THE INFILTRATION METHOD OF LOCAL ANESTHE- 
SIA IN GENITO-URINARY SURGERY. 
By Bransford Lewis, M.D., of St. Louis. 
Professor of Genito-Urinary Surgery and Venereal Diseases, College of Physicians and 
Surgeons; Genito-Urinary Surgeon to the St. Louis Baptist Hospital; Consul- 
tant in Genito-Urinary Surgery to the Missouri Pacific Hospital, the 
City Hospital, the Female Hospital, and to St. Mary’s In- 
firmary, St. Louis. 
Read before the American Association of Genito-Urinary Surgeons, at Niagara Falls, 
N. Y., May 28, 18<J5. 
IN July, 1894, at the German Congress of Surgeons (afterwards presented 
in the Thcrapeutische Monatshejte, No. 9, 1894), Dr. Schleich an- 
nounced and detailed a new method of producing local anesthesia by the 
use of intra-cutaneous (rather than sub-cutaneous) injections of very dilute 
solutions of various drugs; and he indicated the distinctiveness of the 
method by terming it Infiltration Anesthesia. Later, in a monograph en- 
titled “Schmer/.lose Operationen,” Berlin, 1894, the author treated the sub- 
ject more extensively, and gave the results of its use in some three thou- 
sand operations, minor and major. 
During 1894, the method received some attention from the American 
medical press, and was put to practical test by American surgeons. I)r. 
H. V. Wiirdemann, of Milwaukee, presented the subject in an admirable 
manner in the Journal of the American Medical Association. December 29, 
1894- 
The principle of the method consists in injecting intra-cutaneously cer- 
tain solutions and dissipating the sensibility of the peripheral nerves by the 
pressure of the infiltrating fluid, by the anemia which it causes, and by the 
comparatively low temperature at which it is injected—three effects secured 
by the fluid itself rather than by any drug which it may contain. As a 
matter of fact, the drugs used are of only incidental importance. 
It has long been known that the injection of fluids in some consider- 
able quantity would cause a deadening of the sensibility of the part; but 
the induction of this insensibility has not been sufficiently controllable to 
place it within the limits of wide surgical practicability; and the initial pain 
to which it would give rise, was another objectionable feature which dis- 
counted its usefulness. 
By thought and much experimentation these problems, as well as others, 
have been practically overcome by Dr. Schleich; so that for the kind of 
surgery to which the injection of anesthetizing fluids is applicable, whether 
"minor” or "major", the use of the older cocainizing methods is liable to 
be entirely superseded by the infiltration method; and the position of 
chloroform and ether narcosis is already being assailed by those who have 
made practical use of it. « If a syringe-needle be inserted obliquely into the skin, the point reach- 
ing just below the epidermal layer, and a few drops of the proper fluid be 
injected there, an elevated wheal, looking like a mosquito-bite, will be the 
result; and tests with a needle or knife immediately afterwards will show 
the entire area of the wheal to be absolutely insensible, while the sensibil- 
ity of the skin just beyond the edematous area is not disturbed in the 
least. 
Experimentation has shown that the promptitude and practical efficacy 
of the anesthesia so induced depend on several factors: (l) The density of 
,the fluid used; (2) The character and strength of the drug or combination 
of drugs embodied in the solution; (3) The temperature of the latter; (4) 
(The condition (of health or disease) of the tissues to be anesthetized; and, 
(5) The .maintenance of complete edema of the tissue to be operated upon. 
■ Density of the Feuid. It has been found that a physiologic salt so- 
lution, 0.6 per cent, would cause a wheal but not an anesthetic one; while 
a 0.,2 per cent salt solution produced sufficient anesthesia to allow of the 
removal without pain, of a nevus from the neck of the eminent Dr. Berg- 
niann. Solutions of sugar, 3 percent; potassium bromide, 3 per cent; 
: morphine, 0.1 percent; carbolic acid, 0.5 per cent; and caffeine, 2 per cent; 
all show markedly anesthetic effects, while above and below those strengths 
they become irritative and painful. This developes the second-named 
factor, 
1 - The Character and Strength of Drugs Used. While it is a fact 
that the various agents mentioned will produce anesthesia after a certain 
- length of time, the first and primary effect of some of them is irritative, and 
they excite pain until their secondary, anesthetic effect begins to prevail. 
In order to obviate this difficulty, use is made, in the formula, of certain 
drugs (cocaine, morphine) which in proper strength have an immediate 
anesthetic effect, thus doing away with the transient irritative effect of the 
other, secondarily, anesthetic drugs in the combination. This is especially 
important when considered in connection with 
The Condition (of Health or Disease) of the Structures to 
be Operated Upon. While the difference in the primary-irritative and 
the secondary-anesthetic effect may not be so sharply marked in normal, 
healthy tissues, as in the removal of a nevus, in the case of inflamed struc- 
tures (crucial incisions into a carbuncle), it is markedly prominent; and 
unless it were prevented, it would defeat the purpose and advantages of the 
method. Happily, this is accomplished in either of several ways: By using 
such drugs in the combination (cocaine, etc.) as have an immediate anes- 
thetic effect, even though diluted to the degree mentioned; by beginning 
the anesthesia in healthy structures and continuing it by successive injec- 
tions into the unhealthy ones; by producing a temporary spray- 
anesthesia of the inflamed structures, sufficient to allow of the introduction 
of the infiltrating fluid. Of these, the first will be found to be most com- 
monly useful; and it is for that reason, chiefly, that cocaine is used at all. 
However, the point must by emphasized that though cocaine is used in this 
way, it is vastly different from the manner of using it hitherto in vogue; 
since, instead of using a strength of from two to»ten or twenty per cent, the strength entirely capable, by this method, ot producing the anesthesia 
desired is that of one or two hundredths per cent; and instead of a very 
few drops producing a toxic (perhaps a highly dangerous) effect, one or 
two or three ounces may be used without the slightest systemic symptom. 
Temperature of the Injected Fluid. It has been observed that 
the same strength of solution, when used cold, is much more highly anes- 
thetic than if it is warm. For this reason, it is advised to keep the bottle 
of fluid on ice before and during the operation. 
Complete Infiltration. Every tissue of the body, without excep- 
tion (skin, muscles, glands, mucous membrane, nerves, etc.), becomes in- 
sensible to pain when infiltrated in the manner described. This obtains for 
bone and the hard structures, as well as the soft ones. Bone is reached 
either through infiltrating its periosteum or by injecting into the medulla. 
Nerve trunks are anesthetized separately, first by applying five per cent 
carbolic acid solution, and then, through this, inserting {Tie needle and 
fluid. 
Only the infiltrated, artificially edematous tissue is anesthetic, the tis- 
sues just outside of which retain normal acuteness of sensibility. Conse- 
quently, in the course of an operation, with absorption of the infiltrated 
fluid, it is necessary to renew the injections or extend their area co-inci- 
dently with the operative field. After infiltration, the anesthetic condition 
lasts from fifteen to twenty minutes. 
With the proper fluid, anesthesia ensues immediately on its being in- 
troduced into the tissues, and lapse of time is not requisite for developing 
insensibility. This, again, is in marked contrast to the effect of the older 
methods of producing anesthesia. Its advantage is great. 
Hemorrhage. Anemia being one of the effects of the method, it may 
be supposed that there will be less bleeding (oozing) than under ordinary 
circumstances. This is the case. And distortion of the tissues from the 
infiltrated fluid does not cause any especially increased difficulty in secur- 
ing and tying or twisting bleeding vessels. Nevertheless, in operating in 
deeper structures, the use of the syringe-needle involves the risk of piercing 
blood vessels, nerves, etc., for which care must be observed. 
Formula. Ill his various surgical procedures, I)r. Schleich finds the 
following three solutions of graded strengths to answer all purposes: 
Strong Solution, No. 1. 
K Cocain. muriat., .... gr. iii. 
Morph, muriat., .... gr. i-3. 
Natr. chlor., ----- gr. iii. 
Aq. dest., ------ ad .oz. iii. 
rq. Sterilisat., adde sol. acid, carbolic., 5 per cent, gtt. iii. 
Medium-strength Solution, No. 2. 
K Cocain. muriat., - gr. iss. 
Morph, muriat., - - - - gr. i-3. 
Nat. chlor., ----- gr. iii. 
Aq. dest. - - - - - - ad oz. iii. 
rr]. Sterilisat., adde sol. ac. carbolic. 5 per cent, gtt. iii. Weak Solution, No. 3. 
1$ Cocain. muriat., - - - - gr. i-6. 
Morph, muriat., - gr. i-12. 
Natr. chlor., ----- gr. iii. 
Aq. dest., - - - - - ad oz. iii. 
rrj. Sterilisat., adde sol. ac. carbolic. 5 per cent, gtt. iii. 
Solution No. 1, Dr. Schleich uses for operating on inflamed or hyper- 
esthetic areas; No. 2, for most operations; No. 3, for superficial opera- 
tions on nearly normal tissues. 
To carry out the aims of asepsis, he recommends that only sterile so- 
lutions be used; and to this end, he advises that the reservoirs be sealed 
with scorched-cotton stoppers, and that from these smaller vessels should 
be filled at the time of operating. 
I have made use of the infiltration method in operating on buboes 
(enucleation); in opening a prostatic abscess through the perineum; in 
circumcisions and some other minor procedures. 
In working in superficial structures, its effect is all that one could wish 
and beyond criticism. While in the deeper parts of wounds such as met 
with in evacuating prostatic abscess, enucleating buboes, etc., it is more 
difficult to secure complete and absolute anesthesia, on account of the care 
necessary to prevent the injury of deep-lying structures, still, with the in- 
creased skill obtained by practice, objections on this line are removed and 
local anesthesia is effected with proportionately increasing success. It ap- 
pears to me that testicular ablation, for instance, could be done without a 
particle of suffering on the part of the patient. 
The after-pain I have not found to be greater than with other modes 
of anesthesia; and the other disagreeable after-effects of general anesthesia 
are, of course, avoided. Two of my patients were over sixty years old, 
yet they felt as well after as before the operations. No symptom of intoxi- 
cation has become evident in any case that I have observed, and I have not 
been sparing in the use of the fluid. 
I have made use of a larger syringe and longer needle than that recom- 
mended by the author, and I think this faciliates matters considerably, ob- 
viating numerous successive punctures in order to fill up the tissues suffi- 
ciently. The infiltration may be begun with a small syringe and fine 
needle and continued, without pain, with the larger. 
1006 Olive Street.