
the outflow escapes through different compartments.

In irrigating with a single tube, it will prove most satisfactory
to use a colon tube about 20 inches (50 cm.) long and % to 3^^
inch (9 to 12 mm.) in diameter, with the opening at the end. With
this form of tube fluid may be deposited high in the colon or low in
the rectum at will. For infants, a catheter, 16 to 18 French, may be
used. The irrigating tube is connected to the end of the rubber tub-
ing of the irrigator by a T-shaped glass tube, to the long arm of
which is attached a short piece of rubber tubing closed by a clip
(^^g- 599)- The solution is passed into the bowel with this clip
closed, and when it is to be drawn off the inflow of solution is tempo-

ENEMATA AND ENTEROCLYSIS

60 1

rarily stopped by pinching the tubing between the glass connection
and the irrigator, the clip is opened, and the fluid returns through the
same tube and escapes through the long arm of the T-tube into a
waste-pail ready for that purpose. The same thing may be very
simply accomplished with a long colon tube and a funnel (see Fig.
596). The solution is forced in through the funnel, and, when

Fig. 599. — Apparatus for enteroclysis.

sufficient has entered the bowel, the funnel is depressed and the fluid
allowed to escape.

With a double-flow tube irrigations may be carried out far more
conveniently, especially when several gallons of fluid are used at each
irrigation. A very efficient double-flow apparatus, especially for
high irrigating, may be improvised by passing a moderate-sized

Fig. 600. — Kemp's return-flow irrigator.

single-flow tube high into the bowel, alongside of which is inserted a
second tube of larger caliber to carry off the return flow. There are
any number of excellent double-flow irrigators on the market, of
which Bodenhamer's, Kemp's (Fig. 600), or Tuttle's tubes are sat-
isfactory models. These instruments are made of hard rubber so
that they may be readily sterilized. Tuttle's irrigator (Fig. 601)

6o2 THE COLON AND RECTUM

consists of a cyKnder enclosing a smaller tube which opens at the end
of the irrigator. This smaller tube conducts the fluid into the bowel.
The outside cylinder has numerous openings in its sides to carry off
the outflow. It ends in a discharge tube to which a long piece of
rubber tubing is attached to carry off the waste.

A bath- thermometer, a douche-pan or a bed-pan, a slop-pail,
and rubber sheeting to protect the bed complete the necessary
equipment.

Solutions for Irrigation. — In the great majority of cases, unless a
specific action is required from direct contact of remedies with the
surface of the intestine, normal salt solution (dr. i (4 gm.) of salt to
a pint (500 c.c.) of warm water) is used. For cleansing purposes
and to aid in the expulsion of flatus, 5 to 15 lU (0.3 to i c.c.) of oleum
cinnamomi or oleum menthae piperitae may be added to each pint of
solution.

^^^-r - — j^if?--^,T«

Fig. 601. — Tuttle's return-flow irrigator.

The following solutions will be found useful in catarrhal or ulcera-
tive conditions of the lower bowel, according to whether a soothing,
antiseptic, stimulating, or astringent action is desired: aqueous
extract of krameria, i to 20; fluid extract of hydrastis, i to 50; fluid
extract of hamamelis, i to 50; boric acid, i to 20; hydrogen peroxid,
I to 10; thymol, i to 50; carbolic acid, i to 500; bichlorid of mercury,
I to 10,000; permanganate of potash, i to 500; salicylic acid, i to
500; quinin, i to 1000; argyrol, i to 1000; tannic acid, i to 500;
silver nitrate, i to 2000, etc. In using the more powerful and pois-
onous drugs, such as carbolic acid and bichlorid of mercury, for in-
stance, any excess of solution remaining in the bowel at the comple-
tion of the irrigation should be drained off before withdrawing the
tube.

Temperature. — This will depend upon the condition for which the
irrigation is employed and upon the action desired. For simple
cleansing purposes and in the treatment of colitis and dysentery the
irrigation should enter the bowel at a temperature of 100° to 105"^ F.
(38° to 41° C). Hot irrigations (110° to 115° F. (43° to 46° C.)) are
indicated when the stimulating action of heat is desired, or for the

ENEMATA AND ENTEROCLYSIS 603

diuretic effect and to increase the eliminative action of the skin, and
for the effect of heat upon inflammations of neighboring organs.

Cold enteroclysis (65° to 70° F. (18° to 21° C.)) has a beneficial
action upon the whole intestinal tract, toning up the mucous mem-
brane and stimulating the muscular tissue, and so increasing peri-
stalsis. This is indicated in the treatment of internal hemorrhoids,
inflammatory conditions of the rectum, prostate, deep urethra, etc.
In hemorrhage from the bowel, very cold (50° F. (10° C.)) or very
hot (120° F. (49° C.)) irrigations are used. It should not be for-
gotten, however, that prolonged enteroclysis with very hot or very
cold fluid will cause a rise or lowering of the bodily temperature
amounting to several degrees.

Rapidity of Flow. — The fluid should enter the bowel with com-
parative slowness, to avoid exciting peristalsis and to allow the fluid
to be well distributed over the intestinal wall. Elevation of the
reservoir 2 to 3 feet (60 to 90 cm.) for a low irrigation and 3 to 4 feet
(90 to 120 cm.) for the high will give the proper flow.

Quantity. — A continuous irrigaton of from ten minutes to one-
half an hour or more at a time gives the best results in septic condi-
tions, toxemias, inflammations in the organs adjacent to the bowel,
etc. Several gallons of solution are needed for such an irrigation.
On an average, from i to i3-^ pints (500 to 750 c.c.) of solution in
high enteroclysis, and from 2 to 8 ounces (60 to 240 c.c.) in the low
irrigation are kept in the bowel continuously. For cleansing pur-
poses, and in the treatment of diseases involving the mucous mem-
brane of the bowel, the irrigation is continued until the solution
returns dear.

Position of the Patient. — Enteroclysis may be performed with
the patient (i) in the dorsal position, with hips elevated; (2) in the
Sims, or left lateral prone position; and (3) in the knee-chest posture.

When it is desired to irrigate the whole colon, the position
of the patient may be altered to advantage from time to time in
order to allow the force of gravity to act upon the fluid and permit
it to reach all portions of the colon. Elevation of the patient's
hips causes the fluid to gravitate toward the transverse colon, and
thence along this portion of the bowel to the ascending colon if the
patient is shifted from the left side to the right.

Technic. — The apparatus is properly connected and the reservoir
is filled with the solution, first allowing a little to escape from the
nozzle to expel any air and to see that everything works properly.
Practically the same steps are followed in inserting the tube for

6o4

THE COLON AND RECTUM

enteroclysis as Were detailed for giving an enema. The tube, well
lubricated with vaselin or oil, is grasped in the fingers of the right
hand not far from its extremity, while the left hand separates the
patient's buttocks The patient is instructed to strain sufficiently to
relax the sphincter, and the tube is inserted at first upward and
forward for a distance of 2 to 3 inches (5 to 7.5 cm.) and then upward
and slightly backward toward the sacrum. There is very little
difficulty in passing a rectal tube or an irrigating nozzle the necessary
distance for a low irrigation, if the normal direction of the bowel is

Fig. 602. — Showing one method of irrigating the bowel with a single tube.

followed, a well-oiled tube almost slipping in of its own accord at
times. To pass a flexible tube the remainder of the way into the
sigmoid is not so simple, as it is not possible to guide the tube after
it gets 3 or 4 inches (7.5 or 10 cm.) into the bowel, and it has to prac-
tically find its own way along. It will be found a distinct aid, how-
ever, in accomplishing this if the solution is allowed to flow gently as
soon as the anal canal is passed. This tends to make the tube
stiffer and at the same time it straightens out the folds of mucous
membrane and carries the valves out of the way, which might other-

ENEMATA AND ENTEROCLYSIS

60 <

wise form obstructions. When the tube has been inserted to the
desired distance, the reservoir is raised 3 or 4 feet (90 or 120 cm.),
and the washing-out process begins.

In performing enteroclysis with a single tube, i to i>^ quarts
(i to 1.5 liters) of solution — depending upon the capacity and toler-
ance of the individual — are allowed to flow into the bowel before the
fluid is permitted to return. If the fluid enters the bowel slowly and
the desire on the part of the patient to expel it be resisted a few

Fig. 603. — Showing the method of irrigating the bowel by means of a funnel and

colon tube.

moments until it passes well into the colon, no great difficulty will be
encountered. To withdraw the fluid, the outlet placed in the tube
leading from the reservoir is opened (Fig. 602), or, if a funnel con-
stitutes the reservoir, this is simply lowered below the level of the
patient, and the solution escapes through the same tube by which
it entered (Fig. 603). This process of lavage is repeated until the
fluid returns clear.

6o6

THE COLON AND RECTUM

The colon may be more thoroughly irrigated, as already men-
tioned, by altering the patient's position as follows: With the patient
in the Sims position, for instance, and with the hips elevated, the
descending colon is first thoroughly washed out. About ij^ to 2
pints (750 to 1000 c.c.) of solution are then retained, and the patient
is gradually rolled to the dorsal position and then to the right side.
This permits the fluid to pass from the descending colon to the trans-
verse and ascending colon. To allow the solution to gravitate down.

FlG. 604. — Showing the method of irrigating the bowel by means of a retum-flow

irrigator.

the ascending colon to the caput coli, the patient's shoulders are
raised slightly higher than his hips. The process is then exactly
reversed : the shoulders are first lowered, the patient then rolls to the
dorsal position, and finally to the left side again.

In using the double-flow style of irrigator, the outflow tube is
compressed until a pint (500 c.c.) or more of solution runs into the
bowel (Fig. 605), when it is released, the solution still continuing to.
flow in. In this way a current is soon estabhshed, and the descending
colon and rectum are thoroughly washed out. During the irrigation

SALINE RECTAL INFUSIONS 607

the reservoir should not be allowed to become empty, the supply-
being replenished as often as necessary. In withdrawing an irrigator
or a tube with openings upon the side, care should be taken to rotate
the instrument slightly to prevent the mucous membrane from being
caught in the fenestrae.

SALINE RECTAL INFUSIONS

The value of saline infusions in the treatment of hemorrhage and
in the prevention and relief of surgical shock has already been con-
sidered in Chapter V. The rectal infusion, being a somewhat slower
and less effective method of introducing salt solution into the circu-
lation than either the intravenous or the subcutaneous methods, is
used with greater success in the milder forms of shock and hemor-
rhage, and in the severe cases as an adjunct to intravenous infusion
or hypodermoclysis. It has, however, the distinct advantage of
simplicity over the other two methods, requiring no preparation of
the patient and but the crudest form of apparatus; hence its value
as an emergency measure. In septic conditions, toxemias, renal
insufficiency, uremia, etc., the fluid thus introduced into the bowel
is rapidly absorbed, and the skin, kidneys, and liver are stimulated
to increased activity, with the rapid elimination of poisonous prod-
ucts as a result. Rectal infusions are also indicated when it is
desirable to increase the quantity of fluid in the tissues, as, for
example, in cases where large quantities of fluid are lost from purg-
ing, as in dysentery or cholera. It is, furthermore, a most valuable
means of relieving the thirst so frequently complained of after
abdominal operations.

Apparatus. — The equipment will not differ from that used in
giving an ordinary enema. There will be required a thermometer;
a graduated glass irrigating jar or fountain syringe; 6 feet (180 cm.)
of rubber tubing, about 34 to % inch (6 to 9 mm.) in diameter;
and a rectal tube, 20 inches (50 cm.) long and % to J^ inch (9 to
12 mm.) in diameter. In an emergency, a large funnel will answer
as a reservoir, and a large long soft-rubber catheter will take the
place of the rectal tube.

Solution. — Normal salt solution, (dr. i (4 gm.) of salt to a pint
(500 c.c.) of water) is used. For a stimulating effect, whisky or
brandy, oz. ss. to oz. i (15 to 30 c.c.) may be added. In surgical
shock 3oTrt (2 c.c.) of a i to 1000 solution of adrenalin chlorid may
be added to the enema for the purpose of raising blood-pressure.

6o8 THE COLON AND RECTUM

Temperature.^ — The solution should enter the bowel at a tem-
perature of iio° to 115° F. (43° to 46° C). As there is but little
loss of heat on account of the rapidity of the flow, the solution in the
reservoir should be at the same temperature at which it is desired
to have it enter the bowel, or not more than one or two degrees
higher.

Rapidity of Flow. — The fluid should be introduced slowly and not
with such rapidity as to excite intestinal spasm. With this in view,
the reservoir is held not over 3 to 4 feet (90 to 120 cm.) above the
patient.

Quantity. — Small amounts are more apt to be retained by the
bowel. From J-^ pint (250 c.c.) to a quart (1000 c.c.) may be given
at a single injection.

Position of the Patient. — The infusion may be given preferably
with the patient in the Sims position with the hips raised or else
in the knee-chest position. If it is not expedient to move the patient
about, the dorsal position with the hips elevated and with the knees
drawn up may be substituted.

Technic. — The reservoir is filled with the required amount of
solution of the proper temperature, and a thermometer is placed
in it that the temperature may be kept uniform. The rectal tube
should be weU lubricated with vaselin or oil. Some of the solution
is allowed to escape from the tube to expel any air or cold fluid. The
flow is then shut off and the tube is grasped in the fingers of the
right hand about 2 inches (5 cm.) from its extremity while the left
hand separates the buttocks. As the patient strains slightly,
relaxing the sphincter, the tube is gently inserted into the rectum.
In doing this the normal direction of the bowel with the patient in
the dorsal posture — first upward and forward, and then upward
and backward — must be kept in the mind of the operator. When
the internal sphincter is passed, the solution is again allowed to
flow gently, in order to displace any feces, folds of mucous membrane,
etc., that might act as an obstruction, and the tube is pushed on into
the bowel for a distance of at least 8 to 10 inches (20 to 25 cm.).
The reservoir is then raised from 3 to 4 feet (90 to 120 cm.), and the
required amount of solution is introduced. If it is injected slowly
and the tube is passed high up, no difficulty will be found in intro-
ducing and having retained often as much as a quart (1000 c.c.) of
solution. At the completion of the operation the tube is withdrawn
and the patient is instructed to remain quiet in the recumbent
position.

CONTINUOUS PROCTOCLYSIS

609

CONTINUOUS PROCTOCLYSIS

By this method a continuous stream of saline solution is instilled
into the rectum at very low pressure. Given slowly, so as not to
irritate the rectum, enormous quantities of salt solution may be thus
absorbed. It was originally employed by Murphy in the treatment
of septic peritonitis in conjunction with free abdominal drainage,
on the theory that the large quantity of fluid absorbed reverses the
lymph currents, so that, instead of absorption taking place from the
peritoneal surface, the lymphatics pour out fluid and wash out the

Fig. 605. — A very simple apparatus for continuous proctoclysis.

peritoneum, as it were. At the same time, stimulation of the heart
and kidneys results, and with the latter an increased elimination of
toxins and septic material. While employed mainly in cases of
peritonitis, where the results have certainly been marvelous, con-
tinuous proctoclysis will be found an excellent means of infusing
salt solution in any septic condition or general toxemia, shock,
uremia, etc.

Apparatus. — A glass reservoir or a fountain syringe with a capac-
ity of at least 2 quarts (2 liters), 3 to 4 feet (90 to 120 cm.) of rubber
tubing K to H of an inch (6 to 9 mm.) in diameter, and a vaginal

6io

THE COLON AND RECTUM

nozzle of. hard rubber with numerous openings on the sides, bent
at an angle of 35 degrees about 2 inches (5 cm.) from the tip (Fig.
605) forms the simplest apparatus. A aoft-rubber catheter may be
used in place of the hard nozzle, if desired. Hot-water bags or hot-
water cans, which surround the reservoir and prevent the solution
from cooHng, should also be provided. An indicator,
placed in the outflow tube to show the rate of flow,
is a great convenience. A simple one is described
by Dewitt {Surgery, Gynecology and Obstetrics, Febru-
ary, 191 1). The plunger is removed from a 6-inch
(15 cm.) metal- topped glass syringe and the metal
top is perforated with from 2 to 4 holes for the es-
cape of gas, and through the opening for the plunger
is inserted a glass medicine dropper. The upper
end of the dropper is connected with the reservoir
by a short piece of rubber tubing carrying a screw
clamp (Fig. 606), while the tip of the syringe is at-
tached to the rectal tubing. By means of this
simple device the rate of flow may be observed and
an outlet is provided for flatus.

Saxon has devised an apparatus especially for
proctoclysis (Fig. 607), consisting of a copper
bucket, inside of which is placed a glass reservoir for
the salt solution. Between the copper bucket and
reservoir is provided a space of 2}^i inches (6 cm.)
for hot water. A thermometer is placed in the
tubing which leads from the reservoir, and a vent
pipe for the escape of flatus is also provided.

A very simple apparatus is described by Iversen
(Journal of the American Medical Association, June
12, 1909) in which the solution is kept at the re-
quired temperature by means of an 8-candle-power
electric lamp. The mechanism is sufliciently clear
from the accompanying illustration (Fig. 608).
There are a number of more elaborate forms of apparatus made,
however, in which the heat is furnished by a thermoHte warmer or
by electricity.

Solutions. — Normal salt solution (dr. i (4 gm.) of salt to a pint
(500 c.c.) of water), glucose solution, or plain boiled tap water may be
used. The latter has been employed to a great extent in the last few
years, as it has been found that the large bowel tolerates warm water

Fig. 606.—
Modification of
Dewitt 's appK-
ance for regulat-
ing the flow of
solution in proc-
toclysis. (Cran-
don and Ehren-
fried.)

CONTINUOUS PROCTOCLYSIS

6ll

as well as it does saline solutions; furthermore, thirst is more quickly
and effectively relieved.

Glucose may be used in a watery solution in the strength of 2
drams (7.5 gm.) to the quart (liter). Solutions of glucose are espe-
cially valuable as not only are fluids thus supplied, but the patient
also receives a certain amount of carbohydrate food.

Temperature. — The solution should beat a temperature of about
100° to 105° F. (38° to 41° C.) as it enters the rectum, and it must
therefore be at a temperature of from 120° to 130° F. (49° to 54° C.)

Fig. 607. Fig. 608.

Fig. 607. — Saxon's apparatus for continuous proctoclysis. •

Fig. 608. — Iversen's apparatus for continuous proctoclysis, a, Eight-candle-power
electric bulb; h, cock; c, Y-shaped glass connection; d, vent tube for the escape of gas.

in the reservoir. The solution must be kept at a uniform degree
of heat by either constantly replenishing with hot solution or by
surrounding the reservoir with hot-water bags, unless one of the
special heating devices is employed.

Rapidity of Flow. — The salt solution just trickles into the bowel^
not much faster than it is absorbed, at about the rate of 30 to 12a
drops a minute. In this way 3^^ to i3-^ pints (250 to 750 c.c.) will
flow into the rectum in about an hour. The reservoir should be
elevated only from 4 to 18 inches (10 to 45 cm.) above the level of
the rectum, depending upon the rate of absorption, and the elevation

6l2

THE COLON AND RECTUM

of the reservoir must be so regulated that no accuinulation of fluid
occurs in the bowel.

Quantity. — The instillation is practically continuous, and the
quantity of fluid introduced is limited only by the absorbing power
of the rectum. From 6 to 15 quarts (6 to 15 liters) may be absorbed
in twenty-four hours. Murphy has given as much as 30 pints
(15 liters) in twenty-four hours to a child of eleven. It was all re-
tained. Monroe, however, sounds a note of warning against over-
use of this method, claiming that it is possible for a patient to absorb
more fluid than can be elminated, shown by an overfull pulse, by
cough, and by rales from edema of the lungs.

Fig. 609. — Showing the method of administering continuous proctoclysis. (Kelly
and Noble.) a, Adhesive strap fastening the tubing to the thigh; h, vaginal nozzle bent
at an angle of 35 degrees.

Technic. — The reservoir is filled with solution and suflicient
fluid is allowed to escape to expel any air from the tubing. The
right-angled noozle, well-lubricated, is introduced into the rectum
just beyond the sphincter muscle, so that the angle fits closely to
the anus, and is secured in place by adhesive plaster passing to the
thigh (Fig. 609). The reservoir is then raised about 6 inches (15
cm.) — ^just sufficiently high to overcome the intraabdominal pressure
and allow the fluid to trickle into the bowel. Forceps or other means
of constriction should not he applied to the tube to regulate the flow,
unless the apparatus be provided with an accessory vent to carry
off the flatus, as they interfere with the free expulsion of gas through

NUTRIENT ENEMATA

613

the tube or the return of fluid to the reservoir should the patient
strain or vomit. The injection may be stopped every few hours
if the pulse becomes too full or the rectum irritable; in such cases
the tube is not disturbed. Murphy advises that the tube should
not be removed except for defecation, as the constant reinsertion
will prove irritating to the rectum. It is rarely necessary to con-
tinue the proctoclysis for more than three or four days. Exact
technic and almost constant attention on the part of the nurse are
necessary to gain success with this method.

NUTRIENT ENEMATA

The nutrient enema is employed in cases when feeding by the
natural way is undesirable or impracticable. Rectal feeding has its
time limitations, however. The capacity of
the rectum^is small and absorption is consider-
ably slower than by the natural way, so that
only about a quarter of the amount of nour-
ishment necessary for sustenance can be given
in this way. As a temporary expedient or as
an adjunct to natural feeding it is most use-
ful, but for permanent feeding it is quite im-
practicable. If it alone is depended upon for
nourishment, life can rarely be prolonged for
more than four to six weeks, though it is true
that certain exceptional cases have been re-
ported where patients have lived exclusively
upon rectal feeding for longer periods.

Indications. — i. In cases where some im-
pediment to the passage of food exists, as eso-
phageal stricture, new growths encroaching
upon the esophagus, and in pyloric or duode-
nal stenosis. 2. In incessant and uncontroll-
able vomiting. 3. In any condition where it
is desirable to give the alimentary tract a rest,
as in acute inflammation or ulceration of the

upper part of the alimentary canal, acute gastritis, gastric ulcer,
typhoid fever, and lesions of the small intestine. 4. As an adjunct
to natural feeding in any condition when the patient cannot receive
Sufficient nourishment by mouth.

Fig. 61 o. — Funnel
and colon tube for ad-
ministering nutrient ene-
mata.

6i4

THE COLON AND RECTUM

Apparatus. — A large glass funnel, 2 to 3 feet (60 to go cm.) of
rubber tubing yi to % of an inch (6 to 9 mm.) in diameter, and a
plain rectal tube 20 inches (50 cm.) long. No. 35 French in size (Fig.
610) make a simple and very effective apparatus, and one that can
be easily cleaned. If desired, a hard-rubber syringe with a capacity
of from 4 to 6 ounces (120 to 180 c.c.) (Fig. 611) or a Davidson
syringe attached directly to the rectal tube may be used. In children
a No. 18 to 20 French ordinary rubber catheter is substituted for
the rectal tube.

Asepsis. — The tube should be boiled before using, and it must be
carefully cleaned after each injection. Syringes, if employed, should

Fig. 611. — Colon tube and syringe for administering nutritot enemata. (Ash ton.)

likewise be very thoroughly cleansed with soap and water every time
they are used.

Material Employed for Feeding. — Whatever the form of nourish-
ment used, it must be free from all irritating properties and should
be small in bulk, or it will be immediately expelled. As the lower
bowel secretes no digestive ferments, the substances injected must be
of such a nature that they are readily absorbed, otherwise the enema
acts as a foreign body and proves irritating to the bowel. The
food should always be fluid in character and, as far as is possible,
predigested. As a general thing, starches and fats are to be avoided.
Combinations of pancreatinized meat extracts, peptonized milk, and
egg albumen will be found to be most readily taken up by the bowel.
The addition of a small quantity of salt to each egg aids in its absorp-

NUTRIENT ENEMATA 615

tion. Alcohol in the form of red wine, brandy, or whisky may be
incorporated in the enema when a stimulating effect is desired. A
good stimulating enema consists of brandy oz. ii (60 c.c), ammonium
carbonate gr. xx (1.3 gm.), and beef tea q.s. ad oz. viii (240 c.c). A
pint (500 c.c.) of black coffee alone has also a marked stimulating
effect.

One of the most easily absorbed foods which is not irritating to the
bowel is glucose. It may be used in a lo to 15 per cent, solution

The following formulae (Ashton) will be found very useful. In
continued rectal feeding it is well to use them in rotation.

(i) Beef juice oz. iii (90 c.c), and liquor pancreatis dr. ii (8 c.c).

(2) One raw egg; salt, gr. xv (i gm.); brandy or whisky oz. ss.
(15 c.c); and peptonized milk oz. iii (90 cc).

(3) One egg; liquor pancreatis dr. ii (8 c.c); and beef juice oz.
iii (90 cc).

(4) One raw egg, and peptonized milk oz. iii (90 cc). .

(5) Salt, gr. XV (i gm.); beef juice oz. i (30 cc), and peptonized
milk oz. iii (90 c.c).

(6) Yolk of one raw egg; brandy or whisky dr. vi (24 c.c.) ; liquor
pancreatis dr. ii (8 c.c); and beef- tea oz. iii (90 c.c).

Temperature. — Give the injection at a temperature near that of
the body, about 95° F. (35° C.) — never cold or very hot — as peris-
talsis may be excited and the rectum will probably reject the feeding.

Quantity. — Only a small amount of food should be injected at one
time, usually i to 6 ounces (30 to 180 cc), depending on the retain-
ing capacity of the rectum and whether the patient is a child or an
adult. Large quantities are liable to be expelled by the bowel.

Frequency of Feedings. — This will depend upon the quantity taken
at one time. A patient who can retain as much as 6 ounces (180 c.c.)
need only be fed every six hours. Cases where but small amounts are
retained will require three- to four-hour interval feedings.

Care of the Rectum. — A cleansing enema, consisting of salt dr.
ii (8 gm.) to a quart (1000 c.c) of lukewarm water or, if there is much
mucus present, sodium bicarbonate dr. i (4 gm.) to a quart (iocx5 c.c)
of warm water, is given each morning at least an hour before the first
feeding. This serves to wash out of the bowel any particles of waste
matter or mucus; it furthermore cleanses the mucous. membrane and
prepares it for more thorough absorption by stimulating the
circulation.

Position of the Patient. — In giving any retained enema the patient
should preferably be in the Sims position with the hips elevated or ia

6l6 THE COLON AND RECTUM

the knee-chest position. If it is inexpedient to move the patient, the
dorsal position with hips elevated and knees drawn up will suffice.

Technic. — The tube is well lubricated with sterile vaselin or with
sweet oil to facilitate its passage and to avoid irritating the rectum.
The tube is slowly and gently introduced, according to the direc-
tions already given for the introduction of the enema or enteroclysis
tube (see page 598), well into the bowel for a distance of 10 to 12
inches (25 to 30 cm.), so as to prevent expulsion of the food and fur-
nish an extensive surface for absorption. To avoid injecting air,
the tube and the reservoir of the syringe are filled with the material
to be injected before the tube is inserted into the tectum. The fluid
must be injected very slowly. When the proper amount is intro"
duced, the tube is carefully removed and the patient is instructed to
remain quietly in the recumbent position with the lips elevated for
at least half an hour, to lessen the chances of the food being expelled.
In cases of marked irritability of the rectum, 5 to 10 TTt (0.3 to 0.6
c.c.) of the tincture of opium may be added to the enema.

INJECTIONS OF FLUID OR AIR INTO THE BOWEL IN
INTUSSUSCEPTION

The slow injection of bland fluids or air into the bowel may be
employed for its mechanical effect in overcoming an obstruction due
to intussusception. Success from either method, however, depends
largely upon an early diagnosis of the condition, for disinvagination
becomes more difficult in direct proportion to the length of time which
has elapsed from the onset of the symptoms. After the first twenty
four hours of an attack, attempts at reduction by means of hydrostatic
or gaseous pressure are not justifiable, as tight adhesions, which render
reduction impossible, or strangulation and partial necrosis of the gut
with the added danger of rupture may be present. The greatest
objection to this method of treatment lies in the fact that in many
cases it is impossible to tell immediately whether the invagination has
been reduced, and the success of the procedure can only be deter-
mined by allowing the patient to come out of the anesthetic and
carefully observing the symptoms.

Not more than fifteen minutes to a half hour should be consumed
in attempts at relief by these nonoperative measures. In all cases
preparations for operation should be made beforehand so that, should
reduction fail, an immediate laparotomy can be performed. Treat-
ment by injections is,' of course, only applicable when the intussus-

INJECTIONS OF FLUID OR AIR INTO THE BOWEL 617

ception occurs in the large bowel, on account of the obstruction by the
ileo-cecal valve to the passage of fluid or gas into the small intestine.

Treatment by Injection of Fluid. — Apparatus. — A fountain
syringe or a graduated glass irrigating jar as a reservoir and a rectal
nozzle or a large catheter, attached to the reservoir by 6 feet (180 cm.)
of rubber tubing y^i to % inch (6 to 9 mm.) in diameter, should be
provided.

Solutions Employed. — Normal salt solution — salt dr. i (4 gm.)
to a pint (500 c.c.) of water — thin gruel or milk and water may
be used.

Temperature. — As the relaxing effect of heat is desirable, the
solution should be at a temperature of about 105° F. (41° C.) as it
enters the bowel.

Quantity. — The capacity of the colon varies from 10 ounces
(300 c.c.) in a child of five months to a pint (500 c.c.) or more in a
child a year old. Not more than i^i pints (750 c.c.) of solution
should be injected into the bowel of a child under one year. In an
adult, the rectum and colon hold as much as 9 pints (4.5 liters) with-
out undue distention.

Rate of Flow. — The fluid should enter the bowel in a gradual,
steady, continuous flow. From ten to fifteen minutes are consumed
in injecting the given quantity of solution.

Amount of Pressure.^ — Starting with the reservoir elevated about
3 feet (90 cm.), which gives a pressure of less than 2 pounds, the
height may be slowly increased to 4 or 5 feet (120 or 150 cm.) if neces-
sary. A greater pressure than obtained at the latter elevation is not
advisable for fear of rupturing the bowel. This danger should be
constantly borne in mind.

Position of the Patient.— The patient should be in the dorsal posi-
tion, with the hips elevated.

Anesthesia. — Anesthesia with ether to the full surgical extent to
produce muscular relaxation is necessary.

Technic. — The nozzle or catheter is well lubricated with oil or
vaselin, and any air is expelled from the tube. The nozzle is then
inserted into the rectum for several inches, and the reservoir is ele-
vated about 3 feet (90 cm.) and the solution is allowed to flow slowly
into the bowel. Escape of the fluid along the side of the tube is
prevented by tightly packed cotton about the anus and pressing the
buttocks firmly together. While the solution is flowing, the abdomen
may be very gently kneaded or the child may be inverted several times.
Diminution of the pressure necessary to inject the fluid indicates that

6l8 THE COLON AND RECTUM

disinvagination or else a rupture of the bowel has occurred, and the
injection should be immediately stopped.

After a thorough trial by injection, if in doubt as to the result, the
solution is allowed to escape and the patient is examined. If there
were present at the outset a distinct tumor, the success of the proce-
dure will be denoted by its disappearance. A tumor still present and
retaining its full size will, of course, signify a failure, and an immediate
laparotomy should be performed while the patient is still under the
anesthetic.

Treatment by Inflation with Air. — In employing air to distend
the bowel the pressure cannot be so well regulated as with fluid, and,
.furthermore, the weight of the column of water, which in some cases
seems to be an important factor, is lacking.

Apparatus. — A rectal tube or a catheter of appropriate size and an
ordinary bellows or a Davidson syringe will be required. In order to
permit the escape of air the moment it is desired, a T-tube of glass
may be inserted between the rectal tube and the inflation apparatus.
One limb of the T-tube is inserted into the rectal tube, the other into
the tube leading from the inflator, while to the third limb a short
piece of rubber tubing is attached which can be opened or shut by a
clip.

Gases Used. — Ordinary air, oxygen, or carbonic acid gas may be
employed.

Pressure. — The air should be injected very slowly. The best
guide as to the amount to be introduced and the pressure is the dis-
tention produced along the colon and in the abdomen.

Anesthesia. — A general anesthetic should be employed to insure
extreme relaxation.

Technic. — The tube or catheter is introduced well into the rectum
and the inflating apparatus is connected. The air is very gently and
slowly pumped in, while an assistant compresses the buttocks to pre-
vent its escape. Gentle abdominal massage or inversion of the
patient may be tried while the inflation is progressing. Reduction
may be indicated by rumbling sounds or a gush of liquid fecal matter

DILATATION OF RECTAL STRICTURES BY THE BOUGIE

The surgical treatment of rectal strictures consists of: (i) Gradual
dilatation; (2) proctotomy; (3) excision; (4) entero-anastomosis;
and (5) colostomy. Treatment by dilatation, though not often cura-
tive, is a most valuable palliative measure. By means of gradual

DILATATION OF RECTAL STRICTURES BY THE BOUGIE 619

dilatation, the lumen of a stricture may be so much increased in size
that the patient is relieved of his obstructive symptons and may be
kept comfortable for years, provided the dilatation be maintained by
the occasional passage of a bougie.

Exact information as to the site, caliber, length, and thickness of
the constriction should be previously obtained by means of a digital
examination, if within 4 inches (10 cm.) of the anus, or if seated
higher up, by the use of the proctoscope and bougie, as already
described, before any attempt at dilatation is made. The majority of
strictures are situated within, 3 inches (7.5 cm.) of the anus, though
they may be located at any point higher up, or within the anus itself.
The stricture may consist of a ring-like constriction, or a narrowing of
the canal for a distance of i inch (2.5 cm.) or more, or it may be tor-
tuous in shape. The bowel above the stricture is often markedly
dilated and the rectal walls may be so thinned that rupture of the gut
readily occurs upon the use of slight force. At the seat of stricture the
mucous membrane is often ulcerated or replaced by dense scar tissue.

Instruments. — The instrument employed for dilatation should be
a soft-rubber bougie with a conical tip, such as the Wales instrument

Fig. 612. — Wales' bougies.

(Fig. 612). Metal dilators and those of rigid material should be
avoided as dangerous.

Asepsis. — The bougies are to be sterilized before using, and the
bowels should be well cleaned out, the rectum being irrigated with
normal salt solution both before and after each treatment.

Rapidity of Dilatation. — The stricture should be stretched gradu-
ally. Dilatation ought not to be performed rapidly or by divulsion.
Such methods are extremely dangerous, as, apart from the shock, on
account of the laceration of the tissues there is great risk of hemor-
rhage and septic infection.

Frequency. — This depends upon the amount of tenderness and
irritation as the result of the manipulations. If the bougies are
passed at too frequent intervals, irritation and inflammation are

620

THE COLON AND RECTUM

produced which induce the very condition it is intended to correct.
As a rule, the stretching should not take place oftener than every
other day. In some cases, the lapse of two or three days between

Fig. 613. — Method of inserting a bougie into a stricture through a proctoscope.

Fig. 614. — Showing a bougie passed through a stricture.

each treatment is necessary, for the bougie ought not to be reintro-
duced until all signs of the discomfort it has produced have entirely
passed off. Later, when full dilatation has been reached, an interval

COLONIC MASSAGE 621,

up to a month may elapse between each treatment, if it is found that
there is no tendency for the contraction to recur in the interval.

Position of the Patient. — The patient is to be in the Sims position,
with the knee well drawn up, or in the knee-chest position if a procto-
scope is to be used.

Technic. — The bougie is well lubricated and, guided by the right
index-finger, is made to enter the orifice of the constriction; or,
better still, it is inserted accurately into the stricture under the guid-
ance of the eye through a proctoscope introduced to the seat of
stricture (Fig. 613), as recommended by Tuttle. The advantages of
this method are obvious. The greatest gentleness must be observed
in inserting the bougies, and under no circumstances should the
tissues be lacerated. The first instrument should be of such a size
that it enters the stricture with ease. The next one, a size larger, is
left in place for a few moments, and then a third instrument is
inserted if it can be done without pain to the patient. The procto-
scope is then withdrawn and the bougie is left in situ ten to fifteen
minutes.

Following the treatment, an irrigation of hot normal salt solu-
tion is given, and the patient is kept quiet for a quarter to a half-hour.
At the subsequent sittings, it is well to commence with an instrument
a size smaller than the largest one used at the previous sitting. An
increase in the dilatation is attempted at each sitting.

COLONIC MASSAGE

Abdominal massage is indicated for the relief of chronic consti-
pation and its accompanying symptoms the result of atony of the
intestines, in which class of cases, if properly carried out, it is a most
valuable therapeutic measure, tending to strengthen the muscles of
the abdomen and bowel and the tone of the nervous system, as well
as to stimulate the secretory function of the colon and to increase the
peristaltic action. To be of value, however, it should be performed
by one trained for such work. Massage is contraindicated during
menstruation and in pregnancy, and, of course, in the presence of such
pathological conditions as gastric or intestinal ulcers, intestinal
obstruction, appendicitis, hemorrhage from the bowel, inflammation
of the peritoneum, etc.

Time for Massage. — The best time for massage is early in the
morning before breakfast. In cases where this is not possible, care
should be observed that it is not given until at least one hour has
elapsed since the last meal.

622

THE COLON AND RECTUM

Fig. 615. — Deep pressure colonic massage. (Bandler.)

Fig. 616. — Showing the method of kneading the colon. (Bandler.)

AUTO-MASSAGE 623

Duration. — Each treatment should consume from five to fifteen
minutes. The treatments should be persisted in until the regularity
of the stools is re-established, to effect which may require several
weeks or months.

Frequency. — Treatments should be given daily.

Preparations. — The bladder and, if possible, the rectum should be
empty.

Position of the Patient. — The patient lies in the dorsal position
with the shoulders and knees slightly elevated, so as to secure as
much relaxation as possible.

Technic. — The masseur stands upon the patient's left side and
begins his manipulations by making light circular movements (effieur-
age) , starting at the cecum and following the course of the ascending,
transverse, and descending colon. The small intestine and the rest
of the abdomen are similarly manipulated. Then deep pressure and
kneading movements (petrissage) are substituted. In these move-
ments the whole colon is manipulated in the first instance by per-
forming zigzag movements while making deep pressure with one
hand superimposed upon the other (Fig. 615), and, in the second
instance, by raising up deep handgrasps of the abdominal muscles
and the intestines and kneading them by alternately compressing
and relaxing the fingers (Fig, 616). In performing these deeper man-
ipulations one will be governed as to the amount of force that may be
employed by the sensitiveness of the patient. Care should be taken
that the manipulations be not too vigorous, lest some injury to the
viscera result.

AUTO-MASSAGE

Massage may be very effectually carried out by the patient him-
self by rolling a ball over the abdomen, beignning at the cecum and

Fig. 617. — Cannon ball for auto-massage of the abdomen.

following the course of the colon up the right side, then across the
abdomen, and down the left side in the direction of the descending

624

THE COLON AND RECTUM

colon. A cannon ball or a wooden ball filled with shot weighing 3 to
5 pounds (1.4 to 2.2 K.), covered with chamois or flannel (Fig. 617),
may be used for this purpose.

THE APPLICATION OF ELECTRICITY TO THE RECTUM AND

COLON

Electricity is of value in conjunction with the abdominal mas-
sage in all form of constipation, but especially so in the atonic va-
riety. Under the stimulating action of the electric current, the
nerves, muscles, and glandular structures connected with the bowel
are favorably influenced, so that the peristaltic action and the secre-
tion of mucus are increased, at the same time, the contracting power
of the voluntary muscles of the abdomen is strengthened.

Fig. 618. — ^Large flat sponge electrode.

Both the faradic and the galvanic currents are employed, the
former being generally preferred for atonic constipation and intesti-
nal paresis and the galvanic for spastic constipation and painful
neuroses. They may be applied percutaneously or internally.

Apparatus. — For the percutaneous applications a large flat
sponge electrode (Fig. 618) and a small sponge electrode (Fig. 619)
will be required. When it is desired to make internal applications,
a special irrigating rectal electrode, such as Boas' (Fig. 620) or
Kemp's, and a flat abdominal sponge will be required.

APPLICATION OF ELECTRICITY TO THE RECTUM AND COLON 625

Strength of Current. — As there is no means of estimating the
strength of the faradic current, the sensations of the patient should
be the guide, the current being strong enough to cause muscular con-
tractions but no pain. For galvanism, from lo to 15 ma. of current
are ordinarily required.

Duration of Application. — Each treatment should consume from
ten to fifteen minutes.

Frequency. — At first applications are made daily, then every
other day, and, as the conditions improve, once or twice a week.

Fig. 619. — Small sponge electrode.
(Bandler.)

Fig. 620. — Boas' rectal electrode.
(Bandler.)

Time of Application. — Treatments are given with best results at
night, just before the patient retires.

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 positive pole is at-
tached to a large flat electrode, and the latter, well moistened, is
placed over the spinal column. The negative electrode is then

626 THE COLON AND RECTUM

applied to the abdomen for a few minutes at a time, first over the
cecum, then along the course of the transverse colon, and fmally
along the descending colon. This is supplemented by circular
motions with the negative electrode over the same regions. Finally,
the entire abdomen is similarly treated.

2. Rectal Application. — An irrgating electrode attached to the
negative pole of the battery is inserted in the rectum and the positive
electrode is placed over the spine or abdomen. When the current is
turned on, saline solution is allowed to flow slowly through the rectal
electrode, carrying the current to all portions of the colon.

CHAPTER XX
THE URETHRA AND PROSTATE

Anatomic Considerations

The Male Urethra. — The urethra is a closed canal, composed of
erectile and muscular tissue, and lined by. mucous membrane, extend-
ing from the bladder to the external urinary meatus. Its entire
length is from 6M to 9 inches (16 to 23 cm.), depending upon the

Fig. 621. — Section of penis, bladder, etc. (Testut.) i, Symphysis pubis; 2, pre-
vesical space; 3, abdominal wall; 4, bladder; 5, urachus; 6, seminal vesicle and vas
deferens; 7, prostate; 8, plexus of Santorini; 9, sphincter vesicae; 10, suspensory ligament
of penis; 11, penis in flaccid condition; 12, penis in state of erection; 13, glans penis;
14, bulb of urethra; 15, cul-de-sac of bulb, a, Prostatic urethra; b, membranous
urethra; c, spongy urethra.

length of the penis. For purposes of description it is divided into
the following portions, corresponding to the parts through which it
passes: (i) The spongy portion, or pars cavernosa, (2) the membran-
ous portion, or pars membranosa, and (3) the prostatic portion, or

627

628 THE URETHRA AND PROSTATE

pars prostatica (Fig. 621). Clinically and for all practical purposes,
however, it may be divided into the anterior urethra, that portion
lying in front of the anterior layer of the triangular ligament; and
the posterior urethra, the portion lying behind the anterior layer of
the triangular ligament.

The Spongy Urethra. — It extends the entire length of the corpus
spongiosum opening externally upon the glans penis as a vertical slit,
the meatus. The spongy urethra measures on the average about 6
inches (15 cm.). The lumen of this portion of the urethra is not of
the same size throughout, but presents two fusiform dilatations, one
at the bulb, the bulbous urethra, and the other within the glans, the
fossa navicularis.

The mucous membrane is pale pink in color and has opening upon
its surface a number of glands and crypts. In the floor of the bulbous
portion the ducts of Cowper's glands open side by side. Scattered all

Fig. 622. — The interior of the urethra, i, Meatus; 2, fossa navicularis; 3, urethral
glands; 4, orifices of Cowper's glands; 5, Copwer's glands; 6, ejaculatory ducts; 7 sinus
pocularis; 8, verumontanum.

through the mucous membrane of the urethra are the urethral glands
or glands of Littre. Upon the roof, the mucous membrane is studded
with small crypts or diverticula, the lacunae. The orifices of these
lacunae open toward the meatus forming little pockets into which
instruments may find their way and be arrested in their passage.
One of these, the lacuna magna, is especially liable to interfere with
the passage of instruments. It lies in the roof of the fossa navicularis
about I inch (2.5 cm.) from the meatus. These mucous glands and
lacunae are liable to infection and may become the seat of small gonor-
rheal abscesses.

The Membranous Urethra. — It is that portion of the urethra
lying between the two layers of the triangular ligament, and extends
from the apex of the prostate gland to the bulb of the spongy portion.
It measures about 3^^ inch (i cm.) in length. The membranous ure-
thra is the most fixed, as well as the least distensible of all segments of
the urethra. In its course it pierces both layers of the triangular liga-

ANATOMIC CONSIDERATIONS 629

ment and receives prolongations from these structures, and is also
surrounded by the compressor urethrae muscle. Spasm of this muscle
is a frequent hindrance to catheterization and the passage of sounds.
Embedded in the fibers of the compressor urethrae and on either side
of the membranous urethra lie the glands of Cowper, the ducts from
which open in the anterior portion of the bulbous urethra.

The mucous membrane lining this portion of the canal is darker
in color and much more sensitive than that in the spongy portion.

Prostatic Urethra. — It measures ^ to ij^ inches (2 to 3 cm.)
in length and extends from the internal urethral orifice to the poste-
rior layer of the triangular ligament, traversing the prostate gland
from base to apex. In the presence of hypertrophy of the prostate,
the caliber of this portion of the canal may become obstructed or
deformed.

The floor of the prostatic urethra is encroached upon by a fusiform
swelling, the verumontanum or caput gallinaginis. At the front and
most prominent part of the verumontanum is seen the slit-like open-
ing of the sinus pocularis, a blind pouch or diverticulum, usually J^ to
}i inch (6 to 8 mm.) in length, which runs up in the substance of the
prostate beneath the middle lobe. It is regarded as homologous with
the uterus in the female. Within the sinus pocularis or upon its
margins are the slit-like openings of the ejaculatory ducts. On each
side of the verumontanum is a depression, the prostatic sinus into
which the openings of the prostatic ducts empty.

The Caliber of the Urethra.. — The caliber of the urethra varies
greatly. While the average diameter is 0.3 inch (7.5 mm.) or 27
French scale, the individual urethra is not of the same uniform cali-
ber from end to end, there being a number of constricted and dilated
portions. The wide parts are: (i) The pars prostatica, (2) the bulb-
ous urethra, and (3) the fossa navicularis. The narrow portions
are: (i) The meatus, (2) the penoscrotal junction, (3) the membran-
ous urethra, and (4) the internal prostatic opening Of these the
meatus is the narrowest, and in a normal individual an instrument
that wiU pass the meatus should pass the other narrow points.

Normally, the walls of the urethra are in contact and on cross
section the canal appears as a mere slit. In the prostatic portion,
from the projection of the verumontanum, it has the appearance of a
half moon, in the membranous portion it is star-shaped; in the cav-
ernous portion, it appears as a transverse slit; in the glans, as a verti-
cal slit.

630

THE URETHRA AND PROSTATE

Curves of the Urethra. — The anterior urethra is freely movable
and may be made to assume any curve. The posterior urethra is
fixed, however, between the suspensory ligament of the penis and the
internal vesical opening, and its natural curves are important to bear
in mind in the passage of instruments. In the prostatic portion the
direction of the urethra is downward; in the membranous, downward
and forward; and in the spongy portion, forward and slightly upward
for 2 inches (5 cm.), and then sharply downward. Thus two curves
are formed: (i) concave forward, and (2) concave downward. The
latter may be straightened or obliterated by lifting up the penis, but
the first is fixed and can only be straightened by using some force. In
children and in thin individuals, the fixed curve is much sharper,
while in large, stout men it becomes flattened. A distended bladder
or an enlarged prostate lengthens it.

Fig. 623. — The prostate gland and seminal vesicles.

The Prostate Gland. — The prostate is a sexual organ composed
of glandular, muscular, and fibrous tissue, lying in front of the neck of
the bladder. It is pierced above by the urethra and below by the
ejaculatory ducts. In shape it resembles an irregular truncated cone,
the apex of which rests against the posterior layer of the triangular
ligament while the base is directed toward the bladder. In size it
measures about iH inches (4 cm.) transversely, i^i inches (3 cm.)
vertically, and % inch (2 cm.) longitudinally. It weighs 4 to 6
drams (16 to 24 gm.). The size of the prostate is not constant, how-

DIAGNOSTIC METHODS 63 1

ever, varying greatly in different individuals and depending upon the
age of the patient. In a child, the gland is only rudimentary, not
reaching the full size until about the twenty-fifth year. During the
later years of life, it often becomes hypertrophied, not infrequently
enlarging to over twice its original size.

The prostate consists of two lateral lobes which bulge posteriorly
and a so-called middle lobe. The latter is that portion of the gland
which lies between the two ejaculatory ducts directly posterior to the
beginning of the urethra. If enlarged, as occurs when the gland is the
seat of senile hypertrophy, the median lobe forms a projection which
may cause urinary obstruction and interfere with the passage of
instruments. The two lateral lobes meet and become continuous in
front and behind the urethra. The tissue forming this union in front
is spoken of as the anterior commissure and the portion behind as the
posterior commissure or isthmus (pars intermedia).

The Female Urethra. — ^It extends from the neck of the bladder
to the external urinary meatus, curving downward and a little for-
ward. The female urethra measures iji to i3-^ inches (3 to 4 cm.) in
length and-3':i inch (6 mm.) in diameter, but, as it is not surrounded
by resisting structures, it is possible to so dilate it as to admit the
finger. It lies in front of, and is very closely associated with, the
anterior wall of the vagina through which it may be readily palpated.

Its walls, composed of muscular, erectile, and mucous tissue, are
normally in contact, presenting a stellate appearance on cross section.
The mucous membrane is pale in color and is thrown into a series of
longitudinal folds, one of which, on the upper half of the posterior
wall, is quite marked and corresponds to the verumontanum in the
male. The compressor urethrse muscle surrounds .it, between the
layers of the triangular ligament.

Close to the posterior margin of the external urethral orifice on
either side of the mid-line are the tubes of Skene. As in the male, the
external meatus is the narrowest portion. It appears as a vertical
slit, 3<5 to 34 inch (5 to 6 mm.) in length, about i inch (2.5 cm.)
posterior to the base of the clitoris.

Diagnostic Methods

In the examination of the urethra some definite system should be
followed. The first step consists in taking a careful history of the
case. This should embrace the family history, a history of past ail-
ments, and the patient's description of the present trouble, its onset,

632 THE URETHRA AND PROSTATE

duration, etc. While in some cases of urethral disease exhaustive
questioning of the patient is superfluous, it will be found that an exact
history will often be of the greatest aid in arriving at a correct
diagnosis.

The examiner should then take up more in detail the symptoms
complained of by the patient. It should be ascertained whether the
patient has or has had a urethral discharge, and, if so, its character ;
whether it is sufficient to stain or stiffen the linen, or whether it sim-
ply glues the lips of the meatus together ; whether it occurs only with
the first urine passed, or in the intervals as well; whether there is any
discharge with defecation ; also whether defecation is accompanied by
pain about the prostate or rectum. It is important to inquire into
the act of urination, ascertaining whether the passage of urine causes
any pain, and, if so, its character, and whether the pain is present at
the beginning or end of the act; also whether there is an increased fre-
quency in urination. The patient should be questioned as to the
character of the stream of urine, its force and caliber; whether there is
any dribbling; whether the stream is interrupted or suddenly stopped,
such as would be the case with enlargement of the prostate or in the
presence of a vesical calculus. The character of the urine passed
should also be inquired into; whether the presence of blood has been
noted, and whether shreds are present, and their character. More
exact information upon these latter points, however, will be obtained
after a complete examination of the urine.

Having questioned the patient along the lines above indicated,
secretions and discharges, if present, should be collected for examina-
tion (see pages 283, 295), and then the actual examination of the
urethra and prostate may be taken up. The methods available for
this include: (i) glass tests and injection tests for the purpose of lo-
cating the seat of the discharge, (2) inspection, (3) palpation, and (4)
instrumental examination. The use of instruments, however , should
not he undertaken if there is an active discharge from the urethra for
fear of aggravating the inflammation and producing such complica-
tions as abscess, stricture, etc. It is far better to postpone such ex-
ploration until the severity of the inflammation and the discharge
have been reduced by the use of injections or irrigations.

GLASS TESTS

A number of tests have been employed for the purpose of deter-
mining whether the seat of the pus has its origin in the anterior or

GLASS TESTS 633

posterior urethra. The simplest of these are known as the two-glass
test and the five-glass test.

The Two=»glass Test. — It is performed as follows : The patient is
instructed to hold his urine for three or four hours, and upon present-
ing himself for examination he is told to urinate into two glasses or
graduates. He should pass about 2 ounces (60 c.c.) into the first
glass and the remainder into the second. If the contents of the first
glass, in which are collected the washings from both the anterior and
posterior urethra, contains pus or shreds revealed by holding the glass
before a strong light and the contents of the second glass is clear, it
may be inferred that the anterior urethra is involved, but the pos-
terior urethra, if at all, only slightly so. If, on the other hand, the-
contents of both glasses are cloudy or contains shreds, it shows that
there is sufiicient secretion from the posterior urethra to have escaped
into the bladder and discolored its contents, or that the secretion come
from the bladder itself, the ureters, or kidneys. In the former case,
the contents of the first glass is more turbid than that in the second
glass; while in the latter conditions there is but little difference
between the two specimens.

Another method and one that is more certain in differentiating
between an anterior and posterior urethritis, consists in first thor-
oughly irrigating the anterior urethra with a warm boric acid or
normal salt solution by means of a catheter introduced as far as the
bulb, and then having the patient urinate into two glasses. If the
contents of both glasses are clear, we may be sure the posterior ure-
thra is free. Pus or shreds appearing in the second glass indicate a
posterior urethritis, or that they come from the bladder or beyond.

The Wolbarst Five=glass Test. — This is more reliable than the
the two-glass test in determining the source of shreds or pus. The
technic is as follows: The patient presents himself with a full bladder,
having held his urine for 4 or 5 hours. The meatus is thoroughly
washed off to remove any adherent secretion, and the anterior ure-
thra is irrigated by means of a hand syringe with sterile water.
These washings are collected in the first glass and represent the con-
tents of the anterior urethra. Further irrigation of the anterior
urethra is performed until it is certain that the urethra is clean as far
back as the cut-off muscle, and these washings are collected in glass
two, or the control anterior urethral glass. A soft sterile catheter is
next introduced into the bladder and a sample of its contents is
drawn off into a third glass. This represents the bladder urine. If
this specimen proves to be clear and free from shreds, the catheter is

634 THE URETHRA AND PROSTATE

removed and the patient is instructed to void an ounce or two (30 to
60 c.c.) of urine into a fourth glass. This glass represents the con-
tents of the posterior urethra and, if it contains shreds or pus, it is
evident they originate in the posterior urethra as the anterior urethra
and bladder are clean. If it should be found, however, that the con-
tents of the second glass is not clear, that is, if the bladder urine is
cloudy, the catheter is left in place and the bladder is emptied and is
then washed out with sterile water, allowing from 4 to 6 ounces (120
to 180 c.c.) of clear solution to remain. The catheter is then removed
and the test is carried out as before for the fourth glass. The pros-
tate is' next thoroughly massaged and the patient then voids the
Xirine or solution containing pus expressed from the prostate and
seminal vesicles into a fifth glass. If desired, the right and left
seminal vesicles may be massaged and their contents collected in
similar manner in a sixth and seventh glass as is done in the sevm
glass test of Pedersen.

INJECTION TEST

For the purpose of differentiating between an anterior and a pos-
terior urethritis, the anterior urethra may be injected with a solution
that will color the shreds in that portion of the canal. A i per cent,
solution of methylene blue is employed. By means of a blunt-
pointed urethral syringe the anterior urethra is filled with the methy-
lene blue and the patient is instructed to hold the solution in the ure-
thra for about a minute. The solution is then allowed to escape.
If upon urination the shreds appear blue, they come from the ante-
rior urethra; unstained shreds from the posterior urethra. A micro-
scopical examination may be necessary, however, to determine
whether the shreds remain unstained. In making this test it is
essential that the patient should not have urinated for some time
previously.

INSPECTION

In the Male. — In the male, inspection of the urethra without
the aid of instruments is hmited to the meatus and the exterior of the
canal as far as the peno-scrotal junction. Swelling, signs of inflam-
mation, new growths, etc., which present externally may thus be
recognized. While comparatively limited in scope, inspection should
never be neglected, but should form part of the routine examination.

Position of Patient. — The patient may stand or lie flat upon a
table.

INSPECTION

635

Technic. — The penis is elevated so as to bring its under surface to
view and any abnormalities are noted. The presence or absence of a
discharge should also be determined. By stripping the urethra from
the scrotum forward by means of the index-finger applied externally,
the presence of any discharge may be demonstrated. If present,
some should be deposited upon a slide, and later should be stained and
examined for gonococci.

In the Female. — In the female, the mouth and the vaginal sur-
face of the canal in its entire course may be inspected.

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

Technic. — The operator, sitting in front, separates the labia and
notes the condition of the meatus and searches for signs of inflamma-

FiG. 624. — Method of stripping a dis-
charge from the urethra. (Ashton.)

Fig. 625. — Method of inspecting
urethral orifice in the female.
(Ashton.)

the

tion, the presence of new growths, eversion of the mucous membrane,
discharges, etc. The presence of the latter may be more readily dem-
onstrated by stripping the canal from the bladder forward by means
of a finger passed into the vagina (Fig. 624). The mouth of the ure-
thra may be exposed by drawing the lips apart by means of the
fingers, one placed on each side as shown in Fig. 625. In this manner
the orifices of Skene's glands may be exposed. Finally, the index-
finger or a speculum is passed into the vagina and its posterior wall is
depressed, so that the whole extent of the vaginal surface of the ure-
thra is exposed. In this manner tumors, dilatations, cysts, saccula-
tions, etc., will be noted.

63^

THE URETHRA AND PROSTATE

PALPATION

In the Male. — ^Like inspection, palpation of the urethra is of
limited value, especially in the male. By it, however, changes in the
consistency, sensitiveness, and form of the canal may be recognized.

Fig. 626. — External palpation of the urethra.

Position of Patient. — The urethra may be palpated with the
patient standing or in the dorsal position. To palpate the prostate

Fig. 627. — Showing the method of palpating the prostate gland.

the patient should be placed in the knee-chest position, or should
bend over with the hands resting upon a chair and the thighs separated.

PALPATION

637

Technic. — In palpating the urethra the penis should be grasped
just behind the glans between the thumb and the forefinger of the left
hand, and, while putting the organ on the stretch, the penile portion
of the urethra is palpated between the thumb and the forefinger of the
right hand (Fg 626). It should be noted whether the urethra is
elastic, as it normally is, or whether it is hard, indurated, or nodular.
An inflamed urethra will be painful to the touch and will feel tense
and swollen. A urethral abscess appears as a painful swelling bulg-
ing the wall of the canal. A cancerous growth will be hard, nodular,
and adherent. By inserting a sound and then palpating the urethra

Fig. 628. — Combined rectal and instrumental examination of the prostate gland.

upon it more valuable information may be obtained, as changes in the
consistency of the canal will be accentuated.

To palpate the membranous urethra and prostate a rectal exami-
nation will be necessary. For this the bladder should preferably
contain a little urine. The operator, standing upon the patient's left,
inserts his right forefinger, protected by a finger cot and well lubri-
cated, into the bowel (see Palpation of the Rectum, page 579).
After passing the sphincter, the examining finger comes in contact
with the membranous urethra for a space of M inch (i cm.), and then
the prostate gland is reached. Normally, the latter is not very dis-
tinctly felt, but in the presence of hypertrophy it readily is, and some-
times it is so enlarged that it may be palpated bimanuaUy. Points
of tenderness, softening, painful swellings-, or a general enlargement

638 THE URETHRA AND PROSTATE

should be looked for and any difference between the two lobes, should
be noted. The condition of the seminal vesicles should likewise be
investigated. They lie above each lobe of the prostate extending
upward and outward, but are not palpable, unless enlarged or
thickened by disease.

If desired, the seminal vesicles and prostate may at this time be
massaged for the purpose of obtaining their secretions for examina-
tion. This is done by carrying the finger up over each seminal ves-
icle in turn and, while making firm pressure, carrying the finger
downward over the lobe of the prostate toward its base. The massage
will force the discharge into the urethra and it may then be collected
upon a clean slide by stripping the urethra from behind forward.

At times a combined examination with the finger in the rectum
and an instrument in the urethra will be of assistance in exploring the
prostate. A bladder sound or other metallic instrument is intro-
duced into the bladder, and, by engaging the prostate between it and
the examining finger (Fig. 628), the extent of hypertrophy as well as
the amount of induration may be ascertained.

In the Female. — In the female, the entire canal may be ex-
plored by palpation through the vagina and valuable information
is thus often obtained

Position of Patient. — The patient is placed in the dorsal position.

Technic. — The examiner, sitting in front, separates the labia with
the fingers of his left hand, while he palpates with his right index-
finger. The meatus is first examined by pressing with the examining
finger, placed just outside the vaginal outlet, up against the symphysis.
Then by means of the index-finger in the vagina the whole length of
the urethra may be explored by tracing the course of the canal back as
far as the bladder. By rolling the urethra with the index-finger from
side to side and exerting pressure upward upon the canal with the
inferior and posterior surfaces of the symphysis as points of counter-
pressure, changes as to sensitiveness, consistency, or form of the canal
may be readily recognized.

EXAMINATION BY SOUNDS AND BOUGIES

Having obtained all the informaton possible by the means al-
ready detailed, an instrumental exploration of the urethra, provided
the latter is not the seat of an acute inflammation, for the purpose of
determining the presence or absence of strictures is the next step.
While such symptoms as a gleety discharge, dribbhng at the end of

EXAMINATION BY SOUNDS AND BOUGIES

639

urination, malformation in the shape of the stream, difficulty in start-
ing the stream, retention of urine, etc., may point strongly to the
presence of a stricture, they are by no means infallible, and it is only
by a careful local examination of the urethra that the diagnosis of

Fig. 629. — Blunt steel sound.

stricture can be absolutely made. For the purpose of simply locating
a stricture and determining its size, sounds and bougies are employed,
while for determining the length of the contracture the bulbous
bougie or bougie a boule is necessary.

Fig. 630. — Flexible urethral bougie.

In inserting an instrument into the urethra, the utmost gentleness
is required. The instrument should be passed slowly so that, if an
obstruction is suddenly encountered, there will be no danger of pro-
ducing injury to the canal; even the slightest force should always he

Fig. 631*. — Filiform bougies.

avoided. It is only by cultivating a delicate touch and keeping in
mind the anatomical variations in the urethra that painless manipu-
lation of urethral instruments is possible. In making such an exam-

FiG. 632. — Female sound. (Ashton.)

ination it should be remembered that the passage of an instrument
for the first time may result in a severe chill, and a rise of tempera-
ture. To prevent this, it is well to terminate the examination with an

640

THE URETHRA AND PROSTATE

instillation of i to 1500 nitrate of silver to lessen the urethral conges-
tion. After one exploration the urethra should be given a rest for a
few days, as not infrequently the irritation produced aggravates a
chronic urethral discharge.

Instruments. — Blunt steel sounds of the proper curve (Fig. 629)
are preferable for the exploration of strictures of large caliber. There
is considerable risk of injuring the urethra when
a rigid steel instrument of a size smaller than 15
French is used, and it is safer for those not especi-
ally skilled in the manipulation of urethral in-
struments to employ woven-silk olivary bougies
(Fig. 630) in examining small strictures. A set
of these instruments from the smallest size made
up to No. 20 French should, therefore, be at
hand. The best are made in France. For finding
the channel through very tight strictures whale-
bone filiform bougies (Fig. 631) are necessary.
They are provided with small bulbous points from
which they taper for an inch (2.5 cm.) or so until
the full size of the shaft is reached. To facilitate
the entrance of these instruments into tortuous
canals the tips may be softened in hot water and
then bent into various shapes, as curves, spirals,
angles, etc. For diagnostic purposes the filiforms
should be about 12 inches long (30 cm.). For ex-
ploring the female urethra a slightly curved steel
sound is employed (Fig. 632).

Asepsis. — Metal instruments are boiled for
five minutes in a i per cent, soda solution. The
best makes of the silk-elastic instruments may
also be boiled, but some of the others will not last
long if so treated, and it is safer to sterilize them
in formalin vapor for twenty-four hours and then
rinse well in sterile water before using. A special apparatus (Fig.
633) is required for this, however. It consists of a glass cylinder
about 16 inches (40 cm.) long with a perforated plate near the top
for holding the catheters and in the base a receptacle for formalin
table-ts. In its absence the instrument may be soaked in a i to 20
carbolic acid solution followed by immersion in a saturated boric
acid solution and rinsing in sterile water. Whale-bone bougies may

Fig. 633. — For-
malin sterilizer for
urethral instru-
ments.

a, Top; b, rack
for catheters; c, con-
tainer for formalin.

EXAMINATION BY SOUNDS AND BOUGIES

641

be boiled, though they will not stand prolonged boiling. The ex-
aminer's hands should be as carefully cleansed as for any operation. '

The glans penis should be first washed with soap and water, then
with a I to 5000 bichlorid solution followed by sterile water. The
urethra is irrigated with a warm saturated solution of boric acid or
with a I to 5000 solution of potassium permanganate both before
and after the examination.

Position of the Patient. — The patient should lie in the dorsal
position with his shoulders slightly raised and thighs flexed and
rotated somewhat outward, and near that side of the table upon
which the operator stands. The operator takes his place just above
the patient's hips, facing the patient's body, upon whichever side
of the table is most convenient for him — generally the left side is
chosen.

Technic. — In beginning the examination the largest instrument
that will pass the meatus should be introduced. As the meatus is the

Fig. 634. — First step in inserting a urethral sound.

narrowest portion of the urethra, any instrument that can be intro-
duced through it will pass along the entire canal, unless some con-
traction is present. Should the meatus be abnormally small, it may
be enlarged by an incision (see page 679). The operator grasps the
penis behind the corona between the ring and the middle fingers of the
left hand and with the thumb and index-fingers of the same hand he
retracts the foreskin and separates the lips of the meatus. The sound,
warmed and well lubricated with one of the Irish-moss preparations,
is grasped lightly between the fingers of the right hand, and is gently
introduced into the meatus. As the point of the instrument is in-

642

THE URETHRA AND PROSTATE

serted in the meatus the handle should lie parallel to the abdominal
wall and in line with the fold of the groin (Fig. 634). From this posi-
tion the handle is gradually swept to the center line (Fig. 635), and the

Fig. 635. — Second step in inserting a urethral sound.

Fig. 636. — Third step in inserting a urethral sound.

instrument is further introduced with its point first hugging the floor
of the urethra and then gently following the roof of the canal through
the rest of its course into the bladder. The instrument is then

EXAMINATION BY SOUNDS AND BOUGIES

643

pushed onward and downward, the penis being drawn over it until the
point of the sound is deep in the bulbous urethra (Fig. 636). The
handle is next gradually raised to a perpendicular and is then de-

FiG. 637. — Fourth step in inserting a urethral sound.

^^^^^^^^^^J?^

Fig. 638. — Showing false passage of sound from depressing the handle of the instrument

too soon.

pressed, thus permitting the point of the instrument to follow the
fixed curve of the urethra beneath the pubic arch (Fig. 637).

Care must be taken, however, not to raise the handle of the instru-
ment too soon, that is before the beak has entered well into the bulb-

644

THE URETHRA AND PROSTATE

ous uretha, as otherwise its point will be made to lodge against the
upper part of the anterior layer of the triangular ligament instead of
entering the membranous portion (Fig. 638). Again, the sound may

Fig. 639. — Showing the tip of the sound caught in the bulb at the anterior layer of the

triangular ligament.

Fig. 640. — Method of lifting up the tip of the sound obstructed by the lower portion

of the triangular ligament.

fail to enter the membranous uretha from the point lodging in the
bulbous urethra against the lower portion of the triangular ligament

EXAMINATION BY SOUNDS AND BOUGIES

645

(Fig. 639). This may be avoided by depressing the handle and at the
same time by lifting up on the point of the instrument with the fin-
gers inserted behind the scrotum so as to press against the perineum
(Fig. 640).

Having passed the beak of the sound into the membranous
urethra it is then made to traverse the remainder of the canal and to
enter the bladder by sweeping the handle forward and downward
between the thighs (Fig. 641), provided, of course, that no obstruc-
tion has been encountered. While this is being done the free hand
should make pressure over the pubes in order to relax the suspensory
ligament of the penis.

By rotating the sound about its own axis it can readily be ascer-
tained whether the beak has entered the bladder or is still in the

Fig. 641. — Final step in inserting a urethral sound.

prostatic urethra. Furthermore, by sweeping the beak of the instru-
ment about the vesical neck any irregularity or disproportion between
the two lobes of the prostate will be noticed.

If an obstruction is met in any portion of the canal, the instrument
should be slightly withdrawn, and the penis put on the stretch, so as
to straighten out any folds of mucous membrane in which the point
of the instrument may have caught. If it then fails to pass, the
obstruction is due either to spasm or to an organic stricture. When
the seat of obstruction is in front of the bulbous urethra, spasm may
be ruled out, but an obstruction at the bulbo-membranous junction or
in the membranous urethra, on the other hand, is often caused by
spasm. To determine this, the instrument is not withdrawn, but

646

THE URETHRA AND PROSTATE"

should be kept firmly and gently pressed against the face of the ob-
struction for a few moments, when, if spasm were the cause, it will in
time subside so that the instrument can be readily passed into the
bladder. Furthermore, upon attempting to withdraw the instru-
ment, that characteristic grasping of the instrument such as is found
in the presence of a tight organic stricture will be absent. When an
obstruction is met deeper than 63-^ inches (16 cm.) from the mea-
tus, or in the prostatic urethra, stricture may be ruled out; such an
obstruction may be due to an enlarged prostate, a stone, or spasm of
the internal sphincter. ;

Fig. 642. — Showing the method of passing a filiform bougie through a small stricture
by first filling the canal with filiforms.

In this way the presence of a stricture is determined and its dis-
tance from the meatus is readily estimated. To ascertain its caliber
is the next thing. When the examining instrument encounters the
stricture no force should be used in attempting to make it pass;
instead, that particular instrument is withdrawn, and smaller sizes
inserted in succession, substituting flexible bougies for steel instru-
ments below a No. 15 French, until an instrument is found that will
readily pass. If even the smallest-size bougies will not pass, filiforms
should be used. As a general rule, no attempt should he made to pass
a filiform on the same day that other exploration has been attempted ^ for
after repeated attempts have been made to pass an instrument, the
9pening in the stricture becomes distorted from pressure of the sounds
or bougies, and for a time is impassable even to a filiform. In using

EXAMINATION BY THE BOUGIE X BOULE 647

filiforms it should be remembered that, owing to their small size, they
are liable to be obstructed from being caught in folds of mucous mem-
brane or in the orifices of the glands and ducts so abundant through-
out the urethra, and it is very easy to make a false passage with one of
these instruments if undue force is used. If a filiform catches in a
pocket or fold of mucous membrane, it should be withdrawn slightly,
and then gently advanced, or it may be gently rotated as it is ad-
vanced. Sometimes the passage of a filiform will be greatly facili-
tated by injecting sufficent sterile oil through the meatus alongside
the filiform to thoroughly distend the canal, and then, while keeping
the lips of the meatus closed, the instrument is gently advanced.

When once an instrument has entered the stricture there can be
no doubt of this fact from the tightness with which it is grasped by
the stricture, a sensation, which, once recognized, will not be for-
gotten. Should the operator be unable to find the opening with a
single filiform, the canal may be filled with them and, by first ad-
vancing one and then another, it will usually be possible to make one
engage in the stricture (Fig. 642). Failing by this maneuver, a
urethroscope may be introduced down to the face of the stricture
and through it the instrument may be passed under direct vision.

After such exploration the urethra should be irrigated with warm
normal salt solution or with a warm saturated solution of boric acid.

EXAMINATION BY THE BOUGIE X BOULE

The bougie a boule or bulbous bougie is employed for the purpose
of determining the size and length of a stricture. The usefulness of
this instrument is limited to the anterior urethra, as, if passed into
the membranous portion, the compressor urethras muscle is liable to
contract about the bulb of the instrument and give a sensation of
stricture. Furthermore, when the canal is the seat of more than
one stricture, it is frqeuently impossible with the bougie a boule to
detect the deeper ones, as those in the anterior portion of the canal
may be so tight that the passage of an instrument sufficiently large
to detect the deeper ones is out of the question.

Instruments. — The bulbous bougie consists of a flexible shaft, upon
the end of which is mounted an acorn-shaped tip. The head of the
instrument should be short and should join the shaft at rather an
abrupt angle. They are made of metal or of woven material with
a rubber head (Fig. 643). The latter are preferable as being less
rigid. These instruments are made in sizes from 5 to 40.

648

THE URETHRA AND PROSTATE

Asepsis. — The proper sterilization of these instruments has al-
ready been described in detail (page 640). The hands of the opera-
tor are to be thoroughly cleaned. The glans penis should be washed
off with soap and water, and then wiped with a swab wet with a i to
5000 bichlorid of mercury solution, followed by sterile water. The

^^^^^^ir:SS^?^^m^^f^mf^m^rr^'^f^<:

Fig. 643. — Urethral bougies a boule.

urethra should be irrigated with a i to 5000 potassium permanganate
solution, or a saturated solution of boric acid both before and after
examination.

Fig. 644. — Method of estimating the length of a urethral stricture. The bougie k
boule arrested at the face of the stricture.

Position of Patient. — The patient lies upon a firm table in the
dorsal position. The operator stands upon the side most convenient
for him, facing the patient's body and just above his hips.

Technic. — As large an instrument as will pass the meatus is
chosen. The operator grasps the penis behind the corona between
the middle and ring fingers of the left hand, and with the thumb

EXAMINATION BY THE BOUGIE X BOULE

649

and forefinger of the same hand retracts the foreskin and opens the
meatus. The bougie, well lubricated and held lightly between the
thumb and first two fingers of the right hand, is introduced until an
obstruction is met (Fig. 644). The distance of the obstruction from
the meatus is measured upon the shaft and the instrument is with-
drawn. Successively smaller sizes are introduced until a size that will
pass the stricture is reached. From this the size of the stricture is
determined. The instrument is passed entirely through the stricture,
and is then withdrawn until resistance caused by the shoulder of the
instrument striking the distal face of the stricture is felt (Fig. 645).

Fig. 645. — Method of estimating the length of a urethral stricture. The base of
the bougie a boule withdrawn until in contact with the distal end of the stricture.

The shaft is then grasped at the meatus as a guide, and the instrument
is removed. The distance from the meatus to the shoulder is then
measured, and subtracting the previous measurement from this gives
the length of the stricture. In this way the entire anterior urethra
to the bulbo-membranous junction may be explored and strictures,
if present, cahbrated.

In exploring the deep urethra the shaft of the instrument, if of
wire, should be bent to correspond to the normal curve of the canal.
It is then introduced in the same manner as a sound (see page 641).
As already mentioned, spasmodic contraction of the compressor
urethrae muscle may simulate stricture. After removal of the bougie
the urethra should be irrigated with boric acid solution.

650 THE URETHRA AND PROSTATE

URETHROMETRY

It is a method of measuring the caHber of the anterior urethra by
means of a special instrument, the urethrometer. This instrument-
has an advantage over a sound or bougie in that it can be introduced
through a narrow meatus and strictures of large caliber can be de-
tected and measured. At the same time, several strictures may be
examined by one insertion of the instrument. The method is, how-
ever, more irritating to the urethral mucous membrane than the use
of a sound of bougie, and is it only applicable to the anterior urethra.
In inexperienced hands it is often an unreliable method of examina-
tion, as strictures that do not exist may be imagined to be present,
which turn out to be the normal constrictions of the canal.

Instruments. — The urethrometer of Otis (Fig. 646) consists of a
small straight cannula marked off in inches and half-inches, ending in
a series of short metallic arms hinged upon themselves, and upon the
shaft of the instrument, which may be enlarged into a bulb-like shape

Fig. 646. — Otis' urethrometer. a, Instrument open; &, instrument closed; c, rubber
stall to cover the end of instrument.

of any size — ^from 16 to 45 French — by turning a thumb-screw at the
proximal end of the instrument. A dial and indicator show the
extent of expansion. A thin rubber stall is drawn over the end of
the instrument when closed, for the purpose of protecting the urethra.

Asepsis. — The urethrometer is boiled in a i per cent, solution of
carbonate of soda. The external genitals are thoroughly cleansed,
and the urethra is irrigated with a mild antiseptic solution. The
operator's hands are sterilized in the usual way.

Position of Patient. — The patient is placed in the dorsal recum-
bent posture.

Technic. — The closed instrument, warmed and lubricated, is
introduced through the meatus and is passed as far as the bulbo-
membranous junction. The bulb is then expanded by turning the
thumb-screw upon the proximal end of the instrument until the pa-
tient feels a fulness in the perineum. This indicates the normal size
of that portion of the urethra. The instrument is then slowly with-

ESTIMATION OF THE LENGTH OF THE URETHRA 65 1

drawn until an obstruction is met, when the instrument is screwed
down until it is of sufficiently small size to pass and is then again en-
larged and drawn forward. In this way the entire anterior urethra
may be measured, and strictures located and calibrated. It should
be remembered when employing this instrument that the urethra is
not of uniform caliber, but normally is the seat of dilatations and
constrictions. Thus, the bulbous urethra is the widest and most
distensible portion, and the meatus the most contracted. More or
less constriction of the canal is also encountered at the peno-scrotal
junction.

At the completion of the operation the canal is irrigated with an
antiseptic solution.

ESTIMATION OF THE LENGTH OF THE URETHRA

This procedure is of value in determining whether the prostate is
enlarged. For practical purposes the length of the urethra is the
distance it is necessary to pass a catheter from the meatus before
urine begins to flow. This may vary from 63^ to 9 inches (16 to 22
cm.), but on the average it is 7H to 8}^ inches (19 to 21 cm.). A
marked increase beyond the normal in the urethral length indicates
that the prostatic urethra is lengthened and that the prostate is
therefore enlarged.

Instruments. — An ordinary silk gum-elastic catheter or a catheter
marked off in inches (Fig. 647) may be employed.

Asepsis. — The catheter is boiled or immersed in a i to 20 carbolic
acid solution followed by rinsing in sterile water. The external

■ ■ ' ■ ^ ■

Fig. 647. — Cathether marked off in inches.

genitals are thoroughly cleansed and the urethra is irrigated with a
mild antiseptic solution. The operator's hands are also thoroughly
cleansed.

Position of Patient. — The dorsal position is employed.

Technic. — The catheter, well lubricated, is introduced into the
bladder until urine begins to flow. It is then withdrawn until the
flow just stops and the point where the catheter protrudes from
the meatus is noted. The distance from this mark to the eye of the
catheter represents the length of the urethra. If the catheter passes

652

THE URETHRA AND PROSTATE

without obstruction and urine begins to flow when the eye of the
catheter is a distance of from 7M to 83^:4 inches (19 to 21 cm.)
from the meatus, we may conclude that the prostate is not enlarged.
On the other hand, a marked increase in the distance the catheter
has to travel indicates an increase in the length of the prostatic
urethra.

URETHROSCOPY

It consists in direct inspection of the interior of the urethra
through a metal tube by the aid of suitable illumination. While in
the routine examination of the urethra direct inspection is not al-
ways necessary, the urethroscope becomes a valuable instrument for

Fig. 648. — Instruments for urethroscopy, i, Chetwood's tubes; 2, tube with light

in place; 3, applicator.

the diagnosis of conditions in which the pathological changes are
slight and of such a character as not to be detected by means of the
sound or bougie. Lesions of the mucous membrane may be thus
accurately located and their character definitely determined. Fur-
thermore, by means of the urethroscope, it is possible to make local
applications directly to diseased areas or to remove calculi, foreign
bodies, polypi, etc. (see page 673). The instrument is also some-
times of value in the treatment of strictures, as by its aid it is possi-
ble to discover the opening of a very tight or eccentrically placed
stricture and insert a filiform under direct vision.

URETHROSCOPY

653

To successfully employ the urethroscope care and gentleness in
manipulation are absolutely essential and the operator must have had
considerable experience in its use and must be familiar with the
normal appearance of the different portions of the urethra in order to
properly interpret the findings. If strictures exist or the caliber of
the canal is below 22 French; preliminary dilatation by means of
sounds should be carried out. In acute gonorrhea the use of the
urethroscope is contraindicated.

Apparatus. — The urethroscope consists of a metal tube supplied
with an obturator to aid in its introduction and an electric light for
illuminating its interior. The tubes for use in the anterior ure-
thra are straight and are 4 to 5 inches (10 to 12 cm.) long, while those
for the posterior urethra are 5 to 6 inches. (12 to 15 cm.) long; a

Fig. 649.^Swinburne's urethroscope for examining the posterior urethra.

straight tube may be used in the posterior urethra or the tube may
be obtained with the distal end slightly curved to facilitate its intro-
duction, as the Swinburne urethroscope (Fig. 649) or the Goldschmidt
instrument. The caliber of the tubes is from 22 to 32 French. The
illumination is furnished through a two- or four-volt lamp from a
four- to six-dry-cell battery. In the Chetwood instrument, the
illumination is supplied by means of a delicate cold lamp at the
distal end of the instrument, while in the Otis urethroscope the
light is placed at the proximal end of the instrument. In their
stead, a head light and Klotz tube (Fig. 650) may be employed.

In addition to the urethroscope long slender applicators wrapped
with cotton are necessary.

Asepsis. — The tube and applicators should be boiled for five
minutes in a i per cent, soda solution, while the lamp may be im-
mersed in a I to 20 carbolic acid solution and then in alcohol. The
operator's hands should, of course, be sterile. The glans penis is
washed with soap and water, and is then wiped with a i to 5000
bichlorid of mercury solution. The urethra is to be irrigated with

654

THE URETHRA AND PROSTATE

a warm saturated solution of boric acid or i to 5000 potassium
permanganate solution.

Position of Patient. — The patient should be upon a flat table in
the recumbent position for anterior urethroscopy and in the litho-
tomy position for examination of the posterior urethra.

Fig. 650. — Klotz's urethral tube.

Anesthesia. — Cocain is not to be used if it can be avoided, as it
alters the appearance of the mucous membrane somewhat and by
deadening sensibility it conceals valuable information as to the con-
dition of the canal. Hyperesthesia of the urethra, if present, may be
lessened to a considerable degree by the passage of a full-sized sound
once or twice before the intended examination.

— ^— Tr-'i-' ^-^ I T r t

Fig. 651. — Method of mserting the urethroscope

Technic. — A tube as large as will pass through the meatus should
be used, as very little information is obtained by inspection through
a small tube. If the meatus is abnormally small, it should be cut
(see page 679). The patient voids his urine just before the ex-
amination is begun. Before proceeding with the examination, the
patient is instructed to tell the operator if any particular sensi-

CRETHROSCOPy

65s

live spot IS encountered while the instrument is being passed. The
penis is held vertically upward in the fingers of the left hand, and
the tube, well warmed and lubricated, and with the obturator in
place, is inserted through the meatus (Fig. 651), and thence onward
until it meets an obstruction or reaches the bulbous urethra, pro-
vided the anterior portion of the canal only is to be examined.
If the prostatic urethra is to be inspected, the tube is inserted all
the way into the bladder. This is accomplished by turning the

Fig. 652. — Showing the method of examining the anterior urethra through the ure-
throscope.

instrument down between the thighs to an almost horizontal posi-
tion as soon as its point reaches the bulbous urethra and, at the
same time, making gentle upward pressure upon the point of the
instrument by means of the fingers on the perineum. In this way
the point of the instrument is made to pass through the opening
in the triangular ligament. The tube is then gently pushed on into
the bladder. Inserting a straight tube into the posterior urethra is
generally painful and it may not be possible without employing
local anesthesia; introduction of the curved urethroscope is much
less disagreeable for the patient.

656

THE URETHRA AND PROSTATE

As soon as the instrument is inserted to the desired depth, the
obturator is removed, the light is turned on, and, as the tube is
slowly withdrawn, the different portions of the mucous membrane
are inspected as they appear in the end of the urethroscope (Fig.
652). If a clear view of the mucous membrane is interfered with
by blood or secretion collecting in the end of the tube, long appli-
cators covered with cotton should be inserted through the instru-
ment and the mucous membrane mopped dry; care should be taken
not to push the tube back in the canal after the examination has
once begun without inserting the obturator, as the edges of the tube
might cause damage to the parts.

Before one can become competent in recognizing pathological
conditions it is necessary that the examiner should be acquainted

Fig. 653. — The appearance of the
upper portion of the prostatic urethra.

(After Stern.)

Fig. 654. — The appearance of the
middle portion of the prostatic urethra.
(After Stern.)

with the normal appearance and color of the urethral mucous mem-
brane. Beginning at the posterior urethra in a normal case the
central figure appears as a cone, the mucous membrane, which is
of a dark red color, being thrown into longitudinal folds. As the
instrument is withdrawn, the verumontanum comes to view in the
form of a semilunar curve with the convexity upward (Fig. 653)
and the mucous membrane appears of a bright red color. By slightly
changing the position of the instrument, it is possible to obtain a
view of the sinus pocularis and openings of the ejaculatory ducts
(Fig. 654). Upon the further withdrawal of the instrument, the
ridge of the verumontanum becomes gradually less marked and the
mucous membrane takes on a paler hue. In the membranous
urethra the central figure appears as a cone with a central dot.

URETHROSCOPY

657

the mucous membrane extending out in radiating folds (Fig. 655).
In the bulbous urethra the central figure changes to a vertical slit
with the mucous membrane bulging on each side (Fig. 656). In
this portion of the canal the mucous membrane is still paler in color.

Fig 655. — The appearance of the mem-
branous urethra. (After Stern.)

Fig 656. — The appearance of the bul-
bous urethra. (After Stem.)

The central figure then gradually changes from a vertical slit to a
triangular opening (Fig. 657), and at the penoscrotal junction it
takes the form of a transverse slit with radiating folds extending to
the periphery (Fig. 658). In the pendulous urethra the central

Fig. 657. — The appearance of the
perineal portion of the spongy urethra.
(After Stern.)

Fig. 658. — The appearance of the
urethra at the penoscrotal junction.
(After Stern.)

figure again becomes cone-shaped (Fig. 659) and, finally, at the
meatus it appears as a vertical slit, the color of the mucous membrane
changing from a pale pink to a purplish hue.

In examining the urethra through the urethroscope it should be

658 THE URETHRA AND PROSTATE

first ascertained whether the normal elasticity of the canal is im-
paired or not. This is accomplished by noting the central figure as
the tube is withdrawn. In chronic inflammatory conditions the
urethra becomes more or less rigid and does not immediately collapse
over the end of the urethroscope as it is withdrawn ; instead, the cone-
like central figure often becomes elongated or else distorted from
being contracted at certain points, if the inflammation is a localized
one, and, in addition, the whole mucous membrane in such cases
not infrequently becomes of a paler hue than normal. Changes in
the appearance of the mucous membrane should also be noted. In
chronic urethritis there will at times be found localized congested
areas, granular patches which frequently bleed, and superficial

Fig. 659. — The appearance of the pendulous urethra. (After Stem.)

ulcerations covered with secretion. Inflamed lacunae appear as red
openings upon the surface of the mucous membrane from which will
frequently be seen exuding drops of pus. Retention cysts, polypi,
etc., are readily diagnosed by this means. If, during the examina-
tion, it is desired to more closely study the condition of the mucous
membrane at any particular spot this may be accomplished by
pushing that part into the field by digital compression upon the
urethra below the end of the urethroscope.

After removal of the tube the anterior urethra should be irri-
gated with a warm saturated boric acid or normal salt solution, and,
if the instrument has been passed into the deep urethra, the bladder
should also be irrigated.

URETHROSCOPY IN THE FEMALE

The female urethra being shorter and capable of greater dis-
tention than that of the male lends itself more readily to examination
by the urethroscope.

URETHROSCOPY IN THE FEMALE

6S9

Instruments. — Short male endoscopic tudes or a regular female
urethroscope may be employed. They may be obtained with the
light at the distal end or, as in the Kelly tubes (Fig. 660), with the
light reflected from a head mirror. The female urethroscope should
be about 3 inches (7.5 cm.) long. The tubes vary in size anywhere
from 24 to 36 French

Fig. 660. — Kelly's uretliral- tube-speculum.

A Kelly cone-shaped urethral dilator (Fig. 661) should be pro-
vided for dilating the meatus. Applicators or alligator-jawed forceps
and absorbent cotton will also be required.

Asepsis. — The tubes, applicators, etc., may be boiled for five
minutes in a i per cent, soda solution. The lamp is sterilized by
immersion in a i to 20 carbolic acid solution and then rinsed off in

Fig. 661. — Kelly's cone-shaped urethral dilator. (Ashton.)

alcohol. The vulva and the external urethral orifice are sterilized
by washing with tincture of green soap and water, next with a i to
5000 bichlorid of mercury solution, and finally with sterile water.

Position of Patient. — The dorsal posture is employed.

Anesthesia. — If the urethra is hyperesthetic, a small pledget of
cotton saturated with a 2 per cent, solution of cocain is placed in
the mouth of the urethra for a short time before the operation.

66o

THE URETHRA AND PROSTATE

Technic. — The urine is voided before the examination begins.
If necessary, the meatus is dilated sufficiently to admit a good-sized
tube by means of a Kelly dilator (Fig. 662). The instrument, with

Fig. 662. — Showing the method of dilating the urethra. (Ash ton.)

the obturator in place and well lubricated, is then inserted into the
mouth of the urethra and is carefully passed into the bladder (Fig.
66^,). The obturator is next removed and the lighting apparatus is

Fig. 663. — Introduction of the urethroscope Pig. 664. — Showing the method of

into the female urethra. (Ashton.) inspecting the female urethra through

the urethroscope. (Ashton.)

properly adjusted. The instrument is then gradually withdrawn
while the examiner notes the condition of the mucous membrane as
it falls over the end of the tube (Fig. 664).

HAND INJECTIONS FOR THE URETHRA 66t

At the internal urethral orifice there appears through the urethro-
scope a large opening surrounded by a narrow ring of mucous mem-
brane. As the instrument is withdrawn the central figure becomes
first more oval and then lower down appears as a transverse slit with
the mucous membrane thrown into folds that radiate to the pe-
riphery. Finally, at the external orifice the central figure appears
as a vertical slit, while the mucous membrane appears thrown into
a number of radiating folds. A posterior fold is especially marked
in the upper portion of the canal ; it is a continuation of the trigone.

The points to be noted in the examination have been sufficiently
dealt with under the technic of male urethroscopy and will not be
repeated here.

Therapeutic Measures
HAND INJECTIONS FOR THE URETHRA

The injection of solutions into the anterior urethra by means of a
small hand syringe is employed either for simple cleansing purposes
in preparation for the passage of urethral instruments or for the
purpose of treating anterior urethritis. The efficiency of injections
in limiting acute gonorrhea is a question and it is doubtful if they
have much effect outside of removing the irritating discharges and
cleansing the mucous membrane. They may, however, be pre-
scribed in the acute stages in the form of mild antiseptic solutions
to be used by the patient himself as an adjunct to irrigations carried
out by the physician. In the declining stages of the disease or when
the condition becomes chronic, astringent injections are of un-
doubted value in reducing, the congestion and thus drying up the
thin discharge that remains.

When injections are employed, certain precautions should be
observed. In the first place, mild solutions are preferable to very
strong ones, as being less irritating to the mucous membrane.
They should not be strong enough to cause more than temporary
pain or stinging, otherwise they are likely to do more harm than
good. In the second place, the greatest gentleness in making the
injection is necessary to avoid injuring the urethral mucous mem-
brane. Furthermore, while it is desirable that the solution should
be brought into contact with all the folds and depressions of the
mucous membrane, it is important that the fluid should not be in-
jected into the bladder, which, however, rarely happens, as the
cut-off muscle interposes a barrier. If it should occur, infective

662

THE URETHRA AND PROSTATE

material will necessarily be carried back into the deep urethra with
a good chance of starting up a posterior urethritis and epididymitis.
For this reason, only a small quantity of fluid should be injected at
a time and that without force. Used with these precautions, in-
jections may be safely employed by the patient himself when desired.
The Syringe. — The best form of instrument for injections is a
hand syringe with a capacity of about 2 3^^ drams (10 c. c). It
should be preferably of glass so that it can be sterilized by boiling.
The nozzle should be cone-shaped (Fig. 665) that it may fit into the
meatus, and it should be seen that it is perfectly smooth. Before
using, the syringe should be tested to see that the piston moves
easily and without any jerks. A basin should also be provided
to receive the solution that flows back from the urethra.

Fig. 665. — Urethral syringe.

Solutions Employed. — Many solutions with soothing, astringent,
or antiseptic properties are employed, a few of which are given:

Sedative Injections

I^. Fl. ext. hydrastis,
Aquae destil.,

I^ Morph. sulph.,
Cocainae,
Muc. acaciae,
Aquae destil.

TTlxx-xxx (1.2-2 c.c.)
5i (30 c.c.)
gr. viii (0.5 gm.)
gr. iv (0.26 gm.)
§i (30 c.c.)
q.s.ad 5ii (60 c.c.)

Astringent Injections

I^. Zinci sulphatis,

Aquae destil.
I^ Zinci sulphocarbolatis

Aquae destil.,
I^. Plumbi acetatis,

Aquae destil.,
I^. Zinci acetatis,

Aquas rosa.

Antiseptic Injections

^. Sol. protargol,

I^. Sol. argyrol,

I^. Sol. potass, permanganat.,

^. Sol. bichlorid of mercury,

gr. iv-viii (0.26-0.5 gm.)

Siv (120 c.c.)

gr. vi-xii (0.4-0.8 gm.)

5iv (120 c.c.)

gr. iv-xii (0.26-0.8 gm.)

5iv (120 c.c.)

gr. i-xv (0.065-1 gm.)

51(30 c.c.)

0.25 to I per cent.
5 to 10%
1-5000 to 3000
1-30,000

HAND INJECTIONS FOR THE URETHRA

66s

Temperature. — The solution should be used at about the tem-
perature of the body.

Quantity. — Only sufficient quantity of the solution to distend
the anterior urethra should be injected at a time. At first about
3i (4 c.c.) should be used; later this maybe increased toSiii (12 c.c).

Frequency. — The injections may be employed three to six times
daily, depending upon the severity of the case. As the symptoms
improve they may be given less frequently. It should be remem-
bered, however, that in some cases after a time the continued use
of injections may prevent a discharge from entirely disappearing,
and it is necessary to stop them entirely for a week or more before
a cure is obtained.

Fig. 666. — Method of giving a urethral injection.

Position of Patient. — Injections may be given with the patient
lying recumbent or sitting upon the edge of a chair.

Preparation. — The glans penis and the lips of the meatus should
be washed off with a i to 5000 solution of bichlorid of mercury.

Technic. — The patient urinates immediately before the injection
is given so as to wash out as much of the discharge as possible and
also that he may not have to urinate soon afterward, thus allowing
the solution to remain in contact with the urethra the maximum
length of time. The syringe is then filled with from i to 20 drams
(4 to 8 c.c.) of solution, and any air is expelled by depressing the
piston while the tip is elevated. The penis is held back of the corona
between the thumb and forefinger of the left hand, while with the

664

THE URETHRA AND PROSTATE

right hand the nozzle of the syringe is inserted into the meatus,
far enough to completely occlude the meatus and prevent leakage,
and the solution is gently injected into the urethra and immediately
allowed to escape. A second syringeful of solution is then injected
into the urethra until the latter is well distended (Fig. 666). The
syringe is then removed and the meatus is held together for from three
to five minutes so as to keep the solution in contact with the mucous
membrane (Fig. 667). The solution is then allowed to run out into
the receptacle provided for the purpose.

Fig. 667. — Second step in injection of the urethra, holding the solution in the urethra.

IRRIGATIONS OF THE URETHRA

Irrigation of the urethra is accomplished by flushing out the
canal with copious quantities of mild antiseptic solutions. It is a
method employed extensively in the treatment of acute gonorrhea.
To be effective large quantities of fluid must be used, and the urethra
must be so distended that the solution comes in contact with all
recesses and folds in the mucous membrane.

It is claimed that under the irrigation method of treatment,
properly employed, the intensity of the symptoms is much lessened
and the duration of the attack shortened. On the other hand,
many authorities oppose this form of treatment on the ground that
it increases the dangers of prostatic infection and that the virulence
of the infection is increased. If gentleness is observed and the pre-

IRRIGATIONS OF THE URETHRA

665

caution is taken not to give the anterior injection under too great
pressure, that is, not to force the solution into the bladder, as is so
frequently done, the danger of complications is slight. It is not a

Fig. 668. — Valentine irrigator and Chetwood's urethral irrigating nozzle.

method of treatment, however, that can be placed in the hands of
the patient, but it should always be carried out by the physician.
Both the anterior and the posterior urethra may be irrigated.

Fig. 669. — Chetwood's alternating cut-ofiF.

Apparatus. — An irrigating reservoir that can be raised or lowered
to any desired height at will, such as Valentine's, a Chetwood two-
way blunt glass urethral nozzle, a waste-pail, and two pieces of rub-

666 THE URETHRA AND PROSTATE

ber tubing, one about 8 feet (240 cm.) long for connecting the inflow
with the irrigator and another, a short piece, leading from the out-
flow tube to the waste-pail, are required for anterior irrigations.
While not absolutely necessary, an alternating irrigating clamp
(Fig. 669) is a convenience.

For irrigating the posterior urethra a No. 12 to 18 French soft-
rubber catheter with a smooth beveled eye, and a large glass syringe
(Fig. 670) should be provided.

Fig. 670. — Syringe and catheter for irrigating the posterior urethra.

Solutions. — Mild antiseptic solutions are employed. Those most
frequently used are:

Permanganate of potash, 1-6000 to i-iooo

Bichlorid of mercury, 1-30,000 to 1-10,000

Silver nitrate, 1-15,000 to 1-2000

Temperature. — The solutions should be used at about the body
temperature.

Quantity. — About a quart (i liter) of solution should be used in
an anterior irrigation.

For posterior irrigations from 4 to 12 ounces (120 to 360 c.c.) of
solution are employed.

Frequency. — Early in the disease, when the discharge is free, two
daily irrigations give the best results. Later, one irrigation a day is
sufl&cient.

Height of Reservoir. — The reservoir should not be raised above
4 feet (120 cm.). Such an elevation will give all the necessary dis-
tention of the urethra without forcing the solution beyond the an-
terior urethra. If it produces pain, the pressure should be reduced
by lowering the reservoir or partially pinching off the inflow tube.

Position of Patient.^For anterior irrigations the patient may
stand or be seated upon the edge of a chair, while for a posterior
irrigation the patient should be in the dorsal position.

Preparation of Patient. — For protecting the clothes the patient
may wear a rubber apron in which is provided an opening for the

IRRIGATIONS OF THE URETHRA 667

penis (Fig. 671). The glans penis and lips of the meatus should be
washed off with a i to 5000 bichlorid of mercury solution.

Technic. i. Anterior Irrigations. — The patient should empty
his bladder before each treatment. The operator holds the penis

Fig. 671. — Apron for protecting the patient during a urethral irrigation.

behind the glans between the thumb and forefinger of the left hand
and, compressing the rubber inflow tube between the thumb and in-

FiG. 672. — Method of giving an anterior urethral irrigation.

dex-finger of the right hand, inserts the glass nozzle into the meatus.
He then releases the inflow tube, at the same time closing the out-

668

THE URETHRA AND PROSTATE

flow tube by means of his right Httle finger. As soon as the urethra
is filled with solution the inflow tube is again pinched, at the same

Fig. 673.— First step in irrigating the posterior urethra. Catheter is inserted mto
the bladder until urine begins to flow.

Fig. 674.— Second step in irrigating the posterior urethra. The catheter is with-
drawn until its tip lies in the deep urethra and the solution is then injected.

time removing the little finger and thus opening the outflow tube.
By thus alternately opening or shutting the inflow tube, and at the

INSTILLATIONS 669

same time shutting or opening the outflow, the urethra is alternately
distended with solution and emptied without the necessity of remov-
ing the nozzle. This alternate filling and emptying of the urethra
is much easier to perform with the scissor-like clamp of Chetwood
than with the fingers. It takes about five minutes to thus irrigate
the urethra with i quart (i liter) of solution.

2. Posterior Irrigations. — The anterior urethra is first irrigated
as just described. A No. 12 to 18 French catheter, well lubricated
with one of the Irish-moss preparations, is then inserted into the
urethra with the eye upward until urine just escapes (Fig. 673).
After the bladder is emptied, the catheter is withdrawn i inch
(2.5 cm.) until its point lies in the prostatic urethra and from 4 to
12 ounces (120 to 360 c.c.) of the antisepic solution are gently in-
jected (Fig. 674). The posterior urethra is thus washed backward
toward the bladder. The catheter is then removed and the patient
is instructed to void the contents of his bladder, thus giving a final
washing from behind forward to both posterior and anterior urethrae.

INSTILLATIONS

Instillations are employed when it is desired to medicate the
urethra with small quantities of strong solutions. They are lin-
dicated in chronic gonorrhea, but should not be used in acute cases;
they are specially useful in chronic posterior urethritis. Instila-
tions are also valuable in the treatment of sexual neurasthenia when
inflammatory lesions are present in the posterior urethra. The ob-
ject of such injections is to induce a hyperemia of the tissues with
the hope that it will be followed by absorption of the old as well as
the new products of inflammation and by a return to normal. It
is a method that may be applied to the anterior or posterior urethra.
Instillations should not be employed in cases where injections or
irrigations of weak solutions are followed by irritation, and they
should likewise be avoided in posterior urethritis when the prostate
and seminal vesicles are the seat of an acute inflammation.

The Syringe. — While the instillation may be given by means of a
flexible catheter and small syringe, a special instrument, such as
Keyes' modification of the Ultzmann syringe (Fig. 675), will be
found more satisfactory. The latter consists of a long curved
nozzle of German silver, provided with a central opening, to the
proximal end of which is attached a large hypodermic syringe with
the piston graduated in minims.

670

THE URETHRA AND PROSTATE

Asepsis. — The syringe should be sterilized by boiling for five
minutes in a i per cent, solution of sodium carbonate. The glans
penis and meatus are then washed with warm water and soap,
followed by a I to 5000 bichlorid of mercury solution.

Solutions Employed. — In using instillations it is well to start with
a weak solution, employing it till the urethra becomes tolerant, and
then to gradually increase the strength. The solutions most fre-
quently made use of are:

Silver nitrate
Thallin sulphate,
Copper sulphate,
Argyrol,
Protargol,
Ichthyol,

0.5 to 2 per cent.
3 to 10 per cent.

1 to 4 per cent.
10 to 20 per cent.

0.25 to 10 per cent.

2 to 10 per cent.

Fig. 675. — Keyes-Ultzmann instillation syringe.

Temperature. — The solution should be given at about the tem-
perature of the body — say 100° F. (38° C.) .

Quantity. — Ten or twenty minims (0.6 to 1.25 c.c.) of solution are
injected at a time.

Frequency* — Instillations may be given at from forty-eight- to
seventy-two-hour intervals. As a general rule, a second injection is
not to be given until all irritation from the first has subsided.

Position of the Patient. — The patient should be lying down upon a
bed or table.

Technic. i. Posterior Instillations. — The patient should void
his urine previous to the instillation, and the anterior urethra is
first cleansed . by an injection of weak antiseptic solution. The
syringe, filled with the desired amount of solution, and with the
nozzle well lubricated with some nonoily lubricant, as one of the
Irish-moss preparations, is carefully introduced in the same manner
as one would pass a sound (page 641) until its point lies behind the
compressor urethrae muscle in the membranous urethra (Fig. 676).
This will be at a distance of about <,}/2 to 6 inches (14 to 15 cm.)
from the meatus or roughly when the shaft of the instrument is at

INSTILLATIONS

671

an angle of 45 degrees with the horizon. From 5 to 20 drops (0.3
to 1.25 c.c.) of solution are then slowly injected. Care must be
taken in withdrawing the nozzle of the instrument not to permit
any solution to drip from the point along the anterior urethra. To
avoid this, the piston of the syringe should be withdrawn slightly
before the nozzle is removed.

Generally there is considerable burning upon urination following
a posterior instillation and at times there may be pain and tenesmus
and some discharge during the first twenty-four hours. As a rule,
these symptoms subside within six to twenty-four hours. If the

Fig. 676. — Showing the syringe in position for deep urethral instillation.

reaction is severe, however, the patient should remain quietly in bed
and an opium suppository should be introduced into the rectum and
heat applied to the perineum.

2. Anterior Instillations. — In giving an anterior instillation the
same preparations are followed as for a posterior instillation. The
nozzle of the instrument, well lubricated, is then carefully intro-
duced as far as the bulb of the urethra and about 20 drops (1.25
c.c.) of solution are injected. The solution follows the instrument
as it is withdrawn, medicating the whole anterior urethra. A piece
of cotton should be placed over the glans and worn for a few hours

672 THE URETHRA AND PROSTATE

to prevent any excess of solution escaping from the meatus and
soiling the patient's clothing. The cotton may be readily secured
in place by means of a loose-fitting elastic band placed behind the
corona.

APPLICATION OF OINTMENTS TO THE URETHRA

Astringent and stimulating ointments are at times employed in
the treatment of chronic urethritis instead of instillations. They
are considered by some authorities more efficient than the use of
drugs in solution, as being more penetrating and more lasting in
effect.

Instruments. — Ointments may be applied to the whole urethra,
in which case an ordinary sound or a cupped sound (Fig. 677) is
employed or they may be brought into contact with any particular
area by means of Tomasoli's or some other form of ointment syringe
(Fig. 678). This latter instrument consists of a hollow curved
catheter-like nozzle and a plunger for forcing the ointment out at
the end.

Formulary. — Unna's ointment for use with sounds consists of:

I^. 01. cocae, §iii(90C.c.)

Cerae flav., 5ss (2 gm.)

Argent, nitratis, gr. xv (i gm.)

Bals. peruviani, 5ss (2 c.c.) M.

Fig. 677. — Cupped sound.

The mixture is melted over a hot-water bath and the sound is then

dipped into it and the ointment is permitted to solidify by cooling.
Finger's Ointment consists of:

^. Argent, nitratis or cu. sulphatis, gr. xv (i gm.)

01. olivae, 5iss (5.6 c.c.)

Lanolin, giii (90 c.c) M.

Another consists of:

I^. Pot. iodidi., 3ss (2 gm.)

lodi. pur., gr. v (0.3 gm.)

01. olivae, 3ss (2 c.c.)

Lanolin, 3i (30 c.c.) M.

URETHROSCOPE IN THE TREATMENT OF URETHRAL DISEASES 673

Preparations. — The patient's bladder should be empty. The
glans penis and meatus are washed with soap and water, followed by
a I to 5000 bichlorid of mercury solution.

Technic. — When a sound is employed, as large a one as will
comfortably pass the meatus is coated with the ointment, or if a
cupped sound is used, the depressions are filled with the ointment,
and it is passed through the urethra and is left in place about five
minutes. The ointment melts and thus medicates the entire urethral
mucous membrane.

Fig. 678. — Urethral ointment syringe.

In employing a special ointment carrier the instrument is partly
filled with the ointment and, after being well lubricated, it is passed
as far as the diseased area. The piston is then inserted and is pushed
through the instrument forcing the ointment out the end into the
urethra.

THE URETHROSCOPE IN THE TREATMENT OF
URETHRAL DISEASES

By means of the urethroscope or an open wire speculum (Fig.
679) lesions in the urethra may be accurately located and efforts at

Fig. 679. — Open wire urethral speculum.

treatment can be thus focused on the exact seat of the disease.
Endoscopic treatment is thus of great value in the presence of
localized lesions of the urethra which, resisting the ordinary methods
of treatment by irrigations, instillations, etc., are often the cause of
a persistent gleety discharge. For example, through the urethro-
scope and by the aid of suitable instruments, strong applications

may be made to granular patches, erosions, and ulcerations; sup-
43

674

THE URETHRA AND PROSTATE

purating glands or follicles may be incised and small growths may be
removed from the canal under direct vision.

The technic of using the urethroscope has previously been fully
described (page 652) so that the application of the instrument to

Fig. 680. — Urethral probe.

the treatment of various urethral conditions will simply be outlined
in a general way. As has been already emphasized in previous
pages, it is essential that one should be familiar with the normal ap-

FiG. 681. — Method of making applications to the urethra through the urethroscope.

pearance of the urethra before attempts to employ the instrument

for treatment are made. Furthermore, the greatest gentleness in

manipulation is necessary to avoid injury to parts already diseased.

In the treatment of congested and granular patches, erosions,

XTRETHROSCOPE IN THE TREATMENT OF URETHRAL DISEASES 675

and ulcerations, local applications of silver nitrate or copper sulphate
may be used by means of cotton-wrapped probes through the
urethroscope previously passed to the seat of the disease (Fig. 681).
In this way strong solutions of these drugs — 30 to 60 gr. (2 «to 4
gm.) to the ounce (30 c.c.) — which would be extremely irritating if

Fig. 682— Urethral knife.

applied to the whole mucous membrane, may be applied. If the
diseased areas are numerous and extensive the strength of the appli-
cations should be somewhat weaker — say 5 to 10 gr. (0.3 to 0.6 gm.)
to the ounce (30 c.c). When using the stronger solutions, care
should be taken to make the application exactly to the diseased area

Fig. 683. — KoUmann's urethral syringe.

and not to leave any excess of solution to run over the healthy mucous
membrane. Such applications should not be made too frequently —
not oftener than once a week — as usually an acute urethritis, often
accompanied by a bloody discharge, is set up. This, as a rule,
subsides in twenty-four to forty-eight hours.

Fig. 684. — Urethral curet.

Areas of induration may be incised through the urethroscope by
means of a urethral knife (Fig. 682). Two or 3 drops of a 4 per cent,
solution of cocain with adrenalin chlorid should be applied to the
diseased area by means of a cotton-wrapped probe, and the incision
may then be made without pain. In the same manner abscesses

676 THE URETHRA AND PROSTATE

of Littre's glands or inflamed follicles may be opened. A discharg-
ing crypt or follicle may be injected every few days with a few drops
of a peroxid of hydrogen solution by means of Kollmann's syringe and
cannula (Fig. 683). Polyps and papillomata may be removed by a
urethral curet (Fig. 684) or by caustics. If pedunculated, a wire
snare (Fig. 685) or the galvanocautery snare may be employed. In

Fig. 685. — Urethral snare.

any case the area of operation should be first cocainized in the manner
above described.

THE DIRECT APPLICATION OF COLD TO THE
URETHRA BY THE PSYCHROPHORE

In the treatment of spermatorrhea and sexual neurasthenia where
the urethra is congested or hyperesthetic the direct application of
cold to the deep urethra by means of the cold-water sound or psy-
chrophore is often of value. An ordinary cold sound is also employed
in treating such conditions, but is not so effective, as the instrument
soon becomes warm from contact with the urethra. With the psy-
chrophore it is possible to keep a continuous cold application in the
urethra as long as is desired.

Apparatus. — The psychrophore is a double-current closed sound
within the outer sheath of which are two canals, one for the inflow
of cold water and the other for the outflow, which communicate
near the terminal end of the instrument, thus permitting that portion
of the instrument to be kept cold. The inflow canal is connected
with a rubber tube leading from a douche bag or irrigating jar
(Fig. 686).

Temperature. — The temperature of the water should be about
50° to 40° F. (10° to 5° C.) to start with. As the urethra grows more
tolerant the temperature may be lowered.

Duration of Treatments. — The sound should be left in place for
from five to ten minutes at a sitting.

PROSTATIC MASSAGE

677

Frequency. — Treatments may be given daily or on alternate
days.

Technic— An instrument as large as the normal caliber of the
urethra should be used. It is well lubricated and gently inserted in
the same manner as a sound (page 641) until the curved portion lies
in the membranous and prostatic portions of the urethra. The tub-
ing from the reservoir is then connected with the inflow canal and
a current of cold water is allowed to pass through the instrument,
escaping from the outflow canal into a basin provided for the purpose.
In this way the hyperesthetic urethra is exposed to the mechanical
effect of the sound and the sedative action of cold.

Fig. 686. — Apparatus for applying cold water to the urethra.

PROSTATIC MASSAGE

Massage of the prostate gland by means of the finger in the rec-
tum is frequently employed, and with good results, in the treat-
ment of chronic prostatitis in which the inflammation extends deep
in the gland tissue. The object is to express from the prostate into
the posterior urethra as much as possible of the purulent contents
of the gland and to cause absorption of the products of inflammation
from indurated areas. It is also used for the purpose of emptying
the distended seminal vesicles and hastening resolution. It should
not be employed in acute prostatitis or acute vesiculitis, and care
should be taken not to perform the massage too vigorously, other-

678

THE URETHRA AND PROSTATE

wise the tissues will be bruised and the inflammation will be aggra-
vated.

Fig. 687. — Position of the patient and method of introducing the finger into the
rectum in prostatic massage.

Fig. 688. — Showing the method of massaging the prostate.

Duration of Treatment. — The massage should be carried out for
two or three minutes at a sitting.

MEATOTOMY 679

Frequency. — Unless followed by irritation, treatments may be
given once every four or five days.

Position of Patient. — The operation may be performed with the
patient bending forward over a chair or in the knee-chest position.

Technic. — If possible, the patient's bladder should be full. The
operator wears a rubber glove on the right hand or a finger cot on his
right index-finger and, after lubricating the index-finger, introduces
it into the rectum (Fig. 687), carrying the finger high up on one side
over the seminal vesicle. Firm but gentle pressure is then made
with the finger over the seminal vesicle and the finger is slowly
drawn down over the vesicle toward its duct and also over the cor-
responding lobe of the prostate (Fig. 688). This procedure is then
repeated upon the opposite side, and finally over the central portion
of the gland. All portions of the gland are thus massaged, but
special attention should be paid to those portions that are enlarged
or diseased.

After completing the massage the patient urinates, thus empty-
ing the bladder of pus and debris expressed by the massage.

MEATOTOMY

Meatotomy consists in dividing a narrow meatus. It may be
required as a preliminary to the passage of large instruments into
the urethra or bladder and in the presence of urethral inflammation,
when the size of the meatus is such that free drainage is interfered
with. If properly performed, it is an operation without danger.

Instruments. — The incision is best made with an Otis meatome
(Fig. 689) or with an ordinary blunt-pointed straight bistoury.

Location of Incision. — The meatus should be cut exactly in the
median line upon the floor of the urethra.

Fig. 689. — Otis' meatome.

Preparations. — The glans penis and meatus should be washed
with soap and water followed by a i to 5000 solution of bichlorid of
mercury. The anterior urethra should be irrigated with a saturated
boric acid solution.

Anesthesia. — To render the operation painless the line of pro-
posed incision is infiltrated with a o.i per cent, solution of cocain
or a 0.5 per cent, procain solution introduced through the frenum or,

68o THE URETHRA AND PROSTATE

if desired, by the topical application of a weak cocain solution (see
page 87).

Technic. — The operator retracts the foreskin and, steadying the
penis between the thumb and forefinger of his left hand, inserts the
knife, with the cutting-edge down, into the urethra for a distance of
I 3^^ inches (4 cm.). The meatus is then incised exactly in the mid-
line by drawing the knife out. To allow for subsequent contraction
it is well to incise the canal to a size larger than is desired to perma-
nently maintain it — a meatus that will give passage to a No. 30 F.
sound is sufficiently enlarged. If it is found upon inserting an in-
strument that the constriction has not been entirely cut, any remain-
ing bands should be divided.

At first there may be some hemorrhage from the incision, but
this can usually be controlled by inserting a plug of gauze for an inch
(2.5 cm.) or so within the meatus. Should the bleeding be severe,
the incision should be grasped between the thumb and forefinger
placed on either side of the frenum and should be compressed until
the hemorrhage stops.

The After-Treatment. — This consists in passing a full-sized
straight sound through the meatus, at first daily and then every
second day for a week or ten days, otherwise the narrowing is apt
to reform. When meatotomy is performed as a preliminary to
instfumental examination, the exploration may be performed at
the same sitting.

THE TREATMENT OF STRICTURES BY INSTRUMENTAL

DILATATION

The methods of treatment applicable to organic stricture of the
urethra include gradual dilatation, continuous dilatation, and cut-
ting the stricture either from within — internal urethrotomy — or
from without — external urethrotomy. Two other methods, namely,
divulsion and electrolysis, which are sometimes described in text-
books, are now practically obsolete. Divulsion is so dangerous that
it has been abandoned, while electrolysis is an operation that is of
doubtful benefit and has never found much favor.

Intermittent dilatation of strictures by the passage of instru-
ments of increasing size should be the method of choice when pos-
sible, as, if properly performed, it is without danger. It is, of course,
only applicable to strictures which are permeable, but a large pro-
portion of such may be successfully treated by this method. It is

THE TREATMENT OF STRICTURES 68 1

especially suited to those strictures which are fairly recent, soft, and
dilatable. For old strictures with considerable scar tissue forma-
tion, which are rigid and unyielding, attempts at dilatation are apt
to fail, so, if after a fair trial of the method in these cases it does not
give results, more radical means of treatment should be substituted.
Again, intermittent dilatation is not apt to be successful when ap-
plied to the so-called resilient strictures; these, while dilatable, are
so elastic that they recontract between treatments, and little, if
any, advance is made beyond a certain point. Strictures which are
irritable, that is, those in which attempts at dilatation are followed
by pain and spasm resulting in retention of urine, those in which the
passage of instruments is followed by chills and fever, those compli-
cated by numerous false passages and suppurating fistulous tracts,
and all strictures near the meatus should be cut. For strictures
complicated by cystitis, intermittent dilatation is, likewise, un-
desirable on account of the dangers of pyelonephritis, these require
cutting of the stricture and free drainage of the bladder.

Before making any attempt to treat strictures, the number of
strictures, their exact location, their size, and their extent should be
determined by instrumental exploration of the urethra, and sufficient
time for the tissues to react — at least seventy-two hours — should
elapse after such an examination before the dilatation is begun.
Strictures may occur at any point in the canal except in the prostatic
urethra, but the most frequent sites are: (i) in the region of the
bulbomembranous junction, (2) within 2H inches (6 cm.) of the
meatus, and (3) near the penoscrotal junction. They may be single
or multiple, and in shape annular or tortuous. The opening is
seldom situated in the center of the stricture, but generally lies to one
side of the median line of the urethra.

All strictures have a tendency to contract and in time cause
more or less impediment to the urinary flow with serious results to
the whole urinary tract. The urethra immediately behind the
stricture is the first to feel the effects of this obstruction and the
canal at this point becomes more or less dilated and the mucous mem-
brane is thinned out. Urine collects in this dilated portion and de-
composes, with the result that an inflammation is set up accompanied
by a gleety discharge. This may in time go on to ulceration and
extravasation of urine with the formation of false passages and fis-
tulae. The effect of the urinary obstruction is also felt upon the
bladder. It first hypertrophies and may later become thinned and
dilated, and it is not uncommonly the seat of cystitis. In time

682

THE URETHRA AND PROSTATE

inflammation and dilatation of the ureters and kidney follow, re-
sulting in pyelitis and pyelonephritis.

Mention is made of these complications because their presence,
or absence, and severity, if present, are of direct practical impor-
tance in determining the method of treatment to pursue. If should
further be borne in mind that the stricture itself is usually congested
and the mucous membrane is softened and inflamed, so that in per-
forming dilatation the greatest care and gentleness are necessary to avoid
lacerating and contusing the already irritated tissues. Roughness or
carelessness in introducing the instrument can do only harm. The
beneficial effects of dilatation depend not only upon the mechanical
distention to which the urethra is subjected, but also upon the
simple presence of the instrument which stimulates the tissues to a
mild reactionary hyperemia, which is accompanied by softening
and absorption of the scar tissue. If more than this is done, that is,
if the tissues are so irritated that an inflammation is induced, the
value of the treatment is lost and the original trouble is simply
aggravated.

Instruments. — For strictures above No. 15 French conical steel
sounds of proper curve are employed. These may be of the style

Fig. 690. — Conical steel sound.

shown in Fig. 690, or those with a double taper (Fig. 691) may be
used. The latter instrument has a slight advantage in that, the
shaft being smaller than the shoulder, dilatation of the deeper parts
is effected without unduly stretching the meatus. For strictures

Fig. 691. — Double-taper steel sound.

in the pendulous urethra in front of the bulb a straight conical sound
(Fig. 692) may be employed; such an instrument should not be used,
however, in the deep urethra.

Kollmann dilators are used in preferance to sounds by some

THE TREATMENT OF STRICTURES

683

operators. They are made on the principle of the Otis urethrometer
with four blades regulated by a thumb-screw at the proximal end

Fig. 692. — Straight steel sound.

of the instrument. A dial and indicator show the extent to which the
blades are separated. Two styles of dilators are generally em-

FiG. 693. — Kollmann's straight dilator.

Fig. 694. —Kollmann's curved dila-
tor for the posterior urethra with irrigat-
ing attachment.

ployed — a straight one for the anterior urethra (Fig. 693) and a
curved instrument (Fig. 694) for the posterior urethra. Some are

684

THE URETHRA AND PROSTATE

supplied with attachments for irrigating the urethra. A rubber
sheath is provided with these instruments to be drawn over the
blades (Fig. 695) and so avoid injuring the urethral mucous mem-
brane when the instrument is being closed. This is not used, how-
ever, with the irrigating dilators. When closed the instrument
measures 20 French and may be expanded to 45 French. On account

Fig. 695. — Rubber sheath in position.

of their small size, they may be used for dilating strictures in the
presence of a narrow meatus without first cutting the latter.

With small steel instruments there is a considerable chance of
making a false passage and always the danger of inflicting trauma-
tism, so that for strictures of a smaller size than No. 15 French, soft

Fig. 696. — Flexible urethral bougie.

instruments should be employed. Flexible olivary bougies (Fig.
696) are the best in this class of cases, as they find their way through
the stricture with greater ease and there is less danger of making a
false passage. They are made of woven material covered with
rubber and the best are of French make.

Fig. 697. — Gouley tunneled sound and filiform.

For dilating tight strictures whalebone filiform bougies and tun-
neled sounds (Fig. 697) should be provided. The filiforms should
be at least 18 inches (45 cm.) long and of such size that the tunneled
sounds will slip easily over them. Care should be taken not to use
rough or spHt fiHforms. In fact, any instrument, no matter what the
variety, must be perfectly smooth and sound; imperfect instruments
should be discarded as unsafe.

THE TREATMENT OF STRICTURES 685

Asepsis. — The strictest asepsis should be observed in regard to
the instruments used. Metal instruments should be boiled for five
minutes in a i per cent, solution of sodium carbonate. Filiforms
and the newer gum-elastic instruments will stand moderate boiling.
They may also be sterilized by formaldehyd vapor, after which they
should be well rinsed in sterile water; or they can be immersed first in
a I to 20 carbolic solution and then in a saturated solution of boric
acid.

The glans and meatus should be washed with soap and water
followed by a I to 5000 bichlorid of mercury solution. The urethra is
irrigated both before and after each treatment with a saturated solu-
tion of boric acid or a i to 5000 permanganate of potash solution, and,
if the bladder is infected, it should likewise be irrigated, provided the
stricture is sufl5ciently large to admit a catheter.

The same regard to cleanliness should also apply to the operator's
hands.

Rapidity of Dilatation. — This can only be determined by a study
of the individual case. It is important, however, not to do too much
dilating at a time. It should not be carried to a point where discom-
fort or pain is caused. If the stretching is too rapid, it practically
amounts to divulsion' with its attendant risks of inflammation and
sepsis. Furthermore, tearing of the stricture results in new formation
of tissue which in turn contracts. In the case of tight strictures the
introduction of a second instrument after the first is sufficient. In
other cases the dilatation may be carried further, using three or four
instruments in all.

Frequency of Treatment. — After the passage of an instrument a
reactionary hyperemia sets in and this should be given time to subside
before instruments are reintroduced. A lapse of three to seven days
should, therefore, occur between treatments — on an average an inter-
val of about five days. One will be guided, however, partly by the
amount of contraction that takes place between treatments and also
by the toleration of the urethra. Instruments should never be passed
so frequently as to produce irritation. Very contractile strictures
require the frequent passage of sounds, while for those that are easily
dilated and do not readily reform longer intervals may be allowed.
After the stricture has been stretched to 28 or 30 French, the inter-
vals between the treatments may be increased, at first to once a week,
then once or twice a month, and finally to several times a year.

Extent of Dilatation. — There is no fixed rule to be followed as to
the extent to which a stricture is to be dilated. Various scales have

686

THE URETHRA AND PROSTATE

been devised for determining the approximate size of the urethra
from comparison with the circumference of the penis, but they are
not accurate. As a general rule, dilatation of the stricture to the
size of the meatus, provided it is of normal caliber, is sufficient.

Position of Patient. — The patient should be in the dorsal position
with his shoulders sKghtly raised and thighs a little flexed and rotated
outward. The operator takes his place just above the patient^s
hips and facing toward the patient's body, upon whichever side is
most convenient for him.

Anesthesia. — ^Local anesthesia is only necessary where the patient
is nervous and the urethra hyperesthetic, or upon the first passage
of a sound after urethrotomy, as properly introduced instruments
should cause little or no pain. In such cases the urethra is w^U

Fig. 698. — First step in passing a sound.

distended with a 0.2 per cent, solution of cocain and adrenalin solu-
tion and the solution is confined in the urethra for fifteen minutes by
holding the meatus closed.

Technic. i. Large Strictures. — Under this heading will be con-
sidered strictures above 15 French in size.

With Sounds. — ^A sound of a size that will easily pass through the
stricture — determined by previous exploration — is warmed, well
lubricated with lubrichondrin or other Irish-moss preparation, and
is very gently introduced in the following manner: The operator
grasps the penis behind the corona between the ring- and middle
fingers of the left hand and with the thumb and index-fingers of the
same hand he retracts the foreskin and separates the lips of the mea-
tus. The sound is grasped lightly between the thumb and first two

THE TREATMENT OF STRICTURES

687

fingers of the right hand and is carefully inserted into the urethra.
At this stage the handle of the instrument should be parallel to the
abdominal wall and in line with the folds of the groin (Fig. 698). As

Fig. 699. — Second step in passing a sound.

Fig. 700. — ^Third step in passing a sound.

the sound is pushed onward and downward, the handle of the instru-
ment is gradually swept to the center line (Fig. 699) and is then slowly
raised to a perpendicular so that its beak passes beneath the pubic

688

THE URETHRA AND PROSTATE

arch (Fig. 700) into the membranous urethra. Unless the stricture
be in the deep urethra, it is not necessary to insert the sound into the
bladder — the instrument should simply be passed through the stric-
ture. To insert the instrument the full distance, the handle is
brought forward and downward between the thighs (Fig. 701).
When the point of the sound reaches the stricture, the utmost
gentleness in manipulation should be used in engaging it in the
stricture, and no attempt to enforce the instrument along should be
made, until it is certain that its point has entered the opening in the
stricture. Having passed the sound entirely through the stricture,

Fig. 701. — Fourth step in passing a sound.

it is removed by a reversal of these steps and a second one is intro-
duced. If this causes pain or spasm, it is immediately withdrawn,
and no immediate further attempt to dilate is made. If, however,
the urethra tolerates the second instrument, a third one may be
introduced.

At the next sitting the dilatation is begun by inserting a sound one
size larger than the first instrument used at the previous treatment,
and the dilatation is increased one or two sizes as before. In this way
the treatments are continued until the desired degree of dilatation is
obtained.

The passage of the sound will cause more or less smarting, but it
is only transitory. At times a few drops of blood may follow the
removal of the instrument. The next act of urination is apt to be

THE TREATMENT OF STRICTURES 689

painful, and not infrequently the gleety discharge is increased for
twenty-four or forty-eight hours. The patient should be warned of
these symptoms beforehand.

With the Kollmann Dilator. — The rubber sheath is drawn over the
instrument. The dilator, closed and well lubricated, is then intro-
duced to the seat of constriction and dilatation of the canal is then
produced to any desired extent by turning the thumb-screw at the
end of the instrument. The stretching must be performed very
gradually and with great care, as these instruments are so powerful
that severe trauma may be caused by a too rapid dilatation. If the
patient complains of pain, or if an undue amount of resistance is felt,
the dilatation should be stopped. Having effected the desired
amount of dilatation, the instrument is left in place for several

Fig. 702. — Method of inserting a flexible bougie through a urethral stricture.

moments before it is closed and removed. At subsequent treatments
the dilatation is increased one or two numbers each time.

2. Small Strictures. — For small strictures, that is, below 15
French, soft bougies are employed. A bougie of a size that will read-
ily enter the stricture is selected. The penis is held straight up and
upon the stretch in the fingers of the left hand after the manner de-
scribed above, and the bougie, well lubricated, is carefully passed
straight down to the seat of obstruction (Fig. 702), provided the
latter is in the anterior urethra. An instrument can thus be readily
passed straight as far as the bulbomembranous junction, but here it
is apt to be obstructed. To pass this point and enter the deep ure-
thra, the bougie should be introduced bent as much as possible to
44

690

THE URETHRA AND PROSTATE

the shape of a curved sound, and, when the point reaches the bulb,
slight pressure should be made with the fingers on the perineum (see
Fig. 640). When the instrument strikes the face of the obstruction,
gentle attempts are made to engage its point in the stricture. This
accomplished, the instrument is pushed on entirely through the
stricture, and the dilatation is proceeded with in the same manner as
when using sounds. Steel instruments may be substituted for the
bougies when the dilatation has been carried as high as 15 French.

3. Filiform Strictures.— In the beginning of the treatment of a
filiform stricture it often requires the greatest perseverance and skill
to enter the bladder, as frequently the stricture is of such small caliber

Fig.

703.

-Method of passing a filiform bougie through a stricture by first filling
the canal with filiforms.

or the opening is so situated that it is extremely difficult to engage
even a fine filiform. Once, however, the filiform is inserted, the main
difficulty is surmounted. In introducing filiforms the same method
is employed as for straight bougies. The penis, grasped in the fingers
of the operator's left hand, is put upon the stretch and the filiform,
well lubricated, is inserted along the floor of the canal. If the point
of the instrument is obstructed by a fold of mucous membrane or the
opening of some lacuna, it should be withdrawn slightly and then
slowly reinserted. When the face of the stricture — the location of
which has been previously determined — obstructs the further ad-
vance of the filiform the instrument should be slowly rotated making
attempts to engage its point in the stricture the while, but without
using any force. Sometimes by distending the canal with warm

THE TREATMENT OF STRICTURES ,691

sterile oil it is possible to enter the filiform in the opening of the
stricture. Failing with one filiform, a second may be inserted beside
the first one and the same manipulation is carried out as with the first.
If still unsuccessful, additional filiforms are inserted until the ure-
thra contains six or seven of them. Then gentle attempts are made
to pass each in turn, and usually one will finally slip into the opening
(Fig. 703), whence it can be readily passed into the bladder. If,
after a fair trial, it is impossible to insert an instrument, it is better to
give up the attempt for the time being, and try again a few days
later. Sometimes upon a second or third trial the opening will be
readily located. Gentle manipulation combined with perseverance
will result in success in the great majority of cases, but, if it is impos-

Fig. 704. — Method of passing a tunneled sound over a filiform.

sible to pass the instrument by these means, a urethroscope may be
introduced as far as the obstruction and the filiform inserted by
direct sight.

Having finally passed a filiform, the smallest size tunneled sound
should be inserted over it as a guide (Fig. 704). If there has been
much manipulation in passing the filiform, the operator's efforts had
best stop at this, or, at the most, a second sound is introduced. At
the next sitting the filiform is again inserted and the dilatation in-
creased by inserting larger instruments over it as a guide. After
some dilatation has been thus obtained, soft bougies may be sub-
stituted for the filiforms and tunneled sounds, and the treatments
may be carried out as outlined above.

692. THE URETHRA AND PROSTATE

Accidents and Complications Attending Dilatation. — There are
several troublesome as well as serious complications that may follow
the passage of urethral instruments.

Shock,— In some cases, in spite of the utmost gentleness in ma-
nipulation, the passage of a sound produces sufficient shock to cause
the patient to faint or collapse. It is more likely to occur in patients
upon whom an instrument is passed for the first time, especially if
they are of a distinctly nervous type and look upon the operation
with fear and apprehension.

Much may be done in preventing such a complication when the
nervous element is in evidence by avoiding pain through the use of
local anesthesia. Should fainting occur, the patient's head is to be
immediately lowered and stimulants administered if necessary.

Urethral Chill and Fever. — A form of urinary septicemia spoken of
as urethral chill and fever is liable to follow urethral instrumentation.
It may be the result of absorption of toxic elements which are present
in the urine, in the urethra, or are introduced from without with the
instrument, or it may be the result of shock to the kidneys. The
condition may be of a mild type — in which case a few hours after
the passage of the instrument the patient is seized with a chill fol-
lowed by fever, more or less prostration, and within twenty-four
hours recovery — or it may be severe and progressive and eventually
result in the death of the patient.

Preventive treatment, which is of the greatest importance, should
consist in rigid asepsis, gentle manipulation of urethral instruments,
and antiseptic irrigations or instillations after any instrument has
been used. Actual treatment comprises rest in bed, quinin in 5- or
lo-grain (0.3 to 0.6 gm.) doses, and the administration of genito-
urinary antiseptics. In the presence of urinary suppression, hot
baths or hot packs and stimulants are indicated.

Inflammation of the Urethra, Prostate, or Bladder. — Inflammation
of the stricture, prostatitis, or cystitis may follow as a result of injury
to the urethra or vesical neck from rough or careless introduction of
instruments or from failure to pay due regard to cleanliness. The
inflammation may extend, in addition, from the urethra down the
ejaculatory ducts and set up an epididymitis. In the presence of
such complications, attempts at dilatation should cease until the
acute period is passed and appropriate treatment should be directed
to the cure of the complication.

Hemorrhage. — At times considerable hemorrhage may result from
the passage of instruments. This, as a rule, indicates a false passage

THE TREATMENT OF STRICTURES 693

or an attempt at too great a degree of dilatation at one sitting.
Bleeding may occur, however, in some cases where the urethra is
markedly congested with scarcely any injury to the tissues. The
bleeding usually stops of its own accord. If excessive, the patient
should be kept quietly in bed and cold applications should be applied
to the perineum.

False Passage. — ^Another accident that may result from the use of
urethral instruments is the formation of a false passage by forcing
the instrument through the urethral wall into the surrounding tissues.
It is more liable to happen when using rigid instruments of small size
and probably occurs more frequently than is recognized. When a
false passage is made, there will generally be free hemorrhage at the
time or upon withdrawal of the instrument, and the patient will com-
plain of severe pain and may show signs of shock. At the same time,
the operator, while conscious that the instrument has passed the
obstruction, will recognize that the point is not in the urethra from
the direction of the handle. In such a case, if an examination is
made by the rectum, the point of the instrument will be found in the
perineum near the rectal wall. Furthermore, the instrument, if it be
a rigid curved one, cannot be rotated about its own axis as would be
the case were its point in the bladder.

Following such an accident, if the patient can urinate, the treat-
ment should be expectant in the main; that is, he should be put to bed
and given urinary antiseptics and carefully watched. Should extra-
vasation of urine occur or an abscess develop, prompt and free
drainage should be established and perineal urethrotomy should be
performed.

CONTINUOUS DILATATION

Continuous dilatation consists in inserting a filiform or small
bougie through a stricture and leaving it in place for twenty-four or
forty-eight hours. By the end of this period more or less absorption
of the stricture has taken place, so that there is some dilatation, and
a larger instrument may then be inserted. It is a method that may
be sometimes employed for securing dilatation of tight strictures not
amenable to gradual dilatation, and is worthy of trial in such cases
before resorting to a radical cutting operation. The method has its
objections, however, in that it is necessary to keep the patient under
constant observation and in bed; furthermore, irritation from the
instiument in the urethra is apt to cause urethritis which may in turn

694 THE URETHRA AND PROSTATE

lead to cystitis. The method is contraindicated in the presence of
cystitis or if renal complications exist.

Instruments. — Filiform (see Fig. 631) or soft bougies (see Fig. 630)
may be employed.

Asepsis. — Rigid asepsis is, of course, imperative. The instru-
ments are to be sterilized as already described (page 640). The penis
and meatus are washed with soap and water, followed by a i to 5000
bichlorid of mercury solution. The urethra should be irrigated with
a I to 5000 permanganate of potash or saturated boric acid solution,
and the bladder should be likewise irrigated with boric acid solution,
if possible, upon changing the instruments.

Technic. — The instrument is passed through the stricture after
the method already described for intermittent dilatation (page 689),

Fig. 705. — Showing the method of securing a bougie or catheter in the urethra. (After
Sinclair, Polyclinic Journal, July, 1908.)

and is then securely fastened in place. There are several methods of
doing this, but the following is the simplest and most effective.
Four pieces of adhesive, each about 4 inches (12 cm.) long and }ii inch
(6 mm.) wide are secured to the bougie (which for a space of an inch
(2.5 cm.) in front of the meatus has been thoroughly dried and from
which all grease has been removed) in such a way that one strip lies
upon the dorsum, one on the ventral surface, and one on either lateral
surface of the penis. When a foreskin is present, it is drawn down
over the glans and each strip is carried over it and caused to adhere to
the penis. An additional strip of adhesive i inch (2.5 cm.) wide
is placed horizontally about the penis just behind the corona cover-
ing the four small strips (Fig. 705) This strip should not entirely
encircle the penis, thus avoiding any danger of constricting it.
Where there is no foreskin, a piece of gauze should be interposed be-
tween the glans and the small strips. A liberal sterile gauze dressing
is then wrapped about the penis and the protruding instrument, and
the whole is supported by means of a T-bandage. The urine escapes
along the side of the bougie into the gauze, which should be changed
when saturated. Within twenty-four or forty-ei'ght hours the bougie

CONTINUOUS DILATATION 695

is removed, and the stricture will be found sufficiently stretched to
permit the easy introduction of a larger instrument. This is left in
for the same length of time, and upon its removal gradual dilatation
may be begun.

When there is retention of urine, the filiform is passed as before,
a tunneled catheter is passed over it as a guide into the bladder
(page 690) , and the urine is drawn off. The bladder is then irrigated
and the catheter removed, but the filiform is secured in place as de-
scribed above. Usually urine will begin to pass along the bougie in
a short wliile, but if not it may be withdrawn as often as necessary
by means of a tunneled catheter.

CHAPTER XXI
THE BLADDER

Anatomic Considerations

The bladder is a musculomembranous reservoir for the reception
of urine, lying behind the pubes and in front of the rectum in the
male and the uterus in the female. The bladder may be described
as having (i) a summit, or apex; (2) a base, or fundus, which rests
upon the rectum and into which open the ureters; (3) a body, or
middle portion; and (4) a neck, or constricted portion, opening into
the urethra. It has an average physiological capacity of from 6 to

Fig. 706. — Showing the space above the pubes through which it is possible to enter the
bladder without opening into the peritoneum.

9 ounces (180 to 270 c.c), and a normal maximum capacity of 24
ounces (720 c.c), but, under certain pathological conditions, it may
become enormously distended without rupture. Its shape and posi-
tion depend to a certain extent upon whether it is empty or full.
When empty, it lies well behind the pubes, and upon median section
appears triangular in outline; when partially filled, it becomes
rounded in outline; and, when completely distended, it becomes oval
and rises partly from the pelvis into the abdominal cavity.

696

ANATOMIC CONSIDERATIONS

697

The peritoneum partially covers the anterior surface and sides
of the bladder, and entirely covers the superior surface, extending
posteriorly as far as the level of a transverse line passed between the
upper limits of the seminal vesicles, whence it is reflected to the
rectum in the male, while in the female it is reflected to the uterus.
When the bladder becomes distended, the peritoneum is carried from
the anterior abdominal wall with it, so that in retention of urine
with distention it becomes possible to empty the viscus by passing
an aspirator into it above the pubes without fear of entering the
peritoneal cavity (Fig. 706).

Fig. 707. — The interior of the bladder, i, Trigone; 2, orifice of ureter; 3, muscular
layer; 4, mucous membrane; 5, interureteric line; 6, prostate gland.

Beneath the peritoneal coat lies the muscular layer. It consists
of three coats: external, middle, and internal. The external is com-
posed of fibers arranged longitudinally and in thick bundles over the
anterior and posterior surfaces, but forming a comparatively thin
layer at the sides. The fibers of the middle coat have a circular
arrangement. They are thickest at the neck where they form the
internal vesical sphincter. The internal layer is thinner than either
of the others. Some of its fibers are arranged longitudinally and
others circularly.

The mucous coat is composed of stratified pavement epithelium.

698 THE BLADDER

It is of a pale salmon color. When the bladder is distended, the
mucous membrane forms a smooth lining for the interior, but is
thrown up into thick folds when the viscus is empty, except over the
portion known as the trigone where it is always smooth. The
mucous membrane of the bladder is comparatively insensitive to
touch when in a normal condition, as it has a scant nerve supply, the
most sensitive portion being over the trigone. The trigone is a
smooth triangular space at the base of the bladder, the apex of which
corresponds to the opening of the urethra and the base to a line
passing between the orifices of the two ureters (Fig. 707).

The ureters pierce the bladder wall obliquely and appear upon the
mucous membrane as round openings or oval slits directed forward
and inward. These orifices are from i to iH inches (2.5 to 4 cm.)
apart and about i inch (2.5 cm.) from the beginning of the urethra.

Diagnostic Methods

When examining a case of suspected bladder disease the symp-
toms complained of should first receive careful attention. In addition
to the usual questions, information bearing upon the act of urina tion
should be sought, ascertaining whether there is frequency of urina-
tion, whether there is urgency, whether the act is difficult, whether
pain is present and, if so, its relation to the passage of urine, whether
the force or caHber of the stream is changed, etc., etc.

Frequency of urination is common in all bladder affections where
the mucous membrane is inflamed. It is also a symptom of vesical
stone, tumor, foreign body, or an enlarged prostate. In the presence
of stone this symptom is more marked when the patient is up and
about or after exertion, while in the case of an enlarged prostate it is
more pronounced at night. Frequent micturition may, however,
occur when the bladder is healthy, as in diabetes, in hysteria, in those
who drink large quantities of water, in those whose urine contains
excessive amounts of uric acid or oxalates, etc.

Urgency of micturition, or the feeling of being compelled to pass
urine the instant the desire is felt, points strongly to inflammation of
the bladder or the prostate. Inflammation or irritation of the ure-
thra may also cause it. It is, however, sometimes observed as the
result of certain mental emotions, as fright or apprehension, or mental
suggestions, such as the sound of running water. Irritating urine and
diseases of the nervous system are also causes.

With a history of painful micturition, it is important to determine
the seat of the pain and the exact relation it bears to the act of urina-

EXAMINATION OF THE URINE 699

tion. Pain from prostatitis is generally felt in the perineum or rec-
tum, pain in bladder disease is felt over the pubes, in kidney disease in
the loins. A vesical calculus, however, will frequently cause pain in
the head of the penis. Pain at the beginning of urination, as a rule,
points to some obstruction to the outflow of urine or to inflammation
of the urethra, or it may be the result of very irritating urine. If it
occurs during micturition, it may be caused by inflammation of the
urethra, prostate, or bladder wall. Pain at the end of urination
occurs when a vesical calculus is present or when there is inflamma-
tion involving the neck of the bladder or the prostate. In acute
prostatitis pain is also present upon defecation. When pain is pres-
ent in the intervals between the acts of urination, it may be caused by
a vesical calculus, tumors, or prostatic abscess. When such pain
is increased upon exertion and entirely relieved by rest in the dorsal
position, it is believed by some writers to be pathognomonic of ves-
ical calculus.

Difncuty of urination, as a rule, indicates stricture of the urethra
or an enlarged prostate. Changes in the caliber of the stream gener-
ally point to stricture. In the presence of enlarged prostate, disease
of the bladder wall, and in some nervous affections, the force of the
stream may be greatly diminished, so much so as to amount to a mere
dribbling. A vesical calculus may at times cause a sudden stoppage
of the stream, and this is frequently accompanied by sharp pain.

While a complete history should always be obtained, at the same
time too much importance should not be placed upon symptoma-
tology in the diagnosis of vesical affections. The symptoms are often
deceptive, as they may be common to diseases involving the bladder,
kidneys, or urethra. Even when they clearly point to the bladder
as their seat of origin, they are sometimes of but little value in dif"
ferentiating between the various morbid conditions that may affect
this organ. An accurate diagnosis can only be arrived at by a physical
examination along the lines detailed below.

The methods available for examination of the bladder include
urinalysis, inspection, percussion, palpation, sounding, cystoscopy,
tests of the capacity, the sufficiency, and the absorption power of the
bladder, and the X-rays.

EXAMINATION OF THE URINE

A complete chemical, microscopical, and bacteriological examina-
tion of the urine should be made in all cases of suspected disease of

700

THE BLADDER

the bladder or kidneys. The proper method of collecting the speci-
men for such examination has been previously described (page 305),
but it is outside the province of this work to describe urinalysis; for
this the reader is referred to some of the numerous works devoted to
the subject. The diagnostic significance of modifications in the nor-
mal condition of the urine as far as applies to vesical and renal disease
will, however, be briefly considered.

The quantity of urine passed normally by a healthy adult amounts
on an average to 50 ounces (1500 c.c.) in twenty-four hours, but this
may be greatly modified even in health, depending upon the season of
the year, the quantity of water imbibed, the amount of exercise taken,
the condition of the nervous system, etc., etc. In certain diseases, as
fevers, in affections accompanied by night-sweats or diarrhea, chronic
parenchymatous and acute nephritis, in blockage of a ureter by an
impacted stone or by a twist, in shock, hemorrhage, etc., the output
of urine may be greatly decreased (oliguria). On the other hand, an
increased quantity of urine (polyuria) will be found in hysteria, in
the presence of interstitial changes in the kidney, from the use of
diuretics, in diabetes, in renal tuberculosis, in pyelitis, etc. .

In bladder affections the daily output of urine generally remains
unchanged and, in the presence of marked changes in this respect,
involvement of the kidneys or some constitutional disease may be
implied.

The specific gravity of the urine for a normal individual is fixed at
1.018 to 1.025 ^t 60° F. (16° C). The specific gravity is closely
related to the amount of solids excreted, so to be of value the test
should be applied to a mixture of the urine voided during twenty-four
hours.

In diseases of the bladder the specific gravity is unaffected, but in
renal disease it may be markedly changed. A low specific gravity
and an increased output of urine, when the bladder is diseased, points
strongly to pyelitis or pyelonephritis.

The odor of urine is faintly aromatic, the more marked the greater
the proportion of solids. The taking of such drugs as copaiba,
cubebs, turpentine, and sandalwood modify this characteristic odor.
In diabetic coma the odor of the urine resembles that of chloroform
from the presence of acetone and diacetic acid. Urine that has
undergone ammoniacal decomposition, as is frequently the case in
chronic cystitis, has the characteristic and offensive odor of stale
urine. Urine coming from a bladder which communicates with the
rectum by a rectovesical fistula has an odor of skatol. In the pres-

EXAMINATION OF THE URINE 7OI

ence of ulcerations within the bladder, especially ulcerating tumors,
the urine will be foul-smelling and may even have a distinct odor of
putrefaction.

The color of the urine is a light or dark amber depending upon the
concentration. The presence of blood gives the urine a bright red or
reddish black hue, depending upon whether the hemorrhage is recent
or old. Bile gives a dark yellow or brownish color with a greenish
tinge. In chyluria the urine appears milky. Fevers render the urine
darker than normal. Various drugs may also modify the color, thus
senna, rhubarb, and santonin may color the urine a golden-yellow
or deep red hue, methylene blue gives a greenish-blue color, and
poisoning from carbolic acid, chlorate of potash, or creosote makes
the urine smoky or black.

Transparency. — Normal urine should be clear and transparent
when voided. In bladder diseases the urine is, as a rule, turbid.
Turbidity may be caused by urates, phosphates, blood, pus, epithe-
lium, chyle, or bacteria. The turbidity caused by urates disappears
upon heating the urine, that due to phosphates clears up upon the
addition of one or two drops of acetic acid.

In bacteriuria, as is seen after the passage of unclean instruments,
the turbidity is slight and remains unchanged upon standing, upon
the application of heat, or in the presence of acetic acid. The
condition is recognized by the aid of the microscope.

The turbidity produced by pus is increased upon heating the urine,
and does not disappear upon the addition of an acid. Furthermore,
upon allowing such a specimen to stand a few hours, it will be found
that the pus settles to the bottom leaving the rest of the fluid clear.
A simple test for the presence of pus is to add a little solution of
potassium hydrate to the suspected specimen; in the presence of pus
a gelatinous precipitate is formed.

The reaction of urine is normally slightly acid. The acidity is
increased in fevers, gout, lithemia, rheumatism, chronic Brights dis-
ease, etc., and upon a diet composed chiefly of proteids. A vegetable
diet and large quantities of fluids render the urine neutral or alkaline.

In diseases of the bladder the urine may be acid or alkaline, thus
in acute cystitis the urine is usually acid. In chronic cystitis it may
be either acid or alkaline, always the latter in the presence of ammoni-
acal fermenation, but when due to the gonococcus, tubercle bacillus,
or colon bacillus it is acid. In uncomplicated cases of pyeHtis and
pyelonephritis the urine also has an acid reaction.

702 THE BLADDER

Albuminuria. — Albumin in the urine is not to be considered an
invariable sign of kidney disease. It may result from a number of
local causes, such as blood, pus, prostatic secretion, etc., due to an
inflammation involving the kidney pelvis, ureter, bladder, prostate,
or urethra, without the existence of organic disease of the kidney.
Furthermore, a transient albuminuria is not infrequently the result
of the diet, the amount of excercise taken, nervous shocks, toxins in
the blood, etc. So that it becomes of the greatest importance to
decide whether an albuminuria is of renal origin or is the result of
other pathological conditions, and sometimes this is a difficult matter.
The two may exist together.

Hematuria. — Blood in the urine may have its source in any part of
the genitourinary tract, as the urethra, prostate, bladder, ureters, or
kidneys. While it is not always possible to determine the source of
the hemorrhage from an examination of the urine, there are certain
characteristic differences in hemorrhages from these different regions.

Urethral hemorrhage may arise from acute urethritis or inflamed
strictures, or may follow traumatism to the canal, the passage of in-
struments, etc. In urethral hemorrhage, if the source is from in front
of the compressor urethrae muscle, the blood appears independently
of urination, and may escape from the meatus freely, in drops, or in
the form of long clots. If from the posterior urethra, the blood finds
its way backward into the bladder and when of considerable quantity,
uniformly discolors the urine. If, however, the posterior hemorrhage
is slight, the first and last portions of the urine passed may be blood-
tinged while the intermediary portion will be clear.

Vesical hemorrhage may follow the sudden and complete emptying
of the bladder in retention, or it may be due to trauma, the passage
of instruments, varicosities, stone, inflammation, ulcer, tuberculosis,
tumors, etc. The urine in a recent vesical hemorrhage may be
comparatively clear at first, or only slightly discolored, becoming
more so as the bladder is emptied, until it finally has a bright red color
or consists of almost pure blood. It may contain large clots which
have no definite shape, and, if long retained, they appear black and
tarry. The reaction of the urine is generally alkahne.

Renal hematuria may be due to inflammation, congestion, trauma,
stone, tuberculosis, tumors, the use of strong diuretics, etc., etc. The
blood will be thoroughly mixed with the urine, imparting to the latter
a smoky tint or deep red-brown color. It will be found that the cor-
puscles are greatly changed and without coloring matter, often
appearing as mere shadows, but in cases of ruptured kidney or in

EXAMINATION OF THE URINE

703

severe renal hemorrhage from other cause, they may remain unaltered
and the urine will be much lighter in color. The urine during renal
hemorrhage and just after is generally acid in reaction unless the
bleeding has been severe or pus is present. Large clots are seldom
formed unless the blood coagulates after reaching the bladder, but
there may be found casts of the kidney tubules or cylindrical-
shaped clots from the ureters.

A more positive diagnosis between hematuria of renal origin and
that of the bladder may be made by introducing a catheter and thor-
oughly washing out the bladder with a warm normal salt solution,
being careful to wash out all the clots. If the blood is of renal origin,
the last washings will consist of clear fluid and will remain clear until
more blood flows from the ureters. If, on the other hand, the bleed-
ing arises from the bladder, it will be found impossible to completely
free the fluid from blood.

By means of a cystoscopic examination (page 713) the bladder
may be excluded as the source of the blood if it is found free from
disease, or it may be possible to see blood escaping from one or other
ureter. (See also the absorption test, page 713.)

Pyuria. — Pus in the urine is a common accompaniment of bladder
diseases and also those affecting the urethra and kidneys. Pyuria is
a symptom of suppuration or catarrh in the genitourinary tract, thus
it will be found in pyonephritis, pyelitis, tuberculosis, cystitis, ure-
thritis, etc. It is characterized by cloudy urine in which a thick
yellow sediment settles upon standing.

A differential diagnosis between urethral pus and bladder pus may
be made by having the patient void his urine in two glasses (page 633).
If the urethra is the source, the first glass of urine will be found cloudy
and the contents of the second glass clear or nearly so. When the
bladder is affected the contents of both glasses will be equally cloudy.

In deciding between vesical and renal pyuria, it should be borne in
mind that in the former condition the amount of albumin will be
slight and there will be no renal casts, but bladder epithelium will be
found, while in urine containing pus from the kidney albumin will be
found in a greater proportion than can be accounted for by the
amount of pus, and casts may be present. The use of the catheter or
cystoscope will, however, furnish more exact evidence as to the source
of the pyuria.

To apply the first test, the bladder is thoroughly washed with a
warm normal salt or boric acid solution through a catheter until the
fluid returns clear. The catheter is then clamped and allowed to

704 THE BLADDER

remain in place ten or fifteen minutes, and what urine has entered the
bladder in the meantime is drawn off. If this last specimen is again
turbid we may conclude that the pus comes from the kidneys.

On cystoscopic examination, if the bladder be found free from
disease, this evidence points to the kidney as the source of pus. The
diagnosis may be made absolute if pus is seen exuding from the ure-
ters or a sample of urine obtained by ureteral catheterization con-
tains pus.

INSPECTION

Inspection of the bladder without the aid of instruments is ex-
tremely limited in value. By inspection of the abdomen, it is possi-

FiG. 708. — Vaginal inspection of the bladder. (Ashton.)

ble to recognize a distention of the bladder, and, in the female, by
means of a vaginal inspection, some information as to the condition
of the floor of the bladder may be gained.

Position of Patient. — For ordinary abdominal inspection the
patient lies flat on the back with the body uncovered from the um-
bilicus to the knees, and with the legs extended in the same plane as
the body.

For inspection through the vagina the patient should be in the
dorsal posture.

Technic. i. Abdominal Inspection. — The examiner takes his
position upon one side of the patient and carefully notes any change
in the size or shape of the hypogastrium. A distended bladder

PALPATION 705'

appears as an ovoid tumor with the narrow end down, situated above
the symphysis generally in the median line.

2. Vaginal Inspection. — The examiner sits facing the vulva, and,
by retracting the perineum with the index-finger of the left hand
introduced within the vagina (Fig. 708), the anterior vaginal wall
is exposed for inspection. In this way a displacement of the
bladder, protrusion from distention, or a vesicovaginal fistula may
be recognized.

PERCUSSION

Percussion of the bladder is chiefly of use in determining the
presence or absence of distention. The percussion note over the
hypogastrium is normally tympanitic. When the bladder becomes
distended with fluid, there will be a fluctuating tumor above the
symphysis which gives a flat percussion note and tympany at the sides.
If, however, coils of intestine fill the space between the bladder and
the abdominal wall, as is sometimes the case where the intestines
become adherent as the result of pelvic peritonitis, percusion will
furnish but imperfect information, as a tympanitic note may be ob-
tained and yet the bladder be distended. Any doubt as to the pres-
ence of distention should be immediately settled by passing a catheter
into the bladder.

PALPATION

In the case of thin individuals with relaxed abdominal walls pal-
pation will often give valuable information, but in fat or very muscu-
lar patients it is of limited use. The palpation may be performed
abdominally or bimanually. The latter method yields the most
valuable information. Distention, large foreign bodies, calculi, or
tumors, and tender areas may be thus recognized, and an idea as to
the thickness and sensibility of the bladder walls may be obtained.
It is an especially useful method to employ in examining the bladders
of children.

Digital palpation of the bladder by means of a finger introduced
through a perineal or suprapubic wound or through the urethra in the
female are methods now rarely employed for diagnosis alone, as we
have other equally efficient and more simple means of examination.

Position of Patient. — For abdominal palpation the patient should
be in the dorsal posture with the thighs flexed and the body uncovered
from the umbilicus down. This or the knee-chest posture may be

employed for bimanual examination.

'•706

THE BLADDER

Anesthesia. — In stout individuals or those with rigid abdominal
walls, it may be impossible to make a satisfactory bimanual examina-
tion without the aid of general anesthesia.

Fig. 709, — Abdominal palpation of a distended bladder.

Technic. i. Abdominal Palpation.— The^ examiner stands upon
the left side of the patient, and, placing his right hand flat upon the

Fig. 710. — Bimanual palpation of the bladder.

abdomen just above the pubes, gently palpates the hypogastric region
by means of his finger tips. In thin individuals, if distention is

SOUNDING 707

present, a fluctuating tumor will be recognized. By requesting the
patient to breathe deeply with the mouth open and at the same time
pressing the ulnar border of the hand deeply toward the pelvis, it is
often possible to outline the swelling of a distended bladder more
distinctly (Fig. 709). Such manipulation will frequently cause the
patient to evince a desire to urinate.

2. Bimanual Palpation. — The bladder should be first emptied.
The index-finger of the right hand or the index and middle fingers, if
possible, are introduced into the rectum in the male or the vagina
in the female, after first being well lubricated. The four fingers of
the left hand are then placed above the symphysis, and, while they
make counter pressure toward the base of the bladder, the entire
viscus is palpated bimanually (Fig. 710).

SOUNDING

Palpation of the interior of the bladder by means of a suitable
sound is a method of exploration employed in cases of suspected
stone, foreign bodies, or tumors. The sound is also of value in
testing the sensitiveness of the bladder walls and in estimating the

Fig. 711. — Thompson stone searcher.

amount of intravesical enlargement of the prostate (page 637) and in
the diagnosis of cystocele in the female.

While sounding is a fairly reliable method in searching for a stone,'
there are certain difficulties and sources of error that should be borne
in mind. A stone may be encrusted with blood and mucus and so be
missed entirely, or it may be encysted with only such a small por-
tion exposed that it may be difficult to reach it, or it may lie behind
an enlarged middle lobe of the prostate. Very small stones may like-
wise be missed or they may be so light that slight shock imparted
by contact of the instrument is unnoticed. A tumor, or a contracted
thick bladder wall encrusted with lime salts or phosphates may give
a sensation that is confused with the click of a stone.

Instruments. — For sounding the male bladder a Thompson metal-
lic searcher (Fig. 711) is employed. This instrument has a fairly
large beak, flattened from side to side, which joins the shaft at an

7o8 THE BLADDER

angle of 120 degrees. The shaft should be slender — 12 to 15 French
scale — so it can be readily moved back and forth or rotated from
side to side within the urethra. The Handle of the instrument is
supplied with a guide which indicates the direction of the beak.

Asepsis. — The sound is boiled for five minutes in a i per cent,
sodium carbonate solution. The external genitals are cleansed with
soap and water followed by a i to 5000 bichlorid of mercury solution.
The hands of the operator should be sterilized in the usual way.
The urethra should be irrigated with a saturated solution of boric
acid or a I to 5000 permanganate of potassium solution. The blad-
der is emptied and irrigated with boric acid solution.

Position of Patient. — The patient should be in a recumbent posi-
tion with the hips raised several inches higher than the head and the
thighs extended flat.

Preparations of the Patient. — The rectum should be empty.
About 4 ounces (120 c.c.) in an adult and 2 ounces (60 c.c.) in a child
of a saturated boric acid solution or a normal salt solution should
be introduced into the bladder so as to permit easy movement of
the searcher and to prevent the stone from being concealed in the
folds of mucous membrane.

Anesthesia. — As a rule, no anesthesia is necessary. In sensi-
tive cases the instillation of a few drops of a 2 per cent, solution of
cocain into the posterior urethra will sufi&ce, or the bladder may be
filled with 5 ounces (150 c.c.) of a warm o.i per cent, solution of
cocain to which is added 20 drops (1.25 c.c.) of adrenalin chlorid.
This is to be retained fifteen to twenty minutes. If the bladder is
extremely irritable and the patient nervous, a general anesthetic
may be administered. In children a general anesthetic is usually
necessary.

Technic. — The instrument is well lubricated with lubrichondrin
or one of the other Irish-moss preparations and is introduced in the
same manner as a sound (page 641). When the beak of the instru-
ment reaches the triangular ligament, the fingers ®f the left hand are
applied to the perineum and assist in guiding the point into the open-
ing. The handle of the sound is then brought down between the
thighs and the instrument is at the same time gently pushed into
the bladder. As the instrument traverses the fixed curve of the
urethra, pressure should be made over the region of the pubes to
relax the suspensory ligament of the penis (see Fig. 637). To be
sure the point is within the bladder, the instrument should be intro-
duced a distance of about 8 inches (20 cm.).

SOUNDING

709

A systematic examination of the entire bladder is then per-
formed. The instrument, being held lightly between the thumb
and the forefinger of the right hand, is first inserted to the full length,
and is then slowly withdrawn, rotating the beak from side to side,
so that the point of the sound is brought into contact with every por-
tion of the bladder wall. In this way any thickness or rigidity of
the bladder wall, as is found in hypertrophy, chronic inflammatory
conditions, and in the presence of firm growths, may be recognized.
In the same manner the sensitiveness of the organ may be tested.
Normally, the bladder has but little sensation to touch except in the
region of the trigone. In cases of posterior urethritis this region may

Fig. 712. — Palpation of a stone lodged above the vesical openings.

be markedly hyperesthetic. Local areas of increased sensitiveness
point to ulceration or new growths, while in cases of cystitis the entire
bladder will be sensitive.

In examining for suspected stone the search should be carried out
in the same systematic manner, carrying the instrument to the fun-
dus first and then tapping each lateral wall in succession as the in-
strument is withdrawn to the vesical neck. The upper wall of the
bladder is then palpated by depressing the handle of the instrument
well down between the thighs, and as an aid the bladder wall may be
depressed toward the instrument by means of the free hand placed
above the pubes. In this way a stone located above the vesical open-
ing may be located (Fig. 712). The beak of the sound is then rotated
and turned downward. In doing this, if the point catches in the
mucous membrane, the handle should be depressed so as to lift the
beak clear of the floor. The posterior prostatic region is then ex-

7IO

THE BLADDER

plored. Should the prostate be enlarged, the handle of the instru-
ment should be raised, somewhat, and, with a finger in the rectum,
it will be possible to bring a stone, if one is present, within reach of
the instrument (Fig. 713).

When the sound strikes a stone, the examiner will recognize the
fact by a distinct chck that may sometimes be heard as well as felt.
Some idea as to the consistency of the stone may be gained from the
sharpness of the ring; a high-pitched metallic chck generally indi-
cates a hard stone (oxalate), while a dull low-pitched sound would
indicate a soft stone (urate). It is also possible to determine whether

Fig. 713. — Palpation of a stone lodged behind the prostate with the aid of a finger

in the rectum.

a stone is rough or smooth from the sensation imparted as the beak
of the instrument is drawn over its surface. If possible it should
be ascertained whether a stone is movable or fixed by attempting to
dislodge it with the beak of the instrument or by changing the posi-
tion of the patient, that is, after the stone is located, the sound is
withdrawn and the patient is put in the knee-chest posture, on re-
suming the dorsal position, the instrument is again inserted and any
change in the position of the stone is noted.

To determine the size of the stone, the beak of the instrument is
carried to the posterior surface and the position of the meatus is
marked on the shaft. The instrument is then slowly withdrawn,
tapping the stone the while, until the anterior border is reached and
the relation of the meatus to the shaft is again noted. Subtracting

TEST OF THE BLADDER CAPACITY Jit

the latter measurement from the first one gives approximately the
length of the stone in its antero-posterior diameter. The transverse
diameter may be likewise estimated by tapping the stone from side
to side.

At the completion of the operation the instrument is removed by
a reversal of the steps taken in its insertion, and the bladder is
irrigated with a warm saturated solution of boric acid, followed by a
deep urethral instillation of i to 1500 silver nitrate solution.

TEST OF THE BLADDER CAPACITY

By distending the bladder with fluid its capacity is readily esti-
mated, and from this it may be determined whether the bladder is

Fig. 714. — Catheter and syringe for estimating the bladder capacity.

normal, atonic, or contracted. If large quantities of solution can be
injected without inducing contractions, it may be inferred that atony
or paralysis exists, but if, on the other hand, the bladder is in an in-
flamed condition or is contracted, it will often not be possible to
inject more than an ounce (30 c.c.) or so without the patient com-
plaining of distention.

This test is also useful in the diagnosis of a ruptured bladder.
By injecting a definite amount of solution into the bladder and noting
the quantity that returns, the presence or absence of rupture may be
readily recognized. In performing this test, however, it is neces-
sary to inject 6 to 8 ounces (180 to 250 .c.) of fluid, as small amounts
may give misleading results.

Apparatus. — An ordinary soft-rubber catheter for the male or a
glass catheter for the female and a large syrmge, such as a Janet or
Record (Fig. 714), are required.

Asepsis. — The apparatus is sterilized by boiling and the exami-
ner's hands are to be thoroughly cleansed. The external genitals
are washed with soap and water, followed by a i to 5000 solution
of bichlorid of mercury, and the urethra is irrigated with a satu-

712

THE BLADDER

rated solution of boric acid or a i to 5000 solution of potassium
permanganate.

Position of Patient. — The patient should be in the dorsal position
upon a flat table.

Technic. — The catheter, well lubricated, is introduced into the
bladder and all the urine is drawn off. The syringe is then filled
with a warm (100° F. {^S° C.)) saturated solution of boric acid or
normal salt solution, and the solution is slowly injected into the
bladder (Fig. 715). As soon as the patient complains of distention,
the injection is stopped and the quantity of fluid that has entered
the bladder is estimated. The syringe is then disconnected from

Fig. 715. — Method of distending the bladder with fluid when estimating its capacity.

the catheter and the fluid is allowed to escape from the bladder
through the catheter.

ESTIMATION OF RESIDUAL URINE

Normally, with micturition the bladder empties itself almost
completely, but, if the evacuation of urine is interfered with by
obstruction from a stricture or an enlarged prostate or from the con-
dition of the bladder itself, as, for example, in atony, cystocele, etc.,
the evacuation will be incomplete and more or less residual urine
will remain. The amount of residual urine often has a bearing upon
the prognosis as well as the treatment to be pursued in a given case,
and its estimation is thus of some importance.

Apparatus. — All that is required is a Mercier catheter with a
coude curve and a glass graduate. .

Asepsis. — The catheter is sterilized by formalin vapor or by
immersion in a i to 20 carbolic acid solution followed by rinsing in

CYSTOSCOPY

713

sterile water. The external genitals are cleansed in the usual way,
and the urethra is irrigated with a mild antiseptic solution. The
hands of the operator should likewise be sterile.

Technic. — The patient is instructed to empty his bladder as
completely as possible while in the upright position. He is then
placed in the dorsal position. The catheter, well lubricated, is in-
troduced into the bladder, and any urine that remains is drawn off
into the graduate and is measured. This may amount to from i
dram (4 c.c.) to several ounces. If there is more than 2 ounces
(60 c.c.) of residual urine, it is certain that some interference with
the voluntary evacuation of the bladder exists. Observation of the
flow of urine from the catheter may also furnish valuable information.
If the urine is expelled in a strong gush, it indicates that the muscu-
lar structure of the bladder is competent, while, if it simply escapes
by gravity, an atonic condition is probably present.

THE ABSORPTION TEST

A test sometimes employed to determine whether blood in the
urine has its source in the bladder consists in injecting a solution of
iodid of potassium into the bladder and later testing the saliva for
iodin. Ordinarily there will be no absorption from the healthy
bladder, but, if raw or ulcerated surfaces are present, absorption of
the iodid of potassium is quite rapid and iodin will be eliminated in
the saliva.

Apparatus. — There will be required an ordinary soft-rubber irri-
gating catheter, a Janet syringe, and a test-tube.

Asepsis. — The usual aseptic precautions employed when intro-
ducing an instrument into the bladder should be observed.

technic. — The patient first empties his bladder. The soft
catheter is then introduced and the bladder is well irrigated with nor-
mal salt solution. From 2 to 3 ounces (60 to 90 c.c.) of a i per cent,
solution of potassium iodid are then injected into the bladder and the
catheter is removed. At the end of ten or fifteen minutes some of
the patient's saliva is collected in a test-tube and is tested for iodin.
This is readily done by adding a few drops of a dilute solution of
cooked starch and stirring with a glass rod dipped in fuming nitric
acid. If iodin is present in the saliva, the mixture will turn blue.

CYSTOSCOPY

Cystoscopy is the inspection of the interior of the bladder by the
aid of an instrument especially devised for the purpose, the cysto-

714

THE BLADDER

scope. It is a method of examination that may be of the greatest
value when employed by an expert, but it is of limited use in the
hands of the inexperienced, for it is absolutely essential that the
examiner be familiar with the appearance of the normal bladder be-
fore he can recognize and correctly interpret pathological conditions,
and this can only be learned by practical experience.

By a cystoscopic examination properly carried out it is possible
to obtain an accurate picture of the interior of the* bladder and to
study the appearance of the ureteral orifices as well as the condition
of the urine that escapes from them; that is, whether it contains pus
or blood. Cystoscopy thus becomes of service not only for diagnosis
of obscure vesical affections that may escape recognition by other
means, but also in the diagnosis between a possible vesical and kidney
lesion.

The method has, however, certain limitations. It cannot be
employed with success in the presence of marked hypertrophy of the
prostate, when the bladder is greatly contracted, or when there is
an active vesical hemorrhage going on which obscures the view. It
is contraindicated in the presence of acute urethritis, acute prosta-
titis, epididymitis, or acute cystitis. The urethra must, as a rule,
be of a caliber of 22 to 24 French, and, if the meatus is narrow, it
must be first cut, or, if strictures are present, they must be suffi-
ciently dilated before the instrument can be introduced.

Instruments. — Cystoscopes are of two types, the direct view, in
which the light is on the convex side of the beak and the eye looks
down a straight tube through a window in the distal end, and the
indirect view, in which the light is placed on the concave side and the
image is reflected at right angles to the eye-piece, thus giving an
inverted picture. Some of the newer indirect view instruments,
however, give an upright picture.

For the simple examination of the bladder the use of an indirect
view cystoscope gives the best results, as with such an instrument the
roof, floor, and walls of the bladder — excepting a part of the posterior
wall — may be readily inspected. The examination may be satisfac-
torily performed either by means of a special exploring cystoscope,
such as the Nitze, Otis, Schapira, etc., or by means of one of the
ureter-catheterizing cystoscopes to be described later on (see page
759). The exploring cystoscope has an advantage over the cathe-
terizing instruments, however, in that its shaft being small the exam-
ination is less painful.

The Nitze instrument (Fig. 716) is the oldest type of the indirect

CYSTOSCOPY

715

or right-angled view cystoscope. It consists essentially of a metal
tube 9 inches (23 cm.) long and from 15 to 24 French scale in size,
having at the distal end a short beak fitted with a small electric lamp
and on the concave side of the instrument at the point where the beak
joins the shaft a lens, beneath which is placed a prism. From the
prism the image is reflected at right angles through a series of lenses
to the eye-piece. A small knob soldered on the circumference of the
eye-piece indicates the position of the cystoscopic window. The
instrument is fitted with two-way stopcocks for irrigation should the
lens become cloudy. Space does not permit a description of the
many modifications of the Nitze instrument, each of which has ad-
vantages of its own.

The illumination for cystoscopes may be furnished from a six-
or eight-cell battery or from the street current provided a controller is
employed.

Fig. 716. — Nitze's cystoscopes*.

Additional instruments required are a Janet syringe, holding
from 3 to 4 ounces (90 to 120 c.c), or an irrigating jar, and a catheter.

Asepsis. — FormaHn vapor may be employed or the instrument
may be immersed in a i to 20 carbolic acid solution for ten minutes
followed by rinsing in alcohol and then sterile water. The external
genitals should be cleaned with soap and water followed by a i to
5000 bichlorid solution. The examiner's hands are to be likewise
sterilized.

Position of the Patient. — The examination is performed with the
patient in the Kthotomy position and with his buttocks close to the
edge of the table or, as preferred by some operators, in the semi-
recumbent posture. The best form of table to use is one provided
with uprights which are surmounted with double inclined rests about
15 inches (37 cm.) above the level of the table for the support of the
patient's thighs and knees (Fig. 717). It is a great convenience to

7i6

THE BLADDER

have a table provided with a wheel within reach of the operator, by
turning which it may be raised or lowered at will.

Anesthesia. — ^Local anesthesia of the urethra is generally neces-
sary, though in exceptional cases cystoscopy may be performed with-
out anesthesia. The instillation into the deep urethra of a few drops
of a 2 per cent, solution of cocain may be sufficient. A sensitive
bladder may be rendered anesthetic by first emptying it and then
filling it with 5 ounces (150 c.c.) of a warm o.i per cent, solution of
cocain to which is added 20 drops (1.25 c.c.) of adrenalin and having

Fig. 717. — Table with Bierhoff's leg supports for cystoscopy. (Greene and Brooks.)

the whole amount retained for fifteen to twenty minutes. Guyon's
method of obtaining local anesthesia consists in injecting into the
rectum three-quarters of an hour beforehand a mixture containing:

Antipyrin,

Laudanum,

Water,

gr. xiv (0.9 gm.)
lllx.(o.6 c.c.)
5iii (90 c.c.)

In some adult cases, where the urethra, bladder, or prostate are
extremely sensitive, and in children general anesthesia may be
required.

Preparations. — The bladder should first be emptied and should
then be thoroughly irrigated with a saturated solution of boric acid
by means of a catheter and Janet syringe until the fluid returns clear,
as a satisfactory examination can be made only in a clean bladder. If

CYSTOSCOPY

717

an irrigating cystoscope is employed, the irrigation may be performed
through the sheath of the instrument. Four to 6 ounces (120 to
180 c.c.) of a saturated solution of boric acid or normal salt solution
are then injected into the bladder and allowed to remain so as to
smooth out the folds of mucous membrane and furnish space for the
cystoscope to be moved about.

If there is bleeding from the bladder sufficient to interfere with
the examination, a solution of i to 3000 adrenalin chlorid may be
injected through the catheter and allowed to remain for about ten or
fifteen minutes, when it is drawn off and the bladder is distended.

Fig. 718. — Position of the cystoscope for inspection of the root ot the bladder.

Everything that will be required during the examination should
be placed near at hand, and the cystoscope light should be tested
under water before the instrument is introduced.

Technic. — The instrument after being thoroughly tested, is lubri-
cated with glycerin or lubrichondrin and is gently passed into the
bladder in the same manner one would pass a sound. Great care
should be taken not to use any force in introducing the instrument.
If there is any difficulty in making the beak enter the opening in the
triangular ligament, pressure applied on the perineum by the fingers
of the free hand will assist in its passage into the membranous urethra
(see Fig. 640) . As soon as the instrument has entered the bladder, it
can be freely moved about.

The operator then takes his seat with his eyes on a level with the
ocular end of the instrument, the light is turned on, and the interior of

7i8

THE BLADDER

the bladder is systematically inspected, care being taken not to touch
the mucous membrane with the light. It should be remembered that
in using a prism form of indirect view cystoscope the image will be
reversed, as in the laryngoscope. The instrument being introduced
with its beak turned up, the roof of the bladder will first come into
view (Fig. 718). In order to see as much of this portion of the blad-
der as possible, the instrument should be rotated first in one direction
and then in the other and then pushed farther in, repeating these
movements until the entire roof has been inspected. By depressing
or elevating the shaft a more complete view of the anterior or poste-
rior wall is obtained. The beak of the instrument is then rotated so
that it faces toward the floor of the bladder (Fig. 719), and the instru-

FiG. 719. — Position of the cystoscope for inspection of the floor of the bladder.

ment is withdrawn until the prostate appears as a clear dark red cres-
cent. If hypertrophied, it will appear deformed in the picture, and
the degree of its enlargement and its location may be recognized.
The instrument is next pushed slowly backward in the median line
as far as the fundus, the examiner carefully inspecting the floor of the
bladder as the instrument is advanced. By slightly rotating the
instrument first to one side and then to the other a large extent of the
floor may be viewed.

The mucous membrane normally has a salmon or grayish-pink
tint and is smooth and glossy with the superficial vessels standing
out here and there. When acutely inflamed, it becomes a dark red
color and has a velvety appearance and there is a general hyperemia
so that the small blood-vessels disappear. In chronic inflammation
the mucous membrane may take on a grayish tint and the folds

CYSTOSCOPY IN THE FEMALE 719

appear much thickened. This region should be carefully examined
for small stone, tuberculous ulcers, and new growths.

Having inspected the floor, the instrument is turned 45 degrees to
one side and is gradually withdrawn from the fundus. In this way
the opening of the ureter on that side will come to view as an oblique
slit or as a small dimple (Fig. 720) in a prominent papilla, and, if it is
watched, it will be seen to emit a gush of urine every ten to fifteen
seconds. If not immediately found, the interureteric line, which runs
transversely across the central field between the two ureters, should
be identified and, by tracing this to one side or the other, the ureteral
orifice may be located. The appearance of the ureteral orifice should
be carefully inspected for signs of ulceration, erosions, or inflamma-
tion which might indicate a diseased kidney on that side, and likewise
the character of the urine which escapes should be noted, i.e., whether
clear, purulent, or bloody.

Fig. 720. — Appearance of the ureteral orifices.

The lateral wall is carefully inspected as far as the vesical neck.
The instrument is then rotated 90 degrees to obtain a view of the
opposite side and it, including the ureter of that side, are examined
while the instrument is slowly passed to the fundus again. Follow-
ing some such scheme, the entire bladder may be inspected except
a portion of the posterior wall which is invisible with an indirect view
instrument. During the examination it is well to shut off the light
at intervals so as to allow the instrument to cool.

At the end of the examination the light is turned off and the
instrument is carefully withdrawn, taking care to see that the beak is
again turned up before this is done. The patient's bladder is then
emptied and irrigated with boric acid solution.

CYSTOSCOPY IN THE FEMALE

The examination of the female bladder may be pertormed by
using an ordinary male cystoscope or a somewhat shorter female

720

THE BLADDER

instrument. Such examination, which is less difficult than in the
male on account of the short length of the urethra, requires no sepa-
rate description, as the technic differs in no essential way from the
method used in the male. Another method of vesical inspection is

Fig. 721 — Instruments for cystoscopy in the female, i, Electric-lighted open-
tube cystoscope; 2, urethral dilator; 3, urine evacuator; 4, alligator- jawed forceps; 5,
ureteral searcher.

Fig. 722. — Kelly's open-tube cystoscope.

by means of Kelly's open straight tubes and atmospheric distention
of the bladder.

Instruments. — For cystoscopy according to Kelly's method there
will be required: Kelly's specula, or some of their modifications,
an electric head light or head mirror, a Kelly dilator to stretch the

CYSTOSCOPY IN THE FEMALE 72 1

external urethral orifice, a urine evacuator to draw off residual urine,
alligator forceps for holding cotton swabs, and a ureteral probe for
probing the mucous membrane or locating the ureteral orifices
(Fig. 721).

The specula consist of cylindrical tubes 3 % inches (8 cm.) long,
of equal length' throughout, and in sizes of from % inch (5 mm.)
in diameter up to % inch (20 mm.). Those below No. 12 are gen-
erally employed for diagnostic purposes. The tubes are of German
silver or nickel-plated, each having a conical expansion at the ocular
end to which is fastened a strong handle (Fig. 722) Each tube is
supplied with an obturator having a conical end-piece. The illumi-

FiG. 723. — Enlarged view of an electric-lighted open-tube cystoscope

nation is furnished by reflected light or from an electric head light,
the latter being preferable. These specula, however, may be ob-
tained furnished with an electric light at the distal end (Fig. 723), an
instrument which simplifies the operation for one not accustomed to
the use of a head light.

The urethral dilator is a cone-shaped metallic instrument which
gradually increases in size from the point until at the base it meas-
ures i%5 inch (16 mm.) in diameter. The instrument is graduated
so that the examiner can determine the required amount of dilatation.

The urine evacuator is necessary for the purpose of removing the
urine that collects in the floor of the bladder which would otherwise

722

THE BLADDER

interfere with the examination. It consists of a suction bulb at-
tached by means of a long delicate rubber tube to a small perforated
glass bulb. In the Luys' open tube cystoscope an aspirating tube is
incorporated in the instrument.

Asepsis. — All the instruments with the exception of the light car-
rier may be boiled for five minutes in a i per cent, soda solution.
The latter may be steriHzed by immersion in a i to 20 carbolic acid
solution followed by rinsing in sterile water. The operator's hands
should be carefully sterilized and the external genitals and mouth
of the urethra should be cleansed with soap and water, followed by
a I to 5000 solution of bichlorid of mercury.

Fig. 724. — Method of dilating the urethra. (Ashton.)

Position of Patient. — Two positions are employed, the dorsal and
the knee-chest. In the dorsal position the patient lies with the head
and thorax resting on the table and the hips elevated 8 to 10 inches
(20 to 30 cm.) upon cushions so as to raise the pelvis and permit the
bladder to distend with air when the cystoscope is introduced.
While the dorsal posture is the least wearing on the patient, it is not
suited for stout persons. In such cases, the knee-chest posture, with
the knees separated 10 or 12 inches (25 or 30 cm.), is more suitable.

Preparations of Patient. — Before the patient is placed upon the
table the rectum and bladder should be emptied.

Anesthesia. — Local anesthesia is generally sufficient except in
very nervous women. A pledget of cotton saturated with a 2 per
cent, solution of cocain introduced upon an applicator within the

CYSTOSCOPY IN THE FEMALE

723

meatus and allowed to remain for five minutes will anesthetize the
urethra sufficiently to allow it to be dilated.

Technic. — As a rule, it is first necessary to dilate the urethral

Fig. 725. — Method of holding the open- tube cystoscope during its introduction into

the bladder.

orifice; the rest of the canal, being very dilatable, is easily stretched
by the cystoscope in its passage. The dilator is lubricated with one
of the Irish-moss preparations and is introduced into the urethra with
a slight boring motion until the required amount of dilatation is

<W~rr

Fig. 726. — Inspection of the female bladder through an open-tube cystoscope.

reached (Fig. 724). Dilatation to about No. 12 on the dilator is
generally sufficient. A speculum of a size from 7 to 10, depending
upon the age of the patient, is then selected. It should be grasped in

724

THE BLADDER

the operator's right hand, the cylinder l5dng between the index and
middle fingers, with the thumb against the obturator, as shown in
Fig. 725. With the fingers of the left hand the labia are separated
and the speculum, well lubricated, is introduced through the urethral
orifice, whence it is gradually pushed into the bladder following the
urethral curve under the pubic arch. Upon removal of the obtura-
tor, air rushes in distending the bladder. If, when the patient is in
the knee-chest position, the bladder does not balloon up, two fingers

Fig. 727. — Method of removing residual urine during a cystoscopic examination.

may be introduced into the vagina so as to distend it with air.
The illumination is then turned on, or, in the absence of a self-
illuminated speculum, the light from the electric head light or head
mirror is thrown into the bladder through the speculum, and the
bladder is systematically examined (Fig. 726).

By alternately moving the speculum from side to side and depress-
ing or elevating the handle all portions of the bladder may be
inspected. If the patient is in the dorsal posture, urine soon collects
in a pool on the base of the bladder, and this must be removed as
often as required by means of the evacuator (Fg. 727). By means of
the cotton mops held in the alligator forceps, mucus, blood, or pus
that may obscure a clear view of the mucous membrane may be
wiped away.

IRRIGATIONS 725

SKIAGRAPHY

The X-rays are sometimes used in locating a vesical stone which,
from being buried in a pocket or being situated behind the prostate,
may escape detection by other means. The success of the skiagraph
depends to a large extent upon the composition of the calculus. Oxa-
late and phosphate stones cast a dense shadow, but those composed
of urates and uric acid cast very faint shadows, and so may be
missed entirely. The bony walls of the pelvis may likewise interfere
and give a negative result. To secure a satisfactory radiograph it
is essential that the bowels be emptied by a purge administered the
night before followed by an enema in the morning.

By injecting into the bladder a solution of bismuth or one of the
silver salts and taking a radiograph immediately, much valuable
information as to the size and position of the bladder and the presence
or absence of diverticula, sacculations, tumors, or obstruction at the
vesical neck may be obtained.

Bismuth is used in a 10 per cent, watery solution. Of the silver
salts, collargol ih 2 to 10 per cent, solution and argyrol in 25 per cent,
solution are generally employed. Eight ounces (250 c.c.) of solu-
tion will be sufficient.

Therapeutic Measures
IRRIGATIONS

Irrigation of the bladder may be employed either for simple
cleansing purposes, as is required in preparation for an instrumental
examination or operative procedure, or to produce a local effect up>on
the mucous membrane. Irrigations are thus of the greatest value in
the treatment of various inflammatory affections of the bladder. In
acute cystitis, however, on account of the distention produced, they
often increase the pain and may aggravate the trouble. They should
be employed, however, in acute cases if the bladder does not com-
pletely empty itself and there is decomposition of urine. Irrigations
are also contraindicated where the bladder cannot hold more than i
ounce (30 c.c.) of fluid without exciting a desire to urinate; in such
cases, instillations should be substituted.

There are two methods of performing vesical irrigation; (i) by
injecting the fluid in sufiicient quantity to distend the bladder and
having it retained a short time before allowing it to escape, and (2)
by using a double-flow catheter which allows the fluid to escape as fast

726

THE BLADDER

as it flows in. In the majority of cases the former is the preferable
method as a certain amount of distention of the bladder is necessary
in order to wash out pus, bacteria, and debris from the folds of
mucous membrane.

Apparatus. — A large glass funnel, 4 feet (120 cm.) of rubber
tubing, a soft-rubber catheter, a large glass graduate, a thermometer,
and a waste-pail are required (Fig. 728).

A double-flow soft catheter (Fig. 729) may be employed in place of
the ordinary catheter if desired. When this is used a graduated glass
irrigating jar should take the place of the funnel.

Fig. 728. — Apparatus for bladder irrigations.

Asepsis. — The apparatus is boiled and the thermometer sterilized
by immersion for 10 minutes in a i to 500 bichlorid of mercury solu-
tion followed by a thorough rinsing in sterile water. The operator's
hands should be thoroughly scrubbed.

Solutions Used. — Normal salt solution (5i (4 gm.) of salt to the
pint (500 c.c.) of water), a saturated solution of boric acid, silver
nitrate i to 1 5,000 to i to 5000, potassium permanganate i to 8000 to
I to 4000, bichlorid of mercury i to 100,000 to i to 5000, formalin
I to 5000, oxycyanid of mercury i to 5000 to i to 2000, carboHc acid,
etc., are among the numerous agents employed.

It is always well to begin the treatment with the weaker solutions
and gradually increase the strength as indicated. " After an irrigation
with a poisonous drug, the bladder should be douched with normal
salt solution to prevent absorption.

Temperature. — The irrigating fluid should be at a temperature of
100° to 105° F. (38° to 41° C).

IRRIGATIONS

727

Quantity.— The irrigations should be continued until the fluid
returns clear. As a rule about i pint (500 c.c.) of solution will be
sufficient.

Fig. 729. — Return-flow soft-rubber catheter.

Fig. 730. — Irrigation of the bladder by the single-catheter method.

Frequency. — When there is profuse suppuration and rapid decom-
position of urine, the irrigations are employed twice a day. In a
mild case daily irrigations or on alternate days will suffice. A lapse of
one or two days, however, should intervene when very strong solu-
tions are employed.

728

THE BLADDER

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

Preparation of Patient. — The bladder should be empty. The
external genitals are washed with soap and water followed by a i to
5000 bichlorid of mercury solution, and the urethra is irrigated with a
boric acid or i to 5000 potassium permanganate solution.

Technics — i. Single Catheter Method. — The catheter, well lubri-
cated, is gently passed into the bladder, and any residual urine is

Fig. 731. — Irrigation of the bladder with a double-flow catheter.

allowed to escape. The funnel is filled with from 3 to 6 ounces (90
to 180 c.c.) of the solution, and the tubing leading from the funnel is
attached to the catheter, first taking care to see that air or any cold
solution is expelled from the tube. The funnel is then raised 2 or 3
feet (60 to 90 cm) above the patient and the solution is permitted to
slowly flow into and distend the bladder. As soon as the patient
complains of the distention, the flow is shut off. After allowing the
solution to remain in the bladder a few moments, the funnel is low-
ered below the level of the bladder and the fluid is allowed to escape

AUTOIRRIGATIONS 729

into the waste-pail (Fig. 730). The funnel is then refilled and the
process repeated until the fluid returns clear.

In performing the irrigation care must be observed not to overdis-
tend the bladder. Just how much can be injected at a time depends
upon the individal case, but it should not be sufficient to cause any
pain. Entrance of air into the bladder should also be guarded
against.

2. Double-flow Catheter Method. — The technic varies a little from
that just described. The catheter is passed into the bladder and the
irrigating tubing is attached to the inflow tube of the catheter. The
reservoir, filled with the entire amount of fluid to be used during the
irrigation, is then raised 2 to 3 feet (60 to 90 cm.) above the bladder
and the solution is allowed to flow. As fast as it enters the bladder, it
is carried off again through the outflow tube (Fig. 731); but, by
occasionally compressing the outflow tube, the bladder may be more
or less completely filled before the fluid is permitted to escape.

AUTO -IRRIGATIONS

While it is not advisable to allow a patient to irrigate his own
bladder in the presence of a severe cystitis, auto-irrigation may be
safely performed for the purpose of keeping the bladder clean by those
who are compelled to lead a catheter life The patient should, how-
ever, be carefully instructed how to sterilize the catheter, his hands,
etc., and in the proper method of performing the irrigation, and he
should be fully warned of the dangers of neglecting to follow the
strictest rules of cleanliness.

Apparatus. — A douche bag with a capacity of i quart (i liter), 4
feet (120 cm.) of rubber tubing, a T-shaped glass tube, a soft-rubber
catheter, and a waste-pail comprise the necessary outfit. The
T-shaped glass connection is placed between the catheter and the
tubing of the reservoir and to its long arm is attached another piece
of tubing that leads to the waste-pail. A shut-off clip is placed on the
tube leading from the irrigator and another upon the waste tube

(Fg. 732)-

Solution Used. — It is better not to entrust the patient with strong
antiseptic solutions; instead a saturated (4 per cent.) solution of boric
acid should be used. It is prepared by dissolving about 5 teaspoon-
fuls (20 gm.) of boric acid crystals in i pint (500 c.c.) of hot water.

Position of Patient. — The irrigation is most conveniently given
with the patient sitting in a chair and with the waste-pail on the floor
between the legs.

730

THE BLADDER

Technic. — The reservoir is filled with i pint (500 c.c.) of warm
(105° F. (41° C.)) boric acid soluton and is hung on a hook about 3
feet (90 cm.) above the level of the bladder. The patient then intro-
duces his catheter into the bladder and draws off the urine The
solution is allowed to flow from the tubing to expel any air or cold
fluid, and the tubing is then .connected with the catheter. The
solution is allowed to flow into the bladder until there is a feeling of

Fig. 732. — Apparatus for auto-irrigation of the bladder.

distention, when the flow is shut off and the outflow pipe is opened
allowing the fluid to escape into the waste-pail. The process is
repeated until the reservoir is emptied.

INSTILLATIONS

Instillations differ from irrigations in that a smaller quantity of
solution is used and the fluid is allowed to remain in the bladder.
Stronger solutions can thus be employed and it is possible to obtain a
more lasting effect upon the mucous membrane than from an irriga-
tion. Instillations are very useful in all cases of cystitis, but espe-
cially those in which the inflammation is particularly severe about the
trigone and vesical neck.

The immediate effect of the instillation is to induce a moderate
congestion accompanied by an increased desire to urinate and sortie
pain,but this soon passes off and is followed by reaction and a gradual
relief of the symptoms.

Sjrringe. — A Keyes-Ultzmann syringe will be required (Fig. 733).
When, however, it is desired to inject more than 12 dram (2 c.c.)

CYSTOSCOPIC TREATMENT 73!

of solution, a soft-rubber catheter and glass syringe of the desired
capacity should be substituted for the above.

Solutions Used. — Silver nitrate beginning with a i to 1500 solu-
tion increased to 5 per cent., protargol i to 20 per cent., bichlorid of
mercury i to 10,000 to i to 5,000, a 10 per cent, emulsion of iodoform
and glycerin, etc., are of ten employed.

Quantity. — As a rule about 15 to 30 lU (i to 2 c.c.) are injected,
but when it is desired to medicate a large surface, as much as i dram
(4 c.c.) or more may be used.

Frequency. — Instillations may be employed every other day to
every third or fourth day according to the reaction they provoke.

Position of Patient. — The dorsal position is used.

Preparations of Patient. — The bladder should be empty, and if
there is residual urine it should be drawn off by a catheter. The
external genitals are cleansed and the urethra is irrigated with a
boric acid solution.

Technic. — The syringe is first filled with the desired amount of
solution. The nozzle, after being well lubricated with lubrichon-

Fig. 733. — Keyes-Ultzmann instillation syringe.

drin, is then introduced in the same manner employed in passing any
curved urethral instrument (see page 641) until its point lies in the
prostatic urethra. This will be when the shaft of the instrument has
been depressed between the legs to an angle of a little less than 45
degrees with the horizon. The required amount of medication is
then slowly injected into the prostatic urethra, whence it flows over
the vesical neck and trigone. In removing the syringe the piston
should be first withdrawn a little so as to prevent any solution leaking
from it along the urethra.

When using the catheter method of instillation, the same technic
as for a posterior urethral irrigation (page 670) is followed.

CYSTOSCOPIC TREATMENT

In the hands of an expert the cystoscope becomes an instrument
of great value in treating vesical lesions. While cystoscopic treat-
ment is more difficult in the male than in the female, such procedures

732

THE BLADDER

as removing small calculi and foreign bodies, dilating the ureteral
openings, snaring small growths, the curettage of ulcers, the direct
application of strong solutions of silver nitrate to diseased areas by
means of a cotton- tipped probe, etc., may be satisfactorily per-
formed, even in the male, by a physician of skill and experience.

Instruments. — For male cases, a direct-view-air-distention cysto-
scope provided with a perforated window and bulb-aspirator (Fig.
734) is necessary. In the female, Kelly's tubes (page 720) or some
of their modifications are employed.

iQO

Fig. 734. — Bransford Lewis operating cystoscope. (Lewis in Keen's Surgery.)

Technic. — The method of exposing and treating diseased areas is
performed in the same manner in which the bladder is inspected
(pages 717, 723) and requires no further description here. In
making applications of strong solutions, however, care should be
taken to bring the solution only in contact with the diseased area and
not to saturate the applicator with an excess of solution.

FULGURATION OF VESICAL GROWTHS BY THE HIGH
FREQUENCY CURRENT

While the use of the high frequency current for the destruction of
neoplasms has been employed for a number of years in the treat-
ment of superficial and cutaneous growths, the adaptation of this
method of treatment to the destruction of vesical papillomata is of
comparatively recent date. Beer of New York in 19 10 being the first
to suggest it. Since then Keyes, Jr., and others have reported upon
the use of this form of treatment in vesical growths, both benign,

FULGURATION OF VESICAL GROWTHS 733

and malignant, and in the benign papillomata the results have
been uniformly successful. Against malignant growths, however,
unless very small, the high frequency current has not proved more
than a palliative measure.

Briefly the method of treatment consists in the repeated applica-
tion of the high frequency current to the tumor by means of an insu-
lated wire introduced into the growth through the aid of a cystoscope.
The current produces an intense reaction in the tissues to which it
is appHed, followed by necrosis and the gradual sloughing away of the
growth. Both the Oudin (monopolar) and the d'Arsonval (bipolar
currents have been employed, but the former being less penetrating
and destructive is generally used.

Properly appHed the treatments are practically painless unless
the electrode comes in contact with the bladder wall.

Apparatus. — An ordinary direct or indirect catheterizing cysto-
scope (see page 759), a Janet syringe, a catheter, a heavily insulated
6-ply copper wire cable to fit into the catheter chamber of the
cystoscope, and a high frequency machine with a Oudin resonator
are required.

Asepsis. — The same as for a cystoscopic examination (see page

7i,s).

Position of Patient. — The same as for a cystoscopic examination
(seepage 715).

Anesthesia. — General anesthesia is not required. The methods
of obtaining local anesthesia have been fully described (see page
716).

Strength of Current. — The spark gap should be 1/8 to 1/4 of an
inch (3 to 6 mm.). A wider gap gives greater voltage and produces
too strong a reaction.

Duration of Each Treatment. — The current is applied to one spot
for from 15 to 30 seconds at a time, and the number of applications'
will depend upon the size of the growth. Each treatment should not
average more than from 3 to 5 minutes.

Frequency of Treatments. — Ordinarily treatments are given at
intervals of from 4 to 7 days. In very sensitive bladders an interval
of from 10 days to 2 weeks may elapse between treatments.

Preparations of the Patient. — The external genitals are cleansed
with soap and water, followed by a i to 5000 bichlorid of mercury
solution. The bladder is emptied and thoroughly irrigated and from
4 to 6 ounces (120 to 180 c.c.) of sterile water are allowed to remain
for purposes of distention.

734

THE BLADDER

Technic. — Having tested the cystoscope and the high frequency-
current, the cystoscope, well lubricated and with the electrode in
one of the catheter chambers is introduced into the bladder (see page
717). The end of the wire to be introduced into the tumor, should
have been previously cut off flush with the insulation. The tumor
is located and the electrode is inserted into it as near the base as

Fig. 735. — Destruction of vesical growth by means of the high frequency current*

(After Oudin.)

possible (Fig. 735). The current is then turned on for 15 to 30 sec-
onds and a rapid blanching of the tissues at the point of contact
occurs. The wire is then allowed to cool and is reinserted into
another portion of the tumor and the dessication continued until the
whole mass has been treated. At subsequent treatments portions of
the growth that remain viable are similarly dealt with. When the
entire mass has sloughed away the base is likewise treated.

CATHETERIZATION OF THE BLADDER

Catheterization of the bladder is indicated in all cases of complete
retention of urine and in some cases of partial retention, as, for
example, in prostatic hypertrophy when the residual urine amounts
to more than 2 ounces (60 c.c). Retention may be the result of
obstructon from stricture, spasm of the compressor urethrae muscle,
hypertrophy or congestion of the prostate, clots of blood, calculi,
foreign bodies or tumors in the bladder or urethra, perineal abscess,
traumatism, etc., etc., and as the result of defective expulsion power
of the bladder through impairment of the nervous mechanism, as in
hysteria, certain diseases of the brain and spinal cord, shock, fevers,

CATHETERIZATION OF THE BLADDER

735

after the use of certain drugs, following rectal operations, etc., etc.
The probable cause of the retention should, if possible, be ascertained
before attempts to pass a catheter are made.

Retention may come on suddenly or gradually. In the presence
of acute retention there is great desire, but inability, to urinate, ac-
companied by severe and aching pain in the abdomen and perineum.

Fig. 736. — Soft-rubber catheter.

Unless the condition is relieved, the symptoms rapidly grow worse
and the patient lapses into a comatose state. When the retention is
gradual in onset, these severe symptoms are sometimes absent even
in cases of enormous distention, and it may be only the dribbling of
the overflow from the overdistended bladder that the patient com-
plains of, the so-called ^' false incontinence." Physical examination
will, however, reveal an elastic fluctuating tumor occupying the

Fig. 737. — Silver catheter.

hypogastrium, which is dull on percussion and becomes more
prominent with the patient standing erect.

Instruments. — An assortment of the various forms of catheters
should be on hand. For the ordinary cases of retention, uncompli-
cated by stricture or an enlarged prostate, a soft-rubber Nelaton
(Fig. 736) or a blunt silver catheter with a short curve (Fig. 737) may
be employed.

73^

THE BLADDER

In the presence of strictures a gum elastic olivary catheter (Fig.
738) and a set of Gouley's tunneled catheters and filiforms (Fig. 739)
will be required. In place of the latter a whip catheter (Fig. 740)
may be employed. This consists of a flexible gum elastic catheter
tapering off for several inches into a filiform.

Fig. 738. — Gum-elastic olivary catheter.

rs~-gg=^

Fig. 739. — Gouleys tunneled catheter and filiform.

Fig. 740. — Whip catheter.

The best form of catheter to use when the prostate is enlarged is a
Mercier coude catheter (Fig. 741) . The slight angle at the end of this
instrument permits it to override an obstruction. Guyon's mandrin
coude catheter (Fig. 742) and a long-curved prostatic catheter
(Fig. 743) should also be provided. The caliber of the insruments
for this class of cases should be fairly small, say from 15 to 18 French.

CATHETERIZATION OF THE BLADDER

737

Asepsis. — The greatest care should be taken to avoid infection of
the bladder. Metal and rubber catheters, as well as the better make
gum elastic instruments are boiled for five minutes. Instruments

Fig. 741. — Catheters with a coud6 and bicoud6 curve.

that will not stand boiling are steriHzed by formalin vapor (page 640)
or by immersion in a i to 20 carbolic acid solution followed by rinsing
in sterile water. The operator's hands are to be sterilized as care-
fully as for any operation.

Fig. 742. — Guyon's mandarin coud6 catheter.

Quantity of Urine Withdrawn. — Except when the distention is
slight and of short duration, the bladder should not be emptied com-
pletely at the first catheterization. As the result of long-standing
vesical distention there occurs a dilatation of the ureters and renal

O "O*

Fig. 743. — Silver prostatic catheter.

pelvis with changes in the kidney structure, and a sudden evacuation
of the urine is apt to be followed by suppression of urine, or hemor-
rhage from the vesical mucous membrane or kidneys may result from

738

THE BLADDER

the sudden relief of pressure upon the distended veins. Therefore,
not more than 8 ounces (240 ex.) of urine should be withdrawn at the
first catheterization, gradually increasing the amount at subsequent
catheterizations.

Fig. 744. — Showing the method of passing a soft rubber catheter.

Fig. 745. — Showing soft-rubber catheter passed into the bladder.

Frequency. — As a rule, in complete retention the bladder requires
emptying every four to eight hours. When the catheter is employed
for withdrawing the residual urine of prostatic hypertrophy the
frequency will depend upon the amount of residual urine. Thus, if

CATHETERIZATION OF THE BLADDER

739

this amounts to from 2 to 4 ounces (60 to 120 c.c), one daily catneteri-
zation before the patient retires in the evening will suffice, if it
amounts to from 4 to 6 ounces (120 to 180 c.c), the catheter should
be used twice a day, i,e., in the evening and morning, larger quanti-
ties of residual urine demand that the bladder be emptied three or
four times a day.

Position of Patient.— Catheterization should be performed with
the patient in the dorsal position with his shoulders slightly raised
and thighs somewhat flexed and rotated slightly outward.

Fig. 746. — Showing an ordinary catheter obstructed by an enlarged middle lobe of

the prostate gland.

Preparation of Patient. — The glans penis and meatus should be
washed with soap and water, followed by a i to 5000 bichlorid of
mercury solution and then sterile water. The urethra is irrigated
with a warm saturated solution of boric acid or a i to 5000 solution
of potassium permanganate.

Technic. — i. In Cases Uncomplicated by Stricture or Enlarged
Prostate. — A full-sized soft-rubber catheter is tried first. It is well
lubricated and, while the penis is held upright, is slowly fed into the
urethra a little at a time (Fig. 744). If the catheter becomes ob-
structed, the penis should be put upon the stretch to obliterate any
wrinkles in the mucous membrane, and the instrument is again
advajiced as before or by rotating it while the attempt is made to
make it pass. In this way a soft instrument can usually be made to

740

THE BLADDER

enter the bladder when the retention is simply due to defective expul-
sive power. In withdrawing a catheter the instrument should be
compressed between the thumb and forefinger, or the tip of the finger
should be placed over the opening at the proximal end to prevent
the urine which remains in the catheter from dripping out and wetting
the patient's clothes.

In cases of spasmodic stricture, failing in attempts to pass a soft
instrument, a full-sized metal catheter should be resorted to. Such
a catheter is passed precisely as one would a sound (see page 641).

Fig. 747. — Showing a coude catheter passing the obstruction.

When the point of the instrument has been introduced as far as the
obstruction, it should be held pressing steadily against the face of
the stricture for a few minutes until the spasm passes off, when it
may be easily slipped into the bladder.

2. In the Presence of Stricture. — In dealing with a retention due to
stricture a small soft-rubber catheter should be given first trial. If
unsuccessful, attempts may be made to pass an olivary pointed
catheter. If this fails, a filiform should be introduced through the
stricture (see page 690) and a Gouley tunneled catheter passed over
this as a guide, or, in its stead, a whip catheter' may be employed.
Should the stricture be of such small caliber that it is only possible
to insert a filiform, the latter should be left in place to act as a capil-
lary drain, taking care, however, to fasten it in such a way that it
cannot slip out (page 694). In this way the bladder will empty it-

CATHETERIZATION IN THE FEMALE 741

self in a few hours, and, by the end of twenty-four hours, sufficient
dilatation will usually have taken place to allow the passage of a
tunneled catheter. Failing to pass even a filiform the bladder should
be aspirated (page 746).

3. In the Presence of Prostatic Hypertrophy. — A soft flexible cath-
eter should be tried and then a coud6 catheter. The latter will often
succeed where a soft catheter fails because the bend of the tip of this
instrument keeps the point in contact with the upper wall of the ure-
thra and thus permits it to more easily override a median prostatic
enlargement (Fig. 747). Sometimes, if an ordinary coud^ catheter
will not pass, an elbowed catheter with a stylet can be made to do so.
With this instrument it is possible to elevate the point more sharply,
when obstructed, by withdrawing the mandarin a little, so that the
point of the instrument passes upward over the obstruction into the
bladder.

After repeated and unsuccessful efforts with the above instrument
a metal prostatic catheter should be tried before resorting to aspira-
tion. Great gentleness should be employed in its introduction to
avoid making a false passage. Sometimes assistance in guiding its
point may be derived from placing a finger in the rectum.

CATHETERIZATION IN THE FEMALE

Catheterization of the female bladder is a simple procedure. It
should always be done, however, by direct sight; the old method of
passing a catheter by touch carries with it the great risk of infection.

Fig. 748. — Glass female catheter. (Ashton.)

Instruments. — A glass female catheter, 5 inches (13 cm.) long and
1/5 of an inch (5 mm.) in diameter with a gentle curve in opposite
directions at both ends (Fig. 748), is the best instrument to employ.

Asepsis. — The catheter is boiled for five minutes and the opera-
tor's hands are carefully scrubbed in soap and water, followed by
immersion in an antiseptic solution.

Position of Patient. — The patient should be in the dorsal position
with the thighs flexed and the legs well separated.

Preparations of Patient. — The external genitals and meatus are
cleansed with soap and water followed by a i to 5000 bichlorid of
mercury solution.

742

THE BLADDER

Technic. — The operator separates the labia with the thumb and
forefinger of the left hand so as to expose the meatus. The catheter,
held near the proximal end in the fingers of the right hand, is then

•'iG. 749. — Method of passing a catheter in the female. (Ashton.)

Fig. 750. — Showing the method of preventing urine dripping from the catheter as
it is withdrawn. (Ashton.)

introduced through the urethra into the bladder (Fig. 749). When
the bladder has been emptied, the forefinger is first placed over the
proximal end of the catheter to prevent the escape of the urine it
contains (Fig. 750) and the instrument is then withdrawn.

CONTINUOUS CATHETERIZATION

743

CONTINUOUS CATHETERIZATION

A catheter may be introduced into the bladder and left in place in
cases where drainage of the bladder for a brief period is desired. It
may be employed in chronic cystitis accompanied by the presence of
large amounts of pus, frequent urination, and tenesmus, in vesical

Fig. 751. — The Pezzer retention catheter.

hemorrhage, and in cases of obstruction from an enlarged prostate
where the constant introduction of a catheter causes spasm or hemor-
rhage, or where catheterization is difficult. The bladder is thus put
at rest and at the same time is kept constantly emptied, the bene-
ficial effects of which are shown by a rapid decrease of the inflamma-

FiG. 752. — The Malecot retention catheter.

tion and congestion, decline of the fever, and relief of the pain and
tenesmus. Continuous catheterization is also indicated in wounds of
the urethra or after certain operations upon the urethra when it is de-
sirable to prevent the contact of infected urine with raw surfaces.

Jection

l)||lllllllliiiwllllil))llll)|j)i|

Fig. 753.— Stylet in place in Malecot catheter, o, Mandarin pushed forward; ft,

mandarin withdrawn.

At first, when the catheter is inserted, there may be a feeling of
weight in the perineum, but this soon passes off. In some instances a
mechanical urethritis is set up which may persist until the instrument
is removed and, if neglected, urethral abscess or extension of the
infection backward into the bladder may result.

744

THE BLADDER

Instruments. — A plain soft-rubber catheter of about i8 French
with the eye near the end or the retention catheters of Pezzer or
Malecot may be employed. The Pezzer catheter (Fig. 751) has a
flange to rest against the vesical neck, while the Malecot instrument
(Fig. 752) has wings on either side. When introduced over a stylet
(Fig. 753), these projections are made to disappear, but reappear
when the stylet is removed.

Duration. — This will depend upon the toleration of the urethra.
In some cases, continuous drainage may be kept up for over two
weeks, without the catheter causing much irritation; in others, the

Fig. 754. — Showing the method of securing a catheter in the bladder. (After Sinclair,
Polyclinic Journal, July, 1908.)

presence of an instrument in the bladder produces so much irritation
and vesical spasm that it cannot be used at all.

Preparation of Patient. — The glans penis and meatus are washed
with soap and water followed by a i to 5000 solution of bichlord of
mercury, and the urethra is thoroughly irrigated with a mild anti-
septic solution.

Asepsis. — The catheter should be thoroughly sterilized by boiling
or by formahn vapor and, if the latter method is employed, care must
be taken to remove all trace of the formalin by thoroughly rinsing the
catheter in sterile water. The operator's hands should likewise be
perfectly sterile.

Technic. — i. By the Ordinary Catheter. — If an ordinary rubber
catheter is employed, it is well lubricated and is then introduced in
the usual way until its eye lies just within the bladder. It is quite
important that the point of the catheter be not introduced too far,
for, if so, it will not only fail to drain the bladder properly, but will
irritate the vesical floor. To insure that the instrument is properly
placed, it should first be introduced into the bladder until the urine
flows freely and then slowly withdrawn until the flow just stops,
when it is pushed into the bladder again, this time for a distance of
Ji inch (6 mm.). It is then secured in place as follows:

CONTINUOUS CATHETERIZATION

745

The portion of the catheter protruding from the meatus is thor-
oughly dried and all grease is removed. Then four pieces of adhesive
plaster, each about 4 inches (10 cm.) long and 3<i inch (6 mm.) wide,
are secured to the catheter at the point it emerges from the meatus in
such a way that one strip lies upon the dorsum, one on the ventral
surface, and one on either side of the penis. Each strip is carried
back over the foreskin and is made to adhere to the body of the penis.
An additional strip of adhesive i inch (2.5 cm.) wide is placed hori-
zontally about the penis back of the corona, covering the four small
strips (Fig. 754). Care should be taken, however, not to have this
strip entirely encircle the penis. The penis is then wrapped in sterile
gauze and is supported over one groin by a T-bandage. If upon

Fig. 755. — Malecot retention catheter in place in the bladder.

inspection it is found that the urine escapes freely, the free end of the
catheter is finally connected with a drainage-tube which conducts
the urine to a receptacle at the side of the bed. The receptacle
should be half-full of some antiseptic solution.

If the retained catheter is employed in a case of long-standing
retention where it is dangerous to empty the bladder at once, an
intermittent form of drainage may be employed by discarding the
drainage-tube and simply inserting a plug in the end of the catheter,
which is removed at definite intervals and an increasing quantity of
the urine drawn off each time until it is considered safe to empty the
bladder completely, when the above method is used.

2. By the Self -retaining Catheter. — In inserting a special self-re-
taining catheter, a stylet curved to the shape of a sound is introduced
within the instrument so as to obliterate the projecting collar or
wings (see Fig. 753). When the catheter is in place, the stylet is

746 THE BLADDER

withdrawn, thus allowing the bladder end of the catheter to expand
again so that the catheter is retained in place unless some force is
used in withdrawing it (Fig. 755). In spite of this, however, it is
safer to fix the catheter in place by the method above described,
after first withdrawing it until the resistance shows that the terminal
enlargement is at the vesical neck.

After-care. — The catheter rapidly becomes encrusted with lime
salts, blood, or pus and should, therefore, be changed every two or
three days to permit of its being cleansed. At this time the urethra
and bladder should be thoroughly irrigated with a mild antiseptic
solution and the catheter thoroughly sterilized before it is reinserted.
In the presence of pus or blood the bladder may be irrigated through
the catheter as frequently as seems indicated.

If urethritis develops, the urethra should be irrigated once or
twice daily with a saturated solution of boric acid. This may be
accomplished by withdrawing the catheter until its extremity lies
in front of the bulbous urethra and then flushing out the urethra
from behind through the instrument by means of an irrigating appa-
ratus. The catheter is then pushed back to its original position.
Constant watch should be kept lest ulceration of the urethral wall
develop at the penoscrotal junction from pressure of the catheter.
To avoid this, the penis should be supported in such a position that
the sharp angle formed at the penoscrotal junction when the organ
hangs vertically is obliterated.

ASPIRATION OF THE BLADDER

Suprapubic aspiration of the bladder is indicated as a temporary
expedient when there is complete retention of urine and catheteriza-
tion is impossible from the presence of a tight stricture, prostatic
enlargement, or from any other cause. The operation is easily
performed and, if properly done, is a safe procedure. At times after
a single aspiration the congestion is so much lessened that within a
few hours it becomes possible to pass a catheter, or the patient voids
spontaneously, but, if necessary, the bladder may be emptied several
times a day for several days by this method without danger.

Where a permanent drainage for some time is desired, suprapubic
puncture by means of a trocar and cannula may be performed.
Puncture through the perineum or rectum, on the other hand, should
be avoided as unsafe.

Instruments. — For temporary relief an aspirating needle and
syringe should be employed. The needle should be fairly fine and

ASPIRATION OF THE BLADDER

747

about 3 inches (7.5 cm.) long. The Potain aspirator (Fig. 756) is
the best to use. This instrument has already been described (page
340).

When a trocar and cannula are used, a curved instrument with
the convexity of the curve upmost should be obtained. A scalpel to
nick the skin is also required.

Asepsis. — The instruments are boiled for five minutes in a i per
cent, sodium carbonate solution and the operator's hands are sterilized
in the usual way as for any operation.

Site of Puncture. — The puncture is made in the median line about
J^ inch (i cm.) above the pubes. The extraperitoneal space above

Fig. 756. — Potain aspirator.

the pubic bone is increased when the bladder is distended and a needle
or trocar may be inserted here without danger of entering the perito-
neum. When a number of punctures are made, the site may be
changed a little each time.

Position of Patient.— ^The operation may be performed with the
patient recumbent or sitting partly up.

Preparations of Patient. — The pubes should be shaved and then
painted with tincture of iodin.

Anesthesia.— Sufficient anesthesia is obtained by freezing the
surface tissues with ethyl chlorid or salt and ice to render the opera-
tion painless.

Technic. — i. By the Aspirator. — The suprapubic region is first
carefully percussed to make sure that there are no coils of intestine
lying in front of the bladder. The aspirator is assembled, tested, and

748

THE BLADDER

the air in the bottle exhausted. A small nick is then made in the
skin at the spot chosen for the puncture and the needle, held in the
right hand with the index-finger placed on its shaft as a guide, is
introduced through the tissues, directed downward and backward,
until a lessened resistance signifies that the bladder has been entered
This will usually be when the needle has entered from i>^ to 2^
inches (4 to 6 cm.), depending upon the thickness of the abdominal
wall. The aspirator is then attached and the vacuum is extended to
the needle-point by opening the inflow cock. If no urine is with-
drawn, the needle is introduced still further until fluid is reached.
The contents of the bladder are then partly or completely emptied,
depending upon the duration of the retention and the amount of the
distention (see page 737). ■

In removing the needle, care should be taken to keep up the suc-
tion until the needle is completely withdrawn, otherwise some urine
may escape from the tip of the needle as it traverses the prevesical
space and cause an infection. The site of the puncture is finally
covered with a piece of sterile gauze held in place by adhesive plaster.

2. By the Trocar and Cannula. — A small nick is made in the skin
as before at the chosen site and through this the trocar and cannula
with the convexity up is inserted into the bladder, care being taken to
guard against the instrument entering too deeply by placing the
index-finger on the shaft of the instrument as a guide. The trocar is
then removed and the cannula is secured in place for permanent
drainage by means of tapes. A rubber drainage-tube leading to a
receptacle half filled with an antiseptic solution is fastened to the
cannula.

The bladder, if it contains much pus, may be irrigated through the
cannula once or twice daily. The cannula should be removed and
sterilized every few days. To do this a small catheter is passed
through the lumen of the cannula into the bladder where it is main-
tained while the catheter is being cleansed. The cannula is then
easily reintroduced over the catheter as a guide.

The permanent cannula should be removed as soon as it is possible
to pass a catheter through the urethra without difficulty. The sinus
remaining is allowed to close by granulation.

CHAPTER XXII
THE KIDNEYS AND URETERS

Anatomic Considerations

The Kidneys. — The kidneys are two bean-shaped organs, each
measuring on an average from 4 to 4% inches (10 to 12 cm.) in
length and 2}i inches (6 cm.) in breadth. They lie deeply situated
in the abdominal cavity on each side of the vertebral column behind
the peritoneum, embedded in a loose layer of areolar tissue, the peri-
renal fat, resting upon the diaphragm, the quadratus lumborum,

Fig. 757. — The position of the kidneys and course of the ureters from behind.

and psoas muscles. Surrounding the perirenal fat is a layer of fascia,
complete except along the inner border of the kidney and at its lower
pole, which is firmly attached to the spine and diaphragm, and serves
to anchor the kidney in place.

The. position of the kidneys from behind corresponds to the space
between the upper border of the twelfth dorsal vertebra and the first
and second, or third, lumbar vertebrae. The right kidney generally
lies about J^ to 3^^ inch (8 to 12 mm.) lower than the left on account

749

750

THE KIDNEYS AND URETERS

of the position of the Uver above it, the upper extremity of the right
kidney usually reaching to the level of the lower border of the
eleventh rib and that of the left to the upper border of the eleventh
rib. The inferior pole of the kidney, on the right, reaches to within
i}.i inches (4 cm.) and, on the left, to within 2 inches (5 cm.) of the
crest of the ilium. During deep inspiration or when the patient
stands erect the kidney will descend to a somewhat lower level.
The long axis of the kidney is directed obliquely downward and out-
ward, so that the superior poles lie from M to i inch (i to 2.5 cm.)
nearer the median line than the lower poles.

Fig. 758. — The kidneys and ureters from the front.

Anteriorly, the position of the kidney may be mapped out by pass-
ing a horizontal line through the umbilicus and a vertical line from
the middle of Poupart's Ugament to the costal border perpendicular
to the horizontal line — the former passes just below the lower poles
of the kidneys, while the latter cuts the long axis of the kidney at the
junction of its middle and outer thirds. If the kidney lies to the
outer side of the vertical line or below the horizontal umbilical line,
it is indicative of enlargement or a displacement.

Relations of Kidneys. — Behind, the kidneys are in relation with
the diaphragm, quadra tus lumborum, psoas muscles, and with the
last dorsal, iliohypogastric, and ilioinguinal nerves. The close

ANATOMIC CONSIDERATIONS 75 1

relations of these nerves account for the referred pains sometimes
encountered in diseases of the kidneys.

In front of the right kidney are the under surface of the right lobe
of the liver, the second portion of the duodenum, the ascending colon,
and the hepatic flexure. The left kidney is in relation in front with
the spleen, the fundus of the stomach, the tail of the pancreas, the
splenic vessels, and the descending colon.

Ureters. — The ureters are two in number, one for each kidney.
They measure about 12 inches (30 cm.) in length and have a caliber
equal to that of a goose quill. The ureter begins at the neck of the
renal pelvis opposite the lower pole of the kidney and passes down on
the psoas muscle behind the peritoneum to the brim of the pelvis.
A line drawn on the abdominal wall vertically upward from the junc-
tion of the middle and inner thirds of Poupart's ligament roughly
represents the course of the ureter from the kidney to the pelvic
brim.

The ureter in the male, after crossing the pelvic brim and the
common iliac vessels, passes downward and backward in front of the
sacroiliac joint and enters the parietal attachment of the posterior
false ligament of the bladder. It then passes forward and inward to
the base of the bladder which it enters just above the seminal vesicle,
first passing under the vas deferens.

The ureter in the female, after crossing the pelvic brim and iliac
vessels, passes downward and backward along the lateral wall of the
pelvis as in the male. It then enters the base of the broad ligament
and passes down parallel with the cervix and upper portion of the
vagina, at a distance of about ^i inch (i cm.) external to the cervix
and posteriorly to the uterine artery. After crossing the upper third
of the vagina the ureter enters the bladder opposite the middle of the
vagina. The pelvic portion of the ureter in the female is thus readily
palpated through the vagina or rectum.

The ureters enter the bladder ij^^ to 2 inches (4 to 5 cm.) apart
and, after passing obliquely forward and inward for a distance of %
of an inch (2 cm.) through the bladder wall, they appear on the
mucous membrane about i}i inches (3 cm.) apart and the same dis-
tance posterior to the internal urethral orifice. Through this oblique
insertion of the ureters into the bladder regurgitation of urine when
the bladder is distended is effectually guarded against.

The ureters are composed of three coats, an outer fibrous, a middle
or muscular, and an internal or mucous. Normally the walls are
collapsed and lie in contact. The lumen of the ureter presents three

M^2 THE KIDNEYS AND URETERS

constrictions and two intermediate dilated portions. The constric-
tions are: First, about 2^ inches (6 cm.) from the hilum of the
kidney, second, at the point where the ureter crosses the pelvic
brim, and, third, at its entrance into the bladder.

Diagnostic Methods

In suspected disease of the kidney or ureter a careful history of the
past ailments and present symptoms should first be obtained. Fre-
quently pain will be the only symptom complained of. In such case
its exact location should be determined; that is, whether limited to
the loin or radiating along the course of the ureter, and whether
unilateral or bilateral. Severe attacks of pain radiating from the loin
down toward the bladder, testicle, and thigh are strongly suspicious
of calculus. The character of the pain should also be ascertained;
whether it is dull or aching, or paroxysmal and lancinating, and
whether continuous or periodic. Periodic attacks of sharp pain
accompanied by a considerable diminution in the amount of urine
secreted, followed by reHef of the pain and an abundant flow of urine
are characteristic symptoms of hydronephrosis due to a movable
kidney. The patient should also be questioned as to the character
of his urine, i.e., whether bloody, etc., supplemented by inquiry as to
special points along the Hnes mentioned in the sections upon the
urethra and bladder. This is followed by a thorough physical
examination.

The methods available for examination of the kidneys and ureters
include inspection, palpation, percussion, urinalysis, cystoscopic
examination, ureteral catheterization, pyelometry, segregation of
urine, determination of the functional capacity of the kidneys,
skiagraphy, and exploratory incision.

INSPECTION

On account of the deep situation of the kidney in the abdomen,
inspection gives no information if the kidney is normal. When, how-
ever, the kidney is greatly enlarged it may produce a visible swelling
in the loin or protrude anteriorly and cause a bulging of the lower
ribs upon the side affected.

Inspection should be performed from in front with the patient
lying flat on the back, and also from behind and laterally with the
patient standing and bending forward, so as to make any bulging
more prominent through relaxation of the abdominal muscles.

PALPATION OF THE KIDNEYS 753

PALPATION OF THE KIDNEYS

Palpation is by far the most valuable of the methods of physical
diagnosis for determining the presence of enlargement or displace-
ments of the kidney. While the normal kidney can seldom be felt,
unless the individual is very thin and the abdominal wall is lax, and
then it is ony possible to palpate the lower pole of the kidney, an
increase in the size of the organ or undue mobility is readily recog-
nized. By palpation it is also possible to determine the sensitiveness
of the kidney and in the presence of a tumor, its characteristics —
namely, its size, shape, and whether soft, hard, or fluctuating.

Palpation is sometimes performed with one hand, so placed that
the fingers press in the loin while the thumb Hes on the abdomen
beneath the costal arch, but a more satisfactory method is the
bimanual.

Fig. 759.— Palpation of the kidney with the patient in the dorsal position.

Position of Patient.— The patient should lie flat on the back with
the head and shoulders elevated upon a small pillow and the lower
extremities flexed so as to thoroughly relax the abdominal walls.
Sometimes in cases of movable kidney additional information may be
eUcited by palpating with the patient standing, his body bent forward
from the hips, and with his hands resting on the arm of a chair for
support; or else the patient may assume the lateral position, lying on
the sound side, and with the thighs slightly flexed (Fig. 760).

Preparations of Patient.— Care should be taken to have the colon
empty at the time of the examination; if necessary a cathartic should

754

THE KIDNEYS AND URETERS

be administered the night before for this purpose. All clothing that
is likely to interfere with the examination should be removed.

Anesthesia.— If palpation is difficult through rigidity of the ab-
dominal muscles or from increased sensitiveness, a general anesthetic
may be required in order to make a satisfactory examination.

Technic— The examiner should stand upon the side he wishes to
examine. When palpating the right kidney the fingers of the left
hand are placed under the loin just below the last rib and the right
hand is placed flat on the abdomen below the costal arch (Fig. 759);

Fig. 760. — Palpation of the kidney with the patient on the side.

to palpate the left kidney the position of the hands is reversed. The
patient is instructed to breathe deeply but quietly, and any manipula-
tions should be gentle in character to avoid inciting muscular con-
traction. The kidney descends during inspiration and, if at this time
forward pressure is made with the hand under the loin and the hand
upon the abdomen is pressed backward under the ribs, the kidney,
if enlarged, will be felt. If the kidney is displaced, it may be caught
between the two hands as it descends during deep respiration and
may be prevented from returning to its former position. In the
presence of a tumor, the size, shape, and consistence of the growth
should be determined and its sensitiveness ascertained. Palpation
of the normal kidney causes a peculiar sensation which has been
likened to pressure on the testicle; actual pain will be elicited, how-
ever in the presence of some tumors, kidney calculus, or pus
formation.

Tumors of the colon, gall-bladder, pylorus, spleen, or a peduncu-
lated ovarian or uterine growth may be mistaken for a renal tumor
or a movable kidney. The symptoms complained of and the relation

PALPATION OF THE URETERS 755

of the colon to the tumor, however, will usually settle the diagnosis.
The colon lies in front or to the inner side of the kidney and, if neces-
sary, it should be inflated to more accurately map it out.

At times the so-called " ballottement of the kidney^' may be
obtained if the kidney is freely movable. To elicit this sign sudden
sharp pressure is applied to the loin by the posterior hand, when, if
movable or enlarged, the kidney will be driven forward with a slight
impact against the hand on the abdomen in front.

PALPATION OF THE URETERS

The ureters may be palpated through the abdominal wall, through
the vagina, or through the rectum. Abdominal palpation is only of
value if the patient is thin and the abdominal walls lax, and then it is
only possible to palpate the ureter if thickened or if it contains a
calculus. In some cases, however, if inflamed and painful, the ureter
may be traced from the kidney pelvis to the pelvic brim from the
pain eHcited on palpation. Through the vagina it is possible to
palpate the ureter from the base of the broad ligament to its entrance
into the bladder. Calculi, thickening, or inflammation of this por-
tion of the ureter is thus readily recognized. In the male by rectal
examination the ureter may be palpated in its course from the pelvis
to the bladder.

Positions of Patient. — For abdominal palpation the patient
should lie flat on the back with the head and shoulders slightly ele-
vated and the thighs flexed.

Vaginal or rectal palpation is performed in the dorsal position
with the thighs flexed.

Preparations of Patient. — The bladder and bowels should be
empty at the time of examination.

Technic. — i. Abdominal Palpation. — The examiner stands on the
side to be palpated and first locates the promontory of the sacrum by
deep palpation with the examining hand. The ureter crosses the
pelvic brim at a point about iH inches (3 cm.) to the side of the
promontory and a little bdow it. A thickened ureter may be
palpated at this point if the patient has thin, relaxed abdominal mus-
cles. Beginning at this point, the ureter may be traced upward along
its course by making deep pressure along the outer border of the
rectus muscle (Fig. 761). If the ureter is inflamed, palpation will
elicit pain. On the right side such pain must be differentiated
from that of cholecystitis or appendicitis.

756

THE KIDNEYS AND URETERS

2. Vaginal Palpation. — The right hand is employed to palpate
the right ureter and the left hand for palpation of the left ureter.
The index-finger is inserted in the vagina and is carried to the vaginal

Fig. 761. — Abdominal palpation of the ureter.

Fig. 762. — Vaginal palpation of the ureter. (Ashton.)

fornix corresponding to the ureter to be palpated. From this point
it is pushed upward and outward toward the pelvic wall, and a careful
search is made for the ureter which will be recognized as a flat cord

PERCUSSION

757

passing forward and inward from the pelvic wall around the cervix to
the bladder (Fig. 762). Sometimes, by means of a bimanual exam-
ination, with the external hand placed on the abdominal wall and
exerting downward pressure the ureter may be more satisfactorily
examined.

3. Rectal Palpation. — The right hand palpates the right ureter
and vice versa. The index-finger well lubricated is inserted into the
rectum and is carried upward a little higher than the level of the base
of the seminal vesicle. The finger is then turned toward the lateral
wall of the pelvis and the ureter is sought by moving the finger
backward and forward. It will be recognized as a flat cord-like
structure passing at first downward along the side of the pelvis and

Fig. 763. — Palpation of the ureter per rectum.

then forward. It may be traced as far as the bladder and will be
recognized passing forward and inward from the pelvic wall to the
base of the bladder, where it will be felt a little above the seminal
vesicle.

PERCUSSION

Percussion of the kidney is of slight value unless the organ is
greatly enlarged. At best it is difficult on account of the thick layer
of muscles in the dorsal and lumbar regions and the depth of the
kidney from the anterior abdominal wall. In fat individuals the
difficulties are increased in proportion. Percussion is important,

758 THE KIDNEYS AND URETERS

however, for the purpose of showing the position of the colon in
relation to a tumor occupying the region of the kidney and in
differentiating growths of the kidney from the spleen and liver.

Position of Patient.— To percuss from behind the patient should
lie face downward with a firm cushion or several pillows under the
abdomen to make the lumbar region more prominent (Fig. 764).

For anterior percussion the patient lies in the dorsal posture with
the legs extended.

Preparations of Patient.— The colon must be emptied so as not to
obscure the results.

Technic. — It is necessary to employ very strong percussion to out-
line the organ, but in fat individuals even this may yield unsatis-
factory results. In a normal case the kidney dulness will be found
to extend about 2 inches (5 cm.) below the last rib, merging above

Fig. 764. — Position of the patient for percussion of the kidneys from behind.

into that of the liver or spleen. In a large renal growth percussion
will give dulness extending outward and downward beyond the nor-
mal limits, with colon resonance in front or internal to the tumor.

Tulnors of the spleen or Hver may give much the same area of
dulness, but the colon resonance will be behind. Inflation of the
colon (page 573) may be necessary before its position can be accur-
ately determined.

URINALYSIS

The examination of the urine is of the greatest importance. It
should comprise a complete physical, chemical, microscopical, and
bacteriological analysis. Abnormality may be due to general dis-
eases, renal diseases, or to lesions in the lower genitourinary tract,
so that it is not sufficient to simply recognize a departure from the
normal, but the seat of the trouble, i.e., whether in the bladder, ureter,
or kidney, must be determined and, if the ureters or kidneys are

CATHETER IZING THE URETfeRS 759

affected, which side is involved as well. For this purpose the cysto-
scope and ureteral catheter are of the greatest aid. Other methods
for determining the source of abnormal urinary constituents have
already been described (see page 699).

CYSTOSCOPY (See page 713)
CATHETERIZING THE URETERS

The use of the ureteral catheter is of the greatest diagnostic aid in
diseases of the kidney or ureter, as it is possible by this means to
collect urine separately from each kidney for analysis uncontami-
nated by contact with the bladder or urethra, and to explore the
entire length of the ureter from the bladder to the kidney pelvis.
This method of examination is thus of value in determining whether
both kidneys are present, in estimating the functional capacity of
either kidney, and in the presence of blood or pus in the urine in
determining whether its source is the kidney or the ureter and from
which side it comes. It is also of the greatest aid in recognizing
stricture or calculus of the ureter, hydroureter, hydronephrosis, etc.

Ureteral catheterization has certain drawbacks that should be
mentioned. Under the most favorable conditions it requires con-
siderable skill to catheterize the ureters, and in some cases, compli-
cated by the presence of tight urethral strictures, enlargement of the
prostate, tumors, or thickening of the bladder mucous membrane it
may be impossible. Then there is always present the danger of
carryng infection from the bladder into a healthy ureter or kidney.
With proper aseptic precautions in performing the operation, how-
ever, this danger may be disregarded.

Fig. 765. — Bransford Lewis cystoscope.

Instruments. — Catheterizing cystoscopes, like the exploring cysto-
scopes, are of two types, the direct view and the indirect view.

The direct view cystoscope of which the Brenner, Brown,
Bransford Lewis, Eisner, etc., instruments are types, are arranged
with the light either on the convex side of the beak, or with a window
both on the convexity and concavity so that the light is shed in both

760 THE KIDNEYS AND URETERS

directions, and are provided with a straight observation telescope
having a window at the distal end. The catheter chambers are
placed on the under surface of the telescope so that the catheters
protrude at the lower part of the field of vision in a straight line.
An obturator takes the place of the telescope when the instrument is
being inserted into the bladder.

The indirect catheterizing cystoscope, such as the Nitze, Casper,
Albarran, Bierhoff, Buerger, etc., have the light upon the concave side
of the beak, while the image is reflected at right angles, by means of a
prism, to the eye-piece at the proximal end. The catheter chambers
are enclosed within the sheath of the instrument lying above the
telescope. A small movable tongue or finger, which can be raised or
lowered by means of a screw at the ocular end of the instrument, is
provided for the purpose of changing the angle of the catheters as
they emerge from the instrument. Irrigating cocks are provided
with both styles of cystoscopy

Instruments may also be obtained with which it is possible to
employ either the direct or indirect methods of observation and
catheterization, as McCarthy's composite cystoscope, which has

Fig. 766.— The Bierhoff cystoscope. a, Showing the instrument with the tele-
scope in position for catheterization; b, showing the telescope rotated within the sheath
to facilitate removal of the instrument.

both indirect and direct view telescopes and an indirect double
catheterizing attachment, and the universal cystoscopes of Tilden
Brown and Bransford Lewis, which combine in one instrument direct
and indirect observation and double catheterization by either the
direct or indirect method.

While the choice of the type of instrument must rest with the
individual operator, there is no doubt that in the majority of cases it
is easier to catheterize with the direct view instrument, exceptions
being the presence of intravesicular hypertrophy of the prostate and
a trabeculated bladder, in which class of cases the indirect view
instrument is essential; on the other hand, it is far easier to locate
the ureteral orifices by indirect view.

CATHETERIZING THE URETERS 76 1

The catheters, which are of silk elastic material about 24 inches
(60 cm.) long and 5 to 7 French in size, should be of different colors
to differentiate them. The distal end is either blunt or olive pointed.
Before using, it should be seen that the catheters are smooth and the
eyes perfect; the patency of the catheters should also be tested by
injecting water through them. They are best kept at full length in
glass tubes plugged with cotton at either end.

For the purpose of recognizing calculi the end of the catheter may
be dipped in melted wax (2 parts of dental wax and i part of olive oil)
and allowed to harden in the air (Fig. 767). On coming in contact
with a stone scratch marks will be produced on the wax tip. The
wax catheters can only be used, however, with the direct view instru-
ment and to avoid scratching the wax they should be threaded
through the instrument from the vesical end backward.

Fig. 767. — Wax-tipped ureteral catheter.

In addition to the ureteral catheters an irrigating jar or a Janet
syringe holding 3 to 4 ounces (90 to 120 c.c.) of solution and a soft-
rubber catheter should be provided for irrigating the bladder.

Illumination for the cystoscope may be obtained from a six- or
eight-cell battery or from the street current provided a controller is
employed .

Asepsis. — The cystoscope should be well cleaned with tincture of
green soap and water and is then placed in a i to 20 carbolic acid
solution or 95 per cent, alcohol, or it may be sterilized by formalin.
Before using, it should be rinsed off in a saturated solution of boric
acid. The catheters are sterilized by formalin vapor or by boiling
for one or two minutes in plain water, care being taken to wrap
them separately in gauze to prevent their sticking together and to
place them at full length in the sterilizer. The examiner's hands
are carefully sterilized in the usual way.

Position of Patient. — The patient may be in the lithotomy posi-
tion with the buttocks close to the edge of the table, or as preferred
by some operators in a semirecumbent posture. The table should be
provided with uprights which are surmounted with double inclined
rests for the thighs and knees. (See Fig. 717.)

Anesthesia. — If any anesthesia is necessary, local anesthesia
usually suffices . It may be obtained by the instillation into the deep

762

THE KIDNEYS AND URETERS

urethra of a small quantity of a 2 per cent, solution of cocain or by
filling the empty bladder with 5 ounces (150 c.c.) of a warm o.i per
cent, solution of cocain to which is added 20 drops (1.25 c.c.) of
adrenalin. This must be retained for at least fifteen to twenty
minutes. Guyon's method may also be employed (see page 716).
Tn some few cases it may be necessary to employ general anesthesia;
for children general anesthesia should always be used.

Preparations of Patient. — The external genitals should be
cleansed with soap and water followed by a i to 5000 bichlorid of
mercury solution The bladder is then emptied and thoroughly irri-
gated with a saturated solution of boric acid by means of a catheter
and a large syringe or through the sheath of the cystoscope if the
instrument is supplied with an irrigating cock, until the fluid returns
clear. Four to 6 ounces (120 to 180 c.c.) of a saturated boric acid or
normal salt solution are then injected into the bladder and allowed
to remain for the purpose of distention.

Fig. 768. — Catheterization by the direct method, showing the cystoscope as introduced
and with the vesical end deflected toward the ureter.

If hemorrhage from the bladder is sufficient to interfere with the
operation, a, i to 3000 adrenalin chlorid or i to 15,000 silver nitrate
solution should be injected through the catheter and allowed to
remain in the bladder for ten to fifteen minutes before it is distended.

Technic. — i. Direct Catheterization. — The cystoscope and cathe-
ters having been thoroughly tested, the instrument, well lubricated
with glycerin or lubrichondrin and with the obturator in place, is
introduced into the bladder. The obturator is then removed and the

CATHETERIZING THE URETERS

763

catheterizing telescope is inserted in its place, after which the light
is turned on and the ureteral orifices are sought for. They are lo-
cated at the upper angles of the trigone about ^ inch (2 cm.) from
the median line and i inch (2.5 cm.) from the internal opening of the
urethra. By first locating the apex of the prostate and then pushing
the instrument in about i inch (2.5 cm.) the interureteric line which
passes between the two ureters, forming the base of the trigone, will
come to view and if this is traced to one side or the other the orifice
of the ureter will be recognized in the lateral angle of the trigone. It
may appear either as a slit or as a dimple on the apex of a papilla, and,
if carefully watched, urine will be seen coming from it in intermittent
spurts. It may be extremely difficult to locate the ureter, but a
careful search will usually reveal it. In all manipulations of the
cystoscope it is of the utmost importance to employ extreme gen-
tleness, otherwise bleeding will supervene and interfere with the
examination.

Fig. 769.— Catheterization by the direct method, showing the hpel of the cystoscope
brought close to the mouth of the ureter.

With the direct view cystoscope the instrument is not rotated
about an axis, but the beak is kept constantly pointing upward while
the vesical end is turned from one side to the other or up and down
as the case may be (Fig. 768) . The mouth of the ureter having been
located, the heel of the cystoscope is brought close to it (Fig. 769) and
an attempt is made to engage the catheter in its lumen. The cath-

764

THE KEDNEYS AND URETERS

eter is then slowly and gently threaded up the ureter to the desired
distance (Fig. 770). If the purpose of the catheterization is simply
to withdraw urine from the ureter, the catheter is introduced 3 to 4
inches (7.5 to 10 cm.); in exploring the ureter for stone or stricture,
or to determine whether pus has its origin in the ureter or kidney
pelvis, the catheter should be passed as far as the renal pelvis — 13 to
15 inches (32 to 37 cm.). If less than 11 inches (27 cm.) of catheter
can be inserted, an obstruction must be inferred (Braasch). The
other ureter is located and catheterized in the same manner.

Fig. 770. — Catheterization by the direct method, showing the catheter entering the

ureter.

The light is then extinguished and the catheterizing attachment is
first carefully removed and then the sheath, keeping the catheters in
position in the ureter by threading them through the instrument as
it is withdrawn. Unless the catheters are of different colors, they
should be labeled "left" or "right" in order to distinguish them.
The first urine that flows is discarded and the ends of the catheters
are then wiped off and inserted into sterile bottles plugged with
cotton. A catheter may become plugged with mucus, blood clots,
or pus. If so about 15 ITl (i c.c.) normal salt solution may be in-
jected through it by means of a syringe.

From 2 to 4 ounces (60 to 120 c.c.) of urine are, as a rule, sufii-
cient for examination. While the urine is being collected, the
patient's legs should be released from the crutches holding them and

CATHETERIZING THE URETERS

76s

he should be allowed to assume as comfortable a position as possible.
At the completion of the operation the catheters are carefully re-
moved and the bladder is irrigated with a saturated solution of boric
acid.

Fig. 771. — Catheterization by the indirect method, showing the cystoscope in position.

Fig. 772.-Catheterization by the indirect method, the catheter being pushed into

the instrument until its tip passes slightly beyond the ureteral orifice

2 Indirect Catheterization. -The instrument, well lubricated, is
introduced into the bladder and is then rotated completely around so
that its beak looks posteriorly. The prostate is thus located and by

766

THE KIDNEYS AND URETERS

rotating the instrument through an angle of 30 to 45 degrees the lat-
eral ridge of the trigone may be traced running backward at an angle

Fig. 773. — Catheterization by the indirect method, showing the tip of the catheter
being deflected toward the ureteral orifice by elevating the director.

Fig. 774. — Catheterization by the indirect method, showing the catheter inserted in

the ureter.

from the prostate. At the point of the junction of this ridge with the
interureteric line will be found the ureteral orifice. It should be

CATHETERIZING THE URETERS

767

remembered that with this form of instrument the image will appear
inverted, that is, the prostate will appear at the upper portion of the
field instead of at the lower. Having located the ureteral orifice the
instrument is brought close to it (Fig. 771) and the catheter is pushed
gently forward until its tip passes slightly beyond it (Fig. 772). The
small director is then elevated slightly (Fig. 773) and the catheter is
again pushed forward. If it misses the orifice, the catheter is with-
drawn a little and a second ' attempt made to introduce it. By
pushing the catheter forward a little or withdrawing it and changing
its angle of deflection slightly, it is finally introduced into the ureter
(Fig. 774). The other ureter is then located and the catheter is

Fig. 775. Fig. 776.

Fig. 775. — Removal of the sheath. First step, showing the telescope removed
and the catheters lying loosely in the sheath. (After Buerger, Annals of Surgery^
Feb., 1909.)

Fig. 776. — Removal of the sheath. Second step, showing the ocular end de-
pressed and carried to the left until clear of the catheters. (After Buerger, Annals of^
Surgery, Feb,, 1909.)

introduced in the same way. The catheterizing telescope is then
carefully removed, first turning the deflector down and extinguishing
the lamp. It is sometimes a difficult matter to remove the sheath of
the cystoscope and still leave the catheters in place when using this
form of instrument. The following manipulations, however, de-
scribed by Buerger {Annals of Surgery, February, 1909), simplify
this portion of the operation:

''After having introduced the catheters a little higher than we
would if the instrument were to remain in the bladder, and after

768

THE KIDNEYS AND URETERS

removal of the telescope, the following movements should be carried
out : first, the ocular is depressed and carried a little to the left, thus
separating the beak from the line of the catheters (Fig. 776) ; second,
the whole instrument is rotated to the right on its longitudinal axis
through an arc of 190 degrees, retaining the relative position just
described, thus making the beak point upward (Fig. 777); third
(still in the same plane, with the ocular a little to the left), the ocular
is raised and brought back to the median line in order to bring the
convexity of the beak against the trigone of the bladder ( Fig. 778);
and fourth, the sheath is removed, its inferior aspect being made to
hug the posterior wall of the urethra."

Removal of the Bierhoff instrument is comparatively simple, as
it is arranged so that the telescope may be rotated within the sheath
until the beak points upward without disturbing the catheters (see
Fig. 766).

Fig. 778.
Third step, showing the beak being turned

Fig. 777.

Fig. 777.— Removal of the sheath
upward. (After Buerger, Annals of Surgery, Feb., 1909.)

Fig. 778. — Removal of the sheath. Final step, the beak in position for removal
of the sheath. (After Buerger, Annals of Surgery, Feb., 1909.)

URETERAL CATHETERIZATION IN THE FEMALE

Ureteral catheterization in the female has the same field of
usefulness as when appHed to the male (see page 759). In addition,
catheters are often inserted into the ureters as a guide to their posi-
tion so as to avoid injuring them in difficult pelvic operations. Cathe-
terization may be performed, as in the male, by means of one of

URETERAL CATHETERIZATION IN THE FEMALE

769

the catheterizing cystoscopes, the method of performing which re-
quires no further explanation than that given above, or by means of
open tubes under air distention after the method of Kelly. This
latter method requires separate description.

Instruments.— The ordinary Kelly speculum with illumination
furnished by reflected light or some of the modifications of Kelly's
tubes with the light at the distal end may be employed. The latter
are preferable.

In addition there will be required a cone-shaped urethral dilator,
alligator-jaw-shaped forceps, a residual urine evacuator, Kelly's
ureteral searcher, silk flexible catheters, a metallic catheter, and
hard- rubber flexible sounds (Fig. 779).

Fig. 779. — Instruments for catheterizing the ureters in the female, i, Open-tube
cystoscope; 2, Kelly urethral dilator; 3, residual urine evacuator; 4, alligator-jawed
forceps; 5, ureteral searcher; 6, metal ureteral catheter; 7, flexible ureteral catheters
with stylets; 8, ureteral bougies.

The cystoscope, alligator-jaw forceps, urethral dilator, and
searcher have been previously described (page 720).

The flexible silk catheters are made in two lengths: 12 inches
(30 cm.) long for ordinary ureteral catheterization and 20 inches
(50 cm.) long for catheterization of the kidney pelvis. The tips
are blunt or olivary and have an oval eye about J^ inch (2 cm.)
from the distal end. They may be obtained in sizes running from
He to }i inch (1.5 to 3 mm.) in diameter. A wire stylet is in-
troduced within the catheter to furnish it with the necessary stiff-

770

THE KIDNEYS AND URETERS

ness for passage into the ureter, or forceps, such as Ashton's (Fig.
780), may be employed for this purpose. As an aid in recognizing
a calculus the ends of the catheters may be wax-tipped (see Fig. 767).
Metal catheters are 12 inches (30 cm.) long and K2 inch (2 mm.)
in diameter and are supplied with three eyes situated back of the
point which is conical in shape and slightly curved. They are
employed when a stricture low down in the ureter interferes with the
passage or a flexible catheter.

Fig. 780. — Ashton's forceps for guiding the catheter into the ureter. (Ashton.)

Solid, flexible, hard-rubber bougies are employed in exploring the
ureters or dilating strictures. They are 20 inches (50 cm.) long and
^{2 inch (2 mm.) in diameter. When warmed they become flexible
and in this state may be passed the entire length of the ureter without
danger. For the purpose of locating a stone they may be wax-tipped
(Fig. 781)-

Fig. 781. — Wax-tipped bougie. (Ashton.)

Asepsis. — Great care should be taken to observe all aseptic
details. The operator's hands should be thoroughly cleansed, and
precautions should be taken not to allow the sterile catheters to
touch the table or patient's body during their introduction. Metal
instruments and hard-rubber bougies are sterilized by boiling for five
minutes in a i per cent, soda solution. The light carrier may be
sterilized by immersion in a i to 20 solution of carbolic acid followed
by rinsing in alcohol. Silk catheters are sterilized by formalin
vapor or are boiled for not over two minutes in plain water and are
then placed in cold sterile water to make them stiff. Care should
be taken when boiHng the catheters to place them in the sterilizer
at full length and to wrap them separately in gauze so as to keep
their surfaces from becoming glued together.

After use the catheters should be thoroughly cleaned inside and
outside with warm water and tincture of green soap and then put
away at full length in a glass receptacle.

Position of the Patient. — As for cystoscopy two positions are
employed, namely, the dorsal elevated and the knee-chest. In the

URETERAL CATHETERIZATION IN THE FEMALE 771

former the patient lies with the head and thorax resting on the table
and the hips elevated 8 to 12 inches (20 to 30 cm.) upon a cushion so
as to raise the pelvis sufficiently to allow the bladder to distend with air
when the cystoscope is in place. If the bladder does not inflate with
the patient in the dorsal position, the knee-chest posture is employed.
The latter position is usually necessary in stout people.

Preparations of Patient. — It should be seen that the rectum and
bladder are empty before beginning the examination. The external
genitals are then washed with soap and water followed by a i to
5000 solution of bichlorid of mercury, and the bladder is irrigated with
a warm saturated solution of boric acid until the fluid returns clear.
The solution is then all drained off before the cystoscope is inserted.

Anesthesia. — ^Local anesthesia, obtained by inserting into the
meatus a small pledget of cotton saturated with a 2 per cent, solu-
tion of cocain and allowing it to remain for five minutes, is generally
sufficient. In extremely nervous patients general anesthesia may be
required.

Technic. — The urethra is first dilated and the cystoscope is intro-
duced in the manner already described (page 723). The obturator is
then removed, when, if the patient is in the proper position, air rushes
in and distends the bladder. The light is then adjusted and a search
is made for the ureteral orifices. In doing this it is well to first with-
draw the instrument until the mucous membrane of the internal
urethral orifice begins to close over the end of the instrument, and
then to advance it H to % inch (i to 2 cm.) turned either to the
right or left about 30 degrees from the center line along the dark
lateral ridge of the trigone. The distal end of the instrument is then
brought close to the base of the bladder by raising the handle of the^
cystoscope if the patient is in the dorsal position, or depressing the
handle if the knee-chest position is used. By moving the instrument
carefully about, the mouth of the ureter will be located somewhere
near the end of the cystoscope. It may appear as a small slit, a
distinct hole, or a dark point in the bladder mucous membrane.
If it is not readily found, the speculum should be directed toward its
normal location and a careful search made for it with a ureteral
searcher in the folds of mucous membrane.

Having located the orifice, the end of the cystoscope is brought
close to it and the catheter is introduced. Metal catheters or sounds
are not difficult to introduce. They should be well lubricated and,
while the cystoscope is maintained in position with the left hand, they
are guided by means of the right hand into the ureteral orifice.

772

THE KIDNEYS AND URETERS

Flexible catheters may be introduced in two ways, either by the
use of a stylet to give them stiiOfness or by the aid of a specially made
forceps, such as Ash ton's (see Fig. 780). By the former method the
catheter, well lubricated, with the stylet in place, is gently inserted in
the same manner as a metal catheter into the mouth of the ureter
(Fig. 782). The stylet is then withdrawn and the catheter is pushed
on until it has entered the desired distance. For ordinary purposes
of catheterization this will be 3 or 4 inches (7.5 to 10 cm.). In intro-

FiG. 782. — Catheterization of the ureter in the female by means of a flexible catheter

armed with a stylet.

ducing these flexible catheters care must be observed that the portion
outside the cystoscope does not become contaminated by touching the
patient or the table.

If it is desired to catheterize both ureters, the mouth of the other
one is then located and the catheter introduced in the same manner.
The cystoscope is then withdrawn and the catheters are labeled right
and left to distinguish them. After wiping the ends of the catheters,
they are placed in two small sterile bottles plugged with sterile cotton,
and about 2 to 4 drams (8 to 15 c.c.) of urine are collected from each
kidney (Fig. 783).

URETERAL CATHETERIZATION IN THE FEMALE

773

Variation in Technic— The following method, devised by
Kelly, for collecting urine from one kidney without using a catheter

Fig. 783. — Method of collecting separate urine from each kidney. (Ash ton.)

Fig. 784.— Kelly's method of collecting urine from a kidney without using a catheter.

(After Kelly.)

is sometimes employed when it is undesirable to introduce a catheter
into the ureter for fear of carrying in infection from the bladder or

774 THE KIDNEYS AND URETERS

from other causes. Briefly, it consists in placing the patient in the
knee-chest posture, introducing into the bladder a speculum with the
end cut on the slant, and exposing to view the ureteral orifice from
which it is desired to obtain a specimen of urine. The orifice of the
ureter is then wiped clean and the speculum is held close against the
bladder wall so that the urine escapes into the speculum whence it is
collected by means of a small glass graduate (Fig. 784). In this way
often in a short time sufficient urine may be collected for purposes of
examination.

PYELOMETRY

By distending the renal pelvis with fluid its capacity may be meas-
ured, and from this it may be determined whether the pelvis is
normal, contracted, or dilated. The test is based upon the fact that
if the kidney pelvis is overdistended an artificial renal colic is pro-
duced. A normal pelvis will hold from 1 34 to 4 drams (5 to 15
c.c.) of fluid without pain. According to Braasch if the renal pelvis
has a capacity of less than 50 TTt (3 c.c.) it indicates irritabihty or a
contraction generally due to stone, tumor, acute or chronic pyelitis,
or spasm; a pelvis allowing distention up to i ounce (30 c.c.) may be
found in neurotic subjects, the condition being explained by the pres-
ence of a hysterical anesthesia; while a capacity of 10 drams (40
c.c.) and over indicates hydronephrosis.

Instruments. — A direct or indirect catheterizing cystoscope,
ureteral catheters, a catheter and syringe for irrigating the bladder, a
small syringe with a capacity of 2^ drams (10 c.c.) with a nozzle
that will fit the end of the ureteral catheter, as the Record syringe,
and a glass measuring graduate will be required.

Asepsis. — See under ureteral catheterization (pages 761, 770).

Solution Used. — ^A 2 per cent, boric acid solution, colored with a
drop or two of methylene blue, is employed.

Temperature. — The solution should be at a temperature of about
100° F. (sS'^ C).

Position of Patient. — Same as for ureteral catheterization Cpages
761, 770).

Anesthesia. — (See pages 761, 771).

Preparation of Patient.^ — Same as for ureteral catheterization
(pages 762, 771).

Technic. — A catheter of sufficient size to occlude the ureter and
prevent the escape of the solution beside it is introduced into the
ureter of the a£fected side as far as the pelvis (see ureteral catheteriza-

SEGREGATION OF URINE 775

tion, pages 762, 771). The colored solution is then injected into
the catheter while the operator notices through the cystoscope if any
of it leaks back into the bladder; if not, the injection is slowly con-
tinued until colicky pain is produced in the region of the kidney,
showing that the pelvis is distended. The quantity mjected indi-
cates the capacity of the pelvis.

SEGREGATION OF URINE

Special instruments, known as segregators, which separate the
bladder into two halves through the formation of an artificial dam,
may be employed to collect the urine separately from the kidneys
when a catheter cannot be passed into the ureter or ureteral catheter-
ization is contraindicated. They are easier to employ than the
ureteral catheter and with their use there is no danger of carrying infec-
tion into the ureters, but, on the other hand, they are not so accurate,
as an incomplete watershed may be formed allowing the urine from
the two sides to mingle, and the introduction of the instruments may
incite vesical bleeding and give misleading results. Again, if the
bladder is diseased, the urine obtained is, of course, contaminated and
it is not possible to determine whether the source of blood or pus is
the bladder, ureter, or kidney. If the bladder is very irritable or
bleeds easily, as is the case in the presence of acute cystitis, vesical
calculus, tumors, and prostatic hypertrophy, a segregator should not
be used. In healthy bladders, however, segregation properly per-
formed is fairly reliable.

Instruments. — There are several types of urine separators among
which may be mentioned the instruments of Harris and Luys.

The Harris segregator (Fig. 785) consists of two catheters having
a common sheath except at the distal and proximal ends. The intra-
vesical ends when in contact form a cylinder with a double curve and
are supplied with numerous small eyes which lead to the interior of
the catheter. The extra vesical portion ends in curved metal tubes to
which are connected by means of pieces of rubber tubing two aspirat-
ing bottles. A long lever, connected to the shaft of the instrument by
means of a fulcrum and spring, which is inserted into the rectum or
vagina for the purpose of raising up the bladder wall in the mid-line
in the form of a dam, is also provided.

Luys' instrument (Fig. 786) consists of two catheter tubes sepa-
rated by a metal partition, the vesical end of which has a Benique
form of curve. On the concave side of the intravesical portion is a

776

THE KIDNEYS AND URETERS

small chain covered with a thin India-rubber membrane, so arranged
that, after the instrument is within the badder, by turning a thumb-
screw at the proximal end of the instrument the rubber membrane is
made to partition the badder into two halves. Near the proximal

Fig. 785. — The Harris segregator. (Ashton.)

end are two discharge tubes which empty into small bottles. In
males this instrument causes less discomfort than does the Harris
segregator.

Asepsis. — The instruments and the bottles for collecting the
urine should be sterilized by boiling for five minutes, and the oper-
ator's hands are cleansed as for any operation.

786. — The Luys segregator.

Position of Patient. — In using the Harris instrument the patient
lies flat on the back with the feet, hips, and head on a level and with
the thighs flexed.

The same position is employed in inserting the Luys instrument,
but, when the instrument is in the bladder, the patient is elevated
to a semi-sitting position.

SEGREGATION OF URINE

777

Preparations of Patient. — The rectum should be empty. The
external genitals are cleansed with soap and water followed by a i
to 5000 solution of bichlorid of mercury. The urethra is irrigated
with a I to 5000 solution of potassium permanganate. The bladder
is emptied by means of a catheter and is then irrigated with a satu-
rated solution of boric acid or sterile water. About 5 ounces (150
c.c.) of solution is left in place when using the Harris instrument to
permit manipulation of the instrument, less distention being neces-
sary with the Luys instrument.

Anesthesia.— Local anesthesia may be required if the urethra or
bladder are hyperesthetic.

Technic. — i. Harris' Method, — The instrument, closed so the
catheters form a continuous tube, is well lubricated and is introduced

Fig. 787. — Segregation of urine by means of the Harris segregator. First step, instru-
ment in position in the bladder. (Ashton.)

into the bladder until its beak lies just within the vesical neck (Fig.
787). The proximal ends are then rotated outward so that the ves-
ical ends are made to lie on either side of the ureteral orifices and are
fixed in this position by the small spring at the proximal end of the
instrument (Fig. 788). The long lever, well lubricated, is then in-
troduced into the rectum of the male or the vagina of the female and
is secured by a clamp to the sheath of the catheters. By means of a
spiral spring the rectal or vaginal end is forced upward causing a
longitudinal ridge of bladder wall to be formed in the mid-line be-
tween the two ureteral orifices with the end of each catheter \y\ng at
the bottom of the correspondng compartment of the bladder. The
fluid left in the badder is then allowed to escape from each catheter
until it has all been drained off. The aspirating apparatus is then

778

THE KIDNEYS AND URETERS

attached and the urine is gently sucked out of the viscus from time to
time by means of the suction bulb and is collected in two sterile
bottles (Fig. 789). The instrument must be left in place about half

Fig. 788. — Segregation of urine by means of the Harris segregator. Second step,
vesical ends of the instrument separated. (Ashton.)

Fig. 789. — Segregation of urine by means of the Harris segregator. Third step,
the instrument in place. (Ashton.)

an hour to collect sufficient urine for examination. Care must be
taken to avoid too vigorous aspiration or hemorrhage will be incited.
At the completion of the operation the lever is detached, the cath-
eters are folded back in place, and the instrument is carefully re-

TESTS or KIDNEY FUNCTION

779

moved, following which the bladder is irrigated with a saturated
solution of boric acid.

2. Luys' Method — The rubber dam is first carefully examined to
see if it is intact. The instrument, well lubricated, is then introduced
in the same manner one would insert a sound, depressing the handle
well between the thighs as soon. as the tip enters the prostatic urethra
so as to carry the curved portion into the bladder. As soon as the
instrument is well within the bladder, the patient is raised to a semi-
sitting posture and the diaphragm is raised, carefully keeping the
instrument exactly in the median line. The handle of the instrument
is then elevated until resistance shows that the intravesical portion is
in contact with the base of the bladder. This should be confirmed

Fig. 790. — Showing the method of using the Luys segregator.

by vaginal or rectal palpation. After all solution has been drained
from the bladder, the urine, as it trickles into the bladder, is carried
off by a catheter on each side and is collected in the small tubes at the
proximal ends of the instrument (Fig. 790).

At the completion of the operation the diaphragm is lowered and
the instrument is withdrawn. This is followed by a vesical irrigation
of boric acid.

TESTS OF KIDNEY FUNCTION

The function of the kidney is to maintain the normal concentra-
tion of the fluids of the body by eliminating in the urine waste prod-
ucts of metabolism which, if accumulated in the blood and tissues,
would produce serious results. Numerous tests for determining the
functional efficiency of the kidneys have been devised which are

780 THE KIDNEYS AND URETERS

based on the principles that under conditions of impaired renal
activity, the urine will contain a smaller amount of its normal con-
stituents or will be less able to artificially eliminate certain foreign
substances, while the blood will show a concentration of substances
normally excreted in adequate amounts. These tests may be thus
divided into three classes: (i) Tests of excretion, (2) tests of reten-
tion, and (3) a combination, of tests of excretion and retention.

From a medical standpoint tests of kidney function are of diag-
nostic value in determining the kidney activity in acute and chronic
nephritis, uremia, cardiopathies, arteriosclerosis, and myocardial
insufficiency. They are also of considerable prognostic importance,
as by repeated tests it is possible to determine whether a disease is
progressive, stationary, or responding to treatment.

In surgery, in addition to being a means of estimating operative
risks by showing whether the two kidneys are properly performing
their functions, functional tests are of great importance when the
removal of one kidney is contemplated in determining the activity
of each kidney. But, although they demonstrate which kidney is
functionating best, they are not infallible and do not absolutely
prove that a particular kidney is capable of doing sufficient excretory
work after removal of its mate.

The Elimination of Substances Normally Present in the Urine as an
Index of Renal Function

Urinalysis. — While urinalysis is of great importance in the diag-
nosis of diseases of the kidneys and urinary organs, estimation of the
specific gravity and the amount of water, nitrogen, and salts excreted
by the kidneys is not sufficient by itself in determining the func-
tional capacity of the kidneys, as the quantity of these substances is
markedly influenced by the intake of fluids and food, by exercise, by
the condition of the nervous system, and by the condition of other
organs. It is of little use unless combined with a chemical
examination of the blood, or unless the intake and the
loss through other channels is determined as well. In other words,
it must be combined with a study of body metaboHsm. The most
that can be assumed from an ordinary urinalysis is that, if the elimi-
nation of the constituents of the urine are constantly normal, the
kidney function is probably not deficient, while if there is much
variation from the normal and this is constantly present, the kidney
function is likely to be impaired. Thus, as a test of kidney function.

TESTS OF KIDNEY FUNCTION 78 1

urinalysis alone has only the value of contributory evidence and it is
necessary to employ other tests to corroborate the findings and
determine the extent of deficiency, if present.

Experimental Polyuria Test.— A method of estimating the
functional activity of the kidneys is by the response to the ingestion
of an increased amount of fluid, known as the experimental polyuria
test, devised by Albarran, which consists essentially in obtaining the
urine from each kidney when the patient is dry and comparing the
two specimens and then having the patient drink a large quantity of
water and noting the effect upon the activity of the two kidneys.

The test is based upon the following laws: First, a diseased kidney
has a more uniform function than a healthy one, and the more
extensively its parenchyma is destroyed the less will its function vary
from time to time; second, when one kidney alone is diseased or is
more diseased than the other, if the urinary function is disturbed, its
function is less modified than the other. In other words, if an
increased excretory demand is placed upon the kidneys through the
ingestion of large quantities of water and the urine is collected sepa-
rately, the less diseased organ should show a greater increase in activ-
ity, manifested by the excretion of a larger total amount of fluid and
soKds, though the percentage of solids will be diminished, while the
diseased kidney will show a relatively small or no increase in activity.
The test thus becomes of value not only in examining the renal
function of both kidneys' but also in determining which kidney is
functionating best and the power of each to accommodate itself to
increased demands for excretory work.

Technic. — The patient should not have eaten anything for four
hours or taken any liquids for three hours. A single catheter is
placed in one ureter and the urine from the other side is collected by
means of a small catheter passed into the bladder. The urine which
flows for the first ten or fifteen minutes is discarded in order to permit
the reflex polyuria or oliguria which may follow the introduction of
the ureteral catheter to subside, and the urine that then flows is
collected for half an hour. This is saved for comparison with speci-
mens taken after the administration of the fluid. At the end of half,
an hour the patient is given two to three glasses (300 to 400 c.c.) of
mineral water and the urine is collected separately and examined at
half hour intervals for one and a half hours. For estimating the total
function, ureteral catheterization is not necessary, the urine being
collected by voiding. Not only is the total quantity of urine noted,
but the specimens are tested as to the freezing-point, quantity and

782 THE KIDNEYS AND URETERS

percentage of urea and sodium chlorid, and, if phloridzin has been
given, the amount of sugar is estimated.

Normally the polyuria appears within the first half hour, reaching
its maximum during the third half hour, and then rapidly declines.
The total amount of solids remains constant or increases, while the
the percentage sinks in proportion to the polyuria.

If the functional activity of the kidney is impaired, there is no
polyuria or it is delayed and the content of solids is unaffected.

Test Meal for Kidney Function. — This functional test was
originally suggested by Hedinger and Schlayer in 1914 and was later
more fully elaborated by Mosenthal {Archives of Internal Medicine ,
Nov., 191 5). It is a composite test for substances normally elimi-
nated in the urine, the specific gravity, salt, nitrogen, and water
excretion being determined in 2 hourly periods during the day and
for a 12 hour period at night. The test has come into quite general
use and is of recognized value in the study of renal function and in
the diagnosis of various forms of kidney and cardiac diseases, and
dropsical conditions.

Technic. — The directions for the test meal are contained in the
following form (Mosenthal) :

DIET

Test Meals For Kidney Function
For Date

All food is to be salt-free food from the diet kitchen.

Salt for each meal is to be furnished in weighed amounts. One
capsule of salt containing 2.3 gm. sodium chloride, is furnished with
each meal. The salt which is not consumed is returned to the lab-
oratory, where it is weighed, and the actual amount of salt taken
calculated.

All food or fluid not taken must be weighed or measured after
meals, and charted in the spaces below.

Allow no food or fluid of any kind except at meal times.

Note any mishaps or irregularities that occur in giving the diet
or collecting the specimens.

Breakfast, 8 a. m.

Boiled oatmeal, 100 gm.
Sugar, 1-2 teaspoonfuls%
Milk, 30 c.c.

TESTS OF KIDNEY FUNCTION y^S

Two slices bread (30 gm. each).

Butter, 20 gm.

Coffee, 160 c.c.

Sugar, I teaspoonful. 200 c.c.

Milk, 40 c.c.

Milk, 200 c.c.

Water, 200 c.c.

Dinner, 12 Noon

Meat soup, 180 c.c.

Beefsteak, 100 gm.

Potato (baked, mashed or boiled), 130 gm.

Green vegetables, as desired.

Two slices bread (30 gm. each).

Butter, 20 gm.

Tea, 180 c.c.

Sugar, I teaspoonful. 200 c.c.

Milk, 20 c.

Water, 250 c.c.

Pudding (tapioca or rice), no gm.

Supper, 5 p. m.

Two eggs, cooked any style.

Two slices bread (30 gm. each).

Butter, 20 gm.

Tea, 180 c.c.

Sugar, I teaspoonful. 200 c.c.

Milk, 20 c.c.

Fruit (stewed or fresh), i portion.

Water, 300 c.c.

8 A. M. — No food or fluid is to be given during the night or until
8 o'clock the next morning (after voiding), when the regular diet is
resumed.

Patient is to empty the bladder at 8 A. m. and at the end of each
period, as indicated below. The specimens are to be collected for
the following periods in properly labelled bottles:

8 A. M.-IO A. M., 10 A. M.-12 N., 12 N.-2 P. M., 2 P. M.-4 P. M.,
4 p. M.-6 p. M., 6 p. M.-8 p. M., 8 p. M.-8 A. M.

The above diet contains approximately 13.4 gm. of nitrogen,
8.5 gm. of salt, and 1760 c.c. of fluids and a considerable amount of

784 THE KIDNEYS AND URETERS

purin material in the meat, soup, tea, and coffee. These all act as
diuretics and the test depends upon the manner in which the kidney
responds to these stimuli. Mosenthal emphasizes that the urine
must be collected punctually every 2 hours, that no solid food or
fluid be taken between meals, and that the 12 hour night specimen
be completed before the breakfast is touched. The quantity and
specific gravity of each specimen is determined. Originally the total
and percentage content of salt and nitrogen of each specimen was
also estimated, but it is now considered sufficient if this is limited
to the total day and night specimens.

Mosenthal gives at length the responses and the test in health
and disease, which may be summarized as follows: In normal in-
dividuals the urine will show variations in the specific gravity in the
2 hour specimens of nine points or more from the highest to the
lowest. The quantity of water, salt, and nitrogen eliminated ap-
proximately balances the intake.^ The night urine is of high specific
gravity (1018 or more), is high in its percentage of nitrogen (above
I per cent.), and small in amount (400 c.c. or less), regardless of the
amount of fluid taken or the quantity of urine voided during the day.

When the functional activity of the kidney is diminished, the
night urine usually shows the effects first, the quantity increasing,
the specific gravity being lowered, and the concentration of nitrogen
diminishing. More marked impairment of function is characterized
by a decided lowering and fixation of the specific gravity, a dimin-
ished output of salt and nitrogen, a tendency to total polyuria, and
a night urine showing an increase in volume, low specific gravity,
and low concentration of nitrogen. Fixation of the specific gravity
in additon to occurring in nephritis, may be an indication of im-
paired renal function secondary to extrarenal conditions, as pyelitis,
cystitis with prostatic hypertrophy, hydronephrosis, pyonephrosis,
polycystic kidneys, renal congestion due to cardiac diseases, diabetes,
and anemias.

The Elimination in the Urine of Foreign Substances as an Index of

Renal Function

The Phloridzin Test. — This test depends upon the property of
the healthy kidneys to form sugar from phoridzin. The bladder is

1 The quantity of urine exc/eted will be about 400 c.c. less than the fluid intake, the
loss occurring through the skin, lungs, and intestines. Ninety per cent, of the nitrogen
intake should be eliminated, the balance being lost in the feces. Sodium chloride is
excreted entirely in the urine, except in diarrhoea (Mosenthal).

TESTS OF KIDNEY FUNCTION 785

first emptied and then i6in (i c.c.) of an aqueous solution of phlo-
ridzin containing 0.005 to o.oi gm. (approximately y^^ to \i gr.) of
the drug is injected into the buttock. If the kidneys are healthy,
glycosuria should appear within fifteen minutes to half an hour after
the administration of the phloridzin and should persist for about two
to four hours. Delay in its appearance or the excretion of only small
amounts of sugar points to renal insufiiciency, while an entire ab-
sence of sugar indicates that the kidneys are seriously affected. If
the functional activity of each kidney is to be determined, a catheter
is placed in each ureter and the relative proportion of sugar in the
separate specimens of urine thus obtained is estimated.

Methylene=blue and I ndigo-carmin Test.— Another method
of testing the functional activity of the kidneys is to inject drugs,
such as methylene blue or indigo-carmin, which color the urine after
entering the circulation. For this purpose the bladder is emptied and
i6Tlfi (i c.c.) of a 5 per cent, solution of methylene blue or 5 drams
(20 c.c.) of a 0.4 per cent, solution of indigo-carmin is injected intra-
muscularly. If the kidneys are normal, upon cystoscopic examina-
tion within half an hour after administration of the methylene blue
and within nine to twelve minutes after the administration of the
indigo-carmin, stained urine will be seen escaping from the ureteral
orifices. On account of the slow elimination of methylene blue,
requiring observations over a long period 01 time, this test has not the
same value as the indigo-carmin.

It is claimed for these tests that if the coloring of the urine is de-
layed or its intensity lessened it tends to show that there is some im-
pairment of the renal function.

The Phenolsulphonephthalein Test. — In 1910 Rowntree and
Geraghty proposed a new colorimetric test for estimating the renal
function by using phenolsulphonephthalein. As this drug is very
rapidly and almost exclusively eliminated from the body by the
kidneys, the test is one of the most delicate and reliable for determin-
ing the functional efficiency of the kidneys. When the kidney func-
tion is not impaired, the drug is present in the urine within five to
ten minutes after a subcutaneous injection, from 40 to 60 per cent, of
it being excreted within the first hour and from 20 to 25 per cent,
during the second hour. After an intramuscular injection, the drug
appears in the urine in about the same time as after a subcutaneous
injection, but from 5 to 10 per cent, more is eliminated during the
first -hour. Following an intravenous injection, the drug appears in
the urine in from three to five minutes, and from 35 to 45 per cent, of

786 THE KIDNEYS AND URETERS

it is eliminated within the first half hour and 6^ to 80 per cent, during
the first hour.

The quantity of the drug eliminated during a given time indicates
the excretory capacity of the kidneys, that is, in impaired kidney
activity the appearance of the drug in the urine will be delayed and
the quantity will be diminished according to the amount of kidney
involvement present. It is thus a valuable test in cardio-renal
cases in determining the degree of kidney impairment and in the
diagnosis of uremia from conditions that may simulate it. In all
t)^es of nephritis the elimination of phthalein is decreased. In
surgical work the test is of great value as in addition to furnishing
information as to the functional capacity of the two kidneys it is
possible to determine the amount of work performed by each.

Technic. — Twenty minutes to half an hour before making the test
the patient is given two or three glasses (300-400 c.c.) of water in
order to assure a free urinary secretion. Under the usual aseptic
precautions the patient is catheterized, the catheter being left in the
empty bladder. Sixteen minims (i c.c.) of the standard alkaline
solution of phenolsulphonephthalein containing 0.006 gm. (approxi-
mately 3-fo gr-) of the drug is then injected subcutaneously, intra-
muscularly, or intravenously^ and the time of injection is noted.
The urine is allowed to flow into a test-tube containing a drop of a 25
per cent, solution of sodium hydroxid and the time of the first faint
pinkish tinge is noted. The catheter is now withdrawn, the patient
being required to urinate into a receptacle at the end of an hour after
the first appearance of the drug and in a second receptacle at the
end of the second hour. In the presence of urinary obstruction, the
catheter is left in the bladder, the hourly specimens being separately
collected. Twenty-five per cent, solution of sodium hydroxid is now
added to the urine in sufficient quantity to render it strongly alkaline
and bring out the characteristic color — a brilliant purple red.

To determine the amount of dye present a Duboscq colorimeter or
a modified Hellige hemoglobinometer is employed. The solution
containing the urine is diluted with sufficient distilled water to make i
quart (i liter) and, after thoroughly mixing, a small filtered portion is
compared with a standard in the colorimeter. A simpler and fairly
accurate method is to prepare a series of standard solutions in test-
tubes containing 5, 10, 15, 20 per cent., etc., of the drug up to 60 per

iRountree and Geraghty (Journal of American Medical Association, Sept. 2, 1911)
advocate for general use the intramuscular injection in the lumbar muscles.

TESTS OF KIDNEY FUNCTION 787

cent., and then selecting the standard tube which matches the color
of the diluted urinary specimen.

To determine the functional efficiency of each kidney, the ureters
are catheterized and, as soon as the urine flows freely, the drug is
injected. The time of injection is recorded and the collection of urine
from each side is continued for one hour from the time of the first
appearance of the drug. If the drug is given intravenously the urine
need only be collected for filteen minutes after the appearance of
the drug. The quantity excreted in each specimen is then estimated
as described above.

The Concentration in the Blood of Substances Normally Excreted in
the Urine as an Index of Renal Function

Blood Chemistry. — The estimation of the retention in the blood
of certain nitrogenous products of metabolism is the basis of a number
of tests of kidney function. The most important determinations
from the standpoiut of renal function are the total non-protein
nitrogen, urea, uric acid, and creatinin. Through the failure on the
part of the kidney to eliminate these nitrogenous products which are
present in the blood in a constant amount in health, they are retained
and accumulate in the blood. An estimation of the concentration
of these substances in the blood, therefore, gives a fairly reliable
indication of the renal efficiency, and it becomes of still greater value
if combined with a simultaneous examination of the urine. Tests
of retention are also of the greatest help in prognosis and in furnish-
ing a guide as to the necessity for a restricted protein diet in nephritis.

Retention tests require the collection of from }i to 2j^ drams
(2 to 10 c.c.) of blood from the patient, the technic of which will be
found described on page 302. For the details of the actual quantita-
tive estimations, the reader is referred to works on laboratory technic
or clinical chemistry. It will be only possible here to refer to the
normal concentration of these substances in the blood and the sig-
nificance of variations.

Non-protein Nitrogen in the Blood. — The normal content is from
22 to 30 mg. per 100 c.c. of blood. In health approximately 50 per
cent, of this is represented by blood urea. Non-protein nitrogen is
markedly influenced by, the quantity and quality of the food taken,
and on a full meal with meat diet Tileston and Comfort found an
average rise of 4.7 mg.

A concentration above 30 mg. per 100 c.c. of blood may be re-
garded as indicating some degree of renal impairment. Tileston

788

THE KIDNEYS AND URETERS

and Comfort {Archives of Internal Medicine, Nov., 1914), from obser-
vation of a large series of cases, draw the following conclusions: A
rise of non-protein nitrogen of from 30 to 35 mg. per 100 c.c. of
blood indicates slight impairment of kidney function, from 35 to 50
mg. considerable, and from 50 to 100 mg. a very marked impairment,
while 100 mg. or over is of dangerous significance. They only en-
countered a concentration of over 100 mg. in two conditions besides
uremia, i.e., acute intestinal obstruction and profound anemia from
hemolysis. In disease from 32 to 85 per cent, of the increase is
accounted for by urea.

Urea in the Blood. — In health, blood urea is present in from 11 to
15 mg. per 100 c.c. of blood, forming about 50 per cent, of the non-
protein nitrogen. It is very markedly affected by a high protein
diet, on a full meal with meat diet the rise averaging 2.5 mg. (Tileston
and Comfort). With deficient elimination it accumulates in the
blood and the greater the amount of concentration the more serious-
is the prognosis. A concentration of urea above 15 mg. per 100 c.c.
of blood may be taken as indicative of retention. From 1 5 to 50 mg.
per 100 c.c. of blood are met in moderate degrees of impairment,
and in the presence of from 100 to 200 mg. the prognosis is serious.

Urea and non-protein nitrogen parallel each other to such an
extent that frequently the estimation of only one is made.

Uric Acid and Creatinin in the Blood. — In health uric acid is pres-
ent in from 2 to 3 mg. per 100 c.c. of blood, and creatinin in from i to
1.5 mg. per 100 c.c. of blood. Creatinin on a meat-free diet is en-
tirely of endogenous origin and, for this reason, it is considered by
many as a more rehable indication of renal insufficiency than blood
urea. A rise of creatinin to 3.5 mg. per 100 c.c. of blood is of danger-
ous significance, while 5 mg. usually ineans a fatal result in a short
time.

In studies of renal function in nephritis by Chase and Myers
{Journal of the American Medical Association, Sept. 23, 191 6), it was
observed that high uric acid estimations were frequently found
without any other retention, while creatinin appeared to be retained
only in the last stages of the disease. They found that normally
creatinin is the most readily, and uric acid the least readily, elimi-
nated by the kidney, urea being intermediate, and that therefore
uric acid retention should constitute one of the early signs of incipient
interstitial nephritis, while a considerable creatinin retention should
indicate a grave functional impairment of the kidney and should be a
valuable prognostic sign.

TESTS OF KIDNEY FUNCTION 789

Ambard's Coefficient and the McLean Index of Urea Excretion. —

The relation between the concentration of urea in the blood and urea
excreted by the kidneys as expressed by Ambard's constant or the
McLean index is considered of more value in determining slight
degrees of renal impairment and as an indication of prognosis than
the estimation of blood urea or non-protein nitrogen. Kidney im-
pairment may be thus indicated in cases that show normal ranges
in the blood of nitrogenous products.

Ambard found that when the kidneys are normal certain laws
govern the relationship between the urea content of the blood and
urine. His conclusions, known as Ambard's laws, are as follows:

1. When the concentration of urea in the urine is constant, the
rate of excretion varies directly as the square of concentration of
urea in the blood.

2. When the concentration of urea in the blood remains constant,
the rate of excretion varies inversely as the square root of the con-
centration in the urine.

3. That other factors being the same, the rate of excretion varies
directly with the weight of the individual.

He demonstrated a constant ratio between the concentration of
urea in the blood and the rate of excretion in the urine. This numer-
ical constant, known as Ambard's CoeflScient, is determined by the
following mathematical formula:

Constant {K) = L >< _72. x /

Ur = Grams of urea per liter of blood.

D = Grams of urea excreted per 24 hours.
Wt = Weight of individual in kilograms.

C = Grams of urea per liter of urine.

25 grams per Hter is taken as the standard concentration of urea
in the urine and 70 kg. as the standard weight.

The normal value of the Coefficient is between 0.07 and 0.09.
In impaired function with inability of the kidney to eliminate in
proportion to the concentration of urea in the blood there is a rise in
the constant in proportion to the degree of renal insufficiency. Val-
ues of from 0.09 to 0.12 indicate slight impairment, 0.13 to 0.2 a
moderate degree of impairment, and above 0.2 severe renal
impairment.

McLean modified the above by using a formula adapted from

'J go THE KIDNEYS AND URETERS

Ambard's laws which he has termed the index of urea excretion.
It is determined by the following formula:

^ . .^. DVc X 8.96
'"^^"^') WtX(Ur)^

An index of 100, corresponding to a value for Ambard's Coeffi-
cient of 0.08, is the standard normal index. Variations are expressed
in terms of the normal. Thus an index of 50 equals the rate of excre-
tion of 50 per cent, of normal under conditions of concentration in
the blood and urine. An index below 80 is considered abnormal
and one below 50 in renal disease is an evidence of marked kidney
impairment.

These tests are not available for use in general practice, as they
require very accurate collections of urine and time measurements,
and the servic-es of an expert chemist to carry out the various estima"
tions. For the technic the reader is referred to works on laboratory
methods.

Cryoscopy of the Blood and Urine. — Cryoscopy is the determina-
tion of the Ireezing-point of a liquid compared to that of distilled
water. The underlying principle of this test is that fluids containing
a small amount of solid material give a high freezing-point while
liquids with greater concentration freeze at a lower temperature.
AppKed to the blood and urine, cryoscopy is valuable in determin-
ing the renal activity of the kidneys and in some cases may be of
prognostic value when renal impairment exists. For example, if the
kidneys are doing an insufficient amount of excretory work, there
will be an accumlation of solid material in the blood which will,
therefore, freeze at a lower temperature than normal, and at the
same time the urine in such a case, through impairment of the
power of the kidneys to eliminate properly, will give a higher
freezing-point than normal.

The freezing-point of normal blood is 0.56° C. below that of dis-
tilled water. In weakened anemic individuals, however, it may rise
to —0.55° C. or even as high as —0.53° C. or —0.52° C. If cryo-
scopy of the blood gives a freezing-point below —0.56° C, it is
regarded as indicating some impairment of the renal function with
retention of waste products in the blood. According to Kummell, if
the freezing-point of blood falls to —0.60° C. it indicates such a de-
gree of renal impairment that nephrectomy is contraindicated.

Cryoscopy of the urine is of less value than when the test is ap-
plied to the blood. Healthy urine freezes at — 0.9° C. to — 2° C, and

SKIAGRAPHY y^I

if the freezing-point is higher than -0.9'' C. it is considered to be in-
dicative of insufficient activity. Cryoscopy of urine collected
separately from each kidney by ureteral catheterization will give
more information than when the test is applied to the bulk of urine.

To carry out this test 2^ drams (10 c.c.) of blood and urine are
required. For comparative examination the two should be collected
at the same time, the former by venous puncture (page 302) and the
latter by ureteral catheterization (page 759).

For the technic of cryoscopy, which requires a considerable
amount of skill to properly carry out, the reader is referred to some of
the manuals on clinical laboratory methods.

SKIAGRAPHY

The X-ray is of the greatest aid in the diagnosis of ureteral and
renal calculi. A good picture will give positive information as to the
position of a calculus, that is, whether it is located in the ureter or
kidney and will demonstrate the number and size, as well as the
position of the kidneys. In order to interpret the results of the X-ray
correctly the plate should show the following anatomic landmarks.
The eleventh and twelfth ribs, the transverse processes of the verte-
brae, the crests of the ilia, and the psoas muscle. If these points are
shown, the position of a calculus may be determined with accuracy.
The shadows cast by tumors, fecal concretions, calcified retroperit-
oneal glands, buried sutures which have become calcified, phleboUths,
foreign bodies in the intestines, the thickened tip of an appendix, etc.,
.are sometimes wrongly interpreted as calculi. Such errors may be
avoided if a catheter filled with a 30 per cent, bismuth paste or a
catheter in which a lead wire stylet has been placed is inserted into
the ureter and renal pelvis, and an X-ray is then taken. The shadow
of a calculus will be shown to be in close relation to that produced by
the wire in the ureter. Thus, while a positive picture can usually be
taken as proof of the presence of a calculus, this cannot always be
said of the negative evidence furnished by an X-ray. It must be
remembered that great thickness of the abdominal wall may interfere
with the success of a picture and that the chemical composition of the
stone is also an important element, for while oxalate and phosphate
stones give a deep shadow, those composed of uric acid furnish but
faint shadows and may escape recognition. In all cases to obtain a
successful picture it is absolutely essential that the stomach be empty
and the bowels be thoroughly cleared by a purge given the night
before and an enema the morning of the examination.

792 THE KIDNEYS AND URETERS

Pyelography. — This consists in the injection of an opaque fluid
into the ureter and renal pelvis followed by an immediate radiograph.
This method of diagnosis is of the greatest value in demonstrating the
extent and character of dilatations of the renal pelvis and ureter,
distortions of the pelvis by tumors or stones and of the ureter by the
presence of stones or strictures.

A lo to 15 per cent, solution of collargol, a 50 per cent, solution
of argyrol, a 5 per cent, silver iodid emulsion, and a 10 per cent,
thorium nitrate solution are among those frequently employed.
The catheter is inserted into the renal pelvis and the contents are al-
lowed to run off. A quantity of the warmed opaque solution suffi-
cient to distend the renal pelvis is then allowed to slowly flow in under
the force of gravity; it should not be injected with a syringe, as it
has been shown that collargol solution injected even under moderate
pressure may pass up the tubules into the kidney tissue producing
infarcts. The quantity of fluid used will depend upon the size of the
pelvis previously determined by pyelometry (see page 774) or by the
production of pain when the pelvis is distended. To study the
ureter the catheter is partly withdrawn so that the ureter may be
filled up and distended by the solution. The catheter is then
plugged to prevent the escape of the solution and the opposite side
is similarly injected, a radiograph being taken immediately. The
plugs are finally removed from the catheters and the solution is
allowed to drain off. To aid in removing the solution it is well to
induce a polyuria by giving the patient a glass of water to drink at
the completion of the operation.

EXPLORATORY INCISION

In cases of contemplated nephrectomy where other means of
diagnosis fail to give satisfactory results, an exploratory operation
will determine the exact condition of the second kidney. The kidney
requiring removal is first exposed and thoroughly explored. If its
removal seems indicated, it is replaced for the time being and the
kidney supposed to be healthy is then cut down upon by a lumbar
incision, the capsule is incised, and the organ is palpated and if neces-
sary inspected. If it is found to be healthy, the wound is closed and
the other kidney may then be removed. Should, however, such
exploration reveal serious disease of the second kidney, nephrectomy
is contraindicated.

MEDICATION OF THE RENAL PELVIS AND URETERS

793

Therapeutic Measures

MEDICATION OF THE RENAL PELVIS AND URETERS

Lavage of the kidney pelvis and ureter has been employed with
considerable success in treating subacute and chronic affections of
the kidney pelvis and ureter. The procedure is not difficult for one
skilled in the passage of the ureteral catheter, and properly performed
seems to be without danger. It is not a suitable method of treat-
ment, however, in acute infections, and in chronic cases, even,
other measures should be first given a trial.

Fig. 791. — Medication of the renal pelvis.

Instruments. — In addition to the apparatus necessary for ureteral
catheterization (see pages 759, 769) there will be required a glass
syringe, with a capacity of 2yi drams (10 c.c.) , supplied with a blunt
nozzle sufficiently small to fit into the end of the catheter.

Asepsis.— The same precautions against infection should be
observed as detailed under ureteral catheterization (pages 761, 770).

Solutions Used.— Sterile water, a saturated solution of boric acid,
silver nitrate in the strength of i to 8000 increased in strength up to
I to 2000, protargol i to 500 to 2 per cent., argyrol 2 to 5 per cent.,
collargol 4 per cent., bichlorid of mercury i to 150,000 to i to 16,000
may be employed. Too strong solutions will result in colic.

For the purpose of aiding the passage of an impacted calculus
injections of sterile olive oil have been employed.

794

THE KIDNEYS AND URETERS

Temperature. — The solution should be at a temperature of ioo°

F. (s^"" C).

Quantity. — One to 2 drams (about 5 to 10 c.c.) of solution are
generally injected at a time. If large amounts are employed, over-
distention of the renal pelvis will result with consequent colic.

Frequency. — The treatments may be applied once or twice a
week.

Position of Patient. — Same as for ureteral catheterization (pages
(761, 770).

Anesthesia. — (See pages 761, 771.)

Preparations of Patient. — The same as for ureteral catheteriza-
tion (pages 762, 771).

Technic. — The catheter is inserted into the renal pelvis as pre-
viously described (pages 762, 771). Any fluid or pus collection is
then allowed to drain off, and the tip of the syringe, charged with the
solution, is introduced into the end of the catheter and i or 2 drams
(about 5 to 10 c.c.) of solution are injected. Care must be taken to
see that the syringe contains no air and the injection must be given
very slowly and evenly to avoid a sudden distention of the kidney pel-
vis. The syringe is then disconnected, the patient is raised to a
semiupright position, and the solution is allowed to escape ; if a
small catheter is employed, the solution may, however, escape beside
it into the bladder. This washing-out process may be repeated
until the solution returns clear. The syringe is again connected
with the catheter which is slowly withdrawn, the solution being
injected the while so as to medicate the entire ureter. At the com-
pletion of the operation the bladder is irrigated.

To aid the passage of a ureteral calculus by the injection of olive
oil, the following technic is employed: a ureteral catheter is passed
beyond the stone if possible, and, if not, up to it, and a few drops of
sterile olive oil are injected. This acts as a lubricant and the stone
is often readily passed as a result.

THE DILATATION OF URETERAL STRICTURES

The gradual dilatation of ureteral strictures may be performed by
suitable bougies, introduced with the aid of the cystoscopy While it
is doubtful if a permanent cure can be obtained in many cases by this
method, as such strictures, like those of the urethra, rectum, etc., tend
to recontract in the majority of cases, the patient is greatly benefited
for the time being through relief of the distention of the ureter and

THE DILATATION OF URETERAL STRICTURES 795

kidney pelvis caused by the obstruction. The majority of strictures
are located near the ureteral orifices, and these are most readily di-
lated, though the method may be applied with success to strictures
in any part of the canal.

Instruments.— Dilatation may be effected by means of flexible
whalebone bougies, flexible catheters or, if the stricture is near the
vesical end, by metal catheters. These instruments as well as the
cystoscopes have been already described (pages 759, 769).

Asepsis. — (See pages 761, 770.)

Fig. 792. — Showing the method of dilating a ureteral stricture.
(After Kelly and Noble.)

Frequency of Dilatation. — Treatments are employed every two or
three days.

Position of Patient. — Same as for ureteral catheterization (pages
761, 770).

Preparations. — (See pages 762, 771.)

Anesthesia. — (See pages 761, 771.)

Technic. — The ureteral orifice is located as already described and
the dilator is introduced into the ureter in the same manner as the
ureteral catheter (pages 762, 771). Choosing an instrument that the
stricture will readily admit, it is passed completely through the stric-
ture and is left in place for a few moments and then a larger size is
inserted. At the next treatment the stricture is dilated one or two
sizes more until finally it is stretched sufficiently to admit a No. 5 or
6 catheter with ease. Following each treatment lavage of the kidney
pelvis and ureter may be practised as described above.

CHAPTER XXIII
THE FEMALE GENERATIVE ORGANS

Anatomic Considerations

The Vagina. — The vagina is a musculo-membranous canal ex-
tending from the uterus to the vulva," lying between the bladder and
urethra in front and the rectum behind. With the woman in an erect
posture it is directed downward and forward at an angle of 60 degrees
with the horizon. The anterior wall, which is shorter than the poste-
rior wall, due to the position of the cervix, measures 2 to 2 1/2 inches
(5 to 6 cm.) in length, while the posterior wall measures 3 to 3 1/2
inches (7.5 to 9 cm.). Normally the walls are in contact, but when
distended the vagina becomes conical in shape and larger above than
below. That portion surrounding the cervix uteri is spoken of as the
roof or fornix. It is divided for description into four parts: the ante-
rior fornix, in which is normally felt the body of the uterus ; the pos-
terior fornix, the deepest portion, which is in close relation with the
cul-de-sac of Douglas; and the lateral fornices.

Relations. — Anteriorly, in its lower portion the vagina is in rela-
tion with the urethra and in its upper half with the neck and fundus of
the bladder. Posteriorly, it is in relation with the perineal body in
its lower quarter, in its upper quarter with the cul-de-sac of Douglas,
and between the two with the rectum.

Structure. — It consists of a mucous, muscular, and connective-
tissue coat. The mucous membrane, which is of the squamous va-
riety, exhibits on the anterior and posterior walls numerous ridges,
or rugae, which extend out transversely from a central column. They
are more distinct on the anterior wall.

The muscular coat is arranged in two layers, an inner longitudinal
and an outer circular.

The connective-tissue coat is a thin fibrous structure containing a
few smooth muscle fibers. In its meshes this layer gives support to a
plexus of veins.

The Uterus and Appendages. — The uterus, or womb, is a hol-
low pear-shaped organ lying in the pelvis between the bladder and
the rectum. It measures about 3 inches (7.5 cm.) in length, 2 inches
(5 cm.) in breadth, and i inch (2.5 cm.) in thickness.

796

ANATOMIC CONSIDERATIONS

797

Externally, it is flattened from before backward, and at the point
where the peritoneum is reflected from the uterus to the bladder there
appears a constriction, the isthmus, which corresponds with the posi-
tion of the internal os and divides the uterus into two portions. The
portion lying below the isthmus is the cervix, that part between the
isthmus and a line joining the entrance of the tubes is known as the
body, while the portion above the plane of the entrance of the tubes is
known as the fundus. The cervix in turn is also divided into three
portions : an infravaginal portion, below the attachment of the ante-
rior vaginal wall; a supravaginal portion, above the attachment of the
posterior vaginal wall; and an intermediate portion, lying between
the two.

Fig. 793. — The normal position of the uterus. (Ashton.)

The interior of the uterus measures about 2 1/2 inches r6cm.) in
length and is divided into two portions by the internal os. That
portion of the canal above this point is triangular in shape with the
base upward and with the walls normally in contact. In the cervical
portion the canal is fusiform in shape. The uterus opens into the
vagina through the external os, a transverse aperture having an ante-
rior and a posterior lip, while above it connects with the peritoneal
cavity through the Fallopian tubes.

Position of Uterus. — Normally the uterus lies in a slightly ante-
flexed position with the fundus pointing toward the umbilicus (Fig.
793). Its position, however, is modified from time to time by the
neighboring organs. Thus a distended bladder will push it toward
the sacrum, while a full rectum pushes it forward.

hg2> THE FEMALE GENERATIVE ORGANS

Structure. — The uterus is made up of a mucous, muscular, and a
peritoneal coat. The mucous membrane of the body of the uterus is
smooth and pale in color, with the mouths of numerous tubular glands
opening upon its surface. The lining epithelium is of the ciKated
variety having a motion from within outward.

In the cervix it is firmer in structure and is thrown into numerous
folds, the arbor vitae. These are arranged in the form of a median
ridge on the anterior and posterior walls, from which branch second-
ary ridges in an upward and outward direction. Between these
ridges are located the openings of tubular and racemose glands. In
the upper portion of the cervix the mucous membrane is the same as
that found in the body of the uterus and below it is similar to that in
the vagina.

Extending out from either superior angle of the uterus are the two
Fallopian tubes. They measure 3 to 5 inches (7.5 to 12.5. cm.) in
length and lie in the free borders of the broad ligaments between the
ovaries behind and the round ligaments in front. They are Hned
with ciliated epithelium having a direction toward the uterus. Their
external apertures, the fimbriated extremities, open into the perit-
oneal cavity near the ovary. Internally, each tube opens into the
uterine cavity at its superior angle.

The ovaries, two in number, lie on either side of the uterus, about
on a level with the pelvic brim, near the abdominal extremities of the
tubes. Each ovary measures i 1/2 inches (4 cm.) in length, 3/4 inch
(2 cm.) in breadth, and 1/3 to 1/2 inch (0.8 to i cm.) in thickness.

Diagnostic Methods

In making a gynecological examination the investigation should
comprise an inquiry into the patient's general condition as well as an
examination of the pelvic organs. A clear and concise history of the
subjective symptoms should be the first step in every case. It is
preferable to allow the patient to first detail her own symptoms and to
supplement this by inquiry as to essential points. In doing this it is
well to follow a routine system in order to avoid omitting some impor-
tant point that may have direct bearing upon the case, and also that
the examiner may have a complete record for future reference.

In addition to the usual questions commonly asked in obtaining a
history, special information should be sought in regard to the follow-
ing points: First the menstrual history should be inquired into, ascer-
taining the age at which menstruation began,' the precautions taken

DIAGNOSTIC METHODS

799

during menstruation, the interval between the periods, the regularity
of the periods, the duration of the flow, and its character, whether
painful, whether accompanied by the passage of clots, and whether
scanty or profuse. The latter is especially important, as excessive
menstrual bleeding points to the presence of some pathological
condition.

With a history of painful menstruation the time the pain begins
and ceases in relation to menstruation should be ascertained. It
should also be found out whether there has been any bleeding be-
tween the periods. If the menopause has occurred, its date and the
presence or absence of any bleeding since are to be noted. If the
patient is married, certain data relating to child-bearing should be
sought, comprising the number of children, the dates of* their births,
a history of the labors, whether easy, difficult, or instrumental and
whether they were followed by a long and protracted convalescence.

With a history of abortions or miscarriages the period of preg-
nancy at which they occurred and their probable cause should be
ascertained. At times it is also important to know something of the
marital relations, that is, the frequency of coitus, whether the act is
painful and whether measures to prevent conception have been em-
ployed, and, if so,the methods used.

The patient is next questioned as to the presence or absence of a
vaginal discharge. If present, its character should be inquired into,
whether foul, blood-tinged, or having the characteristics of an ordi-
nary leucorrhea. The quantity of discharge is also to be noted, and
whether it is always present or only occurs midway between the
monthly periods.

Pain is another frequent and important complaint upon which full
information should be sought. The character and situation of the
pain should always be determined. The pain complained of may be
in the form of a headache, a bearing-down feeling, backache, or its
situation may be referred to some part of the pelvis, the coccyx, or the
inguinal region. Inguinal pain generally points to some disease of
the uterine appendages or ligaments; on the other hand, backache is
found as an accompaniment of a number of conditions, such as
chronic constipation, uterine displacements, pelvic tumors, etc., while
pain in the coccyx is often a symptom of neurasthenia. It should
also be ascertained if the pain is modified by menstruation, and if so,
whether it is worse before the flow begins, during the flow, or after-
ward, also whether it is affected by exercise, any sudden jolt or jar,
or by coitus.

8oO THE FEMALE GENERATIVE ORGANS

Finally, since many gynecological patients have in addition to
their pelvic troubles other disorders, the general symptoms and the
functions of other organs should be similarly inquired into. Thus
the patient should be questioned as to her appetite, loss of weight,
nausea and vomiting, and if the latter is present, its character and
relation to the taking of food, the condition of the bowels, and whether
she sleeps well or suffers from nervousness, hysteria, palpitation of the
heart, hot flashes, etc., etc.

The methods available for such examination include abdominal
inspection, palpation, percussion, auscultation, and mensuration,
internal examination by inspection and palpation, the use of specula
and the uterine sound, digital exploration of the uterus, test excision,
test curettage, and exploratory incision.

Preparation of Patient. — Certain preparation of the patient is
essential for a thorough examination, otherwise the results will be
unsatisfactory. If an anesthetic is to be given, the preparations for
such, previously detailed (page i8), should be carried out. In any
case, the bowels should be thoroughly evacuated by means of a mild
purgative taken the day before, followed by an enema on the morning
of the examination. The bladder is emptied spontaneously just
before the patient presents herself for examination.

A suitable examining-table should be provided, and the simpler
it is the better. It should be about 3 feet (90 cm.) high, strong in
construction, provided with adjustable foot-rests, and capable of
being lengthened so that the patient may be placed upon it in the
horizontal position. A small step, to aid the patient in mounting,
is also necessary. A second small table should be placed near at
hand, upon which are placed solutions, instruments, etc., that may be
required during the examination.

When it is necessary to make a vaginal examination in the
patient's home, an ordinary kitchen table or the bed may be utilized.
In the latter case the patient is placed lengthwise across the bed, with
an ironing-board covered by several thicknesses of a sheet placed on
the mattress under the patient's hips, and with the patient's feet
supported on two chairs (Fig. 794).

With the patient in the desired position upon the table it should
be seen that the corsets and any constricting bands are removed from
about the waist and that the patient is so covered by sheets that only
the region to be examined is exposed. For an abdominal examina-
tion two sheets are employed, one draped over the pelvic region and
lower part of the abdomen and the other over the upper abdomen.

GYNECOLOGICAL POSTURES

8oi

For a vaginal examination the sheet is thrown over the lower extrem-
ities and is then separated so as to expose the vulva. If the examiner
is provided with a nurse, these details may be left to her. While a
nurse is not absolutely necessary, it is always preferable to have some
woman present at the examination, not only for the greater comfort
of the patient, but for the protection of the physician against malici-
ous charges at the hands of unscrupulous females.

Fig. 794. — Position of the patient for an examination upon a bed. (Ashton.)

Gynecological Postures. — In examining the female pelvic organs
a number of postures are available. These include the dorsal, the
Sims, the knee-chest, the erect, and the squatting positions.

The dorsal position, which is the best for digital or bimanual
examinations, is obtained by placing the patient, facing the light, flat
on the back, with the hips near the edge of the table and with the
feet supported upon the foot-rests (Fig. 795).

The Sims position is obtained by placing the patient upon her
left side, with the left side of the face, the left shoulder, and left
breast resting upon a flat pillow. The left arm lies behind the back,
the thighs are well flexed upon the body, and the right knee is drawn
up nearer the body than the left (see Fig. 570). In this position an
excellent view may be obtained of the vaginal fornices, the anterior
vaginal walls, and the cervix, but it is not satisfactory for a digital

802

THE FEMALE GENERATIVE ORGANS

examination, as the pelvic organs are more difficult to reach than
with the patient in the dorsal posture.

The knee-chest position is obtained by having the patient kneel

Fig. 795. — The patient in the dorsal position. (Ashton.)

Fig. 796. — Examination with the patient standing erect. (Ashton.)

upon a table, with the thighs at right angles to the legs, the chest
resting upon a pillow placed upon the same level as the knees (see
^ig- 572). In this posture the intestines gravitate toward the dia-

INSPECTION 803

phragm, and the vagina becomes distended so that the numerous
folds of mucous membrane are spread out smoothly.

The Erect Posture. — The patient, with her clothes elevated and a
sheet fastened about her hips, stands with one foot on the floor and
the other resting upon a stool 6 to 8 inches (15 to 20 cm.) high. The
examiner kneels in front of the patient and passing his hand beneath
the sheet, makes a digital examination of the vaginal outlet and the
uterus (Fig. 796). In this position a prolapse of the uterus or a re-
laxation of the vaginal outlet is more readily recognized than in the
dorsal posture.

The squatting posture is sometimes useful in ascertaining the degree
of a uterine prolapse and the relaxation of the vaginal walls. The
patient takes the same position as when at stool and, by a slight
straining effort, any tendency to prolapse is readily made visible to
the examiner.

Asepsis. — In all gynecological examinations every precaution
must be taken to avoid infecting a patient as well as to prevent infec-
tion of the examiner by the patient. All instruments that are used
are boiled for ^lyq minutes in a i per cent, soda solution, and no instru-
ment should be used on more than one patient without resterihzation.
The examiner's hands are sterilized by a thorough scrubbing with
tincture of green soap and water, following by immersion in an anti-
septic solution. The examiner should also see that his finger-nails
are cut short to avoid hurting the patient.

If the patient is suspected of having syphilis or gonorrhea, or in
the presence of a septic discharge, the examiner should protect
himself by wearing rubber gloves previously sterilized. In the
majority of cases it is sufficient to wipe off the vulva with a swab
soaked in a i to 2000 bichlorid solution, but where a profuse or foul
discharge is present a vaginal douche may be required. When it is
desired to obtain a specimen of a discharge for examination, antisepn
tic solutions or douches should be omitted until this has been done.

/. Examination of the Abdomen
INSPECTION

From the appearance of the skin, the shape of the abdomen, and
the effect of respiration upon a tumor valuable information may be
obtained.

Position of Patient. — The patient should lie with the body sym-
metrically placed upon a firm flat table in the horizontal position.

8o4 THE FEMALE GENERATIVE ORGANS

Technic. — With the patient's abdomen entirely exposed and the
Hght falling obliquely upon the abdomen, the examiner inspects it
first fr^m the side and then from the foot of the table (see Fig. 523).
The color of the skin of the abdomen, the presence or absence of
striae, eruptions, scars, edema, and dilated veins, the condition of the
abdominal walls, whether rigid or lax, and the shape and symmetry
of the abdomen should all be noted.

In enlargement of the abdomen due to obesity, the lower portion
of the abdominal wall usually hangs down over the patient's thighs.
In ascites the abdomen is more or less flattened, and the sides
bulge outward. In the presence of pregnancy or an ovarian cyst the
enlargement is smooth and regular, in the former case the abdo-
men being symmetrically enlarged, while an ovarian cyst, especially
if small, may distend one side only. Fibroid tumors may present as
irregular and nodular growths. If a tumor is discovered, the pres-
ence or absence of mobility with respiration and whether the ab-
dominal walls move over the growth should be noted. Evidence cf a
weakened condition of the recti muscles or the presence of a hernia
should also be sought by having the patient strain and cough.

PALPATION

Palpation of the abdomen is the most satisfactory of the methods
of abdominal examination and should form a part of every routine
gynecological examination. By it the presence of tumors, rigidity,
fluctuation, or local tenderness that might escape notice by trusting
simply to a vaginal examination may be recognized, and, in the pres-
ence of an enlargement, its situation, origin, shape, mobility, and
consistency may be determined.

Position of Patient. — The patient lies in the dorsal position, with
the shoulders slightly elevated and the thighs somewhat flexed to
secure thorough relaxation.

Technic. — The examiner first thoroughly warms his hands.
Then, taking his place upon one side of the patient, he systematically
palpates all portions of the abdomen. In doing this the palpating
hand — usually the right — is placed upon the abdomen, palm down-
ward, and firm but gentle pressure is made — sharp pressure with the
finger tips should be avoided as it incites the muscles to contract.
Local or general rigidity of the abdominal wall, sensitive areas, and
the presence of a tumor are thus ascertained.

To differentiate obesity fron^i intraabdominal growths both hands

PALPATION

805

are employed and make deep pressure from the sides toward the
mid-line, at the same time lifting upward on the abdominal walls
(Fig. 797). The situation, origin, size, or mobility of a tumor is

I^ig- 797- —Showing the method of estimating the thickness of the abdominal walls. '

determined by making deep pressure with both hands in all direc-
tions about the mass (Fig. 798). An enlarged uterus is mapped out
in the same manner. In examining the lateral regions of the abdo-

FiG. 798. — Bimanual palpation of an abdominal tumor. (Ashton.)

men bimanual palpation is often of service, one hand being placed
under the flank and making forward pressure while the other hand
palpates the antero-lateral surface of the abdomen.

8o6

THE FEMALE GENERATIVE ORGANS

Fluid collections are recognized by a thrill or wave produced by-
placing one hand with the palm flat on one side of the abdomen and
tapping the abdomen from the opposite side with the fingers of the
other hand. To avoid confusing a wave produced by tapping a fat
abdomen with that of fluid the examiner should have an assistant
place the ulnar edge of his hand firmly on the summit of the abdo-
men while the tapping is performed (Fig. 799). In the case of fat
the wave is then absent.

Fig. 799. — Mehod of differentiating between a wave produced when tapping a fat
abdomen and one containing fluid. (Ashton.)

PERCUSSION

Abdominal percussion is valuable when employed as an adjunct
to inspection and palpation in differentiating between tympany,
ascites, cystic and soHd tumors, and in determining the size and
shape of a tumor, and its origin. To avoid errors, the large intes-
tine should be emptied by an enema before the examination.

Position of Patient. — Percussion is performed, first, with the
patient lying on the back and, then, turned upon the side.

Technic. — The examiner places the palmar surface of the middle
finger of the left hand firmly upon the area to be percussed and,
using the tip of the middle finger of the right hand, bent at a right
angle, as a plexor, strikes quick, sharp blows (see Fig. 529). The
normal resonance of the abdomen is tympanitic except in the regions
of the Hver and spleen where it is dull. Fecal masses, cystic and soHd
tumors, and fluid collections give dulness on percussion. When

PERCUSSION

807

distended intestines overlie a growth, however, the note will be tym-
panitic, and it will be necessary to employ deep and strong percus-
sion to bring out the dulness. By carefully percussing around the

rrYMPA/Vy^

Fig. 800. — Showing the area of dulness and tympany in ascites when the patient is

recumbent. (Ashton.)

margins of a tumor and noting where tympanitic resonance is absent,
it is often possible to determine the origin of the growth.

In the presence of ascites with the patient in the dorsal position,
dulness will be elicited in the flanks, while the center of the abdomen

-^^vCMPANY.

Fig. 801.— Showing the area of dulness and tympany in ascites when the paUent
lies on her side. (Ashton.)

will be tympanitic, as the intestines float to the highest point (Fig.
800). With a change in the patient's position the fluid gravitates to
the lowest point and the location of the duhiess and tympany is like-
wise changed (Fig. 801). On the other hand, the area of duhiess due
to tumors is not affected by changes in the patient's position.

8o8

THE FEMALE GENERATIVE ORGANS

AUSCULTATION

Auscultation is of limited use except in the differential diagnosis
between pregnancy and other tumors. In the former case the fetal
heart sounds and the funic souffle settle the diagnosis. Much impor-
tance cannot be attached to the uterine bruit, however, in the ab-
sence of other signs pointing to pregnancy, as it is also heard in large
fibroid tumors. In some cases of peritonitis it may be possible to
hear a friction note.

MENSURATION

Mensuration of the abdomen is useful in determining whether the
abdomen is symmetrically enlarged or not, in noting any increase of
ascites, and in recording the rapidity of enlargement in a tumor.

Position of Patient. — The measurements are taken with the
patient in the horizontal recumbent position.

Fig. 802. — Showing the measurements taken in recording the growth of an abdominal

tumor.

Technic. — An ordinary tape measure is employed and the follow-
ing measurements are taken: (i) the circumference of the abdomen
at the level of the umbilicus, (2) the distance from the ensiform carti-
lage to the pubes, (3) the distance from the umbilicus to each anterior
superior spine, (4) the distance between the two anterior superior
spines, and (5) the distance from the anterior superior spines to the
pubes (Fig. 802). To have any value for purposes of comparison,
these measurements should be taken from the same points each
time and with the patient in exactly the same position.

INSPECTION 809

//. Examination of the Pelvic Organs

INSPECTION

A careful inspection of the external genitals and the vaginal
orifice should always be made as a routine before a digital examina-
tion, otherwise lesions involving the vulva and neighboring parts
may escape notice. Inflammations, new growths, the presence of
abnormal secretions, prolapse of the anterior or posterior vaginal
walls, lacerations of the perineum, and many other pathological con-
ditions are readily recognized by inspection.

Fig. 803.— Inspection of the vaginal outlet. (Bandler.)

Position of Patient— Inspection is performed with the pa-
tient in the dorsal posture with the feet toward the light.

Technic— The examiner sits or stands facing the vulva and be-
gins his inspection without disturbing the relation of the parts. He
should first note the general appearance of the vulva, whether the
labia are closed or in apposition, and whether the vulva is the seat of

3io THE FEMALE GENERATIVE ORGANS

inflammation, ulcerations, warts, swelling, edema, varicosites, erup-
tions, or excoriations, the latter a frequent accompaniment of a dis-
charge. If a discharge is present, its color, quantity, and other
characteristics should be noted.

The labia are next separated with the fingers of the left hand, and
the entrance to the vagina is inspected (Fig. 803), noticing the color
of the mucous membrane, the presence or absence of the hymen, the
condition of the openings of the ducts of Bartholin and the orifice of
the urethra, and the presence or absence of lacerations, cystocele,
or rectocele. By instructing the patient to bear down or strain
slightly, a prolapse of the anterior or posterior vaginal walls is made

Fig. 804. — Method of exposing the anterior and posterior vaginal walls for inspection.

(Ashton.)

more evident. The hood of the clitoris should also be retracted and
an examination made for adhesions or concretions that may be the
cause of nervous symptoms. By retracting the perineum with two
fingers inserted in the vagina, as shown in Fig. 804, the lower portion
of the anterior and posterior vaginal walls may be brought to view.

EXAMINATION OF DISCHARGES

If an abnormal discharge is present, specimens should be obtained
at this time for later microscopical or bacteriological examination.
The importance of such an examination cannot be too strongly
emphasized. The technic for collecting and preparing the speci-
mens has been previously detailed at length in Chapter XI.

DIGITAL PALPATION

8ii

Palpation by means of the finger is employed to obtain more
complete information as to abnormal conditions of the vulva or
vaginal outlet discovered on inspection, and to determine the condi-
tion of the vagina, vaginal fornices, and the cervix. For a satis-
factory examination of the other pelvic organs, bimanual palpation
is necessary.

Asepsis.— All the aseptic precautions previously detailed (page
803) should be observed.

Fig. 805. — The diagnosis of a cystocele by the aid of a bladder sound. (Ash ton.)

Position of Patient. — The dorsal position is ordinarily employed,
but the erect posture will be found useful in estimating the degree
of a uterine prolapse.

Preparations. — (See page 800.)

Technic. — The examiner first palpates between the thumb and
forefinger of the right hand any abnormal conditions, such as swell-
ings, new growths, etc., about the vulva and the vaginal outlet, and
also the glands of Bartholin for signs of inflammation or thickening.

The labia are then separated between the thumb and index-
finger of the right hand, and the index-finger of the left hand, well
lubricated, is introduced into the vagina. The condition of the
vagina is then investigated, noting the presence or absence of
congenital malformations, its sensitiveness, its temperature, and
whether the vaginal walls have their normal roughness or are smooth

8l2

THE FEMALE GENERATIVE ORGANS

and unduly relaxed. By turning the examining finger palmar sur-
face up the anterior vaginal wall may be palpated and the presence

Fig. 806. — Method of estimating the thickness of the perineum. (Ashton.)

Fig. 807. — Digital palpation of the cervix. (Ashton.)

or absence of an urethrocele or a cystocele may be ascertained. By
introducing a sound into the bladder and palpating its point with the

BIMANUAL PALPATION 813

finger in the vagina (Fig. 805), acystocele, if present, may be more
readily recognized. The posterior vaginal wall is likewise examined
by rotating the examining finger, palmar surface back, and, by
placing the thumb of the same hand near the rectum, the perineum
may be grasped between the two fingers and its firmness and thick-
ness estimated (Fig. 806). The vaginal fornices on all sides of the
cervix are next palpated, noting their depth, any rigidity, indura-
tion, or tenderness.

If the uterus is in a normal position, it will be possible to feel its
body through the anterior fornix, while, if retroverted, the latter will
be felt in the posterior fornix. The condition of the uterus is more
satisfactorily made out, however, by bimanual palpation.

Finally, the cervix is palpated (Fig. 807), noting especially its
size, whether closed or open, whether hard or soft, its mobility, and
its position, that is, whether pointing backward toward the sacrum,
as in retroflexion of the uterus, or pointing forward toward the sym-
physis, as is found when the uterus is retroverted or anteflexed. The
presence or absence of lacerations, erosions, cysts, etc., should also be
determined.

BIMANUAL PALPATION

Bimanual palpation by means of the fingers of one hand in the
vagina or rectum and the fingers of the other hand making counter-
pressure above the symphysis is the most valuable method for in-
vestigating the condition of the pelvic organs. By it one may map
out the size and shape of the uterus and determine its consistency,
position, mobility, and the presence or absence of new growths. The
tubes, ovaries, broad ligaments, etc., may likewise be palpated and
their condition ascertained.

Vagino-abdominal palpation is the most satisfactory and the
more generally employed method. It should be supplemented by
recto-abdominal palpation, however, in any doubtful cases. The
latter method is especially useful in exploring the posterior surface
of the uterus and the appendages in cases of posterior displacement
of the uterus, as these structures may then be more readily reached
from the rectum than from the vagina. Recto-abdominal palpa-
tion is also indicated in children, in the unmarried, and in cases
where the vagina is unduly sensitive or obstructed by tumors or an
imperforate hymen.

To perform a successful bimanual examination it is necessary
that the abdominal walls be thin, relaxed, and free from tenderness

3 14 THE FEMALE GENERATIVE ORGANS

upon pressure, and that the vagina be sufficiently large to admit
the fingers of the examining hand. In the case of individuals with
very muscular, fat, or rigid abdominal walls or a small vagina the
examination is usually unsatisfactory without an anesthetic. In
any case, the examination must be performed with the utmost
gentleness. Rough manipulations accomplish nothing and are cap-
able of causing great harm, especially in cases where the pelvis
contains a tube filled with pus, a thin- walled cyst, an ectopic preg-
nancy, etc.

Asepsis. — For the necessary precautions against infection see
page 803.

Position of Patient. — Bimanual palpation is most satisfactorily
performed with the patient in the dorsal position.

Preparations. — (See page 800.)

Anesthesia. — General anesthesia is not often required in indi-
viduals with thin and relaxed abdominal walls, but in muscular, fat,
or nervous individuals or where the parts are tender and sensitive
an anesthetic may be necessary to secure relaxation. A general
anesthetic should also be employed if any doubt remains as to the
conditions found after an ordinary bimanual examination, and in
all cases where it is necessary to make a vaginal examination upon
virgins.

Technic. — i. Vagino-ahdominal. — The examiner stands facing
the patient a little to one side or the other depending upon which
hand he palpates with. The labia are then separated between the
thumb and forefinger of one hand and the index-finger of the other
hand, or the index- and middle fingers if the parts are sufficiently
relaxed to admit them, are well lubricated and are inserted into the
vagina, while the fingers of the free hand are placed on the abdomen
above the pubes. The external hand is used to steady or depress the
organs while the internal hand does the palpating. As a rule the
left hand is employed to palpate with, being the smaller of the two and
possessing greater tactile sensibility, but the examiner should be
equally proficient with either hand. The last two fingers of the
internal hand should be folded back upon the palm, as shown in Fig.
808, so as to invaginate the pelvic floor and thereby permit the
greatest possible penetration. The palmar surfaces of the fingers of
the internal hand are brought in contact with the cervix and its con-
dition and position are first determined. With the internal fingers
in contact with the cervix and exerting upward pressure the external
hand locates the fundus of the uterus and makes gentle pressure from

BIMANUAL PALPATION

815

above. The length, sensitiveness, consistency, and position of the
uterus are thus determined, and likewise the mobility by making a
series of gentle pushes from 'above and below (Fig. 809).

Fig. 808.— Method of inserting the examining fingers in bimanual palpation. Small
figure shows the method of holding the fingers.

Fio. 809. — Method of determining the
length and mobility of the uterus.
(Ashton.)

Fig. 810. — Method of estimating the
thickness of the uterus, (.\shton.)

By placing the internal fingers in front of the cervix and the fingers
of the external hand behind the fundus the thickness of the uterus
may be estimated (Fig. 810). If the fundus is pressed well forward
by the external hand, the anterior and lateral surfaces may be pal-

8i6

THE FEMALE GENERATIVE ORGANS

pated and any irregularity of the surfaces which might be caused by
fibroids or other growths is noted. By carrying the fingers of the
internal hand posterior to the cervix and pressing the fundus back-
ward the posterior surface is in like manner explored. When the

Fig. 8ii. — Diagnosis of an anteflexion of the uterus by bimanual palpation. (Ashton.)

Fig. 8i2. — Diagnosis of a posterior Fig. 813. — Shows the method of

displacement of the uterus by bimanual palpating the body of the uterus in a
palpation. (Ashton.) posterior displacement. (Ashton.)

fundus is not found in its normal position, it should be sought for
anteriorly near the symphysis, or posteriorly. To palpate for ante-
rior displacements, the internal finger is carried up in front of the

BIMANUAL PALPATION

817

cervix into the anterior fornix, while the external hand exerts pres-
sure downward behind the symphysis. If anteflexed, the fundus will
bexeadily felt between the fingers of the external and internal hands
(Fig. 811), while in posterior displacements the opposed fingers may
be brought together as shown in Fig. 812. In such case the fundus
should then be sought posteriorly by carrying the internal finger
up into the posterior cul-de-sac while external pressure is made by
the external hand from above (Fig. 813).

A posterior flexion will be readily differentiated from a version by
the bend or angle on the posterior aspect of the uterus (Fig. 814).

Fig. 814. — Diagnosis of a posterior flexion of the uterus by bimanual palpation.

(Ashton.)

In the presence of a posterior displacement it should be determined
whether the uterus is mobile or fixed through adhesions by passing
the internal fingers high up posteriorly and by the aid of the external
hand attempting to lift the uterus up.

After thoroughly examining the uterus the condition of the broad
and uterosacral ligaments should be ascertained. By carrying the
fingers up beside the cervix into the lateral fornices and making
counter-pressure from above the condition of the broad ligaments
may be determined, and any pain on pressure, thickening, or indura-
tion noted. Palpation of the uterosacral ligaments through the pos-
terior fornix may be performed in like manner.

The tubes and ovaries should also be examined with reference to
their size, shape, consistency, sensitiveness, position, and mobility.

8i8

THE FEMALE GENERATIVE ORGANS

It is of advantage to use the right hand in palpating the right side
and the left hand for the left side. The examining fingers are in-
serted well up in the lateral fornix beside the cervix in an upward and
backward direction, while the external hand makes deep pressure
downward through the abdominal wall on the corresponding side.
By altering the position of the fingers of the two hands from time to
time the ovary and tube are finally grasped between the opposed
fingers (Fig. 815). Except where the abdominal walls are extremely
thin and the vagina is relaxed, the normal tube cannot be felt, but.

FiG. 815. — Examination of the uterine appendages by bimanual palpation. (Ashton.)

when enlarged, it may be readily recognized as a club-shaped mass
gradually narrowing down as it approaches the uterus. The nor-
mal ovaries, however, are generally palpable as small, oval masses,
somewhat tender upon pressure, on each side of the uterus. When,
as the result of chronic inflammation, extensive adhesive formation
has taken place the tubes and ovaries are often matted together into
irregular masses, and it may not be possible to map them out sepa-
rately. Having examined one side of the pelvis, the same procedure
is repeated upon the other side.

2. Recto-abdominal. — The examiner stands facing the patient and
inserts the well-lubricated index-finger of the left hand high into the
rectum. At the same time the external hand placed on the abdomen

BIMANUAL PALPATION

819

above the symphysis makes counter-pressure, while the uterus and
appendages are carefully palpated (Fig. 816). Care must be taken.

Fig. 816. — Recto-abdominal palpation of the uterus. (Ash ton.)

Fig. 817. — Recto-abdominal palpation of the uterus with the latter drawn toward the
vaginal outlet by means of a tenaculum. (Ashton.)

however, not to exert too much force with the fingers in the rectum
for fear of lacerating or otherwise injuring the bowel.

820

THE FEMALE GENERATIVE ORGANS

By drawing the uterus well down by means of a pair of bullet
forceps caught in the cervix, and then performing recto-abdominal
palpation, a much more complete examination is possible (Fig. 817).
This method, however, should never be attempted when the uterus
is fixed by adhesions or the appendages are inflamed. As a rule,
general anesthesia is necessary. Care should always be taken to
replace the uterus in its normal position at the completion of such
an examination.

EXAMINATION BY SPECULA

By means of suitable specula the mucous membrane of the entire
vagina and cervix may be directly inspected. The use of specula
furnishes little information outside of the color and condition of the

Fig. 818.— Goodell's vaginal speculum. (Ashton.)

mucous membrane and the origin of a discharge, which is not as
readily obtainable by digital palpation. For gynecological treat-
ment and operative procedures, however, specula are indispensable.

Fig. 819. — ^Trivalve vaginal speculum.

Instruments. — Numerous specula have been devised, such as the
bivalve (Fig. 818), the trivalve (Fig. 819), the cyhndrical, the Sims
(Fig. 820), Simon's, the self-retaining weighted speculum, etc., etc.

EXAMINATION BY SPECULA

821

For diagnostic purposes the bivalve and the Sims specula are prob-
ably most commonly employed. To prevent the anterior vaginal
wall from obscuring the view when using the Sims speculum a vag-
inal depressor is also required (Fig. 821). A sponge holder (Fig.

Fig. 820. — Sims' vaginal speculum. (Ashton.)

822) and cotton wipes should be provided for removing secretions.

Asepsis. — The speculum should be sterilized by boiling for five
minutes in a i per cent, soda solution and the operator's hands are
sterilized in the usual way.

Position of Patient. — When the bivalve or trivalve speculum is

Fig. 821.— Vaginal depressor. (Ashton.)

employed the patient should be in the dorsal position. In using the
perineal retractors, such as the Sims, the left lateral, or the knee-
chest position may be employed.

Preparations of Patient. — (See page 800.)

Fig. 822. — Sponge holder and swab.

Technic. — i. With the Bivalve Speculum. — The examiner stands
or sits facing the vulva. Then, with the labia well separated be-
tween the index- and middle fingers of the left hand, the speculum,
warmed and well lubricated, is inserted into the vagina with its

822

THE FEMALE GENERATIVE ORGANS

blades parallel to the vulva opening (Fig. 823). The speculum is
introduced about 2 inches (5 cm.) and is then rotated so that the

Fig. 823. — Method of inserting the bivalve speculum. (Ashton.)

Fig. 824.— Method of exposing the lateral walls of the vagina by means of the bivalve

speculum. (Ashton.)

blades lie parallel with the anterior and posterior vaginal walls. By
widely separating the blades (Fig. 824) a view of the cervix and the
lateral walls of the vagina is obtained. For inspection of the ante-

EXAMINATION BY SPECULA

823

rior and posterior vaginal walls the blades of the speculum are turned
so that they lie parallel with the outlet of the vulva and they are
then opened (Fig. 825). The condition of the entire vaginal mucous

•lUUIUIIIIIIIIIIIIil

Fig. 825. — Method of exposing the anterior and posterior vaginal walls by means of
a bivalve speculum. (Ashton.)

Fig. 826.— Shows the method of inserting Sims' speculum.

membrane may be thus ascertained, and inflammatory conditions,
a fistulous opening, new growths, etc., wiU be readily recognized if
present. If a discharge is present, its origin should be detenmned.

824

THE FEMALE GENERATIVE ORGANS

Fig. 827. — Showing the Sims speculum in place. (Ashton.)

||!iP!llll'l'''''''''''''''''''''''l'Mil/l///l/l//l//"^

Fig. 828. — Method of inspecting the cervix by the aid of the Sims speculum and a
vaginal depressor. (Ashton.)

SOUNDING THE UTERUS 825

The cervix is then inspected, noting its size and shape and
whether it is lacerated or is the seat of inflammation, erosions, cysts,
or new growths, and whether a discharge issues from the external os!
If secretions obstruct the view, they should be carefully wiped away
by means of cotton wipes held by a sponge holder. In some cases,
where the vagina is very long and narrow, a clear view of the cervix
can only be obtained by drawing it down into the vagina by means of
a tenaculum or bullet forceps.

2. With the Sims Speculum.— The shaft of the speculum is grasped
in the operator's right hand while with the left hand the upper
buttock is raised so that the vulva is well separated. The blade of
the speculum, which has been previously warmed and lubricated,
is then inserted into the vagina parallel with the cleft of the vulva
(Fig. 826). The blade is then rotated so that it lies parallel with the
anterior and posterior vaginal walls and is further introduced until
its distal end lies back of the cervix. By making traction backward
and outward the perineum is retracted so that an excellent view of
the anterior vaginal wall and cervix is obtained (Fig. 827). Should
the anterior vaginal wall obstruct the view, it may be drawn out of
the way by means of the vaginal retractor as shown in Fig. 828.

SOUNDING THE UTERUS

The uterine sound, which was formerly employed to a great ex-
tent in gynecological diagnosis is, now seldom used, as little informa-
tion is gained by its use, ouside of determining the length, size, and
consistency of the uterine cavity, that is not as readily obtainable
by other and less dangerous means. The unskilled use of the uterine
sound has often led to the introduction of septic material into the
uterus carried from the vagina or cervix, as well as to the infliction
of serious injury upon the uterine mucous membrane and even per-
foration of that organ. To avoid these risks the position of the
uterus should be ascertained before an attempt is made to introduce
the sound, and, during the attempt, only gentle manipulations of
the instrument should be made; it should never be used as a means of
righting a displaced uterus. The sound should never be introduced
by touch alone, but always with the cervix clearly exposed by means
of a speculum, and in every case the date of the last menstruation
should be ascertained beforehand so as not to interrupt a possible
pregnancy. Its use is contraindicated if the uterus is infected or is
the seat of a malignant disease, or if the uterine appendages are
involved in a suppurative disease.

826

THE FEMALE GENERATIVE ORGANS

Instruments. — The operator will require a vaginal speculum, a
pair of bullet forceps, cotton wipes, a sponge holder, and a uterine
sound (Fig. 829).

The sound is made of flexible metal, about 12 inches (30 cm.)
long and from 1/12 to 1/8 inch (2 to 3 mm.) thick, with a bulbous
tip. The shaft is marked off in inches, and 21/2 inches (6 cm.) from
the distal end is a small protuberance to indicate the normal depth
of the uterus.

Asepsis. — The introduction of a sound or any instrument into the
uterus should be regarded as a surgical operation and should be car-
ried out with every aseptic detail. All the instruments should be

Fig. 829. — Instruments for sounding the uterus, i, Garrigues' weighted speculum;
2, dressing forceps; 3, tenaculum; 4 uterine sound.

boiled for five minutes in a i per cent, soda solution. The external
genitals should be thoroughly cleansed with soap and water followed
by a I to 2000 bichlorid solution and the vagina should be douched
with some antiseptic. The operator's hands are cleansed as thor-
oughly as for any operation.

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

Technic. — The operator sits facing the vulva and, after separating
the labia, introduces the speculum. The anterior lip of the cervix
is then seized by means of bullet forceps and, after being pulled down
into view, is thoroughly wiped off with a cotton swab soaked in a

DIGITAL PALPATION OF THE UTERINE CAVITY

827

I to 2000 bichlorid solution. The sound with its distal 3 inches (7.5
cm.) bent in a slight forward curve is grasped lightly between the
thumb and forefinger of the right hand and is introduced into the
external os, being careful not to touch any portion of the vagina. By
gently depressing its handle the sound should readily glide up the
canal to the fundus. If the point is arrested by catching in a fold of
mucous membrane or at the internal os, gentle manipulation will
usually result in its passage— >rce should never he employed.

Fig. 830. — Showing the method of estimating the length of the uterus by means of

the uterine sound.

Sometimes, when the cervix is bent forward, the sound may be
more readily passed if it is started with the concavity of its curve
turned backward and, as soon as it becomes arrested, rotating it for-
ward. When the tip of the instrument reaches the fundus, the opera-
tor's right index-finger should be moved along the shaft of the instru-
ment until it comes in contact with the cervix for the purpose of in-
dicating the depth of the canal when the instrument is removed
(Fig. 830).

DIGITAL PALPATION OF THE UTERINE CAVITY

Digital exploration of the interior of the uterus is occasionally
required in the diagnosis of intrauterine growths or retained prod-

828

THE FEMALE GENERATIVE ORGANS

ucts of conception which are not revealed by other methods of
examination. With the finger in the cavity of the uterus it is possible
to determine whether the uterus is empty or not, the length and
direction of the canal, and the thickness, consistency, and other
characteristics of the endometrium.

Digital exploration necessitates a thorough preliminary dilata-
tion of the cervix, except in puerperal cases, and should, therefore,
be considered in the same Kght as a surgical operation. It should
not be attempted until the possibility of pregnancy has been excluded
by determining the date of the last menstruation and by a careful
examination.

Fig. 831.— Digital exploration of the uterine cavity. (Ashton.)

Instruments. — Instruments for dilating the cervix are required.
These include a vaginal speculum, a pair of dilators, sponge holders,
and two bullet forceps. (See Fig. 883.)

Asepsis.— Strict aseptic precautions should be observed. The
external genitals are washed with soap and water, followed by a
I to 2000 bichlorid of mercury solution. The vagina is cleansed
with soap and water by means of a sponge on a holder and is then
douched with an antiseptic solution. The instruments are boiled
for five minutes in a i per cent, soda solution and the operator's
hands are prepared with the same care as for any operation.

Position of Patient.— The lithotomy position is employed.

EXPLORATORY INCISION

829

-General anesthesia is required except in postpartum

Anesthesia.

cases.

Technic— The cervix is first dilated sufficiently to admit the
operator's finger (see page 864). The index-finger of the right hand
or, where possible, as in postpartum cases, the index- and middle
fingers are then passed into the uterus, while, with the left hand on
the abdomen, the operator presses down upon the fundus uteri, so
as to bring the uterus within reach of the internal fingers (Fig. 831).
The interior of the uterus is then systematically explored by the in-
ternal fingers.

Fig. 832. — Instruments for an exploratory vaginal section i, Garrigues' weighted
speculum; 2, sponge holder; 3, tenaculum; 4, thumb forceps; 5, sharp-pointed scissors;
6, artery clamps; 7, needle holder; 8, needles; 9, No. 2 catgut.

THE EXAMINATION OF SECTIONS AND SCRAPINGS FROM

THE UTERUS

To determine the nature of a suspicious growth a portion should
be excised for examination. The method of doing this has already
been described (page 307). Where the interior of the uterus is the
seat of suspected disease, scrapings from the endometrium for ex-
amination should be collected by a thorough curettage (see page 868).

EXPLORATORY INCISION

Direct palpation of the pelvic structures is sometimes required in
the diagnosis of obscure pelvic conditions. It may be accomplished
by means of an abdominal incision or through a small opening made
in the cul-de-sac of Douglas. The latter method is preferable, as it

830

THE FEMALE GENERATIVE ORGANS

is not a dangerous operation, and the recovery of the patient is more
rapid than when an abdominal section is performed. The operator
should be prepared, however, to perform any operative procedures,
such as draining a pus sac, removing suppurating tubes, or opening
the abdomen, if the findings indicate it.

Instruments. — There will be required a weighted vaginal specu-
lum, sponge holders, bullet forceps, toothed thumb forceps, sharp-

FiG. 833. — First step in performing a posterior vaginal section, opening into the posterior

cul-de-sac.

pointed curved scissors, artery clamps, curved cutting-edged needles,
a needle holder, and No. 2 catgut (Fig. 832).

Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The external genitals are scrubbed with soap
and water followed by a i to 2000 bichlorid solution, and the vagina
is cleansed by first washing with soap and water and then by means
of an antiseptic douche. The operator's hands are sterilized in the
usual way.

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

Preparation of Patient. — The patient is prepared for general
anesthesia (see page 18) and the bowels and bladder should be empty
at the time of operation.

EXPLORATORY INCISION

831

Fig. 834. — Shows the posterior cul-de-sac opened.

Fig. 835. — Shows the method of palpating a tumor through an incision into th^ pos-
terior cul-de-sac.

832 THE FEMALE GENERATIVE ORGANS

Anesthesia. — General anesthesia is employed.

Technic— The vaginal speculum is placed in the vagina and the
posterior Up of the cervix is seized in bullet forceps which are given
to an assistant to hold. The operator then picks up the posterior
vaginal wall by means of thumb forceps at a point in the mid-Hne,
just back of where it is reflected from the cervix, and with a pair of
scissors makes a transverse incision about i inch (2.5 cm.) long
through the vaginal wall (Fig S^s)- The vaginal wall posterior to
the incision is then separated by blunt dissection from the under-
lying peritoneum for a short space (Fig. 834). The peritoneum thus
exposed is then picked up and a transverse opening, sufficiently
large to admit the fingers, is made in it. Through this opening the
pelvic structures may be thoroughly palpated by the finger (Fig.
835), and if desired the appendages may be brought down to view
and inspected.

At the completion of the operation the opening in the peritoneum
and that in the vaginal wall are closed by a few catgut sutures.

Therapeutic Measures
VAGINAL IRRIGATIONS

Vaginal irrigation, or douching, may be employed for simple
cleansing purposes, as in leucorrhea or in preparation for operative
procedures; for the purpose of bringing soothing, astringent, or anti-
septic solutions in contact with diseased vaginal or cervical mucous
membrane; and as a means of applying heat to the pelvic organs to
relieve congestion or inflammation, to hasten involution after labor,
to control uterine hemorrhage, etc. In pregnancy and during
menstruation douches should be used with caution.

Apparatus. — There will be required a large glass irrigating jar or
douche bag, a bath thermometer, 6 feet (180 cm.) of rubber tubing,
1/4 inch (6 mm.) in diameter, leading from the reservoir to the
douche nozzle, a glass vaginal douche nozzle, and a douche pan
with a spout to which is attached a piece of rubber tubing sufficiently
long to convey the waste fluid to a slop pail (Fig. 836).

The douche nozzle should preferably be of glass without any
curve and having perforations on the sides, but with none at the end
(Fig. 837). With such an instrument there is little danger of the
solution entering the uterus in cases of a patulous cervix.

VAGINAL IRRIGATIONS

^SS

Asepsis.— The greatest care should be taken against infection
especially in puerperal cases. The apparatus should, therefore, be
boiled for five minutes in plain water and the thermometer should be
sterilized^ by immersion in a i to 500 bichlorid of mercury solution,
after which it is rinsed in sterile water. The attendant's hands

836. — Apparatus for vaginal douching.

should be cleansed in the usual way and the external genitals should
be washed with soap and water followed by a i to 2000 bichlorid
solution. When the patient administers the douches herself, the
dangers of infection and the proper means of avoiding it should be
carefully explained to her.

Fig. 837. — Enlarged view of a glass vaginal douche nozzle.

Solutions Used. — Among the many solutions used for vaginal
injection are the following: Plain sterile water; normal salt solu-
tion— salt 5i (4 gni-) to the pint (500 c.c.) of boiled water; boric
acid 2 per cent.; thymol i to 1000; lysol i per cent.; creolin i p)er
cent.; tannic acid 5i (4 gna-) to the quart (liter); alum acetate 3i
(4 gm.) to the quart (liter); permanganate of potash i to 20cx>;
bichlorid of mercury i to 5cxx); carbolic acid i per cent, etc. The

834

THE FEMALE GENERATIVE ORGANS

use of poisonous drugs, such as the latter two, should he followed by a
douche of sterile water or saline to avoid any danger of absorption.

Temperature. — Ordinarily the irrigation is given at a tempera-
ture of ioo° to los"" F. (38° to 41° C). When the stimulating and
vascular constricting effect of heat is desired, however, the temp-
erature should be from 115° to 120° F. (46° to 49° C).

Quantity. — ^At least i gallon (4 liters) of solution should be used
at a time. If it is desired to obtain a prolonged effect from the heat,
several gallons may be used over a period of fifteen to thirty minutes.

Fig. 838. — Showing the correct (a) and the incorrect (b) method of giving a vaginal

douche. (Ash ton.)

Height of Elevation. — This is important, since, if the reservoir is
elevated too high, the pressure will be so great that solution may be
forced into the uterus. An elevation of 2 to 3 feet (60 to 90 cm.) is
amply sufficient.

Frequency. — This will depend upon the purposes of the douche
from once a day to three or more times daily.

Position of Patient. — The patient lies in bed on a douche pan in
the dorsal position, with the knees flexed, or else recumbent in a bath
tub. The douche should not be taken with the patient sitting on the
toilet.

Technic. — The labia are widely separated with the finger of the
left hand and with the right hand the nozzle is introduced into the
vagina, first, however, allowing the solution to flow in order to expel

LOCAL APPLICATIONS TO THE VAGINA AND CERVIX 835

any air or cold fluid. The desired amount of solution is then per-
mitted to enter the vagina which balloons up under the influence of
the distention and thus allows the solution to come in contact with
its entire surface (Fig. 838).

In cases of a relaxed vagina, it is necessary to compress the vaginal
outlet about the douche tube in order to obtain this distention.
This procedure should, however, be used with caution in puerperal
cases, for, if the intravaginal pressure be too great, some of the
solution will necessarily be forced into the uterus. During the irri-
gation care must be taken to protect the patient's body from cold
by suitable covering.

LOCAL APPLICATIONS TO THE VAGINA AND CERVIX

Local applications are employed in treating inflammations of the
vagina and the vaginal portion of the cervix. They may be made by
means of cotton- tipped applicators or by tampons (see page 837).

=CCE

z
Fig. 839.— Instruments for making local applications to the vagina, i, Bivalve

speculum; 2, applicator.

The former method should be employed when it is desired to medi-
cate localized areas of inflammation or ulceration or to employ
strong solutions.

Instruments. — There will be required a bivalve vaginal speculum
and a metal applicator or a pair of dressing forceps (Fig. 839).

Asepsis.— The instruments are boiled in a i per cent, soda solu-
tion for five minutes and the external genitals are cleansed with soap-
and water followed by a i to 2000 bichlorid of mercury solution.
The operator's hands should likewise be clean.

Solutions Used.— Tincture of iodin, silver nitrate gr. xx to xxx
(1.3 to 2 gm.) to the ounce (30 c.c), argyrol 50 per cent., copper
sulphate gr. v to xx (0.3 to 1.3 gm.) to the ounce (30 c.c), zinc sul-
phate gr. V to XX (0.3 to 1.3 gm.) to the ounce (30 c.c), etc, are
among the solutions generally employed.

S36

THE FEMALE GENERATIVE ORGANS

. Frequency.— Applications may be made every three or four days.

Position of Patient. — The patient should be upon a firm table in
the dorsal position.

Technic. — The diseased area is exposed by means of a speculum
and, after removing any mucus or secretion, the surface it is desired
to medicate is wiped dry. An applicator or dressing forceps wrapped
with cotton is then dipped in the solution and the saturated swab is
thoroughly rubbed over the diseased area. Following this a light
vaginal tampon is inserted and allowed to remain in place twelve to
twenty-four hours.

APPLICATION OF POWDERS TO THE VAGINA

Powders are sometimes employed with success in place of liquids
in the treatment of chronic vaginitis, especially if ulcerated surfaces
are present.

Fig. 840. — Instruments or the application of powders to the vagina, i,
speculum; 2, dressing forceps; 3, powder blower.

Bivalve

Instruments. — A vaginal speculum, dressing forceps, and a
powder blower are required (Fig. 840).

Formulary. — Soothing or astringent powders, such as boric acid,
zinc oxid, bismuth subnitrate, calomel, tannic acid, glycerole of tan-
nin, acetanilid, alone or in combination, are frequently employed.

VAGINAL TAMPONS

837

Position of Patient. — The patient should be in the dorsal posture.

Technic. — The vagina is first well cleansed with a douche. A
speculum is then inserted and, by means of a cotton swab held in a
dressing forceps, the mucous membrane is thoroughly dried. The
entire inflamed surface is then coated with the desired powder ap-
plied by means of the powder blower. A light tampon is finally
inserted and is left in place for twenty-four hours.

VAGINAL TAMPONS

Vaginal tampons are used for a variety of purposes, namely, to
bring medication in contact with the vagina or the cervix in the treat-

FiG. 84i.-Showing the method of making a cotton vaginal tampon.
(KeUy and Noble.)

ment of inflammations involving these structures, to protect and
keep separated inflamed or ulcerated vaginal walls, to apply glycerm

SsS

THE FEMALE GENERATIVE ORGANS

for its depleting effect upon the uterus and pelvic organs, to support
a prolapsed ovary, for the purpose of stretching adhesions or sup-
porting the uterus by distention of the vagina and fornices, and alone
or in combination with the uterine pack to control hemorrhage from
the uterus.

Tampons should not be left in place more than twenty-four
hours, as they tend to become foul and offensive, and strings should
aways be attached so that they may be removed by the patient.
The patient should, of course, be informed of the exact number of
tampons inserted.

Instruments. — Bivalve and Sims' specula and dressing forceps
are required.

The Tampon. — Tampons are made of absorbent cotton, lambs'
wool, or gauze. For carrying medication absorbent cotton is prefer-

FiG. 842. — Vaginal tampon,s in position.

able, while for purposes of support lambs' wool or gauze, having
more body, are best.

The cotton tampon is made by cutting a flat layer of absorbent
cotton into an oblong shape, placing a heavy silk string about 14
inches (35 cm.) long, across one end as shown in Fig. 841, and rolling
the cotton about the string. On tying the string the two ends of the
cotton roll are brought together and, at the same time, the string is
buried in and securely fastened to the cotton.

Lambs' wool tampons may be made in the same manner or a silk
string may be simply tied to the center of a wad of the wool.

A gauze tampon should consist of a single piece of gauze 3 feet
(90 cm.) or more long, depending on the capacity of the vagina and

VAGINAL TAMPONS

839

the firmness with which it is to be packed, and folded to a width of
about 2 inches (5 cm.).

The Medicated Tampon.— The tampon is made as above de-
scribed and is then saturated with the desired medication. For this
purpose the following drugs are employed : Ichthyol and glycerin 25
per cent., boroglycerid, glycerite of tannic acid 20 per cent., argyrol
10 to 25 per cent., protargol 2 per cent., etc. When indicated, the
tampon may be covered with some of the powders mentioned on page
836 in place of these solutions.

Asepsis.— The instruments should be boiled and the tampons
thoroughly sterilized. The external genitals are washed with soap

Fig 843. — Shovrs the method of packing the vagina with the patient in the Sims

position.

and water followed by a i to 2000 bichlorid of mercury solution. The
operator's hands are cleansed in the usual way.

Position of Patient. — For inserting the medicated tampon the
patient may be in the dorsal posture, but, when it is desired to thor-
oughly pack the vaginal vault for the purposes of support and to con-
trol hemorrhage, the Sims or the knee-chest posture is preferable.

Preparations of Patient. — The bladder and bowels should be
empty. Any clots or secretions are wiped from the vagina and the
entire vagina is then swabbed out with a i to 2000 bichlorid of mer-
cury solution.

840 THE FEMALE GENERATIVE ORGANS

Technic. — For applying a medicated tampon a bivalve speculum
is inserted and the tampon, soaked in the medicanient, is carried in
dressing forceps to the desired spot. A wool tampon is then inserted
to retain the first one in position and, while the tampons are held
securely in place by means of the dressing forceps, the speculum is
removed, care being taken that the strings attached to the tampons
are left hanging from the vagina (Fig. 842).

The tampon is to be removed by the patient within twenty-four
hours, at which time a cleansing douche should be taken.

• To thoroughly pack the vagina, as is necessary, for example, for
the control of hemorrhage, the patient being in the Sims or the knee-
chest posture, a Sims speculum is inserted and the posterior vaginal
wall is put upon the stretch. Then, by means of a pair of dressing
forceps, the entire vagina is thoroughly tamponed with a strip of
gauze, beginning with the posterior vaginal fornix, then filling the
lateral and anterior fornices, and, as the rest of the vagina is packed,
gradually withdrawing the speculum (Fig. 843). A T-bandage is
then applied to retain the pack in place. Such a pack properly
inserted will control any ordinary hemorrhage from a nonpuerperal
uterus, but in severe hemorrhages and in postpartum cases the
uterus also should be tamponed (page 847).

Removal of the packing in twelve or twenty-four hours should be
followed by a cleansing douche.

THE INTRAUTERINE DOUCHE

Uterine douches are employed in the treatment of septic conditions
affecting the uterus, to control hemorrhage, and for cleansing the uterus
after curettage and other intrauterine operations. Certain precau-
tions in their use are necessary. They should always be given
iby the physician himself and the same care and attention to
^ cleanliness should be observed as in any operative procedure. It is
absolutely essential that a free and unimpeded return of the solution
be provided by having the cervix well dilated or by employing a
return-flow irrigating nozzle, otherwise there is danger of overdis-
tention of the uterus with resulting shock or of the fluid being forced
into the tubes. Furthermore, the use of poisonous drugs, such as car-
holic acid or hichlorid of mercury , should always he followed by an in-
trauterine irrigation of sterile water or of normal salt solution.

Apparatus. — There will be required a glass irrigating jar or a large
douche bag, a thermometer, 6 feet (180 cm.) of rubber tubing, 34

THE INTRAUTERINE DOUCHE

841

inch (6 mm.) in diameter, connecting the reservoir and the douche
nozzle, a douche pan with a spout to which is attached a piece of rub-
ber tubing sufficiently long to convey the returning fluid to a waste
pail (see Fig. 836).

There are several forms of intrauterine douche nozzles. When
the cervix is widely dilated, as in postpartum cases, a curved glass

-*«=

Fig. 844. — Glass intrauterine douche nozzle.

nozzle with the openings upon the sides, such as the Chamberlain
tube (Fig. 844), is sufficient.

In other cases it is necessary to employ some form of return-flow
nozzle. The Fritsch-Bozeman nozzle (Fig. 845) is the safest of these.

Fig. 845. — Fritsch-Bozeman return-flow uterine douche nozzle. (Bandler.)

It consists of an outer tube fenestrated near the tip, with a second
opening upon the under surface of the instrument near its lower end
for the return flow. Inside this outer tube is a smaller inflow tube.
This instrument requires some dilatation of the cervix, however,

Fig. 846. — Return-flow dilating catheter. (Ash ton.)

before it can be introduced and where this is lacking a smaller instru-
ment, such as Talley's intrauterine catheter (Fig. 846), may be em-
ployed. The latter consists of a curved metal catheter with two
heavy wires on its under surface, which may be expanded or closed by
turning a small thumb-screw. The catheter is introduced into the
uterus with the wires lying close to the catheter and, when in the

842

IHE FEMALE GENERATIVE ORGANS

Uterus, the wires are expanded, thereby dilating the cervix suffi-
ciently to permit a return of the injected solution.

Instruments.^ — In addition to the above apparatus a vaginal
speculum, a sponge holder, and a pair of bullet forceps are required
(Fig. 847).

Asepsis. — The apparatus and instruments should be sterilized by
boiling and the thermometer by immersion in a i to 500 bichlorid of
mercury solution followed by rinsing in sterile water. The external
genitals are first washed with soap and water and then with a i to
2000 bichlorid of mercury solution. The vagina is cleansed by means

Fig. 847. — Instruments for intrauterine douching, i, Garrigues' weighted speculum;
2, sponge holder; 3, tenaculum.

of a I to 5000 bichlorid of mercury douche, followed by sterile water.
The operator's hands are sterilized in the usual way.

Solutions Used. — Plain sterile water, normal salt solution — salt
3i (4 gm-) to the pint (500 c.c.) of water, i to 10,000 to i to 5000
bichlorid of mercury, 50 per cent, alcohol, 0.5 per cent, solution of
lysol, 0.5 per cent, solution of creolin, silver nitrate i to 1000, etc.,
etc., are among the solutions employed-.

Temperatures. — Ordinarily the temperature of the solution is
about 105° F. (41° C.) . Where the stimulating and constricting effect
of heat is desired, the temperature of the solution should be 115° to
120° F. (46° to 49° C).

Quantity. — About i quart (i liter) of solution is used at a time.

THE INTRAUTERINE DOUCHE

843

Rapidity of Flow.— The fluid should not be allowed to enter the
uterus more rapidly than it can escape^ otherwise there is danger of its

Fig. 848. — Inserting the douche nozzle when the cervix is well dUated.

being forced into the tubes. Therefore, the reservoir should not be
elevated more than 2 feet (60 cm.).

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

Fig. 849. — Method of giving an intrauterine douche in a postpartum

Tecnnic— If the cervix is well dilated so that the entrance of the
douche nozzle is not interfered wath, the latter may be inserted by
touch alone, as foUows: One or two fingers of the left hand are passed

844

THE FEMALE GENERATIVE ORGANS

into the vagina and the external os is thus located. The douche
nozzle, with the solution flowing so as to avoid injecting any air, is
then inserted into the uterus by the right hand, being guided through
the cervix by the fingers of the left hand (Fig. 848). The nozzle is
then gently passed to the fundus of the uterus and the cavity is thor-
ougly irrigated. The return flow must be carefully watched to see
that it is not obstructed. It is well to place the left hand exter-
nally over the fundus uteri in puerperal cases to prevent any possible
over distention of the uterus and opening up of the sinuses (Fig. 849).

Fig. 850. — Shows the method of giving an intrauterine douche with a return-flow

nozzle.

To introduce the douche nozzle by sight, the posterior vaginal
wall is retracted by means of a speculum, and, if the cervix is not
readily accessible, it is drawn down into the vagina by means of bullet
forceps caught in its anterior lip. The cervix is then wiped off by
means of a swab on a sponge holder wet with a i to 2000 bichlorid of
mercury solution, and a return-flow nozzle is inserted by direct
sight, taking care to have the solution first flowing (Fig. 850). In
inserting the nozzle extreme gentleness should be used to avoid in-
juring the tissues or possibly perforating the uterus. The, latter
accident has happened frequently enough to warrant this caution.

INTRAUTERINE APPLICATIONS

The application of drugs with an astringent or caustic action to
the mucous membrane of the uterus is employed in the treatment of

INTRAUTERINE APPLICATIONS

84s

endometritis alone or in conjunction with curettage. The best re-
sults are obtained, however, when intrauterine applications are used
after a preliminary curettage.

The indiscriminate employment of intrauterine applications
often do more harm than good. They should only be employed in
cases where thorough asepsis can be obtained, and then only with
the cervix sufficiently dilated to allow thorough subsequent drainage.
The procedure, therefore, is one that rises to the dignity of an opera-
tion and should not be attempted as a part of the office treatment.

Fig. 851.

-Instruments for making intrauterine applications, i, Garrigues weighted
speculum; 2, sponge holder; 3, tenaculum; 4, applicator.

The position and size of the uterus and the condition of the other
pelvic organs must be determined by bimanual examination before-
hand. In the presence of adnexal involvement or other complica-
tions intrauterine applications are contraindicated.

Instruments. — There should be provided a vaginal speculum,
sponge holders, bullet forceps, and two uterine applicators (Fig.. 851).

Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The external genitals are washed with soap and
water followed by a i to 2000 bichlorid solution. The vagina is
douched with a i to 5000 bichlorid of mercury solution followed by
sterile water. The operator's hands are likewise sterilized as for any
operation.

Solutions Used. — Sulphate of zinc 5 to 10 per cent., chlorid of
zinc 5 to 10 per cent., silver nitrate 5 to 10 per cent., p)erchlorid of

846

THE FEMALE GENERATIVE ORGANS

iron 5 per cent., ichthyol 5 to 10 per cent., tincture of iodin 50 per
cent., Churchill's solution of iodin, pure carbolic acid, etc., etc., may
be employed.

Position of Patient. — The patient is placed in the dorsal position.

Technic. — The vaginal speculum is inserted and the cervix is
drawn down into view by means of bullet forceps which seize the
anterior lip. Any secretion or collection of mucus is then wiped away

Fig. 852. — Shows the method of making an intrauterine application.

from the external os by means of a swab soaked in a i to 2000 bi-
chlorid solution, and the cervix is dilated if necessary (see page 864).
A small thin layer of dry cotton is then securely wound round an
applicator, taking care that the tip of the instrument is well covered.
The swab thus fashioned is to be of such size that it will readily pass
the cervix. The applicator is curved to the shape of the canal and is
passed into the uterus for the purpose of removing any secretions and
thus allow the solution to come in contact with all portions of the
mucous membrane. A second applicator, similarly wrapped with
cotton, is dipped in the solution. Any excess of fluid is squeezed
from the cotton and the application is then made to the interior of the
uterus, carrying the cotton-tipped applicator well up to the fundus
and moving the instrument about in the cavity (Fig. 852) . A vaginal
tampon is finally inserted, which is removed in twenty-four hours.
The patient should remain quiet for a day or two, and, if a strong
caustic has been employed, she should be warned that at first there
will be an increased discharge.

TAMPONING THE UTERUS

847

Tamponage of the uterus may be required to control severe uter-
ine hemorrhage, to secure dilatation of the cervix for the expulsion of
the uterine contents or in preparation for intrauterine manipulations,
and to aid in the separation of retained products of conception. The
technic of tamponing the uterus for the control of hemorrhage is

3 -^

Fig. 853. — Instruments for tamponing the uterus, i, Garrigues* speculum; 2, sponge
holder; 3, tenaculum; 4, uterine dressing forceps; 5, uterine packer.

something with which every physican should be familiar, as occasions
may arise when the operation is demanded without delay as a life-
saving measure; at the same time it should be regarded as a surgical
procedure and one that should always be performed under thorough
aseptic precautions. The position and size of the uterus should be
ascertained by bimanual examination beforehand, otherwise the
uterus may be injured in attempting to insert the packing.

Instruments. — A Simon or a Garrigues speculum, sponge holders,
two bullet forceps, a pair of uterine dressing forceps, or a cannula and
packer are required (Fig. 853). In the majority of cases a pair of
curved dressing forceps may be employed for inserting the packing,
but, where the cervix is not well dilated, a special packer, such as is
shown in Fig. 854, by means of which the packing is pumped into the
uterus through the cannula, is more convenient.

Packing Material. — The most satisfactory material to employ
for packing is sterilized gauze. This should be folded into strips 2

848

THE FEMALE GENERATIVE ORGANS

inches (5 cm.) wide for use when the cervix is well dilated and into
strips >^ inch (i cm.) wide for an incompletely dilated cervix.
Care should be taken to see that the strips are so folded that no

Fig. 854. — Showing the cannula and plunger of the uterine packer separated.

frayed edges are exposed. The gauze is best kept in long strips
packed in sterile glass tubes.

Asepsis. — The instruments are boiled for five minutes in a i per
cent, soda solution. The patient's external genitals are washed with

Fig. 855. — Method of tamponing the uterus with a long strip of gauze inserted by

means of dressing forceps.

soap and water, followed by a i to 2000 bichlorid solution and the
vagina is first cleansed with soap and water and then douched with a
I to 5000 solution of bichlorid of mercury. The operator's hands are
sterilized as for any operation.

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

Preparations of Patient. — The patient's bladder and bowels
should be empty.

TAMPONING THE UTERUS 840

Technic— Any clots are first wiped out of the vagina. The cer-
vix is exposed by means of the speculum and the anUrior and |K)s-
terior lips are seized in bullet forceps which are given to an assistant
to hold. A strip of gauze is then seized in dressing forceps in such a
way that the gauze falls over the end of the forceps so as to avoid
inflicting any injury upon the tissues and is carried to the fundus.
Successive sections of the gauze are inserted in the same manner until
the cavity is filled (Fig. 855), Whenever possible, a single strip of
gauze should be employed. While inserting the gauze the operator's

Fig. 856. — Method of using the uterine packer,

free hand should be kept upon the abdomen in order to control the
uterus, and care should be taken that the gauze does not come in
contact with anything that is not sterile. The end or ends of the
gauze, if more than one strip is used, should be left projecting into
the vagina, so that it may be easily found, when the gauze is to be
removed, which should be within twenty-four hours of its insertion.

In cases of severe hemorrhage the vagina also should be packed
(see page %2> l) j taking care, however, to tie the vaginal strip to that
within the uterus or else to bring the ends of both vaginal and uterine
strips to the vaginal outlet. Upon removal of the gauze a vaginal
douche should be given.

In tamponing the uterus by means of the special packer shown in
Fig. 854, the cervix is exposed as before and is drawn down by means

of bullet forceps. The cannula is then inserted into the uterus and a

850 THE FEMALE GENERATIVE ORGANS

narrow strip of gauze is caught on the sharpened end of the piston and
is carried into the uterus by a pumping motion of the piston (Fig.
856).

BIER'S HYPEREMIC TREATMENT IN GYNECOLOGY

Passive hyperemia by means of special forms of suction cups
applied to the cervix uteri has been employed with good results in
cases of puerperal and other forms of infection of the cervix and
uterus, in ulcerations of the cervix, in chronic metritis, and in amenor-
rhea. The use of cups is contraindicated, however, if the adnexa are
inflamed.

In dysmenorrhea there have been numerous favorable reports
from the application of large suction cups to the breast once or twice
a day for periods of fifteen to thirty minutes, beginning a few days
before the date of expected menstruation and continuing the treat-
ments till the end. Pelvic exudates have also been treated with
success by means of hot-air boxes in. which the pelvis and hips rest.

The apparatus for obtaining active and passive hyperemia, as
well as the method of its use, have been previously described in
Chapter X.

PELVIC MASSAGE

; Pelvic massage after the method of Brandt has been employed for
the purpose of hastening the absorption of pelvic exudates through
Stimulation of the circulation and lymph currents, to stretch or sepa-
rate old adhesions, to stimulate contractions in the uterus, and to
strengthen and tone up weakened or thickened pelvic ligaments. In
certain selected cases this method of treatment has value. Pelvic
massage must never he employed^ however , in the presence of acute
inflammation or with pus collections in the tubes or pelvis, so that the
diagnosis must be carefully made in every case before it can be safely
attempted, and then it should only be performed by the physician
himself. In individuals with erotic tendencies it should be avoided.

Duration of Treatments. — The massage is performed for about ten
minutes at a sitting.

Frequency. — Treatments are given daily.

Position of Patient. — The patient should be in the dorsal posture.

Preparations. — The bladder and bowels should be emptied before-
hand and the clothing should be loosened from the abdomen

Technic. — Under all aseptic precautions two fingers of the left
hand are introduced into the vagina and are carried up to the part to

PELVIC MASSAGE

be massaged. Then, by means of the right hand placed on the abdo-
men, at first gentle circular movements and then deep pressure

Fig. 857. — Showing the position of the hands in commencing pelvic massage.

Z 3

Fig. 858. — Instruments for scarification of the cervix, i, Bivalve speculum; 2, sponge
holder; 3, tenaculum; 4, narrow-bladed bistoury.

manipulations are made over the diseased part, which, at the same
time, is raised and fixed within reach of the external hand by the

852

THE FEMALE GENERATIVE ORGANS

internal fingers. The manipulations should be begun each time
over the periphery of the diseased part and should always be made
with the greatest care and with the absence of any approach to
roughness.

When employed for the purpose of gradually stretching adhesions
or contracted ligaments, gentle intermittent traction is applied to the
uterus through the internal and external hands in a direction opposite
to the point of the fixation (Fig. 857). By thus gradually stretching
the adhesions and through the stimulating effect of the manipulations
the fibrous tissue is gradually absorbed and the muscular and elastic
tissues become regenerated. Such manipulations are especially use-
ful when used in conjunction with hot douches and tampons in gradu-
ally replacing a uterus bound down by adhesions.

SCARIFICATION OF THE CERVIX

The withdrawal of blood from the cervix is a valuable therapeutic
measure in cases of chronic congestion of the uterus and pelvic organs.

Fig. 859. — Method of scarifying the cervix by punctures. (Ashton.)
Fig. 860. — Scarification of the cervix, showing the method of making the superficial

incisions. (Ashton.)

It is also employed with good results for the relief of the pain and colic
of delayed menstruation due to pelvic congestion.

Instruments. — ^A vaginal speculum, sponge holders, bullet forceps,
and a narrow-bladed bistoury are required (Fig. 858).

Asepsis.— All aseptic precautions should be observed. The
instruments are to be boiled for five minutes in a i per cent, soda solu-

PESSARY THERAPY

853

tion, and the hands of the operator are prepared as for any operation.
The external genitals are cleansed with soap and water, followed
by a I to 2000 bichlorid solution, and the vagina is douched.

Position of Patient.— The patient should be in the dorsal posture.

Technic. — The cervix is exposed by the speculum and, after being
mopped off by means of a wipe moistened in a i to 2000 bichlorid
solution, is seized by the bullet forceps and is drawn well down to-
ward the vaginal outlet. Numerous punctures are then made by
means of the point of the bistoury to the depth of J^ to H inch
(6 to 12 mm.) around the circumference of the cervLx (Fig. 859), or,
instead of punctures, cross cuts may be employed (Fig. 860). In
this way from H ounce (15 c.c.) to 2 ounces (60 c.c.) of blood may
be withdrawn. A tampon of ichthyol and glycerin or tannin and
glycerin is then inserted into the upper portion of the vagina, to be
removed within twleve hours.

PESSARY THERAPY

Pessaries are employed for the purpose of maintaining a retrodis-
placed or prolapsed uterus in place and to support a cystocele. In
the case of a prolapse of the uterus or a cystocele a pessary is only of
value as a palliative measure where operative relief is refused or is
undesirable on account of the age or condition of the patient. In a
certain proportion of retrodisplacements, however, a prof)erly fitted
pessary will in time produce a cure, the most favorable cases being
those in which the displacement is only of short duration as, for
example, after confinement. The only cases of displacement in which
pessary therapy is suitable are those where the pelvic floor has suffi-
cient tonicity to give support to the pessary and where the displace-
ment is not complicated by pelvic lesions. Their use is contraindi-
cated in the presence of considerable enlargement or a prolapse of the
ovary, hydrosalpinx, pyosalpinx, or new growths, and where the
uterus is bound down by adhesions. Some cases of adhesions, how-
ever, under appropriate treatment by medicated tampons, hot
douching, etc., may be so stretched, or even be made to disappear,
that later a pessary may be satisfactorily employed.

Pessaries are not designed as a means of replacing a uterus, but
simply to hold the organ suspended in proper position after it has
been replaced. This it does by distending the vaginal walls, and not
through any force exerted by the instrument upon the uterus itself.
Every pessary should be fitted to the individual case, and it is here

854

THE FEMALE GENERATIVE ORGANS

that the experience of the physician counts for much. When properly-
fitted, the pessary should never cause any pain or even make the patient
conscious of its presence, and it may be worn for years, with certain

Fig. 86 1. — Hodge-Smith pessary. Fig. 862. — Hodge pessary. Fig. 863. — Ring pessary.

Fig. 864. — Gehrung's pessary.

Fig. 865. — Skene's pessary.

Fig. 866. — Cup or ring (a) pessary with external support. (Ashton.)

precautions as to cleanliness, to be mentioned later, without harm.
On the other hand, an ill-fitting pessary or one employed in a case
not suitable for such treatment is distinctly harmful. It should,
therefore, always be impressed upon the patient that if the least pain

PESSARY THERAPY 8$$

or an undue amount of leucorrhea results from the insertion of the
pessary, she shoald report to the physician immediately, or else
remove the pessary herself.

Pessaries. — Pessaries are made of hard rubber in a great variety
of shapes. For retrodisplacemcnts the most commonly employed is
the Hodge-Smith (Fig. 86i). If, however, the pelvic floor is relaxed,
a Hodge pessary (Fig. 862) is preferable, as its wide lower bar renders
it less liable to slip out. This type of pessary acts in such a way
that the force is exerted upon the posterior cul-de-sac and the
uterosacral ligaments, so that the cervix is pulled backward and the
uterus is thus tipped forward.

Ring pessaries (Fig. 86^) are also employed in retrodisplacements
where there is not sufficient support for the ordinary pessary. They
act by so distending the vagina in all directions that the uterus is
supported by the lower vaginal structures. The ring should be
smooth and fairly thick, at least 3^:4 inch (6 mm.), so as to avoid any
danger of its eroding through the vaginal walls. The ring pessary
is also employed for retaining a prolapsed uterus in place; but in
many cases of prolapse, the perineum is so relaxed that the pessary
immediately sKps out, and some sort of pessary held in place by an
abdominal support, such as is shown in Fig. 866, will be necessary.

For supporting a cystocele Gehrung's anteversion p)essary (Fig.
S64) or Skene's pessary (Fig. 865) is often used with success.

As previously stated the pessary should be fitted to each individual
case. The shape of the pessary may be readily changed by first
coating the instrument with oil or vaselin and then softening it by the
heat of an alcohol lamp. When it has been moulded to the desired
shape it is hardened again by immersion in cold water. The ten-
dency is to employ too large a pessary, which is dangerous, as it may
exert undue pressure upon the vaginal wall and produce excoriations,
or in time even ulcerate through. On the other hand, if the pessarj'' is
too small, it will not remain in place. The safest plan is to measure
the vagina in each case and shape the pessary accordingly. The
depth of the vagina is determined by carrying two fingers as high as
possible into the posterior cul-de-sac and measuring the distance from
the inferior border of the symphysis, while the width is estimated by
noting the distance to which the two fingers in the vagina may be
separated. About }i inch (i cm.) should be deducted from the
former measurement for the correct length of the pessary.

Asepsis. — The ring pessary may be sterilized by boiling, but the
others, if so treated, lose their shape; prolonged immersion in some

856 THE FEMALE GENERATIVE ORGANS

antiseptic solution, such as i to 500 bichlorid of mercury, should be
employed instead. Instruments that may be required are boiled
and the hands of the operator are sterilized in the usual manner.
Position of Patient. — For inserting the pessary the patient is ordi-

■ Fig. 867. — First step in replacing a retroverted uterus. (Ashton.)

narily placed in the dorsal posture, though in some cases the knee-
chest position may be used to better advantage.

Preparations of Patient. — The bladder and bowels should be
empty, and the clothing well loosened.

Fig. 868. — Second step in replacing a retroverted uterus. (Ashton.)

Technic. — i. Replacement of the Retroverted Uterus. — There are
two methods of replacement: (i) By bimanual manipulation, and
(2) with the patient in the knee-chest posture The former method
is usually effective if the abdominal walls are not thick and rigid and

PESSARY THERAPY

857

the vagina is sufficiently roomy. It is performed as follows: Two
fingers of the left hand are introduced into the vagina and are carried
up into the posterior cul-de-sac where they exert pressure in an

Fig. 869. — Third step in replacing a retroverted uterus, (.\shton.)

upward and forward direction upon the body of the uterus (Fig. 867).
As the uterus is thus elevated, the right hand is placed upon the
abdomen, and an attempt is made to hook the fingers behind the fun-

^^c:^

Fig. 870.— Second method of replacing a retroverted uterus. First stq>. (Kelly and

Noble.)

dus (Fig. 868) . The fundus is then pulled forward by the fingers of
the external hand while the internal fingers are shifted to the an-
terior fornix, where they make backward pressure upon the cervix

SsS

THE FEMALE GENERATIVE ORGANS

and the lower segment of the uterus (Fig. 869). Sometimes, how-
ever, it is not possible to raise the fundus past the promontory by
this method. In such a case the anterior lip of the cervix should be

Fig. 871. — Second method of replacing a retro verted uterus. Second step. (Kelly and

Noble.)

Fig. 872. — Second method of replacing a retro verted uterus. Third step. (Kelly and

Noble.)

grasped in bullet forceps^ and the whole uterus is then pulled down
toward the vaginal outlet (Fig. 870). At the same time the index-
finger of the left hand covered with a glove is inserted into the rectum

PESSARY THERAPY

859

and the fundus is elevated past the promontory (Fig. 871). The
cervix is then pushed backward (Fig. 872), the bullet forceps are re-
moved, and reposition is completed bimanually as described above.
If these manipulations fail, the patient should be placed in the
knee-chest posture and the posterior vaginal wall retracted by means
of a Sims or Simon speculum. This frequently results in the uterus
falling forward through the effect of gravity. If it does not, the cer-
vix should be grasped with bullet forceps and pulled upward and out-
ward toward the vaginal outlet, while the fundus is pushed forward
by means of a pair of dressing forceps armed with a pledget of
cotton carried up into the posterior cul-de-sac (Fig. 873). The

Fig. 873. — Replacement of a posterior uterine displacement in the knee-chest
position. Showing the cervix drawn forward and the fundus swinging clear of the
promontory.
(Ashton.)

Illustration a shows the fundus pushed anteriorly by direct pressure

patient is then slowly and carefully turned to the dorsal position,
and a bimanual examination is made to determine if the uterus is
still in position before a pessary is inserted.

In all manipulations toward replacement of a uleruSy the utmost
gentleness should he employed. If the patient is very sensitive or the
abdominal walls rigid, it is preferable to give a general anesthetic
rather than employ force.

86o

THE FEMALE GENERATIVE ORGANS

2. Introduction of Pessaries. — To insert the ordinary retroversion
pessary, the left index-finger is carried into the vagina and the vaginal

Fig. 874. — First step in introducing a retroversion pessary.

wall is retracted, while with the right hand, the pessary is introduced
at first obliquely (Fig. 874), and then turned so that it lies transversely

Fig. 875. — Showing the pessary in the vagina with the posterior bar in contact with

the cervix. (Ashton.)

in the vagina (Fig. 875). The index-finger of the left hand is then
shifted so that it lies under the anterior bar with its tip resting upon

PESSARY THERAPY

86l

the posterior bar (Fig. 876). The posterior bar is then pressed down-
ward and backward until it lies behind the cervix (Fig. 877). After
the pessary has been introduced, the patient is examined while in the
erect position to see if it fits properly. A properly fitting pessary

Fig 876. — Second step in introducing a retroversion pessary, depressing the
posterior bar and inserting it behind the cervix. (Ashton.)

Fig. 877. — Showing the retroversion pessary in place. (Ashton.)

Fig. 878.— First step in introducing a ring pessary.

should hold the uterus in place and at the same time should not be
so tight that the examining finger cannot be passed between the
vaginal walls and the pessary on aU sides.

862

THE FEMALE GENERATIVE ORGANS

The ring pessary is introduced in much the same way, that is, the
left index-finger retracts the posterior vaginal wall while with the
fingers of the right hand the pessary is introduced obliquely into the
vagina (Fig. 878). It is then turned transversely and is manipulated

Fig. 879. — Shows the ring pessary in place.

Fig. 880. — Showing Skene's pessary in place. (Ashton.)

by the internal fingers until it lies in proper position with its opening
surrounding the cervix (Fig. 879).

Skene's cystocele pessary is introduced into the vagina in the same
manner as the retroversion pessary, with the posterior bar lying
behind the cervix, and the broad anterior bar supporting the bladder
(Fig, 880).

PESSARY THERAPY

863

Gehrung's cystocefe pessary is more difficult to introduce. The
following method is employed: The pessary is placed upon a table in
such away that it rests upon its inferior arch, with the two curves,

Fig. 881. — First step in introducing Gehrung's j>essary.

right and left, facing toward the operator, who then grasps the curve
L between the thumb and forefinger of the right hand, and inserts
curve R into the right side of the vagina (Fig. 881) and then curve L

Fig. 882. — Gehrung's pessary in position.

into the left side. The pessary is then manipulated into such p<^-
tion, that the superior arch lies up in front of the uterus, the inferior
arch under the pubic arch, and the two curves R and L on the pos-
terior vaginal wall (Fig. 882).

364

THE FEMALE GENERATIVE ORGANS

After-care. — Within three or four days after introduction of the
pessary, the vagina is inspected to determine whether there is any
erosion from undue pressure of the pessary. The patient is then
examined once every month or six weeks, at which time the pessary is
removed and well cleansed before re-insertion and the vagina is
examined for signs of ulceration, which, if present, necessitate the
removal of the pessary and the substitution of medicated tampons
until healing has been effected. Once a week and after each men-
strual period the patient should take a warm boric acid or soapsuds
douche for cleansing purposes, while, if there is irritation from the
presence of the pessary, a daily douche should be administered. In
cases where the displacement is accompanied by considerable uterine
congestion and enlargement, a hot vaginal douche should be given
night and morning (see page 832). In all cases the physician should
impress upon the patient the necessity of reporting if at any time the
pessary causes any pain or discomfort.

DILATATION OF THE CERVIX

Dilatation of the cervix, while a small operation, is one of con-
siderable importance, as it forms a part of many gynecological pro-

7, s

Fig. 883 — Instruments for dilating the cervix, i, Garrigues' speculum; 2, sponge
holder; 3, tenaculum; 4, uterine sound; 5, Goodell dilators; 6, Fritsch-Bozeman return-
flow irrigator.

cedures. Thus it may be required as a preliminary to exploration of
the interior of the uterus, intrauterine irrigations and applications,

DILATATION OF THE CERVIX

86s

curettage, and to secure sufficient dilatation for the extraction of
retained secundines following an incomplete abortion. Dilatation
of the cervix is also employed for the cure of dysmenorrhea and ster-
ility dependent upon cervical stenosis. The operation should always
be performed under all aseptic precautions and after the position of
the uterus and the condition of the appendages have been first deter-
mined by bimanual examination. Pelvic peritonitis, pelvic abscess,
pyosalpinx, etc., are contraindications to. dilatation, unless the pro-
cedure is to be immediately followed by operative treatment of these
conditions.

There are two methods of performing dilatation: (i) Gradual
dilatation by means of sponge, laminaria, or tupelo tents, and (2)
rapid dilatation. The former method, besides being painful, is no
longer looked upon with favor on account of the dangers of infection
and will not be described.

Fig. 884. — Hegar's graduated dilators. (Sandier.)

Instruments.— A self-retaining speculum, a sponge holder, two
bulle.t forceps, a uterine sound, two pairs of Goodell's dilators (a
small and a large size), and a Fritsch-Bozeman return-flow irrigator
are required (Fig. 883). Some operators prefer to employ graduated
sound dilators, such as Hanks' or Hegar's (Fig. 884), in place of the
glove stretcher form of dilator, as producing less laceration of the
cervical tissue.

Asepsis. — The instruments are boiled in a i per cent, soda solu-
tion for five minutes and the operator's hands are thoroughly
cleansed.

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

posture.

Anesthesia.— While the operation may be performed under local
anesthesia by infiltrating the cervical tissue with a 0.2 per cent.
solution of cocain or a i per cent, procain solution, and inserting a
pledget of cotton saturated with a 4 per cent. soluUon of cocain into
•the cervical canal, general anesthesia will be found preferable in the
majority of cases. . ^

866

THE FEMALE GENERATIVE ORGANS

Preparations of Patient. — The bladder and bowels are to be
empty. The hair is shaved or closely cut from the labia and the
external genitals are washed with soap and water followed by a i to
2 GOO bichlorid solution. The vagina is then washed with soap and
water by the aid of a swab on a sponge holder and this is followed by a
douche of i to 5000 bichlorid.

Technic. — The speculum is introduced into the vagina and the
anterior cervical lip is seized by bullet forceps and is drawn toward

Fig. 885. — First step in dilatation of the cervix. The cervix exposed and drawn

down by a tenaculum.

the vaginal orifice (Fig. 885). The cervix is then swabbed with a
I to 2000 bichlorid solution. A sound is next introduced for the pur-
pose of determining the direction of the uterine canal, and this is
important in order to avoid perforating or otherwise injuring the
uterus with the dilators in case of a retrodisplacement or a sharp ante-
flexion. The small size Goodell dilator is then inserted into the cer-
vix, carefully manipulating it past any obstruction from the internal
OS, but above all avoiding the use of any force. With the instrument
through the internal os the dilators are gradually expanded, first in
one direction and then, after rotation of the instrument, in another,

DILATATION OF THE CERVIX

867

until a moderate amount of dilatation has been obtained, wnen the
large size dilator may be substituted. The dilatation is thus con-
tinued, the operator being guided as to the force he may exert by the
amount of resistance offered by the cervix, until the cervix has been
sufficiently stretched for the purposes of the operation.

At the completion of the operation the uterus is irrigated through
a Fritsch-Bozeman double-flow tube. Following the operation the
patient should remain in bed three to four days during which time a

Fig. 886. — Second step in dilatation of the cervix. Shows the method of dilating
by means of Goodell's dilators.

daily vaginal douche of warm 4 per cent, boracic acid solution or ster-
ile water is given.

Dilatation by means of the Hegar style of dilator is comparatively
simple. The cervix is exposed and drawn down as above, and then,
beginning with the small ones, successive larger sizes of the dilators
are inserted into the cervix (Fig. 887), lubricating each sound with
sterile vaselin before its introduction. In using the smaller sized
sound great care must be observed against making a false passage in
case any obstruction is offered by the internal os.

868

THE FEMALE GENERATIVE ORGANS

When dilatation is performed for sterility due to stenosis, some
operators follow the operation by introducing into the cervix a hard-
rubber stem, such as is shown in Fig. 888, for the purpose of maintain-
ing the dilatation. The stem is froni 22 to 25 French in size and is

Fig. 887. — Showing the method of dilating the cervix by means of the graduated

dilators of Hegar.

provided with a groove upon its lateral wall for the escape of dis-
charges. It has this objection, however, that it is liable to irritate the
cervical lining.

Fig. 888. — Intrauterine stem pessary. (Bandler.)

CURETTAGE

Curettage, or the scraping of the inner lining of the uterine cavity
may be performed for the purpose of removing diseased mucosa in
chronic endometritis, for the purpose of obtaining tissue for subse-
quent microscopic examination in suspected cancer of the uterus, and
as a preliminary to repair of the cervix and operations upon the uter-
ine appendages. In puerperal cases the operation is indicated for the
removal of pieces of decidua or placenta retained after labor or follow-
ing incomplete abortions.

CURETTAGE

869

The operation is contraindicated in cancer of the uterus except to
obtain tissue for examination and as a preliminary to a radical opera-
tion and likewise in pelvic peritonitis, pyosalpinx, pelvic cellulitis/
ectopic pregnancy, etc., unless as a preliminary to a laparotomy.!
Curettage is dangerous in the presence of submucous fibroids, as
sloughing of the growths may result through injury from the curet.
In streptococcus infections of the uterus, the operation, if performed
at all, should be done with caution, as new channels for infection arc

f 8 s 10

Fig. 889. — Instruments for curettage, i, Garrigues' weighted speculum; 2 sponge
holder; 3, tehacula; 4, uterine sound; 5, Goodell dilators; 6, Fritsch- Bozeman nozzle;
7, Sims' curets; 8, Martin's curet; 9, blunt curet; 10, placental forceps; 11, uterine
dressing forceps.

opened up by the curet a nd extension of the process to the deeper
tissues is liable to follow.

A curettage should always be performed under the strictest asep-
sis and with care and gentleness, as a false passage may easily be
made through the wall of the uterus with the curet or dilator; espe-
cially is this liable to happen in septic conditions and in puerperal
cases where the uterine wall is soft. The position of the uterus and
the condition of the adnexa should be ascertained beforehand by
means of a bimanual examination.

Instruments. — A Simon or a Garrigues self-retaining speculum,
sponge holders, two bullet forceps, a uterine sound, a pair of large and
small Goodell dilators, Sims' curets, a Martin curet, a large blunt

870

THE FEMALE GENERATIVE ORGANS

curet, placental forceps, uterine dressing forceps, and a Fritsch-
Bozeman return-flow irrigator will be required (Fig. 889).

Asepsis. — All the instruments are boiled for five minutes in a i per
cent, soda solution, and the operator's hands are sterihzed as for any
operation.

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

Anesthesia. — General anesthesia is necessary.

Fig. 890. — Dilatation and curettage of the uterus. Illustration a shows the
endometrium being removed with Sims' curet; illustration b shows the mucous mem-
brane on the fundus being removed with Martin's curet. (Ashton.)

Preparations of Patient. — The bladder and bowels are to be
empty. The hair is shaved or cut from the labia and the external
genitals are washed with soap and water followed by a i to 2000
bichlorid solution. The vagina is first thoroughly cleansed with
soap and water by means of a swab on a sponge holder and is then
thoroughly douched with a i to 5000 bichlorid of mercury solution.

Technic. — i. Nonpuerperal Cases. — The cervix is exposed by
means of the speculum and the anterior or both the anterior and
posterior lips are caught by means of bullet forceps and are drawn
well down toward the vulva. The cervix is then wiped with a swab
soaked in a i to 2000 bichlorid solution and, after first determining
the direction of the canal, the cervix is dilated in the manner de-
scribed on page 866. The entire uterus is then thoroughly scraped

CURETTAGE gyi

with a sharp curet of the largest size that will pass through the cer-
vix. This should be done in a systematic manner— for example, be-
ginning with the anterior wall, the curet is carried to the fundus and
is then withdrawn along the front wall and out of the uterus in one
sweep. Any adherent tissue is wiped off the curet and the instru-
ment is reinserted and withdrawn over another section of the an-
terior wall. The process is repeated until the entire anterior wall has
been scraped, and then the two side walls and the posterior wall are
similarly dealt with. A Martin curet is then substituted for the

Fig. 891. — Shows the uterine cavity being swabbed out with pure carbolic add.

(Ashton.)

Sims instrument and the fundus is well scrap>ed. The cavity is then
irrigated with sterile water or normal salt solution by means of the
return-flow catheter in order to remove any debris or loose shreds of
tissue, and a light packing is inserted for a few moments to dry the
cavity. The packing is then removed and the uterine caxity is
swabbed with pure carbolic acid introduced by means of a cotton swab
on dressing forceps (Fig. 891) . In doing this care must be taken not to
touch the vagina with the carbolic acid and to remove any excess of
acid from the swab before inserting it in the cervix. The vagina is
then cleansed, the bullet forceps are removed from the cervix, and a
light vaginal tampon is placed in contact with the cervix. The
vulva is finally covered with a gauze pad.

2. Puerperal Cases. — Unless the cervix is already dilated, it should
be stretched sufficiently to admit one or, if possible, two fingers. The

872

THE FEMALE GENERATIVE ORGANS

operator then inserts the index- and middle-fingers or, if this is not
possible, the index-finger of the right hand into the uterus and, while
counter pressure is made over the fundus with the left hand, he thor-
oughly explores the cavity and separates any retained material by
means of the internal fingers (Fig. 892). Large pieces of tissue thus
loosened may be then removed by means of placental forceps. The
cavity of the uterus is then irrigated with normal salt solution or with
sterile water and is lightly scraped with a large dull curet. In doing
this great care and gentleness are necessary to avoid perforating the

Fig. 892. — Digital currettage of the uterus. (Ashton.)

uterus. Sharp curets should never he employed in puerperal cases.
After a final exploration with the finger, the cavity is again irrigated
and the operation is concluded by cleansing the vagina and covering
the vulva with a sterile gauze pad secured in place by a T-bandage.
Only in cases where the operation is accompanied by severe bleeding
or where it is desired to introduce contraction in a flabby organ is it
necessary to pack the uterus (see page 847) . If this is done, the pack-
ing should be removed in twenty-four hours.

After-care. — The vagina should be douched daily with a i to 5000
warm bichlorid solution followed by sterile water or normal salt so-
lution. In cases of curettage for simple endometritis the patient may
be allowed out of bed within a week, in other cases the duration of
the stay in bed will depend upon the condition of the patient.

INDEX

Abdomen, aspiration of, 350
auscultation of, 808
auto-massage of, 623
inspection of, 516, 803
local anesthesia in operations on, 102
mensuration of, 808
palpation of, 518, 804
percussion of, 806
Abdominal examination of rectum and
colon, 571
inspection of bladder, 704
massage, 621
palpation of bladder, 706
of ureters, 755
Abscess cavities, bismuth paste for, 276
collection of discharges from, for
bacteriological examination, 294
Absorption power of stomach Penzoldt
and Faber test, 536
test of, 536
test of bladder, 713
Accessory sinuses, anatomy of, 361
lavage of, 389

passive hyperemia in diseases of, 396
skiagraphy of, 378
Accidental pneumothorax, following arti-
ficial pneumothorax, 276
Accidents during anesthesia and their

treatment, 65
A. C. E. general anesthetic mixture, 50
Active hyperemia, 267
Acupuncture, 184

vaccination by, 222
Administration of antimeningococcus
serum in meningococcus meningitis,

336 . , . , .

of antiserum m cerebrospmal menin-
gitis, 33(>

in poliomyelitis, 337
of antitetanic serum in tetanus, 337
of arsphenamin, 206

by rectum, 213

intravenous, 206, 209
of arsphenaminized serum, 338
of chloroform, drop method, 36

vapor method, 39
of diphtheria antitoxin, 214
of drugs by rectum, 595
of ether, closed method, 32

drop method, 30

semiopen method, 32

vapor method, 33
of ethyl chlorid, 49
of general anesthetics, 1 7

Administration of neoarsphenamin, azz
intramuscular, 213
intravenous, 215
by rectum, 213
of neosalvarsan, 211
of nitrous oxid, 42
and ether, 45
of salvarsan, 206
of salvarsanized serum in cerebral

syphilis, 338 _
of serum in poliomyelitis, 337
After-effects of general anesthetics, 72
After-treatment of cases of general anes-
thesia, 74
Agglutination tests in transfusion of

blood, 140
Air, hot, active hyperemia by, 267
inflation of bowel with, in intussus-
ception, 618
of colon with, 574
of stomach with, 524, 525
injections of, in intussusception, 616,
618
Albarran's cystoscope, 760
Albumin in urine, 702
Albuminous expectoration after aspiration

of chest, 347
Albuminuria, 702

Alcohol for injections of fifth nerve, 225
Alligator forceps, intracannular, 486
Alligator-jawed forceps, Kelly's, 769
Allis' ether inhaler, 26, 27
Allport's ear syringe, 423
Alton's method for preparation of paraf-

fine tubes, 154
Ambard's coefficient in urea excretion, 789
Anachlorhydria, 528
Anal canal, anatomy of. 568
Analysis, gastric, fractional method of,

533
Anesthesia, Bier's venous, 110
chloroform, 34

apparatus, 36

suitable cases, 35
epidural, 122
ether, 24

apparatus, 26

suitable cases, 25
ethyl chlorid, 47
apparatus, 48
suitable cases, 48
general accidents during, 65

A. C. E. mixture for, 50

administration of, 17

873

874

INDEX

Anesthesia, general, after-effects, 72
after-treatment following, 74
anesthol for, 50
asphyxiation from, 66
Billroth mixture for, 50
cardiac paralysis during, 70
care of bowels before, 18

of patient, 25
C. E. mixture for, 50
delayed poisoning from, 'j^
• diet before, 18
drugs used for, 17
duration of, 22
intravenous, 58

physical examination before, 19
postoperative paralyses following, 73
precautions in, 18
preliminary use of drugs, 19
preparation of mouth, 19

of patient for, 18
renal complications of, 73
respiratory complications of, 73

paralysis during, 70
Schleich's mixture for, 50
stages of, 22
Vienna mixture for, 50
infiltration, 88
insufflation, intratracheal, 52
intravenous general, 58
intubation, 51
local, 76

advantages, 77
B-eucain in, 83
by freezing, 86
by surface application of anesthetic

drugs, 87
cocain in, 81

conduction of operation under, 85
disadvantages, 77
drugs employed for, 81
ethyl chlorid in, 87
in abdominal operations, 102
in hernia operations, 103
in operations on anus, 106

on bladder, 88

on eye, 87

on face, 96

on fingers, 102

on head, 95

on inflamed tissues, ioq

on larynx, 87

on lips, 96

on lower extremity, 106

on lower jaw, 96

on mouth, 96

on neck, 97

on nose, 87

on penis, 105

on rectum and anus, 106

on scalp, 95

on scrotum, 105

on thorax, 98

on upper extremity, 99

on urethra, 87, 105
methods of producing, 80
preparation of patient for, 84

Anesthesia, local, procain in, 83

■ quinin and urea hydrochlorid in, 84

suitable cases, 78
lumbar, 115
nitrous oxid, 39
and ether, 45

apparatus, 45
apparatus, 41
suitable cases, 40
oil-ether colonic, 64
parasacral, 125
rectal, 61
sacral, 122

scopolamin-morphin, 65
special methods of, 51
spinal, 45
tracheal, 56
venous, no
Anesthetic, choice of, 17
mixtures, 49

paralyses, postoperative, 73
Anesthetics, general, administration of, 17

local, 76
Anesthetist's supplies, 21
Anesthol, 50

Ankle-joint, exploratory puncture of, 329
Anoci-association, 77
Anterior crural nerve, blocking of, 106
nares, 358.

inspection of, 366
rhinoscopy, 366
tibial nerve, blocking of, 108
Antimeningococcus serum, administra-
tion of, in meningococcus meningitis,336
Antitetanic serum, administration of, in

tetanus, 337
Antitoxin, diphtheria, administration of,
214
after-effects of, 216
complications following, 218
reduction in mortality rate by, 218
syringe, 215
Antrum of Highmore, anatomy of, 361
Anus, dilation of, 581, 582
inspection of, 571, 579
local anesthesia in operations on, 106
palpation of, 572
Application, direct, of cold to urethra by
psychrophore, 676
intrauterine, 844
local, to cervix, 835

to vagina, 835
of caustics to ear, 427
to larynx, 462
to nose, 386
of electricity to rectum and colon, 624
of ointments to urethra, 672
of powders to larynx, 465
to nose, 388
to vagina, 836
Applicator and mouth-gag, Sajous', 449
Arsphenamin, administration of, 206
by rectum, 213
intravenous, 209
in syphilis, 206
preparation of solution of, 208

INDEX

87s

Arsphenaminized serum, administration

of, in cerebral syphilis, 338
Arterial anesthesia, 114
Artery to vein transfusion, 143
Artificial leech, 199, 200

pneumothorax, production of, 270

respiration, 68, 69

sera for infusions, 169

gum acacia solutions, 170
Hare's formula for, 169
Locke's formula for, 170
Ringer's formula for, 169
Szumann's formula for, 170
Arytenoid cartilages, anatomy of, 437
Ascites, aspiration of*abdomen for, 350
Ash ton's forceps, 770
Asphyxiation during general anesthesia,

66
Aspirating bulb, Boas', 529

needle, 339

syringe and needles, 313

trocar, 340
Aspiration, 339

of abdomen in ascites, 350

of bladder, 746

of pericardium, 347

of peritoneal cavity, 350

of pleura, 339

of stomach contents, 529, 533

of tunica vaginalis, 354
Aspirator bottle for stomach contents, 530

Connell's heat vacuum, 342

Dieulafoy, 340, 341, 342

Potain, 340, 341, 747

secretion, Jackson's, 455

syphonage, 343
Atomizer, Davidson, 384

De Vilbiss, 384

steam, 466

Whitall Tatum, 384
Atropin as preliminary to general anes-
thesia, 19
Aural speculum, Boucheron's, 408
electric-lighted, 409
Gruber's, 408
Toynbee's, 408

stethoscope, 417
Auricular nerve, great, blocking of, 95
Auriculotemporal nerve, blocking of, 95
Auscultation of abdomen, 808

of colon, 573

of stomach, 523
Auscultatory method of determining

blood-pressure, 132
Auto-irrigation of bladder, 729
Auto-massage, 623

cannon ball for, 623
Autoscopy, 450

Babcock's formulae for solutions for

spinal anesthesia, 116
Bacteriological examination, collection of
blood for, 302
of discharges and secretions for, 290
from abscess cavity, 294
from eyes, 295

Bacteriological examination, collection of
dischafRes and secretions
from nose and accesMiy
sinuses, 294
from serous cavities, 394
from urethra. 295
from uterus, 296
from vaffina, 296
of wounds in Carrel-Dakin treatment,
247
Ball, cannon, for auto-massage, 624
Ballottement of kidney, 755
Bandage, elastic, for passive hyperemia,

256
Bardet's stomach electrode, 563
Barker's solution for spinal anesthesia, 1 16
Beck's bismuth paste formula;, 277

syringe for bismuth paste injections, 277
Bed, ether, 75
Bellocq's cannula, 398
Bennett's ether inhaler, 29
gas and ether apparatus, 45
nitrous oxid inhaler, 41
Bermingham nasal douche, 380
B-eucain as local anesthetic, 83
Bicoud6 catheter, 737
BierhofT's cystoscope, 760
Bier's active hyperemia, 267
cannula for venous anesthesia, no, m
passive hyperemia, 250

by constricting bands, 255

by cups, 261

in diseases of nose and accessory

sinuses, 396
in gynecology, 850
of head, 259
of neck, 259
of scrotum, 261
of shoulder, 260
of testicles, 256, 261
venous anesthesia, 1 10
Billroth 's esophageal sound. 506
general anesthetic mixture. 50
Bimanual palpation of bladder, 707

of pelvic organs, 813
Binnafont method of catheterizing Eus-
tachian tube, 423
Bismuth paste. Beck's formula;, 277

for diagnosis and treatment of fistu«

lous tracts, 276
injections, syringe for, 277
Bistoury, 184

Bivalve rectal speculum, 583
vaginal speculum, 820, 821
Bladder, absorption test, 713
anatoniy of, 696
aspiration of, 746
auto-irrigations of, 729
calculus in, x-ray in detection of, 725
capacity of, 696

test of, 711
catheterization of, 734
after-care, 746
in presence of prostatic h>'pertrophy,

741
of stricture, 740

876

INDEX

Bladder,continuous catheterization of, 743
cystoscopic examination of, in female,
719
in male, 713
examination of, 698
female, catheterization of, 741
inflammation of, after passage of ure-
thral instruments, 692
inspection of, 704
instillations of, 730
irrigations of, 725

local anesthesia in operations on, 88
palpation of, 705
papilloma of, fulguration of, by high

frequency currents, 732
percussion of, 705
skiagraphy of, 725
sounding of, 707

stone in, Thompson's searcher for, 707
tumors, fulguration of, by high fre-
quency currents, 732
Blake's ear syringe, 424 . '

Bleeding, 185
Blocking, nerve, 93
of anterior crural nerve, 106

tibial nerve, 108
of auriculo-temporal nerve, 95
of brachial plexus, 99
of branches of trifacial nerve, 97
of cervical plexus, 160
of digital nerves, 102
of dorsal nerves, 105
of external cutaneous nerve, 106
of frontal nerve, 95
of genitocrural nerve, 103
of great auricular nerve, 95

occipital nerve, 95
of iliohypogastric nerve, 103
of ilioinguinal nerve, 103
of inferior dental nerve, 96, 97
of infraorbital nerves, 96
of intercostal nerves, 98
of lingual nerve, 96
of lumbar nerves, 103
of meatal nerve, 96
of median nerve at wrist, loi

in arm, 100
of musculospiral nerves, 100
of posterior tibial nerve, 108
of radial nerve, loi
of sciatic nerves, 106
of small occipital nerve, 95
of superior laryngeal nerve, 98
of supraorbital nerve, 95
of temporomalar nerve, 95
of thoracic nerves, 103
of ulnar nerv^, at wrist, loi
in arm, 100
Blood chemistry, 787
collection of, for bacteriological ex-
amination, 302
for microscopical examination, 297
concentration in, of substances nor-
mally excreted in urine, as index of
renal function, 787
■ creatinin in, 788

Blood, cryoscopy of, for determination

of kidney function, 790
expectoration of, after aspiration of

chest, 347
groups for transfusion, method of de-
termining, 141
Moss' classification, 141
in urine, 702

non-protein nitrogen in, 787
serum, human, injection of, 137, 164

Welch's apparatus for collecting, 165
significance of, in vomitus, 515
smear, for microscopical examination,

method of making, 298
tests for functional capacity of kidneys,

787
by cryoscopy, 790
creatinin in, 788
non-protein nitrogen in, 787
lirea in, 788
uric acid in, 788
transfusion of, 137. See also Trans-
fusion of blood.
urea in, 788
uric acid in, 788
washing, 187
Blood-pressure, determination of, 127
auscultatory method, 132
diastolic, 127
normal, 128
systolic, 127

variations of, in disease, 134
in health, 128
Blower, powder, s^S
Blunt curet, 869

Boas' apparatus for esophageal lavage, 503
aspirating bulb, 529
rectal electrode, 624, 625
Bodenhamer's irrigator, 601
Bodine's formula for cocain and salt solu-
tion, 82
Bougies a boule, examination of rectum
by, 591
of urethra by, 647
urethral, 648
dilatation of esophageal strictures by,.
504
of rectal strictures by, 618
esophageal, 491, 506
Eustachian, 430, 431

medicated, 431
examination of esophagus by, 490
of rectum by, 590
of urethra by, 638, 647
urethral, 639, 684
Wales', 590, 591, 619
wax- tipped, 770
Boucheron's aural speculum, 408
Bowel, lavage of, 593
Brachial plexus, blocking of, 99
Braun's novocain solutions, 84
Breathing tube, pharyngeal, 52
Brenner's cystoscope, 759
Brewer's method of transfusion of blood,.
148
transfusion tubes, 148

INDEX

877

Bronchoscope, Jackson's, 454

Killian's, 454
Brown's cystoscope, 759
Buerger's cystoscope, 760
Bulb, aspirating, Boas', 529

form of cupping glass, 194

Calculi in bladder, Thompson's searcher
for, 707
in kidneys, skiagraphy of, 791
ureteral, skiagraphy of, 791
Cancer, gastric, secretory curve in, 535
Cannon ball for auto-massage, 623
Cannula and plunger of uterine packer,
848
and trocar for aspirating, 350
Bellocq's, 398

Bier's, for venous anesthesia, no, iii
Brewer's transfusion, 148
Crile's transfusion, 144
Elsberg's transfusion, 149
Lindeman's transfusion, 151
Southey's, 193
Trendelenburg's tracheal, 57
Capacity of bladder, 696
test of, 711
of kidney pelvis, 774
of renal pelvis, 774
Carbonic acid gas, inflation of stomach

with, 524, 525
Cardiac paralysis during general anesthe-
sia, 70
Carrel apparatus for instillation of
wounds, 237, 238, 239
tubes for disinfection of wounds, 240
Carrel-Dakin technic for sterilizing
wounds, 234
apparatus for, 237-241
bacteriological examination of

wound in, 247
cleansing of wound in, 242
Daufresne's method for prepara-
tion of solution for, 235
debridement in, 242, 243
dressing wound, 246
dressings for, 241
in penetrating wounds, 244
in perforating wounds, 246
in superficial wounds, 243
instillation tubes, arrangement

of, 243-246
instillations in, 242
solution for, 235-237
technic, 242
Carrel's method of sterilizing wounds, 234

of transfusion of blood, 143
Cartilage, arytenoid, anatomy of, 437
cricoid, anatomy of, 436
thyroid, anatomy of, 436
Casper's cystoscope, 760
Catheter and syringe. Eustachian, 429
bicoud^, 737
coud^, 737
Eustachian, 428
female, 741
Gouley's tunneled, 736

Catheter, gum-elagtic, 736
Guyon's, 737

intrauterine, Tallcy's, 84X
Mal6cot, 743
Pezzer, 743
return-flow, 727
silver, 735

prostatic, 737
soft-rubber, 735
ureteral, wax-tipped, 761
whip, 736
Catheterization, continuous of bUdder»
743
for .inflation of middle ear, 419
of Eustachian tube, 419

Binnafont or Kramer method, 423
LQwenberg method, 420
of female bladder, 741
of male bladder, 734

in presence of prostatic hypertio-
phy, 741
of stricture, 740
of ureters, direct view method, 762
in female, 768
in male, 759

indirect view method, 765
Caustics, application of, to ear, 427
to larynx, 462
to nose, 386
to uterus, 844
C. E. general anesthetic mixture, 50
Cecum, anatomy of, 566
Cerebral syphihs, administration of sal-

varsanized serum in, ^^S
Cerebrospinal fluid, normal, and its patho-
logical variations, 335
meningitis, administration of antiserum

in, 336
Cervical plexus, blocking of, 100
Cervix, collection of discharges from, for
microscopical examination, 285
dilatation of, 864

examination of, by speculum, 820, 825
local applications to, 835
scarification of, 852
Chamberlain's intrauterine douche nozzle,

841
Chapin's urine collector, 305
Chetwood's alternating cut-ofif, 665

urethral irrigating nozzle, 665
Chill, urethral, 692
Chloroform, administration of, 37
drop method, 36
vapor method, 39
anesthesia, 34
apparatus, 36
suitable cases, 35
delayed poisoning from, 73
dropper, 27
inhalers, 36, 37
Chromic acid method of fusing, on probe,

387
Clamp, Crile's, 144
Citrate method of blood transfusion, 156

solution for transfusion of dtratcd
blood, 157

878

INDEX

Citrated blood, transfusion of, 156
Closed method of administering ether, 32
Clover ether inhaler, 28
Coakley's transilluminator, 376
Cocain as local anesthetic, 81
Bodine's formula for, 82
in spinal anesthesia, 115
morphin preliminary to, 85
solutions, preparation of, 81
sterilization of, 82
Coefficient, Ambard's, 789
Cold, direct application of, to urethra by
psychrophore, 676
enteroclysis, 603
local anesthesia by, 86
Collection and preservation of pathologi-
cal material, 279
of blood for bacteriological examination,
302
for microscopical examination, 297
of discharges and secretions for bac-
teriological examination,
290
from abscess cavity, 294
from eyes, 295

from nose and accessory si-
nuses, 294
from serous cavities, 294
from urethra, 295
from uterus, 296
from vagina, 296
of feces, 307
of gastric contents, 306
of sputum, 304
of urine, 305
Colon, anatomy of, 566
application of electricity to, 624
ascending, anatomy of, 567
auscultation of, 573
descending, anatomy of, 567
inflation of, 573

for diagnostic purposes, 573
irrigation of, 594, 599
massage of, 621
palpation of, 572
percussion of, 573
sigmoid, anatomy of, 567
skiagraphy of, 576
transverse, anatomy of, 567
Colonic anesthesia, oU-ether, 64

massage, 621
Color of urine, 701
Columns of Morgagni, 569
Concentration in blood of substances nor-
mally excreted in urine as index of renal
function, 787
Connell's heat vacuum aspirator, 342

pharyngeal breathing tube, 68
Constipation, electrotherapy in, 624
Continuous catheterization of bladder,
.743 .
dilatation of urethral strictures, 693
proctoclysis, 609
Creatinin in blood, test for kidney func-
tion, 788
Crib arranged for steam inhalations, 467

Cricoid cartilage, anatomy of, 436
Crile's anoci-association, 77

clamps, 144

method of blood transfusion, 143, 145
of intraarterial infusion, 178
of intubation anesthesia, 51
transfusion cannula, 144
Croup kettle, 466

Crural nerve, anterior, blocking of, 106
Cryoscopy of blood and urine, test for

kidney function, 790
Culture, smear, method of making, 290

stab, method of making, 289

streak, method of making, 288, 289

tubes, inoculation of, method, 287
Cupped sound, 672
Cupping, 194

dry, 196

glass, 194

wet, 197
Cups for abstracting blood, 195

for passive hyperemia, 262

pessary, 854

suction, for passive hyperemia, 263
Curet, blunt, 869

Martin's, 869

Sims', 869

urethral, 675
Curettage, 868

nonpuerperal cases, 870

puerperal cases, 871
Curtis and David apparatus for trans-
fusion, 154
Curves, secretory, of stomach, 535
Cutaneous nerve, external, blocking, 106
Cystoscope, Albarran's, 760

Bierhoff's, 760

Brenner's, 759

Brown's, 759

Buerger's, 760

Casper's, 760

direct view, 714

electric-lighted, 721

Eisner's, 759

indirect view, 714

Kelly's, 720

Lewis', 732, 759

Nitze's, 714, 715, 760

Otis', 714

Schapiras', 714
Cystoscopic treatment, 731
Cystoscopy in female, 719

in male, 713

Dakin-Carrel technic for disinfection of

wounds. See Carrel-Dakin.
Dakin's hypochlorite solution, 234
solution, preparation of, by Daufresne's
method, 235
properties of, 235
test of alkalinity of, 237
titration of, 237
Daufresne's method of preparing Dakin's

solution, 235
David and Curtis apparatus for trans-^
fusion, 154

INDEX

879

Davidson's atomizer, 384

syringe and stomach tube for inflating
stomach, 525
Dawbarn's method of intraarterial in-
fusion, 179
Death from chloroform anesthesia, 34

sudden, after aspiration of chest, 347
Deglutition murmur, 523
Dench's vaporizer, 428
Dental nerve, inferior, blocking of, 96, 97
Depressor, tongue, Kirstein's, 448

vaginal, 821
Debridement in preparation of wounds for

disinfection by Carrel-Dakin technic,
242, 243
De Vilbiss atomizer, 384
Dewitt's apparatus for regulating flow in

proctoclysis, 610
Diastolic blood-pressure, 127
Dieulafoy aspirator, 340, 341, 342
Digital nerves, blocking of, 102

palpation of cervix, 812

of nasopharynx, 375

of pelvic organs, 811

of uterine cavity, 827

Dilatation of anus, 581, 582

of cervix, 864

of esophageal strictures by bougies,

504
of rectal strictures by bougie, 618
of rectum, 581, 582
of ureteral strictures, 794
continuous, 680, 693
Dilator, Hegar's, 865
Kelly's, urethral, 659
Kollmann's curved, 683
straight, 683
Diphtheria antitoxin, administration of,
214
after-effects of, 216
complications following, 218
reduction in mortality rate by, 218
Direct and indirect view gastroscopy,
combined, 546
application of cold to urethra by psy-
chrophore, 676
to nose, 386,
laryngoscopy, 447
palpation of pelvic organs, exploratory

incision for, 829
tracheo-bronchoscopy, 453
transfusion, 143
view gastroscopy, 543

method of catheterization of ureters,
762
Discharges, collection of, for bacteriologi-
cal examination, 290
vaginal, examination of, 810
Disinfection of wounds by Carrel-Dakin
technic, 234. See also Carrel-Dakin.
Dorsal nerves, blocking of, 105 -
position for gynecological examination,
80 1
Double-flow catheter, 727
Douche, Bermingham's nasal, 380
hot-air, 268, 269

Douche, intrauterine, 840
nozzle, 841
nasal, 379
stomach, 552

Einhom's, 553
vaginal, 832
nozzle, 833
Drainage in edema of lower extremities,

192
Drop method of administering chloro-
form, 36
ether, 30
Drugs, administration of, by rectum, 595
as preliminary to general anesthesia, 19
employed for local anesthesia, 81
hypodermic injoction of, 201
intramuscular injection of, 201
used for general anesthesia, 17
Drum membrane, anatomy of, 464
determination of mobility of, 411
incision of, 432
massage of, 432
Dry cupping, 196
inhalations, 468
Duck-bill rectal speculum, 583, 584
Duodenal feeding, 559
pump, Einhom's, 559
ulcer, secretory curve in, 535

Ear, anatomy of, 401
application of caustics to, 427
examination of, 405
inflation of, 415
inspection of, 407
instillations for, 425
speculum, Boucheron's, 408
electric-lighted, 409
Gruber's, 408
Toynbee's, 408
syringe, 423
Allf)ort's, 423
Blake's, 424
syringing, 423 .^ . * ^ , ,

Edelmann's modification of Galton s

whistle, 414
Edema, acupuncture for, 184
of glottis, scarification in, 191
of lower extremities, drainage in, 192
Effusions, pleural, following artificial

pneumothorax, 276
Einhom's duodenal pump, 559
esophagoscope, 49*
gastrodiaphane, 537
stomach douche, 553
electrode, 563, 564
Elastic bandage for passive h>'peremia,

256 . ,

garter for producing obstnicUve hypere-
mia of neck, 256
Elbow-joint, exploratory puncture of,

327
Electric head light, 365
Electric-lighted cystoscope, 721

speculum, 409 .

Electricity, application of, to rectum and

colon, 624

88o

INDEX

Electrode, Boas' lectal, 624, 625

Einhorn's, 564

large flat sponge, 624

small sponge, 625
Electrotherapy in constipation, 624

in diseases of stomach, 563

in tumors of bladder, 732
Elimination in urine of foreign substances
as index of renal function, 784

of substances normally present in urine
as index of renal function, 780
Elsberg's method of transfusion of blood,
148

transfusion cannula, 149
Eisner's cystoscope, 759
Embolism, gas, following artificial pneu-
mothorax, 275
Emphysema, subcutaneous, following arti-
ficial pneumothorax, 276
Endoneural infiltration, 93
Enemata, 594

drugs administered by, 595

nutrient, 613

purgative, 595
Enteroclysis, 594, 599

cold, 603

hot, 603

with double tube, 601

with single tube, 600
Epidermic puncture, vaccination by, 222
Epidural anesthesia, 122
Epiglottis, anatomy of, 436

method of drawing forward during
anesthesia, 67
Epsom salts for spinal anesthesia, 116
Erect position for gynecologic examina-
tion, 803
Esmarch elastic bandage for obstructive
hyperemia, 256

mask, 26
Esophageal bougies, 491, 506
a boule, 491

lavage, 502

sounds, 491, 506
Billroth's, 506
Schreiber's, 506, 507

strictures, dilatation of, 504

tube, Symond's, 509, 510
Esophagogastroscope, Hill-Herschell, 540,

541
Esophagoscope, Einhorn's, 498

Jackson's, 498, 499

Mikulicz's, 498, 499
Esophagoscopy, 498
Esophagus, anatomy of, 488

auscultation of, 489

dilatation of strictures of, 504

examination of, by sounds and bougies,
490

intubation of, 508

lavage of, 502

normal constrictions of, 488

palpation of, 490

percussion of, 490

skiagraphy of, 502
Estimation of residual urine, 712

Ether, administration of, closed method,
32
drop method, 30
semiopen method, 32
vapor method, S3
anesthesia, 24
apparatus, 26
suitable cases, 25
bed, 75
Ethmoidal sinuses, anatomy of, 362
Ethyl chlorid, administration of, 49
anesthesia, 47
apparatus, 48
suitable cases, 48
as local anesthetic, 87
inhalers, 48
spra}^ tube, 86
tube, 47
Eucain B, 83

Eustachian bougie, 430, 431
catheter, 428

and syringe, 429
tube, anatomy of, 404
catheterization of, 419
inflation of, by catheter, 419
Politzer's method, 417
Valsalva's method, 416
medication of, 429
Ewald-Boas test breakfast, 527
Ewald's test of motor power of stomach,

536
Examination of discharges, 810
Expectoration, albuminous, after aspira-
tion of chest, 347
of blood after aspiration of chest, 347
Experimental polyuria test for kidney

function, 781
Exploratory incision for inspecting kid-
neys, 792
for palpation of pelvic organs, 829
laparotomy, 547
puncture, 311

of ankle-joint, 329 • _

of elbow- joint, 327
of hip-joint, 327
of joints, 326
of kidneys, 325 •
of knee-joint, 328
of liver, 322
of lung, 317
of pericardium, 318
of peritoneal cavity, 321
of pleuia, 312
of shoulder-joint, 326
of spleen, 324
of wrist- joint, 327
Expression of stomach contents, 529, 532
External cutaneous nerve, blocking of,

106
Extraction of stomach contents for ex-
amination, 529, 533 . .
Extremities, local anesthesia in operations
on, 99, 106
lower, edema of, drainage in, 192
Extubation, 476
Extubator, O'Dwyer's, 469

IND5X

88i

Eyes, collection of discharges from, for
bacteriological examination,
29s.
for microscopical examination,
282
local anesthesia in operations on, 87

Faber and Penzoldt test for absorption
power of stomach, 536

Face, local anesthesia for operations on, 96

Fallopian tubes, anatomy of, 798
palpation of, 817

False passage from urethral instrumenta-
tion, 693

Feces, bacteriological examination, 594
chemical examination of, 594
collection of, for examination, 307
examination of, 594
macroscopical examination, 594
microscopical examination, 594

Feeding by gavage, 555
by rectum, 613
duodenal, 559

during esophageal intubation, 512
intubation cases, 475

Fenestrated-blade rectal speculum, 583,

584
Fever, urethral, 692
Fifth nerve, anatomy of, 225, 226
first division of, injection of, 228
injections of, for tic douloureux, 225

for trifacial neuralgia, 225
second division of, injections of, 229
third division of, injections of, 230
Filiform bougies, urethral, 639, 684
Finger palpation of rectum, 580
Fingers, local anesthesia in operations on,

102
Finger's ointment, 672
Fistulous tracts, bismuth paste for diagno-
sis and treatment of, 276
Five glass test, 633
Floyd needle for artificial pneumothorax.

Fluids, injection of, in intussusception, I

616, 617
Forceps, Ashton's, for guiding urethral
catheter, 770

intracannular alligator, 486

Kelly's alligator-jawed, 769

placental, 869

uterine dressing, 869
Foreign substances eliminated in urine,

as index of renal function, 784
Formalin sterilizer for urethral instru-
ments, 640
Fractional method of gastric analysis, 533
Freezing, local anesthesia by, 86
Fritsch-Bozeman douche nozzle, 841
Frontal nerve, blocking of, 95

sinus, anatomy of, 362
lavage of, 394

transillumination of, 376, 377
Fulguration of vesical growths by high

frequency current, 732
Function, kidney, tests of, 779
56

FuDCtional capacity of kidneys, deter-
mination of, 779
by Ambard's coefficient, 789
by blood examination, 787
by cryoscopy, 790
by McLean index, 789
by urinalysis, 780
experimental polyuria test for,

indigo-carmin test for, 785
methylcnc-blue test for, 785
phenolsulphonephthalein test

for, 785
phloridzin test for, 784
test meals for, 782
Fusing chromic acid on probe, 387

Galton's whistle, Edelmann's modifi-
cation, 414
Garrigues' weighted speculum, 826
Gas embolism following artificial pneumo-
thorax, 275
injection of, into pleural cavity, 270
Gastric analysis, fractional method of, 533
object, 527
carcinoma, secretory curve in, 5^5
contents, collection of, for examination,
306
extraction of, for examination, 529,

533

douching, 552

juice, composition of, 527

lavage, 547

secretion, composition of, significance
of variations in, 527

ulcer, secretory curve in, 535
Gastrodiaphane, Einhom's, 537

Lynch's, 537, 538
Gastrodiaphany, 537
Gastroscope, Jackson's, 540

Mikulicz's, 539

Rosenheim's, 539
Gastroscopy, 539

combined direct and indirect view,
546

direct view, 543

Jackson's technic,.543
Gavage, 555
Gehrung's pessary, 854
General anesthesia, 17. See also Ants-

thesidy general.
Generative organs, female, anatomy of,

796
Genitocrural nerve, blocking of, 103
Glass tests, 632
five, 633
two, 63^
Glottis, scarification of, 191
Glucose in acidosis, 613

in continuous proctoclysis, 610

in nutrient enemata, 615
Goodell's vaginal speculum, Rao
Gouley's sound, 684

tunneled catheter, 736
Goyanes* method of arterial anesthesia,

114

882

INDEX

Gravity method of administering serum

by lumbar puncture, 337
Great auricular nerve, blocking of, 95

occipital nerve, blocking of, 95
Gruber's aural speculum, 408
Gum acacia solutions, infusion of, 170
Guyon's catheter, 737
Gwathmey's gas and ether apparatus, 46

nitrous oxid gas a;nd oxygen inhaler, 43

oil-ether colonic anesthesia, 64

vapor apparatus, 28, 30
Gynecologic examinations, 798
Gynecological positions, 801

Hand injections for urethra, 661

Hare's formula for artificial serum for in-
fusions, 169

Harris' method of segregation of urine, 777
segregator, 775

Hartmann's tuning forks, 414
vaporizer, 428

Hays' pharyngoscope for inspection of
nasopharynx, 370

Head lamp, electric, 365
light, Kirstein's, 448
local anesthesia in operations on, 95
passive hyperemia of, 259

Hearing tests, 413

Heart, massage of, 71

Heat vacuum aspirator, Connell's, 342

Hegar's dilators, 865

Hematuria, 702

Hemolysis, tests for, in blood transfusion,
139

Hemorrhage after passage of urethral in-
struments, 692
control of, tamponing nose for, 397

Hernia, local anesthesia in operations for,
103

Hewitt's nitrous oxid gas and oxygen in-
haler, 42

High frequency current in vesical
growths, 732
tracheotomy, 478, 483

Highmore, antrum of, anatomy of, 361

Hill-Herschell esophagogastroscope, 540,

Hip-joint, exploratory puncture of, 327

Hodge pessary, 854

Hodge-Smith pessary, 854

Hoecht method for injection of sciatic

nerve, 232
Hot enteroclysis, 603
Hot-air, active hyperemia by, 267

boxes for active hyperemia, 268

douches for active hyperemia, 268, 269
Houston's valves, 569
Hydrocele- aspiration and injection of,

354
Hydrotherapy of rectum, 594
Hyperacidity, 528
Hyperchlorhydria, 527
Hyperemia, active, 267

passive, 250
by constricting bands, 255
by cups, 261

Hyperemia, passive, in diseases of nose
and accessory sinuses/ 396

in gynecology, 850

of head and neck, 259

of scrotum, 261

of shoulder, 260

of testicles, 256, 261
Hypersecretory curve, 535
Hypoacidity, 528
Hypochlorhydria, 528
Hypodermic injection of drugs, 201

syringe, 201, 202
Hypodermoclysis, 180
Hyposecretory curve, 535

Iliohypogastric nerve, blocking of, 103
Ilioinguinal nerve, blocking of, 103
Illumination for rhinoscopy, 363
Incision, exploratory, for inspecting kid-
neys, 792
^ ^ for palpating pelvic organs, 829
in laryngotomy, 478
in tracheotomy, 478
of drum membrane, 432
of membrana tympani, 432
Index, McLean, 789
Indigo-carmin test for functional capacity

of kidneys, 785
Indirect and direct view gastroscopy
combined, 546
transfusion, 149

by citrate method, 156
by Kimpton-Brown method, 155
by Lindeman method, 150
by paraffined tubes, 153
by syringe method of Lindeman, 150
of Unger, 152
view method of catheterization of
ureters, 765
Infantile paralysis, administration of

antiserum in, 337
Inferior dental nerve, blocking of, 96, 97
Infiltration anesthesia, 88
endoneural, 93
of large nerve trunk, 94
of skin, 91, 92
perineural, 93
Infiltrator, Matas', 89

Morrow's, 90
Inflamed tissues, operations on undfer local

anesthesia, 109
Inflation in intussusception, 616^

of colon for diagnostic purposes, 573
of middle ear, 415, 428

Politzer's method, 417
through catheter, 419
Valsalva's method, 416
with medicated vapors, 428
of stomach, 524
by air, 524, 525
by carbonic acid gas, 524, 525
Infraorbital nerve, blocking of, 96
Infusions, intraarterial, 177
intravenous, 170
of gum acacia solutions, 170
of physiological salt solution, 167

IKDEX

883

Infusions, rectal, 607

saline, 607
subcutaneous, 180
Inhalations, dry, 468
mask, 468
steam, 465
Inhaler, Allis' ether, 27
Bennett's ether, 29

gas and ether, 45

nitrous oxid, 41
care of, 30
Clover's ether, 28
Esmarch's chloroform, 26
Gwathmey's gas and ether, 46

nitrous oxid gas and oxygen, 43

vapor, 30
Hewitt's nitrous oxid gas and oxygen,

42
Junker's chloroform, 36
Schimmelbusch chloroform, 27, 48

steam, 466
Ware's ethyl chlorid, 48
Injection, hand, for urethra, 661
hypodermic, of drugs, 201
intramuscular, of drugs, 201

of neoarsphenamin, 213
intravenous, of arsphenamin, 206, 209

of neoarsphenamin, 213
of bismuth paste for diagnosis and

treatment of fistulous tracts, 276
of fifth nerve for neuralgia, 225
of first division of fifth nerve, 228
of fluid or air into bowel in intussuscep-
tion, 616
• of gas into pleural cavity, 270
of human blood serum, 137, 164
of sciatic nerve, 231
of second division of fifth nerve, 229
of solutions into Eustachian tubes,

429

of third division of fifth nerve, 230

test for urethral pus, 634
Inoculating culture tubes, method, 287
Inspection of abdomen, 516, 803

of anus, 571, 579

of bladder, 704

of ear, 407

of external genitals, 809

of kidneys, 752

by exploratory incision, 792

of larynx, 440

of nasopharynx by Hays' pharyngo-
scope, 370

of nose, 363

of rectum, 579

of stomach, 516

of trachea, 440

of urethra, 634, 635, 652, 658

of vaginal orifice, 809
Instillation syringe, Keyes-Ultzmann,
669-670, 731

tubes, for Carrel-Dakin disinfection of
wounds, 238-240
Instillations for bladder, 730

for ear, 425

of urethra, 669

Instrumental di'atation of urethral stric-
tures, 680
continuous, 693
Insufflation anesthesia, intratracheal, 5a
Insufflations for larynx, 465

for nose, 388
Insufflator, laryngeal, 464

nasal, 388

Sajous', 389
Intercostal nerves, blocking of, 98
Internal examination of rectum, 577
Intraarterial infusion, Crile's method, 178
Dawbarn's method, 179
of salt solution, 177
Intracannular alligator forceps, 486
Intramuscular injection of drugs, 201

of neoarsphenamin, 213
Intrastomachic application of electricity

to stomach, 565
Intratracheal insufflation anesthesia, 52
Intrauterine applications, 844

douche, 840
nozzle, 841

stem pessary, 868
Intravenous administration of neoars-
phenamin, 213

anesthesia, apparatus for, 58, 59

general anesthesia, 58

infusion of salt solution, 170

injection of arsphenamin, 206, 209
of neoarsphenamin, 213
Intubated patients, feeding, 475
Intubation anesthesia, 51

O'Dwyer instruments for, 467

of esophagus, 508

of larynx, 468

tube and introducer, 469, 472
Intussusception, injections of fluid or air

into bowel in, 616
lodipin test of motor power of stomach,

536
Irrigating nozzle, urethral, Chetwood's,

66s
Irrigations of bladder, 725

of bowel, 593

of rectum, 594, 599

of urethra, 664

stomach, 552

vaginal, 832
Irrigator, Bodenhamer's, 601

double-flow rectal, 601

Kemp's, 601

return-flow, 601, 602

Tuttle's, 601, 602

urethral, Valentine's, 665
Isosecretory curve, 535
Isotonic preserving fluid for red cells,

preparation of, 162
Iversen's apparatus for proctoclysis, 610

611

Jackson's bronchoscope 454
direct view larjngoscope, 55
escphagoscope, 49*» 499
gastroscope, 540
laryngoscope, 447

884

INDEX

Jackson's secretion aspirator, 455
separable speculum for passing broncho-
scope, 455
technic of gastroscopy, 543
Janeway's sphygmomanometer, 130, 131
Jaw, lower, local anesthesia in operations
on, 96
method of holding forward during
anesthesia, 67
Joint, exploratory puncture of, 326
Junker's chloroform inhaler, 36

Kaliski's transfusion needle, 158
Kelly's cystoscope, 720
method of collecting urine from ureter

without ureteral catheter, 773
rectal speculum, 583, 585
urethral dilator, 659
tube-speculum, 659
Kemp's irrigator, 601
Kettle, croup, 466
Keyes-Ultzmann instillation syringe,

669-670, 731
Kidneys, anatomy of, 749
ballottement of, 755
exploratory puncture of, 325
function of, tests of, 779
functional capacity of, determination,
blood tests for, 787
by cryoscopy, 790
experimental polyuria test for,

781
indigo-carmin test for, 785
methylene-blue test for, 785
phenolsulphonephthalein test for,

785
phloridzin test for, 784
test meals for, 782
inspection of, 752
• by exploratory incision, 792
palpation of, 753
pelvis, capacity of, 774
lavage of, 793
medication of, 793
percussion of, 757
position of, 749
pyelography of, 792
relations of, 750
skiagraphy of, 791
Killian's bronchoscope, 454
laryngoscope, 451
method of laryngoscopy, 450
Kimpton-Brown method of blood trans-
fusion, 155
transfusion tubes, 153
Kirstein's head light, 448

tongue depressor, 448
Klotz's urethral tube, 654
Knee-chest position, 578

for gynecologic examination, 802
Knee-joint, exploratory puncture of,

328
Knife, urethral, 675
KoUmann's curved dilator, 683 "
straight dilator, 683
urethral syringe, 675

Kramer or Binnafont method for cathe-
terizing Eustachian tube, 423

Kulenkampff's method of blocking bra-
chial plexus, 99

Lactic acid in stomach contents, 528
Lamp, head, electric, 365
Laparotomy, exploratory, 547
Laryngeal insufflator, 464

knife, protected, 191

nerve, superior, blocking of, 98

probe, 460

spray, 461
Laryngoscope, Jackson's, 55, 447 ;

Killian's, 451
Laryngoscopy, 440

direct, 447

suspension, 450, 452
Laryngotomy, 477, 478, 481
Larynx, anatomy of, 436

application of caustics to, 462

direct applications for, 462

dry inhalations for, 468

examination of, 439

inspection of, 440

insufflations for, 465

intubation of, 468

local anesthesia in operations on, 87

palpation of, by probe, 460

scarification of, 192

skiagraphy of, 460

spraying of, 461

steam inhalations for, 465
Lavage of accessory sinuses, 389

of bowel, 593

of esophagus, 502

of frontal sinus, 394

of maxillary sinus, 390

of sphenoidal sinus, 395

of stomach, 547

of ureters and renal pelvis, 793
Leech, artificial, 199, 200

varieties, 198
Leeching, 197
Leube's test of motor power of stomach,

536
Levy and Baudouin needle and stylet,

227
Lewis' operating cystoscope, 732

universal cystoscope, 759
Limb, scarification of, 192
Lindeman's syringe method for indirect
transfusion of blood, 150

transfusion cannula, 151
Lingual nerve, blocking of, 96
Lips, local anesthesia in operations on, 96
Lithotomy position in rectal examination,

578
Liver, exploratory puncture of, 322
Local anesthesia, 76. See also Anesthesia,
local.

applications to vagina and cervix, 835
Locke's formula for artificial serum for

infusions, 170
Locomotor ataxia, arsphenamin in, 206
Low tracheotomy, 479, 486

INDEX

885

Lowenberg method for catheterizing

Eustachian tube, 420
Lower extremities, edema of, drainage in,
192
local anesthesia in operations on, io6
jaw, local anesthesia in operations on,

96
tracheo-brohchoscopy, 459
Luer's hypodermic syringe, 202
Lumbar anesthesia, 115
nerves, blocking of, 103
puncture, 329
as means of administering therapeutic
sera, 336
vertebrae, anatomy of, 329, 330
Luinbard's glass nasal tulDCS for anesthe-
sia, 29
Lung, exploratory puncture of, 317

tuberculous, artificial pneumothorax
for, 270
Luy's method of segregation of urine, 779

segregator, 775
Lynch's gastrodiaphane, 537, 538

modification of Killian's hook spatula,
452

Malaria, arsphenamin in, 207

Malecot retention catheter, 743

Manometer for artificial pneumothorax,
272

Martin's curet, 869

Mask, inhalation, 468

Massage, abdominal, 621
auto-, of abdomen, 623
colonic, 621
of ear-drum, 432
of membrana tympani, 432
of prostate, 638, 677
of stomach, 561
pelvic, 850

Matas' massive infiltrator, 89

Maxillary sinus, anatomy of, 361
lavage of, 390
transillumination of, 376, 378

McLean index in urea excretion, 789

Meals, test, for kidney function, 782

Meatome, Otis', 679

Meatotomy, 679

Median nerve, at wrist, blocking of, loi
in arm, blocking of, 100

Medicated bougie, 431
tampon, 839

Medication by rectum, 595
of Eustachian tubes, 429
of renal pelvis and ureters, 793

Meltzer and Auer's method of intratra-
cheal insufflation anesthesia, 52

Membrana tympani, anatomy of, 404
determination of mobility of, 411
incision of, 432
massage of, 432

Membranous urethra, anatomy of, 628

Meningitis, meningococcus, administra-
tion of antimeningococcus serum in, 336

Mensuration of abdomen, 808

Mental nerve, blocking of, 96

Method of collecting blood for 1>tcterio-
logical examination, 302
feces, 307

gastric contents, 306
sputum, 304
urine, io^
of determining blood groups, 141
of inoculation of culture tubes, 287
of making l>Iood smears, for micro-
scopical examination, 298
smear culture, 290

preparations for microscopical ex-
amination, 279
stab culture, 289
streak culture, 288, 280
Methylene-blue test for functional ca-
pacity of kidneys, 785
Microscopical examination, blood for,
collection of, 297
smear preparation for, method of
making, 279
Middle ear, inflation of, 415, 428

with medicated vapors, 428
Mikulicz's esophagoscope, 498, 499

gastroscope, 539
Mixture, anesthetic, 49
Morgagni's columns, 569

valves, 570
Morphin, preliminary to cocain, 85
to general anesthesia, 19
to spinal anesthesia, 119
Morrow's infiltrator, 90
Mortality rate, reduction of, by diphtheria

antitoxin, 218
Mosenthal's test meal for kidney func-
tion, 782
Moss' classification of blood groups for

transfusion, 140
Motor functions of stomach, test of, 536
Mouth, collection of discharges from for
microscopical examination, 281
local anesthesia in operations on, 96
Murphy's proctoscope, 584
Muscular rheumatism, acupuncture in,

185
Musculospiral nerves, blocking of, 100
Myles' nasal speculum, 366

Nares, anterior, 358
inspection of, 366
posterior, 358

digital palpation of, 375
inspection of, 367 ,

Nasal douche, 379

Bermingham's, 380
douching, 379

hemorrhage, tamponing for, 397
probe, 373

speculum, Myles, 366
spray, 383
syringe, 382
tubes, Lumbard's, 29
syringing, 3^2
Nasopharynx, digital palpation of, 375
inspection of, by Hays^ phar>'ngoscope^
370

886

INDEX

Neck, local anesthesia in operations on, 97

passive hyperemia of, 259
Needle, aspirating, 339
Floyd, for artificial pneumothorax, 273
hypodermoclysis, 181
Kaliski's transfusion, 158
Neoarsphenamin, administration of, 211
by rectum, 213
intramuscular, 213
intravenous, 213
preparation of solution, 212
Neosalvarsan. See Neoarsphenamin,
Nerve blocking, 93
Neuralgia, trifacial, injections of fifth

nerve for, 225
Neuritis, acupuncture in, 185
New York Board of Health antitoxin
syringe, 216
vaccination outfit, 220
Nitrogen, non-protein, in iDlood, test for

kidney function, 787
Nitrous oxid, administration of, 42
and ether, administration of, 46
anesthesia, 45

apparatus, 45
inhaler, 45, 46
and oxygen inhaler, 42, 43
anesthesia, 39
apparatus, 41
suitable cases, 40
inhaler, 41
Nitze's cystoscope, 714, 715, 760
Non-protein nitrogen in blood, test for

kidney function, 787
Normal cerebrospinal fluid and its patho-
logical variations, 335
systolic blood-pressure, 128
Nose, anatomy of, 358
and accessory sinuses, collection of dis-
charges from, for bacteriological ex-
amination, 294
application of caustics to, 386
collection of discharges from, for micro-
scopical examination, 282
douching, 379
examination of, 363
inspection of, 363
insufflations for, 388
lavage of, 389

local anesthesia in operations on, 87
palpation of, 373
by probe, 373
passive hyperemia in diseases of, 396
probing of, 373
spraying, 383
syringing, 382
tamponing, 397
Novocain. See also Procain.
Braun's formula for, 84
in spinal anesthesia, 116
Nutrient enemata, 613

Occipital nerve, great, blocking of, 95

small, blocking of, 95
Odor of urine, 700
O'Dwyer intubation instruments, 469

Oil-ether colonic anesthesia, 64
Ointment, application of, to urethra, 672

Finger's, 672

syringe, 673

Unna's, 672
Ossicles of ear, 403
Otis' cystoscope, 714

meatome, 679

urethrometer, 650
Otoscope, Siegle's, 412
Otoscopy, 407
Ovaries, anatomy of, 798

palpation of, 817

Palate retractor. White's, 370
Palpation, bimanual, of pelvic organs, 813
digital, of nasopharynx, 375

of pelvic organs, 811

of uterine cavity, 827
of abdomen, 518, 804
of anus, 572
of bladder, 705
of colon, 572
of esophagus, 490
of Fallopian tubes, 817
of kidneys, 753
of larynx by probe, 460
of nose by probe, 373
of ovaries, 817
of pelvic organs, exploratory incision

for, 829
of prostate, 636
of rectum, 572, 579

by whole hand, 582
of stomach, 518
of ureters, 755
of urethra, 636, 638
of uterus, 813
Papilloma of bladder, destruction by high

frequency currents, 732
Paracentesis of abdomen, 350
pericardii, 347
thoracis, 339
Paraffine tubes, Alton's, method of pre-
paring, 154

for indirect transfusion of blood, 153
Paralysis, anesthetic, postoperative, 73
cardiac, during general anesthesia, 70
infantile, administration of serum in

respiratory, during general anesthesia

Parasacral anesthesia, 125
Paresis, arsphenamin in, 206
Passive hyperemia, 250

by constricting bands, 255

by suction cups, 261

in diseases of nose and accessory
sinuses, 396

in gynecology, 850

of head and neck, 259

of scrotum, 261

of shoulder, 260

of testicles, 256, 261
Paste, bismuth, in diagnosis and treat-
ment of fistulous tracts, 276

INDEX

887

Pathological material, collection and
preservation of, 279
variations of normal cerebrospinal
fluid, 335
Pelvic massage, 850
organs, anatomy of, 796
digital palp*ation of, 81 1
examination of, 809
palpation of, explorator>' incision for,

829
recto-abdominal palpation of, 813,

818
vagino-abdominal palpation of, 813,
814
Pelvis, renal, capacity of, 774
lavage of, 793
medication of, 793
Penis, local anesthesia in operations on,

105
Penzoldt and Faber test of absorption

power of stomach, 536
Pepsin in stomach contents, 529 •
Percussion of abdomen, 806
of bladder, 705
of esophagus, 490
of kidneys, 757
of stomach, 521
Percutaneous application of electricity
to colon, 625
to stomach, 565
Pericardicentesis, 347
Pericardium, aspiration of, 347
exploratory puncture of, 318
Perineural infiltration, 93
Peritoneal cavity, aspiration of, 350

exploratory puncture of, 321
Pessary, cup, 854
Gehrung's, 854
Hodge, 854
Hodge-Smith, 854
intrauterine stem, 868
introduction of, 860
ring, 854
Skene's, 854
therapy, 853
Pezzer catheter, 743
Pharyngeal breathing tube, 52
Pharyngoscope, Hays', for inspection of

nasopharynx, 370
Pharynx, collection of discharges from,
for microscopical examination, 281
inspection of, 370
Phenolsulphonephthalein test for func-
tional capacity of kidneys, 785
Phlebotomy, 185
Phloridzin test for functional capacity of

kidneys, 784
Physiological salt solution, infusion of, 167
Platinum needles for cultures, 287
Pleura, aspiration of, 339
exploratory puncture of, 312
injections of gas into, 270 .^ . ,

Pleural effusions following artificial
pneumothorax, 276
shock following artificial pneumothorax,
275

Pleuroccntcsis, 339
Pneumatic oto5co{)c, Sicglc's. 419
Pneumothorax, accidental, following arti-
ficial pneumothorax, 276

after aspiration of chest, 547

artificial, production of, 270
Poisoning, delayed chloroform, 73
Poliomyelitis, administration of aoli-

serum in, 337
Politzer's method of inflation of middle

ear, 417
Polyuria, experimental, test, for func-
tional capacity of kidneys, 781
Position, dorsal, for gynecological ex-
amination, 801

erect, for gynecologic examination, 803

for aspiration of pleura, 345, 346

gynecological, 801

knee-chest, 578
for gynecologic examinations, 802

lithotomy, 578

Sims, for gynecologic examination, 801

squatting, 579
for gynecologic examination, 803
Posterior nares, 358

digital palpation of, 375
inspection of, 367

rhinoscopy, 367

tibial nerve, blocking of, 108
Postoperative anesthetic paralyses, 73
Potain aspirator, 340, 341, 747
Powder blower, 388

laryngeal, 464
Powders, application of, to larynx, 465
to nose, 388
to vagina, 836
Preservation and collection of patholog*

ical material, 279
Preserved red cells, transfusion of, 161
Probe, examination of rectum by, 592

fusing chromic acid on, 387

laryngeal, 460
. nasal, 373

palpation of larynx by, 460
of nose by, 373

urethral, 674
Probing lar>'nx, 460

nose, 373
Procain as local anesthetic, 83

in parasacral anesthesia, 125

in sacral anesthesia, 123

in spinal anesthesia, 116
Proctoclysis, continuous, 609

Iversen's apparatus. 610, 611

Saxon's apparatus, 610, 611
Proctoscope, examination of rectum by,

583

Tuttle's, 585
Proctoscopy with Kelly's instrument, 587

with Tuttle's instrument, 590
Prostate, 627

anatomy of, 630

inflammation of, after passage of ureth-
ral instruments, 692

massage of, 638, 677 ,

palpation of, 636

888

INDEX

Prostatic catheter, silver, 737
hypertrophy, catheterization in, 741
urethra, anatomy of, 629
Psychrophore, 676, 677
direct application of cold to urethra by,
676
Pulmonary tuberculosis, artificial pneu-
mothorax in, 270
Pump, Einhorn's duodenal, 559
Punch, skin, for removal of superficial

growths, 309
Puncture, epidermic, vaccination by, 222
exploratory, 311
of ankle-joint, 329
of elbow- joint, 327
of hip- joint, 327
of joints, 326
of kidneys, 325
of knee-joint, 328
of liver, 322
of lung, 317
of pericardium, 318
of peritoneal cavity, 321
of pleura, 312
of shoulder-joint, 326
of. spleen, 324
of wrist- joint, 327
for parasacral anesthesia, 126
for sacral anesthesia, 124
for spinal anesthesia, 117
lumbar, 329

as means of adrninistering therapeutic
sera, 336
spinal, 3 29. See also Lumhar puncture.
venous, method of making, 302
Purgative enemata, 595
Pus in urine, 703
Pyelography of kidneys, 792

of ureters, 792
Pyelometry, 774
Pynchon's vaporizer, 428
Pyuria, 703

Quantity of urine passed in twenty-four

hours, 700
Quinin and urea hydrochlorid as local

anesthetic, 84

Radial nerve, blocking of, loi
Ransohoff's method of arterial anesthesia,

114^
Reaction of urine, 701
Rectal administration of arsphenamin,
213
of neoarsphenamin, 213
anesthesia, 61

application of electricity to colon, 626
bougie £l boule, 591
electrode. Boas', 624, 625
feeding, 613
inflation, 616

infusion of salt solution, 607
irrigations, 594, 599
irrigator, Bodenhamer's, 601
Kemp's, 601
Tuttle's, 601, 602

Rectal palpation of ureter, 757
probe, 592
speculum, bivalve, 583

duckbill, 583, 584

fenestrated-blade, 583, 584

KeUy's, 583, 585

Murphy's, 584

Sims', 583

Tuttle's, 585
strictures, dilatation of, by bougie, 618

surgical treatment of, 618
tubes, 597
valves, 569
Recto-abdominal palpation of pelvic

organs, 813, 818
Rectum, abdominal examination of, 571
administration, of arsphenamin and
neoarsphenamin by, 213

of drugs by, 595
anatomy of, 567
and anus, local anesthesia in operations

on, 106
application of electricity to, 624
dilation of, 581, 582
examination of, by bougie k boule,.
501

by bougies, 590

by probe, 592

by proctoscope, 583

by sounds, 590

by speculum, 583

feeding by, 613
hydrotherapy of, 594
inflation of, with air, 618

with fluid, 617
inspection of, 571, 579
internal examination, 577
irrigations of, 594, 599
lavage of, 593
medication by, 595
palpation of, 572, 579

by finger, 580

by whole hand, 582
proper, anatomy of, 568
skiagraphy of, 576
strictures of. dilatation of, by bougie-

618
Red blood corpuscles, preserved, trans-
fusion of, 161
Rehfuss tube for fractional gastric anal-
ysis, 534
Relapsing fever, arsphenamin in, 207
Removal of fragments of tissue for exami-
nation, 307
Renal cotiiplications of general anesthesia,

73 . •

hematuria, 702
Rennin in stomach contents, 529
Replacement of retroverted uterus, 856
Residual urine, estimation, 712
Respiratory complications of general anes-
thesia, 73

paralysis during general anesthesia, 70-
Retractor, White's palate, 370
Retroverted uterus, replacement of, 856
Re vaccination, 224

INDEX

889

Rhinoscopy, 363
anterior, 366
posterior, 367
Riegel's test dinner, 527
Ring pessary, 854
Ringer's formula for artificial serum for

infusions, 169
Rinne's test of hearing, 415
Riva-Rocci sphygmomanometer, 129
Robertson's apparatus for collecting blood
for preserved red cells transfusion,
162
for syphoning oflf supernatant fluid,
163
method of transfusing preserved red
cells, 162-164
Robinson's apparatus for artificial pneu-
mothorax, 272
Rogers' sphygmomanometer, 131
Rosenheim's gastroscope, 539

Sacral anesthesia, 122

Sacrum, anatomy of, 122, 125

Sajous' applicator and mouth-gag, 449
insufflator, 389

Saline solution, infusion of, 167
intraarterial infusion of, 177
intravenous infusion of, 170
rectal infusions of, 607
subcutaneous infusion of, 180

Salvarsan. See Arsphenamin.

Salvarsanized serum, administration of , in
cerebral syphilis, ^$&

Saxon's apparatus for proctoclysis, 610,
611

Scalp, local anesthesia in operations on,

95
Scarification, 190

of cervix, 852

of glottis, 191

of larynx, 192

of limb, 192

of tonsil, 191

vaccination by, 221
Schapira cystoscope, 714
Schimmelbusch mask, 26, 27, 48
Schleich's general anesthetic mixture, 50
Schreiber's esophageal sound, 506, 507
Sciatic nerve, blocking of, 106

injections of, 231
Sciatica, injections for, 231
Scoop powder blower, 388
Scopolamin-morphin anesthesia, 65
Scrotum, aspiration of, 356

local anesthesia in operations on, 105

passive hyperemia of, 261
Secretions, collecting for bacteriological

examinations, 290
Secretory curves of stomach, 535

variations in, in health and disease

535
Segregation of urme, 775
Harris^ method, 777
Luy's method, 779
Segregator, Harris', 775
Luy's, 775

Semiopcn method of admintstering ether

Sera, artificial for infusions, i6q
Serous cavities, collection of discharses
from, for bacteriological examination
294
Serum, arsphenaminizcd, 338
blood, human, injection of, 137, 164
salvarsanized, 338

Welch's apparatus for collecting, 165
Shock after passage of urethral instru-
ments, 692
pleural, 275
Shoulder, passive hyperemia of, 260
Shoulder-joint, exploratory puncture of,

326
Siegle's pneumatic otoscope, 412
Silver catheter, 735
Sims' curet, 869
position, 577

for gynecological examination, 801
rectal speculum, 583
vaginal speculum, 821
Sinus, ethmoidal, anatomy of, 362
frontal, anatomy of, 362
lavage of, 394

transillumination of, 376, 377
maxillary, anatomy of, 361
lavage, 390

transillumination of, 376, 378
sphenoidal, anatomy of, 362
lavage of, 395
Sinuses, accessor>% lavage of, 389

passive hyperemia in diseases of, 396
skiagraphy of, 378
tuberculous, bismuth paste for, 276
Skene's pessarj-, 854
Skiagraphy of accessory sinuses, 378
of bladder, 725
of esophagus, 502
of intestines, 576
of kidneys, 791
of larynx, 460
of rectum, 576
of stomach, 546
Small occipital nerve, blocking of, 95
Smear, blood, for microscopical examina-
tion, method of making, 298
culture, method of making, 290
preparation for microscopical examina-
tion, 279
from cer\'ix, 285
from eyes, 282

from mouth and phar>'nx, aSz
from nose, 282
from urethra, 283
from uterus, 286
from vagina, 285
Snare, urethral, 676

Sodium citrate method of blood trans-
fusion, 156
Solution, Dakin's. Sec Dakin's solution.
Sounding of bladder, 707
urethra, 638
uterus, 825
Sounds, cupped, 672

890

INDEX

Sounds, esophageal, 491, 506

Billroth's, 506

Schreiber's, 506, 507
examination of esophagus by, 490

of rectum by, 590

of urethra by, 638
Gouley's, 684
urethral, 639
Southey's trocars and cannula, 193
Specific gravity of urine, 700
Specula, bladder, Kelly's, 720
ear, Boucheron's, 408

electric-lighted, 409

Gruber's, 408

Toynbee's, 408
examination of pelvic organs by, 820

ot rectum by, 583
nasal, Myles', 366
rectal, bivalve, 583

duck-bill, 583, 584

fenestrated-blade, 583, 584

Kelly's, 583, 585

Murphy's, 584

Sims', 583

Tuttle's, 585
Sims' rectal, 583
urethral, 673

Kelly's, 659
vaginal, bivalve, 820, 821

Goodell's, 820

Sims', 821

trivalve, 820
weighted, Garrigues', 826
Sphenoidal sinuses, anatomy of, 362

lavage of, 395
Sphygmomanometer, Jane way's, 130,

131

Riva-Rocci, 129

Rogers', 131

Stanton's, 130
Sphygmomanometry, 127
Spinal anesthesia, 115

canal, puncture of, 329
Spleen, exploratory puncture of, 324
Sponge holder and swab, 821
Spongy urethra, anatomy of, 628
Spray, laryngeal, 461

nasal, 383
Spraying, nasal, 383

of larynx, 461
Sputum bottles, 305

collection of, for examination, 304
Squatting position, 579

for gynecologic examination, 803
Stab culture, method of making, 289
Stanton's sphygmomanometer, 130
Steam atomizer, 466

inhalations, 465

inhaler, 466
Sterilization of cocain solutions, 82

of salt solutions, 169

of wounds by Carrel method, 234
Sterilizer, formalin, for urethral instru-
ments, 640
Stethoscope, aural, 417
Stockton's stomach electrode, 563

Stomach, absorption power of, Penzoldt
and Faber test, 536
anatomy of, 513
auscultation of, 523
capacity of, 514
contents, analysis of, fractional method,

composition of, 527
curves of, 535
examination, 526, 527
extraction of, 529

aspiration method, 529, 533
expression method, 529, 532^
lactic acid in, 528
pepsin in, 529
rennin in, 529 •
douche, 552

Einhorn's, 553
douching, 552
electrode, Bardet's, 563
Einhorn's, 563
Stockton's, 563
Wegele's, 563
electrotherapy in diseases of, 563
exploratory laparotomy of, 547
inflation of, 524
by air, 524, 525
by carbonic acid gas, 524, 525
inspection of, 516
irrigation of, 552
lavage of, 547
massage of, 561

motor power of, Ewald's test, 536
iodipin test, 536
Leube's test, 536
tests for, 536
palpation of, 518
percussion of, 521
secretory curves of, 535
skiagraphy of, 546
splashing sounds in, 523
succussion sounds in, 523
transillumination of, 537
tube and Davidson syringe for inflating
stomach, 525
Rehfuss, 534
washing out, 547
x-TSLv examination of, 546
Stools. See Feces.
Stovain in spinal anesthesia, 116
Streak culture, method of making, 288, 289
Strictures of bladder, catheterization in,
740
of esophagus, dilatation of, by bougies,

504
of rectum, dilatation of, by bougie, 618
of urethra, dilatation of, 680

continuous, 693
ureteral, dilatation of, 794
urethral, determining size and length of,
647, 648
Stylet needle for spinal puncture, 330
Subcutaneous drainage in edema, 192
emphysema following artificial pneumo-
thorax, 276
infusion of salt solution, 180

INDEX

891

Suction cups for passive hyperemia, 263
Sudden death after aspiration of chest,

347
Superior laryngeal nerve, blocking of, 98
Supraorbital nerve, blocking of, 95
Suspension laryngoscopy, 450, 45a
Swab and sponge holder, 821
Swinburne's urethroscope, 653
Symond's esophageal tube, 509, 510
Syphilis, arsphenamin in, 206

cerebral, administration of salvarsan-
ized serum in, 338
Syphonage aspirator, 343
Syringe, antitoxin, 215

Davidson, 525

ear, 423

Allport's, 423
Blake's, 424

Eustachian, 429

for bismuth paste injections, 277

hypodermic, 201, 202

instillation, Keyes-Ultzmann, 669-670,

731
method of Lindeman for indirect trans-
fusion of blood, 150
of linger for transfusion of blood,
150, 152
nasal, 382
ointment, 673

transfusion, Unger's instrument for, 152
urethral, 662
KoUmann's, 675
Syringing of ear, 423
Systolic blood-pressure, 127

normal, 128
Szumann's formula for artificial serum
for infusions, 1 70

Talley's intrauterine catheter, 841
Tampon, 838
medicated, 839
vaginal, 837
Tamponing nose for control of hemor-
rhage, 397
uterus, 847
Temporal nerve, blocking of, 95
Test, absorption, of bladder, 713

blood, for functional capacity of kid-
neys, 787
breakfast, Ewald-Boas, 527
dinner, Riegel, 527

Ewald's of motor power of stomach, 536
experimental polyuria, for kidney func-
tion, 781
five-glass for urethral pus, 633
for agglutination of blood, 140
for hearing, 413
for hemolysis of blood, 139
indigo-carmin for kidney function, 785
iodipin, for motor power of stomach,

536
Leube's, of motor power of stomach, 536
meal, Mosenthal's, for kidney function,

782
methylene-blue for functional capacity
of kidneys, 785

Test of absorption power of stomach, 536
of acutencss of hearing. 413
of bladder capacity 711
of kidney function, 770

of motor power of stomach, 536
Penisoldt and Fab
power of stomach, 536

aoso

rption

phonolsulphonephthalein, for functional

capacity of kidne>'s, 785
phloridzin, for functional capacity of

kidne>*s, 784
Rinne's, of hearing, 415
two-glass for urethral pus, 633
voice, for hearing, 413
watch, for hearing, 413

Weber's, of hearing, 415
Testicles, obstructive hyperemia

of.

method of producing, 261
Tetanus, administration of antitetanic

serum in, 337
Therapeutic sera, lumbar puncture ai

means of administering, 336
Thompson's stone searcher, 707
Thoracentesis, 339
Thoracic ner\'e, blocking of, 103

local anesthesia in operations on, q8
Thyroid cartilage, anatomy of, 430
Tibial nerve, anterior, blocking of, 108

posterior, blocking of, 108
Tic douloureux, injections of fifth nerve

for, 225
Tissues for examination, removal of, 307
inflamed, o[>e rations on, under local
anesthesia, 109
Titration of Dakin's solution, 237
Tongue depressor, Kirstein's, 448
Tonsil, scarification of, 191
Towel cone, 28

Toxic effects following injections of bis-
muth paste, 277
Toynbee's aural speculum, 408
Trachea, anatomy of, 438
examination of, 439
inspection of, 440
Tracheal anesthesia, 56
Tracheo-bronchoscopy, direct, 4S3
lower, 459
upper, 458
Tracheoscopy, 440
Tracheotomy, 477
high, 478, 483
low, 479, 486
tube, 480
Transfusion cannula, Brewer's, 148
Crile's, 144
Elsberg's, 149
Lindeman's, 151
needle, Kaliski's, 158
of blood, 137

agglutination reactions m, 140
arter>' to vein, 143
Brewer's method, 148
citrate method, 156
contraindications, 138
Crile's method, I43» »4S
direct, 143

892

INDEX

Transfusion of blood, Elsberg's method,

148
indications, 138
indirect, 149

by paraffined tubes, 133

by syringe method of Lindeman,

ISO
Kimpton-Brown method, 155
Moss' classification of groups for, 140
position of donor and recipient, 144
preserved red cells, 161
• quantity transfused, 142
rapidity of flow, 143
repetition of, 143
selection of donor, 139
syringe method, of Unger, 152
tests for hemolysis in, 139
variations in technic, 148
of preserved red cells, 161
Robertson's apparatus for collecting
blood for preserved red cells, 162
for syphoning off supernatant fluid,
163
syringe, Unger's instrument for, 152
tube, David and Curtis, 154

Kimpton-Brown, 153
U. S. Army apparatus for citrated
blood, 157, 159
Transillumination of frontal sinus, 376,

377
of maxillary sinus, 376, 378
of stomach, 537
Transilluminator, Coakley's, 376
Transparency of urine, 701
Trendelenburg tracheal cannula, 57
Trifacial nerve, anatomy of, 225, 226
branches, blocking of, 97
neuralgia, injections of fifth nerve for,

225

Trivalve vaginal speculum, 820
Trocar and cannula for aspirating, 350

and syringe for aspirating and in-
jecting hydrocele, 355

aspirating, 340

Southey's, 193
Tropacocain in spinal anesthesia, 116
Tubes, Carrel, for wound disinfection, 240

culture, inoculation of, method, 287

David and Curtis transfusion, 154

esophageal, Symond's, 509, 510

ethyl chlorid, 47

for esophageal lavage. Boas', 503

intubation, 469, 472

Kimpton-Brown transfusion, 153

Klotz's urethral, 654

paraffine, Alton's method of preparing,
154

pharyngeal breathing, 52

rectal, 597

Rehfuss stomach, 534

speculum, urethral, Kelly's, 659

stomach, 525
Rehfuss, 534

stomach-douche, 553

tracheotomy, 480

urethral, Klotz's, 654

Tuberculous lung, artificial pneumothorax
for, 270

sinuses, bismuth paste, for diagnosis
and treatment ot, 276
Tunica vaginalis, aspiration of, 354
Tuning forks, Hartmann's, 414
Tuttle's irrigator, 601, 602

proctoscope, 585

rectal speculum, 585
Two-glass test, 633

Ulcer, duodenal, secretory curve in, 535

gastric, secretory curve in, 535
Ulnar nerve at wrist, blocking of, loi

in arm, blocking of, 100
Unger's instrument for syringe trans-
fusion, 152
method of blood transfusion, 152
Unna's ointment, 672
Upper extremity, local anesthesia in
operations on, 99
tracheo-bronchoscopy, 458
Urea excretion, Ambard's coefficient
and McLean index in, 789
in blood, test for kidney function, 788
Ureteral calculi, skiagraphy of, 791
catheter, wax-tipped, 761
catheterization, direct view method, 762
in female, 768
in male, 759

indirect view method, 765
medication, 793
palpation, 755
strictures, dilatation of, 794
Ureters, anatomy of, 751

catheterization of, direct view method,.
762
in female, 768
in male, 759

indirect view method, 765
lavage of, 793
medication of, 793
palpation of, 755
pyelography of, 792
Urethra, 627

anatomy of, 627, 631
application of cold to, by psychrophore,.
676
of ointments to, 672
caliber of, 629

collection of discharges from, for bac-
teriological examination, 295
for microscopical examination, 283
curves of, 630
dilatation of, complications following,,

692
estimation of length, 651
examination oi, 631
by bougie a boule, 647
by sounds and bougies, 638
glass tests, 632
hand injections for, 661
injection test for pus, 634
inspection of, 634, 635, 652, 658
instillations of, 669
irrigations of, 664

INDEX

893

Urethra, local anesthesia in operations on,
87, 105
membranous, anatomy of, 628
palpation of, 636, 638
prostatic, anatomy of, 629
spongy, anatomy of, 628
strictures of, dilatation of, 680
continuous, 693
Urethral bougie, 639, 684
a boule, 647, 648
chill, 6q2
curet, 675
dilator, Kelly's, 659
. KoUnmnn's, curved, 683

straight, 683
diseases, urethroscope in treatment of,

673
fever, 692
filiforms, 639, 684
inspection, 634
instillations, 669

irrigating nozzle, Chetwood's, 665
irrigations, 664
knife, 675
mucous membrane, normal appearance

of, 656, 657
ointment syringe, 673
probe, 674
pus, determination of, glass tests for, 632

injection for, 634
snare, 676
sound, blunt, 639
conical, 682
cupped, 672
double-taper, 682
straight, 683
speculum, 673
strictures, dilatation of, 680
continuous, 693
estimation of size and length of,
647, 648
syringe, 662

Kollmann's, 675
tube, Klotz's, 654
tube-speculum, Kelly's, 659
Urethritis after passage of urethral sound,

692
Urethrometer, Otis', 650
Urethrometry, 650
Urethroscope, 653
female, 659

in treatment of urethral diseases, 673
Swinburne's, 653
Urethroscopy in female, 658

in male, 652
Uric acid in blood, test for kidney func-
tion, 788
Urinalysis, 758
as test of kidney function, 780
in bladder disease, 699
in kidney disease, 699, 758
Urine, albumin in, 702
blood in, 702

collection of, for exanunation, 305
from infants, 306
in presence of incontinence, 300

Urine, color of, 701
cryoscopy of, lor determination of func-
tional capacity of kidneys, 793
elimination of foreign Bub«tancet in, u»
i ndex of renal funrtion. 7R4
of substances normally present in, m
index of renal function, 780
examination of, 699, 758
odor of, 700
. pus in, 703
quantity of, passed in twenty-fottr

hours, 700
reaction of, 701
residual, estimation of, 712
segregation of, 775
Harris' method, 777
Luy's method, 779
specific gravity of, 700
substances normally excreted in, con-
centrated in blood, as index of renal
function, 787
transparency of, 701
U. S. .\rmy apparatus for transfusion of

citrated blood, 157, 159
Uterine cannula and plunger, 849
douche, 840
nozzle, 841

Chamberlain's, 841
Fritsch-Bozeman, 841
Talley's, 841
packer, 848, 849
Uterus, anatomy of, 796

collection of discharges from, for bac-
teriological examination. 2q6
for microscopical examination^
286
curettage of, 868
digital palpation of, 827
douching, 840
palpation of, 813
position of, 797

retroverted, replacement of, 856
scrapings from, examination of, 829
sections from, examination of, 829
sounding of, 825
tamponing, 847

Vaccination, 219

by acupuncture, 222

by epidermic puncture, 222

by scarification, 221

shield, 222
Vacuum, heat, aspirator, ConneD s,

342
Vagina, anatomy of, 796

application of powders to, 836

bimanual palpation of, 813

collection of discharges from, for bac-
teriological examination. 296
for microscopical examination, 285

digital palpation of, 81 1

douching of, 832

examination by specula, 820

inspection of, 809

local applications to, 835 ' ^

relations of, 796

894

INDEX

Vaginal depressor, 821
discharges, examination of, 810
douche, 832

nozzle, 833
inspection of bladder, 705
irrigations, 832
palpation of ureters, 756
speculum, bivalve, 820, 821
Goodell's, 820

Sim's, 821 ^

trivalve, 820
tampons, 837
medicated, 839
Vagino-abdominal palpation of pelvic

organs, 813, 814
Valentine's irrigator, 665
Valsalva's method of inflation of middle

ear, 416
Valves of Morgagni, 570

rectal, 569
Vapor method of administering chloro-
form, 39
ether, s3
Vaporizer, Bench's, 428
Hartman's, 428
Pynchon's, 428
Venesection, 185
Venous anesthesia, no

puncture, method of making, 302
Vertebrae, lumbar, anatomy of, 330
Vesical growths, fulguration of, by high

frequency currents, 732
Vienna general anesthetic mixture, 50
Vincent's apparatus for blood transfusion,
154
method of determining blood groups,
141
Voice test for hearing, 413
Vomiting after anesthesia, 72
Von Hacker's method of dilating esopha-
geal strictures, 507
von Mikulicz's esophagoscope, 498, 499

Wales' bougies, 590, 591, 619
Ware's ethyl chlorid inhaler, 48

Washing out stomach, 547

Watch test for hearing, 413

Wax-tipped bougie, 770
ureteral catheter, 761

Weber's test of hearing, 415

Wegele's stomach electrode, 563

Weighted speculum, Garrigues', 826

Welch's apparatus for collecting blood
serum, 165

Wet cupping, 197

Whip catheter, 736

Whistle, Gal ton's, Edelmann's modifica-
tion, 414

Whitall Tatum atomizer, 384

White's palate retractor, 370

Wolbarst five-glass test, 633

Wounds, sterilizing by Carrel-Dakin
technic, 234
apparatus for, 237-241
bacteriologic examination in, 247
cleansing of wound, 242
debridement in, 242, 243
dressing wound, 246
dressings for, 241
in penetrating wounds, 244
in perforating wounds, 246
in superficial wounds, 243
instillation tubes, arrangement

of, 243-246
instillations in, 242
solutions for, 235-237
technic, 242

Wrist- joint, exploratory puncture of, $27

X-RAY examination of accessory sinuses,
378
of bladder, 725
of esophagus, 502
of intestines, 576
of kidneys, 791 •

of larj'-nx, 460
of rectum, 576
of stomach, 546

Yaws, arsphenamin in, 207

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