PRACTICAL LOCAL ANESTHESIA AND ITS.SURGICAL TECHNIC BY ROBERT EMMETT FARR, M.D., F.A.C.S. MINNEAPotlS,' MINN. ILLUSTRATED WITH 219 ENGRAVINGS AND 16 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 1923 Copyright LEA & FEBIGER 1923 PRINTED IN U. S. A. TO THAT UNFORTUNATE INDIVIDUAL THE PATIENT WHO, FATE HAS DECREED, MUST UNDERGO SURGICAL TREATMENT THIS VOLUME IS SINCERELY DEDICATED PREFACE. Tins book is an expression of the author's views on the subject of local anesthesia as developed by his observation and by his own experience. Its aim is to present to the medical profession the advantages of local anesthesia to patient and to surgeon, and to describe the practical details of methods of administration and of operative technic employed in its use. As far as possible, stress has been laid upon the particular methods which have proven best in the author's experience. Spinal anesthesia has been omitted as his experience with it has been limited. Every effort has been made to portray, in as vivid a manner as the ability of the author permits, the simplest and most efficient means of using local anesthesia. At the risk of being tedious, by introducing what might be considered an unnecessary amount of detail, the author has endeavored to present the methods which have carried him through the critical stages of the various operations. Illustrations in the form of drawings and photographic reproduc- tions have been freely used wherever they were considered of advan- tage in helping to clarify the text. To illustrate the feasibility of performing the various types of operation under local anesthesia, case reports have been inserted. For the sake of convenience the book is divided into three parts: In Part I, consisting of Chapters I to VI, inclusive, certain problems are considered in connection with anesthesia, including equipment, technic and a description of the sensory nervous system. In Part II, which comprises Chapters VII to XII, inclusive, the subject has been considered regionally, all portions of the body, aside from the abdomen, being treated. In Part III, which includes the final six chapters, the surgery of the abdomen is considered. It is the author's belief that the actual method of operating has a most important bearing upon the success which will attend any surgical procedure under local anesthesia. Hence points in surgical technic have been described with more than ordinary detail. It is hoped that sufficient descriptive material regarding both the technic of administering anesthesia and the technic of operating has been introduced to point the way with clarity and encourage the surgeon to adopt a certain degree of uniformity in his methods. VI PREFACE The necessity for teamwork among assistants in the treatment of patients and the importance of the psychic factor have been espe- cially considered. The author wishes to express his appreciation of the loyal and untiring efforts of his associates, who have so willingly worked with him in an effort to broaden the application of the local anes- thesia method. Especial thanks are due to Drs. S. R. Maxeiner, E. W. Gilroy (deceased), M. E. Rose and C. W. Brunkow: Dr. Maxeiner, who, first as assistant and later as associate, aided the author greatly, especially in the study of the nervous system upon the cadaver; Dr. Gilroy for his experimental work on the toxicity of the local anesthetics; and Drs. Rose and Brunkow for their study and observation regarding the alkaline reserve in rela- tion to local anesthesia and special aid in preparing Chapters I and II. The author desires also to acknowledge the many courtesies ex- tended by Dr. Charles A. Erdman, of the University of Minnesota, whose kind offices made it possible to carry out Studies in the anatomical laboratory. lie is also indebted to Dr. Paul W. Wipperman for proofreading the manuscript and offering many valuable suggestions in relation thereto. His thanks are also due to Miss Ann Nyquist, R. N., his former and first psycho-anesthetist, whose efficient services and initiative made manifest the great advantages offered by this now indispens- able aid. In the assembling of this volume the tireless and painstaking efforts of Dr. Brunkow, Miss Ella May Thompson, R. N., who is now the author's psycho-anesthetist, and his faithful secretaries, Miss Blanche W. Scallen and Miss Helen J. Cribb, R. N., have been invaluable. The author's thanks are due to the artist, Air. Ralph L. Witherow, by whom most of the drawings were made. He wishes also to express his thanks to Messrs. Lea & Febiger for the care exhibited and the many helpful suggestions in publishing this book. To the master technician in local anesthesia, this work will, perhaps, make no appeal, but it is the author's hope and desire that this book may, in some small degree, help the less experienced to avoid the many pitfalls which the writer has encountered in his own experience with local anesthesia. Furthermore, it is his firm conviction that a simple presentation of the subject, such as this aims to be, will enable the earnest and interested student to improve, to some extent, his ability to use this form of anesthesia, thus increasing his efficiency and providing greater safety and com- fort for his surgical patients. R. E. F. Minneapolis, Minn., 1923. FOREWORD. The writer, having been selected twenty years ago to review the progress and present the status of Local Anesthesia before an International Congress, experiences peculiar pleasure in the oppor- tunity, here afforded, to review again in this masterpiece the enor- mous progress made in both the art and science of Local Anesthesia. With the announcement of the discovery of the first drug (cocain) possessing local anesthetic properties, came a wave of enthusiastic adoption by surgeons of a long-sought ideal. In its wake, as promptly, came disasters and disappointments. Seeking still further, innumerable substitutes were found and lauded-still with similar results. Why there have been so many failures dimming the glory of each new remedy, so much misgiving in the surgical and the lay mind, has never been so clearly presented and con- cisely explained as in this book, the result of twenty years' study and work, concentrated on the solution of this problem. Induction of local anesthesia in any given area involves ana- tomical, surgical and psychic factors which in the past were ignored, overlooked or unthought of by the novice, and which account for the frequent early failures! However, the problem has been studied from every conceivable angle, and every beneficial influence has been utilized by Dr. Farr, so that his success has been phenomenal and most grati- fying; and may be duplicated by anyone willing to profit by his experiences. With every aspect of the specific problem studied and logically weighed, conclusions have been reached that, while convincing, are presented in a refreshingly modest manner. His many personally devised improvements in instruments, technic and accessory aids have been by him lightly passed over; his wonderfully systematized approach to his final demonstration that Local Anesthesia now rests upon a fixed and solid foundation is confirmed by his presentation of actual clinical case histories, fully illustrated, for every part of the body, even the brain. Lewis L. McArthur. Chicago, 1923. CONTENTS. PART I. ANESTHETICS, AND THEIR PROBLEM-EQUIPMENT- TECHNIC-ANATOMY OE THE SENSORY NER- VOUS SYSTEM. CHAPTER I. The General Anesthetics. Toxicity and 111 Effects 18 Effects on the General System 18 Effects on Special Organs and Tissues 21 Gangrenous Pneumonia and Lung Abscess 22 Ether 24 Ethanesal 25 Chloroform 26 Nitrous oxide 28 The Dangers of General Anesthesia 29 Mortality of the General Anesthetics 31 CHAPTER II. The Local Anesthetics. Methods of Producing Local Anesthesia 33 Cold 33 Pressure 34 Phenol 34 Cocain 35 Beta-eucain 35 Tropacocain 36 Stovain 37 Alypin 38 Apothesin 38 Allocain-S 39 Nirvanin 39 Quinin and Lrea Hydrochloride 40 Benzyl Alcohol 41 Benzylcarbinol 42 Saligenin (Salicain) 42 Butyn 43 Epinephrin 44 Novocain (Procain) 45 Acidosis Research upon Patients after Using Local Anesthesia ... 48 Relative Desirable Properties of Local Anesthetics 52 CHAPTER III. The Anesthesia Problem. The Patient's Interests 55 The Choice of an Anesthetic 55 Safety 56 Efficiency 56 Comfort 58 X CONTENTS Some Special Advantages of Local Anesthesia During Operation 61 Advantages Before and After Operation 63 The Attitude of the Patient in Relation to Local Anesthesia and Upon What it Depends 64 General Intelligence of the Patient 66 The Psychic Aspect of a Surgical Case 66 The Question of Discussing the Form of Anesthesia with the Patient 68 The Necessity of Attention to Psychic Aspects by Attendants . . 69 "Psychic Shock," 70 Preliminary Narcotics 72 Narco-local Anesthesia 72 The Hospital in Relation to the Anesthesia Problem 74 Medical Teaching in Relation to Local Anesthesia 74 The General Practitioner in Relation to Local Anesthesia 75 The Nurse versus the Physician Anesthetist 76 The Surgeon His Own Anesthetist 77 The Progress of Local Anesthesia and Upon What It Depends . . . 78 Mixed Anesthesia 78 Psycho-local Anesthesia 79 Operating by Fractional Method 80 CHAPTER IV. Equipment and Armamentarium. Necessity for Special Equipment 82 The Operating Table 83 Tilting 84 Syringes 85 Needles for Infiltration 86 The Pneumatic Injector 88 Detailed Description of the Pneumatic Injector 92 Other Uses for the Pneumatic Injector Pneumoperitoneum 95 Operating Room Lighting 95 The Elephant Trunk Lamp 97 The Automatic Wire-spring Retractor 97 The Automatic Lifter 101 Description of the Automatic Lifter 103 The Goiter Clamp ' 104 The Prostatic Retractor 106 The Viscera Retainer 106 CHAPTER V. General Technic. The Principles of the Application of Local Anesthesia to Surgery . . Ill A Definition of the Terms Employed Ill Infiltration Anesthesia Ill Regional or Conduction Anesthesia Ill Infiltration Block 112 Venous Anesthesia 112 Arterial Anesthesia 114 Sacral Anesthesia 115 Parasacral Anesthesia 119 Trans-sacral Anesthesia . 121 Paravertebral Anesthesia 122 Splanchnic Anesthesia 124 Posterior (Kappis) 124 Anterior Splanchnic Anesthesia (Kappis and Author's) .... 125 Handling the Abdominal Viscera 129 Brachial Anesthesia 129 Narco-local Anesthesia 132 contents XI Synergistic Anesthesia 133 The Preparation of a Patient for an Operation Under Local Anesthesia . 135 Psychic 135 The Application of Regional Anesthesia 136 Direct Infiltration versus Regional Anesthesia 137 Desirability of Simplifying the Technic of Local Anesthesia and Some Advantages of Infiltration Anesthesia 139 The Choice of Methods of Administering Local Anesthesia .... 143 Infiltration Anesthesia Technic 144 Some of the Causes of Failure of Local Anesthesia in Abdominal Surgery 147 General Considerations Regarding the Induction of Local Anesthesia after the Time has Arrived for the Giving of the Anesthetic . . . 148 The Introduction of the Anesthetic Solution 149 Technic 149 The Initial Wheal 149 Anesthetization of the Skin Line 149 Intradermal Method 149 The Author's Subdermal Method 150 The Painless Secondary Intradermal Wheal 150 The Technic of Deep Layer Infiltration 151 Safety of Deep Infiltration 152 The Technic of Skin Incision and Opening the Abdominal Cavity 153 Surgical Technic and Some of the Adjuncts Demanded by Local Anesthesia 154 Sponging 154 Tying of Ligatures 154 Forceps Tie (Grant) 156 The Three-forceps Tie (Author's) 156 The Four-forceps Tie (Author's) 156 The Gauze Retractor 156 Operating Room Deportment .159 The Psycho-anesthetist 160 Surgical Strategy 161 Music 162 Miscellaneous 162 Hypodermoclysis (Bartlett) 162 Skin-grafting-Thiersch's Method 163 Preparation of Field for Application of Graft .... 163 Preparation of Field for Removal of Graft 164 Pedicle Flaps and Wolff Grafts 164 CHAPTER VI. The Anatomy of the Sensory Nervous System. Nerves of the Head and Face 166 The Trigeminal Nerve 166 The Ophthalmic Nerve 166 The Lacrimal Nerve 166 The Frontal Nerve 166 The Nasociliary Nerve 167 The Maxillary Nerve 167 The Zygomatic Nerve 167 The Mandibular Nerve and Branches 168 The Lingual Nerve 169 The Inferior Alveolar Nerve 169 The Facial Nerve 169 The Glossopharyngeal Nerve 169 The Vagus Nerve 169 The Spinal Nerves 170 The Cervical Nerves 170 The Cervical Plexus 170 The Brachial Plexus 172 The Thoracic Nerves 173 XII CON TENTS The Lumbosacral Plexus 175 The Lumbar Nerves 175 The Iliohypogastric Nerve 175 The Ilioinguinal Nerve 176 The Genitofemoral Nerve 176 The Lateral Femoral Cutaneous Nerve 176 The Obturator Nerve 177 The Accessory Obturator Nerve 177 The Femoral Nerve 177 The Saphenous Nerve 177 The Sacral and Coccygeal Nerves 178 The Posterior Femoral Cutaneous Nerve 178 The Sciatic Nerve 178 The Tibial Nerve 179 The Common Peroneal Nerve 180 The Pudendal Plexus and Branches 181 The Perforating Cutaneous Nerve 182 The Pudendal Nerve 182 The Inferior Hemorrhoidal Nerve 182 The Perineal Nerve 182 The Dorsal Nerve of the Penis 182 The Visceral Branches 182 The Muscular Branches 182 Anococcygeal Nerves 182 The Sympathetic Nervous System 182 The Celiac Plexus 183 PART II. LOCAL ANESTHESIA IN SURGERY OF ALL REGIONS OF THE BODY EXCEPT THE ABDOMEN. CHAPTER VII. Local Anesthesia in Surgery of the Head and Face. The Nerve Supply of the Scalp 185 Anesthesia of the Scalp 186 Duration 189 Excision of New Grow'ths 190 Atheromata 190 Surgery of the Skull 190 Fractures of the Vault of the Skull 190 Operations Upon the Brain 191 Subtemporal Decompression 193 The Ear and Mastoid 194 Anesthesia of the Tympanic Cavity 194 The Nerve Supply of the Face 197 Surgery of the Face 197 Anesthesia 198 Blocking of the Trigeminus Nerve 198 The Ophthalmic Nerve 198 The Maxillary Nerve 200 The Mandibular Nerve 202 Skin Plastics 220 Hare-lip 220 CONTENTS XIII Surgery of the Mouth and Throat 222 The Tonsils 222 Tonsillectomy 222 Infiltration 222 Surgery of the Tongue 224 The Palate 226 CHAPTER VIII. Local Anesthesia in Surgery of the Neck. General Considerations 229 Advantages 229 Cooperation of the Patient. ' 229 Nerve Supply of the Neck 229 Methods of Inducing Anesthesia 230 Deep Cervical Infiltration 230 Tuberculous Glands and Malignant Disease . 239 The Thyroid . 237 Thyroidectomy in Non-toxic Cases 237 Anesthetic and Surgical Technic 237 Toxic Thyroids 243 Ligation of the Thyroid Arteries 243 Thyroidectomy in Toxic Cases 243 The Larynx 246 Nerve Supply of the Larynx 246 Laryngectomy . ... 246 Technic of Anesthesia 246 CHAPTER IX. Local Anesthesia in Surgery of the Breast, Thorax and Spine. Surgery of the Breast 251 Benign Tumors-Frozen Sections ' 251 Technic of Anesthesia 251 Suppurative Mastitis ' 254 Technic of Anesthesia for Drainage 254 Malignant Tumors 254 Excision of the Breast 254 Radical Excision 256 Surgery of the Thorax . 261 The Thoracic Nerves 261 Thoracentesis ■ ... . 262 Anesthesia Technic 262 Costectomy . . . i i i 263 1 echnic of Anesthesia 263 Empyema ...... 264 Negative Pressure 264 Massive Rib Resections ' 264 Surgery of the Spine 267 Technic of Anesthesia 268 CHAPTER X. Local Anesthesia in Surgery of the Extremities. General Considerations 271 Application of Local Anesthesia to Fluoroscopic and Radioscopic Examination 271 Local Anesthesia of the Hands and Feet 271 Local Anesthesia of the Fingers and Toes 272 Transverse Infiltration Block 275 XIV CONTENTS The Reduction of Fractures and Dislocations 276 'Pho Reduction of Fractures and Dislocations in Children . . 278 'rhe Reduction of Malunited Fractures in Children 281 Bone Transplants 283 Technic of Anesthesia . : 283 Amputations 286 Technic of Anesthesia 286 The Upper Extremities 286 The Lower Extremities 287 Suppurative Arthritis 289 Technic of Anesthesia for Drainage 289 Osteomyelitis 290 Acute Osteomyelitis 290 Technic of Anesthesia for Drainage 290 Chronic Osteomyelitis 290 Choice of Methods of Producing Local Anesthesia in the Upper Extremities 291 Surgery of the Shoulder and Clavicle 291 Nerve Supply of the Shoulder and Clavicular Region 291 Technic of Anesthesia 292 Brachial Anesthesia 292 Surgery of the Elbow-joint 294 Arthroplasty 294 Surgery of the Wrist 297 Nerve Supply of the Wrist 297 Surgery of the Hip 297 Nerve Supply of the Lower Extremity to the Region of the Hip-joint 297 Open Operation 298 Technic of Anesthesia 298 Fractures and Dislocations 299 Technic of Anesthesia 299 Arthroplasty of the Hip . • 302 Fracture of the Femur . . . ' 302 Closed Operation 302 Technic of Anesthesia 302 Open Operation 303 Technic of Anesthesia 303 The Knee-joint 305 The Nerve Supply 305 Technic of Anesthesia 306 Fracture of the Patella 307 Technic of Anesthesia 307 Floating Cartilages 307 The Leg 308 Fractures, Closed Operations 308 Surgery of the Ankle-joint 310 Nerve Supply 310 Special Fractures 310 Pott's Fracture 310 The Cadivilla Pin 311 Hallux Valgus (Bunions) 311 Technic of Anesthesia 311 Varicose Veins of the Leg 312 CHAPTER XI. Local Anesthesia in Surgery of the Genito-urinary System. Anesthesia and Genito-urinary Surgery 315 Local Anesthesia in Surgery of the Kidneys . 316 Nerve Supply . 316 Technic of Anesthesia 317 CONTENTS XV Local Anesthesia in Surgery of the Kidneys- The Kidney 319 Sensation 319 Incision 319 Delivery of the Kidney 321 The Ureter ' 323 Calculi 323 Technic 324 Grave Surgical Problems 325 The Bladder 328 Cystoscopy 328 Suprapubic Cystotomy 329 Method of Opening Bladder 329 Local Anesthesia in Suprapubic Prostatectomy 331 Sacral Anesthesia 331 Technic of Infiltration 331 Prostatic Retractor 332 Perineal Prostatectomy. Abscess 338 The Male Urethra 338 Stricture 338 The Penis '. . . 340 Nerve Supply 340 Circumcision 341 Amputation of the Penis for Malignant Disease 341 Hypospadias 341 Varicocele 341 Skin Sterilization 341 Technic of Infiltration 342 Hydrocele-Orchidectomy-Vasectomy 342 Technic of Infiltration 343 Vasotomy 344 The Female Genitalia (External) . . . ' 344 Nerve Supply 344 General Considerations 345 Methods of Obtaining Anesthesia 345 Psychic Considerations 346 Vaginal Examinations in Virgins 348 Operations upon the Labia-Cysts-Neoplasms-Abscesses 348 The Nerve Supply 348 Technic of Anesthesia 348 Operations upon the Clitoris 349 The Nerve Supply 349 Operations upon the Perineum 349 The Nerve Supply of the Perineum 349 Perineorrhaphy 349 Technic of Anesthesia 349 Operations upon the Cervix and Uterus-Curettage 352 The Nerve Supply 352 Technic of Anesthesia 352 Anterior Colporrhaphy 354 Technic of Anesthesia 354 The Uterus 354 Interposition Operation 354 Infiltration Block 354 Anesthesia 354 Vaginal Hysterectomy 356 Technic of Anesthesia 356 Miscellaneous Operations 357 Atresia of the Hymen 357 Artificial Vagina 358 Pelvic Abscess in Women , , , 360 XVI CONTENTS CHAPTER XII. Local Anesthesia in Surgery of the Rectum and Anus. Surgery of the Rectum and Anus 362 Preparation of the Patient 362 Choice of Local Anesthetic Methods 362 Nerve Supply of this Region 363 Technic of Circumferential Infiltration 363 Sphincter Divulsion 366 Rectal Examination 368 Hemorrhoids, Ulcers, Fissures and Polypi 369 Fistula-in-Ano 369 Infiltration Block 370 Carcinoma of the Rectum 373 Prolapse of the Rectum 373 Postoperative Comfort 377 Quinin and Urea Hydrochloride 377 PART III. LOCAL ANESTHESIA IN SURGERY OF THE ABDOMINAL WALL AND CAVITY. CHAPTER XIII. Local Anesthesia in Surgery of the Abdomen. General Considerations 379 Intraperitoneal Pain Sense 379 Position of the Patient 384 Retraction 385 Direction, Site and Choice of Incisions 385 The Resultant Scar 387 Relative Importance of the Division of the Muscular as Com- pared with Aponeurotic Tissue 388 Conservation of the Blood Supply 389 Conservation of the Nerve Supply 389 Anticipated Pathology 390 Facility with Which incisions May be Made ami Closed 390 The Relaxation Afforded During and After Operation . 391 Technic 391 Closure 394 The Making of the Incision 397 Technic 397 Muscular Relaxation 398 Duties of the Psycho-anesthetist 398 Abdominal Exploration . 399 The Examination of the Abdominal Organs 400 Viscero-parietal Adhesions 401 CONTENTS XVII CHAPTER XIV. Local Anesthesia in Surgery of the Abdominal Wall (Hernia). Hernia 402 Inguinal Hernia 402 Nerve Supply 402 Skin Sterilization 403 The Induction of Local Anesthesia 403 Femoral Hernia 406 Incisional Hernia 406 Transplantation of Fascia 407 Epigastric Hernia 411 Umbilical Hernia and Lipectomy 411 Strangulated Hernia 415 CHAPTER XV. Local Anesthesia in Surgery of the Upper Abdomen. Position of the Patient upon the Operating Table 419 The Stomach 419 Avoidance of Clamps 420 Gastroenterostomy (Anterior) 420 Gastroenterostomy (Posterior) 421 Ulcers 423 Perforated Gastric and Duodenal Ulcers-Acute and Chronic 423 Sleeve Resection 427 Neoplasms (Malignant) 428 Resection for Carcinoma 428 Hypertrophic Pyloric Stenosis 430 The Liver 438 Cysts, Abscess and Rupture 438 Gall-bladder and Ducts 440 Technic of Anesthesia 440 Opening of Abdominal Cavity 441 Cholecystostomy 441 Sensation of the Gall-bladder 441 Cholecystectomy 441 Exposure 441 Anterior Splanchnic Anesthesia .......... 443 Technic of Exposing the Gall-bladder 446 The Method of Removing the Gall-bladder 446 Bile Ducts 453 Choledochotomy 453 The Pancreas 457 The Spleen 458 CHAPTER XVI. Local Anesthesia in Surgery of the Intestines. Special Considerations 459 Diagnosis 459 Treatment of Simple Conditions 459 Treatment of Complicated Conditions 460 Resection for Cancer . 460 Colostomy 463 Technic of Operation 463 Intussusception 463 XVIII CONTENTS Intussusception in Children 465 Tuberculous Peritonitis 466 Intestinal Obstruction from Other Causes 468 Technic of Temporary Drainage of Distended Bowel 469 The Rubber Towel Method (Author's) 469 Enterostomy 470 Peritonitis Ileus 470 CHAPTER XVII. Local Anesthesia in Surgery of the Appendix. Appendicitis 471 Special Considerations 471 Acute or Subacute 471 Medical Management 471 Surgical Management 471 Preoperative Management 471 Operative Management 471 Effect of Anesthesia upon Postoperative Course .... 472 Position upon the Operating Table 472 Incisions 472 Chronic Appendicitis 472 The Transverse Abdominal Incision 473 Technic of Subdermal Infiltration 476 Technic of Deep Infiltration 476 Technic of Opening the Abdomen 478 Technic of Meso-appendix Infiltration 478 Technic of Delivering Appendix 479 Appendicectomy under Varying Conditions 480 Acute Appendicitis . 480 Abdominal Infiltration and Muscular Relaxation 481 Technic of Delivering Acute Appendix 482 Intra-abdominal Abscess 484 Technic for Drainage 484 Superficial Abscess 486 Technic for Drainage 486 The Appendix and Pelvis 487 Special Considerations 487 Position upon Operating Table 488 CHAPTER XVIII. Local Anesthesia in Surgery of the Pelvis. Pelvic Blocking 489 Skin Sterilization 489 Incisions for Pelvic Operations 489 Exposure 489 Adjuncts to Pelvic Operations 492 Technic of Intra-abdominal Pelvic Infiltration and Blocking .... 494 Anterior Splanchnic Anesthesia 494 The Uterus 495 Hysteropexy 495 Myomectomy 496 Abdominal Hysterectomy 497 Panhysterectomy 498 Fallopian Tubes 500 Cesarean Section 502 The Ovary 503 Postoperative Drainage 507 PRACTICAL LOCAL ANESTHESIA. PART I. ANESTHETICS-EQU1PMENT-TECHNIC-ANAT0MY OF THE SENSORY NERVOUS SYSTEM. CHAPTER I. THE GENERAL ANESTHETICS. As time goes on new discoveries are found in the various sciences, many of which are epoch making. Certainly the discovery of general anesthesia is such. It has filled a great need in the advance- ment of surgery and will continue to do so. Notwithstanding this fact its use is accompanied by dangers and its unsatisfactory admin- istration is not an infrequent occurrence. The pathology in the case, the ability of the anesthetist, and other circumstances all have an important bearing on the outcome. Many of the profession fail as yet to see the great value and true scope of local anesthesia in general surgery. It has been frequently exemplified in the history of medicine that a large proportion of the medical profession holds back and refuses to accept big truths when they are presented. The application of these truths may even meet and relieve unsatisfactory conditions and yet they will excite prejudice and be attacked by many con- servative physicians. The conservative attitude of the medical profession in regard to the question of local anesthesia may be clearly noted by con- trasting it with the attitude of the dental profession. It is difficult to demonstrate any great degree of excellence of local over general anesthesia in dentistry that does not apply to general surgery as well. However, the individual members of the dental profession have considered no effort too great to acquire a knowledge of its use and to overcome the technical difficulties connected with its 18 THE GENERAL ANESTHETICS administration; and they have adopted it almost universally, with untold benefit to their clientele. The teachers and moulders of thought in the dental profession have been careful to see that their pupils were given the advantages offered by the newer dis- coveries of the application of local anesthesia, while it must be admitted that the conservatism of the medical profession has not operated to the equal advantage of their patients. In the following discussion of the general anesthetics the ill effects, dangers and discomforts of each will be considered, as it is only by the elimination of these, the undesirable features, that progress is made in considering substitutes. TOXICITY AND ILL EFFECTS. Effects on the General System.-Authorities agree at present that the general anesthetics produce an acidosis in the body, the degree of which varies with the anesthetic used, the duration of anesthesia, and the previous general condition of the* patient. In speaking of conditions other than diabetes that are characterized by an acid intoxication, II. G. Wells1 states, "Most prominent of these so-called acid intoxications is that following a few days after anesthesia, particularly with chloroform.'' It has been shown, especially by Brewer and by Helen Baldwin2 that acetone is nearly always present in the urine during the first twenty-four hours after the administration of either chloroform or ether, and occasionally diacetic acid appears on the second or third day after. Ross,3 who reports some observations on the occurrence of acidosis following operation, brings out the importance of proper interpretation of urinalyses. Many of her patients excreted diacetic acid and acetone but gave none of the symptoms of acidosis, namely, nausea, vomiting, headache, restlessness or in severe form with deepening coma, fever, tachycardia, hyperpnea or death. Others who did not show acetone or diacetic acid in the urine did have symptoms and thus the urinalysis is of value only when elimination parallels acid body formation. When all the acid bodies formed are excreted they do not encroach upon the alkali reserve of the blood and thus determination of blood carbon dioxide (Van Slyke) would seem to be a preferable guide. But even this is not thought by some to be as accurate as the determination of the H-ion concentration of the blood (('rile), which has been shown to be reduced immediately after ether or nitrous oxide are given. 1 Chemical Pathology, p. 457. 2 Jour, of Biol, ('hem., 1906, 1. 239. 3 Some Observations on the Occurrence of Acidosis Following Operation, Am. Jour. Surg., Anes. Supp., October, 1921. 35, 121. TOXICITY AND ILL EFFECTS 19 Ross further found that the symptoms of acidosis were much less marked in cases having had local anesthesia and that ether anesthesia resulted in more marked symptoms than where nitrous oxide and oxygen were used. The urinary findings were not per- fect with local anesthetics but showed less evidence of acidosis than did the cases which had had ether or nitrous oxide and which showed about an equal number of acid bodies. Some of the most severe cases of acidosis were those having had a general anesthetic for but a short time as in the removal of tonsils and adenoids and she concludes that the length of time for the operation or anesthetic is not an important factor. However, toxemia, starvation and fear were shown to increase the acid bodies of the urine. E. Graham1 states: "The phenomenon of narcosis is always accompanied by a condition of diminished oxidation. It there- fore always indicates a condition of more or less severe asphyxia of the tissues, even if the frequency and depth of the respirations of the narcotized subject are normal." Ross advocates ether colonic anesthesia to eliminate suboxy- genation as well as fear. J. Loeb3 has shown that an asphyxiated tissue always becomes acid. It is not surprising, therefore, that every surgical general anesthesia induces many of the signs of an acid intoxication. As is well known also, an existing acidosis is always aggravated by general anesthesia. He further states that ether and nitrous oxide cause these toxic effects less readily than does chloroform, because of the formation of the mineral (hydrochloric) acid when the latter is used. McClendon3 in an experimental study on the effects of anesthetics (ether, chloroform, chloretone and alcohol) on cells of a marine jelly fish (Cassiopea) found that respiration was not depressed nor were the cells affected by ether in concentration sufficient to abolish nerve and muscle activity. Only when stimuli causing muscular contraction were applied was respiration depressed, and this due to carbon dioxide, but not due to the acidity of carbonic acid. In addition he found that the anesthetic caused an increase in the diffusion of salts away from the cells, in some cases ten times and with death resulting. He therefore suggests that because substances leave the cells more rapidly when anesthetized there is a real danger from an overdose. Crile4 likewise has shown that the nerve cells exhibit a disinte- 1 Jour. Am. Med. Assn., November 17, 1917, p. 1666. 2 From Article by E. Graham, Jour. Am. Med. Assn., November 17, 1917, p. 1666. 3 Effects of Anesthetics on Cells, Am. Jour. Surg., Anes. Supp., October, 1921, 35. 104. 4 Crile and Lower: "Shock," 1921. 20 THE GENERAL ANESTHETICS gration and fading of the Nissl bodies during general anesthesia with ether. Jeanbrau, Cristol and Bonnet,1 in a limited number of cases report that acidosis occurred in all cases with various forms of anesthesia, except with spinal, using procain (syncain). Normally the blood carries the carbon dioxide away from the tissues to the lungs in combination with its alkalies. The most important and most abundant alkali is sodium bicarbonate which in the lungs is decomposed into the carbonate, and carbon dioxide which escapes into the alveolar air. The carbonate thus formed goes back to the tissues where it combines with more carbon dioxide. The acids, when introduced into the blood during anesthesia, combine with these alkalies forming neutral salts which are eliminated in the urine, and in this way the amount of alkali in the blood is reduced, with a consequent reduction in the capacity of the blood to carry carbon dioxide away from the tissues. Consequently, in general anesthesia the carbon dioxide produced in metabolism accumulates in the tissues where it is formed, and blocks the processes of oxidation, so that the patient suffers from asphyxia exactly as if he were deprived of air. Some patients are, of course, more susceptible to the production of acids in the blood by the administration of general anesthesia than are others because of the presence of such conditions as dia- betes, certain febrile diseases, carcinoma, gastro-enteritis, certain nervous diseases, inanition, and toxemias from septic absorption, in all of which there is already a varying degree of acid intoxication. Hence a general anesthetic in these conditions tends to augment the pathological processes and to weaken the patient's defense against them and therefore to raise the mortality of the operative procedures. Postoperative shock is another general condition which bears a definite relationship to general anesthesia. The two are inti- mately associated. To what degree the general anesthetics con- tribute directly to the causation of shock seems to be still an open question. F. C. Mann2 states: "Deep etherization may produce most of the symptoms of shock. The continued depressed state following deep anesthesia, while primarily due to the anesthetic, is soon complicated by the resulting factors of low blood-pressure, sub- normal temperature, and other changes." It is most likely true that postoperative shock is produced by 1 Anesthesia Acidosis, Abstract Jour. Am. Med. Assn., August, 1921, 77, 652. 2 Jour. Am. Med. Assn., 1917, 69, 371-374. EFFECTS ON SPECIAL ORGANS AND TISSUES 21 several combined contributory factors, the relative importance of each varying in different individuals. But these factors, such as hemorrhage, mechanical trauma to the viscera and other tissues, are undoubtedly of greater importance in general anesthesia because the unconscious condition of the patient frequently permits of their unnecessary occurrence and on account of other reasons which will be referred to later more in detail. EFFECTS ON SPECIAL ORGANS AND TISSUES. In considering the effects of the general anesthetic substance on the special or separate organs in the body, each anesthetic will be considered individually. It is not the purpose of the author to dwell at great length on this subject as the toxic effects of ether and chloroform particularly are cpiite widely taught and known. It is generally conceded by the leading anesthetists that the open method of etherization is the safest. The ether-vapor rectal anesthesia, ether-oil colonic anesthesia, and intravenous methods have been tried and with some success but they may have suf- ficient objections and dangers to outweigh their few advantages. The open method is perhaps the best method because the patient receives a larger amount of oxygen in the inspired air, and it is by far the most commonly used of all the methods. The fact that this method is the safest does not mean that it has not its dangers. Its safety depends to a great extent upon the anesthetist as it is not difficult to give an overdose of the drug. Ether, further- more, does not lose its toxic properties when given by this method, although its toxicity perhaps may be reduced somewhat. The first effect of ether, on being inhaled, is upon the respira- tory passages. It is a powerful stimulant to these organs, increasing the respiratory rate during the early stages. When given by the open method the inspired air will be twenty to thirty degrees cooler than the air of the room. Because ether is irritating, the mucous membranes of the mouth, pharynx and larynx become swollen, an increased amount of mucus and saliva are secreted, and this is drawn down by the deeper inspirations into the depths of the lung and even into .the alveoli, especially when sufficiently deep to abolish the reflexes of the respiratory system. The bron- chial tree itself becomes chilled, the epithelial lining becomes con- gested and often petechial hemorrhages are found in the bron- chioles and alveoli. Every prolonged ether narcosis is followed by small pneumonic foci in the lungs with mucus and extravasated blood cells in the alveoli, and some round-cell infiltration. This 22 THE GENERAL ANESTHETICS may occur after a shorter operation in the predisposed or suscepti- ble.1 Thus is laid the foundation for a subsequent pulmonary edema or a postoperative bronchitis or pneumonia. Gangrenous Pneumonia and Lung Abscess.-One sees from time to time in literature statements indicating that lung complications are not more common following general anesthesia than when local anesthesia has been employed. In these articles various authorities are quoted and the experience of certain individuals is detailed. As a rule these observations are made upon groups of patients that are the recipients of the utmost care during the administration of general anesthesia. Incidentally it might be said that in many of these reports a com- parison is made between the effects of local and general anesthesia by those who are observers upon the same series of cases. In most instances it will be found that local anesthesia has been reserved for the cases that carry the greatest hazard and which, therefore, are, or should be, most susceptible to lung complications. While pneumonia is in a certain percentage of cases of undoubted embolic origin and while surgery of the upper abdomen is all too frequently followed by pneumonia, even when local anesthesia is used, it stands to reason that, other things being equal, the lung which contains foreign material aspirated during operation under general anesthesia must be less able to cope with such embolic processes and with the other etiological factors which are potentially present in every surgical case. The individual who is under general anesthesia presents at least a lowered irritability of the tracheal reflexes. With a care- less anesthetist these reflexes may be quite completely abolished. Undoubtedly the natural protection offered the pulmonary system by these reflexes has its threshold of safety lowered during the inhalation of general anesthesia. II. E. Robertson2 has been able to demonstrate the presence of gastric contents in the center of localized lung abscesses in cases which came to autopsy. Were this condition looked for more frequently its presence would undoubtedly be demonstrated. It seems to us that it is perfectly obvious that lung complications, aside from embolic (and even here local conditions after general anesthesia are more favorable for the development of the embolic processes) are more prone to follow the administration of general than local anesthesia. It requires a long series of observations to establish clinical facts, and it will undoubtedly require considerable time to demon- 1 Dickinson, G. K.: Am. Jour. Surg., January, 1918, p. 24. 2 Personal Communication. GANGRENOUS PNEUMONIA AND LUNG ABSCESS 23 strate the truth or fallacy of this premise. The facts will, per- haps, not he demonstrated with satisfaction until such time as observers are able to compare local and general anesthesia in a large series of cases in which each is administered with equal skill. Incidentally, it should be most definitely understood that the terms employed should be made as significant as possible, to-wit: Any patient receiving any amount of general anesthesia should not be classed with operations done under local anesthesia. In reaching conclusions, therefore, the methods should be strictly classified under general anesthesia, local anesthesia and mixed anesthesia. The local irritation of ether may explain in part the vomiting which is so often a prominent feature of its administration. The irritant vapors reach not only the throat, but also the stomach with the mucus swallowed, and the irritation in both of these regions may cause reflex vomiting. There is probably some central effect also in the production of vomiting, as this undesirable effect is occasionally caused by nitrous oxide, in which local irritation plays no part. Reimann1 states that he found the more excessive nausea and vomiting in those cases which showed the greater degrees of acidosis, and this would tend to bear out a theory of central stimulation of the vomiting center. Caldwell and Cleveland2 found a reduction of blood carbon dioxide of 12 to 14 per cent with the various anesthetics and claim that the difference between local and general anesthesia is negligible and that the postoperative course is not affected by the preliminary administration of sodium bicarbonate. This would tend to disprove such a theory for they also found that nitrous oxide and oxygen inhalation produced less nausea and vomiting than the other inhalants, yet the carbon dioxide of the blood was diminished fully as much as with ether. Truly enough there are so many other factors such as infection3 endocrine disturbance4 diet and preparation to be considered, besides the anesthetics and the laboratory reading and interpretation of the Van Slyke method that one cannot help giving the clinical symptoms just consideration. The question, " 1 )oes less nausea and 1 Administration of Carbon Dioxide after Anesthesia and Operation, Jour. Am. Med. Assn., February 12, 1921, 76. 437. 2 Surg., Gynec. and Obst., 1917. 25, 23. 3 Hirsch, E. F.: Changes in Leukocytesand Alkali Reserve of Blood in Experi- mental Infections, Jour. Infec. Dis., March, 1921, 28, 1275. 4 Underhill, F. P., Nellans, C. T.: The Influence of Thyroparathyroidectomy upon Blood-sugar Content and Alkali Reserve, Jour. Biol. Chern., October, 1921, 48, 24 THE GENERAL ANESTHETICS vomiting prevail after local anesthesia as compared to general," is in the large percentage of cases answered in the affirmative. Ether.-The kidney seems to be affected in a certain number of cases of ether anesthesia, as is shown by the appearance of albumin, casts and occasionally red blood cells in the urine, or an increase in these substances if already present. Various observers have recorded 12 to 39 per cent of cases showing this phenomenon.1 The early effect of ether is to increase the secretion of urine. Later during full anesthesia the secretion of urine is almost completely arrested. On removal of the anesthetic the kidneys rapidly recover from this depression, and there is hyperaction lasting for some hours.2 The effect of ether upon the kidneys is merely one mani- festation of a general intoxication of the system from the drug. Degenerations of the parenchymatous organs throughout the body have been revealed and these are most prominent in the kidneys.3 The action of ether upon the nervous system is similar to that of chloroform and of a large amount of alcohol, consisting in a progressive paralysis of various centers, frequently, however, being preceded by a short stage of stimulation. As the anes- thesia deepens the centers of consciousness and other brain centers become entirely paralyzed, and finally the spinal cord is involved, the reflexes disappear and the muscles eventually completely lose their tonicity. The respiratory and vasomotor centers, however, are not paralyzed until a still larger quantity of the drug has been used. The art of administering anesthesia consists in avoiding as far as possible encroachment of the ill effects of the drug upon these last mentioned centers. The heart rate is increased, often to 90 or 100 per minute, the internal vessels are constricted and the blood-pressure is raised in spite of a peripheral vasodilatation. Prolonged ether anes- thesia causes depression of the heart and relaxation of the splanchnic circulation. Blood destruction takes place during ether anesthesia although this is not always apparent because of the concentration of the blood due to preliminary treatment and sweating during the administration. J. C. DaCosta and J. L. Kalteyer4 state: "The color index almost always falls and the number of corpuscles increases, showing marked blood destruction and increased pro- duction of corpuscles deficient in hemoglobin. . . . The hemo- globin is absolutely reduced after etherization, as shown by reduc- tion in individual corpuscular hemoglobin value." 1 Goodwin: Therap. Gaz., May, 1905. 2 Thompson: British Med. Jour., March 25, 1905. 3 Hirsch, M.: Centrail)!, f. d. Grenz, d. Med. Chir., December 31, 190S. 4 Boston Med. and Surg. Jour., June 13, 1901. GANGRENOUS PNEUMONIA AND LUNG ABSCESS 25 The coagulation time is markedly decreased, most marked from the seventh to the tenth days.1 Conditions which comprise the contraindications of ether anes- thesia vary according to different authors. But in a consideration of the general and local toxic effects of the drug, as briefly given above, it would seem that ether is contraindicated in the follow- ing conditions: 1. Respiratory disorders comprising all acute affections, especially of the lower passages, and chronic disorders such as tuberculosis, pulmonary emphysema, so frequently found in the aged, and bronchitis with profuse secretions. 2. Cardiovascular disease accompanied by a high blood-pressure, particularly aneurysm and advanced arteriosclerosis; all decom- pensated hearts whether due to myocardial change or vascular disease, and weakened hearts so often found in septic patients as well as in alcoholics. 3. Acute nephritis, chronic parenchymatous nephritis and even the arteriosclerotic type are contraindications. 4. Diabetes mellitus and, finally, pronounced anemias definitely contraindicate the use of ether, as does traumatic shock without demonstrable hemorrhage. Strange as it may seem, ether in itself is not an anesthetizing agent but is the vehicle of ketones, aldehydes and mercaptans and it is the latter two which are particularly harmful, and the first which is responsible for anesthesia. Wallis found that good anesthetic ether free of aldehydes and mercaptans when treated with finely divided potassium permanganate yielded a pleasant smelling residue which proved to contain the ketones so essential to the production of a relatively good and safe anesthetic. lie further found that by treating the ketones with carbon dioxide and ethylene and using the middle series, that when mixed with pure ether in varying proportions, a loose chemical combination resulted which he called Ethanesal, a new general anesthetic. Ethanesal was used by Hewer2 in 500 surgical cases and he reports that respiration was not increased as much as with ether, the breathing was quieter and more like the chloroform type of breath- ing and that there was less mucous-membrane irritation, less salivation and there were fewer postoperative respiratory com- plications than after the use of ether; the blood-pressure changed less than when ether was used, the pulse pressure remained higher and no ill effects were noted in cases with organic heart disease; cerebral excitement was less marked and analgesia easily pro- 1 Hamburg and Ewing: Jour. Am. Med. Assn., November 7, 1908. 2 A New General Anesthetic: Its Theory and Practice, The Lancet, June 4, 1921, 1, 1173. 26 THE GENERAL ANESTHETICS duct'd: Postoperative acidosis was not observed and three diabe- tics took the anesthetic well; toxic patients also took the anes- thetic well; vomiting was absent in 48 per cent of cases, occurred once before regaining consciousness in 42 per cent and postoperative taste and smell of the anesthetic were practically nil. Thus in an attempt to secure an anesthetic that will be safer than the ether usually used these workers seem to be at least partially rewarded and their very efforts to do so testify to the fact that the ether generally used is harmful. Chloroform. Ether and chloroform resemble each other closely in their general effects, but differ in certain points of importance. Cushny1 states that chloroform is about three to three and a half times as depressant to the central nervous system as ether, while, on the other hand, its action on the heart is at least eight times as great as that of ether. As ether has to be given in more concentrated form to produce anesthesia it produces more irritation of the air passages than does chloroform. The latter produces anesthesia with less difficulty and the stage of excitement is less violent and prolonged. It splits up into substances, the chlorine bodies, which are extremely toxic. The toxic effect of ether is usually exerted on the respiratory system, inducing pulmonary edema or postoperative pneumonia or upon the renal system, inducing nephritis. The deleterious effects of ether frequently occur immedi- ately after operation while those of chloroform do not manifest themselves for several days. Chloroform is distinctly a depressant of the circulatory system. This action on the vasomotor center, which causes a vasodilatation and accumulation of blood in the larger vascular trunks of the body, and hence a fall of blood-pressure, is perhaps the primary and main cause of death in chloroform anesthesia. An infrequent and also different action of the drug is a reflex inhibition of the heart by way of the vagus, produced, it is said, by an irritation of the' endings of the fifth nerve in the nasal mucous membrane, an action which has caused death after only a few whiffs of the drug have been taken. More than twenty-five years ago, Vugar found that prolonged or repeated chloroform anesthesia gave rise to fatty degeneration of the liver, causing this organ to lose its power of carrying on its functions as a detoxicating organ and of fulfilling its role in metab- olism. Whipple and Sperry2 have shown by a series of experi- ments that chloroform narcosis continued for any considerable length of time invariably causes central necrosis of the liver in animals and that this necrosis, if extreme, will cause death. They 1 Text-book of Pharmacology. 2 Johns Hopkins Hosp. Bulletin, September, 1909. GANGRENOUS PNEUMONIA AND LUNG ABSCESS 27 state: "The essential change is an extreme necrosis and fatty degeneration of the liver. There may be numerous ecchymoses and hemorrhages into the peritoneum or upper intestinal tract. The pancreas may show many areas of fat necroses and ecchy- mosis. The kidney and heart may present a moderate grade of fatty degeneration.'' La Rocque1 in discussing the effects of general anesthetics upon the liver by a review of the literature concludes that chloro- form and ether both produce a cholemia of about the same duration and degree. The question as to whether this is caused by poison- ing of the circulatory red corpuscles with resulting hiking, or to intoxication of the hepatic cells, or to asphyxia with lessened oxidation and acid intoxication is not answered. Delayed chloroform poisoning, a condition which is usually fatal, comes on from one to six days after the administration of the drug. It is characterized clinically by the somewhat sudden appearance of irritability, restlessness, fright and moaning and even toxic delirium with rapid pulse, nausea and vomiting and later stupor, rise in temperature, Cheyne-Stokes breathing, irregu- lar heart action and death. It is characterized pathologically by advanced fatty changes, particularly in the liver, with congestion and areas of necrosis in the kidneys and brown atrophy of the heart. Many such cases have been reported. Weill and Vignard2 state: "The writers have encountered a series of fatalities after operations for appendicitis which they ascribe to the injurious action of chloroform on the liver. The disturbances developed on the first or second day after operation, the patients showing signs of extreme and progressive weakness, sometimes accompanied by jaundice and blackish vomiting. The patients all succumbed in two or three days, and extremely severe lesions were discovered in the liver in every instance. The lesions of peritonitis could never cause such fulminating toxic accidents, and there were no signs of inflammation of the liver, merely a total cellular necrosis with the aspect observed in pernicious jaundice." The conditions comprising the special contraindications to chloroform anesthesia may be summarized as follows: Cardiac and circulatory disorders with the clinical signs of feeble heart action, dyspnea and arrhythmia including all acute affections of the pericardium, myocardium and endocardium. Respiratory disorders which interfere with the free movements of respiration and the complete aeration of the blood, as neo- plasms, inflammatory lesions and emphysema. In this connection enlarged bronchial glands and thymus may be mentioned. 1 Effects of General Anesthetics on the Liver, Bull. No. 19, The National Anes- thesia Research Society, February, 1922, p. 1. 2 Lyon Chir., December, 1908. 28 THE GENERAL ANESTHETICS Kenai disorders with albumin and casts in the urine. Hepatic disorders as cirrhosis or yellow atrophy. Nitrous oxide is claimed by many to be the safest of all the general anesthetics and when combined with oxygen, its most dreaded effect, asphyxia, may be readily avoided. It is true that this gas is the least toxic of the general anesthetics and produces, there- fore, less histological changes in the various organs. Anesthesia is produced by its depressing effects on the brain centers. It exerts very little effect on the cardiovascular system directly and the respiratory centers, although slightly depressed by the drug itself, are stimulated by carbon dioxide if an asphyxia! condition of the blood occurs. Not much could be said, therefore, concerning the toxicity of this substance, but in this connection it might be well to consider a few' of its other phases. There are many advocates of this anesthesia for major surgical procedures. The margin of safety is small but this fact is not a danger, if the anesthetist be an expert. But it is surprising to find the comparatively recent increasing number of deaths reported occurring during the administration of this anesthetic. And it is not only surprising but somewhat astounding to find after thorough investigation that not a few surgeons who advocate it have failed to report deaths due to it. This in most instances is pure neglect as doubtlessly most of its sponsors are actuated only by scientific motives. In the chapter on anesthesia in Johnson's Operative Thera peasis. Connell1 states in regard to nitrous oxide oxygen anesthesia that "since the extensive introduction of this gas into general surgery, the reported and unreported deaths have probably far exceeded those from ether." J. F. Baldwin2 of Columbus who calls it the most dangerous anesthetic has reported a number of cases in which death can be definitely attributed to tlu* nitrous oxide-oxygen anesthesia and concluded that the death rate in that city had been 1 per cent. After making a careful test with one hundred successive cases of nitrous-oxide anesthesia, compared with a similar number of ether anesthesias by the drop method, Ochsner3 says he "found no difference in the course of the anesthesia, nor in the comfort of the patient, but there was a little more bronchial irritation following operation when nitrous-oxide-oxygen gas had been used." He found the method cumbersome and permanently abandoned it. One sees frequently in reviewing the1 literature on nitrous-oxide- oxygen anesthesia tht* statement, especially by those who favor 1 Johnson's Oper. Ther. 2 Med. Rec., July 29, 1916. 3 Manual of Surgery, 1915. THE DANGERS OF GENERAL ANESTHESIA 29 its usage, that it causes death only by asphyxia and if the mixture contains sufficient oxygen, or if oxygen is pushed on the appearance of cyanosis, asphyxia does not occur. This can hardly account for the many sudden deaths which have occurred during apparently tranquil administrations without any of the recognizable danger signals of asphyxia appearing. Some of these deaths have occurred as quickly as six minutes after the patient entered the operating room and some while the gas was being given as a preliminary to ether. They took place without any warning and were apparently due to heart failure. It is definitely established that nitrous oxide is an extremely dangerous drug in the hands of the1 untrained, and to be considered comparatively safe it must be administered by an expert. THE DANGERS OF GENERAL ANESTHESIA. The dangers of general anesthesia are many when one pauses to consider them. The causation or augmentation of an acidosis, the pulmonary irritation contributing to a postoperative pneumonia among the other toxic effects of the drugs enumerated in the pre- vious pages, are all dangers which must be ascribed to the direct action of the anesthetics. The direct danger, usually the only one considered by the laity, and by some operators, is death during administration. Many series of statistics have been compiled as to the death rate of each anesthetic but they differ greatly and are perhaps of very little practical value. The part played by faulty surgical technic, surgical accidents, unskilled operating and the previous serious condition of the patient with lowered resistance is difficult to ascertain in many cases, and frequently the death on the operating table was assumed to be due to the anesthetic. However, death from the anesthetic during the operation is a possible danger and must be remembered. In this connection one should not except nitrous-oxide-oxygen anesthesia, which even Crile states is the most dangerous in unskilled hands. And everyone knows how often it is given by a nurse or intern who is unskilled in its adminis- tration. The death rate of this anesthesia from 1905 to 1911 according to one report was 1 in every 657.1 Most important among what may be termed the indirect dangers is perhaps tissue trauma. Unnecessary traumatization of the tissues occurs in two ways. To shorten the duration of the anes- thetic, the surgeon hastens through the operation and in so doing tears and bruises the tissues instead of carefully dissecting them. 1 Sajous' Cyclopedia, vol. 9, p. 149. 30 THE GENERAL ANESTHETICS The unconsciousness of the patient allows the operator not only to do this but to handle, sometimes roughly and needlessly, such organs as the intestine, stomach and gall-bladder. Many times has the author seen in the best and largest clinics in the country, the surgeon actually fighting the loops of bowel as they insisted on protruding from the abdominal wound during general anes- thesia, until the gut became congested and even bled. This pro- trusion of the bowels is due to the positive intra-abdominal pres- sure which often exists. This needless trauma is undoubtedly a great factor in the production of shock, as has been brought out by F. C. Mann1 and many others. Fatal accidents have occurred on the operating table from objects such as false teeth or tobacco plugs falling into the air passages and causing asphyxia. Vomited material has also been drawn into the larynx in many cases. A less serious danger and cause of labored and stertorous breathing or even asphyxia is the falling back of the tongue into the throat due to the relaxation of the muscles. This, of course, may be relieved at once by drawing the tongue forward but it is a cause for anxiety when not recog- nized by the anesthetist. Similar symptoms may be caused also by an accumulation of saliva, mucus or blood in the throat. After leaving the operating room and returning to the bed, the indirect dangers from the anesthetic may continue to occur. Dur- ing the awakening, vomiting occurs very frequently and this together with struggling which is sometimes seen, causes a strain on an abdominal or herniotomy wound which may attain dangerous proportions. It is difficult to say just what proportion of incisional hernias are due directly to postoperative strain but this is no doubt an important factor. Head and neck wounds may be soiled by material vomited both during the operation and also during the awakening of the patient. The helplessness of the patient before he has fully regained consciousness is accountable for another accident which is not uncommon. That is burning with hot water bottles which have been placed about him. The spread of infectious material and other accidents are referred to in Chapter 111, under a consideration of the anesthesia problem. All these dangers may appear superfluous to the reader, but they are realities and occur not infrequently. Thompson2 of the school of general anesthetists, in a review of the postoperative morbidity in its relation to general anes- thetics appreciates the dangers and attempts to ward off the unde- 1 Jour. Am. Med. Assn., 1917, 69. 371 374. 2 Postoperative Morbidity in its Relation to General Anesthesia, Edinburgh Med. Jour., June, 1921, 26, 356. MORTALITY OF THE GENERAL ANESTHETICS 31 sirable features by means of a prophylactic regime which is highly laudable and with few exceptions is not only applicable when local anesthesia is substituted but should be demanded. Jie would ward off nausea and vomiting and a tendency to lowered alkali reserve by avoiding fasting and purgation, and by preliminary administration of sodium bicarbonate until the urine is no longer acid. He emphasizes the importance of gentleness in operative manipulations and the avoidance of unnecessary movements as well as chilling during the transfer of patients to and from the operat- ing room. He advocates the use of atropine and morphine to reduce the amount of general anesthetic to the minimum, prefers nitrous oxide and oxygen to ether and refrains entirely from giving ether to one who has recently had bronchitis. Other authorities on general anesthesia realize its dangers and Guedel1 suggests a remedy in a recent report on the " Present Status of General Anesthesia" by restricting its administration to physicians and dentists who have taken graduate study in this specialty. Baily2 in a review of 1000 cases of general anesthesia likewise believes that except in emergencies general anesthetics should be given only by expert anesthetists, and these should possess a medical degree and license to practice medicine and surgery. MORTALITY OF THE GENERAL ANESTHETICS. The statistics which have been compiled on deaths occurring during and from general anesthesia are abundant and extremely variable. The more one studies the literature on this subject, the more he is impressed with the fact that such statistics are practically worthless. As one writer, W. Hamilton Long3 has said, "One is reminded at times of the axiom, 'Figures don't lie, but liars will figure,'" or as Sir Berkeley Moynihan has said, "One can prove almost anything by statistics, even the truth." There are logical reasons why our statistics do not represent the actual truth. When death occurs during an operation, it is not an easy matter satisfactorily to prove that the anesthetic is the cause. A thorough postmortem examination is necessary to decide this and this procedure is perhaps not undertaken in the majority of cases. Doubt as to the real cause of death in these uninvestigated cases simply tends to prompt the surgeon not to report the case. Thus many deaths are never reported, especially those occur- 1 Present Status of General Anesthesia. Some Observations and Conclusions, Boston Med. and Surg. Jour., August 4, 1921, 185, 147. 2 One Thousand Cases of General Anesthesia. Some Observations and Conclu- sions, Boston Med. and Surg. Jour., August 4, 1921, 185, 147. 3 Kentucky Med. Jour., May, 1919, p. 200. 32 THE GENERAL ANESTHETICS ring in doctors' offices and in residences where operations are performed, or in hospitals which keep no careful systematic records. Those occurring in the hands of the inexperienced, as interns and nurses, are very apt not to he reported. Possibly the fact that death due to the anesthetic does not help the reputation of either the surgeon or anesthetist, results in a tendency to suppress the truth. However, some of the most reliable statistics will give us an idea of the comparative or relative safety of the substances used. The figures given by Gwathmey1 in his great work on anesthesia are perhaps the most reliable today: Nitrous-oxide-oxygen, no deaths in 8585 cases. Ether alone, 28 deaths in 157,453 cases, giving a death ratio of 1 in 5623 cases. Nitrous-oxide-ether, 6 deaths in 41,435 cases with a ratio of 1 in 6905 cases. Chloroform, 8 deaths in 16,390 cases-ratio 1 in 2048. These statistics were gathered, however, before nitrous-oxide- oxygen came into such general use as it is today. Not infrequently in more recent literature do we find deaths reported from this anesthetic. It is difficult to say, therefore, what even an approxi- mate ratio would be in this case. Crile states that in unskilled hands it is the most dangerous of all anesthetics. Inasmuch as it has its definite limitations and is undoubtedly given by many who are incompetent the author feels that it is not much safer, if as safe, than ether. However, the rapid improvement in the method of its administration should make its use more trust- worthy as time goes on. It has its most successful application when given with local anesthesia as Crile has shown. Hewitt's English statistics are approximately the same as those of Gwathmey. A. S. McCormick2 gives the following statistics: Chloroform: Death rate, 1 in 2000 cases. In warm climates it is safer, the ratio being 1 in 8000 cases. Nitrous Oxide: Nitrous oxide is a dangerous anesthetic. It is safer when combined with oxygen, but is losing ground. The death rate was 1 in 657 cases from 1905 to 1911. Ether: Ether is the safest and best of all the general anesthetics. As to the death rate the figures vary: Wharton's ratio-1 in 16,000 cases. Baldwin's ratio-1 in 50,000 cases. Roosing's ratio (Denmark) -1 in 56,000 cases. Mayo Clinic-Ether was given 49,037 times in thir- teen years (1900 to 1912) without causing death. Ethyl Chloride: Death rate, 1 in 2500 cases. 1 Anesthesia Text-book. 2 Summit County Medical Society, Akron, Ohio, November 1, 1916. CHAPTER IL THE LOCAL ANESTHETICS. It is unnecessary to write at length concerning the history of local anesthesia. Many excellent accounts of the innumerable attempts macle to produce local anesthesia since ancient and medieval times may be found in the literature, especially in some of the text-books on this subject. Suffice it to say that the important discoveries which have done most toward developing our modern successful methods of inducing anesthesia locally are the following: In 1853, Alexander Wood of Edinburgh discovered that hypo- dermic injections could be given by means of a hypodermic needle. This led to the introduction of drugs beneath the skin where they could come in direct contact with the many branching sensory nerve fibers and their endings and also the larger nerve trunks. This discovery was without much value, however, until a suitable drug could be found which when injected into the tissues would exert a quick local anesthetic action. The second most important step therefore came in 1884 with the introduction of cocain by Carl Koller, although the alkaloid had been first isolated by Gardeka in 1855. Shortly after the introduction of this drug, operations such as amputations, tracheotomies and herniotomies were suc- cessfully performed without pain to the patient. The toxicity of cocain was nevertheless a drawback and accounted for many unhappy results. It may be said, therefore, that in the history of local anesthesia there is a third milestone representing the intro- duction of novocain by Einhorn in 1905. This drug, which is used most extensively today, is much less toxic than cocain and besides possesses other qualities which make it almost ideal in this work. METHODS OF PRODUCING LOCAL ANESTHESIA. Cold.-Besides the above method of producing local anesthesia, which is by far the most extensively used, there is another which may be said to have its place in minor surgery, namely, cold. This was first applied as far back as the sixteenth century but possessed little if any practical value until Richardson in 18GG devised the ether spray or atomizer in which drugs such as ether, ethyl bromide, ethyl chloride and others, which have low boiling 34 THE LOCAL ANESTHETICS points, could be used. More recently the ether spray of Richardson has been replaced by sprays of more rapid action. Ethyl chloride, methyl chloride and liquid carbonic acid gas are the drugs which are most used today since they have a much lower boiling point than ether, produce intense cold on evaporation, and freeze the tissues very quickly. As these substances change to gas at room temperature and under normal atmospheric pressure they must be kept in containers under pressure. Although this method of producing local anesthesia has been used in a few instances in quite extensive major surgical procedures, its real value lies in the performance of such superficial minor operations as the opening of furuncles or subcutaneous abscesses, or in the removal of splinters from beneath the skin. It is a time- saver in these simple procedures. Pressure.-Prolonged pressure when exerted upon any part of the body causes a numbness and if continued long enough an anesthesia of that part. This fact was observed centuries ago and this procedure was resorted to for many years in order to obtain decreased nerve sensibility in surgical procedures. The method fell into disrepute eventually both because the pressure exerted caused much pain and not infrequently atrophic changes and even necrosis peripherally, and also because more efficient methods were discovered. Constriction or pressure is practically never used today to produce local anesthesia, unless perhaps by some of the uncivilized races. Phenol.-The escharotic action of carbolic acid when applied to the skin limits its employment to but a few areas and here anes- thesia may be produced more quickly by a cold spray or the injection of cocain or one of its substitutes. The injection of a weak car- bolic solution into the tissues is accompanied by pain and is likely to be followed by tissue necrosis. Sorisi1 and others have recommended the use of pure carbolic acid as an anesthetic for making incisions in infected cases where drainage is to be employed and where primary healing is not to be expected. He describes the technic thus: A dry scalpel is dipped into phenol and the back of the scalpel and the point of the blade is passed over the skin to be incised. After waiting a few minutes the scalpel is again dipped into the phenol and the incision begun. Repeated carbolizations of the scalpel are required as the incision progresses. lie has used it successfully in over 3000 cases. Other agents which have been claimed in past years by some workers to be useful in the field of local anesthesia, but which have been discarded after the introduction of better and more 1 Jour. Am. Med. Assn., May 3, 1919, 72, 1288. METHODS OF PRODUCING LOCAL ANESTHESIA 35 active drugs are chloroform, alcohol, morphin, sodium and potassium bromide, chloral, brucin and antipyrin. Cocain.-Cocain is methyl benzoylecgonin, the formula being C5H7(CH3)NCH(OCOCH5) - (CH2COOCH3). The two official preparations of the drug are the alkaloid and the hydrochloride. Death has been recorded following very small doses, for example as 16 and 40 mgm. On the other hand, patients have been given over 1 gm. subcutaneously and survived. Walter Wildenrath1 gives a good bibliography of cocain poisoning. A non-fatal intoxi- cation is characterized at first by nervousness, rapid pulse, increased reflexes, deepened respirations and vertigo. Later nausea and vomiting follow and there may be clonic spasms of the muscles of the limbs. The pupils become markedly dilated. It was not until twenty-five years after the discovery of cocain in 1857 that the attention of the medical profession was directed to its remarkable anesthetic properties. It was first used in surgery of the nose, throat, rectum and urethra, by direct application of 5 to 20 per cent solutions to the mucous membranes of these parts. It became very popular in a short time as its use was extended to the performance of many different operations in general surgery and also in dentistry, by injecting its solutions into the tissues. But cases of acute poisoning and death began to occur with increas- ing frequency. The danger of the formation of the drug habit was also observed. It was not long before the profession realized that cocain was not the ideal drug in this field. Not only its dangerous qualities but its irritating effect upon the tissues and the impossibility of sterilizing it in solution without deterioration were factors which led to its abandonment as a local anesthetic except in eye and nasal surgery, and perhaps occasionally in throat and urethral operations. It was the necessity for the elimination of these undesirable qualities that gave rise to the long research in synthetic chemistry by which a series of substitutes were discovered. These com- pounds, which belong to several general chemical groups, possess the common property of producing local anesthesia, and, as has been brought out by Eggleston and Hatcher of Cornell University, resemble one another very closely in their important pharmaco- logical actions, such differences as are shown being chiefly quantitative. In testing out the value of these substitutes, isotonic solutions of cocain have been used as a standard of comparison. Only the more important of these substitutes will be considered. Beta-eucain. -Beta-eucain is one of the first compounds dis- covered by the synthetic chemist (Vinci, 1897) to be less toxic 1 Friedreich's Blatt, f. gericht. Med., 1911, 62, 215, 36 THE LOCAL ANESTHETICS than cocain. It is a benzoyl derivative and chemically closely re- lated to tropacocain. The hydrochloride and lactate are employed, the latter being used when strong solutions are desired as it is more soluble (to 22 per cent) than the former. Its solutions are stable and may be sterilized by boiling after which adrenalin is added. It has been used quite extensively in nasal operations and found to be safer than cocain and yet as efficient in producing anesthesia, although a stronger solution must be used. Various authors have reported its successful usage in the performance of major operations such as herniotomies, thyroidectomies, appendectomies, breast amputations and gastrostomies.1 We have tested this drug and find that though an excellent anesthetic, it must be used with caution on account of its high toxicity. As to its toxicity, the opinions of investigators vary. All are agreed, however, that it is less toxic than cocain. Only a few cases of acute poisoning have been reported in the literature. Kraus2 reports a severe reaction following the injection of 10 cc of a 2 per cent solution into the urethra. Way3 also records a serious intoxication with convulsions following infiltration for circumcision of 0.12 gm. in solution. Marcinowski has reported 2 cases of intoxication. Beta-eucain was for some time the most satisfactory substitute for cocain in general surgery and hence served as a stepping stone in the progress of local anesthesia. Its solutions cannot be rapidly injected in infiltration work without discomfort and they are quite slowly diffusible, a ten to thirty minute delay being necessary before the operation can be begun with complete anesthesia. Its use today is confined largely to dentistry and to work in the nose. Tropacocain.-Tropacocain was first isolated from the coca plant by Giesel, 1891. It is made synthetically and is a white crystalline powder readily soluble in water. The hydrochloride is used and its solutions may be sterilized by boiling without des- troying its properties. It has been found that it is much less toxic than cocain but must be used in much more concentrated solutions to obtain the same degree of anesthesia. In infiltration work, it produces a greater irritation than does cocain solutions and its effects are of shorter duration. By some who are experienced in spinal anesthesia, first suggested by J. L. Corning4 in 1885, who, however, used 2 per cent cocain in 1 Witherspoon: St. Louis Med. Review, March 24, 1906. 2 Deutsch, med. Wchnschr., 1906, 32, 67. 3 Jour. Roy. Army Med. Corps, London, 1914, 23, 209, 4 New York Med. Jour., October 31, 1885. METHODS OF PRODUCING LOCAL ANESTHESIA 37 his experiments on dogs, it is said that tropacocain is the ideal agent for this procedure. The author has had no experience with it. G. MacGowan1 of Los Angeles has used it for more than fifteen years intraspinally, giving 6 to 12 eg. of the dry powder, dissolved in the spinal fluid, and reports but 1 case in which the patient manifested alarming toxic symptoms. G. F. Thompson2 has used it in 1000 cases. Stovain.- Stovain is a white powder easily soluble in water. It was first introduced by Tourneau3 as a substitute for cocain. There are many disadvantages connected with its use. Its solutions are decomposed when heated to 120° C., and it is said that adrenalin cannot be used with it. Many who have used it for infiltration anesthesia have found it to be irritating and painful, even in weak solutions. French surgeons have recommended it highly for spinal anesthesia but there have been many unfavorable reports of it in this field, espe- cially in some foreign journals. Some workers recommend it for instrumental examination of the urethra and bladder, instilling about 15 cc of a 1 per cent solution. The technic for spinal anesthesia as used by Dr. Morrison4 who has done 11,000 cases requires the use of a platinum needle 6 cm. (2 inches) long. The patient is seated with the back arched when possible. The space indicated is chosen and as much fluid is withdrawn as is wished to be injected. He uses a stovain solution made up in 0.7| cc ampoules and adds j to 1 mm. strychnin, and after the injection he is able to do bilateral herniotomies, hydroceles, ventral herniotomies, thoracostomy, hysterectomies, nephrectomies, splenectomy, etc., and he uses this form of anesthesia in 97 per cent of his surgical operations. In operations about the head and neck, he uses local anesthesia. Headache has been the principal and most persistent objection to his technic, and he has been unable to eliminate this drawback. This he attributes to over-activity of the patient after the injection, as it is usually more pronounced in the minor cases. In cases of overdose manifested by anxiety, pallor, and nausea, he gives 2 tablespoons of brandy by the mouth and 20 minims of camphor in oil by hypodermic, and employs artificial respiration. Ilertz5 injects 0.25 gm. caffein subcutaneously as a prophylaxis; and, at the slightest sign of mydriasis, pallor or relaxation of the sphincter, 1 California State Jour. Med., January, 1916, p. 6. 2 Journal-Lancet, June 1, 1921, 41, 318. 3 Allen, Local Anesthesia, p. 83. 4 British Med. Jour., November 5, 1921, p. 745. 6 Paris Medical, March 11, 1922. Abstract, Jour. Am. Med. Assn., April 29, 1922, 78, 1348. 38 THE LOCAL ANESTHETICS he repeats the injection of caffein and in grave cases, he injects the caffein directly into the spinal canal, lowering the head. Recently Gosset and Monod1 have reported a series of cases in which stovain was used and they believe spinal anesthesia is reliable for operations below the thorax and have never had a fatality in their more than 2000 applications of it. They refrain from its use, however, in cases of hypotension, subnormal tempera- ture, tuberculosis and acute peritonitis. They attribute 2 fatalities to the ether which superimposed defective spinal stovain anesthesia in these 2 cases of acute peritonitis, and advise against this form of anesthesia in such condition. At Salpetriere during 1921, 442 surgical operations were done with spinal anesthesia, 300 with ether, 71 by nerve blocking and 3 with chloroform. Alypin.-Like stovain, this is a derivative of the benzoyl group and was introduced in 1905 by Impens and Hofman.2 It is a white crystalline neutral powder, very soluble in water and is not precipitated by alkaline fluids. Its solutions may be boiled for ten minutes without impairing its properties and it is compatible with adrenalin. A review of the literature on this drug shows a great difference of opinion regarding its action and toxicity. Some observers have lauded it while others assert that the anesthesia produced is very weak.3 It has been found that its lethal dose in dogs and cats is about double that of cocain. A. II. Miller4 has reported a series of 103 cases in which alypin was used. 35 of these were minor surgical operations and 68 genito-urinary. In 100 cases, the analgesia was perfectly satisfactory, in 2 it caused serious difficulty, and in 1, instant death. In this case 8 cc of a 10 per cent solution were introduced into the urethra and bladder. Death followed in about twelve minutes, being preceded by convulsions. Alypin only partially meets some of the shortcomings of cocain. Injection of its solutions into tissues as ordinarily used often causes a slight burning, and usually is followed by some hyperemia. In some cases a slight inflammation has resulted. Its use is recom- mended by many for eye, nose and throat operations, and by a few for the genito-urinary tract. Apothesin.- Apothesin, a synthetic drug, is the hydrochloride of diethylamino-propylcinnamate. It is easily soluble in water, making a stable solution and hence may be sterilized by boiling. This drug is listed in the "Described but Not Accepted'' depart- 1 Paris Medical, March 11, 1922. Abstract Jour. Am. Med. Assn., April 29, 1922, 78, 1348. 2 Arch. f. d. Ges. Physiol., 1905, 110, 21. 3 Wolff Freudenthal: Med. Rec., July 20, 1912. 4 Jour. Am. Med. Assn., July 17, 1914. METHODS OF PRODUCING LOCAL ANESTHESIA 39 ment of New and Non-official Remedies, but is ineligible to inclusion in New and Non-official Remedies, as its makers claim for it an efficiency1 and low toxicity which are not justified by acceptable scientific evidence. The Council on Pharmacy and Chemistry of the American Medical Association states in its recent report that the toxicity of apothesin is to the toxicity of cocain as 20 is to 15 and that it has about twice the toxicity of procain. It is used quite extensively by some surgeons for infiltration anesthesia and would be a most valuable drug if there were not others which are more efficient and less toxic. Allocain-S.-A comparatively new local anesthetic known as allocain has been discovered by Seiko Kubota in the pharmaco- logical laboratory of the Japanese Medical School at Mukden. It is a white odorless powder consisting of fine needle-like crystals with a bitter taste. It dissolves easily in water with a neutral or slightly acid reaction. Its chemical reactions resemble very much those of cocain. It is a weak base and is easily precipitated from solution of its salts in the presence of alkalies. After experimenting on frogs and rabbits, Kubota concludes as follows:2 1. Allocain-S. possesses a stronger anesthetic power than pro- cain and a weaker one than cocain. 2. It is less toxic than either cocain or procajn. 3. Subcutaneous injections cause a slight local irritation. 4. It inhibits the growth of both streptococci and staphylococci. 5. It possesses a good character as a local anesthetic in many respects, but on the other hand, it has also some unfavorable quali- ties. On account of the slight irritation by its acid solutions and of its precipitations by tissue fluids, its use is limited. In a later report the same author states that this substance has been tried in several hundred cases of operation with success. The results in these cases are in accord with the above conclusions. A slight irritation at the moment of injection was sometimes noted and in a few cases, a slight necrotic action was observed where it was applied several times in the same place. There is no record of the type of these operations nor how extensive they were. The reporter also fails to state how much of the drug was used in a single case. More recently a method of preparing this substance so that its solutions are less irritating to the tissues has been reported. Nirvanin.- Nirvanin represents the most valuable member for infiltration anesthesia, of what is called the orthoform group. It is a white crystalline powder, and unlike the other members of 1 Council Report: Jour. Am. Med. Assn., January 24, 1920, p. 265. 2 Jour. Pharmacol, and Exper. Therap., February, 1919, 12, 361. 40 THE LOCAL ANESTHETICS this group, is readily soluble in water. Its solutions may be sterilized by boiling and may be used with adrenalin. It is used in 1 to 5 per cent solutions. This drug has not been used very extensively to produce local anesthesia, especially in major operations. Those who have employed it, report satisfactory results when it is used for the production of limited infiltration anesthesia. It has a use in dentistry. The other members of the group are orthoform, subcutin, anes- thesin, zykloform and propaesin and are only slightly soluble in water. They have been used in dusting powders and ointments upon the skin; in suppositories and ointments in the rectum or vagina; and also in the nose, throat and intestinal tract. Anes- thesin is said to be the most efficient. Quinin and Urea Hydrochloride.-Practically the only quinin salt of value in local anesthesia is the double hydrochloride of quinin and urea. This salt, used in water solutions of from 0.25 to 1 per cent, was introduced into practice by Thibault1 in 1904. The quinin and urea compound is made by dissolving quinin hydrochloride in hydrochloric acid, adding pure urea, filtering the mixture through glass wool, and allowing it to crystallize. The crystals are white and soluble in an equal part of water. Its anesthetic action is thought by some to be due to coagulation of the protoplasm of the peripheral nerves. The fact that quinin and urea hydrochloride has not become popular as a local anesthetic is in part due to the formation of a fibrous exudate in the tissues after they are infiltrated with it. It is claimed this seriously delays the healing of the wounds. Hertz- ler, Brewster and Rogers2 state that this induration and thicken- ing, instead of being cellular, is due to a purely fibrinous exudate which is nearly all absorbed in the course of a few weeks or months, and when a 0.25 per cent solution is used, this induration does not occur to any notable degree. The drug has two great advantages. It is perhaps the least toxic of all the local anesthetics. The difference in toxic power between cocain and the quinin salt may be expressed by a ratio of at least 40 to 1. No constitutional effects may be feared from its free use, except in individuals with a marked idiosyncrasy. The second advantage is the long duration of its anesthesia. This varies greatly according to different observers, but frequently decreased sensation exists for several days. In such operations as the removal of hemorrhoids, when pain is likely to persist for some time, infiltration of the tissues with a 0.25 per cent solution 1 Jour. Arkansas Med. Soc., September 15, 1907. 2 Jour. Am. Med. Assn., October 23, 1909. METHODS OE PRODUCING LOCAL ANESTHESIA 41 of quinin and urea has a distinct advantage. It has been observed also by many workers that the drug possesses a decided hemostatic effect, especially when 1 to 4 per cent solutions are used. The author uses a 1 to 600 solution routinely in all operations about the anus and in tonsillectomies, but only after completing the operations under novocain anesthesia. This procedure results in prolonged anesthesia with much comfort to the patient and it profitably utilizes the hemostatic effect of the drug, thereby pre- venting secondary oozing. The fibrinous reaction does not inter- fere with the normal healing by granulation of these wounds. We have found that the introduction of quinin solutions into the skin causes a momentary burning or painful sensation. Benzyl Alcohol.-In testing the taste of this drug, 1). I. Macht1 found that it produced a numbness of the tongue. Following this discovery, experiments proved that this drug produced anesthesia of the sensory nerve endings. Benzyl alcohol is a simple organic compound, its formula being C6HaCH2OH. It is a clear liquid with a faint aromatic odor. Its boiling point is high, 204.7° at 760 mm. pressure. Hence its solutions may be sterilized by boiling without destruction of the active principle. It is soluble up to 4 per cent in water and is used in from 0.5 to 4 per cent solutions. It is compatible with adrenalin. Macht after a careful series of experiments reports the following regarding its efficiency and toxicity: A 1 per cent solution applied to the tongue produces anesthesia which may last one-half hour. A 1 per cent solution in the con- junctival sac produces anesthesia of the cornea as early as one to two minutes. Very slight irritation of the conjunctiva was noticed. A pledget of gauze soaked in a 1 per cent solution of benzyl alcohol in normal saline placed about the dissected sciatic nerve of a dog, paralyzed sensory conduction in about five minutes. Experi- ments on dogs and rabbits indicate that its toxicity is very low. A dog weighing 8.7 kilos was given intravenously 44 cc of a 4 per cent solution in saline with only mild toxic symptoms and a partial general anesthesia. Recovery was complete in one-half hour. Another dog weighing 7.3 kilos was given the same dose without any toxic symptoms. Macht also found that injection of 1 to 4 per cent solutions produced no marked irritation or destruction of the tissues, at least no more than that produced by an equivalent amount of quinin-urea hydrochloride. He reports its successful use in about fifty minor operations in which the anesthesia was efficient and very satisfactory. 1 Jour. Pharmacol, and Exper. Therap., April, 1918. 42 THE LOCAL ANESTHETICS Sollmann1 after a series of experiments has concluded that benzyl alcohol is a fairly efficient anesthetic for intact mucous membranes, greatly surpassing procain; ranking about with alypin and beta-eucam; and somewhat weaker than holocain or cocain. Its action is not as lasting as that of cocain and even 1 per cent solutions produce considerable smarting. He states that com- mercial solutions in ampoules appear to deteriorate somewhat, so that it is preferable to use freshly made solutions when possible. As far as one can learn from the literature, benzyl alcohol has not been used very extensively in major operations. The author has had no experience with the drug in local anesthesia. Benzylcarbinol. - Hjort and Eagan2 claim that benzylcarbinol, or rose oil, an aromatic side-chain alcohol, possesses local anes- thetic properties which from laboratory studies seem to be superior to those of benzyl alcohol. The toxicity of rose oil, as determined on white mice and dogs, is about the same as that reported by Macht for benzyl alcohol. See page 41. Its solubility is sufficient for its therapeutic use. Saligenin (Salicain).-Saligenin or salicyl alcohol (CglEOII- CH20H), allied chemically to benzyl alcohol, has been shown to possess greater local anesthetic properties than the above mentioned drugs by Hirschfelder3 and others. From experiments on the exposed sciatic nerve of the frog, injections into frog lymph sacs and subcutaneous injections in man, they show that the presence of the hydroxyl group in the ring increases the anesthetic power of saligenin and homosaligenin whereas the prolongation of the side chain, or when the hydroxyl group is covered with a methyl or an ethyl group, the anesthetic power is diminished. The toxicity of saligenin is quite low. 1 gm. per kilo given subcutaneously causes depression and transient paralysis of the hind legs in rabbits, but 0.125 to 0.5 gm. per kilo does not produce albumin or casts in the urine of rabbits or dogs. The lethal intra- venous dose was found to be 0.4 to 1 gm. per kilo for dogs so that rapid intravenous injection of more than necessary to perform an ordinary minor surgical operation in man produced little effect on the respiratory center and only a slight fall of blood-pressure in dogs. Of all the phenolic alcohols, it was concluded that saligenin was the least toxic, had the least tendency to wheal formation, stood highest in selective action of sensory nerve blocking and that it induced anesthesia longer than procain or benzyl alcohol. 1 Jour. Pharmacol, and Exper. Therap., July, 1919, p. 355. 2 Ibid., November, 1919, p. 28. 3 Ibid., June, 1920, 15, 4. METHODS OF PRODUCING LOCAL ANESTHESIA 43 Nine tonsillectomies, 2 sebaceous cyst removals, 2 great-toe matrix removals, an inguinal hernia, a mandibular block and 16 cystoscopies are reported in which saligenin (2 to 4 per cent) was used successfully by various surgeons. The author has used saligenin in 25 instances of major surgery, over one-half of the operations being very extensive in character, notably perforating gastric ulcer, intrathoracic goiter of the toxic type and abdominal hysterectomy. There was not the slightest sign of toxicity although comparatively large amounts of the solution were used. However, it was found that the action of the drug was somewhat slow as compared with novocain and that in solution weaker than 2 per cent anesthesia was unsatisfactory. On account of its low toxicity this drug bids fair to become exceed- ingly useful. The more recent use of this drug by the author gives the impression that at least 4 per cent solution must be used in order to obtain satisfaction. Butyn.-Butyn is a normal sulphate of a base resembling the base of procain but differing in that it possesses a butyl group in place of the ethyl group and a propanol group in place of the ethanol group in the procain base. Its formula is as follows: (NH2C6H4- COO(CIl2)3N(C-4H9)2)2 H2 SO4. As a local surface anesthetic it is proposed as a substitute for cocain in eye and throat work. A 0.5 per cent solution on the normal human conjunctiva is more efficient than a 1 per cent solution of either cocain or eucain and it is non-irritant. When given hypodermically in rats it is two and a half times as toxic as cocain but intravenously in cats the lethal dose equals that of cocain. Thus it does not appear promising for injections or spinal anesthesia since it is more toxic than procain. A committee of the Section on Ophthalmology of the American Medical Association1 reports the successful use of butyn in practi- cally all operations on the eye and in some of the nose and throat. It also concludes that butyn is more powerful than cocain, a smaller quantity being required; it acts more rapidly than cocain and the action is more prolonged; it is less toxic than cocain; it does not dry the tissues as does cocain; it does not change the size of the pupils, and it has not the ischemic effect of cocain. For ophthalmic work a 2 per cent solution is used and four instillations, three minutes apart produce the anesthesia desired for all of the commoner operations of the eye. In nose and throat work 2 to 5 per cent solutions are used. It may be boiled to sterilize and epinephrin may be added as with other solutions. 1 Jour. Am. Med. Assn., February 4, 1922, 78, 343. 44 THE LOCAL ANESTHETICS Epinephrin. - This drug has had a marked effect upon the prog- ress of local anesthesia. In this connection it may be well to briefly review epinephrin, as described by Sollmann.1 It is the active principle of the medulla of the suprarenal gland. Chemically it is an amin derivative of catechol and can be pre- pared synthetically. It behaves as a feeble base and might be classed as an alkaloid, and is represented by the following formula: C6H3(OH)2CHOHCH2MHCH3. Epinephrin is identical with the "chromaffin substance" of the suprarenal medulla discovered by Vulpian in 1856 and shown by Henle in 1865 to produce a green color with ferric chloride, pink to brown with alkalies, iodine or chlorin, or by oxidation, which may help to account for some of the various colored solutions noted after standing. The concentrated solutions deteriorate unless preserved with sulphite or chloroform. When dilute they deterior- ate within a few hours. V. Fuerth and Abel, in 1898, paved the way for the isolation of the active principle in crystalline form, and this was done by Takamine and Aldrich in 1901, and Abel in 1903. Abel and Macht also found considerable epinephrin in the parotid gland of the tropical toad (Bufa Agna). The structural constitution was determined by Jowett in 1904, although Aldrich established the empirical formula in 1902. The synthesis of the compound was accomplished by Stolz in 1904, Dakin in 1905 and Flacher in 1908. Since then various names, as adrenalin and suprarenin, have been used by the various manufacturers. "The typical action consists in a highly specific stimulation of the physiological endings of the entire sympathetic system, or when very dilute solutions are used the opposite effects may ensue. Thus the effect on any given organ depends upon whether such stimulation is augmentory, inhibitory or indifferent. The most important practical manifestation consists in a rise of blood- pressure from peripheral stimulation of the vasoconstrictor mechanism of the systemic vessels and of the accelerator mechanism of the heart." The systemic action is very brief. Oral administration is entirely ineffective and intramuscularly it is moderately effective. Locally it arrests capillary hemorrhage and enhances the anesthetic effect of cocain (synergism; Esch, 1910) and its derivatives, and decreases their toxicity by delaying systemic absorption. Injection into the nasal submucosa has been shown by Pilcher (1914) to be almost equivalent to intravenous injection. None 1 A Manual of Pharmacology, 1918. METHODS OF PRODUCING LOCAL ANESTHESIA 45 is absorbed through the nerves (Meltzer, 1909). Landau (1914) states that epinephrin does not produce glycosuria in man as it does in rabbits but that it increases the sensitiveness to an ali- mentary glycosuria. Meltzer and Auer1 made an ocular study of the bloodvessels in the rabbit's ear and showed conclusively that a subcutaneous injection of epinephrin causes a constriction of all the vessels of that ear. This is quite intense but the outstanding feature is its duration, three to eight hours. The period between the time of injection and the onset of constriction is longer the farther away the injection is from the principal artery. There is practi- cally an immediate paling of the entire ear and constriction of the central artery and vein with all the branches when an injection is made near the artery. The muscular sheath of the vessels is reached through the adventitia and not through the lumen and intima. After constriction there is a tendency to dilatation, and injection in one ear with constriction may result in dilatation of the other, which, however, is of short duration. Experimental work by Braun regarding the combined action of novocain-epinephrin, will be mentioned later and much credit must be given this worker for placing the use of the solution upon a stable, practicable basis following his application of it to numerous surgical operations. Novocain (Procain).-Novocain, a white crystalline powder, is chemically closely related to stovain and alypin. Its formula is as follows: CH2-(C6H4.NH2.COO).CH2[N(C2H5)2]-HC1. It is soluble in an equal part of cold water giving a neutral reaction. Its solutions possess slight antiseptic properties, may be repeatedly sterilized by boiling without marked effect upon the anesthetic properties, and may be kept for long periods of time (a quality not possessed by all other agents), without undergoing any change. Sodium bicarbonate may be added to the solutions without causing precipitation. When absorbed from the tissues, the general physiological action of novocain differs from that of cocain only in degree, as is the case with most of the other agents. As to its relative toxicity, the reader is referred to the latter part of this chapter. Locally, it exerts a prompt and pronounced anesthetic action which is greatly intensified by the addition of adrenalin, more so than with any of the other anesthetics. Although it is unnecessary to use stronger than a 2 or 4 per cent solution, a 10 per cent solution may be injected into the tissues without causing any irritation. There is no after-pain nor tendency toward the production of tissue necrosis, as with cocain. 1 Jour. Pharjnacol. and Exper. Therap., April, 1921, No. 3, 62, 17/, 46 THE LOCAL ANESTHETICS Novocain is but mildly toxic. Tt is perhaps because of its low toxicity more than to its many other favorable qualities, that this drug has become the most widely used of all the local anesthetics. Allen1 states: "After a rather extended experience, including a large number of cases embracing the entire field of surgery in which this agent has been almost exclusively used, we have failed to note a single case in which there has been any unpleasant local or constitutional action." At the present time in the literature reports may be seen of the injection of comparatively large amounts of novocain solution without ill effect. The author has seen W. W. Babcock inject 385 cc of a 1 per cent solution (3.85 gm.) the patient showing not the slightest toxic effect. While it is perhaps inadvisable to inject such large doses the fact that they can be injected without the patient showing any reaction proves that when properly safe- guarded novocain is an exceedingly safe drug. Novocain, like all other drugs, should be injected preferably in a weak solution and the dose should be measured in the strength of the solution rather than in its total amount by weight. In administering 5000 injections of the drug, Fischer failed to note a single case of serious intoxication. Granville MacGowan2 of Los Angeles states: "In a very free use of it, ever since its introduction, I have never seen more dis- agreeable symptoms than a slight nausea, or a momentary faint- ness following its use." The latter has used as high as 300 cc of a 1 per cent solution. The author has used the drug in thousands of cases and has never seen any serious toxic effects. 570 cc of a 0.5 per cent solution is the largest dose he has administered. According to Braun, 1.25 gm. (20 gr.) of novocain can be injected without fear of intoxication. That is 250 cc (8 oz.) of an 0.5 per cent solution or 125 cc of a 1 per cent solution. The toxicity of the drug is further reduced by the addition of from 2 to 5 drops of 1 to 1000 solution of adrenalin (epinephrin) to each 30 cc of novocain solution, which retards its absorption. In fact, the effects produced by the addition of this drug are nothing less than remarkable. Besides being prolonged, the anesthesia produced is intensified so that solutions of equal strength nearly equal in activity those of cocain. The experiments of Professor Braun3 show clearly the remarkably favorable action obtained by the combination of adrenalin preparations with novocain besides its total absence of all irritation. It should be remembered, however, 1 Local Anesthesia, 1914, p. 89. 2 California State Jour. Med., January, 1915. 3 Deutsch, med. Wchnschr., 1905, No. 42. METHODS OF PRODUCING LOCAL ANESTHESIA 47 that prolonged boiling decomposes the adrenalin; hence the latter should be introduced just before the operation. However, the adrenalin solution may be sterilized by initial boiling of the stock solution. For infiltration novocain solutions may be used in a strength of from 0.25 to 1 per cent. We prefer a solution between 0.7 and 1 per cent. This, when combined with adrenalin, gives a most satisfactory anesthesia, especially in infiltration work. Braun,1 an eminent pioneer in local anesthesia in abdominal work, infil- trates the tissues with novocain and adrenalin dissolved in suit- able percentages in a solution consisting of potassium sulphate, 4 parts, sodium chloride, 7 parts, and distilled water, enough to make 1000 parts. Sollmann states that potassium sulphate en- hances the anesthetic action of novocain so that by the addition of 2 per cent of the former the latter can be reduced 0.1 per cent. After a careful series of experiments2 he concludes that mixtures of the anesthetic with potassium sulphate give only a simple sum- mation and that this would be of some advantage in reducing the required amount of the anesthetic, the conditions being more favorable than with mucous membranes which give not even summation; but too much should not be expected from the potas- sium mixtures. In contrast to the many general and local toxic manifestations of the general anesthetics, considered in the preceding chapter, is the almost total absence of perceptible changes in the body following the use of novocain. Like ether, chloroform or any other drug used in anesthesia, novocain is capable of producing severe, or even fatal, acute poisoning in man, but moderately large doses, when absorbed either intravenously or subcutaneously, show almost no noticeable change either upon the circulation or respiration. Also the blood-pressure remains practically unchanged. Gros asserts that upon the addition of 1 part of sodium bicar- bonate for every 4 parts of novocain employed, the anesthetic effect of the latter is at least doubled or trebled. Sollmann3 con- cludes that anesthetic salts may be mixed with an equal volume of 0.5 per cent sodium bicarbonate solution without the loss of efficiency and with a saving of one-half of the anesthetic when mucous membranes are to be anesthetized. Alkalization does not increase the efficiency of novocain used in infiltration, however, and in this respect he also states that the anesthetic action of potassium sulphate or chloride is not great enough to be of real value, yet that it may be well to use a 1 per cent solution (isotonic) 1 Zentralbl. f. Chir., 1913, 1513. 2 Sollmann, Torald: Jour. Pharmacol, and Exper. Therap., No. 1, vol. 40, p. 79. 3 Therapeutic Research Reports, 1918, p. 20. 48 THE LOCAL ANESTHETICS which is equivalent to 0.125 per cent novocain, instead of sodium chloride. The author has tried the various combinations of drugs which it is claimed enhance the action of novocain and has been unable to satisfy himself that with the exception of adrenalin, any of the drugs recommended possess great advantage. ACIDOSIS RESEARCH UPON PATIENTS AFTER USING LOCAL ANESTHESIA. Recent experiments conducted in the author's clinic by AI. E. Rose1 and lately reported, others by C. W. Brunkow at St. Mary's Hospital, Minneapolis, and another series by S. R. Maxeiner and Frank Hirschfeld at Minneapolis General Hospital, which have not been reported, tend to show that novocain produces a decrease in the alkali reserve of the blood, which is, however, less frequent and less marked than that following the use of general anesthetics. The alkali reserve of the blood of the surgical patients was deter- mined by Airs. McGrath at St. Alary's Hospital and Dr. Ikeda and staff of the Minneapolis General Hospital, before and after operation according to the technic of Van Slyke,2 and the change, if any, noted. The operations included such major procedures as herniotomy, appendectomy, hysterectomy and cholecystectomy. The table on page 49 shows the results obtained by Dr. Rose. A summary of this table shows that of the 38 patients, 22, or 58 per cent, showed no decrease in the blood bicarbonate after opera- tion. 16, or 42 per cent, showed a decrease varying from 1.5 to 10 volumes per cent, the average decrease being 4.5 volumes per cent. In all cases, however, the average fall was but 1.9 volumes per cent. The table on page 50 will briefly outline the results obtained in a later series at St. Alary's Hospital, showing the nature of the cases, the extent of the operation, the amount of anesthesia used and the effect on the alkali reserve of the blood. From this table it will be noted that there was found a decrease in blood bicarbonate in most of the cases with an average drop of 4.6 volumes per cent but in none was there a real acidosis (below 50 volumes per cent). The average preoperative alkali reserve was found to be 68.7 and the average first day postoperative 64.1. By groups the greatest average drop in alkali reserve of the blood was that of laparotomies (6.1), involving cholecystectomy, hysterectomy, appendectomy, herniotomy; then the perineal group with a drop of 6 volumes per cent; next the genito-urinary 1 Illinois Med. Jour., No. 1, vol. 41, p. 6, ? Jour. Biol. Chem., 191?. ACIDOSIS RESEARCH UPON PATIENTS 49 TABLE I. Amount of novocain used in cc. Carbon dioxide capacity of blood before operation. Carbon dioxide capacity of blood after operation. Decrease in volume per cent. 1. Dislocation outer end left clavicle ...... 90 63 65 63 2. Chronic endometritis, cyst, Bartholin gland 90 52 53 55 3. Exophthalmic goiter . 90 51 52 54 4. Cholecystectomy .... 165 57.5 51 52 6.-5 5. Herniotomy 120 60 52 51 8 6. Suspension, appendectomy . 120 40 46 46 7. Hysterectomy .... 120 48 52 51 8. Cholecystectomy .... 150 53 51.5 52.5 1.5 9. Myomectomy, rectopexy 120 56 61 66 10. Appendectomy .... 90 60 63 64 11. Appendectomy .... 105 66 60.5 61.5 12. Appendectomy and suspen- sion 90 63.5 59.5 61 4 13. Nephrectomy 75 62.5 57.5 60 5 14. Appendectomy and suspen- sion 90 72 67 69.5 5 15. Cholecystectomy .... 150 51 56.5 54 16. Prostatectomy .... 75 58 48 46.5 10 17. Appendectomy . . . 120 65 65.5 70.5 18. Perineorrhaphy, colporrha- phy, suspension 150 61 59 59.5 2 19. Dissection of glands of neck 110 56 60 60.5 20. Appendectomy .... 90 64 66 64 21. Nephrostomy 75 56 54 53.5 2.5 22. Herniotomy 100 68 60.5 66 7.5 23. Nephrectomy 75 55 50 51 5 24. Hysterectomy .... 60 53.5 51.5 53 2 25. Appendectomy .... 90 54 54 56 26. Varicocele 60 57 59 57 27. Herniotomy 90 59 60.5 61 28. Suspension, amputation cer- vix . 120 56 56 59.5 29. Cholecystectomy, appendec- tomy 140 54 56 54.5 30. Cholecystectomy .... 120 52 50.5 52.5 1.5 31. Gastroenterostomy 120 67 71.5 74 32. Appendectomy .... 120 58 60 62 33. Hemorrhoidectomy . 90 58.5 59 59 34. Herniotomy 135 59 56 58.5 3 35. Suspension, right salpingec- tomy, right oophorectomy, appendectomy .... 120 63 66.5 66 36. Cholecystectomy .... 150 56 56 56.5 37. Appendectomy .... 135 51 55 54.5 50 THE LOCAL ANESTHETICS TABLE II. Case. Operation and diagnosis. Remarks. Novocain 0.7 to 1 per cent, No. cc infiltration. Carbon dioxid capacity of blood one day preopera- tive. Carbon dioxid capacity of blood one day postopera- tive. I Carbon dioxid capacity of blood postoperative day as indicated by number. Decrease in CO» capacity of blood in one day. Genito-urinary. 1 Extraperitoneal left ureterotomy 240 75 68 64 4 7 and transplant of ureter into bladder. Bilateral hydropyoureter with left ureteral stricture, chronic cysti- tis with atonia. 2 Repair of left rui tured kidney. 240 76 70 6 Drainage of infected perirenal hematoma. Traumatic etiology. complicated with contusion of abdomen. 3 Left nephrectomy. Chronic left pyopyelitis with pyelonephrolith- iasis; obesity; hypertension. f Instilla- I 240 66 66 56s 6O4 82n 0 4 Cystoscopy (nephrectomy day fol- lowing. See previous case). | tion in | t bladder of 1 1 2 per cent | ( novocain. 60 79 66 13 Group average 72 68 4 The Extremities. 5 Skin plastic, pedicle flaps over ex- cised x-ray ulcer right calf region. 180 73 68 5 6 Homogenous skin transplant to 150 60 62 62« + 2 region of excised x-ray ulcer right calf region. 7 Arthroplasty left elbow with fascia [ Brachial 1 lata transplant between resected | saligenin | bone ends. ( 180 cc ) 30 66 50 62, 15 Chronic infectious anchylosis left N2O2 + 0 | I elbow. ( lj hrs. j 8 Excision fibrosarcoma skin left 180 72 702 2 thigh. 9 Excision subcutaneous fat and ex- f Sciatic block ] ternal muscle fasciae of medial N2O2 + () 30 78 60 IS and lateral sides of left thigh and . leg for elephantiasis. 1: 25 m. 1 11 hrs. j (1%) Group average 68 67 1 Perineal. 10 Hemorrhoidectomy 90 68 54 726 14 Excision breast tumor (benign). 60 11 Dissection fistula in ano. [ Quinin- 1 •j urea HC1 ) 180 90 90 210 74 65 9 12 Dissection fistula in ano. I (1 : 600) j Sacral. 63 61 64 2 6 13 1 Perineorrhaphy uterine suspension appendicectomy. 68 62 6 Group average •• Laparotomies. 14 Cholecystectomy, drainage; chole- 210 61 58 3 cystitis, cholelithiasis, chronic 15 myocarditis. Cholecystectomy, drainage; chole- cystitis; cholelithiasis. N2O2 + O2 240 66 66 662 72s 0 + ether 16 Appendicectomy; subacuteappen- 10 min. 180 66 60 dicitis; uterine retroflexion. entire operation 30 min. ACIDOSIS RESEARCH UPON PATIENTS 51 Case. Operation and diagnosis. Remarks. Novocain 0.7 to 1 per cent, No. cc, infiltration. Carbon dioxid capacity of blood one day preopera- tive. Carbon dioxid capacity of blood one day postopera- tive. Carbon dioxid capacity of blood postoperative day as indicated by number. । Decrease in C2O capacity of blood in one day. 17 18 19 20 21 22 23 Subtotal hysterectomy; double salpingectomy; ovarian resection; drainage. Chronic pelvic peri- tonitis; salpingitis. Appendicectomy, uterine suspen- sion; perineorrhaphy. Uterine retroversion, cystocele, rectocele. Cecostomy, carcinoma of rectum. Bilateral herniotomy, inguinal. Umbilical herniotomy, lipectomy. Bilateral herniotomy (inguinal). Bilateral herniotomy (inguinal). Group average Very obese. 240 210 90 180 120 150 180 64 70 62 75 72 78 62 67.6 59 64 58 682 58 68 56 61.5 6O2 41i 683 64< 48s 703 62 s 5 6 4 7 14 10 6 6.1 The Head, Neck and Breast. 24 25 26 27 Excision xanthoma of breast. Thyroidectomy, substernal cystic; degenerative colloid, left lobe, Adenoma, right lobe. Dissection neck; carcinoma lower lip. Chronic infected mastoid from bullet wound received twenty years before operation. Otitis, mastoiditis, suppurative brain cyst and meningitis. Bul- let removed from right mastoid region. Group average Brachial. ] Died with-j ) in 24 hrs. ) J J 210 30 180 45 90 68 68 73 68 69.2 62 s 60 74 66 65.5 52 s 80t 80s 664 72; 685 4 8 4-1 2 3.7 table 11.-Continued. Grand average preoperative, 68.7. Grand average first day postoperative, 64.1. Grand average drop, 4.6. group with 4 volumes per cent drop; the head, neck and breast group with a drop of 3.7 volumes per cent and finally the extremities with but 1 volume per cent decrease. This would seem to indicate that possibly the type of operation affects the alkali reserve more than the amount of novocain used, for no proportionate relationship between the amount of solution injected and the decrease of alkali reserve could be established. In fact some of the greatest drops occurred where comparatively small amounts of novocain were used. The above table also shows the variability of the alkali reserve in some cases as follow-up determinations were made. However, in most cases a rapid return to or above the preoperative reading is shown. 52 THE LOCAL ANESTHETICS The following table indicates the results obtained at the Minnea- polis General Hospital and shows an average decrease of 3 volumes per cent. TABLE III. Case. Diagnosis. Amount of novocain used in cc. Carbon dioxid capacity of blood before operation. Carbon dioxid capacity of blood post- operative day as indicated by number. Decrease in volume per cent. 1 Visceroparietal adhesions 150 69.1 69.12 0 2 Hemorrhoids 30 64.34 57.62 7 3 Inguinal hernia 90 61.4 60.54 1 4 Inguinal hernia, umbilical hernia 150 67.2 69.24 5 Left inguinal hernia .... 90 67.2 Sl.Os 16 6 7 Right inguinal hernia with forty- eight-hour postoperative reten- tion Left inguinal hernia .... 90 90 65.3 67.2 66.2 69.13 Grand average preoperative, 65.96. Grand average postoperative, 63.24. Grand average drop, 3.428. As the number of cases studied is relatively small, our con- clusions must be guarded. However, a comparison of these results with those obtained by other investigators1 working with ether would seem to indicate that the decrease in the alkali reserve of the blood following novocain anesthesia is less frequent and less marked than that following general anesthesia. RELATIVE DESIRABLE PROPERTIES OF LOCAL ANESTHETICS. A local anesthetic to be efficient must possess certain requisites. Most important, it must be very remotely a systemic poison. It must not of itself be a cause of pain, either before its action is established or after it has ceased. It must be soluble in solutions which have approximately the same osmotic pressure as the body fluids; that is, the solutions must be isotonic with these fluids. It must not be absorbed rapidly from the tissues and therefore must be compatible with adrenalin. Its solutions must not deteri- orate upon boiling. Finally it must be able to paralyze the nerve cells in very dilute solutions. 1 Reimann and Bloom: Jour. Biol. Chem., 1913, 36, 211; W. S. Carter, Arch. Int. Med., No. 3, vol. 26, 319; W. H. Morris, Jour. Am. Med. Assn., May 12, 1917, 68, 1391. DESIRABLE PROPERTIES OF LOCAL ANESTHETICS 53 It has been shown that when the solutions of some of the local anesthetics are injected into the tissues, an irritation or burning sensation is produced. This is true of cocain, beta-eucain, tro- pacocain, stovain, alypin and allocain-S. and quinin. Adrenalin may be used with advantage with all except stovain and quinin and urea hydrochloride. The relative toxicity is perhaps the most important feature which must be considered. As has been said before, although the large number of compounds which have been introduced as sub- stitutes for cocain are of a quite diverse chemical nature, they simulate one another very closely in their pharmacological actions, their differences being chiefly quantitative. When large enough doses are given, a severe or even fatal poisoning is produced. This has been brought out by Cary Eggleston and Robert Hatcher1 of Cornell University. These investigators, after a very careful and extensive series of experiments performed on cats, in which the toxic symptoms show a close similarity to those produced in man, have shown that procain is the least toxic. This result was obtained by rapid intravenous injection and the order of the several drugs used as to their relative toxicity is as follows: Mgm. per kgm. Novocain 40 to 45 Nirvanin . 30 to 35 Stovain . . 25 to 30 Tropacocain 18 to 22 Apothesin 20 Cocain ' 15 Beta-eucain 10 to 12.5 Alypin and Holocain 10 These workers also found that "the toxicity of the local anes- thetics for the cat, after subcutaneous injection, depends upon the ratio between the rate of absorption and that of elimination, and the local anesthetics can be divided into two classes with reference to that ratio. Five, or more than five, times the minimal fatal vein dose of alypin, apothesin, beta-eucain, nirvanin, procain, stovain and tropacocain can be injected subcutaneously in the cat without causing death, while four, or less than four, times the fatal vein doses of cocain and holocain similarly injected prove fatal.'' The drugs of the first group of which novocain is one, are eliminated with great rapidity, within a few minutes after their injection, by their destruction in the liver. Cocain and holocain are eliminated much more slowly. Piquand and Dreyfus2 after intravenous injections of the various local anesthetics in rabbits, give the following results: 1 Jour. Pharmacol, and Exper. Therap., August, 1919, No. 5, 13, 433. 2 Cited by M. V. Tyrode, Boston Med. and Surg. Jour., July 7, 1910. 54 THE LOCAL ANESTHETICS The fatal dose per kilo body weight is as follows: Alypin 0.017 gm. Cocain 0.0183 gm. Beta-eucain 0.019 gm. Tropacocain 0.02 gm. Stovain 0.03 gm. Novocain-epinephrin 0.046 gm. Novocain 0.063 gm. These results, it will be seen, are very similar to those obtained by Eggleston and Hatcher. To the above table might be added: 1. Butyn, which as has been mentioned, equals cocain in toxicity when given intravenously, but is two and a half times as toxic when given hypodermically; and 2. Saligenin, which has a lethal dose of 0.4 to 1.0 gm. per kilo. The relative efficiency of the various local anesthetics is another very important feature to be considered in selecting a drug to be used. Not a few men have endeavored to determine the degree of anesthesia produced by these drugs as compared with that of cocain. One of the most careful investigators in this field has been Torald Sollmann of Western Reserve University, and his contributions are undoubtedly most valuable. He has reached his conclusions by using the intradermal wheal method, which involves the finest nerve fibrils and possibly the sensory endings. The end point or absence of sensation in this method is subjective and not very delicate, but he states its accuracy is about that of other methods and sufficient for practical purposes. The method is regarded as the best for comparing absolute anesthetic efficiency and the results obtained are what may be expected in infiltration anesthesia. Sollmann's1 conclusions are as follows: "For injection anesthesia, cocain, novocain, tropacocain and alypin are about equally efficient. Beta-eucain is one-half and quinin-urea is one-fourth as active. Apothesin, antipyrin and potassium chloride are one-eighth as active." "The duration of action of these drugs varies but these differences are insignificant when compared with the differences that are pro- duced by the addition of epinephrin." The experimentation of Piquand and Dreyfus led to the classi- fication of the different local anesthetics or combinations thereof as follows in the order of decreasing strength: 1. Cocain. 2. Procain-epinephrin. 3. Procain, alypin. 4. Stovain, tropacocain, beta-eucain. They conclude that procain-epinephrin is a very active agent and next to the least toxic. 1 Jour. Pharmacol, and Exper. Therap., No. 1, 11, 79. CHAPTER III. THE ANESTHESIA PROBLEM. THE PATIENT'S INTERESTS. In approaching this subject one must consider primarily the best interests of the patient, all other considerations being of second- ary importance. While the expenditure of the surgeon's energy and time, matters of economy, difficulty of acquiring the necessary training, the problem of educating the laity, and many other factors may present themselves as more or less objectionable con- comitants of a method of producing anesthesia, it would seem proper to give the patient's welfare precedence over all of these. The patient's safety is without question the most important factor in every case in which it becomes the surgeon's duty to administer treatment; next in importance is the efficiency of the treatment to be administered. The patient's safety is paramount, but no anesthetic should be considered appropriate for a given case unless it allows the surgeon to carry out the required procedure with dispatch and completeness and without embarrassment. Efficiency should be insisted upon, and unless an operation can be carried out with efficiency under the use of local anesthesia, general anesthesia is quite obviously indicated. The one great advantage of general over local anesthesia is that under its influence all opera- tions can be performed. With local anesthesia the performance of certain operations is impossible even in the most skilful hands. The majority of operations may be carried out with less embarrass- ment to the surgeon under general anesthesia, but the class of operations in which the opposite is true is gradually increasing. For instance, the "silent abdomen," and one might say the "silent field" in other parts of the body, notably the head, face and thorax, under perfect local anesthesia, in many instances give the surgeon a marked advantage over the conditions met when general anesthesia is used, unless the latter is almost perfectly administered, which is perhaps more often the exception than the rule. It is agreed by all that certain surgical problems may be best solved by the use of local anesthesia. Differences of opinion relate THE CHOICE OF AN ANESTHETIC. 56 THE ANESTHESIA PROBLEM to the scope and variety of problems which may be considered in this class. The author believes that these differences are very largely the result of a general inadequacy in training and skill in proper methods of administration of local anesthesia and in the special surgical technic required for its successful use. The advan- tages accruing to the surgeon skilled in the use of local anesthesia are many. Assuming as our premise, that the three main factors in the choice of an anesthetic are safety, efficiency and comfort, let us take each of these in turn and discuss them in relation to local anesthesia. Safety.-It will be admitted, I believe, that considered from the standpoint of toxicity alone local anesthesia is safer in its immediate as well as its remote effects than is general anesthesia. This advantage of local anesthesia constitutes its outstanding point of excellence, and would doubtless cause its acceptance as the anesthetic of choice were it not for its actual and alleged disad- vantages. The necessity for operative speed is largely eliminated. The knowledge that the patient who is inhaling general anesthesia is taking a poison into his system, the quantity of which depends quite exactly upon the length of time during which he is inhaling the drug, must impel the conscientious surgeon to an effort to complete his operation with the greatest possible dispatch. As a result operative accidents and errors are much more likely to occur than they are under local anesthesia, the use of which allows and demands deliberation and care, and gives the surgeon an opportunity to make careful, methodical, refined manipulations. Its use eliminates the element of time as a factor of safety, renders it possible for the surgeon to carry out his work with the utmost deliberateness, and makes it unnecessary that all operations be concluded in the shortest possible time. The elimination of the necessity for haste makes it possible to place clamps and ligatures, perfect dissections, complete the toilet of the peritoneum, and to perform many other technical manipulations with much greater care and efficiency than is possible when working at top speed. There can be no doubt that a method of anesthesia which reduces the necessity for haste adds to the safety of the patient who is undergoing an operation. Efficiency.-In a comparison of methods it is assumed that the performance of an efficient operation will be made possible without suffering on the part of the patient and without embarrassment on the part of the surgeon. The efficiency of local anesthesia, or, in other words, the opportunity offered the surgeon to carry out the various surgical procedures by its use, is the subject of great diversity of opinion and varies to such an extent in the judgment of different surgeons that few are agreed as to the position the method should 57 THE CHOICE OF AN ANESTHETIC occupy. The results obtained from its use depend very largely upon the skill and training of those who essay to use it-skill and training which embody not only a knowledge of the principles and practice of inducing anesthesia, but also a knowledge of, as well as the ability to apply, the special surgical technic which must be employed in order to operate successfully under this form of anes- thesia. Those who have concentrated upon the use of local anes- thesia and have developed a fair degree of skill in the method of its administration and in the proper methods of operating under its use, have presented sufficient evidence to make clear the fact that a fairly large percentage of surgical operations may be efficiently performed by the use of this method. It would seem that the time has arrived for surgeons to take stock and to make a sincere attempt to ascertain the facts in relation to the anesthesia problem. If the element of safety is best assured by the use of local anesthesia, and the protection which is the right of every surgical patient is withheld because the surgical profession in general through lack of training is unable to use the method effici- ently, this training and skill must be more widely disseminated throughout the surgical world. Sufficient evidence is at hand to demonstrate that with increased experience every surgeon may rapidly broaden the scope of local anesthesia in his own practice and bring its advantages to an increasing number of patients. At the present time many surgeons with practically no training whatever consider themselves equipped to perform operations under local anesthesia. The author has in his possession hundreds of letters from physicians, in which he is asked for information regard- ing the local anesthesia technic for the performance of some particu- lar operation. In these letters of inquiry the inquirer usually adds that he has a patient upon whom he intends to operate presently, and is therefore desirous of obtaining this information. Even surgeons of repute often have only a limited knowledge of the use of local anesthesia. These same men would without doubt freely admit that none but the most perfectly trained experts should be allowed to administer a general anesthetic, yet without any special training or experience in the use of local anesthesia, they appear to be quite willing to proceed to use it upon their patients. Until this attitude changes we must expect to have the efficiency of the method assailed. As the efficiency of the method depends upon the surgeon's training and skill in its use, it would seem fully as incum- bent upon all surgeons to prepare themselves for the efficient administration of local anesthesia in all cases in which its use is of advantage to the patient as it is to furnish a skilled anesthetist to every patient requiring a general anesthetic. If this standard is met, the author is convinced that the sum total of instances in which 58 THE ANESTHESIA PROBLEM local anesthesia is the method of choice will exceed that in which anesthesia by inhalation is plainly indicated. Comfort. -Comfort, though of less importance than safety and efficiency, is yet of sufficient moment to merit the attention of every surgeon, and anything which may contribute to lessen the disagree- ableness of surgical operations and their sequela1 should not be overlooked or neglected. This phase of the subject presents many angles for one's consideration. One must think of the psychic as well as of the physical discomforts which a patient must undergo; and, as these discomforts vary both in kind, duration and intensity, the total or combined effects of all of the disagreeable features connected with the treatment of an individual should be considered in drawing conclusions, rather than the effects to be endured or eliminated during the limited period of the actual operation. An analysis of the causes of discomfort connected with surgical operations will show that in all cases in which local anesthesia is at all applicable, it is the method of choice from the standpoint of comfort, provided only that it is properly administered and accom- panied by the correct operative technic. Discomfort connected with a surgical operation may be divided into three well defined stages or periods: (1) The period before the operation (when the suffering is largely psychic in character); (2) the period of discomfort during the performance of the opera- tion; and (3) the period of postoperative discomfort. Apprehension is the greatest cause of the suffering which precedes the operation and this may be greater with one form of anesthesia than with another. However, the possible suffering of a patient from apprehension regarding anesthesia may be more than offset by the assurance that comes from the belief that the method of anesthesia to be employed offers advantages over other methods in safety, efficiency and postoperative comfort. This assurance may also more than compensate for the mental discomfort accom- panying the performance of an operation upon a conscious patient. To the average patient the thought of postoperative discomfort is often more distressing than the thought of the operation itself, but to many surgeons postoperative discomfort is considered the inevitable and necessary concomitant of a surgical operation. These surgeons therefore minimize or entirely ignore the patient's very real physical distress following an operation under general anes- thesia, while at the same time they place great emphasis upon the mental suffering resulting from apprehension and upon the possi- bility of pain incident to the performance of an operation under local anesthesia. Thus it is suggested, when comparing the relative merits of the different forms of anesthesia in relation to comfort, that not one or the other advantage or disadvantage should be THE CHOICE OF AN ANESTHETIC 59 overemphasized, but that the sum total of comfort or suffering connected with a surgical operation should be considered. The actual suffering which a patient must undergo during the performance of an operation under local anesthesia will depend upon a number of factors. He is confronted with certain disturbing anticipations. He has many things to consider regarding the ordeal through which he is to pass-the danger to his life, the possibility of failure to obtain a cure and the probability of a period of great pain and discomfort following the operation. His mental discomfort will depend upon his temperament, his confidence in his surgeon and his faith in his surgeon's methods. The stronger his faith, the less will be the mental torture and "psychic incom- patibility" caused by his apprehension; whereas the weaker his faith, the greater will be his suffering before and during the opera- tion. The apprehension which results from lack of faith serves also to exaggerate and intensify the actual physical suffering that the patient is compelled to undergo during the operation. This subject will be further elaborated under a discussion of the psychic aspect of the surgical case, but I deem it of sufficient importance to discuss it in considering the elements which may have a bearing upon the patient's comfort. We know that without faith the slightest needle prick, or even the contact of a gauze sponge with the skin may cause certain patients considerable pain, whereas the establishment of confidence and a cooperative spirit in a candidate for operation may and indeed does bring about an attitude which makes it possible for the patient actually to discount any physical pain which may be produced during the introduction of the anesthetic or during the performance of the operation. It follows therefore, that the establishment of this faith or feeling of confidence in the mind of the patient is one of the prime requisites for doing satisfactory work under local anesthesia. How this faith is to be established is an important question. Undoubtedly the most important single factor in its speedy establishment will be the routine performance of local anesthesia operations without the production of unnecessary pain. Conversely the longer surgeons insist upon inflicting avoidable suffering upon their patients during operations attempted under the use of local anesthesia, the more tardy will be the dissemination of faith among prospective patients. It is the writer's conviction that the use of proper methods of introducing anesthetic solutions into the tissues combined with an appropriate surgical technic and the judicious addition of general anesthesia in all cases in which an operation begun under local anesthesia cannot be completed without pain, if sufficiently widely adopted by the surgical profession, would rapidly reduce to a minimum the mental and physical suffering 60 THE ANESTHESIA PROBLEM which a percentage of patients must now endure before and during operation. Postoperative discomfort, while due to a wide variety of causes and varying with the condition of the patient and the operative pro- cedure employed, can without question be alleviated by modifica- tions of the methods which are to a large extent definitely under the control of the surgeon. The amount of postoperative discomfort following any particular operation will reflect to a marked degree the manner in which the procedure has been carried out. Exhaus- tion from trauma due to severe traction and extensive handling of organs, exposure of the tissues, hemorrhage, prolonged or poorly administered anesthesia by inhalation, will with absolute certainty be followed by an increased amount of postoperative suffering in the majority of cases. Postoperative thirst, nausea and vomiting, the prolonged taste of noxious gases, intestinal distention, back strain, and the suffering due to such complications as bronchitis and pneumonia, all contribute to increase the sum total of the surgical patient's postoperative discomfort. The convalescence of the patient will depend somewhat upon the anesthetic used, the manner of its administration and the manner in which the operation is done. Unskilful work will be reflected not only by increased postoperative discomfort, but also by other disagreeable sequelae, such as delayed convalescence, an increased hospital bill, increased nursing expense and increased expense incurred by the patient's relatives, who may deem it necessary to remain in the vicinity of the afflicted one during his sickness. Thus delayed convalescence must be added to the sum total of the discomforts which a patient must undergo. We must therefore, when considering the choice of anesthesia, reckon with this factor as well as with others. It is impossible to measure the aggregate discomfort which patients may suffer from postoperative complica- tions alone. After-pa in.-Hertzler states that the use of novocain solutions in the tissues is productive of an increased amount of wound pain following operation. As his experience did not coincide with that of the author a series of experiments were carried out in an effort to determine, if possible, the facts in relation to postoperative wound pain. The impression of the author had been that patients were much more comfortable after an operation under local anesthesia than where general had been used, although the fact that there was no loss of consciousness allowed them to appreciate wound pain earlier when local anesthesia was employed. Therefore a number of patients who were operated upon under general anesthesia, for conditions requiring bilateral operations (bunions, hernia, etc.) SPECIAL ADVANTAGES OF LOCAL ANESTHESIA 61 were injected. In these cases novocain-adrenalin solution was injected in one side and the other used as a control. The amount of after-pain complained of showed no difference in the two sides. About one-third of the patients presented an equal amount of pain on the two sides, one-third complained more of the side which had been injected with the solution, and one-third complained less of the injected side. Therefore it was concluded that novocain solutions per se are not the cause of increased wound pain. SOME SPECIAL ADVANTAGES OF LOCAL ANESTHESIA DURING OPERATION. One of the most important qualities of an anesthetic rests in the opportunity it offers the surgeon for carrying out an operation under the most favorable conditions. No other anesthetic can present the so-called "silent field'' with the degree of perfection possible under local anesthesia. The absence of forced or variable respira- tory excursion; the flaccidity of the muscles whose reflexes should be completely abolished by local anesthesia; the absence of local engorgement of the circulatory system; the advantages offered by the cooperation of the patient which is so helpful when it is desirable to demonstrate the hernial sac, the gall-bladder, the surface of the lung, the mucosa of the rectum, the vagina, or the oral cavity; the ability to use the vocal cords; the production of pain by the manipulation of an organ in an effort to reproduce the painful sensations of which the patient previously complained, are all of decided advantage to the surgeon when operating upon the conscious patient. What for instance could give one more satisfaction than the cheery "Good morning" of the patient who is undergoing a thyroid- ectomy, when uttered between the time of clamping and sever- ing the tissues in the region of the recurrent laryngeal nerve? Compare the opportunities for dissection of the lateral region of the neck under the two methods of anesthesia. With general anesthesia it is not uncommon to find the internal jugular vein distended to the diameter of one's thumb, while under local anesthesia this vessel may be distended or allowed to collapse practically at the patient's will. In fact, under local anesthesia, venous hemorrhage is largely under the control of the patient. In abdominal work the absence of engorgement of the local circula- tory system not only greatly aids in reducing hemorrhage but offers even more assistance in presenting to the surgeon organs in which the blood supply is decreased to such an extent that they may be manipulated and operated upon with satisfying facility. The presence or absence of marked respiratory excursion which is under 62 THE ANESTHESIA PROBLEM the control of the will of the patient also gives the surgeon a decided advantage when operating under the use of local anesthesia. This relates not only to operations upon the brain, neck, thorax, rectum and vagina, but also upon the bladder and especially upon the intraperitoneal viscera. The "negative" intraperitoneal pressure which presents when the abdomen is opened under local anesthesia offers an opportunity to observe the tissues and to carry out opera- tive procedures under conditions which are almost ideal, (Fig. 202, page 473 and Fig. 215, page 493.) When demonstrating this the term "autopsy operation" suggests itself, because the conditions presented closely resemble those found at autopsy upon the fresh cadaver. The flaccid organs lie in their normal positions and may be examined and manipulated at will provided the manipulation does not exceed certain bounds. In addition, the cooperation of the patient makes it possible to maintain the organs in an absolutely quiescent state for a reasonable period of time. If desired, the patient may at will extrude certain viscera into the operative field (Fig. 196, page 449). This attribute of local anesthesia is of use especially in dealing with the stomach, gall-bladder and in hernia operations. The orthodox introduction of gauze packs for the forcible removal of the small intestine from the pelvis, in removing the appendix and in many other intra- peritoneal operations is not only unnecessary but of no advantage to the surgeon when using local anesthesia, and is exceedingly undesir- able from the standpoint of the patient's best interests. The less trauma inflicted upon the intra-abdominal viscera in this manner the better for the patient. The proper use of local anesthesia combined with strategy will in a large percentage of cases allow one to make the necessary displacement of the intra-abdominal viscera without the use of the gauze pack forced home by the surgeon's strong right arm. In septic conditions within the abdomen the excursion of the viscera during and after operation is undoubtedly often the cause of the dissemination of septic material into uncon- taminated fields. Here the use of local anesthesia offers the best opportunity for the reduction of this excursion and as a result the tendency toward further spreading of peritonitis. In another portion of this work the subject of dissemination of septic material about the abdominal cavity as a result of forced respiratory excur- sion and especially on account of postoperative vomiting which under local anesthesia is reduced to a minimum, is discussed at greater length. Suffice it to say here that the author believes that spreading infection after operation may be minimized by the use of local anesthesia. The reduction of trauma to the lowest point compatible with the performance of an operation is best effected by the use of local ADVANTAGES BEFORE AND AFTER OPERATION 63 anesthesia. The deliberation in operating which is demanded and allowed, the careful handling of tissues which is so desirable, the conditions requisite for the employment of feather-edge dissection, and the elimination of the necessity of forcing the viscera about by the use of sponges, with the well-known effect which the need for the avoidance of trauma has upon the surgeon and his enhanced respect for tissues when he is working under local anesthesia, all offer advantages to surgical patients which cannot be overestimated. For the realization of this, local anesthesia is largely responsible. The demand that it makes in this regard, as well as the opportunity it offers for operative finesse, cannot fail to result in that improve- ment of surgical technic, which the best interests of the patient requires. While the advantages just enumerated relate especially to the period of the operation itself, and while many others might be mentioned; the use of local anesthesia also presents attributes of advantage to the patient during both the preoperative and post- operative periods. With this method preoperative starvation is usually unnecessary, the withholding of either solid or liquid food not being so necessary where this form of anesthesia is to be used. The patient and his friends may be assured that an operation under this method offers the greatest safety that it is possible to give; that during the same time the amount of actual labor and perspiration that he will have to put forth will be negligible; that there will be absence of struggling; that there will be no bodily trauma such as joint dislocation, sacro- iliac subluxation, back or muscle strain, nerve pressure, injury to the eyes, or to the tongue, swallowing of teeth, burning from hot- water bottles and traumatization by attendants who only too frequently are careless in handling anesthetized patients. He may have the additional assurance that following the operation there will be decreased danger from the after effects of the operation and from the anesthetic; that his heart, lungs, liver and kidneys will be taxed to a lesser degree after local than after general anes- thesia; that the amount of postoperative nausea, vomiting, gas pains, and general depletion will probably be less marked; that the wound strain and pain consequent upon retching and vomiting will be practically eliminated; that the probability of death, immediate or remote, from the effect of local anesthesia is almost nil, that the postoperative discomfort resulting from thirst will be reduced to a minimum; that his dressings and wounds will not be soiled by vomitus; that he will not fall out of bed during recovery ADVANTAGES BEFORE AND AFTER OPERATION. 64 THE ANESTHESIA PROBLEM from the anesthetic; that infectious processes will not be unduly disseminated by muscular activity and vomiting; and that intra- peritoneal infections will not be spread by visceral excursion, result- ing from the retching, vomiting and struggling during and after the induction of anesthesia. In addition he will have the satisfaction of knowing that by this method the surgeon had been offered the opportunity to perform the operation in as efficient a manner as is possible. Incidentally, he may obtain some satisfaction from the knowledge that the surgeon whom he has employed is the one who performs his operation, and that it has not been detailed to some assistant who was not his choice. He may also learn something of the decorum of the operating room, and have removed prejudices which his mind may have harbored regarding the sincerity or seriousness of those who take part in the operation. THE ATTITUDE OF THE PATIENT IN RELATION TO LOCAL ANESTHESIA AND UPON WHAT IT DEPENDS. Patients vary greatly in regard to their attitude toward physicians, hospitals and surgical operations. Much may depend upon the temperament, nationality, age, sex, general intelligence, and medical intelligence, but aside from certain social types with which we must always reckon, the greatest influence upon the patient under local anesthesia is exerted through his intelligence and previous training. It has been my observation that those patients who are in a position to estimate judiciously the merits of local versus general anesthesia have in a large percentage of cases decided in favor of the local method. I refer to individuals who have been operated upon one or more times by each of the methods. Those deciding in favor of general anesthesia were usually in the class that had been caused pain during operations under local anesthesia. Many of these, after further experience with general anesthesia, expressed a preference later for the local method. While appreciating the fact that it is extremely difficult to evaluate properly the merits of any method when judged purely from the standpoint of the patient's choice, on account of the great variety of factors which enter into the formation of the patient's opinion, extended experience and a careful collection of data allows one to form impressions which may be of more or less value. The opinion of the patient may vary with the length of time that has elapsed since the operation. For instance, the patient who has complained of one or more kinds of discomfort, before, during or after operation may upon reflection be extremely friendly to the particular form of anesthesia used. On the other hand, a patient who has not shown the slightest outward THE ATTITUDE OF THE PATIENT 65 sign of discomfort during the same relative period may, upon mature reflection, decide that some other method would have been more acceptable. Again, the associations of the patient either immediately or remotely following an operation may be such that a favorable verdict will be withheld on account of prejudices engen- dered by the unfavorable comment of those with whom he has come in contact. One must take all of these matters into account in making an effort to arrive at proper conclusions. Averages only are to be considered, and those only after the most careful investiga- tion of a comparatively large number of cases. In the crystallization of the lay opinion with regard to this subject there are therefore three important factors which are of influence: (1) The degree of physical discomfort which the patient is compelled to undergo-a matter which is largely under the control of the surgeon and the hospital corps; (2) the environment of the patient before, during and after operation, a factor which may be influenced to some extent by those who have the patient's treatment in charge, but which is to a large extent educational and dependent upon the dissemination of propaganda which is favorable to the method; (3) a factor which presents itself to a more limited degree, namely, the temperament, or mental make-up of the patient. The vast majority of patients who are psychically incompatible with the local method are made so by the antilocal attitude which permeates the medical as well as the lay mind, although there are undoubtedly a few individuals who are so constituted that even under the most favorable auspices they can- not possibly accept the local method with enough poise to eliminate psychic disturbances which are sufficiently grave to offset the advantages of local anesthesia. Here again, we must reckon with the law of averages, and the greatest good to the greatest number must be our criterion in arriving at a decision. The surgeon who in this day and age fails to take into account and to attach the full importance to the psychic elements relating to the care of his patients must be considered in a category with those who are withholding from their clientele an important and necessary adjunct to treatment, even though they are at the same time administering a fair measure of well directed treatment. The patient's comfort may be largely dependent upon attention to this feature and response to treatment is also dependent upon it. Too frequently the patient is considered a "case" and the surgical condition is treated from the mechanical standpoint alone, while the fact that the patient is a complex organism with a mental as well as a physical aspect is often lost sight of. People vary to as great an extent in relation to their mental make-up as they do in relation to the variety of surgical lesions which they present. Mental 66 THE ANESTHESIA PROBLEM states bordering upon insanity are not uncommon and even the insane present surgical lesions which may or may not be a causative factor in their mental derangement. A composite picture must be very definitely drawn of each case in order that the surgeon may institute appropriate therapy and as a rule the surgical therapy must be accompanied by constant attention to the psychic aspects of the case. It is generally recognized that one who is afflicted with a physical ailment is apt to be below par mentally. The question of anesthesia presents itself as one of the factors with which the patient must cope and the foregoing remarks apply as well to one form of anesthesia as to another. General Intelligence of the Patient.- The educated, refined, sensitive patient, even of the neurotic type, is one of the most amenable to the method. On the other hand, the dull, poorly educated and otherwise stoical individual is apt to be more suspicious, less willing to obey instructions, much less amenable to reason and therefore more subject to "psychic incompatibility." It is significant that from the psychic standpoint the author's work has proven more successful in the care of private patients than in his service at a charity hospital. The Psychic Aspect of a Surgical Case.-The greatest factor in reducing the fear and worry incident to the use of local anesthesia is a knowledge on the part of the patient that the operation is to be a painless procedure. If, in addition, he can be made to understand the many other advantages of the method the result is often the antithesis of what one might anticipate; the patient enters into the spirit of the thing and actually tries to appear to the best possible advantage. At best the undergoing of a surgical operation is an exceedingly unpleasant experience, and in making comparisons between methods we can only argue that one method is more disagreeable or less disagreeable, as the case may be, than some other. For instance a person who has had an unfortunate experience with one method is ready on this account to accept any other method. Thus large numbers of patients who have had unsatis- factory experiences with general anesthesia are very easily brought into line for the administration of local anesthesia. This otherwise most desirable force is however, largely offset by the fact that local anesthesia as usually employed allows the patient no alterna- tive but to support general anesthesia in the future. Without doubt the spectacle so often seen of the struggling, squirming patient with all muscles contracted, "the veins standing like whipcords upon his brow," while he squeezes an attendant's hands with all his might and begs his surgeon to have mercy, while the latter, not knowing how to give local anesthesia successfully, is frantically substituting that worthless commodity "vocal" anesthesia-may be responsible 67 THE ATTITUDE OF THE PATIENT for the fact that the inroads of local into the field of general anes- thesia are not greater. As the greatest element in the reduction of psychic trauma is the education of the surgeon as well as the patient, improvement along this line is certain to take place and psychic trauma will largely disappear as the method is more universally adopted. This is sure to follow if it is made more worthy of adoption. Local anesthesia has been laboring under a handicap on account of its complete or partial failures and on account of the ignorance of the laity concerning its many advantages. As soon as the laity has an opportunity to unlearn the untruths taught by the medical profes- sion regarding it the use of the method will become more general. Already a sufficiently large variety of operations are being success- fully performed under its influence to make a profound impression. When the fact becomes established that complaints of pain by the patient are usually direct and positive evidence of inefficiency on the part of the administrator of the anesthetic, and not in any manner to be construed as a shortcoming of the anesthetic per se, we may expect to see the psychic element assume a much less important role. The time is fast approaching when men will be ashamed to admit that they cannot perform certain operations painlessly under local anesthesia, when other surgeons are doing them so regularly and consistently. The excuses now offered to inquiring patients when surgeons are requested to do operations under local anesthesia should not prevail. While the medical profession is slow to change from old and well established methods the laity is not slow in demanding changes provided they believe these changes represent an improvement. Assuming that the proper technic is to be used and that the surgeon is to perform a comparatively painless operation, much may be done and indeed everything possible should be done to aid the patient in meeting the ordeal. This psychic aid begins with the first visit of the patient and continues as long as he is under treatment. The attendants should have constantly in mind the welfare of all prospective surgical patients and begin the preparation at once. The deportment of the office force, the nurses, the interns, surgical assistants and the surgeons is of the utmost importance. The details of preparation will appear in another chapter but I would here emphasize the fact that no effort should be spared to remove every possible cause of irritation and to handle the patient in such a manner as to gain his confidence. The manner of giving a bath or an enema at the beginning of the sojourn in the hospital may largely influence a patient. Errors of the attendants in any part of their work may be the means of putting the patient in a mood which is incompatible with the calm, placid quiescence which 68 THE ANESTHESIA PROBLEM is sought. Bathing a patient with water of a temperature which is disagreeable to him, placing him upon a cold bed-pan, shaving the abdomen with a dull razor and a score of similar errors may serve to upset the hypersensitive individual who too often feels that he is already the victim of sufficient trouble. As a rule all preparations should be made as long as possible before the operation and everything should be done to bring the patient's mind into a tranquil state. This may best be accomplished by attention to such details as those mentioned above. The tactful answering of the patient's questions is also an important element. A good rest the night preceding the day of operation and the absence of company and "fussing" upon the morning of the operation are conducive to the patient's interests. A liberal amount of fluids and in some cases even a limited amount of solid food are desirable supportive measures. During the journey to the operating room, roughness while transferring the patient from the bed to the cart or from the cart to the operating table, which may cause needless suffering, should be avoided. The conversation, if any, carried on in the operating room should be such as is calculated to inspire confidence. The din of metal instruments and basins, exposure to too great cold or heat, the application of irritating lotions to sensitive skin areas, an uncomfortable position upon the table, constriction of any part by tight strapping, the sudden application of cold or hot solutions to the skin, especially if made without warning, strong light reflected into the eyes, careless draping-for instance, allowing a sheet to fall over the patient's face and perhaps to remain there until complaint is made-itching of the nose, thirst, fear of falling off the table, exposure of the genitalia, and a host of other annoying factors must be anticipated and met by appropriate measures. In short, the whole chain of attendants should be on the qui vive, but exert every effort to prevent the patient from being in the same condition. The machine should run so smoothly and the team- work should be so perfect that no feeling of the tenseness which naturally exists is transmitted to the patient. The Question of Discussing the Form of Anesthesia with the Patient.-For a number of years it was the author's practice to spend considerable time with each patient discussing among other matters the merits of local anesthesia, when going over the questions which have to be threshed out after deciding that an operation is to be performed. Whether or not it is advisable to discuss at length this phase of the subject with a prospective patient or his friends is an open question. Increasing experience has led to the belief that the better plan is to allow the patient to understand that this detail, like all others connected with the operative procedure, should be left to. the surgeon who is in charge of the case. Some patients, THE ATTITUDE OF THE PATIENT 69 of course, demand a discussion of the anesthesia. When asked con- cerning the method to be used, the author usually replies that he knows more about this particular subject than the patient can hope to know, as he has studied it and thought about it for many years, and that if the patient is willing to place himself in the hands of the surgeon for the performance of an operation he ought to be willing to allow him to use his own judgment regarding this point. The patient is then assured that every effort will be made to furnish him the greatest protection and comfort possible. This preliminary line of argument will usually bring out the patient's preconceived notions and one can then act accordingly. Should the patient be "prolocal," only a few words are necessary to clinch his confidence; if "antilocal," arguments may be used setting forth the well- known advantages of the method although these arguments do not as a rule increase the confidence of the patient. At least this has been the author's experience. Much more efficient is the state- ment that the patient may have general anesthesia if he so desires, but that he had better leave the matter to his surgeon. A much better plan and one which is calculated to develop the maximum of confidence and faith on the part of the patient is to introduce a former patient who has undergone an operation successfully by the local method. This procedure is the most satisfactory known and should the former patient voluntarily recommend the method -that is, without coaching on the part of the surgeon-the effect of this spontaneity and sincerity is quite sure to make a favorable impression. Should the operations happen to be of the same general nature the matter is usually settled beyond question. The success attending this method has been so universal that one may feel assured that the introduction of local anesthesia into all fields will not be greatly interfered with by the psychic incompatibility of patients. The length of time demanded for its more universal adoption will depend only upon the manner in which it is applied. The patient himself will be the medium through which propaganda favorable to the use of local anesthesia will be distributed. The Necessity of Attention to Psychic Aspects by Attendants.- The personnel of the staff whose duty it is to carry out the pro- cedures which are necessary in relation to the making of the diagnosis and the treatment of surgical patients should have these considera- tions constantly in mind. From the time the patient presents himself until he is discharged each person associated with his treatment should be well schooled not only in his duties in regard to the refinements of diagnosis and surgical treatment but in addi- tion should as nearly as possible approach automatism in the proper attention to the psychic aspect of the case. Even under conditions where the surgeon himself has not the time to give attention to 70 THE ANESTHESIA PROBLEM detail to each patient the morale of his corps of assistants should be such that the amount of mental as well as physical trauma and suffering may be reduced to the minimum. While there is no adequate method of estimating the amount of pain or anguish suffered by a patient while undergoing diagnosis and surgical treatment, the estimation of this factor being largely a matter of judgment on the part of the observer, there is no doubt that with proper effort much may be done to reduce the patient's suffering. The dread of what is to happen would seem to be almost as great a cause of anxiety as the actual suffering which is to be experienced. If this is true, is it not possible greatly to reduce this factor by the expenditure of properly directed effort? A failure to appreciate the necessity of making the ordeal as pleasant as possible has in the past caused patients a great deal of unnecessary suffering. Obviously surgical treatment must necessarily be accompanied by pain and discomfort and a knowledge of this fact contributes largely to the anguish of anticipation in each case. "PSYCHIC SHOCK." What effect the mental attitude of a patient has and what part it plays in the bringing about of that condition universally known as surgical shock is still a mooted question. The condition known as shock, though imperfectly understood from an etiological stand- point, is rather easily recognized, and the numerous factors which produce it are comparatively well known. Among these factors fear must undoubtedly be considered, the prominence it assumes depending largely upon the judgment of the individual observer. Crile and many others believe that the psychic element is extremely important among the factors that bring about this condition of depression of the vital forces. While it is undoubtedly true that the depressant effects of fear are obvious in a certain percentage of surgical cases and while their elimination is desirable, the writer is under the impression that this factor has been greatly exaggerated when offered as an argument against the use of local anesthesia. A consideration of this subject must take into account the various factors upon which fear in a patient is based. The three main causes of fear in the prospective patient are: 1. Fear of the outcome following operation. 2. Fear or dread of the disagreeableness connected with the ordeal. 3. An unreasoning fear or dread of an operation in an individual who may fear neither death nor the disagreeable effects of an operation. Now, should a patient be placed in either of the first two classes, [PSYCHIC SHOCK 71 or in both, as he usually is, why should there not be a lessening of the fear of a fatal outcome, provided the patient knows that local anesthesia is more safe than is general anesthesia? Again, if a patient be grouped in Class 2 and dreads the disagreeable effects connected with an operation, why should there not be a lessening of the psychic shock resulting from fear, provided the patient knows that the amount of suffering will probably be less than he would experience if a general anesthetic were used? A careful canvassing of the situation for many years has convinced the writer that the dread of the loss of consciousness is the most objec- tionable element connected with an operation. The possibility that he may not recover from the anesthetic is always before a patient's mind. Also the realization on the part of the patient that he is to be relieved to a large extent of the postoperative sequelae of general anesthesia, to-wit: thirst, nausea, vomiting, gas pains, wound-strain, kidney or lung irritation, and so forth, has a markedly reassuring effect and is largely responsible for the absence of psychic shock in these patients, although the opposite is supposed to be true. The fact is that a vast majority of patients do worry at the approach of an operation but experience with some thousands of cases under each form of anesthesia has convinced the author that the odds are in favor of local anesthesia by a wide margin. This margin will be greatly increased in the future, as the technic of local anesthesia improves and as patients realize more fully the greater comfort, ease and safety with which a large percentage of operations may be performed under local anesthesia. This realiza- tion will greatly reduce the number of patients in ('lasses 1 and 2, and even ('lass 3 will diminish as the horror of operations decreases in the minds of the laity. Indeed, the large inroad that local anesthesia is making into the field of general anesthesia is a potent cause in the reduction of the number which may be so classified. Notwithstanding all this, there will remain individuals who ask to be relieved temporarily of their mental processes and to have their operations done under general narcosis. The members of this class undoubtedly suffer from some degree of psychic shock and many of them might be operated upon under general anesthesia with less depression than would attend the use of a local anesthetic. The choice of anesthesia must rest with the judgment of the surgeon but in no case should the surgeon force local anesthesia upon a reluc- tant patient. In previously published articles the author has stated that our patients may to some extent be educated to any particular form of anesthesia. One has only to observe the different methods used in the various large clinics and to talk with patients who have been 72 THE ANESTHESIA PROBLEM there in order to realize that though the various methods are extremely diverse and some, at least, are somewhat antiquated the patients are fairly well satisfied and willing to defend the method that has been used upon them. Such is the plasticity of the human mind. The patient is easily taught that a certain kind of anesthesia is superior to all others and a satisfactory experience makes him a staunch propagandist. It is only a matter of proper dissemination of the facts. A proper use of local anesthesia will bring this about; while the abuse of the method, which is altogether too widespread, will delay it somewhat. PRELIMINARY NARCOTICS. Narco-local Anesthesia (See Chapter V, page 132).-Much has been written for and against the practice of giving some drug or combination of drugs to the prospective patient before the administration of anesthesia for the performance of an operation. Various objects have been the aim of those who have resorted to and have supported this practice. As a rule, preliminary doses of hypnotic drugs are used for the purpose of bringing the patient to the ordeal through which he must pass with the senses somewhat blunted in order that he may be more easily narcotized when general anesthesia is used. When local anesthesia is to be employed preliminary drugging is too often resorted to for the purpose of blunting the patient's senses so that he will not so acutely realize the torture to which he is apt to be subjected as the work proceeds. Undoubtedly the use of preliminary medication reduces the amount of general anesthesia necessary and its almost universal and increas- ing use would serve to attest its merit. When used as an adjunct to local anesthesia its merits are to some extent offset by certain abuses which have crept in. Liberal doses of such drugs as mor- phin, scopolamin and cactin, in combination, have been found to so dull the senses that almost any operation may be performed without the addition of other anesthesia. Some surgeons who have had difficulty in establishing good local anesthesia have found in this preliminary medication a panacea for all their "local" troubles, so to speak, and have with the aid of huge and possibly dangerous doses of these preliminary drugs, been able to perform painless operations. It is a mistake to class this work as "local anesthesia." As a matter of fact the use of the local anesthetic in these cases plays only a minor part, and without the aid of the preliminary medica- tion the operation could not be done under local anesthesia provided by the technic employed. Such a spectacle was presented at a recent large clinical meeting when in the presence of several hundred PRELIMINARY NARCOTICS 73 surgeons a patient was brought in so completely ''knocked out" that she could not respond to questions and was operated upon for a walnut-sized tumor of the thyroid under so-called local anesthesia. Even with the patient in this mental condition, the operation was accompanied with so much resistance on the part of the patient that the operator was greatly embarrassed. It was perfectly obvious even to a novice that this patient could not have been operated upon under the technic employed without the preliminary narcotic. The question as to whether or not it is desirable or safe to give a massive, or in fact any dose of these drugs, will be discussed elsewhere; but the point to be made here is that preliminary medica- tion, whether safe or harmful, if given for the purpose of obtunding pain which is to be experienced by the patient because the surgeon has failed properly to block with local anesthesia, is reprehensible in the extreme, and should be so considered by those who essay the use of the method at all. This point cannot be too clearly under- stood nor too strongly emphasized. He who cannot do an operation painlessly under local anesthesia alone should not hide behind the veil of the preliminary narcotic. As a preventive measure against psychic shock the preliminary hypodermic may be indicated, but for the prevention of pain it should have no place. The most logical reason for the use of preliminary medication is for the purpose of tiding the patient over the hours which precede the operation. Provided the surroundings are proper only small doses are required, and the solace obtained by their use is gratifying. In order to so narcotize a patient that a departure may be made from the correct local technic and the anesthesia reduced in amount, the dosage of the preliminary narcotic must be large and if the reports in the literature are correct, such dosage is not without danger. As the essential reason for advocating the use of local anesthesia is its safety, the addition of any factor which reduces this element is to be deprecated. Once the safety of preliminary medication has been established, the increased solace insured by its use will more than offset the somewhat disagreeable after-effects which may follow. Nausea and vomiting are the most important of these. Harris1 has reduced these complications greatly by the elimination of preliminary medication. Van Iloosen,2 on the other hand, who uses larger doses of scopolamin and morphin over longer periods than any one perhaps, reports almost an entire absence of disagreeable sequelae. 1 Discussion of A. E. Hertzler's Local Anesthesia in the Prevention of After Pain and Shock, Trans. Western Surg. Assn., 1914, p. 309. 2 Scopolamin and Morphin Anesthesia, Manz, Chicago, 1915. 74 THE ANESTHESIA PROBLEM THE HOSPITAL IN RELATION TO THE ANESTHESIA PROBLEM. For all institutions it would seem that the future must demand the presence of one or more skilled local anesthetists who are competent successfully to use this form of anesthesia. In large institutions there should be several of these. In the smaller institutions throughout the country, where the services of a skilled general anesthetist are obtained with difficulty, the necessity for skilled and more extensive use of local anesthesia is of relatively greater importance. While the necessity for local anesthesia is not so great in the large institutions where general anesthesia is successfully administered and the margin of safety of local over general anesthesia is narrower, it is significant that a skilful general anesthetist,1 in offering to the world the synergistic combination of morphin and magnesium sulphate, page 133, points out with evident satisfaction that by the use of this combination of drugs general anesthesia may be avoided and only local anesthesia used in the performance of major surgical operations. Why is it (if general anesthesia when skilfully administered is said to be entirely satis- factory by some of the most influential and experienced surgeons of our time) that such an authority in its administration as is Dr. Gwathmey exhibits such evident satisfaction in the development of a combination of drugs which may permit surgeons to dispense with its use? There must be a reason. To those who have used local anesthesia extensively this reason is only too apparent. MEDICAL TEACHING IN RELATION TO LOCAL ANESTHESIA. In this connection the author desires to call attention to the dearth of teaching in relation to local anesthesia in the medical schools of this country. The interns who come to Minneapolis have little or no training in the use of local anesthesia, the principles of which are not given them while they are attending the medical school. There is, perhaps, but one medical school in this country which has a department for the teaching of local anesthesia. It seems deplorable that such neglect prevails. If one were to take the sum total of the time spent in teaching students the technic of the performance of gastrectomy, removal of the hypophysis cerebri, aneurysmorrhaphy and other similar subjects, each of which is of intense interest although of little practical use to the recent graduate, it would be found that much time had been spent with but small tangible return-at least from a practical standpoint. 1 Gwathmey, James Taylor: New York City. 75 GENERAL PRACTITIONER AND LOCAL ANESTHESIA With a view to supplying their real needs, may it not be hoped that the medical graduates of the future will be equipped with more than a slight general knowledge of this subject and that the medical colleges will in the future graduate men who have at least a working knowledge of the general principles upon which local anesthesia is based. The future will undoubtedly evidence a great change in the atti- tude toward this subject notwithstanding a statement recently made at a meeting of the Minnesota State Medical Association by the head of the Department of Surgery, that the students at our medical school were not taught to use local anesthesia for the reason that the acquisition of the technical knowledge required might inter- fere with the ability of the student to acquire the necessary knowl- edge in relation to the diagnosis and treatment of disease. While the position taken by this professor of surgery is unquestionably extreme and would be concurred in by few, it may yet be said to throw some light upon the woful lack of preparation on the part of our recent graduates in relation to the use of local anesthesia. THE GENERAL PRACTITIONER IN RELATION TO LOCAL ANESTHESIA. The more extended use of local anesthesia should surely act as a boon to the isolated practitioner of medicine, who by its use might frequently be saved the necessity of calling to his aid some individual perhaps more or less incompetent to administer general anesthesia. For this reason, if for no other, it would seem that graduates in medicine should be instructed, not only in the fundamentals of local anesthesia, but should have a practical working knowledge of its use as well. To illustrate: Suppose a country practitioner is called to a farmhouse to treat a fracture of the leg in an aged person. Under conditions as they are at present he would probably be compelled to call upon a brother practitioner to administer anesthe- sia while the appropriate treatment was applied. Let us consider for a moment some of the possibilities which such a plan offers. To begin with, the loss of time on the part of the physician is no small item. Furthermore, as few physicians are well trained in the administration of general anesthesia, the protection offered the patient under the circumstances mentioned is not great. The immediate and remote possibilities of trouble as a direct result of the anesthetic are sufficiently great to compare fairly in seriousness with the pathological conditions for which the patient is being treated. Provided the accident has happened directly after the patient has partaken of a large meal, the giving of a general anes- thetic would necessarily be especially hazardous. After the applica- 76 THE ANESTHESIA PROBLEM tion of splints, a plaster cast or an extension apparatus and while the patient is recovering from the anesthetic one of the physicians must remain to supervise the post-anesthetic period. Contrast the above picture with the treatment of a similar condition by the use of local anesthesia. The calling of a second physician would be unnecessary. The presence of food in the patient's stomach would be of minor importance. The physician, if properly trained in the use of local anesthesia might in a few minutes anesthetize the patient's limb so that reduction of the fracture or application of the proper splints or dressings could be made without great inconvenience to the patient. The probability of the development of pneumonia, one great danger of general anesthesia especially when given under these conditions and many other disadvantages could in this manner be eliminated. The reduction of dislocations, the suturing of lacerated wounds, the drainage of abscesses, the performance of many minor opera- tions-almost all operations if they be performed outside of a well- equipped hospital-demand the use of local anesthesia much more frequently than it is employed at present. In short, the develop- ment and training of students should be such as to equip them with the obvious advantages of local anesthesia where its use is so clearly indicated. THE NURSE VERSUS THE PHYSICIAN ANESTHETIST. The present day shows such an improvement in the methods of administering general anesthesia that the aforementioned features do not appeal with the force with which they might a decade or two ago, and yet what percentage of surgeons has the good fortune to have associated with it an anesthetist upon whom they can depend absolutely? How many surgeons of today would prefer to depend upon someone else for this important detail provided they could without too much outlay take care of it themselves? This phase of the subject is worthy of more than passing notice. Although the methods of administering general anesthesia have shown a remarkable improvement, the matter of developing anes- thetists is not a simple one. The controversy as to whether nurses shall be trained for this important work, or whether it shall eventu- ally be left entirely in the hands of physicians is yet to be decided. No matter what the ultimate outcome may be it would seem that considerable time must elapse before physician anesthetists will be available for even a fair percentage of the cases demanding anesthesia. To completely supply the demand for anesthetists with physicians would seem to be entirely out of the question. It is obvious that the class of surgeons who are most poorly equipped THE SURGEON HIS OWN ANESTHETIST 77 for the administration of general anesthesia are the ones who would derive the greatest benefit from the use of local anesthesia; and it is apparent that its use is being developed with considerable rapidity in the smaller clinics and institutions, where many important advances in medicine and improvements upon existing methods have been made. Perhaps the restricting traditions which prevent large institutions from adopting newly developed methods (a condition which does not prevail to such an extent with the individual or in the smaller institutions) have brought about this result. THE SURGEON HIS OWN ANESTHETIST. Regarding the employment of skilled local anesthetists there is some difference of opinion. Perhaps the ideal method would be to train certain individuals in the administration of local anesthesia. These individuals could prepare the patient for the surgeon so that he might proceed with the operation without the necessity of encumbering himself with details connected with the administration of the anesthetic. This method has been attempted in a number of clinics and for certain operations in which regional anesthesia only is necessary, even nurses have been trained so that they could administer anesthesia and present the patient to the surgeon for operation while the anesthetist proceeded to prepare the next patient. For such operations as the repair of inguinal hernia, thoracotomy, or operations where brachial anesthesia is required this method may prove satisfactory, but while methods of inducing local anes- thesia remain as they are at present, the greatest satisfaction will not be derived from this method. The difficulty of establishing complete and certain anesthesia and turning the patient over to the surgeon ready for operation places upon the local anesthetist a handicap, which at the present stage of our knowledge is too great to be overcome except in instances like those cited above. Again, many operations demand the use of local anesthesia in regions which cannot well be reached before a certain portion of the operation is completed. Another point, local anesthesia though comparatively safe should be used in as small amounts as possible in each instance, and it is perhaps advisable to administer the solution as required, feeling one's way, as it were, and reinforcing the anesthesia wherever necessary as the operation proceeds. When depending upon an anesthetist this most desirable method is impracticable. As a matter of fact the possession of proper equip- ment eliminates the necessity for a separate anesthetist. With proper equipment the induction of anesthesia usually requires less than five minutes of the surgeon's time and the labor incident thereto is negligible. The patient's knowledge of the fact that the 78 THE ANESTHESIA PROBLEM surgeon is always in absolute control of the administration of the anesthetic makes the giving of the anesthetic by the surgeon himself especially desirable, as the surgeon, of all concerned, is usually the one in whose hands the patient would prefer to trust his destiny. Aside from the solace and assurance which the patient receives from the realization of the fact that this important detail is entirely under the control of his surgeon, the satisfaction accruing to the surgeon himself as a result of this realization cannot be over- estimated. Especially is this true with the class of surgeons who are unable to obtain the assistance of a skilled anesthetist. While the detail of administering the anesthetic is looked upon by many surgeons as an added burden, one must in taking stock, consider the counterbalancing effect offered by the opportunity he has to control his own anesthetic. THE PROGRESS OF LOCAL ANESTHESIA AND UPON WHAT IT DEPENDS. To those who are especially interested in local anesthesia and who believe in its efficiency, an obvious duty presents itself. They must, by example, as well as by precept, reduce as far as possible the actual discomfort which is inevitably associated with operations performed under local anesthesia. Furthermore, in the handling of patients they should make every effort to modify the present environment, and establish conditions which will reduce the psychic incompatibility which results from improper teaching, misunder- standing and carelessness. This improvement in the environment of patients before, during and after operation, will go far toward reducing the distinctly mental sufferings which they now undergo. By careful selection surgeons should eliminate those who for the present at least, are unfit for the application of local anesthesia. In order to popularize local anesthesia these essential details must be most assiduously worked out to as high a point of perfection as possible. The attention of surgeons must repeatedly be called to them and their necessity must be emphasized again and again. Objectionable features must be recognized and methods for over- coming them must be developed and presented to the profession. In deciding upon a change from local anesthesia to mixed anes- thesia at some stage of an operation the surgeon's judgment may be taxed to a considerable degree. He should keep in mind the best interests of the patient and as well the interests of future patients, which depend more or less indirectly upon the action taken in each MIXED ANESTHESIA. 79 PSYCHO-LOCAL ANESTHESIA operation. Again, when carrying out an operation under local anesthesia one should consider the effect upon visiting physicians, nurses and friends of the patient. A question frequently to be decided relates to whether it would be to the best interests of the patient to continue the operation under local anesthesia even though a certain amount of distress will ensue, rather than establish general anesthesia. Border-line cases place a rather severe tax upon the surgeon's judgment in this regard. It would seem that the safest rule to follow would be to allow the patient to be the judge and to have him understand that he may at any time request anesthesia by inhalation. However, there is a small percentage of individuals that may complain of pain or distress during some stage of an operation while the muscles lie flaccid and intraperitoneal pressure remains negative or neutral, and when the surgeon feels morally certain that the patient is not suffering physical pain. In these instances it is the surgeon's duty to decide whether or not he will ignore the patient's protest and continue the operation under local anesthesia, or superimpose general anesthesia. Many of these individuals when talking subsequently about their experience upon the operating table will state that everything went along fine and that their anesthesia was entirely satisfactory. Again, a certain number of individuals who have made no complaint upon the operating table will state after the operation that they suffered during its performance. Furthermore in arriving at his decision the surgeon should be influenced by the factor mentioned above- the effect the complaint will have upon prospective patients as reflected by his impressions and the impressions of those who are witnessing the operation. PSYCHO-LOCAL ANESTHESIA. This term has been applied to the method of superimposing general upon local anesthesia by what one might properly term camouflage. In other words the patient is "bluffed" into thinking he is taking general anesthesia. The type of individuals demanding this method-that is the type in which the complaint made is out of proportion to the possible distress produced-makes the use of this method quite efficient. As a rule these individuals, as a class are susceptible to camouflage anesthesia and, are more promptly susceptible to ether than nitrous oxide, because the odor of ether is much more easily appreciated. Ether, on account of its antidotal properties, may not be considered especially undesirable for this class as a strong competitor of nitrous oxide. In numerous instances the patient has been allowed to inhale ether while carrying out that portion of the operation in 80 THE ANESTHESIA PROBLEM which local anesthesia could not entirely prevent pain. Certain of these patients have used less than 20 cc during a period of ten minutes and yet have felt convinced that they were under general anesthesia. In such cases the toxicity of ether need not be con- sidered. Suggestion has played a part for, as stated above, these patients are so constituted mentally that they fall easy subjects to suggestion at the hands of the psycho-anesthetist. Only those who have had an opportunity to observe the ease with which one may camouflage general anesthesia by the method detailed above can realize its possibilities and advantages when used under the proper indications. The nitrous oxide analgesia of Crile is an excellent example of the application of this principle. Observation of the work of this master will convince one of its efficiency. However, the author feels that a reversal of the order which Crile uses and the thorough establishment of local anesthesia before administering any amount of general anesthesia will be found of the utmost advantage in assisting one to dispense with the last mentioned to a large extent. If on the other hand, the patient's mentality is so obtunded that he cannot cooperate with the surgeon the latter has no opportunity to check the effects of his work and to determine the actual thorough- ness of his anesthesia. Research in relation to local anesthesia will perhaps demand that the surgeon sacrifice his personal interests and that he occasion- ally violate in a slight degree the orthodox rule of allowing the patient the privilege of choosing general anesthesia. It is perfectly obvious that the technic for the performance of any operation cannot be perfected in any school except that of experience. However, after a surgeon has had considerable experience in the use of local anesthesia the best interests of all concerned will probably demand that general anesthesia be added without awaiting too definite indications. In this border-line class-a class that will vary some- what with the individual experience and mental attitude of the surgeon-perhaps the best procedure to follow is to substitute mixed anesthesia or psycho-local anesthesia (pages 78-79) without too great delay. OPERATING BY FRACTIONAL METHOD. One of the most important advances of modern surgery is perhaps a realization that surgical therapy should be applied with the least amount of injury to the human organism which is compatible with acceptable treatment. The "fractional" method of operating furnishes one of the means by which the patient's resources may be conserved, It is well known that the great depletion following OPERATING BY FRACTIONAL METHOD 81 extensive surgical operations which are accompanied by hemorrhage, trauma, exhaustion from pain, the absorption of anesthetics, dehydration, etc., result in delayed convalescence and in some instances leave an indelible impression upon the economy of the individual. In patients who require multiple operations, the plan of operating in successive stages, while prolonging the operative period some- what, at times, offers an excellent opportunity to circumvent the dire complications mentioned above. The treatment of exophthalmic goiter and malignant disease of the bowel are notable examples of conditions in which the fractional method of operating has met with signal success. Local anesthesia lends itself most ideally to the fractional regime. In conditions requiring an attack upon different regions of the body, operations may be performed under local anesthesia in successive stages with but a few days intervening between the different steps, without carrying the patient to the point of extreme exhaustion. The advantages of this method should be applied more frequently. (See Case Report No. 14,590, page 412.) CHAPTER IV. EQUIPMENT AND ARMAMENTARIUM. NECESSITY FOR SPECIAL EQUIPMENT. The satisfactory use of local anesthesia requires an armamenta- rium and operating room equipment which is more or less adapted to its demands and which differs in many details from those required when general anesthesia is used. Just as the training and com- portment of the operating squad and, in fact, of the whole hospital personnel, may largely influence success in carrying out a surgical procedure, so may the details connected with the operating room equipment have a great deal to do with the surgeon's ability to operate successfully under local anesthesia. The conscious patient will demand a measure of comfort and a degree of care which may be entirely unthought of for one under general anesthesia. The general equipment of the operating room should be such that the execution of the routine connected with the operation may be done deftly and with dispatch, and the arrangement of the room should be such as to make this possible (Fig. 9, page 94). From the technical standpoint the armamentarium used in operating when local anesthesia is used should include every appli- ance that will in any manner lessen the injury to the human organism and yet be compatible with a proper and efficient surgical procedure. While manual dexterity, training and a refined mechanical technic are of the utmost importance to a surgeon, the assistance which is to be derived from the instruments he uses is by no means negli- gible. Refined, careful, smooth and delicate technic cannot be expected with crude, cumbersome and ill-adapted instruments. A bloodvessel may be as easily clamped by a fine-pointed artery forceps as with a large angiotribe and with much less injury to the adjacent tissues. A medium-sized, properly shaped needle will carry a ligature through the tissues as well as will a much coarser one and without necessitating so much driving force. The use of sharp scalpels and scissors often means the difference between success and failure in carrying out the work. Again, the manner of using these instruments may greatly influence the result. Attention may be called to the difference in effect between making an incision with a scalpel by a series of gliding strokes, more or less parallel with the plane of the tissues and of making the same by forceful perpendicular pressure. THE OPERATING TABLE 83 Attention to details goes far toward lessening the handicap under which the surgeon who is accustomed to operating under the use of general anesthesia finds himself when he attempts the use of local anesthesia. In an effort to bring to the patient as great comfort as possible, the use of the following accessories has been adopted in the author's operating room. The principle of insuring the patient against discomfort has been kept constantly in mind and the complaints of patients have been the basis upon which technical improvement has depended. The application of local anesthesia has been looked upon as more or less of a system in itself, that its successful use demands not only a revised and improved surgical technic, but an improvement in the general technic of administering to the comfort of the patient as well. The following suggestions relate largely to the matter of com- fort. However, details of the system have been kept constantly in mind and many of the adjuncts described have been designed or supplied because we have found them indicated when operating upon a conscious patient. This equipment, some of which is of original design but much of which is but a modification of the handiwork of others, is pre- sented, as are the other suggestions contained in these pages as a reflection of long experience regarding the demands of local anes- thesia. The following descriptions are to be looked upon as leads only and the author well recognizes the shortcomings of many of the devices described. THE OPERATING TABLE. The operating table, Fig. 1, should be equipped with accessories which are calculated to give the patient the greatest degree of comfort possible. Supports for sustaining the patient in position when the table is tilted should be well padded so that he will not find it necessary to complain of pressure, Fig. 1-B. A simple device has been the utilization of a segment of the inner tube of an automobile tire as a padding for these supports, Fig. 1-D. They are equipped with valve stems and are inflated with air. Arm Rests.-The arms are placed in concave arm rests and may lie at the patient's sides or be extended at right angles. The wrists may be secured by leather straps which, while preventing the patient from inadvertently bringing the hands in contact with the aseptic field, allow some freedom of movement and at the same time, do not constrict the parts, Fig. 1-C, and Fig. 84, page 251. The legs likewise are secured by metal bands which retain but do not constrict the limbs. They also permit the patient to have a limited amount of freedom, Fig. 1-E. For the lithotomy 84 EQUIPMENT AND ARMAMENTARIUM position special knee holders are necessary adjuncts if the con- scious patient is to be expected to maintain this position for con- siderable periods without making complaint. It has been found that the leg holder illustrated in Fig. 1-1 meets the requirements almost ideally, provided the patient's limbs are first placed in the proper position and the leg holder then adjusted to fit this position. (Fig. 141, page 346.) Fig. 1.-The operating table and equipment; A, universally adjustable leg holder; B, pneumatic supports for lateral tilting; C, adjustable arm rests; D, pneumatic shoulder supports; E, thigh restraints. Tilting.-It is desirable to use an operating table upon which provision is made for lateral tilting (Fig. 202, page 473) so that in abdominal cases the force of gravity may be utilized in bringing the various viscera into view. All tilting of the table should be accomplished by means of the worm drive so that the tilts may be made gradually without any jerky motion. This applies also to obtaining the Trendelenburg position. Provision should like- wise be made for the assumption of the reversed Trendelenburg position. 85 SYRINGES The operating room utensils should, as far as possible, be con- structed with the idea of eliminating unnecessary noise. Noise- less casters, fiber basins, etc., are desirable. SYRINGES. The great variety of syringes on the market attests the dis- satisfaction generally encountered with their use. If large enough to obviate the necessity of frequent filling, a syringe is apt to be more or less cumbersome. Also syringes of great capacity inter- fere more or less with the ability of the operator to gauge accurately the location of his needle point when injecting at some distance from the surface. Likewise the increased distance between the hand and the needle point makes it difficult to control the latter when introducing it. Another objection to large syringes is the fact that the increased friction between the plunger and the barrel necessitates an especial outlay of force in making the injection. In fact this defect is present more or less in all syringes. Not infrequently a slight amount of rotation of the piston is necessary in order to make it advance and this maneuver necessitates the grasping of the barrel of the syringe with one hand, a procedure which will almost surely interfere with the accurate control of the needle point. Smaller syringes or those of a size compatible with the proper finesse for the making of a smooth, equable infil- tration must be filled repeatedly unless one of the self-filling types of syringe, which will be described later, be used. Even the most satisfactory of these, unless perfectly made, will at times "stick," necessitating the rotation of the piston before it can be advanced. Ordinarily the small syringe of perhaps 5 cc capacity, with rings for the thumb and fingers may be the most deftly manipulated. With a larger syringe one cannot readily appreciate or "visualize" what is taking place at the distal end of a long needle. Syringes above 10 cc capacity will be found unsatisfactory. In Rovsing's Surgery of 1914 a self-filling syringe devised by Dr. A. Madsen of Denmark is described. Since this time several varieties of self-filling syringes have been devised. The most satisfactory of these are of glass or combined glass and metal con- struction, having a one-way valve connected with a piece of tubing which runs to a receptacle containing the anesthetic solution. This arrangement obviates the necessity for detaching the needle and refilling the syringe when it is empty and eliminates one of the disadvantages of the syringe. The use of the glass syringe allows one to aspirate whenever this is deemed advisable so as to eliminate the possibility of injecting the anesthetic solution into the bloodvessels. As this possibility may be practically eliminated 86 EQUIPMENT AND ARMAMENTARIUM by constantly moving the needle point while the injection is being made, the importance of this feature is not great. However, experience has shown that when using a self-filling syringe more or less air is apt to collect in the syringe as the plunger is with- drawn in refilling. It is a great source of satisfaction, therefore, to be able to note the contents of the syringe at all times, and it is for this reason that the glass is superior to the metal syringe. The Dunn Syringe, manufactured by the MacGregor Instru- ment Company, is one of the most satisfactory instruments of this kind to be found on the market. It has the objection common to all syringes that muscle tire is not eliminated, that one must delay while the plunger is drawn back for the refilling and that the injection of deep cavities is difficult or impossible because the hand and syringe stand between the eye of the surgeon and the needle point. It also shows to disadvantage when the necessity arises for making the injection "around the corners" in inacces- sible locations, the hand frequently being placed in an awkward position so that it is impossible to know the location of the needle point and to direct the needle as desired, while making the injection. The same disadvantage presents when one attempts to inject in deep cavities, as in the vagina, pelvis, region of the cystic duct, etc. For buccal injections the instrument devised by Fischer is per- haps the most satisfactory. Another excellent syringe for this work is the Vim, Kalo-Kain, manufactured by DeSanno and Hoskins, Inc. NEEDLES FOR INFILTRATION Needles should be long, fine and slightly flexible. The most satisfactory needles have been made of steel or duro gold, ranging in size from 20 to 23 gauge and from 5 to 10 cm. in length. Gold- plated needles possess the great advantage of flexibility, dura- bility and cleanliness, but lack the strength of the steel needle. If needles of finer gauge are used it is difficult to prevent bending. The needles illustrated in Fig. 2 represent a satisfactory type. The author has designed special adapters and bayonet-lock needles, an arrangement which has proven quite satisfactory. The steel and gold-plated needles equipped with bayonet-lock and adapters to correspond, are shown in Fig. 3. The adapter, Fig. 3A, effectually prevents the needle from slipping off or becom- ing loose. One of the overt acts which not infrequently causes trouble, especially when doing intraperitoneal work, is the jump- ing off of the needle when the solution is allowed to flow through it. Many times during laparotomies an expulsive effort has been thus excited which resulted in the extrusion of the intestines, and NEEDLES FOR INFILTRATION 87 upon one occasion the needle was lost for a considerable length of time. The gold-plated needles are extremely flexible, and in a large percentage of work this attribute is desirable (see Fig. 4). Both the steel and gold-plated needles are equipped with bayonet- Fig. 2.-Local anesthesia needles (actual size) Fig. 3.-Author's special bayonet-lock needle (flexible and constructed of steel or duro gold): A, adapter for same; B, stone for sharpening needles. 88 EQUIPMENT AND ARMAMENTARIUM locks with adapters to correspond (Fig. 3). The adapter, Fig. 3-1, effectually prevents the needle from slipping off or becoming loose. The removal and replacement of a needle of this type requires but a moment of time. Fig. 4.-Showing flexibility of needle THE PNEUMATIC INJECTOR. Assuming that an anesthesia by infiltration will be the method of choice in a fair percentage of cases and assuming further that rather liberal amounts of the local anesthetic solution may and should be introduced in order to assure satisfactory results, the actual means by which this infiltration is to be made assumes a relatively important role. A realization of this led the author to the development of the pneumatic injector (Fig. 5). This apparatus, more than any other element-and as a matter of fact more per- haps than all other items of equipment-has, by reducing to a minimum the labor, inconvenience, time and margin of error made the use of local anesthesia a delight in his clinic. Where direct infiltration or infiltration block is to be used this instrument has its ideal application; even in doing nerve blocking, especially in infiltration block, its use has been found to be highly satisfactory. The field to be covered may be traversed system- atically without the necessity of delay, without the expenditure of 89 THE PNEUMATIC INJECTOR energy, without the muscle tire which accompanies the use of the syringe and without the liability of "losing one's place," which is so apt to happen while syringes are being refilled. But, above all, the Fig. 5.-The pneumatic injector for introducing local anesthetic solutions: A, cylinder for anesthetic solution; B, graduated glass gauge; C, detachable posts; D, heavy metal base; E, pressure tank (oxygen or carbon dioxide); F, tubing; G, towel rack; H, flexible metal tubing; I, cut-off (see Fig. 6). 90 EQUIPMENT AND ARMAMENTARIUM most important advantage of the pneumatic injector is the elimi- nation of inadvertent motion at the point of the needle caused by the muscular effort required for forcing the syringe piston, often with the hand in an awkward position. The pneumatic injector cut-off may be grasped with about the same force as one would use in writing with a fountain pen. The "pistol grip" effect (Fig. 6) allows one to control absolutely and to "feel" almost perfectly the position of the point of the needle. The position of the hands Fig. 6.-Valve or cut-off of pneumatic injector: A, hand piece of valve; B, ball and socket joint; C, needle holder; D, adapter. Note pistol-grip effect of cut-off; E, special bayonet-lock needle; F, record needle. does not change and the fluid is injected into the tissues with the lightest kind of pressure upon the valve. The simplicity of this maneuver and the possibility which it allows of "putting over" the early portion of the infiltration upon the apprehensive patient is of the greatest advantage. The apparatus is now practically "fool-proof," and while at first appearance it might seem com- plicated, the only portion of it with which the surgeon comes in contact is the acme of simplicity. With the details of filling, THE PNEUMATIC INJECTOR 91 supplying pressure and the like the surgeon need not concern him- self. (See Figs. 5, 6, 7 and 8 for detailed description of the pneumatic injector.) Fig. 7.-"Sterile" nurse "setting up" pneumatic injector: A, unfolding tubing; B, introducing tubing into socket; C, dropping yoke over lug on base of pneumatic injector; D, tightening set screw. Note: Tubing automatically remains in place. 92 EQUIPMENT AND ARMAMENTARIUM Detailed Description of the Pneumatic Injector.- Fig. 5, page 89, shows the pneumatic injector assembled and ready for use. Before "setting up,'' the anesthetic solution is introduced into cylinder Aby means of a sterile funnel, after unscrewing the cylinder cap. Note: The adrenalin should be added to the solution before introducing the latter into the cylinder. The graduated gauge B is of glass and allows one to note at a glance the amount of solution present Fig. 8.-Operative mechanism of pneumatic injector: A, pressure tank; B, gas intake valve, by which gas is allowed to enter cylinder A, Fig. 5; C, outlet valve by which fluid is allowed exit through tubing F, Fig. 5; D, pressure gauge; E, safety valve. or being used. The cylinder A requires sterilization only once or twice a month and this may be best done in an autoclave. The tubing F, G, II, I, is sterilized for each operation. It may be coiled and placed in the tray with the instruments. The posts C, upon which the cylinder is mounted on the base 1), may be detached from the base of the cylinder A as may the pressure tank E after which cylinder A may be wrapped and autoclaved. The cut-off, Eig. 6, which is the only portion of the apparatus THE PNEUMATIC INJECTOR 93 with which the surgeon conies in contact, is designed to fit the hand of the operator with a "pistol-grip" effect. The tubing A is a filter, B is a ball-and-socket joint, C is a needle holder which retains the record needle F in place, I) an adapter (see Fig. 3-A, page 87) for the bayonet-lock needle, E. "Setting up" Pneumatic Injector, Fig. 7. After the introduction of the solution into cylinder A, Fig. 5, the tubing, which may be sterilized with the instruments, is attached to the cylinder base by the sterile nurse. A shows the tubing folded, B shows the tubing being introduced into its socket, C shows the nurse adjusting the yoke of the tubing over the lug of the cylinder base. The tubing will now remain automatically in place while the nurse forces home the setscrew, as shown in I). The needle may now be attached (see Fig. 6) to the cut-off and after evacuating the air from the tubing by turning on the pressure and opening the cut-off, the apparatus is ready for use. Operative Mechanism of the Pneumatic Injector, Fig. 8. Fig. 8 shows the operative mechanism of the pneumatic injector. After the "setting up" process is completed, the pressure is turned on by opening valve on tank A. The intake valve B is then opened, allowing gas pressure to enter cylinder A (Fig. 5, page 89); outlet valve C is then opened, allowing the fluid to enter the tubing and cut-off. D registers the amount of pressure; from 25 to 75 pounds is required, depending upon a number of factors, to wit: the speed with which one wishes to inject the solution, the character of the tissues to be injected and the size of the needle, as well as the rapidity with which it is moved. E is the safety valve which "blows off" at 100 pounds. As soon as the patient is draped, the pneumatic injector may be moved to an appropriate position (see Fig. 9, page 94) and a towel adjusted, isolating the sterile field from the apparatus (see Fig. 161, page 384). Equipment becomes an important factor during certain stages of difficult operations and it is at these trying times that one needs every artifice in order to overcome the handicap under which he is placed. Most operations can be carried through with little difficulty except for the fact that at two or three points some more or less insurmountable obstacle presents itself. It is here that the cut-off, with the long, fine needle firmly attached, with automatic pressure on tap, and a perfect light, and therefore a perfect view of the field, enables the surgeon to place the anes- thetic at exactly the right point and with the least disturbance to the patient, thus effectually surmounting one of the greatest obstacles. The operating room floor plan as illustrated in Fig. 9 shows the 94 EQUIPMENT AND ARMAMENTARIUM position of the pneumatic injector before and during operation. The instrument after being "set up" may be moved to the desired position near the operating table either by the sterile nurse or by SUPPLY TABLE STERILE SUPPLY TABLE UNSTERILE SUPPLY TABLE „ SVROEON z o F er 55 O 2o in 52 CO _ Ct U. in o in I Fig. 9.-Operating-room, floor plan. SPECTATORS BENCH REVERSED POSITION/ OF ANESTHETIST 1ST ASSISTANT^ 2ND ASSISTANT^ ANESTHETIC SUPPLY TABLE the anesthetist. The sterile nurse may grasp the instrument by the sterile tubing in order to move the injector about. If after "setting up" a sterile towel be placed over the tubing, the cut- OPERATING ROOM LIGHTING 95 off and towel-rack, and the apparatus placed at the edge of the isolated field it is entirely out of the way. Fig. 9 shows the arrangement of the author's own operating room. Other Uses for the Pneumatic Injector Pneumoperitoneum.-This apparatus lends itself to a variety of other uses, such as the making of irrigations and injecting formalin-glycerin solutions into joints, but the most important use to which it has been put, aside from the one for which it was originally designed, is in producing pneumo- peritoneum. Using an oxygen or carbon-dioxide tank for pressure, the cylinder which has been previously filled with sterile water is evacuated by pressure from the tank. We now have the water in the cylinder replaced by filtered gas. All that remains is to introduce the needle into the peritoneal cavity and to grad- ually inflate it at leisure. About 5 pounds' pressure is used and the injection is made at any rate desired, depending largely upon the effect produced upon the patient. OPERATING ROOM LIGHTING. A good light is one of the indispensables in an operating room. The visualization of the tissues, especially in deep cavities, is one of the prime essentials for efficient and satisfactory work under local anesthesia. It is practically impossible to operate in deep cavities under natural light without being compelled to depend in a considerable measure upon the sense of touch, rather than that of sight. Most surgeons, because of a realization of this fact, have equipped their operating rooms with some sort of spot-light and one almost always sees a lamp of this kind standing in every operating room. However, most of these lights are poorly con- structed and are not adaptable to the service for which they are intended. They usually lack adjustability, are unstable and throw before the operator's eyes a glare which in many instances makes them a menace rather than an aid. In the carrying out of important work below the surface of the body we have come to depend almost entirely upon artificial light. A good operating light should give ample illumination where it is wanted without the production of heat so intense that the surgeon and his assistants are uncomfortable when working under it even for any length of time. In order to obtain sufficient illumination when working in deep cavities, so that one may depend upon the sense of sight rather than the sense of touch, it is necessary to eliminate the shadows produced by the heads of the operator and his assistants. Furthermore, on account of the fact that the plane of operation is changed so frequently, the direction of the light should be under 96 EQUIPMENT AND ARMAMENTARIUM control. For instance, it may be necessary to direct the light into the pelvis, beneath the lower surface of the liver to the region of the common duct, beneath the abdominal wall to the region of the spleen or ureter, into the oral cavity, into the vagina or rectum, into the thorax, etc. In order that these various cavities may be illuminated, no matter in what plane the wall surrounding the opening leading to them lies, it is essential that the light comes from a variety of sources and that the plane in which the lights Fig. 10.-Author's "elephant-trunk" operating room lamp. (Portable, universally adjustable and self-cooling.) are clustered be adjustable. We have found that the light of the Bartlett type gives more satisfaction than does a lamp in which all the light comes from one source. In order, however, to obtain the maximum benefit from such a light, its plane must maintain a constant relation to the plane of the operative field and further- more the distance between the light and the operative field must not vary to any great extent, and should be under control. Lights, therefore, of the Bartlett type which are permanently fixed to the THE AUTOMATIC WIRE-SPRING RETRACTOR 97 operating room ceiling, even though their planes are adjustable, have proven disappointing on this account. They necessitate frequent excursions of the operating table in order to bring the field of operation into line with the area of the most intense illumi- nation and this distance from the operating field cannot be regulated. As it is necessary when working under the local method to dissect carefully with sharp instruments and with but slight traction and as deep structures cannot be readily dislocated and brought to the surface while working under this form of anesthesia, an adjustable light which eliminates shadows and illuminates all deep cavities is desirable. Fig. 10 illustrates a lamp which effectually fulfils these requirements. The Elephant Trunk Lamp.-For the reasons above cited the elephant trunk lamp, Fig. 10, was designed and it proved to be satisfactory in every detail except one; that is, that in order to obtain the maximum intensity of light, a rather uncomfortable amount of heat was produced by the radiation from the bulbs. Therefore, a ventilation fan was established at the proximal end of the horizontal tube which carries the cluster of lights. This fan, which is operated by a noiseless motor, carries the heated air away. The horizontal tubing, as well as the lamp shades, are constructed with air-tight joints and the accumulated heat from the lamp is thus effectually removed. This lamp possesses the attributes required at some stage of almost every operation. The lamp is equipped with a heavy base, which gives stability, mounted upon noiseless casters and stands sufficiently far from the operat- ing table so that the surgeon and his assistants may walk between it and the operating table without danger of a break in asepsis. The plane of the cluster of lights may be changed at will by means of a tiller wheel, and the distance of the cluster from the operative field may be adjusted by means of a crank and worm drive. For ligations or emergency operations in the patient's room this light is most satisfactory, as a nurse may transport it from one room to another, at will. The utilization of the time and energy of an assistant and the inability of an individual to constantly retain a retractor in position without change for any considerable period of time has led to the development of various types of self-retaining instruments. Most of these are of the rigid type, possessing great strength and are potentially destructive in character. When introduced into a wound they are usually forcibly expanded and as their construction offers the surgeon considerable leverage, the result is that the THE AUTOMATIC WIRE-SPRING RETRACTOR. 98 EQUIPMENT AND ARMAMENTARIUM desired exposure is obtained and continued too frequently with damage to the retracted tissues. An appreciation of the fact that perfect exposure and instrument contact are desirable makes good retraction practically a necessity. The use of local anesthesia makes special demands in this regard. Fig. 11.-Author's automatic wire-spring retractors. Nos. 1, 2, and 3, for skin and muscle retraction, and 4, for abdominal, bladder and vaginal surgery. It was in an effort to obtain the advantages of the self-retaining retractor and at the same time to avoid some of the shortcomings mentioned, that led to the development of the Automatic Wire- spring Retractor which practically fulfils the demand for retraction in most of the surgical fields. (Figs. 11, 12.) THE AUTOMATIC WIRE-SPRING RETRACTOR 99 The Automatic Wire-spring Retractor presents many desirable attributes. Rigidity is eliminated. The application of this instrument results in a gradual, symmetrical, constant, automatic spreading of the wound, which is exceedingly desirable when using any form of anesthesia, but especially so under the use of local Fig. 12.-Various types of abdominal retractors. (Nos. 5, 6 and 7.) anesthesia. It produces a gradual, elastic stretching of the muscles without traumatization of the tissues and without the excitation of reflex action. The use of this form of retraction has demonstrated the fact that incisions are found to increase gradually in size for several minutes following the introduction of the retractor and 100 EQUIPMENT AND ARMAMENTARIUM this without producing reflex contraction, or what might be called a combative action on the part of the muscles. The avoidance of this combative action is especially desirable in all work under local anesthesia since the occurrence of muscle spasm is usually accompanied by discomfort on the part of the patient. The Automatic Wire-spring Retractor has its most important application in surgery of the abdomen, where a combative action on the part of the muscles is not only discomforting to the patient, but is likely to result in an expulsive effort, with the extrusion of more or less of the contents of the abdominal cavity. COIL SPRING Fig. 13.-Retractor with coil spring for grasping ligatures. The substitution for retraction by an assistant, which is always more or less "jerky," by the constant steady pull of the auto- matic retractor and the avoidance of trauma, are the special points of excellence of this instrument. In case the enlargement of a wound becomes necessary the automatic spring retractor will immediately take up the slack, thus requiring no further readjustment. This instrument is available in various sizes and strengths. Thus it is applicable to almost every incision in which retraction is required. Furthermore, the small amount of space which it requires makes it possible to superimpose one upon another with- out in any manner interfering with or encroaching upon the opera- tive field. Thus in the hernia operation one pair of retractors THE AUTOMATIC LIFTER 101 may be used to separate the skin and fat layers, a second the layers of the external oblique and if necessary another set may be intro- duced more deeply. When closing the incision the retractors may be removed in an order inverse to that in which they were introduced and thus at all times present to the surgeon a perfect view of the various tissues. Fig. 13 shows a retractor with a coil spring attachment which may be utilized for retaining the loose ends of ligatures when occasion requires. This obviates the necessity of picking these ends up with forceps. In elevating the abdominal wall (vertical retraction) the strong, smooth retractor Fig. 14 is used. (Fig. 170, page 396.) Fig. 14.-Retractor used for elevating abdominal wall. THE AUTOMATIC LIFTER (Fig. 15). A constant source of discomfort and in many instances the cause of a great deal of pain is the transportation of the injured or very ill patient to the operating room and back to bed. Crile overcomes the pain in desperate cases by the administration of a light gas analgesia in bed and this analgesia is continued until the patient is once more returned to bed after the operation is com- pleted. The indications may be met to some degree by the use of the utmost care in handling patients but even where every pre- caution is used the making of the four shifts which are usually necessary is always a source of discomfort to the patient. True, the return trip from the operating room may be made with the patient unconscious, provided general anesthesia is used, and yet how frequently a patient is seen who has just undergone a severe operation and who is in fair condition, go into collapse during the trip back to his room. It is at this critical stage that rough handling is most apt to be disastrous, even though the patient is unconscious. It only serves to emphasize the fact that trauma, so inimical to the best interests of our patients, whether they are awake or asleep, should be reduced to the minimum in every case. In relation to the use of local anesthesia, the avoidance of dis- comfort during the voyage to and from the operating room assumes an especially important role. It is essential that pain and dis- comfort be avoided, provided this can be done, and by the use of 102 EQUIPMENT AND ARMAMENTARIUM the Automatic Lifter, Fig. 15, this has been shown to be entirely possible. It makes no difference what the nature of the illness may be, by means of this apparatus any patient may be trans- ported from the bed to the operating table, or vice versa, with almost no discomfort whatever. The elimination of the orthodox method of lifting patients has been a source of the greatest satis- faction. In the use of the narco-local method the apparatus is invaluable, as the patient can be transferred without realizing that he is being moved, even under the influence of very light doses. Fig. 15.-Author's automatic lifter. A, B and C, leather stretcher pads; D and E, supplementary straps; F, lifting mechanism; G, vertical post; H, crank. Insert- Patient elevated and wrapped in blanket. Fracture cases, those with septic joints, or those with acute abdominal conditions should be transported with the minimum amount of trauma not only because such treatment insures increased comfort, but in order that actual local injury may be avoided. In localized abdominal abscesses the possibility of intraperitoneal rupture is always present and the author has seen a number of patients in which this accident has happened. The adjustment THE AUTOMATIC LIFTER 103 of a patient to the desired position upon the operating table is also often fraught with difficulty, especially when dealing with the desperately sick. With this apparatus a nurse, unaided, may transport a patient of any weight without disturbing him in the least. The apparatus is especially useful in transporting the unconscious or helpless patient. The illustrations demonstrate more clearly than the text could possibly do some of the various uses to which this apparatus is adapted. Fracture cases, and in fact, all cases may be transferred without change of the relative positions of the limbs or trunk. Description of the Automatic Lifter.-The Automatic Lifter, Fig. 15, consists of a frame constructed of angle iron and mounted upon ordinary hospital stretcher wheels. A, B, and C represent the leather supports, and combined they form the hammock in which the patient lies while being transported. The hammock being divided into three parts, A, B and C, may be easily placed beneath the patient. The extremely ill, as those with bad fractures, may be lifted upon the leather straps, I) and E. The lifting mechanism, F, consists of a parallelogram, which is elevated and lowered by the means of a worm drive. In changing its position this parallelogram follows the geometric law that the opposite sides of a parallelogram always remain parallel to each other. This makes it possible to maintain the post G, in a vertical position parallel with the frame of the elevator when the patient is raised and lowered by the means of the worm drive and crank, H. As soon as the patient is elevated from the bed a blanket may be wrapped about him as shown in the insert. In case a patient is extremely ill one may use stiff leather straps with which to raise him, until the soft leather pads are placed. One can always find space through which to push the leather straps. In case a plaster cast is to be applied one may use straps exclusively beneath the affected area and withdraw them after the application of the cast. Obviously if all straps are brought into contact with the patient's body and the tension upon all of them is made equal the patient must leave the bed with no change in the relative position of the parts. Ever present danger of disseminating septic material about the abdominal cavity, before, during, and after operation has been referred to. The automatic lifter becomes at pnce the surgeon's ally in the effort to prevent this spread of infectious material. It makes it possible for the surgeon to receive the patient upon the operating table in the condition in which he was seen before he left the bed; and after an operation, which should be accomplished with the least possible trauma and soiling, it insures the patient's 104 EQUIPMENT AND ARMAMENTARIUM return to bed in the same condition in which he was when he left the operating table. Practically all of the author's patients are transferred to bed following an operation by the means of this device and all who might be caused pain during the transfer to the operating room are likewise conveyed upon this apparatus. As an adjunct to local anesthesia and the general method of hand- ling the sick, it is most valuable. THE GOITER CLAMP (Fig. 16). In thyroid surgery, even in the absence of pain, the frequent grasping and dropping of a mobilized gland is a constant source Fig. 16.-Author's goiter clamp of embarrassment to the surgeon and patient alike and while the surgeon may become accustomed to grasping and regrasping a slippery gland when working under general anesthesia, this dis- turbing element will frequently cause complaint on the part of the patient and may often result in embarrassment of respiration. Small tumors may perhaps be most easily grasped by towel pins. However, large tumors or those that are difficult to handle may be easily controlled by the use of the goiter-holding forceps. Fig. 16. THE PROSTATIC RETRACTOR 105 As soon as the gland is mobilized it is grasped by the parallel rings of this forceps, the handle of which is turned over to an assistant. It then becomes the assistant's duty to prevent the patient from complaining, by holding the gland at all times in proper relation to the trachea to which it is attached. Incidentally, the clamp prevents bleeding from the gland itself and reduces to a large degree the number of artery forceps necessary, as it is found they need only be applied to the proximal limb of each vessel before it is divided. Its use may also prevent the squeezing "goiter juice" from the gland in toxic cases, a factor which is thought by Fig. 17.-Bainbridge forceps. some authorities to be responsible for some of the sequelae of opera- tions of this type. Fig. 78, page 241, shows the goiter clamp in use. In goiter and abdominal work, the delicate forceps devised by Bainbridge (Fig. 17), are also found to be of assistance when dividing the muscles. While effectually preventing hemorrhage they cause a minimum amount of trauma. In our stomach and intestinal work these instruments have been found very satisfactory, and have been used largely to replace the heavier clamps, except where crushing is desirable. 106 EQUIPMENT AND ARMAMENTARIUM THE PROSTATIC RETRACTOR. The prostatic retractor was devised for transfixing and elevating the prostate during the operation of suprapubic prostatectomy. Fig. 18, also Figs. 132 and 133, pages 333 and 334. Fig. 18.-Author's prostatic retractor. Closed and open. THE VISCERA RETAINER. One of the most distressing conditions with which one meets is the extrusion of the abdominal viscera while closure of the abdo- men is being made. While operations may, as a rule, be com- pleted with a perfect negative pressure one may find, especially in acute inflammatory conditions or in the case of umbilical hernia, Fig. 19.-Author's viscera retainer: B, reversed rubber glove applied. THE VISCERA RETAINER 107 that the peritoneal cavity does not present sufficient space, so to speak, to accommodate all of the abdominal viscera. For the pur- pose of meeting this contingency the viscera retainer (Figs. 19 and 20) was devised. Its use effectually eliminates the trauma to which the viscera are subjected when gauze is used and its easy Fig. 20.-Author's viscera retainer in use. removal substitutes another of the shortcomings of the gauze pad, which is always difficult to remove and is apt to bring intestine and omentum away with it. The viscera retainer is placed with the blades closed within a reversed rubber glove, the fingers of which are allowed to remain unturned. A dry glove may be used or the glove may be moistened before introducing the instrument. 108 EQUIPMENT AND ARMAMENTARIUM The author prefers to use the dry glove for the reason that the intestines and omentum adhere to the dry rubber for a short period Fig. 21.-Prostatic "hook." (Curved elevator.) of time and, therefore, do not creep around and into the field. The deeper layers of the wound may be brought into apposition until the wound is reduced to about 5 to 7 cm. in length, Figs. Fig. 22.-Heavy bone shears. 19 and 20. The blades of the retainer may then be closed and the instrument withdrawn. The glove may be left in situ, to be with- drawn later, or may be removed with the retainer if desired. Fig. 23.-Moynihan cystic duct clamp. Fig. 21 represents a curved elevator, designed for bone work but which has been utilized by the author in the enucleation of the prostate. THE VISCERA RETAINER 109 Fig. 24.-Pratt's rectal dilators. Fig. 25.-Fenestrated rectal dilator. 110 EQUIPMENT AND ARM AM ENT Alii U M Fig. 22 represents bone shears of the heavier type, employed in the division of ribs, the bunion operation,laminectomy, and such opera- tions. Its great strength allows one to divide bones with a minimum of traction and manipulation. Fig. 26.-Author's rubber-tipped intestinal forceps. Fig. 23. This instrument, called the Moynihan clamp, is designed for the clamping of the cystic duct and on account of its length is especially desirable when using local anesthesia. Fig. 24.-Varieties of the Pratt rectal dilator (see page 109). Fig. 25. Fenestrated rectal dilator (see page 109). Fig. 26. Rubber tipped intestinal forceps. CHAPTER V. GENERAL TECHNIC. THE PRINCIPLES OF THE APPLICATION OF LOCAL ANESTHESIA TO SURGERY. The technology of the establishment of anesthesia by the local method is graphically depicted in the literature upon this subject. Concretely, it comprehends the injection of an anesthetic solution into or in the immediate vicinity of the sensory nerve supply of the part which is to be attacked surgically. The principles of the method of producing anesthesia or analgesia by bringing solutions of certain drugs into contact with the sensory nerves are fairly well understood. They are the same regardless of the extent of the surgical procedure. The removal of a small sebaceous cyst under local anesthesia differs only in degree and not in principle from the removal of a lipoma weighing many pounds. A Definition of the Terms Employed. - Various descriptive terms have been developed in order to designate the different methods which are used in inducing local anesthesia. Infiltration Anesthesia. -Infiltration anesthesia, which was first introduced by Schleich, who, with Reclus, developed this method extensively, comprehends bringing the anesthetic solution into contact with the ultimate arborizations of the sensory nerves (see pages 137 to 149). Regional or Conduction Anesthesia. -Interrupting the nerves at any point along their course proximal to their peripheral endings has been termed "regional" or "conduction" anesthesia (see page 137). Regional or conduction anesthesia may be brought about by bringing the solution into contact with a nerve, a method which has been termed perineural anesthesia, or by injecting the solution directly into a nerve, intraneural anesthesia, or by injecting the solution into a vein, venous anesthesia (see page 112), an artery, arterial anesthesia (see page 114), or by injecting into the spinal canal, intraspinal anesthesia. Various other terms have been suggested to describe amplifica- tions or modifications of the regional methods; for instance, the 112 GENERAL TECHNIC circumferential infiltration of Hackenbruch, which is merely a peri- neural or intraneural blocking of the nerves supplying a given area (Fig. 30, page 129). Infiltration Block.--Regional and conduction anesthesia in the refined sense comprehend the accurate deposition of a small amount of solution exactly in the region of or within the nerve sheath. The attainment of such accuracy is somewhat difficult and a more or less general infiltration in the approximate region in which the nerve is known to lie is often substituted. This method we have designated infiltration block (see Figs. 42, 43, 44, page 187). VENOUS ANESTHESIA. Venous anesthesia was devised by Bier in 1908. Braun considers it a very effective method and the following is his description of the technic (see Braun, page 163): "The entire extremity is sterilized, elevated and made bloodless by a rubber band carried from the toes or fingers to above the place where the injection is to be made. Immediately above this bandage a second rubber band is passed about the extremity. The first bandage is then removed for a distance of about a hand-breadth and not more than three hand-breadths from the upper bandage. At this point the second compression bandage is placed. For peripheral portions of a limb direct anesthesia can be carried out with one constricting band which, however, should not be placed higher than the middle of the forearm or leg. Operations on infected tissues should only be carried out by indirect vein anesthesia. For this purpose a compression band is placed above the infected area, and at this point the bandage for producing anemia begins. The second compression bandage is then placed above the latter. Just under the upper constricting band one of the larger sub- cutaneous veins, such as the cephalic, basilic, median or great saphenous, is freely exposed under infiltration anesthesia. In order to render the location of the veins certain it is advisable, before applying the bandage for producing the anemia, to mark the course and position of the vein, or expose the vein before applying the bandage. The author advises the latter method, so that the patient will not be allowed to suffer from the compression bandage remaining unnecessarily long upon the limb. "The syringe recommended by Bier is of 100 cc capacity,1 con- nected with a cannula by means of a thick-walled rubber tube. The cannula is provided with a cock so that it may be closed, and has two furrows at its end for the purpose of tying it into the vein. 1 The pneumatic injector, Fig. 5, p. 89, is excellent for this purpose. VENOUS ANESTHESIA 113 The cannula is tied into the vein in the same manner as for salt infusions, except that it is tied into the peripheral and not the central end of the vein. Injections are made under even pressure, or, as occasionally happens, very strong pressure, until the vein valves are overcome, 0.5 per cent novocain solution without supra- renin; 40 to 50 cc for the upper extremity and 70 to 200 cc for the lower extremity, depending upon the thickness of the limb. If during the injection some of the smaller branches are seen to spurt they must be immediately closed with hemostatic forceps. After completing the injection the cannula is closed by means of the cock and the vein is ligated and cut, the small wound being closed by suture. Complete anesthesia will occur throughout the entire transverse section of the limb in about five minutes; indirect anesthesia as well as complete motor paralysis in the peripheral part of the limb follows in about five to fifteen minutes. At this time the peripheral constricting band can be removed in case it interferes with the performance of the operation. "The anesthesia lasts as long as the upper constricting band is kept in place. As soon as it is removed, sensation returns in a few minutes. According to the observation of Bier, the addition of suprarenin to the novocain solution does not prolong vein anes- thesia very materially, but it frequently prevents an even distribu- tion of the injected solution throughout the transverse area, for which reason it should not be used. "Vein anesthesia should be used in suitable cases and is without danger. Poisoning from novocain need not be feared following its use. The cases most suitable for vein anesthesia are resection of joints and amputations from about the middle of the thigh or upper arm downward. This method should not be used when operating for diabetic gangrene (Bier). It is also a question whether this method should be used in septic infections, as it is possible to open a vein which is infected, even if some distance from the diseased area. "The upper constricting bandage causes severe pain after a short time. Perthes has devised a compressor which has relieved this somewhat. Momburg advises after anesthesia has set in that a second compression bandage be placed in the area of direct anesthesia and the bandage causing the pain removed. The rapid return of sensation following the removal of the bandage is very inconvenient in amputations, as the operation must have been previously com- pleted, hemostasis being rendered very difficult. The literature on the subject of vein anesthesia is very scanty. Schlessinger believes it is possible to dispense with the artificial anemia by the injection of larger quantities of novocain solution. lie punctures a congested vein with a thin trocar, places the constricting bandage. 114 GENERAL TECHNIC and injects. This method does not explain, however, the manner in which the pressure of the vein valves is overcome. Jerusalem, Mantelli, Hitzrot, Goldberg, and Petrow report successful results with this method. Von Eiselberg states in the discussion of the report of Jerusalem that he only used the vein anesthesia when other anesthetic methods were contraindicated. The author holds this ingenious method of Bier to be a valuable addition to our anesthetic methods in performing aseptic operations upon the extremities when the usual local anesthetic methods are not possible. Bier himself limits this method of anesthesia to those cases in which local anesthesia is not possible." ARTERIAL ANESTHESIA. Quoting further from Braun (page 166): "Goyanes, a Spanish surgeon, reported in 1909 the practical application of arterial anes- thesia, and stated in 1910 that he had performed amputations and resections in 23 cases with its use. In 20 of these cases complete anesthesia was obtained. Oppel performed many operations upon the hand and foot, using the radial, dorsalis pedis, femoralis and brachialis as arteries of injection. The leg is made anemic and ligated; below the constricting ligature the artery is exposed and the anesthetic injected by means of a fine needle. Goyanes used for this purpose 50 to 200 cc of a 0.5 per cent novocain-suprarenin solution. Smaller doses were found insufficient by Oppel. Goyanes recommended this method particularly for the upper extremity, using lumbar anesthesia for the lower extremity. "Hotz has recently controlled the experiments made for arterial anesthesia. He recommends that the artery be exposed under local anesthesia and the leg made anemic just as in vein anesthesia ligated above. A fine needle is then passed obliquely into the artery and a 0.5 to 1 per cent novocain solution with suprarenin injected. For the brachial artery 20 to 25 cc are necessary. For the femoral artery 40 cc of a 0.5 per cent novocain-suprarenin solution should be used. One or two minutes after the injection complete anesthesia occurs in the area supplied by the artery. Following the use of stronger novocain solutions (3 per cent) severe pain occurs. After relieving the constricting bandage sensation returns immediately. In this manner ten operations were per- formed on the hand, forearm, foot and leg. In three lean patients it was found possible to inject the novocain solution into the femoral and brachial arteries without exposing them. In these cases the injection was rapidly made and the leg immediately ligated. "Injurious effects were never observed. This method, according to Hotz, does not enter into serious competition with inhalation or SACRAL ANESTHESIA 115 local anesthesia. It is of value in tuberculous patients, in the aged with bronchitis and heart lesions, and other cases which are not suitable for general anesthesia. "That the extremity must be ligated above the anesthetized area and that sensation returns very quickly after releasing the constricting bandage is a disadvantage that exists with arterial anesthesia just as with vein anesthesia. Arterial anesthesia possesses the added disadvantage over vein anesthesia in that it is much more difficult to find the artery than a superficial skin vein. This method should scarcely be given further consideration in anesthesia of the upper extremity, as plexus anesthesia is a much easier procedure. "The above-named authorities, as well as Girgolaw, claim that the intra-arterial introduction of an anesthetic is less toxic than that introduced intravenously, but this is of no practical importance, as the ligating of an extremity according to the method of Bier renders such danger impossible. Experiments which the writer made on animals in 1900 also contradict any such theory. The toxicity of these methods depend upon the manner of injection. If cocain is injected into a previously ligated or clamped artery its toxic action is naturally much less than if this poison were injected into a vein with an uninterrupted circulation. If, however, the cocain is injected into the circulation of a vein previously ligated or clamped, as is done in Bier's vein anesthesia, the toxic action will naturally be much less than if injected directly into an unobstructed artery. Therefore, we can say with equal right that cocain injected intravenously is less toxic than when injected intra-arterially." SACRAL ANESTHESIA. Cathelin was the first to inject anesthetic solutions into the epidural space by the route of the sacral foramen. During recent years this method of obtaining anesthesia of the nerves arising from the sacral canal has been employed rather extensively. The technic of its establishment is comparatively simple, and although there is some margin of error, the method has decided advantages and is indeed the method of choice for the treatment of a variety of conditions. There is no unanimity of opinion regarding the amount or strength of solutions required. On the one hand it is recommended that an amount not to exceed 30 cc of 0.5 of 1 per cent novocain-adrenalin be used, while again recommendations for the use of 100 to 120 cc of 1 per cent solution have been made. There is also considerable variation in the height to which anesthesia may be obtained. Also the intensity varies to a considerable degree. Occasionally an anesthesia up to the third or fourth thoracic 116 GEN FAI AL TECHNIC nerves has been observed. Ninety to 120 cc of a 0.5 or 1 per cent novocain solution has given us the best results. Steel needles, sizes 17 to 21, from which the temper has been removed by annealing, are used (Fig. 27, A and B). One type is equipped with blunt obturators which facilitate passage along the sacral canal and safeguard them from entering the veins. The patient is placed in the prone position (see Fig. 28). The skin and subcutaneous tissues over the sacrococcygeal junction are anes- Fig. 27.-Author's needles for sacral anesthesia. A, sharp; B, blunt with obturator. thetized and a small puncture of the skin made with a tenotome in case the blunt needles are used. When sharp needles are used it is not necessary to make the preliminary puncture. After the introduction of the needle through the sacrococcygeal mem- brane and into the sacral canal the fluid is introduced slowly, being careful to avoid complaint of pain along the course of the nerves. In the experience of the author slight toxic symptoms are not uncommon in this form of anesthesia, and in very fat women the sacral hiatus is sometimes difficult to locate. Provided this form SACRAL ANESTHESIA 117 of anesthesia is proven safe it would seem probable that it will become the method of choice for pelvic, rectal and bladder work. The toxic symptoms consist of pallor, accelerated pulse and nervous- ness, but they have seldom been alarming. One case of infection followed the introduction of the sacral needle which necessitated drainage. The Case report is included because it is the only one in which an infection following sacral injection has occurred in the author's clinic. Since the dura is not punctured, this complication need be treated only like any infected wound by establishing liberal drainage. Trans-sacral Sacral.. Parasacral .. Fig. 28.-Anesthesia of the sacral nerves. A, Trans-sacral; B, sacral; C, parasacral. Case No. 14004. Mrs. E. K. R. Female, aged thirty-eight years, married, entered the hospital March 22, 1921. History.-The patient complains of severe stabbing pains in the left loin, which have a sudden onset, last but a few seconds and are followed by an aching sensation for several minutes, preventing a deep inspiration. She has backaches frequently, as well as soreness in bladder region, with urgency a few minutes after emptying the urinary bladder. Physical examination and fluoroscopy negative, but on her first visit the urine showed both pus and red blood cells. ])iagnosis.- Suspected kidney lesion (not proven). Operation.-Cystoscopy; ureteral catheterization; pyelograms. Anesthesia.-Sacral injection, 90 cc 0.7 per cent novocain- adrenalin solution being used. The cystoscopic findings were negative, but eight days after the examination the patient began having pain in the region of the 118 GENERAL TECHNIC sacrum and referred down both legs with slight redness at site of the sacral injection. Five days later a seropurulent discharge from the puncture wound presented and a week later liberal drainage under circuminfiltration was established, after which healing was uneventful. Note.-Since the above complication has occurred rigid attention has been paid to the care of the site of injection, first, sealing the puncture wound with rubber cement, and second, aiming to prevent a pool of water from accumulating and bathing the sacrum. The greatest satisfaction in attempting to locate the sacral hiatus has been found by using a long, fine needle for the purpose of making the initial wheal as well as the infiltration down to the bone. This infiltration is carried out by a series of advances and recessions with the needle which at each advance is made to take a different angle. As the needle approaches the sacrum its advance will be interrupted in case the point strikes this bone. If, however, the needle point should enter the sacral hiatus this resistance will not be felt and one may be certain that the needle point has entered the canal. The needle is then detached from the syringe or cut-off and used as a guide for the introduction of the regular needle which is used for making the sacral injection. Since using this method the sacral canal has invariably been located. James E. Thompson,1 in a most interesting article entitled "An Anatomical and Experimental Study of Sacral Anesthesia" states: "Sacral anesthesia has become so firmly established in the surgical clinic of the John Sealy Hospital, Galveston, Texas, as one of the safest and most valuable means of producing local anesthesia in the regions supplied by the sacral nerves that it has passed completely beyond the experimental stage. It is used as a routine procedure in all operations on the anal canal and lower rectum, in perineal operations, in external urethrotomies and in operations on the body of the penis. Also, when combined with local infiltration of the abdominal walls in cystotomies and suprapubic prostatectomies." lie follows closely Harris of Chicago and injects but 30 cc of the solution into the sacral canal. To this amount of solution he adds 10 drops of a 50 per cent solution of sodium chloride. He states that he repeats the injection without hesitation in case he fails to obtain anesthesia. The second injection has always produced perfect anesthesia. He has never seen toxic symptoms. In appended charts, made by Prof. William Keiller, he shows the area of distribution and intensity of anesthesia and finds that they present considerable variation, in some instances anesthesia as high as the tenth thoracic appearing. In making experimental injec- 1 Ann. Surg., 66, 718-722. PARASACRAL ANESTHESIA 119 tions upon the cadaver he found that the solution was never injected within the dura mater. In every case injected the colored solu- tion used was found above the third thoracic. It was also found that while the injection was being made the solution flowed from both external iliac veins. Thompson suggests "that the needle had probably punctured a large vertebral vein and that the fluid was being forced into the systematic venous system. The possi- bility of repeating this in the living subject is suggested." Thompson collected a variety of sacra, examining 33 specimens in all, and he found considerable variation in their shape as well as in the contour of the sacral canal. Harris and others have called attention to the same thing. This variation in shape and contour furnishes one of the shortcomings of sacral anesthesia, inasmuch as one may on this account have difficulty in entering the canal with the needle. PARASACRAL ANESTHESIA (Fig. 28). The sacral nerves may also be reached from in front; that is, by passing the needle between the rectum and the sacrum. This is known as "parasacral anesthesia." (Fig. 28, page 117.) Braun states that the method of Franke and Posner, who attempted to locate the pelvic nerves by making injections in the region of the sympathetic ganglion of the uterine cervix, using a needle 15 cm. long, is less simple than it is to block the sacral nerves at their point of emergence from the sacral foramen. He says (Braun, page 319): ''In this way the pelvic nerves, the entire pudendal plexus and the posterior cutaneous femoral nerve are interrupted and a com- plete anesthesia of the pelvic organs and lower part of the pelvic peri- toneum is obtained. This procedure we will call parasacral conduc- tion anesthesia, deriving the idea from the paravertebral anesthesia of Sellheim and Lawen, in which the injection was also made into the nerve trunks as they leave the spinal canal. "The technic for parasacral injections is as follows: The two points of injection lie 1.5 to 2 cm. from the median line to the right and left of the sacrococcygeal articulation. Inspection of the inner surface of the sacrum shows that in the lower part, between the second and fifth sacral foramen, there is very little curvature to the bone, which makes it possible to push the needle forward in a straight line along the inner surface from the point mentioned to the second sacral foramen, without losing the contact between the point of the needle and the bone. Above the second sacral foramen the point of the needle must necessarily strike the bone and, there- fore, cannot be inserted farther. In the adult this point is 6 to 7 cm. from the point of entrance, not taking into consideration the soft structures. 120 GENERAL TECHNIC "The patient is now placed in the lithotomy position and the needle inserted in a direction parallel with the inner surface of the lower half of the sacrum; with the point of the needle the edge of the sacrum is sought for. Feeling the way past the edge of the sacrum the needle is pushed along the inner surface of this bone parallel to its median plane until it strikes the bone at the depth mentioned. The entire distance from the second to the fifth sacral foramen is injected with 20 cc of a 1 per cent novocain-suprarenin solution. No injection should be made until contact with the bone is felt. The needle is now drawn back to the edge of the sacrum and is directed at a small angle toward the innominate line, always pushing it parallel to the median plane. In this direction the needle penetrates deeper than before, until it again strikes the bone above the first sacral foramen at a distance of 9 to 10 cm. from the point of entrance, the soft parts not being taken into considera- tion; at this point 20 cc of 1 per cent novocain-suprarenin solution is injected. The final injection of 5 cc of the solution is made between the rectum and the coccyx from the same point of entrance. The same injection is made on the opposite side; altogether 100 cc of the solution are required. The needle must be 12 cm. long. The author makes this injection without the aid of a guiding finger in the rectum, as the empty bowel is not easily injured and evades the needle. If the operator is doubtful on this point, then the position of the needle should be controlled by the finger, especially in making the injection to the first sacral nerve. This method has been used in prostatectomies, in operations for complete prolapse of the uterus, both with and without artificial fixation of the uterus, in extirpation and resection of the rectum for carcinoma, the rectum being painlessly dissected as far as the flexure. "The anesthesia extends higher up than Lawen's sacral anesthesia and affects the same segments. In consequence of the blocking of the posterior cutaneous femoral nerve, the skin of the posterior surface of the thigh always becomes insensitive as far as the popliteal space. The sphincter ani is necessarily paralyzed. The urethral prostate and bladder are both totally insensitive. Anesthesia of the parietal peritoneum does not extend high enough for an extirpation of the uterus, for, as is well known, a high lumbar anesthesia is necessary for this purpose. That part of the peritoneum supplied by the sacral plexus alone is confined to the floor of the pelvis. Parasacral anesthesia is a most reliable form of anesthesia; more so than sacral and without secondary effects. This reliability is attributed to the fact that the course taken by the needle is deter- mined by its point of contact with the bone." TRANS-SACRAL ANESTHESIA 121 TRANS-SACRAL ANESTHESIA1 (Fig. 28). The method of introducing trans-sacral injections according to Pauchet is as follows: "Place the patient in the extended posture with the face down- ward. Draw a line from one iliac crest to the other. Identify and mark the points over the sacral cornua to each side of the sacral hiatus and then draw a line directly over the median line of the spinous processes from the level of the iliac crests downward. Next locate points 4 cm. to each side of the midline along the line connecting the iliac crests and from these points pass two lines directly over the two sacral cornua. These two lines will pass directly over the two rows of sacral formina. Commencing at the top, the first sacral foramen is found on the line directly opposite the tip of the spinous process of the fifth lumbar vertebra. At a point 3| cm. (35 mm., or the breadth of a thumb) below on the same line will be found the second foramen. Two and one-half cm. (25 mm., or approximately the breadth of a thumb) farther down is the third; 2 cm. (20 mm. or the width of the little finger) still farther down is the fourth; and 1| cm. (15 mm. or approximately the width of the little finger) below this is the fifth. The anatomical landmarks are as follows: The first sacral foramen is opposite the fifth lumbar spinous process; the second foramen is just medial to the prominent postero-inferior spine of the ileum, and the fifth sacral foramen is exactly outside the sacral cornua. The first foramen is about 35 mm. from the median line; the second, 30 mm.; the third, 25 mm.; the fourth 20 mm.; and the fifth 15 mm. The skin is then prepared with iodine and alcohol in the usual way and Pauchet makes five dermal wheals on each side at the points over- lying the sacral foramina, using a fine needle. (The author's technic differs in that he makes but one painful wheal and from this one makes the remaining ones by the subintradermal method. (See Fig. 31, page 149.) Then commencing at the top with a 9 cm. needle the operator can readily find the foraminal opening by feeling about with the point of the needle and he can tell he is in by suddenly sensing the absence of resistance, as well as noting when the patient complains of a disagreeable sensation in the abdomen or legs as the needle pierces the nerves. The needle should penetrate to a depth of about 25 mm. for the first foramen, 20 mm. for the second, 15 mm. for the third, 10 mm. for the fourth and 5 mm. for the fifth. Five cc of a 1 per cent solution are injected at each opening.'' 1 Sherwood-Dunn: Regional Anesthesia, Technic of Victor Pauchet, 1920, p. 207. 122 GENERAL TECHNIC "The operation can be begun in about fifteen minutes and the anesthesia lasts from one and a half to two hours. The injections anesthetize the labia, prostate, bladder, rectum, anus, uterus, and the skin of the posterior surface of the thigh." PARAVERTEBRAL ANESTHESIA. The following is a liberal translation from the work of Prof. Heinrich Brann1 regarding paravertebral anesthesia: "The nervi thoracales pass out of the intervertebral foramina of the thoracic vertebrae and soon after their exit give off connecting branches, the rami communicantes to the sympathetic nervous system, and then divide into anterior and posterior divisions. The latter go to the muscles of the back and innervate the skin to the right and left of the midline. (The anterior divisions are distributed chiefly to the parietes of the thorax and abdomen.) "The labors of Neumann and Kappis have determined beyond dispute that the sympathetic nervous system alone is the carrier of sensation in the abdomen. The rami communicantes of the sympathetic nervous system are the pathways through which the sensory nerve fibers that originate in the sympathetic ganglia and plexuses are conducted to the spinal nerves, the cord and the brain. This is done in part by continuity and in part by means of the nervi splanchnici. In the pelvis this role is taken over by the autonomic nervus pelvicus. "The idea of paravertebral blocking was originated by Sellheim (1905), who attempted to interrupt the eighth to the twelfth inter- costal nerves, as well as the iliohypogastric and ilioinguinal at their points of exit from the vertebral column. This was done for the purpose of doing abdominal operations, giving accurate directions for passing the needles. "The technic calls for the introduction of the needle 2 to 3 cm. lateral to the interspinous line until the vertebral arch is reached, gliding laterally over the edge of the arch between the transverse processes and then proceeding from 1 to 2 cm. farther, striking the nerves as they emerge from the foramina at the posterior surface of the vertebral arch. Sellheim's attempts were indeed not without success but failed because the anesthetics obtainable at that time were not efficient. He intended, by the way, an intercostal anes- thesia in the sense above mentioned, for at that time nothing was known of the role played by the sympathetic nerves and the rami communicantes with regard to the conduction of pain sensation from the abdomen. This was demonstrated later by Kappis. 5th edition, 1919, Chapter XIII, p. 320. 123 PARAVERTEBRAL ANESTHESIA "Lawen (1911) again took up these attempts and named the procedure 'paravertebral anesthesia.' He reports inguinal hernia operations and one nephrectomy, having interrupted the lower dorsal and upper lumbar nerves. "The practical experiences of Kappis and Finsterer affirmed that paravertebral blocking of sufficient intercostal and lumbar nerves anesthetized not only the abdominal wall but the whole cavity as well, thereby giving complete relaxation of the abdominal parietes and motor paresis. "During the past few years paravertebral anesthesia had been employed quite extensively in abdominal surgery. Indeed, Siegel in reporting 1000 cases designates it the anesthesia of choice for all abdominal operations as well as for gynecological and vaginal operations in conjunction with parasacral anesthesia. The failures are said to be rare with this method, especially when both para- vertebral and parasacral are combined, and there is no doubt that the method is useful in doing laparotomies because a painless abdominal cavity and a relaxed abdominal wall are obtained. "In the technic of paravertebral anesthesia it is important to block the rami communicantes and sympathetic nerves as well as the spinal. For that reason the needle must be guided quite near the vertebral column. The best point of orientation for passing the needle to the body of the thoracic vertebra is the inferior border of the ribs and not the transverse vertebral bodies as preferred by some. Braun agrees with Siegel that it is not necessary and perhaps not even possible to locate any single nerve with the needle point, and the most efficient block is assured by ample infiltration of the region containing the nerves with a 0.5 per cent solution of novocain- adrenalin. The technic differs from the one described for inter- costal injections to a certain extent. A strip of skin 5 cm. lateral to the spinous processes is anesthetized and the lower border of the rib (twelfth) is found with the needle, which is then withdrawn a bit and directed mesially at an angle of 120 degrees for 2 cm. It follows the lower costal border crossing the angle between the rib and transverse process. One may strike the transverse process, which can be avoided by withdrawing and raising the needle so that it passes in front of the same on reinserting. While inserting the needle one must begin injecting to avoid pain. A total of 15 to 20 cc of the solution is injected into each space, and when this is done there occurs an almost continuous infiltration along the vertebral column so that fluid escapes from a needle, which is inserted in an adjoining space. The inferior border of the twelfth rib is usually taken as the starting point and the needle is left in position until the first lumbar is located. This is done by passing an 8 to 10 cm. needle through the anesthetized skin and aiming at the transverse 124 GENERAL TECHNIC process of the first lumbar vertebra. The lower border of the process is passed mesially and caudally 2 cm. and then 20 cc of the solution are injected. In the same way the second and third lumbar nerves, each 6 cm. lower, are blocked. The fourth and fifth lumbar nerves cannot be reached in this manner but they are unimportant with regard to abdominal sensation of pain. Next, the eleventh rib, then the tenth and so forth up to the fifth are injected similar to the twelfth.'' The segmentary innervation of the abdominal organs by sensory nerve fibers may be outlined after the animal experiments of Kappis as follows: Stomach Upper small intestine Liver Spleen Dorsal 6 and 7 Lower small intestine Large intestine Kidneys Dorsal 8 to lumbar segments Lumbar segments Dorsal 8 to 12 Practically, this is of small importance because the lower and higher fields of innervation in the abdomen overlap. Therefore a considerable number of segments must be blocked to anesthetize any great part of the abdomen. Kappis concluded from embryo- logical evolutionary studies that the gut is innervated bilaterally in its entire course and one must therefore block bilaterally even for unilateral laparotomies. Posterior (Kappis).-With regard to the removal of sensations of the abdominal and other organs, Braun1 makes the following observation and gives a description of Kappis's method of establish- ing splanchnic anesthesia: "The most successful attempt to remove the abdominal sensa- tions of a circumscribed larger segment of the abdominal cavity in a simple and reliable manner without the aid of narcotics is founded, I believe, upon the fact that the sensory nerve fibers of pain for the upper abdominal organs (liver, gall-bladder, stomach, duodenum and the proximal small intestine) run exclusively in the course of nn. splanchnici to the spinal cord. "The n. splanchnicus major joins the vena azygos at the antero- lateral surface of the twelfth thoracic vertebra and passes between the crus mediale and crus intermedium diaphragmatis through the SPLANCHNIC ANESTHESIA. 1 Local Anesthesia, translation by Shields, p. 354. SPLANCHNIC ANESTHESIA 125 diaphragm. The n. splanchnicus minor either takes the same course or it runs a little farther laterally through the diaphragm. Both nerves having entered the abdominal cavity lie alongside the aorta in the loose tissue under the insertion of the omentum minus in the posterior abdominal wall and at the level of the celiac artery pass into the celiac plexus. This region is accessible with the needle from behind as well as in front. "The direction from behind has been described and used by Kappis. The manner of passing the needle is as follows: "The patient lies in a lateral position. A needle 12 cm. long is inserted into the skin at a point 7 cm. lateral to the line of the spinous processes and at the lower border of the twelfth rib and is then passed obliquely in the direction of the vertebral body. As soon as the needle has touched the vertebra it continues to feel its way past the body or centrum. When that is accomplished it should be passed 1 cm. farther. It rests now in or at the lateral insertion of the diaphragm to the vertebral body, where also the nervi splanchnici are situated. The same procedure is carried out on the other side. Kappis injects 20 to 40 cc of a 1 per cent novocain-suprarenin solution on each side and then passes farther downward upon the lateral aspects of the lumbar vertebrae and there again injects 15 to 20 cc of the solution. The abdominal wall is made insensible by these regional injections." Braun further states: "Kappis has executed more than 200 operations (most of them upon the stomach and gall-bladder) with this method and says that with increasing practice failures have seldom occurred." In this connection it is interesting to note that Braun recommends proper preparation of the patient with scopolamin and states that this must not be omitted in cases in which splanchnic anesthesia is to be induced by the method of Kappis. Anterior Splanchnic Anesthesia.-Wendling was the first to make the suggestion to anesthetize the splanchnic region from the anterior root through the intact abdominal wall. Braun gives the following description of the Wendling technic: "Anterior Splanchnic Anesthesia (Wendling).-The point of entrance is found 0.5 cm. to the left of the middle line and 1 cm. below the extremity of the ensiform process. A needle inserted vertically at this point reaches usually at a depth of not more than 6 cm. (having passed the liver and the free abdominal cavity) the retroperitoneal structures under the insertion of the lesser omentum. Wendling injected here 50 to 80 cc of a 1 per cent novocain-suprarenin solution and in 26 cases got a very good anesthesia of the organs of the upper abdomen-once a failure." Braun further states that Wendling renders the abdominal 126 GENERAL TECHNIC parietes painless by regional infiltrations. Wendling warns one to beware of intravenous injection in the vascular regions, since he had novocain poisoning in one case because of injecting a vein uninten- tionally. Braun states: "I do not believe that Wendling's method will find many imitators. Even granted that after Wendling's experi- ments injuries of the gastro-intestinal tract are not to be feared, this is only met providing the organs lie in their normal positions but not when the stomach is displaced and adherent. In cases of old stomach ulcers the transverse colon may indeed lie under Wendling's point of attack. However, in my opinion, in doing operations in the upper abdomen there is not any need to inject the nn. splanchnic! before the abdomen is opened, for in the open it is done so much better, guided by the eyes and the palpating fingers. We have to remember that Dollinger, Finsterer, Hacken- bruch and others have already recommended for stomach operations to secondarily infiltrate the lesser omentum." Braun, himself, prefers to establish splanchnic anesthesia through the anterior route. He further states: "In stomach operations I proceed as follows: After a real careful regional infiltration the abdomen is opened in the middle line. The left hepatic lobe is gently and carefully lifted up with a Hat retractor. With the index finger of the left hand one feels for the anterior surface of the first lumbar vertebra, which is situated at the level of the ensiform process. One feels the pulsating aorta, which is pushed over to the left. The finger is resting on the right lateral part of the anterior surface of the vertebral body, covered at this place only by a thin layer of soft parts, the insertion of the diaphragm and the posterior peritoneum. "Next one passes a needle 12 cm. long along the finger against the bone. It should strike the bone immediately. In case it does not, then it has been guided wrongly. In this manner vessels cannot be injured, especially the vena cava, which lies aside farther to the right. However, precaution is to be used, as is observed also in all other regions of the body to change the needle a little if perhaps some blood escapes from it. If such is not the case, the left index finger is withdrawn and without changing the position of the needle 50 cm. of 0.5 per cent novocain-suprarenin solution is in- jected. "In the same manner one finds with the right index finger the left antero-lateral surface of the first lumbar body and pushing the aorta aside to the right one guides the needle again along the finger and one injects another 50 cm. of the solution. In this way a very extensive infiltration is achieved of the anterior and lateral aspects of the vertebral column, i. e., the soft parts which cover it and SPLANCHNIC ANESTHESIA 127 which contain the nn. splanchnici and the large ganglia lying in front of the aorta. "All these manipulations should be done gently and carefully. All pulling of the lesser omentum and spreading of the abdominal wound and any examination of the cavity should be particularly avoided before the injections have been made. In all the injections it is shown that the place where the solution shall be put is to be reached only by pushing aside the stomach, the lesser omentum and the aorta. It appears almost impossible to strike it through the intact abdominal wall, as Wendling does, without uncontrollable injuries being done." The author agrees with Braun that the anterior splanchnic anesthesia of Wendling will probably never become popular. The posterior splanchnic anesthesia of Kappis is undoubtedly efficient, and when indicated will prove decidedly useful. The anterior method of Braun, however, has so many advantages over the other two that it seems probable that it will prove the method of choice with many surgeons. A modification of the method of Braun has given gratifying success in obtaining anesthesia, permitting one to do most of his abdominal work without pain to the patient. The author's method of establishing anesthesia within the abdomi- nal cavity is predicated first upon the establishment of an efficient anesthesia of the abdominal wall and second upon the use of a surgi- cal technic which decreases to a great extent the demand for com- plete anesthesia within the peritoneal cavity plus the addition of but a small amount of solution retroperitoneally. In other words, by adopting a surgical technic which would meet the demands of the situation, by observing the effect of the manipulation of the intra- peritoneal organs and structures, and by adding extremely small amounts of local anesthetic solutions the writer has been able to carry out these operations. Exposure has been the sheet anchor and it is felt that any operation within the peritoneal cavity is entirely possible provided the nerve supply of the region proximal to the organs and tissues to be attacked may be visualized. The form of splanchnic anesthesia employed is a simple subperitoneal infiltration made along the path of the splanchnic nerves which one desires to interrupt. A simple infiltration beneath the peri- toneum in the region of the cystic duct, for instance (Fig. 29), will result in almost immediate anesthesia of this region so complete as to permit the carrying out of any operation upon the gall-bladder and ducts. After anesthetizing the abdominal wall it is entirely a matter of exposing the region, and the method of obtaining this exposure is detailed on page 397. The various steps in the operations are dependent upon each other 128 GENERAL TECHNIC and the success of each is largely dependent upon the preceding steps. Thus if the abdomen is opened without obtaining a negative intraperitoneal pressure it will be impossible to obtain the desired exposure and a simple anterior splanchnic block similar to that described will be impracticable. The success of the method will therefore depend largely upon one's ability to master the details and to meet the demands of the portion of the operation which precedes the time for establishing anterior splanchnic anesthesia. It has not been found necessary, nor has it seemed desirable to use the more complicated methods to any extent. Although their use is justified in all cases in which the necessity arises, the demands of the situation can usually be met by these means. More detailed descriptions will be found in the discussions of Surgery of the Abdomen, Chapters XIII to XVIII. Fig. 29.-Anterior splanchnic anesthesia. (Gall-bladder.) To illustrate the possibilities of the method just described the following statistics are offered, giving the percentage of cases upon which the author has been able to operate successfully under infiltration of the abdominal wall, combined with his surgical technic and method of anterior splanchnic anesthesia. These statistics include patients of all ages, children as well as adults, and cover the period during which the present technic has been employed. Of 145 pelvic operations of all descriptions started under local anesthesia, 130, or 90 per cent, were finished with the same. In 15 general anesthesia was added. Of 140 gall-bladder operations started with local anesthesia, BRACHIAL ANESTHESIA 129 130, or 95 per cent, were finished with the same. In 10 cases general anesthesia was added for varying lengths of time. Of 220 appendix cases, 48 per cent, of which were acute or sub- acute, started under local anesthesia, 215 or about 98 per cent, were finished with the same. In 5 cases general anesthesia was added. HANDLING THE ABDOMINAL VISCERA. 'rhe lifting and handling of the abdominal viscera by gloved fingers or gauze is difficult. In deep wounds the hand will usually completely obstruct the view unless the viscus is dislocated and brought to the surface. The slippery organs are difficult to hold in the gloved hand and, not uncommonly, gauze is used in order to overcome this difficulty. Some form of long, rubber-tipped forceps is desirable for this purpose. They do not obstruct the view, the various organs can be effectively manipulated and trauma is largely eliminated by their use. Fig. 26, page 110, illutrates a type of forceps which is satisfactory for this purpose. Here, as else- where, the use of long delicate instruments allows the handling and distinguishing of the tissues and to depend upon direct visualization rather than the sense of touch. In hypertrophic pyloric stenosis, for instance, it is often extremely difficult to elevate the hyper- trophied pylorus which frequently lies posterior to the pyloric antrum and deep beneath the liver edge, provided the fingers alone are depended upon. On the other hand, with the establishment of a perfect negative pressure (See page 147) and the use of long deli- cate forceps this structure may be elevated into the abdominal incision with the utmost ease. BRACHIAL ANESTHESIA (Fig. 30). For work upon the upper extremity brachial anesthesia has been employed extensively. When the nerve trunks are reached by the needle point this form of anesthesia is certain, complete and immedi- ate. With a little experience one may learn to establish brachial anesthesia with but a small margin of error. However, its estab- lishment requires the cooperation of the patient, who must report to the surgeon when paresthesia appears. Another shortcoming of the method relates to the greater difficulty in striking the brachial plexus with the patient in the recumbent position, and as many patients cannot assume the upright posture, this factor becomes a real drawback. Brachial anesthesia will last for approximately one and a half hours and will therefore allow one to carry out almost any manipula- tion or operation upon the upper extremity. Fig. 30 shows the relation of the brachial plexus to the surround- 130 GENERAL TECHNIC ing structures and also the direction of the needle. The introduc- tion of the needle should be preceded by the establishment of an initial wheal at the midpoint of the clavicle. The following is a description of the technic of Kulenkampff (from Braun) :r Fig. 30.-Brachial plexus anesthesia. "It is advisable, whenever possible, to have the patient in the sitting posture while being anesthetized. The patient needs no previously administered opiate, but he should certainly be informed of the paresthesia, which radiates to the fingers and which will arise when the needle penetrates the plexus, and he should be instructed to state when he feels these sensations. This is the only way to positively determine when the needle has reached the right spot. The next step is to palpate the subclavian artery, which is done by making gentle pressure with the finger. In many cases the pulsation is visible more often to the right than to 1 JLpcaJ Anesthesia, Brachial Anesthesia, Kulenkampff's Method, p. 352, 131 BRACHIAL ANESTHESIA the left, which may be explained by varying anatomical relations. A wheal is placed directly outward from the spot where the artery disappears behind the edge of the clavicle. The spot almost without exception will correspond to the middle of the clavicle. At this same point, as a rule, a downward prolongation of the external jugular vein, which is usually visible, also crosses the clavicle. Here we insert a fine needle 4 to 6 cm. long, without syringe, in the direction which it should take to strike the spinous process of the second or third dorsal vertebra. The plexus lies rather close to and under the fascia. As soon as the needle touches it, radiating paresthetic sensations are complained of in the fingers supplied by the median nerve which lies superficially, and of the radial nerve which lies deeper and posterior to the median nerve. If at a depth of 1 to 4 cm. the first rib is felt, it indicates that the plexus must lie more superficially. If paresthesia is not obtained at once, it must be sought by slightly changing the position of the needle. Very often, from an unnecessary anxiety about the sub- clavian artery, the needle is inserted too far outward. If blood Hows from the needle, its direction must be changed. As soon as paresthesia occurs, attach the syringe to the needle and inject 10 cc of a 2 per cent novocain-suprarenin solution. If paresthesia evidences itself in the region supplied by the median nerve, a part of the solution should be injected a few millimeters deeper. Finally, 10 cc more are injected so as to be distributed in the immediate surroundings, the direction of the needle being very slightly changed during this injection. "The operator should not make the injections before the pares- thesia occurs. If there is a pronounced paresthesia of the median as well as the radial nerve, it indicates that a complete sensory and motor paralysis of the arm will occur after one to three minutes. It is usually necessary to wait ten to fifteen minutes, but if after this length of time the paralysis is not complete, it will be advisable to make another injection of 5 to 10 cc of a 4 per cent novocain- suprarenin solution. Paresthesia will not be felt after this latter injection and results are more or less uncertain." The patient is quite likely to change position during the intro- duction of the needle and the search for the bundles of nerves. The head is apt to be rotated or the patient may elevate the shoulder upon the affected side. It is well repeatedly to caution him during the introduction of the needle so that the relations of the parts be not disturbed. When making the injection the fluid should be introduced slowly so that the nerve structures will not be torn. As a rule about two minutes should be allowed to elapse during the introduction of 5 cc of solution, 132 GENERAL TECHNIC NARCO-LOCAL ANESTHESIA. (See Chapter HI, Page 72.) When doses of narcotics of sufficient size are administered to establish the condition known as "twilight sleep" the method should be designated "narco-local" anesthesia, and a careful distinction should be made between this condition and one where the faculties remain alert and the preliminary medication has been given merely for its "tiding over" effect. Two articles describing this method appeared upon the same date, May 1, 1916: one from the Freiburg Clinic by Kroenig and Sieger1 and the other by the author.2 Various combinations of drugs have been used for the purpose of establishing "twilight sleep." However, the author has used but few: morphin and hyoscin, morphin and scopolamin, morphin and magnesium sulphate and morphin and atropin, or some of the substitutes of morphin such as pantopon. The use of morphin and scopolamin was begun in 1904, at which time practically all surgery was done under general anesthesia. Divided doses were usually used and the total amounts have varied from | gr. morphin and 1-400 gr. scopolamin to | gr. morphin and (4T gr. of scopolamin. The size of the dose must depend upon a number of circumstances. The age, weight and temperament of the patient are influencing factors. However, a more important con- sideration is the surroundings in which the patient is placed at the time the drugs are given. The matter of assuring the patient a perfect night's rest on the night preceding the operation is also an influencing factor. We have already referred to the absence of unnecessary fussing with the patient on the morning of the opera- tion. If narco-local anesthesia is to be employed the drugs should be given hypodermically and in repeated fractional doses, the first dose being given as soon as the patient awakes. The curtains should be drawn, the room made quiet and visitors excluded. In transporting the patient to the operating room the utmost gentle- ness should be employed (see Chapter III, page 72). Music is a valuable adjunct in these cases. The amount of the drugs to be used cannot be specifically stated here. Usually the responsibility for this is placed upon the psycho-anesthetist, who watches the patient from time to time and orders the medication in doses sufficient to bring the patient to the operating room in the condition desired. Experience indicates that massive doses should not be used and the effect of the narcotic should not be depended upon for the production of anesthesia. It is unnecessary to bring the patient 1 Surg., Gynec. and Obst., No. 5, 12. 524. 2 Farr, Robert Emmett: Narco-local Anesthesia, St. Paul Med. Jour., May, 1916. 133 SYNERGISTIC ANESTHESIA into a condition of deep sleep and but small doses are required in order to make him more or less oblivious to what is transpiring, especially if other details are carefully looked after and irritation avoided. In one series of cases (300 in number) in which a complete " twilight sleep" was attempted it seemed that with proper attention to detail it was unnecessary to deeply narcotize prospective candi- dates for operations under local anesthesia, at least with any combination of drugs which has been presented up to the present time. The performance of operations under local anesthesia with- out pain to the patient makes the employment of heavy doses of narcotics more or less unnecessary, and experience seemed to show that the psychic demands are not sufficiently great to require their use in exceedingly large doses. In dealing with extremely nervous patients or those with toxic thyroids, preliminary medication becomes a somewhat important ally, especially in the cases with thyroid complications (see Chapter VIII, page 243; Chapter III, page 72). In these patients the drugs are administered in doses of sufficient size to eliminate the psychic disturbances and to make the patient more or less oblivious to what is going on about him. However, the amount required for this purpose is maintained at a minimum by proper handling of the patient and proper control of his surroundings. The trial trips to the operating room which are made on days previous to the operation also serve to cut down the amount of preliminary drugging which is required in order to obtain the desired effect. SYNERGISTIC ANESTHESIA. As a substitute for scopolamin and morphin, Gwathmey,1 has made an extensive study of the synergistic action of magnesium sulphate when combined with morphin sulphate and given hypo- dermically. He concluded from animal experiments and clinical observations at the Presbyterian Hospital, New York, that (1) general analgesia cannot be obtained with morphin sulphate and magnesium sulphate; (2) that morphin sulphate gr. | and 2 cc of a 25 per cent magnesium solution repeated three times hypo- dermically at short intervals as of one-half hour just before operation gave a more complete analgesia and relaxation with nitrous oxide and oxygen than could be obtained with ether, that the amount of oxygen that could be used was greater (35 per cent plus) when the synergistic method was followed and (3) that the magnesium sul- phate so used with morphin increased the effectiveness of the latter from 50 to 100 per cent. 1 Synergistic Colonic Analgesia, Jour. Am. Med. Assn., January 22, 1921, 76, 222. 134 GENERAL TECHNIC The author has used this combination of drugs somewhat exten- sively during the past two years, and while he believes its use en- hances the effect of the morphine somewhat, he cannot satisfy him- self that it does so to the degree which Dr. Gwathmey suggests. He finds that some caution is necessary in regard to the manner of administration. A number of sloughs have occurred in cases in which the nurse injected the magnesium sulphate intradermally, and even subdermally. The hypodermic injection should be made entirely subdermally and not intradermally and preferably intra- muscularly. Furthermore, it should be given slowly. The experience of the past six years has not clarified the narco- local situation to any extent. The writer is still of the opinion that this form of anesthesia, especially if followed by small doses of scopolamin and morphine for two or three days after operation, will give the patient the greatest comfort of any method produced to date. In fact, it can be made to practically eliminate all the dis- agreeable subjective features connected with an operation. It seems that no other form of anesthesia compares with it. The relaxation, quiet, absence of engorgement of the tissues and the time allowed for the work all combine to make this the most ideal method of anesthesia yet evolved. However, the question of its safety submitted in the paper referred to has not been answered with satisfaction. Too many reports indicate that this large dosage is dangerous and the literature contains many reports of deaths following the administration of scopolamin in large doses. In Chapter 11,1 this subject is referred to more in detail under the pharmacology of the drugs used as a preliminary to local anesthesia. To summarize, it may be said that preliminary medication bears much the same relation to local as it does to general anesthesia and is therefore to be considered as a source of solace to the patient in either case. The indications for its use are about as marked in one as in the other. As an adjunct it does reduce the amount of general anesthesia used. It does not materially alter the quantity necessary when local anesthesia is employed. Its main advantage is in tiding the patient over the hours immediately preceding the operation, and this event assumes much the same importance in all cases and is as necessary when general as when local anesthesia is used, although this fact is apparently not generally recognized. Massive doses of narcotic drugs given for the purpose of replacing local or general anesthesia are too dangerous to be recommended. Moderate doses of standardized drugs, when carefully controlled, are of the utmost importance and their advantage probably largely offsets the disadvantage. THE PREPARATION OF A PATIENT 135 THE PREPARATION OF A PATIENT FOR AN OPERATION UNDER LOCAL ANESTHESIA. Psychic.-The preparation of a patient for operation under local anesthesia involves many considerations both psychic and physical. One must remember that at the present time local anesthesia is under a decided handicap as regards the mental attitude of the prospective patient. This handicap is no different from that under which general anesthesia labored before people had become accustomed to its use and the degree varies with the education of one's clientele. Obviously, the patient who has never heard of the method, or one who has heard nothing but unfavorable reports concerning it, will approach an operation with prejudice against it. The same condition prevails in the patients who have undergone an operation under so-called local anesthesia which was a failure. Attention has already been called to the necessity of paying attention to every detail which will reduce or eliminate the causes of irritation and worry on the part of the patient from the time he comes under treatment; also that the preliminaries, such as shaving, douching, bathing and saying farewell to friends, should be disposed of the day before the operation, if possible. The night preceding the operation should be one of rest for the patient if it is at all possible to attain this desideratum. A wakeful and uneasy night is a potent factor in disturbing the tranquility of a patient. The writer does not hesitate to give a liberal dose of some somniferent, such as veronal, trional or even morphin, when pain presents, to every patient the night preceding operation. The manner of handling patients during the hours which just precede the operation is one of the perplexing problems for all who have made a study of the patient's comfort and have endeavored to allay the anguish of anticipation with which most people are to a greater or lesser degree afflicted. It is well to instruct the nurses to avoid the usual routine of awakening the patient when he is having a sound sleep and to omit the ordeal of a bath or rub to which he is unaccustomed. Instead the patient is allowed to sleep until he requests some service. He is given to understand this the night before and many patients will sleep quite late in the morning if undisturbed by the night-nurse, who is usually much like the obliging Pullman porter who gets the passengers up sufficiently early so he may have his work cleaned up when the train pulls in. A light breakfast, consisting largely of fluids, but depending, of course, upon the nature of the operation to be performed, may be allowed. The friends are usually not allowed to see or converse with the patient and as a rule the shedding of tears, wailings, expressions of sympathy as well as advice and fond farewells are excluded from the 136 GENERAL TECHNIC preoperative program. The morning paper, prayer-book or other reading matter are not objectionable unless preliminary narcotics are administered. In such cases the shades are drawn, the doors closed and every effort made to have the patient doze away the hours which otherwise might pass disagreeably, and at a cost to the patient's economy which as yet have not been measured or calculated. THE APPLICATION OF REGIONAL ANESTHESIA. Both venous and arterial anesthesia have points of excellence and under certain conditions give satisfactory results. Venous anesthesia is a strong competitor of brachial anesthesia for producing anesthesia of the region of the elbow joint. Arterial anesthesia has limited advantages, although it may be indicated occasionally in work upon the extremities. Its employ- ment necessitates an exposure of a vessel supplying the part, which is more or less of a disadvantage. Regional anesthesia finds its most appropriate fields in the work upon the jaws, mastoid, neck, upper extremity, thorax and inguinal canal. Even in these localities, in some instances it must be reinforced by infiltration anesthesia, except perhaps in the case of the trigeminus nerve and the brachial plexus. The blocking of the trigeminal at, or just distal to, the Gasserian ganglion is a proced- ure which gives absolute anesthesia. However, we have found that with an infiltration anesthesia about the area to be operated upon, combined with infiltration in the course of the branches of the nerve, a satisfactory anesthesia maybe obtained (Figs. 49-58). In this way we avoid the nausea and vomiting and possible danger of the intracranial injection and reduce the margin of error which exists, even in the hands of the most expert, in reaching the ganglion. The blocking of the inferior dental nerve may be accurately done and it has almost no margin of error. In the tonsillar operations regional blocking is desirable in order to avoid obscuring the field of operation, which results from infiltration of the pillars. Here the subcapsular infiltration is also acceptable. In all work upon the neck the cervical nerves should be blocked but the anesthetic should be reinforced by a subdermal infiltration along the lines of incision and the field of operation should be circumscribed subdermally as well. Nothing can be more satisfactory than brachial anesthesia which was first used by Crile, who exposed the nerves before injecting, a technic which was simplified by Kulenkampff (Fig. 30, page 130). The anesthesia is immediate, certain and easy to induce. The amount of solution required is small. However, in order success- 137 DIRECT INFILTRATION-REGIONAL ANESTHESIA fully to carry out this procedure, oue must have the full and intelli- gent cooperation of the patient, and this naturally eliminates this form of anesthesia in a certain percentage of cases. Children and nervous, ignorant or unreasoning adults cannot give the surgeon the information regarding the contact of the needle point with the nerve bundles upon which the success of this procedure so largely depends. Anesthesia may be obtained without the cooperation of the patient by making an infiltration in the region of the plexus instead of definitely transfixing the nerve bundles, but on account of the close proximity of the subclavian vessels one will prefer to make a transverse infiltration block of the limb lower down, as shown in Fig. 99, page 274, or to employ venous anesthesia. In work upon the chest, regional anesthesia is of much value. The bony landmarks render the locating of the nerves easy and certain, and the margin of error is small. The use of the method in the operation for the radical removal of the breast has made this method a routine procedure and by its use the author has been enabled to perform this operation painlessly under local anesthesia. In the benign diseases of the breast, on the other hand, infiltration anesthesia is most satisfactory in our hands. Thoracotomies, costectomies, and the like, are best done under a combined regional and infiltration anesthesia. The operation for inguinal hernia is best done under regional block as an infiltration would obscure and interfere with the identi- fication of the tissues; but even here the time may be greatly shortened by employing a subdermal infiltration along the line of the proposed incision, (Fig. 171, page 404). In work upon the hip, for example, the nerve supply is best reached by an infiltration anesthesia, while lower down " infiltration block" may be used. The femoral, superficial external peroneal and anterior tibial are easily located and blocked. However, the blocking of the sciatic is not easy, and the "spearing" for the other nerves is not the simplest thing in the world. The writer much prefers a transverse block by the infiltration method, shown in Fig. 100, page 274, making a special effort to deposit a generous amount of the solution near the location of the larger nerve trunks. DIRECT INFILTRATION AND REGIONAL ANESTHESIA CONTRASTED. In general terms the methods which are available to the surgeon are some form of infiltration or regional anesthesia. The merits of these two methods it seems wise to evaluate somewhat at length. The adoption of local anesthesia will be influenced, to some degree, by the choice of methods on the part of surgeons who use local 138 GENERAL TECHNIC anesthesia in the future. On this account the following discussion is introduced: There is no question that the ideal method of producing local anesthesia, looked at from a purely academic standpoint, is by the regional method. It sometimes has the advantage of minimizing the amount of solution used. The field of operation is not disturbed. Its successful exhibition shows such a clear knowledge of anatomy on the part of the surgeon who employs it successfully and its results are so spectacular that it at once appeals to the observer, as well as to the reader, as the most precise, scientific, safe and therefore the most desirable method of securing local anesthesia. Indeed, if it were not for some of the shortcomings which this method presents in actual practice it would leave little to be desired. However, one must consider conditions as they present themselves rather than from the standpoint of the ideal. It is perfectly obvious that the vast majority of surgeons fail to avail themselves of the benefits of local anesthesia, although these benefits are perfectly apparent, and indeed are admitted by most surgeons at the present time. Why, then, do the majority of surgeons fail to make use of these advantages? It is believed that one of the most potent reasons is the fact that the methods thus far presented are rather difficult for the average surgeon to acquire, and that even after their acquisition they are found to be tedious and irksome and unless the technic be especially well mastered the results are liable to be disappointing. While it is unquestionably desirable to employ only a minimum amount of solution in each case, many other important factors present themselves for consideration. A sufficient amount of solution to produce analgesia must be used. The solution should be injected in such a manner that the patient is caused a minimum amount of discomfort while the injection is being made. (This applies not only to the actual introduction of the needle and the solution but to the manner of preparing special fields, as when regional anesthesia is used.) The element of time is important and the amount of time consumed should therefore be reduced to a minimum on account of its advantage to the surgeon as well as to the patient. The expenditure of energy on the part of the surgeon should be as slight as possible. While the first of these requirements-the establishment of anal- gesia-is an absolute necessity and admits of no half-way methods, the importance of time and expenditure of energy is more or less relative; these factors, however, must be reckoned with in the competition offered by general anesthesia. In this competition with general anesthesia it must be remembered that the matter of Simplifying the technic of local anesthesia 139 administering the anesthetic, when local anesthesia is used, often becomes the duty of the surgeon himself and cannot as a ride be detailed to a subordinate. It is therefore desirable that the details of the actual administration be simplified as much as possible and in addition that the acquisition of the requisite training be simplified and all complicated and difficult methods be eliminated whenever less complicated ones will answer the purpose. Unquestionably the method which is most easily acquired and is the simplest of execution and the most devoid of complicated details is that known as direct infiltration in the region where the incision is to be made. With the proper equipment this method of producing analgesia possesses the attributes of speed, painlessness and accuracy, and demands the minimum outlay in energy and training on the part of the surgeon-extremely important points in relation to the question of the more universal adoption of local anesthesia. Even where regional anesthesia is used we find it more satis- factory to make what I have designated as "infiltration block" than to endeavor to accurately place the needle point upon or within the nerve tissue. The trigeminus, brachial plexus and the sciatic nerve may be transfixed by the needle, but in the case of most of the other nerves we prefer to deposit a liberal amount of the solution in the region where the nerve is known to lie. In so doing less accuracy is required and, in my experience, the results are more certain. The details relating to this method will be further con- sidered in the respective discussions of operations upon the various regions of the body. DESIRABILITY OF SIMPLIFYING THE TECHNIC OF LOCAL ANESTHESIA AND SOME ADVANTAGES OF INFILTRATION ANESTHESIA. The future development and the more universal use of loeal anesthesia will depend to a great extent upon our ability to make the technic so simple and easily acquired that it will be more readily available to surgeons than is now the case. Undoubtedly most surgeons could master the technic of regional anesthesia would they but give it the required amount of attention. But even many of those who recognize its advantages consider that the expenditure necessary in order to become expert in the work is too great. Even the expert at times grows tired, as Hertzler says, "of spearing for nerves." The novice certainly becomes easily discouraged and is apt to forsake the method long before he has acquired sufficient skill to return him much satisfaction. Even from the patient's standpoint the technical difficulties of making multiple nerve blocks are annoying and the reports given by some of these patients 140 GENERAL TECHNIC constitute one of the cogent reasons why local anesthesia is at times in bad repute. The easier the induction of local anesthesia is made for the surgeon, the greater the speed with which it is done, the less the patients are disturbed by its administration, the less pain they suffer, and the more easily the technic is acquired the more satisfactory will the use of this method be found. Take, for instance, the operation for the removal of the appendix: Should the patient first be turned upon his face or left side and have his back prepared for a paravertebral injection and have an attempt made to spear the nerves supplying the region of the proposed operation, then change his position and have a new field prepared and the operation begun after the delay of some fifteen minutes? or, should the patient be placed in position for operation and only one field prepared, the anesthetic introduced, utilizing only two or three minutes, and the operation be begun at once? Anesthesia will be equally good with either method, but, on the one hand, much time has been consumed, the patient has been repeatedly pricked by a needle in an unanesthetized area, two fields have been sterilized instead of one and there has been demanded of the surgeon a minute, technical knowledge which can be gained only by much work upon the cadaver and repeated attempts upon the living sub- ject. Again, one might ask "What is the objection to direct infil- tration in such a case?" The solution does no harm to the tissues, the difference in the amount used is insignificant, the tissues are in no way obscured by its use, and after comparatively few attempts the novice may acquire a working knowledge of the method once it is properly explained and demonstrated to him. During recent years, upon three different occasions, the author demonstrated to visiting surgeons that the novice can master the technic of infiltration anesthesia with comparative ease. The argument was advanced that inasmuch as he had concentrated upon this work for many years, it appeared easy and simple to him, but that others would be unable to do the work with satisfaction without prolonged and intensive training. On each of these occasions it so happened that the assistant had been in service not to exceed six weeks, and had never performed an appendi- cectomy. In order to prove the point, the assistant was ordered to administer the anesthetic and to proceed with the operation. In each case the anesthesia was classed as "ideal" and was satis- factory in every way. None of these young men had assisted in more than five similar operations and no special effort had been made to teach them the technic, and yet each found himself equipped to perform an appendicectomy under local anesthesia after this brief period of training. It is improbable that this would have held true had regional methods been employed. It is not wished to SIMPLIFYING THE TECHNIC OF LOCAL ANESTHESIA 141 detract in any manner from the excellent and deserved standing which regional anesthesia undoubtedly enjoys and the author is unreservedly in agreement regarding its possibilities. Yet there are a great many operations which lend themselves to the use of infiltra- tion anesthesia, and for these the technic may not only be more easily acquired but more easily and rapidly applied, and with a smaller margin of error than when regional anesthesia is attempted. In the excellent monograph upon regional anesthesia by Sherwood- Dunn (page 168), in which he describes the Victor Pauchet technic, which may be said to reflect to some extent the present status of the situation in France, the comment is made that in order to secure complete anesthetization for pelvic surgery it is necessary to block the 6 lower thoracic, 3 lumbar and 3 sacral nerves on each side. This would actually mean a blocking of 24 separate nerves in order to secure complete anesthesia. It is small wonder that the same author concludes that local anesthesia is not satisfactory for pelvic surgery and states that they prefer intraspinal anesthesia and use it as a routine procedure. If those who are to be considered experts in the use of local anesthesia give the surgical profession the impression that it is necessary to master and use this complicated technic in order to do abdominal surgery, it may be taken as a foregone conclusion that the method will not be accepted by any but a few specially trained experts who are enthusiastic enough to perfect themselves in its use. If, on the other hand, surgeons can be made to realize that a proper infiltration of the abdominal wall, together with splanchnic anesthesia, will enable one to perform many, and indeed most of the abdominal operations, that this infiltration can be learned with comparative ease, and that with proper equipment analgesia can be established in from three to five minutes, and that the operation may then be begun at once, the prospect of obtaining its adoption will be greatly enhanced. The main difficulty seems to lie in convincing surgeons, and even expert local anesthetists, that a procedure so simple will give the desired results. As a matter of fact, infiltration anesthesia may be said to be almost ideal for the simple pelvic operations, such as the removal of an appendix, suspension of the uterus, and the removal of small fibroids or ovarian cysts. Even in the presence of adhesions and complicated pathology, many of the conditions may be met with a great deal of satisfaction, provided the proper strategy is employed. With the addition of sacral anesthesia, the induction of which is much more simple than the induction of anesthesia by the paravertebral method mentioned above, pelvic work of any character may be performed under local anesthesia. Considering the relative merits of direct infiltration and para- vertebral block, for instance, it might be well to refer to the follow' 142 GENERAL TECHNIC ing comments made by Prof. Braun concerning paravertebral anesthesia :l To anesthetize the larger part of the abdominal cavity by para- vertebral anesthesia requires the blocking of a considerable number of segments. Kappis reports that the intestine is supplied bilater- ally in its entire course, and thus an operation on but one side of the abdominal cavity calls for bilateral blocking. Pelvic operations require in addition blocking of the sacral plexus and Reinhard and Siegel combine paravertebral with parasacral anesthesia. Reports of (1) abdominal laparotomy show that 22 skin punctures and 330 cc of 0.5 per cent solution are required; (2) pelvic laparotomy, 20 punctures and 400 cc; (3) vaginal, uterine and adnexa operation, 10 punctures and 400 cc, which were all bilateral; and a nephrectomy with 12 unilateral punctures and 240 cc. Braun and Kappis did not get anesthesia of the appendix with unilateral paravertebral injections, but only anesthesia of the abdominal wall and parietal peritoneum, and to get the desired anesthesia, Braun suggests a much simpler method. A unilateral paravertebral block in the kidney operation likewise does not produce complete anesthesia of the pedicle. On the other hand Jurasz did 2 cholecystectomies (complicated) with but a unilateral block. Aside from the above features, the technic of paravertebral blocking is not easy for the beginner, which is the case with any technical procedure. I nder no circumstances must the needle be allowed to approach too near the intervertebral spaces. Wilms, Franke and Kappis noted severe collapses following paravertebral injections, which they explained by novocain entering the spinal canal. Muroya, in previous experiments, had shown that novocain is more toxic in paravertebral administration than when injected subcutaneously. Close adherence to the technic of the various authors should avoid puncturing the intervertebral spaces them- selves, especially if one does as Siegel does-that is, make the point of initial injection a considerable distance from the midline. Jurasz also is right when he says that it is not necessary to blame the bad effects to entrance of novocain into the spinal canal, but that the total dose of novocain used is too great. When one considers that Kappis uses as much as 3.3 gm. of novocain in 1.5 per cent solution and Siegel 2.3 gm. in 0.5 per cent solution, one must consider this argument. It must be admitted that the weaker solution of Siegel is the more commendable in warding off bad effects. 1 Braun, H,: Local Anesthesia, 5th edition, 1919, p. 334, METHODS OF ADMINISTERING LOCAL ANESTHESIA 143 Because of the numerous injections (20 to 22) required in para- vertebral anesthesia, the patience of both surgeon and patient is heavily tried. Braun agrees with Hartel in spite of the recom- mendations of Reinhard and Siegel, that the question of regional anesthesia in abdominal operations, by means of paravertebral injections, has not yet been satisfactorily solved. Thus it is interesting to note that this master in the use of local anesthesia is not wedded entirely to the regional method, as he states that simple infiltration suffices for many varieties of abdomi- nal operations. His realization that, through strategy, the avoid- ance of traction, the abolition of reflexes, and so forth, one is per- mitted to carry out these procedures is apparent. When one considers the amount of solution used and the extensive and complicated technic required for carrying out a paravertebral block it is not to be wondered at that a man with the experience and judgment of Braun is somewhat dubious concerning the advantages of the paravertebral method. In the experience of the author it is unusual to spend more than five minutes in inducing anesthesia by the direct infiltration method. Furthermore, it is unusual to use more than 200 cc of solution in order to obtain anesthesia of the abdominal wall. Even to the expert, direct infiltration presents advantages which cannot be gainsaid, and to the novice the development of knowledge concern- ing the technic of paravertebral block seems an insurmountable obstacle. The end-result may be said to be an inhibitory influence upon the surgeon who otherwise might gradually develop ability to employ local anesthesia. THE CHOICE OF METHODS OF ADMINISTERING LOCAL ANESTHESIA. The choice of methods is influenced by a variety of factors. Intraspinal anesthesia, which is the ultimate refinement of the conduction or regional method, has not been used to any extent by the author on account of his belief that in the hands of any but the most expert this form of anesthesia subjects a patient to unnecessary hazard. While it is his belief and hope that ere long methods will be developed whereby the average surgeon may use intraspinal anesthesia with safety, his impression is that at the present time too many lives will be lost by a surgeon while developing a knowledge of the technic to justify its use as a routine measure by the average surgeon. An argument often brought forward in the presentation of the merits of regional anesthesia is that this method requires the use of less solution than does the infiltration method, with attending 144 GENERAL TECHNIC decrease in danger from absorption. It is questionable whether the alleged advantage is a great one, as some of the solution used in infiltration anesthesia escapes through the incision which is made directly through the edematous area, while all the solution used in regional anesthesia remains to be absorbed. While the author does not believe that its absorption has a very deleterious effect upon the economy of the patient, the point must be recognized in forming judgment upon the relative merits of the two methods- regional versus infiltration anesthesia. As a matter of fact the reports from the clinics of those who use paravertebral anesthesia fail to convince one that the regional method, in abdominal work at least, is to any extent a conserver of the anesthetic solution. On account of its Haws, the author feels that regional anesthesia meets in direct infiltration a competitor with so many points of excellence that, in many instances, the "ideal" may well be replaced by this more practical method. Direct infiltration possesses the obvious advantages of speed, simplicity, wide application, and the important attribute that the technic may be acquired and accom- plished with comparative ease. True, in the hands of the expert, regional anesthesia is efficient in certain areas, and the more expert one becomes, the more perhaps may he depend upon this form of anesthesia. It is believed, however, that for routine abdominal work where direct inHitration is not contraindicated it will more and more become the method of choice in the hands of the average surgeon. The conclusions of Braun, arrived at only after rich experience, are very significant. The conviction holds that direct inHitration, which is extremely simple provided the proper equipment, strategy and a refined surgical technic be used, will make infiltration anes- thesia a worthy competitor of the paravertebral method. Infiltration Anesthesia Technic.-As stated above a most impor- tant factor is the actual manner of introducing the anesthetic solution. If one bears in mind that the introduction of the anesthetic comes at a time when the apprehension of the patient is the greatest, when the method, so to speak, is more or less on trial and when every painful sensation is apt to be magnified by the apprehensive patient, it is perfectly obvious that at this stage of the procedure actual discomfort must be reduced to a minimum. Here the nerve block or regional anesthesia is less reassuring than is infiltration anesthesia. By the observance of the rules laid down later on in this chapter, (page 149) it is possible to make a complete infiltration of a given field almost without any painful sensation, except in the production of the first wheal, provided the injection is made at the proper cadence and the necessary precautions are taken. From the standpoint of the psychic element alone it would seem 145 METHODS OF ADMINISTERING LOCAL ANESTHESIA expedient to simplify as much as possible the methods of producing local anesthesia. The equipment, technic and manner of handling the patient, the esprit de corps of the operating force, all play a part in reducing that disturbing element known as "psychic incom- patibility." In using infiltration anesthesia one may make use of the advantages to be derived from the non-necessity of changing the patient's position and preparation of two fields. The psychic disturbances are not nearly so marked in cases in which the patient may be placed comfortably upon the operating table and allowed to remain without change of position while the anesthesia is being given and the operation proceeds. It is not an uncommon practice with the author to "slip over" the operation upon the conscious patient without his knowledge of the fact that he is being operated upon. The psycho-anesthetist gives the patient the impression that he is being prepared and many times an operation may be com- pleted, or nearly completed, before the patient realizes that it is actually in progress. In using regional anesthesia no such oppor- tunity is offered. In a recent monograph on the subject of local anesthesia the statement is made that the infiltration of the skin from beneath is a painful procedure-if anything, more painful than the production of intradermal wheals when these are made in the usual manner from without. On the contrary experience demonstrates that intradermal wheals may be made frpm beneath without the slightest sensation of pain. A realization of this fact and the application of the principle involved is the most important factor in the painless introduction of local anesthesia solutions. By making all secondary wheals from beneath, as shown in Fig. 31, page 149, the painful sen- sations produced by the needle are at once eliminated. In a lipec- tomy, for instance, it may be necessary even though a 10 cm. needle is used to puncture the skin at ten or a dozen different points in order to sufficiently anesthetize the field. The average individual will not lie and complacently submit to this procedure without at least reflecting upon the assurance that he had been given, that the operation would be painless. The illustrations in works on local anesthesia show, in some instances, six or even eight points at which intradermal wheals are made in the unanesthetized skin. Only the most stoical and phlegmatic, or those deeply narcotized by preliminary hypodermics, will submit to this procedure without offering complaints. During a visit to a clinic of a most excellent surgeon the author saw this point well illustrated. The patient, a splendid candidate, was prepared for the hernia operation. As a preliminary, four points were marked upon the skin, outlining the proposed area to be injected. The marking was done with a needle, a little cross 146 GENERAL TECHNIC being made upon the skin at each point. This procedure was not especially painful. However, the patient, although not particu- larly apprehensive, complained, the vociferousness of his complaint being in exact ratio to the number of crosses made. That is, the complaint elicited by the making of the fourth cross was approxi- mately four times as vigorous as the one following the making of the first. The next step consisted in making an intradermal wheal at each of the designated points. The production of the first wheal was accomplished by a still more vigorous complaint, the patient moving about somewhat on the table and the surgeon manifesting some embarrassment, the fact being apparent that both of these individuals were beginning to lose their self-control. After some argument the second wheal was attempted but the patient refused to permit further wheals to be made. The surgeon then called for general anesthesia and the operation was performed under its influence. One must bear in mind that the introduction of a hypodermic needle through the skin is accompanied by exactly the same amount of pain as is the introduction of a sewing needle through the skin, and, while no one will object greatly to this procedure being carried out once, its repeated performance will seldom be tolerated. Even where regional anesthesia is employed, the intradermal wheals should be made from beneath, as illustrated on page 149, Fig. 31, so that the needle punctures necessary for reaching the separate nerves will be entirely painless. In the chapter on Abdominal Surgery this subject is considered somewhat more in detail. The comparative harmlessness of novocain, if used in weak solution, 0.5 to 1 per cent, and properly retained in the tissues by the use of adrenalin or the tourniquet, has given a great impetus to the infiltration method. In addition, the complete establishment of anesthesia before beginning the operation has also made this method extremely practical and satisfactory. And, finally, the development of the Pneumatic Injector (see Fig. 5, page 89) has made the induction of the anesthetic so simple, easy, accurate and rapid that the former complications, difficulties, errors and partial failures have, in the author's clinic, almost entirely disappeared. A certain established routine technic for a definite region, or for the performance of a certain operation, will result in a definite, fixed response on the part of the tissues with almost no margin of error. There need be little guesswork about this matter. The margin of safety is sufficient so that the surgeon may establish anesthesia in every case. Other things being equal, a certain area will demand a definite amount of the solution, and this amount need only be increased in case the mental attitude of the patient is such that any error might lead to trouble with this SOME CAUSES OF FAILURE OF LOCAL ANESTHESIA 147 particular patient. Provided the solution is deposited in the tissues which are known to require it there will be but slight danger in using a sufficient amount to insure anesthesia. SOME OF THE CAUSES OF FAILURE OF LOCAL ANESTHESIA IN ABDOMINAL SURGERY. NEGATIVE PRESSURE * What are the usual causes of failure to obtain a satisfactory working condition when the abdomen has been opened under local anesthesia? Surgeons have frequently said to the writer when discussing this subject, " I can open the abdomen without any complaint on the part of my patient, but as soon as the abdomen is opened the intestinal coils present themselves in the incision and, unless forcibly restrained, protrude through the wound." When this occurs the intestines must be forcibly restrained by means of gauze pads and this restraint will be responded to by the patient and by his abdominal muscles in no uncertain manner. Forcible restraint of the abdominal viscera under pressure will almost invariably cause a reflex expulsive effort, which will only serve further to increase the intra-abdominal pressure. Thus a vicious circle, so called, has been established; the increased pressure upon the viscera produces an increase in the expulsive effort which, in turn, demands a further increase in pressure. When this condi- tion presents itself it will usually be necessary to administer general anesthesia and complete the operation under its use. Though such a condition may be present occasionally when using local anesthesia under the best of auspices, it should not, as a rule, be met with and its occurrence is almost always a direct evidence of inefficiency in the manner of inducing local anesthesia or in the type of surgical technic employed. Experience during recent years has shown that it is not only entirely possible to avoid the positive intra-abdominal pressure when the abdomen is opened, but to find in its stead what is termed "negative pressure." While there are exceptions to this rule, notably in acute abdominal conditions in which marked distention is present or in individuals with chronic recurring types of trouble who develop extreme sensitiveness of the intraperitoneal organs and tissues, it is safe to say that the "negative pressure," so called, can usually be obtained. Even in the presence of peritonitis with distention a perfect anesthesia of the abdominal wall, combined with the proper technic when making the incision, will usually present a condition of quiescence of the viscera and, even though the organs do not fall away from the abdominal wall, there will be no effort * Referred to in an article read before the section on Obstetrics, Gynecology and Abdominal Surgery at the Sixty-eighth Annual Session of the American Medical Association, June, 1917, and in Journal-Lancet June 1, 1917, 148 GENERAL TECHNIC at protrusion. Under these conditions one may by the use of vertical retraction and the careful application of gauze pads carry out rather extensive procedures upon even acute cases. While it is realized that there are certain individuals and types in which this negative pressure cannot be obtained, just as there are types of cases and individuals that are incompatible with the use of local anesthesia, the cause of failure lies usually with the surgeon, rather than with the patient. GENERAL CONSIDERATIONS REGARDING THE INDUCTION OF LOCAL ANESTHESIA AFTER THE TIME HAS ARRIVED FOR THE GIVING OF THE ANESTHETIC. Perhaps the most important period to be bridged while carrying a patient through the ordeal of a surgical operation under local anesthesia is that during which the anesthesia is actually being introduced. The success or failure of the procedure is dependent to such a large extent upon the deportment of the surgeon during these few minutes that one may predict on the one hand a smooth, efficient anesthesia with a successful operation upon a contented patient, or on the other a disgruntled, irritated or apprehensive patient, whose confidence has been lost at the very beginning, and upon whom a successful operation cannot be carried out because of technical errors which have crept in. As a rule the condition described is due to the fact that the patient has been subjected to pain during the infiltration and making of the incision, notwithstanding the fact that he may not have complained. Surgeons differ very materially in their estimate of this factor. Some call a procedure "painless" when a patient is continually flinching and making grimaces in direct consonance with each painfid maneuver on the part of the surgeon, or even when mild restraint is necessary. Others call a procedure "painless" when they have been repeatedly called upon to reinforce the anes- thesia, while some even consider a procedure "painless" when the patient is fervently grasping some friendly bystander by the hand and hanging on for dear life. In the introduction of the solution certain fundamental principles must be followed in order to insure success, no matter whether regional or infiltration anesthesia is used. The less the delay after the patient enters the operating room and the smoother the action of the operating room force in making the preparation, the better will be the mental condition of the patient and the lighter will be the tax put upon the surgeon in carrying out the operative procedure. The surgeon's confidence and in fact the confidence of his staff of helpers will be vividly reflected in the patient's demeanor. THE INTRODUCTION OF THE ANESTHETIC SOLUTION 149 THE INTRODUCTION OF THE ANESTHETIC SOLUTION. Technic. -The Initial Wheal (Fig. 31, A).-When introducing the solution the development of the initial wheal is accompanied by certain preliminaries which are designed to relieve the tension under which the patient may be laboring. These preliminaries vary, depending upon the circumstances, but usually consist of a slight sponging, pinching or patting of the skin over the field of operation. As the first needle prick is about to be made the psycho-anesthetist cautions the patient, stating that the doctor is about to administer a hypodermic. At the same time the surgeon may request the patient not to move when he feels the needle-prick. When these Fig. 31.-Painless method of inducing anesthesia. A, initial wheal; B, secondary intradermal wheal made from beneath (painless); C, subdermal infiltration with needle receding. precautionary measures are omitted the unprepared patient is surprised; his confidence, which already may be more or less nega- tive in quantity, is apt to be shaken and a slight movement on his part is apt to result in dislodging the needle point, thus making it necessary to repeat the procedure. Each detail alone, though of apparently minor importance, assumes great significance when all of the small errors in technic are considered in the aggregate and it is the cumulative effect of a series of minor "overt acts" which is most often the cause of failure in carrying out an operation under the use of local anesthesia. Anesthetization of the Skin Line. - Intradermal Method.-The skin may be anesthetized by means of either an intradermal or sub- 150 GENERAL TECHNIC dermal infiltration. The method of making the intradermal injection is as follows: The needle point is introduced beneath the superficial layers of the skin and the solution is deposited directly into the layers of which the skin is composed, a skin wheal being made. The needle is then withdrawn, reintroduced near the edge of this initial wheal, and an adjacent area of skin is edematized. This process is con- tinued to any extent desired. This method results in the estab- lishment of immediate anesthesia, the main objection to its use being its irksomeness and the necessary loss of time when using it. We have replaced this method of anesthetizing the skin by the subdermal method, except in the anesthetization of the points upon the skin through which the needle must be inserted (Fig. 31, B and C, page 149). The Author's Subdermal Method.- The production of subdermal anesthesia is brought about by the introduction of the needle through an intradermal skin wheal and advancing it beneath and parallel to the skin, the solution being deposited directly beneath the skin layer, either while the needle is advancing or receding (Fig. 31, C, page 149). The subdermal infiltration, if made in close proximity to the internal layer of the skin, will produce anesthesia in a period of from one to three minutes. The employment of a subdermal infiltration has the advantage of speed and ease of execution, as the tissues through which the needle passes are non- resistant to both the needle and the injected fluid. By the use of this method an area of approximately the length of the needle may be almost instantly anesthetized with one stroke. The Painless Secondary Intradermal Wheal.- This method has an additional advantage, which is of prime importance in the introduc- tion of local anesthetic solutions. By its use one is enabled to develop secondary intradermal wheals (Fig. 31, B, page 149) from beneath without the production of pain. One may therefore, by making use of the subdermal infiltration for anesthetizing the skin and the subdermal route for the production of secondary wheals, greatly reduce the irksomeness and the time required for anesthe- tizing a given area and-a most important consideration-one may by following out this plan avoid the necessity of repeatedly pricking the unanesthetized skin of the patient. After making the initial wheal one important point is to be kept constantly in mind-the patient is to feel no more needle pricks throughout the procedure of making the infiltration. It matters not at how many points the skin is to be pierced by the needle, the unanesthetized skin must not be pierced. This may be avoided by the use of the following technic: The long needle is introduced through the initial wheal and advanced beneath and parallel to the skin THE INTRODUCTION OF THE ANESTHETIC SOLUTION 151 surface in the subdermal fat to a point within 2 to 3 cm. of its hilt. Just in advance of the needle point the skin surface is made to curve inward by making pressure upon it with the finger (see Fig. 31, B), or by the use of a flexible needle the point may be made to travel upward and engage in the skin. This is done by elevating the base of the needle as it advances, thus curving the needle. This painless method of anesthetizing the skin is the most important single factor in the technic of the administration of local anesthesia, and careful attention to the execution of its minutest detail will do much to facilitate the work. On the other hand when following the usual technic, or that usually seen at least where the patient is repeatedly pricked in an unanesthetized area, we must expect even the most stoical to ask for an interpretation of the term " painless." Even where the intradermal wheals are continued from the initial wheal and the skin infiltration for any distance, too rapid injection will cause pain. Besides, this process is slow, laborious and unnecessary. The subdermal infiltration will be found to give complete anesthesia in from two to four minutes and, as the deeper layers should be anesthetized before the incision is begun, this amount of time is sure to elapse before the incision can be made. The Technic of Deep Layer Infiltration.-After the outline has been made upon the skin by the more or less regularly placed wheals and the line of subdermal infiltration is made, the deeper layers are anesthetized before making the skin incision. There are many reasons why the method of injecting the tissues layer by layer while incising should be discarded, at least as a routine procedure. The delay occasioned by its use is in itself a sufficient reason to condemn it, especially as the complete infiltration is so satisfactory. It is felt, however, that the main objection to it is based upon the greater likelihood of the production of pain when this plan is followed. The immediate infiltration of the deeper layers gives the anesthetic time in which to act upon these tissues while the pre- liminary incision is being made, vessels secured and towels applied to the skin. Except in very fat persons one may quite accurately recognize the different layers as they are reached by the needle point and the required amount of solution may then be deposited. An approximate estimate of the thickness of the different layers, as well as a knowledge of the relative sensitiveness of the various tissues to be injected, is essential. Any errors as to the thickness of the different layers are to be checked by the impression made upon the patient as sensitive areas are encountered. In the abdominal wall, for instance, after the subdermal infiltration is made, the next layer of interest to be encountered is the aponeurosis. This layer can be recognized by its "feel" and by the fact that the patient will manifest signs of discomfort when it is reached, though if care is 152 GENERAL TECHNIC used this discomfort is slight. The anesthetist can usually catch the change of expression on the part of the patient, but a more desirable guide is the slight muscular contraction which invariably accompanies any appreciable insult to sensitive tissues. Once the approximate depth of this layer is estimated the fluid is deposited in sufficient quantity to produce anesthesia ahead of and about the needle point for some distance, thus making further punctures possible without the patient or the local part realizing that it is being done. A perfect knowledge of the anatomy of the region allows one to make the injection without any complaint on the part of the patient, and with only slight muscular protest. Of course, one must regulate the speed and amount of anesthetic used in a given area by the sensitiveness of the tissues, a condition dependent upon the location of the area attacked, as well as upon the make-up of the individual patient. For instance, one patient may allow the complete blocking for an appendectomy in two minutes without the slightest local or general protest, while in another patient of about the same dimensions five minutes may be required for the same procedure. The deep layers of muscles in the abdominal wall, while containing some sensory nerves, are relatively devoid of sensa- tion and need very little of the anesthetic. But, as there is little objection to the use of the solution here, it is better to play safe and to continue the injection as the needle advances toward the pre- peritoneal fat, which is the most sensitive tissue beneath the skin. This tissue is therefore approached and entered with a constant stream flowing from the needle. As soon as the slightest sign is manifested by the patient, or even if no signs, local or general, are shown, the area about the point of the needle is "soaked," the needle withdrawn and new fields attacked by a repetition of the procedure. The same precautions should be used by the surgeon when he is about to enter an area which may be sensitive, as when the first wheal is made. It is usually well to say, "Let me know whether you feel this," or "Is this sensitive?" Safety of Deep Infiltration. -There seems to be much timidity on the part of surgeons regarding the making of deep infiltrations into the abdominal wall. The dangers from this procedure are more apparent than real, and experience shows that they are practically nil. The author has repeatedly advanced the needle through the abdominal wall with the abdomen open and the fluid flowing from the needle in order to learn what takes place when this maneuver is carried out. Colored solutions have sometimes been used for this purpose. It has been found that, provided the needle is slowly advanced, the preperitoneal tissue becomes swollen from the out- flowing fluid and the peritoneum generally floats away from the needle point and is not subject to puncture, provided the needle is THE INTRODUCTION OF THE ANESTHETIC SOLUTION 153 not advanced rapidly (Fig. 211, page 490). The peritoneum may be punctured, reproducing the condition we have in the intraperitoneal injections of guinea-pigs and other animals in which, as is well known, intestinal injury does not occur. This fact is now estab- lished beyond question and should have a marked influence in simplifying the technic. In the case of visceroparietal adhesions the needle may be intro- duced either through the incised abdominal wall, that is, extra- peritoneally or upon the visceral side of the "white line," in order to bring about an infiltration of the visceroparietal junction. This maneuver will allow one to painlessly introduce the solution where it is required. While carefully carrying out the above methods in the minutest detail the field of infiltration is gone over methodically and sys- tematically with the object of not missing a fraction of a cubic centimeter. It is here that the use of the Pneumatic Injector (see Fig. 5, page 89) assumes a special role of superiority over the syringe. The constant source of supply of the solution relieves the operator of the necessity of filling or changing syringes, a maneuver which is prone to make the surgeon "lose his place" and to miss a small area, which may correspond to the location of a sensory nerve. Again, the lightness and adaptability of the cut-off allows one to develop an ability to "feel" the location of the needle point and to introduce and direct the needle with the greatest ease. The greatest advan- tage, however, is the elimination of "muscle tire," as the fluid is injected by the simple "tripping" of the thumb-piece of the cut-off, the hand never out of position and but slight muscular effort required. Once the sensitive tissues are thoroughly edematized anesthesia should be complete almost immediately, or at least before the various layers are reached by the scalpel. The skin may be incised directly after the deep injection is completed, and a secondary cleansing with iodin, alcohol or some other solution, is made. Technic of Skin Incision and Opening of the Abdominal Wall (See Fig. 212, page 490).-In making the incision in abdominal cases it is well to avoid making pressure upon the abdominal wall. Even with a perfect anesthetization the pressure produced by the use of a dull scalpel, especially in unskilled hands, will cause the patient discomfort even in the "interval" case, while in cases of acute or subacute infection pressure will not be tolerated. In order to meet this contingency the skin should be elevated between two pairs of towel clips while the incision is being made (Fig. 212, page 490). A sharp scalpel is used and multiple gliding strokes are made rather than a forceful pressure of the blade through the tissues. The delay necessitated by the placing of towels for skin exclusion allows the 154 GENERAL TECHNIC deep tissues sufficient time in which to become anesthetized and the incision is carefully carried down through the succeeding layers, care being taken not to slacken for an instant the vigilance regarding the elevation of the abdominal wall until the peritoneum is finally opened. SURGICAL TECHNIC AND SOME OF THE ADJUNCTS DEMANDED BY LOCAL ANESTHESIA. The no-hand-touch and feather-edge dissection which mark such an improvement in the newer surgical technic is most compatible with the use of local anesthesia; indeed, those most expert in the use of local anesthesia must be credited, to some extent, at least, with abetting the aforementioned improvement in the technic of general surgery. It is safe perhaps to say that as a universal proposi- tion the demands of local anesthesia and the patient's best interests are in this regard more or less identical. Sponging.-The simple procedure of sponging bleeding surfaces is much abused. As a rule, the small vessels will cease to bleed almost instantly through the formation of a clot in their severed ends, provided the clot is not forcibly removed by sponging. The average abdominal incision may be made almost without the use of artery forceps if this principle is recognized. Rough sponging will prevent Nature's styptic action and cause the bleeding to continue. In the author's clinic suction has been used largely to replace the use of sponges. A universal use of this principle will serve greatly to reduce the amount of oozing and will insure a better visualization of the field of operation. One must be exceed- ingly careful in the manner of sponging when doing abdominal work under local anesthesia. This point is frequently illustrated. Each new assistant must be repeatedly cautioned regarding it. As a rule, the less experience this individual has the more easily he will be trained to respect the tissues when sponging. The assistant who has had considerable experience in general surgery under inhalation anesthesia is almost always the worst offender, not only in regard to sponging, but in his manner of retracting wounds, applying artery forceps and in many other ways. One of the simplest ways of drying the field, especially in deep cavities in the abdomen, is by suction. This method causes less trauma and is more efficient than any other. It is deserving of more universal adoption. Tying of Ligatures.-The method of tying ligatures, while perhaps not of great importance, might be mentioned as a good indication of the respect a surgeon may develop for the tissues. SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 155 The drawing of ligatures back and forth through the gloved hand is not conducive to the carrying out of an aseptic technic, and while tying ligatures with the hands may be done deftly and satis- Operators right hand Operators left hand Fig. 32.-The forceps tie of Grant. A, B, C and D, tying first knot factorily on the surface of a wound, the carrying out of this procedure in deep cavities where the space is somewhat limited is almost sure to result in traction. The forceps tie, described by Grant, is so 156 GENERAL TECHNIC easily learned and so well fulfils the requirements that it is to be recommended in local anesthesia work. We have amplified the technic of the forceps tie, as shown in Figs. 32, 33, and 34, and have described them as the three-forceps and four-forceps method. The following description is reprinted from Surgery, Gynecology and Obstetrics:1 The Three-forceps and Four-forceps Knot. -In the tying of liga- tures during a surgical operation, it is desirable to use methods which conserve ligature material, eliminate handling of the ligatures by the gloved hands, facilitate tying in deep, narrow cavities, and possess the attribute of speed. The forceps tie described by Grant in Surgery, Gynecology and Obstetrics, May, 1918, page 559, possesses these attributes to a greater degree than does any other method. The method of Grant is shown in Fig. 32, A, B, C and 1). To complete the knot the forceps in the operator's right hand, B, is placed beneath the ligature instead of above it. The methods devised by the author, namely, the "three-forceps" tie and the " four-forceps" tie, are illustrated in Figs. 33 and 34, A, B, C and D, and are simply an amplification of the method of Grant. The Three-forceps Tie.-The "three-forceps" tie utilizes the assistant's hand, one of which is usually free. The technic is as follows: After the first portion of the Grant knot is tied the assistant presents the forceps (Fig. 33, A), preferably with the point directed toward the operator's face. The operator then loops the ligature about the assistant's forceps (Fig. 33, B) and "feeds" the short end of the ligature to the assistant (Fig. 33, 0). The assistant then simply makes taut the short end (Fig. 33, D) while the operator draws the ligature over the end of the assistant's forceps and forces the knot home. In working in deep cavities the operator may assist in completing the knot by making pressure upon the short end of the ligature with the needle holder, which he holds in his right hand (Fig. 33, D). The Four-forceps Tie.-The "four-forceps" tie is simply a duplica- tion of the Grant knot, except that while the operator is tying the first portion of the knot the assistant prepares for the second step (Fig. 34, A). By the time the operator has completed the first half of the knot (Fig. 34, B) the assistant is ready to grasp the short end and complete the knot (Fig. 34, 0). In case it is thought advisable to lock any of these knots a second revolution of the ligature may be made about the forceps. The Gauze Retractor (Fig. 35).-One of the most simple methods of grasping the kidney, the distended gall-bladder, an ovarian cyst 1 Farr, Robert Emmett: The Three-forceps and Four-forceps Knot, Surg., Gynec. and Obst., October, 1920, pp. 408, 409. SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 157 Operators left hand Assistants Tight hand Operators right hand Fig. 33.-Author's three-forceps tie utilizing assistant's forceps in completing forceps tie of Grant, 158 GENERAL TECHNIC or any tumor mass which cannot be readily grasped by any of the ordinary grasping instruments is to employ a strip of gauze for this purpose. Figs. 35, page 159, and 131, page 445, will illustrate the use of gauze as a retractor. We have found the gauze retractor especially efficient in elevating the gall-bladder and kidney. The gall-bladder, Assistants right hand Assistants left hand • r Operators right hand Operators left hand Fig. 34.-Author's four-forceps tie. While operator completes first portion of knot the assistant prepares A to complete the knot B and C. which is acutely distended, may be manipulated by means of the gauze retractor without the danger of rupturing and spilling its contents. The same is true of kidneys that are distended with septic material. The placing of the gauze tractor upon the dis- tended gall-bladder is extremely simple. The ends of a folded strip of gauze are*grasped in 7me hand while the center is fixed by a long SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 159 pair of forceps and carried down over the viscus. While it is held in this position the surgeon simply twists the ends until the gauze fits snugly about the gall-bladder. A second hemostat may then be placed upon the gauze in close proximity to the gall-bladder, thus fixing the tractor in place. In placing the tractor upon the partially mobilized kidney more strategy is required. The gauze is held as described above and as soon as one pole of the kidney has been freed the center of the loop of gauze is carried between the kidney pole and the pedicle by means of long curved forceps. The adjacent portions of the gauze strip are forced deeply into the wound and allowed to remain until the opposite pole of the kidney is freed to a degree that will allow the tractor to surround the kidney along a line between its pedicle and the meridian. One has now but to cross the ends of the gauze over each other, place forceps upon them and twist the two ends together until the pedicle only remains grasped in the loop of the gauze. Fig. 35.-Gauze gall-bladder retractor. Operating Room Deportment.-The average patient enters the operating room with an attitude of more or less anxiety and appre- hension, with which may be mingled elements of fear, loneliness and often actual distrust. Even when none of these elements is manifest one or more of them are undoubtedly present, at least in the subconscious mind. Nothing will serve to crystallize these mental processes more effectually than the failure on the part of the operating room force to function smoothly. The question of com- fort, quiet and the avoidance of irritations, combined with proper deportment, will go far toward reassuring the patient. In this connection it is believed that perhaps one of the most important items is the manner in which the anesthesia is actually induced. A patient is much more perturbed when sacral anesthesia is induced and his position on the operating table has to be changed before the operation is begun than when a comfortable position is assumed 160 GENERAL TECHNIC before the anesthetic is given and no change is made in the patient's position between the giving of the anesthetic and the performance of the operation. The Psycho-anesthetist.-While it is perfectly true that certain operations may be carried out with a small margin of error under local anesthesia, it is also true that for the present at least a con- siderable percentage of operations will demand the use of general anesthesia. A surgeon who essays to do a portion of his surgery under the influence of local anesthesia must therefore be equipped so that he may offer his patient mixed or general anesthesias as the occasion requires. In order to do this he must have associated with him someone who is especially trained for this work. The presence of such an individual is fully as necessary when local anesthesia is to be used as when inhalation anesthesia must be given. The fact that anesthesia by inhalation may become neces- sary during the performance of almost any operation under local anesthesia makes the presence of an anesthetist more or less impera- tive. The author has proposed the term "psycho-anesthetist" for this individual, the first word of the term referring especially to the duties which the anesthetist is called upon to perform when local anesthesia alone is being used, and the second signifying the duty of this individual when general anesthesia is used. This individual should by preference be a woman, and a tactful trained nurse is usually employed for this purpose. The attributes of loyalty, enthusiasm and tact, a combination of which is so desirable, are found most available in the trained nurse. She should be thoroughly instructed and should have considerable experience in the administration of general anesthesia. She may then be taught to manage the psychic aspects of the surgical case. She should become adept in answering the questions put to her by the patients, with whom she should become acquainted as soon as they enter the hospital. She should be taught to answer questions diplomatically and to handle the patients firmly yet delicately. She should at least superintend the transportation of the patients to and from the operating room, and while in the operating room she should meet every requirement in offering the patient the maximum of comfort. In addition to acting in this capacity she may perform a number of other functions in the operating room and become an important cog in the surgical wheel. The influence of such an individual in a hospital, provided she is happily chosen, will be decidedly beneficial. Her constant efforts toward preventing patients from suffering discomfort cannot help but be transmitted to those about her, especially the student nurses. A psycho-anesthetist should look especially to the patient's comfort while he is upon the operating table, and, besides replying 161 SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA tactfully to the patient's questions, she should furnish him with water or other refreshments if permitted, apply cold compresses to the forehead and eyes, fan him, record the pulse and blood-pressure from time to time, record the amount of anesthetic solution being used, record and transmit to the surgeon the impressions of the patient and his behavior and reaction to manipulations. She should change the position of the table as the surgeon desires, adjust the light, look after the ventilation of the operating room, and in a host of other ways aid in making the "machine" run as smoothly as possible. Within a short time such an individual will learn to anticipate the various stages of the induction of the anesthetic and of the operation, at which painful sensations may be provoked, and by warning the patient, aid the surgeon greatly, in meeting difficult situations. The psycho-anesthetist can, better than anyone else, instruct the patient how to breathe properly when the abdomen is opened, so as to avoid expulsive effort and to present the ideal "negative pressure," which is so much to be desired. She will see to it that the patient does not cough, sneeze or laugh at a time when such an act would embarrass the surgeon. In the case of nausea or vomiting her presence will enable the surgeon to anticipate this disaster and to guard against evisceration in case it occurs. To her care may be entrusted the decision as to whether or not mixed anesthesia should be employed. She can in most instances decide quite definitely whether or not the patient is suffering physical or psychic injury. Therefore, the presence of a tactful psycho- anesthetist, who should not in any way, however, be considered a substitute for perfect local anesthesia, is at the same time a most valuable adjunct in carrying out the method. Surgical Strategy. It is perhaps unnecessary to remind the reader that in the development of strategy, so important in over- coming obstacles which present themselves, it was necessary to make frequent attempts to accomplish what was apparently impos- sible. A large percentage of the various operative procedures carried out in the author's clinic during the past seventeen years has been begun under local anesthesia, each operation being carried on until it became evident that general anesthesia must be employed for its completion. Every failure has been carefully recorded and an effort made to evolve definite strategic methods either as to the manner of introducing the anesthetic or the manner of applying surgical technic which would meet and overcome the obstacles which had made the call for general anesthesia necessary. A constant application of this principle soon made apparent the fact that for carrying out most of the operative procedures strategic methods which would overcome these obstacles could be developed in a fair percentage of cases. In this investigation the vast majority 162 GENERAL TECHNIC of patients presenting themselves have been operated upon under local anesthesia alone, the author feeling that for the purpose of such investigation the use of preliminary hypodermic medication or mixed anesthesia would cause more or less interference with the research. While it was most implicitly believed that preliminary medication is an important and necessary adjunct to the use of local as well as general anesthesia, and that general anesthesia should be superimposed upon straight local anesthesia the moment the local method for any reason fails to prevent discomfort or to permit the completion of the operation in a manner compatible with the demands of the case, the adoption of the method referred to above has enabled the author to develop a strategy which has, in his hands at least, markedly enlarged the scope of local anesthesia. Straight local anesthesia, narco-local anesthesia, local anesthesia following the use of moderate doses of preliminary hypodermics, and mixed anesthesia have all been employed in series after series of cases in an effort to determine the merits of each, and it is significant that a careful review of our work has established the fact that concomitant with an improvement in the technic of induc- ing local anesthesia, as well as with the establishment of a surgical technic compatible with the demands, the necessity for preliminary medication and the necessity for resorting to mixed anesthesia has become less and less. Music.-Appropriate music has been tried and in a large per- centage of cases it serves to distract the patient's attention from the details of the preparation. He is usually allowed to have the Victrola running if he so desires. For the patient who enjoys music the apparent time consumed by the preparation and making of the operation is somewhat reduced. Music will not reduce the pain sense nor will it in any manner act as a substitute for the surgeon's incompetency, but it will, in the absence of pain, con- tribute a fair measure of solace to a large percentage of patients while they are undergoing operations under local anesthesia, and our impression is that it has proven a valuable adjunct in the work. Miscellaneous.-Hypodermoclysis (Bartlett).-Bartlett has sug- gested the use of a small amount of novocain in the fluid used for hypodermoclysis in order to make the introduction of fluid beneath the skin a painless procedure. This method has been employed extensively during the last two years. In order to make certain of its efficiency novocain solution has been injected on one side and plain saline solution in the other side, as a control; and while occasionally the patient may have complained of some distress from the weak novocain solution, as a rule the procedure was entirely painless. This was practically never the case when saline solution alone was employed. Bartlett recommends of 1 per cent solution. 163 SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA This method is a most excellent one, and after giving a liter of the solution containing the novocain, a second liter may be given painlessly without the novocain, owing to the persisting anesthesia. Case No. 15,676 was given 70,000 cc in a seven weeks' interval by the above method. Skin-grafting.-Thiersch's Method.-For several years we have transferred Thiersch grafts under the use of local anesthesia, except in cases in which psychic considerations interfered. Ina number of instances it was possible to perform the operation of skin grafting even in children. Preparation of Field for Application of Graft.-Either the regional method or infiltration block may be used both for the purpose of anesthetizing the area from which the skin is to be removed and for preparing the field for the reception of the graft. It is well known that granulation surfaces are generally devoid of pain sense, except at the edges where they join the skin margin. However, the base- ment membrane from which the granulations arise is usually some- what sensitive. Topical applications have been suggested as a means of anesthetizing granulation areas when preparing them for the reception of skin grafts, but for the reasons mentioned this method is unsatisfactory, as the solution is, as a rule, unable to reach the tissues in which sensation lies. Occasional success of this method can perhaps be explained by the assumption that in the cases in which preparation of the field was not painful the condition was due to lack of acute pain sense in the tissues and not due to the application of the anesthetic solution. Where Reverdin grafts are to be applied it is, as a rule, unnecessary to anesthetize the recipi- ent field. Provided the field is supplied by sensory nerves which may be interrupted by regional methods this is the simplest procedure to follow, and the technic for regional blocking should follow the general principles laid down for the interruption of these particular nerves. However, in the majority of cases regional methods cannot be applied, or, at least, may be difficult of application. Under such circumstances the simplest procedure to follow is to make an infiltration block about and beneath the field. In making this block the plan outlined ■ on page 149 should be followed. The blocking should begin proximal to the field which is to be anesthetized. A subdermal infiltration is produced proximal to the field and carried about the field laterally. It is usually unneces- sary to block the distal side of the field, except in cases in which the skin area remains sensitive. When the circumferential subdermal infiltration is completed, one may, by continuing the infiltration beneath the field of granulation, using long, fine needles and infiltrat- ing from the proximal side, isolate the basement membrane from the 164 GENERAL TECHNIC underlying tissues. Provided the field is extremely large, one need have no hesitation in introducing the needle through the granulation area near the center of the field and carrying it in divergent direc- tions from a central point which has been anesthetized. In very large fields this process may be repeated as often as is necessary. Following this technic the field may be immediately prepared by curettage or by any other method that may be deemed advisable. Preparation of the Field for the Removal of the Graft.-The manner of anesthetizing the field for the removal of Thiersch grafts will depend upon the location from which the graft is to be removed. As the surface of the thigh is the area most often used for this purpose, and the application of regional anesthesia in this location is simple and comparatively certain, the regional method becomes the method of choice in this work, One or more nerves, usually the femoral, or one of its cutaneous branches, may be interrupted by the introduction of a few cubic centimeters of a 2 per cent solution of novocain-adrenalin into, or about its trunk, and a sufficient area thus prepared for the removal of the graft. If, for any reason, however, regional methods are not acceptable, isolation of an area by means of a subdermal infiltration is indicated, and the same rules as those laid down for the anesthetization of the recipient field may be followed. As a rule, removing skin which has been previously infiltrated with solutions containing adrenalin has been avoided. However, experiments have shown that pieces of skin so infiltrated have resulted in "takes" as frequently as have uninfiltrated pieces of skin which were used as controls. Pedicle Flaps and Wolff Grafts.-The transferring of pedicle flaps and Wolff grafts may be carried out under precisely the same technic as that described for Thiersch's graft. Theoretically, the use of adrenalin would not seem advisable. However, in a number of instances success has attended the transfer of the pedicle flaps and whole skin (Wolff method) where adrenalin solutions had been used. The use of adrenalin is practically unnecessary in this work, and it may be dispensed with, or reduced to a small amount, as the time required for anesthesia is short. It is good practice to anesthetize and prepare the recipient field first so that all oozing will have subsided by the time the donating field is prepared for the graft. Comfort of the patient demands that perfect anesthesia prevail and that the operation be carried out with precision and dispatch. The transfer of pedicle flaps, always a trying ordeal, upon both patient and surgeon, especially when the use of plaster-of-Paris fixation is required, may be greatly facilitated by "rehearsing" one or more times before the operation, at which time the cast, in which the limbs are to be encased, is applied. Before applying SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 165 the cast a model corresponding to the proposed skin flap should be made from a piece of gauze and attached to the skin by adhesive tape along a line corresponding to the base of the proposed flap, and appropriate pads fitted exactly as they are to be used after the completion of the operation, and the cast applied with the limbs in proper relation to each other. The cast may then be divided and removed. The padding may be retained in its original form, labeled and sterilized, to be ready for use after the operation, at which time it may be replaced and the plaster cast reapplied. This method has the great advantage of reducing the time required for operation, and decreases the patient's discomfort and fatigue. It is the most effectual means for the prevention of pressure sores, which are difficult to avoid if the ordinary method is employed. Incidentally the visits of the patient to the operating room preceding the time of operation present many advantages from a psychic standpoint. PHYSIOLOGICAL DIAGNOSTIC TEST UNDER LOCAL ANESTHESIA. A point mentioned occasionally in this work and one which cannot be too strongly stressed relates to the opportunity offered the sur- geon not infrequently to test out through cooperation of the con- scious patient the accuracy of diagnosis in cases in which there is some doubt. One may by manipulating alternately the gall-bladder and appen- dix, the appendix and the enlarged or cystic ovary or Fallopian tube, or visceroparietal adhesions obtain from the patient a definite statement as to which maneuver, if any, reproduces the original symptoms. To the author's mind this method compares favorably with the information gained in making a wide abdominal exploration under general anesthesia. CHAPTER VI. THE ANATOMY OF THE SENSORY NERVOUS SYSTEM. The sensory nerve supply of the head and face is derived almost entirely from the trigeminal nerve. (Plate I.) The spinal nerves coming up from below supply areas in the region of the occiput, the ears and the lower jaw. All other portions of the head and face are supplied by the fifth nerve except the outer ear, which is supplied by an auricular branch of the vagus as well as the auricular branch of the cervical plexus; the tympanic membrane, which is supplied by the branches from the glossopharyngeal, the sympathetic carotid plexus and the otic and petrosal ganglia; the base of the tongue, which is also supplied by the latter. The Trigeminal Nerve.-The trigeminal nerve is the largest cranial nerve and emerges from the side of the pons near its upper border. It has a motor root which is small and a sensory root which is large. The sensory root fibers arise from the cells of the semilunar ganglion and are divided into three main branches, the ophthalmic, maxillary and mandibular. (Plate II.) The ophthalmic and maxillary consist exclusively of sensory fibers while the mandibular is joined outside the cranium by a motor root which supplies the muscles of mastication. The Ophthalmic Nerve (A\ Ophthalmicus').-The first sensory division of the trigeminal supplies branches to the cornea, the ciliary body and the iris; to the lacrimal gland and conjunctiva; to a portion of the mucous membrane of the nasal cavity, septum and narium, and to the skin of the eyelid, eyebrow, forehead and nose. It enters the orbit through the superior orbital fissure just after dividing into three branches, the lacrimal, frontal and naso- ciliary. The Lacrimal Nerve (n. lacrimalis).-The lacrimal is the smallest of the three branches of the ophthalmic. It enters the orbit through the narrowest part of the orbital fissure and runs along the upper border of the Rectus lateralis, giving off branches to the gland, conjunctiva and the skin of the upper eyelid (Plate I). The Frontal Nerve (n. frontalis).-The frontal is the largest branch of the ophthalmic, and is practically a continuation of the main nerve. It enters the orbit through the superior orbital NERVES OF THE HEAD AND FACE. 167 NERVES OF THE HEAD AND FACE fissure, and lies between the Levator palpebrae superioris and the periosteum. It divides into the supratrochlear and stipraorbital. (Plate I.) The Supratrochlear Branch (n. supratrochlearis), supplies the skin of the lower part of the forehead, close to the middle line, and sends filaments to the conjunctiva and skin of the upper eyelid. The Supraorbital Branch (n. supraorbitalis) passes through the foramen of the same name, giving off filaments to the upper eyelid and ends in a medial and lateral branch which supplies the integu- ment of the scalp, reaching nearly as far back as the lambdoidal suture. Both branches send twigs to the pericranium. The Nasociliary Nerve (n. nasociliar^s).-The nasociliary, or nasal nerve, is intermediate in size between the frontal and lacrimal, and passes inward to the medial wall of the orbital cavity through the anterior ethmoidal foramen, supplying the mucous membrane of the front part of the septum (internal nasal branch) and the lateral wall of the nasal cavity, also giving off an external nasal branch which supplies the skin of the ala and apex of the nose. The Long Ciliary Nerves inn. ciliares long!), which arise from the nasociliary, are distributed to the iris and cornea. Another branch, the Infratrochlear Nerve (n. infratrochlearis), passes to the medial angle of the eye and supplies the skin of the eyelid and side of the nose, the conjunctiva, lacrimal sac and the caruncula lacrimalis. The nasociliary nerve also gives off ethmoidal branches (nn. ethmoidales) which supply the ethmoidal cells and sphenoidal sinus via the posterior branch, and the short ciliary nerves which arise from the ciliary ganglion and supply the ciliaris muscle, iris and cornea. The Maxillary Nerve (N. Maxillaris) (Plates I and II).-The superior maxillary nerve, or the second division of the trigeminal, is also a sensory nerve. It is intermediate both in position and size, between the ophthalmic and mandibular. It leaves the skull through the foramen rotundum, crosses the pterygopalatine fossa and enters the orbit through the inferior orbital fissure, traverses the infraorbital groove and canal in the floor of the orbit and appears upon the face at the infraorbital foramen, where it becomes the infraorbital nerve. Its first branch, the middle meningeal nerve (n. meninges medius') travels with the artery of the same name and supplies the dura mater. The Zygomatic Nerve (n. zygomaticus), by way of the temporal branch of the temporomalar, supplies the skin of the side of the fore- 168 ANATOMY OF THE SENSORY NERVOUS SYSTEM head, and the malar branch of the same nerve supplies the skin on the prominence of the cheek. (See Plate I.) The Posterior Superior Alveolar Branches (rami alveolares supe- riores posteriores) descend on the tuberosity of the maxilla and give off branches to the gums and mucous membrane of the cheek. They also supply the membrane lining the maxillary sinus and send twigs to the molar teeth. (Plate II.) The Middle Superior Alveolar Branch (ramus alveolaris supe- rior medius) supplies the two premolar teeth. The Anterior Superior Alveolar Branch (ramus alveolaris supe- rior anteriores) supplies the upper incisor and canine teeth. It also gives off a nasal branch which supplies the mucous membrane of the anterior part of the inferior meatus and the floor of the nasal cavity. The Inferior Palpebral Branches (rami palpebrales inferiores) supply the skin and conjunctiva of the lower eyelid. The External Nasal Branches (rami nasales externi) supply the skin of the side of the nose and the septum mobile nasi. The Superior Labial Branches (rami labiates superiores) are distributed to the skin of the upper lip, the mucous membrance of the mouth and labial glands. This trunk also gives off the palatine nerves (nn. palatini), most of which are derived from the spheno- palatine branches of the maxillary nerve, to the roof of the mouth, soft palate, tonsil and lining membrane of the nasal cavity. The Anterior Palatine Nerve (n. palatinus anterior) supplies the mucous membrane and glands of the hard palate, the gums and both surfaces of the soft palate. The posterior inferior branches supply the inferior nasal concha, the middle and inferior meatuses and both surfaces of the soft palate. (See Fig. 62; page 222.) Another branch, the middle palatine nerve (n. palatinus medius),1 distributes branches to the uvula, tonsil and soft palate. Accord- ing to Gray this nerve is occasionally wanting. The posterior palatine nerve (n. palatinus posterior) is also dis- tributed to the uvula, soft palate and tonsil. The posterior superior nasal branches (rami nasales posteriores superiores) supply the septum and lateral wall of the nasal fossa, the mucous membrane covering the superior and middle nasal conchae, the lining of the posterior ethmoidal cells and the posterior part of the septum. The Mandibular Nerve and Branches (N. Mandibularis; Inferior Maxillary Nerve) (Plates I and II).-The mandibular nerve supplies the teeth and gums of the mandible, the skin of the temporal region, 1 Gray's Anatomy: Twentieth edition, p. 893. PLATE I LACRIMAL N. \ / SUPRATROCHLEAR N.- SUPRAORBITAL N. - TEMPORAL BR. OF TEMPORO-MALAR INFRATROCHLEAR N. NASAL NERVE- INFRAORBITALA NERVE V MALAR BR. OF TEMPORO "MALAR .AURICULO-TEMPORAL NERVE BUCCAL NERVE MENTAL NERVE- Sensory Areas of the Head, Showing the General Distribution of the Three Divisions of the Fifth Nerve. (Modified from Testut.) FINTEL II Sensory root Motor root' Auriculotemporal nerve Distribution of the Maxillary and Mandibular Nerves, and the Submaxillary Ganglion. (Gray.) PLATE III ANTERIOR AURICULAR BRANCHES TO MEATUS PAROTID BRANCHES COMMUNICATING TO FACIAL -* POSTERIOR TEMPORAL .ZYGOMATICOFACIAL TEMPORAL BRANCH OF BUCCAL -INFRAORBITAL -ARTICULAR ^BUCCINATOR AURICULO- ' TEM PORAL INFERIOR DENTAL M ENTAL I MYLOHYOID LINGUAL Mandibular Division of the Trifacial Nerve. (Testut.) PLATE IV ^Hypoglossal N. VagusN. Glossopharyngeal X. Hypoglossal Nerve, Cervical Plexus, and their Branches. (Gray.) PLATE V Termination of supratrochlear of infratrochlear of nasociliary The Nerves of the Scalp, Face, and Side of Neck. (Gray.) PLATE VI Lateral anterior thoracic Medial anterior thoracic Musculocutaneous '- Median Med. antibrach. cutaneous Radial - Deep br. of radial Superfic. br. of radial Volar interosseous Ulnar Dorsal branch _ Deep branch- Nerves of the Left Upper Extremity. (Gray.) PLATE VII Ii i tercostobra ch la I T. 2, Superfic. br. of radial- C. 6. 7. 8. Cutaneous Nerves of Right Upper Ex- tremity. Anterior View. (Gray.) Diagram of Segmental Distribution of the Cuta- neous Nerves of the Right Upper Extremity. Anterior View. (Gray.) PLATE VIII Intercosto- brachial ~ T. 2, Medial . brachial cutaneous T. 1. 2. Median C. 5.6. 7.8. Cutaneous Nerves of Right Upper Extremity. Posterior View. (Gray.) Diagram of Segmental Distribution of the Cutaneous Nerves of the Right Upper Ex- tremity. Posterior View. (Gray.) NERVES OF THE HEAD AND FACE 169 the auricle, the lower lip, the lower part of the face, the mucous membrane of the anterior two-thirds of the tongue and the muscles of mastication via the motor branches. The temporomandibular joint is supplied by the masseteric nerve (n. massetericus). (Plate III.) The skin over the buccinator and the mucous membrane lining its inner surface are supplied by the buccinator nerve (n. buccin- atorus; long buccal nerve). (Plates II and III.) An important branch is the auriculotemporal nerve (n. auriculo- temporalis) (Plate II) which divides into two branches, straddling the middle meningeal artery and running backward past the neck of the mandible, ascending over the zygomatic arch, which supplies the skin covering the front of the helix and tragus, via nn. auriculares anteriores and the temporal region via rami temporales superficiales. (Plate I.) The branches to the external acoustic meatus (n. meatus auditorii externi) supply the skin lining of the ear and the tympanic mem- brane. The Lingual Nerve (n. lingualis) (Plates II and III) supplies the mucous membrane of the anterior two-thirds of the tongue, the mucous membrane of the mouth and the gums. The Inferior Alveolar Nerve (n. alveolaris inferior; inferior dental nerve) (Plate III) of the mandibular nerve, gives off branches to supply the canine and incisor teeth via the incisive branch, the molar and premolar teeth via the dental branches, and the skin of the chin and mucous membrane of the lower lip via the mental nerve. (Plate I.) The Facial Nerve (N. Facialis; Seventh Nerve).-The facial nerve possesses some sensory fibers known as the greater superficial petrosal nerve, which supplies the mucous membrane of the soft palate and the nervus intermedins (pars intermedii of Wrisberg), which supplies the anterior two-thirds of the tongue and the middle ear. The Glossopharyngeal Nerve (N. Glossopharyngeus; Ninth Nerve). -This nerve gives off a few sensory filaments to the mucous membrane of the pharynx, fauces and palatine tonsil (Fig. 62, page 222) and the nerve of taste to the posterior one-third of the tongue (fasciculus solitarius). The Vagus Nerve (N. Vagus; Tenth Nerve; Pneumogastric Nerve). -This nerve gives off a branch, the superior laryngeal (n. laryn- geus superior), the internal branch (ramus internus) of which supplies the mucous membrane of the larynx, the epiglottis, the base of the tongue, the epiglottic glands, the aryepiglottic fold and the mucous membrane surrounding the entrance of the larynx as low down as the vocal folds. 170 ANATOMY OF THE SENSORY NERVOUS SYSTEM It also gives off the recurrent nerve (n. recurrens; inferior or recurrent laryngeal nerve), which communicates with the internal branch of the superior laryngeal and gives off a few filaments to the mucous membrane of the lower part of the larynx. Another branch, the auricular branch (ramus auricularis; nerve of Arnold), which reaches the surface by passing through the tym- panomastoid fissure, supplies the back of the auricula and the posterior part of the external auditory meatus. THE SPINAL NERVES (NERVI SPINALES). The spinal nerves emerge from the spinal canal through the intervertebral foramina. There are 31 pairs, as follows: cervical, 8; thoracic, 12; lumbar, 5; sacral, 5; coccygeal, 1. The Cervical Nerves (Nn. Cervicales).-The cervical nerves are 8 in number. The anterior divisions of the upper four cervical nerves unite to form the cervical plexus (Plate IV). Those of the lower four cervical together with the greater part of the first thoracic form the brachial plexus. (Fig. 36.) The Cervical Plexus (Plexus Cervicalis).-The cervical plexus is situated opposite the upper four cervical vertebrae and is beneath the sternocleidomastoideus. It possesses two groups of branches, the superficial and deep. The superficial branches are as follows: The Smaller Occipital Nerve (n. occipitalis minor), (Fig. 41, page 186) arising from the second cervical, sometimes also from the third, and passing upward along the side of the head, behind the ear, supplies the skin in this region. It gives off an auricular branch to the upper and back part of the ear. The Great Auricular Nerve (n. auricularis magnus), (Fig. 41, page 186) arising from the second and third cervical nerves, gives off an anterior branch (ramus anterior; facial branch) to the skin of the face over the parotid gland, and a posterior branch (ramus posterior; mastoid branch) to the skin over the mastoid process and on the back of the lower part of the ear. It also gives off a branch which pierces the ear and is distributed to the lobule and lower part of the concha. The Cutaneous Cervical (n. cutaneus colli; superficial or trans- verse cervical nerve), Plate V, arises from the second and third cer- vical nerves, turns around the posterior border of the sternocleido- mastoideus at about its middle, passes obliquely forward and supplies the antero-lateral parts of the neck. This nerve per- forates the deep cervical fascia near the anterior border of the muscle and makes its division beneath the platysma. Its ascend- ing branches (rami superiores) pass upward to the submaxillary THE SPINAL NERVES 171 region and supply the skin of the upper and front part of the neck. Its descending branches (rami inferiores) supply the skin of the side and front of the neck as low as the sternum. The Supraclavicular Nerves (nn. supraclaviculares; descending branches (Plate V), arise from the third and fourth cervical nerves. Ple^tuS brachial id Interdental muddles and Side and front of dhe^t" Fig. 36.-A, origin of the nerves to be anesthetized in radical breast operation; B, anatomy of superficial nerves of upper part of chest; C, branches of brachial plexus supplying muscles beneath the breast. A. 1, N. phrenicus; 2, Nn. supra- claviculares (integument of chest down to fourth rib); 3, N. suprascapularis; 4, N. subclavius; 5, N. thoracalis longus (serratus magnus); 6, Nn. thoracales anteriores (pectoral muscles); 7, N. intercostalis I; 8, N. intercostalis II; 9, N. intercostalis III; 10, N. intercostalis IV; 11, N. intercostalis V; 12, N. intercostalis VI. B. 1, M. trapezius; 2, Nn. supraclaviculares posteriores; 3, Nn. supraclaviculares posteriores; 4, M. sternocleidomastoideus; 5, V. jugularis externa; 6, M. platysma; 7, Nn. supra- claviculares anteriores; 8, Nn. supraclaviculares medii. C. 1, N. subclavius; 2, V. et A. subclavius; 3, Nn. thoracales anteriores; 4, clavicle; 5, N. suprascapularis; 6, M. deltoideus; 7, M. pectoralis minor and major; 8, N. thoracalis longus; 9, M. serratus anterior; 10, N. phrenicus; 11, clavicle; 12, N. intercostalis I; 13, M. pectoralis major; 14, M. pectoralis minor. 172 ANATOMY OF THE SENSORY NERVOUS SYSTEM They descend in the posterior triangle of the neck and become cutaneous near the clavicle, where they divide into anterior, middle and posterior branches. The anterior supraclavicular nerves (nn. supraclaviculares anteriores; suprasternal nerves') supply the skin as far as the midline and also the sternoclavicular joint. The middle supraclavicular nerves (nn. supraclaviculares medii; supraclavicular nerves) supply the skin over the pectoralis major and deltoideus. The posterior supraclavicular nerves (nn. supraclaviculares pos- teriores; supra^acromial nerves) supply the skin of the upper and posterior parts of the shoulder. The Brachial Plexus ())lexus brachialis) (Fig. 36, A and C).- The brachial plexus is formed by the union of the anterior divisions of the lower four cervical nerves, combined with the anterior division of the first thoracic. The plexus extends from the lower part of the side of the neck to the axilla, its direction being almost at right angles to the clavicle at the middle point. This plexus supplies the whole of the upper extremity, and fortunately, from the standpoint of the local anesthetist, its bundles form a more or less compact cord from a point an inch or more above the clavicle to a point the same distance below this bone. Above the clavicle the brachial plexus gives off the long thoracic nerve (n. thoracalis longus; external respiratory nerve of Bell; pos- terior thoracic nerve) to the serratus anterior (Fig. 36, C.). The Dorsal Scapular Nerve (n. dorsalis scapulae; posterior scapular nerve) supplies the rhomboidei. The Suprascapular (n. suprascapidaris) supplies the supraspi- natus and infraspinatus muscles and the shoulder joint. The pectorales major and minor are supplied by the anterior thoracic nerve (n. thoracales anteriores), which are given off just below the clavicle. (Fig. 36, C [3].). A number of other muscular branches are given off in the axillary region, viz., nn. subscapular es. Practically, the brachial plexus must be reached near its origin, preferably just above the clavicle, for the purpose of producing anesthesia of the upper arm and shoulder joint. The forearm may be anesthetized in the same manner, or from this region dis- tally the individual nerves may be interrupted. The divisions of the brachial plexus that concern us are the median, ulnar and radial. The Median Nerve (n. medianus) (Plate VI) extends along the middle of the arm and forearm to the hand. Its fibers are derived from the sixth, seventh and eighth cervical and first thoracic nerves. It usually lies in front of the brachial artery at the elbow THE SPINAL NERVES 173 joint and becomes more superficial as it approaches the wrist, where it is found between the tendons of the flexor digitorum sublimis and the flexor carpi radialis. This nerve gives off prac- tically no branches in the arm, but supplies important sensory branches to the elbow joint. It is the important nerve of sensa- tion of the palm of the hand via the medial and lateral branches of the ramus cutaneus pahnaris n. mediani. (Plates VII and VIII.) The Ulnar Nerve (n. ulnaris) (Plate VI), derived from the eighth cervical and first thoracic nerves, lies along the medial side of the arm and supplies the elbow, where it rests in a groove between the medial epicondyle and the olecranon; in the forearm it is sub- fascial. At the wrist it divides into a dorsal and a volar branch. It gives off important articular branches to the elbow joint, and with the median nerve supplies sensation to the palm of the hand via ramus cutaneus pahnaris of n. ulnaris. (Plate VII.) The Radial Nerve (n. radialis); musculospiral nerve (Plate VI), is the largest branch of the brachial plexus and arises from the poste- rior cord. Therefore, it comes from the fifth, sixth, seventh and eighth cervical and first thoracic nerves. It gives off several muscu- lar branches, a posterior brachial cutaneous nerve (n. cutaneus brachii posterior), which supplies the skin on the dorsal surface of the arm nearly as far as the elbow, and the dorsal antibrachial cutane- ous nerve (n. cutaneus antibrachii dorsalis), which supplies the skin of the lower half of the arm. Ultimately the radial nerve divides into four digital nerves, supplying the skin on the radial side and ball of the thumb, the radial side of the index finger, the adjoining sides of the index and middle fingers and the adjoining sides of the middle and ring fingers. (Plates VII and VIII.) The Thoracic Nerves (Nn. Thoracales) (Plates IX and X).-The thoracic nerves are twelve in number on either side. Eleven are termed intercostal and the twelfth lies below the last rib. The intercostal nerves (nn. inter costales) are distributed to the parietes of the thorax and abdomen. The first two nerves also supply fibers to the upper limb, the next four are distributed over the thorax, the lower five supply the thorax and abdomen and the twelfth supplies the abdominal wall and the skin of the buttock. The posterior divisions arise close to the point of origin from the spine and supply the muscles and skin of the posterior part of the trunk via the medial and lateral branches. (Fig. 37.) The first thoracic nerve sends a branch to the brachial plexus, and gives off a smaller branch, the first intercostal nerve, to the front of the thorax. The anterior divisions of the second, third, fourth, fifth and sixth thoracic nerves, which supply the thorax exclusively, run 174 ANATOMY OF THE SENSORY NERVOUS SYSTEM forward in the intercostal spaces below the vessels. Each gives off a lateral cutaneous branch, ramus cutaneus lateralis (Fig. 37) at a point midway between the spine and sternum. The anterior branches of rami cutanei laterales run forward near die sternal border between the intercostal muscles to the side and the forepart of the chest. They are easily located by reason of their relation with the ribs. In order that their cutaneous dis- tribution to the forepart of the chest and the skin over the mamma may be interrupted it is necessary to block them at a point proximal to the origin of the lateral cutaneous rami. Posterior division 'Intercostal nerve Pleura Rami com- ' municantes Recurrent branch Sympathetic ganglion Lateral cutaneous Transversus thoracis Internal mam. art. Anterior cutaneous Fig. 37.-Diagram of the course and branches of a typical intercostal nerve. (Gray.) The posterior branches of rami cutanei laterales supply the skin over the scapula and Latissimus dorsi. A branch of the second intercostal nerve, which does not divide into an anterior and a posterior branch, named the intercosto- brachial nerve, (Plate IX) supplies the skin of the upper half of the medial and posterior part of the arm. Frequently a branch from the third intercostal sends filaments to the axilla and medial side of the arm. The anterior divisions of the seventh, eighth, ninth, tenth and eleventh thoracic nerves are continued onward to supply the THE LUMBOSACRAL PLEXUS 175 abdominal wall and are called the thoracico-abdominal intercostal nenes. They lie betweem the internal oblique and the trans- versalis, and perforate the sheath of the rectus abdominis, ending as anterior cutaneous branches to the skin of the abdomen. The origin and arrangement of the branches correspond with that of the other intercostal nerves. The lateral cutaneous branches supply the skin of the abdomen and back. The anterior division of the twelfth thoracic nerve communicates with the iliohypogastric nerve, lies in front of the quadratus lum- borum and runs in the same plane and is distributed in the same manner as the lower intercostal nerves. Its lateral cutaneous branch is large and perforates the internal and external oblique and descends over the iliac crest to supply the skin on the front part of the gluteal region, nearly as far as the greater trochanter (Plates IX and X). THE LUMBOSACRAL PLEXUS (PLEXUS LUMBOSACRALIS) The anterior divisions of the lumbar, sacral and coccygeal nerves form the lumbosacral plexus. It is frequently joined by a branch from the twelfth thoracic. This plexus is divided into three parts -the lumbar, sacral and pudendal plexuses. The Lumbar Nerves (Nn. Lumbales, Plate XI).-The anterior divisions of the lumbar nerves (rami anteriores) pass obliquely outward behind the psoas major. The first three and a portion of the fourth form the lumbar plexus. The smaller part of the fourth joins with the fifth to form the lumbosacral trunk, which assists in the formation of the sacral plexus (Plate XIV). The arrangement of this plexus is not constant. The first lumbar nerve, frequently accompanied by a twig from the last thoracic, divides into an upper and lower branch. The upper and larger branch divides into the iliohypogastric and ilioinguinal nerves, which are of great importance in connection with operations for inguinal hernia. The lower and small branch communicate with a branch of the second lumbar to form the genitofemoral nerve. The remaining branches of the plexus divide into ventral and dorsal divisions, the obturator nerve being formed by the ventral division of the second nerve, combined with the ventral divisions of the third and fourth nerves. The lateral femoral cutaneous nerve is formed by the smaller dorsal divisions of the second and third nerves, the femoral nerve being formed b\ larger branches from the dorsal divisions of the second and third, combined with a branch from the fourth. The Iliohypogastric Nerve (n. iliohypogastricus). (Plate X).-This nerve is of the greatest importance from the standpoint of local 176 ANATOMY OF THE SENSORY NERVOUS SYSTEM anesthesia. It arises from the first lumbar nerve, passes in front of the quadratus lumborum to the iliac crest, perforates the transversus abdominis near the iliac crest, and beneath the internal oblique divides into a lateral cutaneous branch (ramus cutaneus lateralis; iliac branch) and an anterior cutaneous branch (ramus cutaneus anterior; hypogastric branch). The lateral branch (ramus cutaneus lateralis) pierces the internal and external oblique above the iliac crest and is distributed to the skin of the gluteal region just behind the lateral cutaneous branch of the last thoracic nerve. (Plates IX and XIII.) The anterior branch (ramus cutaneus anterior) runs between the internal oblique and the transversalis to a point about one inch above the external ring, and is distributed to the skin of the hypo- gastric region. (Plate XII.) The iliohypogastric nerve communicates with the last thoracic and ilioinguinal nerves. (Plate XI.) The Ilioinguinal Nerve (n. ilioinguinalis).-This nerve is also important in its relation to local anesthesia. It is smaller than the iliohypogastric, and arises from the first lumbar nerve. It lies just below the iliohypogastric, perforates the transversus abdominis in front of the iliac crest, pierces the internal oblique, distributing filaments to it, and, accompanying the spermatic cord, is dis- tributed to the skin of the upper and medial part of the thigh. (Plate XII.) It supplies the upper part of the scrotum and root of the penis in the male and the mons pubis and labium majus in the female. This nerve and the iliohypogastric complement each other, the latter often entirely replacing the ilioinguinal, which may be absent. The Genitofemoral Nerve (n. genitofemoralis; genitocrural nerve).- This nerve arises from the first and second lumbar nerves. It lies more deeply under the peritoneum and divides into the external spermatic and lumboinguinal nerves. (Plate XIV.) The external spermatic nerve (n. spermaticus externus; genital branch of the genitofemoral) passes through the inguinal canal, descends behind the spermatic cord to the scrotum, supplies the cremaster, and sends some fibers to the skin of the scrotum. In the female it accompanies the round ligament of the uterus. The lumboinguinal nerve (n. lumboinguinalis; femoral or crural branch of the genitofemoral) accompanies the external iliac artery, enters the sheath of the femoral vessels and supplies the skin on the anterior surface of the upper part of the thigh (Plate XII.) The Lateral Femoral Cutaneous Nerve (n. cutaneus femoral is lateralis; external cutaneous nerve) arises from the posterior divisions of the second and third lumbar nerves (Plate IX), having an anterior PLATE IX 1NTERCOSTO- BRACHIAL ANTERIOR CUTANEOUS NERVES OF THORAX ANTERIOR I CUTA- I NEOUS | NERVES OF | ABDOMEN LATERAL CUTA- | NEOUS OF III TO - XI THORACIC ) LATERAL CUTA-I NEOUS OF ILIO- HYPOGASTRIC J LATERAL CUTA- NEOUS OF XII THORACIC ) ANT. CUTANEOUS - OF X, XI, AND I XII THORACIC Cutaneous Distribution of Thoracic Nerves. (Testut.) PLATE X I NTER NAL CUTAN EOUS « INTERCOSTO BRACHIAL LATERAL CUTANEOUS) BRANCHES OF III I TO XI THORACIC ) LATERAL CUTA-'| NEOUS OF XII THORACIC J ILIOHYPOGASTRIC- Intercostal Nerves, the Superficial Muscles having been Removed. (Testut.) PLATE XI The Lumbar Plexus and its Branches. (Gray.) PLATE XII Sural-A'i Deep peronceal Sural S. 1.2. Deep peronceal LA. 5. Cutaneous Nerves of Right Lower Extremity. Front View. Diagram of Segmental Distribution of the Cutaneous Nerves of the Right Lower Extremity. Front View. PLATE XIII Fig. 1. Fig. 2. Fig. 8. Superior gluteal " Pudendal _ Nerve to - obturator intemus Post. fem. cutaneous Perineal _ branch Descending_ cutaneous Tibial -] Common peroneal Peroneal anastomotic Med. sural . cutaneous Tibial ' Medial calcaneal Tibial S. 1.2. Fig. 1.-Cutaneous Nerves of Right Lower Extremity. Posterior View. (Gray.) Fig. 2.-Diagram of the Segmental Distribution of the Cutaneous Nerves of the Right Lower Extremity. Posterior View. (Gray.) Fig. 8.-Nerves of the Right Lower Extremity. Posterior View. PLATE XIV LATERAL FEMORAI GENITO- FEMORAL^ FIFTH LUMBAR SY M PATHETIC TRUNK LUM BO-SACRAL CORD SUPERIOR GLUTEAL RAMUS COMMUNICANS EXTERNAL SPER- MATIC BRANCH OF GENITO-CRURAL LU M BO - I N GU I N A L BRANCH OF - GENITO-CRURAI VISCERAL x BRANCHES NERVE TO L ^LEVATOR ANI ^..HEMORRHOIDAL BRANCH OF PUDIC PUDENDAL PERI NEAL POST. FEMORAL EXTERNAL SUPER- FICIAL PERINEAL INTERNAL SUPER- FICIAL PERINEAL LEFT DORSAL-- DORSAL NERVE OF PENIS ''■NERVE TO BULB IN FERIOR PUDEN DAL Sacral Plexus of the Right Side. (Testut.) PLATE XV - I N FERIOR CER - s VICAL GANGLION _ VISCERAL BRANCHES THORACIC NERVES- RAMI COMMUNICANTES- * VISCERAL » BRANCHES - THORACIC CHAIN OF GANGLIA RIGHT VAGUS SPLANCHNIC GANGLION GREATER _ SPLANCH N IC LESSER SPLANCHN IC BRANCH OF VAGUS •TO CELIAC GANGLION CELIAC AXIS LOWEST splanchnic" SEMILUNAR GANGLION k SUPERIOR MESENTERIC ARTERY AND PLEXUS CELIAC PLEXUS QUADRATUS. LUM BORUM RENAL PLEXUS Plan of Right Sympathetic Cord and Splanchnic Nerves. (Testut.) PLATE XVI Diaphragmatic ganglion Hepatic artery Suprarenal gland Left celiac ganglion Superior mesenteric artery ' Greater splanchnic nerve Lesser splanchnic nerve Greater splanchnic nerve Right celiac ganglion Aorticorenal ganglion Aorticorenal ganglion Lowest splanchnic nerve Renal artery Renal artery | Superior mesenteric ganglion Sympathetic J trunk Communicating branch Branch to aortic plexus Sympathetic trunk Inferior mesenteric artery Branch to aortic plexus Inferior mesenteric ganglion Sacrovertebral angle. Common iliac vein Common iliac artery Abdominal Portion of the Sympathetic Trunk with the Celiac and Hypogastric Plexuses. (Henle.) THE LUMBOSACRAL PLEXUS 177 branch which supplies the skin on the anterior and lateral parts of the thigh as far as the knee, and a posterior branch which pierces the fascia lata, supplying the skin from the level of the greater tro- chanter to the middle of the thigh posteriorly, (Plates XII and XIII). The Obturator Nerve (n. obturatorius) arises from the anterior divisions of the second, third (largest) and fourth lumbar nerves, passes behind the common iliac vessels lateral to the ureter, entering the thigh through the upper part of the obturator foramen, where it divides into an anterior and a posterior branch. (Plate XI.) The anterior branch (ramus anterior) gives off branches to the hip joint and to the skin of the tibial side of the leg as low down as its midpoint. The posterior branch (ramus posterior) supplies the obturator, muscles and usually gives off an articular branch to the knee joint. The Accessory Obturator Nerve (n. obturatorius accessorius), according to Gray, is present in 29 per cent of cases. It supplies the capsule of the hip joint. The Femoral Nerve (n. femoralis; anterior crural nerve), the largest branch of the lumbar plexus, and an important sensory nerve, arises from the dorsal divisions of the second, third and fourth lumbar nerves (Plate XI). A large part of the nerve is continued to the thigh, where it gives off anterior cutaneous branches, which comprise the intermediate cutaneous nerve (ramus cutaneus ante- rior; middle cutaneous nerve) and the medial cutaneous nerve (ramus cutaneus anterior; internal cutaneous nerve). (Plate XII.) The intermediate cutaneous nerve pierces the fascia lata about 7.5 cm. below Poupart's ligament and divides into two branches which travel together along the forepart of the thigh, supplying the skin as low as the front of the knee. These, with the medial cutaneous nerve and the infrapatellar branch of the saphenous, form the patellar plexus. The medial cutaneous nerve supplies the medial side of the thigh. (Plate XIII.) The Saphenous Nerve (p. saphenous; long or internal saphenous nerve) is the largest cutaneous branch of the femoral nerve. (Plate XII.) It passes along the tibial side of the leg, accompanied by the great saphenous vein, and at the lower third of the leg divides into two branches, one of which continues along the margin of the tibia, supplying the front and medial sides of the leg, ending at the ankle joint; the other passes in front of the ankle and is distrib- uted to the skin of the medial side of the foot as far as the ball of the great toe. The muscular branches of this nerve supply the knee joint. 178 ANATOMY OF THE SENSORY NERVOUS SYSTEM THE SACRAL AND COCCYGEAL NERVES (NN. SACRALES ET COCCYGEUS). (PLATE XIV.) The anterior divisions of the sacral and coccygeal nerves form the sacral and pudendal plexuses (Plate XIV). These nerves lie along the back of the pelvis between the piriformis and the pelvic fascia, and are therefore in front of the sacrum. They furnish ven- tral branches to numeruos muscles of the buttock and thigh, their most important contribution being the sciatic and pudendal nerves. The first and second branches of these plexuses, the superior and inferior gluteal nerves, supply the gluteal muscles and the tensor fasciae latae. The Posterior Femoral Cutaneous Nerve (n. cutaneus femoral is posterior; small sciatic nerve) supplies the skin of the perineum, the posterior surface of the thigh and leg and the lower and lateral gluteal regions. (Plate XIII.) It arises from the dorsal divisions of the first and second and the ventral divisions of the second and third sacral nerves, and passes through the greater sciatic foramen, lying beneath the gluteus maximus, and in the thigh, beneath the fascia lata (Plate XIV). It passes over the long head of the biceps femoris to the back of the knee, and accompanies the small saphenous vein to about the middle of the back of the leg. It gives off three or four gluteal branches which supply the skin over the lower and lateral part of the gluteal muscle. The perineal branches (rami perineales) are important. They are distributed to the upper and medial side of the thigh. The inferior pudendal (long scrotal nerve) passes in front of the tuberosity of the ischium, pierces the fascia lata, and in the perineum lies just beneath the superficial fascia, supplying the skin of the scrotum in the male (Fig. 138, page 343; Fig. 140, page 345) and the labium majus in the female. Practically the whole of the skin covering the back and medial side of the thigh and the upper part of the back of the leg and the popliteal fossa is supplied by this nerve. (Plate XIV.) The Sciatic Nerve (n. ischiadicus; great sciatic nerve) is formed by branches of the fourth and fifth lumbar, as well as the first, second and third sacral nerves and is the largest nerve in the body. It leaves the pelvis through the greater sciatic foramen, lies between the greater trochanter of the femur and the tuberosity of the ischium, and at the lower third of the thigh it divides into the tibial and common peroneal nerves (Plate XIII). It gives off articular branches (rami articulares) to the hip joint. These are sometimes derived from the sacral plexus. It also gives off muscular branches (rami musculares) to the muscles of the thigh. THE SACRAL AND COCCYGEAL NERVES 179 The Tibial Nerve (n. tibialis; internal popliteal nerve) is the largest branch of the sciatic. It arises from the ventral branches of the fourth and fifth lumbar and the first, second and third sacral nerves. It lies at about the middle of the popliteal fossa and accompanies the popliteal artery and the posterior tibial vessels down the back of the leg. At a point between the heel and the internal malleolus of the tibia it divides into the medial and lateral plantar nerves. (Figs. 38 and 39.) In the leg the tibial nerve lies deep beneath the muscles of the calf. (See Fig. 100, page 274.) Lower down it lies beneath the deep fascia. It gives off articular branches (rami articular es) to the knee joint and the ankle joint, and muscular branches (rami musculares) to the muscles of the leg. Fig. 38.-Medial view of nerve supply of ankle. 1, V. et A. tibialis posterior and N. tibialis; 2, N. saphenus; 3, V. saphena magna; 4, N. saphenus rami cutanei mediales; 5, N. plantaris medialis (tibial); 6, N. tibialis rami calcanei mediales. The medial sural cutaneus nerve (n. cutaneus sura medialis; n. communicans tibialis) lies along the lateral margin of the tendo calcaneus, behind the external malleolus, unites with the anasto- motic ramus of the common peroneal to form the sural nerve, which becomes the lateral dorsal cutaneous nerve supplying the lateral side of the foot and the little toe (Plate XII). The medial calcaneal branches (rami calcanei mediates; internal calcaneal branches) supply the skin of the heel and the medial side of the sole of the foot (Fig. 38). The medial plantar nerve (n. plantaris medialis (Fig. 38); internal plantar nerve), gives off cutaneous branches to the skin of the sole of the foot, muscular branches to the muscles of the foot and articular branches to the articulations of the tarsus and meta- tarsus. It gives off a proper digital plantar nerve, which supplies the flexor hallucis brevis and the skin on the medial side of the great toe, and finally divides into three common digital nerves 180 ANATOMY OF THE SENSORY NERVOUS SYSTEM (nn. digitales plantares communes). The first common digital nerve supplies the adjacent sides of the great and second toes, the second the adjacent sides of the second and third toes, and the third the adjacent sides of the third and fourth toes (Fig. 39). The lateral plantar nerve (n. plantaris lateralis; external plantar nerve), (Fig. 39), supplies the skin of the fifth toe and the latter half of the fourth, much as does the ulnar nerve in the hand. Fig. 39.-Nerve supply of foot-plantar view. 1, N. digitales plantares proprii; 2, N. digitales plantares communes; 3, N. plantaris medialis; 4, N. plantaris lateralis. Fig. 40.-Nerve supply of foot-dor- sal view. 1, Vena saphena magna; 2, N. cutaneus dorsalis intermedius; 3, N. cutaneus dorsalis medialis; 4, Nn. digitales dorsales hallucis lateralis et digiti secundi medialis (peroneus pro- fundus). The Common Peroneal Nerve (n. peronaeus communis; external popliteal nerve; peroneal nerve) arises from the dorsal branches of the fourth and fifth lumbar and the first and second sacral nerves. It lies along the lateral side of the popliteal fossa, winds around the neck of the fibula and gives off articular branches to the knee. The lateral sural cutaneus nerve (n. cutaneus sura lateralis; lat- eral cutaneous branch) supplies the skin of the posterior and lateral surfaces of the leg (Plate XIII). THE PUDENDAL PLEXUS AND BRANCHES 181 The common peroneal nerve at its bifurcation gives off the deep and superficial peroneal nerves. The Deep Peroneal Nerve (n. peronceus profundus; anterior tibial nerve) travels in conjunction with the anterior tibial artery to the front of the ankle joint. In the leg it gives off muscular branches, an articular branch to the ankle joint, and a lateral terminal branch supplying the muscles, as does the medial terminal branch. The metatarsophalangeal joint of the great toe is supplied by an interosseous branch. The Stiperficial Peroneal Nerve (n. peronoeus and superficialis; musculocutaneous nerves) supplies the skin over the greater part of the dorsum of the foot. It pierces the deep fascia at the lower third of the leg and divides into the medial and intermediate dorsal cutaneous nerves. The medial dorsal cutaneous nerve (n. cutaneus dorsalis medialis; internal dorsal cutaneous branch), Fig. 40, passes in front of the ankle joint, divides into two digital branches, one supplying the medial side of the great toe and the other the adjacent side of the second and third toes. This nerve supplies the skin of the medial side of the foot and ankle. The intermediate dorsal cutaneous nerve (n. cutaneus dorsalis intermedins; external dorsal cutaneous branch) Fig. 40, passes along the lateral part of the dorsum of the foot and supplies the con- tiguous sides of the third and fourth, and of the fourth and fifth toes. It also supplies the skin on the lateral side of the foot and ankle. The branches of the superficial peroneal nerve supply the skin on the dorsal surface of all the toes excepting the outer side of the little toe, and the adjoining sides of the great and second toes, the former being supplied by the lateral dorsal cutaneous nerve and the latter by the medial branch of the deep peroneal nerve. (Fig. 40.) THE PUDENDAL PLEXUS AND BRANCHES (PLEXUS PUDENDUS). (PLATE XIV.) The pudendal plexus is not sharply marked off from the sacral plexus. It is usually formed by branches from the anterior divi- sions of the second and third sacral nerves, the whole of the anterior divisions of the fourth and fifth sacral nerves, and the coccygeal nerve. It gives off the following branches: Perforating cutaneous .... Second and third sacral. Pudendal Second, third and fourth sacral. Visceral Third and fourth sacral. Muscular Fourth sacral. Anococcygeal Fourth and fifth sacral and coccygeal. 182 ANATOMY OF THE SENSORY NERVOUS SYSTEM The Perforating Cutaneous Nerve (n. clunium inferior medialis) supplies the skin over the medial and lower parts of the gluteus maximus. The Pudendal Nerve (n. pudendus; internal pudic nerve) arises from the ventral branches of the second, third and fourth sacral nerves, reaches the perineum through a sheath of the obturator fascia (Alcock's canal) and divides into the perineal nerve and the dorsal nerve of the penis or clitoris. Before dividing it gives off the inferior hemorrhoidal nerve (Plate XIV). The Inferior Hemorrhoidal Nerve (n. hcemorrhoidalis inferior) sup- plies the sphincter ani externus and the skin around the anus. The Perineal Nerve (n. iJerinei) divides into the posterior scrotal (or labial) and muscular branches (Plate XIV). The Posterior Scrotal (or Labial) Branches (nn. scrotales (or labiates) posteriores; superficial perineal nerves) pierce the fascia of the urogenital diaphragm and are distributed to the skin of the scrotum in the male and the labium majus in the female. The nerve to the bulb, of the muscular branches, supplies the mucous membrane of the urethra and the corpus cavernosum urethrae. The Dorsal Nerve of the Penis (n. dorsalis penis) travels forward along the margin of the inferior ramus of the pubis and ends on the glans penis and the corpus cavernosum penis. In the female the nerve takes the same course. It is very small and supplies the clitoris (n. dorsalis clitoridis). The Visceral Branches.-The visceral branches arise from the third and fourth, and sometimes from the second, sacral nerves, to supply the bladder and rectum, and in the female, the vagina. The Muscular Branches.-The muscular branches with cutaneous filaments derived from the fourth sacral supply the skin between the anus and coccyx. Anococcygeal Nerves (nn. anococcygei).-These nerves arise from the fifth sacral nerve and give filaments to the skin in the region of the coccyx. THE SYMPATHETIC NERVOUS SYSTEM. The sympathetic nervous system supplies all the smooth muscles and the various glands of the body as well as the striated muscle of the heart, and is the conductor of sensation within the abdomen. It is characterized by numerous ganglia and complicated plexuses. Efferent sympathetic fibers leave the central nervous system and end in sympathetic ganglia, being known as preganglionic fibers. From the ganglia, postganglionic fibers arise which carry impulses THE SYMPATHETIC NERVOUS SYSTEM 183 to the different organs. In addition, afferent or sensory fibers connect many of these structures with the central nervous system. The peripheral portion of the sympathetic system is connected with the central nervous system by three groups of efferent fibers -the cranial, thoracolumbar and sacral. Sympathetic trunks extend from the base of the skull to the coccyx, lying in front of the bodies of the vertebrae. The ganglia of each trunk are dis- tinguished as the cervical, thoracic, lumbar and sacral. (Plate XV.) The sympathetic nervous system is connected with the spinal nerves through the gray and white rami communicantes. The Celiac Plexus (solar plexus) is the largest of the three sym- pathetic plexuses and consists of two large celiac ganglia and their nerve network surrounding the celiac artery and the root of the superior mesenteric artery behind the stomach and in front of the crura of the diaphragm. The greater and lesser splanchnic nerves from above join this plexus, which gives off numerous secondary plexuses. (Plate XVI.) PART LI. LOCAL ANESTHESIA IN SURGERY OF ALL REGIONS OF THE BODY EXCEPT THE ABDOMEN. CHAPTER VIL LOCAL ANESTHESIA IN SURGERY OF THE HEAD AND FACE. THE NERVE SUPPLY OF THE SCALP. (Fig. 41, also Plate I.) The frontal region is supplied by n. supratrochlearis and n. supraorbitalis, both branches of n. ophthalmicus, the first division of n. trigeminus (v). The lateral region is supplied by (1) ramus zygomaticotemporalis, a branch of n. maxillaris, the second division of n. trigeminus; (2) rami temporales superficiales of n. mandibularis, the third division of n. trigeminus, and (3) ramus temporalis of n. facial. These branches are distributed to the superficial temporal fascia and the skin. The occipital region is supplied by (1) n. auricularis magnus (II, III C), which gives off a posterior or mastoid branch; (2) n. occipitalis minor (II C); (3) n. occipitalis major (II C); and (4) the third occipital nerve (III C). The mastoid region is supplied by the mastoid or posterior ramus of n. auricularis magnus (II, III C). The ear is supplied by (1) nn. auriculares anteriores to the helix and tragus; (2) n. meatus auditorii externi to the external meatus and tympanic membrane, both of which are branches of n. mandib- ularis, the third division of n. trigeminus; (3) ramus auricularis (nerve of Arnold), from n. vagus (x) to the back of the auricle and external canal; (4) ramus auricularis of n. occipitalis minor (11 C) to the upper and back part of the auricle; and (5) ramus posterior of n. auricularis magnus (II, III 0) to the back of the auricle, lobule and lower part of the concha. While the distribution of these nerves is fairly constant and 186 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE their position may be learned and quite accurately located by the needle when administering local anesthesia they overlap each other in the areas which they supply, and in introducing anesthesia the greatest satisfaction will result from a complete infiltration block across the path of the nerves (Fig. 42), except when only a simple incision is to be made. A circumferential injection may be made in most cases, infiltrating thoroughly all tissues of the scalp (Figs. 43 and 44). Accurate knowledge of the nerve supply allows one to deposit the solution a little more freely at the points where the main branches are known to lie (Fig. 45). Fig. 41.-Nerve supply of scalp and face. 1, N. auriculotemporalis of N. mandib- ularis; 2, N. auricularis posterior of N. facialis; 3, N. occipitalis major (II C.); 4, N. occipitalis minor (II C.); 5, N. auricularis magnus (II, III C.); 6, ramus zygo- maticotemporalis of N. maxillaris; 7, N. supratrochlearis of N. ophthalmicus; 8, N. supraorbitalis of N. ophthalmicus; 9, N. lacrimalis of N. ophthalmicus; 10, N. infratrochlearis of N. ophthalmicus; 11, N. nasalis of N. ophthalmicus; 12, N. infra- orbitalis of N. maxillaris; 13, ramus zygomaticofacialis of N. maxillaris; 14, N. buccinatorius of N. mandibularis; 15, N. mentalis of N. mandibularis. ANESTHESIA OF THE SCALP. It is to be noted that the various nerves radiate toward the crown and more or less at right angles to a line passing transversely around the head just above the eyes and ears and about the occiput. These nerves may therefore be interrupted upon this line, pro- ducing anesthesia in the parts above. The conformation of the skull is such that it lends itself ideally both to regional and "infil- ANESTHESIA OF THE SCALP 187 Fig. 42.-Circumferential infiltration block of the scalp. (Horizontal.) Fig. 43.-Circumferential infiltration block of the scalp. (Occipital.) 188 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE tration block" anesthesia. An adequate line of infiltration across the course of the nerves will give anesthesia. One must bear in mind that the nerves arising from the various branches overlap each other to a considerable degree. One should block a rather wide area, and as it is to be considered safe to interrupt all nerves leading to the scalp, there is no objection to widely circumscribing any area that is to be dealt with (Fig. 43). In case one-half of the scalp is to be operated upon the horizontal infiltration with an antero-posterior infiltration along the midline (Fig. 44) is indicated. The infiltration over the crown effectually interrupts the nerves Fig 44.-Circumferential infiltration block of the scalp. (Parietal-frontal.) from the opposite side. When operating upon the posterior por- tion of the scalp the horseshoe-shaped infiltration block is efficient (Fig. 43). The anesthesia required for operations upon the scalp is the same whether or not the skull is to be opened. Intracranial injections are unnecessary. In this region the effect produced by the adrenalin is most helpful. It reduces the size of the blood- vessels and thus lessens the tendency toward hemorrhage and greatly facilitates operative procedures on the skull. The bone itself is insensitive and may be sawed, crushed or cut by means 189 ANESTHESIA OF THE SCALP of the DeVilbiss forceps without painful sensation to the patient. The brain tissues themselves are not sensitive excepting near the base of the skull, although traction upon the dura at any point may cause referred pain. The author has in two instances had patients complain of pain when traction upon the dura was made in the frontal region. In one case the pain was referred to the eyes. Fig. 45.-Sectional view of infiltration block of the scalp with nerve supply. 1, N. supratrochlearis of N. ophthalmicus; 2, N. supraorbitalis of N. ophthalmicus; 3, N. lacrimalis of N. ophthalmicus; 4, ramus zygomaticotemporalis of N. maxillaris; 5, N. auriculotemporalis of N. mandibularis; 6, N. occipitalis minor (II C.); 7, N. occipitalis major (II C.) Duration.-As the effect of the anesthetic disappears in from one and a half to two hours, and as it may be impossible to com- plete certain operations in this time, many surgeons feel that some other anesthetic should be employed. However, the author has not had the least hesitancy in repeating the dose of anesthetic in case sensation begins to return before completion of the operation. A more decided drawback in his experience has been the fatigue 190 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE of which the patient is apt to complain during a prolonged operation. This should be anticipated and guarded against by placing the patient in as comfortable a position as possible and by so arrang- ing the drapes that the patient may shift about slightly from time to time and thus reduce the irksomeness to some degree. Care should also be taken to supply the patient with water and plenty of fresh air. In making the infiltration or infiltration block, the method described on page 149 (Fig. 31) is followed with the utmost care. The initial wheal is made after cautioning the patient, and all other intradermal wheals are made from beneath (Fig. 31, B). The fluid is injected freely, especially in the regions where the nerve trunks are known to lie (Fig. 45). Among the special advantages of local anesthesia in work in this region are the reduction of hemorrhage, the absence of engorge- ment of the cerebral vessels and the reduction of shock. Excision of New Growths.-For the purpose of excising new growths it is well to make the line of anesthesia sufficiently remote from the edge of the growth so that radical excision will not be interfered with. Every effort should be made to avoid injecting tissues in which there is the slightest suspicion of malignancy. This work may be carried out after the infiltration block with a high degree of satisfaction by carefully following the plan laid down on page 149. Atheromata.-Atheromata may be excised following an infiltration about the base, the needle being introduced repeatedly until it reaches the bone. Where large numbers of atheromata are present, covering a considerable area, the infiltration block described in Figs. 42, 43 and 44 becomes the method of choice. SURGERY OF THE SKULL. Fractures of the Vault of the Skull.-In all fractures of the vault, simple or compound where surgical intervention is considered necessary, local anesthesia may be used. In cases in which the injury is severe, or the general condition of the patient is bad, local anesthesia should be used, even in children. It is well in these cases to introduce the anesthetic solution remote from the point of injury, as in this manner the possibility of dissemination of infection is avoided, and one is less likely to be compelled to reinforce the anesthesia on account of the extension of the fracture beyond its apparent limits. Children must be restrained while the anesthetic is being introduced, but the remonstrance is no greater than, and seldom as great as, when general anesthesia is employed. Once anesthesia is established the necessary surgical work may SURGERY OF THE SKULL 191 be carried out with despatch, and without greatly increasing the depression which is usually already present in these cases. Operations upon the Brain.-The blocking of the various areas is shown in Figs. 42 to 45, pages 187-189. Under this anesthesia the corresponding areas of the skull may be trephined without discomfort to the patient. The great reduction in the size of the bloodvessels produced by the adrenalin aids materially in exposing the skull. In most instances the various methods of preventing hemorrhage from the scalp may be dispensed with. While there is some hemorrhage from the larger arteries, unless an excessive amount of adrenalin is used, this may be easily controlled by the application of artery forceps. The skull may be entered by any of the numerous methods, with the exception of the mallet and gouge, which causes too much discomfort. Sawing of the bone, while it does not produce pain, is somewhat annoying to some patients. However, it is tolerated in most cases without great complaint. Once the brain surface is exposed the operative pro- cedure is, if anything, less difficult than when general anesthesia is employed on account of the absence of engorgement of the vessels. (Cases No. 8096 and 11485.) Report of Case No. 8096. The following case is briefly reported in order to call attention to the location of referred pain during an operation: L. B., entered the hospital on March 3, 1915. Diagnosis: Brain tumor in the left arm and leg center. Operation: Decompression, Ligation of varicosities. The patient was given a preliminary hypodermic of morphin gr. | and scopolamin gr. one hour before the operation, and at the beginning of the operation he was given another hypodermic of morphin gr. |, as he seemed to be rather nervous. 100 cc of a 1 per cent novocain-adrenalin solution were injected along the line indicated in Fig. 44, page 188. Ten minutes after making the infiltration a horseshoe-shaped Hap was turned down on the right side over the vault of the cranium. The skull was opened by means of the Martell drill and a bone flap was turned down by the use of a motor saw and dura guard. This procedure was entirely painless to the patient, and he did not even complain of the grating of the saw. After opening the dura the surface of the brain was found to present many dilated veins and the tissue appeared to be inflamed. Touching the surface of the brain caused the patient to remark that he had sensation in the left hand directly. A small portion of the tissue was removed and the large vessels ligated. No distinct tumor was found. The 192 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE dura was adherent mesially and was carefully elevated, after being incised. The dura was then partially closed and the Hap sutured into place, a small catgut drain being inserted. The patient made a prompt operative recovery. Note.- Traction upon the dura was followed by complaint of slight headache and if continued the patient stated that it gave him severe pain back of his eyes. Pressure upon the brain sub- stance with a moist sponge produced sensation in the left hand, but no pain. As an example of the removal of a growth involving both the skull and brain, the following report is given: Fig. 46.-Photograph of case No. 11,485. Endothelioma. Report of Case No. 11485. E. C., aged forty-eight years, entered the hospital, April, 1916. This patient was seen in consultation with Dr. Earl R. Hare, of Minneapolis, who performed the operation with the writer's assistance. The patient had been struck upon the head in childhood. Ue presented a large tumor upon the vertex of the skull, which had been of slow growth, but had progressed more rapidly during the past year. lie complained of headaches, and presented a tumor which seemed to involve the skull (see Fig. 46). A radiogram showed the growth to be intimately connected with the bone. Operation: Excision of tumor on April 19, 1918. 193 SURGERY OF THE SKULL Anesthesia: 90 cc of a 0.5 per cent novocain-adrenalin solution. Circumferential infiltration similar to that described in Figs. 42, 43 and 44, pages 187 and 188. The scalp was reflected back by the means of a crucial incision. The cranial cavity was entered by the means of a bone trephine, and with the De Vilbiss forceps a channel was cut around the tumor, approximately 2 cm. from its outer border. The longitudinal sinus was ligated. As the bone was pried out of its position, it carried with it adherent dura from an area 6 cm. in diameter. The dura was widely excised and a considerable amount of brain tissue, which seemed to be infiltrated, was taken away with the growth. The removed dura contained a growth as large as an olive. The piece of bone removed was circular, was about 16 cm. in diameter and 8 cm. in thickness at its thickest point. A celluloid plate was introduced and the wound closed with silkworm gut. This patient had no pain that could be directly attributed to the operative procedure, although he stated at times that his head ached during the operation. He made an uneventful recovery, the celluloid plate healing nicely into place. The growth recurred at a later period. The pathological report was endothelioma. Subtemporal Decompression.-This operation may be performed under a direct infiltration or infiltration block. Only 30 to 40 cc of solution is necessary to anesthetize the whole area. Under this method the operation of decompression becomes almost a minor one. We usually puncture the skin at one point only, and pass the needle in various directions until the field of operation is completely saturated. Case No. 10783. Report of Case No. 10783. A. B., aged forty-two years, entered the hospital on November 5, 1917, referred by Dr. H. II. Kimball. A diagnosis of advanced optic neuritis was made. The patient was seen in consultation by Dr. W. A. Jones, who advised subtemporal decompression. Anesthesia: 60 cc of a 0.7 per cent novocain-adrenalin solution were used. A transverse infiltration block was made just above the external ear with a vertical limb along the proposed line of incision. The skull was opened over an area of 5 x 7 cm. The dura was opened after the ligation of two arterial branches. The opening was covered by the temporal muscle. The skin was closed with silk- worm gut. Note.-In this instance the patient remarked at the finish of the operation that if this was all there is to such an operation he would not mind having one every day. This simple procedure is almost a minor operation under local anesthesia. 194 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE THE EAR AND MASTOID. Anesthesia of the Tympanic Cavity.-Braun gives the following description for obtaining anesthesia of the middle ear and mastoid: "In case of destruction of the drum the mucous membrane of the tympanic cavity can be anesthetized by dropping into the ear a few drops of a 10 to 20 per cent solution of cocain or alypin. The complicated shape of this cavity makes it difficult to obtain an even distribution of the anesthetic which not infrequently interferes with complete anesthesia. Tiefenthal's injection through Fig. 47.-Infiltration block for mastoid operation. the unruptured drum has already been mentioned. Neumann claims that if fluid be injected beneath the upper wall of the external auditory canal, the soft parts will be separated from the bone and the fluid must pass under the drum membrane and the mucous membrane of the tympanic cavity and in this manner cause both the drum and the tympanum to become completely anesthetized." Neumann1 has described this injection as follows (see Fig. 48): "The needle is passed through the cartilage and beneath the periosteum of the upper wall of the external auditory canal about 0.5 to 1 cm. from the beginning of the bony part. This 1 Quoted from Braun. THE EAR AND MASTOID 195 point of injection can be readily determined by moving the ear up and down, the cartilaginous portions forming a fold where it adjoins the bony part. Another means of distinguishing this boundary is the difference in appearance between the cartilaginous and the bony part of the canal. The former appears dull, while the latter is glossy. After fixing the point for injection, the needle is passed in an oblique direction upward until the bony canal is felt; the anesthetic solution is then injected under medium pressure. It will be necessary to wait about ten minutes before anesthesia is complete." With the patient's head lying on the healthy side, begin by instilling a few drops of a 20 per cent alypin or cocain solution with the addition of suprarenin into the external auditory canal. Inas- much as the drum is usually destroyed, the solution itself enters the tympanic cavity and can act upon the mucous membrane during the subsequent injection. This is not always necessary. The opening of the mastoid process and the antrum under local anesthesia was attempted before this method was tried for the radical operation (Reclus, Schleich, Scheibe, Thies, Alexander, Neumann). Inasmuch as these cases usually belong to the acute septic type, it is well to consider carefully the advisability of inject- ing into such an operative field. According to the author's judg- ment there must be very definite conditions contraindicating the use of general anesthesia before local anesthesia should be attempted. At any rate, this method of anesthesia will be used much more frequently in the radical operation than in cases of acute otitis. In perforation of phlegmonous suppurations these injections are not permissible. For the opening of the antrum the Neumann injection is not necessary, and the operator should proceed as in the radical opera- tion. For the simple opening of the mastoid cells, infiltration of the soft parts is sufficient. Attempts have been made to block the glossopharyngeal nerve at the base of the skull by injections through the mouth, but with- out result. However, Ilirschel has apparently succeeded in block- ing the glossopharyngeal and vagus by means of an injection between the condyle of the lower jaw and the mastoid process. Whether it will be possible to block the upper branches supplying the organs of hearing remains to be seen. The author has used the circumferential infiltration block illus- trated in Fig. 47, and has had equally good results with a simple infiltration of the nerves by making a deep infiltration below both in front and behind the mastoid. He has also employed the technic of Neumann (Fig. 48) and has completed a number of radical mastoids under this scheme, 196 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE There may possibly be some objection to the infiltration method directly over the mastoid process in case infection is already pres- ent in the soft tissues. However, no ill effects have been found to follow this method when carried out in other parts of the body. In case there is any question concerning this point, it is a simple matter to block the mastoid or posterior ramus of the auricularis magnus nerve (II, III C) at its origin between the second and third cervical vertebrae. In fact, the infiltration block in this region can be used in the place of the circumferential block with marked success. Success has not followed attempts at blocking the nerve supplying the organs of hearing, which is of course unneces- sary in cases in which only the mastoid cells are to be drained or eviscerated. Fig. 48.-Anesthetizing the internal ear. (Technic of Neumann.) Report of Case No. 11609. G. M., a female, aged fifty-four years, entered the hospital on July 18, 1918. Diagnosis: Subacute mastoiditis. Operation: Radical mastoid. Anesthesia: Following the technic of Braun (Fig. 47), 40 cc of a 1 per cent procain-adrenalin solution were injected around the ear. A fine needle was then introduced just posterior to the auditory canal after the method of Neumann (Fig. 48) and 2 cc of the solution injected here. The radical operation was then performed. The patient made no complaint throughout the operation, except in relation to her position upon the table, which caused her to complain of pain in her arm and shoulder, SURGERY OF THE FACE 197 Note.-In a number of cases the author has encountered some difficulty in obtaining complete anesthesia of the middle ear. Curettage of the Eustachian tube cannot usually be accomplished without the production of pain, and it is perhaps advisable to use topical applications of cocain here. THE NERVE SUPPLY OF THE FACE. (Plate II and Fig. 41, page 186.) The frontal region as mentioned before is supplied by n. supra- trochlearis and n. supraorbitalis of the first division of n. trigeminus (v). The upper eyelids are supplied by (1) n. lacrimalis; (2) n. infra- trochlearis; (3) n. supratrochlearis; (4) n. supraorbitalis, all of which are branches of n. ophthalmicus, the first division of n. tri- geminus (v). The lower eyelids are supplied by n. infratrochlearis. The conjunctiva is supplied by (1) n. lacrimalis; (2) n. supra- trochlearis; (3) n. infratrochlearis, also from the ophthalmic division of n. trigeminus and by (4) rami palpebrales inferiores of n. maxil- laris, the second division of n. trigeminus (v). The nose is supplied by (1) external nasal branch to the ala nasi; (2) n. infratrochlearis to the side of the nose; (3) internal nasal branches to the septum and lateral wall, all of which are branches of n. ophthalmicus, the first division of n. trigeminus, and (4) rami nasales externi of n. maxillaris, the second division of the same nerve and which supply the septum and lateral wall. The cheek is supplied by (1) ramus zygomaticofacialis of the second division of n. trigeminus (v), (2) n. buccinatorius of the third division of the same nerve, and (3) ramus anterior of n. auricularis magnus (1, III C.) The upper lip is supplied by rami labiales superiores of n. maxillaris, the second division of n. trigeminus. The lower lip and chin are supplied by n. mentalis of n. man- dibularis, the third division of n. trigeminus (v). SURGERY OF THE FACE. The blocking of the trigeminus nerve and its various branches is extensively described in most of the works upon local anesthesia, and in this text the subject will be covered only in a general way, referring more particularly to the important operations upon the face, and description of methods which have given the author the greatest satisfaction. Figs. 54 and 56, pages 214 and 215, show the relative locations of 198 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE the second and third divisions which may be reached by the means of various landmarks. The ganglion also may be reached by several routes which will be described later. Excision of the superior maxilla may be successfully performed after the blocking of the maxillary division (Fig. 54). This blocking should be reinforced by a cir- cumferential subdermal infiltration (Fig. 53), page 214. The inferior maxilla may be operated upon after blocking by one of the various methods here given. Anesthesia.-Blocking of the Trigeminus Nerve (Fifth) (Plate II).-Matas must be given credit for being the first to block the trigeminus nerve at the base of the skull. Braun gives this sub- ject in sufficient detail that I feel no better description could be given than to quote somewhat extensively from his excellent book: "The blocking of one or more branches of the trigeminus nerve is advisable in nearly all operations upon the face which are not confined to the skin or subcutaneous tissue. The blocking can be carried out, according to the demands of the operation, either at the points of exit of the nerve trunks at the base of the skull in the course of one or more of their branches, or intracranial in the Gasserian ganglion itself. "Anesthesia of the trigeminus nerve at the base of the skull was first performed by Matas in the foramen rotundum. Bocken- heimer, at the suggestion of Payrs, likewise carried out this pro- cedure. The first contribution and description of several operations upon the face was published by Peuckert. The method has since been materially improved following the introduction by Schloesser of alcohol injections in the treatment of trigeminal neuralgia and by the work of Ilaertel. We are indebted to Offerhaus for his important communications in reference to the technic of injection of the third branch of this nerve. He devised this method inde- pendently, following his experiments with alcohol injections. He likewise used anesthetic substances to render operations painless. "For the central trigeminus injection the long, thin needles Nos. 5 and 6 should be used. The needle-holder will be found very helpful with needles of this length.'' The Ophthalmic Nerve (Plate II). -"The peripheral branches on the forehead are easily reached by a subcutaneous injection of 5 to 10 cc of a 1 per cent novocain-suprarenin solution made trans- versely above the eyebrows. (See Figs. 41 and 45, pages 186 and 189.) The area of this anesthetic field is quite variable and the principle as previously laid down should always be followed, that in operations upon the forehead and scalp large operative fields should always be circuminjected. "The trunk of the ophthalmic nerve cannot be directly injected, SURGERY OF THE FACE 199 inasmuch as it usually divides into its branches the lacrimal, frontal and nasociliary before entering the orbit. The nasociliary passes through the annulus tendineus into the apex of the orbit and innervates the eye. Its two branches, the ethmoidal nerves, leave the apex of the orbit and pass into the anterior and posterior ethmoid foramen. The frontal and lacrimal lie entirely outside of the apex of the orbital wall and like the ethmoidal nerves are inaccessible to injections in the posterior portion of the orbit. "Deep Blocking.- The walls of that portion of the orbit which are straight and not concave are particularly suitable for injection, and serve as a guide for the needle to the orbital apex beyond the muscular covering, keeping the needle in constant contact with the bone. These conditions are found along the lateral walls and the upper portion of the median wall of the orbit. In other places where the point of the needle cannot be held in contact with the bone there is always danger of injury to the eyeball. The use of curved needles cannot be recommended, as the exact location of the point is never known. The lateral point of injection lies immediately above the outer canthus of the eye. The needle is passed with its point constantly in contact with the bone to a depth of 4.5 to 5 cm. and here crosses the superior orbital fissure. The point encounters the distal border of this fissure in the upper wall of the orbit which prevents its further introduction. About 2.5 cc of a 2 per cent novocain-suprarenin solution is injected in the neighborhood of the superior orbital fissure. "The point of entrance for the median orbital injection lies one finger-breadth above the inner canthus of the eye. The needle is again passed to a depth of 4 to 5 cc, keeping it at all times in con- tact with the bone, and the same quantity of solution injected at this point. "The lateral orbital injection blocks the frontal and lacrimal nerves which is necessary in operations in the orbit and frontal sinuses. The frontal nerve and its branches can likewise be blocked farther forward in the orbit by injections made above the bulb. "The median orbital injection blocks the anterior and posterior ethmoidal nerves which supply the mucous membrane of the cribriform plate of the ethmoid, frontal and sphenoid sinuses. Besides these parts the anterior ethmoidal nerve supplies a portion of the nasal mucous membrane and then passing from the nose at the junction of the cartilaginous and bony part is distributed in the skin of the tip of the nose and its surroundings. The median orbital injection is, therefore, necessary in operations upon the nasal cavities and other accessory sinuses. "After the injection a mild, transient protrusion of the bulb and edema of the upper lids occurs. The injections into the orbit 200 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE cause very little pain if the points for injection are first made insensitive by means of a wheal. The injected fluid is entirely outside of the muscular boundaries of the orbit, for which reason the sensory nerves of the bulb, ciliary nerves, ciliary ganglion and the optic nerve are not, as a rule, affected. If the nerves just mentioned are to be anesthetized the solution must be injected behind the bulb and within the muscle boundaries of the orbit. "Serious disturbances following orbital injections and injury to the bulb are practically impossible. Small hematomata occur occasionally in the orbital fat, particularly following the lateral injections, but are of no consequence. Krefel observed amaurosis lasting ten minutes following an injection into the orbit. It is possible that this occurrence may have been more frequently observed than reports indicate, inasmuch as the optic nerve can be affected by the anesthetic as well as by the anemia consequent upon the use of suprarenin. Another case of temporary amaurosis following local anesthesia for empyema of the frontal sinuses has been reported by Jassenetzky. This condition occurred on the day following the operation and was due to an inflammatory edema of the orbit, and inasmuch as the case was a septic one it is very questionable whether the injection had anything to do with the inflammatory symptom." The Maxillary Nerve (Plate II). -"The peripheral branches of this nerve are the infraorbital, superior, posterior and median alveolar nerves. The latter penetrate the upper jaw posteriorly to the maxillary tubercle. Both of these branches are readily blocked. "The infraorbital foramen can be reached by passing a needle beneath the upper lip where the submucosa is reflected from the alveolar process along the anterior surface of the upper jaw to the point of emergence of this nerve, or, better, by passing the needle from without directly into the infraorbital foramen. The injection after either method is made with 2 cc of a 2 per cent novocain- suprarenin solution. When passing the needle from without into the infraorbital foramen, a fine one should be used and inserted just beneath the lower orbital border and passed until it touches the bone, where a small quantity of a 2 per cent novocain-suprarenin solution is injected, following which the opening of the canal is sought with the needle. The injection of 1 cc of a 2 per cent solution is sufficient for blocking the nerve. The following structures are anesthetized: The lower eyelids, the upper lip, the larger part of the alse of the nose (skin and mucous membrane), a part of the skin and mucous membrane of the cheek, the labial mucous membrane, the anterior portion of the upper alveolar process and its periosteum, the anterior wall of the upper jaw and the pulp of the central and lateral incisor teeth." SURGERY OF THE FACE 201 Matas's first method of reaching the maxillary nerve in the foramen rotundum was by passing the needle below the lower border of the zygoma and along the surface of the upper jaw through the pterygopalatine fossa. Schloesser used this route for alcohol injections. In order to reach the nerve from this position the needle is introduced at a point behind the lowest palpable angle of the malar bone. From here it passes inward and upward through the masseter muscle and along the posterior surface of the superior maxillary bone. The nerves lie approximately 5 or 6 cm. from the surface. One should depend, however, upon the paresthesia or pain produced by contact of the needle with the nerve tissue. The author has used from 5 to 10 cc of 1 per cent novocain-adrenalin solution. Matas and Payr reached the foramen rotundum by pass- ing the needle directly through the orbit. Braun gives the follow- ing directions. "A point is chosen for injection where the lower edge of the orbit meets the outer edge. The needle is passed into the orbit at this point in an almost vertical direction and kept in constant contact with the bone forming the floor of the cavity. The inferior orbital fissure is now sought and recognized by the needle passing into it. As soon as this happens, the end of the needle is lowered so that it will assume a horizontal position, which prevents it passing into the infratemporal fossa or into the orbital fat, which is also to be avoided. A false passage will be recognized by the absence of resistance to the progress of the needle. This resist- ance always occurs when the proper direction is taken and causes immediate radiation of paresthetic sensations which fre- quently require the injection of a few drops of the novocain-supra- renin solution. At a depth of about 5 cm. the needle will be in the foramen rotundum and there encounter the bony obstruction at the base of the skull. After a successful injection, anesthesia will immediately occur in the entire area of distribution of the maxillary nerve. Injections which have been only partially suc- cessful require ten to twenty minutes before the full effect is obtained. After these injections the corresponding half of the face becomes anemic in consequence of the action of the suprarenin on the end branches of the internal maxillary artery. "One of the secondary effects which may follow injection into the pterygopalatine fossa, besides small hematomata on the posterior surface of the upper jaw, is paralysis of the muscles of the eye, particularly the oculomotor nerve, due to the needle occasionally passing through the inferior orbital fissure into the orbit. This paralysis disappears with the return of sensation. Although the dangers following injections for purposes of anesthesia are slight one must be particularly careful with alcohol injections. Alcohol 202 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE must never be introduced until after the nerve has been blocked with anesthetics in order to prevent these secondary effects on the muscles of the eye. "Injection through the orbit does not cause paralysis of the muscles of the eye, inasmuch as the needle passes entirely out of the orbit, for which reason alcohol injections can be made much more safely by this route. Hematomata on the floor of the orbit and in the upper lid occasionally occur after orbital injections." Report of Case No. 13960. This case illustrates the block of the maxillary division of the fifth nerve according to the method of Braun: L. M., female, aged twenty-four years, entered the hospital in August, 1920. Diagnosis: Right maxillary sinusitis. Operation: Denker's operation with drainage. Anesthesia: Maxillary nerve block with 22 cc 1 per cent novocain-adrenalin. Anesthesia Technic: Blocking of the maxillary division of the right trigeminus with novocain-adrenalin solution. The needle was introduced at a point 2 cm. posterior to the external canthus of the eye just below the zygoma. Paresthesia was felt in the right side of the face and 2 cc of a 2 per cent novocain-adrenalin solution was injected. Within a minute towel pins could be placed upon the lip. The lip was retracted and the sinus opened, curetted and drained without the production of pain. This patient developed a slight exophthalmos of the right eye directly after the injection. The right pupil dilated and there was disturbance of vision for two or three hours, when the con- dition disappeared. The Mandibular Nerve.-The mandibular nerve may best be ap- proached at a point on the inner surface of the lower jaw in the region of the lingula (Figs. 57 and 58, page 216). It may also be blocked in the foramen ovale as it leaves the skull (Fig. 56, page 215). Halstead was perhaps the first one to block the nerve inside the oral cavity. Braun calls the depression upon the ramus of the inferior maxilla in which the nerve lies the "trigonum retromolare." For the injection of this nerve within the mouth the use of long needles is advisable. The direction of the needle should be from the region of the canine tooth on the opposite side diagonally across the mouth, the needle lying in a plane parallel to the biting surface of the teeth. A wheal is made in the mucous membrane over the position of the nerve and the needle is advanced until it reaches the bone. It then follows the bone backward until it SURGERY OF THE FACE 203 is felt to drop over the lip of bone lying directly in front of the trigonum retromolare (Fig. 58, page 216), 5 to 10 cc of a 1 percent novocain-adrenalin solution will give anesthesia in the corre- sponding half of the lower jaw and in approximately one-half of the tongue. The anterior branches of the nerves may be anesthetized by entering the needle into the mental foramen which lies in a line drawn across the supraorbital and infraorbital foramina and is generally below the space occupied by the first and second bicuspid teeth. Braun states: "The shortest and most certain way of reaching the foramen ovale is from without, the needle being passed just below the border of the zygoma, and if the directions of Offerhaus are followed there is almost certainty that the anesthetic solution will not only be injected around the foramen ovale but directly into the trunk of the mandibular nerve where it emerges from the skull. "Offerhaus found, after accurate measurement of 50 skulls, that the line connecting the articular tubercle lies just in front of the maxillary articulation, and intercepts the two points which are just a few millimeters below and, as a rule, the same distance in front of both foramen ovale. "Inasmuch as the mandibular nerve after its emergence from the skull passes forward and downward, the intertubercular line crosses these nerve trunks exactly at the foramen ovale. "Offerhaus also noted that the distance between the alveolar processes of the maxilla measured from the outside behind the last molar tooth corresponds within a few millimeters to the dis- tance between both foramen ovale, so that if the width of the alveolar processes is subtracted from the length of the intertuber- cular line, and this result divided by 2, the result will give within a few millimeters the distance of the foramina from the articular tubercle of the same side. According to the measurements of Offer- haus the minimum distance would be 3.6 cm. and the maximum 4.7 cm., the usual distance being 3.7 to 4.3 cm. In order to find the direction and length of the intertubercular line in the living patient, Offerhaus constructed an apparatus, the points of which if placed on both articular tubercles, the direction of the intertubercular line is indicated by the adjustable points of the instrument and the distance between both tubercles is measured on the sliding scale. "The injection is performed in the following manner: On the side where the injection is to be made the articular tubercle is marked by a wheal and the point on the opposite side marked with a blue pencil. The distance between the outer side of the alveolar process of the maxilla behind the last molar teeth is measured with ordinary compasses and with Offerhaus compasses the length of 204 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE the intertubercular line is determined. For example, if these distances are 5 and 14 cm. the points will be 4.5 cm. distant from the point of insertion of the needle. A small cork placed on the needle, about 1 cm. farther than the above-mentioned length, will show how far the needle should be inserted and also allow for additional play. The needle, however, should never penetrate deeper than this. The Offerhaus compasses are again placed upon the head and the needle passed into the tissues in the direction indicated by the points on the compasses. Exactly at the point determined the patient will complain of radiating pains in the lower jaw. As a rule, the resistance of the thick nerve trunk can be felt at the needle-point, and at times the needle can be pushed into this trunk. After the needle is in the nerve trunk a very few drops of a 2 per cent novocain-suprarenin solution are suf- ficient; if near the nerve trunk 5 cc of this same solution are injected. The blocking of the nerve often occurs instantaneously, but never requires more than five to ten minutes." ''The following description of the injection of the foramen ovale is somewhat simpler than the above. The point of entrance for the needle is marked just below the middle of the zygoma and the needle is inserted in an almost transverse direction. This direction is easily determined by holding a skull with the direction marked by a sound alongside the head of the patient. At a depth of 4 to 5 cm. the end of the needle touches the bone, the pterygoid pro- cess. In this injection the needle is about 1 cm. distant from the foramen ovale. This distance is marked on the needle with the movable piece of cork. The needle is then withdrawn as far as the subcutaneous connective tissue and is passed back again at a slight angle to the same depth and possibly a few millimeters more. The characteristic radiating pains will then occur. "This last method can be further simplified by computing the depth at which the foramen ovale is found. As a rule the author combines both methods in directing the needle, but passes it some- what more anteriorly than Offerhaus, feeling for the base of the pterygoid process. Then, as already mentioned, the needle is directed slightly backward and inserted 0.5 to 1 cm. more than the previously computed distance. Hematomata or other secondary effects never follow injections into the foramen ovale when made from without. "The methods described by Ostwalt and Schloesser for the injec- tion of alcohol into the foramen ovale cannot be compared with the method just described, for certainty and freedom from danger. In this method Ostwalt passes a long angular needle through the wide- open mouth behind the last molar tooth through the external SURGERY OF THE FACE 205 pterygoid muscle and, by using the external lamina of the ptery- goid process as a guide, reaches the foramen ovale. Schloesser for like purposes locates with the finger in the mouth the lower end of the wing of the sphenoid, passing a long straight needle through the cheek, coming out just below the finger in the mouth, and then through the mucous membrane and under the finger toward the wing of the sphenoid above, until the resistance of the base of the skull is felt. The needle point must now lie a few millimeters in front of the foramen ovale." "The exploratory puncture and injection of the Gasserian ganglion1 through the oral cavity as described by Ostwalt and Offerhaus has very little in its favor, as is admitted by Offerhaus. Apart from the almost impossible asepsis, the needle approaches the flattened ganglion too acutely and does not have sufficient ' play,' so that it promptly punctures the upper dural sheath of the cavum meckeli." "Haertel has described a very exact method for directing the needle in puncture of the Gasserian ganglion, which is in part similar to Schloesser's. His method is likewise of great value in the interruption of the third branch of the trigeminus." What would appear to be an excellent plan for reaching the second and third divisions of the trigeminal nerve and one with which the author has had no experience is described by Francis C. Grant2 of Philadelphia. Dr. Grant states in part: "Any attempt to reach a nerve trunk lying deep beneath the skin, and emerging from bony orifices in the skull, requires definite landmarks and angles as guides to the approach. In this clinic there has recently been developed an instrument called a zygo- meter (see Figs. 49 and 50) which helps in great measure to deter- mine accurately the point on the face at which the needle should be introduced to reach a particular nerve trunk. Using this instrument to standardize the points of insertion of the needle through the skin, we have worked out, in a series of cases in the dissecting room, the angles in the horizontal and vertical plane through which the needle must pass from this fixed surface point to enter the nerve trunk. In the case of the second division of the trigeminus, which is the more difficult of the two branches to inject, three points of approach were used, and the angles taken by the needle in penetrating the nerve were ascertained. For the third division, owing to the relative ease of injecting it, only 1 Haertel, F.: Gasserian Ganglion Injection through Oral Cavity, Arch. f. klin. Chir., 1912, 100, 199. 2 Anatomic Study of Injection of Second and Third Divisions of Trigeminal Nerve (from the Clinic of Dr. C. H. Frazier, University Hosp., Philadelphia), Jour. Am, Med. Assn., 1922, 78, 794. 206 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE one fixed point was employed, and its corresponding angles were determined." The calvarium was removed from every specimen in order that the point of the needle be accurately ascertained. The approach for the second branch is subzygomatic, 3.5 cc being injected anterior to the ear. In 162 attempts it was impossible to reach the second branch of the nerve in only 4 instances. In 19 cases it was necessary to open the lower jaw to avoid impinging upon the coronoid pro- cess. In 13 of the 19 cases this occurred on both sides. Fig. 49.-Injecting third division of fifth nerve from 2 cm. mark: Method of measur- ing angle (110 degrees) in vertical plane with protractor. (Grant.) Grant further states: " In spite of these efforts to establish a uniform procedure it was found that in only 53 of the 81 cases in which both sides were measured did the angles in corre- sponding planes on right and left agree within a margin of error of 5 degrees. In the other 28 cases, 21 varied within 10 degree and the remaining 7 showed a discrepancy of from 10 to 20 degrees. The error seemed as great in one plane as in the other. This variation is an evidence of how markedly the two sides of the skull may differ. The depth at which the nerve was reached varied between 5 and 5.5 cm. from the surface. It is believed that a SURGERY OF THE FACE 207 penetration greater than 5.75 cm. would be attended with con- siderable risk of damaging important structures through the passage of the needle point into the posterior part of the orbit or nose. "To inject the supramaxillary nerve by this method the needle is inserted at the 3.5 cm. mark on the lower border of the zygo- meter. The point of the needle should be directed inward at an angle of 98.5 degrees in the horizontal plane and 115 degrees in the vertical plane, as described. The needle passes below the Fig. 50.-Injecting third division of fifth nerve from 2 cm. mark: Method of measur- ing angle (90 degrees) with protractor in the horizontal plane. (Grant.) zygoma. At this point it may at once be obstructed by the coronoid process of the mandible. If so, the jaw should be opened, which will allow the needle to pass. The vertical angle should now be increased a trifle, thus deflecting the needle-point slightly above the exact point at which the nerve is to be sought. At about 4.5 cm. depth a bony process will be met which is the pterygoid plate. Next the vertical angle should be decreased slightly by lowering the needle point. Then the point is slid forward over the upper anterior edge of the pterygoid plate into the spheno- maxillary fissure, where, at a depth of from 5 to 5.5 cm., the nerve is reached. The sensation of sliding forward into a cleft over the edge of the pterygoid plate is very striking and makes the 208 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE experienced operator feel sure of a successful injection. In the 4 cases of a series in which it was impossible to transfix the nerve by this route, the interference seemed to be due to an anterior development of the pterygoid plate, which prevented the needle point from passing anteriorly to it with any chance of hitting the nerve. The dangers in the use of this method are twofold: If the needle point is held too high and inserted more than 5.5 cm., it is possible to enter the orbit through the posterior part of the sphenomaxillary fissure; if held too low and advanced too far, the needle tip will pierce the thin, bony walls of the nasal cavity or pass through the sphenopalatine foramen into the posterior nares. " Subzygomatic Injection of the Maxillary Division from Five- centimeter Mark.-The second approach to the superior maxillary division of the trigeminus is through a point 5 cm. anterior to the external auditory meatus. The zygometer is in the same position as in the previous method, and the angles the needle shaft forms with the skin are measured in the same fashion as from above downward and from before backward. In a series of 120 injections on 60 cadavers the average for the horizontal angle was 87 degrees and for the vertical angle, 138 degrees. There was no variation between the angles at which the nerve was reached on the right and left side of more than 10 degrees. 55 of the 60 cases showed a variation between the two sides of less than 5 degrees. In every case it was possible to reach the nerve. The point of entrance of the needle is so far forward that the instrument must be passed below the malar, which accounts for the larger vertical angle. In general, this is the route used in the intra-oral method advocated by Schlosser1 and Ostwald,2 this method being an extra-oral modi- fication of their technic. " Suprazygomatic Injection of Maxillary Division.-The third avenue of approach that we studied is suprazygomatic. With the zygometer in the standard position the superior border of the zygoma and the temporal border of the malar bone are outlined by palpation. The apex of the angle formed by the junction of these two bones is approximately 3.5 cm. anteriorly on the base line of the zygometer. Using this point for the insertion of our needle in a series of 60 injections in 32 cases, the average angle in the horizontal plane is 100 degrees and in the vertical plane, 87. In 2 cases on the right and the left side in the same case it was found impossible to reach the nerve trunk by this approach. In 23 of the 30 cases the right and the left angles agreed within 5 degrees. The other 7 cases right and left conformed within 10 degrees. 1 Munchen, med. Wchnschr., April 30, 1897. 2 Presse med., December 16, 1905. SURGERY OF THE FACE 209 "The needle is inserted above the zygoma at the 3.5 cm. mark almost perpendicularly in the vertical and slightly forward in the horizontal plane. The point impinges first on the posterior wall of the maxillary antrum and is carried along this wall and slightly downward to pass under the upper anterior curved edge of the pterygoid plate. By holding close to these two bony landmarks, the nerve is reached at about 4.5 cm. from the surface. If the needle be inserted too far the lateral wall of the nose may be pierced, although this is not a serious mishap. The needle is at all times well below the level of the optic nerve and anterior to the larger bloodvessels. This, therefore, is a safe procedure, and the angles are fairly constant. But from the number of trials required before the nerve could be reached in many cases, and with total failure in 2 out of 32, we fear that clinically this method may not be as satisfactory as was hoped. "Injection of the Mandibular Division.-For injection of the mandibular division of the trigeminal nerve, only one approach was considered. Injection of this branch is relatively so simple and satisfactory that no other method is needed. With the zygo- meter in the standard position, the 2 cm. mark on the lower bar was selected. This corresponds approximately to the point of election described by Levy and Baudouin. Through this point, 162 injections were made on 81 cadavers. The nerve was easily reached in every case. The horizontal angle averaged 91 degrees, ami the vertical angle 108 degrees. In 52 of the 81 cases the angles for injection on the left and right corresponded within 5 degrees, in 26 within 10 degrees; in 3 cases, the variation was more than 10 degrees. In the 3.5 cm. approach to the second division, the angles measured in 53 of the 81 cases were equal within 5 degrees right and left. In 40 of these 53 cases in which the second division measurements were in accord on either side, the third division measurements were also closely similar. These figures only go to prove the variability of structures on the opposite sides of the same skull. "The needle is inserted below the zygoma opposite the 2 cm. mark on the lower bar. The direction is perpendicular to the skin in the horizontal plane, and a little upward in the vertical plane. Once the zygoma is passed, the needle point should be deflected slightly upward to strike the floor of the middle fossa. This bone is followed backward, bearing at the same time some- what forward to avoid the middle meningeal artery, which passes through the foramen spinosum just posterior to the foramen ovale until, at a depth of 4.5 cm., the nerve is reached. By thus keep- ing the needle point high, it was possible in every case studied to inject the entire ganglion through the foramen ovale if such a 210 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE procedure should be deemed necessary. If it does not seem desir- able to affect the whole ganglion but only the third division, the needle point should be held a trifle lower. The nerve will then be pierced somewhat beyond its exit through the foramen. If the direction of the needle is accurate, the nerve will always be reached within 5 cm. of the surface. The needle point should never be allowed to penetrate to a greater distance than 5 cm. Summary. " 1. In 162 subzygomatic injections of the supramaxillary division of the fifth nerve from the 3.5 cm. mark: " (a) The average angle was 98.5 degrees in the horizontal and 115 degrees in the vertical plane. "(6) In 65 per cent of injections, the angles for the right and left sides corresponded within a margin of error of 5 degrees. "(c) In 25 per cent of the cases there was a variation of 10 degrees in the corresponding angles on the two sides. "(d) In 10 per cent of the cases the variation was between 10 and 20 degrees in the corresponding angles on the right and left. " (c) The percentage of failures to reach the nerve was 4.7. "2. In 128 subzygomatic injections from the 5 cm. mark: " («) The average horizontal angle was 87 degrees and the vertical angle, 138 degrees. " (6) In 91 per cent of the subjects, the corresponding angles on the right and left were equal within a margin of error of 5 degrees. "(c) In the remaining 9 per cent, the variation was 10 degrees or less. " (d) There were no failures to reach the nerve by this route. "3. In 62 suprazygomatic injections from the 3.5 cm. mark on thirty-two subjects: " (a) The average vertical angle was 87 degrees, and the horizontal angle, 100 degrees. "(6) In 72 per cent of the cases, the corresponding angles on the right and the left agreed within 5 degrees. " (c) In 22 per cent of the cases the difference in the corre- sponding angle, right and left, was 10 degrees. "(d) In 6 per cent of the cases it was impossible to reach the nerve by this route. "4. It was always possible to reach the nerve in every case, SURGERY OF THE FACE 211 right and left, by one of these three methods. In no case were all successful. "5. In 162 subzygomatic injections of the mandibular division of the trigeminus from the 2 cm. mark: "(a) The average vertical angle was 108 degrees, and the horizontal angle, 91 degrees. " (6) In 62.2 per cent the corresponding angles on the right and left agreed within 5 degrees. "(c) In 32.1 per cent the angles varied within 10 degrees. " (d) In 3.7 per cent the angles varied more than 10 degrees. " (e) In 75.4 per cent of the cases in which the corresponding angles of injection by this route agreed within 5 degrees, the angles of injection for the supramaxillary division from the 3.5 cm. mark by the subzygo- matic route also varied less than 5 degrees. " (/) There were no failures to reach the mandibular division by this route." The Van Allen method1 of injecting the Gasserian ganglion is as follows: "The method of approach is by way of the orbit, the pathway is the median wall of the orbit and the portal of entrance is the sphenoidal fissure. The needle is guided by touch until its prog- ress is obstructed by the bony fossa lodging the ganglion. A Patrick cranial needle 10 cm. long and 1.5 mm. in diameter with a snug stylet is used and the needle point is ground back 3 or 4 mm. so that the stylet acts as a blunt probe leaving the sharp pointed needle when the stylet is withdrawn. (Figs. 51 and 52.) " The patient is placed in the dorsal position and the upper and inner angle and median wall of the orbit are infiltrated with 1 per cent novocain-adrenalin (see Fig. 51). An incision 3 or 4 mm. long is made just below the superior oblique muscle, using the pulley as a guide and extending it to the orbital plate. The peri- osteum is loosened with the scalpel point for 0.5 cm. Then the needle with stylet in place is inserted into the slit and passed back- ward and toward the mouth until the median wall of the orbit is felt to slope away to the floor. Using the upper and inner angle of the orbit as a fulcrum, the junction of the wall and floor is fol- lowed until a bony obstruction is reached, which is the lower margin of the sphenoidal fissure. The needle point is lifted over the obstruction and passed into the fissure (Fig. 52). The shaft of the needle is held firmly against the inner angle of the orbit and the tip lodged within the lower extremity of the sphenoidal fissure, the stylet is withdrawn and the needle driven straight through 1 Transorbital Puncture of the Gasserian Ganglion, Annals of Surgery, 1921, 74, 525, 212 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE the middle cranial fossa until bony resistance is felt when it will be in the ganglion as evidenced by facial pain. The depth varies from 8.5 to 10 cm. Fig. 51.-A. Van Allen's needle used in puncture of the Gasserian ganglion (greatly enlarged): B, right eye illustrates the direction taken in inserting the needle; C, right eye illustrates position of needle when ganglion is reached. "The dangers of this method are: (1) rupture of the median wall of the orbit; (2) puncture of the cavernous sinus with throm- bosis but not hemorrhage; and (3) puncture of the silent area of the brain without ill effects. If the first attempt fails, dis- continue the method for this case. SURGERY OF THE FACE 213 "Eighty per cent of the 5 cases reported were successful." The most extensive operations which one is called upon to per- form in this region are excisions for malignant disease. The fore- going pages furnish excellent descriptions of the various methods of producing anesthesia for operations upon the face. Fig. 52.-Anterior view of the right orbit indicating first portion of needle path (Van Allen.) In making excisions of the superior maxilla, the author has made a subdermal infiltration as illustrated in Fig. 53, before blocking the maxillary nerve (Fig. 53, A). In making the maxillary nerve block an infiltration along the course of the nerve as shown in Fig. 54 will suffice. In operating upon the inferior maxilla, the subdermal infiltration Fig. 53.-Anesthesia for excision of superior maxilla, subdermal infiltration and A. block of the maxillary branch. Fig. 54.-Sectional view of Fig. 53. 1, N. ophthalmicus; 2, N. maxillaris; 3, ganglion semilunare (Gasseri); 4, N. mandibularis; 5, N. lingualis. Fig. 55.-Anesthesia for excision of inferior maxilla. Subdermal infiltration for block dissection of neck. A, block of the cervjical plexus; B, block of the mandibular branch, n. trigeminus. Fig. 56.-Sectional view of Fig. 55. A, block of cervical plexus; B, block of the mandibular nerve. 1, N. ophthalmicus; 2, N. maxillaris; 3, ganglion semi- lunare (Gasseri); 4, N. mandibularis; 5, N, lingualis. Fig. 57.-Transoral block of mandibular nerve. Fig. 58.-Sectional view of Fig. 57. 1, A. maxillaris interna; 2, N. ophthal- micus; 3, N. buccinatorius; 4, ganglion semilunare (Gasseri); 5, N. mandibularis; 6, N. alveolaris inferior. SURGERY OF THE FACE 217 also precedes the blocking of the mandibular nerve as shown in Figs. 55, B and 56, B. In case the dissection of the glands of the neck is to be carried out the blocking of the cervical nerves (Figs. 55, A and 56, A) should be made. (See Fig. 68, page 231.) The most simple method of reaching the mandibular branch is the transoral route (Figs. 57 and 58). Cases Nos. 11349, 14106 and 15752 are respectively examples of carcinoma of the alveolar process of the inferior maxilla and the lip and Case No. 14169 is one of fracture of both maxilla1 and skull, all of which were treated surgically under local infiltration. Report of Case No. 11349. K. L., aged fifty-six years, entered the hospital on June 4, 1918. Diagnosis: Carcinoma of the alveolar process of the right inferior maxilla. After preliminary cleansing of the teeth the patient was operated upon in two stages. First Operation: Preliminary excision of the glands of the neck. Second Operation: Resection of the inferior maxilla. Anesthesia: June 5, the patient was given a hypodermic of morphin |, scopolamin The classical infiltration block of the cervical nerves (Fig. 68, page 231) was made. In addition a subdermal infiltration (Fig. 55, page 215) was made, the upper line extending well upon the cheek. The incision was made parallel to and above the clavicle and continued upward along the anterior border of the trapezius. A flap was dissected forward, the sternocleidomastoid muscle divided low down and a block dissection of the neck was made, the parotid gland being removed. Several enlarged glands in the neck were identified and removed. Microscopical examination of these showed them to be benign. The wound was closed with drainage. The patient left the hospital in a week without sub- mitting to the radical operation. After a delay of another week he returned and complete excision of the growth was attempted. Second Operation: June 22, 1918. Anesthesia: The patient was once more given a preliminary hypodermic and, as it was impossible to reach the mandibular branch from within the mouth, direct infiltration was depended upon. Subdermal infiltration from the lobe of the ear to the mid- line in front was made. This infiltration was carried below the angle of the jaw and then deeply into the neck at the base of the tongue; 90 cc of a 0.6 of 1 per cent novocain-adrenalin solution were used. The lower jaw was divided at the mental foramen and dislocated 218 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE behind. A portion of the tongue and the pillars of the fossae of the corresponding side were removed, the cautery being used in dividing the soft tissues. The patient made an uneventful recovery without any complications. The growth, however, returned within a short time. Note.-This patient had perfect anesthesia by the method of infiltration block. The mandible was reached from the inferior aspect and the only reinforcement required was during the dis- articulation of the temporal mandibular joint. Report of Case No. 14106. W. S. W., aged forty-one years, entered the hospital January 17, 1921. Diagnosis: Epithelioma of the lower lip. Operation: Block dissection of neck and excision of growth. Anesthesia: Local infiltration and cervical block. The growth appeared on the right lower labial border about five months before, and was cauterized one month before coming to the hospital. Operation: Bilateral block dissection of neck, excision of growth. A circumferential subdermal infiltration from the angles of the mouth downward and outward to the midpoint of the sternocleido- mastoid muscle and along the anterior border of this muscle to the clavicle was made on each side, as well as a bilateral infiltration block of the second, third and fourth cervical nerves. 120 cc of a 0.5 per cent novocain-adrenalin solution were used. Anesthesia was ideal. Transverse incision was made beneath the ramus of the jaw, with the Hap dissected well below the cricoid cartilage, and block dissection upward with "V" shaped excision of the lip followed. This patient waited on himself throughout his con- valescence and developed no nausea, vomiting or thirst. The following cases show the possibilities of direct infiltration when for some reason the mandibular division cannot be blocked near its exit from the skull. Report of Case No. 14169. N. J., aged thirty-seven years, entered the hospital on March 3, 1921. He had sustained a fracture of the base of the skull and a fracture of the left superior maxilla in addition to a fracture of the lower jaw. Diagnosis: Fracture of base of skull, left superior maxilla and left mandible. Operation: Wiring of the fragments of mandible. SURGERY OF THE FACE 219 Anesthesia: Local infiltration block with 2 per cent saligenin. On account of the injury to the upper jaw and base of the skull it was deemed unwise to attempt a mandibular block at the point of exit of the mandibular branch. Direct infiltration was there- fore depended upon and this was made, using a 2 per cent solution of saligenin, along the line of the proposed incision, with a trans- verse block 3 cm. proximal to the line of fracture, the needle being introduced from below upward along the ramus of the jaw on the inner side. The fragments were drilled and wired without pain to the patient. This case illustrates the possibility of using direct infiltration when for any reason the mandibular branch cannot be blocked at its point of exit from the skull or upon the inner surface of the ramus of the jaw. Report of Case No. 15752. R. S., aged eighty-two years, entered hospital June 1, 1922. Diagnosis: Carcinoma of the inferior maxilla. Operation: Excision. History: Growth appeared along left alveolar margin three to four months before entering hospital. Examination: Growth now extends from midline in front to the region of second molar. Operation: Excision of mandible June 4, 1922. Anesthesia Technic: Transoral mandibular block 10 cc of 1 per cent novocain-adrenalin solution. A subdermal infiltration was made at right angles to the mouth beneath the chin, transversely backward to about the midline of the neck. The lower lip was divided in the midline, the right mental nerve was blocked at the mental foramen. The bone was divided on a line with the right lateral incisor and with the sub- lingual and submaxillary glands and the gland-bearing tissues of the neck was turned outward and to the left. (See Eig. 59.) The mandible was then divided at the junction of the horizontal with the vertical ramus and removed. Before uniting the soft tissues the remaining ends of the lower jaw were drilled and a horseshoe- shaped brass wire was inserted in order to maintain the bones in proper position. The mucous membrane was sutured with chromic gut, the sublingual tissue being anchored to the temporary metal mandible. The skin incision was closed with silkworm gut with ample drainage through the floor of the mouth. l?ig. 60 shows the patient at the completion of the operation. The patient was tired but the pulse remained about 80. There was no change in his general condition. The patient did well for six days and was 220 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE sitting up when his death occurred without warning. No autopsy was allowed but it was assumed that he died of pulmonary embolism. His lungs had shown no signs of pneumonia up to the time of his death. In the case of fractured mandible it is usually impossible to reach the third division by the transoral route. The same is true in malignant disease of the jaw extending well up along the ramus. In such cases it is desirable to block this branch near its origin. See mandibular block (Grant), Fig. 55, page 215. Fig. 59. Case No. 15752.-Carci- noma of the lower maxilla during oper- ation. Fig. 60. Case No. 15752.-Carci- noma of the lower maxilla at the com- pletion of operation. SKIN PLASTICS. Plastics upon the face are usually done in the same manner, the infiltration being but the work of a moment. As a rule it is made at some distance from the lines of incision, although this is not important. The thickening of the tissues caused by the infil- tration we find is rather an advantage than otherwise in the final coaptation of the wound by the suture, as it enlarges the structures with which one has to deal. The action is very transient. All the external soft tissues of the face may be blocked by injecting the corresponding nerves at their point of exit, but here a direct infiltration is exceedingly simple and satisfactory. Hare-lip. -Of late, operation upon hare-lips in infants under local anesthesia has been found satisfactory. A slight infiltration is made along the lines indicated in Fig. 61; a submucous injection is made along the alveolar border in the region of the root of the nose and the operation then proceeds without delay. One might SKIN PLASTICS 221 assume that the edematization of the tissues would interfere with the apposition of the parts, but such is not the case. Quite obviously if the tissues on either side of the cleft are increased equally in thickness as a result of the infiltration, the ultimate coaptation of the denuded edges meets with no interference. Indeed, it has been found that the increased thickness of the tissues, resulting from the infiltration, offers a better opportunity to obtain neat coaptation, as the increased thickness of the lips makes them more easy to handle. These babies frequently show a normal temperature during the day following operation, whereas those who have taken ether usually show a marked elevation of temper- ature and a tendency to bronchial irritation. Fig. 61.-Showing lines for infiltration block in hare-lip operations, Report of Case No. 14300. B. I)., aged twelve weeks, entered the hospital, March 3, 1921. Diagnosis: Hare-lip and cleft palate. Operation: Plastic repair of lip. (Second step-Brophy pro- cedure.) Anesthesia: Local infiltration. History: Reposition of alveolar processes with Brophy wiring, eight weeks previously. Two weeks previously, removal of wires. Anesthesia Technic: An infiltration block was carried out along the lines indicated in Fig. 61, the child being forcefully restrained while the injection was being made. The restraint for the initial wheal about equals that of ether induction. As anesthesia of the lips became established they were elevated by means of towel pins and a submucous infiltration along the alveolar processes wras 222 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE carried out. The classical operation was then completed with- out difficulty. Note.- This patient did not vomit after the operation. Ue took food almost immediately and his temperature was 98 degrees on the following day. His maximum temperature remained under 100 degrees. In the author's experience children show much less tendency to bronchial irritation and postoperative elevation of temperature when local, rather than general anesthesia, is employed. Fig. 62.-Nerve supply of the tonsil. A, Nn. palatini; B, N. glossopharyngeus; C, rami tonsillares. 1, ganglion semilunare (Gasseri); 2, ganglion sphenopalatinum (Meckel); 3, Nn. palatini (anterior, middle and posterior); 4, N. glossopharyngeus; 5, tonsil; 6, rami tonsillares. SURGERY OF THE MOUTH AND THROAT. The Tonsils.-The sensory nerve supply of the tonsil region is as follows: 1. Rami tonsillares, branches of n. glossopharyngeus (IX) supply the palatine tonsil, forming a network. 2. Sensory branches from the sphenopalatine ganglion of n. trigeminus. 3. N. palatinus medius, n. palatinus posterior, of n. maxillaris, second division of n. trigeminus. (Fig. 62.) Tonsillectomy.-Infiltration.-It is desirable to avoid infiltration of the pillars when doing tonsillectomy under local anesthesia. SURGERY OF THE MOUTH AND THROAT 223 It is much better to reach the nerve supply at a distance. (Figs. 62 and 63.) When blocking is done in this manner the position of the tonsil is not obscured by the edema. The nerve supply is blocked as illustrated in Fig. 62 and 63, A, B and C. An infiltration block is used and the needle-point is kept moving while the injection is being made. In this manner one avoids the possibility of introducing any considerable amount of solution into a vessel. Fig. 63.-Anesthesia for tonsillectomy. (See Fig. 62.) An injection at (A) anesthetizes the posterior palatine branch of the maxillary division of the trigeminus and with the needle at (B) the plexus of nerves from the glossopharyngeus and the spheno- palatine ganglion are reached, and at (C) (which point is dis- tinguished by putting the palatoglossal muscle on the stretch) the anesthesia of the arborizations of some nerves of the inferior pole of the tonsil completes the injection. A very satisfactory method is the subcapsular injection of the solution, but this method demands more finesse and skill of the surgeon than when the infiltration block, described above, is carried out. 224 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE The tissues in which these nerves lie are best visualized by depressing the tongue. Finally, a small amount of the solution is deposited external to the tonsillar capsule. Approximately 8 cc of 0.7 of 1 per cent solution are required, and anesthesia is complete almost immediately. In these cases a careful blocking with quinin and urea hydrochloride 1 to 600 in all raw surfaces will have a marked effect in preventing the distress which follows operation, especially in adults, and will aid in reducing the liability Fig. 64.-Blocking the lingual nerve. Sublingual method to postoperative hemorrhage. The practice of making local appli- cations of strong solutions of cocain to the mucous surface of the throat is extremely dangerous and entirely unnecessary. Surgery of the Tongue. The nerve supply of the tongue is as follows: Anterior two-thirds; n. lingualis, a branch of the third division of the n. mandibularis. Base and posterior one-third: Rami lingualis, branches of n. glossopharyngeus and ramus interims of the superior laryngeal branch of n. vagus. (Plate II.) SURGERY OF THE MOUTH AND THROAT 225 Operations upon the tongue may be accomplished after a bilateral injection of the lingual nerve (Figs. 64 and 65) or a mandibular block (Fig. 56, page 215, and page 205). It is advisable to make the injection bilateral, provided work of an extensive nature is to be done. The author has excised half the tongue for malig- nant disease a number of times under this method of anesthesia. He has not attempted the complete removal of the tongue under local anesthesia, although the removal of portions of the Fig. 65.-Sectional view of Fig. 64.- 1, A. maxillaris interna; 2, N. ophthalmicus; 3, N. buccinatorius; 4, ganglion semilunare (Gasseri); 5, N. mandibularis; 6, N. lingualis. tongue under this method is a comparatively simple matter. Com- plete excision of the tongue, if ever indicated, should not be attempted without an excellent exposure, and with perfect exposure it should be possible, and it would seem to be feasible, to infiltrate the base of the tongue below the point of excision. Allen states that general anesthesia is indicated in complete excision of the tongue, but, in view of the fact that most of these patients succumb to pulmonary infection, local anesthesia would seem to be indicated. 226 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE The operation should be possible under a nerve block of the inferior dental and lingual on both sides and a transverse block below. If the growth is so extensive that this block would be inadequate it is doubtful if an operation of any kind would be indicated. The preliminary division of the lower jaw at the symphysis menti (after Kocher) would be of advantage. The author has not had the opportunity of performing this operation. Fig. 66.-Anesthesia for operations upon the soft palate. A, B, C, points for blocking nerves of palate. (See page 168 and Fig. 62.) The Palate.-After early adolescence the palate may be anes- thetized by blocking the n. palatinus posterior, n. palatinus medius, and n. palatinus anterior of n. maxillaris, second division of n. trigeminus and n. nasopalatinus (Fig. 62, page 222). Cleft palate plastics have been performed by the local method upon a patient as young as fifteen years. (Case No. 11400.) The absence of hemorrhage, the cooperation of the patient and the almost entire elimination of disagreeable sequelae would seem to indicate that local anesthesia should be used more frequently in cleft palate work in the adult, and also in the removal of tumors of the palate. The line of cleavage between the bone and the mucoperiosteum of the palate may be infiltrated with a solution, under pressure, SURGERY OF THE MOUTH AND THROAT 227 thus greatly facilitating the elevation of the latter. The adrenalin greatly reduces the amount of hemorrhage and in the few cases in which the author has used it healing was excellent. The points of injection are illustrated in Fig. 66, A, B and C, using about 50 cc of 2 per cent novocain-adrenalin solution. Cases Nos. 14115, 14281 and 11400 show the application of the above method in surgery of cleft palate. Report of Case No. 14115. E. M., aged twenty-five years, entered the hospital on January 21, 1921. Diagnosis: Cleft palate. Operation: Plastic repair. Anesthesia: Novocain-adrenalin solution. The nerves illustrated in Fig. 62, page 222, were blocked at points R, B and C, Fig. 66, with a 2 per cent novocain-adrenalin solution, 30 cc in all being used. In addition to the nerve block an effort was made to separate the soft tissues from the bone by the "blowing-off" process. This was signally successful, the subsequent raising of the mucoperiosteum being greatly facilitated by this preliminary maneuver. The palate united completely with the exception of an opening the size of a lead-pencil at the midpoint. This opening was later closed after making a local infiltration with novocain-adrenalin solution. Report of Case No. 14281. K. E., aged twenty-six years, entered the hospital on May 27, 1921. Diagnosis: Cleft palate and hare-lip. Operation: Plastic repair. Anesthesia: 60 cc of a 2 per cent novocain-adrenalin solution were used. The blocking in this case was similar to that referred to in the case of E. M., above, and the anesthesia was ideal. Healing was perfect throughout the line of suture. Report of Case No. 11400. The youngest patient upon whom the author has operated for cleft palate under local anesthesia was A. M., aged fifteen years, who entered the hospital on March 8, 1918. Diagnosis: Cleft palate. Operation: Plastic repair, 228 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE Anesthesia: Local infiltration, novocain-adrenalin 2 per cent. Under ideal anesthesia this complete cleft was repaired and the repair was followed by primary healing. This boy had been operated upon twelve years previously, and notwithstanding the presence of scar tissue perfect anesthesia was obtained. Note.-This was the first case of cleft palate the author operated upon under local anesthesia, and it was done on March 8, 1918. At the beginning of the operation a 0.7 of 1 per cent novocain- adrenalin solution was employed, but it was found unsatisfactory on account of the presence of scar tissue and 2 per cent was sub- stituted. Since that time about 50 cc of a 2 per cent solution has been employed for each operation. CHAPTER VIII. LOCAL ANESTHESIA IN SURGERY OF THE NECK. GENERAL CONSIDERATIONS. Advantages.-In this region local anesthesia presents many special advantages over general. By its use hemorrhage is greatly reduced; (1) through the action of the adrenalin solution; (2) through the reduction in local engorgement of the bloodvessels, especially the veins. Under local anesthesia we have frequently demonstrated the fact that a patient may control at will his own bleeding from the internal jugular vein, an expulsive effort causing the blood to spurt from the wounded vessel, perfect repose causing the vessel to cease bleeding and deep inspiration causing a negative pressure in the vein. Cooperation of the Patient.-Under local anesthesia the co- operation of the patient is obtained, as his head may be turned from side to side at will, respirations may be controlled, ability to use the voice may be ascertained, the patient may go through the process of swallowing if directed to do so and the interference caused by the presence of an anesthetist is not encountered. Following the operation the respiratory function is not impaired and the chance of soiling wounds by vomitus is reduced to a minimum. The work upon the neck, aside from that in which the trachea is manipulated, may be carried out with the same dispatch, and if desired, practically the same technic as when general anesthesia is used. Operations upon the thyroid, larynx and trachea require a more refined technic than is usually seen when general anesthesia is employed. NERVE SUPPLY OF THE NECK. The sensory nerve supply of the neck is as follows: The skin of the neck is supplied by (1) n. cutaneus colli (II, III C) to the antero-lateral regions, by way of the ascending branches which supply the upper front part, and the descending branches to the side and front as low as the sternum; (2) a cervical communicating branch of the facial; (3) nn. supraclaviculares anteriores (III, IV C) also to the lower and front part of the neck and (4) medial branches of the posterior divisions of the third, fourth and fifth cervicals which supply the posterior or dorsal region. 230 LOCAL ANESTHESIA IN SURGERY OF THE NECK The muscles and fascia of the neck are supplied by branches of practically the same cervical nerves mentioned above and the over- lapping of the trigeminal with the cervical cutaneous nerves does not always take place at the mandibulo-cervical line, which requires that the terminal branches of the mandibular division of n. tri- geminus be also included in the sensory nerve supply of the neck. (Plate IV.) METHOD OF INDUCING ANESTHESIA. The skin and the cervical fascia are the most sensitive structures. While blocking of the cutaneous colli will give anesthesia of the superficial structures of the neck, the deep structures cannot be manipulated under this anesthesia alone and more extensive anes- thesia is necessary for work that is at all extensive. The second, third and fourth cervicals should be blocked at or near their point of exit from the cervical vertebrae. This blocking should be bilateral for work that traverses the midline in front. As the terminal branches of the nerves cross the midline and over- lap the trigeminus branches, it is advisable to block the skin around the field of operation by a subdermal infiltration. It has been the custom of the author also to make a subdermal infiltration along the proposed line of incision. This procedure allows one to make the incision as soon as the injection is finished. Otherwise some delay is necessary while the solution disseminates into the nerve structures. The subdermal infiltration, which is but the work of a moment, is made directly under the eye and all large vessels can be seen and avoided. A subdermal infiltration will render incisions almost bloodless and give good anesthesia during the early stages of the operation, at which time the patient is liable to be most appre- hensive. DEEP CERVICAL INFILTRATION In making the deep cervical infiltration block the suggestions of Braun have been followed with some modifications. His instruc- tions are to drop a vertical line from the tip of the mastoid process downward 7 cm. and slightly backward, forming an acute angle with the sternocleidomastoid. This line marks the point of emergence of the second, third and fourth cervical nerves, and according to Braun's technic the needle is introduced transversely through a series of punctures made along this line. The author has modified this technic to some extent. An intradermal wheal is made at about the midpoint of this line by introducing a needle through a previously anesthetized area anteriorly and carrying it back through the subdermal fat, making this wheal from beneath. All of the deep blocking is then made through this wheal (Figs. 67 and 68). DEEP CERVICAL INFILTRATION 231 Fig. 67.-Anesthesia for block dissection of the neck, showing lines of subdermal infiltration, and A, block of cervical plexus. Fig. 68.- Sectional view of Fig. 67. 1, N. cervicalis I; 2, N. cervicalis II; 3, N, cervicalis III; 4, N. cervicalis IV. A, cervical block showing position of needles. 232 LOCAL ANESTHESIA IN SURGERY OF THE NECK The needle is introduced first in a slightly upward direction, then introduced transversely and again introduced in a slightly down- ward direction. In reintroducing the needle it need not be withdrawn from the skin but must be withdrawn from the cervical fascia each time that its direction is changed. The injection is made as follows: Before injecting, the needle is advanced until it touches the transverse process of one of the cervical vertebrae or until it impinges upon a nerve. It is then slowly withdrawn, the injection being made while it is receding and while it travels a distance of 1 or 2 cm. Should the needle impinge upon a nerve, a circumstance which is manifested by a slight shock to the patient (a circumstance which is desirable rather than otherwise), the injection should be made without withdrawing the needle. But a small amount of the solution is necessary under these conditions. It is the practice of the author to introduce the needle four or five times into the deeper tissues in making a single infiltration block of one side. The margin of error is slight and the discomfort to the patient is negligible. The only structures of note which are to be avoided are the deep jugular vein and the carotid artery, and these lie well in front of the path of the needle and the vertebral artery, which will not interfere, provided the needle point is kept moving. A possible source of error comes from making the injection on a line too far posterior, and in this case the nerve trunks might not be reached by the solu- tion. Should malignant or tuberculous tissue present along the line through which the needle is to be passed, the injection may be almost as easily made from behind. One has only to keep in mind the "geography" of the parts and bring the needle point into the proper area before the injection is made. Careful adherence to this technic should give complete anesthesia to the lateral half of the neck. Twenty to 30 cc of a 0.5 to 1 per cent solution is ample for each side. A subdermal infiltration along the ramus of the jaw interrupts the branches of the trigeminus, some branches of which supply the upper portion of the neck (Fig. 67). Provided the sublingual and parotid regions are to be attacked it may be desirable to block the mandibular branch, as described on page 215. However, good anesthesia has usually been obtained by the use of a subdermal infiltration, combined with an infiltration internal to the ramus of the jaw, made from below and after the ramus had been exposed in the dissection. TUBERCULOUS GLANDS AND MALIGNANT DISEASE. As the surgical removal of tuberculous glands of the neck and malignant tissue comprehends a complete excision of all gland- TUBERCULOUS GLANDS AND MALIGNANT DISEASE 233 bearing tissue this operation should not be attempted under local anesthesia without the establishment of a complete interruption of the cervical nerves as described on page 230. The greatest dissatis- faction results from an attempt at removal of apparently isolated groups of tuberculous glands which are firmly attached to or are beneath the cervical fascia when complete anesthesia has not been established. In malignant disease also one should prepare before the operation is begun to carry out a complete dissection and thus avoid the embarrassment of finding that the anesthesia is incomplete at some stage of the operation. Removal of branchial cysts and all tumors demanding an extensive dissection should be preceded by a complete blocking of the cervical nerves. Small tumors which are adherent to the skin may be excised under circumferential infiltra- tion. Abscesses may be drained under direct infiltration. Cases No. 14205, 9751, 12271, 12498, 11694 and 13911 are respectively examples of suppurative and tuberculous cervical adenitis in children and in the aged, as well as carcinoma of the lower lip and carbuncle of the neck, all of which were treated surgically with local anesthesia. Report of Case No. 14205. The following case, one complicated by malnutrition, will illustrate the application of local anesthesia in children in whom the establish- ment of general anesthesia would seem especially hazardous: B. I)., aged nine months, the child of a physician, entered the hospital on February 27, 1921. This child had suffered from malnutrition since birth, and at the time he entered the hospital presented a fluctuating mass in the left side of the neck, with which he had been ill for three weeks. Diagnosis: Suppurative cervical adenitis. Operation: Incision and drainage. Anesthesia: Local infiltration, 20 cc of a 0.5 per cent novocain- adrenalin solution. The child was forcibly restrained and a direct infiltration was made over the swelling, using 20 cc of a 0.5 of 1 per cent novocain- adrenalin solution. The skin was picked up with towel pins to avoid pressure and a transverse incision was made down to the cervical fascia. At this point the operation was delayed while the cervical fascia was infiltrated. This layer was then picked up with towel pins and a sharp-pointed hemostat was forced through and spread widely, opening the abscess. Report of Case No. 9751. W. A., aged five years, entered hospital January 3, 1916. Diagnosis: Tuberculous cervical adenitis. 234 LOCAL ANESTHESIA IN SURGERY OF THE NECK Operation: Complete dissection of the neck. Classical subdermal infiltration and block of the cervical nerves. Transverse incision 12 cm. in length. Anesthesia: 90 cc of 0.7 of 1 percent novocain-adrenalin solution. A mass of glands the size of an adult fist was excised, and although anesthesia was not complete, and the child complained during the deeper part of the dissection, and anesthesia had to be reinforced, the operation was completed without the child crying (Fig. 69). Fig. 69.-Photo of case No. 975, cervical adenitis before operation. Report of Case No. 12271. R. H., aged nineteen years, entered the hospital on September 9, 1919; referred by Dr. H. W. Wittich. Diagnosis: Bilateral cervical adenitis (tuberculous). Operation: Block dissection of the neck (right side). Anesthesia: Local infiltration, cervical nerve block. 160 cc of a 0.7 of 1 per cent novocain-adrenalin solution were used, and a rhomboid subdermal infiltration was made, combined with an infiltration block of the second to the fifth cervical nerves at their points of exit (see Fig. 68, page 23). The patient had received very extensive treatments with the roentgen ray and her neck presented a mass of scar tissue. A complete block dissection was made under perfect anesthesia (Fig. 67, pages 231-235, and Fig. 70). On October 3, 1919, the patient reentered the hospital for a dis- section of the opposite side and the same procedure was carried out. Note.- This case illustrates the excellence with which local anesthesia of the neck may be used even in the presence of scar tissue, which makes these dissections difficult. TUBERCULOUS GLANDS AND MALIGNANT DISEASE 235 The following case illustrates the application of local anesthesia in the removal of multiple tuberculous foci in old and otherwise handicapped individuals. Fig. 70.-Tuberculous cervical adenitis block dissection of neck, photograph taken during operation. (Case No. 12271.) Report of Case No. 12498. S. J., male, aged seventy-two years, entered the hospital on December 26, 1919. Diagnosis: (1) Tuberculous cervical adenitis. (2) Tuberculous epididymitis and orchitis (right side). Operation: (1) Block dissection of neck. (2) Right orchidectomy. History: This patient had had enlarged glands of the neck, right side, for three years. These had begun to break down during the past three weeks. One month ago noted swelling and soreness of the right epididymis. Seminal vesicles not tender. Prostate enlarged somewhat. Anesthesia Technic: December 29, 1919, the tuberculous testicle and epididymis were removed under local anesthesia, 75 cc of 0.5 per cent novocain-adrenalin solution were used, making an infiltra- tion block of nn. ilioinguinal and iliohypogastric, and as the cord was exposed it was thoroughly infiltrated. The pudic nerves were blocked as shown under hydrocele (Fig. 139, page 344). The patient was allowed to leave the hospital in a few days and he returned March 3, 1920, at which time he had a complete dissec- tion of the right side of his neck, using the anesthesia technic described on page 231, Figs. 67 and 68, 120 cc 0.5 per cent novocain- adrenalin solution being employed. The following case will illustrate the technic of classical dissection of the neck followed by excision of epithelioma of the lower lip. 236 LOCAL ANESTHESIA IN SURGERY OF THE NECK Report of Case No. 11694. C. M., male, aged fifty-two years, entered hospital September 7, 1918. Diagnosis: Epithelioma of lower lip. Operation: Block dissection of neck; excision of growth. Anesthesia: Local infiltration; bilateral cervical block. History: Patient has not smoked for three years. During the last three weeks he has presented a growth on the lower lip, right side. Anesthesia Technic: The classical infiltration block, similar to that described in Figs. 67 and 68, except that it was bilateral. Both sides of the neck were carefully dissected, although no enlarged nodes could be palpated. Fig. 71.-Carcinoma of the lip. Photo of Case No. 11694 undergoing block dissec- tion of neck. A transverse excision of the lower lip was then made. Photo Fig. 71 shows the patient undergoing the operation. The following case illustrates the application of infiltration block in cases of carbuncles, of which we have removed many by this method. Report of Case No. 13911. P. C., aged forty-five years, physician, entered the hospital on July 16, 1920, presenting a large carbuncle on the back of his neck. He objected strenuously to taking general anesthesia. Diagnosis: Carbuncle of neck. Operation: Excision. 237 THE THYROID Anesthesia: Infiltration block, using 60 cc of 0.5 of 1 per cent novocain-adrenalin solution. Operation: The infiltrating needle was carried 5 cm. beyond the outer edge of the carbuncle until the latter had been completely isolated from its nerve supply, when it was removed, absolutely without pain to the patient. The base was then cauterized and packed. The wound healed kindly. THE THYROID. The nerve supply to the thyroid is as follows: The thyroid nerve supply consists of sympathetic nerves derived from the middle and inferior cervical ganglia, but in the surgery of this gland the sensory nerves of the neck (Plate IV) are involved. To review, they are (1) n. cutaneus colli (II, III C), (2) nn. supraclaviculares anteriores (III, IV ('), (3) a communicating cervical branch of n. facialis and (4) terminal overlapping branches of the mandibular division of n. trigeminus, thus showing that in the surgery of the thyroid the second to fourth cervical and the fifth and seventh cranial nerves are involved as well as the very important closely lying n. recurrens of the vagus as it passes through this region to the larynx. Thyroidectomy in Non-toxic Cases. Anesthetic and Surgical Technic.-Thyroidectomy demands bilateral blocking of the second, third and fourth cervical nerves, as described on page 230. The operation is facilitated by the making of a subdermal infiltration over the surface of the gland. The technic employed by the author is as follows: Superficial and Deep Infiltration.-A wheal is made at any convenient point over the surface of the gland and from here the whole area is raised by a subdermal infiltration, Fig. 72. The veins can be seen and easily avoided. The solution may be used in generous amounts. From the posterior border of this field the needle point is carried beneath the shin on each side to a position about 3 cm. below the mastoid process and a wheal is painlessly produced from beneath. From this wheal the second, third and fourth cervical nerves are blocked at their point of emergence from the spine (Fig. 72, J, A', Fig. 68, page 231). Approximately 30 cc of solution is used subdermally and 15 cc of solution used in the blocking of the cervical nerves on each side. The incision may then be made without delay and the flaps dissected upward and down- ward. The use of the Automatic Retractors, Figs. 73 and 74, facilitates this procedure by carrying the divided skin edges apart and by eliminating rough or asymmetrical traction and pressure, which are a common cause of complaint when carelessly performed. 238 LOCAL ANESTHESIA IN SURGERY OF THE NECK The gland should be approached by means of sharp dissection, using forceps to elevate the structures as they are being cut (Fig. 74). Good exposure by clamping and cutting the muscle layer, as shown in Figs. 75 and 76, will facilitate dissection. The most Fig. 72.-Anesthesia for thyroidectomy. Subdermal infiltration, and A, A', block of cervical plexus. Fig. 73.-Thyroidectomy. Skin incision showing action of wire spring retractors. THE THYROID 239 sensitive region encountered will be the area through which the superior thyroid vessels and sympathetic nerves enter the gland. While formerly it was our practice to forcibly separate the gland laterally from the surrounding structures, we have found that Fig. 74.-Thyroidectomy. Muscles exposed. Fig. 75,-Thyroidectomy. Preparation for division of muscles. Bainbridge forceps (Fig. 17) applied. 240 LOCAL ANESTHESIA IN SURGERY OF THE NECK excision is much simplified by beginning at the medial side above. As the gland is separated from the trachea slight traction may be made upon the superior thyroid vessels. The slightest discomfort Fig. 76.-Thyroidectomy. Muscle divided. Automatic spring retractor in place. Fig. 77.-Thyroidectomy. Gland mobilized. Goiter holding forceps in use. to the patient demands an immediate infiltration of the upper pole, which now conies plainly into view. In the case of large tumors, as soon as a sufficient amount presents it is grasped by the goiter 241 THE THYROID clamp (Fig. 16, page 104, and Figs. 77 and 78). By means of this instrument the gland may be perfectly controlled, pressure upon the trachea may be avoided and, provided a large amount of the gland is grasped by the clamp, bleeding from the gland and the forcing of " goiter juice" into the patient's body are prevented. Incidentally the number of hemostats required is greatly reduced, it being necessary to place forceps only upon the proximal side of the pedicle. When severing the gland from its mesial attachment to the trachea it is desirable to require the patient to speak after the placing of each pair of artery forceps and before the tissues are severed. The patient may be asked to say "Good-morning." Should the Fig. 78.-Photograph of patient undergoing thyroidectomy. Goiter holding forceps in use. voice show hoarseness, the artery forceps must immediately be removed and replaced at a greater distance from the trachea. In this manner one may avoid the possibility of severing the recurrent laryngeal nerve. The routine use of the above method of obtaining anesthesia, regardless of the size of the gland, will be found advisable. The nerve supply of the thyroid does not vary, regardless of the size of the gland. Therefore, the large intrathoracic goiters may be as easily removed from the standpoint of the anesthesia as may the smaller ones. Under local anesthesia, by observing the above- mentioned rules of procedure the patient may, with but slight 242 LOCAL ANESTHESIA IN SURGERY OF THE NECK assistance on the part of the operator, expel his tumor from the chest cavity after the superior restraining bands are severed and entirely without discomfort. Cases No. 14588 and 13951, which follow, are included as examples of mildly toxic colloid goiters treated surgically under local anes- thesia. Saligenin was used in the latter. Report of Case No. 14588. C. C. II., male, aged forty-six years, entered the hospital on I )ecember 5, 1921. Diagnosis: Toxic colloid goiter. Operation: Partial lobectomy. Anesthesia: Local infiltration and cervical block. Fig. 79.-Photograph of Case No. 14588 undergoing thyroidectomy. 120 cc of a 0.5 per cent novocain-adrenalin solution were used and a classical subdermal infiltration and cervical block was made. 60 cc of 0.5 per cent novocain-adrenalin solution were introduced subdermally and 30 cc were used on each side for blocking the cervical nerves. A large intrathoracic colloid goiter was removed from the left and a small adenoma from the right. Fig. 79 shows a photograph of the patient during the operation. Report of Case No. 13951. Saligenin 2 per cent has been employed a number of times, using a similar technic with equally good results. The low toxicity of this drug makes its employment seem desirable. G. E., aged fifty-five years, entered the hospital on August 16, 1920. THE THYROID 243 Diagnosis: Intrathoracic toxic thyroid adenoma. Operation: Partial lobectomy. Anesthesia: Local infiltration and cervical block. 120 cc of a 2 per cent solution of saligenin were used. A classical infiltration and infiltration block was made, and an ideal anesthesia obtained. Toxic Thyroids.-Ligation of the Thyroid Arteries.-A preliminary ligation of the thyroid vessels, only one of which should be ligated at a single sitting, becomes one of the most excellent means of preparing the toxic case for the radical operation. Necessary as is the obtaining of perfect anesthesia for the performance of the major operation, this to my mind is of secondary importance as compared with the avoidance of any pain whatever during any of the ligations. None of these ligations are called operations in the patient's presence and each, like the preliminary trips to the operating room is referred to as a "treatment." While surgical judgment, founded upon experience and careful observation, combined with the various laboratory aids, is extremely helpful in arriving at an opinion as to when to perform the various ligations and when to perform the major operation, nothing has given more satisfaction in indicating the time to ligate or to operate than the reaction of the patient to the various trips to the operating room for the purpose of administer- ing "treatment." Technic.-Ligation of the Thyroid Arteries.-The ligation of the superior or inferior thyroids may be made under direct infiltration. It is well to outline carefully the exact location at which one desires to make the incision, otherwise too profuse edematization of the tissues may result in the loss of one's landmarks. The skin is anesthetized and a fine needle introduced vertically until the fascia is reached. One need not hesitate to use a considerable amount of the fluid, keeping the needle moving while the fluid is being introduced. Provided one wishes to obtain a good exposure of the vessels a fairly extensive infiltration is necessary. Tinker has called attention to the fact that there may be several superior thyroid branches and complete anesthesia of the whole area involved is desirable so that an excellent exposure may be obtained. Thyroidectomy in Toxic Cases.-The surgical removal of the toxic thyroid demands a slight departure from that used in the simple case. The amount of adrenalin should be reduced to the minimum. 1 luring recent years the author has employed only 1 minim of 1 to 1000 adrenalin to 30 cc of solution. An effort should be made to establish the most perfect anesthesia possible. The psychic element becomes a very important factor in the surgical treat- ment of this disease and the reader is referred to the chapter on the preparation of the patient (page 135) for details. Experience 244 LOCAL ANESTHESIA IN SURGERY OF THE NECK has shown that many of these individuals present a high degree of intelligence and a desirable cooperative spirit. True, they may present marked evidences of apprehension. Much depends on the successful carrying out of the preoperative schedule, but the out- standing cause of increased excitability, rapid pulse, restlessness, complaint of extreme heat, thirst, etc., almost always follows failure to obtain complete and thorough anesthesia. Crile perhaps deserves the credit for the so-called "stealing" of the operation in the toxic thyroic case; there are a number of methods of carrying out this procedure. One must obtain the consent of someone who is responsible for the patient and make full arrangements concerning the treatment. The patient is to be kept in ignorance regarding the operation and yet authority must be given the surgeon so that he may perform an operation at any time he deems it advisable; even though the patient gains an indistinct impression that an operation is to be performed, it is desirable to allow him to think that the date set is more or less distant so that he will not be particularly apprehensive, as these patients are apt to be, provided they are allowed to plan on a definite day, as is the rule, in the case of other types of operations. The plan that the author has followed has been to obtain permis- sion to carry out the surgical treatment in the manner in which his judgment dictates. The patient is then offered every aid in a medical way (rest, fluids, quiet, digitalis, sedatives, etc.) that one can furnish. In addition the course of preliminary treatment is begun; this consists (1) in giving the patient a sterile hypodermic early each morning. Stock solution of novocain is usually employed for this hypodermic on account of the fact that it may be given without distress to the patient. (2) The leather stretcher pads (page 102 Fig. 15, J, B, C) are placed beneath the patient with as little disturbance as possible. (3) The patient is given no food but allowed to drink freely of liquids until the third step of the treat- ment has been completed. (4) The patient is carefully,transported to the operating room by means of the automatic lifter (Fig. 15, page 102) and carefully placed upon the operating table. (5) The neck is bathed with alcohol or some other substance which has a distinct odor capable of perception by the patient. (6) A hypo- dermic needle is introduced beneath the skin and allowed to remain for a few minutes while the neck is pressed upon and certain maneu- vers carried out which simulate as nearly as possible the preliminary steps of the average thyroidectomy or ligation. (7) The patient is given to understand that this camouflage trip to the operating room constitutes a " treatment." (8) The patient is now returned to bed after a bandage has been applied to the neck and encouraged in every manner possible to think that his trip to the operating room THE THYROID 245 has been a success and that he has withstood the ordeal well. (9) A careful chart of the pulse-rate and general condition of the patient is kept and the frequency of the "treatments" is regulated by the patient's reaction. The record of the patient's reactions furnishes one with a new basis upon which to estimate the relative safety of surgical attack. Case No. 8691 is an example of an extremely toxic goiter which was successfully treated surgically by the use of local and narco-local anesthesia. Report of Case No. 8691. C. I)., female, aged twenty-one years, student at University. Diagnosis: Exophthalmic goiter. Operation: Multiple ligations. Injection of quinin-urea hydro- chloride. Lobectomy. Anesthesia: Narco-local and local infiltration. History: The patient's symptoms date back only two months. She entered the hospital December 13, 1915, and was discharged May 3, 1916. The pulse ranged from 120 to 160. Iler eyes were extremely prominent and she was in a very toxic condition. She was unable to retain food, had marked diarrhea and tremor and had lost fifty pounds in weight. Treatment: Rest, sedatives and radio-therapy were employed for twenty-two days when the right superior pole was ligated and divided under local anesthesia. During the operation the patient's pulse became so rapid that it could not be counted. At the end of twenty-four hours it was 170 and of extremely poor quality. This ligation was thought advisable as the patient's condition had been growing steadily worse. Digitalis was employed with good effect, the pulse dropping to 150 on the third day, and one month later the pulse averaged 125 to 135. Five weeks after the ligation of the right superior thyroid the left lobe of the gland was injected with 4 cc of quinin-urea hydrochloride, 30 per cent. Injection of Quinin and Urea Hydrochloride. - The skin was anesthetized with novocain solution and the needle was inserted into the gland, the quinine solution being injected into various portions of the gland, with only slight pain to the patient. Nine days later a second injection of 40 per cent quinine was made into the same lobe. The patient gradually improved. On April 30, four and a half months after admission, an attempt was made to get the patient into a sitting posture, but the pulse reached 150 to 160 upon each attempt. May 29, five and a half months after admission, after two preliminary hypodermics of morphin and scopolamin, one and two hours respectively before the time of operation, the classical local anesthesia injection was made, and a 246 LOCAL ANESTHESIA IN SURGERY OF THE NECK lobectomy was performed, removing 4 of the gland. The patient's pulse reached 180 during the operation. In twenty-four hours it was 160 and in forty-eight hours 120. The patient was dis- charged from the hospital on June 7, the pulse averaging about 100. She has since gained sixty pounds in weight and is in excellent health. Note.- During one of the intervals this patient vomited every- thing she ingested over a period of eleven days. Narco-local anes- thesia was used in this case during each operative procedure, excepting the first, and it was following the first operative pro- cedure that the method of stealing the operation was first attempted, the plan described on page 243 being carried out. THE LARYNX. Nerve Supply of the Larynx.-The nerve supply of the larynx is as follows: The larynx itself is supplied by (1) the internal laryn- geal branch of the superior laryngeal (vagus), which is distributed to the mucous membrane of the larynx and base of the tongue, (2) the external branch of the same nerve which is motor and supplies the cricothyroideus, (3) the recurrent laryngeal (n. recurrens), also of the vagus, which supplies the rest of the laryngeal muscles and also sends a few sensory filaments to the laryngeal mucosa, and (4) the sympathetics. Laryngectomy.-This operation should, it is believed, almost always be performed under local anesthesia and in at least two, as Crile has so well shown, or perhaps better, three stages. Technic of Anesthesia.-In removing this organ it is necessary to perform a posterior infiltration block of the cervical nerves (Fig. 68, page 237). The technic employed for the producing of anes- thesia is as follows: Superficial and Deep Infiltration.-A subdermal wheal is made in the midline in front and a subdermal infiltration of sufficient extent to allow free elevation of the skin is made (Fig. 80). A vertical infiltration block is then made from the upper part of the neck downward posterior to the larynx and trachea medial to the large vessels, (Fig. 81, A and B; A1 and B1). The skin flap is raised and the larynx and trachea isolated from the surrounding structures, iodoform gauze being packed about these organs and allowed to remain. At the second operation a subdermal infiltration of the skin may be painlessly made by beginning in the subdermal fat at the edge of the wound. Before dividing the trachea a few minims of 4 per cent cocain solution should be introduced into it by means of a fine needle which passes between the tracheal rings. The patient is instructed to hold the breath for a few seconds and to avoid coughing if possible. Anesthesia of the tracheal THE LARYNX 247 Fig. 80.-Laryngectomy. Subdermal infiltration and lines of incision. Fig. 81.-Laryngectomy. Deep infiltration (A and B). Insert: A7 and B7 show points of injection. 248 LOCAL ANESTHESIA IN SURGERY OF THE NECK mucous membrane is in this manner easily obtained and prevents the distressing symptoms which usually follow the opening of the trachea. As the lower end of the larynx is grasped and elevated an infiltration may be made along its posterior surface and around it at some distance from the tissue which is to be removed. This effectually blocks the internal and external branches of the superior laryngeal nerve and the recurrent laryngeal nerve and will render the removal of the voice box practically painless. The cooperation of the patient in such an operation as this is extremely desirable. In case the three-stage operation is selected the anes- thetization of the voice box from within is necessary during its removal. Cases Nos. 11548 and 13702 are examples of laryngeal polypi with tracheotomy and carcinoma of the larynx, both of which describe the manner of doing laryngectomy by the use of local anesthesia. Report of Case No. 11548. C. IT., female, aged twenty-three years, referred by Dr. J. D. Lewis, entered hospital July 20, 1918. History: Tracheotomy had been performed upon this patient twenty years previously. She had worn a tracheotomy tube ever since. The polypoid growths are now presenting about the trache- otomy wound, which is low, and are interfering with respiration. It was therefore thought advisable to explore the voice box to deter- mine if an effort could be made to restore the normal canal. Diagnosis: Laryngeal polypi; tracheotomy. Operation: Laryngotomy, excision of polypi, laryngectomy. Anesthesia: Local infiltration block. First Operation: Classical infiltration block (Figs. 80 and 81) was made. Larynx was opened in the midline in front and a number of polypi removed, using scissors, curette and cautery. They arose principally from the anterior commissure. An island of skin was left between the incision in the larynx and the old opening in the trachea. A rubber tube was placed in the larynx and allowed to remain. The incision was closed with drainage. The patient had relief for some time and could even breathe through the normal channels, but within three months the granulation-like masses began to appear once more about the tracheal opening and laryn- gectomy was decided upon. Second Operation: October 16, 1918. Anesthesia: A wide infiltra- tion was made, using 90 cc of 0.5per cent novocain-adrenalin solution. The incision was made and the trachea divided just above the original tracheotomy wound. The larynx was found greatly enlarged and the postlaryngeal area was deeply infiltrated and THE LARYNX 249 involved the anterior wall of the esophagus, 10 cm. inches of which were removed with the larynx. A considerable portion of the thyroid gland was removed with the mass. The esophagus was sutured over a rubber tube which passed through the mouth and was allowed to remain in situ. The wound was drained extensively, skin being closed with silkworm sutures. The patient's pulse and color did not change during operation. The anesthesia was ideal. This patient has remained well to date. Fig. 82 shows the patient immediately after the laryngectomy had been performed. Fig. 82.-Laryngectomy. Photograph of Case No. 11548, at completion of operation. Report of Case No. 13702. II. J., female, aged fifty-four years, entered hospital March 23, 1920. Diagnosis: Carcinoma of larynx; inferior compartment. Operation: Laryngectomy (two stages). Anesthesia: Local infiltration. History: The patient has had gradually increasing sore throat and hoarseness for six months. First Operation: March 27, 1920. Exposure of the larynx and trachea and insertion of gauze pack. Anesthesia Technic: Two preliminary hypodermics, scopolamin gr. and pantopon gr. |, 60 cc of novocain-adrenalin 0.5 per cent were used in making the classical block (Figs. 80 and 81). An exces- sive amount of thyroid tissue interfered somewhat and a portion of the right lobe was excised. The wound was thoroughly packed with iodoform gauze. Second Operation: Laryngectomy. April 3, 1920. Anesthesia: Novocain-adrenalin, infiltration block; external to the region of the wound 75 cc of 1 per cent solution were injected. The packing was removed and a few drops of 4 per cent cocain solution were injected into the trachea by means of a fine needle. 250 LOCAL ANESTHESIA IN SURGERY OF THE NECK The trachea was divided below the larynx and the whole voice box removed. There was but slight tracheal irritation on account of the action of the cocain. The anesthesia was ideal in every way. The patient was able to sit up in bed, her pulse being 100 and Fig. 83.-Laryngectomy. Photograph of Case No. 13702, undergoing operation for removal of the larynx. regular. Nourishment, was introduced through an esophageal tube, which was allowed to remain in situ. The patient's pulse reached 140 at the end of twenty-four hours and she died on the third day, from pneumonia. Fig. 83 shows photograph of patient during operation. CHAPTER IX. LOCAL ANESTHESIA IN SURGERY OF THE BREAST, THORAX AND SPINE. SURGERY OF THE BREAST For the purpose of discussion this subject may conveniently be divided into the treatment of benign and malignant disease. The patient's position upon the operating table should be as comfortable as possible and at the same time the surgeon should have every opportunity to work to advantage. Fig. 84.-Surgery of the breast, comfort. Fig. 84 shows the method usually employed. A lateral tilting of the table (page 473) allows both the surgeon and assistants access to the field. The arm is comfortable and yet restrained. Benign Tumors.-Frozen Sections.-Technic of Anesthesia.- Tumors which are frankly benign, provided they are superficial, may be excised under a direct infiltration, but as the diagnosis is often in doubt, the plastic resection is commonly employed. For the purpose of excising benign tumors and for removing tissue for immediate microscopical examination the method illustrated in Fig. 85 is the one of choice. The pectoral fascia is infiltrated so as to allow the elevation of the breast to the extent required. 252 SURGERY OF THE BREAST, THORAX AND SPINE Tumors lying in the lower half of the breast demand an infiltration only as high as the nipple line. Tumors in the upper half demand an infiltration similar to that used for simple excision of the breast, and this infiltration is made with more facility from above. In these cases it is well to carry the needle from the line of infiltration which marks the site of the future incision under the skin along the outer side of the breast, developing intradermal wheals from below (Fig. 31, page 149) at the points where the needle is to be reintro- Fig. 85.--Benign tumors of the breast. A. B. Subdermal infiltration, and A', B', infiltration block. Insert: Sectional view of same. duced (Fig. 85, A and B). Two or three wheals will usually suffice for this purpose. Through these wheals the long, fine needle may be introduced beneath the pectoral fascia from above and the organ quickly isolated from its sensory nerve supply (Fig. 85, .1 and B). In performing the operation one must bear in mind that the attach- ment of the tissues outside the line of infiltration is not devoid of sensation and that if the breast is roughly manipulated the patient may be caused pain. It is well to mark the site of the tumor by placing a towel clip upon the skin directly over it, and after the SURGERY OF THE BREAST 253 breast has been elevated through the incision in the fold below the tumor may be identified and gently forced into view by means of Fig. 86.-Method of exposing benign tumors of the breast. Towel clip identifies tumor. Insert shows sectional view. Fig. 87.-Benign tumors of the breast. Photograph of Case No. 13555 during operation. Forceps everting tumor. the towel clip (Fig. 86). The fact that the patient is not inhaling a general anesthetic is of decided advantage in these cases, as the 254 SURGERY OF THE BREAST, THORAX AND SPINE examination of the tumor may thus be made with greater delibera- tion. Eig. 87 shows K. L. undergoing an operation for the removal of a breast tumor of unknown pathology through the Warren incision and her case illustrates the technic of removing the breast in benign disease which this proved to be. Report of Case No. 13555. Mrs. K. L., female, aged fifty years, entered the hospital on January 16, 1920. Diagnosis: Cystic adenoma of breast. Anesthesia: Infiltration along the line of Warren, beneath the breast, using 120 cc of a 0.5 of 1 per cent novocain-adrenalin solution. Operation: Excision of the right breast. The incision was sub- dermal and was carried around one-half the circumference of the breast. The breast was then separated from the pectoral fascia by introducing solution beneath it, the needle passing through the anesthetized area of skin. The breast was dissected upward and everted and a portion of the tissue taken for the purpose of making frozen sections. A pathological diagnosis of cystic adenoma was made by Dr. E. T. Bell. The anesthesia was then completed and a subdermal infiltration made outlining the site of the upper incision. A transverse incision was made and the breast completely removed. Suppurative Mastitis. -Technic of Anesthesia for Drainage. Superficial abscesses in the breast may be opened under local infiltration. It is well to make the incision between towel pins which elevate the skin and thus avoid pressure upon the deeper tissues, which are sensitive. A considerable experience with such cases has led the author to believe that no ill effects follow an infiltration down to the septic pockets. In many instances multiple incisions have been made for the purpose of establishing adequate drainage. However, one is confronted in these cases with an extremely sensitive inflamed organ and usually a patient who has suffered considerably, and here the psychic element becomes an important factor. Many of these patients will, therefore, more properly fall into the class for gas analgesia. On the other hand, chronic suppurations and tuberculous fistula3 demanding radical excision lend themselves favorably to a circumferential block about the area to be excised. In making this infiltration one should introduce the solution well away from the contaminated area and the needle point should be carried beneath the pectoral fascia, thus practically isolating the breast from its nerve supply. Malignant Tumors.- Excision of the Breast.-The nerve supply of the skin involved in radical excision of the breast for cancer is from (1) nn. supraclaviculares (anterior, middle and posterior) SURGERY OF THE BREAST 255 (Ill, IV C), which are distributed to the upper part of the chest, shoulder and the region of pectoralis major and the deltoideus muscles; (2) the thoracic intercostal nerves (II, III, IV, V, VI, T) which give off anterior and lateral cutaneous branches from the anterior divisions of the main thoracic nerves and supply the skin Fig. 88.-Excision of the breast. Nerve supply of tissues involved. 1, N. occipitalis major; 2, N. auricularis magnus; 3, N. vagus; 4, ganglion cervicale superius; 5, N. supraclaviculares; 6, N. dorsalis scapulse; 7, N. accessorius; 8, N. suprascapularis; 9, N. intracostalis III; 10, Nn. thoracales anteriores; 11, N. thoracales longus; 12, N. subscapularis; 13, N. intercostobrachialis; 14, N. thoraco- dorsalis; 15, N. axillaris; 16, N. musculocutaneus; 17, N. radialis; 18, N. hypoglossus; 19, N. laryngeus superior; 20, N. hypoglossus (ramus descendens); 21, ansa hypo- glossi; 22, ganglion (cervicale), medium et inferius; 23, N. laryngeus inferior; 24, N. recurrens dextra; 25, N. vagus dextra; 26, N. recurrens sinistra; 27, N. vagus sinistra; 28, N. intercostalis VI; 29, N. phrenicus; 30, truncus sympatheticus. of the thoracic wall and the mamma; (3) the lateral cutaneous branch of the second thoracic (intercostobrachial nerve) crosses the axilla and supplies the skin of the upper part of the arm adjoining the axilla. Fig. 88 (also see Fig. 36, page 171) shows the nerves which must be blocked in making the radical operation. 256 SURGERY OF THE BREAST, THORAX AND SPINE The pectoralis major and minor muscles and fascia are supplied by (1) nn. thoracales anteriores (lateral V, VI, VII C; medial VIII, C, I T), which come from the brachial plexus. The latissimus dorsalis is supplied by the thoracodorsal nerve (n. thoracodorsalis V, VI, VII C), also of the brachial plexus. The serratus anterior is supplied by n. thoracalis longus, the external respiratory nerve of Bell (V, VI, VII C). The deltoideus is supplied by the anterior branch of n. axillaris (V, VI C). The intercostales, subcostales, levatores costarum and serratus posterior are supplied by branches of the upper thoracic intercostal nerves. In addition to the nerves mentioned, which it will be seen arise from the third cervical to the sixth thoracic, there must also be considered the main trunks of the brachial plexus, (1) n. ulnaris (VIII, C, I T); (2) n. medianus (VI, VII, VIII, C, I T); and (3) n. musculocutaneus (V, VI, VII, C) as they pass through the axilla in conjunction with the axillary vessels. Radical Excision.-Whether the advantages to be derived from the use of local anesthesia in these cases in which the diagnosis is certain are sufficiently great to offset the disadvantages, such as the time required to make the blocking, the discomfort incident to and the rather complicated technic involved in making it, is an open question. It is an established fact that an excellent anesthesia may be produced by the local method. The anesthesia will endure sufficiently long to allow of the most painstaking and thorough work. The facility for operating is excellent and the after-effects are much less disagreeable than when general anesthesia has been administered. However, as the majority of patients with carcinoma of the breast are fair surgical risks and withstand the radical operation well, and as the results even with general anes- thesia are very good, it is probable that the performance of this operation under local anesthesia will remain, for some time at least, in the hands of those who may be said to be partial to local anesthesia and who are especially familiar with its use. The author's experience is limited to 20 cases, and while appreciating the diffi- culties which present, he feels that its relative safety makes its use desirable in the hands of the surgeon who is familiar with the use of local anesthesia. It would seem advisable that the poor surgical risks, at least, should be operated upon by this method. In performing radical excision of the breast physical comfort of the patient's body assumes considerable importance, as one position must be maintained over a comparatively long period. The method described on page 251 effectually meets the require- ments (Fig. 84). SURGERY OF THE BREAST 257 Technic of Anesthesia.-It will be seen that one must deal with the brachial plexus, the first six or seven thoracic nerves upon the side involved, and the intercommunicating nerves down the midline in front as they cross over from the opposite side. While formerly we depended upon a circumferential infiltration in these cases the amount of solution required made it seem advisable to depend more upon the regional method. The technic which we have employed during the last four years is as follows: Brachial anes- thesia is established by the method of Kulenkampff (Fig. 30, page 130). The thoracics from the first to the seventh are blocked paravertebrally following the establishment of a subdermal infiltra- Fig. 89.-Excision of the breast. A cervical block. Subdermal infiltration made from initial wheal in front, preparatory to intercostal block. tion (Fig. 89). Approximately 15 cc of a 1 per cent novocain- adrenalin solution is injected into the region where each nerve is known to lie (Fig. 90), the needle being introduced just below the border of the rib, advanced 1 cm. and the solution allowed to flow in as the needle is withdrawn, the injection being terminated as the needle is retracted to the rib border. The third step in establishing anesthesia consists in infiltration of the tissues beginning at the center of the sternum above and extending down the midline as far as desired (Fig. 91). In beginning this infiltration a long needle is introduced through the wheal which has been made for the purpose of establishing brachial anesthesia. In this manner a 258 SURGERY OF THE BREAST, THORAX AND SPINE subdermal wheal may be established near the suprasternal noteh and from this point the subdermal infiltration may be carried out. The method recommended by Willy Meyer of performing this operation from above downward allows one to reach the nerve supply early in the operation and to reinforce areas which may have been Fig. 90.-Excision of the breast. Sectional view of intercostal block. 1, N. acces- sorius; 2, N. supraclavicularis; 3, first rib; 4, plexus brachialis. missed in making the original infiltration. Also, the time required in making the axillary dissection will permit of the maximum action of the anesthetic solution upon the intercostal nerves so that one will have the full advantage of the anesthetic in areas supplied by these nerves when they are reached. SURGERY OF THE BREAST 259 One should, however, raise all skin flaps as a preliminary measure and perhaps even perform the lower part of the dissection before dissecting the axilla to avoid the possibility of being compelled to reinforce the anesthesia of the intercostals which may disappear provided one is too long delayed in carrying out the axillary dis- section. This embarrassment has befallen the author upon more than one occasion. The choice of methods will depend somewhat upon one's speed as an operator. Fig. 91.-Excision of the breast. A, cervical block; B, brachial anesthesia; C, subdermal block nerves from opposite side. Note: Blocking cervical nerves at A renders transverse subdermal infiltration unnecessary. Cases No. 9041, 9996 and 14315 are examples of malignant tumors of the breast and show the methods of treatment under local anesthesia. Report of Case No. 9041. Mrs. C. 1)., female, aged fifty years, entered hospital April 30, 1919. 260 SURGERY OF THE BREAST, THORAX AND SPINE Diagnosis: Carcinoma of the right breast; diabetes mellitus; adiposity. Operation: Radical excision of breast. Anesthesia: Brachial block; local infiltration. // istory: The patient's weight was 280 pounds. She has just passed the menopause. She has had swelling and soreness in right breast for several weeks with some yellowish discharge from nipple. Her only other complaint was edema of the lower limbs. Patient has had diabetes for a number of years and the urine contained a large amount of sugar at each examination. She was placed under diabetic management. Operation May 10, 1919. Technic of Anesthesia: Infiltration block preceded by brachial anesthesia, 20 cc of 1 per cent novocain-adrenalin solution being used. As an intercostal block was not carried out in this case it was necessary to reinforce the anesthesia in the axillary line. Both muscles were removed, the total amount of solution reaching 540 cc. of 0.5 per cent. (The largest amount ever used by the author.) The tumor mass weighed 4| kgm. The wound measured 30 x 40 cm. A complete dissection of the axilla was made. The patient showed no signs of toxicity notwithstanding the large amount of solution used and the pulse-rate at the completion of the opera- tion was 84. Fig. 92.-Excision of the breast. Photograph of Case No. 9996 during operation, Report of Case No. 9996. M. B. S., female, aged forty-nine years, married Diagnosis: Carcinoma of the left breast. SURGERY OF THE THORAX 261 Operation: Radical removal of the breast, April 2, 1916. Anesthesia: Brachial block; intercostal block; circumferential infiltration, 0.5 of 1 per cent novocain-adrenalin solution. In this case brachial anesthesia was performed and followed by a subdermal infiltration, circumscribing the field of operation. The intercostals were blocked in the postaxillary line. Anesthesia was ideal. The axilla was dissected first and a piece of the serratus magnus muscle was sutured over the vessels and nerves. 360 cc of solution were used, while in the case of I). II., 2-10 cc were used, and 180 cc of a 0.7 per cent novocain-adrenalin solution has answered the purpose in a number of cases. Fig. 92 shows the patient undergoing operation. Report of Case No. 14315. D. II., female, aged fifty years, entered hospital December 15, 1921. Diagnosis: Carcinoma of the right breast. Operation: Radical excision of the breast. Anesthesia: Brachial block, intercostal block, midline infiltration; 240 cc of 0.7 of 1 per cent of novocain-adrenalin solution. Preliminary blocking according to the technic described on page 257, Figs. 89, 90 and 91, the first to the seventh thoracic nerves being blocked. 10 cc of the solution were used in the region of each nerve. Brachial anesthesia, midline infiltration. A Wolff graft was used to close the skin defect. In this case the anesthesia was excellent, although the amount of solution used was comparatively small. This technic, which has been applied in the last twelve cases, would seem to be the most satisfactory method of producing anesthesia for radical amputation of the breast. SURGERY OF THE THORAX. The Thoracic Nerves.-The thoracic nerves are twelve in number, each nerve emerging below the corresponding vertebra and rib. Eleven are intercostal, the twelfth lying below the last rib (see Plate IX). The first thoracic emerges from the spinal canal below the neck of the first rib and is divided into two parts. The upper part enters into the formation of the brachial plexus and the lower part courses forward in the first intercostal space and supplies the upper inter- costal muscles. The second thoracic passes forward in the second intercostal space and supplies the muscle and courses forward and supplies the skin of the front of the chest over the second intercostal space. The third, fourth, fifth and sixth thoracic nerves appear on the 262 SURGERY OF THE BREAST, THORAX AND SPINE posterior wall of the thorax and extend forward between the inter- costal muscles as far as the middle of the chest wall. At the side of the chest wall they pierce the internal intercostal muscles and lie upon the pleura and the aponeurosis of the external intercostal muscle and end by supplying the skin on the front of the chest wall corresponding to the intercostal space to which they belong. The seventh, eighth, ninth, tenth and eleventh have the same course and communications as the preceding nerves in the thoracic wall, but course forward in the abdominal wall and finally reach the anterior abdominal wall and become cutaneous by piercing the rectus and anterior layer of its sheaths. The twelfth thoracic nerve emerges below the last rib and passes outward and downward in the posterior abdominal wall beneath the psoas muscle, pierces the transversalis muscle, the posterior sheath of the rectus, then the anterior sheath and supplies the skin. As one of the main drawbacks of general anesthesia relates to the invitation to lung complications following its use, and as thoracic surgery is in the main concerned with disease of these organs or the pleural membranes, we have at once a most important reason for the substitution of local for general anesthesia whenever it is feasible. The sensory nerve supply is so easily reached and the landmarks for locating it are so clear that, with the indications and contraindications mentioned above, it is surprising that there still remains any doubt in the mind of surgeons regarding the choice of anesthesia in a large percentage of chest cases. The novice can in a few lessons be taught to block the intercostal nerves and the blocking of a sufficient number of these will give one anesthesia which will allow the performance of almost every variety of opera- tion which may be required in this region. The lung tissue is not sensitive and as the chest wall may be thoroughly anesthetized there is almost no limit to the operative procedures which may be carried out. Thoracentesis.- Anesthesia Technic. Every case of thoracentesis should be preceded by the use of local anesthesia. The initial wheal is made over the point where the needle is to be introduced, and the path over which the needle is to travel anesthetized by passing a needle vertically through the chest wall, injecting as the needle advances. As the pleura is approached the needle should be advanced slowly and a comparatively large amount of solution injected. A larger needle may now be substituted for the fine one and aspiration carried out. Should one desire to explore in another locality this process may be repeated, the wheal for such exploration being made by the subcutaneous method (see Fig. 31, page 149). If intercostal drainage only is desired this may usually be carried SURGERY OF THE THORAX 263 out without reinforcing the anesthesia already established. In case immediate operation is decided upon the anesthetic already injected reduces the amount needed for this procedure. As these patients are apt to be in poor physical condition it is well to use special precautions to prevent suffering during the introduction of the anesthetic. The injection should be slowly made and all lines of incision blocked by a subdermal injection. The method of having the patient inform the surgeon when anes- Fig. 93.-Costectomy. A, intercostal block for rib resection. Insert: Sectional view of same. thesia is established must be discarded. The surgeon must so master the technic that he will know that anesthesia precedes his surgical work and it should not be necessary to ask the patient whether this or that maneuver causes pain. It has long been the custom of surgeons to plunge the trocar through the chest wall of the helpless patient without regard for his feelings. It is my opinion that local anesthesia should precede this operation in all instances. Costectomy.-Technic of Anesthesia.-Should rib resection be decided upon the following technic is recommended. A sub- 264 SURGERY OF THE BREAST, THORAX AND SPINE dermal infiltration is made along the line of the proposed incision and at least three intercostals are blocked well proximal to the point of resection. One often builds a transverse wall across the line of incision at the proximal end (see Fig. 93). The operation can then be carried out exactly as upon the cadaver. There is no pain, no hemorrhage, and provided the patient is not coughing there is no expulsive effort. It is important to use rib shears of adequate power so that the amount of manipulation may be reduced to the minimum. The instrument shown in Fig. 22, page 108, has been found satisfactory. Its great power makes the cutting off of the rib a simple matter and this obviates the necessity of gouging and twisting the chest wall. The proximal end of the rib should be divided first, otherwise an incomplete anesthesia might have to be reinforced twice. It is obvious that good anesthesia at the proximal point of resection insures good anesthesia at the distal point. Empyema. - Negative Pressure.-Just as we find a negative pres- sure following perfect anesthesia of the abdominal wall do we find here also the identical condition. That is, a patient may retain the pus in his pleural cavity or expel it at will, pr< Tided he is able to avoid coughing, and in all of my cases the patients ave been able to control the cough for a few moments at least. Even in cases with a collapse of one lung and the pleural cavity completely filled with pus the pleura may be opened with the patient in the proper position and the cough may be controlled and no discharge of pus take place. The author evacuated as high as four liters of pus in the twelve hours succeeding operation in a case in which the radio- gram taken before the operation showed a total collapse of one side, and yet under perfect anesthesia the pleura was opened and the fluid was not found to be under pressure. In the cases in which a rib resection is made a purse-string suture of catgut is usually placed about the proposed line of incision through the pleura before opening the latter. A drainage tube is held ready for introduction, its outer end being clamped in the jaws of an artery forceps. The patient is instructed to breathe carefully as the pleura is incised. If these instructions are carried out one may note as the pleura is opened the fluid moving with respiration and under no pressure. The drainage tube is then quickly intro- duced and the purse-string suture tied about it. The author has carried out this procedure in a comparatively large series of cases and believes that with proper technic and under proper conditions the above detailed conditions will usually prevail. Massive Rib Resections.-Resection of a large area of the chest wall may be accomplished under an infiltration block as described above (Fig. 94). The operation recommended by Emil Beck, in SURGERY OF THE THORAX 265 which the pedicle skin flap is used, may be carried out almost ideally under an intercostal block, supplemented by a subdermal infiltra- tion outlining the flaps of skin (Fig. 94). Drainage of osteomyelitis, the dissection of fistula? and the removal of necrotic segments of rib lend themselves well to the use of local anesthesia under the above technic. Fig. 94.-Plastic resection of thorax. Subdermal infiltration. Insert: Sec- tional view of intercostal block. Cases No. 11865 and 11027 are examples of empyema and lung abscess respectively which were treated surgically under local infiltration and paravertebral intercostal block. Report of Case No. 11865. F. C., male, aged twenty-seven years, entered hospital March 10, 1918. 266 SURGERY OF THE BREAST, THORAX AND SPINE Diagnosis: Empyema; followed by persistent sinus. Anesthesia: Paravertebral intercostal block. Operation: Skin plastic (Emil Beck). History: Patient had developed empyema nine months previously. Rib resection was performed, and although the patient gradually recovered there remained a sinus in the left chest between the ninth and tenth ribs in the postaxillary line. The sinus discharged a thin seropurulent material, and roentgen rays of the sinus when filled with bismuth paste showed its dimensions to be approximately 10 cm. long and 5 cm in diameter, and to be directed mesially and toward the sternum. The patient had had irrigations with Dakin's fluid and had been given repeated injections of Beck's paste. The general condition was fair. Fig. 95.-Plastic resection of chest wall. Photograph of Case No. 11865 during operation. No preliminary hypodermics. An intercostal block with novocain-adrenal in from the fifth to the twelfth rib was made. The wound was enlarged by the removal of portions of the two adjacent ribs and the further removal of the ends of the rib which had been formerly excised. The sinus was larger than anticipated from the radiograms. It was thoroughly curetted and packed until hemorrhage ceased. Two large skin flaps were then dissected from the chest wall, one above and one below, and turned into the sinus. In three months the sinus ceased discharging and in eight months the skin-lined depression had become completely obliterated. Fig. 95 shows the patient undergoing Beck's skin plastic operation. Report of Case No. 11027. C. R., female, aged nineteen years, pregnant, entered hospital January 12, 1918. Diagnosis: Pulmonary abscess. Operation: Costectomy; drainage and Beck's plastic. SURGERY OF THE SPINE 267 Anesthesia: Local infiltration and paravertebral intercostal block. History: Radiograms, physical examination and aspiration showed the presence of an abscess the size of a fist in the right thoracic cavity on a level with the nipple line. A rib resection was made under local anesthesia and after evacuat- ing the cavity the procedure detailed for Case No. 11865 was carried out, with the following modifications in technic: As an extensive paravertebral anesthesia had not been carried out a subdermal infiltration was made outlining the flaps, which were dissected up and turned into the cavity. The patient showed no reaction from this operation. Twelve days later she went through a normal labor, giving birth to a healthy male child and in three months the cavity was completely lined with healthy skin. Six months later the cavity was completely obliterated. The debilitated individuals with tuberculosis, bronchiectasis or other conditions demanding massive collapse of the chest wall are among those who must urgently demand recourse to local anesthesia. It is gratifying to note the trend of opinion among those who are doing a large amount of this work. They are, as a rule, most partial to the use of local anesthesia. SURGERY OF THE SPINE. The nerves supplying the structures involved in an operation upon the spine are the medial and lateral cutaneous and muscular branches of the posterior divisions of the spinal nerves from the second cervical to the last sacral inclusively, the coccygeal nerve (n. coccygeus) and the recurrent posterior branches of the lateral cutaneous branches of the anterior divisions of the thoracic nerves. The operations upon the spine are usually considered formidable procedures. The position required is such that the administration of inhalation anesthesia is more or less awkward. Not infrequently these patients are poor surgical risks, and it would seem therefore that local anesthesia would be desirable for work in this region, provided it could be used with satisfaction. The spine is extremely deeply situated, except at its extremities. Rather large amounts of anesthesia are necessary and the spinal membranes are very sensitive. The blocking of the nerve supply to the spinal column is readily made and there is no great difficulty in exposing the cord under local anesthesia. However, in attempts to remove tumors connected with the dura extreme pain was experienced and in one case the use of ether became necessary. No attempt was made to infiltrate the membranes themselves, though it would seem that this might easily be done through a fine needle and that infiltration would probably do no permanent damage. One would, of course, 268 SURGERY OF THE BREAST, THORAX AND SPINE be compelled to use extreme care in order to avoid the introduction of the solution in the canal where it might be carried to the brain. The author's experience in surgery of the spine is so limited that he has had little opportunity to test these points. A number of surgeons have reported operations under local anesthesia and their reports are so optimistic that one wonders why those who Fig. 96.-Laminectomy. A, subdermal infiltration and infiltration block. Insert: B B, sectional view of same. have abundant material do not further develop the method. This field offers a favorable ground for research. Technic of Anesthesia.-A subdermal infiltration is made on either side of the spine, 5 cm. from the midline, and through these lines the deep injection is made as indicated in Fig. 96. After the exposure has been effected, the anesthesia may be reinforced between the SURGERY OF THE SPINE 269 transverse processes if required. The bony structures may be removed by forceps or with a chisel, but, as stated above, the membranes are extremely sensitive. If during the manipulation one should happen to come in contact with unblocked spinal nerves, the patient is apt to complain of very disagreeable sensations. With any technic so far described the whole operation cannot, with certainty, be painlessly performed under local anesthesia alone. Possibly the most desirable method would be to admin- ister a small amount of nitrous oxide or ether during the time that the cord and its numerous nerves are to be manipulated. The rest of the work is perfectly feasible under local anesthesia. The exploration of fracture cases and the removal of foreign bodies are accomplished with comparative ease. Cases No. 9202 and 12024 are examples of spinal cord tumors, the former of which was removed under local infiltration block alone and the latter requiring inhalations of ether for but a few minutes. Report of Case No. 9202. F. H. B., female, aged fifty years, married, entered hospital June 28, 191(5. Diagnosis: Tumor of the spinal cord; recurrent. Operation: Excision of the tumor, July 1, 1916. (Patient had been operated upon seven years before for a spinal cord tumor in the same location.) Preliminary Medication: She was given two preliminary hypo- dermics, | gr. pantopon and gr. scopolamin. Anesthesia: Local infiltration block. Infiltration was made from the first cervical vertebra to the fifth dorsal. The arch and lamina of the seventh cervical vertebra were removed, several laminae below this having been removed at the previous operation. The dura was exposed at the lower end of the incision, and in this manner the scar tissue was easily separated from the cord, and without special complaint on the part of the patient. A tumor was found beneath the dura on the right side of the cord, at about the center of the incision. The tumor extended around to the front, apparently perforating the dura, and was intimately connected with the vertebral wall. As the growth infiltrated the bone complete removal could not be accomplished. The only painful sensations complained of by the patient were referred to the region of the arm, which was described as a stinging pain and a feeling of numbness. Curettage of the body of the vertebra was painless. 270 SURGERY OF THE BREAST, THORAX AND SPINE Report of Case No. 12024. P. B. S., female, aged thirty years, married, entered hospital, May 15, 1919. Diagnosis: Spinal cord tumor, in the region of the sixth dorsal vertebra. Operation: Laminectomy; excision of tumor, May 17, 1919. Preliminary Medication: Given a hypodermic of | gr. pantopon and 2J0 gr. stable scopolamin, two hours before operation. This dose repeated one hour later. Anesthesia: Local infiltration. 150 cc of a 0.5 of 1 per cent novocain-adrenalin solution was used, extending from the fifth to the tenth dorsal vertebrae. The spinous processes were clipped away, without pain, and the lamina of the sixth, seventh, eight and ninth vertebrae were removed with rongeurs. Exposure of the dura was made without pain. However, the incision of the dura caused the patient to cry out. A tumor about 3 cm. long and 3 cm. wide was removed from beneath the dura after giving the patient a few inhalations of ether, as the slightest manipulation of the growth caused the patient the most excruciating pain. The cord was found to be markedly compressed, and although this patient made a good operative recovery, removal of the tumor gave no relief from symptoms. CHAPTER X. LOCAL ANESTHESIA IN SURGERY OE THE EXTREMITIES. GENERAL CONSIDERATIONS. Advantages of Local Anesthesia in Fluoroscopic and Radiographic Examinations.-When using general anesthesia for the reduction of fractures it is not an uncommon occurrence for the surgeon to be compelled to repeat his manipulations or to make further attempts at reduction after the patient has recovered from the anesthetic. As it is often considered undesirable to continue general anesthesia over an extended period, any delay in the developing of radio- grams may interfere with proper completion of the reduction. Under local anesthesia these conditions do not obtain. With the conscious patient fractures may be examined under the fluoroscope or radiographed at will even without the aid of a portable radiographic apparatus with much less difficulty than is the case when the patient is under general anesthesia. The fact that local anesthesia continues from one and a half to two hours gives an opportunity for repeated examinations and, if necessary, repeated attempts at reduction. This is one of the most important and satisfactory attributes of local anesthesia when employed in this field. When reductions of the upper extremities are to be made there is the added advantage that the patient is able to transport himself from the surgery to the roentgen-ray department and back to bed, eliminating much lifting during the various procedures and actually helping, in many instances, during the treatment by steadying his body and keeping his position in the chair or on the table and, later, by holding padding and cast material in place. Local Anesthesia of the Hands and Feet.-In producing local anesthesia in the hands and feet certain well-established principles should be followed. It is well known that the integument upon the palms of the hands and the soles of the feet is not only extremely thick and leathery, making it difficult for one to pass the needle, but that these surfaces are highly sensitive as well. One should therefore begin the anesthetization of these regions upon the dorsal surface. The initial wheal should always be made upon the dorsal surface of the hands or feet and through this wheal the 272 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES needle may be advanced in any direction between the bones toward the plantar surface, the skin of the plantar surface being anesthetized from within. As the needle impinges upon the skin the injection should be continued with some force until the needle has traversed the skin and the point has come into view. Nothing will destroy the poise of a patient so quickly as repeated needle pricks upon the unanesthetized skin of the palmar surface of the hand or fingers or upon the sole of the foot. Even though the whole operation is to be made upon the plantar surface the needle point should approach from the opposite side and anes- thesia established in the manner described above. The hand and foot may be anesthetized by an infiltration block at the wrist or ankle joint respectively. The location of the nerves in this region is superficial, and they are easily reached by the injecting needle. The ulnar, median and radial may be anesthetized with great precision, as may also the terminal branches of the tibial, common peroneal and femoral. (Plates VI and XI.) Local Anesthesia of the Fingers and Toes.-In anesthetizing the fingers and toes an infiltration block is all that is necessary. As the nerves run upon the lateral aspect of the digits the solution may be introduced in more liberal quantities in these regions. However, it requires but a moment to thoroughly infiltrate the soft tissues at the bases of the fingers and toes and there is no margin of error in the resulting anesthesia. Special refinements in technic, such as attempts to accurately locate the nerve trunks, are unnecessary. An infiltration block gives the most excellent result that it is possible to obtain. If more than one digit is to be anesthetized the needle may be carried siibdermally from one base to the next. All secondary intradermal wheals should be made from beneath (see page 149, Eig. 31). Infiltration or infiltration block may be used in the removal of growths or in doing plastic operations upon the extremities. In many cases interruption of the entire sensory nerve supply is unnecessary and a local block may be used here as in other regions of the body. As an example of the application of the infiltration method as well as the use of local anesthesia in children the following case is of interest: Report of Case No. 10047. K. M., aged eight years, entered the hospital September 3, 1917, referred by Dr. George Walker. Diagnosis: Hemangioma of right arm. Operation: Excision of the tumor. Technic of Anesthesia: Local infiltration. GENERAL CON SI DERA TIONS 273 History: Since birth the patient had presented a tumor on the anterior aspect of the right arm. The tumor was approximately Fig. 97.-Tumor of arm. (Hemangioma.) Photograph of Case No. 10047, before operation. Fig. 98.-Tumor of arm. Photograph of Case No. 10047, during operation for excision of tumor. 20 cm. in length and 8 cm. in width, and fluctuated. The aspirated fluid was reddish and showed 50,000 red blood cells per cubic milli- meter. 274 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES A circular infiltration block was made above the tumor, the needle being introduced directly toward the humerus until the Fig. 99 Fig. 100 Fig. 99.-Transverse infiltration block of arm and forearm. 1, N. cutaneus anti- brachii dorsalis; 2, N. radialis; 3, N. cutaneus antibrachii lateralis; 4, N. medianus; 5, radius; 6, N. radialis; 7, N. cutaneus antibrachii lateralis; 8, humerus; 9, N. ulnaris; 10, N. cutaneus antibrachii medialis (ramus ulnar); 11, N. cutaneus antibrachii medialis (ramus volar); 12, N. interosseus antibrachii volaris; 13, N. ulnaris; 14, N. medianus; 15, N. cutaneous antibrachii medialis (ramus volar). Fig. 100.-Transverse infiltration block of thigh and leg. 1, femur; 2, fibula; 3, tibia; 4, N. cutaneus femoris posterior; 5, N. ischiadicus et peroneus communis; 6, N. femoralis; 7, N. saphenus; 8, N. suralis; 9, N. tibialis; 10, N. saphenus; 11, N. peroneus profundus. GENERAL CONSIDERATIONS 275 growth was practically isolated from its nerve supply, 120 cc of 0.5 of 1 per cent novocain-adrenalin solution being used. An incision 20 cm. long was made and the tumor dissected out. It arose from the attachment of the deltoid to the humerus in front of the biceps, from which it could be peeled, but its attachment to the deltoid was so intimate that a portion of this muscle had to be removed with the tumor. Fig. 101.-Transverse infiltra- tion block of thigh. A, B and C, subdermal infiltration. (An- terior view.) Fig. 102.-Transverse infiltration block of thigh. B, C, D and E, subdermal infiltration. (Lateral view.) Note.-This child laughed throughout his operation and enjoyed every moment of it. When 1 pricked him with the needle in administering the anesthetic and apologized by saying, "Excuse me,'' he responded, "You're excusing yourself altogether too much.'' Figs. 97 and 98 before and during the operation show the extent of the tumor and also the mental attitude of the child. Transverse Infiltration Block.-If, for any reason, regional, Tenons or arterial anesthesia are contraindicated transverse infil- tration block may be used when operating upon the extremities, 276 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Fig. 99 illustrates the manner of making the infiltration block-a cir- cular strip of skin is anesthetized by the method described (Fig. 31, A, B, C, page 149). The needle point is then carried down to the region where the sensory nerve trunks are known to lie. As a rule it is well to establish the infiltration block from 7 to 15 cm. proximal to the site of operation. In case one is concerned regarding the question of toxicity, a constrictor may be applied. Conversely, should a tourniquet be used, the question of toxicity is thereby automatically eliminated. In removing the constrictor some care is necessary. The removal should be gradual. As a rule the longer the time between the making of thei nfiltration and the removal of the constrictor the less will be the liability to toxic absorption of the anesthetic solution. Fig. 103.-Transverse infiltration block of thigh. A, B, C, D and E, subdermal infiltration. (Sectional view showing infiltration block of the main nerve trunks.) 1, N. femoralis; 2, N. saphenus; 3, femur; 4, N. ischiadicus et peroneus communis; 5, N. cutaneus femoris posterior. Fig. 100 shows the application of the principle of infiltration block to the lower extremity. Fig. 101 shows the subdermal infiltration of the thigh and illus- trates the manner in which this may be painlessly done. Fig. 102 is a continuation of the subdermal infiltration. Fig. 103 shows the infiltration block in the region of the large nerves. THE REDUCTION OF FRACTURES AND DISLOCATIONS. Fractures of either the upper or lower extremities may be reduced by either the closed or open method under local anesthesia. In case the patient will cooperate brachial anesthesia can be estab- THE REDUCTION OF FRACTURES AND DISLOCATIONS 277 lished and any fracture or dislocation of the upper extremities may be treated (Fig. 30, page 130). Cases No. 9374, 8850 and 14154 are examples of fractures of the upper extremity which were treated surgically under local anesthesia. M. S. C., male, aged sixteen vears, entered hospital November 26, 1915. Diagnosis: Fracture-dislocation of the shoulder-joint. Operation: Open operation and reduction of fracture and fixation of fragments. Report of Case No. 8850. Fig. 104.-Fracture-dislocation of the shoulder joint. Roentgenograph of Case No. 8850, after operation. Anesthesia: Brachial block 10 cc, 2 per cent novocain-adrenalin solution and local infiltration (50 cc of 1 per cent novocain solution. History: Two months previously the patient was thrown from an automobile, injuring his shoulder-joint. Effort had been made to reduce the dislocation, roentgen rays had not been taken and he entered the hospital because of limitation of motion of the arm. Anesthesia Technic: The brachial plexus was blocked and a subdermal infiltration was made along the proposed line of incision which was over the anterior portion of the deltoid. The anesthesia was absolute. The deltoid was split and the head of the humerus was reduced into its socket. The humeral shaft was ad justed to the head and a screw inserted diagonally through the shaft and into the head of the bone. Fig. 104 shows the roentgenograms after the operation. 278 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES The Reduction of Fractures and Dislocations in Children. In case the cooperation of the patient cannot be obtained we have not attempted the reduction of fractures or dislocations of the humerus or shoulder-joint respectively, nor the elbow-joint in young children. Below the elbow-joint the infiltration block is efficient (Fig. 99, page 274) and the child may be restrained, if need be, while the infiltration block is being made. Case No. 14154 illustrates some points of advantage of the method. The following case will illustrate the application of brachial anesthesia in fractures of the forearm: Fig. 105.-Colles's fracture, brachial anesthesia. Photograph of Case No. 9374 directly after reduction of fracture. Report of Case No. 9374. A. B. I)., aged twenty-eight years, entered the hospital, November 3, 1916. Diagnosis: Fracture of the lower third of the left radius. Brachial Anesthesia: 5 cc of 2 per cent novocain solution were used and anesthesia was complete in five minutes. Operation: Relaxation was perfect, the fracture reduced and moulded splints applied without pain to the patient. Fig. 105 shows patient immediately after reduction and appli- cation of moulded splints. 279 THE REDUCTION OF FRACTURES AND DISLOCATIONS Report of Case No. 14154. E. K. M., aged twelve years, entered office on February 20, 1921. Diagnosis: Fracture of the right radius and ulna. (Figs. 106 and 107.) Operation: Reduction of fracture-closed method. (Figs. 108 and 109.) Anesthesia: Transverse infiltration block; 40 cc of 1 per cent novocain-adrenalin solution being used. Fig. 106.-Anteroposterior view. Fig. 107.-Lateral view. Figs. 106 and 107.-Fracture of radius and ulna. Roentgenogram of Case No. 14154, taken before reduction. History: Boy fell, striking on right hand, fracturing wrist. Roentgenogram showed a transverse fracture of both radius and ulna about 5 cm. above the wrist joint. A transverse block was immediately made at a point 5 cm. above the line of fracture. The fractures were reduced-a moulded plaster splint was applied and the boy allowed to return home on the street car with his mother. 280 LOCAL ANESTHESIA IN SURGERY OE EXTREMITIES Note.-This case is mentioned to illustrate certain points. The child's mother was a widow without funds. The child came to the office during office hours on a busy afternoon. The necessity of preparing him for general anesthesia, as well as the necessity of employing an anesthetist or sending the child to the hospital, the amount of time required in order to carry out the necessary treatment were factors which entered into the handling of the Fig. 108 Fig. 109 Figs. 108 and 109.--Fracture of radius and ulna. Roentgenogram of Case No. 14154, taken directly after reduction under transverse infiltration block. case. Under the plan mentioned above an assistant anesthetized the arm, the author reduced the fracture, the technician made the roentgenograms, and the assistant then applied the necessary dressing. The total expenditure of time by the author was less than five minutes. Furthermore, the child left the office travel- ing on his own power before the close of office hours. From an economic standpoint the use of local anesthesia in such a case presents many advantages. THE REDUCTION OF FRACTURES AND DISLOCATIONS 281 The Reduction of Malunited Fractures in Children.-The author has operated upon a number of fractures of the femur in children under twelve years of age and finds that they lend them- selves especially well to local anesthesia and come through the operation in much better condition, as a rule, than when general anesthesia is administered. The following cases will illustrate the application of the method. Report of Case No. 9774. F. I). A., female, aged twelve vears, entered hospital June 17, 1916. Diagnosis: Fracture of femur; malunion; malposition. Operation: Reduction with Gratton osteoclast, seven weeks after injury. Anesthesia: Local infiltration block, 7 cm. above the point of fracture. 90 cc of 0.5 per cent novocain-adrenalin solution were used. Fig. 110.-Fracture of the femur in children. Photograph of Case No. 9774, taken during reduction of malunited fracture of the femur. Gratton osteoclast in action. The child's limb was small, and, therefore, but a moderate amount of solution was required. The thigh was heavily padded with felt and the Gratton instrument applied (see Fig. 110). The bone was refractured and the result checked up by roentgenograms before the removal of the Gratton instrument. This child had no pain at the point of fracture, but complained moderately of the stretching of the muscles, which gave some distress in the region of the knee joint. However, the anesthesia was entirely satis- factory and the child partook of a hearty meal while the plaster cast was being trimmed. 282 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Fig. 110 shows a photograph made during the reduction with the Gratton osteoclast in action. Our youngest case was a boy, aged seven years, who submitted to an open operation for the reduction of malunited fracture of the femur about nine weeks after the accident. He was bribed into avoiding the shedding of tears, by a gift of five silver dollars. Report of Case No. 14118. R. M. C., aged seven years, male, entered hospital on January 26, 1921. Diagnosis: Fracture of right femur at junction of upper and middle third. Operation: Open reduction of fracture. Anesthesia: Transverse local infiltration block, using 120 cc of 1 per cent novocain-adrenalin solution. History: The patient was struck by an automobile two days before entering the hospital and coming under the care of the author. On first entering the hospital, Buck's extension was applied with leg in vertical position. The patient was irrational and was handled with difficulty. The Buck's extension was substituted by a Thomas splint, as the fracture was oblique and complete reduction could not be brought about. The boy con- tinued irrational and was restrained with difficulty, and it was assumed that he had sustained a brain injury. It was found impos- sible to overcome the fracture by extension, and an open operation was decided upon as soon as the mental condition improved. Two weeks after the accident a local infiltration was made along the outer aspect of the thigh and a deep circular block was made on a line just below the great trochanter. (Fig. 101, page 275.) Through a 15 cm. incision the fragments were exposed and the bone ends were turned out, freshened and reduction made, the fragments being held in place by a heavy wire suture. The patient became somewhat pale at the end of the operation, which required one and a half hours, although there was but slight loss of blood. He was given $5.00 as a bribe and went through the operation without crying. Note.-This patient, while showing some reaction, returned to bed in better condition than has usually been the case with this type of operation. Prompt union followed. BONE TRANSPLANTS 283 BONE TRANSPLANTS. The transfer of bone grafts may be accomplished under local anesthesia quite as easily as may be the open reduction of fractures. In addition to the establishment of anesthesia at the point of fracture, it is necessary to anesthetize the area from which the transplant is to be obtained. In case the rib is to be used, the technic employed in Chapter IX, page 263, is to be recommended. As most bone transplants are obtained from the anterior surface of the tibia and the blocking of this region is so simple, the pro- cedure presents little difficulty. Technic of Anesthesia.-A subdermal infiltration may be made along the line of the proposed incision, and through this the needle point may be carried alternately from one border of the tibia to the other subdermally. The infiltration should be carried well above the upper end of the position of the transplant, and at this point the needle should be introduced posterior to the tibia and a liberal amount deposited. An equally satisfactory procedure is the establishment of a rhom- boid infiltration over the area from which the transplant is to be removed, the lateral boundaries of the rhomboid corresponding to the external and internal borders of the tibia. Through this subdermal infiltration area, the needle may be introduced vertically until it reaches the periosteum and the site of the transplant isolated. No attempt should be made to introduce the solution subperios- teally. Cases Nos. 8674 and 8338 are examples of bone trans- plants done under local infiltration and infiltration block. Record of Case No. 8338. Mrs. C. C. I)., aged fifty years, entered hospital January 5, 1915. Diagnosis: Giant-cell sarcoma of distal end of right ulna. Operation: Excision of tumor and bone transplant from tibia. Anesthesia: Brachial block; local infiltration on leg. History: The patient complained of numbness in both wrists. An aching pain developed in the right wrist, which began to swrell five months ago. The swelling was most marked over the ulnar surface and the other joints were normal. Roentgen rays showed rarefaction of ends of metacarpals and phalanges with an enlargement of distal end of ulna, which was extremely rarefied and trabeculated. (See Fig. 111.) Anesthetic and Operative Technic: Brachial block was done with the patient in a reclining position and 20 cc of 2 per cent novocain- adrenalin solution were used. A circumferential block of Hackenbruch using 0.5 per cent of 284 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES novocain-adrenalin was made over the anterior surface of the right leg outlining the bone segment to be removed from the tibia. During this time the brachial anesthesia had become established and an incision from the middle of the forearm to about 5 cm. below the styloid process was made. The ulna was freed and about 8 cm. of its distal end was resected. A transplant was next removed from the tibia and modelled to articulate with the carpal joint, after which the small end was driven into a drill hole in the ulnar fragment to hold it in place. (See Fig. 112 A.) Note.-The only unpleasant sensation throughout the operation occurred when the saw plunged deeply into the marrow of the tibia. Fig. 111.-Roentgenogram of Case No. 8838, before operation, showing both normal and abnormal wrist. Report of Case No. 8674. H. C. A. aged twenty-seven years, entered hospital January 30, 1915. Diagnosis: Ununited fracture of the right radius and ulna at the midpoint. Operation: Intramedullary autotransplant. Anesthesia: Brachial block, 10 cc of 2 per cent novocain-adrenalin solution; local infiltration for removal of graft. History: Four months previously the patient had been thrown from a buggy, breaking both bones of the forearm. Board splints and plaster casts had been applied, but the bones had failed to heal and patient had presented himself to Dr. Knut Hoegh for exami- Fig. 112.-Roentgenogram of Case No. 8838. A. Immediately after operation; B, taken one month after operation; C and D, taken fifteen months after operation. 286 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES nation, through the courtesy of whom the author was allowed the privilege of performing the operation. Operation: The patient was given J gr. morphin and scopol- amin at 9 a.m. on February 2, 1915. At 10 a.m. the operation was performed. Brachial anesthesia was established with the patient sitting in a chair, 10 cc of 2 per cent novocain-adrenalin being used. A large rhomboid infiltration was then made on the anterior surface of the leg. The site of the fractures was then reached by two incisions and the ends of the bones freshened. With a large drill the marrow cavity was reamed out and dowels were prepared from bone removed from the tibia. These dowels were fitted into place, the wound sutured and the patient made an uneventful recovery. Note.-The anesthesia for the removal of the transplant was obtained by a subdermal infiltration of the leg and in addition the needle was carried down to the periosteum, making an infiltration along the line which marked the line of the transplant to be removed. AMPUTATIONS. The condition of patients requiring major amputations is usually such that the use of local anesthesia is especially desirable. All large nerve trunks should be injected with absolute alcohol for the purpose of preventing pain and the development of neuromata. Technic of Anesthesia. -The technic to be employed for the amputation of the upper or lower extremity will depend upon circumstances. The Upper Extremities.-In the upper extremity brachial anes- thesia or the venous anesthesia of Bier are the methods of choice, although in amputations below the elbow infiltration block pre- sents many advantages. It is unnecessary to prepare the skin in other fields. Transverse block presents no margin of error and toxicity may be absolutely eliminated by the use of the tourniquet. The method is especially simple and efficient in thin individuals where the nerves may be easily located. But a small amount of solution is required and with the use of the tourniquet the amount administered becomes relatively unimportant. Venous anesthesia (see page 112) is efficient for amputation below the upper third of the humerus. The technic of its establish- ment, while comparatively simple, is rather more complicated than the other methods. In septic cases it should not be employed. Amputation at or near the shoulder-joint demands brachial anesthesia with the addition of a subdermal infiltration along the lines of incision, as shown in case No. 7610, AMPUTATIONS 287 Report of Case No. 7610. K. C. J., male, aged nineteen years, entered hospital November 12, 1914. Diagnosis: Crushing injury to arm. Operation: Amputation of left arm. Anesthesia: Brachial block. History: The left arm had been cut in a corn shredder twenty- four hours previously. The physicians in the country had cut away the loose tissue, leaving a considerable amount of bruised skin and muscle. After rest and the application of moist dressings for a period of eight days there was a line of demarcation indicating that the stump, which was 20 cm. in length, would have to be reduced to 10 cm. in order to obtain healthy skin flaps. Brachial Anesthesia: 10 cc of a 2 per cent novocain-adrenalin solution were injected into the brachial plexus, after paresthesia of the nerves had been excited by the needle point. The anesthesia of the skin and other tissue was good but it was necessary thoroughly to anesthetize each of the large nerves as they were exposed before severing them. The Lower Extremities.-Amputation at or below the hip is best performed under infiltration block or direct infiltration, preferably, however, under a combination of the two. (See Figs. 101, 102, 103, page 275.) Venous anesthesia may be used and it presents decided advantages in certain cases (page 112.) Regional anesthesia also has points of advantage in this field. In amputations above the knee one can depend upon an infil- tration block, combined with local infiltration along the lines of incision and a reinforcement by the means of a concentrated solution (4 per cent procain-adrenalin) in the large nerve trunks as they appear. As one approaches the ankle, say in the lower half of the leg, an infiltration block (see Fig. 100, page 274) is efficient and the rules laid down for amputations of the arm apply. (Fig. 99, page 274.) Cases Nos. 13712 and 12198 involved amputations of the leg, which were done under transverse infiltration block. Report of Case No. 13712. In the aged or debilitated, local anesthesia is especially desirable. Mrs. A. C. I)., aged eighty-five years, entered hospital March 29, 1920. Diagnosis: Gangrene of right foot (senile). Operation: Amputation of leg. Anesthesia: Transverse infiltration block. 288 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Technic of Anesthesia: A transverse infiltration block was made 12 cm. below the knee, including a subdermal infiltration along the line of incision (Fig. 100, page 274), and 90 cc of 0.7 of 1 per cent novocain-adrenalin was used. The endosteum was the only tissue found to be sensitive throughout the operation. The patient made a rapid recovery and was discharged from the hospital in two weeks. Fig. 113 shows the patient during the operation. Fig. 113.-Amputation of the leg. (Senile gangrene.) Photograph of Case No. 13712, during operation. Report of Case No. 12198. Mrs. II. J. I)., aged seventy years, entered hospital August 5, 1919. Diagnosis: Varicose ulcer of leg with malignant degeneration. Operation: Amputation of leg. Anesthesia: Transverse infiltration block. History: Patient had varicose ulcers of leg for fifteen years. Varicose veins for thirty years. Three months ago an ulcerated area became angry in appearance and the leg increased in size. Technic of Anesthesia: A transverse infiltration block below knee joint was made (Fig. 100, page 274), using 90 cc of 0.7 per cent novocain-adrenalin solution. Amputation at upper third of the leg. The operation was entirely painless and the patient's condition was without change. SUPPURATIVE ARTHRITIS 289 Primary healing resulted and the patient left the hospital twelve days later. Amputation of the thigh, when local infiltration is used, should be made by beginning the incision in front, shaping the anterior or external flap as the case may be and carefully dividing the respective muscles as they appear, watching constantly for the sharp contraction which indicates that the nerve supply has not been interrupted. Infiltration should be used freely as the ampu- tation proceeds, provided the indications arise. As the femur is exposed the anesthesia may once more be reinforced directly under the vision, the needle being carried behind the femur and the solution liberally injected. The bone should be sawed in two before the posterior flap is made. As soon as the femur has been divided the sciatic nerve may be carefully exposed and well blocked proximally, using about 5 cc of a 4 per cent novocain-adrenalin solution. A few minutes should be allowed to elapse after this blocking before the sciatic is divided. In the meantime the tissues laterally may be divided and as soon as the sciatic is divided the posterior flap may be outlined. When the operation is carried on in this manner anesthesia is easily obtained and an excellent opportunity for obtaining hemostasis is offered. SUPPURATIVE ARTHRITIS. Technic of Anesthesia for Drainage.-Suppurative processes in and about any of the larger joints may be attacked, incised and drained under direct infiltration, omitting the circuminjection described for aseptic operations. Liberal incisions are desirable and a good exposure is essential, provided there is any doubt regard- ing the location of the abscess. We have made openings and counter openings in a number of cases upon individuals who were extremely ill, and in no instance have we seen any untoward local effect from the infiltration. Case No. 12491, which follows, illus- trates drainage of a suppurative hip under local infiltration anes- thesia. Report of Case No. 12491. Mrs. E. C. IL, aged forty-five years, entered hospital December 18, 1919. Diagnosis: Septic arthritis of left hip. Operation: Arthrotomy and drainage. Anesthesia: Local infiltration, 180 cc of 0.5 per cent novocain- adrenalin solution. Operation: Patient was given an injection of scopolamin gr. and pantopon | gr. two hours before operation and one hour 290 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES before. Infiltration was made along the lateral aspect of the thigh and a longitudinal incision was made down to the abscess cavity. 500 cc of creamy pus escaped-the finger was introduced and the hip-joint was explored. A long, curved forceps was intro- duced and after infiltrating the gluteal region an incision was made down to the forceps. Dakin's tubes were introduced through the counter opening and passive motion was carried out daily. The patient was discharged from the hospital with a movable hip on February 8, 1920. OSTEOMYELITIS. Acute Osteomyelitis.-Technic of Anesthesia for Drainage.- Osteomyelitis of the acute type demanding only incision and drainage lends itself especially well to the use of local anesthesia. In cases where the disease has advanced beyond the bony con- fines the production of anesthesia is similar to that described elsewhere for the opening of abscesses. A small infiltration of the skin and tissues overlying the abscess is all that is required. Direct infiltration of the tissues should be made, the needle being carried directly to the bone, provided the latter is to be tre- phined. The trephining of the bone should be made with a drill, as the use of the mallet and gouge is apt to cause the patient more or less pain. Chronic Osteomyelitis. In chronic osteomyelitis the infiltration should be sufficiently extensive so that any operative procedure required may be carried out. As a rule an infiltration block placed 5 to 7 cm. proximal to the upper limit of the lesion will bring about sufficient anesthesia to allow the removal of sequestrse and the per- formance of curettage or any other necessary procedure. Provided one desires to make the implantation of pedicle flaps according to the method of Emil Beck, it is necessary only to out- line such flaps by making a subdermal infiltration beneath the area from which they are to be raised. Case No. 11808, shows the application of the above method in treating chronic osteo- myelitis. Report of Case No. 11808. Mrs. II. S. 1)., aged twenty-nine years, entered hospital on November 19, 1918. Diagnosis: Chronic osteomyelitis (bone abscess) of the right tibia. Operation: Channeling excision of necrotic tissue and intro- duction of Beck skin Haps. Anesthesia: Circumferential infiltration block, 90 cc of 1 per cent novocain-adrenalin solution. SURGERY OF THE SHOULDER AND CLAVICLE 291 History: Patient had a discharging sinus over the upper end of the right tibia when she was seven years old. No further trouble was noted until she was in an accident six weeks before entering hospital. Now has continuous pain at the upper end of the tibia. The roentgenogram shows a shadow from 2 to 3 cm. long and 2 cm. wide at the upper end of the right tibia. Technic of Anesthesia: 90 cc of novocain-adrenalin solution was introduced circumferentially-the needle passing laterally and posteriorly to the tibia just below the knee-joint. A small dis- charging sinus was excised, the periosteum elevated and a channel cut by means of the mallet and gouge, removing approximately one-third of the circumference of the tibia. A number of chisel points were broken because of the eburnation of the bone. The endosteum was found to be sensitive but thorough curettage was made. Pedicle flaps were turned in on each side and good results followed. CHOICE OF METHODS OF PRODUCING LOCAL ANESTHESIA IN THE UPPER EXTREMITIES. Dislocation of the shoulder may be reduced after making the brachial plexus block of Kulenkampff, and if for any reason one is unable to locate the brachial plexus a direct infiltration into the joint with a circumferential block proximal to the joint will give sufficient anesthesia and relaxation so that reduction may be accomplished. Dislocation of the elbow-joint may be reduced under brachial anesthesia or the venous anesthesia of Bier (Chapter V). Dislocation of the carpal bones and phalanges may be reduced after a transverse block at or above the wrist joint or by the establishment of brachial anesthesia. The three nerves supplying the hand are easily located at this level (Fig. 99, page 274, also Plate VI), and a perineural infiltration may be made in the region of each, following which anesthesia will be complete in about fifteen minutes. SURGERY OF THE SHOULDER AND CLAVICLE. Nerve Supply of the Shoulder and Clavicle Region.-The skin over the region of the shoulder is supplied by nn. supraclaviculares posteriores (UI, IV C) to the upper and posterior part of the shoulder; the anterior and lateral brachial cutaneous nerves of n. axillaris (V, VI C) to the region of the deltoid; n. intercostobrachialis (II T) to the axillary region and proximal arm. The muscles and fascia are supplied by muscular branches of these nerves. 292 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES The shoulder joint is supplied by articular branches of n. supra- scapularis (V. VI. C). The skin over the region of the clavicle is supplied by nn. supra- claviculares anteriores and nn. supraclaviculares medii (II. IV. C.) (see Fig. 36, A, B, and C, page 171). Technic of Anesthesia.-Fracture, dislocation or other affections of the clavicle may be operated upon under direct infiltration com- bined with a deep injection along the upper border of this bone. Care must be taken to avoid the large vessels which lie directly beneath the bone. If the injection is made with the needle point impinging upon the bone there is no danger of injecting a vessel. After exposing the clavicle, anesthesia may be reinforced when- ever it is found to be necessary. One may, however, with a little care, completely anesthetize this region before any operative procedure is begun. This technic has been employed frequently even for the reduction of fractures of the clavicle by the closed method. The application of the first dressings may in this manner be converted into a pain- less procedure. Brachial Anesthesia.-For all operative work upon the upper extremity, including the reduction of fractures and dislocations, the brachial anesthesia of Kulenkampff offers many advantages. When established it gives excellent anesthesia. Its accomplish- ment is not difficult and, provided the injection is made slowly and certain precautions observed, it is comparatively safe (Fig. 30, page 130). In order to produce this anesthesia it is essential that one has the cooperation of the patient, for in no other manner can one be cognizant of the fact that the needle point has been introduced into the nerve bundles. Also, the injection is most easily made with the patient in a sitting posture. Where for any reason it is impossible for a patient to assume a sitting position additional difficulties are encountered in locating the nerve, as the direction of the needle along the lines of certain anatomical landmarks is interfered with. The close proximity of the subclavian vessels to the bundles of the brachial plexus makes necessary special precautions if one is to avoid the introduction of the solution directly into the circu- lation. As the needle point must be stationary when the solution is injected it is well to use a fairly large needle and to delay and aspirate one or more times while the solution is being introduced. The introduction of the solution should be made slowly so that the nerve tissues will not be torn or traumatized. From time to time there have appeared in the literature reports of the loss of func- tion which was supposed to have resulted from injury to the brachial 293 SURGERY OF THE SHOULDER AND CLAVICLE plexus after the induction of this form of anesthesia. The author's experience with several hundred cases with no untoward after- effects makes him feel like offering the suggestion that such effects are unlikely to follow if the solution is injected sufficiently slowly to avoid traumatization. Cases Nos. 10014, 11555 and 12187 are examples of shoulder subluxation, dislocation and fracture of the humerus respectively, which were treated surgically by the use of brachial block. The following case will illustrate the application of brachial anesthesia to simple subluxation of the shoulder joints: Report of Case No. 10014. K. J. M., aged fifty years, entered the hospital on August 18, 1917. Diagnosis: Subluxation of the left shoulder-joint. Operation: Reduction by closed method. Anesthesia: Brachial block (Fig. 30, page 130), using 5 cc of a 1 per cent solution. There was numbness of the hand seven minutes after the injection of the brachial plexus. Complete relaxation was obtained and reduction was accomplished by manipulation. In this case, induction of anesthesia and reduction of the dis- location required but ten minutes. Report of Case No. 11555. Mrs. N. B. C., aged thirty-five years, entered hospital June 3, 1918. Diagnosis: Fracture-dislocation of head of right humerus. Operation: Reduction by manipulation. Anesthesia: Brachial block. The plexus was located instantly and 5 cc of a 1 per cent novocain-adrenalin solution were used. Anesthesia was complete in five minutes. Reduction was made with the aid of the fluoroscope. Strohmeyer pad placed in axilla and dressings applied. Report of Case No. 12187. B. M. I)., aged twenty-four years, entered hospital August 8, 1919. Diagnosis: Oblique fracture of the humerus. Operation: Reduction by closed method. Anesthesia: Brachial block. 294 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES History: Patient entered hospital with a fracture which had been sustained two hours before his examination. The left humerus showed a spiral fracture with considerable shortening. Anesthesia: Brachial anesthesia (Fig. 30, page 130), using 10 cc of a 1 per cent novocain-adrenalin solution. Operation: Reduction was made directly under the fluoroscope and a modified Thomas splint applied. The patient was allowed to leave the hospital thirty minutes after entering. SURGERY OF THE ELBOW-JOINT. The nerve supply of the region of the elbow-joint is as follows: (See Plates V, VII and VIII.) The skin overlying this region is supplied by (1) n. intercosto- brachialis (II. T) to the medial side of the arm and not beyond the elbow-joint; (2) n. eutaneus brachii posterior from n. radialis, V. VI. A IT. VI11. C. I. T., also to the medial side; (3) n. eutaneus antibrachii dorsalis, also from the radial to the lateral and posterior distal third of the arm and the dorsal part of the proximal half of forearm; (4) n. eutaneus antibrachii lateralis of n. musculo- cutaneus, V. VI. C. to the lateral side of the forearm; (5) n. cuta- neus antibrachii medialis, VIII. C. I. T., to the medial side of the forearm. The elbow-joint proper is supplied by articular branches of n. medianus V. VI. VII. VIII. C. I. T. and n. ulnaris VIII. C. I. T. The muscles and fascia of this region are supplied by branches of the ulnar, median, radial and musculocutaneus nerves, and it will be noted that the nerve supply of this region is primarily from the fifth cervical to the first thoracic nerves. Arthroplasty.-The choice of the methods of producing local anesthesia of the elbow-joint lies between the brachial anesthesia of Kulenkampff (Fig. 30, page 130) and the venous anesthesia of Bier (Chapter V). The margin of error is perhaps greater in the case of brachial anesthesia. The other method allows one an excellent opportunity for carrying out the technical details of the operation. In case a fat-fascia-transplant is to be used the technic described on page 164 may be used in isolating from its nerve supply the area from which the transplant is to be obtained. The following case will illustrate the use of brachial and infil- tration anesthesia in the performance of this operation. Report of Case No. 14221. M. I. K., aged twenty-six years, entered the hospital April 13, 1921. Diagnosis: Ankylosis of the elbow-joint, following suppurative arthritis. SURGERY OF THE ELBOW-JOINT 295 Operation: Arthoplasty of the elbow-joint. Technic of Anesthesia: Brachial block and local infiltration (saligenin). Anesthesia: Brachial anesthesia (Fig. 30, page 130), using 10 cc of saligenin, 4 per cent. The patient was extremely nervous and presented a typical picture of psychic incompatibility, being hypersensitive and suspicious. Her lack of cooperation during the establishment of the brachial anesthesia left us in doubt as to whether the plexus had been located. The anesthesia about the elbow-joint was incomplete and a local infiltration was employed to reinforce it. 180 cc of a 2 per cent solution of saligenin were used. Fig. 114.-Arthroplasty of elbow-joint. Photograph of Case No. 14221, after operation. (Brachial anesthesia.) Operation: The bones were exposed and the classical Murphy operation performed, with the exception that the transplant of fascia and fat was taken from the thigh of the same side, as the tissues of this nature about her elbow were extremely scant. Pri- mary healing resulted. Fig. 114 is a composite photograph of this patient showing the range of motion after operation. Venous anesthesia furnishes also an excellent method for making elbow operations, as it permits of no margin of error. Report of Case No. 15494. O. S. G., female, aged eighteen years, entered hospital March 6, 1922. 296 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Diagnosis: Unreduced dislocation of right elbow. Operation: Open method of reduction. Anesthesia: Venous anesthesia of Bier. History: The patient had chronic glomerular nephritis; blood urea-N., 99 mgm. per 100 cc; blood creatinine, 4.9 mgm. per 100 cc; blood Van Slyke, 54 per cent; P. S. P. excretion, 0 during two- hour period. 90 cc of a 1 per cent novocain-adrenalin solution were injected into the median basilic vein as described on page 112. The anesthesia was complete and immediate. The elbow-joint was remodelled, two incisions being made. A large amount of callus was removed from the semilunar notch of the ulna. The Fig. 115.-Arthroplasty of elbow joint. Photograph of Case No. 15494, during operation. (Venous anesthesia.) (Bier.) wound healed kindly, but one week after operation the patient showed marked symptoms of uremia and for several days her life was despaired of. She finally recovered, although, of course, her lease on life is rather short. Note.-This girl underwent this severe operation without an immediate reaction and the reaction she did show did not appear until one week after the operation. From experience with cases of this kind one is led to feel that general anesthesia over a long period of time as is necessitated by such a condition is absolutely contraindicated. Venous or brachial anesthesia are entirely satis- factory. Fig. 115 shows the patient during the operation. SURGERY OF THE HIP 297 SURGERY OF THE WRIST. Nerve Supply of the Wrist. -(Plates VI, VII and VIII.) The skin over the region of the wrist is supplied by (1) n. cutaneus antibrachii cutaneus lateralis of n. musculocutaneus (V. VI. VII. C) to the lateral and dorsal side; (2) n. cutaneus antibrachii medialis (A llI. C. I. T.) to the ulnar side of the wrist; (3) n. cutaneus anti- brachii dorsalis of n. radialis (V. VI. VII. VIII. I. T.) to the posterior ridge; and (4) a cutaneous branch of n. ulnaris (VIII. C. I. T.). The joint and fascia are supplied by branches of the ulnar, radial and median nerves. All operations upon the hand may be performed after establish- ing conduction anesthesia brachial block or by an infiltration block at the wrist joint as shown in Case No. 12277. Report of Case No. 12277. II. J. C., aged sixty-three years, entered hospital September 10, 1919. Diagnosis: Dupuytren's contraction of left hand. Operation: Excision of palmar fascia-Keen's incision. Technic of Anesthesia: Infiltration block at the wrist catching the ulnar and median nerves. Anesthesia was immediate and complete. The classical operation was performed. SURGERY OF THE HIP. Nerve Supply of the Lower Extremity in the Region of the Hip- joint.-The skin overlying the region of the hip-joint is supplied by: (1) n. cutaneus femoris lateralis (II. III. L.), which supplies the anterior and lateral sides; (2) n. lumboinguinalis, which is a branch of n. genitofemoralis (1. II. L.) and supplies the anterior surface; (3) n. ilioinguinalis (I. L.) to the medial thigh; (4) ramus cutaneus lateralis of n. iliohypogastricus (I. L.) to the gluteal region; (5) ramus cutaneus lateralis of the twelfth thoracic to the front part of the gluteal region; (6) the lateral cutaneous branches of the posterior divisions (I. II. III. L.) to the buttocks; and (7) the lateral branches of the posterior divisions of I. II. III. S. to the posterior part of the buttocks. The hip-joint is supplied by (1) an articular branch of the anterior part of n. obturatorius (II. III. IV. L.), which enters through the acetabular notch; (2) by another articular branch of the femoral nerve (n. femoralis) (II. III. IV. L.); and (3) by articular branches from the nerve to the quadratus femoris (IV. V. L. I. S.) and from the tibial part of the sciatic nerve (n. ischiadicus) (IV. V. L. I. II. III. S.). 298 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES The muscles and fascia are supplied by branches from these various nerves. Therefore, the nerves from the first lumbar to the third sacral are involved. It will be seen that the sensory nerve supply to this joint and to the tissues which one must traverse when attacking it surgically is somewhat complicated and that its interruption by conduction anesthesia is by no means a simple procedure. We have depended upon direct infiltration of the tissues for the production of anes- thesia of the hip-joint, varying the technic to meet the indications. Open Operations.-Open operations upon the hip-joint may be carried out as follows: Technic of Anesthesia: A subdermal infiltration along the line of the proposed incision is made, followed by a subfascial infil- tration down to the femur. In making the deep infiltration a wall of anesthesia may be built both behind and in front of the femoral neck. If possible the patient should be placed upon the unaffected side. The landmarks should be carefully noted. There is practically no structure upon the posterior surface that will interfere with infiltration. A long, fine needle may be carried directly to the bony surface of the ilium and the injection made with the point of the needle constantly moving. In front it is necessary only to avoid contact with the large vessels which lie well medial to the path of the needle. From 90 to 180 cc of solution may be required, depending upon the size of the patient. Every effort must be made to secure physical comfort for the patient's body during the carrying out of the operation. Movements of the affected limb must be made cautiously at first, and always with the anticipation of pain, until one is assured, after careful experi- mentation, that anesthesia is complete. While at rest the limb should be rigidly supported and the utmost care observed in pre- venting sudden motion in it, that for instance which might result from the dropping of the limb by a careless assistant. As the incision advances the anesthesia may be reinforced providing the blocking has not been complete. As soon as the femoral neck and head can be definitely located any further manipulations should be preceded by the introduction of about 30 cc of the solution in close proximity to as well as into the joint. At this stage it is possible to reach the nerve branches which course through the acetabular foramen, and which are not so easily accessible at the beginning of the operation. Perfect exposure of the tissue planes must be insisted upon here as in all other operative procedures if local anesthesia is to be successfully employed. By following these simple rules and working deliberately and without haste the hip-joint may be painlessly exposed for any operation which SURGERY OF THE HIP 299 may be required in this region. The acetabulum or iliac bone may be chiselled, curetted or drilled into without pain to the patient, provided the region has been properly anesthetized. Case No. 11298 exemplifies an open operation with bone pegging for ununited fracture of the femur by the use of local infiltration. Report of Case No. 11298. V. F., aged fifty-three years, entered hospital on January 25, 1918. Diagnosis: Ununited fracture of neck of left femur. Operation: Open operation and bone pegging. Anesthesia: Local infiltration, 120 cc of a 0.5 per cent novocain- adrenalin solution. History: Seven months before entering the hospital, patient fractured the neck of the left femur while at work in a mill. Operation: Direct infiltration was made along the line of incision proposed by Dr. A. J. Gillette, about 120 cc of a 0.5 per cent solution being used. The hip-joint was exposed, the fractured sur- faces freshened and two beef-bone pegs were inserted through drill holes. The incision was closed and a plaster spica applied. The patient went through this operation entirely without pain and cooperated with us while the plaster cast was being applied. Staphylococcus infection followed the operation but did not greatly delay convalescence. Fractures and Dislocations.-Technic of Anesthesia.-The reduc- tion of fractures and dislocations has been accomplished with considerable less difficulty than was anticipated, although experience with this class of work has been comparatively small. The technic as described for the open operation is carried out with the exception of the making of the subdermal infiltration. In place of this a number of secondary wheals are made upon the skin, advancing the needle through the initial wheal, which is usually made directly over the greater trochanter. From this point a wheal is made at a point on the skin directly in front of the acetabulum and external to the location of the femoral vessels. One or two wheals are made below the greater trochanter and one or two on the posterior surface of the buttock at points which will permit one to infiltrate thoroughly the tissues about the acetabulum, the greater trochanter and the femoral neck. As soon as the infiltration has been accom- plished it will be found possible to abduct the limb sufficiently so that a skin wheal may be made on the inner side of the thigh, if this is thought desirable, close to the perineum, through which the acetabulum may be reached and the circuminjection of the joint completed. The following case report is inserted to illustrate the application of the method: 300 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Report of Case No. 13400. M. F. IL, aged twenty-one years, entered hospital September 25, 1921. History: While playing football, patient was tackled and thrown, striking on his left hip. lie was unable to use the limb and has had considerable pain since the injury. Complaint: Injury to left hip. General Examination: Negative. Examination of Left Lower Limb: Left foot was rotated inward, lying across the instep of the right foot, with the left knee lying against the right. Limb partially flexed. Muscles extremely tense. Greater trochanter above Nelaton's line. Fig. 116.-Dislocation of the hip. Roentgenogram of Case No. 13400, showing dislocation. Diagnosis: Dislocation of left hip. Operation: Reduction by closed method. Technic of Anesthesia: Local infiltration. Operation: No preliminary hypodermics. An infiltration block was made, using 90 cc of a 1 per cent novocain-adrenalin solution, following the direction of the femoral neck with a 12 cm. needle. Before 90 cc were injected the large muscles were completely relaxed. Slight movement of the femur was painless and the limb was per- SURGERY OF THE HIP 301 Fig. 117.-Dislocation of the hip. Roentgenogram of Case No. 13400, after reduction. Fig. 118.-Dislocation of the hip. Photograph of Case No. 13400, directly after reduction- 302 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES fectly comfortable, whereas he had been suffering considerable pain before the injection was made. 90 cc more were used, with the result that the boy could be lifted from the stretcher and laid on the floor without producing pain. Five minutes after the injection was finished the dislocation was reduced by manipulation. Two assistants held the pelvis in contact with the floor while the surgeon made the manipulations, assistance being necessary in order to lift the head over the rim of the acetabulum. The fifth attempt was successful. Roentgenograms show the condition before (Fig. 116) and after (Fig. 117), and the photograph (Fig. 118) was taken directly after the reduction. Arthroplasty of the Hip. The anesthesia recpiired for carrying out the procedure known as arthroplasty of the hip-joint differs in no manner from that described for anesthetizing the region of the hip-joint for the treatment of other conditions, such as the open operation for fracture. The following case will serve as an illustration: Report of Case No. 10603. C. T. R., aged fourteen years, entered hospital February 3, 1917. Diagnosis: Ankylosed right hip with acute flexion. Operation: Arthroplasty, Murphy operation. Technic of Anesthesia: Local infiltration and nitrous oxide and oxygen. (Mixed anesthesia.) History: Two years ago the patient developed suppurative arthritis of right hip, which is completely ankylosed in rather marked flexion. Operation: February 6, 1917. A circumferential block of the hip-joint was carried out, using 180 cc of a 0.5 per cent novocain- adrenalin solution. The classical Murphy operation was performed, using a pedicle flap of fat and fascia. This patient was given nitrous oxide and oxygen during the manipulation of the hip, which was necessary for mobilization purposes. The presence of the scar tissue was considered a con- traindication to local infiltration and spinal or general anesthesia might be more satisfactory in such a case. Furthermore, this patient's wound suppurated profusely, and although it is our experi- ence that local infiltration does not reduce the resistance of the tissues, this case proved to be rather unsatisfactory in its outcome. FRACTURE OF THE FEMUR. Closed Operation. -Technic of Anesthesia.-The reduction of simple fractures of the femur by the use of local anesthesia may FRACTURE OF THE FEMUR 303 be made following a transverse block at a point 10 to 15 cm. above the line of fracture or, if high up, the technic may be made to correspond closely to that used for operations upon the femoral neck. This technic will suffice for fractures of the upper third. Fractures below this may be reduced after the transverse block has been made, with the addition of a liberal injection about the seat of fracture. Open Operation.-We have in a number of instances reduced both recent and old fractures of the femoral shaft by the open method. Perfect local anesthesia gives good relaxation of the muscles and as these operations are always a tax upon the patient's strength we feel that local anesthesia is especially indicated in this field. Technic of Anesthesia.-A subdermal infiltration should be made along the line of incision followed by a transverse block at the level of the upper end of the incision combined with a circum- injection of the femur. The injecting needle should be carried alter- nately in front of and behind the bone. (Figs. 101, 102 and 103, page 275.) The solution must be used liberally and in stout indi- viduals we have employed as high as 300 cc. It may be well in these cases to apply a tourniquet just above the field of operation in order to reduce the possibility of toxicity. However, in a fairly large experience the author has seen no ill effects from the use of from 200 to 300 cc of 0.5 to 0.7 of a 1 per cent novocain-adrenalin solution. Perfect relaxation is obtained and the tendency to bleeding is greatly reduced. Liberal incisions and good exposure are desirable. Provided a transplant is to be made a subdermal infiltration may be made along the line of the proposed incision through which it is to be removed. Through this a rectangle may be marked out upon the tibia by carrying the needle point directly to the periosteum along two lines, one external to and the other medial to the outlines of the transplant. By the time one is ready to remove the transplant anesthesia will be found complete in this region. As an example of a handicapped individual presenting a severe injury demanding an open operation the following case may be cited: Report of Case No. 11862. Mrs. S. E. B., aged seventy-one years, entered hospital December 18, 1918. Diagnosis: Supracondyloid T-fracture of the right femur. (Fig. 119.) Operation: Incision, reduction and application of screws. Anesthesia: Transverse infiltration block. 304 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES History: Thirteen days before admission to the hospital the patient had sustained a severe injury to the right knee by falling down stairs. No subsequent efforts at reduction had been made. Roentgenographic plates showed a transverse fracture of the femur beginning 8 cm. above the knee-joint, dividing the condyles and extending into the knee-joint. There was practically 8 cm. shorten- ing, the lower distal fragment being displaced backward. The patient was short and stout. The urine contained a moderate amount of albumin, hyaline and granular casts. Technic of Anesthesia: Infiltration block, novocain-adrenalin, 180 cc. Fig. 119.-Fracture of the femur, lower end. Roentgenogram of Case No. 11862, before operation. The patient was given no preliminary hypodermic medication. She was placed upon the extension apparatus, great care being taken to make her as comfortable as possible. She was held in position by applying the extension screws, and the skin was pre- pared by painting with iodin. The line of incision-25 cm. in length-was infiltrated, each excursion of the needle bringing its point in contact with the femur. An especially large deposit of solution was made just posterior to the bone in the region of the fracture. The bone was exposed and the fragments gently separated by the use of a scalpel and chisel. In the meantime the traction screws were brought into play, and the lower fragments were gradually brought down to the proper level. One long screw THE KNEE-JOINT 305 and a stove bolt were introduced, after drilling the bones in order to prevent a recurrence of the displacement (for radiogram before operation see Fig. 119) after operation, the fractured surface being rather oblique. This patient left the table with a pulse of 80; there was no hemorrhage, no shock, no pain, and she presented no post- operative complications. Fig. 120 shows the reposition of the fragment. Fig. 120.-Fracture of the femur, lower end. Rpentgenogram of Case No. 11862, after operation. THE KNEE-JOINT. (Fig. 100, page 274, and Plates XII and XIII.) The Nerve Supply.-The knee-joint is supplied by an articular branch of the common peroneal nerve, n. peroneus communis (IV. V. L. III. S., and sacral plexus) by (2) three articular branches of n. femoralis (II. III. IV. L.) by (3) an articular terminal branch of n. obturatorius (II. III. IV. L.) by (4) an articular branch of n. ischiadicus (IV. S. L. I. II. III. S.) and by (5) articular branches of n. tibialis (IV. V. L. I. II. III. S.). Thus it is seen that the joint is supplied by nerves from fourth lumbar to third sacral. The skin overlying the knee-joint is supplied by cutaneous branches (intermediate, medial and saphenous) of n. femoralis (II. III. IV. L.) which supply the sides and front of knee, and n. cutaneus femoris posterior (I. II. III. S.) which completes the supply over the popliteal space. The muscles and fascia are supplied by muscular branches of practically the same nerves mentioned above. Thus the supply 306 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES of the skin over the knee-joint is from second lumbar to third sacral. Technic of Anesthesia.-The technic of producing anesthesia in and about the knee-joint will depend somewhat upon the nature of the operative procedure which is to be carried out. Resection, the reduction of complicated fractures and arthro- plasty demand a transverse block well above the joint, combined with a subdermal infiltration along the lines of incision. (Fig. 121.) Fig. 121 Fig. 122 Fig. 121.-Anesthesia of the knee. Transverse subdermal infiltration. Disten- tion of joint with anesthetic solution. (See next Fig. 122.) Fig. 122.-Anesthesia of the knee. Distention of joint with anesthetic solution. Sectional view of Fig. 121. 1, tendon of rectus femoris muscle; 2, bursa supra- patellaris; 3, femur; 4, ligamentum collaterale fibulare; 5, tendon of popliteus muscle. 6, bursa M. popliteus; 7, fibula; 8, tibia; 9, cavum articulare; 10, patella; 11, ligamentum patella; 12, bursa infrapatellaris profunda. In most of the work upon the knee-joint it is desirable to make a subdermal infiltration along the proposed line of incision and to follow this by the instillation into the joint of 30 to 60 co of the anesthetic solution. By the time the incision reaches the joint capsule, which is also a sensitive structure and requires infiltration the solution will have acted upon the sensitive joint membranes and fairly good anesthesia will result. (Fig. 122.) THE KNEE-JOINT 307 Fracture of the Patella.-Technic of Anesthesia.-In suturing a fractured patella simple infiltration carried well past the lateral limits of the patella will produce excellent anesthesia. It is neces- sary only to carry the line of infiltration above the line of fracture and the needle should strike the femur at every stroke. (Fig. 121.) In these cases the knee-joint should be distended with novocain- adrenalin solution before the operation begins (Fig. 122), as anes- thesia of the joint surfaces is desirable in case clots are to be removed. Case No. 1403 is the author's first case of fracture of patella operated upon under local anesthesia. Report of Case No. 1403. R. I). A., aged eighteen years, entered hospital January 11, 1908. Diagnosis: Transverse fracture patella-left. Operation: Incision, suture with catgut. Technic of Anesthesia: Local infiltration 0.5 per cent novocain- adrenalin solution. A direct infiltration by a series of intradermal wheals. The skin was anesthetized and incised. The incision was made through the skin and fat and the tissues infiltrated at the patient's demand. The anesthesia was reinforced repeatedly, using syringes, and with some distress to the patient. The aponeurotic tissues were united with chromic catgut and the patient made an uneventful recovery. Note.-This case was one of my early ones and in its treatment the technic of that epoch was employed. It is interesting to com- pare this technic with that described on page 308, Case No. 7623. Floating Cartilages.-The removal of loose bodies and loose cartilages allows a more simple technic, as follows: The line of incision is anesthetized in the usual manner and through the anesthetized skin a needle is introduced until it reaches the capsule of the joint. After carefully anesthetizing the capsule the needle point is carried through the capsule into the joint which is then thoroughly distended with the solution (Fig. 122). The incision may now be made, and if one does not proceed too rapidly the joint surface will be found to be anesthetized when the joint is finally opened. In the removal of loose cartilages it has been found that the posterior attachments remain sensitive and it is well after making the first incision to reinforce the anesthesia at this point before severing the cartilage. Provided both sides of the knee are to be attacked one may pass a blunt-pointed forceps transversely across the joint. This marks the area over which anesthesia is to be established on the opposite side. The incision may then be carried down to the point of the forceps where it presents. 308 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES Case No. 7623 shows the surgical management of loose cartilage of the knee-joint by an open operation under local and intra-capsular infiltration. Report of Case No. 7623. II. E. T., aged twenty-four years, entered hospital December 15, 1914. Diagnosis: Loose cartilage in knee-joint. Operation: Excision of loose cartilage. Anesthesia: Local subdermal and intracapsular infiltration. History: Upon awakening one morning three years previous to his entry into the hospital he found his left leg locked with the knee in semi-flexion, although he had been perfectly well when he retired the night before. Some swelling, and disability followed for two weeks. Since that time the limb has been weak and locks fre- quently. Technic of Anesthesia: Infiltration block, 0.5 cc of 1 per cent novocain-adrenalin solution. On December 16, 1914, patient was operated upon. lie was given morphin gr. | and scopolamin gr. T^, one hour before opera- tion. A rhomboid subdermal infiltration of novocain 0.5 of 1 per cent was made over the internal aspect of the knee. A fine needle was introduced into the joint and 60 cc of the solution were allowed to flow into the joint. The Jones incision was made, the joint capsule opened and the loose cartilage removed. 10 cc of | of 1 per cent quinine and urea hydrochloride solution were deposited in the joint at the close of the operation. Later, the patient, however, suffered severe pain and required several hypodermics during the following twenty-four hours. THE LEG. Fractures, Closed Operations.-In fractures of the leg, as in fractures elsewhere, it is well to make a transverse block well above the point of fracture and to allow considerable time to elapse before attempting reduction. Fractures about the ankle-joint as well as those of the foot may be reduced under a transverse block at a point from 5 to 10 cm. above this joint. The nerve trunks are well marked out by easily mastered landmarks, and not more than 60 or 90 cc of solution are required. The use of a rubber tourni- quet is advantageous in these cases and allows one to make the injection freely. The removal of the tourniquet should be made gradually, as its sudden removal, if made early, may be the means of allowing a considerable amount of the solution to be taken up by the circulatory system in a short period of time. This cir- 309 THE LEG cumstance may be followed by faintness, pallor and increased pulse rate in the patient. Case No. 11641 is an example of fracture of the leg reduced and immobilized painlessly by a transverse local infiltration block. Report of Case No. 11641. L. G. C., aged thirty-nine years, entered hospital August 4, 1918. Diagnosis: Fracture of the leg at the lower third. (Both bones were broken and there was great displacement.) Operation: Reduction of fracture. Anesthesia: Transverse infiltration block of leg. Technic of Anesthesia: 90 cc of 0.5 of 1 per cent novocain-adren- alin solution were injected on a line 5 cm. above the site of the fracture (Fig. 100, page 274), and in ten minutes anesthesia was complete. The leg was angulated nearly to a right angle and the fractured ends, which were only slightly oblique, were brought in contact and the leg straightened, thus overcoming the shortening. Moulded plaster splints were applied. In this case relaxation was perfect, and there was no pain. The following case will illustrate the use of conduction anes- thesia in fractures of the leg: Report of Case No. 9400. B. J. J., aged forty-nine years, entered the hospital November 7, 1916. Diagnosis: Fracture of both bones of right leg at the midpoint. Operation: Reduction of fracture, closed method. Anesthesia: Sciatic nerve block. History: Man fractured his leg in a fall a few hours previously. Technic of Anesthesia: The sciatic nerve was blocked at the gluteal fold, the needle point causing paresthesia along the course of the nerve. Fifteen cc of a 2 per cent novocain-adrenalin solution were slowly injected and anesthesia was complete in ten minutes. The fractured fragments which overlapped each other consider- ably were replaced by extension and manipulation. There was excellent relaxation and reduction was made without pain, after which a plaster-of-Paris cast was applied. Note. - In other cases, however, one may be less fortunate in reaching the sciatic, for even when this nerve trunk has apparently been injected, anesthesia has not always been complete. 310 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES SURGERY OF THE ANKLE-JOINT. (See Plates XII, XIII and Fig. 38.) Nerve Supply.-The ankle-joint is supplied by (1) an articular branch of n. tibialis (IV. V. L. I. II. III. S.); (2) articular branches of n. plantaris medialis (of tibial) (IV. V. L. I. II. III. S.) to the tarsometatarsal articulation; and (3) an articular branch of n. peroneus profundus branch of the common peroneal (IV. V. L. I. U.S.). The skin overlying the ankle-joint is supplied by (1) the n. saphenous of n. femoralis (II. III. IV. L.) on the medial side; (2) the medial and intermedia! dorsal cutaneous branches of n. per- oneus superficialis, which in turn comes from n. peroneus communis (IV. V. L. I. II. S.) and supply the dorsal and lateral surfaces of the ankle; and (3) the n. suralis which is a branch of n. tibialis (IV. V. L. I. II. III. S.) and supplies the posterior surface. Thus the nerve supply of the ankle is seen to arise primarily from the fourth lumbar to the third sacral and by terminal branches of the femoral, common peroneal and tibial, corresponding to the ulnar, median and radial of the wrist. Special Fractures.-Pott's Fracture.-Fractures in and about the ankle-joint are among the most simple to treat under local anesthesia. An infiltration block 5 to 10 cm. above the point of injury gives excellent anesthesia and relaxation. (Fig. 100, page 274.)' The following case report will serve to illustrate the application of local anesthesia in injury to the ankle-joint. Report of Case No. 7188. J. T. M., aged seventv-eight vears, entered hospital January 20, 1916. Diagnosis: Pott's fracture-left. Operation: Reduction by closed method. Anesthesia: Transverse infiltration block, 90 cc of 0.5 per cent novocain-adrenalin solution used. A transverse infiltration block was made 6 cm. above the ankle- joint. Perfect relaxation resulted and the limb was dressed with plaster in the inverted position. Note.-This patient was extremely feeble, her home was in another city, she was visiting her sister who lived in my vicinity and she had just partaken of a heavy dinner. The above pro- cedure was carried out with almost no inconvenience and the patient continued her visit without interruption. HALLUX VALGUS 311 The Cadivilla Pin.- Technic of Anesthesia.-The introduction of the Cadivilla pin is preceded by the development of an initial wheal in the skin at the point where the pin is to be inserted. Through this wheal the needle is introduced in a direction vertical to the skin surface and the tissues between the skin and the bone thoroughly infiltrated. (In case the broken fragments are to be manipulated the transverse block, page 274, Fig. 100, should be established.) This technic is then repeated upon the opposite side. The skin is then incised and a drill forced through the bone. This procedure may be as easily carried out in the home as in a hospital. In introducing a traction pin through the os calcis (Anscheutz) the same technic is employed. The drilling of the bone is not painful, provided the periosteum is anesthetized. Anesthesia should be established on both sides before drilling the bone. Fig. 123.-Anesthesia technic for bunion operation. A, B, C and D, subdermal infiltration; E, infiltration block. HALLUX VALGUS (BUNIONS). Technic of Anesthesia.-The operation for bunions or for any operation, in fact, upon this portion of the foot may, provided the 312 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES proper technic is followed, be done under local anesthesia with the greatest satisfaction. The anesthesia should be absolute. Its establishment should be painless except for the production of the primary skin wheal and there is no margin of error. The rules laid down on page 149 (Fig. 31), in relation to intradermal and sub- dermal wheals and on page 271, regarding the manner of anesthe- tizing the plantar surfaces of the hands and feet should be rigidly observed. Approximately 60 cc of a 1 per cent solution of novo- cain-adrenalin are required for each foot and the operation may be begun as soon as the injection is finished. It has been the author's practice to anesthetize both feet, beginning the operation upon the foot which was first anesthetized as soon as the anesthetic had been injected into the second foot. Figs. 123 and 124 show the technic of making the infiltration. Fig. 124.-Anesthesia technic for bunion operation. A, B, C, D and E, infil- tration block. VARICOSE VEINS OF THE LEG The sensory nerve supply (see Fig. 125) of the lower limb lends itself especially well to the production of local anesthesia for the excision of varicose veins. Fig. 126 shows a satisfactory technic for this work. A transverse infiltration is made at the upper- most point at which the vein is to be attacked and this injection should be carried down to the muscular aponeurosis. Two rows of subdermal infiltration are carried along the course of the veins to a point just above the knee and here another transverse line is made. From this point one may carry the needle subdermally and make the initial wheals from beneath and establish as many transverse lines of infiltration as may seem necessary for the per- formance of the subsequent operation. After the establishment VARICOSE VEINS OF THE LEG 313 of anesthesia above, such a high percentage of the nerve filaments will be anesthetized that infiltration below need be only moderate in amount. Fig. 125 Fig. 126 Fig. 125.-Anesthesia technic for varicose veins of the leg. Subdermal infiltra- tion and infiltration block. Fig. 126.-Sensory nerve supply of tissues involved in anesthesia for varicose veins of the leg. 1, N. lumboinguinalis; 2, V. saphena magna; 3, rami cutanei anteriores N. femoralis; 4, rami cutanei N. obturatoris; 5, rami cutanei anteriores N. femoralis; 6, V. saphena magna; 7. N. saphenus (branch of N. femoralis); 8, ramus infrapatellaris of N. saphenus; 9, rami cutanei cruris medialis of N. saphenus. 314 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES The time required is practically negligible as the injection may be made very rapidly. The author has in numerous instances performed the complete operation on both legs in less than forty minutes, including the establishment of anesthesia. The amount of solution required will depend largely upon the size of the individual. Extremely fat patients require much more than thinner ones. However, it is seldom necessary to use more than 180 cc of a 1 per cent solution, which is of course a perfectly safe procedure. Case 13903, which follows, shows the practical application of the above method. Fig. 127.-Anesthesia technic for varicose veins of the leg. Photograph of Case No. 13903 during operation. C, points to multiple incisions. Report of Case No. 13903. H. J., aged sixty-nine years, entered hospital July 19, 1920. Diagnosis: Varicose veins of both legs. Osteomyelitis of the right great toe. (Chronic.) Operation: Trendelenburg ligation and excision; amputation of toe. Anesthesia: Local infiltration using 120 cc of a 1 per cent novo- cain-adrenalin solution. The operation was done without pre- liminary medication and the veins were ligated and excised under the technic illustrated by Fig. 126. The toe was amputated under infiltration block (Fig. 124). The patient whose picture is shown in Fig. 127, ate his luncheon at the completion of the operation and showed not the slightest reaction. CHAPTER XL LOCAL ANESTHESIA IN SURGERY OF THE GENITO-URINARY SYSTEM. ANESTHESIA AND GENITO-URINARY SURGERY. Unquestionably there is a elose relation between renal function and the ability of patients to withstand surgical procedures. It is also true that patients demanding operations upon the kidney or, in fact, upon any part of the urinary tract are apt to suffer from more or less interference with renal function. It is important to meet the demands of this class of patients with every possible safeguard. The deleterious effects of ether and chloroform upon the economy of a patient with defective kidney function are well known. These patients should be compelled to carry only the lightest load possible when undergoing any surgical procedure and this becomes even more imperative when this procedure involves the urinary system. The anesthesia by inhalation which does the least amount of damage is nitrous oxide and oxygen. Nitrous oxide and oxygen alone may not offer sufficient relaxation to permit of the performance of an efficient operation without the addition of ether or local anesthesia. Nitrous oxide and oxygen combined with local is the more desirable, and local anesthesia alone has in this field one of its best opportunities to exhibit all of its advantageous qualities, provided that under its use the surgical procedure may be carried out efficiently. Having in mind the preponderance of evidence showing that the absorption of novocain does comparatively the least damage to kidney tissue, as is true of its effects upon the tissues of the other vital organs, the method of choice has been the use of local anesthesia in all genito-urinary cases in which the operation could be completed with efficiency and without distress to the patient. The observation of R. Morain1 that albumin appeared in the urine frequently after even small doses of novocain had been injected has not been confirmed to any great extent by others. The author's research in this field, carried out in a large number of cases in which novocain-adrenalin had been injected in amounts varying from 0.5 to 2 gm. showed the presence of albumin and casts only occasionally in cases which had shown normal urine before operation. 1 Zentralbl. f. Chir., Leipsic, July 10, 1921, pp. 489 504. 316 SURGERY OF THE GENITO-VRINARY SYSTEM A perusal of the literature and a fairly extensive observation of the work of other surgeons and their methods fail to reveal a great deal of enthusiasm for the use of local anesthesia in major genito-urinary surgery. The attitude shown by the authors of works upon local anesthesia has not until quite recently been such as to win many advocates to the method. The technic has now been developed to such a degree that by its use, when combined with proper strategy, almost any operation upon the genito-urinary tract may be performed under local anesthesia. The advantage of having a patient undergo an operation with a normal amount of fluid in his system, the avoidance of the deleterious effects of general anesthesia, the possibility of reducing shock, hemorrhage and trauma, are demands that can no longer be ignored if the patient is to be accorded the maximum of safety. Sacral anesthesia (Fig. 28, page 117) plus a suprapubic infiltration permit of the performance of almost any operation upon the bladder. Even transperitoneal operations upon the bladder, of whatever nature, may be carried out by means of a preliminary sacral anesthesia combined with an infiltration of the abdominal wall and an anterior splanchnic anesthesia, and may be performed in all cases in which a negative intra-abdominal pressure can be obtained. Operations upon the lower end of the ureter present the greatest difficulty. The most successful method in the author's hands has been the infiltration block of the sensory nerves supplying the peritoneum, combined with sacral anesthesia and a liberal infiltra- tion of the periureteral tissues proximal to the field of operation as dissection carefully progresses. Calculi have been removed from every portion of the ureter, resections of the base of the bladder and uretero-vesical anastomoses have been performed under this plan, generally with the production of only a small amount of discomfort. The abolition of the reflexes of the abdominal muscles, tilting of the table, steady, continuous retraction, perfect exposure and the avoidance of speed are prime essentials which favor local anesthesia. It is possible that the performance of operations upon the kidney and ureter under local anesthesia will not become common on account of the somewhat complicated technic, but the author's experience leads him to conclude that patients with crippled cardio- renal systems should, whenever possible, have the benefit of this method. LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY. Nerve Supply.-The nerves to be blocked in kidney operations are the ninth, tenth, eleventh and twelfth thoracic and the ilio- LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 317 hypogastric nerve (I, L.) to the skin and muscles (see Plate IX), plus the splanchnic nerves to the kidney. The nerves of the kidney itself are derived from the renal plexus of sympathetics which is formed by branches of the celiac plexus and ganglion, the aortic plexus and the lowest lesser splanchnic nerves. The renal plexus also communicates with the spermatic plexus, which accounts for pain referred to the testicle in some cases of kidney affection. Fig. 128.-Surgery of the kidney; anesthesia technic; subdermal infiltration; secondary wheals from beneath and intercostal infiltration block. Technic of Anesthesia.-The thoracic nerves can be easily blocked. In order to reach and effectually block the nerve supply of the kidney the drug must be administered in the proper manner; that is, it must be given in sufficient quantities and in the correct location to produce anesthesia. A squirt here and there will not 318 SURGERY OF THE GEN ITO-U RIN ARY SYSTEM suffice. Layer-by-layer infiltration will also prove tedious and disappointing. Nerve blocking near the point of exit from the spine or an infiltration-block sufficient to build a wall of anesthesia between the central nervous system and the kidney are the methods which will give most satisfaction. In either of these procedures one must use a sufficient quantity of the drug to produce anesthesia, and as the area to be blocked is a comparatively large one, a con- Fig. 129.-Surgery of the kidney; anesthesia technic; infiltration and paraverte- bral block; sectional view of Fig. 128. 1, rib XII; 2, diaphragm; 3, liver; 4, adrenal body; 5, perirenal fat; 6, kidney; 7, perirenal fat. siderable amount of the solution is required. The author employs infiltration and infiltration block and avoids spearing for nerves whenever possible. With long, fine needles the area to be blocked is gone over methodically from one end to the other, concentrating of course in the region where the nerve trunks, are known to lie. (Figs. 128 and 129.) In case it is desirable to follow the ureter down toward the bladder the skin may be anesthetized by a subdermal infiltration and the LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 319 deeper tissues by a thorough blocking of the ilioinguinal and ilio- hypogastric nerves. In case a kidney operation precedes the operation upon the ureter it is not usually necessary to reinforce the anesthetic when dealing with the ureter. The Kidney. -Sensation.-It has been found that the freeing of the pelvis and ureter is not painful, though it may be made so if the dissection is roughly done or if the anesthesia is not perfect. Likewise, the division of the fibrous capsule and paren- chyma may be made without pain. The clamping of the vessels is painful unless the splanchnics are blocked. As soon as the vessels are exposed (and this exposure should be accomplished with the utmost delicacy) an infiltration should be made in the tissues sur- rounding them. In this manner the branches of the splanchnic are reached and in a few moments good anesthesia will obtain. One should, if possible, apply the proximal clamp first when double- clamping the pedicle to avoid causing a repetition of the disagreeable sensation which may occur if complete anesthesia has not been established. The ligation of the vessels after clamping is not painful unless traction is made upon the pedicle. All sensation may be removed from the kidney pedicle by the establishment of posterior splanchnic anesthesia under the method of Kappis (see page 12). However, it has been found unnecessary to employ this technic under infiltration and a strategy which gives a good exposure, combined with splanchnic infiltration after exposure. Incision.-For kidney operations some modification of the trans- verse incision of Pean has been found the most satisfactory (Fig. 130). This incision may be extended toward the midline in front as far as one desires and curved upward from behind. In the "close-coupled" body and in those in which the kidney lies high or is difficult to deliver, the twelfth rib may be divided with bone forceps and mobilized (Fig. 131). By uncovering the rib from without and cutting only part way through it, injury to the pleura may be avoided. The incision usually begins at the outer edge of the rectus and its posterior limit is the anterior border of the ilio- costalis lumborum (sacrolumbalis muscle), but it may be carried farther backward, if desired. In the actual exposure and mobiliza- tion of the kidney the approach through the fascia and fat is made from behind. Here more novocain-adrenalin can be introduced between the lumbar muscles and the kidney, provided there is any complaint on the part of the patient. The fatty capsule is cut rather than torn and the kidney freed by clipping the retaining tissues as they are held between forceps, all of the manipulations being made directly under the eye if possible. The absence of pain will allow sufficient relaxation of the abdominal wall so that the kidney may 320 SURGERY OF THE GEN ITO-URI NARY SYSTEM be pushed forward into the abdominal cavity. Here, as in intra- peritoneal operations, perfect anesthesia will allow of relaxation of the abdominal walls and the contents of the abdominal cavity will gravitate to the opposite or lower side. This allows consider- able space in front through which the kidney may be viewed and manipulated. With the rib divided and retracted one can generally see the upper pole and slip a piece of tape about the pedicle (Fig. 131, Fig. 130.-Surgery of the kidney; incision, exposure and retraction. also see Fig. 195, page 445). Some strategy may be required in difficult cases in order to deliver the kidney without too vigorous manipulation. To illustrate the point, one might mention the comparative ease with which the densely adherent kidney, sur- rounded by perinephritic inflammatory tissue, may be mobilized by subcapsular enucleation. Stripping the fibrous capsule from the kidney instead of attempting to enucleate the complete inflammatory LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 321 mass will often convert an almost impossible situation into a com- paratively simple one. Delivery of the Kidney.-For the purpose of elevating the kidney from its bed the use of the gauze retractor (see Fig. 131) is most desirable. As soon as one pole of the kidney is freed the central point of a piece of tape or gauze may be carried beneath it. The other kidney pole may then be freed and the gauze carried beneath Fig. 131.-Surgery of the kidney; twelfth rib divided; exposure; gauze tractor in use. the second pole. One may then, by twisting the ends of the tape upon each other, absolutely control the kidney. Tension of any desired degree may be exerted upon the tape, thus giving one complete control of hemostasis. The kidney may be lifted out of its pocket by this means even though only one pole can be grasped by the tape. However, as a rule the tape may be slipped around both poles. 322 SURGERY OF THE GENITO-URIN ARY SYSTEM Report of Case No. 10221. W. W. G., male, aged fifty-five years, entered hospital January 3, 1917. Diagnosis: Left nephrolithiasis; left ureterolithiasis. Operation: Left nephrectomy and left ureterectomy. Technic of Anesthesia: Paravertebral block. Local infiltration. The patient was given two preliminary hypodermics of | gr. morphin and gr. scopolamin one and two hours respectively before operation. Paravertebral anesthesia was established from the seventh thoracic to the crest of the ilium. The transverse Pean incision was made with its anterior extremity directed downward. The twelfth rib was divided. Exposure of the kidney which had, upon preoperative investigation, been found to be functionless, showed a greatly enlarged organ, with densely adherent peri- nephritic tissue. The fibrous capsule was, therefore, divided and a subcapsular enucleation of the kidney made. By means of the gauze tractor (see Fig. 131), the vascular pedicle was exposed and splanchnic anesthesia established. The stump was then painlessly divided and a greatly thickened ureter dissected free for a distance of 15 cm. Without reinforcing the anesthesia a low muscle splitting, extraperitoneal incision was made in the region of the internal inguinal ring. The lower end of the ureter was freed, and divided below the position of the ureteral calculus, which roentgenograms had demonstrated to be present. Paraffine drains were inserted. Note.-In this case the ureter was freed nearly to the bladder attachment, without reinforcing the anesthesia, and without pain to the patient. However, the greatest care was exercised in freeing the parietal peritoneum. Report of Case No. 14572. M. W. P., aged fifty-two years, entered hospital November 19, 1921. Diagnosis: Pyonephrosis and nephrolithiasis (left). Operation: Nephrectomy. Anesthesia: Infiltration block; paravertebral block. History: The patient weighed 105 kilograms and her blood- pressure averaged 225. She was in a very septic condition, her temperature ranging from 101 ° to 103°, with a pulse from 100 to 120. Cystoscopic investigation revealed pyonephrosis and roentgen rays showed kidney stones. Anesthesia: Infiltration block, using 180 cc of a 1 per cent novo- cain-adrenalin solution. A subdermal infiltration was made first along the line of incision, which was transverse. A subdermal infiltration was then made 8 cm. lateral to the midline, extending THE VRETER 323 from the seventh rib to the ilium. This was followed by a para- vertebral infiltration block (Fig. 129, page 318). The twelfth rib was mobilized. The kidney, with fully 2 to 3 cm. of perirenal fat which was densely adherent on account of a marked perinephritis, was mobilized and elevated by means of a gauze tractor, and splanchnic anesthesia established. Three clamps were placed upon the pedicle and the kidney, which was the size of a cocoanut containing pus and a number of stones, was removed. The patient was given 2000 cc of a saline with yg- per cent novocain solution hypodermically twice a day following the operation, and she made an uneventful recovery. The following case illustrates the use of local anesthesia in acute kidney conditions: Report of Case No. 14266. M. II. I)., aged twenty-one years, entered the hospital on May 15, 1921. Diagnosis: Ruptured kidney with infected hematoma. Operation: Incision, drainage and suture of the kidney. Anesthesia: Local infiltration block. History: The patient had been injured in a motorcycle accident. He was extremely tender in the region of the left kidney and his urine showed a large amount of blood. His pulse, which was 90 upon his entrance into the hospital, rose to 115 in twelve hours. The following day his pulse was 120 and his temperature 100; he had a severe chill, and the pain in the region of the left kidney was severe. Technic of Anesthesia: A classical infiltration was made, using 150 cc of a 0.7 of 1 per cent novocain-adrenalin solution (Fig. 128, page 317). A transverse incision was made and a retroperitoneal hematoma opened and drained. One liter of dark, clotted blood and urine was evacuated. The kidney presented at the base of the cavity and showed a transverse rupture at about the midline. By means of perfect retraction, a good light and a long needle holder the two halves of the kidney were sutured together with chromicized gut without disturbing the organ. Drainage tubes were introduced and the wound closed. The boy made an uneventful recovery and presented normal urine within two weeks after the operation. THE URETER. Calculi.-The author has in a number of instances exposed the ureter under local anesthesia. The abdominal wall has been 324 SURGERY OF THE GEN ITO-URINARY SYSTEM incised after a direct infiltration plus an infiltration block well above the point at which the exposure is to be made. As soon as the peritoneum is reached it is carefully infiltrated as are the tissues behind the peritoneum in the region of the psoas muscle. The patient is tilted laterally, and by means of a negative intra- abdominal pressure, exposure is facilitated. We have removed ureteral stones from every portion of the ureter under local anes- thesia by the use of this method. Stones lying near the distal end of the ureter are most difficult to reach by this method and the attempt should be preceded by the establishment of a sacral anes- thesia. (See Case No. 10221, page 329.) In April, 1918, the author1 described a method of removing calculi from the distal end of the ureter under the use of local anesthesia, as follows: "While the exposure of the lower half of the ureter by the extra- peritoneal route for the purpose of removing calculi is generally referred to as a simple procedure, observation of a number of operations performed by surgeons of repute leads to the conclusion that this operation may, and in fact does, at times present diffi- culties which are embarrassing. This is especially true in obese patients and, more particularly, when stones are located well down toward the bladder. Within the last few months a surgeon of renown was observed to labor quite strenuously for a period of half an hour trying to locate the ureter. Bands of tissue were incised three or four times under the impression that the ureter was being opened before it was finally definitely located. This is not at all an uncommon experience. Furthermore, the manipula- tions required in order to identify and free the ureter will in many instances dislodge the offending stone, thus complicating matters and making an upward or downward chase necessary. "With the peritoneum open, there is no difficulty in locating the lower half of the ureter. With the pelvis free, one needs only to await one vermicular wave of the ureter in order definitely to locate it, and stones can usually be distinguished at a glance. It has been shown that transperitoneal cystotomy is a safe procedure. Transperitoneal ureterotomy should be equally safe. The opening of the peritoneal cavity allows one to deal with intraperitoneal pathology where indicated and, in the author's opinion, simplifies the technic. This is especially true for stones located in the lower third. " Technic.-The median incision is made just above the pubes and the pelvis is freed of intestine and carefully coffer-dammed with gauze. The vermicular wave of the ureter is watched for and the 1 Robert Emmett Farr: The Removal of Calculi from the Lower Ureter by the Transperitoneal Route, Am. Jour. Urol., April, 1918, THE URETER 325 location of the stone determined. The peritoneum is then incised mesially to the ureter and the latter elevated by the use of uterine tenacula. A urethral sound or curved forceps is then directed beneath the peritoneum external to the ureter, freeing it from the lateral wall. A stab-wound through the anterior abdominal wall is then made to meet the sound, and a cigarette drain inserted down to the ureter extraperitoneally. After the extraction of the stone and closure of the ureter the peritoneal wound is everted with catgut and the abdominal wall closed." Grave Surgical Problems.-The following cases, on account of the grave surgical problems which they presented, are reported somewhat in detail. They illustrate in a graphic manner not only the necessity of giving a crippled patient every available chance, but as well the satisfaction with which such problems may be solved by the use of local anesthesia. Report of Case No. 8229. S. J. A., aged fifty-two years, entered hospital on March 3, 1915. Diagnosis: Left ureteral lithiasis; pyoureter; pyonephrosis. First Operation: Ureterotomy (left). March 6, 1915. Roentgen- ray examination showed three shadows at the level of the anterior superior spine. The ureteral catheter showed one of these to be within the ureter. Technic of Anesthesia: Direct infiltration of abdominal wall with 120 cc of a 0.5 per cent novocain-adrenalin solution. A 15 cm. oblique incision down to the peritoneum was made. The anesthesia was reinforced here, infiltrating the peritoneum, which was then stripped inward, exposing the ureter. Two peri- ureteral calculi were removed, the ureter opened and one large cal- culus removed from its lumen. A ureteral catheter was inserted, passing upward to the kidney and the wound partially closed. The patient was allowed to return home for a month while his condition, which had been extremely bad, greatly improved. Upon his return all excretion from the left kidney was discharged through the drainage wound. An effort to reestablish the ureteral tract showed that it was impossible at this time to introduce a ureteral catheter into the left side. It was likewise impossible to pass a catheter from above through the ureter into the bladder. Second Operation: Suprapubic cystostomy, April 10, 1915. The bladder was opened under an infiltration, using 60 cc of a 0.5 per cent novocain-adrenalin solution, and the ureteral meatus was dilated. A catheter was then passed up along the ureter into the kidney and out through the suprapubic opening and the ureteral 326 SURGERY OF THE GEN ITO-URI N ARY SYSTEM sinus was allowed to close. The catheter was withdrawn in ten days and the patient remained in excellent health for fourteen months, when he began to develop pain in the left kidney and showed signs of sepsis. Cystoscopic examination showed that it was impossible to pass a catheter by the site of the former ureter- ostomy wound. The secretion from the left side at this time was almost entirely purulent in nature. Nephrectomy was therefore decided upon. Third Operation: June 1, 1916, nephro-ureterectomy. 210 cc of a 0.5 per cent novocain-adrenalin solution were used as a paraver- tebral infiltration block, and a large adherent pyonephrotic left kidney and ureter removed. The patient made a splendid recovery and has remained entirely well. Note.-This case illustrates the fact that the ureter may be operated upon under local anesthesia even under the most adverse circumstances, provided the peritoneum is infiltrated when encoun- tered, and provided the paravertebral block has been carried down sufficiently far to include the ilioinguinal and iliohypogastric nerves. Ureterectomy may be accomplished during the nephrectomy operation without especially increasing the difficulties from the anesthesia standpoint. The following case presented even greater difficulties. Report of Case No. 14391. G. J., aged fifty-nine years, maximal weight 80 kgm., present weight 56 kgm., entered hospital September 9, 1921. Diagnosis: Double hydropyo-ureter; functionless left kidney. Operations: (1) Cystostomy; (2) vesico-ureteral anastomosis; (3) nephrectomy. Anesthesia: Sacral block; local infiltration: Paravertebral block. History: Seven years ago patient began having difficulty in emptying bladder. Later he began to have increased frequency. Five years ago he visited a clinic, and a diagnosis of cystitis was made. Medicine and irrigation relieved the condition somewhat. Two months before he came under observation he began to have more difficulty in emptying the bladder, and four weeks later was once more examined, when a cystoscopic examination was made at the same clinic. A diagnosis of chronic cystitis and some disease of the sacral nerves was made. On the patient's entrance to the hospital, the bladder was found distended with urine, and was emptied by the gradual method. The prostate was not enlarged. The urine contained blood and pus. A cystoscopic examination, under sacral anesthesia, showed THE URETER 327 the following: Chronic cystitis; golf-hole ureter on the left, contracted white meatus on the right. Ureteral catheterization resulted in the withdrawal of blood and pus from both ureters. Pyelograms and ureterograms showed: Double pyonephrosis, double pyoureter. The right ureter was dilated by the simultaneous introduction of two catheters. After the first successful attempt it was found impossible to introduce an instrument of any kind into the left ureter. The patient was drowsy and uremic from the time he entered the hospital, and the phthalein output varied from day to day, averaging between 20 and 30 per cent. After dilation of the right ureter the patient improved somewhat. First Operation: Five weeks after admission. Suprapubic cystos- tomy. On October 15, 1921, a suprapubic cystostomy was done under local infiltration, which had been preceded by sacral anesthesia. The right ureter was widely dilated with a series of urethral sounds. An effort was made to enter and dilate the left ureter, but it was unsuccessful, and, on account of the patient's condition, further operative measures were not attempted. The patient's condition greatly improved. Second Operation: Vesico-ureteral anastomosis. On November 5, 1921, almost two months after entrance, the left ureter was exposed extraperitoneally under local anesthesia, and an effort made to introduce an instrument into the bladder, from above, through the ureter. This effort being unsuccessful, a dressing forceps was introduced through the cystostomy wound and made to impinge upon the bladder fundus, which was then incised and a catheter drawn through, with its end projecting through the cystostomy wound. The ureter was then opened at a favorable point above the stricture, and the upper end of the catheter inserted well into the dilated portion of the ureter. A vesico-ureteral anastomosis was thus established by anchoring the ureter to the bladder wall with chromi- cized gut. The first ureteral incision was then closed and the incision in the abdominal wall closed, after cigarette drains had been inserted. The patient rapidly recovered. The catheter was withdrawn in ten days and the suprapubic wound healed. The patient gained 16 kgm., and weighed 73 kgm. five weeks after leaving the hos- pital. On April 1, 1922, the patient began to have attacks of left-sided colic, temperature rising to 104° and accompanied by rigors. He reentered the hospital April 17, 1922. The function of the right kidney at this time was 25 per cent by the phthalein test and on April 27, 1922, was 30 per cent. His 328 SURGERY OF THE GENITO-URINARY SYSTEM intake averaged between 3200 and 3500 cc and output 2700 cc. The left kidney was practically functionless. Accordingly a left nephrectomy was performed notwithstanding the presence of a greatly crippled right kidney. Diagnosis: Double hydropyo-ureter; functionless left kidney. Third Operation: Left nephrectomy, April 27, 1922. Anesthesia: Local infiltration block, 180 cc of a 1 per cent novo- cain-adrenalin solution along the line of incision which was trans- verse, combined with paravertebral from the seventh to the twelfth thoracic. The patient received one preliminary hypodermic of morphin sulphate gr. | with 2 cc of 25 per cent magnesium sulphate. A transverse incision was made with a vertical limb posterior. The twelfth rib was divided. Excellent exposure was obtained and the kidney was mobilized by sharp dissection, splanchnic anesthesia being introduced along the pedicle under direct vision. The ureter was followed down for several inches and its stump ligated. The wound was closed with drainage. The patient had but slight reaction and the lowest intake was 2000 cc and output 1400 cc in twenty-four hours. He gained rapidly. The phthalein remained about 25 per cent, the blood chemistry was normal and he was discharged May 16, 1922. Ue now weighs 80 kgm. THE BLADDER. Cystoscopy.-The necessity for the use of anesthesia in the per- formance of cystoscopic examinations would seem to be a matter of temperament with the individual who is to carry out the pro- cedure. As a rule the suffering is not considered sufficiently great to justify the use of general anesthesia. When general anesthesia is employed the rapid excursions of the bladder to and fro resulting from respiratory efforts of the patient may render the examination more or less difficult. It is a pleasure to note that cystoscopists are experiencing a change of heart in relation to the amount of grief which these sufferers should be compelled to endure. The demand for a cystoscopic examination is in itself usually evidence that infection or some other condition which tends to increase the sensitiveness of the bladder and urethra is present in the genito- urinary tract. It is well known that the simple passage of a sound in the male urethra may cause a patient to faint. Most surgeons would not think of performing any other operation which would bring about such a result without anesthesia. Also, it is well to remember that the difficulty of making a cystoscopic examination or catheterizing of the ureters is greatly increased by the mis- behavior of a patient who is undergoing pain. In case the bladder is the seat of disease, as in the presence of cystitis, especially the THE BLADDER 329 tuberculous variety, this organ will show a high degree of irritability. Its dilatation with fluid will be difficult on account of the spasm of the bladder and abdominal rigidity and in many other ways the examination may prove difficult and greatly handicap the cystos- copist. Six years of experience with sacral anesthesia (Fig. 28, page 117) has convinced the author that its use is indi- cated in these cases, almost without exception, especially for the purpose of making the first and second examinations. After repeated examinations the bladder becomes more tolerant and a satisfactory examination may be made after the instillation of 60 cc of a 2 per cent novocain-adrenalin solution thirty to forty minutes previous to the time of examination. The ideal local conditions prevailing under a perfect sacral anesthesia make this form of anesthesia appear to the author the one of choice for cysto- scopic examinations. It is to be hoped that this method of anesthesia will be shown to be safe and that the margin of error in its establishment will decrease with further experience. Suprapubic Cystotomy.-Method of Opening Bladder.-In order to insure an added degree of comfort in all cases in which the catheter can be introduced, the opening of the bladder is preceded by a thorough irrigation and emptying of this viscus. Before the draping of the patient the bladder is therefore emptied. To the outer end of the catheter is attached a rubber tube which extends down between the limbs to the level of the patient's feet, at which point a rubber bulb is attached. As the space of Retzius is exposed the bladder may be inflated with air in order to facilitate the dissection. The added comfort to the patient which results from maintaining a dry field is much appreciated. Technic of Anesthesia.-The method described in Chapter V, page 149, should be followed. With long, fine needles the anes- thesia should be carried down to or even through the bladder wall before the incision is made. The base of the infiltrated area should be wide, going well out to either side of the bladder wall and the needle point should be carried to the pubic bone and beneath it when anesthetizing the lower end of the field. As the bladder wall is exposed it may be infiltrated, provided the anesthetic has not already reached it. The operation for the removal of vesical calculi is a simple pro- cedure under infiltration anesthesia. The following case is typical. Report of Case No. 10221. W. W. G., male, aged fifty-five years, entered hospital June 5, 1917. Diagnosis: Vesical calculus. 330 SURGERY OE THE GEN ITO-URINARY SYSTEM Operation: Suprapubic cystotomy; removal of calculus. Technic of Anesthesia: Suprapubic infiltration. No preliminary hypodermics were given. A transverse infiltra- tion, using 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution, was made. The bladder was opened after distention with air and a stone the size of a hen's egg was removed. One may remove calculi of moderate size through a suprapubic stab wound with the cystoscope as an aid, as shown in the following excerpt from The Urologic and Cutaneous Review.1 "Opinions regarding the most satisfactory manner of removing calculi from the bladder are as yet quite diversified. Small stones may be removed through the urethra, especially in the female, whose urethra may be easily dilated to a considerable size. Very large stones must be crushed or delivered through an adequate incision in the wall of the bladder. The crushing operation is not entirely satisfactory; if done without general anesthesia it is a rather severe ordeal for the patient, and, in any event, a possible nucleus may be left for the formation of new calculi in its wake, as one cannot be certain that all particles have been washed out. "On account of their great size, or because of such conditions in the bladder as diverticula, encrusted mucosa, or a state of the mucosa which renders visualization impossible, a certain per- centage of calculi demand cystotomy. There is, however, especially in the male, rather a large proportion of cases in which the stones are of moderate size and the condition of the bladder sufficiently healthy that the simple removal of the stones, without crushing, and with the minimum injury to the patient, both locally and generally, is desirable. It is for the handling of this class of cases that the following technic has been suggested. " Technic.- The patient is prepared as for cystoscopy with the addition of a suprapubic shave. About an hour before operation the bladder is irrigated, and about 2 ounces of 1 per cent novocain left in situ after a thorough emptying of the viscus. Suprapubic infiltration, including all layers of the abdominal wall and the anterior wall of the bladder, is made over an area about three inches in diameter. A cystoscope is then introduced, the bladder dilated and orientation established. A stab-wound is then made just above and as close as possible to the pubic bone. With an ordinary or stone-grasping forceps this stab-wound is dilated to the approximate size of the stone which, under the guidance of the assistant looking through the cystoscope, is easily grasped and withdrawn. The procedure is so easy and can be done so quickly, that collapse of the bladder from the escape of the fluid through the suprapubic wound 1 Robert Emmett Farr, M.D.: A Simple Method for the Removal of Moderate Size Vesical Calculi; The Urologic and Cutaneous Review, 1918, No. 5, 22. LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 331 does not occur. Should there be any delay, the fluid may be replenished with sufficient rapidity to enable one to make use of the cystoscope. "The advantages of this procedure are that it is relatively safe, relatively painless and relatively simple. It inflicts upon the patient the minimum of trauma and the period of convalescence is brief." LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY. It is the author's belief that suprapubic cystostomy as a prelimi- nary operation in the case of prostatic hypertrophy should usually be performed under local anesthesia. A simple infiltration of the abdominal wall along the proposed line of incision is all that is required as stated above. Allen and others have successfully performed prostatectomy under local anesthesia by means of an infiltration of the prostatic capsule immediately after the bladder has been opened. In establishing anesthesia of the prostatic region, Allen protects the rectal mucosa by the means of a finger inserted into the rectum. This technic necessitates the introduction of a finger into the rectum and restricts the operator to the use of one hand for the purpose of making the infiltration. The author has performed a number of prostatectomies under infiltration of the prostatic capsule, but during the past six years has made use of sacral anesthesia (see Fig. 28, page 117) as a pre- liminary to the suprapubic infiltration and has been gratified in obtaining by this method practically perfect anesthesia in every case. For a number of years narco-local anesthesia was used in combina- tion with topical applications and suprapubic infiltration. (See Case No. 7289, page 335.) The author's experience has been confined largely to the removal of the prostate through the suprapubic route and during recent years this procedure has followed the preliminary cystostomy in nearly every instance. Sacral Anesthesia.-After the introduction of from 90 to 120 cc of a 1 per cent novocain-adrenalin solution into the sacral canal (see Fig. 28, page 117), the suprapubic infiltration is made. The following description relates to the performance of a supra- pubic operation under the method that we have been using during the past six years. It has worked out very satisfactorily. Technic of Infiltration.-It is perhaps best to enlarge the bladder opening in these cases after making a circumferential infiltration according to Hackenbruch, as the tissues in the region of the 332 SURGERY OF THE GENITO-URINARY SYSTEM previously made cystostomy opening are inflamed and possibly somewhat infected. The initial wheal is made from beneath after introducing the needle through the raw surface of the preliminary cystostomy opening and carrying it along beneath the skin laterally for about 5 or 6 cm. By this maneuver and by making all additional wheals from beneath we may establish the circle of infiltration about the proposed incision without producing pain. The patient is placed in a moderate Trendelenburg position and wire-spring retractors are inserted into the wound in the bladder, which should be of sufficient size to allow a perfect view of the interior of the bladder. A negative intra-abdominal pressure will allow the bladder to dilate to its full capacity and good illumination will bring about the visualization of the field. In not a single case has there been the slightest sensation of pain during the removal of the gland. It is desirable in these cases to avoid the introduction of the finger into the rectum and, in order to obviate the necessity of using the rectal finger, the prostatic retractor (Fig. 18, page 106) has been devised. Figs. 132 and 133 illustrate the modus operandi of this instrument. The dissection may be carried out without making great traction, provided the gland is gently elevated. Long, curved scissors are used in the enucleation. The anterior portion of the gland is best freed by an elevator (Fig. 21, page 108) or by the use of the index finger. Following this technic no case has shown a pulse-rate above 90 while upon the operating table and, as a rule, the pulse has remained at about 70 throughout the operation. Prostatic Retractor.-The following is the author's description of the prostatic retractor which appeared in Surgery, Gynecology and Obstetrics, in November, 1920: "The first manipulation of a surgeon when doing a suprapubic prostatectomy is to place one, or more often two, fingers of one hand in the rectum in order to aid the enucleating finger of the other. There is no question but that asepsis is more easily preserved and the technic of the operation more refined when the rectal manipulation is eliminated. In addition to this factor, the rectal dilatation markedly interferes with a smooth anesthesia. If general anes- thesia is used, a deeper narcosis is necessary upon dilating the sphincter. Under local anesthesia the introduction of the fingers into the rectum is a serious handicap. "The instrument which the author has devised will effectually do all and even more than the rectal finger can do, thus eliminating the necessity of the latter. "The prostatic retractor, closed (Fig. 132), is introduced into the internal urethra for a distance depending upon the approximate 333 LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY size of the prostate. The prongs are then opened (Fig. 133), taking hold in the gland tissue, by turning the circular top of the instru- ment. " The accompanying figures demonstrate clearly the modus oper- andi of the retractor. With it in place the prostate may be elevated Fig. 132.-Surgery of the prostate; application of prostatic retractor closed; instrument introduced into urethra. to any degree that is compatible with its mobility, and the enucleation can be made largely under direct vision. Scissors dissection, done directly under the eye, may be advantageously used to expose one- half or two-thirds of the gland, after which the remaining portion may be freed by the enucleating finger or hook (Fig. 21, page 108). 334 SURGERY OF THE GEN ITO-U RIN ARY SYSTEM "Further experience may show that the prongs of the instrument may need to be modified as regards their size and shape. However, Fig. 133.-Surgery of the prostate; application of prostatic retractor; retractor open and elevating prostate. LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 335 the first model has proved very satisfactory and has greatly facilitated operations which have been done entirely under local anesthesia." In the following case, infiltration of the peri-prostatic tissues was necessary in addition to narco- and topical anesthesia as no preliminary sacral anesthesia had been established. Report of Case No. 8936. L. N., aged seventy-three years, entered the hospital December 14, 1915. Diagnosis: Prostatic hypertrophy. Anesthesia: Local infiltration and narco-local. History: Had had frequent urination continuously for the past five years, and had had several attacks of retention of urine, for which he had been catheterized. Rectal examination showed a rather large, hard and somewhat nodular prostate. First Operation: Suprapubic cystostomy was made under an infiltration of quinine and urea hydrochloride, using | of 1 per cent solution. Eleven days later a prostatectomy was performed. Patient was given | gr. morphin and gr. scopolamin two hours before and the dose repeated one hour before the operation. Second Operation: Prostatectomy. Anesthesia was narco-local and infiltration of prostatic capsule, using quinine and urea hydro- chloride | of 1 per cent. The prostatic capsule was infiltrated and the enucleation of the gland was begun. The patient complained of pain and novocain-adrenalin solution was then injected to reinforce the anesthesia. The prostate was removed with difficulty, although without pain to the patient after the injection of the novocain-adrenalin solution. Microscopic examination showed the gland to be adenocarcinoma. Note.-In this case both the introduction of the quinine and urea hydrochloride solution and manipulation of the gland were painful. Relief was almost instantaneous after the use of novocain-adrenalin solution was begun. The following case is one in which the narco-local method, combined with topical application and infiltration, was used. This was before sacral anesthesia had been adopted as an adjunct. Report of Case No. 7289. B. F. M., male, aged sixty-six years, entered hospital April 20, 1914. 336 SURGERY OF THE GENITO-URINARY SYSTEM Diagnosis: Prostatic hypertrophy; residual urine 400 cc, cathe- terized four times a day for two weeks when suprapubic prosta- tectomy was performed. Operation: Prostatectomy. Technic of Anesthesia: Narco-local anesthesia. Suprapubic infil- tration with novocain-adrenalin solution, using 60 cc of a 0.5 of 1 per cent novocain-adrenalin solution. One hour before operation 120 cc of a 10 per cent quinine and urea hydrochloride solution had been deposited in the bladder. A hypodermic of | gr. of pantopon and scopolamin was given three hours, and again one hour before operation. No infiltration of periprostatic tissues was done. The patient was extremely drowsy. There was no resistance and patient showed no signs of pain throughout the operation, the opportunity for which was perfect in every respect. A few hours after operation the patient withdrew the catheter, left the bed and walked about the room, without any apparent ill effects. This is one of the pos- sible objections to narco-local anesthesia. The following case shows the application of the method in extreme old age. Report of Case No. 10929. G. G. O., male, aged eighty years, entered hospital July 5, 1917. Diagnosis: Hypertrophy of the prostate gland. Anesthesia: Local infiltration block, sacral block. History: For a number of years patient has had intermittent attacks of retention of urine. The urethra admits a soft catheter and the residual urine is 300 cc. First Operation: Suprapubic cystostomy. Technic of Anesthesia: A classical infiltration block was made using 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution. The bladder was opened with a negative pressure. Prostate was seen to project into the bladder on account of a greatly enlarged central lobe. Above the prostate was a well-marked diverticulum. The patient made a splendid recovery from his drainage operation and on July 19, twelve days after the preliminary cystostomy, supra- pubic prostatectomy was performed. Preliminary sacral anesthesia was established using 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution. The classical supra- pubic infiltration was then made with 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution. The prostate was large in this case, and projected well into the bladder. It was removed by scissors dissection, being elevated by the use of the prostatic retractor. The highest pulse-rate recorded for this patient before, during and after the operation was LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 337 88. lie returned home in three weeks after the operation and remained well until four years later, when he began to suffer excru- ciating pain in the bladder, with frequent urination, pyuria and delirium. Third Operation: Cystoscopy and suprapubic cystostomy with removal of vesical calculus. The cystoscopy was made under sacral anesthesia April 22, 1921, 90 cc of a 0.5 per cent novocain-adrenalin solution being used. At this time the patient was desperately ill, and the urine was loaded with pus. Cystoscopy showed a large vesical calculus, and the roentgenogram showed two calculi of approximately the same size as the one seen through the cystoscope. On April 28, 120 cc of a 0.5 per cent novocain-adrenalin solution was injected into the sacral canal. Foilowing the introduction of this solution the patient had a slight convulsion, the pupils becoming dilated and respirations became rapid. The pulse did not change perceptibly. Supra- pubic infiltration was made about the old scar and the bladder opened. A dumb-bell stone was removed, one end of which pre- sented in the bladder, while the other end w'as encased in a divertic- ulum. The bladder was quickly packed and drained and the neck of the diverticulum dilated, and although the patient was delirious for three weeks he finally made a satisfactory recovery. The following case illustrates the use of local anesthesia in debilitated individuals where the margin of safety is extremely small. Report of Case No. 14505. C. W., male, aged seventy-seven years, entered the hospital September 28, 1921. Diagnosis: Prostatic hypertrophy. Anesthesia: Local infiltration; sacral block. History: The patient was delirious. There was residual urine to the amount of 800 cc. His liquid intake was 3500 cc and his output 2500 cc. The bladder was emptied gradually. One week after entering the hospital his blood chemistry showed urea nitrogen 36.4 mgm. per 100 cc, creatinine, 3.06 mgm. per 100 cc and sugar, 0.11 per cent. His phthalein ranged between 24 and 40 per cent total for two hours. After nine days of intermittent catheterization a suprapubic cystostomy was performed. Following this operation his phthalein output remained around 40 per cent total for two hours. His intake was 3000 cc and his output 2500 cc. One week after the performance of the suprapubic cystostomy the patient became decidedly worse. His intake was 4200 cc and his output 1200. He was delirious. Three days later his intake was once more 3500 338 SURGERY OF THE GENITO-URINARY SYSTEM cc and his output 2500. He was drowsy most of the time. Two weeks after the suprapubic cystostomy he began to improve, and sixteen days after the operation he sat up in a chair. One month after the operation his intake averaged 3600 cc per day and his out- put 3100 cc. He had gained greatly in strength. His phthalein total output for two hours averaged 50 per cent. Technic of Anesthesia, First Operation: Local suprapubic infiltra- tion. Technic of Anesthesia, Second Operation: Sacral and infiltration, using 90 cc of a 1 per cent novocain-adrenalin solution. The bladder was opened through a vertical incision. The prostate was large and smooth. It was elevated by means of the prostatic retractor (see Figs. 132 and 133, pages 333 and 334). Although the gland was smooth, malignant disease was suspected because of the difficulty of removal. At the close of the operation the patient's pulse was seventy. One-half hour after returning him to bed he had a severe chill. His urinary output the following twenty-four hours was 750 cc. The second twenty-four hours his urinary output was 2000 cc and his intake 3500 cc. A note shows that the patient's condition on the second day was as before the operation. He sat up on the seventh postoperative day and made an uneventful recovery. Microscopic diagnosis, adenocarcinoma. PERINEAL PROSTATECTOMY. ABSCESS. Perineal prostatectomy may be done under a direct infiltration plus blocking of the pudic nerves or under sacral or parasacral anesthesia. Prostatic abscesses and suppurative infections of the seminal vesicles demand sacral, parasacral or general anesthesia. These patients are apt to be hypersensitive and apprehensive and the psychic factor plays a larger part in them than it does in cases where infection is not present. THE MALE URETHRA. Stricture.-Sacral anesthesia is the ideal anesthesia for operative work upon the urethra. Under its influence internal or external urethrotomies or dilatations may be performed. The instillation of solutions of novocain-adrenalin 2 to 4 per cent into the urethra will, if retained for a period of thirty minutes, offer sufficient anesthesia for the passage of sounds and the urethro- scope or even the cystoscope in cases in which the bladder is not too sensitive, as the result of disease. In urethral strictures sacral is perhaps the most satisfactory method by which anesthesia may be established, THE MALE URETHRA 339 Report of Case No. 12048. J. L., physician, aged forty-six years, entered hospital May 10, 1919. Diagnosis: Multiple urethral strictures. Operation: Urethral dilatation. History: The patient complained of retention of urine. The urethra presented multiple strictures and filiforms were introduced with difficulty. Technic of Anesthesia: Sacral injection. A gradual dilatation was done after 30 cc of a 1 per cent novocain- adrenalin solution had been injected into the sacral canal. Fili- form bougies were introduced and a hollow sound was passed over one of these. The urethra was dilated up to No. 30, French scale, but the anesthesia would not permit of further increase. Six days later 45 cc of a 1 per cent novocain-adrenalin solution were intro- duced into the sacral canal and twenty minutes later the urethra was dilated to No. 32 French scale. The sound could be introduced only to the membranous portion. The patient was advised to have an external urethrotomy, but he asked to come in later for this operation. On July 7, 1919, he reentered the hospital, when 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution were injected into the sacral canal. This time a filiform bougie was passed into the bladder and the Otis dilator was passed over this guide. The stricture was dilated to No. 47 French scale. Sounds were then passed until the urethra admitted a No. 29 without difficulty. The anesthesia was ideal. On July 21, 1919, the patient refused to allow the passage of sounds because of the severe pain the attempt caused, and sacral anesthesia was once more administered. 75 cc of a 0.5 of 1 per cent novocain-adrenalin solution were used, and the urethra was dilated up to No. 30 French scale. The anesthesia was excellent. Note.- This patient, an intelligent physician, after his first experience insisted upon having sacral anesthesia established before submitting to further dilatations. We have occasionally found that anesthesia has been incomplete after using this technic, but generally when less than 60 cc of the novocain-adrenalin solution had been used. Report of Case No. 11334. S. G. M., aged nineteen years, entered the hospital February 5, 1918. Diagnosis; Congenital urethral stricture, 340 SURGERY OF THE GENITO-URINARY SYSTEM Operation: Dilatation of urethra. Anesthesia: Sacral block. History: For the last four years he had had difficulty in voiding. Frequent attempts to pass sounds had been unsuccessful. A diagnosis of urethral stricture (congenital) was made. Technic of Anesthesia: 60 cc of a 1 per cent novocain-adrenalin solution were injected into the sacral canal, which was entered by the needle without difficulty. After twenty minutes' anesthesia was still incomplete, but the patient submitted to a dilatation with the Otis dilator, which had been passed over a urethral bougie. This procedure caused him considerable pain. One week later 90 cc of a 1 per cent novocain-adrenalin solution were injected into the sacral canal and numerous attempts were made to sound the urethra. The anesthesia was incomplete up to one hour, at which time a No. 30 French sound was introduced, with but slight pain to the patient. Fig. 134.-Circumcision; anesthesia technic. Proximal circumferential block. Fig. 135.-Circumcision; anes- thesia technic. Longitudinal infil- tration. THE PENIS Nerve Supply.-The penis is supplied by the right and left nn. dorsalis penis, the deepest divisions of the pudendal nerve, arising from the second, third and fourth sacral nerves and the pudendal plexus (see Plate XIV); and by the ilioinguinal nerve (first lumbar) which supplies the root of the penis, THE PENIS 341 Circumcision.-The extremely sensitive areas are the frenum and the glans. One may make a local infiltration or a transverse block, as desired. We have employed both the direct infiltration in the region of the foreskin and the infiltration block at the base. Infiltration of the foreskin has proven satisfactory. The initial wheal is made near the base of the penis, the needle point carried distally beneath the skin and the foreskin "ballooned up" with the anesthetic solution (see Figs. 134 and 135). Adrenalin is withheld from these solutions and the "ballooning" of the foreskin renders the operation more simple than it would otherwise be. The vessels may be plainly seen and ligated, and the structures are so magnified that the introduction of sutures is facilitated. Amputation of the Penis for Malignant Disease.-The technic described in producing anesthesia for the operation for oblique inguinal hernia made bilaterally, with the addition of the blocking of the femoral on each side, will suffice for a complete dissection of the inguinal glands, and the additional blocking of the pudic branches will suffice for the amputation of the penis. (See Fig. 171, page 404.) Hypospadias.-This operation may be performed under a trans- verse blocking at the base of the penis with the addition of a sub- dermal injection of the scrotal wall, provided portions of this tissue are to be used in making the plastic. Varicocele.-The nerves involved in the operation for variocele are those lying over the region of the spermatic cord. The skin over this region is supplied by: (1) The lumboinguinal nerve (n. lumboinguinalis; femoral or crural branch of the genito- femoral) (I. II. L.) and the ilioinguinal nerve (n. ilioinguinalis) (I. L.) which supplies the skin of the thigh immediately below the ilioinguinal ligament. (2) The anterior cutaneous branch or hypo- gastric branch of the iliohypogastric nerve (n. iliohypogastricus) (I. L.), and the anterior division of the twelfth thoracic nerve supplying the hypogastric region above the ligament. (See Fig. 160, page 380.) The spermatic cord is supplied by the external spermatic nerve (n. spermaticus externus) or genital branch of the genitofemoral (I. II. L.) which supplies the cremaster. The spermatic plexus from the sympathetic and pelvic plexuses as well as the genital branch of the genitofemoral are found in the cord. Skin Sterilization.-Operations in this region demand much care in the sterilization of the skin. It would seem to be preferable to make the skin incision above the base of the scrotum whenever possible. Irritating solutions should not be allowed to come in contact with the unanesthetized scrotal integument. Should it be 342 SURGERY OF THE GEN ITO-URI NARY SYSTEM necessary to sterilize the scrotum it is well to use solutions that are non-irritating or to follow the plan suggested in Chapter XIV under the description of the operation for inguinal hernia. In this manner the scrotum may be anesthetized before being sterilized. Technic of Infiltration.-A subdermal infiltration is made along the line of the proposed incision (Fig. 136). The injection is then carried down to the cord at the point where it emerges from the external inguinal canal. About 60 cc of solution are introduced, care being taken to keep the needle point constantly in motion. Vertical retraction during the making of the incision and exposure Fig. 136.-Varicocele; anesthesia technic; subdermal infiltration. Fig. 137.-Varicocele; anesthesia technic; blocking of genitofemoral branch. will serve to easily identify the tissues. As the cord appears anesthesia may be reinforced, otherwise manipulation may cause the patient discomfort (Fig. 137). Hydrocele.-Orchidectomy.-Vasectomy.-The sensory nerves in addition to those mentioned under "Varicocele" which are involved in a hydrocele are as follows (see Fig. 138, also Fig. 160, page 380): Those of the scrotum are derived from: 1. The ilioinguinal nerve (n. ilioinguinalis) (I. L.), supplying the upper part of the scrotum. 2. The external spermatic nerve (n. spermaticus externus), a THE PENIS 343 branch of the genitofemoral (I. II. L.), supplying a small part of the scrotum. 3. The posterior scrotal branches (nn. scrotales posteriores) of the perineal nerve (n. perinei) which are terminations of the pudendal nerve (II. III. IV. S.), and are also called the superficial peroneal nerves. (See Fig. 138.) 4. The inferior pudendal branch (long scrotal nerve) of the posterior femoral cutaneous nerve (n. cutaneus femoralis posterior) (I. II. III. S.). Fig. 138.-Nerve supply of male perineum, scrotum and penis. Technic in Infiltration.-For this operation a subdermal injection is made along the line of the proposed incision and from this line is carried around the neck of the scrotum to a point well past the midline both on the anterior and posterior surfaces (Fig. 139). As soon as the sac is identified it is well to make a thorough infiltration near its neck and as soon as the cord is seen one may inject the spermatic plexus from the sympathetic and the filaments from the pelvic plexus as they course along with the cord. It has also been suggested that the injection into the sac of a few drops of con- centrated novocain solution might be desirable, as a preliminary, but the author has not found this technic necessary in his work. 344 SURGERY OF THE GEN ITO-URINARY SYSTEM All operations upon the scrotum, such as orchidectomy, vasectomy and the like, may be performed under this technic. Vasotomy.-Vasotomy may be done under a simple skin infiltra- tion along the scrotal wall at the appropriate point. The vas may be identified before or after anesthetizing the scrotal wall and brought to the surface by grasping it with the thumb and finger. A small amount of solution injected above the point at which the vas is to be opened will give one sufficient anesthesia for this opera- tion (Fig. 137). Fig. 139.-Hydrocele; anesthesia technic; subdermal infiltration. THE FEMALE GENITALIA (EXTERNAL) Nerve Supply.-The nerve supply to the external female genitalia, vagina and cervix is as follows (Fig. 141): The labia are supplied by the ilioinguinal (I. L.) and the posterior labial branches (nn. labiales posteriores; superficial peroneal nerves) of the perineal nerve (n. perinei), in turn coming from the pudendal nerve (II. III. IV. S.). rriie clitoris is supplied by n. dorsalis clitoridis, one of the deepest divisions of the pudendal nerve. THE FEMALE GENITALIA 345 The vagina is supplied by the visceral branches from the third and fourth and sometimes the second sacral nerves communicating with the plexuses of the sympathetic (vaginal plexus), which is a part of the hypogastric plexus. The levator ani is supplied by muscular branches of the fourth sacral nerves. The cervix is supplied by the hypogastric and ovarian plexuses and by branches from the third and fourth sacral nerves. Fig. 140.-Nerve supply of rectum and female perineum. General Considerations.-Methods of Obtaining Anesthesia.- The nerve supply (Fig. 140), with the exception of the hypogastric plexus, may be interrupted by the induction of sacral anesthesia, or by conduction anesthesia along the course of the nerves. Excel- lent anesthesia may be obtained by either method. Infiltration block, combined with direct infiltration, is perhaps the method of choice. The upper portion of the vagina and the uterus demand additional anesthesia and the infiltration of the tissues is all that is required. In case the dissection is carried extremely high when performing a perineorrhaphy one may expect complaint provided only the pudic nerves have been intercepted, and this should be anticipated and the anesthesia reinforced before causing the patient 346 SURGERY OF THE GEN ITO-URIE ARY SYSTEM pain. All work upon the uterus demands a circumferential block about the cervix and extending well up into the broad ligaments. A preliminary infiltration using a colored solution before opening the abdomen will give one much aid and one's technic may be improved rapidly by this means. Sacral, parasacral or trans- sacral anesthesia are also entirely satisfactory for operations upon the female genitalia. The author prefers infiltration and infiltration block on account of the speed and simplicity with which it may be established, and it also admits but slight error. Fig. 141.-Lithotomy position. Comfort equipment of operating table, showing pillows, legholders and armholders. Insert: Shows patient draped; pneumatic injector in position; cut-off B hanging on special forceps. (See Fig. 142.) Psychic Considerations.-In performing surgical operations upon the female genitalia psychic considerations must assume an impor- tant role. In no other class of operations is the surgeon called upon to depart so radically from the routine commonly seen in hospital practice where patients are being operated upon while unconscious under general anesthesia. While the custom which prevails may perhaps be considered acceptable where general anesthesia is used, the use of local anesthesia demands the utmost vigilance in respect to shielding the patient from all unnecessary indignities which may 347 THE FEMALE GENITALIA result from careless manipulations or needless exposure. Bodily comfort is a prime essential. (Fig. 141.) Fig. 142 shows the cut- off-holding forceps (see Fig. 141 B). While the establishment of local anesthesia is not difficult, the carrying out of any operative procedure upon the external genitalia of the female demands more than the simple prevention of pain. It requires the development of a system in relation to the care and management of these cases that will offer sufficient reassurance to Fig. 142.-Special hook forceps upon which cut-off is hung. (See Fig. 141, B.) overcome the normal and natural apprehension inherent in most women under such circumstances. Minute attention to detail and the careful exclusion of all sources of error in carrying out a properly established regime is absolutely essential. Attention to the various points enumerated on page 346 and Chapters III, page 69, and V, page 135, applies here with special emphasis. Careful covering of the eyes, prevention of unnecessary exposure, the elimination of unnecessary noise, especially the prohibition of conversation on the part of visitors who may be present and the constant reassurances of a tactful psycho-anesthetist will usually suffice to reduce to a minimum the so-called psychic incompatibility which may be present in these cases. 348 SURGERY OF THE GENITO-URlNARY SYSTEM The precautions detailed have not been suggested as a result of any untoward experience by the author, as in his hands local anesthesia has, as a rule, been more readily accepted by women than by men. It would seem, however, that too much care could not be exercised in offering these individuals every possible safeguard to the inherent modesty present in all normal women. Vaginal Examinations in Virgins.-Anesthesia for vaginal examina- tions and uterine or cervical operations in virgins or sensitive women who have not borne children, should be preceded by an infiltration of the labia laterally and of the posterior vaginal margin. In these individuals the introduction of instruments into the vagina and the dilatation of this organ for the purpose of exposing the cervix are usually the cause of considerable complaint which may be obviated in the above mentioned manner. A preliminary establishment of anesthesia of the perineum will allow, and in fact produce, a satis- factory dilatation of the vagina, so that the work upon the cervix or uterus may be carried on without embarrassment. This simple procedure will allow a vaginal examination to be made without discomfort and should an operation prove necessary it may be carried out at once without the necessity of repeating the anesthesia. A great deal of vaginal work must be performed in conjunction with and preliminary to abdominal work, and here the method has considerable advantage. The delay necessary in making prepara- tion for the abdominal operation always necessitates prolonging general anesthesia and time becomes a more or less important factor. Where novocain is used the element of time is relatively unimportant inasmuch as the patient is not inhaling an anesthetic during the period of preparation. While it is possible for a skilled anesthetist to reduce the amount of general anesthesia greatly during this period, the fact remains that but a comparatively small percentage of patients who are being operated upon today receive the benefit of such skill. The operations which present in this region are those upon the labia, clitoris, perineum, urethra, vaginal wall, cervix and uterus. Operations upon the Labia. -Cysts.-Neoplasms.-Abscesses. The Nerve Supply.-The nerve supply to the labia is derived from the ilioinguinal (n. ilioinguinalis) I. L.) anteriorly, and the posterior labial branches (nn. labiales posteriores; superficial peroneal nerves (II. III. IV. S.) of the pudendal nerve posteriorly (Fig. 140, page 345.) Technic of Anesthesia.-All operations upon the labia may be performed under direct infiltration or infiltration block. Labial cysts and other tumors, in the absence of malignancy, may be 349 THE FEMALE GENITALIA isolated from their nerve supply by an infiltration block. Cysts and abscesses of the glands of Bartholin may be incised or excised under an infiltration block, although in the presence of infection the use of sacral anesthesia may be desirable. Malignant disease of the labia, unless very limited in extent, is best carried out under the influence of sacral anesthesia. Careful attention should be paid to points detailed above, as this region demands special care in the prevention of pain and exposure. Operations upon the Clitoris. -The Nerve Supply.-The nerve supply of the clitoris is derived from n. dorsalis clitoridis, one of the deepest divisions of n. pudendus (II. III. IV. S.). This organ is extremely sensitive, and demands the most careful interruption of its nerve supply, provided its sensation is to be obtunded. The treatment of malignant disease here, as well as in the labia, unless very limited in extent, is best carried out under the influence of sacral anesthesia combined with infiltration block, described above. Operations upon the Perineum.-The Nerve Supply of the Peri- neum.-The perineum is supplied by the pudendal nerve and branches of the anococcygeal nerves (nn. anococcygei) (VI. V. S. 1 Coccygeal), (Fig. 140, page 345). Perineorrhaphy.-Technic of Anesthesia.-The nerve supply of the perineum being so easily reached makes the anesthetization of this structure a simple procedure. The infiltration block should be wide and extensive. The technic for the establishment of local infiltration which permits of perineal repair is as follows: Infiltration Block.-An initial wheal is made just within the vaginal margin (Fig. 143), the needle point entering the vaginal mucosa as this area is not especially sensitive. From this point the needle is carried alternately beneath the mucosa of the respective labii to a point near the clitoris, a submucosal infiltration being made, (Fig. 144, A). The needle is now introduced through secondary wheals which have been made in the mucosa from beneath, at points lateral to the vaginal outlet (Fig. 144, B and B'). The tissues are infiltrated as the needle advances. The triangular ligament is pierced as may be determined by its feeling of resistance, as well as by the fact that it is slightly sensitive and may elicit a complaint from the patient. Just beyond the triangular ligament a liberal supply of fluid is deposited, the needle being withdrawn and reintroduced in a slightly different direction until an area approximately the size of a walnut has been thoroughly edematized. This procedure is repeated on the opposite side. The anesthesia resulting from this injection is sufficient to permit of the most extensive plastic opera- tion one may be called upon to perform in this region. Complete 350 SURGERY OF THE GEN ITO-URINARY SYSTEM Fig. 143.-The perineum; anesthesia technic; initial wheal. Fig. 144.-The perineum; anesthesia technic; A, labial and subdermal infiltration; B and B', points for blocking the pudic nerve, THE FEMALE GENITALIA 351 lacerations demand that an additional infiltration be made external and posterior to the rectum. As an aid to the separation of the vaginal mucous membrane a fairly extensive infiltration may be made between the vaginal and rectal walls, "ballooning" up the septum if one so desires (Fig. 145). This technic has certain points of advantage. The tissues are rendered thicker and thus more distinct, and the vaginal and rectal walls are separated and hemos- tasis is abetted. Any type of operation may be performed and the anesthesia, provided it is insufficient, may be reinforced without stint. There are two stages of the operation during which reinforcement is most Fig. 145.-The perineum; anesthesia technic. "Blowing off" or separating vaginal from rectal mucosa, wire-spring retractor separates labia. apt to be required; first, when an extremely high separation of the vaginal mucosa along the anterior rectal wall brings one in contact with the higher group of nerves which supply this region-the hypogastric plexus-and which have not been reached by the original infiltration. Direct infiltration just beneath the vaginal mucosa is all that is required to meet this contingency. The second stage at which reinforcement may be required is during the application of the widest of the tension sutures which coapt the separated portions of the levator ani. An infiltration made external to the highest point at which the sutures are carried through the levator ani will result in complete and satisfactory anesthesia. Any 352 SURGERY OF THE GENITO-URINARY SYSTEM edematization which may have been produced by the infiltration will have disappeared sufficiently early so as not to interfere with the introduction of sutures and the completion of the operation. Operations upon the Cervix and Uterus.- Curettage. The Nerve Supply.-The uterine cervix is supplied by the hypogastric and ovarian plexuses and by branches from the third and fourth sacral nerves. Technic of Anesthesia.-Sacral, parasacral, trans-sacral anesthesia, or infiltration block may be employed. Fig. 146.-Vaginal dilatation after anesthetizing. A and B, wire-spring retractors. Infiltration Block.-Here, as elsewhere, the main difficulty presents in obtaining exposure. A good position on the table, perfect light, good anesthesia of the vaginal outlet and intelligent retraction are essential aids in obtaining this exposure (Fig. 146). The cooperation of the patient may also be enlisted. The patient may be asked to raise the hips slightly, or to cough or strain, thus bringing the cervix into view. A long handled hook, or a Barrett tenaculum (Fig. 147), may be introduced without discomfort, and by its use the cervix may be deflected from one side to the other, bringing the various sulci into view. The cervix may be best anesthetized by a circumferential infiltration (Figs. 147 and 148), THE FEMALE GENITALIA 353 Provided intrauterine work is to be done the infiltrating needle should pass well up laterally to the uterus, and approximately 30 cc of solution should be deposited in each broad ligament at a depth of 2 to 4 cm. Under this anesthesia dilatation, amputation of the cervix and intrauterine operations may be carried out. Fig. 147.-The cervix and uterus. Anes- thesia technic. Pericervical and broad ligament-infiltration block. Fig. 148.-Vaginal anesthesia. Infil- tration of the anterior vaginal wall. This case below is cited to show the application of local anesthesia in cases of retained placenta where the patient had become exsangui- nated : Report of Case No. 10036. L. C. G., female, aged thirty-three years, entered hospital August 28, 1917. Diagnosis: Incomplete abortion. Secondary anemia. Anesthesia: Local infiltration. Operation: Removal of secundines. History: There had been an accidental abortion one week pre- viously, and the patient had been bleeding profusely ever since. Her hemoglobin was 42 per cent; she was extremely pale and her condition seemed hazardous. She fainted repeatedly before being taken to the operating room. Anesthesia: 40 cc of a 0.5 per cent novocain-adrenalin solution was used and a circular infiltration was made about the cervix which was large and edematous. After gentle dilatation the uterus was curetted with gauze upon 354 SURGERY OF THE GEN ITO-URINARY SYSTEM the end of a dressing forceps. A large amount of material was scraped out. The operation under this technic was entirely painless and the patient made an uneventful recovery. Anterior Colporrhaphy. - Technic of Anesthesia. -This operation may be performed after making a rhomboid submucous infiltration (Fig. 148), and is facilitated by the "blowing up" process, or the depositing of an excessive amount of solution between the vaginal and bladder walls, a method similar to that described for peri- neorrhaphy (Fig. 145, page 351). When making this infiltration the needle point should be carried well laterally and should be directed posteriorly and away from the bladder wall. The Uterus.-Interposition Operation. Infiltration Block. Ordi- narily the cervix may be grasped without producing pain. How- ever, many patients do complain of pain when this procedure is attempted. It has, therefore, been my practice to produce a wheal before the cervix is grasped by the tenaculum. A good exposure will allow this. The technic for rendering the cervix and the uterine mucosa anesthetic is as follows: With a 10 cm. needle, a wheal is made to the right or left of the cervix (Fig. 147). The needle is then advanced from 3 to 5 cm. parallel to the midline of the uterus, or diverging somewhat, traction being made on the cervix the while. As the needle is withdrawn the fluid is allowed to escape into the parametrium. The direction of the needle is changed with each stroke and an effort is made to inject the tissues to each side of the uterus, 20 to 30 cc of solution being used. This procedure is repeated on the opposite side, when dilatation of the cervix may be accomplished. For operations on the cervix, exclusive of malignant disease, a ring of infiltration is made around the cervix in the vaginal vault, this infiltration being allowed to extend well into the tissues about the cervix throughout the entire circumference. Anesthesia. - The satisfactory performance of this operation under local anesthesia requires good anesthesia of the perineum and anterior vaginal wall and this may be obtained by the methods described on page 353; with the addition of a liberal infiltration between the cervix and bladder. The needle should be carried well up along the posterior bladder wall, reaching the peritoneum in this region. An excellent exposure is a prerequisite for the performance of this operation under local anesthesia. The only pain associated with its performance occurs when the uterus is delivered and traction is made upon the round ligaments. While able to prevent most of this pain by preceding the operation with a wide infiltration between the uterus and bladder one may be unable to prevent all the pain caused by traction upon the round ligaments THE FEMALE GENITALIA 355 at the time the uterus is being delivered. It is possible to block the round ligaments directly as they are brought into view, but thus far a means has not been developed by which they can be anesthetized before delivering the uterus. It would seem that one might block these structures from above by introducing the needle through the external inguinal canal, depositing a liberal supply of solution in the region where the round ligament emerges from the abdominal cavity. The uterus is best delivered by depressing the cervix into the hollow of the sacrum and applying small cat's paw retractors, "hand-over-hand," to the fundus of the uterus. Some strategy is required in order to carry out this procedure under local anesthesia but experience with more than a score of these cases with but a small amount of difficulty leads to the belief that a technic will soon be developed by which this operation will be performed with facility and dispatch under simple infiltration anesthesia. Under sacral, trans-sacral or parasacral anesthesia, the operation may also be performed with satisfaction. However, should it be found possible to establish the direct infiltration upon a practicable basis this would eliminate the more or less irksome technic required by the more complicated methods demanded by the establishment of sacral anesthesia. Report of Case No. 10032. Mrs. E. I). F., female, aged fifty-three, entered hospital August 27, 1917. Diagnosis: Uterine prolapse, third degree with large vesicocele. Operation: Watkins interposition; perineorrhaphy. Anesthesia: Classical infiltration block using 45 cc of a 0.5 of 1 per cent novocain-adrenalin solution in perineum. A circum- ferential block about the cervix was made, using 30 cc of the same solution. The patient noticed some distress during delivery of the uterus into the vagina. The round ligaments were blocked as soon as they appeared, 4 cc of novocain-adrenalin solution being used in each. The classical Watkins operation was performed. The perineum was then repaired by the split septum method. Anes- thesia was ideal. Patient's pulse was 80 at end of operation, and she had no postoperative nausea, vomiting or gas pains, and made an uneventful recovery. Report of Case No. 10290. Mrs. A. A. C., female, aged sixty-two years, entered hospital May 6, 1917. Diagnosis: Uterine prolapse (third degree); hemorrhoids. 356 SURGERY OF THE GENITO-URINARY SYSTEM Operation: Interposition operation (Watkins); perineorrhaphy. Hemorrhoidectomy | gr. morphine and Tgr. scopolamin given one hour before operation. Anesthesia: Classical infiltration block of perineum. A circum- ferential infiltration was made about the cervix, 120 cc of a 0.5 per cent novocain-adrenal in solution being used. An especially liberal amount of the solution was deposited anteriorly. The cervix was amputated, the peritoneum opened, and the uterine body brought into view by depressing the cervical stump backward. The patient being in the moderate Trendelenburg position no intestine appeared in the incision. The fundus was delivered by means of small cat's paw retractors and the round ligaments were infiltrated as soon as they were visualized. The classical Watkins operation was performed. The perineum was then repaired. The pulse was 70 at the completion of the operation. A circumferential infiltration was then made about the rectum, and the sphincter moderately dilated. Hemorrhoids were removed by the clamp and cautery technic. This patient vomited once directly after the operation, but had no further nausea or vomiting throughout her convalescence, which was uneventful. Vaginal Hysterectomy.- Technic of Anesthesia.- Trans-sacral, parasacral, sacral (see page 117) or infiltration anesthesia may be used. We favor infiltration anesthesia over the other forms, and shall describe it in more or less detail. The author's experience with vaginal hysterectomy is limited, as he much prefers the abdominal route for this work. However, occasionally patients are seen with uterine conditions for which it is deemed best to use the vaginal route. The performance of this operation under local anesthesia, while presenting difficulties, can be accomplished with entire satisfaction, provided certain principles be rigidly followed. The introitus should be anesthetized in order to allow relaxation of the vagina. In this manner one may have sufficient room in which to carry out the operation and the obtaining of an exposure will not be accompanied by discomfort to the patient. Perfect exposure, combined with a wide infiltration about the uterine cervix and extending well up into the broad ligaments will give splendid anesthesia. In making this block the exposure is facilitated by grasping the cervix with a tenaculum. In making the infiltration, one should not hesitate to carry the needle point sufficiently deep to obtain anesthesia of the peritoneal surface. The regions of the uterine arteries are the most sensitive. The infiltration between the bladder and uterus and between the rectum and uterus proves to be of advantage just as it does when used as a preliminary to abdominal hysterectomy. It serves to separate the MISCELLANEOUS OPERATIONS 357 uterus from the bladder and rectum and therefore, to reduce the liability of injury to the walls of these structures. As soon as the infiltration is completed and the cervix has been circumscribed by an incision in the vaginal vault, the peritoneal cavity is entered from in front. The incision should be liberal so that the uterus may be turned into the vagina without a great amount of traction. As soon as the round ligaments are seen they are liberally infiltrated with novocain-adrenalin solution. Traction upon the round liga- ments is the cause of distress and whenever possible this should be anticipated. Usually a liberal infiltration will eliminate complaint. The author has performed this operation a number of times since 1907 and during recent years he has, by adhering to the above detailed technic, been gratified to find that in the majority of cases the operation could be completed with almost no distress. The following case will illustrate the manner of performing a vaginal hysterectomy by means of infiltration block alone, and also the benign effect of this method of treatment: Report of Case No. 9200. A. I. M., female, aged thirty-six years, entered the hospital October 15, 1916. Diagnosis: Cancer of the cervix uteri. Operation: Vaginal hysterectomy. Anesthesia: Local infiltration. History: This patient had been a victim of chronic Bright's disease for a number of years. She had been bleeding constantly from the cervix and uterus and was in a rather critical condition. Her hemoglobin was 50 per cent. The cervix presented a cauliflower growth. The uterus was entirely free and easily brought to the introitus. Technic of Anesthesia: A wide circular infiltration was made about the cervix uteri, the needle being carried well up into the broad ligaments at every stroke, and 90 cc of a 0.5 of 1 per cent novocain- adrenalin solution were used. Operation: Vaginal hysterectomy. Quinine and urea hydro- chloride, 1 to 600, was thoroughly infiltrated into the stump of the broad ligaments after they were sutured. Her pulse at the close of the operation was 72. She began taking fluid immediately after operation. The anesthesia was ideal in every respect. MISCELLANEOUS OPERATIONS. Atresia of the Hymen.-Atresia of the hymen and other mal- formations in this region may quite obviously be operated upon under simple infiltration block of the pudic nerves. (See page 350.) 358 SURGERY OF THE GENITO-URINARY SYSTEM Report of Case No. 10917. • F. W., female, aged fifty-eight years, married, entered the hospital July 2, 1917. Diagnosis: Atresia of hymen. Anesthesia: Local infiltration. Operation: Dilatation. History: The patient had been married two weeks. Examination showed the hymen to be greatly thickened. It was impossible to introduce the index finger. She presented herself because of this condition, having just embraced matrimony. Technic of Anesthesia: Classical infiltration was made similar to that described on page 350, Fig. 144. A small rectal dilator was introduced and the vaginal entrance gradually dilated. Stellate incisions were made in the hymen until three fingers could be introduced into the vagina. The anesthesia was perfect and the patient remained in the hospital but two days. Artificial Vagina. As an illustration of the application of local anesthesia to intra-abdominal, intestinal and vaginal operations the establishment of an artificial vagina will serve. The author's experience in this class of cases is limited and yet the successful application of local anesthesia when meeting the demands of these operations has been most gratifying. As an example of this distressing condition and an operation which is somewhat unusual, but which was carried through by means of local anesthesia with entire satisfaction, the following case may be recited: Report of Case No. 10871. Miss A. S. C., aged nineteen years, entered hospital June 12, 1917. Diagnosis: Congenital absence of vagina. Operation: Procedure of Baldwin. First Operation: Pelvic laparotomy, intestinal loop exclusion. Anesthesia: Local infiltration anesthesia, 120 cc of a 0.5 per cent novocain-adrenalin solution and sacral anesthesia 90 cc were used. A midline infiltration and incision were made with the patient in Trendelenburg position and knees widely separated on kneeholders (see Fig. 141, page 346). The ovaries and tubes were found to be apparently normal. The uterus was absent, but a suggestion of it remained between the mesial extremities of the round ligaments. The round and broad ligaments were infiltrated, a loop of small bowel resected, leaving its mesentery intact, and a lateral anas- tomosis made between the divided ends. The assistant sitting between the patient's knees introduced sharp pointed scissors into MISCELLANEOUS OPERATIONS 359 the incomplete vagina from below, gently spreading the blades between the rectal and bladder walls. An incision was then made through the peritoneum between the ends of the round ligaments and the channel completed from above. The purse-string sutures at the ends of the excluded intestine which had been left long were grasped by a dressing forceps passed up from below and by this means the bowel was drawn into position thus forming a lining for the newly made vagina. The abdomen was closed without drain- age and the patient made a good recovery. The blades of a long dressing forceps were then introduced and clamped upon the apposing surfaces of the transplanted loop of intestine and allowed to necrose their way through. The lower ends of the transplanted intestine retracted considerably during the next two weeks, leaving approximately 5 cm. of the newly formed vagina denuded of mucous membrane. Fig. 149.-Artificial vagina. Roentgenogram of Case No. 10871. Vagina outlined by a condom distended with barium. Second Operation: Plastic repair. Accordingly six weeks later, under sacral anesthesia, a plastic operation was made employing the labia, which were fortunately extremely pendulous. The mesial half of each labium majora after being dissected free from the outer portion was sutured to the lower end of the retracted intestine after making a wide dilatation of the vagina which showed a marked tendency to contract. These tissues healed kindly into place and 360 SURGERY OF THE GENITO-URIN ARY SYSTEM the young woman lias since married and has for several years enjoyed normal intercourse and has succeeded in keeping her husband in blissful ignorance of the true condition. Fig. 149 shows a roentgeno- gram which was taken of a condom distended with barium and placed in the vagina. Pelvic Abscess in Women.-The drainage of pelvic abscesses may be carried out under sacral, trans-sacral or parasacral anesthesia or under a direct infiltration of the posterior vaginal fornix (pages 117 and 353). The psychic aspect of these cases is important and must be kept constantly in mind. The individual who is afflicted with profound sepsis may object to the use of local anesthesia and suffer, as indeed all septic cases may, from severe psychic disturbances. The percentage of cases so reacting is comparatively small. Thus one should not insist too strongly upon the use of local anes- thesia in these individuals. A light nitrous-oxide oxygen anesthesia will allow the introduction of vaginal pelvic drainage with great facility and has the further advantage of allowing one to break down and make multiple abscesses confluent. The training of patients will have much to do with their psychic reaction and this point is especially noticeable in relation to this class. In the author's experience it is not uncommon to carry out these procedures under local anesthesia as described in cases No. 15470 and 13633. Report of Case No. 15470. Miss L. II. N., aged twenty years, single, entered the hospital February 20, 1922. Diagnosis: Pelvic abscess of specific origin. Operation: Postcervical drainage. Anesthesia: Local infiltration. History: Patient had been ill for eight weeks. First Operation: February 21, 1922. Pelvic drainage through vagina. Technic of Anesthesia: The infiltration was made along the labia, retractors were inserted, the cervix was grasped with a tenaculum and liberal infiltration was made posterior to the cervix. This was followed by an incision, long curved scissors being introduced into the abscess and spread. A large amount of pus was evacuated and tube drainage established. Note.-This young woman went through the operation without much distress either physical or mental and one month later under- went a pelvic laparotomy under infiltration of the abdominal wall, combined with anterior splanchnic anesthesia, at which time the MISCELLANEOUS OPERATIONS 361 uterus, Fallopian tubes, a left ovarian abscess and a right ovarian cyst were removed with very satisfactory anesthesia. The technic used was practically the same as that of Case No. 13587 (page 501). Suprapubic as well as vaginal postoperative drainage was established, the latter following the method described on page 507. The drainage of pelvic abscess under sacral anesthesia is well illustrated by the following case: Report of Case No. 13633. I). S. R., female, aged twenty-three years, entered the hospital on February 7, 1920. Diagnosis: Pelvic abscess of specific origin. Operation: Vaginal drainage. Technic of Anesthesia: Sacral anesthesia, 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution being introduced into the sacral canal. In about fifteen minutes the vaginal canal was easily dilated by the use of specuhe and the cervix was grasped with the tenaculum without the patient experiencing pain. An incision was then made in the posterior vaginal fornix and a large pelvic abscess opened and drained, also without pain. CHAPTER XII. LOCAL ANESTHESIA IN SURGERY OF THE RECTUM AND ANUS. SURGERY OF THE RECTUM AND ANUS. Many rectal conditions which call for surgical treatment are comparatively of a minor nature, and the simplicity, comfort and safety offered by the use of local anesthesia must, if realized, induce individuals with these afflictions to present themselves with less reluctance; and, therefore, at an earlier period than when the procedure is made to seem a major one by the use of general anes- thesia. Preparation of the Patient.-In rectal operations preoperative treatment is simplified as much as possible. Laxatives are avoided and the rectum is evacuated before operation by the administration of a warm suds enema. The application of irritating antiseptics is also avoided. Comfort upon the operating table is insured. Excellent exposure of the parts is insisted upon but the most scrupu- lous care should be taken to avoid unnecessary exposure of the patients. Intelligent male patients may be allowed to retract the external genitals with one hand encased in a sterile towel. Choice of Local Anesthetic Methods. For all operations on the lower rectum and anus a direct circumferential infiltration or sacral anesthesia may be used. Sacral anesthesia is preferred only in cases in which direct infiltration is interfered with by local disease, such as abscesses, fistulae and cancer. Direct infiltration has several points of advantage. The position of the patient remains the same during the establishment of anesthesia and the performance of the operation. There is almost no margin of error as far as obtaining anesthesia is concerned and the time required for the establishment of anesthesia is less than five minutes. The induction of anesthesia is almost painless. Sacral anesthesia (Fig. 28, page 117), on the other hand, generally demands a change in position after the anesthetic has been intro- duced. It has a certain percentage of error. It may be impossible to enter the canal, needles may be broken off and toxic symptoms are more common under this form of anesthesia. The establish- ment of sacral anesthesia requires much more time than does simple infiltration and also demands a higher degree of skill and more training. It cannot always be established without pain. SURGERY OF THE RECTUM AND ANUS 363 Parasacral anesthesia (page 117) is still more difficult of accom- plishment. Trans-sacral anesthesia (page 117) is not required for the more simple rectal operations and its use may be reserved for operations upon growths higher up in the bowel. The Nerve Supply of This Region.-The skin of the anorectal region is supplied by cutaneous filaments of the fourth sacral, the anococcygeal nerves and by perineal branches of n. pudendus and n. posterior cutaneus femoris. (Fig. 138, page 348.) The sphincter ani externus is supplied by branches of the inferior hemorrhoidal branch of n. pudendus (III. IV. and sometimes II. S.) and by muscular branches of the fourth sacral as well as by sympathetics of the middle hemorrhoidal plexus. The internal sphincter is entirely involuntary and supplied by the sympathetics. The rectum is supplied by visceral branches of II. III. IV. S., which are motor and innervate the longitudinal fibers and inhibit the circular. The sympathetics on the other hand stimulate the circular and inhibit the longitudinal fibers. The "defecation center" is independent of the brain, being located in the lumbar region of the spinal medulla governing the sphincters and muscle fibers of the rectum and anus. The nerves supplying the anus are the nerves that come out of the sacral foramina and supply the rectosigmoid region and include from the second to the last sacral. (Plate XIV.) Technic for Circumferential Infiltration.-The injection is begun by making a small skin wheal 2 or 3 cm. from the anal margin (Fig. 150). All subsequent wheals are made from beneath by the method illustrated in Fig. 31, page 149. In order to carry out this portion of the technic, intelligent assistance is required. The anus, located as it is in a sulcus, presents more difficulty than does the ordinary flat or gently rounded surface, as presented, for instance, by the abdominal wall. It is well to make the initial wheal at a point lateral to and midway between the anterior and posterior anal margins. From here the needle point may be carried along under the skin close to the anal margin until it reaches the median raphe, either anteriorly or posteriorly, where a secondary wheal may be developed. The subdermal infiltration between the initial wheal and the secondary wheal may accompany either the advance or retreat of the needle point and the surgeon may note the elevation of the skin as the fluid is introduced. The needle may now be introduced through the initial wheal and carried to the opposite pole of the anal margin, where the above procedure is duplicated. In this manner one-half of the anal margin is anes- thetized and wheals are thus produced at the central points in front of and behind the anus. The needle point may now be 364 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS introduced through the first secondary wheal at the midline (gen- erally the anterior wheal is found most convenient) and from here the needle may be carried subdermally to a point opposite the location of the initial wheal, where another skin wheal is made, and this quadrant of skin anesthetized. Through this wheal the needle may be inserted and may be conveniently carried across the remaining quadrant which leads to the sulcus between the Fig. 150.-Surgery of the rectum and anus. Anesthesia technic: subdermal circumferential infiltration. gluteal folds behind the anus. Gentle retraction of the skin by the assistant will serve to straighten out the lines along which the needle point is to travel and greatly facilitate the working out of this part of the infiltration. Flexibility of the needle also facilitates the carrying out of this procedure. A circular ring of anesthesia just external to the anal border is thus established. Through this anesthetized skin the needle may be introduced in a plane at right angles to the skin surface and SURGERY OF THE RECTUM AND ANUS 365 parallel to the wall of the rectum. The use of a fine needle 7 to 10 cm. long is desirable. (Figs. 2, 3, 4, pages 87 and 88.) One should aim to establish a wall of infiltration about the rectal canal. The infiltration should be most complete in the posterior lateral areas, but little being required in the anterior quadrant. In making this infiltration it is essential to observe the rule that the needle point be kept constantly in motion while the fluid is emerging from Fig. 151.-Surgery of the rectum and anus. Anesthesia technic: perirectal infil- tration; fenestrated speculum in use (Fig. 25, page 109). Insert shows sectional view. it. The presence of large vessels in this region is a constant source of danger unless this rule be rigidly observed. As soon as the rectum has been surrounded by a wall of infiltration to a depth of 5 to 8 cm. one may conveniently, and without distress to the patient, introduce the fenestrated speculum (Fig. 25, page 109 and Fig. 151) and spread its blades to a degree which will allow one to visualize the rectal mucosa. If sensation still remains thy 366 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS anesthetic may now be conveniently reinforced by a submucous infiltration made directly under the vision. The presence of abscesses or suspected malignant disease pro- hibits the use of the above technic and either an infiltration block at a greater distance from the rectal wall should be made or sacral anesthesia should be resorted to in these cases. Fig. 152.-Surgery of the rectum and anus. Anesthesia technic. Photograph of divulsion of the sphincter; Pratt's dilator (Fig. 24, page 109) and Sims's speculum in action. Sphincter Divulsion. In the simple cases divulsion of the sphincter may now be accomplished, and in its accomplishment bilateral, symmetrical, stealthy, gradual stretching should be rigidly observed. For this some form of mechanical device (Fig. 24, page 109) should have precedence over the fingers or thumbs. The blades of the dilator shown in the figure may be spread gradually SURGERY OF THE RECTUM AND ANUS 367 as the muscle relaxes under the effects of the anesthetic, without being subjected to an intermittent strain, or what might be called "repeated insults," each of which has the effect of stimulating in the muscles a reflex contraction. In making the divulsion, when the lateral limits have been reached and a greater dilatation seems desirable a Sims's speculum may be used for the purpose of making Fig. 153.-Surgery of the rectum and anus. Anesthesia technic. Photograph of patient with divulsion of the sphincter completed. a gradual pull in the anterior direction. (Fig. 151 and 152.) In order to facilitate this stage of the procedure the gloved hand may be introduced with the back upward between the blades of the dilator and the dilatation increased by forcing the dilator back- ward and the Sims's speculum forward. The establishment of perfect local anesthesia in rectal cases by abolishing the reflexes renders divulsion of the sphincter much more simple as a rule than 368 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS when general anesthesia is used. As soon as complete divulsion has been accomplished the necessary operation may, of course, be carried out. Fig. 154, A, B, and C, represent steps of the hemor- rhoid operation by the clamp and cautery method. Fig. 154.-Hemorrhoidectomy. Clamp and cautery method. A, B and C, representing various steps of operation. Rectal Examination.- While many rectal examinations may be made without the use of anesthesia, a certain percentage of individuals suffer exquisitely from the introduction of instruments into the rectum. The tenesmus exhibited by the sphincter which has undergone long periods of irritation from disease makes the introduction of instruments difficult and painful. It would seem advisable to refrain from making rectal examinations in a certain percentage of these cases until anesthesia had been established. The same rule as that used for cystoscopy might be applied. The author has made it a practice for a number of years to refrain from making rectal examinations in cases in which it was more or less obvious that an operation was necessary until after anesthesia had been established; and even where the necessity for an operation seemed probable and an attempt at examination proved painful, be has, without hesitation, anesthetized the region in order to SURGERY OF THE RECTUM AND ANUS 369 make the examination more complete and, at the same time, pain- less. Hemorrhoids, Ulcers, Fissures and Polypi.-Anesthesia for the operation for hemorrhoids may be established by the use of the circumferential infiltration, described on page 363, or by the use of sacral anesthesia. Infiltration block combined with direct infiltration is the method of choice. The technic described on page 149 is carried out with the utmost attention to detail, every effort being made to avoid causing the patient pain while the injection is in progress. The sphincter is divulsed by the use of the Pratt speculum (Fig. 24, page 109), and one should not be unduly hasty in carrying out this procedure. Deliberation is essential to success at this stage of the operation. Any method one chooses may be used in the treatment of the condition as the anesthesia, if carefully established, admits of no margin of error. It is the author's rule to complete the operation wherever possible without the patient's knowledge; that is, the patient is made to believe that he is being prepared for the operation, and not infrequently we are able to complete every detail before informing him. This method is especially desirable in patients who are at all appre- hensive. Excisions of ulcers, fissures and polpi may be carried out under the same method as that described for the hemorrhoid operation. Fistula-in-Ano.- Local anesthesia for the treatment of fistula-in- ano may be established by means of a direct circumferential infil- tration, direct infiltration or sacral anesthesia. As a rule, it has been found well to avoid the use of direct infiltration in these cases and to give preference to an infiltration block at some distance from the field of operation. Sacral anesthesia is perhaps the method of choice, but in its use one should be especially careful to avoid carrying infection into the sacral canal. The establish- ment of sacral anesthesia will permit of the most extensive dis- section in this region and its use in the treatment of this condition is highly satisfactory. The divulsion of the rectal sphincter as a preliminary is of decided advantage in making the dissection. Excellent light, a com- fortable position on the table and good retraction are also desir- able adjuncts. One of the advantages of anesthesia by infiltration when operating for fistula is offered by the hemostatic effect of the adrenalin. Both infiltration block and sacral anesthesia offer to the surgeon the opportunity of operating upon a silent field, which is so much to be desired in procedures of this kind which may in some instances present more or less technical difficulty. While, theoretically, sacral anesthesia would seem most desir- able in cases of fistula-in-ano and ischiorectal abscess, direct infil- 370 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS tration has been found to be quite satisfactory. Sacral anesthesia involves the possibility of carrying infection into the sacral canal provided the infective processes for which the patient is being treated approach the area through which the needle is to be inserted. In all cases the element of infection must be considered. How- ever, the objection to infiltration anesthesia in these cases, which relates to the possible spread of the infective organisms by means of the infiltrating needle, is believed to be more theoretical than Fig. 155.-Fistula-in-ano. Anesthesia technic; subdermal circumferential infiltra- tion and deep infiltration block. real. Considerable experience in circumferential infiltration in complicated cases of fistula-in-ano and direct infiltration for the purpose of draining ischiorectal abscesses have failed to show any practical objection to this method. There are in this region no tissues which can be injured by direct infiltration. In these con- ditions the opportunity offered for painstaking, careful dissection and the bloodless and silent field are much to be desired. Infiltration Block.-In making an infiltration block for the dis- section of fistula-in-ano one should make the injection at a dis- SURGERY OF THE RECTUM AND ANUS 371 Fig. 156.-Fistula-in-ano. Dissection of tract. Fig. 157.-Fistula-in-ano. Photograph of Case No. 11775, during operation. 372 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS tance as great as possible from the fistulous tracts. A subdermal rhomboid is made at a distance of 2 to 3 cm. from the fistulous tract and extending about the anus (Fig. 155). Through this anesthetized area of skin the needle is introduced vertically, begin- ning preferably posteriorly and interrupting the nerves of the region as near their point of exit as possible. The deep infiltra- tion should, as a rule, extend completely about the rectum. This tissue presents no structures which may be damaged by the needle. After complete divulsion of the sphincter the author has as a rule injected a solution of methylene blue into the fistulous tract for the purpose of making identification of the tissues more easy. A simple expedient is the introduction of a flexible silver wire through the fistulous tract before beginning the dissection. The tract and wire may then be completely dissected out, thus reducing the margin of error which is always present to obstruct our efforts at complete ablation of the pathological process (Fig. 156). Fig. 157 shows a photograph of Case No. 11775 undergoing an operation for this condition and the following case illustrates the various steps carried out in the operating room. This case will illustrate the application of infiltration block in the treatment of fistula-in-ano of an extensive degree: Report of Case No. 9331. G. C. S., aged fifty-six years, entered the hospital on October 10, 1916. He weighed 140 kilograms and presented multiple fistuhe with four skin openings about the anal region. Diagnosis: Fistula-in-ano (multiple). Operation: Excision of the fistulous tracts, October 14, 1916. Anesthesia: Circumferential infiltration block. A circumferential infiltration block, using 210 cc of a 0.5 of 1 per cent novocain-adrenalin solution, was made surrounding the rectum and extending external to the most distant opening, which was located 17 cm. from the anal margin on the left of the buttock. Methylene blue solution was injected into the tracts after thoroughly divulsing the sphincter. The fistulous tracts were completely dis- sected out and the wound packed widely open. No sutures were placed. A complete infiltration block with quinine and urea hydro- chloride, 1 to 600, was used. The patient had no pain after the operation and postoperatively there was great difficulty in keep- ing the skin edges separated on account of the extreme adiposity of the patient. At one point, during the absence of the author from the city, the skin healed across, giving a channel beneath it. Upon his return a sound was passed through this channel and the skin once more divided without the use of anesthesia and without SURGERY OF THE RECTUM AND ANUS 373 sensation to the patient. Our records show that this incision was made seventeen days after the operation, the anesthesia still remain- ing was assumed to be from the use of quinine ami urea. Note.- This patient had no reaction following his operation and the incision and tissues remained healthy throughout. This case serves to illustrate very well the aid that may be derived from the use of quinine and urea hydrochloride, besides the extent to which dissections of this nature may be carried out under an infil- tration block. Carcinoma of the Rectum. -Malignant disease of the rectum makes a great demand upon local anesthesia for two reasons. First, if limited in extent the excision of malignant growths becomes as simple under the local method as are any of the other operations which it may be necessary to perform in this region. Secondly, the average case of cancer of the rectum demanding wide resection is always a desirable candidate for local anesthesia on account of the additional safety offered by this method. The condition of these patients and the mortality resulting from cancer of the rectum would seem to demand the additional safeguard offered by local anesthesia. Several methods are available: (1) Growths appearing low in the rectum may be removed after the establishment of an infil- tration block, made well away from the area involved; (2) sacral anesthesia (page 117) may be employed, or (3) parasacral anes- thesia may be established by the anterior approach of Braun (page 117). Growths higher up in the rectum, which demand the Kraske operation, for instance, may be removed absolutely without pain following the method of trans-sacral blocking, described on page 117. The establishment of this anesthesia, while slightly more irksome than others, will, if combined with a paravertebral block, give an anesthesia as high as desired and, as stated above, has advantages which are well worth the additional effort. Prolapse of the Rectum.-Rectal prolapse of a mild degree which will respond to treatment by linear cauterization may be treated under a circumferential infiltration block about the rectal canal. However, many of these patients require, in addition, an intra- peritoneal operation. The following technic is especially satis- factory in this class. Sacral anesthesia (page 117) is established. A linear cauterization of the protruding rectal mucosa is first made. The picking up of the rectal mucosa by means of artery forceps is greatly facilitated by the cooperation of the patient who, by straining, may cause the rectal mucosa to evert to any desired degree. (Fig. 158.) In cases in which the rectal mucosa recedes automatically with the patient in the recumbent posture the aid 374 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS offered by the patient's cooperation is most desirable. The patient should be instructed to force the rectal wall outward by straining and when the limit is reached one may pick up the mucous membrane at the desired points, the amount of bowel wall which is extruded under these conditions being an excellent indication to the surgeon of the length of the lines which are to be cauterized. Following the cauterization, the abdominal wall may be infiltrated with the patient in the exaggerated Trendelenburg position and tilted well to the right. A left rectus incision is made, carefully observing the precautions laid down in Chapter XVIII, page 489, every effort being made to obtain a negative pressure when the abdomen is opened. Provided the pelvis is free of small intestine, an anterior Fig. 158.-Prolapse of the rectum. (Cooperation of patient.) Photograph of Case No. 14259. Voluntary extrusion of mucosa. splanchnic anesthesia is at once established and the mesosigmoid thoroughly infiltrated with novocain solution. The operation which the author has performed for this condition has been to displace the rectosigmoid to a position behind the posterior parietal peritoneum. It is, therefore, essential to anesthetize the parietal peritoneum not only along the pelvic brim but along the posterior abdominal wall to the left. The height to which the anesthesia is carried will depend upon the redundancy of the rectosigmoid. With this anesthesia practically any procedure which one chooses may be carried out. As examples of the above the following Case Reports Nos. 11461 and 14259 are offered: SURGERY OF THE RECTUM AND ANUS 375 Report of Case No. 11461. This case well illustrates the simplicity with which simple rectal prolapse of mild degree may be treated under local anesthesia: J. L. H., aged sixty years, entered the hospital April 12, 1918. Diagnosis: Rectal prolapse. Operation: Linear cauterization. Technic of Anesthesia: Circumferential infiltration. Ninety cc of a 0.5 of 1 per cent novocain-adrenalin solution were introduced, making a wide infiltration block about the rectum. The patient was instructed to strain and force the mucous membrane out. Several artery forceps were then placed upon the rectal wall and linear cauterizations made. The skin about the rectum was punctured at several points and 60 cc of 1 to 600 quinine and urea hydrochloride were used as an infiltration block for the purpose of preventing postoperative pain. Fig. 159.-Prolapse of the rectum. Photograph of Case No. 14259. Mucous membrane grasped, ready for linear cauterization. Report of Case No. 14259. Mrs. J. H., aged fifty-two years, entered hospital May 9, 1921. Diagnosis: Prolapse of rectum. Operation: Linear cauterization of rectum and abdominal recto- pexy. 376 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS History: Aggravated constipation for a number of years. Has been bleeding from bowel three years. Bowel protrudes with each bowel movement. Anesthesia: Local infiltration for the abdominal wall using 90 cc of a 1 per cent novocain-adrenalin solution and sacral anesthesia using 60 cc of a 1 per cent novocain-adrenalin solution. Multiple linear cauterization was done without divulsing the sphincter. The cooperation of the patient made it possible to obtain the exposure shown in Fig. 159 and the cauterization was carried out before open- ing the abdomen. The abdomen was opened by a left rectus incision under infiltration anesthesia with the patient in an exaggerated Trendelenburg position. A perfect negative pressure resulted and a modified Moscowitz operation was carried out, throwing the rectosigmoid behind the posterior parietal peritoneum. The following case will serve to illustrate the carrying out of the operation for rectal prolapse when associated with disease of the adnexa, necessitating other pelvic work. Report of Case No. 13561. C. G. M., aged fifty-two years, entered hospital January 23, 1920. Diagnosis: Moderate-sized uterine fibroids; prolapse of the rectum (marked degree), kyphosis, pelvic deformity. Operation: Myomectomy; uterine suspension; rectopexy; linear cauterization. Anesthesia: Local infiltration; anterior splanchnic. The abdomen was opened after a midline infiltration, using 90 cc of a 0.7 of 1 per cent novocain-adrenalin solution. Although a negative intra-abdominal pressure was obtained the conformation of the patient's body was such that the small intestine, a part of the stomach and practically the whole of the colon lay below the pelvic brim. The patient presented a marked kyphosis with almost an obliteration of the upper abdominal cavity. Therefore a rubber towel was placed above the incision and the whole mass of small intestine and the transverse colon were turned out upon this towel, where they were retained by the use of warm pads throughout the operation. The uterine fibroid proved to be intraligamentous. An anterior splanchnic anesthesia was established, the round ligaments were blocked and the fibroid, which was the size of a large orange, was removed. The round ligaments were shortened and a rectopexy was performed by mobilizing the pelvic colon and placing it in a retroperitoneal position. The anesthesia is recorded as ideal in this case, the intestines being eviscerated and returned to the abdominal cavity without SURGERY OF THE RECTUM AND ANUS 377 sufficient distress to cause the patient to complain. Traction, however, was carefully avoided and the patient showed no signs of distress when the intestines were returned to the abdomen. Second Operation: Twelve days after the performance of this operation a circumferential infiltration was made about the anal canal and the sphincter divulsed. Four linear cauterizations of the rectal mucous membrane were made. The patient made an uneventful recovery. Note.-This case, complicated as it was by the presence of a subperitoneal uterine fibroid growing directly out from the cervix, and a deformed pelvis and spine which caused practically an oblit- eration of the upper abdominal cavity, presented complications which offered a prospect of considerable difficulty in completing surgical treatment under straight local anesthesia. However, the combination of sacral anesthesia, a moist rubber towel, eviscer- ation of the small intestine and anterior splanchnic anesthesia made this operation practically as simple as was the operation of Case No. 14259, reported above. Postoperative Comfort. -Quinin and Urea Hydrochloride.-In all granulating wounds in this region, aside from those which result from the excision of malignant disease, quinin and urea hydro- chloride, 1 to 600, may be used with advantage for the purpose of reducing postoperative discomfort. The author has seen anesthesia following the use of this drug last for seventeen days (Case No. 9331),although, as a rule, the anesthesia does not last more than twenty-four or forty-eight hours, and its action is by no means constant. PART III. LOCAL ANESTHESIA IN SURGERY OF THE ABDOMINAL WALL AND CAVITY. CHAPTER XIII. LOL AL ANESTHESIA IN SURGERY OF THE ABDOMEN. GENERAL CONSIDERATIONS. 1. The nerves of the abdominal wall and the peritoneum (Fig. 160. See Plates IX and X). The skin of the abdominal wall is supplied by the: (1) Thoracico- abdominal intercostal nerves (VII. VIII. IX. X. XI. T.) which give off anterior and lateral cutaneous branches; (2) the twelfth thoracic nerve; and (3) ramus cutaneous anterior or the hypogastric branch of the iliohypogastric nerve (I. L.), which supplies the skin of the hypogastric region. The muscles and fascia are supplied by practically the same nerves, the anterior cutaneous branches of the thoracico-abdominal nerves giving off muscular branches to the recti muscles, and the lateral cutaneous branches of the same nerves giving muscular branches to the external oblique muscles of the abdomen. The peritoneum, as has been shown by Kappis and others, receives its nerve supply from the sympathetics. Intraperitoneal Pain Sense.-Much has been written about the pain sense of the different intraperitoneal structures. Few authorities agree upon this important subject, each giving the results of his own studies and observations. Careful study has been made of the works of Hertzler, Lemander, Haller, Bichat, Weber, Bloch, Richet, Kast and Meltzer, Ritter, Wilms, Propping, Ramstrom, Langley, Bayliss and Starling, Cannon, Auer, Kuntz and Mackenzie, and in addition, a large series of the author's own cases were carefully observed in order to clear up, if possible, some of the disputed points, doing over the literature will show one the marked contrast in the reports of the different 380 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN observers, and, aside from theoretical or anatomical grounds upon which arguments are based, one is convinced that much of the difference of opinion is due to the fact that the findings are far from constant in different individuals and vary even under similar conditions and greatly under a variety of conditions. The various stages of peritonitis from different causes greatly influence the Fig. 160.-Nerve supply of the abdominal wall. 1, costa XII; 2, N. intercostalis XII; 3, rami musculares; 4, M. transversus abdominis; 5, N. iliohypogastricus; 6, ramus musculares; 7, ramus cutaneus lateralis, N. iliohypogastricus; 8, N. ilio- inguinalis; 9, rami cutanei anteriores, N. intercostalis VIII; 10, sheath M., rectus abdominis; 11, M. obliquus internus abdominis; 12, rami cutanei anteriores, N. inter- costalis XII; 13, funiculus spermaticus. sensitiveness of the parietal peritoneum and the viscera. The general condition of the patient must be taken into account and it must not be forgotten that the patient who has been a sufferer with a painful retroversion or recurrent interval appendicitis may respond differently than will an individual who is the subject of some other pathological condition. It is generally taught that the parietal peritoneum only is sensitive and that the viscera are GENERAL CONSIDERATIONS 381 devoid of pain sense in the absence of traction upon the mesentery. The author's observation indicates that this is not entirely true. Traction upon the intestine even without traction upon the mesen- tery may cause pain; heat applied to the exposed intestine will produce cramps which are described as gas pains. A young man of excellent poise and intelligence stated that the introduction of the needle through the wall of his intestine was painful, and a careful test showed that he could feel the needle pass through his intestinal wall even though his eyes were covered and an effort made to deceive him. Traction upon the mesentery was here carefully excluded. The parietal peritoneum in the absence of inflammation is insensitive to light touch or even to scratching. However, pinching and traction are disagreeable. In disease this structure is sensitive even to light pressure. This is especially true of certain areas as, for instance, the cul-de-sac. The results of observation will also vary with the manner in which experi- ments are made. A brisk, quick action will cause complaint when the same act stealthily performed may be readily tolerated. One observer states that the mesoappendix may be clamped without pain and backs up his opinion by observations upon a series of fifty cases, while another finds that this structure is always sensitive, especially in acute appendicitis. The facts are that the sharp application of a hemostat to the mesoappendix will elicit a com- plaint from the conscious patient who has not had preliminary medication unless cocain has been used. (Some authors state that cocain acts as a general analgesic but I have had no experience with it.) However, if one slowly and carefully applies the clamps the patient may not remonstrate. Many factors must be con- sidered in making this simple observation. Whereas, as a rule, the patient who is undergoing an operation under local anesthesia is ready to complain at the slightest opportunity, and may even complain when not being hurt, with the hope of making the surgeon more cautious, one must not forget that he may have been compelled to suffer so much during the delivery of the appendix that by com- parison the clamping of the mesoappendix may not bring forth a complaint. In no other manner can an observation of this kind, which is so at variance with the author's own experience, be explained. Thus it has been frequently found that a strong clamp may be placed upon the mesoappendix, provided it is forced down very slowly, with only slight complaint on the part of the patient. It is known that the base of the appendix may be clamped with no pain sense after the mesoappendix has been blocked or divided. The ovarian pedicle, the cystic duct, and even the fundus of the uterus are tender and cannot be attacked without causing pain, 382 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN although the latter may be found to be almost insensitive in some cases. The large vessels in the mesentery are sensitive and even those in the omentum, if clamped close to their origin, may show pain sense. There is, therefore, an opportunity to perform opera- tions upon most of the pelvic viscera when the above-mentioned areas can be blocked before the operative procedure is begun. Pathological conditions which cannot be handled without traction upon the mesentery, mesoappendix or posterior abdominal wall may not lend themselves to this form of anesthesia. However, here again is a good illustration of the difference between careful and rough handling of the tissues. A perfect exposure with a perfect negative pressure may and often does give one the oppor- tunity to see the retaining bands which anchor the tissues to the posterior abdominal wall with the aid of only slight traction while the bands are cut with scalpel or scissors and the parts liberated. A good exposure will give one the opportunity of reinforcing the anesthesia. When the necessity for traction can be anticipated the tissues upon which traction is to be made should be blocked at their points of origin from the abdominal wall. In a number of instances adherent pus tubes have been removed by following this plan. Masses which appear to be very adherent and resistant will be found to shell out easily at times after cutting the "key" bands under direct vision. The important point is to locate the lines of cleavage with as slight an amount of traction as possible and to dip the retaining bands as they appear.1 It is interesting to note the opinion of Heinrich Braun in relation to the performance of laparotomies under local anesthesia. He states that: " To do laparotomies under local anesthesia with success depends on a series of circumstances which must be well considered in the individual case. It was an old experience after the discovery of the ether atomizer that occasionally a painless skin incision sufficed to open the abdomen and possibly for an operation upon organs which possess little or no sensation of pain. The local anesthesia by cocain and its substitutes has brought a substan- tial progress in so far as it was possible to get a real interruption of sensation with ease and sufficient safety while severing the abdominal layers from skin to peritoneum. "If the operative field lies essentially within or next to the abdominal wall, as in the majority of hernias, or if a simple incision reveals at once the organs to be operated upon, lying adjacent to the anterior abdominal parietes, further manipulation within the abdomen is unnecessary, then the anesthesia of the abdominal wall alone is sufficient. Incisions into the stomach and gut, the liver, 1 Braun: Local Anesthesia, p. 296. GENERAL CONSIDERATIONS 383 gall-bladder and the rest of the abdominal organs are not painful. The behavior of these organs either in the state of inflammation or normal is alike. Yet every pull at the intestines and every touch or tear on the parietal peritoneum, if not under the influence of the anesthetic, produces the abdominal sensations of pain, but quite indistinctly localized. "Between the aponeurosis and the peritoneum the injected fluid spreads quite far around so that a broad strip of peritoneum becomes insensible. "Certain laparotomies may be done entirely with local anesthesia without the aid of narcotics following this simple infiltration of the line of incision. To these belong the gastrostomy with trans- rectus incision. While infiltrating the abdominal layers from both ends of the line of incision, one must make sure that the needle penetrates both rectus sheaths and reaches the preperitoneal tissue. That is indeed not difficult, since by the penetrating needle one can sense the resistance of the aponeurosis very accurately. We operate in like manner for tuberculous ascites and abscesses of the liver which are accessible from the abdomen. Also in the establishment of intestinal fistulae most generally the simple infil- tration suffices but in cases of ileus one must handle the needle with great care to avoid spearing the part of the intestine to be opened which lies distended and pressed against the abdominal wall. "An essentially broader field of operation inside of the abdominal layers is rendered insensible if the simple infiltration of the incision area is replaced by regional circuminfiltration. "Usually, however, this is not the case. On the contrary, every examination of the abdominal organs-the introducing of the hand, the placing and removing of compresses, the loosening of adhesions-is so painful that further operation cannot be thought of. Ways and means had to be found, therefore, to meet the painful sensations given rise to by the organs of the abdominal cavity. Last, but not least, in many operations, especially in the lower parts of the abdomen, we cannot do without the artificial relaxation of the muscular layers.'' The author's experience does not entirely coincide with that expressed above. While it is extremely desirable and indeed necessary to obtain relaxation of the abdominal walls in order to do intra-abdominal surgery there are many conditions which can be met under the use of this anesthesia alone by employing strategy and local infiltration at the proper points. One of the most surprising experiences was the realization of the extent to which abdominal explorations might be carried under simple infiltration of the abdominal wall. With relaxed 384 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN parietes, vertical retraction, combined with a negative intra-abdominal pressure and tilting of the table so as to make use of the force of gravity, one is frequently able to explore the upper abdomen through a pelvic incision and vice versa. (See abdominal exploration, page 379.) Position of the Patient.-As stated in the chapter on General Technic, much may be gained by tilting the operating table so as to bring the body of the patient into a suitable position. For upper abdominal work the reversed Trendelenburg with the tilt to the right or left may change the position of the abdominal Fig. 161.-Patient draped and showing position of pneumatic injector. A, leg holder; B, lateral body support; B', shoulder brace; C, operating field guarded by towel hooked on towel rack; D, arm supported for comfort and blood-pressure reading. organs, and likewise the aspect of the surgical problem, to a con- siderable degree. While this fact has long been recognized in rela- tion to the surgery of the pelvis, surgeons seem slow to realize how much may be gained by the tilting of the table when working in the upper abdomen. The lateral tilts (see Fig. 202, page 473), if made in the presence of a perfect negative intra-abdominal pressure, will often shift the small intestine to one side of the midline, leav- ing the ascending or descending colon, as the case may be, in the other half. In order to obtain these results, it is of course neces- sary to thoroughly abolish the reflexes and to tilt the patient's GENERAL CONSIDERATIONS 385 body as a rule to an angle of about 30 degrees. Fig. 161 shows the patient on the table with the pneumatic padded braces in place for the lateral tilts and Trendelenburg position. Retraction.-In abdominal work good exposure is a sine qua non to success. It is to be hoped that the day of finger retraction is soon to pass. It is incompatible with asepsis and the desired result can be much more easily attained by the use of proper retrac- tors which will take up less room and, as a rule, do the work much more satisfactorily. Harsh retraction will produce much the same effect as inefficient anesthesia. Instances have occurred in which an otherwise ideal local anesthesia was converted into a failure and general anesthesia found necessary because a careless assistant allowed the abdominal wall to slip from a retractor, thus causing a contraction of the abdominal muscles and an ex- pulsive effort, resulting in the extrusion of a large mass of intestinal coils. The most important point about retraction, when working under local anesthesia, is that it be steady; that is, continuous and not intermittent or jerky. "Stealthy" is the word which best describes the manner of doing our work most satisfactorily under local anesthesia. Retraction should be symmetrical, if possible; that is, equal on the opposite sides of the wound, especially if continued for a long time. Forceful retraction, if made slowly, carefully and methodically, is not usually objected to (see pages 98-100, Figs. 11, 12 and 13). Direction, Site and Choice of Incisions.-While local anesthesia does not contraindicate the use of any particular incision its use demands an adequate exposure of the pathology present, and when operating under its influence great advantages may be gained from a proper selection of the abdominal incision. In the author's experience the transverse or "L" incision has given the most excellent exposure when working in the upper abdomen, and he has used it almost exclusively since 1910. With proper equip- ment one may anesthetize and enlarge any abdominal incision at the rate of about 2 or 3 cm. per minute. (See Case No. 15117.) Note.- This case illustrates the possibility of carrying the incision from one field to another should the necessity arise. Although this patient was in a grave condition at the beginning of his operation, his condition improved steadily throughout the pro- cedure. The incision, 30 cm. in length, was prepared by infil- tration anesthesia with a loss of time not to exceed ten minutes and the operation was carried out with dispatch and without embarrassment. Explorations of this character are almost ideal under the use of infiltration anesthesia. The wound may be enlarged to any desired extent as the necessity arises. 386 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN Report of Case No. 15117. S. B. R., aged seventeen years, entered the hospital January 21, 1922. Diagnosis: Gunshot wound of abdomen. Operation: Laparotomy; retroperitoneal drainage. Anesthesia: Local infiltration 180 cc of novocain-adrenalin solution. History: Twelve hours previously patient had been struck by a bullet which entered the abdomen in the right loin. The roentgen rays showed the bullet in the left pelvic wall posteriorly, there being no wound of exit. The patient was given 250 cc of citrated blood and one liter of physiological saline intravenously. Under infil- tration anesthesia the abdomen was opened on a line extending diagonally from the twelfth rib behind where the bullet entered. The external oblique was divided in line with its fibers and the retroperitoneal space opened. A large amount of clotted blood was removed, the peritoneal cavity was then opened by extending the incision across the abdomen to the midline below the umbilicus. Considerable blood and serum escaped. The mesoappendix was found perforated. The intestinal tract was gone over system- atically, each loop being returned as soon as it was examined. No perforation was found. Drainage was inserted and the incision, which was 30 cm. in length, was sutured. The patient's pulse remained unchanged throughout the operation. His color improved greatly and he was returned to bed in good condition. Recovery was uneventful for two weeks when he began to evidence edema and tenderness, first in the right leg and then in the left, accompanied by severe pain. The patient died on February 17, with a diagnosis of thrombosis of the femoral and iliac veins and of the inferior vena cava, which was confirmed at autopsy. Therefore, one should not hesitate to enlarge the incision in any direction when unexpected pathology is encountered or when other conditions arise which make this procedure seem advisable. The realization of the ease with which this may be done effectually eliminates the necessity for making the original infiltration far beyond the limits of the regular incision and meets the criticism that other pathology cannot be reached. The direction, site and length of the abdominal incision has such an intimate relation to the success or failure of local anes- thesia in abdominal surgery that the following article,1 which appeared in 1919, seems apropos: 1 Farr, Robert Emmett: The Trans-rectus Incision in the Upper Abdomen, Minnesota Medicine, May 1919. GENERAL CONSIDERATIONS 387 The Trans-redus Incision in the Upper Abdomen. -"The proper performance of an intra-abdominal operation demands an incision through the abdominal wall of sufficient length to allow the surgeon, in so far as it is possible, to do his work unhampered by the inter- ference of the abdominal parietes. During recent years long incisions have been made with less hesitancy and with a corre- sponding improvement in surgical therapy. Nevertheless, every effort should be made to conserve the abdominal parietes as far as may accord with the proper handling of the intra-abdominal problem. It may be true that under absolute asepsis rather long incisions heal as rapidly as do short ones, but this ideal does not always obtain. In any event, the conditions which tend to pro- duce incisional hernia are favored by the long scar; also, the forces acting are, in some degree, proportionate to the length of the scar. When pathological conditions demand long incisions, the injury to the abdominal wall becomes at once of relatively minor importance. Long incisions may even be indicated in order to arrive at a diagnosis in some cases, but too often this is evidence of failure on the part of the surgeon to complete his differential diagnosis before operation." In a former contribution1 on this subject the author stated: "When work in both the upper and lower abdomen is called for in the same patient, it may be a mistake to prolong an incision from one to the other field, especially the pararectal incision. Perhaps it is better to make a second incision in those cases. The slight loss of time will be compensated by decreased trauma from forceful manipulation and by allowing more thorough work, besides the avoidance of severing the nerves and its ill effects." Additional experience of the past ten years affords no reason to change the previously expressed opinion. Certain usages have become established regarding the direction of incisions, structures to be conserved, etc. In this connection the following points should be considered: (1) The appearance of the resultant scar; (2) the relative importance of the division of muscular as compared with aponeurotic tissue; (3) conservation of the blood supply; (4) conservation of the nerve supply; (5) anticipated pathology; (6) the facility with which the incision may be closed; and (7) the relaxation afforded during and after operation. 1. The Resultant Scar.-While the appearance of an abdominal scar is relatively unimportant, it is desirable that any incision be placed so that the scar will be as sightly as possible. Incisions along Langer's lines result in the least objectionable scars. 1 Farr, R. E.: Abdominal Incisions, Journal-Lancet, November 1, 1912. 388 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 2. Relative Importance of the Division of the Muscular as Compared with Aponeurotic Tissue.-Without going minutely into the question of the dynamics of the abdominal wall, certain points may be considered in this connection. Though the lateral pull on the abdominal wall may not be greater than the vertical, vertical tension is easily reduced by decreasing the distance between the ensiform cartilage and the pubes (Fig. 162). There is no way in which the lateral tension can be so diminished. The relative merits of muscular and aponeurotic tissue as supporting structures are still sub judice. A study of the structures of the abdominal wall shows that the bundle of fibers of aponeurotic tissue to a large extent lie transversely. It is a well-known fact that, even Fig. 162.-Abdominal incisions. Showing method of relaxing abdominal wall in closing transverse incision. with marked diastasis of the rectus muscle, hernia does not occur without a separation of the aponeurotic fibers. Inasmuch as the aponeurotic tissue of the abdominal wall runs in a general trans- verse direction, and as lateral tension, which cannot be readily overcome, is apparently greater than the vertical, it would appear that Kocher's1 dictum that the rectus muscle is the least important structure of the abdominal wall may be correct. Two main objections are made to the division of the rectus muscle: (1) It is said that it retracts between the anterior and posterior sheaths and cannot be reunited unless some method is used to prevent this retraction, and (2) objection is also made that the hemorrhage is troublesome and is somewhat hard to control 1 Chirurgische Operationslehre, 1907, J. Aufl. GENERAL CONSIDERATIONS 389 as it comes directly from the cut surfaces of the muscle. Perthes1 has advised the introduction of sutures on either side of the pro- posed incision, and it is not unusual to see those who employ this incision delay approximately ten minutes for the introduction of these sutures. From the author's observation he must conclude that the procedure of suturing the rectus muscle to its sheath for the purpose of preventing its retraction is entirely unnecessary, though for the purpose of hemostasis it may be desirable. For many years he has observed the so-called retraction of the rectus muscle with the following results: When the incision strikes a transverse line, there is no retraction. In most instances the cut edges of the aponeurosis do not lie as near together as do the cut edges of a muscle. If the incision goes through the red muscle it is followed by some retraction, the degree dependent upon the distance of the incision from a transverse line. The end nearest the transverse line will show a certain amount of muscle projecting beyond the aponeurosis; the end farthest away may show a muscular retraction within the sheath, but in every case observed thus far there has been a positive amount of muscle beyond the edge of the aponeurosis; that is, the ends of the muscle were closer together than were the edges of the aponeurosis. In all cases examined a proper closure of the sheaths of the rectus (aponeurosis) has resulted in an intimate contact of the divided ends of the muscle. 3. Conservation of the Blood Supply.-In the presence of suffi- ciently free anastomosis, the division of the bloodvessels is relatively unimportant. Even with division of the main blood supply, incisions through extremely vascular areas heal with great rapidity. This is well illustrated in work about the face, and clinical experi- ence goes to show that the deep epigastric and inferior mammary arteries may be divided with impunity. 4. Conservation of the Nerve Supply.-The abdominal wall is supplied by the lower thoracic nerves which travel obliquely down- ward and forward at the sides but enter the rectus muscle as large bundles in a transverse direction when they begin to subdivide into fine branches (Fig. 160). Unless made with extreme care the pararectal incision must destroy one or more of these nerves which are regarded by many authorities as the most important structures in the abdominal wall. Atrophy unquestionably results when any considerable area of the abdominal wall is deprived of its nerve supply. Numerous instances of weakness of the abdominal wall have been observed subsequent to the long pararectal inci- sion. The researches of Quain2 would indicate that viscero-parietal 1 Deutsch. Ztschr. f. Chip., 1912, No. 37, 129, 493. 2 Trans. Western Surg. Assn., 1913, pp. 353, 369. 390 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN adhesions are more prone to develop in cases in which the nerves of the abdominal wall have been divided. 5. Anticipated Pathology. Above the navel the transverse incision offers the most adequate exposure of the various pathological conditions. The gall-bladder, stomach ami even the appendix if not adherent in the pelvis can be readily dealt with. In most instances retraction of the abdominal wall, both upward and downward, is possible, so that good exposure is usually obtained. By supplementing this incision with the near-midline vertical incision when necessary one is afforded perhaps the most ideal exposure it is possible to obtain. In the matter of choosing incisions, a great deal can be accomplished by varying the size and direction according to the pathology anticipated. Fig. 163.-Gall-bladder incision. Right rectus muscle exposed and mobilized. X X, marks linea alba. 6. Facility with Which Incision May be Made and Closed.-All authorities agree that it requires more time to enter the abdomen by the transverse route. This is especially noted when Perthes's method of muscle suture is employed or if the bleeding vessels in the severed muscles are clamped individually. With the method to be illustrated presently, however, the element of time is negli- gible. In closing, the procedure is relatively simple. One has to deal with two layers of aponeurotic tissue, and a point of utmost importance is the fact that the fibers of this tissue lie in bundles parallel with the line of incision, so that in closing one may pass GENERAL CONSIDERATIONS 391 the sutures around the fibers and avoid "cutting out," which is not uncommon when closing the vertical incision. In closing the incision, the relaxation afforded by the proper posture of the patient makes it possible to unite the edges of the transverse cut in a relatively short time. When the vertical cut is added to the transverse, the strong lateral pull is at once encountered and the problem becomes more difficult. In this connection an important observation has been impressed upon the writer in comparing the tension upon the sutures used in the vertical cut with that upon those employed in the transverse arm of the "L" incision. In no instance has he found the lateral tension as easy to overcome as the vertical. The transverse incision always comes together more easily than the vertical. 7. The Relaxation Afforded during and after Operation.-That one may obtain greater accessibility through the transverse incision than through the vertical incision of equal length is generally admitted, and most observers agree that there is less postoperative discomfort after the transverse incision. This is true and is prob- ably due to two important factors: (1) The better exposure afforded by the transverse incision allows the surgeon to do his work with less trauma, and (2) the line of incision may be relieved of tension to some extent by having the patient assume a proper posture (Fig. 162). Technic.-The author wishes to outline the incision in the upper abdomen as he employs it, and call attention to the modifications commonly used. Generally speaking, the gall-bladder is exposed by a division of the right rectus muscle above the navel at a level which corresponds roughly to the lower border of the liver (Fig. 163). The stomach is exposed by a division of the left rectus (Fig. 165). In each of these incisions the linea alba is crossed (Fig. 166). If the pathology lies high, the incision may be supple- mented by a vertical limb which may be extended to the ensiform if need be (Fig. 168). In making this latter, the linea alba is avoided as a matter of preference, and division is made of first the anterior and then of the posterior sheath of the rectus from 1 to 2 cm. from the linea alba (Fig. 164). In alarge number of instances the appendix has been removed through the transverse gall-bladder incision without extending it. For the control of hemorrhage the methods illustrated (Figs. 163, 164, 165, 166, 167) have been devised. A light, angular Pean forceps is placed with one blade behind the muscle, the other in front and made to include the aponeurosis. The muscle is divided between these clamps, which are allowed to remain throughout the operation. The upper segment of the muscle is gently loosened from the transversalis, which is then split in the direction of its 392 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN fibers, or, as Meyer1 has suggested, it may be divided in a diagonal direction corresponding in its course to the Kocher gall-bladder Fig. 164.-Gall-bladder incision. Right rectus divided between muscle clamps. Curved incision of posterior sheath. Fig. 165.-Gall-bladder incision (left). Stomach and spleen incision (right) X X, marks linea alba. 1 Transverse Abdominal Incisions, Ann. Surg., 1915, 62, 573-575. GENERA L CONSIDERA TIONS 393 incision. The author's preference is for a curved incision in the posterior sheath which in a general way follows the line of the incision Fig. 166.-Trans-rectus incision across both muscles. X, marks linea alba. Fig. 167.-Trans-rectus incision completed. Note exposure. in the anterior sheath. It is, however, somewhat farther from the midline and slightly higher than the one in front of the rectus. 394 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN The posterior Hap, therefore, has a curved rather than a rectangular form (Fig. 164). Drainage is established by means of a stab-wound, generally above the incision in the Hap, but below in case the drainage tube would more naturally lie in this position. Postoperative hernia is in this way guarded against to some extent. Enthusiastic reports concerning the transverse incision might lead to the belief that hernia does not occur following it. The author's experience shows that hernia may take place in cases that suppurate or in which drainage has been carried out through the incision proper. He has had no hernia in cases that healed primarily, and his impression is that hernia is less liable to occur when the trans- verse incision is employed. Fig. 168.-Gall-bladder incision. Closure; drainage through stab-wound. X, linea alba. Closure.-A mattress suture (Fig. 168), continuous or interrupted, closes the peritoneum and transversalis muscle, everting the former and taking up some of the slack in the posterior sheath, thus aiding in the approximation of the cut ends of the muscle. The anterior layer may be imbricated, provided this is necessary, in order to approximate the muscle, using a continuous or interrupted mattress suture (Fig. 169). The vertical incision still holds the fort, especially in large clinics where old customs are wont to linger longest, though certain modi- fications are being made with increasing frequency. The past GENERAL CONSIDERATIONS 395 six years have witnessed a vast change in this regard. It is most significant that those who have seen fit to try the transverse incision even a limited number of times are prone to resort to it rather frequently. Boeckman1 was a pioneer in the use of the transverse incision. lie does not hesitate to divide the rectus muscle either above or below the navel. During recent years, Moschcowitz2 has made rather extensive use of the incision, and recently Lilienthal3 has been favorably impressed with it. Willy Meyer favors com- bining the transverse with the vertical incision in the midline, dividing the transversalis and peritoneum diagonally after raising the rectus muscle. Quain4 reports several hundred cases in which he has used the transverse incision with great satisfaction. McArthur's5 incision, when used for the cases for which he recom- Fig. 169.-Sectional view of abdominal wall after closure. mends it, is excellent. It conserves the blood supply, muscle, aponeurosis and the very important nerve supply. One should not hesitate to change it to the transverse or vertical in case more room is needed. The writer has chosen a transverse skin incision when using it. The impunity with which the rectus muscle may be divided should be kept in mind by all surgeons. If the advantage of this point is utilized in certain cases an excellent exposure may often 1 Transverse Abdominal Incisions, St. Paul Med. Jour., 1910, No. 12, p. 255. 2 Transverse Incisions in the Upper Abdomen, Ann. Surg., 1916, 64, 268-289. 3 Discussion, Trans. Am. Med. Assn., 1917, p. 1845. 4 The Transverse Incision in the Upper Abdomen, Journal-Lancet, 1917, 37, 657. 6 A Modified Incision for Approaching the Gall-bladder, Surg., Gynec. and Obst., 1815, 20, 83-84. 396 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN be obtained, which with the vertical incision is impossible, and frequently an almost impossible proposition may be converted into a smooth, easy operative procedure. One should not become wedded, so to speak, to any particular incision. In certain types the vertical, Robson's or Bevan's modification of the same gives the best possible exposure. In the broad, flat, corpulent type the trans-rectus cut will afford the best approach. The advantages of the vertical cut may be used if desired. The practice of vary- ing the incision to suit the case, depending upon the conformation of the patient's body and the pathological problems present, has given the greatest satisfaction. Recently a cholecystectomy was done through the classical McBurney appendix incision made well below the navel as the gall-bladder lay in this position. Fig. 170.-Viscero-parietal adhesions. Vertical retraction. When making abdominal incisions it is desirable in many instances to avoid pressure upon the underlying structures. Acute cases, ner- vous people or children, demand that the abdominal wall be lifted while incising. The skin may be grasped with towel pins (Fig. 212, page 490) and after its division and the nicking of the fascia this structure may also be elevated. Likewise the peritoneum may be gently retracted and when opened the abdominal wall may be elevated by placing a retractor beneath its surface (Fig. 170). This demands the careful anesthetization of the peritoneum to a point some distance away from the incision. One need not hesitate to reinforce the anesthesia by introducing the needle GENERAL CONSIDERATIONS 397 subperitoneally after the abdomen is opened for the purpose of injecting the solution. The Making of the Incision.-Technic.-When making the incision one can readily note the general contour of the patient's abdomen and the tension under which the muscles are laboring, and can gauge quite accurately the course of events which will ensue directly the peritoneum is incised. The amount of com- plaint and resistance offered by the patient's tissues may also be noted; in fact, a general observance of the operative field will fre- quently enable the surgeon to note in advance whether or not he has obtained complete anesthesia. The muscle whose nerve supply has not been blocked will demonstrate that it is still " awake" by undergoing a contraction when it is attacked. This will often permit the surgeon to anticipate complaints on the part of the patient, and when this contraction does take place the evidence that more anesthesia is required in this locality should be heeded. By so doing one may frequently avoid causing the patient suffi- cient pain to bring out a complaint. It is, in other words, a more delicate sign than having the patient complain vocally of pain. If, as has already been said, when the peritoneum is approached one notes by the signs mentioned above that the abdominal viscera will protrude because they are held under pressure when the peritoneum is opened the procedure had better be given up as a failure and general anesthesia administered. On the other hand, if proper relaxation obtains, the peritoneum may be opened between forceps which are steadily retracted upward with some degree of force. It is essential when incising the abdominal wall to use some form of automatic retraction so that a perfect exposure may be secured without too much manipulation of the tissues (Fig. 214, page 492). Under ideal anesthesia the condition differs little from that found in a fresh cadaver at autopsy. As soon as the peritoneum is nicked the air enters the peritoneal cavity and the force of gravity carries the viscera to the lowest possible level away from the abdominal incision. (See page 147.) Favorable pelvic cases, when placed in the Trendelenburg position, with "ideal" anesthesia and a properly retracted abdominal wall, will show no small intestine below the pelvic brim. The left lateral tilt and a slight Trendelenburg will show the cecum and terminal ileum lying 4 or 5 cm. away from the abdominal wall without the necessity for any search whatever. (Fig. 202, page 473.) In the upper abdomen the lower portion of the stomach, duodenum and gall-bladder and the transverse colon may be inspected at leisure without withdrawing any of these organs from the abdominal cavity and without the placing of sponges. The author has termed this ideal condition, which is really the "answer" 398 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN in abdominal surgery under loeal anesthesia, "negative pressure" and its degree vividly portrays in each case the manner in which the anesthesia has been introduced and the care with which the abdominal wall has been opened. Negative pressure is the reward one receives for applying proper technic when entering the abdomen. Positive pressure, the protrusion of the viscera and failure mean, as a rule, faulty technic. Muscular Relaxation. - Duties of the Psycho-anesthetist (See also page ]()()). - While the abdomen is being opened much may be done to bring about the ideal condition of complete muscular relaxation which is so essential for successful intra-abdominal surgery. An adjunct of vital importance is the "psycho-anesthetist" who sits at the patient's head during the operation and looks after his com- fort and records the blood-pressure, pulse and respiration. Tactful cooperation on the part of this individual will be found of great assistance. In addition to her other duties her efforts should be directed especially toward aiding in securing relaxation. Again let it be stated emphatically that complete muscular relaxation must always be the goal toward which the surgeon should strive if he is to attain the greatest success in this work. The tension which is always present when a patient winces and struggles under the manipulation of the surgeon prevents the complete abdominal relaxation so necessary for the proper performance of any abdominal operation. The surgeon must realize, when attempting laparotomies under local anesthesia, that success can be obtained only by the use of a technic which permits of relaxation. The author contends that such relaxation may be obtained in most cases, and perhaps in all, provided one's technic is sufficiently good. For those who are not able to secure this relaxation in a reasonable percentage of cases, abdominal surgery under local anesthesia will continue to be a Herculean task, and as a consequence they will quite probably continue to condemn the method in the future as they have in the past. It is hoped that a more universal realization of the facts will change the attitude of that large percentage of surgeons who maintain that only certain classes of cases should be undertaken under local anesthesia and will convince them that almost all classes of cases can be operated upon successfully by this method and that it is already being done daily by those who are accomplished in this art. As a rule, when the abdomen of an apprehensive patient is uncovered upon the operating table the tension under which he is laboring will be plainly manifest. The abdominal muscles, instead of being relaxed, will be tense and rigid and the normal depressions which show when a patient is at rest will be absent. This is most plainly seen when the Trendelenburg position is GENERAL CONSIDERATIONS 399 assumed. Here the relaxed individual will present a depression in both iliac fossae. The pubes and anterior-superior spines will be prominent and the upper abdomen will bulge forward, as it will contain most of the viscera. In the tense patient this con- dition does not obtain. The recti are contracted and stand out as ridges on either side of the midline. Contraction of the lateral groups obliterates the depressions normally found below the navel, and it is evident that the viscera have not gravitated to the more dependent portions of the abdomen. Unless this condition can be overcome by the introduction of the anesthetic with the aid of suggestions and instructions from the psycho-anesthetist, who coaches the patient in regard to his manner of breathing and the avoidance of straining, grunting, coughing or laughing, general anesthesia had better be administered before the peritoneum is finally opened. Few operations can be performed without relax- ation. Certainly under such conditions none can be performed painlessly, and a painful operation is neither fair to the patient nor to the method, and should not be performed. Abdominal Exploration. -Perhaps the most potent argument in relation to the question of local versus general anesthesia in ab- dominal work-at least in the minds of the surgeons who favor general anesthesia-relates to the question of abdominal explora- tion. While there is undoubted truth in the statement that wide ab- dominal explorations are facilitated by the use of general anesthesia more than by the use of local, those who are familiar with the use of local anesthesia realize the fact that with increasing experience abdominal explorations may be made in a fair percentage of cases. It must be admitted that the abdominal exploration is, as a rule, a substitute for a complete diagnosis, and it is accepted. I think, that it should not be made in any case in which it can be avoided. A more earnest effort at its avoidance would undoubtedly result in a reduction of the number of abdominal explorations and with great benefit to surgical patients. Furthermore, in the author's experience it has been unusual to find gross surgical pathology which could be recognized upon blind exploration with the gloved hand which could not be rather accurately anticipated after all points in the patient's history, a thorough physical examination and a proper collaboration of laboratory data had been coordinated. Better surgery demands the elimination of the extensive blind exploration of the abdominal cavity, as far as possible. Obscure cases will always demand such exploration. However, an effort to cure the patient should relate especially to his symptoms and surgeons should make it a rule to anticipate the particular path- ology for which they are opening the abdomen. The author has little patience for instance, with the surgeon who 400 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN at 8 A.M., opens the lower abdomen for the performance of some pelvic operation and blithely introduces his gloved hand into the upper abdomen, turning his back to the patient the while, and reports that the right kidney, the left kidney, the spleen, the gall- bladder, the common duct, the pancreas, the stomach and the duodenum, each in its turn, is entirely normal, while within an hour the same surgeon may be seen to open the upper abdomen and spend ten, twenty or thirty times as long going over similar organs of another patient and yet be unable to decide whether or not pathology is present-a point he decided an hour before without the use of his eyes and without the slightest hesitation. Take, for instance, the simple question of the presence or absence of gall-stones within the gall-bladder. On numerous occasions a distended gall-bladder after its removal has been passed to visiting physicians to find that they have had the greatest difficulty in stating whether or not there were gall-stones present. Again on frequent occasions the author himself has been unable to decide this question positively before emptying the gall-bladder; and he has been surprised to find scores of small stones in a gall-bladder, which had previously been palpated with negative results. One feels, therefore, that the argument that abdominal explor- ations cannot be carried out under local anesthesia must be largely discounted for the above-mentioned reasons. First, that the blind abdominal operation should be limited as far as possible; and second, that when it is necessary it may be quite successfully made, provided the proper local anesthesia technic is followed; and third, mixed or psycho-local anesthesia may be added while the exploration is being made, provided this becomes necessary. (See pages 78 and 79.) The Examination of the Abdominal Organs. The comparative ease with which the abdominal organs may be examined under conditions of complete relaxation, as contrasted with the difficulty encountered in making such an examination under the conditions usually seen when watching abdominal operations, may be brought out by comparing of the inspection of a herd of live stock under varying conditions. Under ideal conditions we would open the barnyard gate and look over a herd of live stock resting peacefully within the enclosure. The condition of each would be noted, even though an occasional one might need to be moved about in order to obtain a better view. If, on the other hand, when the gate is opened the whole herd, or a goodly portion of it, rushes headlong into the gateway and must be forcibly restrained the inspection cannot be detailed or satisfactory. This com- parison, though a homely one, is nevertheless not greatly over- drawn. GENERAL CONSIDERATIONS 401 The superiority of visual over digital examination has been discussed elsewhere and nowhere does it apply more aptly than in abdominal surgery. Though much valuable information may be gained by palpation, inspection is and will always remain the great purveyor of the facts concerning the actual conditions pres- ent. Unfortunately, there is a class of cases in which a negative intra-abdominal pressure cannot be obtained, regardless of the form of anesthesia used, and here we must depend to a large extent upon other senses than that of sight. A discussion of the mode of procedure in case a proper exposition of the internal organs cannot be brought about will be taken up later. For the present we will concern ourselves with cases which are classed as amenable to the technic described above. Viscero-parietal Adhesions.-Viscero-parietal adhesions are usually considered somewhat difficult to handle under the use of local anesthesia, and indeed are usually considered sufficient reason to contraindicate its use. Nothing could be further from the facts if the author's own experience may be taken as a criterion. The adhesive bands themselves are without sensation, and provided the abdomen is opened without pain, with perfect relaxa- tion, under a negative intra-abdominal pressure, and its wall lifted vertically as the peritoneum is opened the adhesions will be visualized exactly as at autopsy, and may be cut upon the " white line," where they join the parietal peritoneum. As traction upon the parietal peritoneum causes pain the vertical retraction of the abdominal wall should be carefully graduated. The weight of the piece of intestine or other viscus which may be suspended from the abdominal wall may be sufficient to cause the patient discomfort. However, if one lifts the abdominal wall to a slight degree only the adhesions may be visualized and the anesthetic introduced into the pro-peritoneal fat by introducing the needle through the abdominal wall or from the peritoneal side (Fig. 170). Viscero-visceral adhesions may be divided without the use of intraperitoneal anesthesia. The only requisite is the avoidance of traction upon the posterior parietal peritoneum, and even this structure tolerates sufficient traction to allow one to identify the retaining bands, which may then be divided with a scalpel or scissors. Exposure and the absence of expulsive effort are the prime essentials in meeting the surgical demands in these conditions. The abolition of the abdominal reflexes, vertical retraction, tilting of the table combined with a negative intra-abdominal pressure, the cooperation of the patient and the judicial use of local anes- thetic solutions will make it possible for one to meet the indications, CHAPTER XIV. LOCAL ANESTHESIA IN SURGERY OF THE ABDOMINAL WALL (HERNIA). HERNIA. The operation for inguinal hernia illustrates one of the early applications of local anesthesia to major surgery. Its easy estab- lishment, simplicity, safety and the opportunity offered for the performance of a perfect anatomical reconstruction under ideal conditions have made its acceptance widespread. However, we still find much objection to it on a variety of grounds. Psychic incompatibility is said to contraindicate its use. Alexis v. Moschcowitz, for instance, states that when working under local anesthesia, the surgeon is handicapped and lacks the opportunity to do thorough work. He considers it satisfactory for the simpler cases, but for the large or complicated hernia he recommends general anesthesia. In the experience of the author, the size of a hernia modifies in no manner the technic, as the nerve supply is the same whether it is large or small. Incisional hernia and umbilical hernia, no matter how large or how complicated, are among the simpler operations under this method of anesthesia. It is difficult to find any condition which is better adapted to the use of this form of anesthesia than is hernia of the abdominal wall. Inguinal Hernia.-Nerve Supply.-(Fig. 160, page 380; and Plates IX and X.) The nerves involved in this operation are those supply- ing the skin, the inguinal canal and its region, the scrotum in the male and the labium in the female. The skin, fascia and muscles of the inguinal region are supplied by the anterior cutaneous branch of the twelfth thoracic nerve, the iliohypogastric (n. iliohypogastricus I. L.) and the ilioinguinal (n. ilioinguinalis I. L.). The skin just beneath the ilioinguinal ligament is supplied by the lumboinguinal branch of the genito- femoral nerve I. II. L. The cremaster is supplied by the external spermatic (n. sper- maticus externus) or genital branch of the genitofemoral nerve, I. II. L. The cord is supplied by the spermatic plexus of the sympathetics from the pelvic plexus and also contains the genital branch of the genitofemoral mentioned above as it passes to the scrotum. HERNIA 403 The scrotum is supplied by the nerves mentioned under hydrocele (seepage 344). They are the ilioinguinal (n. ilioinguinalis I. L.), the external spermatic (n. spermaticus externus) of the genito- femoral and the inferior pudendal or long scrotal branch of the posterior femoral cutaneous (n. cutaneus femoralis posterior I. II. III. S.). The nerve supply of the labia is derived from the ilioinguinal (n. ilioinguinalis I. L.) and the posterior labial (nn. labiales posteri- ores) or superficial perineal branches of n. pudendus II. III. IV. S. Skin Sterilization.-The problem of skin sterilization becomes an important one when performing the operation for inguinal hernia under local anesthesia, as the application of many of the antiseptics in use will, if allowed to reach the scrotum or labia, give rise to discomfort. This contingency may be met in the following manner: The solutions may be painted upon the skin until the border of the sensitive area is reached and this area may then be anesthetized by a subdermal infiltration through the needle which has pierced the skin well above the danger line. As soon as anesthesia is established a protective towel or gauze pad may be securely anchored to the skin below the external ring, thus effectually excluding the unsterile field from the field of operation. The Induction of Local Anesthesia.-It is usually possible to establish such perfect anesthesia in these cases that no reinforce- ment is necessary after the operation is begun, and while there is no great objection to blocking the nerves as they appear or to using an additional amount of the solution should the patient complain of pain at any time during the operation, we have usually con- sidered the necessity for this an indication that the technic has been somewhat defective. The technic for establishing anesthesia for surgical repair is as follows: The initial wheal (Fig. 171) is made at the outer end of the pro- posed line of incision A, and from here the subdermal infiltration is made along this line B. As the region over the external ring is reached the injection is carried down into the scrotum or labia, as the case may be, and 10 to 15 cc deposited here, C. From the initial wheal the needle is now carried to a point 2 cm internal to the anterior-superior spine I), and another intradermal wheal is made here from beneath. Through this wheal the remainder of the anesthetic solution is introduced. The needle is inserted vertically until it is felt to pierce the aponeurosis of the external oblique and at this point a fairly large amount (approximately 30 cc) of solution is deposited (Fig. 171). The two nerves, n. ilioinguinal and n. iliohypogastric, here lie upon the internal oblique muscle and will be bathed by the solution as it is injected between these layers, 404 SURGERY OF THE ABDOMINAL WALL The next step is the infiltration of the peritoneum (Fig. 171, insert "fluid"), catching the terminal nerves from the eleventh and twelfth thoracic at the same time, which come down from above. This injection is made by passing the needle down through the internal oblique and, while advancing slowly, building a wall of anesthesia transversely from Poupart's ligament laterally to the edge of the rectus muscle. For the average case a total from 60 to 90 cc of solution is ample but good anesthesia requires that a liberal infiltration be made. This is not meant to indicate that one should needlessly inject the solution into the tissues. Fig. 171.-Inguinal hernia. Anesthesia technic. A, B, C, subdermal infiltration; D, wheal for deep infiltration. Insert: Sectional view of same. The time required for making the injection is from two to five minutes and the incision may be made without delay. The skin may be elevated with towel clips (Fig. 212, page 490.) Sharp dissection should be the rule. The Trendelenburg position will aid in ridding the sac of its contents and a perfect exposure may be had by the application of the automatic spring retractors. No surgeon should allow himself to be handicapped by incomplete anesthesia nor should he blame his patient or the solution if he finds himself in trouble. The margin of error when the proper technic is followed is very slight and when trouble arises it is usually an easy matter to fix the responsibility. The operation the author HERNIA 405 employs is that described by Torek, in which the vas deferens is separated from the vessels and, as this operation comprehends going well into the abdominal cavity, it should be the most severe test to which the method could be put in the treatment of inguinal hernia. Fig. 172.-Inguinal hernia. Photograph of Case No. 13402, during operation. Cord, veins and sac presenting. Fig. 173.-Inguinal hernia in children. Photograph of boy, aged four years, during operation. Fig. 172 shows a patient undergoing an operation. The sac, vas and veins are shown in the photograph of Case No. 13402. Children may be operated upon with great satisfaction under this method. As previously stated children may be bribed or coaxed into good 406 SURGERY OF THE ABDOMINAL WALL behavior and they often attempt to "show off" during the operation. (Fig. 173). This shows a boy aged five years of whom a motion picture has been shown before a number of medical conventions. It is one of the early cases. As an example of multiple operations and the possibility of meeting complicated conditions the following case may be related: Report of Case No. 15652. S. C. D., male, aged four years and nine months; entered hospital April 7, 1922; referred by Dr. H. G. Franzen. Diagnosis: Bilateral undescended testicle; bilateral oblique congenital inguinal hernia; phimosis. Operation: Bevan operation for replacement of testicles; Ferguson repair of inguinal hernia; circumcision. Anesthesia: Local infiltration 90 cc novocain-adrenalin solution. Operation: The method of restraint illustrated in Fig. 181, page 431, was applied but its use was found unnecessary. An infiltration block as illustrated in Fig. 171, page 404, was employed, 90 cc of a 1 per cent novocain-adrenalin solution being used. The psycho-anesthetist was supplied with five silver dollars as a bribe for the purpose of obtaining godd behavior on the part of the boy during the operation. The testicles were placed in the scrotum, bilateral hernial repair accomplished and circumcision performed without remonstrance on the part of the boy. For technic of infiltration for circumcision see page 340. Primary healing followed. The patient left the hospital on April 22, ten days after the operation. Femoral Hernia.-For this operation the blocking is even more simple than for inguinal hernia. One must be prepared, however, in a strangulated femoral hernia to bring the bowel out above for resection and this procedure will be considered under strangulated hernia. A transverse block down to the peritoneum is made on a line corresponding to the external inguinal canal and, in addition, the line of incision is blocked in the usual manner. It is well to make a deep infiltration external to the femoral canal to catch the branches of the femoral nerve (n. femoralis). (II. III. IV. L.) Incisional Hernia.-In the production of anesthesia in incisional hernia the infiltration for simple laparotomy is practically multiplied by two. The injection should be made rather wide of the scar and bilateral in order to avoid the possibility of visceral puncture. In case there are parieto-omental or visceral adhesions present, and there usually are, they may be readily exposed by making vertical retraction, and a subperitoneal infiltration should precede the cutting of these attachments (Fig. 170, page 396). A perfect negative HERNIA 407 pressure and vertical retraction will show the adherent intestine or omentum hanging from above much like bunting hanging from a ceiling. The following case will illustrate the application of local anes- thesia in the repair of large incisional hernise: Report of Case No. 13908. D. A. A., physician, male, aged thirty-four years, entered the hospital July 21, 1920. Diagnosis: Incisional hernia. Operation: Herniotomy. Anesthesia: Circumferential infiltration block. History: This patient had been operated upon one year previously for acute appendicitis and presented a large right rectus incisional hernia. Anesthesia: A circumferential infiltration was made about the old line of incision, blocking from the costal margin on the right to the anterior superior spine. 120 cc of a 0.5 of 1 per cent novocain- adrenalin solution were used. Operation: The old scar was excised and the abdominal cavity opened with the patient in the Trendelenburg position and tilted to the left. A negative intra-abdominal pressure was secured. The colon and small intestine were found adherent to the anterior abdominal wall. The adhesions were cut upon the white line, no ligatures being required. The abdominal layers were identified and closed with imbrication. The operation was entirely painless. The patient vomited once while being returned to bed. He made an uneventful recovery. Note.-This patient came with the request that the operation be performed under local anesthesia on account of his former experience with general anesthesia. Transplantation of Fascia.-In some cases it may be necessary to introduce fascia on account of the great attenuation of the tissues of the abdominal wall. At first thought this might be considered a contraindication to the use of local anesthesia. However, the preparation of the field for the removal of a transplant of fascia is an exceedingly simple procedure. It requires only the outlining of a skin incision on the thigh by a subdermal infiltration and an injec- tion into the fascia along the line where it is to be excised. With proper equipment but two minutes are required for the establish- ment of anesthesia for the taking of fascial transplant. It is an absolutely painless procedure and exceedingly easy of accomplish- ment. Hernial defects in the upper abdomen demanding transplantation 408 SURGERY OF THE ABDOMINAL WALL of fascia may be repaired by the pedicle flap method, an intercostal block being made in the mammary line bilaterally and made sufficiently high to permit dissection of the flaps. The following is a description of a method of dealing with this class of cases, which is reprinted from Surgery, Gynecology and Obstetrics.1 "The closure of defects in the abdominal wall has presented difficulties to surgeons and many ingenious methods have been devised in an effort to bring about a cure in this class of cases. Silver wire, silver chain, linen, silk, plastic methods, and the intro- duction of grafts of bone and fascia have been utilized-the most satisfactory perhaps being the transplant of fascia lata from the thigh. While in the absence of infection these grafts, as a rule, live and heal in place, their nourishment must come from surround- ing tissues, thus placing a rather severe strain upon one's asepsis. The presence of slight infection is apt to be inimical to success. It would seem desirable to use, whenever possible, a transplant of fascia, or fascia and muscle combined, whose circulation is not entirely cut off." The following cases, presenting defects in each instance larger than one's open hand, permitted the writer to make use of the method described below, and in each instance resulted in a perfect closure of the defect. Case I.-Mrs. M. M., aged fifty-five years, weight 250 pounds, extremely adipose. The writer had operated upon this patient in 1905 for cholelithiasis, a cholecystostomy being done. In May, 1914, a large amount of gangrenous bow'd was turned out through an incision at the ninth costal margin on the left. A resection was done later, with a lateral anastomosis of the colon, drainage being required. A year later, 1915, the gall-bladder was removed on account of cholecystitis and cholelithiasis. There was practically no muscular tissue left in the upper abdominal wall and a hernia resulted over the area shown in Fig. 174 (1.) This figure, a composite drawing of Cases I, II and III shows the relative size and position of defects, and also the approximate size of pedicle flaps and locations from which they were obtained. The next fall, 1916, she was operated upon for repair of her hernia. The abdominal cavity was opened by an incision 30 cm. in length, and the edges of the aponeurosis identified. The viscero-parietal adhesions were carefully freed and all raw surfaces excluded. There now presented a defect 10 cm. in width and approximately 25 cm. long, extending from one costal margin to the other and well below. A vertical incision was made over the sternum, and the 1 Farr, Robert Emmett: Closure of Large Hernial Defects in the Upper Abdo- men, Surg., Gynec. and Obst., February, 1922, pp. 264-265. 409 HERNIA sheath of the pectoral muscles exposed as high as the nipple line (Fig. 175). A quadrangular flap 25 cm. long with the base below and composed of pectoral fascia and a considerable amount of muscle was dissected downward until a flap approximately 15 cm. in width had been raised. This flap was then sutured over the hernial opening, chromic gut being used. Fig. 174.-Incisional hernia. Pedicle-flap and fascia transplant. 1, 2, and 3, shows defects and outlines of flaps for covering same. Case II.-Mr. L. C., aged seventy-three years, operated upon January 15, 1921. This patient had had six operations in the upper abdomen by other surgeons for alleged gastric trouble, and presented a large hernia extending from the umbilicus to the ensiform, the defect being about 10 cm. wide and 15 cm. long. (Fig. 174 (2)). The patient had suffered extreme distress upon taking food and belched continually. Operation: The aponeurotic edges were freed, the viscero-parietal adhesions and all raw surfaces were carefully covered. In this case there was no parietal peritoneum with which to close the abdomen. After the application of tension sutures the incision presented a 410 SURGERY OF THE ABDOMINAL WALL defect 10 by 15 cm. The procedure illustrated was carried out. The flap taken from the chest wall was applied to the upper portion of the defect. The aponeurosis of the external oblique was employed to complete the closure (Fig. 174, (2) ). A pedicle flap with a mesial base was turned in from either side and overlapped at the midline. (See insert Fig. 175.) This patient has remained entirely well and is greatly improved symptomatically. Fig. 175.-Incisional hernia. Pedicle-flap and fascia transplant. Shows flap 1 (Fig, 174), sutured in place. Insert: shows 2 (Fig. 174), with flaps sutured in place. Case III.-Mrs. W. A., aged fifty years. On April 22, 1920, a choledochotomy was performed for the relief of chronic jaundice due to an impacted stone. On May 9 the patient developed severe hemorrhage from the wound. Blood transfusion decreased the clotting time of the blood and a massive pack prevented further hemorrhage. Subphrenic abscess with infection of the pleura was diagnosed on June 3, when posterior drainage with rib resection was HERNIA 411 done. Lung abscess developed on May 18, so that the patient had communication between the bronchus and the opening in the abdominal wall. The patient slowly recovered and returned to the hospital on March 30, 1921, for repair of a massive incisional hernia which had taken place through the L-incision for the original gall- stone operation. Operation: The abdominal wall presented no muscular tissue and a fair amount of tension upon the aponeurotic edges left a defect approximately the size of one's hand (Fig. 174, (3) ). In this case a rectangular flap with the base lying along the costal margin, its lower portion utilizing the upper part of the external oblique on the right, was turned down from the chest wall and with it the defect was effectually closed as in Fig. 175. In each of these cases drainage was employed for twenty-four hours, and in Case III a slight suppuration took place at the upper angle of the wound. The patient, however, apparently has a splendid abdominal wall, although the time is too short for one to feel at all certain about a permanent result. The lower portion of the thorax furnishes one with the ideal conditions for the procuration of a pedicle flap as the protection of the ribs furnishes adequate insurance against the possibility of weakening the area from which the flap is obtained. The pedicle- flap method, provided flaps can be obtained without too greatly reducing the strength of the area from which the flaps are obtained, may be effectually applied to ventral hernia in any part of the abdominal wall. Epigastric Hernia.-Epigastric hernia presents no difficulties and is one of the most simple procedures under local anesthesia. A circumferential infiltration block only is required. In performing operations of this nature adequate exposure should be insisted upon by making an adequate incision. Umbilical Hernia and Lipectomy.-The technic which the author has employed in operations for the repair of umbilical hernia has depended upon the surgical problem which presented itself for solution. Much will depend upon the dimensions of the hernia, and whether or not lipectomy is to be performed at the same time. Simple small herniee may be operated upon following a circum- ferential subdermal infiltration, plus a circumferential edematization of the fascia and peritoneum. The subcutaneous fat, which is usually abundant, need not be infiltrated. The infiltration of the layers should be made at some distance from the borders of the hernial tumor. The amount of solution necessary in the case of a small hernia is not great. Cognizance should be taken of the fact that the hernial sac may extend some distance beneath the skin and assume a more or less mushroom shape. Under these condi- 412 SURGERY OF THE ABDOMINAL WALL tions careless introduction of the needle too close to the apparent limits of the sac may result in the puncture of the contents of the sac with the consequent spread of infection. Should there be the slightest doubt, or should one's experience be limited, it is perhaps desirable to defer the injection of the fascial and peritoneal layers until they have been exposed in the incision. The subdermal infiltration of the skin along the lines of incision will allow one to incise down to the fascia and thus avoid the possibility of introduc- ing the needle into the intestine. In the case of large or complicated hernise, especially where lipectomy is to be performed, the following procedure has been devised: The line of incision is carefully marked out upon the abdominal wall by the use of a sponge saturated in iodine solution, or if iodine has been used upon the skin for the purpose of sterilization a sponge saturated in alcohol will answer the purpose. The line for the upper incision is curved rather sharply downward at its extremities. This line is now anesthetized by the method described in Fig. 31, page 149, a 10 cm. needle being used. Following the subdermal infiltration along the upper line only, an incision is made through the skin and fat until the fascia is brought into view. As the fascia is approached some care must be exercised as the fat which lies in close proximity to this tissue contains some sensory nerves, especially in the region of the large perforating vessels. The skin is now protected, and a subfascial infiltration quickly made at the bottom of the incision. At the extremities of the incision the needle is directed downward along the abdominal wall, beneath the fascia, and in this manner a transverse block is established with resulting anesthesia of that portion of the abdominal wall below the incision. The upper segment of the fat about the sac is now dissected well downward until at least half of the neck of the sac is identified. One may now complete the lower portion of the incision, as anes- thesia of this region will be found to be complete and the remainder of the operation may be carried out without embarrassment. Vertical retraction of the abdominal wall will usually suffice for the return of the contents of the sac into the abdominal cavity. As an example of the application of the above technic, the follow- ing Case Report No. 14590 is presented. This case also demon- strates the necessity for, as well as the advisability of, carrying out multiple operations in successive stages when such procedures are indicated. Report of Case No. 14590. Mrs. J. K. S., aged thirty-nine years, weight 110 kilograms, entered the hospital December 14, 1921. Diagnosis: Umbilical and incisional hernia; uterine prolapse; varicose veins of both legs; hemorrhoids. HERNIA 413 First Operation: December 22,1921; lipectomy; repair of hernia; division of viscero-parietal adhesions; suspension of the uterus. Second Operation: January 11, 1922; perineorrhaphy; hemorrhoid- ectomy. Third Operation: January 20, 1922; double Trendelenburg ligation and excision of veins. Anesthesia: Local infiltration. History: Patient had undergone a gall-bladder operation eight years previously and an operation for the repair of an umbilical and incisional hernia two years before presenting herself for treat- ment. Her weight was 110 kilograms, blood-pressure 240 over 160. The urine contained a trace of albumin and hyaline casts. She was the mother of twelve children. Fig. 176.-Incisional hernia. Photograph of Case No. 14590 before operation. Physical examination (Fig. 176) showed a pendulous abdomen with a hernial sac containing practically all of the movable abdominal viscera. The uterus was prolapsed to the third degree and both limbs showed marked varicosities and an excessive amount of edema. The patient was placed in bed on medical treatment for eight days, when the abdomen was opened under local anesthesia as described in Chapter XIV. All the viscero-parietal adhesions were divided and the sac was found to contain stomach, large and small intestines and greater omentum. The upper incision, which was 50 cm. in length, was carried down to the aponeuroses after making a subdermal infiltration. A subaponeurotic infiltration was then 414 SURGERY OF THE ABDOMINAL WALL carried out from the linea alba in the epigastrium to the anterior- superior spine on each side. A perfect negative pressure was obtained and the viscera were allowed to drop into the abdomen Fig. 177. Incisional hernia. Photograph of Case No. 14590, during operation. by force of gravity alone. A salt pad was placed over the hernial ring and the lower incision carried out without the introduction of Fig. 178.-Incisional hernia. Photograph of Case No. 14590, after operation. additional anesthesia. A large elliptical piece of fat and skin was removed. The upper abdominal wall was retracted vertically and extensive viscero-parietal adhesions were divided, freeing the HERNIA 415 pylorus and duodenum from the abdominal wall. The greater omentum was sutured over the denuded portion of the parietal peritoneum. The patient was then placed in the Trendelenburg position and the round ligaments attached to the anterior surface of the uterus, suspending in anteversion. The "-p" shaped incision was closed by overlapping the four rectangular flaps which were held in position by means of mattress sutures of chromicized catgut. Cigarette drains were placed in the angles of the incision. The closure was completed by means of "Figure-of-eight" silkworm-gut sutures. Primary healing followed. The patient lost weight constantly upon a restricted diet and the blood-pressure fell to 170 over 130. The second operation was done on January 11, 1922. The perineum was repaired under infiltration anesthesia (see Figs. 143 and 144, page 350; Fig. 145, page 351; Fig. 158, page 374). The hemorrhoids were removed by the clamp and cautery after an infiltration block (see page 365). The third operation was performed nine days later and the varicose veins were ligated and excised under an infiltration de- scribed on page 313. The patient was discharged on February 7, eight weeks after entering the hospital, cured. Iler total loss of weight while in the hospital was 50 pounds. The blood-pressure averaged 170 during the final weeks of her stay in the hospital and the albumin dis- appeared entirely from her urine. Note.-This patient vomited but once during the performance of these operations. The condition of the kidneys, the high blood- pressure, the excessive fat and the numerous surgical problems present, considering the outcome, would lend weight to our con- tention that such problems may be met in the manner described above or by the use of the principles which were followed in this case. Figs. 176, 177 and 178 show the patient before, during and after operation. Strangulated Hernia.-While all forms of hernia of the abdominal wall are amenable to the use of local anesthesia, the necessity for its use is urgent only in a comparatively small percentage of cases. In the great majority of hernia operations the general condition of the patient is good and the operation carries a low mortality under any form of anesthesia. Local anesthesia is recommended here more for the increased comfort, the lessened morbidity, the slightly low- ered risk, both immediate and remote, and the opportunity afforded for doing a more refined operation than when general anesthesia is used. In strangulated hernia many of these features assume more im- portance, and the factor of safety in the severe cases where delay has taken place stands out above all others. In many of these cases 416 SURGERY OF THE ABDOMINAL WALL the induction of general anesthesia alone may be sufficient to snuff out the spark of life that remains. Even the milder cases should have the benefit of every factor of safety, but unfortunately the extreme cases only are selected for local anesthesia in some of the clinics which are thought to represent the most advanced methods in use at this time. Every attention should be given to the general condition of these patients, gastric lavage for regurgitant vomiting being one of the most important items. It is difficult to reconcile the adminis- tration of a general anesthetic with the best surgical judgment in the case of a patient with regurgitant vomiting and all it implies, for an operation attempted as a last resort. It would seem that there could be no possible excuse for such a procedure with the expedient of local anesthesia at hand. The technic does not differ from that described for the various operations for simple hernia. Every condition to be met can be dealt with as well and many conditions can be handled with more facility than when general anesthesia is used. The stimulating effect of the solution at once improves the patient's condition and local conditions are made more favorable for operations than when general anesthesia is used. The congested, engorged, heaving tissues so often met with in these cases when under general anes- thesia are very unlike the placid, quiet, blanched condition produced by the use of local anesthesia. In several instances the author has performed intestinal resection under the influence of local anesthesia when the use of general anesthesia even for the first stage of a two- stage operation would have been considered extremely hazardous. The life-saving expedient of emptying the bowel at operation through a trocar introduced at several different points along the tract may be carried out to almost any degree in patients in whom general anesthesia could not be continued sufficiently long to allow this to be done. (See page 469.) In multilocular herniae, or those having a number of compart- ments to the sac, it is often necessary to traumatize a great deal of tissue in freeing the different loops. Large umbilical herniae may contain as many as fifteen or twenty of these sacs. Now, provided one of the distal loops should become obstructed, the loops above this point will distend rapidly and we may find a large number of strangulated herniae, so to speak, in a single case. One is here confronted with a large number of obstructions at once and as it is often impossible to judge which one is the "key," the only method of procedure is to free the coils as they present. This most tedious task may be carried out under local anesthesia without greatly reducing the patient's resources, while under general anesthesia such a procedure in an advanced case would be extremely 417 HERNIA hazardous. After the incision has been made and the neck of the sac injected, one has only to sit down and methodically free the adherent coils. An enterostomy in these cases leaves much to be desired at the second operation and should be avoided if possible. The following case will illustrate these points: Report of Case No. 7305. Mrs. C. I). E., female, aged fifty-four years, entered hospital March 20, 1914. Diagnosis: Strangulated umbilical hernia. Chronic myocarditis. Anesthesia: Local infiltration block. Operation: Reduction and repair. History: The patient weighed 125 kilograms. She entered the hospital with a strangulation of two days' duration, in the sac of a recurrent umbilical hernia. Her pulse was weak and the patient was cyanotic. The tumor was the size of a basket ball and required an incision 108 cm. in length to surround it. 360 cc of a 0.5 per cent novocain- adrenalin solution were introduced and the sac was opened. It was found to be multilocular and each compartment contained one or more adherent loops of the small or large bowel. As it was impos- sible to decide which was the first loop caught, and as every loop had become strangulated due to backing up of gas and fecal material, an attempt to free the constricted coils in logical order was made, the effect upon the patient being carefully noted as the work pro- ceeded. After working one and three-fourths hours the effect of the anesthetic wore off and the condition of the patient seemed to grow steadily worse. The addition of 90 cc of novocain-adrenalin solution made it possible to continue the dissection. It required four hours in all to complete the operation and although the patient was pulseless a part of the time, the pulse rate at the end of the operation was 140. A large amount of fluid was given intravenously and hypodermically. The patient made an uneventful recovery, going home by auto after five weeks. Strangulated or incarcerated femoral hernia may be treated under the usual technic and should intestinal resection become necessary, the abdomen may be opened from above by making a direct infiltra- tion. Simple strangulated femoral hernia may be operated upon with little more difficulty than is the case when strangulation is not present. Case No. 12249 is one of incarcerated femoral hernia and shows the application of local infiltration in the required surgical procedure. 418 SURGERY OF THE ABDOMINAL WALL Report of Case No. 12249. Mrs. W. M. N., aged fifty-five years, entered hospital August 26, 1919. Diagnosis: Incarcerated femoral hernia. Operation: Reduction and repair. Anesthesia: Local infiltration. History: Six hours before operation patient had a severe attack of abdominal pain in the region of the left femoral canal at the site of a hernia which she had had for many years. The hernial tumor became greatly increased in size and at the time of operation was the size of a large grape fruit. Technic of Anesthesia: A local infiltration of a 0.7 per cent novo- cain-adrenalin solution-200 cc-was made. A transverse incision was made, the sac was opened and found to contain a large amount of omentum and two dark coils of small intestine. The omentum was removed after freeing adhesions, the neck of the sac enlarged and as the constriction was removed the dark intestine became pink and was returned to the abdomen. Undoubtedly the most potent reason for avoiding general anes- thesia in intestinal obstruction from any cause is the danger of inhaling regurgitated fecal material. This reason alone is sufficient to remove strangulated hernia? from the realm of inhalation anesthesia for all time. CHAPTER XV. LOCAL ANESTHESIA IN SURGERY OE THE UPPER ABDOMEN. The surgery of the following organs lying in this region will be discussed: stomach, duodenum, liver, gall-bladder, pancreas and spleen. Position of the Patient upon the Operating Table.-The reverse Trendelenburg position, with a tilting to the right in case the spleen or the greater curvature of the stomach is to be dealt with, and to the left when dealing with the gall-bladder, will often given one a most excellent opportunity for performing operations in the upper abdomen. The advantage to be gained by tilting of the table and the aid of the force of gravity is not as great as that offered in the region below the umbilicus. However, even in this region one can, by placing the patient upon an incline and by carefully maintaining the duodenum, colon and stomach in a position of downward trac- tion, deal successfully with the pathology of the gall-bladder and ducts in a large percentage of cases. During the last five years the author has done over 90 per cent of these operations under local anesthesia. THE STOMACH. Operations upon the stomach for benign disease are most easily performed through a transverse incision across the recti muscles. It is the author's custom to incise the linea alba and the mesial portion of one or both rectus muscles, retracting vertically the while until an exploration has been made. In these cases the round ligament of the liver should be blocked before the abdominal wall is incised and the incision may then be carried vertically upward at any point which may seem desirable. Operations upon the duodenum and pyloric region of the stomach should be preceded by the induction of anterior splanchnic anesthesia (Fig. 29, page 128). The splanchnic area may be exposed by gentle upward traction of the liver edge while the duodenum and pylorus are gently drawn downward, when a liberal supply of novocain-adrenalin is introduced beneath the peritoneum. The gastro-hepatic omentum should be infiltrated before being divided and it is well also to deposit some of the solution in the region of the larger vessels as they appear during dissection. 420 SURGERY OF THE UPPER ABDOMEN Pylorectomy, the Finney operation and the excision of ulcers may be carried out under this plan. Avoidance of Clamps.-In benign diseases the author has generally avoided the application of clamps to the stomach wall. Bleeding vessels should be caught in fine hemostats as the stomach wall is incised and by the use of these instruments the stomach wall is elevated, thus effectually controlling the same and preventing the escape of gastric contents. As soon as the stomach is opened all fluid within it may be removed by means of suction. Gastroenterostomy (Anterior).-Anterior gastroenterostomy re- quires the use of no anesthesia within the abdominal cavity, but does require the application of a surgical technic of a type which is compatible with local anesthesia. With the abdomen opened and a perfect negative pressure the colon may be carefully lifted out, traction being avoided, and the proximal end of the jejunum picked up. The jejunum should be identified by vision rather than by exploration, although one may in some instances be compelled to reach down and find it with the finger. This becomes necessary provided the patient is straining and forcing the small intestine into the field. However, with the establishment of good local anesthesia this contingency does not arise. In almost every instance one is able to see the jejunum and distal end of the duodenum before handling the small intestine at all. The following case will illustrate the benign effect of the applica- tion of local anesthesia for the relief of pyloric stenosis due to malignancy: Report of Case No. 9145. C. B. D., male, aged forty-seven years, entered the hospital July 8, 1916. There was great emaciation. Diagnosis: Cancer of the pylorus, with obstruction. Operation: Gastroenterostomy. Anterior. Anesthesia: Local infiltration. History: On July 9, 1916, the patient was operated upon and a diagnosis of cancer of the pylorus, with obstruction, was made. The tumor was large and fixed. Technic of Anesthesia: Local infiltration using 120 cc of a 0.5 of 1 per cent novocain-adrenalin solution. Preliminary Medication: | gr. pantopon and scopolamin. Operation: An infiltration was made across both recti, which were divided, and the abdomen opened under negative pressure. An exposure of the liver showed metastasis in this organ. The stomach tumor was fixed. The colon was gently lifted out and the proximal jejunum visualized. A point on the jejunum distal to THE STOMACH 421 the ligament of Treitz was defined by the means of forceps and an anterior gastroenterostomy performed, as it seemed impracticable to attempt to dislodge the adherent stomach. No intraperitoneal anesthesia was employed. At the completion of the operation the patient's pulse was 72. He took fluids by mouth immediately and sat up within a few hours. The operation was entirely painless. Gastroenterostomy (Posterior).-Posterior gastroenterostomy requires only anesthesia of the abdominal wall, plus careful manip- ulation and the avoidance of traction. The jejunum is identified by the manner mentioned under the description of anterior gastro- enterostomy. The mesocolon is incised and the opening gently spread, the point at which the stomach is to be opened having been previously identified by means of a clip which has been placed at the lower border of the stomach, anterior to the gastrocolic omentum. As soon as the rent is made in the colonic mesentery an ap- propriate point upon the stomach wall is identified by means of this clip, which gently forces the lower border of the stomach into view. The stomach wall is now picked up by two clips and by means of gentle traction, aided by a few deep inspirations on the part of the patient, may usually be raised well above the ab- dominal wall. After the placing of sponges no further traction will be found necessary and the use of clamps is avoided. Incisions in the stomach or intestine are each preceded by the making of a puncture through all coats. A scissors point is then introduced and the requisite incision completed. In this manner added traction is avoided. It is well to suture the colonic mesentery to the stomach wall before anastomosis is begun, for to do so after the anastomosis is completed may necessitate traction. The introduction of pon- derous packs should be avoided. It is especially desirable to avoid the introduction of too long or too heavy a pack beneath the point of anastomosis, as the removal of such a pack may cause the patient some distress. The following case will illustrate the excision of ulcer with pylo- roplasty : Report of Case No. 13079. R. C. F., aged fifty-eight years, referred by Dr. T. A. Peppard, entered the hospital March 20, 1920. Diagnosis: Chronic gastric ulcer (prepyloric). Operation: Resection of ulcer; pyloroplasty. Technic of Anesthesia: Local anesthesia, 120 cc of a 0.7 of 1 per cent novocain-adrenalin solution, with a "T" infiltration of the abdominal wall. 422 SURGERY OF THE UPPER ABDOMEN Both recti were divided with a vertical incision up the midline. The abdomen was opened with perfect negative pressure. The gastric side of the pylorus presented an indurated mass the size of a large olive, extending along the lesser curvature. A plastic resection was made without the use of clamps, closure being made with chromic gut. The abdomen was closed without drainage. The next case will illustrate the satisfactory manner in which old and debilitated individuals may be operated upon by the use of local anesthesia. Report of Case No. 14121. A. J. S., aged eighty-two years, entered the hospital January 29, 1921. Diagnosis: Duodenal ulcer with threatened perforation. Olieration: Posterior gastroenterostomy. Anesthesia: Local infiltration. History: Patient had had stomach trouble for two years and had had about fifty attacks of severe pain, with an acute exacer- bation of the trouble two days previous to his entry into the hospital. The upper abdomen was found to be extremely tender and rigid and his stools showed microscopic blood. He passed 630 cc of urine in twenty-four hours, with a specific gravity of 1026. The urine showed albumin, hyaline and granular casts. The leukocyte count was 6600. Barium roentgen rays showed a filling defect in the duodenum. A preoperative diagnosis of duodenal ulcer with threatened perforation was made. His condition became steadily worse and four days after his entry into the hospital the abdomen was opened. Technic of Anesthesia: 90 cc of a 0.7 of 1 per cent novocain- adrenalin solution was infiltrated into the abdominal wall. An "L" incision was made, dividing the right rectus muscle, and the abdomen opened with a perfect negative pressure. The gall-bladder appeared normal but there was a mass in the region of the pylorus, apparently on the duodenal side. The region about the ulcer was adherent to the parietal peritoneum and the adhesions, being recent, were easily separated. A posterior gastro- enterostomy was performed after the method of Moynihan except that the clamps were not used. The ulcer area was turned in with chromic catgut stitches and a piece of the greater omentum placed over it. The patient was immediately placed on ulcer management. He did not vomit but on the fourth day developed hypostatic pneumonia. He was placed in a sitting posture, and sat up in a chair on the sixteenth day. THE STOMACH 423 Ulcers.-Perforated Gastric and Duodenal Ulcers; Acute and Chronic.-The surgical treatment of acute perforated gastric or duodenal ulcer demands the infiltration of the abdominal wall, a liberal incision, and in a certain percentage of cases, anterior splanch- nic anesthesia. The author has not operated upon any of these cases without the preliminary use of morphine, as in most cases the pain has been so great that the patient was well narcotized before entering the operating room. The perforated ulcer may be attacked, provided proper exposure is obtained, without distress to the patient, and may be dealt with as the condition requires. In acute perforations gastroenterostomy has been avoided and the condition treated by cauterization, excision, or simple closure of the ulcer. All cases encountered during the past fifteen years have been done under local anesthesia. The following interesting observation has been made in a number of cases. Even when morphine failed to control the pain before operation the careful blocking of the abdominal wall resulted in great reduction of the pain, and always in material relief from muscular spasm. The following case offers a splendid example of this point: Report of Case No. 14526. M. B. C., aged sixty-three years, entered hospital October 17, 1921, at 5 p.m. Diagnosis: Perforated duodenal ulcer. Operation: Excision and suture. History: This patient had had symptoms for twenty-five years. The present attack began at noon. Technic of Anesthesia: Novocain-adrenalin 1 per cent by infil- tration of 150 cc solution. Operation at 6 p.m.: An "L" incision dividing the right rectus was made. The patient had had gr. | morphine sulphate without relief and the parietes were extremely rigid. As soon as the infil- tration was made the pain subsided and rigidity decreased markedly. The abdomen was opened with a negative pressure, the duodenum was separated from the liver and an opening 0.5 cm. in diameter was exposed. The ulcer was excised, the edges cauterized and a plastic closure with catgut was carried out. Drainage was employed and the patient made an uneventful recovery. The surgical treatment of chronic perforated ulcers demands an anterior splanchnic anesthesia in addition to an infiltration of the abdominal wall. Case No. 11791 illustrates the means by which chronic perforated gastric ulcer may be handled under local anesthesia. 424 SURGERY OF THE UPPER ABDOMEN Report of Case No. 11791. E. W. 1)., aged sixty-eight years, referred by Dr. E. L. Gardner, entered the hospital November 7, 1918. Diagnosis: Perforated gastric ulcer with possible malignancy. (See Roentgenogram, Fig. 179.) Fig. 179.-Gastric ulcer (chronic, perforated). Roentgenograph of Case No. 11791. Operation: Excision of the ulcer-bearing area. Anesthesia: Local infiltration and anterior splanchnic. History: Patient weighed 45 kilograms at the time she entered the hospital, while her normal weight was 55 kilograms. She had had gastric symptoms for two years and five weeks before entering the hospital she had experienced a sudden sharp pain in the epigas- trium, followed by nausea and vomiting. She remained in bed a few days and a considerable soreness continued. THE STOMACH 425 Technic of Anesthesia: Local infiltration, 150 cc of a 0.5 of 1 per cent novocain-adrenalin solution being used. An infiltration was made across the left rectus, with a vertical limb. The left rectus was then divided and the abdomen opened under a negative pressure. The pylorus appeared normal. Anterior splanchnic anesthesia was established and the lesser omen- tum divided. In the lesser curvature a mass the size of a lemon could be felt. The abdominal wall was retracted vertically, salt packs were inserted and the gastric wall was elevated by means of tacking forceps. An incision was made in the anterior wall of the stomach and this organ was carefully emptied by suction. The ulcer was excised with scissors down to the region of the pan- creas to which it was attached by inflammatory adhesions. A perforating point connected directly with the surface of the pancreas. The mass was easily separated without hemorrhage and without painful sensation to the patient. All bleeding points in the severed stomach wall were ligated and the edges united by two layers of chromic gut. A cigarette drain was inserted into the lesser peri- toneal cavity and the abdomen closed in layers. At the beginning of the operation the patient's pulse was 80, and at the close, 70. There was no change in blood-pressure or color. She was dis- charged fifteen days later. Patients in desperate condition from perforated ulcers may sometimes be operated upon under this system to great advantage. See Case No. 13058, which follows: Report of Case No. 13058. C. J., aged sixty years, entered the hospital December 3, 1920. Diagnosis: Perforated duodenal ulcer. Operation: Pylorectomy. Anesthesia: Local infiltration and anterior splanchnic. History: The patient had been on an ulcer regime for two weeks. On December 6, he was seized with a sudden severe pain at 1 a.m., and a hypodermoclysis was begun beneath the pectoral muscles. A diagnosis of a perforating ulcer of the duodenum was made, and he was operated upon, a resection being done. A transverse infiltration was made across the upper abdomen and a vertical limb was added to this. One-half hour before the operation he had been given a hypodermic of morphine gr. |, without relief of pain. He was cyanotic and his pulse was 160. Immediately upon blocking the abdominal wall the muscles became relaxed to some degree and he volunteered the information that the pain had been much relieved. The abdomen was opened with- out extrusion of the viscera. 426 SURGERY OF THE UPPER ABDOMEN Examination showed an angry-looking, thickened mass in the duodenum which presented a perforation on the anterior surface. An attempt was made to close the perforation, but the tissues were so friable that the sutures cut through. It seemed that only by a resection could the indications be met, although the patient's condition was such that this course seemed hardly justified. Anterior splanchnic anesthesia was established. The duodenum was partially mobilized and a "V"-shaped piece, including the tumor, was excised between clamps. A large stomach tube was then passed through the esophagus and made to emerge through the pylorus. From there it was introduced into the jejunum a distance of 15 cm. It was but a moment's work to introduce a continuous catgut suture along the severed edge of the duodenum, reestablishing a canal. The abdomen was then hastily closed with drainage. For a period of fourteen hours following the operation the patient's pulse could not be felt at the wrist. 250 cc of hot water were introduced into the jejunum every three hours. He made a slow but uninterrupted recovery. He was once more placed on the ulcer management and remained fairly well for six months. However, he began to have recurrent attacks of vomiting and an examination fourteen months after the operation showed food retention, hyperchlorhydria and stenosis at the point of the duodenal resection. A pneumoperitoneum showed extensive visceroparietal adhesions between the umbilicus and the ensiform. On January 11, 1922, the patient reentered the hospital. Diagnosis: Recurrent duodenal ulcer; duodenal stenosis, incisional hernia; visceroparietal adhesions and left inguinal hernia. Operation: Posterior gastroenterostomy; division of adhesions; repair of incisional hernia. Technic of Anesthesia: Infiltration block and anterior splanchnic. A circumferential infiltration block was made about the site of the former incision and the abdomen opened with negative pressure. The abdominal wall was retracted vertically, and the greater omentum, transverse colon and anterior surface of the pylorus were separated from the parietal peritoneum without causing hemorrhage. The duodenum was examined and found to con- tain a hard mass, causing constriction. An anterior splanchnic anesthesia was established and a posterior gastroenterostomy performed after the method of Moynihan. The abdominal parietes presented a defect approximately 10 cm. long. The intercostal nerves were blocked in the nipple line and a flap of skin and sub- cutaneous tissue raised, after which a reversed pedicle flap of pectoral fascia, 18 cm. long and 12 cm. wide, was dissected down- THE STOMACH 427 ward from the thoracic wall and sutured to the lower edge of the abdominal hernia. (See page 407.) The patient's pulse at the close of the operation was 80. He went through his convalescence without nausea, vomiting or thirst, but developed a septic bron- chitis about the fourth day, which annoyed him for three or four days. Twelve days after the performance of the gastroenterostomy a left inguinal hernia was repaired under local anesthesia after the method of Torek. Sleeve Resection.-Sleeve resection for hour-glass stomach re- quires infiltration of the abdominal wall, and anterior splanchnic anesthesia. The following case will illustrate the technic of this procedure: Report of Case No. 9216. F. S. C., aged sixty-three years, entered the hospital May 16, 1916. Diagnosis: Chronic gastric ulcer with an hour-glass contraction. Operation: Sleeve resection. Anesthesia: Local infiltration and anterior splanchnic. History: The patient weighed 50 kilograms, while her normal weight was 55 kilograms. For a number of years the patient had had distress two or three hours after each meal, which was relieved by food and soda. This condition had continued for ten years, and seemed to be worse in the spring and fall. A year before entering the hospital she had had a severe hemorrhage from the stomach. She was frequently compelled to get up at night to take food and soda for the pain. Roentgen rays of the stomach showed an hour-glass contraction. Preliminary Medication: Morphin gr. | and scopolamin gr. i 2 ° O' Technic of Anesthesia: Local infiltration block. A transverse infiltration was made across the upper abdomen, and both recti divided. This was followed by a vertical infiltration, and an incision from the midline to the ensiform. A perfect negative pressure was obtained. The stomach presented a stricture at the midpoint with a thickened mass in the lesser curvature. The stomach was freed over its central area after injecting the lesser omentum with novocain-adrenalin solution. Clamps were placed directly on either side of the mass, extending from the greater to the lesser curvature. A sleeve resection was made and the stomach reconstructed by the use of chromic catgut sutures, the shoemaker stitch being used. The abdomen was closed with- out drainage. 428 SURGERY OF THE UPPER ABDOMEN Note.- The small intestine was not seen at any time during the operation. At the close of the operation the patient's pulse was 76. There was no postoperative nausea or vomiting, and she made an uneventful recovery. The accompanying chart (Fig. 180) shows the pulse rate before, during and after the operation, covering in all a period of one week. Fig. 180.-Hour-glass stomach. Postoperative chart of Case No. 9216 following "sleeve" resection. Neoplasms (Malignant). -Resection for Carcinoma. -Gastric re- section for carcinoma is possible under infiltration of the ab- dominal wall, combined with anterior or posterior splanchnic anesthesia. The welfare of these patients demands the use of every artifice known to surgery in order to safeguard them against the dangers connected with such an extensive procedure as gastric resection. The incision should be ample and in some cases we have not hesitated to divide two or three ribs and draw back a flap at the costal border in order to avoid making too much traction upon the stomach wall. The splanchnic anesthesia may be reinforced at any time when a vessel is encountered, although the stomach wall itself need not be infiltrated. The following case will illustrate the application of local anes- thesia to surgery of malignant disease of the stomach, with the combined use of abdominal infiltration and anterior splanchnic anesthesia: THE STOMACH 429 Report of Case No. 9214. 1). E., aged sixty years, entered the hospital August 17, 1916. Diagnosis: Cancer of the greater curvature of the stomach. Operation: Gastric resection. Technic of Anesthesia: Local infiltration and anterior splanchnic. A transverse infiltration across both recti was made, using 150 cc of a 0.5 per cent novocain-adrenalin solution. The abdomen was opened with perfect negative pressure and a large tumor in the greater curvature presented in the incision. The lesser omentum was infiltrated with novocain-adrenalin solution and divided. After a thorough examination of the liver, which revealed no signs of metastasis, it was decided that the case was probably operable. The retroperitoneal space, which was exposed after dividing the gastrohepatic omentum, was carefully infiltrated with novocain-adrenalin solution. The duodenum was then divided between clamps and the stomach turned out to the left. This was entirely painless. The stomach was divided between clamps beyond Hartmann's line. This maneuver also was painless. The jejunum was anastomosed to the lower portion of the gastric incision, the remainder of which was closed with linen. The patient's pulse was 74 at the completion of the operation, with no change in his color or general condition, except that he was tired. The operation required one hour and thirty minutes. His recovery was uneventful. The next case illustrates how the mobilization of the chest wall facilitates extensive gastric resections in desperate cases. Report of Case No. 13658. J. M., aged fifty-two years, entered hospital March 2, 1920. Diagnosis: Carcinoma of stomach. Operation: Gastric resection. History: The patient has had gastric symptoms since September, 1919. There are no obstructive symptoms. Examination shows a large mass at the pyloric end of the stomach, undoubtedly malig- nant in nature. Technic of Anesthesia: Intercostal block of left side in nipple line from the fifth rib downward. Transverse infiltration across the recti with a vertical limb in the midline. Operation: T-incision. Abdomen opened with a perfect negative pressure, only stomach and colon being visible. The liver showed no involvement. The tumor was freely movable and occupied 430 SURGERY OF THE UPPER ABDOMEN the mesial half of the stomach, extending well up on the lesser curvature. The stomach lay extremely high and the growth extended well under the costal margin. A skin flap was raised and several ribs were divided near the nipple line, thus allowing the chest wall to be retracted and giving an excellent exposure. An anterior splanchnic anesthesia was established, the lesser omentum being divided and ligated. The pylorus was then divided between clamps and the stomach turned to the left, all retaining bands being infiltrated before division. This procedure was entirely painless. Resection was then made without the use of clamps, the bleeding vessels being picked up as they appeared. The jejunum was located. The Polya operation was then per- formed. The abdomen was closed without drainage. The patient went on smoothly for ten days, at which time he began to have pain in his upper abdomen, progressive weakness and sank rapidly, dying on the twelfth day. Autopsy showed a necrosis of the cardiac end of suture line with gangrene of the wall of the stomach over an area approximately the size of a silver dollar. Note.-This patient went through his operation, which was very extensive, without shock or depression, and under the technic employed the anesthesia was ideal. However, possibly some error was made in the technic whereby the gastric blood supply was not properly conserved. No local infiltration was made in the region where the necrosis appeared so that the anesthesia could not have been a causative factor in the production of the gangrene. Hypertrophic Pyloric Stenosis.-There is no field in the whole domain of surgery in which the advantages of local over general anesthesia are so definite and clear cut as in the surgical treatment of this debilitating condition. By the judicious use of local anes- thesia and careful attention to the technical details the operation for the relief of this condition is brought close to the border-line between major and minor surgery. These little babies who usually weigh less than one-half the amount they did at birth are extremely hazardous risks, and the administration of general anesthesia is sufficient, in a certain percentage of cases, to sever the remaining thread of life. Provided the obstruction can be overcome with- out adding too greatly to the depression already present, or with- out increasing the depletion of other vital forces to too great an extent, the opportunity for spectacular results is amazing. Local anesthesia in these cases, in order to be successfully carried out, must be fortified by many other adjuncts. The following plan, developed in the author's clinic, will be given somewhat in detail, as it is believed that the difference between success and THE STOMACH 431 failure in handling patients of this type is intimately associated with attention to a number of more or less important details. Before the beginning of the operation the child's stomach should be emptied by the passage of a tube, and as much fluid and gas as possible expressed by making firm pressure upon the abdominal wall. The patient should be restrained by the method shown in Figs. 181 and 182. We have found the following arrangement of PSYCHO- ANESTHETIST OPERATING TABLE Fig. 181.-Method of restraining children during operation. the table most satisfactory. A small arm-table is placed at right angles to the rectangular operating table and the child is laid upon it with its body encased in a thick pad of sterile cotton. The feet are anchored to the opposite side of the operating table and the anesthetist, who is seated at the child's head, grasps the arms in her hands and is thus prepared to make traction upon the child's body whenever necessary. The abdominal wall is sterilized and 432 SURGERY OR THE UPPER ABDOMEN the sterile drapes are applied, the operating table being used as an instrument table. The surgeon sits at the right of the child and his assistant at the left (Fig. 185). But 15 to 30 cc of solution are required to anesthetize the abdominal wall (Fig. 184). Fig. Fig. 182.-Hypertrophic pyloric stenosis. Restraint of child. Fig. 183.-Hypertrophic pyloric stenosis. Ensemble pneumatic injector psycho- anesthetist, sterile towel guard and instrument table, child ready for operation. 185 shows the abdominal field isolated by sterile drapes, the position of the psycho-anesthetist and the pneumatic injector separated from the sterile field by means of a sterile towel which is attached THE STOMACH 433 to the towel rack. A sufficient amount of solution should be used to insure the establishment of absolute anesthesia. The abdominal Fig. 184.-Hypertrophic pyloric stenosis. Anesthesia technic; infiltration of abdominal wall. Fig. 185.-Hypertrophic pyloric stenosis. Photograph, ensemble, surgeon, assistant and psycho-anesthetist. wall should be elevated while the incision is being made (Fig. 185, also Fig. 212, page 490). 434 SURGERY OF THE UPPER ABDOMEN It is important to make the incision at about the level of the lower border of the liver. We prefer the transverse incision, which if made at this level and without pain to the patient, obviates the necessity of combating coils of small intestine during any stage of the operation. Fig. 186.-Hypertrophic pyloric stenosis. Photograph of skin elevation during incision. As soon as the abdomen is opened, one may, by carefully retract- ing the liver's edge, visualize the hypertrophied pylorus, provided the stomach, which is always thick-walled and large, has previously Fig. 187.-Hypertrophic pyloric stenosis. Pylorus delivered. been completely emptied. Should the stomach obscure the view of the pylorus it may be gently retracted toward the left by means of a small retractor covered by a piece of gauze. As soon as the pylorus is visualized it may be grasped with a pair of delicate intestinal forceps (Fig. 26, page 110) and elevated into the incision THE STOMACH 435 in such a manner as to form a barrier to the extrusion of the intestines should the child strain during the remainder of the operation. (Fig. 187.) The delivery of the pylorus is made by means of deli- cate forceps which are preferable to the use of one's fingers. The latter demand more room and a larger incision, and are more apt to cause the child distress. While the assistant steadies the pylorus, Fig. 188.-Hypertrophic pyloric stenosis. Ranmistedt's operation. Insert shows line of ipcision. the surgeon may carefully perform the Rammstedt operation (Fig. 188) under the most favorable conditions, i. e., the "silent" field. Just before returning the pylorus to the abdomen a fine suture may be introduced into the upper flap of the divided pyloric ring, and, after its return, the needle carrying the suture may be passed through a tab of omentum, which may thus be anchored over the pyloric incision. (Fig. 189.) We have, in 436 SURGERY OF THE UPPER ABDOMEN repeated instances, performed these operations without the child crying or making any expulsive effort throughout the whole pro- cedure. Fig. 189.-Hypertrophic pyloric stenosis. Rammstedt's operation, omental graft in place. Insert: Sectional view of same. Case Reports Nos. 13831 and 11746 show the manner in which hypertrophic stenosis in infants may be treated surgically under local anesthesia. Report of Case No. 13831. B. S. M., aged three weeks, entered the hospital June 4, 1920. Diagnosis: Hypertrophic pyloric stenosis. Operation: Rammstedt pyloric incision. Anesthesia: Local infiltration. THE STOMACH 437 History: The patient had had regurgitant vomiting since birth, at which time he weighed 3600 gm. At the time he entered the hospital he weighed but 1800 gm. A diagnosis of congenital hypertrophic pyloric stenosis was made. Technic of Anesthesia: Local infiltration of abdominal wall. The Rammstedt operation was performed under local anesthesia. Just before opening the abdomen the stomach was emptied by passing a tube through the esophagus and making pressure upon the abdominal wall. 20 cc of a 0.7 of 1 percent novocain-adrenalin solution were used. A transverse infiltration was made (see Fig. 184, page 433) and the right rectus divided. The incision lay just above the edge of the liver. The liver was gently retracted and the pylorus was seen and delivered by means of rubber-tipped thumb forceps. The Rammstedt operation was done. One suture held a piece of omentum over the pyloric incision and 180 cc of normal saline solution were injected into the peritoneal cavity before closing the incision. The baby began taking mother's milk at once, and vomited but once, four days later. He made an uneventful recovery and was discharged from the hospital four days after the operation. Note.- This patient was cyanotic at the time of the operation. He was extremely emaciated, and in the judgment of the author the worst risk he has had in this class of cases. Report of Case No. 11746. G. M., aged three weeks, entered hospital October 7, 1918, when weight was 1800 gm. Diagnosis: Hypertrophic pyloric stenosis. Operation: Rammstedt's operation. (Pyloric incision.) Anesthesia: Local infiltration. History: Baby commenced vomiting when ten days old. Vomit- ing has been persistent. Patient has lost 1300 gm. in weight. Technic of Anesthesia: 30 cc of 0.5 per cent novocain-adrenalin solution were injected transversely across the upper abdomen. (Fig. 184, page 433.) The patient was carefully wrapped in cotton and the restraint applied (Fig. 181, page 431). Iodine preparation of the skin fol- lowed. The incision was made between towel pins and the child did not cry. The stomach was emptied by the passage of a tube just before the abdomen was opened. The pylorus showed a marked hypertrophy as it was brought up with the long intestinal rubber-tipped forceps. The pyloric muscle was divided and the omentum was tacked over the mucosa with one fine catgut stitch. The abdomen was closed and the child made an uneventful recovery. 438 SURGERY OF THE UPPER ABDOMEN THE LIVER. Cysts, Abscess and Rupture.-The liver tissue may be cut or sutured without pain to the patient, and one may therefore per- form any operation upon this organ under local anesthesia, pro- vided the tissues can be visualized. The author's experience in operating upon the liver under local anesthesia is confined to cases of liver abscess and rupture of the liver. Cysts.-Cysts may be excised or incised without additional anesthesia after the abdomen has been opened, provided traction on the liver has been avoided-otherwise anterior splanchnic anesthesia will be demanded. Abscess.-Abscesses may be drained with facility under this form of anesthesia, and the technic described above should be adequate, as it details the method of exposing this organ. Rupture. Rupture of the liver presents a condition which should, when it is possible, be treated by the use of local anesthesia. The following case will illustrate this point: Report of Case No. 12402. C. J., aged nine years, entered hospital November 5, 1919, at 11 P.M., giving the following history: Eleven hours previously the patient was struck by an auto and thrown to the ground. When seen by Dr. T. J. Moynihan, who referred the case for operation, the boy was in a dazed condition, but showed no abrasions upon the body. He was placed in bed and left with an attendant, and eight hours later, when the doctor was hurriedly summoned, was found to be in serious condition. He was sent to the hospital and the author was called to see him in consultation. The. child at this time showed rapid and shallow respiration. He was extremely pale and unconscious. His pupils were dilated; the pulse imperceptible and the abdomen was distended and dull in both flanks. The patient was ordered at once to the operating room, and as the woman who had been driving the auto by which the boy was struck volunteered to act as donor, 400 cc of blood were withdrawn as rapidly as possible. The condition of the boy was so desperate that an assistant reported to the operating room that there was no necessity of bring- ing the boy up, as he would be dead before arriving there. Not- withstanding the fact that two hours previously the boy's pulse was 120 to 130, when he entered the operating room he was appar- ently breathing his last and the transfusion of citrated blood was begun (without previous grouping). While his associates trans- THE LIVER 439 fused the boy, the author began infiltrating the abdominal wall with 0.5 per cent novocain-adrenalin solution along the midline. The transfusion and infiltration began simultaneously and within three minutes the child's pupils contracted rapidly and the pulse soon became perceptible. A 15 cm. midline incision was made and a large quantity of fresh blood escaped from the abdominal cavity. The liver was inspected and seemed normal, although shrunken and pale. The intestinal tract and spleen were carefully gone over and no lesion demonstrated. It was therefore necessary to "dry out" practically the peritoneal cavity, as it was apparent that the child was still bleeding, and finally fresh blood could be seen welling up through the foramen of Winslow. The gastro- hepatic omentum was quickly opened and the subhepatic fossa sponged out, when an examination showed the liver ruptured pos- teriorly and separated from its normal attachments. The bleeding area was quickly packed with gauze. The peritoneal cavity was filled with physiological saline solution and closed. A rubber dam was placed about the packs isolating them from the raw surfaces. At the close of the operation the boy's pulse was plainly per- ceptible with a rate of 140. He was conscious, was placed in bed in the Trendelenburg position and given morphine sulphate, gr. He was in the operating room two hours. Two hours after the completion of the operation the pulse once more became imper- ceptible, the child complained of air-hunger and death seemed imminent. The transfusion was repeated, 300 cc of citrated blood being given. Following this the recovery of the child was uneventful. He remained in the hospital three weeks, most of which time was occupied in efforts to extract the gauze from the abdominal cavity. Note.- This child was given 120 cc of 0.5 per cent novocain- adrenalin solution before the circulation had received an appre- ciable amount of the citrated blood. It will be noted that immediately after the administration of the anesthetic solution a marked change in the child's condition supervened. This probably was due largely to the action of the adrenalin. However, in a number of similar instances this transformation has been duplicated and it is believed that novo- cain also is to be considered more or less of a stimulant under such conditions. Unfortunately, however, the stimulating effect is not, as a rule, maintained over any considerable length of time. While it seems probable that the adrenalin may be credited with a marked effect upon the recuperative power in individuals who are depleted, the conviction is not complete that its intravenous administration in physiological salt solution has produced the spec- tacular results which have followed the use of the novocain- adrenalin combination. 440 SURGERY OF THE UPPER ABDOMEN GALL-BLADDER AND DUCTS. The position of the patient on the table is a very important ad junct to the success of gall-bladder surgery under local anesthesia and the reverse Trendelenburg should be established before the anesthesia is started. The incisions which give the best exposure of the gall-bladder and ducts are the diagonal trans-rectus incision of Kocher or the transverse incision of Maylard combined, when necessary, with a vertical incision at or near the midline.. (See page 392.) Fig. 190.-Gall-bladder. Anesthesia technic; subdermal infiltration of abdominal wall. F, wheal for deep infiltration block. Technic of Anesthesia.-The incision is preceded by an infil- tration of the abdominal wall, special care being taken to deposit a liberal amount of solution into the region of the round ligament of the liver. This is done by introducing the needle through the linea alba in the midline, high up. A secondary infiltration block is made along the costal border (Fig. 190), in order to prevent pain in this region when retraction is used after the abdomen has been GALL-BLADDER AND DUCTS 441 opened. The height of the transverse incision should be governed, to some extent, by the position of the lower border of the liver. Opening Abdominal Cavity.-As is the rule when making other abdominal incisions, the abdominal wall is retracted vertically while being incised (see Fig. 212, page 490), and every effort is made to enter the abdomen without the patient's knowledge, or rather without the abdominal muscles knowing of the intrusion. In this manner a combative action on the part of the muscles is avoided. Every effort is made to obtain the much desired negative pressure. Success will give one the opportunity of making an examination of all the organs in this region and they may be seen lying and even functioning, normally or abnormally, as the case may be. Cholecystostomy.-Simple drainage of the gall-bladder under local anesthesia offers no special difficulty and may be carried out under anesthesia of the abdominal wall only. However, if one is to combine with cholecystostomy a complete exploration of the ducts and an examination of the pancreas, the operation offers considerable difficulty if it is to be performed under local anesthe- sia exclusively. The operation of cholecystectomy has been found much less trying under this form of anesthesia than that of chole- cystostomy when the latter is combined with complete exploration of the ducts. The exposure which is so desirable in working upon the ducts is more difficult to obtain before the freeing of the gall- bladder has been accomplished. After freeing the gall-bladder the exploration of the ducts becomes comparatively more simple. One may, however, by placing a gauze pad over the gall-bladder and lower surface of the liver, carefully retract these organs up- ward; then by retracting the stomach and duodenum downward one may' visualize the ducts and palpate them after the estab- lishment of anterior splanchnic anesthesia. Sensation of the Gall-bladder.-The gall-bladder which is not acutely' inflamed is not tender, provided traction is avoided. There- fore, aspiration of the gall-bladder, suture of its wall, the removal of gall stones which lie freely within its cavity and the placing of drainage tubes may all be accomplished without pain if, as stated above, traction is avoided. Any attempt, however, to manipulate the acutely inflamed and distended gall-bladder will be apt to bring forth strenuous complaint on the part of the patient. Cholecystectomy.-The author has performed cholecystectomy in approximately 90 per cent of gall-bladder cases during the last ten y'ears and most of these have been done exclusively^ with local anesthesia. The technic which he has found most satis- factory will be described. Exposure.-After removal of the gall-bladder has been decided upon, three long narrow dry gauze sponges are carefully' intro- 442 SURGERY OF THE UPPER AR 1)0MEN duced, the introduction of each being followed by the placing of a wire spring retractor. (See Fig. 12, page 99.) One of the gauze sponges is placed against the upper surface of the duodenum and transverse colon and the long loop of the retractor forces this organ downward toward the pubes. Morris's pouch is likewise packed and a retractor of the same type forces the colon out of the field and to the right. A third pack and retractor forces the stomach and pylorus to the left. If collapsible, the gall-bladder fundus is now grasped by a pair of noncutting artery forceps. Fig. 191.-Gall-bladder. Cholecystectomy. Anesthesia technic; gall-bladder "blowing off." Gauze packs omitted for purpose of clarity. The patient is requested to inhale deeply and as he does so, the gall-bladder will be forced out through the incision where its position may be maintained during exploration (Figs. 191 and 192). While the liver advances during deep inspiration its edge may be retained by means of gentle pressure with a retractor and, as the process is repeated, it will effect a slight rotation of the liver within the abdominal cavity (Fig. 193). Each forced inspiration will increase one's view of the gall-bladder and in certain individuals it may be possible, by continuing this process, to deliver the gall-bladder GALL-BLADDER AND DUCTS 443 well out of the abdominal cavity. One should be careful to avoid traction upon the gall-bladder and should be satisfied with simple retention of the organ in the position to which it is brought by the patient's respiratory efforts. (Figs. 195, 196 and 197.) Fig. 192.-Gall-bladder. Sagittal view. Excursion of liver during respiration Anterior Splanchnic Anesthesia.-As soon as this process has been carried out to the extent which allows one to visualize the region of the origin of the cystic duct, anterior splanchnic anesthesia may 444 SURGERY OF THE UPPER ABDOMEN be established. This is accomplished by the introduction of a few cubic centimeters of novocain-adrenalin solution just beneath Fig. 193.-Gall-bladder. Saggital view. Showing rotation of liver and exposure of gall-bladder. (Anterior splanchnic anesthesia, shown in Fig. 29. From Ani- mated Motion Pictures.) the peritoneum on either side of the line of the common duct and as high up as possible (Fig. 193, and Fig. 29, page 128). In certain cases one may now remove the gall-bladder by first dividing the GALL-BLADDER AND DUCTS 445 cystic duct (Fig. 194). However, it has been found much more simple to remove the gall-bladder fundus first, simply because Fig. 194.-Gall-bladder (cholecystectomy). Clamping of cystic duct. Fig. 195 -Gall-bladder, gauze tractor. Photograph of Case No. 13722 undergoing cholecystectomy. 446 SURGERY OF THE UPPER ABDOMEN the fundus is the first portion met and may be attacked without as much manipulation as is found necessary if the attack is to be begun at the cystic duct. Large, thickened gall-bladders, or those acutely distended and upon which forceps cannot be applied, may often be controlled by the gauze retractor (see Fig. 35, page 159). Fig. 195 shows a patient undergoing an operation. The gall- bladder is being controlled by the use of the gauze tractor. It may be noted that this organ is enlarged, its walls thickened and that the use of the gauze tractor greatly facilitates its manipulation. Technic of Exposing the Gall-bladder.-The patient may at will, by making a deep inspiration, show the gall-bladder or a large portion of the stomach to the surgeon, or even to the spectators. The pathological conditions may be noted and digital examination, if carefully made, may be carried out almost to any extent, pro- vided traction is avoided. By retracting the abdominal wall upward adhesions may be visualized (Fig. 170, page 396) and treated by cutting along the white line without the least difficulty. The greatest difficulty is encountered in heavy, obese individuals, whose livers lie well above the costal border. In these patients it may be best to establish a posterior splanchnic anesthesia by the method of Kappis (page 124) before entering the abdomen. However, the use of the reversed Trendelenburg position and forced inspiration has made it possible to visualize the gall-bladder and to establish splanchnic anesthesia by the anterior method in nearly all cases. The Method of Removing the Gall-bladder.-Before excision of the gall-bladder is begun the needle is inserted beneath the peritoneal coat of the gall-bladder, close to the liver edge (Fig. 191, page 442), and the organ is "blown off,'' or, in other words, separated from the liver surface by forcefully injecting novocain-adrenalin solution. The peritoneal coat may then be divided and the dis- section completed. The time required for freeing the gall-bladder allows the anterior splanchnic anesthesia to take effect. Not infrequently the anesthesia is so profound that sufficient traction may be made upon the gall-bladder to tear the cystic duct directly in two without affording the patient pain. After the removal of the gall-bladder the common and hepatic ducts may be explored without embarrassment, provided the lower edge of the liver is well inverted beneath the costal margin (Fig. 193, page 444). In the author's experience the delivery of a considerable portion of the liver upon the chest wall is not tolerated by the conscious patient without complaint of pain and, indeed, the patient under general anesthesia will in every instance resent profoundly this insult, as is evidenced by the increase in pulse rate, the change in the frequency and depth of respiration, signs which call for GALL-BLADDER AND DUCTS 447 deep anesthesia. Splanchnic anesthesia should be established before the operative procedure on the- gall-bladder is begun providing exposure can be obtained. The following case involved the gall-bladder, stomach and appendix. Report of Case No. 11521. J. H. C., aged forty-five years, entered the hospital May 9, 1918. Diagnosis: Cholecystitis; cholelithiasis; pyloric stenosis; recur- rent appendicitis. Operation: Cholecvstectomy; pyloroplasty; appendicectomy, May 11, 1918. Technic of Anesthesia: 150 cc of a 0.6 of 1 per cent novocain- adrenalin solution were used in making an "L" infiltration of the abdominal wall. (Fig. 163, page 390 and Fig. 190, page 440.) The abdomen was opened with a negative pressure and the liver was extremely high. The gall-bladder was white, thickened and contained stones. The pylorus was rigid and contracted from the scar of an ulcer. With the patient in reversed Trendelenburg position the liver edge was turned upward by means of a smooth retractor, the gall-bladder was grasped and the patient requested to take a number of deep inspirations. By this method the region of the cystic and common ducts was visualized and anterior splanch- nic anesthesia was established. The gall-bladder was removed, fundus first, and pyloroplasty was then performed. The patient was then tilted to the left and the Trendelenburg position taken. Vertical retraction showed the appendix and it was grasped and removed in the usual manner. A cigarette drain was placed through the upper flap of the incision. Note.- This patient did not vomit following her operation. She returned to bed with a pulse of 80 and made an uneventful recovery. The following case is cited to illustrate the use of local anesthesia in acute septic conditions associated with the gall-bladder: Report of Case No. 14207. I). R. S., physician, aged forty-eight years, entered the hospital March 30, 1921. Diagnosis: Suppurative cholecystitis; cholelithiasis; perforation of gall-bladder; localized peritonitis. Anesthesia: Local infiltration. Operation: Incision and drainage. History: Patient has had frequent attacks of upper abdominal cramps which are evidently associated with the gall-bladder. Two weeks prior to his entry into the hospital he had suffered a severe attack of pain similar to his former attacks, followed by a rise of 448 SURGERY OF THE UPPER ABDOMEN temperature and extreme illness. His temperature averaged 102° since the beginning of this attack. Examination showed a distinct tumor in the upper abdomen in the region of the gall-bladder. The mass was extremely tender. A diagnosis of localized abscess, with probable gall-bladder perforation, was made. Technic of Anesthesia: Infiltration, using 120 cc of a 0.7 of 1 per cent novocain-adrenalin solution in the abdominal wall. The right rectus muscle was divided and the general peritoneal cavity opened without the extrusion of the viscera. All tissue was divided between forceps which elevated the abdominal wall, thus avoiding pressure upon the tumor which was extremely tender. Above the incision the tumor mass was seen to be adherent to the parietal peritoneum. The general peritoneal cavity was packed and a blunt-pointed forceps used to separate the line of adhesions. From 200 to 300 cc of thick, creamy, bile-stained pus was evacuated by suction and a number of gall-stones were found lying free in the cavity of the abscess. This patient was in a critical condition, with marked myocardial degeneration and albumin and casts in the urine. He had been taking huge doses of morphine for two weeks and although extremely septic and nervous, he went through the operation without any material change in his condition and he stated that he enjoyed it. This case furthermore illustrates the use of local anesthesia in acute septic conditions in the upper abdomen as well as the facility with which extensive operative procedures may be carried out if surgical interference becomes necessary and the hazard connected with the use of inhalation anesthesia is considered to be too great. Two weeks following the operation he was up in a chair and he made an uneventful recovery. Report of Case No. 13722. Mrs. A. C. E., aged thirty years, entered hospital March 15, 1920. Diagnosis: Hydrops of the gall-bladder. Operation: Cholecystectomy. Technic of Anesthesia: 120 cc of a 0.5 of 1 per cent novocain- adrenalin solution. No preliminary hypodermic medication. An "L" infiltration of the abdominal wall and an "L" incision dividing the right rectus muscle between clamps were made. The gall-bladder was large, firm and distended. The pancreas, duodenum and stomach were examined, but the colon and small intestine were not seen. The pylorus, duodenum and Morris's pouch were gently excluded by gauze packs and the use of wire- spring retractors. Voluntary, forced inspiration caused the gall- bladder to protrude well outside the abdominal cavity, after which GALL-BLADDER AND DUCTS 449 gentle traction upward brought the region of the cystic duct into view. (Figs. 191, page 442, and 194, page 445, and 29, page 128.) A long fine needle was inserted first to the right and then to the left of the common duct through the posterior parietal peritoneum, and 10 cc of the solution introduced upon each side of the common duct. The needle was then inserted between the gall-bladder and the liver at the point of their distal attachment, and a liberal supply of solution injected between the two organs. The photo- graph shows the ease with which the gall-bladder was visualized under this technic. (Fig. 196.) Fig. 196.-Gall-bladder (cholecystectomy). Photograph of Case No. 13722 during operation. Note exposure obtained without dislocating the liver. Report of Case No. 14398. Mrs. G. II., aged thirty-five years, entered hospital September 26, 1921. Diagnosis: Pulmonary tuberculosis (active); cholecystitis; chole- lithiasis; recurrent appendicitis. Operation: Cholecystectomy; appendicectomy. History: The patient has had tuberculosis of the lungs with sanatorium treatment for eight years and her condition improved. The abdominal condition dates back four months. Gastric symp- toms were so severe that they interfered with the patient's nourish- ment and she was referred by Dr. J. W. Marcley, who felt that unless her nourishment could be improved she would rapidly succumb on account of her pulmonary condition. The patient had also had several attacks of acute appendicitis. Accordingly cholecystectomy and appendicectomy were performed at one sitting under local anesthesia. 1 )r. Marcley thought it would be extremely dangerous to establish general anesthesia in such a case. In fact, 450 SURGE UY OF THE UPPER ABDOMEN her attacks of acute appendicitis had been treated expectantly on this account. Fig. 197 shows a picture of the patient while undergoing operation, the cystic duct being plainly visible in the field. The patient withstood the operation without any signs of trouble and without appreciable effect on the lung condition. The gastric symptoms have entirely disappeared. Fig. 197.-Gall-bladder. Photograph of Case No. 14398, showing voluntary exposure of gall-bladder and cystic duct. The possibility of making multiple incisions and doing multiple operations under local anesthesia is illustrated by the following case: Report of Case No. 10073. J. M. D., aged thirty years, entered hospital September 12, 1917. Diagnosis: Appendicitis; cholecystitis; uterine retroversion. Operation: Appendicectomy; cholecystectomy; hysteropexy. Anesthesia: Local infiltration (multiple incisions) anterior splanchnic. History: The patient was a deaf mute and it was therefore difficult to obtain a history of her symptoms, which were more or less obscure. She was just over a well-established attack of acute appendicitis which had begun several days previously. She was placed on management for a few days until she had entirely recovered. Her history showed that she had had undoubted attacks of cholecystitis and on bimanual examination the uterus was found to be retroverted, which fitted her symptoms of back- ache. GALL-BLADDER AND DUCTS 451 Technic of Anesthesia: Twelve days after entrance to hospital, classical infiltration block was made using 60 cc novocain-adrenalin solution of 0.5 of 1 per cent. The gridiron incision showed the appendix in the pelvis and practically normal. It was removed through the incision, which was small. The right rectus was then divided after an infiltration block across it and the gall-bladder, which was white and thickened, and to which the omentum was adherent, was removed after making an anterior splanchnic infil- tration. These two operations having consumed but forty minutes and the diagnosis having been changed after exploration had been made to subacute cholecystitis rather than appendicitis and the patient being in excellent condition, it was deemed advisable to replace the uterus in its normal position. Accordingly a midline infiltration and incision was made below the navel, the round ligaments shortened and the abdomen closed. This patient made an uneventful recovery. Note.-But 210 cc of novocain-adrenalin solution were used in order to carry out the three operations. The time required for making the three operations was one and a half hours, including the making of the infiltration and the closure of the three incisions. From the standpoint of diagnosis this case is not especially gratify- ing; however, it illustrates the comparative ease with which one may carry out multiple procedures under the use of local anesthesia. The error in diagnosis in this case must be given as the reason for making three incisions instead of two. However, we have in a number of instances operated for conditions in the upper abdomen and the lower abdomen, besides doing vaginal work, all at one sitting and with no more embarrassment than when general anes- thesia is employed. As examples of the extensive operative manipulation in the abdomen under local anesthesia the following cases may be cited: Report of Case No. 15427. Mrs. G. M., aged thirty-four years, entered the hospital January 26, 1922. Diagnosis: Subacute cholecystitis; viscero-parietal adhesions; retroversion of the uterus and right ovarian cyst. Operation: Cholecystectomy; division of adhesions; excision of ovarian cyst; and hysteropexy. Anesthesia: Local infiltration block. History: Patient had been operated upon five years before by the author for exophthalmic goiter, local anesthesia being used. She made a perfect recovery from this operation, and has remained 452 SURGERY OF THE UPPER ABDOMEN well as far as her thyroid is concerned, but the patient now comes to hospital for treatment of abdominal condition. Technic of Anesthesia: The abdomen presented four vertical scars, the result of former operations, and an infiltration block was made at the edge of the right rectus muscle on one side of the scars and along the midline on the other side extending from the costal border to a point 8 cm. below the umbilicus, 250 cc of a 1 per cent solution of novocain-adrenalin being used. The old scars in the skin were excised and a right midline incision 25 cm. long was made, with the patient in the Trendelenburg position, a perfect negative pressure, and a pelvis free of intestines was obtained. Several loops of small bowel and a large amount of the greater omentum were found adherent to the parietal peri- toneum. The adhesions were all divided without reinforcing the anesthesia. The round ligaments were plicated. A right ovarian cyst the size of an orange was removed after blocking the ovarian pedicle. The lower 8 cm. of the incision were sutured and a reverse Trendelenburg position was substituted for the Trendelenburg and the upper abdominal viscera examined. The diagnosis of cholecystitis was confirmed. The stomach, colon and duodenum were carefully excluded from the field by means of pads and the wire spring retractors, and the gall-bladder was removed by the technic described on page 440. The time required for the completion of the operation including the introduction of the anesthetic was one hour. The patient's pulse was 80 at the completion of the operation. She did not vomit following the operation but developed a slight bronchitis the following day. Her temperature rose to 100.4° and her pulse to 100 on the second day, but on the sixth day both were normal. Note.-This case illustrates a considerable series of this type in which multiple operations have been done under direct infiltration of the abdominal wall with practically the same facility one would meet in carrying out the same procedure on the cadaver. As an example of the removal of both the gall-bladder and appendix, through a trans-rectus incision, the following case may be cited: Report of Case No. 10008. Diagnosis: Chronic cholecystitis; recurrent appendicitis. A. M., entered hospital August 22, 1917. Operation: August 23, 1917: Cholecystectomy; appendicectomy. Technic of Anesthesia: Local infiltration; anterior splanchnic; novocain-adrenalin solution, 120 cc of a 0.5 of 1 per cent being used. A transverse infiltration was made across the right rectus, 3 cm. above the umbilicus. The anesthesia was continued from the BILE DUCTS 453 outer end of this line diagonally along the costal margin. The right rectus was divided between muscle clamps and the abdomen presented perfect negative pressure. The stomach, pylorus and duodenum were palpated and examined visually and were found to be normal. The gall-bladder was large and white and pressure upon this viscus reproduced some of the patient's former symp- toms. A clamp was placed upon the fundus and the patient instructed to take repeated deep inspirations. An anterior splanch- nic anesthesia was produced by the injection of novocain-adrenalin solution in the region of common and cystic ducts which came plainly into view even without the use of abdominal packs. The gall-bladder was removed fundus first, the cystic duct divided between clamps and ligated with catgut. A cigarette drain was brought out through a stab wound 2 cm. above the incision. The patient was placed in the Trendelenburg position and rotated to the left. Vertical retraction of the outer angle of the incision showed the appendix adherent at the pelvic brim, also the presence of an extensive pericolic membrane. By the use of long instruments and good light the peritoneal attachments were separated, when the appendix and cecum were brought into the wound and removed in the usual manner. Our records show that the appendix and gall-bladder were removed in this case through a right trans-rectus "compromise" incision with little difficulty. The use of strategy, the tilting of the table and the presence of a negative intra-abdominal pressure and the use of anterior splanch- nic anesthesia were important sheet anchors in the successful accomplishment of this result. BILE DUCTS. Choledochotomy.-An exploration of the ducts may be carried out in most cases. In all cases where the stomach, duodenum, colon and liver are properly retracted and splanchnic anesthesia established the ducts can be gone over methodically and completely under this form of anesthesia. Exposure is the main strategic aim and may generally be achieved by the means described above. When there is difficulty in delivering the gall-bladder on account of a high-lying liver, extensive adhesions, or from any other cause, the procedure may be carried out, although with more difficulty, by following approximately the same methods as those described above, and working within the abdomen rather than outside. This kind of work requires a perfect light, the use of long, delicate instruments and small fine needles, and is facilitated by making use of the forceps tie. The hands should remain outside. To summarize therefore, a perfect anesthesia of the abdominal 454 SURGERY OF THE UPPER ABDOMEN wall, which abolishes the reflexes and allows one to obtain a negative pressure when opening the peritoneal cavity and strategic measures while operating, aided by splanchnic anesthesia, allows one to deal effectively with the surgical diseases of the gall-bladder and ducts in the vast majority of cases without resorting to general anesthesia. The following case is one of common bile duct obstruction treated surgically after the above method. Report of Case No. 10174. J. R. A., aged fifty-eight years, entered the hospital October 28, 1917. Diagnosis: Cholelithiasis; common duct obstruction. Operation: Cholecystectomy; choledochotomy. Anesthesia: Local infiltration; anterior splanchnic. History: Patient had had frequent attacks of gall-bladder colic. One month ago, severe attack of colic followed by relief with jaundice and clay stools. Jaundice is now nearly cleared up. The patient is still pale. The stools show presence of bile and the clotting- time of blood is normal. Technic of Anesthesia: The local infiltration required 120 cc novocain-adrenalin solution. An "L" incision was made and the right rectus was divided between clamps. A small white gall-bladder was found adherent to the duodenum. Adhesions were divided with scissors and anterior splanchnic anesthesia was established. After a number of deep inspirations had been taken by the patient and the gall-bladder, which had been grasped by forceps, had been turned upward, cholecystectomy was per- formed. The common duct was opened and a number of stones removed. A Kehr tube was sutured into the common duct and the abdomen was closed with drainage. The patient's pulse at end of the operation was 80. Recovery was uneventful. The next case will illustrate the facility with which desperate surgical risks may be operated upon under local anesthesia pro- vided certain principles be observed in carrying out the operation: Report of Case No. 13787. A. O., aged seventy-three years, entered hospital September 15, 1920. His maximal weight was 80 kilos, and his weight at the time of entering the hospital was 66 kilos. Diagnosis: Cholecystitis; cholelithiasis; common duct stone. Operation: Cholecystotomy and choledochotomy. Anesthesia: Local infiltration; anterior splanchnic. BILE DUCTS 455 History: For thirty years the patient had had frequent attacks of pain in the upper abdomen, with vomiting and jaundice. Five years prior to his entry into the hospital he had been jaundiced for a short time, and two weeks before entering he had had several attacks of severe pain, accompanied by jaundice. The jaundice increased, and his temperature ranged from 98° to 105°, being of the "steeple" variety. When he entered the hospital the clotting- time of his blood was six minutes, and he was having frequent rigors. A diagnosis of cholecystitis, cholelithiasis, and a common duct stone was made, and it was thought best to operate immediately. Technic of Anesthesia: Classical infiltration block (see Fig. 190, page 440). The abdomen was opened with extreme care, using an "L" incision. The right rectus was divided and a vertical limb of the incision was carried up to the ensiform. A marked localized peri- tonitis presented in the region of the gall-bladder. The field was carefully packed off with gauze pads, and wire-spring retractors were inserted. A perfect exposure was obtained. An attempt was made to grasp the thickened and distended gall-bladder, but this was impossible both on account of the pain produced and because of our inability to find sufficient slack in the gall-bladder wall to grasp it. The liver was therefore gently retracted upward and an anterior splanchnic anesthesia established by injecting on either side of the common duct which came plainly into view. The gall-bladder could then be manipulated without distress to the patient. It was aspirated and found to contain creamy pus. The common duct which was greatly distended was opened and the overflow of bile removed by suction, after which an impacted stone was removed. A Kehr tube was introduced and the common duct sutured over this with chromic gut. The gall-bladder was then opened and several stones were removed. A cholecystostomy was performed and the tubes brought out through a stab wound in the upper flap. The patient's pulse rate remained 75 throughout the operation. The time required for the administration of anesthesia and the completion of the operation was forty minutes. The patient made an uneventful recovery with the exception of the development of a parotitis on the right side. Note.- This case serves to illustrate the use of local anesthesia in acute septic conditions in the upper abdomen, and also shows the facility with which extensive operative procedures may be carried out under local anesthesia if it becomes necessary to inter- fere surgically and the hazard accompanying inhalation anesthe- sia is considered excessive. This operation was entirely without 456 SURGERY OF THE UPPER ABDOMEN shock to the patient and at the end of the operation he was in every way in as good condition as he was at the beginning. The following case illustrates the use of local anesthesia in the presence of complications: Report of Case No. 14301. W. M., aged fifty-eight years, entered the hospital June 13, 1921. Diagnosis: Cholecystitis, with a common duct stone; viscero- parietal adhesions. Operation: Cholecystectomy; choledochotomy; freeing of viscero- parietal adhesions. Anesthesia: Local infiltration; anterior splanchnic. Pneumoperitoneum was performed, using oxygen. Cholelithiasis was demonstrated by means of radiograms after inflation. Technic of Anesthesia: Infiltration, novocain-adrenalin 200 cc of a 0.7 of 1 per cent solution being used. A 15 cm. right rectus incision was made with the patient in reversed Trendelenburg position. The abdomen was opened with a perfect negative pres- sure which seemed to be facilitated by the presence of a portion of the oxygen which had been injected the previous day (see page 95). Viscero-parietal adhesions at the lower end of the incision at the site of the scar of a former operation were divided. The gall-bladder, which was white and thickened and contained many stones, was grasped with a hemostat and the patient instructed to breathe deeply. In this manner the posterior parietal peri- toneum was visualized and infiltrated with the anesthetic solution. Packs were then introduced one to the right in Morris's pouch, one to the left against the pyloric end of the stomach and one below, between the gall-bladder and duodenum. Three No. 6 wire- spring retractors were introduced, thus carrying the stomach and colon out of the field. At this juncture a stone could be seen and felt in the common duct. A needle was inserted between the gall-bladder and the liver beneath the peritoneum. 15 cc of the solution were introduced and the gall-bladder removed, fundus first, leaving 2 to 3 cm. of the cystic duct as a handle for the identi- fication of the common duct. The common duct was opened and the stone removed. (The common and hepatic ducts were opened directly under the vision.) The common duct was then sutured with fine chromic gut, a cigarette drain carried through the abdominal wall and the wound closed. In this patient, who was fairly heavy, the common duct was brought to the level of the rectus muscle during the exploration. The operation was painless, and at the close of the operation the patient's pulse was 70. THE PANCREAS 457 THE PANCREAS. The pancreas may be examined and even manipulated to some extent without any special distress to the patient. An anterior splanchnic anesthesia gives one a sufficient opportunity for the removal of concretions from the pancreatic ducts. Pancreatic cysts may be opened and drained without the use of intraperitoneal anesthesia, although the cyst wall may be infil- trated as it comes into view. Under local anesthesia this is a comparatively simple procedure. The following case report will serve to illustrate the technic: Report of Case No. 13824. J. W., aged fifty-one years, entered the hospital June 3, 1920. Diagnosis: Pancreatic cyst. Operation: Abdominal exploration; excision and drainage of cyst. Anesthesia: Local infiltration. Fig. 198.-Pancreatic cyst. Photograph of Case No. 13824 during operation History: Patient presented a large tumor in upper abdomen. June 4, a pneumoperitoneum was done and roentgenograms taken. Technic of Anesthesia: The infiltration of skin and rectus muscle required 150 cc. A vertical incision was made. A cyst the size of the patient's head presented, with the stomach just below it. The gall-bladder was large and white. The cyst was opened and evacuated by suction. The wall was 0.5 cm. thick filled with dark thin fluid. The posterior wall presented many dark blue hard nodules. Frozen sections showed carcinoma. Cyst packed with iodoform gauze and wound partially closed. Anesthesia was ideal. The patient's pulse, at end of operation, was 70. Fig. 198 shows the patient during the operation while the cyst was being aspirated. 458 SURGERY OF THE UPPER ABDOMEN THE SPLEEN. The spleen may be removed after simple infiltration of the abdominal wall, combined with a liberal infiltration of the splenic pedicle beneath the peritoneum or after the use of a posterior splanchnic anesthesia of the left side. The incision should be liberal, the patient should be in the reverse Trendelenburg position and tilted to the right. When anterior splanchnic anesthesia is to be used, a good exposure of the pedicle should be obtained by means of vertical retraction. The size and mobility of the organ will serve as a guide. Large or immobile spleens demand the preliminary establishment of the anesthesia of Kappis. Posterior splanchnic anesthesia as a preliminary is satisfactory for this operation. CHAPTER XVI. LOCAL ANESTHESIA IN SURGERY OF THE INTESTINES. Special Considerations.-In a consideration of the use of local anesthesia in the treatment of surgical conditions of the intestines, the subject naturally divides itself into two phases: (a) Treatment of Simple Conditions.-Under this are included operations of every nature upon the free and easily movable bowel, namely, resection, enteroanastomosis, colostomy, enterostomy, and other operations in which the indications are met with compara- tive ease after the establishment of anesthesia of the abdominal wall. (fe) Treatment of Complicated Conditions. - The treatment of complicated conditions involves excision for malignant disease and complicated intestinal obstructions, especially those of obscure origin. Diagnosis.-The carrying out of procedures within the abdomen is greatly simplified by the preliminary establishment of an accurate diagnosis, which permits proper planning of the abdominal incision both as regards length and location. Treatment of Simple Conditions.-The surgical treatment of the more simple intestinal conditions under local anesthesia may be carried out with facility and dispatch, provided perfect anesthesia of the abdominal wall is established and the proper strategy employed. The obtaining of a perfect negative intra-abdominal pressure, the use of the force of gravity to carry the viscera away from the field of operation by the tilting of the table, combined with the absence of expulsive effort, go far toward bringing this type of surgery close to ideal. Intestinal resection, enterostomy, colos- tomy, enteroanastomosis and, in fact, all operative procedures upon the free intestine may be carried out without great embarrass- ment provided traction can be avoided, and, fortunately, one may by the use of splanchnic anesthesia even find it possible to exert considerable traction if this should become necessary. The silent field, the absence of expulsive effort, the opportunity offered for deliberation and the possibility of avoiding trauma are of decided technical advantage in carrying out the above-mentioned operations under local anesthesia. 460 SURGERY OF THE INTESTINES Treatment of Complicated Conditions.-In this group may be placed all of the other surgical conditions of the intestines which occur, excepting those mentioned above, such as malignant disease of the intestine-conditions produced by the various forms of perito- nitis, tuberculous conditions, and acute and chronic intestinal obstruction from any cause, including intussusception. In con- sidering the surgery of such diseases it may be well to go into detail regarding the management of a number of conditions in order to illustrate the manner of meeting and overcoming some of the difficulties which present themselves. The following article by the author is an example of a simple means of caring for the septic end of the bowel or other viscera when doing abdominal surgery. A Simple Method of Excluding the Septic End of the Bowel during Intestinal Resection.1 "In doing an intestinal resection, numerous methods have been devised for protecting the peritoneal cavity from contami- nation. The remaining ends of the bowel may be sterilized by cauterization or inverted, and the same treatment may be accorded the portion of the bowel which is to be excised, but this takes time. Eor the method recommended the materials and the septic bowel may be excluded in an instant after its division without the slightest possibility of contamination. "At the first point of division of the bowel a heavy clamp is placed upon the portion which is to remain, while the portion to be excised is grasped by a long-handled forceps, the blades of which have been inserted into two fingers of a sterilized glove (Fig. 199) After the division of the bowel by knife, scissors or cautery the end that is to remain may be treated in the usual manner. The end which is to be removed is held in the forceps, as illustrated (Fig. 200); the operator then grasps the glove at point C with his left hand, and his assistant grasps the glove at points A and B. By making traction, the sleeve of the glove assumes a triangular form, the septic end is then made to disappear by making traction upon the forceps, the glove being turned inside out over the bowel and there securely clamped by means of a forceps. "This principle may be applied in many other operations where a septic mass with a pedicle is to be isolated." Resection for Cancer.-The possibility of establishing a suffi- ciently profound local anesthesia to permit the excision of malig- nant growths in the colon will depend in some measure upon the 1 Farr, R. E.: Surg., Gynec. and Obst., March, 1919. RESECTION FOR CANCER 461 location and extent of the growth, and the mobility of the involved gut. As a rule the greatest difficulty encountered will be met in Fig. 199.-Grasping end of septic bowel before reversing glove. dealing with growths involving the colonic flexures. However, we have been able, by making use of the lateral tilt and paraverte- bral and splanchnic anesthesia, combined with adequate incisions, [Reversing glove over septic end of bowel Fig. 200.-Reversing glove over septic end of bowel. to resect growths in each of the colonic flexures without pain to the patient. The greatest aid in carrying out this work is the 462 SURGERY OF THE INTESTINES attainment of a negative intra-abdominal pressure upon entering the peritoneal cavity. Under these conditions the colonic mesentery may be exposed and blocked before any further manipulation is carried out. It is well to introduce a liberal amount of the solution in the region of the large vessels, and to follow this by a direct infiltration of the external peritoneal leaf, after which the colon may be mobilized without embarrassment. A great barrier to the carrying out of this technic is the presence of distention, but this may usually be anticipated and prevented by proper pre- paratory treatment. In the presence of obstruction, and in fact in other cases as well, we have made it a rule to precede the radical operation by the performance of a colostomy, thereby reducing to a minimum the number of cases in which distention is found (see page 463). The benign influence of local anesthesia and operations per- formed under its use is especially desirable in this class of cases, which should be operated upon whenever possible by the fractional method. The operation for the excision of the sigmoid or rectosigmoid may be done painlessly after an infiltration block of the mesentery, and an anterior splanchnic anesthesia, combined with infiltration block of the external peritoneal leaf of the sigmoid colon. The solution may be used liberally in these regions if precautions are taken against its introduction into the circulatory system, and a perfect anesthesia will almost immediately ensue. The Kraske operation may be carried out under trans-sacral anesthesia (see page 117). The treatment of malignant disease of the rectosigmoid is best carried out by the multiple operation method. The author pre- fers to divide the surgical treatment into three operations as illus- trated in the following case. Report of Case No. 14312. Miss F. I)., aged forty-two years, entered the hospital June 20, 1921. Diagnosis: Carcinoma of rectosigmoid. Operations: First, preliminary cecostomy, June 21, 1921. Second, resection of the rectosigmoid, July 16, 1921. Third, closure of the colostomy wound, October 4, 1921. First Operation: Cecostomy. Technic of Anesthesia: Local infiltration 60 cc of a 1 per cent novocain-adrenalin solution. 'Gridiron incision. The cecum was grasped by rubber-tipped thumb forceps and its mesentery infil- 463 I NT USS USCEPTION trated. The cecum was then delivered, its mesentery perforated and a sealed glass catgut tube introduced transversely beneath the cecum through a perforation and anchored to the skin with catgut sutures. Second Operation: Resection of rectosigmoid. Technic of Anesthesia: Preliminary sacral, 90 cc of a 1 per cent novocain-adrenalin injection; direct infiltration of abdominal wall, 120 cc of a 1 per cent novocain-adrenalin solution and anterior splanchnic. The patient was placed in the Trendelenburg position, and a perfect negative pressure was obtained. Enlarged glands were exposed at the pelvic brim. Anterior splanchnic anesthesia was then established, the solution being introduced beneath the parietal peritoneum above the glands. The colonic mesentery was also infiltrated. The procedure of Balfour was carried out under ideal anesthesia, and the segment of bowel removed was approxi- mately 45 cm. long. Pelvic drainage was introduced, the drains being brought out between the anus and coccyx. The patient became rather pale at the completion of the operation and com- plained of being tired. Third Operation: closure of the cecum. Technic of Anesthesia: Circumferential infiltration block using 120 cc of a 1 per cent novocain-adrenalin solution. Note.-This patient went through the three steps of this pro- cedure without nausea, vomiting, gas pains, thirst or shock, and her operations were painless. Colostomy.-Preliminary anesthetization of the abdominal wall is carried out along the lines laid down for incision of the abdominal wall (pages 149-153). A midline or other incision may be made for the purpose of examining the growth, presence of metastasis, etc. Technic of Operation.-The portion of the bowel which is to be delivered is located by means of direct vision and picked up in long rubber-tipped intestinal forceps. The mesentery is blocked by the introduction of 10 to 30 cc of a 0.1 per cent novocain-adrenalin solution. The mesentery is then perforated by means of a sharp- pointed artery forceps which is spread sufficiently to allow the introduction of a glass catgut tube which has not been previously opened. Silkworm stitches through the skin retain each end of the tube in position. When the method of Mikulicz is to be employed the technic differs only in the making of a slightly larger incision. Intussusception. This disease, which appears most commonly in children, may be treated under local anesthesia, and the critical condition in which the patient frequently comes for operation 464 SURGERY OF TILE INTESTINES makes the use of local anesthesia especially desirable. The author has treated but one case in the adult under local anesthesia and in this case the operation was performed successfully under local infiltration. Report of Case No. 13905. B. M., aged twenty-six years, entered hospital January 20, 1920. Diagnosis: Intussusception. Operation: Reduction of intussusception. History: Patient had a partial intestinal obstruction for six days. Pneumoperitoneum-radiographs showed a mass extend- ing transversely across the upper abdomen. Preoperative Diagnosis: Volvulus or intussusception. Technic of Anesthesia: Saligenin, 2 per cent. Transverse infil- tration 2 cm. above umbilicus, ISO cc of solution used. Fig. 201.-Intussusception. Photograph (retouched) of Case No. 13965 during operation. The incision was made immediately and a perfect negative pressure was obtained. Examination showed an intussusception at the ileocecal valve. No intraperitoneal anesthesia was used. The proximal attachment of the mass extended toward the pelvis. Accordingly, the incision was enlarged downward in the sheath of the rectus a distance of 8 cm. after infiltrating this area. The intussusception was "milked" out of the intussuscipiens without difficulty and without distress to the patient, as shown in Fig. 201. The ileum was then sutured to the ascending colon and the incision closed. Uneventful recovery. Note.-Reduction in this case was made without difficulty and without pain, although the use of some force was necessary. The technic would undoubtedly have been improved had the colonic mesentery been blocked. In this connection 1 desire to refer to a personal communication received from Dr. P. B, McLaughlin of Sioux City, Iowa, in which INTUSSUSCEPTION IN CIIILDltEN 465 he states that during an operation for intussusception in an adult, performed under local anesthesia in February, 1922, he found it impossible manually to reduce the bowel which was invaginated for a distance of 40 cm. As the patient complained of pain, he injected the intestinal mesentery with novocain-adrenalin solution, and had the satisfaction of observing a complete relaxation of the intestinal musculature, releasing the invaginated bowel. He states that the intussusception released itself almost spontaneously. This communication is so recent that the author has had no oppor- tunity to verify it in his own work. However, it would seem reason- able to suppose that the abolishment of the muscular spasm 'would bring about the result described. Intussusception in Children.-For a number of years, all cases of intussusception in children have been operated upon under local anesthesia. The incision has usually been made in the region of McBurney's point, as the invagination nearly always takes place at the ileocecal valve. Most of the cases have been reduced by manipulation, even without the use of local anesthesia in the mesentery. In the future the mesenteric block, as described above, will be used. Case Reports Nos. 13788 and 13961 of intussusception in infants demonstrate the practical application of the above. Report of Case No. 13788. B. N., aged six months, entered hospital May 16, 1920. Diagnosis: Intussusception. Operation: Laparotomy and reduction of intussusception. Anesthesia: Local infiltration. History: Breast-fed baby, well-nourished, and perfectly well until twelve hours before entering the hospital. During these hours the patient had had intermittent abdominal colic and had refused to nurse. He was in a stuporous condition during the intervals between pains. Three-quarters of an hour before enter- ing hospital the patient passed considerable blood and mucus per rectum. No abdominal tumor could be felt by rectum or by abdominal palpation. Technic of Anesthesia: An infiltration block was made over McBurney's region, using 30 cc of a 0.7 per cent novocain-adrenalin solution. Classical McArthur Incision.-The cecum could not be found in its normal location. It evidently had not yet rotated. By making traction upon the greater omentum after hemisection of the right rectus the colon w'as located and easily brought into the wound. It was found greatly thickened and contained a large 466 SURGERY OF THE INTESTINES amount of invaginated ileum. Pressure upon the distal end of the tumor made its reduction easy. The terminal ileum was sutured along the wall of the colon to prevent a recurrence. The appendix looked angry but was not removed. The portion of the bowel that had been invaginated looked extremely dark and the baby, who had been very ill at the beginning of the operation, showed at this stage considerable shock. Under the application of heat, the color of the bowel rapidly improved. The abdomen was closed in layers with chromicized catgut. The patient was discharged, well, May 23, 1920, one week from date of operation. Note.-This baby was operated upon between spasms and made no outcry or remonstrance during operation. It is possible that the stuporous condition of the infant acted as an aid to the anes- thesia. Every opportunity was offered, at any rate, for carrying out the operation. The following case illustrates another phase of the subject: Report of Case No. 13961. T. W., aged three months, entered hospital August 19, 1920. Diagnosis: Intussusception. Operation: Laparotomy and reduction of intussusception. Anesthesia: Local infiltration; novocain-adrenalin solution. In this case examination showed a tumor mass lying transversely across upper abdomen. A classical infiltration block was made for the gridiron incision. One end of the tumor presented beneath the incision and reduction was made without difficulty. The findings were much the same as in Case No. 13788 above. The same operative technic was followed and the abdomen closed without drainage. Note. Before and during the operation up to the time of the reduction of the intussusception this child cried out at short inter- vals and it was necessary to use great caution in preventing the extrusion of small intestine. Immediately after the reduction of the intussusception the patient ceased crying, took a drink of water and appeared quite comfortable while the operation was being completed. The patient was discharged August 26, 1920. It was apparent in this case that the child's remonstrance during the operation was due to the spasm of the intestine rather than to the operative procedure. The bowel in this case was reached without the necessity of making traction and this baby showed practically no shock during or after the operation. Tuberculous Peritonitis.-In many instances only an infiltration of the abdominal wall is required. However, in a number of cases resection of the intestine for localized tuberculous disease has been T UBERC ULO US PERI TONI TIS 467 performed under infiltration anesthesia with entire satisfaction. The condition, as a rule, presents nothing unusual in the technic demanded. This technic has been covered in the preceding pages. Among the most difficult of these cases which the author has been called upon to treat are the following: Report of Case No. 7277. F. M., aged nineteen years, entered hospital February 1, 1914. Diagnosis: Tuberculous peritonitis; tuberculous fistula of the intestine. Operation: Intestinal resection (multiple). Anesthesia: Local infiltration. History: Patient had had several intraperitoneal abscesses drained in 1913. Finally he developed intestinal obstruction in 1914, for which an enterostomy was done. At this time the adhesions were so dense that it was impossible to find any free peritoneal surface, and the author contented himself with an enter- ostomy which was made under the use of local anesthesia. On February 4, 1914, an attempt was made to excise the fistula and close the sinus into the intestine. Technic of Anesthesia: 120 cc of a 0.5 of 1 per cent novocain- adrenalin solution was used. A circumferential infiltration was made well away from the site of the old scar, which, with the fistula, was then excised. The fistula entered the small intestine, and its removal from the loops of surrounding small intestine left two rather large denuded peritoneal surfaces. A considerable amount of tuberculous granulomatous tissue presented and involved the wall of the intestine so that a rather wide excision was considered advisable. The intestine was divided and the ends inverted. A lateral anastomosis was made with catgut. In this case division of the bowel caused complaint on the part of the patient, and he also complained repeatedly when the needle was inserted through the bowel wall, even though traction was avoided. This is the only observation of this nature in the author's experience. (See Perito- neal Pain Sense). Report of Case No. 14392. J. P. M., aged forty-four years, entered hospital September 7, 1921. Diagnosis: Tuberculous peritonitis with obstruction; pulmonary tuberculosis. Operation: Intestinal resection, lateral anastomosis, September 16, 1921. 468 SURGERY OF THE INTESTINES Anesthesia: Local infiltration. History: Pulmonary tuberculosis for ten years and distress in the abdomen for eight years. Three or four weeks ago the patient began to have symptoms of obstruction. Examination showed a localized tumor in the pelvis. Technic of Anesthesia: Local infiltration of abdominal wall with 120 cc of 1 per cent novocain-adrenalin solution. The general peritoneal cavity was found studded with tubercles. About 60 cm. of the ileum were resected, the ends inverted and a lateral anastomosis made. An intestinal fistula began discharging ten days later but finally closed. The patient left the hospital with wounds completely healed in six weeks. His pulmonary condition, which was far advanced, grew progressively worse, and he died a few months later. Note.- The emergency operation was carried out without pro- ducing any apparent change in the patient's condition and is reported here because it is characteristic of the benign influence of the method. Intestinal Obstruction from Other Causes.-The management of cases of intestinal obstruction will depend greatly upon local condi- tions. The greatest difficulty is met in the treatment of cases of more or less obscure etiology, especially when accompanied by marked distention. In case the point of obstruction can be located by the examining finger after the abdomen has been opened it may only be necessary to deal with the local condition presented. The careful introduction of gauze packs and the retraction of the distended bowel may suffice to visualize the point of obstruction. Or a loop of non-distended gut may be distinguished and the point of obstruc- tion located by following the collapsed bowel systematically until the point of obstruction is reached. This procedure is not diffi- cult under local anesthesia, provided the bowel is at once returned to the abdomen as the next portion of it is withdrawn. However, it frequently happens that the operator is confronted by distended intestinal coils which can be controlled only with the greatest difficulty. While it was formerly the author's practice to administer general anesthesia to these patients as soon as the abdomen was opened, he has during recent years departed quite radically from this plan. The method recently worked out for the management of these cases under local anesthesia is as follows: The abdominal wall is opened after the establishment of an infiltration anesthesia. The distended intestines are only tem- porarily restrained while their general condition is ascertained and gangrenous bowel is looked for. An effort is also made to obtain a loop of collapsed gut, in order to locate the point, and likewise the cause, of obstruction. In the event gangrenous bowel is TEMPORARY DRAINAGE OF DISTENDED BOWEL 469 encountered it is allowed to escape through the abdominal incision and the operative procedure which seems indicated is carried out. This can usually be done without the addition of general anesthesia. Should only distended intestine present and it be found impossible to locate and treat the cause of the obstruction, the skin of the abdominal wall is carefully excluded by means of towels. The incision is then surrounded by a rubber sheet upon which the distended coils are allowed to lie as they extrude from the peritoneal cavity. No restraint is offered to the escaping intestine, and we have been gratified to find that the resulting pain experienced by the patient is readily tolerated and that, in some instances, there is practically no pain accompanying this procedure. With the abdomen fairly free of distended intestines it is usually possible to locate and remove the cause of the obstruction, provided the condition is amenable to relief. Following this the surgeon is confronted with the necessity of returning to the peritoneal cavity the eviscerated coils of intestine. In order to do this without trauma and without the use of general anesthesia it is usually necessary to relieve the intestine of its distention. The accomplishment of this condition presents decided advantages. It permits of the return of the intestines to the abdominal cavity without marked pain or distress to the patient, and, in addition, removes from the intestinal tract toxic material which otherwise has a deleterious effect upon the patient. Technic of Temporary Drainage of Distended Bowel-The Rubber Towel Method.-The main objection to temporary drainage of the intestinal tract is the opportunity offered for septic contamination. By adopting the following plan we have reduced to a minimum the possibility of infection. A purse-string suture of linen is passed through the serous coat of a distended loop of bowel at a point opposite the mesentery, and the two ends of this suture are then grasped firmly by a hemostat. A large rubber towel is now placed over the intestinal coils and the ligature is passed through a small perforation near the center of the rubber towel. By this means a small knuckle of intestine may be drawn through the rubber towel and is easily controlled by means of the purse-string ligature. The bowel may now be opened and its contents allowed to escape, either with or without the use of a trocar or suction. While the surgeon controls the ligature, his assistant, with his hands beneath the rubber towel and in contact with the distended intestine, may force the contents of the bowel through the drainage opening. The septic material will escape down the side of the rubber towel into a receptacle. When this procedure is finished the knuckle of bowel may be effectually cleansed of septic material by irrigating it with salt solution, after which the purse-string ligature may be 470 SURGERY OF THE INTESTINES tied and severed, allowing the knuckle of bowel to slip out as the septic towel is removed. This procedure may be repeated as often as one desires until the intestinal tract is completely collapsed. Enterostomy.-Should an enterostomy be considered necessary one has but to introduce a tube into the open bowel and anchor it in position with a ligature. By following this plan the author has been able to operate upon all the desperate cases-the cases most urgently demanding the use of local anesthesia, without the addition of a general anesthetic to the already heavy burden of the patient. Peritonitis Ileus.-In this class of cases one may be forced to meet many of the same conditions as were enumerated under the heading of septic peritonitis. When collections of pus are likely to be encountered or when there is danger of spreading infection the technic laid down on page 484 will be indicated. Abscess cavities should be emptied by suction and every effort made to prevent further dissemination of the infection. By care- ful isolation of the infected part and emptying the abscess cavity, one may be able to visualize or to palpate the point of obstruction. Following the relief of the condition the advantages enumerated under septic peritonitis apply. CHAPTER XVII. LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX. APPENDICITIS. Special Considerations.-Acute or Subacute.- Medical Manage- ment. -In the management of these cases the prevention of the spread of infection beyond its present confines is of the utmost importance. The method of preventing the dissemination of intraperitoneal infection in the absence of operation is not germane to this discussion, but its relation to local anesthesia in the event of surgical interference is exceedingly important. Surgical Management. Once operation is decided upon, there are three periods during which the management of a case may greatly influence the outcome. The first period extends from the time that the operation is decided upon until the operation is begun. The second period extends from the time the operation is begun until it is completed and the third period extends from the time the operation is completed until convalescence is established. Preoperative Management. - During the first period the great danger of the spread of infection is from rough or careless handling of the patient or from struggling incident to the induction of general anesthesia. The author has personal knowledge of 6 instances in which localized intraperitoneal collections of pus were dis- seminated as a result of the rupture of the abscess wall during the first period, as designated above. In 2 instances the careless lift- ing of the patient produced a rupture and in 4 the struggling of the patient during the excitement stage of the induction of general anesthesia resulted in this disaster. It would seem, therefore, that too much stress could not be laid upon the necessity for the utmost care in transporting such patients from the bed to the operating table. Furthermore, there seems to be no denying the fact that the struggling incident to the induction of general anesthesia must be recognized as a possible source of danger. Operative Management.-The danger of disseminating localized infective processes during the second stage should, it seems, be more clearly recognized. The necessity of obtaining a silent field and reducing the respiratory excursion of the intestines, caused by strenuous breathing, struggling, retching or vomiting, 472 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX should be more universally recognized. Cognizance should also be had of the fact that one's most careful endeavors to prevent the dissemination of infection in the peritoneal cavity by the per- formance of the operation without soiling may be too often negatived by the intestinal turmoil which results within the abdomen from vomiting after the completion of a careful operation under general anesthesia. Every effort should be made to prevent the non- adherent coils of intestine from entering the infected field, after, as well as during, operation. It is good practice to use the greater omentum, wherever possible, to prevent this undesirable occurrence. The prevention of vomiting and visceral turmoil are more important, however. Effect of Anesthesia upon Postoperative Course.-Postoperative retching and vomiting and careless handling of the patient, com- bined with bodily activity of the patient during his recovery from the effects of general anesthesia, are the most common causes of the dissemination of infective material during the third stage. Upon a number of occasions opportunities have presented to establish the fact that following abdominal operations under local anesthesia the different organs remain in approximately the same relative position as that in which they were left, provided the patient has been carefully transported back to bed and has not vomited. Conversely, the author has had occasion to record, in a number of instances, where it was necessary to reopen the abdomen after an operation which had been performed under general anes- thesia, that a great excursion had taken place in many of the organs, notably the cecum, the transverse colon, the sigmoid, the stomach and the greater omentum. It is believed that in the management of peritoneal suppurations there exists one of the most important advantages of local over general anesthesia. Position upon the Operating Table.-The table is equipped as for Trendelenburg cases (Fig. 1, page 84), and in addition a support is placed at the left side (Fig. 1, Bf Before beginning the infil- tration a moderate Trendelenburg and a left lateral tilt is assumed (Fig. 202). Incisions. -Recurrent Appendicitis -The choice of an incision for the removal of the chronic appendix has very little bearing upon the local anesthesia problem. However, as a rule the McArthur gridiron incision may be said to be the one of choice, and, as in the author's practice it is used almost universally, the technic detailed will relate especially to this incision. The anesthesia technic for the other incisions may be easily deduced from the description given. (Fig. 203, A, B, and C.) One may, provided more room is required, divide the sheath of the rectus. The incision of Elliott is an excellent one when additional exposure is required. APPENDICITIS 473 The Transverse Abdominal Incision.1-"In the Boston Medical and Surgical Journal, March 29, 1896, J. W. Elliott published a des- cription of a modification of the McBurney incision for appen- dicectomy. A. E. Rockey of Portland, Ore., in the Medical Record, Fig. 202.-Appendicectomy. Transverse section of body at appendix level show- ing lateral tilt, vertical retraction, negative pressure and exposure. A, long rubber- typed forceps; C, cecum. July-December, 1905, strongly recommended the transverse incision for work in the lower abdomen and called attention to the satisfaction with which the appendix could be removed through this incision. In January, 1900, Gwilym G. Davis of Philadelphia 1 Fhrr, R. E.: Am. Jour. Surg., September, 1915. 474 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX once more described this incision in the Annals of Surgery. Boeck- man of St. Paul, in the St. Paul Medical Journal, June 2, 1910, also called attention to this incision, for which he had also been given credit by Charles F. I fenny in the Boston Medical and Surgical Journal, June 3, 1909. Although Boeckman worked out this incision independently and without knowing that it had been used before, he gives Elliott the credit for having first described it. "Having been, since 1910, an ardent advocate of the transverse abdominal incision for all work in the upper abdomen, not excepting that upon the kidney and spleen, it took but a few trials of the Fig. 203.-Appendicectomy. Anesthesia technic. A, B, C, subdermal infiltration and infiltration block. Insert: sectional view of same. Elliott incision to convince the author that it was by all odds the most satisfactory incision for cases in which the so-called gridiron incision of McArthur is ordinarily used, and even for the cases in which the modifications recommended by Wier and Harrington are employed. In a certain percentage of cases bad results follow the incision recommended by Battle2, Jalaguier,3 Kammerer,4 Lennander6, and Edebohls.6 Even where primary healing takes place it is probable that these bad results are due directly to 2 British Med. Jour., 1895. 3 Ann. Surg., 1897. 4 Centralbl. f. Chir., 1898. 6 Ann. Am. Surg., 1899. 6 Med. Rec., 1899. 475 APPENDICITIS nerve injury. As the nerves to the rectus muscle enter at right angles, any vertical incision must necessarily interrupt their continuity. The only reason for making any incision other than the gridiron is on account of the necessity for more room through which to carry out the operative procedure. "With the incision of Elliott ample space may be obtained. Being nearly transverse, it severs the fibers of the external oblique in a diagonal direction. Although Boeckman states that these fibers are subsequently under some tension when closing the wound, such has not been the author's experience. He has found it possible in all cases to imbricate the layers with mattress sutures. Fig. 204.-Appendicectomy. Elliott incision showing muscle layers. "By continuing the incision to the midline and stripping the aponeurosis from the right rectus, this muscle may be retracted to the midline, and in this way an incision 8 to 10 cm. in length may be obtained. The incision may be made at the level of the umbilicus or a few centimeters below, depending upon the pathology one expects to encounter. In case drainage is necessary, it is a good rule here, as in other localities where abdominal drainage is necessary, to provide a separate stab wound and to close the original incision, excepting in cases where one must of necessity leave the original wound open. But one hernia has followed in the author's cases, and this was in a case of suppurative appendi- citis in a physician whose extensive drainage was carried out 476 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX through the outer angle of the wound. As most of this work has been done under loeal anesthesia for over fifteen years, the method has been given a very severe test. "With this incision and vertical retraction, and the patient rotated to the left 30 or 40 degrees, we have been able to see, in most cases, the appendix lying in its natural position and in some cases we have been able to anesthetize the mesoappendix before liberating it from adhesions. "The following points of excellence may be mentioned: Sufficient room, conservation of nerve and blood supply and the cosmetic result of closure. Figs. 204 and 205 illustrate the above-mentioned incision." Fig. 205.-Appendicectomy. Elliott incision opening into abdominal cavity completed. TECHNIC OF SUBDERMAL INFILTRATION. An initial wheal is made at a point at least two cm. external to the point where the proposed site of the transverse incision is to begin and a subdermal infiltration outlines the proposed site of the incision, going well over toward the midline. (Fig. 203, A and B, also insert A', B', C'.) TECHNIC OF DEEP INFILTRATION. The needle is now introduced through the initial wheal (Fig. 203, A), in the direction of the loin, that is, backward and outward, TECHNIC OF DEEP INFILTRATION 477 until it is felt to pierce the external oblique. This layer is readily recognized and even the spectators may note the slight jerk as it is pierced, the muscle usually contracting slightly as it resents the intrusion of the needle. Again, the patient may show signs of pain or distress if one happens to pierce a large sensory branch during this procedure. This contingency should be anticipated in every instance and the patient warned that he may feel some pain. The slight twinge will thus become an aid to the surgeon rather than a menace, as it may be if the patient has been assured that he will feel nothing and then finds himself in disagree- ment with the surgeon. Even asking the patient whether he feels the needle is less satisfactory than the above method, as it is apt to suggest to his mind the possibility: that there is some question in the surgeon's mind about the result expected, and this may be a factor in decreasing the confidence of the patient. As soon as the external oblique is pierced approximately 15 cc are injected between this structure and the internal oblique and the needle is then carried down to the peritoneum, the fluid always being injected in advance. (Fig. 203, Insert A', B', C'.) We have found that this maneuver has the effect of " floating" the peritoneum ahead of the needle point and that the chances of piercing this structure are greatly reduced thereby. However, the introduction of the needle through the peritoneum is without danger provided it is done carefully. When approaching this layer the needle should be advanced slowly. A wall of infiltration block is now made at right angles to the line of the incision, its midpoint corresponding to the initial wheal. This is done by introducing the needle through the external oblique and is not usually noticed by the patient or his muscles. In case, however, there is the slightest evidence of a sensory nerve response this signal calls for the deposit of a more liberal supply of the anesthetic at this point. In fact, a slight response is often desirable as it shows the surgeon the points at which a more generous supply of the solution is demanded. After this block of the nerves is made, the deeper tissues along the course of the proposed incision are infiltrated. This injection is made in a measured, methodical manner, beginning at the outer end of the line and building a wall of anesthesia along it. This wall should be rhomboid in shape on cross-section and the base should be about 5 cm. wide. Each introduction of the needle will cover a certain area, depending upon the size of the needle, the force of the fluid, the resistance of the tissues and the speed at which the needle is advanced. Expe- rience soon teaches one the art of thoroughly covering the field. Usually the needle is introduced vertically at first, then with- drawn until the point is disengaged from the aponeurosis and then reinserted through the deep tissues to the right and then to the 478 LOCAL anesthesia in surgery or the appendix left of the central area. This procedure is repeated at intervals until the proposed line of incision is covered. It is advisable to use a smaller amount of the solution proportionately as the mesial end of the incision is approached, as this area is apt to be already anesthetized from the effect of the solution previously injected. Using the above technic, the introduction of the anesthetic requires from two to five minutes, depending upon the thickness of the abdominal wall, the length of the incision, and, more especially, upon the mental attitude of the patient. The sensitive or appre- hensive patient cannot be injected as rapidly as can the phlegmatic, stoical individual. Again, the patient who adopts an attitude of skepticism regarding the method-one who has to be "shown" before he will be convinced-cannot be infiltrated as rapidly as can the one who, through experience or education, has confidence that the method will succeed. Ina large number of cases perfect anes- thesia of the abdominal wall has been established in less than two minutes and the skin incision made in three. With the proper equipment and the above detailed technic the time required for anesthetizing the abdominal wall, even in the most nervous cases, is negligible. 60 to 90 cc of the solution is the average amount required. Technic of Opening the Abdomen.- The incision is made between towel pins which elevate the skin (Fig. 212, page 490), and in this manner the possibility of distress from pressure is eliminated. The abdominal cavity is approached with the greatest possible care, the different layers of the abdominal wall being retracted vertically before being incised (Fig. 213, page 491). Provided now that good anesthesia has been established we may expect to find a negative intra-abdominal pressure, an inrush of air as the peri- toneum is incised and all small intestines carried well to the left and toward the upper abdomen by the force of gravity. Thus the intestine, instead of protruding through the incision, as is so frequently seen under general anesthesia unless it is very deep, fall away from the incision, allowing the surgeon a view of the local conditions as they exist. (Fig. 202, page 473.) If carefully performed retraction may be made with some force when found necessary, but, as a rule, a low gridiron incision will show some portion of the appendix directly in the field. Since using this technic in every case, generally without the introduction of gauze packs or the use of general anesthesia, the author has been able to locate the appendix no matter how obscure its position might be. One should not hesitate to enlarge the wound by further incision or by careful stretching with the fingers when it is necessary. Technic of Meso-appendix O. T. Infiltration.-As soon as the appendix is located it is lightly held by tissue forceps while the point of the TECHNIC OF DEEP INFILTRATION 479 needle is engaged beneath the peritoneal coat of the meso-appendix O. T. (Fig. 206). The structure is then ballooned up with the novo- cain-adrenalin solution before being secured by an artery forceps. Fig. 206.-Appendicectomy. Anesthetizing the meso-appendix O. T. Technic of Delivering Appendix.-If the appendix can now be delivered it is removed by the usual technic but otherwise the retaining structures are dealt with. Often we find that a division of the meso-appendix will allow the delivery of the organ. Again, adhesions or congenital bands or perhaps a lack of correspondence between the position of the appendix and the location of the abdo- minal incision may make it impossible to accomplish the removal outside of the abdomen. In this event no untoward destruction of the attachments of the cecum is called for and no undue traction should be made upon the cecum, but the work should be done within the abdomen, which is quite as simple a procedure as is the usual one. A curved needle held by a needle holder is substituted for the conventional straight needle, and by using the forceps tie (Figs. 32, 33 and 34, page 155), no difficulty will be encountered. The point of utmost importance is that strategy must be employed in order to obviate the necessity for the use of the dreaded traction. The following case well illustrates some of the difficulties encountered and the manner of dealing with them. W. (). A., aged twenty years, entered the hospital January 6, 1917. Diagnosis: Subacute appendicitis. Operation: Appendicectomy. Record of Case No. 8505. 480 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIN History: The patient was first seen in 1914 when he presented a history of right-sided abdominal pain during the previous year, but examination at that time showed a normal temperature and no tenderness or rigidity. January 2, 1917, he again reported stating that he had been free from pain during the past three years, but during the night it had begun suddenly, awakening him, and was most severe in the region of and to the right of the umbilicus. Nausea began six hours after onset while on a street car and was not accompanied by vomiting. The pain was intermittent in character. Anesthesia: Local infiltration block. The technic as shown in Fig. 203, page 474 was used in making the abdominal infiltration, using 150 cc of a 0.7 per cent novocain- adrenalin solution. A McArthur incision was made and very gentle retraction was employed. The appendix was long and subperitoneal dis- section for about 15 cm. was necessary in its removal, base first- following the technic of anesthesia described (Fig. 207, page 483). Traction on the appendix and meso-appendix gave pain identical with that during his attacks and also induced vomiting. Removal and closure were done in the usual manner. Note.-The patient's postoperative convalescence was com- plicated by urinary retention which, however, may have been due to specific urethritis, and he left the hospital one week after admission. APPENDICECTOMY UNDER VARYING CONDITIONS. Acute Appendicitis. While most surgeons are perhaps willing to admit that the removal of the interval appendix can be accomplished painlessly under local anesthesia, and while many surgeons perform occasional appendicectomies under this method, it is generally considered unsatisfactory in cases of acute disease of this organ, either before or after rupture, and especially so in abscess cases. The author's experience with local anesthesia in these cases is so at variance with the above premise that he can only reiterate what he has so often stated when writing or speaking upon this subject. He believes that there is much less reason for the removal of the interval appendix under local anesthesia than for the handling of acute or subacute conditions by this method. In the former it is more a question of comfort, although it must be admitted that it decreases the liability to complications, lowers the morbidity and lessens the dangers generally; while in the latter its advantages are manifest regarding the points just mentioned, and with relation APPENDICECTOMY UNDER VARYING CONDITIONS 481 to the last point the advantage is so obvious that no argument should be necessary. Here, again, the point of contention relates to the possibility of doing this class of work under local anesthesia without too much discomfort to the patient and with satisfaction to the surgeon. That this work may be done with satisfaction in a large percentage of cases is true, and the different types to be met will be dealt with somewhat in detail even at the risk of repeating matter which is undoubtedly well known to many of my readers. The diversity of opinion and the many questions of an elementary nature which have been asked concerning this particular subject, as well as its unquestioned importance, seem to make it well worth careful consideration. Abdominal Infiltration and Muscular Relaxation.-In acute abdo- minal conditions blocking the thoracic nerves gives relaxation of the abdominal muscles, although perhaps not to the extent seen in chronic conditions. However, one frequently sees abdominal rigidity disappear to a marked degree immediately after the block- ing is done, even though sedatives are not used. In a case of perforated gastric ulcer, for instance, a bilateral regional block brought relief of the muscle spasm and comfort to the patient at once, where | gr. of morphine given some hours before had been found unavailing. The accomplishment of this effect, subsequent to the blocking of the nerves of the abdominal wall, is an important factor in the handling of cases of acute abdominal disease, and while the operation in acute cases is by no means as simple a pro- cedure as in the interval case, it is nevertheless perfectly feasible in the vast majority of cases, and in a fair percentage proves to be so simple that it is a worthy rival of the interval operation in simplicity. It is agreed that the organs in the region of the appendix in the acute case should be manipulated and displaced as little as possible, and, in assuring this ideal condition, local anes- thesia is excellent. Its special advantages will be touched upon as the different conditions are considered. The technic used for entering the abdomen is the same in acute cases as for the interval type, except that perhaps more scrupulous care is used to prevent pressure upon the tender abdominal wall. Upward or vertical traction while incising and after opening the abdominal wall is a prime essential to success. Once the abdomen is opened we are confronted by one of two conditions. The abdo- minal cavity may show the intestines in a state of collapse with negative intra-abdominal pressure, in which case the appendix can at once be seen and dealt with by the technic described for dealing with the interval case; or, marked distention may be present with a positive intra-abdominal pressure, such as is seen when an 482 LOCAL ANESTHESIA IN SURGERY OE THE APPENDIX imperfect anesthetization of the abdominal wall has been made. The mistake which is usually made when this condition is met is to attempt to locate and remove the appendix without first getting a view of the local condition. Technic of Delivering an Acute Appendix.-A perfectly free appendix may be brought up with little difficulty but an adherent one should not be attacked by the method used when the patient is under general anesthesia. Possibly the best plan to follow when one has ascertained that an acutely inflamed appendix is adherent, is to administer nitrous oxide and oxygen while the organ is being liberated and then complete the operation under local anesthesia. The author has thought it best to handle a number in this manner. However, increased experience has taught that many of these cases can be done under local anesthesia alone with almost no distress. In some cases careful palpation in the dark has been rewarded by finding the appendix free and easily delivered. If it does not appear after the most simple and painless manipulation the saline gauze pack is resorted to and direct vision depended upon. The cecum should, as a rule, not be delivered. In inserting the packs pain will not be produced provided proper precautions are observed. The abdominal wall should be elevated by a smooth metal retractor (Fig. 14, page 101, and Fig. 170, page 396), and long narrow saline gauze packs inserted only a short distance into the abdominal cavity. A wall of gauze is built above, mesial to and below the incision, and thus two purposes are served. The cavity is protected to some extent from future soiling and the small intestines are controlled. Retractors of appropriate length are now used to expose the cecum at the ileocecal valve. The mesial aspect may be first inspected and in case this does not reveal the offending organ another small pack may be laid over the cecum, provided it is distended and has a tendency to pro- trude, or it may be forced out of the field mesially by the rubber- tipped thumbs. This search should be painless or nearly so, if done methodically and with care, and should result in locating the appendix. Once any portion of the organ is seen local anesthesia is freely used in the tissues surrounding it (Fig. 207). In case the organ is intact it can usually be freed under this technic with little or no distress to the patient. Even in the presence of a localized abscess or omental wrapping this technic gives satisfactory results. Once freed, it may be removed by the usual technic; in case dense adhesions are encountered or if the patient is extremely sensitive, or if any other difficulty arises the operation may be temporarily interrupted and ether or nitrous oxide and oxygen administered. These patients should not be compelled to suffer pain; a nitrous oxide analgesia may be produced very quickly in these cases, and as APPENDICECTOMY UNDER VARYING CONDITIONS 483 Fig. 207.-Appendicectomy. Anesthesia technic. The adherent appendix. Fig. 208.-Appendicectomy. Anesthetizing the mesocecum. 484 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX soon as the appendix is liberated may be discontinued. Since we have developed the technic for the more perfect exposure we find anesthesia by inhalation necessary only in rare instances and principally in the cases where the appendix is adherent in the pelvis or at some point distant from the incision. Should traction upon the cecum be found necessary its mesentery may be anesthe- tized (Fig. 208) from within or by introducing the needle through the abdominal wall just beyond the external lateral angle of the incision, or by following around any presenting abscess mass by a retroperitoneal infiltration under direct vision, through the abdominal incision. INTRA-ABDOMINAL ABSCESS. Technic for Drainage.-In cases in which the general peritoneal cavity is opened first the technic does not differ materially from that which is to be recommended for operation in acute appendicitis. The abdominal packs should be more massive and should be so placed as to protect the general cavity, although, on account of the absence of straining, the danger from soiling is much reduced when local instead of general anesthesia is employed. After plac- ing the packs it may be found advisable to administer general anesthesia for the critical portion of the operation. However, it has been found that with a good exposure and a liberal infiltration of the tissues about the viscero-parietal union, which must be broken up in order to open the abscess, these cases may be handled without difficulty. The appendix, when found, is dealt with in much the same manner as in other abscess cases. It is significant that this organ is being found and removed in a vastly higher per- centage of abscess cases than was the case when general anesthesia alone was used and speed was the main objective. In removing the packs after placing the drains some strategy is necessary. The abdominal wall should be elevated and the packs removed in order inversely to that in which they were inserted. In this way, even after very extensive coffer-damming has been done, the gauze may be removed without pain. Even in children this technic has been employed with satis- faction. Report of Case No. 10758. M. 1). B., aged seven years, entered hospital July 21, 1920. Diagnosis: Acute appendicitis. Operation: Appendicectomy. History: The patient had been sick twelve hours with appendi- citis. INTRA-ABDOMINAL ABSCESS 485 Technic of Anesthesia: Local infiltration, 60 cc of a 1 per cent novocain-adrenalin solution being used. The abdomen was opened under perfect negative pressure, a large indurated appendix was seen lying mesial to the cecum, the mesoappendix was infiltrated before elevating the organ and was then removed in the usual manner. Fig. 209 shows the patient during the operation and depicts graphically the mental attitude of the child. Note.-This patient's sister had been operated on March 10, 1920, for acute appendicitis, and the patient insisted that she wanted her operation with the same kind of anesthesia. Fig. 209.-Appendicectomy. Photograph of Case No. 10758, aged seven years, during operation. Report of Case No. 13910. E. I). G., aged three years, entered the hospital April 17, 1917. Diagnosis: Acute appendicitis with abscess. Operation: Appendicectomy with drainage. Anesthesia: Local infiltration, 75 cc of a 0.5 of 1 per cent novocain- adrenalin solution, was employed. Anesthesia was established by infiltration method and restraint of the patient was unnecessary. The McArthur incision was used and the free peritoneal cavity opened with negative pressure (Fig. 210). The free peritoneal cavity was then carefully packed off with narrow, moist sponges. The parietal peritoneum was infiltrated and the cecum was carefully separated from the abdominal wall. 180 cc of pus were evacuated by suction. Light was reflected into the abscess cavity and the appendix could be seen projecting from the floor of the abscess wall. It was removed subperitoneally, a catgut ligature being placed around its base. Two cigarette drains were inserted. The omentum which followed the removal of the protective packs was placed about the drains and the abdo- men partially closed. 486 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX Note.- The child made no complaint throughout the operation, she had no postoperative nausea or vomiting, and although the temperature rose to 104° the day following the operation and the pulse became thready, she made an uneventful recovery. Fig. 210.-Appendicectomy. Photograph of Case No. 13910, aged three years, during operation. SUPERFICIAL ABSCESS. Technic for Drainage.-One of the simplest conditions, and one which it seems should seldom require general anesthesia, is the opening of an appendiceal abscess which communicates directly with the parietal peritoneum. Simple infiltration of the abdominal wall is all that is necessary. The incision can then be made between towel pins, thus eliminating pressure pain, and the pus is evacuated, preferably by suction. Once the abscess is completely emptied a careful search may show some portion of the appendix projecting into the cavity or forming a portion of the abscess wall. One is frequently able to remove the appendix in these cases. As a rule no effort is made to invert the stump and generally ligatures are omitted. A clamp is usually placed upon the appendix before its removal and this is allowed to remain in situ for a few days. Oper- ations upon these cases under local anesthesia are well-nigh ideal in every way, the pain is negligible and the patient's energy is con- served to the fullest possible degree. Locally the exposure is per- fect, the tissues remain quiet and the necessity for haste is elimi- nated. Furthermore, the absence of marked manipulation during operation and vomiting after operation are desirable attributes. THE APPENDIX AND PELVIS 487 THE APPENDIX AND PELVIS. Special Considerations.-In doing pelvic work under local anes- thesia the appendix can be reached with ease through the midline incision provided a negative pressure is obtained. The relaxation of the abdominal muscles will usually allow the cecum to drift above the pelvic brim, and often it will travel into the right loin and well out of view. Vertical retraction of the upper right hand corner of the incision with a smooth, stout retractor of the type shown in Fig. 14, page 101, will allow one to see the cecum and generally the appendix also. By means of the rubber-tipped for- ceps (Fig. 26, page 110) it may be brought down and often out of the abdomen if so desired. The base of the appendix is seldom found buried and as soon as seen may be steadied while the meso- appendix is infiltrated. (See Fig. 206, page 479.) In case the appendix is retrocecal the peritoneum should be blocked before incising. (Fig. 208, page 483.) In doing work under local anes- thesia the appendix should be freed by sharp dissection rather than by tearing the adhesions, and only sufficient force should be used to identify the bands when using traction. Severe or even moderate traction upon the appendix or cecum is prone to cause nausea and vomiting and this accident, which is exceedingly dis- tressing to the patient, has the great disadvantage of changing the whole aspect of the procedure. One expulsive effort will usually be sufficient to project coils of small intestine into the field and often out upon the abdominal wall. The result of this occurrence is obvious. The pain resulting from the traction upon the mesentery of one or more coils of intestine thrown out may be severe. This traction may also serve to increase the nausea and cause further vomiting. The pain produced by restraint of the protruding intestine is often severe and the damage which results from gauze pressure against the sensitive serosa covering it will likely mani- fest itself during the convalescence by distention and gas pains. Furthermore, the sudden occurrence of vomiting, provided it happens at a critical time, may in certain instances result in the spread of infective material. The interference with the technic of the operation and the forcing of the operator to complete the work under general anesthesia is not the least distressing feature of this accident. The hazard of vomiting is considered so important that it should be placed before pain as a contraindication of local anesthesia in abdominal surgery, and yet it does not often occur. When it does occur, it is usually due to some overt act on the part of the surgical team, and it may be so sudden in its onset that the damage is already done before one realizes its onset. In another chapter the question of nausea and vomiting and their prevention 488 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX lias been more minutely considered, but I wish to reiterate some of the text here, as traction upon this portion of the intestinal tract is especially apt to cause trouble. On account of the danger of vomiting, it may be considered desirable to the surgeon to complete the pelvic work before the removal of the appendix in some cases. In this maimer we avoid precipitating the small intestines into the pelvis. Position upon Operating Table.-Tilting of the table to the left (Fig. 202, page 473, Fig. 161, page 384) is one more important aid to the gaining of a good view of the appendix, cecum and terminal ileum when doing pelvic work. When operating under local anes- thesia this position is especially desirable. Tables that cannot be tilted may be equipped with pillows and sandbags so as to approximate the same result, but in no other condition can the advantage of attention to details which may seem trivial be better displayed than in locating and delivering an appendix by the aid of a change to or from the Trendelenburg accompanied by a tilting to the left while the assistant at the same time carefully raises the right upper portion of the incision. These maneuvers will almost always show the cecum and appendix. By changing the patient's posture alone it is often possible to bring this structure into the field and thus to avoid the traction which may be so undesirable in its results and which by the use of strategy may be made unneces- sary. This change of position or tilting should be made without active muscular effort on the part of the patient so that the negative pressure may not be overcome. As a rule, when both pelvic work and appendicectomy are to be done, the pelvic blocking is made as soon as the abdomen is opened and before the appendix is removed. The delay thus necessitated allows time for thorough dissemination of the fluid used in the pelvic block and thus the maximum effect of the drug is assured. However, if the appendix is not free, it may be well to reverse this procedure for the aforementioned reasons. CHAPTER XVIII. LOCAL ANESTHESIA IN SURGERY OF THE PELVIS. Pelvic Blocking.-The most sensitive structure with which we must deal in the pelvis is the round ligament and, fortunately, this is easily anesthetized. The ovarian pedicle is sensitive, as is also the peritoneum covering the cul-de-sac. All work in the pelvic region is best done with the patient in the Trendelenburg position, and it is desirable that the position be assumed several minutes before the anesthetic is injected, and that when in this position the patient be at ease and comfortable. The accessories described in Fig. 1, page 84, are valuable adjuncts in obtaining the desired comfort. Soft pillows, pneumatic cushions for the shoulders, metal legholders, which restrain but do not constrict, the avoidance of too sharp flexion at the knee (which, with an exten- sion of the head upon the neck, greatly increases muscular resistance of the abdominal wall) and a careful adjustment of the drapes, all tend to facilitate work in this region. While attention to these details may seem unimportant, success can only follow such attention and he who is not willing to pay heed to the smallest detail and does not recognize the prime essentials-of which the patient's comfort is one of the most important-will continue to bore one with the criticism that local anesthesia is unsatisfactory in pelvic surgery, and advise the use of spinal or general anesthesia. Skin Sterilization.-The greatest care should be exercised that irritating solutions used for sterilizing the skin be not allowed to trickle down between the thighs or reach the external genitalia. This every-day occurrence during general anesthesia cannot be allowed when using local anesthesia and similar intolerable accidents can only be avoided by the constant vigilance of everyone connected with the care of the patient. Incisions for Pelvic Operations.-The author employs the ver- tical incision, as a rule, though that of Pfannenstiel has been used in a fair percentage of cases. The anesthesia is introduced with the patient in the Trendelenburg position and in the manner shown in Fig. 211, and vertical retraction of the abdominal wall is insisted upon during the whole period in which the incision is being made (Fig. 212). Exposure.-After the abdomen has been opened by an incision which is liberal in its proportions, a negative pressure should be Fig. 211.-Abdominal incision. Anesthesia technic; infiltration. Insert: sectional view of same. Fig. 212.-Abdominal incision. Incision between towel pins making vertical retraction. Insert: sectional view of same. EXPOSURE 491 present. Retraction should be made in a vertical as well as a lateral direction, and should be of the elastic gradual type (Figs. 213 and 214), that is, at right angles to the plane of the abdominal wall and the upper or umbilical end of the incision should be elevated first. This increases the capacity of the upper abdominal cavity and generally the force of gravity alone will cause all small intestines to migrate above the pelvic brim (Fig. 215). In case this ideal Fig. 213.-Abdominal incision. Exposure while making same. condition does not prevail and some coils of intestine remain in the pelvis they may generally be picked out and allowed to fall to the upper abdomen by means of the rubber-tipped thumb for- ceps (Fig. 26, page 110). Even though in some instances a fairly large amount of the small intestine hangs over the pelvic brim, this may not materially interfere with the performance of the more simple pelvic operations such as suspensions, appendicectomies and 492 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS the like. The retraction must be carefully made and the force used must be so graduated as to prevent any sudden jerky lifting of the abdominal wall, as this is apt to prove painful to the patient and to cause the much dreaded expulsive effort. As a rule, no sponges are introduced either for the purpose of transferring the intestines from the pelvis to the upper abdomen or for the purpose of holding them in that position. Under ideal conditions sponges Fig. 214.-Exposure of pelvic organs by means of elastic retraction. are not necessary and generally the only reason for using them is to prevent soiling. They may be used if necessary. Adjuncts to Pelvic Operations.-After experiencing some of the difficulties which are apt to beset one in attempting to handle complicated pelvic cases under local anesthesia, the fact becomes evident that if one expects to do this work without administering general anesthesia during some stage of the operation, some adjunct 493 ADJUNCTS TO PELVIC OPERATIONS must be developed as an aid in carrying us through the critical portions of the operation-the portion which is found to cause distress in a certain percentage of cases. Few methods have been tried out that have proved entirely satisfactory. One method which is considered in Chapter III, relates to the use of rather large doses of preliminary hypodermics (narco-local anesthesia). (Pages 72 and 132.) As stated, this form of anesthesia is ideal for Fig. 215.-Pelvis (exposure). Sagittal view; vertical retraction; negative pressure almost any surgical procedure one may be called upon to do. Its main drawback is its alleged danger and one must await more extended use of the method as well as a more careful checking of reports upon its dosage and use before a final verdict is given. The second method is that of preceding the local infiltration with sacral anesthesia (Fig. 28, page 117). The analgesia resulting from the introduction of novocain-adrenalin into the sacral canal is often sufficient, especially with the patient in the Trendelenburg position, to allow one to make free dissections in the pelvis. T rans-sacral anesthesia as a preliminary to pelvic laparotomies will also offer one an opportunity in a certain percentage of cases to carry out extensive pelvic operations. Parasacral anesthesia will, according to Braun, give sufficient anesthesia of the pelvic organs so that in addition to it one needs only to anesthetize the abdominal wall. The writer's experience with this form of anesthesia is limited. With regard to the latter two methods he feels that their use will be somewhat limited in 494 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS the hands of general surgeons, as the technic of their establishment is more or less complicated. A fifth method and one which offers the great advantage of simplicity and ease of application is the injection of the anesthetic solution through the vaginal vault as a preliminary to abdominal pelvic work. This method is described in Chapter X. We have found it especially efficacious in the case of large fibroid tumors in which it was difficult to obtain an exposure from above before removing the tumor. It should not be used in the presence of pelvic infections. Fig. 216.-Anesthesia technic; anterior pelvic splanchnic anesthesia blocking round ligament. TECHNIC OF INTRA-ABDOMINAL PELVIC INFILTRATION AND BLOCKING. Anterior Splanchnic Anesthesia.-The first point to be blocked upon entering the pelvic cavity from above is the round ligament with its n. spermaticus externus. This is accomplished by having the assistant gently lift the abdominal wall in that part of the THE UTERUS 495 incision above the round ligament (Fig. 216), allowing the operator to see some portion of the ligament which is carefully picked up with the long tissue forceps and steadied while the needle is inserted into it. A point well toward the front is chosen as the nerve supply conies from the direction of the abdominal wall. (An excellent procedure is to advance the needle sub peri toneally along the anterior abdominal wall until its point reaches the parietal origin of the round ligament.) A wheal is raised and an effort made to extend the infiltration beneath the peritoneum on both sides of the round ligament. This maneuver is repeated on the opposite side and the subsequent technic will depend upon the operative procedure which is to be carried out. If the appendix is to be removed, this may be done while the solution which has been injected into the round and broad ligaments is given plenty of time in which to disseminate. A delay of a few minutes is desirable rather than otherwise. Anterior splanchnic anesthesia of the sacral plexus may be used as a preliminary to extensive pelvic work in cases in which the pelvic brim comes easily into view. During recent years we have used this method quite extensively, and when the retroperitoneal infiltration can be made directly under the vision it is to be con- sidered the method of choice. (See Chapter IV.) THE UTERUS. Like the adnexa, the uterus presents surgical conditions which are both simple and complicated, and the manner of dealing with them will depend, among other things, upon the kind of pathology present and the operative procedure which is to be undertaken. Hysteropexy.-Many of the various suspension operations may be performed with the anesthesia of the round ligaments (Fig. 216, page 494). If one wishes to pierce the broad ligament beneath the tubes, as in the Baldy-Webster operation, it is only necessary to infiltrate the area about the point of puncture. When the round ligaments are to be attached to the fundus, it may be desirable to produce a wheal at the point where they are to be attached. The raising of the uterus from its pelvic bed may be somewhat disagreeable. If the organ is adherent special precautions are necessary and considerable difficulty may be encountered. The introduction of a ligature beneath each of the round ligaments will facilitate the elevation of the uterus, and this may be further aided by the use of the tenaculum in the fundus, provided one intends to attach the round ligaments to the fundus. As the fundus is elevated adhesions may be divided with the scissors after 496 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS anesthetizing the sacral splanchnics. The introduction of a vaginal pack with the patient to the knee-chest position before the operation will be found to aid the deliverance of the fundus from its pelvic bed, especially in non-adherent cases. In all this work a knowledge of the pain sense of the region will enable the surgeon to anticipate the production of slight pain, which in some cases cannot be avoided, and in this manner an extra effort to be exceedingly gentle may be put forth at the proper time, while in addition the patient may be cautioned regarding the possibility of some disagreeable sensation. In this manner one may carry out many procedures which, if attempted in the manner that one is accustomed to use with general anesthesia, would inevitably result in failure. For the external or internal Alexander operation, the same technic as that used for oblique inguinal hernia is used, in addition to the blocking of the round ligaments when they are encountered. A great aid to the surgeon when making suspension operations under local anesthesia is the preliminary packing of the vaginal vault. One of the "high points" which one must pass comes when the retroverted uterus is lifted from its pelvic bed. Provided a splanchnic anesthesia has been produced manipulations of the uterus may be carried out without stint. However, for the ordinary simple pelvic work such as hysteropexy, anterior splanchnic anes- thesia should not be required. We have found that by placing the patient in the knee-chest position and packing the vagina with gauze the elevation of the uterus has been greatly facilitated after the abdomen had been opened. The packing may be introduced before the patient leaves the bed to go to the operating room. Myomectomy.-Tumors of large size can be handled under local anesthesia provided they lie in a favorable position and have generous pedicles. Large tumors which totally obstruct the view of the pelvis both before and after delivery of the tumor, so that the pedicle cannot be seen and blocked, may not be amenable to this form of anesthesia. Again, tumors with short pedicles or uterine fibroids involving the whole uterus may, on the one hand, so obstruct the view that they will present no chance for the block- ing of the nerves supplying this organ, and, on the other hand, the delivery of such a tumor may put the short pedicle on the stretch as the abdominal wall slips beneath it, so that the patient is caused too great discomfort. In cases of this kind the condition must be met as on page 493. As a rule, however, the round liga- ments can be seen before the delivery of the tumor and they should be generously blocked upon appearing (Fig. 216, page 494), The broad ligaments should also be infiltrated when brought into vjew, care being taken to avoid the veins, which is a comparatively THE UTERUS 497 simple matter, as the subperitoneal injection makes plainly visible the course and the amount of fluid as it flows in. Abdominal Hysterectomy.-The supravaginal amputation of the cervix in uncomplicated cases is one of the most satisfactory oper- ations under local anesthesia. It requires only a blocking of the round and broad ligaments and a subperitoneal infiltration about the uterine cervix before the clamps are applied (Fig. 217). The region of the uterine arteries is sensitive, especially where the blocking has not been perfectly done, and it is the author's practice Fig. 217.-Abdominal hysterectomy. Anesthesia technic; anterior splanchnic anesthesia. X, round ligament block. to clamp down to the artery, divide the broad ligament to this point, and, before clamping the artery, inject a few drops of the novocain-adrenalin solution directly into the region of the proposed incision. Provided the exposure is perfect and the pelvis free of intestines, or nearly so, this operation can be painlessly performed. The most common cause of discomfort will be due to an attempt on the part of the operator to raise the organ out of the pelvis during his manipulations. Traction must be avoided in order to perform the operation painlessly. Blocking of the ovarian and tubal 498 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS pedicles should be made proximal or distal to these organs, depend- ing upon whether or not they are to remain with the patient. Case No. 13348 is an example of a patient who underwent this operation for uterine fibroid with complications. (See also Case No. 13587, page 501.) Report of Case No. 13348. Mrs. S. T. W., aged forty-eight years, entered hospital January 10, 1920. Diagnosis: Uterine fibroids (multiple); double hydrosalpinx; pelvic adhesions. Operation: Abdominal subtotal hysterectomy; salpingectomy; division of adhesions. Preliminary Medication: The patient Was given pantopon gr. | and scopolamin gr. two hours before operation and the dose repeated one hour before operation. Anesthesia: Sacral, 90 cc 0.5 of 1 per cent novocain-adrenalin solution, and infiltration of abdominal wall, 100 cc. Operation: Midline incision from umbilicus to the pubes. The omentum was adherent to the parietal peritoneum. The adhesions were divided along the "white line." The sigmoid and omentum were adherent to a large fibroid tumor, and were separated in the same way. The tumor was then lifted out of the abdomen by means of a myoma screw without pain to the patient. Ilysterosalpin- gectomy was performed between clamps. The operation was completed without the patient's pulse going above 80. In this case no anesthesia was used in the peritoneal cavity. The pre- liminary sacral anesthesia seemed to be sufficient. Panhysterectomy.-In blocking for this operation the same technic is to be employed as for the operation of subtotal hyster- ectomy (Figs. 214, 215 and 216, pages 492-494), except that the tissues between the bladder and cervix in front and the rectum and cervix behind must be thoroughly infiltrated. This is not a difficult procedure and is not to be considered dangerous, if the ordinary precautions are followed. The needle should be made to follow the uterine wall closely and should be kept moving while the injection is being made. (Fig. 217, page 497.) The influx of the solution at once forces the bladder or rectum, as the case may be, far away from the cervix and out of harm's way. Before clamping the uterine vessels the needle should be carried down laterally to the cervix and a liberal amount of the solution deposited on both sides of the uterus. The edema produced, instead of being a hindrance is really an aid in making the dissection, as the bladder and rectum are carried farther away from the field of operation than would otherwise be the case, One has but to hug the wall 499 THE UTERUS of the uterus and vagina to be entirely safe. By the time the vessels are ligated and one is ready to apply the sutures the edema will have largely disappeared. Case No. 15448 is one in which panhysterectomy was performed upon an individual who had marked secondary anemia of toxic fibroid origin. Report of Case No. 15448. Mrs. A. O. I., aged fifty years, entered hospital January 30, 1922. Diagnosis: Uterine fibroid with secondary anemia. Operation: Panhysterectomy. Anesthesia: Local infiltration with anterior splanchnic. History: Patient's hemoglobin was 26 per cent on entering the hospital and it was increased 31 per cent by means of iron hypo- dermically as well as transfusions. Operation: Two weeks after entering the hospital a panhyster- ectomy was performed, using direct infiltration of the abdominal wall combined with anterior splanchnic anesthesia. The abdomen was opened with negative pressure, one gauze pack inserted to prevent soiling and the round and broad ligaments were infiltrated as shown in Fig. 216, page 494. The uterus was then delivered and was the size of a baby's head, soft, and was considered to be possibly sarcoma. Panhysterectomy was therefore performed between clamps. Drainage was instituted with the aid of a preliminary pack in the vaginal vault as described on page 507. Although the pulse and blood-pressure remained unchanged the hemoglobin dropped 6 per cent during the operation. This patient made an uneventful recovery, took nourishment directly after the operation in considerable quantities and showed almost no reaction to the operative procedure, notwithstanding the fact that she was an extremely poor risk. Case No. 13587 (page 501), a profoundly septic case requiring hysterectomy, double salpingectomy and left oophorectomy was also handled by abdominal infiltration and anterior splanchnic anesthesia. Equally good results may be obtained by the preliminary intro- duction of 90 cc of 1 per cent novocain-adrenalin solution into the sacral canal (Fig. 28, page 117). Even better anesthesia may be secured by the establishment of trans-sacral anesthesia. Infiltration through the vaginal vault as a preliminary gives one most excellent anesthesia. (See Fig. 147, page 353.) Report of Case No. 9705. Mrs. N. D., aged forty-four years, entered hospital March 5, 1916. 500 LOCAL ANESTHESIA IN SUHGEHY OF THE PELVIS Diagnosis: Chronic endometritis; bilateral salpingitis; right ovarian abscess; recurrent appendicitis; laceration of perineum. Operation: March 24, 1916. Abdominal hysterectomy. (Sub- total); double salpingectomy; right oophorectomy; appendectomy; perineorrhaphy. Anesthesia: Local infiltration; pelvic splanchnic. Bilateral blocking of the ilioinguinal and iliohypogastric nerves was done as well as subdermal blocking on line of proposed incision, using 120 cc of 0.5 per cent novocain-adrenalin solution. A typical Pfannenstiel incision and flap were made and the abdomen opened with negative pressure. Several adherent loops of intestine were separated from the uterus and tubes by sharp dissection. The small intestine was held above the pelvic brim by means of a gauze pack which was introduced without complaint. The round and broad ligaments and the right ovarian pedicle were infiltrated. The uterus, bilateral pus tubes and the right ovary which con- tained a cyst were removed. The anesthesia was reinforced when the region of uterine arteries was reached. The appendix was adherent to the lateral abdominal wall, the patient having had three attacks of appendicitis. Omental adhesions in this region were divided, the appendix removed, after which the peritoneal toilet was completed and the wound closed. The operation on the perineum followed, using infiltration block with 0.5 of 1 per cent novocain-adrenalin. The perineum was repaired with chro- micized gut. The record shows that this patient did not complain of pain except when sponging in the cul-de-sac was done. Pulse at close of operation was 88. Recovery was uneventful. FALLOPIAN TUBES. All work upon the non-adherent tubes may be done painlessly after the blocking of the round ligament and the mesosalpinx. Densely adherent tubes and tubo-ovarian abscesses come in the same class with the adherent uterus and malignant disease and will be considered later under a special technic which is to be recommended in this variety of pelvic work. However, it is sur- prising how much may be done under a perfect exposure with the pelvis free of intestines, by working entirely in the open, gently lifting the different organs with long tissue forceps and clipping the adherent bands as they appear. In this manner adherent masses which resist finger enucleation and require the use of great force may be cut loose with a scalpel or scissors and removed with comparative ease. Pelvic work should be done only under direct FALLOPIAN TUBES 501 vision. Cases No. 13587 and 10142 are examples of tubal pathology which was removed under local infiltration and pelvic splanchnic block. Report of Case No. 13587. Mrs. J. E., aged thirty-nine years, entered hospital November 25, 1921. Diagnosis: Double pyosalpinx; pelvic peritonitis; right ovarian cyst; recurring appendicitis; and left ovarian abscess. Operation: Subtotal hysterectomy; double salpingo-oophorectomy; appendectomy. Anesthesia: Local infiltration; anterior splanchnic (pelvic). History: This patient had had pelvic drainage of the posterior vaginal fornix established three weeks previously. Anesthesia: 90 cc of a 1 per cent novocain-adrenalin solution were used in infiltrating. The abdomen was opened by a midline incision 15 cm. in length. The pelvis was found free of small intestine, excepting two loops, which were attached to the fundus and one of the tubes respectively. Separation of these adhesions was accomplished without pain to the patient. At the pelvic brim a subperitoneal infiltration with novocain-adrenalin solution was made. Following this both round and broad ligaments were blocked, after gently elevating the abdominal wall at the lower end of the incision. Salt pads were then introduced for the purpose of protecting the general peritoneal cavity from becoming infected. These pads and the intestines above them were held out of the field by the use of wire- spring retractors. With long delicate tissue forceps the distended tubes were elevated and cut free from their pelvic attachments with scissors. A right ovarian cyst and a left ovarian abscess, both adherent in the pelvis, were freed in the same manner. The broad ligaments were then clamped and the anesthesia was rein- forced after cutting between the first pair of clamps on either side, in this manner carrying the solution directly to the region of the uterine arteries. Subtotal hysterectomy was then completed and drainage instituted with the aid of a preliminary pack of gauze in the vaginal vault as described on page 507. Anesthesia in this case was perfect. Note.-The use of a preliminary sacral block would perhaps have rendered the work less difficult. Especially would this be true in a case in which, for any reason, a less excellent exposure had been obtained. Had we, upon opening the abdomen of this patient, been confronted with a pelvis completely filled with coils of small intestine, it might have been impossible to exclude these from the field of operation, at least without delivering them upon 502 LOCAL ANESTHESIA IN SURGERY OP THE PELVIS the abdominal wall, which procedure should be avoided if possible. In a number of cases of this kind the author has been compelled to resort to mixed anesthesia in order to complete the operation without pain. Case Report No. 10142. Mrs. A. C. M., aged twenty-nine years, entered hospital October 15, 1917. Diagnosis: Unruptured ectopic pregnancy. Operation: Right salpingectomy. Anesthesia: Right midline infiltration, using 150 cc of a 0.5 per cent novocain-adrenalin solution. The abdomen was opened with the patient in Trendelenburg position and the pelvis found free of small intestines. The right tube presented a tumor the size of a lemon. A small amount of blood was found in the pelvis. A right salpingectomy was per- formed after an infiltration of the mesosalpinx. No gauze was used in the abdominal cavity. There was no expulsive effort and the anesthesia was ideal in every way. CESAREAN SECTION. Abdominal Cesarean section on account of the factors which furnish its indications often demands the safety offered by the use of local anesthesia. The classical operation may be performed under a simple infiltration of the abdominal wall (see Case Report No. 10796). In these cases it is better to avoid the delivery of the uterus, which is indeed generally unnecessary. The abdomen should be opened with a negative pressure and no sponges should be necessary, as a rule, for the retention of the intraperitoneal viscera. The uterine wall is not sensitive and requires no infil- tration. Should hysterectomy be necessary an anterior splanchnic infiltration of the broad and round ligaments may be carried out after the abdomen is opened. With the more complicated operations, as, for instance, the extraperitoneal operation, a transverse infiltration block extending from the umbilicus to the anterior-superior spine on either side, will answer the purpose. In these cases, operation will be facilitated by an infiltration of the subperitoneal tissue as soon as exposed. Vaginal Cesarean section may be accomplished by the perineal and cervical circumferential block described in Chapter XI, pages 351 and 353. The following case illustrates the application of abdominal section: THE OVARY 503 Report of Case No. 10796. Mrs. I). F., aged twenty-three years, entered hospital March 2, 1917. Diagnosis: Pregnancy; contracted pelvis. Operation: Abdominal Cesarean section. History: This patient had given birth to two children by abdo- minal Cesarean route, ether anesthesia being employed in both instances. Anesthesia: Local infiltration using 120 cc of 0.5 per cent novocain- adrenalin. Operation: At term. Midline infiltration 1 cm. to the left of the umbilicus. Negative intra-abdominal pressure obtained. The uterus was at once incised, without using intraperitoneal anesthesia. The incision proved to be over the placental site and the placenta was pushed aside. An arm presented, it was returned to the uterus, a leg grasped and the child was delivered. This procedure caused the patient no pain. Pituitrin was given hypodermically at this stage and the uterus contracted into a rigid mass. The patient complained of a typical long labor pain throughout the time the placenta was being delivered. Uterus and abdominal incision were then closed, no gauze having been used in the peri- toneal cavity. Note.-In this case the child was introduced to its mother thirteen minutes after beginning of induction of anesthesia. No gauze and no instruments - not even the gloved hand-came in contact with any of the intra-abdominal viscera. There wTas no postoperative nausea, vomiting, thirst or distention. The child weighed 8 pounds 14 ounces. Both mother and child left the hospital in good condition fourteen days later. THE OVARY. In operating upon the ovary under local anesthesia exposure will greatly facilitate the success of any procedure. The normal ovary is not particularly sensitive and may be handled to a certain extent without pain to the patient. However, it should not be subjected to severe pressure and traction must be avoided. As a rule the ovarian pedicle is blocked (Fig. 218) and the organ is steadied while the needle is being introduced through the peritoneal coat. The greatest difficulty is encountered in cases of ovarian cysts or adherent infected ovaries. Large cysts are best evacuated before delivery is attempted. For the purpose of avoiding the possibility of the dissemination of malignant particles the evacuation should be made by suction. (See Fig. 219.) 504 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS Fig. 218.-Ovarian cyst. Anesthesia technic. Anterior pelvic splanchnic anesthesia. Blocking ovarian pedicle. Fig. 219.-Ovarian cyst (malignant). Photograph of Case No. 11936 during operation. Evacuation of cyst by suction. THE OVARY 505 Once the cyst is reduced in size so that delivery may be easily made and the ovarian pedicle exposed blocking may be accomplished before the removal of the cyst. Traction should be most carefully avoided at this juncture. Adherent ovarian cysts offer more difficulty. However, adhesions between the cyst wall and the parietal peritoneum may be divided as they are met by the method described in Fig. 170, page 396. Separation of the other abdominal viscera from the cyst wall is not painful provided strong traction is avoided. The case below is one of cyst formation with adenocarcinoma and shows how suction was utilized to evacuate the cyst in pre- paring for removal: Record of Case No. 11936. Mrs. W. F. A., aged fortv-four years, entered the hospital January 31, 1919. Diagnosis: Ovarian cyst with papillary adenocarcinoma. Operation: Hysterectomy; bilateral salpingectomy; right oopho- rectomy; appendectomy. Anesthesia: Local infiltration; pelvic splanchnic. History: The patient has had frequent "catching" pains in lower right abdomen for past four years. The duration of pains was short and often accompanied by distention of abdomen, nausea and soreness so that the corset was not tolerated. The last attack began a month ago and has not subsided. Her appetite has been poor and bowels sluggish since onset of illness and the patient thinks she has been jaundiced. There have been no urinary symptoms. Menstrual history was negative and she has never been pregnant. Examination showed a large fluctuating tumor occupying the abdominal cavity from the symphysis pubis to the costal margins with bulging in the flanks. Anesthesia and Operative Technic.-A midline infiltration was made using 150 cc novocain-adrenalin solution and the abdomen was opened with a 10 cm. incision. The cyst which presented was punctured with a large trocar. By means of suction as shown in Fig. 219, 6000 cc of brown opaque thick fluid were aspirated so that the partially collapsed tumor could be drawn through the wound. It was found to take origin in the right ovary, which was removed along with both tubes and the uterus, as the malignant character of the cyst was noted on gross examination. Appendi- cectomy was also performed. All raw surfaces were peritonized and the wound was closed without drainage. 506 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS Note.-This patient had an uneventful postoperative convales- cence, but by pneumoperitoneum two and a half years later, on May 30, 1922, a shadow shows across the pelvis in the region of amputated broad ligaments with the patient in Peterson's modified knee-chest position. However, the cervix is freely movable and no mass can be felt. Intraligamentous cysts maybe evacuated following a subperi toneal infiltration and an anterior splanchnic anesthesia proximal to the growth. Infected cases offer the greatest difficulty, and while we have been able to accomplish complete ablation in a large percentage of infected pelvic cases of tubo-ovarian abscesses, the execution of such a procedure offers considerable difficulty. The abdomen must be opened with a perfect negative pressure. The pelvis must be free of small intestine. In other words, the exposure must be perfect. These cases, infected as they are, offer to the operator a peritoneal cavity which is more or less on the qui vive. There- fore it requires every artifice and all of the strategy at one's command to overcome the obstacles presented. A preliminary sacral, trans- sacral or parasacral anesthesia will, in most instances, act as an excellent adjunct. However, with a perfect exposure and the protection of an anterior splanchnic anesthesia preferably at the pelvic brim, combined with the proper surgical strategy, it is sur- prising to what extent one may carry through surgical procedures in badly infected pelvic cases. Case No. 13587 (page 501) is an example of a case in which the whole pelvis presented a mass of infected adherent organs, and yet a hystero-salpingo-odphorectomy was carried out under an excellent anesthesia. Next to exposure the delicate handling of tissues is most essential. Key bands should be cut rather than torn and they may be exposed by gently lifting the adherent organ by means of long, delicate tissue forceps. What has been said regarding the Fallopian tubes applies with equal force in the case of the ovaries. They will be found to be held in place by a few anchoring bands and will be most easily mobilized by the cutting of these bands. It is sur- prising to note the comparative ease with which this plan may be applied in cases which were formerly subjected to great force in making the blind infiltration of abdominal pelvic organs. Case No. 11494, which follows, illustrates the manner in which a large cyst of the ovary accompanied by a dermoid cyst and uterine fibroids was treated surgically with local infiltration and pelvic splanchnic anesthesia: POSTOPERATIVE DRAINAGE 507 Report of Case No. 11494. Miss M. I)., aged twenty-nine years, entered hospital April 26, 1918. Diagnosis: Uterine fibroids; dermoid cyst of left ovary; simple cyst of right ovary, established by means of pneumoperitoneum and roentgen rays. Operation: Subtotal hysterectomy; enucleation of dermoid cyst; excision of ovarian cyst; appendectomy. Anesthesia: Local infiltration; pelvic splanchnic. Midline infiltration below the umbilicus was made. The abdomen was opened with negative pressure. Some of the oxygen from the pneumoperitoneum of twenty-four hours before still remained. The abolition of the muscular reflexes, the presence of free oxygen gas in the abdominal cavity and the Trendelenburg position left the lower half of the abdomen entirely free of small intestine. The wall of the cyst of the right ovary was punctured and the cyst emptied by suction. (Fig. 219.) Vertical retraction of the abdominal wall at the lower end of the incision brought the round and broad ligaments into view, and they were infiltrated with a solution of novocain-adrenalin 0.7 of 1 per cent. A dermoid cyst of the left ovary, the size of a baseball, was shelled out without leakage. The uterine fundus contained numerous interstitial and subserousfibroids. Subtotal hysterectomy and appendectomy were done. Throughout the operation no gauze pads were placed in the abdominal cavity. Following the operation this patient received | gr. morphine hypo- dermically during the first night, and, according to the record, she slept well. There was no nausea or vomiting, and she took fluids in moderate amounts during and immediately after operation. An accurate diagnosis was made in this case by means of roentgen rays after pneumoperitoneum. POSTOPERATIVE DRAINAGE. Where drainage is to be employed in doing pelvic work it has been the author's habit, when this could be anticipated, to care- fully pack the vaginal vault with sterile gauze just previous to operation. When establishing drainage during the abdominal operation a non-absorbing suture is passed through the meshes of this gauze as soon as it is exposed to view from above and the abdominal drain is attached to it. Thus the abdominal drain can be drawn into the vagina as the vaginal gauze (which is attached to a long tape and allowed to hang from the foot of the table) is withdrawn. 508 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS The introduction of drains into the vagina from above is fre- quently the cause of discomfort to the patient and embarrassment to the surgeon. I have found the above-mentioned maneuver a great help here because, as not infrequently happens, some simple detail may interfere more with the performance of an operation under local anesthesia than will the major portions of the procedure. The making of a circumferential infiltration about the uterine cervix may precede the abdominal packing, and therefore the two adjuncts may be carried out as a preliminary to the abdominal operation without a great deal of trouble. INDEX. A Abdomen, gunshot wounds of, local infiltration in, 386 novocain-adrenalin in, 386 opening of, anticipated pathology in, 390 in appendicitis, 478 conservation of blood supply in, 389 of nerve supply in, 389 facility with which incision may be made and closed, 390 importance of division of muscular as compared with aponeurotic tissue, 388 surgery of, local anesthesia in, 379, 419 closure of wound and, 394 direction, site and choice of incision and, 385 duties of psycho- anesthetist and, 398 general considera- tions of, 373 making tbe incision and, 397 muscular relaxation and, 398 position of patient in, 384, 419 relaxation afforded during and after operation and, 391 resultant scar in, 387 trans-rectus incision in upper abdomen, 387 Abdominal cavity, opening of, in surgery of gall-bladder, 441 exploration, local anesthesia in, 399 hysterectomy, novocain-adrenalin in, 498 pantopon in, 498 sacral anesthesia in, 498 scopolamin in, 498 Abdominal incision in exposure of pelvis, 490 infiltration in appendicectomy, 481 organs, examination of, local anes- thesia in, 400 rectopexy, local anesthesia in, 375, 376 viscera, handling of, 129 wall, nerve supply of, 379 opening of, in introduction of anesthetic solution, 153 surgery of, local anesthesia in, 402 Abortion, incomplete, local anesthesia in, 353 infiltration in, 353 novocain-adrenalin in, 353 Abscess, intra-abdominal, drainage of, technic of, 486 of liver, local anesthesia in, 438 of lungs, general anesthesia and, 22 pelvic, local anesthesia in, 360 infiltration in, 360 sacral anesthesia in, 361 pulmonary, local anesthesia in, 266 infiltration in, 267 paravertebral block in, 267 Absence of vagina, congenital, local anesthesia in, 358 Accessory obturator nerve, anatomy of, 177 Acetonuria, general anesthesia and, 18 Acidosis, general anesthesia and, 19 Adenitis, bilateral cervical, novocain- adrenalin in, 234 suppurative cervical, novocain- adrenalin in, 233 tuberculous cervical, novocain- adrenalin in, 235 Adenoma of breast, cystic, 254 local anesthesia in, 254 intrathoracic toxic thyroid, cervi- cal block in, 243 local infiltration in, 243 saligenin in, 243 Air dilatation in cystotomy, 329 Albuminuria, chloroform anesthesia and, 28 Alocain-S as local anesthetic, 39 510 INDEX Alveolar nerves, anatomy of, 168, 169 [ process of inferior maxilla, carci- noma of, 217 excision of glands of neck in, 217 resection of inferior maxilla in, 217 Alypin as local anesthetic, 38 Amputation of arm, brachial block in, 287 local anesthesia in, 287 novocain-adrenalin in, 287 of leg, local anesthesia in, 287 novocain-adrenalin in, 288 transverse infiltration block in, 287, 288 of penis, local anesthesia in, 341 of toe, local anesthesia in, 314 Amputations, local anesthesia in, tech- nic of, 286 of lower extremity, 287 of upper extremity, 286 Anatomy of sensory nervous system, 166 Anemias, ether anesthesia and, 25 Anesthesia, anterior splanchnic, in cholecystectomy, 452 in choledochotomy, 454 in duodenal ulcer, 425, 426 in gastric ulcer, 424, 425 in surgery of gall-bladder, | 443 arterial, 111, 114 technic of, 114 brachial, technic of, 129 circumferential infiltration of Hackenbruck, 112 conduction, 111 general, 17 acetonuria and, 18 acidosis and, 19 chloroform, 26 albuminuria and, 28 arrhythmia and, 27 cardiac disorders and, 27 circulatory disorders and, 27 system and, 26 cirrhosis of liver and, 28 | dyspnea and, 27 enlarged bronchial glands and, 27 thymus and, 27 fatty degeneration of liver and, 26 hepatic disorders and, 28 renal disorders and, 28 respiratory disorders and, 27 yellow atrophy of liver and, 28 Anesthesia, general, dangers of, 29 effects of, on general system, 18 on special organs and tissues, 21 ethanesal, 25 ether, 24 anemias and, 25 blood and, 24 cardiovascular disease and, 25 diabetes mellitus and, 25 heart and, 24 kidneys and, 24 nephritis and, 25 nervous system and, 24 respiratory disorders and, 25 gangrenous pneumonia and, 22 ill effects of, 18 lung abscess and, 22 mortality of, 31 nitrous oxide, 28 postoperative shock and, 20 respiration and, 19 toxicity of, 18 infiltration, 111 advantages of, 139 block, 112 direct and regional compared, 137 technic of, 144 intraneural, 111 intraspinal, 111 local, 33 acidosis research upon patient after using, 48 advantages of, after opera- tion, 63 before operation, 63 cooperation of patient, 61 during operation, 61 "silent field," 61 armamentarium for, 82 attitude of patient in relation to, and upon what it de- pends, 64 automatic lifter in, 101 description of, 103 wire-spring retractor in, 97 causes of failure of, in abdom- inal surgery, 147 choice of methods of admin- istering, 143 definition of terms employed, 111 discussion of, with patient, 68 equipment for, 82 necessity for special, 82 INDEX 511 Anesthesia, local, Farr's pneumatic in- jector in, 88 detailed description of, 92 operative mechanism of, 93 gauze retractor and, 156 general considerations regard- ing induction of, after the time has arrived for giving anesthetic, 148 intelligence of patient and, 66 practitioner in relation to, 75 technic of, 111 goiter clamp in, 104 heavy bone shears in, 108 hypodermoclysis and, 162 intestinal forceps in, 110 introduction of solution in,149 medical teaching in relation to, 74 methods of producing, 33 allocain-S, 39 alypin, 38 apothesin, 38 benzyl alcohol, 41 benzylcarbinol, 42 beta-eucain, 35 butyn, 43 cocain, 35 cold, 33 epinephrin, 44 nirvanin, 39 novocain (procain), 45 phenol, 34 pressure, 34 quinin and urea hydrochloride, 40 saligenin (salicain), 42 stovain, 37 tropacocain, 36 music and, 162 needles for infiltration, 86 operating room deportment and, 159 lighting in, 95 table for, 83 arm rests, 83 tilting of, 84 preparation of patient for operation under, 135 principles of application of, to surgery, 111 progress of, and upon what it depends, 78 prostatic "hook" in, 108 retractor in, 105 Anesthesia, local, psychic aspects, at- tention to, by as- sistants and, 69 of surgical case and, 66 "shock" and, 70 psycho-anesthetist and, 160 rectal dilators in, 109 reduction of trauma and, 62 relative desirable properties of, 52 sponging and, 154 surgical strategy and, 161 technic and some ad- juncts demanded by, 154 syringes for, 85 technic of, desirability of simplifying, 139 tying of ligatures and, 154 Farr's three-forceps and four-forceps tie, 156 Grant's method, 156 viscera retainer in, 106 mixed, 78 narco-local, 72 technic of, 132 parasacral, technic of, 119 paravertebral, technic of, 122 patient's interests in, 55 perineural, 111 problem of, 55 hospital in relation to, 74 psycho-local, 79 regional, 111 application of, 136 of sacral nerves, 117 technic of, 185 splanchnic, technic of, 124 anterior, 125 Farr's method of, 127 posterior, 124 synergistic, technic of, 133 trans-sacral, technic of, 121 venous, 111, 112 technic of, 112 Anesthetic, choice of, 55 after-pains and, 60 apprehension and, 58 comfort and, 58 convalescence and, 60 discomfort and, 58 efficiency and, 56 postoperative discomfort and, 60 safety and, 56 suffering and, 59 solution, introduction of, technic of, 149 anesthetization of skin line, 149 512 INDEX Anesthetic solution, introduction of, technic of, deep layer infiltration, 151 initial wheal, 149 negative intra-abdo- minal pressure,153 opening of abdomi- nal wall, 153 skin incision, 153 Anesthetist, nurse versus physician, 76 surgeon his own, 77 Ankle-joint, nerve supply of, 310 surgery of, local anesthesia in, 310 Ankylosis of elbow-joint, brachial block in, 295 local anesthesia in, 294 infiltration in, 295 saligenin in, 295 of hip, local anesthesia in, 302 Anococcygeal nerves, anatomy of, 182 Anterior colporrhaphy, local anesthesia in, technic of, 354 crural nerve, anatomy of, 177 splanchnic anesthesia in panhys- terectomy, 499 in pelvic operations, 494 in pyosalpinx, 501 thoracic nerve, anatomy of, 172 tibial nerve, anatomy of, 181 Anus, fissures of, circumferential infil- tration in, 369 sacral anesthesia in, 369 nerve supply of, 363 surgery of, circumferential infil- tration in, 363 local anesthesia in, 362 choice of methods of, 362 position of patient in, 362 postoperative comfort in, 377 Apothesin as local anesthetic, 38 Appendiceal abscess, drainage of, tech- nic of, 486 Appendicectomy, abdominal infiltra- tion in, 481 delivery of acute appendix, tech- nic of, 482 local anesthesia in, 447, 449, 450, 452, 479, 484, 485 infiltration in, 480, 485 muscular relaxation in, 481 novocain-adrenalin in, 485 under varying conditions, 480 Appendicitis, acute, 471 local anesthesia in, 484, 485 chronic, incisions in, 472 Elliott's, 475 McArthur's gridiron, 472 transverse abdominal, 473 Appendicitis, deep infiltration in, tech- nic of, 476 delivery of appendix in, technic of, 479 local anesthesia in, 450, 452 management of, medical, 471 operative, 421 preoperative, 471 surgical, 471 meso-appendix infiltration in, tech- nic of, 478 opening of abdomen in, 47 8 negative intra-abdominal pressure,478 position on operating table for, 472 postoperative course of, effect of anesthesia on, 472 subacute, 471 local anesthesia in, 479 subdorsal infiltration, technic of, 476 Appendix, pelvis and, local anesthesia and, 487 position on operating table and, 488 surgery of, local anesthesia in, 471 Arm, amputation of, brachial block in, 287 local anesthesia in, 287 novocain-adrenalin in, 287 hemangioma of, local anesthesia in, 272 transverse infiltration block of, 274 Armamentarium for local anesthesia, 82 Arnold, nerve of, anatomy of, 170 Arrhythmia, chloroform anesthesia and, 27 Arterial anesthesia, 111, 114 technic of, 114 Arthritis of hip, local anesthesia in, 289 suppurative, local anesthesia in, technic for drainage in, 289 Anthroplasty of elbow-joint, local anesthesia in, 295 of hip, local anesthesia in, 302 infiltration, 302 nitrous oxide and oxygen in, 302 Arthrotomy, local anesthesia in, 289 Artificial vagina, local anesthesia in, 358 Aspiration of cysts, local anesthesia in, 457 Atheromata of scalp, 190 Atresia of hymen, infiltration block in, 358 local anesthesia in, 357 Atrophy of liver, chloroform anesthesia and, 28 Auricular nerves, anatomy of, 170 Auriculotemporal nerve, anatomy of, 169 Automatic lifter, 101 INDEX 513 Automatic lifter, description of, 103 wire-spring retractors, 97 B Base of skull, fracture of infiltration block in, 219 Bell, external respiratory nerve of, anatomy of, 172 Benzyl alcohol as local anesthetic, 41 Benzylcarbinol as local anesthetic, 42 Beta-eucain as local anesthetic, 35 Bilateral cervical adenitis, novocain- adrenalin in, 234 Bile ducts, surgery of, local anesthesia in, 453 Bladder, method of opening in supra- pubic cystotomy, 329 surgery of, local anesthesia, 328 Blood, ether anesthesia and, 24 Bone, intramedullary autotransplant of, brachial block in, 284 shears, heavy, 108 transplantation of, local anesthesia in, technic of, 283 from tibia, brachial block in, 283 circumferential block in, 283 local infiltration on leg in, 283 Bowel, distended, temporary drainage of, author's rubber towel method, 469 Brachial anesthesia in excision of breast, 259 technic of, 129 block in amputation of arm, 287 in ankylosis of elbow-joint, 295 in carcinoma of breast, 260 in fracture of radius, 278 in fracture-dislocation of hum- erus, 293 of shoulder-joint, 277 in intramedullary autotrans- plant of bone, 284 in oblique fracture of hume- rus, 293 in subluxation of shoulder- joint, 293 in transplantation from tibia, 283 Brain, decompression of, 191 operations on, infiltration block in, 193 local anesthesia in, 191 novocain-adrenalin in, 193 tumor of, 191 excision of, 192 33 Breast, carcinoma of, brachial block in, 260 circumferential infiltration in, 261 intercostal block in, 261 local anesthesia in, 260, 261 infiltration in, 260 midline infiltration in, 261 novocain-adrenalin in, 260 cystic adenoma of, 254 local anesthesia in, 254 excision of, 254 anesthesia in, technic of, 257 brachial anesthesia in, 259 cervical block in, 259 local anesthesia in, 260, 261 radical, 256 subdermal infiltration in, 259 surgery of, local anesthesia in, 251 tumors of, benign, anesthesia in, technic of, 251 infiltration block in, 252 subdermal infiltration in, 252 malignant, 254 Bronchial glands, enlarged, chloroform anesthesia and, 27 Buccal nerve, anatomy of, 169 Buccinator nerve, anatomy of, 169 Bunions. See Hallux valgus. Butyn as local anesthetic, 43 C Cadivilla pin, 311 Calculi of ureter, local anesthesia in,323 Calculus, vesical, novocain-adrenalin in, 330 suprapubic infiltration in, 330 Cancer of pylorus, local anesthesia in, 420 Carbuncle of neck, infiltration block in, 239 local anesthesia in, 236 Carcinoma of alveolar process of inferior maxilla, 217 excision of glands of neck in, 217 resection of inferior maxilla in, 217 of breast, brachial block in, 260 circumferential infiltration in, 261 intercostal block in, 261 local anesthesia in, 261 infiltration in, 260 midline infiltration in, 261 novocain-adrenalin in, 260 of inferior maxilla, transoral man- dibular block in, 219 514 INDEX Carcinoma of intestines, resection for, local anesthesia in, 460 of larynx, infiltration block in, 249 local anesthesia in, 249 novocain-adrenalin in, 249 pantopon in, 249 scopolamin in, 249 of lip, block dissection for, 236 local infiltration in, 236 of rectosigmoid, circumferential infiltration in, 463 local anesthesia in, 462 infiltration in, 462 novocain-adrenalin in, 462 sacral anesthesia in, 463 of rectum, parasacral anesthesia in, 373 sacral anesthesia in, 373 trans-sacral anesthesia in, 373 of stomach, local anesthesia in, 429 resection for, anterior splanch- nic anesthesia in, 429 intercostal block in, 429 local infiltration in, 429 novocain-adrenalin in,429 Cardiac disorders, chloroform anes- thesia and, 27 Cardiovascular disease, ether anes- thesia and, 25 Cartilages, floating, infiltration block in, 308 local anesthesia in, 308 novocain-adrenalin in, 308 Celiac plexus, anatomy of, 182 Cervical adenitis, bilateral, novocain- adrenalin in, 234 suppurative, novocain-adren- alin in, 233 tuberculous, novocain-adren- alin in, 235 block in carcinoma of neck, 237 in epithelioma of lip, 218 in excision of breast, 259 in goiter, 242 in intrathoracic toxic thyroid adenoma, 243 in thyroidectomy, 237 infiltration block of neck, 230 nerves, anatomy of, 170 Cesarean section, infiltration in, 503 local anesthesia in, 502 novocain-adrenalin in, 503 Chloroform anesthesia, 26 albuminuria and, 28 arrhythmia and, 27 cardiac disorders and, 27 circulatory disorders and, 27 cirrhosis of liver and, 28 system and, 26 dyspnea and, 27 Chloroform anesthesia, enlarged bron- chial glands and, 27 fatty degeneration of liver and, 26 hepatic disorders and, 28 renal disorders and, 28 respiratory disorders and, 27 thymus and, 27 yellow atrophy of liver and, 28 Cholecystectomy, anterior splanchnic anesthesia in, 452 local anesthesia in, 441, 447, 448, 449, 450, 451, 452, 454, 456 infiltration in, 451 Cholecystitis, local anesthesia in, 447, 449, 450, 451, 452 Choledochotomy, anterior splanchnic anesthesia in, 454 infiltration block in, 455 local anesthesia in, 453, 454, 456 infiltration in, 454 novocain-adrenalin in, 456 Cholelithiasis, local anesthesia in, 447, 449 Ciliary nerves, anatomy of, 167 Circulatory disorders, chloroform anes- thesia and, 27 system, chloroform anesthesia and, 26 Circumcision, local anesthesia in, 341 Circumferential block in transplanta- tion from tibia, 293 infiltration anesthesia of Hacken- bruck, 112 block in operations on brain, 193 of scalp, 187, 188, 189 Clavicle, nerve supply of, 291 surgery of, local anesthesia in, 291 Cleft palate, local anesthesia in, 221, 227 Clitoris, dorsal nerve of, anatomy of, 182 nerve supply of, 349 operations on, local anesthesia in, 349 Cocain as local anesthetic, 35 Coccygeal nerves, anatomy of, 178 Cold as local anesthetic, 33 Colloid goiter, toxic, local anesthesia in, 242 Colostomy, local anesthesia in, technic of, 463 Common peroneal nerve, anatomy of, 180 Conduction anesthesia, 111 in surgery of female genitalia, 345 Congenital absence of vagina, infiltra- tion block in, 358 local anesthesia in, 358 novocain-adrenalin in,358 INDEX 515 Congenital absence of vagina, sacral block in, 358 stricture of male urethra, novo- cain-adrenalin in, 340 sacral anesthesia in, 340 of urethra, local anesthesia in, 339 Costectomy, anesthesia in, technic of, 263 local anesthesia in, 266 Curettage, infiltration block in, 352 local anesthesia in, technic of, 352 Cutaneous cervical nerves, anatomy of, 170 Cyst, ovarian, anesthesia and operative technic in, 505 local infiltration in, 505, 507 novocain-adrenalin in, 505 pelvic splanchnic anesthesia in, 505, 507 of pancreas, local anesthesia in, 457 infiltration in, 457 Cystic adenoma of breast, 254 local anesthesia in, 254 duct clamp, 108 Cystoscopy, local anesthesia in, 328 sacral anesthesia in, 329 Cystostomy, local anesthesia in, 326 Cystotomy, air dilatation in, 329 Cysts, aspiration of, local anesthesia in, 457 of liver, local anesthesia in, 438 D Decompression of brain, 191 Deep perineal nerve, anatomy of, 180 Denker's operation in maxillary sinu- sitis, 202 Dental nerve, inferior, anatomy of, 169 Diabetes mellitus, ether anesthesia and, 25 Digital plantar nerve, anatomy of, 179 Dislocations in children, reduction of, 278 of hip, local anesthesia in, 300 infiltration in, 299 novocain-adrenalin in, 299 reduction of, technic of, 299 reduction of, 276 Dissection of neck, local anesthesia in, 234 Divulsion of sphincter, 366 Dorsal antibrachial cutaneous nerve, anatomy of, 173 nerve of clitoris, anatomy of, 182 of penis, anatomy of, 182 scapular nerve, anatomy of, 172 Duodenal ulcer, anterior splanchnic anesthesia in, 425, 426 infiltration block in, 423, 425, 426 local anesthesia in, 422, 423, 425 novocain-adrenalin in, 423 Dupuytren's contraction, inHitration block in, 297 local anesthesia in, 297 Dyspnea, chloroform anesthesia and, 27 E Ear, surgery of, local anesthesia in, 194 Ectopic pregnancy, novocain-adrenalin in, 502 Elbow-joint, ankylosis of, brachial block in, 295 local anesthesia in, 294 infiltration in, 295 saligenin in, 295 arthroplasty of, local anesthesia in, 295 nerve supply of, 294 surgery of, local anesthesia in, 294 Elliott's incision in appendicitis, 475 Empyema, intercostal block in, 266 local anesthesia in, 266 negative pressure in, 264 novocain-adrenalin in, 266 paravertebral block in, 266 Enterostomy, local anesthesia in, 470 Epigastric hernia, local anesthesia in, 411 Epinephrin as local anesthetic, 44 Epithelioma of lip, cervical block in, 218 infiltration block in, 218 local anesthesia in, 218, 236 Equipment for local anesthesia, 82 necessity for special, 82 Ethanesal anesthesia, 25 Ether anesthesia, 24 anemias and, 25 blood and, 24 cardiovascular disease and, 25 diabetes mellitus and, 25 heart and, 24 kidneys and, 24 nephritis and, 25 nervous system and, 24 respiratory disorders and, 25 Ethmoidal nerves, anatomy of, 167 Excision of breast, 254 local anesthesia in, 260, 261 of mandible, local anesthesia in, 219 of palmar fascia, local anesthesia in, 297 516 INDEX Exophthalmic goiter, local anesthesia in, 245 infiltration in, 245 narco-local anesthesia in, 245 quinin and urea hydrochloride in, 245 External cutaneous nerve, anatomy of, 176 plantar nerve, anatomy of, 180 popliteal nerve, anatomy of, 180 respiratory nerve of Bell, anatomy of, 172 spermatic nerve, anatomy of, 176 F Face, anesthesia of, 198 nerve supply of, 197 nerves of, anatomy of, 166 surgery of, local anesthesia in, 185, 197 Facial nerve, anatomy of, 169 Fallopian tubes, surgery of, local anes- thesia in, 500 Farr's automatic lifter, 102 wire-spring retractor, 97 "elephant trunk" operating room lamp, 95, 96, 97 goiter clamp, 704 method of anterior splanchnic anesthesia, 127 needles for local anesthesia, 86 for sacral anesthesia, 116 pneumatic injector, 88 detailed description of, 92 operative mechanism of, 93 "setting-up" of, 93 prostatic retractor, 105 rubber-tipped intestinal forceps, 119 special bayonet-lock needle, 87 subdermal method of anesthetiza- tion of skin line in introduc- tion of anesthetic solution, 150 three-forceps and four-forceps tie, local anesthesia and, 156 viscera retainer, 106 Fascia, transplantation of, in incisional hernia, 407 Fatty degeneration of liver, chloroform anesthesia and, 26 Feet, surgery of, local anesthesia in, 271 Female genitalia, external, anesthesia in, 345 general considera- tions of, 345 methods of obtain- ing, 345 psychic considera- tions and, 346 Female genitalia, external, anesthesia in, sacral, 345 nerve supply of, 344 Femoral hernia, anesthesia in, 406 incarcerated, local infiltration in, 418 novocain-adrenalin in, 418 nerve, anatomy of, 177 Femur, fracture of, local anesthesia in, 281, 282 . infiltration in, 299 block in, 281 novocain-adrenalin in, 281, 282, 299 transverse infiltration block in, 282 ununited, local anesthesia in, 299 supracondyloid T-fracture of, local anesthesia in, 303 Fibroid tumors of uterus, local infiltra- tion in, 507 pelvic splanchnic anes- thesia in, 507 Fingers, surgery of, local anesthesia in, 272 Fissures of anus, circumferential infil- tration in, 369 sacral anesthesia in, 369 Fistula-in-ano, circumferential infiltra- tion in, 369, 372 infiltration block in, 370 local anesthesia in, 372 of intestine, tuberculous, local anesthesia in, 447 Floating cartilages, infiltration block in, 308 local anesthesia in, 307 novocain-adrenalin in, 308 Fluoroscopic examinations, local anes- thesia and, 271 Forearm, transverse infiltration block of, 274 Fractional method, operating by, 80 Fracture of base of skull, infiltration block in, 219 in children, reduction of, 278 malunited, 281 of femur, closed operation, anes- thesia in, technic of, 302 local anesthesia in, 281, 282 infiltration in, 299 block in, 281 novocain-adrenalin in, 299, 304 open operation, anesthesia in, technic of, 303 transverse infiltration block in, 303 local infiltration block in, 282 INDEX 517 Gastroenterostomy, anterior, local infil- tration in, 420 novocain-adrenalin in, 420 local anesthesia in, 420, 422, 426 posterior, local infiltration in, 421, 422 novocain-adrenalin in, 421 Gauze retractors, local anesthesia and, 156 Genito-urinary system, surgery of, local anesthesia in, 315 Genitocrural nerve, anatomy of, 176 Genitofemoral nerve, anatomy of, 176 Glossopharyngeal nerve, anatomy of, 169 Goiter clamp, 104 exophthalmic, local anesthesia in, 245 infiltration in, 245 narco-local anesthesia in, 245 quinin and urea hydrochloride in, 245 toxic colloid, cervical block in, 242 local anesthesia in, 242 infiltration in, 242 novocain-adrenalin in, 242 subdermal infiltration in, 442 Grant's method of injecting the second and third division of trigeminal nerve, 205 Great auricular nerve, anatomy of, 170 sciatic nerve, anatomy of, 178 Gunshot wound of abdomen, local infiltration in, 386 novocain-adrenalin in, 386 H Hackenbruck, circumferential infiltra- tion anesthesia of, 112 Hallux valgus, local anesthesia in, technic of, 311 Hands, surgery of, local anesthesia of, 271 Hare-lip, local anesthesia in, 221, 227 operations for, infiltration block in, 221 Head, nerves of, anatomy of, 166 surgery of, local anesthesia in, 185 Heart, ether anesthesia and, 24 Hemangioma of arm, local anesthesia in, 272 of right brachium, local infiltration in, 272 Hemorrhoidectomy, local anesthesia in, 413 Hemorrhoids, circumferential infiltra- tion in, 369 Fracture of femur, ununited, local anesthesia in, 299 of humerus, oblique, brachial block in, 293 of hip, reduction of, technic of, 299 of leg, closed operation, anesthesia in, 308 local anesthesia in, 309 novocain-adrenalin in, 309 sciatic nerve block in, 309 transverse infiltration block in, 309 of patella, local anesthesia in, 307 Pott's, local anesthesia in, 310 novocain-adrenalin in, 310 transverse infiltration block in, 310 of radius and ulna, local anesthe- sia in, 279 transverse infiltration block in, 279 brachial block in, 278 local anesthesia in, 278 reduction of, 276 of vault of skull, 190 Fracture-dislocation of humerus, brach- ial block in, 293 local anesthesia in, 293 of shoulder-joint, brachial block in, 277 local anesthesia in, 277 infiltration in, 277 Frontal nerve, anatomy of, 166 G Gall-bladder, exposure of, 446 posterior splanchnic anesthe- sia in, 446 hydrops of, local anesthesia in, 448 perforation of, local anesthesia in, 447 removal of, method of, 446 novocain-adrenalin in, 446 sensation of, 441 surgery of, anterior splanchnic anesthesia in, 443 local anesthesia in, 440 opening of abdominal cavity in, 441 negative intra-abdo- minal pressure in, 441 Gangrenous pneumonia, general anes- thesia and, 22 Gasserian ganglion, injection of, 205 Gastric ulcer, anterior splanchnic anes- thesia in, 424, 425 local infiltration in, 424 novocain-adrenalin in, 425 518 INDEX Hemorrhoids, sacral anesthesia in, 369 Hepatic disorders, chloroform anes- thesia and, 28 Hernia epigastric, local anesthesia in, 411 femoral, anesthesia in, 406 incarcerated, local infiltration in, 418 novocain-adrenalin in, 418 incisional, anesthesia in, 406 circumferential infiltration in, 407 local anesthesia in, 407 novocain-adrenalin in, 407 transplantation of fascia in, 407 inguinal, anesthesia in, induction of, 403 infiltration block in, 406 nerve supply of, 402 novocain-adrenalin in, 406 skin sterilization in, 403 local anesthesia in, 402 strangulated, local anesthesia in, 415 infiltration in, 417 novocain-adrenalin in, 417 umbilical, local anesthesia in, 411 Herniotomy, local anesthesia in, 407 Hip, ankylosis of, local anesthesia in, 302 arthritis of, local anesthesia in, 289 arthroplasty of, local anesthesia in, 302 infiltration in, 302 nitrous oxide and oxygen in, 302 dislocation of, local anesthesia in, 300 infiltration in, 299 novocain-adrenalin in, 299 reduction of, technic of, 299 fractures of, reduction of, technic of, 299 nerve supply of, 297 surgery of, local anesthesia in, 297 open operations, tech- nic of, 298 Hour-glass contraction of stomach, local anesthesia in, 427 stomach, sleeve resection for, local infiltration, 427 Humerus, fracture of, brachial block in, 293 novocain-adrenalin in, 294 fracture-dislocation of, brachial block in, 293 local anesthesia in, 293 novocain-adrenalin in, 293 Hydrocele, local anesthesia in, 342 subdermal infiltration in, 344 Hydrops of gall-bladder, local anes- thesia in, 448 Hydropyo-ureter, double, local anes- thesia in, 326 infiltration in, 326 novocain-adrenalin in, 328 paravertebral block in, 326 sacral block in, 326 Hymen, atresia of, infiltration block in, 352 local anesthesia in, 357 Hypertrophic pyloric stenosis, local anesthesia in, 430 infiltration in, 436 novocain-adrenalin in, 437 Hypertrophy of prostate, local anes- thesia in, 335, 337 infiltration in, 335, 336, 337 morphine in, 335 narco-local anesthesia in, 335 novocain-adrenalin in, 335, 336, 338 quinin and urea hydrochlor- ide in, 335 sacral block in, 336, 337 scopolamin in, 335 Hypodermoclysis in local anesthesia, 166 Hypogastric nerve, anatomy of, 176 Hypospadias, local anesthesia in, 341 Hysterectomy, abdominal, novocain- adrenalin in, 498 pantopon in, 498 sacral anesthesia in, 498 scopolamin in, 498 local anesthesia in, 505, 507 vaginal, local anesthesia in, tech- nic of, 356 infiltration in, 357 novocain-adrenalin in, 357 quinin and urea hydrochloride in, 357 Hysteropexy, local anesthesia in, 450, 451, 495 preliminary packing of vaginal vault in, 496 I Iliac nerve, 176 Iliohypogastric nerve, anatomy of, 175 Ilioinguinal nerve, anatomy of, 176 Incarcerated femoral hernia, local infiltration in, 418 novocain-adrenalin in, 418 Incisional hernia, anesthesia in, 406 circumferential infiltration in, 407 novocain-adrenalin in, 407 INDEX 519 Incisional hernia, transplantation of fascia in, 407 Inferior alveolar nerve, anatomy of, 169 dental nerve, anatomy of, 169 hemorrhoidal nerve, anatomy of, 182 maxillary nerve, anatomy of, 168 Infiltration, abdominal, in appendicec- tomy, 481 wall, direct, in calculi of ureter, 325 in pyonephrosis, 325 in pyoureter, 325 anesthesia, 111 advantages of, 139 direct versus regional, 137 technic of, 144 block, 112 in atresia of hymen, 358 in congenital absence of vagina, 358 circumferential, in chronic osteomyelitis, 290 in curettage, 352 in duodenal ulcer, 423, 425, 426 in Dupuytren's contraction, 297 in epithelioma of lip, 218 in fistula-in-ano, 370 in floating cartilages, 308 in fracture of base of skull, 219 of femur, 281 in inguinal hernia, 403 in interposition operations on uterus, 354 in laminectomy, 268 of neck, cervical, 230 subdermal, 232 in nephrolithiasis, 323 operations on brain, 193 for hare-lip, 221 in perineorrhaphy, 349 in prolapse of uterus, 356 in pyonephrosis, 322 in rupture of kidney, 323 of scalp, 187, 188, 189 in tonsillectomy, 222 transverse, in amputation of leg, 287, 288 of arm, 274 of forearm, 274 in fracture of femur, 282 of leg, 309 of radius and ulna, 279 in Pott's fracture, 310 of thigh, 275, 276 in tumors of breast, 252 of spinal cord, 269 cervical block, in carcinoma of neck, 237 Infiltration, cervical block, in thyroid- ectomy, 237 circumferential, in carcinoma of breast, 261 in fissures of anus, 369 in fistula-in-ano, 369, 372 in hemorrhoids, 369 in incisional hernia, 407 in polypi of rectum, 369 in prolapse of rectum, 375, 377 in surgery of anus, 363 of rectum, 363 deep, in appendicitis, 476 in laryngectomy, 246 in thyroidectomy, 237 local, in ankylosis of elbow-joint, 295 in anterior gastroenterostomy, 420 in appendicectomy, 481 in arthroplasty of hip, 302 in carcinoma of breast, 260 of lip, 236 of rectosigmoid, 462 in Cesarean section, 503 in choledochotomy, 454 in cyst of pancreas, 457 in dislocation of hip, 299 in exophthalmic goiter, 245 in fibroid tumors of uterus,507 in fracture of femur, 299 in fractures of patella, 307 in fracture-dislocation of shoulder-joint, 277 in gastric ulcer, 424 in gunshot wound of abdo- men, 386 in hemangioma of right brach- ium, 272 in hydropyo-ureter, 326 in hypertrophic pyloric sten- osis, 436 in hypertrophy of prostate, 335, 336, 337 in incarcerated femoral hernia, 418 in incomplete abortion, 353 in intrathoracic toxic thyroid adenoma, 243 in intussusception in children, 465, 466 on leg, in transplantation from tibia, 283 in operations on palate, 228 in ovarian cyst, 505, 507 in panhysterectomy, 499, 520 in pelvic abscess, 360 in posterior gastroenteros- tomy, 421, 422 in prolapse of rectum, 376 in pulmonary abscess, 217 in pyosalpinx, 501 520 INDEX Infiltration, local, in resection for car- cinoma of stomach, 429 in sleeve resection for hour- glass stomach, 427 in strangulated hernia, 417 in toxic colloid goiter, 242 in tuberculous peritonitis, 467, 468 in vaginal hysterectomy, 357 in varicose veins of leg, 314 meso-appendix, in appendicitis,478 midline, in carcinoma of breast, 261 subdermal, in appendicitis, 476 in excision of breast, 259 in hydrocele, 344 in laminectomy, 268 in laryngectomy, 247 in toxic colloid goiter, 242 in tumors of breast, 252 in varicocele, 342 superficial, in laryngectomy, 246 in thyroidectomy, 237 suprapubic in vesical calculus, 330 transverse, in fracture of femur,303 Infratrochlear nerve, anatomy of, 167 Inguinal hernia, anesthesia in, induc- tion of, 403 infiltration block in, 406 nerve supply of, 402 novocain-adrenalin in, 406 sterilization of skin in, 403 Intercostal block in carcinoma of breast, 261 in empyema, 266 in resection for carcinoma of stomach, 429 nerves, anatomy of, 173 Intercosto-brachial nerve, anatomy of, 174 Intermediate dorsal cutaneous nerve, anatomy of, 181 Internal calcaneal nerve, anatomy of, 179 cutaneous nerve, anatomy of, 177 plantar nerve, anatomy of, 179 popliteal nerve, anatomy of, 179 pudic nerve, anatomy of, 182 saphenous nerve, anatomy of, 177 Intestinal forceps, 110 Intestine, resection of, local anesthesia in, 467 tuberculous fistula of, local anes- thesia in, 467 Intestines, carcinoma of, resection for, local anesthesia in, 460 surgery of, local anesthesia in, 459 diagnosis and, 459 special considera- tions of, 459 in treatment of com- plicated condi- tions, 459 | Intestines, surgery of, local anesthesia in treatment of simple conditions, 459 Intra-abdominal abscess, drainage of, technic of, 484 pelvic infiltration and blocking, technic of, 494 pressure, negative, in introduction of anesthetic solution, 153 in opening of abdomen in appendicitis, 478 in surgery of the gall - bladder, 441 Intradermal method of anesthetization of skin line in introduction of anes- thetic solution, 149 Intraneural anesthesia, 111 | Intraperitoneal pain sense, 379 Intraspinal anesthesia, 111 I Intrathoracic toxic thyroid adenoma, cervical block in, 243 local infiltration in, 243 saligenin in, 243 : Intussusception in children, local infil- tration in, 465, 466 McArthur incision in, 465 novocain-adrenalin in, 465, 466 local anesthesia in, 464, 465, 466 saligenin in, 464 K Kidney, functionless, local anesthesia in, 326 nerve supply of, 316 rupture of, local anesthesia in, 323 infiltration block in, 323 novocain adrenalin in, 323 surgery of, local anesthesia in, 316 delivery of kidney and, 32 incision and, 320 sensation and, 319 technic of, 317 suture of, local anesthesia in, 323 Kidneys, ether anesthesia and, 24 Knee-joint, loose cartilage in, local anesthesia in, 308 nerve supply of, 305 surgery of, local anesthesia in, 305 technic of, 306 L Labia, nerve supply of, 348 operations on, local anesthesia in, technic of, 348 INDEX 521 Labial nerves, anatomy of, 168 Lacrimal nerve, anatomy of, 166 Laminectomy, anesthesia in, technic of, 268 infiltration block in, 268 local anesthesia in, 270 subdermal infiltration in, 268 Laparotomy, local anesthesia in, 465, 466 Laryngeal nerves, anatomy of, 169, 170 polypi, local anesthesia in, 248 Laryngectomy, anesthesia in, deep infil- tration, 246 subdermal infiltration in, 247 superficial infiltration in, 246 technic of, 246 local anesthesia in, 248, 249 novocain-adrenalin in, 249 pantopon in, 249 scopolamin in, 249 Laryngotomy, local anesthesia in, 248 Larynx, carcinoma of, infiltration block in, 249 local anesthesia in, 249 novocain-adrenalin in, 249 pantopon in, 249 scopolamin in, 249 nerve supply of, 246 Lateral femoral cutaneous nerve, anat- omy of, 176 plantar nerve, anatomy of, 180 sural cutaneous nerve, anatomy of, 180 Leg, amputation of, local anesthesia in, 287, 288 novocain-adrenalin in, 288 transverse infiltration block in, 287, 288 fractures of, closed operations, anesthesia in, 308 r local anesthesia in, 309 novocain-adrenalin in, 309 sciatic nerve block in, 309 transverse infiltration block in, 309 surgery of, local anesthesia in, 308 varicose ulcer of, local anesthesia in, 288 veins of, local anesthesia in, 312, 314 novocain-adrenalin in,314 Ligation of thyroid arteries, 243 technic of, 243 Ligatures, tying of, local anesthesia and, 154 Lingual nerve, anatomy of, 169 blocking of, 224 Lip, carcinoma of, block dissection for, 236 local infiltration in, 236 epithelioma of, cervical block in, 218 Lip, epithelioma of, infiltration block in, 218 local anesthesia in, 218, 236 Lipectomy, local anesthesia in, 411, 413 Liver, abscess of, local anesthesia in, 438 cysts of, local anesthesia in, 438 fatty degeneration of, chloroform anesthesia and, 26 rupture of, local anesthesia in, 438 yellow atrophy of, chloroform anesthesia and, 28 Lobectomy, local anesthesia in, 242, 243, 245 Long buccal nerve, anatomy of, 169 ciliary nerve, anatomy of, 167 saphenous nerve, anatomy of, 177 thoracic nerves, anatomy of, 172 Lumbar nerves, anatomy of, 175 Lumboinguinal nerve, anatomy of, 176 Lungs, abscess of, general anesthesia and, 22 M McArthur's gridiron incision in appendicitis, 472 incision in intussusception in chil- dren, 465 Malunited fractures in children, reduc- tion of, 281 Mandible, excision of, local anesthesia in, 219 Mandibular nerve, anatomy of, 168 blocking of, 202 injections at mandibular division, 209 subzygomatic injection at maxillary division of, 208 transoral, 216 Masseteric nerve, anatomy of, 169 Mastitis, suppurative, anesthesia for drainage, technic of, 254 Mastoid operations, infiltration block for, 194 novocain-adrenalin in, 196 Mastoiditis, subacute, local anesthesia in, 196 Maxilla, inferior, alveolar process of, carcinoma of, 217 excision of glands of neck in, 217 resection of inferior maxilla in, 217 carcinoma of, local anesthesia in, 219 excision of, anesthesia for, 215 superior, excision of, anesthesia for, 214 Maxillary nerve, blocking of, 200 nerves, anatomy of, 167, 168 522 INDEX Maxillary sinusitis, Denker's oper- ation in, local anesthesia in, 202 Moynihan's cystic duct clamp, 108 Medial calcaneal nerve, anatomy of, 179 plantar nerve, anatomy of, 179 sural cutaneous nerve, anatomy of, 179 Median nerve, anatomy of, 172 Meningeal nerves, anatomy of, 167 Middle cutaneous nerve, anatomy of, | 177 dorsal cutaneous nerve, anatomy of, 181 meningeal nerve, anatomy of, 167 supraclavicular nerve, anatomy of, 172 Mouth, surgery of, local anesthesia in, 222 Musculocutaneous nerve, anatomy of, 181 Musculospiral nerve, anatomy of, 173 Myomectomy, local anesthesia in, 376, 496 N Narco-local anesthesia, 72 technic of, 132 Narcotics, preliminary, 72 Nasal nerves, anatomy of, 168 Nasociliary nerve, anatomy of, 167 Neck, anesthesia of, methods of indu- ; cing, 230 carbuncle of, infiltration block in, 237 local anesthesia in, 236 deep cervical infiltration block of, j 230 dissection of, local anesthesia in, 234 malignant disease of, 232 nerve supply of, 229 subdermal infiltration block in, 232 surgery of, local anesthesia in, 229 advantages of, 229 cooperationof patient and, 229 tuberculous glands of, 232 Needles for local anesthesia, 86 Negative intra-abdominal pressure in opening of abdomen in appendicitis,478 in surgery of gall- bladder, 441 of abdominal wall, 153 Nephrectomy, local anesthesia in, 319, 322, 526 Nephritis, ether anesthesia and, 25 Nephrolithiasis, infiltration block in, 322 local anesthesia in, 319, 322 Nephrolithiasis, morphin in, 319 novocain-adrenalin in, 322 paravertebral block in, 319, 322 scopolamin in, 319 Nephro-ureterectomy, local anesthesia in, 326 Nerve or Nerves, accessory obturator, 177 alveolar, 168 anococcygeal, 182 anterior crural, 177 thoracic, 172 tibial, 181 of Arnold, 170 auricular, 170 auriculotemporal, 169 buccinator, 169 cervical, 170 coccygeal, 178 common peroneal, 180 cutaneous cervical, 170 deep peroneal, 181 digital plantar, 179, 180 dorsal antibrachial cutaneous, 173 of clitoris, 182 of penis, 182 scapular, 172 ethmoidal, 167 external cutaneous, 176 plantar, 180 popliteal, 180 respiratory of Bell, 172 spermatic, 176 facial, 169 femoral, 177 frontal, 166 genito crural, 176 genitofemoral, 176 glossopharyngeal, 169 great auricular, 170 sciatic, 178 hypogastric, 176 iliac, 176 iliohypogastric, 175 ilioinguinal, 176 inferior alveolar, 169 dental, 169 hemorrhoidal, 182 maxillary, 168 infratrochlear, 167 intercostal, 173 intercosto-brachial, 174 intermediate dorsal cutaneous, 181 internal calcaneal, 179 cutaneous, 177 plantar, 179 popliteal, 179 pudic, 182 saphenous, 177 labial, 168 lacrimal, 166 laryngeal, 169, 170 INDEX 523 Nerve or Nerves, lateral femoral cuta' neous, 176 plantar, 180 sural cutaneous, 180 lingual, 169 blocking of, 224 long buccal, 169 ciliary, 167 saphenous, 177 thoracic, 172 lumbar, 175 lumboinguinal, 176 mandibular, 168 blocking of, 202 transoral, 216 masseteric, 169 maxillary, 167 blocking of, 200 meatus auditorii externi, 169 medial calcaneal, 179 plantar, 179 sural cutaneous, 179 median, 172 middle cutaneous, 177 dorsal cutaneous, 181 meningeal, 167 supraclavicular, 172 musculocutaneous, 181 musculospiral, 173 nasal, 168 nasociliary, 167 ninth, 169 obturator, 177 occipital, 170 ophthalmic, 166 blocking of, 198 palatine, 168 palpebral, 168 perforating, cutaneous, 182 perineal, 178, 182 peroneal, 180 plexus of, brachial, 172 celiac, 183 cervical, 170 lumbosacral, 175 pudendal, 181 sacral, 175 solar, 183 pneumogastric, 169 posterior brachial cutaneous, 173 femoral cutaneous, 178 scapular, 172 scrotal, 182 thoracic, 172 pudendal, 182 radial, 173 recurrent laryngeal, 170 sacral, 178 anesthesia of, 117 saphenous, 177 sciatic, 178 seventh, 169 Nerve or Nerves, small sciatic, 178 smaller occipital, 170 spinal, 170 superficial cervical, 170 perineal, 182 peroneal, 181 supply of abdominal wall, 379 of ankle-joint, 310 of anus, 363 of clitoris, 349 of clavicle, 291 of elbow-joint, 294 of external genitalia of female, 344 of face, 197 of head, 166 of hip, 297 of inguinal hernia, 402 of kidney, 316 of knee-joint, 305 of labia, 348 of larynx, 246 of neck, 229 of palate, 226 of penis, 340 of perineum, 349 of peritoneum, 379 of rectum, 363 of scalp, 185 of shoulder, 291 of spine, 267 of sympathetic system, 182 of thyroid gland, 237 of tongue, 224 of tonsil, 222 of uterus, 352 of wrist, 297 supra-acromial, 172 supraclavicular, 171 supraorbital, 167 suprascapular, 172 suprasternal, 172 supratrochlear, 167 tenth, 169 thoracic, 261 thoracico-abdominal intercostal, 175 tibial, 179 transverse cervical, 170 trigeminal, 166 blocking of, 198 ulnar, 173 vagus, 169 of Wrisberg, 169 zygomaticofacialis, 168 Nervous system, ether anesthesia and 24 Neuritis, optic, local anesthesia in, 193 New growths of scalp, 190 Nitrous oxide anesthesia, 28 Ninth nerve, anatomy of, 169 524 INDEX Nirvanin as local anesthetic, 39 Novocain (procain) as local anesthetic, 45 O Obturator nerve, anatomy of, 177 Occipital nerves, anatomy of, 170 Operating by fractional method, 80 room, lighting of, 95 table for local anesthesia, 83 Ophthalmic nerve, anatomy of, 166 blocking of, 198 deep, 199 Optic neuritis, local anesthesia in, 193 Orchidectomy, local anesthesia in, 235, 342 Osteomyelitis, acute, local anesthesia in in, technic for drainage in, 290 chronic, circumferential infiltra- tion block in, 290 novocain-adrenalin in, 290 of tibia, local anesthesia in, 290 Ovarian cyst, anesthesia and operative technic in, 505 local infiltration in, 305, 507 novocain-adrenalin in, 505 pelvic splanchnic anesthesia in, 505, 507 Ovaries, surgery of, local anesthesia in, 503 P Palate, cleft, local anesthesia in, 221, 227 nerve supply of, 226 operations on, anesthesia for, 226 local infiltration in, 228 Palatine nerves, anatomy of, 168 Palmar fascia, excision of, local anes- thesia in, 297 Palpebral nerves, anatomy of, 168 Pancreas, cyst of, local anesthesia in, 457 infiltration in, 457 surgery of, local anesthesia in, 457 Panhysterectomy, anterior splanchnic anesthesia in, 499 local infiltration in, 499, 500 novocain-adrenalin in, 500 pelvic splanchnic anesthesia in, 500 Parasacral anesthesia in carcinoma of rectum, 373 in pelvic operations, 493 technic of, 119 Paravertebral anesthesia, technic of, 122 block in empyema, 266 in hydropyo-ureter, 326 in nephrolithiasis, 319, 322 Paravertebral block in pulmonary ab- scess, 267 in pyonephrosis, 322 in ureterolithiasis, 319 Patella, fracture of, local anesthesia in, 307 infiltration in, 307 novocain-adrenalin in, 307 Pedicle flaps in skin-grafting, local anesthesia in, 164 Pelvic abscess, local anesthesia in, 360 infiltration in, 367 sacral anesthesia in, 361 laparotomy, local anesthesia in, 358 operations, adjuncts to, 492 anterior splanchnic anesthesia in, 494 incisions in, 489 parasacral anesthesia in, 493 sacral anesthesia in, 493 trans-sacral anesthesia in, 493 splanchnic anesthesia in panhys- terectomy, 500 Pelvis, blocking of, 489 exposure of, 489 abdominal incision in, 490, 491 surgery of, local anesthesia in, 489 skin sterilization in, 489 Penis, amputation of, local anesthesia in, 341 dorsal nerve of, anatomy of, 182 nerve supply of, 340 surgery of, local anesthesia in, 340 Perforating cutaneous nerve, anatomy of, 182 Perforation of gall-bladder, local anes- thesia in, 447 Perineal nerve, anatomy of, 178, 182 prostatectomy, local anesthesia in, 338 Perineorrhaphy, infiltration block in, 349 local anesthesia in, 355, 413 technic of, 349 Perineum, nerve supply of, 349 operations on, local anesthesia in, 349 Perineural anesthesia, 111 Peritoneum, nerve supply of, 379 Peritonitis ileus, local anesthesia in, 470 tuberculous, local anesthesia in, 467 Peroneal nerves, anatomy of, 180 Phenol as local anesthetic, 34 Plexus of nerves, brachial, anatomy of, 172 celiac, anatomy of, 182 cervical, anatomy of, 170 lumbosacral, anatomy of, 175 pudendal, anatomy of, 181 INDEX 525 Plexus of nerves, sacral, anatomy of, 175 solar, anatomy of, 182 Pneumatic injector, 88 detailed description of, 92 operative mechanism of, 93 Pneumogastric nerve, anatomy of, 169 Pneumonia, gangrenous, general anes- thesia and, 22 Pneumoperitoneum, 399 Polypi, laryngeal, local anesthesia in, 248 rectal, circumferential infiltration in, 369 sacral anesthesia in, 369 Posterior brachial cutaneous nerve, anatomy of, 173 femoral cutaneous nerve, anatomy of, 178 scapular nerve, anatomy of, 172 scrotal nerve, anatomy of, 182 thoracic nerve, anatomy of, 172 Postoperative drainage, local anes- thesia and, 507 shock, general anesthesia and, 20 Pott's fracture, local anesthesia in, 310 novocain-adrenalin in, 310 transverse infiltration block in, 310 Pratt's rectal dilators, 109 Pregnancy, ectopic, novocain-adrenalin in, 502 Pressure as local anesthetic, 34 Prolapse of rectum, circumferential infiltration in, 375, 377 local anesthesia in, 375 infiltration in, 376 novocain-adrenalin in, 376 quinin and urea hydrochlor- ide in, 375 sacral anesthesia in, 373 of uterus, infiltration block in, 356 local anesthesia in, 355 novocain-adrenalin in, 356 Prostate, hypertrophy of, local anes- thesia in, 335, 337 infiltration in, 335, 336, 337 morphin in, 335 narco-local anesthesia in, 335 novocain-adrenalin in, 335, 336, 338 quinin and urea hydrochlor- ide in, 335 sacral block in, 336, 337 scopolamin in, 335 Prostatectomy, perineal, local anes- thesia in, 338 suprapubic, local anesthesia in, 331 prostatic retractor in, 332 sacral anesthesia in, 331 Prostatic "hook," 108 Prostatic retractor, 105 in suprapubic prostatectomy, 332 Psycho-anesthetist, local anesthesia and, 160 Psycho-local anesthesia, 79 Pudendal nerve, anatomy of, 182 Pulmonary abscess, local anesthesia in, 266 infiltration in, 267 paravertebral block in, 267 Pylorectomy, local anesthesia in, 425 Pyloric stenosis, hypertrophic, local anesthesia in, 430 infiltration in, 436 novocain-adrenalin in, 437 Pyloroplasty, local anesthesia in, 421, 447 Pylorus, cancer of, local anesthesia in, 420 Pyonephrosis, direct infiltration of ab- dominal wall in, 325 infiltration block in, 322 local anesthesia in, 322, 325 novocain-adrenalin in, 322 paravertebral block in, 362 Pyosalpinx, anterior splanchnic anes- thesia in, 501 Pyoureter, direct infiltration of abdomi- nal wall in, 325 local anesthesia in, 325 novocain-adrenalin in, 325 Q Quinin and urea hydrochloride as local anesthetic, 40 R Radial nerve, anatomy of, 173 Radius and ulna, fracture of, local anes- thesia in, 279 novocain-adrenalin in, 275 transverse infiltration block in, 279 fracture of, brachial block in, 278 local anesthesia in, 278 Radiographic examinations, local anes- thesias and, 271 Rammstedt pyloric incision, local anes- thesia in, 436, 437 Rectal dilators, 109 Rectosigmoid, carcinoma of, circumfer- ential infiltration in, 463 local infiltration in, 462 novocain-adrenalin in, 462 526 INDEX Sacral anesthesia in hemorrhoids, 369 in hydropyo-ureter, 326 in hypertrophy of prostate, 336, 337 in pelvic abscess, 361 operations, 493 in prolapse of rectum, 373 in rectal polypi, 369 in surgery of appendix, 471 of female genitalia, 345 technic of, 115 two-needle method, 116 nerves, anatomy of, 178 anesthesia of, 117 Saligenin (salicain) as local anesthetic, 42 Salpingectomy, local anesthesia in, 502 Saphenous nerve, anatomy of, 177 Scalp, anesthesia of, 186 duration of, 189 atheromata of, 190 circumferential infiltration block of, 187, 188, 189 nerve supply of, 185 new growths of, excision of, 190 Scapular nerves, anatomy of, 172 Sciatic nerve, anatomy of, 178 block in fractures of leg, 309 Sensory nervous system, anatomy of, 166 Seventh nerve, anatomy of, 169 Shock, postoperative, general anes- thesia and, 20 Shoulder, nerve supply of, 291 surgery of, local anesthesia in, 291 Shoulder-joint, fracture-dislocation of, brachial block in, 277 local anesthesia in, 277 infiltration in, 277 novocain-adrenalin in, 277 subluxation of, brachial block in, 293 local anesthesia in, 293 Sinusitis, maxillary, Denker's operation in, local anesthesia in, 202 Skin, incision of, in introduction of anesthetic solution, 153 line, anesthetization of, in intro- duction of anesthetic solution, 149 plastics, local anesthesia in, 221 sterilization of, in inguinal hernia, 403 in surgery of pelvis, 489 in varicocele, 342 Skin-grafting, local anesthesia in, 163 Skull, base of, fracture of, infiltration block in, 219 surgery of, local anesthesia in, 190 vault of, fractures of, 190 Sleeve resection for hour-glass stomach, 427 Rectosigmoid, carcinoma of, sacral anesthesia in, 463 Rectum, carcinoma of, parasacral anes- thesia in, 373 sacral anesthesia in, 373 trans-sacral anesthesia in, 373 examination of, 368 nerve supply of, 363 polypi of, circumferential infiltra- tion in, 369 sacral anesthesia in, 369 prolapse of, circumferential infil- tration in, 375, 377 local anesthesia in, 375 infiltration in, 376 novocain-adrenalin in, 376 quinin and urea hydrochlor- ide in, 375 sacral anesthesia in, 373 surgery of, circumferential infil- tration in, 363 local anesthesia in, 362 choice of methods 362 position of patient in, 362 postoperative comfort in, 377 Recurrent laryngeal nerve, anatomy of, 170 Regional anesthesia, 111 application of, 136 Renal disorders, chloroform anesthesia and, 28 Resection of intestine, local anesthesia in, 467 of stomach, local anesthesia in, 429 Respiration, general anesthesia and, 19 Respiratory disorders, chloroform anes- thesia and, 27 ether anesthesia and, 25 nerve of Bell, anatomy of, 172 Ribs, resection of, anesthesia in, 264 subdermal infiltration in, 265 Rupture of kidney, local anesthesia in, 323 of liver, local anesthesia in, 438 S Sacral anesthesia in abdominal hys- terectomy, 498 in carcinoma of rectosigmoid, 463 of rectum, 373 in congenital absence of vagina, 358 in cystoscopy, 329 Farr's needles for, 116 in fissure of anus, 369 in fistula-in-ano, 369 INDEX 527 Small sciatic nerve, anatomy of, 178 Smaller occipital nerve, anatomy of, 170 Solar plexus, anatomy of, 182 Sphincter, divulsion of, 366 Spinal cord, tumor of, infiltration block in, 269 local anesthesia in, 269, 270 nerves, anatomy of, 170 Spine, nerve supply of, 267 surgery of, local anesthesia in, 251, 267 Splanchnic anesthesia, technic of, 124 anterior, 125 posterior, 124 Spleen, anterior splanchnic anesthesia of, 458 surgery of, local anesthesia in, 458 Sponging, local anesthesia and, 154 Steinman pin, introduction of, technic of, 311 Stenosis, hypertrophic pyloric, local anesthesia in, 430 infiltration in, 436 novocain-adrenalin in, 437 Stomach, carcinoma of, local anes- thesia in, 429 resection for, anterior splanch- nic anesthesia in, 429 intercostal block in, 429 local infiltration in, 429 novocain-adrenalin in, 429 hour-glass contraction of, local anesthesia in, 427 sleeve resection for, local infil- tration in, 427 operations on, avoidance of clamps in, 420 local anesthesia in, 419 resection of, local anesthesia in, 429 Stovain as local anesthetic, 37 Strangulated hernia, local anesthesia in, 415 infiltration in, 417 novocain-adrenalin in, 417 Stricture of male urethra, congenital, novocain-adrenalin in, 340 sacral anesthesia in, 340 multiple, local anesthesia in, 339 novocain-adrenalin in, 339 Subdermal infiltration block of neck, 232 Subluxation of shoulder-joints, brachial block in, 293 local anesthesia in, 293 Subtemporal decompression, 193 infiltration block in, 193 novocain-adrenalin in, 193 Subzygomatic injection at maxillary division of mandibular nerve, 208 Superficial cervical nerve, anatomy of, 170 perineal nerve, anatomy of, 182 peroneal nerve, anatomy of, 181 Suppurative arthritis, local anesthesia in, technic of, drainage in, 289 cervical adenitis, novocain-adren- alin in, 233 mastitis, anesthesia for drainage, technic of, 254 Supra-acromial nerves, anatomy of, 172 Supraclavicular nerves, anatomy of, 171 Supracondyloid T-fracture of femur, local anesthesia in, 303 Supraorbital nerve, anatomy of, 167 Suprapubic cystotomy, local anesthesia in, 325, 329, 330, 335, 336 technic of, 329 method of opening bladder in, 329 prostatectomy, local anesthesia in, 331 prostatic retractor in, 332 sacral anesthesia in, technic of, 331 Suprascapular nerves, anatomy of, 172 Suprasternal nerves, anatomy of, 172 Supratrochlear nerve, anatomy of, 167 Suprazygomatic injection at maxillary division of mandibular nerve, 208 Sympathetic nervous system, anatomy of, 182 Synergistic anesthesia, technic of, 133 Syringes for local anesthesia, 85 T T-fracture of femur, supracondyloid, local anesthesia in, 303 Tenth nerve, anatomy of, 169 Thoracico-abdominal intercostal nerve, anatomy of, 175 Thiersch's method of skin-grafting, local anesthesia in, 163 Thigh, transverse infiltration block of, 275, 276 Thoracentesis, anesthesia in, technic of, 262 Thoracic nerves, 261 anatomy of, 172, 173 Thorax, surgery of, local anesthesia in, in, 251, 261 ' Throat, surgery of, local anesthesia in, 222 528 INDEX Thymus, enlarged, chloroform anes- thesia and, 27 Thyroid adenoma, intrathoracic toxic, cervical block in, 243 local infiltration in, 243 saligenin in, 243 arteries, ligation of, 243 gland, nerve supply of, 237 Thyroidectomy, anesthesia for, 238 in non-toxic cases, anesthetic tech- nic, 237 cervical block, 237 deep infiltration in, 237 surgical technic, 237 superficial infiltration in, 237 in toxic cases, 243 Thyroids, toxic, 243 Tibia, osteomyelitis of, local anesthesia in, 290 Tibial nerve, anatomy of, 179 Toe, amputation of, local anesthesia in, 314 Toes, surgery of, local anesthesia in, 272 Tongue, nerve supply of, 224 surgery of, local anesthesia in, 224 Tonsil, nerve supply of, 222 Tonsillectomy, anesthesia for, 223 infiltration block in, 222 Toxic colloid goiter, cervical block in, 242 local anesthesia in, 242 infiltration in, 242 novocain-adrenalin in, 242 subdermal infiltration in, 242 thyroid adenoma, intrathoracic, cervical block in, 243 local infiltration in, 243 saligenin in, 243 thyroids, 243 Transoral blocking of mandibular nerve, 216 mandibular block in carcinoma of inferior maxilla, 219 Transplantation of fascia in incisional hernia, 407 Trans-sacral anesthesia in carcinoma of rectum, 373 in pelvic operations, 493 technic of, 121 Transverse abdominal incision in appendicitis, 473 cervical nerve, anatomy of, 170 infiltration block, 275 Trigeminal nerve, anatomy of, 166 blocking of, 198 Tropacocain as local anesthetic, 36 Tuberculous cervical adenitis, novo- cain-adrenalin in, 235 fistula of intestine, local anesthesia in, 467 glands of neck, 232 peritonitis, local anesthesia in, 467 infiltration in, 467, 468 novocain-adrenalin in, 467 Tumor of brain, 191 excision of, 192 of breast, benign, anesthesia in, technic of, 251 infiltration block in, 252 subdermal infiltration in, 252 malignant, 254 of spinal cord, infiltration block in, 269 local anesthesia in, 269, 270 novocain-adrenalin in, 270 of uterus, fibroid, local infiltration in, 597 novocain-adrenalin in, 507 pelvic splanchnic anes- thesia in, 507 Tympanic cavity, anesthesia of, 194 U Ulcer, duodenal, anterior splanchnic anesthesia in, 425, 426 infiltration block in, 423, 425, 426 local anesthesia in, 422, 463, 425 novocain-adrenalin in, 423 gastric, anterior splanchnic anes- thesia in, 424, 425 local infiltration in, 424 novocain-adrenalin in, 425 varicose, of leg, local anesthesia in, 288 Ulnar nerve, anatomy of, 173 Umbilical hernia, local anesthesia in, 411 Ununited fracture of femur, local anes- thesia in, 299 Ureter, calculi of, direct infiltration of abdominal wall in, 325 local anesthesia in, 323 technic of, 324 novocain-adrenalin in, 325 surgery of, local anesthesia in, 323 Ureterectomy, local anesthesia in, 319 Ureterolithiasis, local anesthesia in, 319, 325 morphin in, 319 529 INDEX Ureterolithiasis, paravertebral block in, 319 scopolamin in, 319 Ureterotomy, local anesthesia in, 325 Urethra, dilatation of, local anesthesia in, 339, 340 male, stricture of, congenital, 338, 340 sacral anesthesia in, 340 novocain-adrenalin in, 339 sacral anesthesia in, 338 surgery of, local anesthesia in, 338 Uterus, nerve supply of, 352 operations on, local anesthesia in, 352 prolapse of, infiltration block in, 356 local anesthesia in, 355 novocain-adrenalin in, 356 retroversion of, local anesthesia in, 450, 451 surgery of, local anesthesia in, 495 tumors of, fibroid, local infiltra- tion in, 507 novocain-adrenalin in, 507 pelvic splanchnic anes- thesia in, 507 V Vagina, congenital absence of, infiltra- tion block in, 358 local anesthesia in, 358 novocain-adrenalin in, 358 sacral block in, 358 Vaginal drainage, local anesthesia in, 361 examination in virgins, local anes- thesia in, 348 hysterectomy, local anesthesia in, technic of, 356 infiltration in, 357 novocain-adrenalin in, 357 quinin and urea hydrochloride in, 357 Vagus nerve, anatomy of, 169 Van Allen method of injecting Gasse- rian ganglion, 211 Varicocele, local anesthesia in, 341 sterilization of skin in, 341 subdermal infiltration in, 342 Varicose ulcer of leg, local anesthesia in, 288 veins of leg, local anesthesia in, 312, 314 technic of, 313 novocain-adrenalin in, 314 Vasectomy, local anesthesia in, 342 Vault of skull, fractures of, 190 Venous anesthesia, 111, 112 technic of, 112 Vesical calculus, local anesthesia in, 329 novocain-adrenalin, 320 suprapubic infiltration in, 330 Vesico-ureteral anastomosis, local anes- thesia in, 327 Viscera retainer, 106 Viscero-parietal adhesions, local anes- thesia in, 401, 451 W Wheal, initial, in introduction of anes- thetic solution, 149 Wire-spring retractors, automatic, 97 Wolff grafts in skin-grafting, local anesthesia in, 164 Wrisberg, nerve of, anatomy of, 169 Wrist, nerve supply of, 297 surgery of, local anesthesia in, 297 ¥ Yellow atrophy of liver, chloroform anesthesia and, 28 Z Zygomatic nerve, anatomy of, 167 Zygomatico-facialis nerve, anatomy of, 168