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THE LIBRARY

THE UNIVERSITY
OF CALIFORNIA

LOS ANGELES

GIFT OF

SAN FRANCISCO
COUNTY MEDICAL SOCIETY

Hook is due on last date given below. A fin
"harged for each day the book it kept ovf

^ te ~ e

7611

Regional Anesthesia

(VICTOR PAUCHET'S TECHNIQUE)

B. ,SHERWOOD-DU_NN, M.D.

OFFICIER D'ACADKMIE; SURGEON (COLONEL) SERVICE DE SANTE MILITAIRE DE
PARIS; PHYSICIAN TO THE COCHIN HOSPITAL.

WITH 224 FIGURES IN THE TEXT

PHILADELPHIA

F. A. DAVIS COMPANY, PUBLISHERS

ENGLISH DEPOT
STANLEY PHILLIPS, LONDON

1920

BY
F. A. DAVIS COMPANY

PRESS OF

F. A. DAVIS COMPANY
PHILADELPHIA. U.S.A.

Libr-

tuo

300

PREFACE.

FOR thirty years Professor Reclus, of the
Paris Faculte, preached and practised local anes-
thesia. His method consisted in infiltrating the
tissues upon which he proposed to operate with a
weak solution of cocaine — then proceeding with
the operation.

This procedure is well known in France, and
is often employed in minor operations.

Regional anesthesia differs widely from the
method of Reclus. Instead of applying the anes-
thetic to the terminals of the nerves, it is injected
at the point of the origin of the nerve, or along
the trunk near the point of origin, so that the
\vhole region supplied by the nerve and its branches is
anesthetized. All the major as well as the most deli-
cate minor operations can be performed in this way.
The method has gained many adherents since
1914, and its growing popularity has led us to
believe that an exposition of it would be wel-
comed by the American profession.

Professor Victor Pauchet is acknowledged to
be the leading exponent of regional anesthesia in
France, and this book constitutes a resume of his

(iii)

577919

; ' ' <- q ' •', •' /' €-

iv PREFACE.

writings upon this subject, together with those of
P. Sourdat and J. Laboure. In addition there is
included the latest experiences of Pauchet and the
writer, together with Pauchet's recommendations,
inserted during his revision and amplification of
the manuscript before its transmission to the pub-
lishers.

I wish to acknowledge my indebtedness to Dr.
Emilie Jane and Miss Frances Johnson, R. N.,
and to express my high appreciation of the assist-
ance which they have rendered me in the prepara-
tion of this work for publication.

B. SHERWOOD-DUNN.

CONTENTS.

CHAPTER I.

PAGE

GENERAL CONSIDERATIONS 1

Advantages of Regional Anesthesia 1

Disadvantages of Regional Anesthesia 5

CHAPTER II.

ARMAMENTARIUM 12

Syringes 12

Needles 12

Anesthetic 14

General Technique 17

CHAPTER III.

CRANIAL OPERATIONS 37

Treatment of Large Wounds in the Soft Tissues, or of Com-
pound Fractures of the Skull 40

Removal of Malignant Tumors of the Cranium, with Bone

Resection 42

Trephining the Temporal Region 43

Exposure of the Cerebellum 46

CHAPTER IV.

ANESTHESIA OF THE HEAD AND NECK 48

Anesthesia of the Gasserian Ganglion 48

Anesthesia of the Trigeminal Nerve Distribution 57

Regional Anesthesia in Rhinology 80

Regional Anesthesia in Otology 85

Regional Anesthesia in Ophthalmology 91

Regional Anesthesia in Dental Surgery 94

Regional Anesthesia of the Face and Jaws 97

Regional Anesthesia of the Tongue, Floor of the Mouth, Ton-
sils and Palate 105

Regional Anesthesia in Operations of the Neck 109

(v)

vi CONTEXTS.

CHAPTER V.

PAGE

ANESTHESIA OF THE THORAX AND ABDOMEN 128

Intraspinal Anesthesia 128

Nerve-trunk Anesthesia 136

Paravertebral Anesthesia 144

Paracentesis of the Pleural Cavity 153

Thoracotomy for Empyema with Costal Resection 153

Resection of the Second to the Fifth Costal Cartilages for

Rigidity of the Thorax 155

Operations upon the Sternum 158

Thoracotomy for Abscess of the Lung, etc 158

Operations for Tumor of the Breast 160

Operations in the Axilla 162

Abdomen 162

Operations upon the Stomach 165

Median Hypogastric Incision 167

Operations in the Iliac Fossa 169

Umbilical Hernia 186

Inguinal Hernia 188

Femoral Hernia 195

Operations upon the Kidneys 198

Operations upon the Biliary Passages 199

CHAPTER VI.

ANESTHESIA OF THE GENITO-URINARY ORGANS AND RECTUM 200

Anterior Sacral Anesthesia (Pre-sacral) 205

Anesthesia through the Sacral Foramina — Trans-sacral An-
esthesia 207

Operations upon the Bladder 212

Operations upon the Testicles and Scrotum 214

Operations upon the Penis 217

Operations upon the Posterior Urethra 219

Operations upon the Prostate 220

Operations upon the Vulva and Vagina 220

Operations upon the Anus 224

CHAPTER VII.

PAGE

ANESTHESIA OF THE EXTREMITIES 230

Upper Extremity 232

Operations upon the Hand 245

Operations upon the Forearm 258

CONTEXTS. vii

ANESTHESIA OF THE EXTREMITIES (continued).

Upper Extremity, Operations at the Elbow 261

Operations upon the Arm 263

Operations upon the Shoulder 264

Lower Extremity 265

Operations upon the Toes 270

Operations upon the Entire Foot 272

Operations upon the Knee 274

Operations upon the Soft Part of the Thigh 277

CONCLUSIONS 283

INDEX . 285

CHAPTER I.

GENERAL CONSIDERATIONS.
ADVANTAGES OF REGIONAL ANESTHESIA.

ANESTHESIA by injection possesses, as compared
with anesthesia by general narcosis, advantages of
such cardinal importance that, at the very outset,
the reader's attention should be directed to them
as ample justification for the time, labor and
special education required to become sufficiently
expert in its application to permit of its adoption
for general employment.

Lozv Mortality Risks. — Since the concentrated
solutions of cocaine have been replaced by weak
solutions of the less toxic agents, such as sto-
vaine, novocaine, procaine, etc., death from local
or regional anesthesia has disappeared from sur-
gical practice. The writer is unacquainted with
a single case of death due to the employment of
the last named anesthetics.

The relative rarity of death from narcosis
(chloroform, I in 2000; ether, i in 5000) may
make this advantage seem insignificant; but it is
only necessary for an operator to lose one patient
by narcosis, to have this apparently insignificant
advantage brought forcibly to his attention.

(1)

2 REGIONAL ANESTHESIA.

Reduction of Post-operative Dangers. — General
narcosis, aside from its mortality, produces com-
plications which are of great importance because
of their frequent occurrence. They include chiefly pul-
monary complications, caused or aggravated by
etherization, and alterations in the liver and kid-
neys through the action of ether, and particularly
of chloroform. Rapid degeneration of the liver
and kidneys following surgical operations is often
attributed to shock or post-operative infection, but
the fact that these accidents are eliminated by
regional anesthesia would indicate that they are
directly due to the action of the compounds used
in general narcosis, and the superiority of regional
anesthesia is made strikingly apparent in opera-
tions upon subjects suffering with chronic jaun-
dice or renal insufficiency. The nausea and vomit-
ing, which often continue for forty-eight hours
after an operation and are such prominent factors
in reducing the vital forces — especially in patients
with strength already at the lowest ebb — are often
the determining cause of death. These trouble-
some conditions are eliminated in regional anesthesia.

Diminution of Shock. — The reflex action of
traumatism, the unconscious suffering of a patient
even under the full influence of narcosis, is trans-
mitted to the nerve centers, provoking disturbances
which, repeated, result in certain alterations in the
neurons, aiid these alterations constitute shock.

Local or regional anesthesia secures a com-
plete physiological section of the nerves and sup-

GENERAL CONSIDERATIONS. 3

presses completely this influence upon the nerve
'centers.

This fact has been so fully demonstrated that
Crile (of Cleveland) practises local and regional
anesthesia in all of his major operations, even
when employing general narcosis with nitrous
oxide. If comparison is made between a series
of operations for cancer of the stomach under
narcosis and a series under regional anesthesia,
the relative condition of the patients subsequently
offers a striking confirmation of the innocuousness
of the latter procedure.

Absence of Danger from Asphyxia. — Adminis-
tration of ether or chloroform is generally at-
tended by greater or less respiratory disturbances.
Onlookers often have their attention attracted by
the patient's difficulty in breathing, due generally
to mucus collecting in the mouth and nose, espe-
cially in the Trendelenburg position. Not infre-
quently the operator's attention is arrested by the
same difficulty. All of this is absent in injection
anesthesia.

Operations upon the respiratory tract, or in
its vicinity, are greatly simplified and facilitated.
The patient assumes whatever position is desired,
being perfectly conscious. He can at will arrest
his breathing, suppress a cough, or expectorate if
need be. This is of valuable assistance in opera-
tions upon the pleura, larynx, neck, etc. In oper-
ations for goiter it safeguards the recurrent laryn-
geal nerve by allowing the patient to speak, thus
calling attention to the nerve.

4 REGIONAL ANESTHESIA.

Special Advantages in Certain Operations. —
The fan-like distribution of the nerves after thev

•/

leave the large nerve trunks permits the per-
formance of extensive operations once the trunk
has been anesthetized. Thus a bronchial tumor,
or the cervical glands can be removed, or total
laryngectomy or external esophagotomy performed
after preliminary infiltration of the cervical plexus.

Nephrectomy can be painlessly performed after
paravertebral infiltration of six intercostal and
two lumbar trunks; not only are the parietes
rendered insensible, but the kidney can be sutured
or the pedicle liberated and ligated without pain.
The same advantage attaches in operations upon
the liver and stomach. The rectum can be excised
after injecting through the sacral foramen.

Compared with the method of local infiltration,
practised by Reclus, regional anesthesia possesses
the following advantages :

(1) The anesthesia is entirely distinct from the
operation proper, being instituted beforehand, and if
possible, by an assistant in an adjoining room. Con-
sequently, successive operations can be performed
without loss of time.

(2) Once the nerve or nerves have been properly
anesthetized, the anesthesia continues complete for
from one and one-half to two and one-half hours
and the operation is never interrupted to make addi-
tional injections as is often the case in infiltration
anesthesia.

(3) It obviates all danger of necrosis of the tis-
sues, such as sometimes occurs in local infiltration

GENERAL CONSIDERATIONS. 5

where a section of the skin is mobilized in a plastic
operation to cover a denuded surface and is nour-
ished only by a narrow pedicle.

DISADVANTAGES OF REGIONAL ANESTHESIA.

Special Training Required. — Some training in
the practical method of application is required to per-
mit of successful practice of this procedure — though
not more than is necessary for the execution of any
of the simpler types of surgical operations.

As the simplest and most rapid procedure for
securing the necessary experience we advise that
the operator, after reading the detailed descrip-
tions herein presented, first practise finding upon
the skeleton, with needles of varying lengths, the
cranial, spinal, intercostal and sacral nerve for-
amina.

When he has become familiar with the depths
and directions of the various punctures through ex-
ercises upon the skeleton, the student of the method
may then repeat the various operations upon the
cadaver, using the longer and coarser needles and a
fluid containing India ink. Dissection of the more
difficult regions, after such experimentation, will
disclose any faults and soon draw the operator's at-
tention to any necessary corrections. Too much time
need not be spent in this experimental work, how-
ever, before the operator begins upon the living sub-
ject, as no harm results from the injection of the
fluid. But little actual experience is required for the
surgeon to become confident and adept in finding the

6 REGIONAL ANESTHESIA.

nerve trunks, this being facilitated by the more or
less pronounced sensation referred to the terminal
distributions when the point of the needle touches
the nerve trunk, or by the insensibility of the sur-
faces supplied.

It will assist the operator in rapidly gaining con-
fidence and skill if he will use at first a larger amount
and a stronger solution and infiltrate a more exten-
sive area.

Necessity of Gentleness and Skill in Operative
Technique. — It is obvious that where an operation
must be done with the complete consciousness and
oftentimes in full view of the patient, a gentle, un-
hurried, and quiet technique is imperative and is
conducive to a greater degree of satisfaction to
the patient, with better results.

Some operators are accustomed to break up ad-
hesions and carry out many surgical maneuvers with
their hands and fingers. With injection anesthesia
in abdominal operations especially, all pulling, tear-
ing, and rough treatment should be avoided, as even
with complete insensibility of the parts the patient
cannot but be cognizant of the methods employed,
and any such treatment produces an unfavorable
mental impression which is prejudicial to final suc-
cess. The scalpel and scissors should be used for all
necessary separation of parts. Again, it is the habit
of some to employ in their operations a variety of
retractors, which are often the cause of unnecessary
traumatism to the parts. This may also be said of
the employment of an unnecessary number of pres-
sure and rat-tooth forceps.

GENERAL CONSIDERATIONS. 7

It must not be overlooked that a difference exists
between sensation and pain; unnecessary pulling
and handling1 of parts produces a disagreeable sen-
sation which is likely to cause complaint on the part
of the patient.

The more gently and quickly the operator pro-
ceeds, the greater will be his measure of operative
success.

Objection that the Method Procures only a Partial
Anesthesia. — In regional anesthesia it has been our
experience that, out of 20 cases, 12 are completely
insensible; 7 are sufficiently insensible to all neces-
sary manipulations to permit of the operative pro-
cedure without serious complaint on the part of the
patient; while I case out of 20 is found insufficiently
anesthetized and must be given a little ethyl chloride
to overcome the deficiency. Even in this event the
quantity of inhalation anesthetic required is very
slight.

The value of regional anesthesia is demonstrable
by comparison, chiefly writh general narcosis. The
reader need only be reminded of the distressing ex-
periences which attend the beginning and the close
of the latter procedure, and but little experience with
the former will convince any expert operator of its
marked superiority. Apart from the distressing
period of vomiting which follows general narcosis,
the after pains complained of during the succeeding
day and night are usually greatly diminished in
regional anesthesia, and after nephrectomy, lapa-
rotomy, and facial operations a lasting condition of
hypoanesthesia may often be noted, which renders

8 REGIONAL ANESTHESIA.

the injection of morphine or other narcotic during
the succeeding twenty-four hours unnecessary.

True, the patient will often complain at some
time or other during the course of the operation.
One says the table is too hard; another asks if the
operation will not soon be finished; many complain
of suffering because they confound sensation with
pain. One of our patients cried out when he heard
a fragment of his rib fall into the slop basin. These
are minor inconveniences which it is well to be aware
of in order to be prepared for them when they be-
come manifest. The table should be well padded.
In nervous and sensitive cases it is advisable to
.blindfold the patient's eyes and to stop the ears with
cotton.

Before all operations the patient should be given
an injection of scopolamine-morphine, which not
only does not interfere with, but rather assists the
method. Absolute silence should be maintained in
the operating room.

Necessarily the operator must have become
perfected in the details and technique of the regional
form of anesthesia. Any operator who, in the anes-
thetization of his patients, has had to rely upon the
services of different assistants, knows how seldom
a good one is found. The number of patients who
are insufficiently or imperfectly brought under the
anesthetic and bear down or resist during the course
of the operation is legion, while not infrequently
cases absorb too much of the anesthetic, causing the
operator to discontinue his work while the patient
is brought back from the danger line. It is not too

GENERAL CONSIDERATIONS. 9

much to ask, therefore, that the operator intending
to make use of regional anesthesia should carefully
and completely train himself in the details of the
procedure and persevere in his technical practice
until he has reached a satisfactory degree of perfec-
tion, just as he does in any and every other depart-
ment of medical practice.

An important feature that should never be lost
sight of is the psychology of the patient. Those who
accept the method reluctantly, and are anxious, nerv-
ous, and hyper-sensitive, are the difficult subjects;
most of these, however, once the operation has been
satisfactorily concluded, express themselves as com-
pletely satisfied.

On the other hand, there are those who, familiar
with the distress of the after-effects of general nar-
cosis, welcome the new mode of procedure and make
most satisfactory subjects. The mental attitude of
the patient has almost as much to do with the suc-
cess of the operation as the ability of the operator.

The Time Element. — About the same time is
consumed in the administration of regional anes-
thesia as in that of general narcosis. About ten
or fifteen minutes are required for an experienced
assistant to perform the necessary injections in the
former procedure, and another ten minutes must
then elapse for the full effect to become estab-
lished. About the same length of time is re-
quired to obtain the complete effects of inhalation
anesthesia.

Where the operator is dealing with a private
case, it is not often that a few moments more or less

10 REGIONAL ANESTHESIA.

will particularly interfere with the type of technique
he may select, that which is best in his opinion
governing the choice.

In hospital service, where several cases are to be
operated upon, it is essential to have an experienced
assistant for the advance preparation of the cases.
This likewise applies in the administration of a
general anesthetic.

In any event, the loss of a few moments' time is
not to be considered in comparison with the benefits
to the patient that attend the regional form of
anesthesia.

The Claim that Regional Anesthesia is not Equally
Adapted for all Operations. — The beginner in
regional anesthesia may better satisfy both himself
and the patient by giving ethyl chloride, ether, or chlo-
roform to complete the anesthesia if there is complaint
to any degree.

Mixed anesthesias, although not attractive in
theory, cause less shock than simple narcosis.

If a preparatory injection of morphine-scopola-
mine is administered before the introduction of the
procaine-suprarenin and the operation is completed
with the aid of the inhalation narcotics referred to,
the patient will be affected less than by simple nar-
cosis, i.e., he will be less affected by three agents than
by one. For this a theoretical explanation is avail-
able, but such explanation is not so important as the
fact itself which has been learned by actual ex-
perience.

In trephining operations, goiter excisions, total
laryngectomies, prostatectomies, operations for hem-

GENERAL CONSIDERATIONS. 11

orrhoids, radical cure of hernia, and costal resec-
tions, regional anesthesia is a most gratifying pro-
cedure. "With increasing experience, furthermore,
the operator will learn the details of technique that
render this form of anesthesia applicable to any and
all operations.

CHAPTER II.

ARMAMENTARIUM.

Syringes. — The operator should have at his dis-
posal Luer's all glass morphine syringe of i- to 2- mil
capacity, and also a metal and glass syringe of 10-
mil capacity.

My earlier experience was with the Record
syringe, which is very serviceable, but more lately I
have been led to substitute the Collin all metal
syringe (Fig. i), which is to be preferred in that it
is both short, powerful, and unbreakable. The syringe
should be thoroughly water tight and provided at its
top with lateral handles by means of which a firm
hold can be secured.

Needles. — These should be of small caliber, with
a short-beveled point. The smaller the caliber of the
needle, the less painful its introduction. Needles of
the smallest caliber and with long, fine points
should be particularly employed for the formation
of the dermal wheals later to be described.

Platinum needles are expensive and soon be-
come blunted at the point. Steel needles are finer
pointed and remain sharp longer, but are prone
to rust and. are easily broken. I have found it
best to employ either fine steel, or nickel needles.
The latter remain sharp and in good condition the
longest. The junction between the nozzle of the
(12)

ARMAMENTARIUM.

syringe and the needle must permit of no leakage,
the needle remaining in situ while the syringe is
repeatedly removed for refilling. The smooth

Fig. 1. — A 10-mil metal syringe of Collin make, short,
strong, unbreakable, handy and with graduated plunger rod.
The lateral socket enables the operator to make injections
parallel with the surface while using a straight needle.

14 REGIONAL ANESTHESIA.

socket type should be chosen rather than the screw
or bayonet form.

We employ only the straight form of needle.
It is less expensive and more easily obtained, and
when once one is accustomed to its use, it answers
every purpose.

There should be provided needles of four
lengths, viz., 3, 6, 9, and 12 centimeters (Fig. 2). The
3-centimeter needle is used in making the dermal
wheals. It should be sharp pointed. The 12-
centimeter needle is seldom used — chiefly for pre-
sacral injections. The 6- and 9- centimeter needles
serve for all general purposes.

To mark the exact depth to which the needle
is to be introduced, the operator may make a
shield from a piece of boiled cork or a square
of rubber sheeting, to be adjusted upon the needle
at the point desired.

The instruments and receptacles for the solu-
tion should be sterilized in plain boiling water,
without addition of any chemical agent whatever.

Anesthetic. — As anesthetic we have been using
neoca'ine-surrenine (Corbiere], a French prepara-
tion which replaces with perfect satisfaction the
German product novocaine-adrenalin. In prepar-
ing a considerable amount of the solution, to be
kept for some hours, it is best to use the pure
procaine,1 to which can be added immediately be-
fore use the required quantity of adrenin.

1 Procaine being the term now in general use in the United States
in place of neocaine or novocaine, this term will be regularly employed
hereinafter.

ARMAMENTARIUM.

The formulas of the mixtures used are as fol-
lows : (1)25 drops of i to 1000 aclrenin solu-
tion to 200 mils of y* per cent, procaine solution;

Fig. 2. — Four steel needles, respectively, 12, 9, 6, and 3 centi-
meters in length. Each needle is provided with a mandril.
Actually the needles are twice as fine as they are represented
in this illustration.

(2) 25 drops of adrenin to 100 mils of i per
cent, procaine; (3) 25 drops of adrenin to 50 mils
of 2 per cent, procaine; (4) 25 drops of adrenin

REGIONAL ANESTHESIA.

solution to 25 mils of 4 per cent, procaine.
Twenty-five drops of the adrenin solution is the
equivalent of i milligram of adrenin.

We use the 4 per cent, solution but seldom,
for the cranial nerves and brachial plexus; the 2
per cent, solution frequently, as a rule for the
nerve trunks; but the i per cent, and especially

Fig. 3. — From left to right, an ampoule of saline solution
for dissolving the procaine ; a tube containing 2 capsules of
procaine in powder form and 3 sealed flasks containing 150
grams of y2 per cent, solution.

the }/2 per cent, solutions are those most com-
monly employed, the latter for all infiltrations.

It is far cheaper to prepare the solution as re-
quired than to buy it ready made.

The adrenin and procaine come in glass am-
poules. On the evening of the day preceding the
operation these are dissolved in boiled salt solu-
tion. Even more convenient are the procaine tab-
lets which can be dissolved in boiled salt solution

ARMAMENTARIUM. 17

and kept until needed for use, when the required
amount of adrenin is added.

It is inadvisable to attempt to sterilize the
solution after the mixture has been made; this
should be done beforehand. The procaine adrenin
should be added to a hot solution (35° C.) to in-
sure its ready dissolution.

The high percentage solutions should be in-
jected very slowly, and in amounts never exceed-
ing 20 to 40 mils of the y? per cent, solution.
AYe have employed, however, as much as 300 mils
without any harmful effect.

In removal of the breast for cancer, as much
as 250 to 300 mils may be employed; most of it
escapes after the primary incision has been made.

For anesthetizing the viscera, and especially the
peritoneal ligaments, the omental tissues, the meso-
appendix, the mesentery, and the sero-vascular
pedicles, we often employ (following the advice
of Crile, of Cleveland) a i per cent, solution of
quinine and urea hydrochloride,1 injecting as
much as 100 grams in addition to the solution of
procaine-adrenin already used.

GENERAL TECHNIQUE.

Theoretically, regional anesthesia and anesthe-
sia by infiltration, according to the procedure of
Reclus, are two different methods. Practically,
neither of them excludes the other, but, in fact,

1 The product termed by Corbiere urocaine.

18 REGIONAL ANESTHESIA.

they supplement each other and are often em-
ployed in combination.

The principle of regional anesthesia is, not to
infiltrate the field of operation or surrounding tis-
sues, but to secure insensibility by directly inject-
ing the nerves distributed to the region or tissues
surrounding these nerves. To each region cor-
responds a special technique, appropriate for the
insensibilization of the nerves in that region, and
with which the operator must be familiar in order
to succeed.

Necessity of Perfect Asepsis in Regional Anes-
thesia.— In making the injections, the operator
proceeds without gloves, but with hands well dis-
infected, as for an ordinary minor operation. The
instruments and solution must be sterilized. Care
is taken not to dip the syringe into the glass re-
ceptacle containing the solution, particularly if the
syringe has come in contact with the fingers of the
operator and the patient's skin. A special needle
is reserved for drawing up the fluid into the
syringe. It should be constantly borne in mind
that ungloved hands are never aseptic any more
than is the patient's skin.

In practice, the two methods, nerve-block-
ing and infiltration, are usually employed together,
the one aiding and completing the other.

With few exceptions, e.g., anesthesia of the
meso-appendix with urocaine before its section, or
anesthesia of the omental tissues, complete induc-
tion of anesthesia precedes the operative pro-
cedure. No injection should be made during the

ARMAMENTARIUM. 19

operation, which is performed as though the pa-
tient were under general anesthesia; the anesthe-
sia should be complete when the patient is brought
to the surgeon, and there should be no more ques-
tion of it during the operation.

The method does not in any way prolong the
duration of the operation, nor does it leave the
operative field or the incision any longer exposed
to the air.

Preparation of the Field of Operation. — Before
the injections are begun, the skin of the field of

Fig. 4. — A 5-mil syringe of metal and glass.

operation should be disinfected with a 5 per cent,
tincture of iodine. When the injections have been
completed the region should be rubbed with alco-
hol, which will remove the few drops of liquid
injected and the excess of iodine. Next come the
final preparation of the patient, the covering of
the operative field, and the preparation of the
operator and his assistant — during which time the
tissues will have become completely anesthetized.

The Injections. — The syringe (Fig. 4) is held
with the thumb and the second and third fingers

20 REGIONAL ANESTHESIA.

of the right hand (Fig. 5). By virtue of the
flexibility of the operator's wrist, all pressure
other than that in the direct line of the needle
is obviated, to avoid breaking of the needle. The
latter should never be inserted down to its flange.

Fig. 5. — Shows the manner of holding the syringe
during injection. (Reclus.)

The plunger should be pushed home during the
introduction or the removal of the needle, the two
acts being simultaneous (continuous injection of
Reclus}. The minimum quantity of */2 per cent,
solution to be injected is i mil per centimeter of
distance; for the I per cent, solution, slightly less.

ARMAMENTARIUM. 21

The slight edema resulting from the subcutane-
ous injection raises the overlying skin, and the
region injected, rendered ischemic by the adrenin,
becomes definitely pale.

Difficulties arising from edema of the super-
ficial tissues may be obviated by commencing with
deep injections.

Skin JJ7Jicals. — In infiltrating a given region,
it is often necessarv to make successive injections

Fig. 6. — Formation of the dermal wheal. (Pauchet.) The
bevel of the needle point is directed upward and should dis-
appear entirely in the dermis before the intradermal injection
is made.

with needles chosen progressively longer. Again
it is indispensable to mark beforehand the sites
for these injections by the formation of "infra-
dermal wheats" which will render the skin insen-
sitive to the introduction of the needle. The
wheal consists essentially of an intradermal infil-
tration of small diameter (Fig. 6).

A fine, short needle mounted on a syringe filled
with y2 per cent, solution is introduced almost
parallel with the skin surface, with the bevelled

22 REGIONAL ANESTHESIA.

edge upward, directly into the thickness of the
skin. As soon as the opening of the needle has
disappeared, the plunger is pushed down to drive
in a little of the solution. A white swelling in-
stantly forms in the tissues, which take on the
aspect of "orange skin." One or more wheals, ac-
cording to requirements, are thus marked out, and
through them the needles are subsequently intro-
duced for all the necessary injections.

Each injection should be made into the skin
proper, without passage through into the subcu-
taneous cellular tissue, which is made evident by
disappearance of resistance to the needle. If the
skin of the region is delicate and movable, a fold
of it should be taken up between the left thumb
and index finger and the needle introduced at the
top of this fold, meanwhile firmly held. The pain
is very slight and evanescent, disappearing as
soon as the anesthetic solution has been injected.

Injection at Right Angles. — When it is neces-
sary to make an incision at right angles, as for
blood transfusion, the intradermal injections of
Reclus are superfluous, subcutaneous injection be-
ing sufficient to anesthetize the subcutaneous tis-
sue. An intradermal \vheal is made at one end
of the incision; then, with a syringe provided with
a long needle, an injection is made through the
wheal, under the skin, the needle being inserted
parallel to the surface in the subcutaneous tissues
to the full length of the proposed incision or the
distance that the needle permits. Inadvertent
emergence of the point of the needle from within

ARM AMEXTARI L'M.

outward should be avoided, as it is more painful
than entrance of the needle from without in.

Fig. 7. — Subcutaneous infiltration of a straight band of skin
through two dermal wheals at either extremity. (Reclns.) A
needle traverses the dermal wheals without pain when the in-
jection is made slowly. One mil of procaine-adrenin solution to
each centimeter of distance. The illustration presents both a
front and a side view, with curved or angular incisions.

After a few minutes the skin covering the in-
jected tissue will have become insensible, the solu-
tion having anesthetized not only the subcutaneous

Fig. 8. — (A) The injections can be made through 2 wheals
or 1 wheal. (B) Continuous line of injections, as indicated
by the directions of the arrows. (Pauchet.)

tissue, but also the nerve filaments of the adjacent

skin. This is the simplest form of local anesthesia.

If one injection or one needle-length is not

sufficient, one should make two wheals, one at

REGIONAL ANESTHESIA.

each extremity of the proposed incision — or as
many as may be required — and infiltrate from the

Fig. 9. — Injections surrounding a field of operation. (Rec-
lus.~) The 6 wheals are united by bands of infiltration as in-
dicated by the arrows.

two ends (Fig. 7). Curved incisions or injections
at right angles require an injection at the summit
of the curve or angle, or two injections (Fig. 8).

Fig. 10. — Shows the method of infiltrating the curved sur-
face of the forearm through 4 dermal wheals, each wheal be-
ing placed at the summit of the curve. (Pauchet.) The
injections are made in the directions shown by the arrows.

The curvature of the body surface prevents the
penetration of a needle at right angles into the

ARMAMENTARIUM. 25

skin at a single injection. Thus, in injecting the
subcutaneous tissues around the forearm, four
wheals through each of which the needles are
entered from both sides (Figs. 9 and 10) are
required.

Infiltration of a subcutaneous band perpendicu-
lar to the axis of the limb anesthetizes not only
the skin immediately covering the injected tissue,

Fig. 11. — Infiltration of a subcutaneous surface by injec-
tions radiating from dermal wheals 1 and 2 (for the removal
of skin grafts, excision of a chancroid, etc.). (Pauchct.*)

but also all the subcutaneous tissues situated dis-
tally to the injected region (circular anesthesia).
Surface Infiltration. — This consists in the in-
filtration of an area of subcutaneous tissue by I,
2, or more wheals. Through each of these points
a long needle is introduced in all directions, anes-
thetizing the whole of the cutaneous surface bounded
by the wheals. This procedure is serviceable for
the preparation of Thiersch skin grafts (Fig. n).

26 REGIONAL ANESTHESIA.

For the removal of skin tumors, subcutaneous
infiltration of the base of the neoplasm suffices,
without injection of the tumor itself (Fig. 12).

Anesthesia of Silicons Membranes. — The same
directions hold good in the case of mucous mem-
branes, but the wheals are unnecessary. One simply
makes a sub-membranous injection, which renders
the adjacent area of mucous membrane insensible.

Circular Injections. — In certain parts of the
body the sensory nerves of the skin and of the

Fig. 12. — Infiltration of the pedicle of a skin tumor
(molluscum). (Pauchet.)

fascia are continuous. Large portions of the body
surface do not have special nerves from the sub-
aponeurotic region. Hence it is not ahvays neces-
sary, in anesthetizing the skin and subcutaneous
tissues, to inject the cellular tissue; in many in-
stances a subcutaneous injection surrounding the
latter suffices. This is what is termed circular
injection (Fig. 13). At I and 2, two injections
are made; the subcutaneous tissue is infiltrated
from i to 3, i to 4, 2 to 3, and finally from 2
to 4, so that the operative field is surrounded by

ARMAMENTARIUM.

a subcutaneous wall of infiltration in the form of
an elongated lozenge. The long diameter of the
lozenge-shaped area corresponds to the direction
of the incision to he subsequently made. Injec-
tions may instead be made at 3 and 4, if it is more

Fig. 13. — Subcutaneous quadrilateral infiltration through
1 and 2, in the shape of a lozenge, 1, 2, 3, and 4, following
the direction of the arrows. (Reclus.)

convenient. The wall surrounding the operative
field may, as desired, be made in the shape of a
square, circle, etc. The number of wrheals to be
prepared for the injections depends upon the
shape and dimensions of the operative field (Fig. 9).
In some parts of the body, the sensory nerves

REGIONAL ANESTHESIA.

run a prolonged subcutaneous course, supplying
both the surface and the deep tissues. As regards
the upper part of the head, the sensory nerves of
the skin, pericranium, periosteum, and bones all
course through the subcutaneous tissue at the
level of the base of the cranium and forehead.

Fig. 14. — Anesthesia for tapping, as in ascites or pleurisy,
or for the introduction of a radium tube into a tumor.
(Reclus.)

Consequently a simple circular subcutaneous injec-
tion will desensitize large areas on the head, in-
cluding the bones. Anesthesia of a finger is in-
stituted on the same principle. The subcutaneous
tissue of the first phalanx contains all the nerves
of the finger. If a ring be injected around the
base of the finger, the entire finger will be desen-
sitized.

ARMAMENTARIUM. 29

Deep Infiltration. — Simple circular subcutaneous
injections are adequate only in parts of the body
in which the nerve supply is disposed as in the
parts above mentioned. They are not adequate when
the nerve supply is deeply seated. Thus, on the
chin, circular injection of an operative field in the
center of which emerges the mental nerve would
yield only an incomplete anesthesia. One of the
primary essentials in inducing regional anesthesia
is a systematic infiltration of any thick bed of
tissue composed of different layers. An example
of such anesthesia in its simplest form is that of
the line of puncture in ascites or pleural effusion
(Fig. 14).

The point of the injection is marked by a
wheal, a needle of a convenient length inserted,
and an injection made without interruption down
to the subpleural or subperitoneal tissues. The
pleural and the peritoneal nerves require separate
infiltration because they course in the subpleural
or subperitoneal tissues.

Infiltration by Layers. — A systematic infiltra-
tion of a mass of tissues is that which will act
upon all the layers of tissue therein contained
(Fig. 15). One should begin with deep injections
and finish with subcutaneous ones. The needle,
through a wheal, is inserted in a perpendicular
direction to the deepest point. It is then brought
up to the subcutaneous tissue and inserted again,
injecting obliquely toward the middle of the tis-
sue-mass to be infiltrated, and so on. The last
injection is made in a parallel direction under the

REGIONAL ANESTHESIA.

skin. The fluid is injected continuously during
the introduction and withdrawal of the needle. If
the length of the needle will allow, a single wheal
at one extremity or in the middle suffices.

At no point in the body are subperiosteal in-
jections necessary for desensitization of the perios-
teum, which receives its nerves from without and
becomes desensitized through the influence of the
fluid in the tissues which cover it.

Fig. 15. — Osteotomy of the femur. (Pauchet.) Anesthesia
of the diaphysis. Make two wheals, 1 and 2. From these
two points make the injections above and below as shown by
the arrows, forming a liquid sheath round the periosteum. If
the ears of the patient be stopped with cotton, one may saw
or break the bone without causing him pain or nervous dis-
turbance.

Infiltration of thick masses of tissues, as just
described, demands a certain amount of practice.
One must learn to feel with the point of the
needle. One must know at every instant which
anatomical layer is being entered. The hand soon
becomes accustomed to recognizing when the needle-,
point is traversing a resistant layer and when it
again passes into a layer of soft tissues. Injec-
tion through the muscular aponeuroses generally
causes slight pain. Therefore, one should inject

ARMAMENTARIUM. 31

the fluid progressively as the needle is being in-
troduced, following the method of Reclus. By
this procedure injection of a large amount of the
anesthetic into a vein is obviated, while at the
same time, continuous injection insures an equal
distribution of the solution. When an injection

Fig. 16. — Infiltration of a layer of soft tissue through der-
mal wheals 1 and 2. (Pau-chet.) The injections follow the
direction of the arrows down to the bone, the last made being
those entering the subcutaneous cellular tissue.

in the proximity of large vessels is required, it
is best to introduce the needle independently of
the syringe and to inject the fluid only if blood
fails to flow from the needle lumen. Puncture of
a large artery or vein, is, of course, to be avoided,
but it is altogether free of danger if fine needles
are employed.

Injection of a small area suffices whenever a
simple incision in healthy tissue is alone required,

REGIONAL ANESTHESIA.

e.g., for the extraction of a foreign body from
a definitely known situation.

Regional anesthesia likewise permits of secur-
ing insensibility of large fields of operation.

Often infiltration of a single locality will des-
troy sensation in most of the nerves leading to
the field of operation. This is the case, e.g., in
operations at the front of the neck, or for the
cure of femoral or insTtinal hernia. At other

Fig. 17. — Pyramidal injections. (Pauchet.) Through the
dermal wheals 1, 2, 3, and 4, one may painlessly infiltrate four
triangular layers, union of which isolates a pyramid of anes-
thetized tissue. (Removal of a shell fragment, etc.)

times, one must infiltrate simultaneously all the
layers surrounding the operative field.

The technique will be readily understood upon
inspection of a few diagrams.

Fig. 1 6 represents a pyramid. Its summit, 5,
is deeply situated beneath the center of the opera-
tive field, while its base, i, 2, 3, and 4, is at the
cutaneous surface. Its lateral surfaces bound the
field of operation; it is these sides which require*
to be injected.

Dermal wheals, I, 2, 3, and 4, are first marked
out. Through each of these a long needle is

ARMAMENTARIUM. 33

introduced at first toward point 5, then toward
various points situated on the lateral surfaces, e.g.,
from i to 7, 4 to 7, 4 to 6, 3 to 6, 3 to 9, 2 to
9, etc. The field of operation thus becomes de-
sensitized without having been directly reached by

Fig. 18. — Boat-shaped infiltration through dermal wheals
1 and 2. injection of four quadrilateral surfaces, permitting
the removal of a tumor or foreign body. (Pauchet.)

the anesthetic. Often two surface injections suf-
fice to encompass the area perfectly. In other
cases more than four are required, and the de-
signs for injection assume, according to the ex-
tent of the operative field, many varied forms:
cone, base of a cone, a boat-shaped solid, etc.
In Fig. 17 there are two points of entrance, viz.,

34 REGIONAL ANESTHESIA.

I and 2, through which one injects toward 3, 4,
5, 6, and /, and finally infiltrates the subcutaneous
tissue. Fig. 18 shows a field of operation on a
limb; by the type of anesthesia depicted the bone
may be desensitized. For all these injections a ^
per cent, solution is used. A more concentrated
solution, from i per cent, to 4 per cent., injected
in small amounts, is preferable wdierever large
quantities of liquid wrould lead to difficulty or dis-
comfort, as in the orbit, eyelids, foreskin (circum-
cision), fingers, etc.

Small amounts of these concentrated solutions
oftentimes exert a prolonged effect. Injection
of a small quantity of anesthetic may affect not
only the region injected but also the trunk of a
nerve supplying surfaces at a distance.

Perineural or Endoneural Injection by the Sub-
cutaneous Route. — Anesthesia of a large nerve-
trunk is often combined with peripheral infiltra-
tion, and is governed by certain definite principles.
In the first place, the point of the needle must
be brought in contact with the nerve. This is
readily done whenever the nerve is situated near a
bone constituting a landmark, as in the case of
the ulnar nerve, but is more difficult when such
landmarks are absent and when the nerve is sit-
uated in the midst of soft tissues. One of the
most reliable indications of the needle reaching
the nerve is afforded by a paresthesia radiating
toward the- periphery. The sharp pain referred
in the direction of the nerve distribution demon-
strates the contact of the needle with the nerve.

ARMAMENTARIUM. 35

The patient should therefore be told of this be-
fore the needle is introduced and should let the
operator know as soon as the paresthesia is ex-
perienced.

For the injection of large nerves it is well to
use from I to 5 mils of a concentrated solution,
2 to 4 per cent., of procaine-adrenin.

The length of time one must wait after having
made the injection depends upon the manner in
which the nerve has been reached. If the needle
has been introduced into the nerve root, as occurs
in the case of the fifth nerve, abolition of sensa-
tion is instantaneous. If the anesthetic has merely
been injected around the nerve trunk, 5 to 20
minutes elapse before complete insensibility is
established.

Direct Endoneural Injection. — Exposed nerve-
trunks may be desensitized by the injection of a
little 4 per cent, solution — viz., I ampoule — using
a 3-centimeter needle. This procedure is very
satisfactory for operations on nerves. The opera-
tor begins by incising the layers of tissues cover-
ing the nerve, as these have already been injected
with procaine-adrenin. When the nerve has been
located beneath the incision, he injects directly
into the trunk the contents of a 2-mil ampoule
of the 4 per cent, solution.

Choice of Procedure. — The nature of the af-
fection to be operated for — wound, removal of
foreign body or of an inflammatory or neoplastic
tumor — governs the form of the injection, and
one must always be careful to desensitize a large

36 REGIONAL ANESTHESIA.

enough area in order to be prepared for all event-
ualities and have a certain degree of latitude dur-
ing the operation. One should avoid injecting
the line of incision, and keep always at a certain
distance from diseased tissues, particularly if in-
fected. A well defined furuncle should be en-
circled by an injection in the form of a pyramid,
at quite a distance from the inflamed tissues.
Diffuse phlegmons lend themselves to local anes-
thesia only if it is possible to desensitize them at
a distance from the field of operation. Malig-
nancy of a tumor is no contraindication to regional
anesthesia if the entire field can be desensitized
without an injection in contact with the tumor.
One must not forget the temporary ischemia
which adrenin produces in the infiltrated area.
This ischemia is often an advantage, as it reduces
hemorrhage to the point of totally changing the
aspect of certain operations, such as those for
hemorrhoids, resection of the superior maxillary
or of the tongue, laryngectomy, etc. But in plas-
tic operations one must be careful not to ischemize
the base of the flap to be turned back, as this
would compromise its vitality.

For plastic operations of the face, strong solu-
tions of procaine without adrenin should be used;
the solution runs out with the blood, and the anes-
thesia need not last long, as these operations are
always of short duration.

CHAPTER III.
CRANIAL OPERATIONS.

THE sensory nerves supplying the skin of the
forehead, the temples, and the scalp, all pass at
the level of a line encircling the skull from the
eyelids to the external occipital protuberance (Fig.
19). From there, they branch to the summit of

Fig. 19. — Nerve supply of the scalp. (Hirschfeld.) Injec-
tion of a 1 per cent, solution of procaine-adrenin on a line
completely surrounding the head above the ears and eyebrows
completely desensitizes the nerve supply to the scalp.

the cranium, where they spread out under the
skin and the cranial aponeurosis. It is therefore
very easy to anesthetize the entire cranium by a
circular injection at this line. The nerves re-

(37)

REGIONAL ANESTHESIA.

ferred to supply not only the skin and pericranium,
but also the bones of the summit of the cranium
and their periosteum. The dura mater is not sen-
sitive to pain except below the base of the skull;
therefore operations upon the summit are painless.

Fig. 20. — Tumor of the scalp. (Pauchet.) Whether the
condition be a wen, a lipoma, or a sarcoma of the cranium,
infiltration of the epicranium induces complete anesthesia.
The illustration shows a lozenge-shaped injection circumscrib-
ing the tumor through dermal wheals in accordance with the
direction of the arrows.

A simple circular injection under the skin suffices
for trephining and operations on the brain.

Where muscles, however, cover the cranial
bones at the line of injection, they must be in-
jected. A band of infiltration, starting in front '
from the "eyelids, extending to the occiput, and
passing above the arch of the ear, will desensi-
tize the entire cranium above this line. It is not

CRANIAL OPERATIOXS.

necessary to make a subperiosteal injection. The
band of anesthesia just mentioned possesses an-
other advantage: The cranial arteries ascend,
like the nerves, spreading out toward the summit
under the epicranium or, as in the case of the

Fig. 21. — Craniectomy for sarcoma. (Braun.) The frontal
portion of the infiltration is designed to abolish sensibility of
the anastomoses between the frontal and parietal nerves.

temporal arteries, in the muscles. Adrenin con-
tracts them, rendering the operative field relatively
bloodless, and the various methods for arresting
hemorrhage superfluous. At times the large ar-
teries bleed a little and must be clamped; the
small arteries do not bleed. For small fields of op-
eration a y?. per cent, solution suffices; for large
fields, rich in vessels, a i per cent, will yield a
better hemostasis.

REGIONAL ANESTHESIA.

Starting from two wheals which correspond, re-
spectively, to the extremities of the intended incision,
one injects in a lozenge or quadrilateral form 10
to 20 mils of a y2 per cent, solution (Figs. 20,
21, 22).

Fig. 22. — Anesthesia for trephining. (Pauchet.) Observe
the crucial incision. A, the wound. B, dermal wheals. P, a
zone of infiltration 1 centimeter in width surrounding the
wound, as shown by the dotted line down to the bone. This
yields perfect anesthesia and ischemia.

TREATMENT OF LARGE WOUNDS IN THE SOFT

TISSUES, OR OF COMPOUND FRACTURES,

OF THE SKULL.

Several wheals are made around the wound —
as in Fig.- 23, in which there are seven — suffi-
ciently close together for the curvature of the skull
to permit of the needle going under the epicran-

CRANIAL OPERATIONS.

ium. With a I per cent, solution, a narrow band
of infiltration, circumscribing the field of operation
according to the line indicated, is now traced in
the soft, subaponeurotic tissues. Along a distance
of 5 centimeters, about 5 mils of solution should
be injected.

Fig. 23. — Anesthesia of the epicranium around a wound
(Pauchet.') This can be practised in all operations upon the
cranium for war wounds (bone and soft tissues) through as
many dermal wheals as may be necessary to surround com-
pletely the territory with a zone of infiltration, made with a
1 per cent, solution.

The peripheral line of injection should be far
enough removed from the wound to permit of all
necessary excision or enlargement for perfect re-
pair, for any pedicle required or for a dissection
necessary for plastic repair. Only a few moments
are required for complete anesthesia.

In their ambulance on the western fighting
front, in September, 1914, Pauchet and Laboure

REGIONAL ANESTHESIA.

trephined a case for hemiplegia, under local anes-
thesia, with the patient in the sitting position.
After the completion of the operation the patient
walked to the railway station, assisted by a fel-
low-soldier.

REMOVAL OF MALIGNANT TUMORS OF THE
CRANIUM, WITH BONE RESECTION.

The surgeon required to remove a tumor ad-
herent to the skull should at the same time re-
move the skin covering the tumor and a rather

Fig. 24. — Repair of a craniectomy. (Braun.) Shows a
flap to be re-applied as covering to the bony surface excised.
It is well to cover the opening over the brain with a layer of
fascia lata to replace the dura mater and prevent adhesions of
the skin to the deeper surfaces. Skin grafts may be used to
cover the denuded occipital zone when new tissue has grown
over the skull. The opening in the skull should be reinforced
with a chondrocostal piece or a gold plate. All this may be
perfectly done under local anesthesia.

CRANIAL OPERATIONS. 43

large section of bone. The operation will be pain-
less, since the dura mater, together with all the
other local tissues, are insensitive. The anesthesia
should be instituted as already indicated, viz., on
a line extending from the eyes to the occipital
protuberance, the line of the hat band.

Equally good results are obtained in the case
of a sarcoma originating in the periosteum and
adhering to the skin. The surgeon is enabled to
remove painlessly the skin, pericranium, perios-
teum, bone tissues, and dura mater. The brain
surface should under these conditions be recovered
with skin. The liberation of an area of skin pos-
teriorly for this purpose may likewise be effected
without pain.

TREPHINING THE TEMPORAL REGION.

Regional anesthesia permits of removal of
epidural hematomas of the inferior meninges,
craniectomy for decompression (Babinski), and re-
moval of bone fragments and foreign bodies. The
dura mater near the base of the cranium is sen-
sitive, but only moderately so.

Fig. 25 shows how to place the wheals, and
the form of the injection, for the dissection of a
temporal osteocutaneous flap.

One is in the middle of the superior border
of the zygoma; at this point one injects subcuta-
neously a ^2 or I per cent, solution. There is
also to be infiltrated a layer of temporal muscle
as shown in the diagrammatic Fig. 26, represent-

REGIONAL ANESTHESIA.

Fig. 25. — Trephining the temporal region for decompression,
(Pauchet.) The horse-shoe-shaped flap comprises the skin,
the temporal muscle, and the periosteum. The illustration
shows the surrounding band of anesthesia induced through six
dermal wheals. The lower side of the pentagon, wheals 1, 2,
and 6, should be infiltrated down to the bone with a 1 per
cent, solution of procaine-adrenin ; the other sides, with a Yz
per cent, solution.

Fig. 26. — Anesthesia of the base of the pentagon (Fig. 25)
for trephining the temporal region. (Pauchet.) The fan-
shaped infiltration follows the direction of the arrows. Ar-
rows 1 and 2 pierce the temporal muscle and reach the bone;
arrow 3 infiltrates the subcutaneous tissue.

CRANIAL OPERATIONS.

ing a horizontal incision parallel to the superior
border of the zygoma through the skin, temporal

Fig. 27. — Photograph of a craniectomy made in the service
of Dr. Babinski. (Pauchet.) The musculo-cutaneous flap is
held by two clamps ; note that the operation is practically
bloodless on account of the adrenin contained in the solution
injected. The dura mater is not opened.

muscle and temporal bone. The needle is first
introduced through wheal i, perpendicularly
from the surface down to the bone (arrow i)

46 REGIONAL ANESTHESIA.

then obliquely toward the anterior and posterior
margins of the temporal muscle, again down to
the bone (arrow 2) and following a horizontal
plane, and finally even more obliquely in the sub-
cutaneous tissue (arrow 3), from 2 to 6. To in-
filtrate this layer, about 30 mils is required; to
circumscribe the field of operation, about 30 mils
more; in all, about 60 mils of procaine-adrenin
solution.

Removal of the Gasserian ganglion would be
practicable by this method, but at the present time
injection of the branches of the 5th nerve at their
emergence from the ganglion, and their destruc-
tion by alcohol, is preferred.

EXPOSURE OF THE CEREBELLUM.

In 1912 we suggested to Thierry de Martel
the following technique, which this skillful opera-
tor was the first to apply in tumor of the cere-
bellum with complete success. Fig. 28 shows the
situation of the wheals and the shape of the in-
cision for exposing the cerebellar hemispheres. It
is best not to depart from this tracing, even if
one has decided not to touch more than half of
the cerebellum. Points 3 and 9 are placed just
behind the base of the mastoid. From these two
points, as from i, 2, and 10, the necessary injec-
tions are made in the muscles of the neck. Next,
the muscular layer outlined by the points of in-
jection is impregnated with a solution of procaine-
adrenin along the line shown. In the flap itself

CRANIAL OPERATIONS.

no injection is made. This illustration, taken in
conjunction with that for temporal injection (Fig.
26), defines the path of the needle. The point
should penetrate to the transverse processes of the
cervical vertebrae and down to the occiput. Union
of the successive injections by subcutaneous injec-

Fig. 28. — Trephining for a tumor of the cerebellum.
(Pauchet.) The 10 dermal wheals in the form of a trapezium
surround the field of operation with a zone of infiltration.
The proposed flap is shown by the dark line in the shape of
a horse-shoe.

tions follows; 100 to 120 mils of solution are
used, over half of which goes into the muscles of
the neck. Thierry de Martel operated with his
patient sitting astride a chair, with the arms rest-
ing on its back, and his head resting on his arms.
The dura mater of the posterior cerebral fossae
and the cerebellum are insensitive to pain.

CHAPTER IV.
ANESTHESIA OF THE HEAD AND NECK.

THE surgery of the head and the neck is of
interest both to general operators and, particu-
larly, to three classes of specialists, the ophthal-
mologist, the otorhinolaryngologist, and the stom-
atologist.

In these regions the sensory supply is fur-
nished by the fifth nerve and the cervical plexus.
The fifth nerve is predominant in the face. As
several branches often combine in supplying sen-
sation to a single region, it is sometimes neces-
sary in these tissues to combine root or trunk
anesthesia with peripheral infiltration. Or, it may
be necessary to combine root anesthesia with anes-
thesia of the neighboring regions.

We shall first consider synthetically the subject
of anesthesia of the nerve roots and nerve branches,
and then describe the technique for each operation
involved in the three specialties mentioned.

ANESTHESIA OF THE GASSERIAN GANGLION.

The ganglion of the fifth nerve is intracranial.
It rests upon the summit of the petrous portion
of the temporal bone (Fig. 29) in a fold of the
dura mater just above and behind the foramen
ovale, and in the immediate neighborhood of a
(48)

ANESTHESIA OF THE HEAD AND NECK. 49

venous sinus and of the motor nerves of the eye
(fourth and sixth). It has three branches: the
ophthalmic, the superior maxillary, and the in-
ferior maxillary. The ganglion is accessible through
the foramen ovale, an orifice measuring y2 centi-
meter by 2 or 3 millimeters. This foramen is
situated on the floor of the cranium immediately

Fig. 29. — The ganglion of Gasser. (Hvrschfeld.) It rests
upon the summit of the petrous portion of the temporal bone.
From above downward the illustration shows the origin of
the ophthalmic nerve and of the superior and inferior maxil-
lary nerves.

behind the base of the pterygoid process. It cor-
responds, for the superior maxillary, to the outer
side of the last two molars in the sagittal region.
It is located at a depth of 45 millimeters from
the zygoma.

Indications for Gasserian anesthesia are two in
number :

A. Surgical operations on the face.

REGIONAL ANESTHESIA.

B. Alcoholization of the nerve to combat per-
sistent neuralgia (Sicard).

The anesthetist should bear in mind the fol-
lowing precepts :

Fig. 30. — Injection of the Gasserian ganglion through the
foramen ovale. (Braun.) (1) The needle represented by the
dotted lines is introduced 3 centimeters from the commissure
of the lips, in the direction of the zygomatic arch, until it
reaches the subtemporal region between the two maxillary
bones. (2) The black line needle shows the shank raised and
the needle directed toward the zygomatic tubercle. Being kept
in contact with the bone, it reaches the foramen ovale, com-
ing in contact with the fifth nerve, in the terminal branches
of which it provokes pain.

1 I ) Use a fine, sharp, flexible, but strong
needle.

(2) Inject slowly.

(3) Employ a concentrated solution in small
quantities, viz., i to 2 mils of a 2 or 4 per cent,
solution of procaine-adrenin.

ANESTHESIA OF THE HEAD AXD XECK.

In spite of these precautions, vertigo, vomiting
and even symptoms of meningitis are sometimes
observed. These post-anesthetic disturbances do

Fig. 31. — Injection of the Gasserian ganglion (Braun.)
The patient should sit erect, looking directly forward. The
surgeon introduces the needle through the cheek 3 centimeters
from the labial commissure, so directing it that it remains in
the plane of the subject's pupil. The index ringer of the left
hand is introduced into the patient's mouth to make certain
that the needle shall not pierce the mucous membrane. The
needle should be directed between the inferior maxillary and
the tuberosity of the superior maxillary.

not detract from the value of the procedure be-
cause the method of anesthesia under discussion is
employed for serious operations on the face, or
obstinate neuralgia of the fifth nerve, which war-
rant its application.

52 REGIONAL ANESTHESIA.

Technique of the Injection. — The patient may
be in the lying or sitting position. Injection is
easier on a sitting subject, the operator standing
or sitting in front of the patient. A needle 9
centimeters in length should be selected.

The landmarks include some that are appre-

Fig. 32. — Injection of the Gasserian ganglion. (Braun).
The same maneuver as in the preceding illustration. The needle
is first directed at the middle of the zygomatic arch. As soon
as the point touches the bone of the subtemporal region, the
shank is raised so that the point is directed at the zygomatic
tubercle. Being then pushed forward about 1 centimeter, it
will penetrate the foramen ovale.

ciable to sight or palpation and others which are
found by the point of the needle as it is introduced.

(1) When the subject looks straight to the
front the pupil of the eye supplies the direction
of the frontal plane in which the needle must be
directed.

(2) The labial fissure.

(3) The second upper molar.

ANESTHESIA OF THE HEAD AXD XECK.

(4) The ascending- ramus of the inferior
maxillary, the inner surface of which may be felt
by introducing the index finger into the mouth.

(5) The tuberosity of the superior maxillary.

(6) The bone in the subtemporal region; the
needle, when correctly directed, will strike against

Fig. 33. — The sensory nerve supply of the face and neck.
(Hirschfeld.) (1) Ophthalmic. (2) Superior maxillary. (3)
Inferior maxillary. (4) Cervical plexus (anterior branches).

this resistant surface, which is situated in front
of the foramen ovale.

(7) The middle of the zygomatic arch and the
tubercle of the zygoma; the tubercle indicates the
point at which the needle must be directed in
order to enter the foramen; the middle of the
arch indicates the bony region anterior to the
foramen against which the needle must strike be-
fore penetrating the foramen (Figs. 30, 31, 32).

REGIONAL ANESTHESIA.

The cheek is pierced 3 centimeters beyond the
labial fissure, on a line with the lobe of the ear.
The needle is inserted with one hand. With the
index finger of the other in the mouth, the second

Fig. 34. — Removal of a cancer from the velum palati and
left tonsil by transverse incision of the cheek and resection of
the ascending ramus of the inferior maxillary bone after
anesthesia of the Gasserian ganglion. (Pauchet.} The
photograph shows the loosening of the upper fragment of the
inferior maxillary, operated upon by Pauchet and Sourdat.

superior molar and the tuberosity of the superior
maxillary are located within, and the ascending
ramus of the mandible without. The needle is

ANESTHESIA OF THE HEAD AND NECK. 55

to pass in the interval bounded by these bones ;

the finger in the mouth follows the needle point

under the mucous membrane and prevents it from
perforating the latter.

Fig. 35. — The wound is held open after the resection of the
maxillary has been completed. (Pauchet.)

One next aims at the subtemporal region to
strike the bony surface already mentioned. The
needle should be directed somewhat obliquely in-
ward, i.e., in the line of the pupil when the sub-
ject is looking straight ahead. It should be also
slightly oblique upward, i.e., should virtually pass
through the middle of the zygoma, — \vhich can be

REGIONAL ANESTHESIA.

controlled by surveying the patient in profile. Its
point should be behind the second upper molar.
Thus directed, the needle enters the subtemporal
region, which marks the end of the first stage of

Fig. 36. — The tonsillar space is tamponed after the resec-
tion of a part of the pharynx and of the tongue. The borders
of the incised cheek are retracted, showing the extent of the
wound. The tongue is drawn out with the aid of a cord held
by the assistant.

the injection. Care should be taken to do all this
very slowly, in order not to blunt the point of
the needle by contact with the bone.

Then the* point is disengaged and, slightly
raising the shank but still remaining in the plane
of the pupil, the point is advanced about I centi-

ANESTHESIA OF THE HEAD AND NECK. 57

meter, gliding along the surface of the subtem-
poral bone. In profile one aims this time for
the tubercle of the zygoma. Resistance ceases as
the needle enters the foramen ovale. A tense
membrane is traversed about 7 centimeters be-
neath the skin. When the patient notices radiat-
ing pains at first in the superior maxillary nerve,
entrance into the ganglion is indicated. One
should then inject i to il/2 mils of a 2 per cent,
procaine-adrenin, very slowly and gently pushing
the needle in another y2 centimeter.

By the same route, but without entering the
foramen ovale, one may reach the inferior maxil-
lary nerve as it emerges from this foramen and
limit the injection to it. It is difficult clearly to
describe this procedure in words, and we have
therefore attempted to supplement the explanation
and more fully guide the operator by the several
appended cuts.

ANESTHESIA OF THE OPHTHALMIC NERVE.

The frontal, internal and external nasal, and
lachrymal nerves separate from the origin of the
ophthalmic immediately before it enters the orbit.
The ophthalmic is fan-shaped and is situated be-
tween the bony plate and the muscular cone of
the orbit; the injection must, therefore, be made
between these two. The frontal and lachrymal
nerves are situated externally and emerge through
the superior orbital fissure. They are reached
along the external wall of the orbit.

REGIONAL ANESTHESIA.

Fig. 37. — The ophthalmic nerve and its branches. (Testut.)
(1) Ophthalmic. (2) Nasal. (3) Lachrymal. (4) Frontal.
(5) External nasal. (6) Internal frontal. (7) Ethmoidal.

Fig. 38. — Base of the orbit. (Testut.) Zinn's ring, where
the motor muscles of the eye are attached. On the left is
seen the sphenoidal fissure in the center of Zinn's ring. The
nasal nerve and ophthalmic vein are in the ring. The frontal,
lachrymal, and pathetic nerves are in the sphenoidal fissure.

ANESTHESIA OF THE HEAD AXD XECK. 59

The nasal nerves occupy the upper internal
angle of the orbit, and are infiltrated at that
point.

The frontal nerves supply sensation to a tri-
angular area of integument with its base cor-
responding to the entire frontal region above the

Fig. 39. — Supraorbital branches of the ophthalmic nerve.
(Hirschfeld.) To anesthetize these branches, inject parallel
to the superior border of the orbit.

root of the nose and its apex at the scalp (Fig.
40). They also sensitize the frontal sinuses and
the upper eyelids. The nasal nerves supply the
frontal, ethmoidal, and sphenoidal sinuses, the
nasal septum, and the nasal lobes.

Injections may be made from three points, ac-
cording to the operation required.

REGIONAL ANESTHESIA.

(a) Frontal Infiltration. — The operator injects
under the skin 10 mils of a i per cent, procaine-
adrenin, commencing above the external orbital
apophysis and ending above the corresponding
apophysis on the opposite side. The line of in-
jection is shown by the black line in Fig. 40.

Fig. 40. — Injections along the black line anesthetize the
ophthalmic branches of the fifth nerve and render insensible
a triangular area. (Pauchet and Sonrdat.)

(b) External Orbital Infiltration. — This blocks
the frontal and lachrymal nerves.

The needle is introduced at the external angle
and the outer wall of the orbit followed with its
point. At a depth of about 4^2 centimeters the
needle point will come in contact with bone, the

ANESTHESIA OF THE HEAD AND XECK.

orbital vault, and will have passed into the exter-
nal portion of the sphenoidal fissure, where are sit-
uated the frontal and lachrymal nerves. Five mils
of the 2 per cent, solution are now injected, and
the resulting anesthesia will be complete (Figs.
41, 42).

Fig. 41. — Intraorbital injections for infiltration of the
ophthalmic branches. (Braun.) To the left, an external in-
jection, which keeps in contact with the external orbital wall.
At a depth of 4 centimeters the needle point strikes the orbital
vault. It now crosses the extremity of the sphenoidal fissure,
along which pass the lachrymal and nasal nerves. A 1 per
cent, solution of procaine-adrenin is injected.

To the right, an internal injection. The needle follows
the superointernal angle of the orbit, constantly in contact with
the bone and grazing the ethmoidal foramen. At a depth of 4
centimeters it comes in contact with the orbital vault. The
solution is injected while the needle is being introduced.

(c) Internal Orbital Infiltration. — At an equal
distance from the eyebrow and the caruncle, i.e.,
i centimeter above the internal commissure of the
eyelids, the needle is introduced against the supe-
rior internal angle of the bony wall, which should

REGIONAL ANESTHESIA.

be continuously followed. At a depth of 4 or at
most 4^/2 centimeters, 5 mils of a 2 per cent, solu-
tion are injected (Figs. 41, 42).

This last injection anesthetizes the nasal wall
and the ethmoidal, sphenoidal, and frontal sinuses,
as well as the lobe of the nose. It induces

Fig. 42. — Anesthesia of the ophthalmic branches by the
orbital route: (1) External. (2) Internal. (Pauchet.) The
dotted line shows the shape and extent of the orbital orifice.
Needle 1 is entered at the extreme angle of the commis-
sure of the eyelids. It follows the bony wall and stops only
when it comes in contact with the orbital vault, where it crosses
the sphenoidal fissure (see Fig. 41). Needle 2 is entered at
the superior internal border of the orbit, one finger breadth
above the caruncle. The point is kept in constant contact with
the superior internal angle of the bony wall to reach the
ethmoid nerves.

edema of the upper lid, causes, projection of the
eye-ball, and sometimes results in blindness for a
few minutes. The optic nerve is not anesthetized.

ANESTHESIA OF THE HEAD AND NECK.

ANESTHESIA OF THE SUPERIOR MAXILLARY NERVE.

The superior maxillary passes through the
foramen rotundum at the bottom of the pterygo-
maxillary fissure, precisely between the tuberosity

Fig. 43. — Injection of the superior maxillary at the fora-
men rotundum by the external route. (Braun.) The needle is
introduced at the intersection of a vertical line drawn down-
ward following the external border of the orbit and a line
drawn along the inferior border of the superior maxillary bone
(dotted lines).

of the superior maxillary and the base of the
pterygoid process.

(a) External Route (Figs. 43, 44). — Locate
the zygomatic arch with the finger; mark its
lower border with ink; mark the external border
of the orbit in the same manner at the point
where a vertical line drawn from this external

64 REGIONAL ANESTHESIA.

border meets the zygomatic arch (just behind the
lower angle of the body of the malar bone), and
introduce the needle to a depth of 5 to 6 centi-
meters. In this way the nerve is reached at once;
but it is preferable to attain first, with the point
of the needle, the body of the maxillary on its
inclined surface, feeling one's way, and directing
the needle deeply. Suddenly the needle will come

Fig. 44. — The needle is first directed toward the tuberosity
of the maxillary bone, whence it penetrates directly about 4
centimeters and enters the pterygo-maxillary fissure. (Braun.)
When the patient complains of a shooting pain in the teeth,
from 3 to 4 mils of a 2 per cent, anesthetic solution are injected.

to an empty space and touch the nerve, when the
patient will experience a sharp pain in the face
and upper teeth. Five mils of a 2 per cent, pro-
caine-adrenin solution are now injected, and while
withdrawing the needle, 5 mils of a ^ per cent,
solution. To cause the branches of the internal
maxillary to contract, it is often necessary to have
the patient open his mouth, when the needle will
enter more easily (Fig. 45).

ANESTHESIA OF THE HEAD AXD XECK.

Fig. 45. — Anesthesia of the superior and inferior maxillary
through the same orifice. (Pauchet.) The patient is made to
open his mouth. The needle is introduced below the zygo-
matic arch and introduced as far as the pterygoid process, then
partly withdrawn and the point directed slightly forward to
reach the pterygo-maxillary fissure, where it encounters the
superior maxillary nerve at the foramen rotundum. Again the
needle is partly withdrawn and then reinserted about 1 centi-
meter further back, where it reaches the foramen ovale be-
hind the root of the pterygoid process. The foramen ovale
is at a depth of about 4 to 5 centimeters.

REGIONAL ANESTHESIA.

(b) Orbital Route (Figs. 46, 47). — At the
junction of the external, lateral, and inferior bor-
ders of the orbit, a dermal wheal is made and the

Fig. 46. — Anesthesia of the left superior maxillary nerve
at the foramen rotundum by the orbital route. (Braun.) The
needle, which at first is held vertically (Fig. 47), comes in
contact with the floor of the orbit on a level with its in-
ferior external angle. Entering deeper, it reaches a space on
a level with the orbital fissure. Thence it progresses back-
ward almost horizontally, following the direction of the fis-
sure. At a depth of about 5 centimeters it reaches the base
of the cranium and the foramen rotundum. One to 2 mils of
a 2 per cent, anesthetic solution are injected.

point of the needle then introduced almost ver-
tically downward. In order that it shall pass
along the floor of the orbit, it should be directed

ANESTHESIA OF THE HEAD AXD XECK.

slightly backward.

At a depth of about I centi-
meter it will traverse a fibrous layer — the fissure
of the orbital floor. As soon as the needle reaches
this space its flange end should be lowered so as
to bring it almost horizontal, while the head of

Fig. 47. — This figure shows the manner in which the needle
point is made to follow the floor of the orbit. By placing a
rubber shield upon the needle, the surgeon can make the lat-
ter serve as an index of depth in the procedure described in
Fig. 46. (Braun.)

the patient is held quite erect. If the needle is not
horizontal, it will enter the subtemporal space.
Yet it should not be introduced too high up, or
it will enter the eyeball. It should be directed in
the plane of the fissure, i.e., in the direction of
the inferior, external angle. One should always

68 REGIONAL ANESTHESIA.

feel a certain resistance at this point. At a depth
of 5 centimeters, the situation of the needle will
correspond to the foramen rotundum. At this
point it \vill come in contact with the base of the
skull. Five mils of a 2 per cent, solution of neo-

Fig. 48. — Emergence of the infraorbital nerve. (Hirsch-
feld.) On the same vertical line as the supraorbital nerve, it
is situated y2 centimeter below the middle of the lower border
of the orbital foramen.

caine-adrenin are now injected. At times a tem-
porary paralysis of the muscles of the eye, or a
hematoma in the pterygomaxillary fissure, wrill ap-
pear. Both these conditions are incidents devoid
of serious consequences.

ANESTHESIA OF THE HEAD AND NECK. 69

ANESTHESIA OF THE INFRAORBITAL NERVE.

The infraorbital nerve, a branch of the supe-
rior maxillary, is accessible through the cheek.
The lower border of the orbit is marked with a
dermal pencil, a line drawn from the center down-
ward */2 centimeter, and a cross made. This
corresponds to the point of emergence of the in-
fraorbital nerve. The three apertures whence the
infraorbital and mental nerves arise are on the
same vertical line, and correspond to the interval
between the first and second premolars (Fig. 45).
A dermal wheal is made, and the subcutaneous
cellular tissues infiltrated so that contact will not
be painful. Then, with the needle, the infraorbita!
opening is found. Coming in contact with the
bone, the operator feels around while directing the
needle a little higher and outward; soon he be-
comes aware of a small depression and penetrates
into a canal. The patient feels a sharp pain.
One mil of a 2 per cent, solution is now injected.
The anesthesia thus induced extends to the lower
lid, the upper lip, the nasal ala, a part of the
skin and mucous membrane of the cheek, the mu-
cous membrane of the lips, the margins of the
superior alveolar process, as well as the inferior
walls of the superior maxillary and the incisor
and canine teeth.

70 REGIONAL ANESTHESIA.

ANESTHESIA OF THE SUPERIOR DENTAL
NERVES.

(a) Buccal Route. — The zygomatic arch is
located through the mouth. When its most ante-
rior point is felt, the mucous membrane is pierced
and the needle introduced for a distance of i or
2 centimeters. The patient will usually feel pain
in his teeth. Five mils of a 2 per cent, procaine-
adrenin solution are now injected.

(b) External Route. — The zygomatic arch is
located and the same route followed as that taken
to reach the superior maxillary nerve. As soon
as the tuberosity of the superior maxillary is at-
tained, 5 mils of solution are injected. This in-
jection anesthetizes the upper molars and pre-
molars as well as the mucous membrane of the
maxillary sinus (Fig. 29).

ANESTHESIA OF THE NERVES OF THE PALATE.

The inferior palatine nerve emerges from the
posterior palatine canal above the last molar. The
nasopalatine nerve arises in the anterior palatine
canal, in the median line and behind the incisors.
The needle is introduced anteriorly, under the
mucous membrane of the palate, immediately be-
hind the teeth and in the median line. One mil
of a 2 per cent, procaine-adrenin solution is in-
jected. Then, behind the palate, i to 1^/2 centi-
meters within the second molar, or rather, within
the border of the gums, 2 mils of the solution
are introduced. This type of anesthesia, carried

ANESTHESIA OF THE HEAD AXD NECK.

Fig. 49. — To the right are shown the three palatine nerves
descending toward the posterior palatine foramen. To the
left, at the base of the nose, is the ethmoidal branch of the
internal nasal nerve.

Fig. 50. — Anesthesia of the hard palate. (Pauchet.} In
front is the nasopalatine nerve, Y? centimeter behind the
middle incisors. The surgeon injects 1 mil of a 2 per cent,
solution directly under the mucous membrane. Behind, the
nerves emerging from the posterior foramen to the right and
left, 1 centimeter within and above the last molar, 1 mil of
the strong solution is injected beneath the mucous membrane.

72 REGIONAL ANESTHESIA.

out also on the opposite side, permits the surgeon,
with the three points of infiltration, to operate on
the mucous membrane of the hard palate and
periosteum, though not on the teeth.

ANESTHESIA OF THE BUCCAL NERVE.

This nerve rests upon the tuberosity of the
superior maxillary and is distributed over the mu-
cous membrane of the cheek. It is accessible, like
the superior dental nerve, by an injection passing
along the tuberosity and following a vertical line
running from the last upper molar to the last
lower molar.

ANESTHESIA OF THE INFERIOR MAXILLARY
NERVE.

As already pointed out, the trunk of the in-
ferior maxillary nerve is accessible, at its emerg-
ence from the foramen ovale, by the same route
and with the same procedure as was described
for infiltration of the Gasserian ganglion. To
limit the injection to this trunk, it is sufficient to
make the injection upon arriving at but not enter-
ing the foramen ovale. The advance of the needle
should be arrested as soon as the resistance of
the bone ceases, indicating that the anterior bor-
der of the aperture has been passed.

The following mode of procedure reaches the
nerve without risk of penetrating too far, and
the operator should be as familiar with it as with

ANESTHESIA OF THE HEAD AND XECK. 73

the method first described, as certain conditions
may render it preferable, e.g., anatomical deformi-
ties, tumors, etc.

The lower border of the zygomatic arch is
traced on the skin, its exact center found, and

Fig. 51. — Anesthesia of the inferior maxillary nerve.
(Braun.) The operator places a small fragment of cork upon
the needle, as an index. The needle is introduced just below
the center of the zygomatic arch. At a depth of 4 centimeters
the point touches the pterygoid process. With the needle held
firmly in position, the cork is slid down to a level with the
skin. The needle is then partly withdrawn and reintroduced
at an angle, so as to touch a point 1 centimeter behind the
point first reached. When the index cork touches the skin, the
point of the needle is near the foramen ovale and when it
comes in contact with the nerve the patient feels a sharp pain
in the lower jaw. Two mils of a 2 per cent, solution of pro-
caine-adrenin are then injected.

a dermal wheal made at this point. A needle
6 centimeters long is now introduced transversely
to a depth of 4 to 5 centimeters so that its point
will strike against the pterygoid process, which is
i centimeter from the foramen ovale. As a guide
a thread or small piece of rubber, passed over the

74 REGIONAL ANESTHESIA.

needle before its introduction, is now fastened pre-
cisely at a level with the skin. The needle is then
drawn toward the operator, though not withdrawn
altogether, and re-inserted to the depth marked on
the needle, aiming, however, about i centimeter
behind the bony obstruction (pterygoid). The
earlier and later directions of the needle should

Fig. 52. — Direct injection of the inferior maxillary at the
foramen ovale. (Braun.) The needle is introduced at the
junction of the middle and posterior thirds of the zygomatic
arch and directed inward about 5 centimeters, when it will
reach the foramen ovale. If it strikes bone, the latter is the
pterygoid process ; it should then be withdrawn a few centi-
meters and reintroduced further back. The foramen ovale is
located immediately behind the pterygoid process.

form between them an angle of 30°. As soon as
the needle has reached the same depth, though
somewhat posteriorly, it is pushed a few milli-
meters further in, and the patient will feel a
sharp pain in the tongue or the inferior maxillary.
This indicate^, that the needle is in the body of
the nerve (Figs. 51, 52). Five mils of a 2 per
cent, procaine-adrenin solution are now injected.
(See also Offerhaus's procedure, p. 98.)

ANESTHESIA OF THE HEAD AND NECK.

ANESTHESIA OF THE INFERIOR DENTAL
NERVE

This is a large terminal branch of the inferior
maxillary. It diverges at an acute angle from
the lingual nerve and passes between the internal

Fig. 53. — Injection of the inferior dental nerve at the in-
ferior dental foramen. (Brann.) The arrow indicates the
point at which the nerve should be injected. The dotted ar-
row shows the retromolar trigone. The needle should be first
directed to this trigone 1 centimeter above the molar, then
should follow the inner wall of the maxillary bone until its
point reaches the nerve. One to 2 mils of a 2 per cent, solu-
tion are then injected.

pterygoid muscle and the ascending ramus of the
inferior maxillary bone until, arriving at the pos-
terior orifice of the dental canal, it emerges on a
level with the chin through the mental foramen.

Upon examination of an inferior maxillary
bone, there will be found immediately behind the

REGIONAL ANESTHESIA.

last molar a triangular bony surface, limited ex-
ternally by a prolongation of the coronoid process
and within by a ridge of bone which, likewise de-
tached from the process, passes down toward the
inner side of the alveolus of the third molar.

Fig. 54. — Shows the movements imparted to the needle to
reach the inferior dental foramen. (Pauchet.) The lingual
nerve may be reached in the same way.

This small triangle which is normally covered with
mucous membrane, serves as the principal land-
mark in the introduction of the needle.

The patient is seated in front of the operator,
with his mouth wide open. The index finger is
passed into the mouth, the anterior border of the
coronoid found, and within this border the retro-

ANESTHESIA OF THE HEAD AXD XECK.

molar trigone (Braun) located. A needle 9 centi-
meters long is taken in the right hand, and being
kept i centimeter from the inferior canine on the

Fig. 55. — First position of the needle in going for the retro-
molar trigone. (Pauchet.) The needle should at first be kept
in contact with the canine tooth of the opposite side until the
trigone is reached. The handle of the syringe is then swung
to the opposite side, so the needle is on a line with the teeth,
and pushed along the border of the bone to the foramen.

opposite side, on a level with the grinding surface
of the teeth, directed toward the trigone, i.e., the
intra-buccal fold of the coronoid. The point of
the needle penetrates the mucous membrane i
centimeter above and outside of the last molar.

REGIONAL ANESTHESIA.

As soon as the membrane has been punctured the
point strikes against bone; if not, the point is too
far within. Then the operator, feeling his way,
inserts the point of the needle until it reaches the
ridge of the bone (Fig. 54). It should slide

Fig. 56. — Anesthesia of the inferior dental and lingual
nerves on the right side. (Pauchet.) (1) Right inferior den-
tal nerve. (2) Right lingual nerve. (3) Left inferior canine.
The needle is directed from the left lower canine toward the
anterior border of the ascending ramus of the right inferior
maxillary (Position 1). It is then directed to the internal
surface and introduced to a depth of about 2 centimeters
(Position II).

along the inner surface of the inferior maxillary;
then, without losing its contact with the bone,
penetrate 2 to 2.y2 more centimeters, at which
point the operator injects 5 mils of a i per cent,
solution (Figs. 53, 55, and 56).

ANESTHESIA OF THE HEAD AND NECK. 79

AXESTIIESIA OF THE MENTAL NERVE.

On a vertical line passing at the same time
the supra- and infra- orbital nerves and corre-
sponding to the space between the two first lower
molars, is to be found the mental foramen of the
inferior maxillary. This is situated at equal dis-
tances from the superior and inferior borders of
the jaw, and below the interval between the first
and second molars. After passing through the
soft tissues to this point, the surgeon injects a 2
per cent, solution of procaine-adrenin.

ANESTHESIA OF THE LINGUAL NERVE.

This leaves the inferior dental nerve and branches
off to the tongue, describing a curve with an
antero-superior concavity. It should be borne in
mind that this nerve is in the lower part of the
tongue, situated very superficially beneath the mu-
cous membrane.

The procedure is therefore, as follows: The
tongue is held in a compress and brought for-
ward toward the opposite corner of the mouth.
A line of anesthesia 4 centimeters long is made in
the groove formed by the tongue and gums, with
a i or 2 per cent, solution of procaine-adrenin.

This nerve may also be infiltrated by proceed-
ing as for the inferior dental.

80 REGIONAL ANESTHESIA.

REMARKS.

It would seem, at first sight, that in facial op-
erations, anesthesia of the Gasserian ganglion
should prove all sufficient. Actually this is not
the case. In the first place, the severity of the
Gasserian procedure justifies its employment only
in serious interventions, as already pointed out.
It is preferable, therefore, to anesthetize the peri-
pheral trunks. Again, there exist anastomoses
with the cranial nerves or writh branches of the
cervical plexus, which would render the anesthesia
incomplete were it confined to a single nerve
trunk.

Indications for subcutaneous peripheral infiltra-
tion, or for the spraying or application of cocaine
to the mucous membranes, therefore, frequently
exist. These various procedures, trunk anesthesia,
local infiltration, and local application, are of mu-
tual assistance and it is a combination of the
three which . produces a practically complete anes-
thesia.

REGIONAL ANESTHESIA IN RHINOLOGY.

SUBMUCOUS RESECTION OF THE CARTILAGE
OF THE NASAL SEPTUM.

Tampons of a strong solution of adrenin-co-
caine are applied for 10 minutes. A 2 per cent,
solution of „ procaine-adrenin is injected under the
mucous membrane of the septum, both on its con-
vex and its concave surfaces. One should in-
filtrate also, especially if the deviation is exten-

ANESTHESIA OF THE HEAD AND NECK.

sive, the three nerve trunks which together sensi-
tize the septum, above and forward, below and
forward, in the floor and behind.

HYPERTROPHY OF THE LOWER AND MIDDLE
TURBINATES.

Resection of the Upper and Lower Turbinates
and of Nasal Myxomas. — Tampons of cocaine
which contract the mucous membrane usually suf-

Fig. 57. — (1) Ethmoidal branch of the internal nasal nerve.
(2) Nasopalatine nerve which supplies the wall and emerges
through the anterior palatine foramen, behind the incisors.
(Panchet.}

fice. In the case of the upper turbinate, however,
their use is disadvantageous because it diminishes
the already small area concerned. It is prefer-
able, therefore, to infiltrate the affected tissues, as
this augments their volume. In the presence of
numerous polypi, tamponing is tedious and some-
times impossible. We therefore inject the eth-
moidal, nasal, and septal nerves, thus rendering
the parts anesthetic (Fig. 57).

REGIONAL ANESTHESIA.

MOURE'S OPERATION FOR LARGE TUMORS
OF THE BRAIN.

(a) Application of cocaine tampons to the ol-
factory mucosa; (b) infiltration of the ethmoidal

Fig. 58. — Operation of Moure. Resection of the ethmoid
after having displaced downward the ascending branch of the
superior maxillary and enlarged the anterior orifice of the
bones of the nasal fossa without regard to the superior maxil-
lary. (A) Infiltration of the ethmoidal nerve by the internal
orbital route. (5) Infiltration of the superior maxillary nerve
(see Figs. 43 and 44). (C) Emergence of the infraorbital
nerve.

nerves; (c\ infiltration of the superior maxillary
nerve; (d) infiltration of the infraorbital nerve;
(e) infiltration of a line from the corner of the

ANESTHESIA OF THE HEAD AND NECK.

mouth upward, as shown in Fig. 58. Peripheral
infiltration following a broken line uniting the
corner of the mouth with the junction of the
superior maxillary nerve and the base of the nasal
lobe.

INJECTION OF THE MAXILLARY SINUS
(Luc's OPERATION.)

(a) Tamponing the nasal cavity with gauze
soaked with cocaine; (b) infiltration of the eth-

Fig. 59. — Trephining the maxillary sinus. (Laboure.)
(1) Infiltration of the superior maxillary nerve at the foramen
ovale (Figs. 43 and 44). (2) Anesthesia of the ethmoidal
nerve by the internal orbital route (Fig. 41). The subcuta-
neous infiltration is shown by the dotted lines.

moidal and superior maxillary nerves; (c) infiltra-
tion through the mouth of the canine fossa and the
region of the infraorbital nerve (Fig. 59).

REGIONAL ANESTHESIA.

INJECTION OF THE FRONTAL SINUS.

(a) Tamponing the anterior superior nasal
fossa with gauze soaked with cocaine; (.&) infil-
tration of the superior maxillary nerve; (c) infil-

Figs. 60, 61. — Trephining the frontal sinus, one side and
both sides. (Pauchet.) (1) Internal orbital injection (Fig.
41). (2) Point of injection for the superior maxillary nerve
(Figs. 43 and 44). Through the several dermal wheals, the
field of operation is circumscribed along the dotted lines.

tration of the ethmoidal nerves; (d) subcutaneous
and preperiosteal injections surrounding the opera-
tive field (Figs. 60, 61).

ANESTHESIA OF THE HEAD AND NECK. 85

OPERATIONS UPON THE SPHEXOIDAL SINUSES AND
FOR SARCOMA OF THE HYPOPHYSIS.

The endonasal route is followed; submucous
resection of the cartilaginous and bony septum;
infiltration of both sides of the septum and of
the ethmoidal nerves.

REGIONAL ANESTHESIA IN OTOLOGY.
NERVE SUPPLY.

The middle ear receives its sensory supply
from Jacobson's nerve, a branch of the glosso-
pharyngeal, and the superficial petrosal nerve.

The tympanum and external auditory canal are
supplied by two nerves, which enter, the one an-
teriorly, the other posteriorly. The anterior is
the auriculo-temporal nerve, a branch of the supe-
rior maxillary, which supplies the antero-inferior
floor of the external canal. The posterior nerve
is the auricular branch of the pneumogastric.
These nerves enter the canal at the union of its
cartilaginous and osseous portions.

The external ear is supplied by the great auric-
ular nerve, the auriculo-temporal, the lesser occip-
ital, and the auricular branch of the pneumogastric.

The nerve supply of the mastoid region con-
sists of the sub-occipital and the superior cervical
nerves, through branches from the mastoid.

All of these nerve branches intercommunicate,
and practically their respective limits are hard to
define.

REGIONAL ANESTHESIA.

TECHNIQUE.

Anesthesia of the Middle Ear and Tympanum.
-In the middle ear the nerves are superficial and
sub-mucous, and can be desensitized with Bonain's
solution :

I£ Cocaine hydrochloride,
Menthol,

Phenol aa 1 grain.

Adrenin 0.001 grain.

Fig. 62. — Anesthesia of the auditory canal. (Labour e.)
The needle is introduced at the junction of the cartilage and
bone on the superior and posterior walls. When it has pene-
trated 2 millimeters, a 2 per cent, solution is injected.

Upon application of this agent one may pain-
lessly curette vegetations, remove a polyp, or
puncture the tympanic membrane.

For more severe procedures, such as ossiculec-
tomy, the external auditory canal is anesthetized
by the following procedure (Neumann) (Fig. 62) :

ANESTHESIA OF THE HEAD AND NECK. 87

A large speculum is passed into the canal and
inclined backward or laterally, thus bringing into
view the point of junction of the cartilage with
the bone. At this point, above and behind, at the
junction of superior and posterior walls, a needle
is inserted for 2 millimeters, a few drops of solu-
tion slowly injected, and a bony contact felt for.
The bone, when reached, should be followed for
some distance in order to make certain of inject-
ing the remainder of the solution into the sub-
periosteal zone. Such an injection anesthetizes the
upper portion of the tympanum, the vestibule, and
the ossicles. One should wait 10 minutes before
operating.

The injection just described acts in the fol-
lowing manner: On a level with Schrapnel's
membrane, the two epithelial linings meet, the
fibrous tissue of the tympanum being wanting. An
injection of fluid following the epithelium of the
canal penetrates under the epithelium of the mid-
dle ear on a level with the flaccid membrane and
ascends under the mucous membrane that lines
the vestibule, since it is at no time arrested by
any barrier (Molinar1).

Anesthesia of the External Auditory Canal. —
The external auditory canal is supplied by two
nerves which penetrate in front and behind, at
the union of the cartilaginous and bony portions
of the canal. They can be reached either through
the canal or from behind the auricle.

1 Adolph Molinar : "Regional Anesthesia for Operations upon the
Auditory Apparatus."

REGIONAL ANESTHESIA.

The needle is directed backward toward the
tympano-mastoid fissure in the direction of the
pneumogastric. Procaine-adrenin solution is in-
jected while introducing the needle. Then the
latter is withdrawn I centimeter, without entirely
removing it, directed downward, forward, and in-
ward toward the condyle of the maxillary, and

Fig. 63. — Showing a V-shaped injection, in its
relations to the bony parts.

during the course of this movement, 2 mils of
procaine-adrenin solution injected to a depth of
not more than 2 centimeters. After this pro-
cedure, operations for furuncles or exostosis in the
canal can be satisfactorily carried out (Fig. 63).

Anesthesia of the External Ear and Mastoid
Region. — Encircle the external ear and mastoid
region with a series of injections which cross each
other in the superficial and deep tissues (Fig. 64).

It is useless to try to penetrate beneath the
periosteum; its close adhesion renders this impos-

ANESTHESIA OF THE HEAD AND NECK. 89

sible. Besides, such a procedure would be un-
necessary. The bone receives its nerve supply
from without, i.e., from the scalp. The operator
may, if he so desires, inject along the line of the
proposed incision.

Fig. 64. — Anesthesia of the external ear. (Laboure.)
Two wheals, superior and inferior, are made and injections
executed in the direction of the arrows, describing a diamond-
shaped figure about the ear.

These various forms of anesthesia, viz., the ap-
plication of Bonain's mixture to the tympanum or
vestibule; infiltration of the vestibule through the
canal; infiltration of the auriculo-temporal nerves
and the auricular branch of the pneumogastric ;
peripheral anesthesia around the external ear and
mastoid, constitute a series of procedures neces-
sary and sufficient for a number of different oper-

REGIONAL ANESTHESIA.

Fig. 65. — Mastoidectomy. (Labour e.} A subcutaneous
polygon is infiltrated through four wheals, the needle enter-
ing in the direction of the arrows.

Fig. 66. — Petromastoid operation. (Laboure.) After hav-
ing infiltrated as in Fig. 65, three more wheals are made and
injections executed in the direction of the two arrows (£>)
and the arrows (E and F).

ANESTHESIA OF THE HEAD AXD NECK. 91

ations. One may employ one procedure, or an-
other, or all procedures combined, according to the
case.

In general, the relative indications for each
may be stated thus: i. For perforation of the
tympanum: Application of Bonain's mixture,
which drives the blood from the tissues and indi-
cates to the operator the area anesthetized. 2.
For ossiculectomy : Infiltration of the superior
wall of the canal and vestibule, and application of
Bonain's mixture. 3. For furuncle of the canal:
Infiltration of the anterior and posterior nerves by
an injection through the auriculo-mastoid sulcus.
4. For plastic operations on the external ear:
Peripheral anesthesia in circular form instituted
around the external ear as a center. 5. For mas-
toiditis: As in the preceding (Figs. 65, 66). 6.
For curettage: A combination of all the preced-
ing methods.

REGIONAL ANESTHESIA IN OPHTHALMOLOGY.

NERVE SUPPLY.

The orbit and ocular globe receive their nerve
supply from the branches of the ophthalmic. In
addition, the orbital branch of the superior maxil-
lary supplies, through its terminal trunks — the
temporo-malar nerves, — the skin of the temple, of
the malar region, and about the external angle of
the eye (Figs. 37, 38, 39).

92 REGIONAL ANESTHESIA.

TECHNIQUE.

Anesthesia of the ophthalmic nerve and its
branches may be obtained by external and internal
orbital injections, the technique of which has al-
ready been described (Figs. 40, 41, 42, with
several pages describing the ophthalmic and its
branches).

If necessary the anesthesia may be completed
by infiltration of the superior maxillary nerve or
of a few of its branches, as already described
under Anesthesia of the Superior Maxillary.

For completion of the anesthesia in respect of
the ciliary nerves or the ciliary ganglion, the mus-
cular pyramid which immediately surrounds the
ocular globe should be infiltrated. In order to
effect this, one should direct the needle toward the
vault of the orbit, keeping as close as possible to
the outer surface of the eye-ball. Five mils of a
i per cent, procaine-adrenin solution are injected,
and the sub-con junctival tissue also infiltrated. A
needle is introduced into the external commissure
of the eyelids, and pushed down between the con-
junctiva and the bulb. Then, a little to the in-
side, at a depth of 4^ centimeters, i.e., close to
the ciliary ganglion, I mil of a 2 per cent, solu-
tion is injected. Finally y2 mil of this strong
solution is injected under the conjunctiva sur-
rounding the bulb. Thus, whatever be the oper-
ation,— enucleation, etc., — perfect anesthesia will be
obtained.

ANESTHESIA OF THE HEAD AND NECK.

Operations on the Eyelids and Lachrymal
Gland (Fig. 67). — A few drops of cocaine on the
conjunctiva, together with an injection of 2 mils
of a Y* per cent, solution of procaine-adrenin near
the superior bony wall, will anesthetize the upper
eyelid.

Fig. 67. — Anesthesia of the eyelids. (Pauchet.) One injection
through a wheal suffices for each eyelid.

For the lower eyelid, one should inject 2 mils
along the inferior orbital wall, in a fan-shaped
area 2 centimeters deep and 2 across. The infra-
orbital nerve, and the anterior ethmoidal, which
supplies the internal portion of the lower eyelid,
are infiltrated.

Cataract; Iridectomy. — (a) Drop a few drops
of a %o Per cent, solution onto the eyeball, sev-

94 REGIONAL ANESTHESIA.

eral times, as it will then act by absorption. (&)
Inject y?. mil of ]/2 per cent, solution procaine-
adrenin under the conjunctiva.

Enucleation of the Eyeball. — (a) Inject 2 or 3
mils of solution through the external superior
angle. (&) Repeat this procedure at the internal
angle, (c) Infiltrate the superior maxillary nerve
either through the orbit or the malar region.

REGIONAL ANESTHESIA IN DENTAL SURGERY.
NERVE SUPPLY

As regards the upper teeth, the nerves first
follow above the outer side of the tuberosity of
the superior maxillary, then penetrate it in order
to reach the dental pulp. Here they are dis-
tributed also to the periosteum, the mucous mem-
brane, and the alveolar tissue.

The lower teeth are supplied by the inferior
dental nerve, which enters the inferior maxillary
bone at the inferior dental foramen and forms the
inferior dental plexus, then divides into two
branches, one in the bone, — the incisor, which
supplies the incisor teeth, — the other, the mental,
which supplies the chin and lower lip. The lower
gums and tongue are supplied by the lingual
nerve. The region of the incisors is supplied by
branches coming from the inferior dental, mental,
and lingual nerves, all more or less inter-related.

ANESTHESIA OF THE HEAD AND NECK. 95

TECHNIQUE.

Infiltration of the Dental Branches in the
Upper /azcf. — A ^ Per cent solution is used.
From 2 to 10 mils suffices, according to whether
it is desired to anesthetize one tooth or an entire
half of the jaw. As the dental branches lie super-
ficially, immediately under the mucous membrane
in the fold of the gum, the injection is readily
carried out and its result immediate. The point
of injection varies according to the teeth to be
rendered anesthetic:

(a) For the incisors, one should infiltrate the
submucous membrane in the median line, either on
the level of the fraenum linguae or on the nasal
floor near the septum, or at both of these points.

(fr) For the canine and first molars, the injec-
tion is made above the canine tooth.

(c) For the large molars, one infiltrates well
back at the outer border of the tuberosity of the
maxillary, and even at its posterior border if a
curved needle is available. Again, it may be
considered necessary to enter through the cheek,
to a depth of 2^2 centimeters, in the direction of
the superior maxillary nerve.

To permit of convenient infiltration, an aid
should draw aside the labial commissures with
small retractors.

Where the work bears on half the maxillary
arch, infiltration should be carried out along its
entire length.

96 REGIONAL ANESTHESIA.

On principle, one should not infiltrate the trunk
of the superior maxillary nerve. Yet there need
be no hesitation in doing so in cases of severe
buccal septicemia.

Infiltration of the Lower Teeth. — Where the
incisors and canine teeth are concerned, one may
proceed as for the upper jaw, infiltrating the sub-
mucous membrane in order to reach the ramifica-
tions of the mental and incisor nerves.

For the remaining lower teeth this procedure
is insufficient because the inferior dental nerve
lies in the center of the maxillary bone, which is
very thick at this point. One should, therefore,
infiltrate the trunk of the nerve at the dental
foramen as already described. The labial commis-
sure is retracted, the ascending branch of the in-
ferior maxillary nerve found, and 3 to 5 mils of
a y2 per cent, solution of procaine injected into its
center. (Figs. 55 and 56.)

If the buccal cavity is too septic, the inferior
dental nerve can be anesthetized from the outside;
or 2 mils of anesthetic solution may be injected
under the dental collar of the last molars in order
to infiltrate the gingival branches of the buccina-
tor— which, however, are not very large.

Unilateral injections under the gums for the
lower incisors are insufficient because of the anas-
tomoses of the two incisor nerves. To obtain
complete insensibility, both nerves must be infil-
trated even for an operation involving only one
side. Two mils of solution are injected on each

ANESTHESIA OF THE HEAD AND NECK.

side of the median line; at this point there is
a slight depression, the thin, grooved wall of
which permits of absorption of the procaine.

REGIONAL ANESTHESIA OF THE
FACE AND JAWS.

The soft tissues of the face are supplied by
the three branches of the trigeminus, the ramifica-

Fig. 68. — The sensory areas of the head. (Testut.~) (1)
Ophthalmic. (2) Superior maxillary. (3) Inferior maxil-
lary. (4) Cervical plexus (anterior branches). (5) Cervical
plexus (posterior branches).

tions of which are so intermingled as to render
trunk infiltration insufficient for complete anesthe-
sia. Even infiltration of the Gasserian ganglion
of one side yields only an incomplete anesthesia
when the operative procedure is conducted near
the median line.

REGIONAL ANESTHESIA.

Fig. 69. — The measurements of Offerhaus. The "tubercle
line" C D passes a few millimeters in front of and below the
foramen ovale at points A and B. The distance E F from one
superior dental arch to the other, is equal to A B from one
foramen ovale to the other. Measuring C D and E F, sub-
tracting the latter from the former, and dividing the result by
2 yields the distance C A or D B. This procedure constitutes
an alternative method for injecting the superior maxillary
nerve at the foramen ovale. (Cf. pp. 72-74.)

ANESTHESIA OF THE MIDFRONTAL REGION.

The frontal zone is supplied by branches of the
ophthalmic nerve, — lachrymal, frontal, and nasal, —
which ascend from below. It is sufficient, there-
fore, to institute a horizontal line of infiltration,
both intradermal and subperiosteal, passing above
the convexity of the two eyebrows (Fig. 40).

ANESTHESIA OF THE HEAD AND NECK. 99

ANESTHESIA OF THE NOSE, LIPS, AND CHEEKS.

The lobe of the nose is easily rendered in-
sensible by means of a circular infiltration outlin-
ing its base (Figs. 70 and 71). Thus, in the
case of a tumor of the lobe requiring surgical in-
tervention, four injections should be made through

Fig. 70. — Circumscribing the lobe of the nose. (Brawn.)

dermal wheals located as follows: One on the
bridge of the nose, two at the base of the alse,
and the fourth at the base of the nasal septum on
the upper lip.

The upper lip (Fig. 71) may be desensitized by
three lines: One transversal, going from the base
of one ala to the other, and the two others ver-
tical, descending from the extremities of the pre-
ceding points to the labial commissures and also

100 REGIONAL ANESTHESIA.

ascending to meet at the bridge of the nose. Two
bands of infiltration should thus be made, the one
subcutaneous, the other submucous, the needle be-
ing directed parallel with the mucous membrane
by means of a gloved finger introduced under the

HP.

Fig. 71. — Anesthesia of the lobe of the nose and the upper
lip through two wheals, following the direction of the arrows.
(Pauchet.)

Infiltration of the upper lip may usually be
combined with that for the lobe of the nose.
The anesthetized area may be enlarged at will ac-
cording to the necessities of the operation (as in
the pentagon, Fig. 72).

For harelip one should infiltrate a band ex-
tending from the commissure of the lips to the

ANESTHESIA OE THE HEAD AND NECK.

101

infraorbital foramen, connected by a transverse
line across the dorsum nasi.

The anemia produced by the adrenin facilitates
operative work. The tissues are not altered by
peripheral infiltration made at a distance.

Fig. 72. — Anesthesia for facial operations (Pauchet.)
There are two median wheals, central and superior, and two
lateral and inferior wheals. (5) and (6) serve for anesthesia
of the infraorbital nerve. (4) applies in anesthesia of the
ethmoidal nerve. The dotted polygon is a line of infiltration
made with a 1 per cent, solution.

For the lower lip a single dermal wheal should
be made on the chin, and from this point two
divergent lines of infiltration made both under the
skin and under the mucous membrane, with the
needle guided by a finger introduced in the mouth.

The chin and subjacent sy.uphysis menti some-

102

REGIONAL ANESTHESIA.

Fig. 73. — Median section of the body of the inferior maxil-
lary. (Pauchet.) The anterior and posterior sections of the
body of the maxillary bone are infiltrated through three wheals.

Fig. 74. — Anesthesia for resection of the superior maxil-
lary bone. (1) and (la) External and internal orbital injec-
tions. (2) Injection of the superior maxillary nerve. A weak
procaine-adrenin solution is used in instituting the subcuta-
neous bands of infiltration.

ANESTHESIA OF THE HEAD AND NECK.

103

Fig. 75. — Unilateral resection of the lower jaw (Pauchet.)
The inferior dental nerve is injected at the inferior dental
foramen, or the inferior maxillary nerve at the foramen ovale,
and the subcutaneous tissue then infiltrated along the dotted
line.

pig. 75. — Operation on the horizontal portion of the lower
maxillary bone. (Pauchet.) The inferior dental nerve is
anesthetized at the inferior dental foramen or the inferior
maxillary nerve at the foramen ovale, and a subcutaneous
diamond-shaped figure infiltrated through three wheals. The
dark line indicates the incision.

104 REGIONAL ANESTHESIA.

times require to be rendered insensible, e.g., for
the suture of a fracture of the mandible (Fig. 73) :

1 i ) A horse-shoe-shaped band of infiltration
following the lower border of the inferior maxil-
lary bone, both subcutaneous and subperiosteal.

(2) Infiltration of the mental nerve on one, or
better both sides, even if the operation be uni-
lateral.

Resection of the Superior Maxillary (Fig. 74).
— If the lesion is extensive and likely to cause the
surgeon to go beyond the superior maxillary, he
is justified in infiltrating the Gasserian ganglion,
as already explained. Generally, however, it proves
sufficient to proceed thus : ( i ) Infiltrate the supe-
rior maxillary nerve. (2) Infiltrate the inferior
maxillary nerve. (3) Infiltrate the orbital nerves
by two injections in the superior-internal and
superior-external angles. (4) Infiltrate the hard
and soft palates, following the line of incision.

For the lower jaw (Figs. 75 and 76) the in-
ferior maxillary nerve should be infiltrated at the
foramen ovale or at the dental foramen with a
*/2 per cent, solution and the field of operation
circumscribe*d with peripheral injections of a i
per cent, solution. One can then operate on the
bone for suturing or resection. In the event of
cancer at the alveolar border, the nerves should be
infiltrated at the inferior dental foramen. For
disarticulation of the jaw the foramen ovale should
be infiltrated.

ANESTHESIA OE THE HEAD AND NECK.

105

REGIONAL ANESTHESIA OF THE TONGUE, FLOOR
OF THE MOUTH, TONSILS, AND PALATE.

NERVE SUPPLY.

The lingual nerve supplies two-thirds of the
anterior portion of the tongue and the floor of
the mouth; the glosso-pharyngeal nerve supplies
the posterior portion of the tongue, the region of

Fig. 77. — Sensory distributions on the tongue. (Tes-
tut.) (1) Lingual. (2) Glossopharyngeal. (3) Superior
laryngeal.

the tonsils, and the pharynx; the superior maxil-
lary nerve supplies the soft palate and the ante-
rior pillars of the fauces, and the superior laryn-
geal nerve supplies the epiglottis.

One may therefore infiltrate the following
trunks :

( i ) The lingual nerve, within the inferior den-
tal foramen, desensitizing two-thirds of the ante-
rior portion of the tongue and the floor of the
mouth.

106

REGIONAL ANESTHESIA.

(2) The superior laryngeal nerve, in the thyro-
hyoid space (see page 116).

(3) Infiltration of the glosso-pharyngeal and
pneumogastric nerves should be avoided because
it is dangerous; peripheral infiltration must be
substituted.

TECHNIQUE.

Excision of a Tumor of the Margin of the
Tongue. — A triangle enclosing the tumor is out-

Fig. 78. — Anesthesia of the tongue and the buccal floor.
(Pauchet.) With a finger placed over the base of the tongue
the needle is introduced above the hyoid bone until its point
almost touches the finger on the tongue, coming to rest just
beneath the mucous membrane.

lined by two V-shaped bands of infiltration. The
growth caiv then be excised without hemorrhage
or pain.

Excision of an Extensive Cancer or Large
Cyst of the Floor of the Mouth. — A long needle

ANESTHESIA OF THE HEAD AND NECK. 107

is introduced under the chin, above the hyoid bone,
and pushed in vertically toward the base of the
tongue, being received against the tip of the left
index finger, introduced into the mouth as for tra-
cheotomy. This vertical route is first infiltrated,
then through the same wheal one injects succes-
sively from top to bottom and further and fur-
ther out, as many layers as are necessary to form
a fan shaped infiltrated region, the sides of which
extend to the maxillary bones, thus blocking off

Fig. 79. — Injection for transverse incision of the cheek for
cancer of the pharynx or posterior cancer of the tongue.
(Pauchet.)

all the nerves of the anterior portion of the
tongue.

Restricted Operations on the Floor of the Mouth.
— Small tumors of the floor of the mouth may be
infiltrated in a circle, by an injection made from
under the chin, with the needle always guided by
the finger in the mouth.

Removal of Extensive Cancer of the Tongue,
Floor of the Mouth,, and Tonsils. — (i) The two
inferior maxillary nerves are infiltrated at the in-

108

REGIONAL ANESTHESIA.

ferior dental foramen: (2) the base of the tongue
is infiltrated by a subhyoid injection; (3) peri-
oheral infiltration of the operative field is insti-

Fig. 80. — Tonsillectomy (Laboure.) The superior pole is
infiltrated by an injection made in the upper part of the an-
terior pillar. An injection at the base of this pillar infiltrates
the inferior pole. Quinine is employed.

Fig. 81. — Tonsillectomy. (Laboure.) The inferior pillar
is completely infiltrated. Quinine infiltration of the tonsil has
been instituted (white crescent)

tuted; (4) in some cases the Gasserian ganglion
of one side is also infiltrated.

Operations on the Palate. — Anesthesia of both
the soft and hard palate may be obtained by mak-
ing an injection under the mucous membrane in-

ANESTHESIA OF THZ HEAD AND XECK. 1Q9

side of the large molars and behind the middle
incisors. For resection of the bony hard palate,
the two superior maxillary nerves should be in-
filtrated.

In staphylorrhaphies one should avoid using too
much adrenin at the point where the flaps are to
be made.

Tonsillcctoiny (Figs. 80 and Si). — Infiltrate
the two nerve pedicles of the tonsil : ( i ) At the
lower portion of the anterior pillar; (2) at the
upper part of the vestibule, at the junction of the
posterior and anterior pillars.

REGIONAL ANESTHESIA IN OPERATIONS
ON THE NECK.

INFILTRATION OF THE CERVICAL ROOTS.

The soft tissues of the anterior portion of the
neck are supplied by the anterior branches of the
2d, 3d, and 4th cervical nerves, of which the ter-
minal branches — auricular, mastoid, transverse cer-
vical, and siipraclavicular, — emerge at the posterior
margin of the sterno-mastoid muscle (Fig. 82).

Infiltration of these terminal branches at the
posterior border of the sterno-cleido-mastoid de-
sensitizes the skin alone and this is rarely suffi-
cient. In order to obtain a deep anesthesia, the
nerves must be reached at their emergence from
the spinal column, on a level with the transverse
processes of the 3d, 4th, and 5th vertebrae (Fig. 86).

The distribution of the cervical trunks is as fol-
lows (see Figs. 85 and 87) : The second cervical

HO REGIONAL ANESTHESIA.

supplies the nape of the neck and the occipital
region. The third cervical supplies the antero-

Fig. 82. — Superficial branches of the cervical plexus
(Hirschfeld.) These branches should be desensitized by in-
filtration of the soft tissues lying between the mastoid and
the upper margin of the cricoid cartilage, following a ver-
tical line and injecting through 3 wheals.

lateral portions of the neck, from the lower jaw
to the shoulders and the upper portions of the
arms. The roots of the second, third, and fourth

ANESTHESIA OF THE HEAD AND NECK.

Ill

cervical supply the cervical plexus (see Figs. 83
to 85). It is these roots, therefore, that must be
reached in operating on the neck.

Technique. — The line of skin infiltration for
the cervical plexus is vertical, i.e., parallel with

Ophthalmic

Greater
occipital

Mastoid branch
of great auricular

Occipital
foramen

Great auricular

Third cervical

Phrenic

• Supraclavicular

Fig. 83. — Sensory areas of the superficial branches of
the cervical plexus. (Testut.)

the spinal column, and is determined by the two
following points: Above, a point one finger-
breadth below the tip of the mastoid, corre-
sponding to the angle of the jaw; below, a point
5 centimeters lower down and corresponding to
the superior border of the thyroid cartilage. Using
a 6-centimeter needle, the bone should be encoun-

112 REGIONAL ANESTHESIA.

tered at a depth of 5 centimeters, and a fan-
shaped injection of a i per cent, solution of pro-
caine-adrenin made there. About 25 mils is suffi-
cient. The needle should be introduced through

Fig. 84. — Anesthesia of the cervical plexus. (Pauchet.)
On a line joining the mastoid and the tubercle of the 6th cer-
vical transverse process (1 to 3) a layer of soft tissues, ex-
tending from the skin to the spinal column and from the
lower border of the inferior maxillary (1) to a point situated
on a level with the cricoid (2), is infiltrated.

the wheals indicated and the fluid injected as it
is withdrawn. There is thus infiltrated an area
about 5 centimeters square, outlined on the skin
by the preceding line, above and below by a per-
pendicular line passing from these points to the
vertebral column, and involving the tissues bor-

ANESTHESIA OF THE HEAD AND NECK.

113

Fig. 85. — Anesthesia resulting from paravertebral injec-
tion of the cervical plexus (anterolateral and posterior view).
(Testut.)

Fig. 86. — Paravertebral anesthesia of the neck.
Needle (1) is aimed directly at the lateral portion of the ver-
tebra, but it almost touches the vertebral artery. Needle (2)
(Danys) enters 2 centimeters from the spinous process, comes
in contact with the lateral mass of the vertebra, and reaches
the nerve without danger to the vertebral artery.

114

REGIONAL ANESTHESIA.

dering the column between the two perpendicular
lines (Fig. 84).

--J

Fig. 87. — Paravertebral anesthesia of the neck. (Pauchet.)
A B extends from the mastoid to the 6th cervical vertebra.
The white and black dots indicate the dermal wheals. Along
this line the needle enters transversely to infiltrate the nerve
(direct route). The figure shows the needle penetrating ob-
liquely (Danys) 2 centimeters beyond the spinous process and
following the lateral masses of the vertebrae. As soon as it
has passed these a strong solution of procaine-adrenin is
injected.

Danys advises that the needle be introduced
through the posterior surface of the neck, 2 centi-
meters from the interspinous line, in order to avoid

ANESTHESIA OF THE HEAD AND NECK.

115

a possible penetration of the needle into the inter-
transverse space and a consequent wounding of
the vertebral artery. We prefer, however, the
method described above, care being taken not to
penetrate too deeply.

Fig. 88. — Peripheral infiltration for laryngectomy or laryn-
gotomy, circumscribing the larynx. (Laboure.) The wheals
here shown should be joined by subcutaneous and subfascial
bands of infiltration. The wheal corresponding to the thyro-
hyoid space is missing from the polygon. Infiltration of the
two superior laryngeal nerves through the thyro-hyoid mem-
brane is sufficient.

ANESTHESIA OF THE LARYNGEAL
NERVE TRUNKS.

Two nerves supply the larynx, — the superior
laryngeal, and the inferior or recurrent laryngeal.
The latter is almost exclusively motor, whereas
the first is entirely sensory (Fig. 88).

116 REGIONAL ANESTHESIA.

INFILTRATION OF THE SUPERIOR

LARYNGEAL NERVE.

The superior laryngeal arises from the in-
ferior pole of the plexiform ganglion. It is held
against the pharynx by the internal carotid, then
by the beginning of the facial and lingual arteries,
Slightly above the greater cornu of the hyoid bone
it divides into its two terminal branches:

(1) The superior branch (external laryngeal}
follows the vertical insertion of the inferior con-
strictor over the thyroid gland to the crico-thyroid
muscle, which it supplies, and terminates in the
subglottic portion of the mucous membrane of the
larynx.

(2) The inferior branch (internal laryngeal}
continues in the direction of the common trunk,
passes between the thyroid muscle and the hyo-
thyroid membrane, penetrating through the middle
of this membrane, and divides into superior ter-
minal filaments for the epiglottis and base of the
tongue, inferior filaments for the mucous membrane
of the larynx and the arytenoids, and an anasto-
motic termination for the recurrent nerve (ansa
Gallieni).

Technique. — The sensory innervation of the
larynx is constituted almost entirely, — above the
vocal cords at any rate, — by the superior laryn-
geal. As already stated, this nerve penetrates im-
mediately behind the posterior extremity of the
greater cornu of the hyoid bone, under the in-
ferior border of this bone. It follows closely the
thyro-hyoid membrane, courses forward, perforates

ANESTHESIA OF THE HEAD AND XECK. 117

this membrane, and supplies the laryngeal mucous
membrane and the neighboring portions of the
pharynx. A needle 6 centimeters long is intro-
duced in the median line between the thyroid car-
tilage and the hyoid bone, into the thyroid liga-
ment. Once it is in this ligament, the needle is
made to approach the greater cornu of the hyoid
bone, which is easily felt with the finger. This
ligament is now infiltrated on both sides, to the
right and to the left, with 5 to 10 mils of a i
per cent, procaine-adrenin solution.

Infiltration of the Recurrent Laryngeal Nerve.
— Even if this nerve were exclusively motor, its
infiltration would be justified to avoid spasm of
the larynx, but actually it is a mixed nerve.
Couzard and Chevrier infiltrate it thus: "Intro-
duce a straight needle into the angle formed in
the median line by the superior border of the thy-
roid, injecting obliquely below, behind, and out-
side of the angle; come into contact with the in-
ternal face of the thyroid cartilage; guide the
needle diagonally toward the postero-inferior angle
of this cartilage, and inject the solution; it will
distend the recess and bathe the terminal branches
of the recurrent nerve." One to 2 mils of solu-
tion suffices.

These infiltrations of the trunks do not render
local anesthesia unnecessary. Spraying with a 20
per cent, solution of cocaine, tamponage with a 10
per cent, solution, and submucous injection of I
per cent, procaine-adrenin, are all advantageous
adjuncts.

118 REGIONAL ANESTHESIA.

OPERATIONS.

(1) Endolaryngeal Intervention. — (a) One should
first anesthetize by spraying and tamponing with
a 10 to 20 per cent, solution of cocaine the base
of the tongue, the pillars of the fauces and the
larynx.

(b) Infiltration of the two superior laryngeal
nerves should be carried out.

(2) Tracheotomy, Laryngo-fissure, and Laryn-
gostomy. — The methods of anesthesia described
above should be employed, and intradermal and
subcutaneous, peripheral, and trunk anesthesia
added. In cases of laryngo-fissure and laryngos-
tomy, as soon as the larynx is open, one may
apply tampons moistened with a strong solution of
cocaine to the mucous membrane.

(3) Laryngectomy and Goiter Operations. —
These are more extensive procedures, for the per-
formance of which it is necessary to infiltrate the
trunks of the nerves of the plexus and the larynx,
and to institute a subcutaneous peripheral infiltra-
tion surrounding the larynx or the tumor at a
distance.

The harmful actions of chloroform or ether
upon the heart, lungs, and liver are thus avoided,
to the great benefit of patients whose respiration is
affected by disease or who are diabetic. Again,
regional anesthesia permits the patient to clear his
bronchi during the course of the operation, thus
avoiding broncho-pneumonia. Shock is also con-
siderably diminished.

ANESTHESIA OF THE HEAD AND XECK.

119

(4) Ligation of the External Carotid or Thy-
roid Arteries. — The cervical plexus is first infil-
trated, and there is then circumscribed under the
skin and fascia a quadrilateral area extending
beyond the limits of the incision.

(5) Removal of Enlarged Glands and Tiunors
of the Neck. — The cervical plexus of one or both

Fig. 89. — Infiltration for thyroidectomy. (Pauchet.) The
injection to the right infiltrates the branches of the cervical
plexus along the transverse processes of the vertebrae (from 1
to 2). The mass is surrounded at a distance with a sub-
cutaneous and subfascial band of infiltration (2, 3, 4, 5, and 6).
We have performed about 250 strumectomies by Kocher's
method without mortality.

sides is infiltrated and the tumor or lymphatic
mass circumscribed by peripheral injection of a j/2
per cent, procaine-adrenin solution. If the mass
of the tumor or lymphatics extends posteriorly so
as to interfere with the passage of the needle,

120

REGIONAL ANESTHESIA.

the latter may, instead of being introduced trans-
versely or in front, be passed in near the inter-
spinous line, in an anterior or in any intermediate
oblique direction.

(6) Infrahyoid and Suprahyoid Pharyngotomy.
— The thyroid membrane is infiltrated and a peri-

Fig. 90. — Removal of carcinoma of the larynx under
regional anesthesia. (Pauchet.) The organ has been opened
up posteriorly ; the tumor is to be seen on the right vocal cords.

pheral lozenge-shaped area of infiltration made
over the inferior maxillary and the thyroid car-
tilage. During the course of the operation it is
sometimes necessary to infiltrate the tumor over
its entire external surface.

ANESTHESIA OF THE HEAD AND NECK. 121

(7) Thyroidectomy. — Six dermal wheals are
made (Figs. 89 and 90). Points i and 2 cor-
respond to the line of the transverse processes
and serve as landmarks in instituting paraverte-
bral anesthesia of the neck. All the tissues, epi-
dermis, muscles, and nerves are thus infiltrated
until the cervical plexus is reached.

Fig. 91. — Paravertebral anesthesia of the neck. (Danys.)
This figure shows the two methods of reaching the nerve as
it emerges from the spinal canal. Needle 1 aims transversely
for the nerve, but it runs a risk of injuring the artery. Needle
2 enters 2 centimeters from the median line, follows the line
of the vertebrae, comes in contact with the transverse process,
and finally reaches the nerve, while avoiding the vertebral
artery.

With a needle 9 centimeters long, a subcuta-
neous and subfascial band is infiltrated through
the dermal wheals (Figs. 89 and 90). One
hundred grams of a ^ per cent, solution of pro-
caine-adrenin are required. This procedure may
also be employed in the removal of malignant
tumors.

122

REGIONAL ANESTHESIA.

(8) Total Laryngectomy. — A subcutaneous hexa-
gon is made, extending from a point slightly
above the hyoid bone to the angle of Louis. A

Fig. 92. — Infiltration of the anterior aspect of the neck.
(Laboured) This is intended for major operations in this
region, e.g., for cancer of the larynx, goiter, extirpation of
lymphatics of the neck for cancer of the tongue, etc. A, B, C,
and D indicate the method of paravertebral injection of the
cervical nerves. Dermal wheals are made above and below
to circumscribe the operative field.

paravertebral infiltration is then conducted through
two dermal wheals, as in goiter, for the purpose
of anesthetizing the transverse cervical branch.

ANESTHESIA OF THE HEAD AND NECK. 123

Fig. 93. — Large adamantoma of the lower maxillary. (Pauchet.)
On the lower part of the tumor is seen a white, cross-shaped scar, — •
evidence of an operation carried out a few years before. This case
had been recently diagnosed "inoperable sarcoma." The tumor com-
municated with the mouth and secreted pus abundantly. Insomnia.
Liquid diet. Anesthesia was commenced by paravertebral injection of
the cervical plexus, injection of the superior maxillary nerve by the
orbital route, and simple infiltration of the chin and lower lip in the
median line. These three anesthetizing injections enabled the operator
to ligate the external carotid and perform a section from the middle of
the neck to a point beyond the eyelid, extending through the chin and
cheek (see the succeeding figures).

124

REGIONAL ANESTHESIA.

Finally, the superior laryngeal nerve is anesthe-
tized. One must not forget to spray the pharynx

Fig. 94. — Second stage of the operation: Ligation of the
external carotid has been effected. The scalpel has just
divided the skin in front of the tumor.

with cocaine, in order to suppress the reflexes of
deglutition and prevent coughing. Two hundred
to 250 grams of a ^ per cent, solution of pro-
caine-adrenin are required for this operation.

It is in cases such as these that regional anes-
thesia exhibits its superior degree of utility.

ANESTHESIA OF THE HEAD AND NECK. 125

Fig. 95. — Third stage : Resection of the jaw has been completed.
To the left is still seen the needle which has served to infiltrate the
foramen ovale (inferior maxillary). The external carotid having been
previously ligated, there is not much hemorrhage.

126

REGIONAL ANESTHESIA.

Fig. 96. — Anesthesia by infiltration of the cervical plexus and
superior and inferior maxillary nerves. (Pauchet.) An esophageal
tube has been introduced in the nose. The patient is to be fed
through it.

ANESTHESIA OF THE HEAD AND XECK. 127

Fig. 97. — Anesthesia of the cervical plexus and inferior maxillary
nerve for amputation of the tongue by the subhyoid route. (Pauchet.)
The infrahyoid floor has been incised, and the tongue drawn out.

CHAPTER V.

ANESTHESIA OF THE THORAX AND ABDOMEN.

OPERATIONS upon the trunk may be performed
under spinal anesthesia by means of cocaine (Le
Filliatre) or other drugs introduced more or less
high up (Jonnesco) after a series of paraverte-
bral injections, which constitutes the ideal regional
anesthesia for the upper portions of the trunk, or
by lumbosacral injections (Le Filliatre). For in-
tra-abdominal operations and operations in the pel-
vis and on the lower extremities, injection of procaine-
adrenin directly into the lumbar canal offers the
simplest and most complete form of anesthesia.

INTRASPINAL ANESTHESIA.

Personally we prefer regional anesthesia for all
operations upon the head, face, neck and thorax,
as well as all other operations of a local charac-
ter. But for amputation, resection or other ex-
tensive procedures on the lower extremities, as
well as for major intra-abdominal operations on
the liver, stomach, intestines, and pelvic organs,
intraspinal anesthesia possesses certain pronounced
advantages. . It is particularly valuable in opera-
tions for intestinal occlusion, as it paralyzes and
softens the abdominal wall and contracts the in-
testine, practically eliminating the risk of fecal
(128)

THORAX AND ABDOMEN. 129

vomiting- and thereby aiding toward a favorable
prognosis.

Y\ e do not advocate intraspinal anesthesia for
any operation in which regional anesthesia is in-
dicated, e.g., in hemorrhoids, varicocele, perineor-
rhaphy, prostatectomy, amputation of the foot, suture
of the patella, nephrectomy, cholecystotomy, and
all operations on the head, neck and thorax.

The spinal cord proper terminates at about the
level of the junction of the second and third lum-
bar vertebrae, where it becomes filiform. It is
entirely safe to inject directly into the spinal canal
at the space between the third and fourth (Tuf-
fier), fourth and fifth (Chaput), and fifth lumbar
vertebra and sacrum (Le Filliatre), and, with a
little care not to enter the cord, between the first
and second lumbar vertebrae.

Injection into any one of the inter-vertebral
spaces of the lumbar region produces insensibility
of the lower part of the abdomen and the lower
extremities.

Under this form of anesthesia we have per-
formed, at the Molitor Hospital, operations upon
every portion of the leg and thigh.

Some little familiarity and practice is required
for the successful injection of the spinal region.
It is easiest to find entrance to the canal bet\veen
the last lumbar vertebra and sacrum, because here
the space is wide, but as a matter of fact, it is
not difficult to effect an entrance at any one of
the interspaces mentioned.

130 REGIONAL ANESTHESIA.

Injections into the spinal canal are greatly
facilitated by placing the patient in a sitting posi-
tion with head bent over on the arms — the latter
folded upon the knees, — and the back made to
"bow" as much as possible in order to throw the
spinous processes into the greatest possible promi-
nence.

The same degree of aseptic precaution should
be taken for injecting the spinal canal as for a
laparotomy, both as regards the surgeon and the
patient.

A strong needle of rather large caliber, 8
centimeters long, should be selected. With the
index finger -of the left hand the space to be injected
is found, ^2 centimeter from the median line of
the spine, midway between two adjacent spinous
processes. In the center of this space the needle
is introduced in a straight line, pointing slightly
inward toward the median line (Fig. 98). At a
certain depth, which varies according to the con-
formation of the patient, the operator senses con-
tact with the ligamenta subflava and the inter-
laminar ligament, some force being required to
penetrate and the operator experiencing somewhat
the sensation of piercing a tense drum head. As
the needle is pushed through, the silver wire is
removed from its lumen from time to time to see
if a drop of cerebrospinal fluid will appear. When
the fluid drops more or less rapidly, according to
the intraspinal tension, the syringe, containing 2
mils of a 4 per cent, solution, is adjusted, the
spinal fluid slowly drawn out to complete exten-

THORAX AND ABDOMEN.

131

sion of the syringe, the fluid then slowly injected
in part, and the piston redrawn and reinserted
several times to mix the solution with the spinal
fluid and cause it to be more generally diffused

Fig. 98. — Showing point of entrance into the spinal
canal. (Pauchet.)

in the spinal canal. When the syringe has been
finally emptied into the canal, the needle is with-
drawn by a quick movement, slipping the index
finger of the left hand over the puncture for a
moment, then touching it with a drop of iodine
tincture. In from five to fifteen minutes the pa-

132 REGIONAL ANESTHESIA.

tient will experience complete insensibility of the
parts supplied by the nerves involved.

If the injection be made between the I2th dor-
sal and ist lumbar vertebrae, it will produce a
complete anesthesia of the abdominal contents-
stomach, liver, intestines, abdominal walls — as well
as the lower extremities. If it be made between the
fifth lumbar and sacrum it will anesthetize the
perineum, anus and lower extremities. Both to-
gether are recommended for abdomino-pelvic oper-
ations such as hysterectomy or extensive extirpa-
tion of the rectum (Jonnesco).

For feeble, old individuals, and the cancerous,
cachectic, and tuberculous, it is not necessary to
employ the full strength of dose, as for the vigor-
ous patient. The anesthesia is more readily in-
duced in the feeble.

As a precautionary measure it is well to in-
ject, one hour before the operation, an ampoule
of scopolamine-morphine and one of strychnine or
sparteine.

Equalization of the effect of the anesthetic is
greatly facilitated by the repeated filling and par-
tial reinjection of the contents of the syringe into
the spinal canal. If this movement is not readily
performed and something seems to prevent an
easy flow to and from the syringe, the action of
the anesthetic is likely to be imperfect.

Immediately after the injection is made the pa-
tient should be placed recumbent upon the opera-
ting table and covered warmly. For him to re-
main sitting up involves risk of an attack of syn-

THORAX AND ABDOMEN. 133

cope. The ears should be stopped with cotton,
the eyes bandaged, if necessary, and complete
silence ordered. The anesthesia continues for an
hour or more.

Complications. — (a) If cerebrospinal fluid fails
to flow from the needle, either the direction of
the needle is bad and the point has not penetrated
the spinal canal, or the needle is plugged. Only
two or three attempts are required for the oper-
ator to feel confident when he is traversing the
inter-laminar ligaments separating the vertebrae.
If he be satisfied that the direction of the needle
is not at fault, the needle should be withdrawn,
aspirated with the aid of a syringe, and reintro-
duced.

(b) If pure blood appears, the needle has pene-
trated a vein and must be withdrawn and rein-
troduced. If the liquid is mixed with blood, one
should wait a moment for the fluid to become
clear. To inject with bloody fluid destroys the
effect of the anesthetic.

(c) If the liquid appears only in slow drops
and will not fill the syringe when aspiration is
made, it is useless to push the attempt farther.
The needle must be withdrawn, its lumen cleared
with the aid of a syringe, and the needle then re-
introduced.

(d) Incomplete anesthesia or absence of anes-
thesia is due to one of the preceding errors. It
does not occur in the hands of an experienced
operator.

Untoward Sequclcc. — (a) Retention of urine

134 REGIONAL ANESTHESIA.

may be present for several days. The patient oc-
casionally requires daily catheterization for a week
or more.

(b) Vomiting after the operation is very un-
common.

(c) Sciatic neuralgia occurs when the operator
introduces the needle to the outer side of the
vertebra and pierces a nerve.

(d) Headache often follows the injection and
lasts a week. If it is violent, lumbar puncture is
necessary.

(e) Fecal incontinence during the operation.
In the case of a total hysterectomy, this is danger-
ous as the fecal matter may penetrate the vagina
and enter the abdominal cavity. It is wise to
tampon the vagina to safeguard against this
difficulty.

(/) Fever. The temperature may rise and fall
on the first or second day; this is devoid of sig-
nificance.

(g) Labored respiration and asphyxia have
appeared where the injections have been made
high up and the anesthetic has affected the center
of respiration. If the mind is clear, the patient
should be made to talk incessantly and draw in
and blow out the air. If necessary, artificial res-
piration should be resorted to. As soon as the
effect of the anesthetic on the medulla has passed
off, natural respiration will be re-established.

(h) Death. Among 2000 cases Pauchet has
met with 2 deaths. In 5000 cases, Jonnesco had

THORAX AND ABDOMEN. 135

no death. Le Filliatre has had no deaths, either.
Leyden has had 2 deaths. I consider spinal anal-
gesia as involving the same degree of immediate
danger as does chloroform.

(i) Nervous Manifestations. Among 5000
cases Jonnesco observed but one case of nervous
disturbance. Pauchet met with one case of blad-
der retention which continued for three months.
Organic affections not discovered by previous ex-
amination may, of course, exist, and it is cer-
tainly unjustifiable to attribute accidents appearing
a year or more after the operation to the effects
of the anesthetic.

Regions Influenced. — Jonnesco has boldly prac-
tised injection into the spinal canal along its
whole length and specifies the effects of the anes-
thetic in the various regions as follows: —

(1) Injection between the 3d and 4th cervical
vertebrae: Anesthesia of the head and neck.

(2) Cervico-dorsal injection, immediately below
the vertebra prominens: Thorax and upper ex-
tremities.

(3) Between the last dorsal and first lumbar:
The entire abdomen, testicles, and lower ex-
tremities.

(4) Between the last lumbar and the sacrum:
The pelvis, perineum, and anus.

Injection at two points has been recommended
for certain operations, viz., in operations upon the
thorax, one may inject at the cervico-dorsal and
dorso-lumbar levels. For abdomino-pelvic opera-

136 REGIONAL ANESTHESIA.

tions, one should inject at the dor so-lumbar and
lumbo-sacral levels. For other operations, one
injection suffices.

Pauchet says: ''I do not practice injection of
the spinal canal at a point above the intersection
of the 1 2th dorsal and ist lumbar, which insen-
sibilizes the whole abdomen and its wall, prefer-
ring regional and local anesthesia for all opera-
tions above this level."

As in the administration of chloroform, a cer-
tain degree of danger attends the practice of spinal
anesthesia, but the procedure is free of the post-
operative dangers incident to general narcosis. It
•does not affect the viscera (lungs, liver, kidneys,
or suprarenal capsules) and permits of highly
traumatic operations (resection of the femur, dis-
articulation of the hip) with very minor evidences
of shock. It renders the major abdominal opera-
tions more benign because it makes them easier,
serving to contract the intestine, reducing com-
pletely the rigidity of the abdominal wall, and pro-
ducing complete "abdominal silence."

There is no comparison between an operation
for uterine cancer, for cancer of the rectum, and
notably for acute occlusion of the intestine, under
spinal anesthesia and under general narcosis.

NERVE-TRUNK ANESTHESIA.

The thordcic nerves emerge from the interver-
tebral foramina of the thoracic portion of the
spine (Fig. 101). Immediately after their emerg-

THORAX AXD ABDOMEN. 137

ence they give an anastomotic branch to the sym-
pathetic, and afterward divide into two branches:
an anterior and a posterior. The posterior branch
supplies the muscles of the back and skin in the
vicinity of the midline. The anterior branches or
intercostal nerves are situated in the intercostal
spaces near the inferior borders of the ribs. They

Fig. 99. — Intercostal nerves and their distribution. (Hirsch-
feld.) These nerves can be blocked by paravertebral injection
or by simple intercostal injection.

are at first in contact with the pleura, near the
costal angle; afterward they pass between the two
intercostal muscles (Figs. 99 and 100).

The upper dorsal nerves (Fig. 103, D. i, 2,
and 3) supply the internal surfaces of the arm
and of the forearm, and the axillary and mam-
mary regions are supplied likewise by the succeed-
ing nerves, down to the seventh dorsal (D. 7),
inclusive. The intercostal nerves from the 8th to
the 1 2th supply the thorax, and likewise the ab-

138

REGIONAL ANESTHESIA.

Fig. 100. — Interco'stal and lumbar nerves and their distribu-
tion. (Hirsclifeld.) The figure shows the anastomosis of
these nerves with the sympathetic. The needle is introduced
close enough to the vertebral column to infiltrate the com-
municating ramus, the viscera being thus anesthetized.

THORAX AND ABDOMEX.

139

Fig. 101. — The dorsal nerves at their points of emergence.
(Testut.) The figure shows their bifurcation into an anterior
branch (intercostal) and a posterior branch which divides into
two rami.

Fig. 102. — The intercostal space. (Souligoux.) (A) Pos-
teriorly at the point of origin. (B) At the posterior third.
(C) Middle portion. The internal intercostal divides to sur-
round the blood-vessels and nerves.

140

REGIONAL ANESTHESIA.

Fig. 103. — Dorsal paravertebral anesthesia for the viscera.
(Pauchet.) The operator is shown the dorsal points which should be
infiltrated in order to anesthetize corresponding viscera. In practice,
one should inject both higher and lower because of the anastomoses.
The lung, kidney, biliary passages, and spleen are anesthetized by an
injection made upon one side only. For other organs both sides
should be injected.

THORAX AXD ABDOMEX.

141

clomen. Through their anastomoses with the sym-
pathetic, they supply with sensation the following
viscera: Heart (Fig. 103, D. i, 2, and 3); lungs

Fig. 104. — The lumbar nerves at their points of emergence.
(Pauchet.) These nerves are accessible between the trans-
verse processes of the lumbar vertebrae, as are the intercostals
below the ribs.

(D. i, 2, 3, and 4) ; stomach (D. 6, 7, 8, and 9) ;
liver and bile ducts (D. 7, 8, 9, and 10) ; intes-
tines (D. 9, 10, n, and 12); kidneys and ureters
(D. 10, n, and 12); testicles, ovaries, and uterus

142

REGIONAL ANESTHESIA.

(D. IO, n, and 12). To desensitize the viscera
it is necessary to reach the anastomoses with the
sympathetic ( Danys ) .

The lumbar nerves are situated between the
transverse processes of the lumbar vertebrae in
front of the intertransverse muscles, and are sur-
rounded by the attachments of the psoas muscle
(Figs. 100, 104, 105).

Fig. 105. — The lumbar nerves at their points of
emergence. (Hirschfeld.)

The ilio-hypo gastric, ilio-inguinal, and genito-
crural nerves, supplying the anterior abdominal wall,
follow, as the I2th intercostal nerves, the anterior
surface of the quadratus lumborum, i.e., course
between this and the perirenal adipose tissue.
After the 2d lumbar, the nerve trunks are so
closely applied against the vertebrae that they can
only be reached by injections made almost in con-
tact with th^ vertebral column at a distance of 3
centimeters from the median line.

The intercostals and the ist lumbar nerve sup-
nly not only the thoracic and abdominal wall, but

THORAX AXD ABDOMEX. 143

also the serous membranes, the pleurae, and the
parietal peritoneum. The intermediate intercostal
nerves do not anastomose at their points of origin,
but from the I2th there is given off a branch to
the ist lumbar nerve. At the 'level of the skin the
regions supplied by the respective intercostal s so en-
croach one upon the other that the blocking of a
single ncrrc does not abolish cutaneous sensation ;
several must be infiltrated at the upper part of the
thorax to obtain complete anesthesia of a given
region. The skin of the thorax also receives
branches from the cervical and brachial plexuses.

The anesthesia required for operations upon
the spine, thorax, and abdomen may be obtained
by one of two methods.

In the case of a circumscribed operation, such
as resection of one or two ribs, curettage of the
sternum, operation for appendicitis, for simple her-
nia, etc., injections made along the course of the
nerves supplying the field of operation, as des-
cribed further on, will yield a complete anesthesia
limited to the parietes. Such injections are made
around, and at some distance from, the field of
operation. The procedure varies for each opera-
tion in accordance with the nerve supply. This
method has enabled us to dispense with general
and spinal anesthesia for a number of operations,
e.g., in the radical cure of most voluminous her-
nias. It appears to us the ideal procedure for
thoracotomy, and is sufficient for appendectomy
when the acute attack has subsided and provided the
appendix and cecum are free from adhesions. It en-

144 REGIONAL ANESTHESIA.

ables us to do pylorectomy for cancer and very consid-
erable resections of the intestines, provided the
mesentery is injected in addition with a I per
cent, solution of quinine and urea hydrochloride.
When the operation concerns unilateral viscera
—kidneys, liver, spleen, bile ducts, — or any larger
portion of the trunk or abdomen, it is preferable
to employ the following method, which is more
precise in technique and permits of covering a
larger field, viz. : —

PARAVERTEBRAL ANESTHESIA.

Definition. — Paravertebral anesthesia consists in
bathing the thoracic and lumbar nerves at their
points of emergence from the intervertebral fora-
mina of the dorsal and lumbar spine with a solu-
tion of procaine-adrenin. The injection anesthe-
tizes the thoracico-abdominal wall and even the
viscera through the anastomoses with the sympa-
thetic. By injecting a I per cent, solution of
procaine-adrenin 3 to 4 centimeters from the
median line in the intervertebral spaces the sur-
geon is enabled to produce complete anesthesia of
the thoracico-abdominal wall as well as of the
unilateral viscera situated on the same side and
receiving filaments of the sympathetic (liver, bile
passages, spleen, kidneys, ureters).

If the operator desires to anesthetize the entire
abdominal contents (intestines), two series of in-
jections will have to be made, one to the right
and the other to the left of the spinal column;

THORAX AND ABDOMEN.

145

but such an event is exceptional. Paravertebral
anesthesia is useful for operations upon the thorax,

Line of skin
infiltration

, Fig. 106. — Dorsal paravertebral anesthesia. (Pauchet.)
The skin is infiltrated with a band 1 centimeter wide at a dis-
tance of 35 millimeters from the median line. The operator
introduces the needle through this band and feels his way.
The black dots show where the needle should enter to reach
the rib, somewhat laterally to the costo-vertebral articulation.
When the needle has come in contact with the rib, it turns
about its inferior border and proceeds toward a point */> centi-
meter further fonvard and inward to reach the sympathetic
anastomosis. It should be noted that the lower angle of the
scapula corresponds to the spinous process of the seventh dor-
sal and the spine of the scapula to the third dorsal.

neck and abdomen, the breasts, pleurae, lungs, and
for lateral viscera, including the kidneys, liver,

biliary passages, pylorus, cecum, etc.

146 REGIONAL ANESTHESIA.

Technique. — The operator should remember that
the thoracic nerves at their origin are located at
equal distances from the transverse processes and
at a distance of 2 centimeters in front of the
intertransverse space.

The spinous processes from the first to the
sixth are situated at the level of the intertrans-
verse spaces, bounded by the two succeeding ver-
tebrae, and at the level of the nerve immediately
following. Thus, the processes D. I to D. 6 (Fig.
106) correspond to pairs D. 2 to D. 7. The
processes D. 7 to D. 12 are situated opposite the
lower portion of the corresponding intertransverse
space (Fig. no).

The lumbar nerves, at their emergence from
the conjugate vertebral foramina, are situated at
the level of the corresponding spinous process and
slightly above the transverse process of the ver-
tebra immediately following (Fig. 104). They are
therefore accessible through the intertransverse
spaces at a distance of about 3 centimeters out-
side the median line, and are situated I centimeter
in front of the transverse processes (Fig. 106
and 107).

For the Dorsal Nerves. — A needle 6 to 9 centi-
meters long is introduced at a point 3^/2 centi-
meters from the median line. At a depth of 4 to
5 centimeters, when the needle touches the rib,
transverse process or costo-vertebral articulation,
its point is inclined to reach the lower border of
the bone. Then, at an angle of 25°, it is aimed
at the middle line, and its progress terminated

THORAX AND ABDOMEN.

y2 a centimeter beyond. Next, 5 mils of the 1.5
per cent, solution is injected, or 7 to 8 mils of
the i per cent, solution. It is well to move the

Fig. 107. — Intercostal or paravertebral dorsal anesthesia.
(Pauchet.) The first needle is directly in the intercostal space
and in the vicinity of the nerve. The second (dotted line)
has at first come in contact with the rib, but has then been
given an oblique direction downward and has reached the
vicinity of the nerve.

point of the needle to and fro in order to be sure
that the nerve is well bathed and to include the
anastomosis of the sympathetic and the posterior

148

REGIONAL ANESTHESIA.

as well as the anterior branch of the spinal root
(Fig. 1 08).

Two difficulties may arise:

Fig. 108. — Paravertebral dorsal anesthesia. (Pauchet and
Sourdat.) The needle enters at a point 35 millimeters from
the median line, close to the inferior border of the rib; then,
at a point 1 centimeter anterior and internal, it reaches the
nerve root and impregnates the anastomosis with the sym-
pathetic.

(o) If blood comes from the needle, a vein
has been .wounded. The position of the needle
must be changed, otherwise the injection will pass
into the vein, and no anesthesia will be produced.
It is important to bear in mind that when this

THORAX AND ABDOMEN.

149

accident happens, the patient turns pale and ex-
periences nausea.

(b) Penetration into the pleura will cause

Fig. 109. — Direction of the lumbar nerves after their emerg-
ence from the conjugate foramina. (Pauchet.) To reach
these nerves, the needle is inserted at a distance of 3 centi-
meters outside of the spinous process. In the case of the in-
tercostals, at a distance of 3l/> centimeters, with the needle
close to the lower border of the rib, one reaches the nerve
numbered one less than the spinous process serving as land-
mark. In the case of the lumbar nerves, the needle, introduced
at the level of the spinous process, will pass above the upper
border of the corresponding transverse process and come in
contact with the nerve of the same number.

the patient to cough. The needle should be with-
drawn and inclined slightly outward. This acci-
dent, likewise, presents the disadvantage that the

150

REGIONAL ANESTHESIA.

anesthetic is absorbed without producing anesthe-
sia. To obviate it, one should avoid introducing
the needle more than i centimeter after having

Fig. 110. — Paravertebral injection of the dorsal and lumbar
region. (Pauchet.) The needle enters at a point 3^ centi-
meters outside of the dorsal spinous process. Reaching the
lower border of the rib, it then inclines slightly inward, ad-
vances 1 centimeter, and attains the anastomosis of the sympa-
thetic, thus anesthetizing the viscera.

passed the transverse process, or at a distance of
^2 centimeter below the rib itself.

For the Lumbar Nerves. — The needle is intro-
duced at a" distance of 3 centimeters from the
median line. After the transverse process has
been found, at a depth of 4 to 5 centimeters, the

THORAX AND ABDOMEN. 151

superior border is followed around, the point
pushed in for another centimeter, and the injec-
tion made (Figs. 109 and no).

Dermal infiltration is employed at first, and a
straight band, corresponding to the roots to be
injected and parallel with the median line, traced
on the surface of the skin. The band referred
to should be traced as follows :

A very fine, sharp-pointed needle 3 to 5 centi-
meters in length is used. The skin is marked
with a dermal pencil at a distance of 3}^ centi-
meters from the median line (it is difficult to
follow this line exactly without deviation if there
is no landmark). A strip of skin I centimeter
wide is now infiltrated with the patient sitting
bo\ved forward and the shoulders well drawn in
as for spinal anesthesia, or lying down on his
side.

This having been accomplished, the operator,
employing a needle 6 or 9 centimeters long — ac-
cording to its strength — begins injecting the nerves.
The introduction of the needle will be painless.
Each spinous process is sought with the left in-
dex finger (a difficult matter in stout people),
and at the level of the spinous process the needle
is introduced 3^2 centimeters from the median
line until it meets the rib or transverse process.
In muscular subjects the inexperienced operator
must feel his way. When the point strikes the
rib, it should be withdrawn, then directed against
and past the lowrer costal border until the bony
resistance disappears. The operator now contin-

152 REGIONAL ANESTHESIA.

ues to push the needle l/2 centimeter beyond and
injects 5 to 8 mils of the I per cent, solution, at
the same time executing a to and fro movement
in order not to miss bathing the nerve. The in-
jection having been completed, the needle is al-
lowed to remain in place to serve as a landmark.
The operator then locates the spinous process of
the next vertebra below, and at its level and ex-
actly below the needle above, he introduces his
second needle and begins as before. For the third
injection, the second needle is left in place as a
landmark and, if necessary, the first needle used
for the injection.

After the injections are finished about fifteen
minutes are required for the anesthesia to take
full effect. The intercostal space, muscles, pleura,
sternum, and ribs are all rendered insensible. The
skin anesthesia begins one or two interspaces be-
low the first injection. Transversely, it occupies
the intercostal space; anteriorly it reaches the
median line, and posteriorly, it often stops behind
the point where the injections have been made.
If the injections have been practised at points im-
mediately external to the conjugate foramen, the
posterior branch is also blocked and a laminectomy
can be effected.

Sixty to 80 grams of the i per cent, solution
suffice for the anesthetization of 12 nerves. An
absolute anesthesia of the thoracic wall is thus
obtained which extends both anteriorly and pos-
teriorly to the midline.

THORAX AND ABDOMEN. 153

For the upper portion of the thorax, the func-
tions of the cervical plexus must be also inter-
rupted. A subcutaneous band • must be infiltrated
the length of the clavicle and spine of the scap-
ula. If the field of operation involves the axilla
or the supraclavicular fossa, the brachial plexus
should be anesthetized.

For thoracic operations involving only the ribs
and parietes, there is no objection to substituting
intercostal anesthesia for the paravertebral anes-
thesia, i.e., instituting the anesthesia at a more
lateral point on the course of the intercostal nerve
above the region to be operated upon. The tech-
nique of this procedure will be described later.

PARACENTESIS OF THE PLEURAL CAVITY.

With a 3-centimeter needle, the course to be
followed by the trocar passing in from the skin
to the pleura is injected. A y? per cent, solution
proves sufficient; such anesthesia permits of the
use of large trocars without pain.

THORACOTOMY FOR EMPYEMA WITH
COSTAL RESECTION.

The operator is given the choice between a
paravertebral anesthesia or the less radical inter-
costal or pericostal anesthesia, the technique of
which is as follows:

Attention is directed to Fig. in, which rep-
resents three adjacent ribs. Upon the middle one,

154

REGIONAL ANESTHESIA.

the part in black is to be resected; there will
therefore be two intercostal spaces to anesthetize.
Four wheals are marked out and through these
5 mils of the i per cent, solution injected into
the thickness of the intercostal muscles. The
needle point seeks the upper rib and follows its
inferior border until it passes beyond.

Fig. 111. — Resection of a rib. (Sourdat.) An injection
is made in the adjacent intercostal spaces forward and back-
ward on tlie portion of rib to be resected, and followed by
peripheral infiltration, subcutaneously and intramuscularly.

The muscles and subcutaneous tissue are in-
filtrated with 30 or 40 mils of the ^ per cent,
solution in the direction of the arrows. The re-
sulting anesthesia is complete; yet it is well to
bear in mind that the patient will complain if any
traction is made on the ribs, producing torsion of
the costo-vertebral ligaments. The patient may
also complain if he hears the section of the ribs;
it is there^pre well to cut the ribs gently and to
stop the patient's ears. A little girl n years of
age — the niece of a colleague, — upon whom we
did a resection of 3 ribs for interlobar empyema,

THORAX AND ABDOMEN.

155

cried every time she heard the cutting of a rib,
though she had not complained once during the
remainder of the operation, except during the pro-
duction of the dermal wheals. A man 30 years
of age cried out when he heard a costal cartilage
fall into the bucket on the floor.

Fig. 112. — Resection of the costal cartilages. Diagram of
the infiltration for mobilization of the ribs, as for emphysema.
The zone of anesthesia should be extended downward to the
free border of the ribs if it is desired to remove a section of
cartilage to be used for filling in a bony gap in the skull from
trephining.

RESECTION OF THE SECOND TO THE FIFTH COSTAL
CARTILAGES FOR RIGIDITY OF THE THORAX.

From the 2d to the 5th interspace two rows
of wheals are made (Fig. 112) — the outer at the
external ends of the cartilages, the inner along
the sternum. Through each point 5 mils of the

156

REGIONAL ANESTHESIA.

Fig. 113. — Extensive pleurotomy and costal resection for pleu-
ral sinus. Raising the flap of soft tissues.

THORAX AND ABDOMEN.

157

Fig. 114. — Extensive pleurotomy and costal resection for
pleural sinus. (Pauchet.) The wound tamponed at the close
of the operation.

158 REGIONAL ANESTHESIA.

i per cent, solution are injected to enclose the
field of operation in the dotted line, finishing with
50 mils of the ^2 per cent, solution. The same
procedure is followed for operations involving the
pericardium and heart, or for subphrenic abscess
or suppurative costo-chondritis. When decortica-
tion of the lung is practised for a pleural sinus,
it should be remembered that in patients who
have undergone costal resections the ribs have be-
come welded together. Under these conditions it
is indispensable to employ paravertebral anesthe-
sia, intercostal infiltration being no longer possible.

OPERATIONS UPON THE STERNUM.

Five mils of the I per cent, solution are in-
jected on both sides in each space close to the
sternum. The skin and subcutaneous tissues at a
distance are then infiltrated with the ^ per cent,
solution of procaine-adrenin.

THORACOTOMY FOR ABSCESS OF THE LUNG, EX-
TRACTION OF FOREIGN BODIES, OPENING OF
INTERLOBAR ABSCESS, REMOVAL OF
TUMOR OF THE LUNGS, ETC.

A very wide anesthesia of the intercostal nerves
at their origin should be instituted. The operator
may either employ paravertebral anesthesia or in-
filtrate the intercostal nerves at points 5 centi-
meters outside of the line of the spinous proc-

THORAX AND ABDOMEN.

159

Fig. 115. — Wound made for resection of two ribs. (Pauchet.)
Interlobar pleurisy.

160 REGIONAL ANESTHESIA.

esses, i.e., at the lateral border of the mass of the
spinal muscles. The intercostal spaces are more
easily found in this situation than elsewhere.

The operator traces a line with a dermal
pencil at a distance of 5 centimeters from the
spinous processes. Then, with a very fine and
sharp needle 6 centimeters long, a band i centi-
meter wide is infiltrated with the y2 per cent,
solution along this line, with the patient sitting
down, bent forward, and with the shoulders
drawn inward; or lying down on the side. Along
this line and on a level with each spinous process,
an injection is made immediately below the cor-
responding rib. Paravertebral anesthesia, which
renders the lung insensitive, is the procedure of
choice.

OPERATIONS FOR TUMOR OF THE BREAST.

For benign operations on the breast, including
extirpation of adenoma and total extirpation of
the mammary gland, a large subcutaneous lozenge, is
circumscribed through 4 or 5 wrheals. Next, the sub-
mammary tissue is infiltrated, thus completing an
absolute circumferential anesthesia. A large amount
of y2 per cent, solution — 100 or 150 mils — is re-
quired. Half of the liquid runs off with the
blood during the operation. We have injected as
much as 250 mils without any harmful after-effects.

THORAX AND ABDOMEN. 161

REMOVAL OF CANCER OF THE BREAST.

Procaine-adrenin has been used by us several
times for this purpose, not only in thin women,
but also in fat women with some contraindication
to general anesthesia, such as renal insufficiency,
myocarditis, etc. The results were good. At times
inhalation of ethyl chloride became necessary, how-
ever, at the time of dissection of the axilla.

The technique comprises the following steps :

(a) Blocking of the brachial plexus with 10 mils
of the i per cent, solution, injected from above
the clavicle or in the axilla. The latter route
presents the added advantage of anesthetizing
simultaneously the surrounding cellular tissues.

(b) Paravertebral injection from D. I to D. 10
with 50 mils of i per cent, solution. (c) Sub-
cutaneous injection of 100 mils of y2 per cent,
procaine-adrenin, starting at the acromion, follow-
ing the clavicle to block the cervical plexus, then
the midline of the thorax, the lower border of the
thorax, and finally passing backward to the promi-
nence of the latissimus dorsi. In the case of an
obese W'Oman, we employ ordinarily 150 mils of
procaine-adrenin; large amounts of the fluid run
off, however, during the operation. By the use
of hypotonic saline solution the dose of procaine-
adrenin injected may be reduced.

162 REGIONAL ANESTHESIA.

OPERATIONS IN THE AXILLA.

Theoretically, the brachial plexus may be blocked
by supraclavicular injection and the first 5 inter-
costal nerves by paravertebral injection. To the
inexperienced operator we advise, however, merely
an infiltration of the axilla, as explained later.

ABDOMEN.

If the operative procedure required consists
merely of incising an anterior peritoneal abscess,
appendicular or otherwise, simple infiltration of
the wall by Reclus's method is sufficient. For an
operation involving prolonged maneuvers, such as
exploration of the abdomen, recourse must be had
to anesthesia of the wall at a distance and to
paravertebral anesthesia.

(A) Infiltration of the wall at a distance from
the field of operation results in a block of the
nerve supply and yields a perfect anesthesia, but
one which is only parietal. While the viscera are
not reached, the incision, separation, and suture of
the abdominal wall are rendered painless. The
viscera, furthermore, are only slightly sensitive pro-
vided no traction be exerted. This semi-sensibil-
ity on their part permits of the performance of
gastro-enterostomies and intestinal resections under
parietal infiltration, without shock.

In some instances, after the abdomen has been
opened, the anesthesia can be continued by direct

THORAX AND ABDOMEN. 163

injection of quinine and urea solution into the
mesentery. One mil of a I per cent, solution may
be injected into the meso-appendix for appendicec-
tomy, and a few drops of a i per cent, solution
in the vicinity of each omental vessel for resection
of the omentum. Such injections between the two
layers of the peritoneum, along the vessels, gives
a perfect anesthesia; but it is only practicable in
certain special cases. For resection of the stom-
ach, for instance, we anesthetize the nerves of
the organ by infiltrating the peritoneum in the
vicinity of the coronary artery, the pylorus, and
the two gastric omenta. Only very gentle handling is,
however, permissible, or during painful manipula-
tions some drops of ethyl chloride, chloroform, or
ether will have to be administered. The anesthe-
sia is often incomplete, demanding either some
mental encouragement of the patient or a few
whiffs of an anesthetic. In three-fourths of the
cases this method proves effective, and permits of
the performance of severe operations without
shock.

(B) Paravertebral anesthesia, on the other hand,
gives absolute anesthesia, at least on the side of
the body on which it is made. It must be bi-
lateral if the viscera are in or pass beyond the
median line. A choledochotomy, or removal of a
tumor of the cecum, can be perfectly performed
under right-sided paravertebral anesthesia. For a
nephrectomy, or the removal of a circumscribed
tumor of the colon, unilateral anesthesia is like-
wise sufficient. To operate on the stomach (gas-

164 REGIONAL ANESTHESIA.

trectomy) or pancreas, however, both sides must
be injected.

The operator may manipulate throughout the
abdomen by infiltrating from the 5th intercostal
to the 2d lumbar nerve on both sides. The re-
quired 22 injections are, however, distressing and
involve the use of a large dose of procaine-
adrenin.

On several occasions we have made a trans-
verse bilateral incision after paravertebral infiltra-
tion of only 6 nerves on each side; the anesthe-
sia was perfect. For the stomach, we do not em-
ploy this procedure systematically because we pre-
fer the long vertical incision, and we confine the
anesthesia to simple infiltration of the abdominal
wall with injection of quinine and urea in the
mesentery. The two forms of anesthesia may be
combined by (a) making a double paravertebral
injection of the D. 6, 7, 8, and 9 nerves, — 8 in-
jections all told, 4 on each side — to anesthetize
the stomach and epigastric wall, and (b) infiltrat-
ing in the midline below the umbilicus for a dis-
tance of 5 to 6 centimeters with a weak anes-
thetic solution.

Practice with paravertebral injections induces
the surgeon to employ them more and more fre-
quently in his work, as they are particularly
adapted for abdominal surgery. The more experi-
enced the. surgeon in the technique, the more in-
clined he becomes to substitute the procedure for
parietal infiltration. I shall present, however, with
reference to each operation, the details of the

THORAX AND ABDOMEN.

165

latter, pointing out at the same time the precau-
tions to be taken during the course of the opera-
tion under regional anesthesia.

OPERATIONS UPON THE STOMACH.
GASTROSTOMY AND GASTRO-ENTEROSTOMY.

Three dermal wheals are infiltrated, — one at
the level of the ensiform cartilage, the others at

Fig. 116. — Infiltration for supraumbilical laparotomy. Six
wheals. For gastrectomy and gastroenterostomy.

the free borders of the ribs 10 or 12 centimeters
from the first. The subcutaneous cellular tissues
and portions of muscle attached to the costal border
are infiltrated successively in order to block the

166 REGIONAL ANESTHESIA.

nerve filaments that supply the midline over two-
thirds of its length above the umbilicus. The ab-
dominal wall can then be immediately incised,
either to the right or left of this line. Next, the
skin and muscles over the free borders of the ribs
on the left side are infiltrated for a distance of
10, 12, or 15 centimeters.

Manipulations of the stomach being but slightly
painful, all complementary anesthesia is useless.
The infiltration requires from 100 to 120 mils of
the weak solution to completely relax the abdom-
inal muscles. Such anesthesia is sufficient also for
gastro-enterostomy. We inject previously, how-
ever, pantopon or scopolamine-morphine.

GASTRECTOMY.

The same paracostal incision is made, but in a
bilateral form (Fig. 117). The operation is rather
more painful owing to the extensive and pro-
longed manipulation of the stomach involved. If
a complete anesthesia is considered advisable, it
is necessary either to institute a double paraver-
tebral anesthesia (6 nerves on each side) or after
the abdomen is opened to give some whiffs of
chloroform or infiltrate the mesentery with qui-
nine and urea. It will be sufficient to chloroform
the patient slightly during the liberation and ex-
ploration. The suturing and cutting of the intes-
tines are painless. The mental condition of the

THORAX AND ABDOMEN.

167

patient is all-important. There are great contrasts
between individual temperaments. Some patients do
not utter a word during the operation, while others
cry out for an anesthetic and never cease com-
plaining.

Fig. 117. — Infiltration for high laparotomy. (Sourdat.)
Yields a larger area of anesthesia than the preceding. For
gastro-enterostomy ; operations on the gall-bladder and colon.

MEDIAN HYPOGASTRIC INCISIOX.

We seldom practice abdomino-pelvic operations
under local anesthesia. Yet the evacuation of a
tuberculous ascites or the removal of a movable
tumor of the ovary may be very easily effected
with this procedure. The pedicle should be in-
filtrated with a i per cent, solution of quinine and

168 REGIONAL ANESTHESIA.

urea without injecting the viscera; it can then
be easily crushed and tied without pain.

Cesarean section can readily be practised under
infiltration anesthesia. A lozenge-shaped area
three finger-breadths wide, in the median line, is
infiltrated so as to block the musculo-cutaneous
endings of the abdominal nerves. Opening of the
abdomen is thus rendered painless, the peritoneum
having been anesthetized by the blocking of the
parietal nerves. The uterus is almost insensitive;
yet it is well to anesthetize it with quinine and
urea, infiltrating a strip of uterine tissue on each
side of the intended uterine section at a distance
of two or three finger-breadths from the median
line. There is little bleeding.

In hysterectomy, as for cancer, fibroids, or sal-
pingitis, we prefer lumbar spinal anesthesia, but
bilateral paravertebral anesthesia will also serve
the purpose. One must inject twelve pairs on
each side, — the six lower intercostals, three lum-
bar, and three sacral. For the lesser operations,
such as hysteropexy, removal of ovarian cysts,
etc., we prefer a brief general anesthesia.

Hypogastric anesthesia for cystotomy is insti-
tuted through two wheals, the one at the umbili-
cus and the other at the pubis. Through these
one infiltrates, not in the median line, but on
either side, the skin and muscles. The peritoneum
is itself anesthetized. The muscles must be anes-
thetized, and not the linea alba, — that they may be
separated without pain.

THORAX AXD ABDOMEN.

169

OPERATIONS IN THE ILIAC FOSSA.
ILEOCECAL REGION.

Here it is well to institute a sufficiently low
paravertebral anesthesia, i.e., one involving the
last two intercostal nerves and the first three lum-
bar. If, owing to the technical difficulties, the
operator prefers to block the nerves nearer the

Fig. 118. — Infiltration for operative work in the ileocecal
region. (Pauchet.) A diamond-shaped figure under the skin
and in the muscles, circumscribing the future incision, should
be infiltrated. For appendicitis ; ileocecal resection.

field of operation, he can have recourse to infiltra-
tion of the abdominal wall in the following man-
ner (see Fig. 118 and the subsequent illustrations).

Four dermal wheals are made, in the form
of a lozenge. The two lateral wheals are placed,
the one inside the anterior superior spine of the
ilium, the other, two or three finger-breadths from

170

REGIONAL ANESTHESIA.

the middle line. The superior and inferior wheals
are situated, the one at a distance of three finger-
breadths from the first, the other, three finger-
breadths from the second. The muscular layers
should be infiltrated only at the two upper sides
of the lozenge; over the two lower sides only the

Fig. 119. — Deep "fan-shaped" injection to infiltrate the mus-
cular mass at the point of emergence of the nerves of the in-
guino-crural region. (Pauchet.) (D) Rectus abdominis. (B)
Ilio-psoas. (A) Gluteus. (C) Iliac bone. (£) Three direc-
tions of the needle: the first perpendicular to the skin, toward
the subserous cellular tissue; the second, parallel to the skin,
beneath the aponeurosis; the third, intermediate, oblique in the
intermuscular space, where the nerves are found. (1) Dermal
wheal.

subcutaneous cellular tissue is to be infiltrated.
The infiltration of the muscles produces not only
anesthesia of these structures, but also anesthesia
of the peritoneum.

With this procedure we have performed the
following operations: Cecostomy, resection of the
ileocecal segment for cancer or tuberculosis, ap-
pendicectomy, closing of intestinal fistula, and en-
terostomy.

THORAX AND ABDOMEN.

171

The incision in the abdominal wall and the
separation of the wound margins are painless, but
it is necessary to infiltrate the meso-appendix or
the end of the mesentery with quinine and urea
if section of this last structure is indicated.

Fig. 120. — Same as the preceding. (Pauchet.) Horizontal
section at the level of the iliac spine. (1) Rectus abdominis.
(2) and (3) Ilio-hypogastric and ilio-inguinal nerves, situated
at this point between the internal oblique and transversalis
muscles. (4) Genito-crural nerve. (5) Iliac bone. (6)
Parietal peritoneum. (£) Wheal situated two finger-breadths
within the iliac spine and through which the fan-shaped injec-
tion is made.

On the whole, I desire to emphasize the fact
that paravertebral anesthesia for the viscera is
rather to be recommended. The operation for ap-
pendicitis may almost always be performed under
it. We have operated upon children of 8 years,
and with greater facility children of 10 to 15
years, without general anesthesia.

172

REGIONAL ANESTHESIA.

Fig. 121. — Deep, "fan-shaped" injection above the anterior
superior iliac spine. (Pauchet and Sourdat.) To anesthetize
the wall of the iliac fossa, for appendectomy, cecostomy, ileo-
cecal resection. The figure shows the manner of direct injec-
tion, perpendicular to the plane of the wall.

THORAX AND ABDOMEN.

173

Fig. 122. — Oblique injection upward. (Pauchet and Sourdat.)
Note the direction imparted to the syringe and needle.

174 REGIONAL ANESTHESIA.

Fig. 123.— Same injection directed obliquely downward.
(Pauchet and Sourdat.)

THORAX AXD ABDOMEN.

175

Ilia-inguinal
Ilia-hypo gastric

- crural

Fig. 124. — Paracostal anesthesia — costo-iliac and para-iliac. (Pau-
chet.) Anesthesia of the entire abdominal wall (anesthetized zone in
gray). To the right are seen the intercostal filaments supplying the
abdominal wall, and lower down the ilio-hypogastric and ilio-inguinal
nerves, and the genito-crural (vertically directed). To the left of the
figure, A, B, and C show the paracostal infiltration of a portion of
muscle and of the skin (stomach, liver, and duodenum"). C, D, anes-
thesia of the abdominal wall for the ascending colon. E. F. useful for
cecal or appendicular operations and for the radical cure of inguinal
hernia.

176

REGIONAL ANESTHESIA.

Fig. 125.— Appendicitis. (Pauchet and Sourdat.) Incision
of the abdominal wall.

THORAX AND ABDOMEN.

177

Fig. 126. — Appendicitis. (Pauchet and Sourdat.) The ap-
pendix and cecum are brought to the exterior.

178

REGIONAL ANESTHESIA.

Fig. 127. — Anesthesia of the meso-appendix. (Pauchet.)
Interval operation. The needle is inserted between the two
layers of the meso-appendix, in the vicinity of the appendicular
artery. One mil of l/2 per cent, quinine and urea hydrochloride
solution is injected. The operator may then tie and divide,
without pain, the meso-appendix and the appendix itself.

THORAX AND ABDOMEN.

179

Fig. 128. — Quinine and urea anesthesia of the mesenteric
nerves before intestinal resection. (Pauchet.) The needle is
inserted in the first layer of the mesentery, and 1 or 2l/2 mils
of ]/2 per cent, quinine and urea solution injected. The oper-
ator is enabled immediately to cut the vascular pedicle and re-
sect the intestine without pain. In this instance, it is the
transverse colon.

180

REGIONAL ANESTHESIA.

Fig. 129. — Pylorectomy for callous ulcer. (Pauchet.) First
step: Exploration of the abdomen. (Patient from the La Pitie
Hospital).

THORAX AND ABDOMEN.

181

Fig. 130. — Pylorectomy for callous ulcer. (Pauchet.} Pyloric seg-
ment resected. The canal has been incised lengthwise along the greater
curvature, then spread out. Lower down, the great omentum is seen
attached to the greater curvature by an inflamed lymph-gland. The
operative mortality is 8 per cent.

182

REGIONAL ANESTHESIA.

Fig. 131. — Continent jejunostomy. (Pauchet.) For a large
cancer of the stomach. (Patient from La Pitie Hospital).

Fig. 132. — Artificial anus due to wound of the intestine.
(Pauchet.) Military wound from La Pitie Hospital (shell
splinter). Circular enterorrhaphy.

THORAX AXD ABDOMEN.

183

Fig. 133. — Ileocecal segment invaded by cicatricial tuberculosis.
(Pauchet.) To the right the end of the small intestine may be recog-
nized. The cecum has become transformed into a fibrous mass, with
a small, hardly perceptible, mucous canal. (La Pitie Hospital.)

184

REGIONAL ANESTHESIA.

Fig. 134. — Partial gastrectomy for saddle ulcer of the lesser curva-
ture. (Pauchet.') First stage of the operation : Separation of the
omentum by means of the scalpel. The assistant holds the transverse
colon with the left hand; the operator holds the scalpel with his right
hand and with the left the omentum is separated from the transverse
colon for examination of the posterior surface of the stomach. Mor-
tality 8 per cent.

THORAX AND ABDOMEN.

185

Fig. 135. — Specimen from the preceding patient. (Pauchet.) Mid-
dle segment of the stomach, showing a saddle ulcer of the lesser curva-
ture. The resected segment has been laid open along the greater
curvature, to which the omentum is attached below. The center of the
figure, where the ulcer is found, corresponds to the middle of the
lesser curvature.

186

REGIONAL ANESTHESIA.

UMBILICAL HERNIA.

Umbilical hernias and hernias of the linea alba
are operated under lateral infiltration of the mus-
cles, in the same manner as for laparotomy. The
operator infiltrates successively the skin and the

Fig. 136. — Anesthesia for radical cure of a reducible um-
bilical hernia. (Pauchet.) Through the wheals a ring of in-
filtration is made, following the dotted line, vnder the skin
and in the thickness of the muscles.

muscles down to the subserous cellular tissue with
a weak solution. Pauchet, in 1914, operated at
Amiens on an obese woman with a strangulated
hernia in tfie median line, of the size of an adult's
head and containing 1.50 meters of gangrenous
intestine. The patient complained somewhat when

THORAX AND ABDOMEN.

187

the mesentery was ligated, but it did not become
necessary to have her inhale any chloroform. Two
hundred and fifty mils of a ^ Per cent, solution
were employed.

In an extremely obese woman with a simple
umbilical hernia, Pauchet injected as much as 300

Fig. 137. — Location of the wheals and the proper direction
of injection for anesthetization in irreducible umbilical hernia.
(Pauchet.)

mils of the weak solution. Part of the fluid es-
caped, however, during the operation. In making
these injections, 12-centimeter needles were em-
ployed.

For all these operations, the procedure is al-
ways the same. A lozenge-shaped wall of infil-
tration around the umbilicus is established. Through
four w^heals all of the subcutaneous tissue and

188

REGIONAL ANESTHESIA.

muscles are infiltrated, following the lines that
form the lozenge. In cases of umbilical hernia
and post-operative eventration, injection of quinine
and urea into the omentum, about the vessels, is

Fig. 138. — Injection for irreducible umbilical hernia.
(Pauchet.) The infiltration is conducted at a distance from
the ring and through the entire thickness of the wall.

an important preliminary to resection of the omen-
tal membrane, which under this treatment becomes
absolutely insensitive.

INGUINAL HERNIA.

The operation for inguinal hernia is without
doubt, of all operations, that in which regional
anesthesia gives the greatest satisfaction, no mat-
ter how voluminous the hernia may be. That it
is indicated is due to three factors: (i) The
disease itself" is hardly more dangerous than gen-
eral anesthesia; the latter may give rise to a bron-
chitis that is prejudicial to consolidation at the

THORAX AND ABDOMEN.

189

points of suture; (2) the resultant vomiting has
the same tendency; (3) regional anesthesia, which,
it must be recognized, is imperfect for certain
operations, shows its utility for the radical cure

Fig. 139. — Nerve supply of the inguinal region (diagram-
matic). (Pauchet.) Points of emergence of the genito-crural,
ilio-hypogastric, ilio-inguinal, and of an anterior branch of the
12th intercostal. For anesthesia of the inguino-crural region
they should be reached here by injection. The needle should
be introduced within the anterior superior iliac spine.

of inguinal hernia when properly employed, and
the technique for this operation is very simple.
In April, 1916, at the La Pitie Hospital we op-
erated on an inguinal hernia of the size of a
large adult's head, without the slightest pain.

190 REGIONAL ANESTHESIA.

Paravertebral anesthesia will yield a perfect
anesthesia at a distance and seems to us the pro-
cedure of election. No matter how large the her-
nia, it will be sufficient to inject the two lower
intercostal and upper three or four lumbar nerves.
Yet the great majority of surgeons prefer anes-
thesia by localized infiltration of the nerves of
the region, the technique of which is as follows:

Figures 139 and 124 show the innervation of
the groin and of the crural region respectively.
The genital branch of the genito-crural reaches
the spermatic cord through the internal ring and
accompanies it in the canal and in the skin of
the scrotum or of the labia majora. The ilio-in-
guinal is situated above the iliac spine, between
the oblique muscles; it passes under the aponeu-
rosis of the external oblique, emerges from the
inguinal canal upon the anterior surface of the
cord and of the sac, and ends in the skin of the
scrotum or mons veneris. The ilio-hypogastric,
parallel to the preceding and slightly higher up,
makes its way between the two oblique muscles;
reaching the inguinal region, it passes under the
aponeurosis of the external oblique, crosses through
the anterior layer of the sheath of the rectus, and
ends in the skin of the groin. These three nerves
anastomose with each other. It is necessary,
therefore, that all three be anesthetized. They are
all to be found grouped together in a space of 2
or 3 finger-breadths within and above the iliac
spine.

THORAX AXD ABDOMEN.

191

REDUCIBLE INGUINAL HERNIA.

Two wheals are made, the first two finger-
breadths within the anterior superior iliac spine
and the second corresponding to the pubis at the

Fig. 140. — Anesthesia for irreducible inguinal hernia.
(Sourdat.) Location of the two wheals. The arrows show
the direction of the deep injections. The unbroken line out-
lines the subcutaneous infiltration.

level of the external abdominal ring. Through
wheal No. i, infiltration is executed according to
the scheme shown by the arrows in Figs. 119
and 1 20. All the muscular layers situated be-
tween point i and the ilium are infiltrated, using

392

REGIONAL ANESTHESIA.

/ON

Fig. 141.— Same as the preceding. (Sour dot.) A wheal
is made two finger-breadths within the anterior superior iliac
spine. The second wheal is made above the horizontal ramus
of the pubis. The black line shows the subcutaneous infil-
tration.

THORAX AND ABDOMEX. 193

20 mils of a i per cent, solution. A Q-centimeter
needle is introduced perpendicularly, passing through
the aponeurosis of the external oblique, the inter-
nal oblique, and the transversalis muscle. It is
then inserted so as to cover a fan-shaped sector,
and more and more obliquely toward the spine
of the ilium. The muscular layer here is very
thick. This injection reaches the ilio-hypogastric
and ilio-inguinal nerves. Through point i, it is
necessary to infiltrate anew under the aponeurosis
of the external oblique a strip ending at two
points situated, respectively, within and externally
to the hernial ring, using approximately 20 mils of
the weak solution. Through wheal Xo. 2, 10 mils
of the solution are injected in a fan-shaped area
to the line of the cord; the needle should strike
the pubic bone. Through the same point, 10 mils
are next injected in the inguinal canal itself
along the cord. Finally, subcutaneous infiltration
is conducted following the lozenge-shaped figure
shown in the illustration, approximately 100 mils
of the wreak solution — ]/2 per cent. — being used
altogether (Figs. 140 and 141).

IRREDUCIBLE OR STRANGULATED INGUINAL
HERNIA.

Four wheal s are made as indicated in Fig.
142. Through wheal No. i one injects, as before,
against the iliac bone, and continues toward
wheals Nos. 2 and 3, injecting under the aponeu-

194

REGIONAL ANESTHESIA.

rosis. Next, two deep injections are made through
points 2 and 3. While the left hand pushes
laterally inward and outward the hernia mass, the
needle is inserted as far as the pubis, under the

Fig. 142. — Lines of infiltration for inguinal hernia. (Sourdat.)
For irreducible or strangulated hernia.

hernia, and injection made deeply in the canal
through points 2 and 3 along the neck of the
sac. Finally, a subcutaneous injection between the
points 1-2-3 and 2-3-4, is made. For a large
hernia 150 mils of the weak solution may be used.

THORAX AND ABDOMEN.

195

We prefer in such cases the paravertebral form of
anesthesia, which deals with the nerves supplying
the cord. The procedure just described, however,
will likewise give satisfaction (Figs. 142 and 143).

Fig. 143. — Anesthesia of the scrotum for irreducible her-
nia. (Sourdat.) Subcutaneous infiltration of the root cf the
scrotum through a crown of wheals.

FEMORAL HERNIA.

The nerve supply in femoral hernias is essen-
tially that of the inguinal region. The anesthetic
procedure, therefore, is almost the same:

196

REGIONAL ANESTHESIA.

Four dermal wheals are made. Point I occu-
pies the same place as in inguinal hernia, viz.,
two finger-breadths within the anterior superior
iliac spine. Points 2 and 3 are within and out-

Fig. 144. — Reducible femoral hernia. The deep injections
(arrows) and subcutaneous circuminfiltration are made through
wheals 1, 2, 3, and 4.

side of the hernia, respectively, and at both ends
of the intended femoral incision, parallel to the
femoral arch. Point 4 is below the hernial mass.
One starts with the intramuscular injections at
point I. Through this one injects under the
aponeurosis up to and outside of the neck. Then,

THORAX AND ABDOMEX.

197

Fig. 145.— Irreducible femoral hernia. (Pauchet.) A fan-
shaped intramuscular injection is made through point A.
Infiltration of a subcutaneous band surrounding the hernial
tumor and neck is conducted through points A, B, C, and D.

Fig. 146. — Anesthesia of the hernial sac and testicle by
infiltration of the cord. Injection of the cord in the inguinal
canal.

198 REGIONAL ANESTHESIA.

under the femoral arch through point 4, 10 mils
of the solution are infiltrated around the neck, and
very close to it. Finally, subcutaneous infiltration
is effected. The femoral arch is anesthetized by
this procedure. If it be necessary to combine an
inguinal incision with the high femoral incision,
the anesthesia will be sufficient for the purpose.
We have never been compelled to give ethyl chlo-
ride to the patient during the liberation of the
intestine. When, however, in a stout patient, we
contemplated radical cure of a femoral hernia
through the inguinal route, the patient complained
somewhat while we were working deeply, showing
' that the anesthesia had been incorrectly instituted.

OPERATIONS UPON THE KIDNEY.

Nephrectomy is another operation for which
regional anesthesia is indicated. This method
saves the renal tissue in the same way as it does
the hepatic. The anesthesia, moreover, is com-
plete. The lateral position of the subject can be
maintained without the help of an assistant, the
patient's voluntary aid being sufficient. Decortica-
tion of the kidney and the ligation of the pedicle
are painless. We employ unilateral paravertebral
injection of the six lower intercostal and of two
lumbar nerves. When once familiar with the
technique, one no longer finds it necessary to
have the patient inhale any additional anesthetic
at the time of decortication of the kidney.

THORAX AND ABDOMEN. 199

OPERATIONS UPON THE BILIARY PASSAGES.

It is advantageous to perform these without
ether or chloroform, the harmful action of which
upon the hepatic cells is well known. Our first
operations under paravertebral anesthesia were
done upon patients suffering from chronic jaun-
dice,— of two months' standing in one instance
(pancreatic tumor) and in another, six months (for-
mer lithiasis, with acute obstruction of the ductus
choledochus). The post-operative course \vas de-
void of complications, and the operations were ab-
solutely painless, even in the second case, ren-
dered difficult by multiple, long-standing adhesions.
Since then all of our hepatic and biliary opera-
tions have been conducted under paravertebral
anesthesia.

Right-sided paravertebral infiltration of the six
lower intercostals and first two lumbar are re-
quired for the purpose. Here, as in the case of
the kidney and other similar operations, one is
struck by the frequent diminution of post-opera-
tive pain in the succeeding twenty-four hours.
The method allows of the performance of chole-
cystectomy. Vertical or transverse incisions may
be employed provided they do not cross the median
line. The cushion placed under the chest may be
a cause of suffering, which is obviated by a pre-
vious injection of morphine.

CHAPTER VI.

ANESTHESIA OF THE GENITOURINARY
ORGANS AND RECTUM.

THE pelvic organs and external genitalia are
supplied by the internal pudic nerve, the small
sciatic, and the sacral and coccygeal plexuses, which
anastomose with branches from the pelvic sympa-
thetic.

Fig. 147. — Nerve supply of the perineum in the male.
(Pauchet.) Trunk of the internal pudic nerve and branches
of the small sciatic.

The internal pudic nerve emerges from the

pelvis through the great sciatic notch, winds around

the external 'surface of the sciatic spine, traverses

the ischio-rectal fossa, and gives filaments to the

(200)

GENITOURINARY ORGANS AND RECTUM,

201

Fig. 148. — Nerve supply of the perineum in the female.
(Pauchet.) Internal pudic nerve and branches of the small
sciatic.

Fig. 149. — Sensory segments of the perineum correspond-
ing to the last spinal pair. (Pauchet.) The branches S indi-
cate the sacral nerves, with the number of the foramen of
emergence. The branches L are lumbar. The number is that
of the corresponding segment. (See also Figs. 220 and 221.)

202

REGIONAL ANESTHESIA.

skin of the perineum, anus, posterior half of the
scrotum, penis, and vulva. The anterior half of
the scrotum and of the labia majora is supplied
by the genito-crural and the ilio-inguinal. The

Fig. 150. — Pre-sacral anesthesia. (Pauchet.) To reach all
sacral foramina but the first, the needle is introduced between
the anus and coccyx and follows the anterior surface of the
sacrum to each foramen. To reach the first sacral foramen,
the needle is inserted at the same point but is pushed directly
through the tissues to reach the sacral brim When the bone
has been reached, the injection is made.

2d, 3d and 4th sacral pairs constitute the hypo-
gastric plexus, and through it supply the bladder,
prostate, icterus, rectum, and pelvic peritoneum.

Regional anesthesia for the above operations is
simple and easy of application, and the various
regions involved and methods of treatment are

GEXITO-URINARY ORGANS AND RECTUM. 203

Fig. 151. — Trans-sacral anesthesia. (Pauchet.) Note the
depth to which the needle B penetrates to reach the pos-
terior foramen Si. On the contrary B finds the orifice
55 immediately beneath the skin. The needle penetrates ap-
proximately 25 millimeters to reach the first sacral foramen,
20 for the second, 15 for the third, and 10 for the fourth, and
should be driven about 1 centimeter into each canal in order
to reach the anterior as well as the posterior division of the
nerve. It is well to introduce the index finger into the rectum
in order to be certain that the point of the needle is not pene-
trating the rectal wall.

204

REGIONAL ANESTHESIA.

Fig. 152. — Pre-sacral and trans-sacral anesthesia. (Pauchet.)
The tirst of these procedures is indicated in the obese and the
second in thin subjects. In the latter the bony landmarks are
more easily found. Note the direction followed by the pre-
sacral needle for each foramen. The first four anterior arrows
reach the foramina 5, 4, 3, and 2. The needle point should be
kept in constant contact with the concavity of the sacrum, and
should always be parallel to the middle line of this bone. The
arrow dq^tined for Si aims directly at the superior strait of
the pelvis. As soon as it comes in contact with this, the needle
is at the sacral foramen ST. If injury of the rectum is appre-
hended, a finger should be inserted in it during the introduc-
tion of the needle.

GENITOURINARY ORGANS AND RECTUM. 205

fully shown in Figs. 147 to 158. In Fig. 152 are
shown the two methods of application. In thin
subjects the injections are made through the five
sacral foramina. In stout subjects it is often
easier to reach the sacral nerves by introducing
the needle at a point between the rectum and the
tip of the coccyx, and infiltrating the concavity of
the sacrum with a I per cent, solution of pro-
caine-adrenin.

ANTERIOR SACRAL (PRE-SACRAL) ANESTHESIA.

The patient is placed in the dorsal position,
with the thighs flexed upon the abdomen. After
proper preparation of the skin with iodine and
alcohol, an intra-dermal wheal is formed at a
point midway between the anus and the tip of the
coccyx, thus permitting the introduction of the suc-
cessive needles without pain.

Through the wheal thus formed a needle 9
centimeters long is introduced and with its point
the inferior and outer border of the sacrum about
2 centimeters from the median line is found. The
needle is now pushed forward, with its point in
constant contact with the anterior face of the
sacrum, for about I centimeter, which should
bring the point to a level with the fifth sacral
foramen. Five mils of a i per cent, solution are
thereupon injected.

One then continues upward, parallel and at
about 2 centimeters from the median line, keeping
the needle point constantly in contact with the sur-

206 REGIONAL ANESTHESIA.

face of the bone, at a distance of about 1^2 to
2 centimeters from the point already injected,
when it should be at the level of the fourth sac-
ral foramen. Here again 5 mils of I per cent,
solution are injected. Then, with the needle in
contact with the bone and always about 2 centi-
meters from the median line, one proceeds about
1 1/2 to 2 centimeters higher up to the third fora-
men, w7here 5 mils should again be injected. In
the same manner the needle is pushed upward a
fourth time to the second foramen, where the
same amount of solution is again injected. The
needle is next drawn back to the starting point
and the same manipulation repeated on the oppo-
site side of the median line, thus bringing under
control both sets of nerves.

The first needle is now replaced by one 12
centimeters long, the gloved finger placed in the
rectum, and the needle introduced at the same
point. Instead of following the surface of the
bone, however, one next pierces directly upward
to a depth of 9 to 10 centimeters, and with the
finger in the rectum aiding as a guide, aims to
strike the upper part of the sacrum as it tilts
forward. At this depth, about 2^ centimeters
from the median line and against the bone, the
first sacral foramen is attained. Five mils of solu-
tion are injected and the procedure repeated on
the opposite side. The last injection is an extra
precaution. As a rule it is not needed, complete
anesthesia of the parts being secured by injection
of the other four pairs.

GENITO-URINARY ORGANS AND RECTUM.

207

ANESTHESIA THROUGH THE SACRAL FORAMINA —
TRANS-SACRAL ANESTHESIA.

The patient is placed in the extended posture
and face down upon the table. With the aid of

V-5

Fig. 153. — Location of the posterior sacral foramina.
(Pauchet.) MM', middle line of the body. V ', spinous proc-
ess of the 5th lumbar vertebra. /-/' lines joining the iliac
crests. TT', postero-inferior spines of the ilia. H, fourth
sacral spinous process. CC, sacral cornua. X, sacral hiatus.

a dermographic pencil, a line is drawn from the
crest of one ilium to that of the other (Fig.
156, CC). The relationship of the posterior supe-
rior spines of the ilia is shown at EE. The
sacral cornua, BB, are now found and marked.
From top to bottom a line is drawn directly over

208

REGIONAL ANESTHESIA.

the median line from D to A. A point 4 centi-
meters on each side from the median line, on the
line CC ', is marked. This point is connected on

Fig. 154. — Posterior surface of the sacrum, showing the
posterior sacral foramina and sacral nerves. (Pauchet.) A,
the interiliac line. B, line joining the two postero-inferior
iliac spines. M, line joining the two middle spinous processes.
C, horizontal line passing through the two sacra) cornua at
the level of the sacral foramen, 55. The oblique line corres-
ponds to the situation of the sacral foramina; it is located
25 millimeters from the middle line at the level of the two sac-
ral cornua. Note that the lumbo-sacral space, through which
spinal anesthesia may be induced (Le Filliatre) is at the mid-
dle of the interval that separates A from B. K, point cor-
responding to the fourth sacral spinous process. 84 is situated
1 centimeter outside of K.

each side by a line drawn downward to the
point B. * The line passes directly over the five
sacral foramina. Commencing- at the top, the first
foramen is found on this line directly opposite the

GEX1TO-UR1XARY ORGANS AXD RECTUM 209

tip of the spinous process of the fifth lumbar
vertebra (Fig. 153).

At a point ^l/> centimeters below on the same
line will be found the second foramen. Two and
one-half centimeters further down is the third; 2
centimeters down is the fourth, and il/2 below
this is the fifth. The first is about 35 mm. from
the median line ; the second, 30 ; the third, 25 ; the
fourth, 20, and the fifth, 15 mm.

Technique of the Injections. — The spine is
painted with iodine, which is then removed with
alcohol. "With a fine needle five dermal wheals
are injected on each side of the median line at
points overlying the sacral foramina. One com-
mences at the top with a needle 9 centimeters
long; if it does not at once enter the foramen the
operator will readily find the opening by feeling
about with the point of the needle. The latter
should penetrate to a depth of about 25 mm. for
the first foramen; 20 mm. for the second; 15 mm.
for the third; 10 for the fourth, and 5 for the
fifth. Five mils of a I per cent, solution are to
be injected at each opening.

In feeling about with the point of the needle,
seeking the opening, the operator will suddenly
sense the absence of resistance as the needle en-
ters the foramen, and at the same moment the
patient is likely to complain of a disagreeable sen-
sation in the abdomen or legs which is proof that
the nerve has been struck. After fifteen minutes
the operation can be begun. The anesthesia lasts
from one and one-half to two hours.

210

REGIONAL ANESTHESIA.

Fig. 155. — Trans-sacral anesthesia of the pelvic organs and pelvic
peritoneum. The two iliac crests should be felt for and the line AB
marked out. The prominent postero-inferior spine is at C, and the
sacral cornu at D (sacro-coccygeal articulation). C is placed slightly
too high in the sketch. The reader will notice at his right the promi-
nent postero-inferior spine exactly outside of the sacral foramen, 82.
5*5 is exactly outside of the sacral cornu. 82 and Si are separated by
the width of the thumb, as are also S2 and 5j. $4 and S$ are sep-
arated by the width of the little finger; the former corresponds to the
summit of trie sacral hiatus. The sacral foramina are situated on a
line starting from the sacral cornu 15 millimeters from the median
line and ending at the line AB, 35 millimeters from the median line.
Z, the lumbosacral hiatus, is at the same distance from $2 and from
AB. XY corresponds to the 5th lumbar. These landmarks are utilized
in posterior sacral anesthesia as well as in spinal anesthesia.

GENITOURINARY ORGANS AND RECTUM.

211

Sacral injections anesthetize the labia, pros-
tate, bladder, rectum, anus, uterus, and skin of
the posterior surface of the thigh. We use this
method to do prostatectomies, extirpation of the

c J-PJM^A

. " *" "^^^^^™""*T^i""Tr"^^7p^

Fig. 156. — Trans-sacral anesthesia. (Pauchet.) (Posterior land-
marks: Fig. 155). CC, inter-iliac line. EB, BE, a trapezoid figure
the base of which measures 8 centimeters and the summit, 3 centi-
meters. The points BB correspond to the sacrococcygeal articulation
and the cornua of the sacrum; they are located 15 millimeters from
the midline. The 5th sacral foramen is situated immediately outside
of them. Ei, postero-inferior iliac spine (here shown a little high).
The black dot between D and the line Ei, Ei should be at equal dis-
tance from D and Ei, Ei, i.e., in the lumbo-sacral space or area of
election for lumbar puncture. The distance separating each sacral
foramen from the midline is also shown. The finger, T, shows that
there is a finger-breadth of distance between the sacral foramina. The
needle is entering foramen Xo. 4.

212

REGIONAL ANESTHESIA.

rectum, radical cure of prolapsus uteri, all vesical
operations, curettage of the uterus, and catheter-
ization of the ureters in man (for tuberculosis,
cystitis, etc.), but the parietal peritoneum is not
sufficiently anesthetized to permit of a hysterectomy.
(See also Figs. 220 and 221, p. 282.)

Fig. 157. — Trans-sacral anesthesia in man. (Pauchet.)
This permits of operating upon a cancer of the rectum, hemor-
rhoids, prostatic adenoma, tumor of the bladder, amputation of
the penis, etc.

OPERATIONS UPON THE BLADDER.

SUPRAPUBIC CYSTOSTOMY.

To periorm a suprapubic cystostomy, the trans-
sacral and hypogastric forms of anesthesia com-
bined are necessary. For a cystostomy a lozenge

GENITOURINARY ORGANS AND RECTUM. 213

is made the long axis of which corresponds to the
lower half of the distance between the umbilicus
and the pubis. The skin and muscles are infil-
trated with the weak solution. The bladder is
not anesthetized; but infiltration of the space of
Retzius sufficiently diminishes its sensibility. One

Fig. 158. — Trans-sacral anesthesia in woman. (Paucket.)
The gray area shows the region anesthetized by injection of
the sacral nerves (pelvis and perineum). This enables the
surgeon to operate upon cancer of the rectum, hemorrhoids,
prolapsus uteri, or cystocele, and the obstetrician to use for-
ceps without pain.

should add an intravesical injection of 50 mils of
a y? per cent, solution, allowed to remain dur ing-
fifteen or twenty minutes for a simple section and
vesical exploration. The bladder is rendered en-

214

REGIONAL ANESTHESIA.

tirely insensitive by the sacral injections, but the
abdominal wall must be infiltrated in addition be-
fore it is incised.

Fig. 159. — Suprapubic cystostomy. (Pauchet.) The opera-
tor makes two wheals, 1 and 2; then infiltrates the subcuta-
neous cellular tissues for a thumb's width to the right and left,
and the two recti abdominis. Through wheai 1, he injects the
space of Retzius in order to desensitize the bladder.

OPERATIONS UPON THE TESTICLES AND
SCROTUM.

The operator should first anesthetize the cord,
then make a ring of anesthesia about the base of
the scrotum, on both sides. A wheal is made
over the external abdominal ring. With the left
hand, the cord is held firmly over the pubis, a
needle detached from the syringe inserted, the cord

GENITOURINARY ORGANS AND RECTUM. 215

Fig. 160. — Anesthesia of the testicle. (Pauchet.) Infiltra-
tion of the cord by transfixion of it upon the pubis. In order
not to miss the cord, the needle is pushed successively in two
or three divergent directions.

Fig. 161. — Anesthesia of the testicle. (Pauchet.) Infiltra-
tion of the cord. The latter is pinched between the fingers
through the skin, raised between two fingers, and injected.

216

REGIONAL ANESTHESIA.

transfixed upon the pubis, then, after slight with-
drawal of the needle, 5 mils of the weak solu-
tion injected; this infiltrates the cord. To make
certain, the maneuver is repeated and the cord
immobilized upon the pubis, transfixed, and infil-
trated with 5 mils of the weak solution. Then,

Fig. 162. — Operations upon the scrotum. (Pauchet.) A band
of subcutaneous infiltration circumscribes its base.

with the left index finger, the operator finds the exter-
nal inguinal ring, introduces the needle from 6 to
9 centimeters into the inguinal canal, and injects
anew 10 mils of the weak solution.

To anesthetize the scrotum, the operator should
work all the way round its base, starting at the
lower surface of the penis, and, passing around,

GENITOURINARY ORGANS AND RECTUM. 217

infiltrate the subcutaneous tissue until he gets
back to the starting point. He then passes in
front of the perineum and in the genito-crural
folds. The weak solution is sufficient; 50 mils,
more or less, are required.

OPERATIONS UPON THE PENIS.

If it is desired to effect merely a dorsal incision
of the prepuce, with simple section of the frenum,

Fig. 163. — Anesthesia of the prepuce by a coronal
injection. (Pauchet.)

the skin should be infiltrated in the median line
by the "Reclus method" from the anterior aspect of
the prepuce to the corona of the glans. One is
thus enabled to slit the prepuce with scissors and
suture the borders of the wound. A second in-
jection being made at the level of the frenum,
this may be split and one or two sutures taken

218

REGIONAL ANESTHESIA.

in it. We favor this simple operation, rather than
that of circumcision.

If the operator wishes to do an ordinary cir-
cumcision, amputate the penis, or operate upon a
hypospadias, it will be necessary for him to insti-
tute a total anesthesia of the penis in the follow-
ing manner: A wheal is made at the right and
left of the root of the penis, wrhere the cord

/
I

Fig. 164. — Anesthesia of the penis. (Pauchct.) Through
two wheals an injection is made at first deeply up to the roots
of the corpora cavernosa and the suspensory ligament, then
under the skin in circular fashion.

crosses over the horizontal ramus of the pubis.
Through this wheal the needle is introduced up to
the corpora cavernosa, under the suspensory liga-
ment of the penis, and deeply around the penis.
Forty mils of a ^2 per cent, solution of procaine-
adrenin are injected. This injection will anes-
thetize the urethra, corpora cavernosa, glans
penis, etc.

GENITO-URINARY ORGANS AXD RECTUM. 219

OPERATIONS UPON THE POSTERIOR URETHRA.

For suture of the urethra, urethrotomy, etc.,
a wheal is first made in front of the anus in the
median line. Then, through this wheal, the ver-
tical plane of tissue that separates the anus and
rectum behind from the urethra, bulb, and pros-
tate in front is infiltrated. The left index finger
is placed in the rectum and with the right hand
a 9-centimeter needle is taken and passed in in
the median line, very high up between the pros-
tate and rectum; the operator now injects while
withdrawing it. He then begins anew, without
wholly withdrawing the needle, and passes to the
right and to the left, in order to infiltrate a space
9 centimeters high and 2 or 3 wide. This plane
separates the rectum and anus behind from the
prostate and urethra in front. All the subcutane-
ous cellular tissues and the muscles should be in-
filtrated.

Finally, it is necessary to infiltrate the plane
of section corresponding to the incision in peri-
neotomy for operations on the prostate. The op-
erator may in this way go up as high as the
neck of the bladder and the prostate with per-
fect anesthesia. Yet, anesthesia by the sacral fora-
mina is in every way preferable.

220 REGIONAL ANESTHESIA.

OPERATIONS UPON THE PROSTATE.
PROSTATECTOMY.

A choice may be made from one of the four
following methods of anesthesia :

1. Periprostatic infiltration through the bladder.

2. Periprostatic infiltration through the peri-
neum.

3. Anterior sacral anesthesia.

4. Posterior trans-sacral anesthesia.

i. Periprostatic Anesthesia Through the Blad-
der.— (a) The operator begins by anesthetizing
the abdominal wall, as for a cystotomy, then the
space of Retzius. The simple infiltration of these
tissues yields a satisfactory anesthesia. The injec-
tion must be carefully pushed into the entire
thicknesses of the muscles, in order to be able to
separate them without pain.

(b) For anesthesia of the prostate, the blad-
der having been opened, the operator takes a long
curved needle (Legueu?s) and passes through the
mucosa of the bladder around the prostate, with
the finger as guide. Approximately 150 mils of
the weak solution of procaine-adrenin is used.
Five or six minutes after this infiltration the op-
erator may begin removing the prostate.

2. Periprostatic Anesthesia Through the Peri-
neum.— The operator, after having infiltrated the
abdominal wall as in the preceding method for a
suprapubic section, must anesthetize the tissues
between the two ischia, comprising the skin and
soft parts situated between the urethra in front,

GENITO-URINARY ORGANS AND RECTUM.

221

and the rectum and anus behind. This form of
infiltration is useful for all operations upon the
perineum (see Fig. 165).

To reach the prostate, the operator places his
left index finger in the rectum in contact with the hy-
pertrophied organ. With the right hand a 9-
centimeter needle is introduced into the perineum
and guided up toward the prostate by the aid of

Fig. 165. — Anesthesia of the anterior portion of the perineum
through a wheal in front of the anus. (Pauchet.)

a finger in the rectum. When the needle has at-
tained the periprostatic region, 50, 60, or 80 mils
of the weak solution of procaine-adrenin are
injected.

3. Anterior Sacral Method. — This consists in
infiltrating all of the concavity of the sacrum with
a i per cent, solution. The needle should pass
between the rectum in front and the sacrum be-

222 REGIONAL ANESTHESIA.

hind. The operator injects approximately 5 mils
of procaine-adrenin opposite each one of the sacral
foramina. It is unnecessary to inject the upper
foramen (see Fig. 152 and detailed descriptions,
including that of the trans-sacral method, at the
beginning of this chapter).

4. Trans-sacral Method. — The operator must
be experienced before such an anesthesia will
prove perfectly satisfactory, but after some ex-
perience the trans-sacral method, which is by long
odds the best, will be the one chosen.

With this procedure, very little of the anes-
thetic is required, and all that is needed in addi-
tion is the injection of the anterior abdominal
wall.

OPERATIONS UPON THE VULVA AND VAGINA.

The posterior half of the vulva is supplied by
the sacral nerves ; the anterior half, by the ilio-
inguinal and genito-crurals. If the operation in-
dicated is one of minor importance, it is best to
anesthetize the vulva directly. Three wheals are
made, a middle one in front of the anus, and 2
lateral ones at the lower terminations of the labia
majora. The soft tissues outside the labia majora
are then infiltrated, thus completing the anesthe-
sia (Fig. 1 66).

Where it is desired to anesthetize the vesti-
bule of the vagina, the above method is not suffi-
cient. One must infiltrate with the weak solution,
following a frontal plane, in the manner already
described for a perineotomy in the male. To infil-

GENITO-URINARY ORGANS AND RECTUM.

223

trate the recto-vaginal septum, a finger should be
introduced in the vulva or rectum to guide the 9-
centimeter needle. One then infiltrates after Rec-
lus's method, using 100 mils of the solution. After
this one may operate for a recto-vaginal fistula,
perform a perineorrhaphy, etc.

Fig. 166. — Anesthesia of the vulva and vestibule. (Pauchet.)

LIBERATION OF THE VAGINA AND OF THE UTERUS
PROLAPSE, COLPORRHAPHY, COLPOTOMY.

The preceding methods may be sufficient; this
simple infiltration, however, does not anesthetize
the pelvic floor. The vaginal vault should be in-
filtrated in addition. To do this, the cervix of the
uterus is brought down until it shows at the vulva;

224 REGIONAL ANESTHESIA.

a 9-centimeter needle is introduced into the an-
terior cul-de-sac, and 20 mils of solution injected
between the bladder and the cervix (not under
the mucous membrane). Another injection is now
made under the urethral meatus, and this time
right and left injections made on each side under
the mucous membrane; 10 mils of solution are
used. The cervix is pulled to the right and an
injection made into the left lateral cul-de-sac, in-
filtrating the base of the broad ligament, using
15 mils. The operator begins anew on the right
side, then introduces the 9-centimeter needle into
the posterior cul-de-sac, between the vaginal mu-
cous membrane and Douglas's cul-de-sac, injecting
20 mils. The uterus is now released and the
perineum infiltrated as previously described. In all
at least 200 mils are necessary.

A satisfactory anesthesia is obtained in a pre-
cise and simple way with the sacral method; but
by this procedure no hemostasis is assured, while
on the contrary, if infiltration is practised after
Reclus's method, the operation is bloodless. In
perineorrhaphy this is an advantage; from the
anatomical point of view, however, the sacral
method is more attractive, and we give it preference.

OPERATIONS UPON THE ANUS.

The trans-sacral procedure is very satisfactory
in operations upon the anus. The perineal infil-
tration gives not only a good anesthesia, but also
a perfect ischemia. All will agree that to extir-

GENITO-URINARY ORGANS AND RECTUM

225

pate hemorrhoids without the loss of a drop of
blood is ideal. For this reason, we give pref-
erence to the Whitehead operation, and infiltrate
at a distance around the anus and rectum when
the operation is practised, as upon a cadaver.

Four dermal wheals are made in a lozenge
form, one in front of the anus, two laterally, and

Fig. 167. — Anesthesia of the anal region through four
wheals circumscribing the anus and at some distance from it.
(Pauchet.)

the last behind, not too close, two finger-breadths
from the anal orifice (Fig. 167 and 169). Through
these four points all the injections, using l/2 per
cent, solution, are made. Through the perineal
wheal, the needle is introduced, at first perpen-
dicularly to the surface, and afterward in a fan-
shaped manner, right and left, each time 4 or 5

226

REGIONAL ANESTHESIA.

mils of the solution being injected deeply in the
sphincter and under the skin. Through the lateral
wheals fan-shaped injections are also made, paral-
lel to the rectal walls, reaching the levator ani,
and bathing the ischio-rectal fossae, the sphincter,
and the subcutaneous and submucous tissues (Fig.

Fig. 168. — Radiating injections through the lateral wheal.
(Pauchet.) The figure shows the three positions in which the
needle should be placed in order to infiltrate the entire mass of
tissue with quinine through a single wheal.

168). Finally, a mass of tissue is also infiltrated
behind the anus and rectum, in fan-shaped fashion.
The rectum is completely surrounded by the in-
filtration.

GENITOURINARY ORGANS AND RECTUM.

227

Fig. 169. — Radical cure of hemorrhoids by Whitehead's op-
eration. (Pauchet.) Through wheals A, B, C and D, a band
of tissue is infiltrated along the dotted lines. Through the
same wheal deep radiating injections are then made in the
sphincter and adipose tissue of the ischio-rectal fossa, com-
pletely surrounding the ano-rectal cylinder.

Fig. 170. — Peripheral infiltration with quinine for incision
of fistula in ano. (Pauchet.)

228

REGIONAL ANESTHESIA.

At the close of the infiltration, when the latter
has been successful, the sphincter is gaping. In
a few minutes, dilatation, dissection and descent

Fig. 171. — Anorectal segment laid open after extirpation.
(Pauchet.} Trans-sacral anesthesia is employed. The cancer-
ous tumor forms a hollow cylinder.

of the mucosa, resection, and cauterization can be
effected without pain and without hemorrhage of
any account. According to the degree of stout-
ness of the patient, 50 or 100 mils of the solu-

GEXITO-UR1XARY ORGANS AND RECTUM. 229

tion are required. Beginners should place a fin-
ger in the rectum to guide the needle.

Operations for fistula in ano may be done
under the same method of infiltration.

\Ye have often practised total extirpation of
the rectum, with absolute anesthesia — always by
the trans-sacral method. Infiltration is not suffi-
cient. We practice the anterior or posterior
method, according to the degree of stoutness of
the patient.

CHAPTER VII.

ANESTHESIA OF THE EXTREMITIES.

REDUCTION OF FRACTURES OR DISLOCATIONS —
QUENU'S METHOD.

IN 1907, Quenu recommended the use of local
anesthesia for the reduction of fractures and dis-
locations.

The procedure consists in injecting in the
vicinity of the fracture an anesthetic solution so
that the bone ends are bathed with it, the seat
of the fracture being thus rendered insensitive.
The muscles simultaneously relax, and one may
proceed without pain to dress the wound, exam-
ine the parts, reduce, practice radioscopy, etc.
For dislocations, the injection is made into the
synovial sac, then about the dislocated articula-
tion and the insertion of the muscles surrounding-
it. The previously rigid limbs become supple and
mobile, muscular contractions cease, and reduc-
tion becomes easy and painless. A I per cent,
or y2 per cent procaine-adrenin solution is in-
jected, according to the stoutness of the patient.

It will not be necessary to describe the pro-
cedure for every type of fracture or dislocation, the
technique of the injection being practically the
same in a!1v The procedure is easy and devoid
of risk if a fine needle is used. A point at
which the skin is not distended, contused, or trau-
(230)

ANESTHESIA OF THE EXTREMITIES.

231

matized in any way should be selected. In juxta-
articular fractures, the fracture and the joint

Fig. 172. — Anesthesia for reduction of an elbow dislocation.
(Pauchet.) The quinine-urea solution is injected in the syn-
ovial sac of the articulation and infiltrates the insertions of the
muscles about the joint.

should be simultaneously injected. In the lower
extremities this is the procedure of choice. In the
upper, one may, with experience, instead, anes-
thetize the brachial plexus.

232

REGIONAL ANESTHESIA.

UPPER EXTREMITY.

The upper extremity as a whole, below the
shoulder, receives its sensory supply from the
brachial plexus, which becomes united beyond the
scaleni into a single, comparatively narrow, cord.
The upper intercostal nerves contribute in supply-

Fig. 173. — Anesthesia for fracture of the humerus. (Pau-
chet.) The needle is introduced at the site of fracture and
quinine-urea solution injected throughout the region.

ing the axilla with sensation and also furnish a
portion of the sensibility of the skin of the inner
surface of the arm. The skin of the shoulder
region is supplied by filaments from the supra-
clavicular branches of the cervical plexus.

ANESTHESIA OF THE EXTREMITIES. 233

ANESTHESIA OF THE BRACHIAL PLEXUS BY WAY
OF THE AXILLA HIRSCHEL.

The arm is extended in strong abduction (Fig.
174). "With the left hand fixing the axillary
artery, the needle is introduced high up as far as
possible under the pectoralis major, following the
longitudinal axis of the arm. The injection is be-
gun during the introduction of the needle in
order to push aside and avoid wounding the blood-

Fig. 174. — Infiltration of the brachial plexus by way of the
axilla. (Pauchet.) Below the inferior border of the pec-
toralis major, with the arm abducted, the needle is intro-
duced toward the nervous trunks, in a direction parallel with
the axis of the arm.

vessels. With a few syringefuls of the solution,
the median nerve is blocked above, and the ulnar
further anteriorly. To reach the radial nerve, one
must penetrate more deeply under the artery, al-
most to the height of the insertion of the pec-
toralis major. The artery is there surrounded
with injections, and with proper caution injury to
it or to the vein is avoided. Thirty or 40 mils of
the 2 per cent, solution are used.

234

REGIONAL ANESTHESIA.

ANESTHESIA OF THE BRACHIAL PLEXUS BY THE
SUPRACLAVICULAR ROUTE KULENKAMPFF.

The location of the plexus is well shown, with-
in by the subclavian artery, the pulsations of
which can easily be felt; below, by the first rib,
and in front, by the clavicle. Figure 175 shows
the direction of the first rib, the supraclavicular
region being seen in profile. It ascends behind

Fig. 175. — Blocking the nerve trunks of the upper extremity.
(Pauchet.) A, scalenus posticus. B, apex of the pleura. C,
omo-hyoid. D, point where the wheal should be made. E,
subclavian artery. F, scalenus anticus. G, sterno-mastoid.

the clavicle and at a right angle, and is an im-
portant landmark, for it indicates the extreme
point of penetration of the needle. The dermal
wheal should be made at about the middle of the
clavicle, where the first rib crosses it. The arch
of the subclavian artery should be identified; it
also crosses the clavicle at about its middle. Be-
yond lies the apex of the pleura, hidden by the
plexus. Still further, at the external border of

ANESTHESIA OF THE EXTREMITIES.

235

the sterno-cleido-mastoid, will be noticed the scale-
nus anticus, as well as the omo-hyoid, ascending
obliquely from the first rib, and which has been
divided, in order the better to show the course
of the rib. Figure 176 shows the parts as they
present themselves after removal of the skin and

Fig. 176. — Anesthesia of the upper extremity. (Pauchet.)
A, omo-hyoid. B, brachial plexus. C, subclavian artery. D,
scalenus anticus. E, sterno-cleido-mastoid.

the superficial and deep fascia. The transversalis
artery of the neck is seen crossing the nerve
trunks closely superimposed. Figure 177 and those
following show the direction the needle should
take. According to the more or less oblique
direction of the first rib from the spine to the
sternum, the needle, if prolonged, should reach
the spinous process of the second or the third
dorsal vertebra. On the other side are shown
the plexus, the artery, the insertion of the scaleni,
and finally, immediately below the clavicle, the

236 REGIONAL ANESTHESIA.

crescent constituted by the nerves surrounding the
artery. A needle introduced close to the artery
and properly directed should pass through the
middle of the nerve plexus. Almost always the
pulsations of the artery will be transmitted to it.
The narrowness of the interval between the
scaleni is also apparent.

A 6 <•

Fig. 177. — Anesthesia of the brachial plexus. (Kulen-
kampff.) Summit of the thorax. Direction of the needle to
the left. To the right, relationship of the structures in the
vicinity. A, subclavian vein. B, insertion of the scalenus an-
ticus. C, subclavian artery. D, brachial plexus. E, insertion
of the scalenus posticus.

TECHNIQUE OF THE INJECTION.

The patient should, if possible, be placed in
the sitting posture (Fig. 178), and should be
forewarned of the paresthesia radiating to the fin-
gers that will occur when the needle touches the
plexus, being requested to make known the moment
when it appears. The subclavian artery is now
slightly palpated with the finger. Its pulsations

OPERATIONS UPON THE EXTREMITIES.

237

are often visible, especially on the right side.
Just outside of the point where the artery descends
behind the clavicle, with a fine needle, a wheal is
made, which will correspond without exception to
the middle of the clavicle. The external jugular
vein, often visible lower down, crosses the clavicle

Fig. 178. — Supraclavicular anesthesia of the brachial plexus.
(Kulenkampff.) The left index finger locates and protects
the subclavian artery. Laterally to the artery and above the
middle of the clavicle, (X), the needle is introduced in the
direction of the spinous process of the third dorsal vertebra.

at the same point. Through this wheal a fine
needle 4 to 6 centimeters long is inserted and
directed as if one desired to strike the spinous
process of the second or third dorsal vertebra. The
plexus is superficially situated under the aponeu-
rosis. As soon as the needle strikes it, lancinat-
ing pains occur in the fingers supplied by the
median, which is the most superficial, and the

238 REGIONAL ANESTHESIA.

radial, situated behind the median. If the first
rib is encountered at a depth of from I to 3
centimeters, the operator will know that he has
missed and passed the plexus, as it is more super-
ficially placed. If no paresthesia is produced, he

Fig. 179.—- Blocking the brachial plexus. (Pauchet.) The
needle penetrates the skin above and close to the clavicle. It
traverses the plexus at the level of the clavicle and its point
touches the first rib. If the line of direction were prolonged it
would pass through the spinous process of the third dorsal
vertebra.

should try to provoke it by altering- the position
of the needle. Very often, fear of wounding the
artery causes the operator to introduce the needle
too far out. If blood comes from the needle, it
is because a vein or artery has been pierced, and

ANESTHESIA OF THE EXTREMITIES. 239

its direction must be changed. The moment pares-
thesia appears, the syringe is adapted to the
needle and 10 mils of the 2 per cent, solution
injected. If paresthesia is produced only in the

Fig. 180. — Blocking the brachial plexus. (Pauchet.) The
needle is inserted just above the middle of the clavicle. The
left index finger locates the pulsations of the artery and
pushes it out of the way. Abduction of the arm to 45° (Louis
Bazy) lifts away the artery and forms a curve with its con-
cavity directed upward. The needle points toward the spin-
ous process of the third dorsal vertebra. It passes through the
plexus and strikes the first rib.

territory of the median, part of the solution should
be injected some millimeters more deeply. The
needle should be slightly displaced and 10 mils
injected in the immediate vicinity. Under no

240 REGIONAL ANESTHESIA.

circumstances should the injection be made before
production of the paresthesia.

If unquestionable paresthesia has been obtained
both in the territory of the median and that of
the radial in from one to three minutes a com-
plete motor and sensory paralysis will be estab-
lished in the arm. Often one must wait from
ten to fifteen minutes. If, at the end of this time,
paralysis is not complete, 5 to 10 mils of the 4
per cent, solution may be injected. Success will
then, however, be uncertain. After the injection,
the tourniquet may be applied without pain. It is
often useful, for after blocking of the brachial
plexus the arm is habitually hyperemic, the vaso-
motors being paralyzed as after section of the
nerves. The motor paralysis always reaches the
circumflex nerve; but its territory is only hypo-
esthetized or uninfluenced. Other nerves, prob-
ably filaments from the supraclavicular, take part
in the innervation of this region. The anesthesia
lasts from one hour and a half to three hours.

ANESTHESIA OF THE BRACHIAL PLEXUS BY THE
INFRACLAVICULAR ROUTE LOUIS BAZY.

The brachial plexus assumes the shape of a
fan, the axis of which is constituted by the
seventh cervical nerve. The origin of this root
is immediately below the anterior tubercle of the
transverse process of the sixth cervical vertebra
(tubercle of Chassaignac). It is found on a level
with the inferior border of the cricoid cartilage.

ANESTHESIA OF THE EXTREMITIES.

241

The tubercle of Chassaignac is, then, the first
landmark.

After grouping themselves around the seventh
cervical, the other branches of the cervical plexus

Fig. 181. — Infraclavicular anesthesia of the brachial plexus.
(Pauchet.) Amputation of the arm performed on the Meuse
at a spot 6 kilometers from the firing line. The operating
room had been set up by the ambulance orderlies. Surgeon :
Sourdat. Assistant : Louet, auxiliary physician. The patient
is looking toward the camera.

become engaged in the space between the clavicle
and the first rib, and afterward pass perpendicu-
larly to the coracoid process. When the arm is
abducted in such a way that the tangent passing

242

REGIONAL ANESTHESIA.

,... Tubercle of Chassaijjnac

—Brachial Plexus
<— Clavicle

— Coracoid

Line of cricoid 'with V\- cervical --
Cricoid

Fig. 182. — Anesthesia of the brachial plexus by the infraclavicular
route. (Pauchet.) Observe that the cricoid cartilage corresponds to
the transverse process of the sixth cervical (tubercle of Chassaignac).
This tubercle may be found by palpation, and the assistant should
place his index finger there at the time of the injection. To the right,
the coracoid process, and one fingerbreadth within it, the plexus. The
operator introduces the needle here immediately below the clavicle and
directs it toward the tubercle of Chassaignac. The arm having been
abducted to 45°, the axillary artery is separated from the brachial
plexus, drawn away by the two thoracic branches given, off from its
lower aspect. The artery rests on the first rib.

ANESTHESIA OF THE EXTREMITIES. 243

through the apex of the coracoid process strikes
the tubercle of Chassaignac, this line indicates ex-
actly the direction of the brachial plexus, which
is situated one finger-breadth below it. This line
may be considered as the "line of anesthesia,"
and the coracoid process constitutes the second
landmark. In this position the arm forms with
the trunk an angle of 45° (Fig. 184). The axil-
lary artery, held against the arm by its acromio-
thoracic branch, deviates from the brachial plexus,
describing a curve with its concavity upward. As
a result of this, the risk of wounding it is slight.

TECHNIQUE OF THE INJECTION.

The patient is placed upon the table, with his
spinal column resting upon a cushion in such a way
that his shoulders are arched, as though for liga-
tion of the subclavian or axillary under the clav-
icle. The arm, hanging and abducted to 45°, ren-
ders the prominence of the coracoid more appar-
ent, and the plexus more superficial.

The operator places himself on the side to be
operated upon, between the arm and the trunk.
He locates the apex of the coracoid and im-
mediately within it, with the left index finger,
he depresses the soft tissues, as though wish-
ing to make more apparent the prominence of the
coracoid.

Meanwhile the assistant identifies the tubercle
of Chassaignac, over which he places his index
finger. The arm being abducted to 45°, the in-

244

REGIONAL ANESTHESIA.

Fig. 183. — Anesthesia of the brachial piexus by the infraclavicular
route. (Louis Basy.) The two hands show the "line of anesthesia."
The finger of an assistant is placed on the tubercle of Chassaignac;
the surgeon's finger, inside of the coracoid process, which is shown by
dotted lines. Here, within the finger tip, the needle enters immediately
below the clavicle and is directed toward the brachial plexus. It is
well to inject both upward, to the right, to the left, and deeply down-
ward to be sure of reaching all the branches of the plexus.

ANESTHESIA OF THE EXTREMITIES. 245

dex finger of the operator and that of his assist-
ant face each other, and the interval separating
them marks the course of the plexus (Fig. 183).
The line of anesthesia is now traced upon the
skin with y2 per cent, procaine-adrenin solution.

A needle 9 centimeters long is introduced in
the zone of infiltration, almost immediately below
the clavicle. The needle is pointed in such a way
that it grazes the posterior border of the bone.
When the needle has passed slightly beyond the
upper surface of the clavicle, 10 mils of 2.5 per
cent, procaine-adrenin solution are injected. The
arm is flexed as if one wanted to place it upon
the chest. As a result of this maneuver the bra-
chial plexus is relaxed and comes in front of the
needle, when it can be directly penetrated and
anesthetized.

OPERATIONS UPON THE HAND.

The technique of anesthetizing a finger by
means of injections all round it under the skin of
the first phalanx has been well described by Rec-
lus and is too well known to require description
anew. The adjacent parts of the metacarpus may,
however, be anesthetized consentaneously with the
finger.

ANESTHESIA OF A FINGER WITH THE ADJACENT
PORTION OF THE METACARPAL.

Two wheals are made upon the dorsal surface
of the interdigital space, corresponding to its in-

246

REGIONAL ANESTHESIA.

Fig. 184.— Landmarks for injection of the fingers. (Pau-
chet.) The pyramid A shows the depth to which the needle
is introduced, as illustrated in Fig. 187.

Fig. 185.— Manner of holding the syringe in infiltrating the
palm by injection into the interdigital spaces.

ANESTHESIA OF THE EXTREMITIES.

247

ternal and external borders (Fig. 184). A }/2 or
i per cent, solution is freely injected under the
skin in the direction of points A or D in the
palm, and B or C in the back of the hand. Fig.
185 shows the course of the needle in an injection
in the palm through the interdigital space. The
operation should not be started until the anes-
thesia has reached the tip of the finger.

DISARTICULATIOX OF THE MIDDLE FINGER OPERA-
TION UPON THE THIRD METACARPAL BONE.

Four wheals are made (Fig. 186), two in the
interdigital spaces, and two metacarpal, over the

Fig. 186. — Anesthesia of the medius with the head of its
metacarpal ; also anesthesia of the thumb with its metacarpal.
(Pauchet.}

interosseous spaces. The start is made at points
3 and 4. Fig. 189 shows a section of the meta-
carpus and the course followed by the needle.

248

REGIONAL ANESTHESIA.

Fig. 187.— Infiltration of the palm of the hand through two
injections from the dorsal aspect. (Pauchet.)

Fig. 188.— Same as the preceding.

ANESTHESIA OF THE EXTREMITIES. 249

The tip of the left index finger being placed in
the patient's palm, the needle is introduced at 3
and 4, and the injection made perpendicularly
through the interosseous space until the tip of the
needle shows under the skin of the palm at B
(Figs. 187 and 188). At each one of the two

Fig. 189. — Anesthesia of a finger and its metacarpal bone.
(Pauchet.) Longitudinal section of an interosseous space
showing the different directions that the needle should take.
1, deep palmar arch ; 2, superficial palmar arch ; 3, ulnar nerve ;
4, palmar aponeurosis.

injections 5 mils of the ]/2 per cent, solution are
used. Next one infiltrates subcutaneously from
points i and 2, in the palm toward point B, and
upon the dorsum toward 3 and 4. Finally points
3 and 4 are united by a subcutaneous injection.
In all, from 30 to 40 mils of the */2 per cent,
solution are required.

250 REGIONAL ANESTHESIA.

DISARTICULATION OF THE THUMB WITH
ITS METACARPAL.

The interosseous space is first injected, start-
ing from point 6 and introducing the needle to
point A under the skin of the palm (Fig. 186).
Owing to the thickness of the soft parts, 10 mils
of the Y* per cent, solution are required. The next
injection is made subcutaneously from points 5 and
7 toward the palm in A, upon the back of the
hand from 6. About 50 mils of the Y* Per cent,
solution are used. The thenar eminence may thus
be anesthetized without piercing the skin of the
palm, which is very sensitive. The same pro-
cedure may be followed for the fifth metacarpal
and finger.

ANESTHESIA OF SEVERAL FINGERS WITH
THEIR METACARPALS.

Injections made at points i, 2, and 3 (Fig. 190)
anesthetize the second and third fingers. From
point 2 the injection is pushed in the interosseous
space against point A, and from points i and 3
in the palm toward point A. On the back of the
hand one infiltrates under the skin toward point 2.
Injections made at 4, 5, and 6 anesthetize the
third and fourth fingers. Portions of the meta-
carpus may be, as desired, circumscribed in the
anesthetized territory, according as the points of
entry 2 or 6 are placed nearer the fingers or the
wrist. About 50 mils of y* per cent, solution
are required.

ANESTHESIA OF THE EXTREMITIES.

251

190.— Anesthesia of two fingers with the heads of the
metacarpal bones. (Fauchet.)

Fig. 191.— Anesthesia of one finger with the head of its
metacarpal. (Pauchet.) Injections are made along the dotted
lines through wheals at 1 and 2, circumscribing the region to
be operated upon.

252

REGIONAL ANESTHESIA.

ANESTHESIA OF THE SOFT PARTS OF THE PALM.

Any portion of the palm may be anesthetized
by employing the same technique as already des-

Fig. 192. — Anesthesia of a portion of the palm of
the hand. (Pauchet.)

Fig. 193. — Lines of infiltration for minor operations upon
the dorsal aspect of the hand. (Pauchet.)

cribed for anesthesia of the thenar and hypothe-
nar eminences, e.g., in disarticulation of the thumb.
The needle should, however, always be entered

ANESTHESIA OF THE EXTREMITIES. 253

upon the borders of the hand and upon the dor-
sal aspect of the interosseous spaces (Fig. 192).
If it is desired to anesthetize the palm above the in-
dex finger (Figs. 191, 193), the wheals should be
made at points i and 2. Through these two
points, free injections are made toward point A
in the palm, using 30 to 40 mils of the y2 per
cent, solution. In the case of phlegmons of the
hand, one should not inject in the vicinity of the
affected parts, but resort instead to anesthesia of
the brachial plexus.

ANESTHESIA OF THE SOFT PARTS OF THE
BACK OF THE HAND.

In anesthesia instituted for the treatment of
wounds or for the extirpation of ganglions, cysts,
and other tumors, the field of operation is sur-
rounded with a ^2 per cent, solution. Fig. 193
showrs the manner in which the infiltration should
be conducted in different cases. All that is neces-
sary is to surround three sides of the field in the
form of a U, since the nerves descend from the
forearm exclusively. The anesthesia reaches the
periphery by reason of the injection of three sides
and in some cases extends beyond it below the
field of operation. If the injections be made first
under the tendons, and then under the skin, the
anesthesia will include tissues beneath the fascia.

254

REGIONAL ANESTHESIA.

ANESTHESIA OF THE ULNAR NERVE
AT THE ELBOW.

The ulnar nerve is ordinarily palpable above
the epitrochlea, where it can be made to roll under
the finger. In anesthesia it is fixed with the
thumb and index finger of the left hand and the
needle is pushed up to it through the subcuta-
neous tissues and fascia. The moment the nerve
is touched, the patients will feel and complain of

Fig. 194. — Section of the forearm above the wrist. (Pauchet.)
1, Palmaris longus. 2, Median nerve. 3, Ulnar nerve.

the same tingling as is experienced when the
nerve is compressed. The solution is then in-
jected. It should be noted that in many patients
the ulnar nerve, when the arm is flexed, is sit-
uated not behind but in front of the epitrochlea,
and passes behind only when the forearm is in
extension. Anesthesia follows very quickly after
the injection and involves the little finger, the hy-
pothenar eminence, the ulnar border of the hand,
and the fifth metacarpal. For disarticulation of

ANESTHESIA OF THE EXTREMITIES.

255

the little finger and other operations in this
region, there is no simpler procedure (Figs. 195
and 196).

ANESTHESIA OF THE ENTIRE HAND.

The hand receives from the forearm the ulnar,
median and interosseotis nerves, which are all

Fig. 195. — Anesthesia of the ulnar nerve. (Pauchet.) The
nerve trunk is infiltrated in the depression between the epi-
trochlea and the olecranon process. 1. Ulnar nerve. 2. Fibrous
arch. 3. Flexor carpi ulnaris.

three subfascial, together with the endings of the
radial, which are subcutaneous. Fig. 198 presents
a perpendicular section of the forearm above the

256

REGIONAL ANESTHESIA.

Fig. 196. — Anesthesia of the ulnar nerve at the elbow. (Pauchet.)
Anesthesia has been induced by means of an injection of strong pro-
caine-adrenin solution in the depression between the epitrochlea and
the olecranon, as well as by a bracelet of subcutaneous infiltration at
the bend of the elbow. Suture of the ulnar nerve has been com-
pleted. The dissection of the nerve has been effected without any pain.
The wound is sutured with silkworm gut

ANESTHESIA OF THE EXTREMITIES.

257

Fig. 197. — Points of introduction of the needle to reach the
median and ulnar nerves above the wrist. The needle is
pointed and the injections made in the direction of the arrows.

Fig. 198. — Anesthesia of the hand. (Pauchet.*) Transverse
section of the wrist at the level of the inferior radiocarpal
articulation. Note the bracelet-like black line of subcutaneous
infiltration. The arrows represent the deep injections intended
for A, the median nerve, and C, the ulnar nerve. 1. Tendon
of the palmaris brevis. 2. Tendon of the palmaris longus. 3.
Tendon of the abductor longus pollicis. 4. Supinator longus.
5. Flexor carpi ulnaris. 6. Ulnar artery. 7. Ulna. 8. Radius.
9. Pronator quadratus. 10. Radial artery.

258 REGIONAL ANESTHESIA.

wrist, showing the direction in which the needle
should be pushed toward the median and ulnar
nerves. To reach the median at this level, a
wheal is made on the ulnar side of the tendon
of the palmaris longus, and the needle pushed
through the fascia under this tendon. The oper-
ator attempts to touch the nerve with the needle
point. When the patient complains of shooting-
pains, 5 mils of a 2 per cent, solution are in-
jected. Next, 5 mils of the same solution are
injected on the ulnar side of the forearm, above
the pisiform and beneath the tendon of the flexor
carpi ulnaris (Fig. 198). Finally, one infiltrates
through two or three other points in ring fashion
around the forearm — under the skin, then upon
the dorsal surface under the fascia between the
tendons, and up to the interosseous ligament,
using 50 to 60 mils of a ^ per cent, solution.
Complete anesthesia of the whole hand is ob-
tained in from ten to fifteen minutes. This pro-
cedure is simpler than intravenous anesthesia.

OPERATIONS UPON THE FOREARM.

The skin and subcutaneous tissues of the fore-
arm down to its lower third are exclusively sup-
plied by long subcutaneous nerves that emerge
from under the fascia above the elbow. Infiltra-
tion of a transverse band of subcutaneous tissue
on the forearm produces, therefore, an anesthesia
that becomes more or less extensive below the
level of injection, and when a circle of subcuta-

ANESTHESIA OF THE EXTREMITIES.

259

neous tissue above or below the elbow is infil-
trated, the anesthesia extends on all aspects to the
lower third of the forearm.

For operations upon the skin of the upper two-
thirds of the forearm, the field of operation should
be surrounded by injections disposed in the shape

Fig. 199. — Anesthesia of the dorsal surface of the fore-
arm and hand. (Pauchtt.)

of a U with its concavity directed downward,
using the % per cent, solution (Fig. 199). The
unilateral nerve supply of this region renders the
muscular injection unnecessary if the operation is
unilateral.

In the lower third the injection should also be
subfascial on account of the nerves that emerge

260 REGIONAL ANESTHESIA.

from within the forearm. Extensive areas upon
the lower third of the dorsal aspect of the fore-
arm may be anesthetized as follows: Two in-
jections are made upon the borders of the fore-
arm, indicated by the bony ridge of the radius and
ulna (Fig. 199, B). With a long needle the soft
parts of the dorsal surface are infiltrated, begin-
ning with the muscles, then the subcutaneous tis-
sues transversally, with 40 or 50 mils of a ^
per cent, solution. From these two points the
subcutaneous infiltration descends to the wrist and,
if necessary, to the fingers. This procedure is
useful for the treatment of severe wounds of
the soft parts, the extirpation of tumors or cysts,
tuberculosis of the tendon sheaths, etc.

The procedure adapted for the lower half of
the anterior surface of the forearm differs slightly
by reason of the median and ulnar nerves. Two
injections are made upon the sides of the forearm,
and these are joined by infiltrating transversally
close to the bone and the interosseous ligament
at the start, and then in the subcutaneous tissue.
It is useless to try to infiltrate the muscles sep-
arately; this is almost impossible in any case, and
the median and ulnar are not blocked. If the
operative field is in the ulnar distribution, it is
best to inject this nerve at the elbow. If it is in
that of the median, then this nerve should be
anesthetized at the upper extremity of the incision.
Those well trained in anesthesia of the brachial
plexus will give this procedure the preference—
especially in phlegmons, operations on the bone,

ANESTHESIA OF THE EXTREMITIES. 261

amputations and interventions upon the upper half
of the forearm, and in fact, in all operations of
importance below the shoulder.

OPERATIONS UPON THE ELBOW. .

A subcutaneous U-shaped infiltration with con-
cavity downward, using 40 mils of a ^ per cent,
solution, upon the dorsal surface of the elbow,
and instituted through two wheals (Fig. 200),
will permit of extirpation of the olecranon bursa.
To suture a fractured olecranon, t\vo additional
injections are necessary, 3 and 4. One begins by
injecting 20 mils of the l/2 per cent, solution into

Fig. 200. — Anesthesia of the elbow region. (Pauchet.)

the articulation, below the external and internal
condyles. Ten mils are injected under the tendon
of the triceps in the muscles covering the ole-
cranon, first inside and then outside, and finally
the U-shaped subcutaneous injection is made. For
an aseptic arthrotomy — as for the removal of for-
eign bodies — 20 mils of the ^ per cent, solution
are injected in the joint and the capsule and sub-
cutaneous tissue infiltrated along the line of in-
cision. To perform a resection or disarticulation,
blocking of the plexus is necessary.

262

REGIONAL ANESTHESIA.

Fig. 201. — Anesthesia of the upper extremity. (Pauchet.)
A, Blocking of the brachial plexus, producing anesthesia of
the entire upper limb. B, Anesthesia of the forearm and hand.
C, Anesthesia of the hand only. The points 1, 2, 3, 2' and 3'
are the wheals through which the subcutaneous bracelet of in-
filtration is made. The needle employed to infiltrate deeply the
nerve trunks is also introduced through them. 1, Anterior
branch of the radial nerve. 2 and 2', Median nerve. 3 and
3', Ulnar nerve.

ANESTHESIA OF THE EXTREMITIES.

263

OPERATIONS UPON THE ARM.

Local injections are here suitable only for
superficial operations. A simple subcutaneous in-
jection is insufficient by reason of the irregular
and multiple branching of the nerves. A pyram-

Fig. 202. — Anesthesia of the forearm and hand. (Pau-
chet.) Transverse section at the elbow. Note the bracelet of
subcutaneous infiltration marked by a heavy black line. A,
Deep injection to the median nerve. B, Deep injection to the
radial. C, Deep injection to the ulnar. 1, Tendon of the bi-
ceps. 2, Supinator longus. 3, Pronator radii teres. 4, Exten-
sor carpi radialis longus. 5, Flexor carpi ulnaris. 6, Brachialis
anticus. 7, Brachial artery.

idal injection of the operative field is always re-
quired. To anesthetize the skin of the entire sur-
face of the arm, as for Thiersch skin grafting,
one infiltrates superficially all the subcutaneous tis-
sue with a y2 per cent, solution, as for the thigh.

264

REGIONAL ANESTHESIA.

For extensive operations on the bones, amputa-
tions, etc., the plexus is injected above the clav-
icle (Fig. 181).

OPERATIONS UPON THE SHOULDER.

Large lipomas of the shoulder are easily re-
moved after multiple infiltrations have been made

Fig. 203. — Suture of a fracture of the clavicle. (Pauchet.)
Through two injections the clavicle is surrounded, to any ex-
tent necessary, with the anesthetic solution.

all around them. The base of the tumor is
reached with long needles, and the injections are
connected with one another by bands of subcuta-
neous infiltration. A ]/2 per cent, solution is
used, and as much as 200 to 250 mils may be
injected.

ANESTHESIA OF THE EXTREMITIES. 265

Operations on the shoulder are performed after
anesthesia of the plexus. For shoulder disarticu-
lation, the plexus has first to be infiltrated, and
then the subcutaneous tissues at the root of the
shoulder up to the acromion and through the
axilla. The ^ per cent, solution is used.

LOWER EXTREMITY.

It is difficult to anesthetize the lower ex-
tremity by local injections, as it receives its nerve
supply from many different trunks. On the other
hand, spinal anesthesia is very serviceable, and
only a small amount of procaine-adrenin solution,
4 or 5 centigrams, need be used. The injection
is made directly into the spinal canal of the lum-
bar region. In a large number of cases regional
anesthesia is absolutely indicated, and succeeds ad-
mirably. Thus, all operations on the foot — resec-
tion, amputation, tenotomy, suture of the patella,
operations for varicose veins, or on the inguinal
lymphatics, etc., — may be performed with complete
anesthesia by the regional method. We give pref-
erence, however, to lumbar spinal anesthesia for
all major operations, such as resection of the
knee, resection of the hip, and amputation of the
thigh. We probably practice three regional anes-
thesias to every spinal.

The external cutaneous nerve emerges from
under the inguinal ligament immediately within the
anterior superior iliac spine; it descends in an out-
ward direction under the fascia lata, perforates

266

REGIONAL ANESTHESIA.

the fascia, and supplies the skin. It can be
reached two finger-breadths within and below the
anterior superior spine (Figs. 204 and 205).
The technique is as follows: A dermal wheal

Fig. 204. — Injection of the external cutaneous nerve (1)
and of the anterior crural nerve (2). (Pauchet.) 1, Point
where the needle should be introduced to reach the external
cutaneous ; the injection is made in the direction of the arrow,
beneath the fascia and skin. 2, Point of entrance of the needle,
perpendicularly to the surface, to reach the anterior crural
nerve.

is made and the subcutaneous connective tissue
so injected as to make a transverse band 5 or 6
centimeters wide, parallel to Poupart's ligament.
Five mils of the strong solution are then injected
under the fascia, in the same direction as the sub-
cutaneous infiltration. The middle of the infil-

ANESTHESIA OF THE EXTREMITIES.

267

trated area should be situated two finger-breadths
within and below the anterior superior spine.

Fig. 205. — Anesthesia of the external cutaneous -nerve.
(Pauchet.) This nerve is reached at a point two finger-
breadths within and below the anterior superior spine of the
ilium.

The anterior crural nerve is situated imme-
diately outside of the femoral artery and is cov-
ered by a fibrous band (ilio-pectineus). With the
left hand the operator locates the pulsations of the

268

REGIONAL ANESTHESIA.

femoral artery and pushes the latter inward. The
needle is then introduced immediately outside the
artery, just below Poupart's ligament. Where it
comes in contact with a solid band of fascia,
the latter is pierced and 5 mils of the strong

Fig. 206. — Anesthesia of the anterior crural nerve. (Pau-
chet.) A, Spine of the pubis. B, Anterior superior iliac spine.
C, Point half way between the two. The femoral artery is
located with the finger. The needle is inserted one finger-
breadth outside of it to reach the anterior crural nerve.

solution injected while still advancing i centimeter
deeper. The patient should show some muscular
contraction in the thigh, proving that the crural
nerve has been reached. The quadriceps is then
immediately paralyzed.

Infiltration of the above two nerves affords a
broad zone of anesthesia which will permit of

ANESTHESIA OF THE EXTREMITIES. 269

the taking of Thiersch grafts from an extensive
surface of skin.

Infiltration of the great sciatic nerve is very
difficult and uncertain. One may, however, suc-
ceed in the following manner: Bearing in mind
that the nerve is situated in the buttock at the
midpoint of a line passing from the ischium to the
great trochanter, two deep injections are made,
the first at a distance of 2 centimeters outside of
the tuberosity of the ischium, and the other 3
centimeters within the great trochanter. Or, a
single injection may be made at the intersection
of a horizontal line passing through the upper
border of the great trochanter, and a vertical line
passing through the external border of the ischium.
It is indispensable that the patient should experi-
ence a painful sensation in the toes. As soon
as this pain is felt 10 mils of the strong solution
are injected.

Babitzki proceeds as follows: The finger is
introduced in the rectum, the lower border of the
great sciatic notch identified, and its contents, i.e.,
the nerve, pushed outward \vhile the right hand
introduces the needle to meet the nerve.

The lesser sciatic nerve passes below the glu-
teal fold exactly in the middle of the posterior
surface of the thigh, immediately beneath the fas-
cia. It is, therefore, easily accessible.

The obturator nerve is deeply situated. To
reach it with any degree of certainty all of the
proximal internal surface of the thigh should be
infiltrated to a depth of 3 or 4 centimeters.

270

REGIONAL ANESTHESIA.

In operating on the great trochanter or the
neck of the femur, desensitization of the nerve
trunks of the lower extremity is not sufficient; one
must also anesthetize the branches of the genito-
crural and ilio-inguinal by infiltration of the skin
surrounding the root of the extremity.

OPERATIONS UPON THE TOES.

The technique is the same as for the fingers
(Figs. 208 and '209). In the case of the big toe,
three injections are made, two on the lateral sur-
faces and one in the middle of the dorsal surface.

Fig. 207. — Anesthesia of a toe through three dorsal
injections. (Pauchet.)

A subcutaneous ring-shaped injection is made at
the root of the member, and 4 or 5 mils of the
strong solution injected. For the other toes, the
injections are made in the interdigital spaces
(Fig. 209).

Great Toe — Operations for Ingrowing Toe Nail
or Bunion, Amputation. — In disarticulation of the
toe or resection of the head of its metatarsal
bone for hallux valgus, three wheals are made, one on

ANESTHESIA OF THE EXTREMITIES.

271

the internal border of the foot, the second a dorsal
one, above the first interosseous space, and the
third in the first interdigital space. One injects

Fig. 208. — Anesthesia of the great toe with the head of its
metatarsal bone. (Pauchet.)

in the interosseous space, as for the hand. The
needle is inserted in this space until its tip touches
the deep portion of the skin of the sole. Infiltra-
tion is then conducted under the skin from I to

Fig. 209. — Anesthesia of middle toe with the head of
its metatarsal bone. (Pauchet.)

Fifty

3, following the dotted line (Fig. 208).
mils of the weak solution are needed.

Third Toe. — Operations on the metatarsal (Fig.
209). — Four wheals are made as in operations

272

REGIONAL ANESTHESIA.

upon the hand — two on the dorsal surface of the
interdigital spaces, and two on the dorsum of the
foot above the second and third interosseous spaces.
Through i and 2, anesthetic solution is injected
in the interosseous space until the point of the
needle is perceived under the skin of the sole,
then the injection is continued under the skin of
the dorsum toward I and 2. Fifty mils of the
weak solution are required.

Fig. 210. — Tenotomy of the tendo Achillis. (Pauchet.)
TENOTOMY OF THE TENDO ACHILLIS.

A wheal is made on each side, a subcutaneous
diamond formed as shown by the dotted lines in
the illustration (Fig. 210), then infiltration prac-
tised under the tendon itself.

OPERATIONS UPON THE ENTIRE FOOT.

The fbot is supplied by five trunks: The an-
terior and posterior tibial, the internal and ex-
ternal saphenous, and the musculo-cutaneous (Fig.

ANESTHESIA OF THE EXTREMITIES.

273

211). The posterior tibial nerve is injected at
the inner malleolus, i centimeter from the tendo
Achillis (Fig. 211; note the direction of the
needle). The needle is introduced from behind
forward up to the posterior surface of the tibia.

Fig. 211. — Nerves to be infiltrated in anesthetizing the en-
tire foot. (Pauchet.) Section of left leg above the malleoli.
For the anterior and posterior tibial a deep injection is neces-
sary, and a subcutaneous bracelet for the other nerves, viz.,
the external and internal saphenous and the musculo-cutaneous.

The operator feels his way until he produces a
lancinating pain, and then injects 5 mils of the
strong solution. The other wheals are made at
the same level around the leg. A subcutaneous
bracelet is infiltrated, using 50 to 75 mils of the
weak solution, and the strong solution injected to

274

REGIONAL ANESTHESIA.

block the anterior tibial, along the line for liga-
tion of the artery of the same name. The re-
sulting anesthesia is sufficient for resections and
amputations in the infant and adult (Fig. 212).

Fig. 212. — Anesthesia of the entire foot. (Pauchet.)
Horizontal section of left leg above the malleoli. 1, Tibialis
anterior. 2, Extensor proprius hallucis. 3, Extensor communis
digitorum. 4, Tibialis posterior. 5, Tendo Achillis. 6, Flexor
proprius hallucis. 7, Lateral peronei. The black band repre-
sents a bracelet of subcutaneous infiltration. A, Deep injection
for the anterior tibial nerve. B, Deep injection for the pos-
terior tibial nerve.

OPERATIONS UPON THE KNEE.

For a hygroma of the prepatellar bursa, four
wheals are made (Fig. 213), and the subcutane-
ous cellular tissue in the interval then infiltrated.

ANESTHESIA OF THE EXTREMITIES.

275

This procedure is also adapted for the suture of
a fractured patella. The prepatellar fibrous tis-
sues and the articular cavity itself are infiltrated
in the same way with the strong solution. In
suture of the patella, however, 150 to 200 mils of
the weak solution are used; the greater part of
the solution runs out after the incision.

For foreign body in the knee, the foreign body
is first located with the fingers. Then, through a

Fig. 213. — Removal of the prepatellar bursa. (Pauchet.)

dermal wheal, a needle is introduced, followed by
two or three more, to immobilize the foreign
body. The skin overlying it is now infiltrated,
the fascia likewise, an incision made, the foreign
body removed, and the wound sutured. The oper-
ation is brilliant, rapid, and painless.

By the same procedure a transverse arthrot-
omy, with section of the ligamentum patellae and
the lateral ligaments, can very readily be per-
formed. We have in this way removed projec-

276

REGIONAL ANESTHESIA.

tiles embedded in the femoral condyles. Resection
of the condyles can also be done in this way
where the subject is not too stout; but for this
operation we prefer spinal anesthesia. The weak
solution suffices in all cases.

Fig. 214. — Infiltration of a mass of tissue for arthrotomy
of the knee, 1 and 2. (Pauchet.) Above, anesthesia of a seg-
ment of vein.

OSTEOTOMY OF THE FEMUR.

Supracondylar and subtrochanteric osteotomies
may be practised under local anesthesia by in-
filtration. On the outer surface of the thigh, at
a height of 10 centimeters, a subcutaneous and
then a subfascial band is traced. Next the mus-
cular mass is infiltrated, down to the bone. Fin-

ANESTHESIA OF THE EXTREMITIES. 277

ally and still by the same route, a long needle is
introduced in front of and outside of the bone,
and the tissues freely infiltrated. The resulting
anesthesia is perfect, the only steps in the opera-
tion that are disturbing to the patient being the
breaking of the femur or the blows of the mallet.
The same difficulty is experienced in all bone op-

Fig. 215. — Section of the thigh through its lower fourth.
(Pauchet.) Manner in which the injections should be directed
for an osteotomy of the femur.

erations. Section of a rib or the removal of a
cranial flap are alike painless manipulations, but
the patient must be warned beforehand of the
sounds caused by section of bone tissue.

OPERATIONS UPON THE SOFT PARTS OF THE THIGH.

The subcutaneous cellular tissues above the
lesion are infiltrated in order to block the sub-
cutaneous nerves. Next, one infiltrates in front

278

REGIONAL ANESTHESIA.

Fig. 216. — Extensive subcutaneous infiltration through
„ a series of wheals. (Pauchet.)

ANESTHESIA OF THE EXTREMITIES.

279

and behind, and when necessary, below. This
constitutes our routine practice for operations on
varicose veins or for inguinal lymphatic enlarge-
ments (see Figs. 216 and 217). The operation
succeeds very well, but a large amount of the

Fig. 217. — Peripheral infiltration of an inguinal lymph-
node for adenitis. (Pauchet.)

weak solution is required; this entails no danger,
for a large portion of the solution runs out
through the incision. In the removal of varicose
veins we have commonly used 200, 250, and even
300 grams of the weak solution, which is largely
eliminated when the wound is irrigated with hot
saline solution.

REGIONAL ANESTHESIA.

ANESTHESIA OF THE EXTREMITIES.

281

o
U

282

REGIONAL ANESTHESIA.

Figs. 220, 221. — Sacral anesthesia of the lower extremity. (Pau-
chet.) The sacsal trunks, 1 to 4, require to be injected if one is to
obtain the areas of anesthesia shown in the sections S. Sections Lj
and L4 show the anesthesia obtained by paralumbar injection. Sacral
anesthesia of the genital organs is conducted through the third fora-
men. The skin is anesthetized. The reader will note the numbers of
the sacral trunks that must be injected to obtain the desired anesthesia.

CONCLUSIONS.1

Regional anesthesia may be availed of in 80
per cent, of surgical operations. Its success de-
pends upon the ability and experience of the oper-
ator, but the disposition and mental attitude of
the patient also play an important part.

We invite beginners to use it not only in one
type of case, but systematically in all cases, hold-
ing themselves in readiness to use ethyl chloride
to complete the work where necessary.

Cranial nerve anesthesia and the paravertebral,
brachial plexus, and trans-sacral procedures, which
are most efficacious, require actual training. If
our advice to learners is followed, this should not
take a long time. Take a hat pin and a skeleton
and practice introduction into the cranial fora-
mina, as well as into the paravertebral and sac-
ral openings, in accordance with the landmarks
mentioned in this book. Such practice will re-
quire one or two hours. The same experimenta-
tion should then be carried out upon a cadaver.
This will also require about two hours of practice.

After these two series of experiments, trials
may be made upon the living subject.

For the remaining operations, trials should be

1 Pauchet-Sourdat-Laboure : Anesthesia regionale — Doin, publisher,
Paris, 1917.

(283)

284 CONCLUSIONS.

made with the book by one's side, as is done by
the internes in my service.

Be gentle, patient, and persevering in spite of
failures and the aversion of certain patients, and
you will succeed, with signal benefit to most cases
and with general advancement of surgical practice.

INDEX.

Abdomen, anesthesia of, 128, 132,

144, 162, 175, 220
exploration of, 162
Abdominal incision, transverse,

164
wall, anesthesia of, 132, 144,

175, 220

infiltration of, 162
Abscess, interlobar, 158
of lung, 158

operation for. See Phlegmons,
subphrenic, 158

Adamantoma of lower jaw, 123
Adenitis, cervical, 119, 122

inguinal, 265, 279
Adenoma of breast, 160

prostate, 212
Adrenin, use of, 14, 16
Ala nasi, anesthesia of, 69, 99
Alveolar process, superior, anes-
thesia of, 69

Anal fistula, incision in, 227, 229
sphincter, anesthesia of, 226,

227

Anesthesia, Bazy's method of, 240
circular, 25, 26, 88, 89, 99
costoiliac, 175
infiltration, 17, 21, 32
by layers. 29
deep, 29

general technique of, 17
perineal, 224, 225
skin wheals in, 21
subcutaneous, 25
surface, 25

intraspinal. See Spinal.
Kulenkampff's method of, 234,
235, 236

paracostal, 175

parailiac, 175

paravertebral, 144, 163, 190,

283

cervical, 121-123
dorsal, 144-147, 153, 158, 161,

190, 198, 199
lumbar, 150, 168, 169, 190,

198, 199
pericostal, 153
presacral. See Sacral,
regional, See Regional Anes-
thesia.

sacral, 202, 207, 282, 283
anterior, 202, 204, 205, 221
pre-, 202, 204, 205, 221
trans-, 203, 204, 207, 210-212,

219, 222, 224, 229, 283
spinal, 128, 133, 135, 136, 265,

276

complications of, 133
indications for, 128, 265, 276
mortality in, 134
regions influenced in, 135
transsacral. See Sacral.
Anesthetics for regional anes-
thesia, 14, 15, 16
Anterior crural nerve, 266-268
Anterior sacral anesthesia, 205,

221

Anterior tibial nerve, 272-274
Antrum of Highmore, anesthesia

of, 70, 83
Anus, anesthesia of, 132, 182, 211,

224, 225

trans-sacral, 224
artificial, 182
operations on, 224

(285)

286

IXDEX.

Anus, perineal infiltration in oper-
ations on, 224, 225

Appendectomy, 143, 163, 169, 170,
171, 175, 176

Arm, anesthesia of, 232, 240, 241,

258-264
amputation of, 241, 261, 264

Armamentarium for regional an-
esthesia, 12, 14

Arthrotomy of elbow, 261
knee, 275, 276

Ascending colon, operation on, 175

Ascites, evacuation of tubercul-
ous, 167

Asepsis in regional anesthesia, 18

Auditory meatus, anesthesia of

external, 87
furuncle in, 88, 91
exostosis in, 88

Auriculo-temporal nerve, 88

Auricular branch of pneumogas-
tric, 88

Axilla, anesthesia of, 153, 162

Babitski's method, 269

Base of the orbit, 58

Bazy's method, 240

Biliary passages, anesthesia of,

140, 141, 144, 145, 199
Bladder, anesthesia of, 211-213,
219

exploration of, 213

operations on, 212
Bonain's solution, 86, 99
Brachial plexus, anesthesia of,
233-236, 253, 260, 261, 265

Bazy's method, 240

by way of axilla, 233

infraclavicular, 240

Kulenkampff's method, 234-236

supraclavicular, 234-236, 264
Brain tumors, removal of, 82
Breasts, operations on, 145, 160,
161

Broad ligament, infiltration of

base of, 224
Buccal nerve, 72
Buccinator nerve, 96

gingival branches of, 96
Bunion, operation for, 270
Bursa, olecranon, removal of, 261
Bursitis, prepatellar, operation

for, 274-275

Cancer of breast, 161

floor of mouth, 106, 107

ileocecal segment, 170

jaw, 104

larynx, 122

palate, 54

pharynx, 107

rectum, 163, 212, 213, 229

stomach, 182

tonsils, 54, 107

uterus, 136, 168
Canine fossa, infiltration of, 83

teeth, anesthesia of, 69, 95, 96
Carotid artery, ligation of exter-
nal, 119

Cataract operation, 93
Catheterization, anesthesia for,

212

Cecostomy, 170, 172, 175
Cecum, anesthesia of, 145, 163,
170-172, 175

operations on, 163, 170-172, 175
Celiotomy, supraumbilical, 65, 167
Cerebellum, exposure of, 46
Cervical adenitis, 119

nerve roots, infiltration of, 109

plexus, anesthesia of, 111, 119
Cesarean section, 168
Chassaignac's tubercle, 240, 241,

243
Cheek, anesthesia of, 66, 99, 107

transverse incision of, 107
Chin, anesthesia of, 101
Cholecystectomy, 199

INDEX.

287

Cholecystotomy, 129
Choledochotomy, 163
Ciliary ganglion, anesthesia of, 91

nerves, 92
Circular anesthesia, 25, 26, 88, 89,

Circumcision, 218
Clavicle, suture of fracture of,

264

Colon, ascending, operations on,
163, 175

transverse, 179
Colporrhaphy, 223
Colpotomy, 223
Compound skull fracture, 40
Condyles of femur, 275
Cord, spermatic, anesthesia of,

197, 214, 215
Corpora cavernosa, anesthesia of,

218

Costal resection, 153-157
Costo-chondrites, suppurative, 158

iliac anesthesia, 175
Couzard and Chevrier, 117
Cranial operations, 37
Craniectomy for sarcoma, 39
Crile, 17
Curettage, aural, 91

uterine, 212
Cutaneous nerve, external, 265-

267
Cyst of dorsum, 253

floor of mouth, 106, 107

sternum, 143

uterus, 212
Cystocele, 213
Cystotomy, 168, 211
Cystotomy, suprapubic, 212, 214

Danys, 114, 142
Decompression, 43
Decortication of kidney, 198

lung, 158
Deep infiltration, 29

Dental branches, infiltration of, 95
nerves, 70, 75, 94, 96, 103
by buccal route, 70
by external route, 70
Disarticulations, 136, 247, 250,

254, 261, 265, 270
Dislocations, reduction of, 230,

231

Quenu's method of, 230
Dorsal nerves, 137, 139, 144, 146,

163

Dorsum of hand, 253, 259
Duodenum, 175

Ear, anesthesia of, 85-88, 90, 91

drum, puncture of, 86, 91

external, 88, 90, 91

middle, 86

Elbow, anesthesia of, 254-256, 260,
261

arthrotomy of, 261

disarticulation of, 261

dislocation of, 231

removal of foreign bodies in,
261

resection of, 261
Empyema, thoractomy for, 153,

156, 157

Endolaryngeal operations, 118
Endoneural injection, 34, 35
Enterorrhaphy, 182
Enterostomy, 170
Epidural hematoma, 43
Ethmoidal nerves, 81-84, 93

sinus, 62

Eventration, post-operative, 188
Excision of joints. See Resection.
Exostosis, 88
External auditory canal, 87

cutaneous nerve, 265-267

saphenous nerve, 272, 273
Extremities, anesthesia of, 132,
230. See also Arm, Fore-
arm, etc.

288

INDEX.

Eye, anesthesia of, 69, 91, 93
Eye ball, enucleation of, 92, 94
Eyelids, operations on, 93

Face, anesthesia of, 48, 97
and neck, sensory nerve sup-
ply of, 53

Facial operations, 89, 97, 101
Femoral arch, 198

hernia, 195-198

Femur, operations on neck of, 270
osteotomy of, 276, 277
resection of condyle of, 275
spinal anesthesia in resection of,

136
Fibroids of uterus, hysterectomy

in, 168
Fingers, anesthesia of, 245, 247,

249-251, 254

disarticulation of, 247, 250, 254
Fistula in ano, 227, 229
intestinal, 170
recto-vaginal, 223
anesthesia of, 265, 270-273
Foot, operations on, 129, 265, 272,

273
Foramen rotundum, anesthesia at,

63, 66

Forearm, anesthesia of, 260, 261
Formulas, anesthetic, 15
Fracture of skull, 40
Fractures, reduction of, 104, 230,

232, 261, 264

Frenum, anesthesia of, 217
Frontal nerve, 57, 60, 98
Frontal region, anesthesia of, 98
Frontal sinus, 62, 84
Furuncle, anesthesia of, 36
in auditory meatus, 88, 91

Ganglion, removal of, 253, 260
Gasserian ganglion, anesthesia of,

48, 80
injection of, 50

Gastrectomy, 163-165, 184
Gastric cancer. See Stomach,

Cancer of.

ulcer. See Stomach, Ulcer of.
Gastroenterostomy, 162, 165, 166
Gastrostomy, 165
Genitalia, external, anesthesia of,

200, 222
Genito-crural nerve, 142, 189, 190,

202, 222
Genito-urinary organs, anesthesia

of, 132, 141, 144, 167, 168,

197, 200, 211-224
Gingival branches of buccinator

nerve, 96

Glands, removal of, 119
Glans penis, anesthesia of, 218
Glosso-pharyngeal nerve, 106
Goiter operation, 188, 122
Grafts, Thiersch, 25, 263, 269

Hallux valgus, operation for, 270,

271

Hand, anesthesia of, 245, 247,

249-255, 258, 259, 262, 263

infiltration of palm of, 246-248,

252, 253

phlegmon of. See Phlegmon.
Hard palate, anesthesia of, 71, 72
Harelip, operation for, 100
Head and neck, anesthesia of, 48
Heart, operations on, 141, 158
Hematoma, epidural, 43
Hemorrhoids, operations for, 129,

212, 213, 225
Hernia, femoral, 195-198
inguinal, 175-188, 191, 193
of the linea alba, 186
of scrotum, 195
umbilical, 186
Herniotomy, 143, 175
Hip, resection of, 265
Hirschel's method of anesthesia,
233

1XDEX.

289

Humerus, anesthesia of, 264

fracture of, 232
Hygroma of prepatellar bursa,

274, 275
Hypogastric anesthesia, 168

plexus, 202

Hypophysis, sarcoma of, 85
Hypospadias, operation for, 218
Hypothenar eminence, anesthesia

of, 250, 252, 254
Hysterectomy, 132, 168
Hysteropexy, 164

Ileocecal region, operations in,

169

resection, 169, 170, 172
Iliac fossa, operations in, 169
Ilio-hypogastric nerve, 142, 189,

190, 193
Ilio-inguinal nerve, 142, 189, 190,

193, 202, 222
Incision, median hypogastric, 167

transverse abdominal, 164
Inferior dental nerve, 75, 103
laryngeal nerve, 117
maxilla. See Jaw.
maxillary nerve, 57, 72, 102,

103, 125
Infiltration anesthesia, 17, 21, 32,

60, 61, 92, 115.

Infiltration, of canine fossa, 83
of cervical nerve roots, 109
orbital, 60, 61, 92
subconjunctival. 92
Infraorbital nerve, 69, 82, 83, 93
Infratrochanteric osteotomy of

femur, 276

Ingrowing toe nail, 270
Inguinal canal, anesthesia of, 216
Inguinal hernia, 175-188, 191, 193
lymphatics, operations on, 265,

279

Inguino-crural region, anesthesia
of, 170, 175, 189

Injection at right angles, 22

of nerves, 35
Injections, circular, 26

endoneural. 34, 35

perineural, 34

pyramidal, 32
Intercostal nerves, 137, 139. 142,

147, 153, 158

Interlobar abscess, 158, 159
Internal pudic nerve, 200, 201
Internal saphenous nerve, 272, 273
Intestinal fistula, 170

occlusion, 128, 136

resection, 144, 162, 179
Intestines, anesthesia of, 128, 132,
136, 141, 144, 145, 162,
172, 179

Tntradermal wheals, 21
Intraorbital injections, 61
Intraspinal anesthesia, 133
Iridectomy, 93
Ischio-rectal fossa, 226, 227

Jaw, adamantoma of, 123

cancer of, 104

disarticulation of, 104

fracture of, 104

median section of, 102
Jaws, anesthesia of, 97. 102
Jejunostomy, 182
Joints, anesthesia of, 231
Jonnesco, 128, 132, 135

Kidney, anesthesia of, 140, 141,

144, 145, 198, 199
operations on, 198

Knee, operations on, 129, 265, 274-
276

KulenkampfFs method of anes-
thesia, 234-236

Labia, anesthesia of, 211
Lachrymal gland, anesthesia of, 93
nerve, 57, 60, 98

290

INDEX.

Laminectomy, 152

Laparotomy, 165, 167

Laryngeal nerves, 106, 115-118

Laryngectomy, 115, 122

Laryngo-fissure, 118

Laryngostomy, 118

Laryngotomy, 115

Larynx, cancer of, 122

Le Filliatre, 128

Leg, amputation of, 265, 280, 281

Legueu's needle, 220

Levator ani, anesthesia of, 226 . .

Ligation of external carotid, 119,

123, 124, 125
thyroid artery, 119
Limbs, anesthesia of, 230
Linea alba, hernia of, 186
Lingual nerve, 76, 77, 79, 105
Lipoma of shoulder, 264
Lips, anesthesia of, 69, 99, 100,

101
Liver, anesthesia of, 132, 141, 145,

175, 199

Luc's operation, 83
Lumbar nerves, 138, 142, 144, 146,

150

Lung, abscess of, 158
anesthesia of, 140, 141, 145, 158
decortication of, 158
tumor of, 158

Malignant tumors. See Tumors.
Mammary gland. See Breast.
Mandible. See Jaw.
Mastoidectomy, 90
Mastoiditis, operation for, 90, 91 I
Mastoid region, anesthesia of, 88
Maxillary bones, resection of,

102-104
nerve, inferior, 57, 72, 102, 103,

125

superior, 63, 65, 66, 82-84, 94
sinus, 70, 83
Meatus, external auditory, 87

Median hypogastric incision, 107

nerve, 233, 257, 258, 260
Medius, anesthesia of, 247
Mental nerve, 79
Mesenteric nerves, 179
Mesentery, injection of, 144, 163,

164
Meso-appendix, infiltration of,

171, 178
Metacarpals, anesthesia of, 245,

247, 249-251, 254
Metatarsals, anesthesia of, 270,

271

Middle ear, 86
Mid-frontal region, anesthesia of,

Molinar, 87

Mortality risks of regional anes-
thesia, 1

of spinal anesthesia, 134
Moure's operation, 82
Mouth, floor of, anesthesia of, 105

cancer of ,106, 107
Mucous membranes, anesthesia of,

26
Musculocutaneous nerve, 272, 273

Nasal cavities, anesthesia of, 80

myxoma, removal of, 81

nerve, 81, 98

polyp, 81

septum, resection of, 80

wall, anesthesia of, 62
Nasopalatine nerve, 81
Neck, operations on, 109, 119, 121

of bladder, anesthesia of, 219

of femur, operations on, 270
Needles for regional anesthesia,

Neocaine-surrenine, 14
Nephrectomy, 129, 163, 198
Nerve-blocking, 18, 35
Nerves, anesthesia of. See In-
dividual Nerves.

1XDEX.

291

Xose, anesthesia of, 69, 80, 99
Xovocaine-adrenalin, 14

Obstetrical forceps, anesthesia for

application of, 213
Obturator nerve, 269
Offerhaus's measurements, 98
Olecranon bursa, 261

suture of, 261
Ophthalmic nerve, 57, 60, 92

frontal infiltration of, 60, 92
Ophthalmology, anesthesia in, 91
Orbital infiltration, 60, 61, 92
Ossiculectomy, 86, 91
Osteotomy of femur, 276
Otology, regional anesthesia in, 85
Ovary, anesthesia of, 141, 167,
168

tumor of, 167, 168

Palate, anesthesia of, 54, 70-72,

105, 108, 109
and tonsil, cancer of, 54

Palatine nerves, 70

Palm of hand, infiltration of.
See Hand.

Pancreas, operation on, 164

Paracentesis abdominis, 167
thoracis, 153

Paracostal anesthesia, 175

Parailiac anesthesia, 175

Paravertebral anesthesia. See An-
esthesia, Paravertebral.

Patella, suture of, 129, 265, 275

Pauchet, 136, 186, 187

Pelvic organs, anesthesia of, 200

Penis, operations on, 212, 217, 218

Pericardium, operations on, 158

Pericostal anesthesia, 153

Perineorrhaphy, 129, 223, 224

Perineotomy, 219, 220

Perineum, anesthesia of, 132, 200,

221, 223, 224
nerves of, 200, 201

Perineural injection, 34
Periosteum, anesthesia of. 30
Periprostatic infiltration, 220
Peritoneum, anesthesia of, 143
Petromastoid operation, 90
Pharyngotomy, 120
Pharynx, cancer of, 107
Phlegmons, anesthesia of, 36,
253, 260

of forearm, 260

of hand, 253
Pituitary, sarcoma of, 85
Plastic operations, 36
Pleurae, anesthesia of, 143, 145, 152
Pleural cavity, paracentesis of,

153

Pleurotomy, 156, 157
Pneumogastric nerve, 106

auricular branch of, 88
Polyp aural, 86

nasal, 81

Posterior nerves, anesthesia of.
See Xerve, Anesthesia of.
Post-operative eventration, 188
Pre-patellar bursa, hygroma of,

274, 275

Prepuce, incision of, 217
Pre-sacral anesthesia, 202, 204,

205, 221

Procaine-adrenin, 14
Prolapsus uteri, 212, 213, 223
Prostate, anesthesia of, 211, 219,

220
Prostatectomy, 129, 212, 220-222

post-sacral anesthesia in, 222

pre-sacral anesthesia in, 221
Prostatic adenoma, 212
Puncture for ascites, 167

of pleural cavity, 153

of tympanum ,86, 91
Pus-tubes, 168
Pylorectomy, 144, 180
Pylorus, anesthesia of, 145, 180
Pyramidal injections, 32

292

INDEX.

Quadriceps extensor, anesthetic

paralysis of, 268
Quenu's method of anesthesia.

230
Quinine and urea hydrochloride,

17, 144. 163. 164. 167, 171.

178, 179, 188, 226, 227, 231

Radial nerve, 233
Reclus, 1, 20

continuous injection of, 20
Recto-vaginal fistula, 223

septum, 223

Rectum, anesthesia of, 132, 163,
200, 211, 228, 229

cancer of, 163, 212. 213, 229

extirpation of, 132, 136, 212,

213, 228, 229

Recurrent laryngeal nerve, 117
Regional anesthesia, 1, 17

absence of danger of asphyxia
in, 2

adrenin in, 16

advantages of, 1, 4

anesthetics for, 14, 15, 16

armamentarium for, 12

asepsis in, 18

disadvantages of, 5

duration of, 4

failures in, 7

formulas used in, 15

gentleness and skill in, 6

indications for, 11, 128, 283

injections in, 19, 22

mixtures used in, 14

mortality risks of, 1

needles for, 12

novocaine-adrenalin in, 14

partial anesthesia in, 7

post-operative dangers in, 2

preparation of operative field
in, 19

procaine in, 16

procaine-adrenin in, 14

Regional anesthesia, psychology of

patient in, 9, 283
scopolamine-morphine before, 8,

shock in, 2
syringes for, 12
time element in, 9
training required for, 5, 283
unequal adaptability of. 10
Regional anesthesia in cranial op-
erations, 37
dental surgery, 94
ophthalmology, 91
otology, 85
rhinology, 80
of face and jaws, 97
floor of mouth, 105
ear, 85

head and neck, 37, 48, 109
nasal cavities, 80
palate, 105
teeth, 94
thorax, 128
tongue, 105
tonsils, 105
Resection, ileocecal, 169, 170, 172

submucous, 80

Resection of condylesof femur, 275
costal cartilages, 155
elbow, 261
foot, 265
intestine, 144
knee, 265

maxillary bones, 102-104
metatarsals, 270, 271
nasal septum, 80
omentum, 163, 188
ribs, 143, 153, 154, 159
Retromolar trigone, 76, 77
Retzius, infiltration of space of,

213, 214, 220

Rhinology, anesthesia in, 80
Ribs, anesthesia of, 152, 153, 158
resection of. See Resection.

IXDEX.

293

Sacral anesthesia, 202, 283
of genital organs, 282
foramina, anesthesia through,

207

plexus, 200, 201, 222
Salpingitis, 168
Sarcoma of hypophysis, 85
Scalp, tumor of, 38
Sciatic nerve, great, 200, 201, 269

lesser, 269

Scopolamine-morphine, 8, 10
Scrotum, anesthesia of, 195, 214-

216

operations on, 214
Septal nerves, 81
Septic buccal cavity, 96
Septum, recto-vaginal, 223
Serous membranes, anesthesia of,

143

Shoulder, anesthesia of, 264
disarticulation of, 265
lipoma of, 264
Sinus, ethmoidal, 62
frontal, 62, 84
maxillary, 70, 83
nasal, 62. 70, 83. 84. 85
sphenoidal, 62, 85
Skin-grafting. 25, 263, 269

wheals, 21

Skull wounds, anesthesia for, 40
Space of Retzius, 213, 214, 220
Spermatic cord, anesthesia of,

197, 214, 215
Sphenoidal sinus, anerthesia of,

62. 85
Sphincter ani, anesthesia of, 226,

227
Spinal anesthesia, 128, 133, 135,

136, 265, 276

column, anesthesia of, 152
Spleen, anesthesia of, 140, 144
Staphylorrhaphy. 109
Sternum, anesthesia of, 143, 152, 158
curettage of, 143

Stomach, anesthesia of, 132, 141,

145, 163, 165, 175, 180
cancer of, 182
operations upon, 163, 180
resection of, 163, 164, 166
ulcer of, 180, 181, 184
Subconjunctival infiltration, 92
Subphrenic abscess, 158
Superior dental nerve, 70
laryngeal, 116, 118
maxillary, nerve, 63, 66, 82-84,

Supraclavicular fossa, 153
Suprapubic cystostomy, 212, 214
Symphysis menti, anesthesia of,

101

Syringes for regional anesthesia,
12

Teeth, anesthesia of, 69, 70, 94-96

Tendo Achillis, 272

Tendon sheaths, tuberculosis of,

253, 260

Tenotomy of foot, 265
Testicle, anesthesia of, 141, 197,
214, 215

operations on, 214
Thenar eminence, 250
Thierry de Martel, 46
Thiersch grafts, anesthesit for,

25, 263, 269
Thigh, amputation of, 265

anesthesia of skin of, 211

operations on soft parts of,

277, 278
Thoracic nerves, 136, 139, 144

rigidity, 155

walls, anesthesia of, 144, 153
Thoracotomy, 143, 153, 156-158
Thorax, anesthesia of, 128. 140,

141, 143-145, 152, 153
Thumb, anesthesia of, 247, 250
Thyroid artery, ligation of, 119
Thyroidectomy, 119, 121

294

1XDEX.

Tibial nerve, anterior, 272-274
Toes, anesthesia of, 270, 271
Toe nail, ingrowing, 270
Tongue, anesthesia of, 79, 105-

107, 122, 127
Tonsillectomy, 108, 109
Tonsils, anesthesia of, 105

cancer of, 107
Tracheotomy, 118
Trans-sacral anesthesia, 203, 204,
207, 210-212, 219, 222, 224,
229, 283
Transverse abdominal incision, 164

colon, operations on, 179
Trephining, 40, 42, 43
Trochanter, operations on, 270
Tuberculosis of ileo-cecal seg-
ment, 170

tendon sheaths, 253, 260
Tuberculous ascites, 167
Tumors, malignant, 36, 39, 42, 54,
104, 106, 107, 122, 136,
158, 161, 163, 168, 170,
182, 212, 213
Tumors of bladder, 212

brain, 82

breast, 160, 161

cecum, 163

colon, 163

cranium, 39, 42

dor sum, 253, 260

forearm, 260

hypophysis, 85

ileocecal segment, 170

jaw, 104, 123

larynx, 122

lung, 158

mouth, 106, 107

nasal cavities, 81

neck, 119

ovary, 167, J68

palate, 54

pharynx, 107

Tumors of prostate, 212

rectum, 163, 212, 213, 229

scalp, 38

shoulder, 264

stomach, 182

tongue, 106, 107, 122, 127

tonsil, 54, 107

uterus, 136, 168, 212
Turbinates, removal of, 81
Tympanum, anesthesia of, 86, 91

Ulcer of stomach, 180, 181
Ulnar nerve, 233, 254, 256, 257,

260

Umbilical hernia, 186
Ureter, anesthesia of, 141, 144,

212

Ureteral catheterization, 212
Urethra, anesthesia of, 218, 219

suture of, 219
Urethrotomy, 219
Urocaine, 17

Uterus, anesthesia of, 132, 141,
168, 211, 214

cancer or fibroids of, 136, 168

curettage of, 212

liberation of, 223

prolapse of, 212, 213, 223

Vagina, anesthesia of vault of,

223

vestibule of, 222, 223
liberation of, 223
Varicocele, 129
Varicose veins, 265, 279
Vesical exploration, anesthesia

for, 213
operations, 212
Vestibule, anesthesia of, 87
Vulva, operations on, 222, 223

Wheals, 21

Whitehead operation, 225, 227

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